Volume 209 Issue 10

Australia needs a more systematic and nationally coordinated approach to manage the escalating health burden arising from incarcerated older people

Natasha A Ginnivan · Tony G Butler · Adrienne N Withall

Engaging clinicians through trials networks may represent a critical and cost-effective investment that improves quality of care, patient outcomes and standards of care even before the results of trials are known

John R Zalcberg · Michael Friedlander

We need to establish guidelines and a framework to ensure the development of effective, safe and relevant health apps, with appropriate regulatory oversight

Rahul Barmanray · Esther Briganti

A national clinical care standard for colonoscopy highlights key components of quality, safety and patient experience

Anne Duggan · Iain J Skinner · Alice L Bhasale

Informed use of digital learning technologies can contribute to effective learning experiences

Helen Wozniak · Rachel H Ellaway · Peter GM de Jong

Clinicians should be mindful about the potential renal effects of cefepime

Luke Vlismas · Hannah Coleman · Tom N Lea-Henry · Bobby Chacko

The focus should primarily be on avoiding unnecessary long term prescribing of PPIs

Peter Bytzer

We need to move beyond managing end organ complications to reducing cardio-renal risk across the spectrum of kidney function

Brendon L Neuen · Vlado Perkovic

Ensure that cardiovascular disease risk factors are adequately controlled may reduce mortality

Wai H Lim · David W Johnson · Carmel Hawley · Charmaine Lok · Kevan R Polkinghorne · Matthew A Roberts · Neil Boudville · Germaine Wong

Social media has the potential to change the face of public health messaging

Keira M Glasgow · Catherine R Bateman-Steel · Bradley Pope · Mark J Ferson

More frequent gluten testing would reduce the risk for people with coeliac disease

Emma P Halmos · Dean Clarke · Catherine Pizzey · Jason A Tye-Din

Prompt evaluation and immediate empiric therapy are essential for averting fatal outcomes and chronic neurological sequelae

Miles H Beaman

The revised colorectal cancer screening guidelines recommend screening modality based on risk according to age and family history

Mark A Jenkins · Driss Ait Ouakrim · Alex Boussioutas · John L Hopper · Hooi C Ee · Jon D Emery · Finlay A Macrae · Albert Chetcuti · Laura Wuellner · D James B St John

To the Editor: Doctors for the Environment Australia welcomed MJA’s recent planetary health issue.1 It could not come at a more crucial time. Human health and the environment are inextricably linked, and medical professionals have a vital role in actively protecting health through care of the environment. However, it was disappointing that little emphasis was given to the need to significantly mitigate greenhouse gas emissions, and to the important advocacy role that medical professionals share to raise awareness of the urgency of delivering Australia’s Paris Agreement commitment. Global temperature rises greater than 1.5–2°C will adversely affect planetary health, sustainable development and nearly all future health goals.2 Further temperature increases will be catastrophic to sea level rises and the food and ecosystems on which human life depends. While countries such as France and China move ahead on mitigation measures, Australia is, at best, slow to understand the urgency or, at worst, an active global laggard. Australia is one of the OECD countries most vulnerable to climate change;3 it is among the top seven countries contributing to 60% of the world’s biodiversity loss,4 and yet it is not transitioning jobs or future wealth towards sustainable energy. All while human-induced environmental threats to the global riches of the Great Barrier Reef, the Northern Territory and the Pilliga and Tarkine forests are fast becoming this generation’s environmental legacy. Doctors should urgently raise awareness of the threats to health from climate change, advocate to mitigate the threats, and show in practice that transitioning to low carbon societies in energy, diet and transport have health co-benefits. The greatest global health threat of the 21st century posed by climate change is also health’s greatest opportunity.5 Australian medical staff can systematically push the planetary health agenda into university training, specialist colleges, hospitals, clinics and communities. We are well placed to do so.

Selina N Lo · Kaiya Ferguson · Eugenie Kayak · Kingsley Faulkner

To the Editor: In 2007 and again in 2012, we highlighted in the Medical Journal of Australia1,2 the limited access Australian prisoners had to essential health protection measures. Six years on, we can only report that progress has been minimal (Box). In August 2012, the Australian Capital Territory Chief Minister announced the implementation of a needle exchange program for prisoners in the ACT; 6 years later, the ACT government retracted its commitment. Canada has recently agreed to a pilot prison-based needle exchange, with a commitment to national implementation in 2019. Human immunodeficiency virus (HIV) is still not a concern in Australian prisons, although bleach provision and condoms are still severely restricted in Queensland and the Northern Territory, and effectively not available in Victoria and Tasmania. Hepatitis B immunisation coverage continues to improve, and chronic hepatitis B infection is not increasing among Aboriginal and Torres Strait Islander prisoners.3 The availability of direct-acting antiviral treatments for hepatitis C infection for all Australians, including prisoners, has some Australian prisons already reporting treatment achievements commensurate to international treatment targets for 20304 — the term “micro-elimination” has been applied to facility by facility reduction of burden of this infection. However, despite reductions in hepatitis C in Australian prisons, the risk of transmission is ever present.5 The predictors of successful return to the community include housing, employment and maintenance of relationships;6 yet, private family (conjugal) visits are only allowed in some Victorian prisons and in one South Australian prison farm. Visits are definitely not available to ACT prisoners, since previous enabling policy was repealed in 2014. Safer sex is still an elusive aspiration for the majority of Australian prisoners and their families. Tattoo and body piercing programs are being implemented in prisons in Luxembourg and Catalonia, Spain. Despite this activity being successfully regulated in the community, there are still no verifiable reports of sanctioned programs in Australian prisons. In 2012, we questioned Australia’s commitment to protecting the health of prisoners.2 With changes in prison harm reduction programs internationally (notably, Canada) underpinned by legal challenges, we foresee that similar proceedings could have a place in finally driving reform in Australia. Box – Progress in Australian prisoners’ access to essential health protection measures Jurisdiction Changes since 2012 Australian Capital Territory Bleach available in single unit sachets; micro-elimination of hepatitis C from the only prison; private family visits ceased; support for a prison needle exchange program withdrawn New South Wales Micro-elimination of hepatitis C from several prisons Northern Territory No notable changes Queensland Still considering opiate replacement therapy; micro-elimination of hepatitis C from one prison South Australia Private visits available at one prison farm Tasmania Micro-elimination of hepatitis C from one prison Victoria Micro-elimination of hepatitis C from several prisons Western Australia Poor uptake of hepatitis C treatment

Michael H Levy · Carla J Treloar

To the Editor:Legislation mandates that all adult medical records be retained for a minimum of 7 years from the time of last patient contact, after which they can be destroyed. Exceptions to this requirement exist for young patients, and there are state-by-state variations, but there is no legislative requirement to retain records of patients who have implantable, high-risk devices. This is disturbing because many of these devices have an in vivo lifespan that exceeds 7 years. Of particular concern are patients with breast implants whose records may have been destroyed before a diagnosis of breast implant-associated anaplastic large cell lymphoma, which has an average latency period from implant to diagnosis of 9 years.1 Later presentations of this lymphoma are not uncommon, with latency intervals up to 23 years;2 therefore, it is imperative that implant details are retained to enable us to better understand the pathophysiology of this potentially fatal disease, which has been strongly associated with deeply textured surface implants. While the Australian Breast Device Registry (ABDR) is a safe repository for secure information on patients who are registered, those patients who are not may be at risk of losing important information about their implants. Furthermore, the expected lifespan of in vivo breast implants is at least a decade,3 so records may have been discarded at the time of patients presenting with serious implant-related problems. In our efforts to improve the safety of patients with breast implants, 30% of whom are breast reconstruction cases for cancer or congenital deformities, we encourage all practitioners to ensure that their patients are registered with the ABDR so their implant details are securely stored.4 In an effort to preserve the details of all Australian patients with breast implants, the ABDR can also store patient implant details retrospectively and will accept information from Australian patients having cosmetic tourism surgery overseas, after which significant complications can arise.5 It may be time, however, for legislation to be enacted to lengthen the mandatory retention period for patients with high-risk devices or to make it legally compulsory for practitioners inserting high-risk devices to enrol all patients into a clinical quality registry such as the ABDR.

Rodney D Cooter · Ingrid Hopper · John J McNeil

To the Editor:The National Bowel Cancer Screening Program will reduce the burden of colorectal cancer, saving lives and money.1 The benefits of the program, however, rely on both public and private sectors to deliver colonoscopy, surgery and, if necessary, advanced cancer care. Public confidence in the whole program is likely to be affected by the affordability, ability and availability of these frontline services. Some public hospitals are unable to reliably deliver timely colonoscopy (ie, within 120 days).2,3 Private practice is an efficient and, for many, affordable option, but there is considerable variation in price. Furthermore, pricing information is often not readily available before referral and can be complicated by multiple separate fees. In contrast, the public hospital system is affordable (free), but there may be issues of availability due to waiting times. The ability of the colonoscopist is relevant to both settings, with adenoma detection rate a well validated quality indicator.4 To test the performance of a discounted, anaesthetist-assisted, private colonoscopy service for high-risk public patients, we conducted the following observational study in a metropolitan practice. Through efficiencies and cost sharing, we provided colonoscopy for a discounted out-of-pocket fee of $310 ($300 for the colonoscopy plus $10 for the bowel preparation kit). We performed 100 colonoscopies and diagnosed seven cancers, with an adenoma detection rate of 66% and a median wait of 29 days. These colonoscopies, if performed publicly, would have cost the state budget over $190 000, at approximately $1900 per colonoscopy (Margaret Clark, South Australia Health, personal communication; July 2018). In contrast, the total cost of this program was about $94 895, comprising the total patient payment of $31 000 plus the total combined bulk-billed fee for clinicopathological services of $63 895. This program did not cost-shift, it cost-saved about $95 105. Private and public services should provide current information to general practitioners, patients and government concerning their affordability (total out-of-pocket fee), ability (http://recert.gesa.org.au/recertified.php) and availability (waiting time from GP referral to colonoscopy). The $310 out-of-pocket fee is unlikely to be the equilibrium price for self-funded colonoscopy in Australia and investment in public colonoscopy remains important. Nevertheless, we suggest that patient autonomy and access would be improved by real time accurate information about their colonoscopy options to allow them to make a rational choice. This would help optimise the benefits of the National Bowel Cancer Screening Program and allow public and private sectors to work together to eradicate bowel cancer death in Australia.

Peter Bampton · Tarik Sammour · Gregor JE Brown · David G Hewett · Daniel L Worthley

To the Editor:Lichen planus is an autoimmune mucocutaneous inflammatory disorder. Diagnosis is often made clinically and confirmed on biopsy.1 Hypertrophic lichen planus is a distinct subtype characterised by pruritic, hyperkeratotic plaques. Histopathological findings may not have the typical features of lichen planus and can mimic squamous cell carcinoma (SCC).2 Distinguishing between hypertrophic lichen planus and SCC can be difficult for clinicians and pathologists. In our dermatology practice, we encountered three patients initially diagnosed with SCC, but on review, the cases were consistent with lichen planus. One patient was a 52-year-old woman presenting with asymmetrical, raised and violaceous lesions to her lower legs. She was referred to a skin cancer clinic that performed biopsies of these lesions, which were reported as well differentiated SCC. These lesions were excised, but they were recurrent and were excised again. The second patient was a 54-year-old man who presented with a one-year history of eruptive raised, violaceous lesions to his chest and legs. Biopsies were reported as SCC and multiple lesions were excised by a general surgeon. The third patient was a 77-year-old woman with a 2-year history of pruritic lesions to the lower legs (Box). Biopsies were reported as well differentiated SCC. Each of these patients underwent numerous excisions before being referred to our practice. The patients were reassessed and new biopsies taken, and the clinical picture was discussed with a dermatopathologist. Hypertrophic lichen planus was confirmed as the diagnosis in each of these patients, and they responded well to prednisone, acitretin and topical steroid treatment. SCC may arise in long-standing hypertrophic lichen planus, but it should be emphasised that cases of supposed SCC with atypical history should not be treated without consideration of the many mimics of SCC, including pseudoepitheliomatous hyperplasia, irritated seborrhoeic keratosis, coral reef granuloma, hypertrophic lupus erythematosus and hypertrophic lichen planus. Clinicians should provide clinical description and a list of potential differentials when referring to a pathologist. Adequate biopsy depth is important, as lichenoid activity may only be present at the tips of the rete ridges, which may be missed on a superficial biopsy. These cases highlight the difficulties in distinguishing hypertrophic lichen planus from SCC. In the cases we described, correct diagnosis was made after re-evaluation and clinicopathological correlation. Box – Figure showing violaceous hyperkeratotic patches on the patient’s lower leg, with original biopsies reported as squamous cell carcinoma (A). Histopathology showed a lichenoid inflammatory infiltrate confined to the tips of the rete processes (B)* * Infiltrate is composed of predominantly lymphocytes with few eosinophils and plasma cells. While these features are typical of hypertrophic lichen planus, superficial shave biopsies may not capture the lichenoid infiltrate at the rete processes.

Emily X Shao · Benjamin Carew · James Muir

Announced at GP18 last month, the RACGP’s annual award winners are the best of the best

Compiled by Cate Swannell

This calendar will be updated each month. If you have an event you would like to add, please include relevant details in an email to cswannell@mja.com.au

Cate Swannell