Volume 209 Issue 8

It is crucial to facilitate cross-sectoral coordination, collaboration and investment to improve outcomes for adolescents and young adults with rare and low survival cancers

Adam Walczak · Pandora Patterson · David Thomas

Effective responses in policy and practice are essential to manage overdiagnosis and the sustainability of the health system

Ray Moynihan · Alexandra L Barratt · Rachelle Buchbinder · Stacy M Carter · Thomas Dakin · Jan Donovan · Adam G Elshaug · Paul P Glasziou · Christopher G Maher · Kirsten J McCaffery · Ian A Scott

A 40-year-old female Australian rules football player presented to a rural emergency department with a 3-hour history of swelling and pain in her right upper limb

John WP Wong · Fiona WY Lai · Ian Wilson

In 2017, Australia celebrated the 50th anniversary of the anti-D program, which uses the plasma of special donors to protect the babies of millions of Australian women

James Thyer · Janet Wong · Amanda Thomson · Barbara Bell · Catherine Hyland · Daniel Challis

Clinicians are no longer gatekeepers to privileged information, but rather interpreters, problem solvers, and advisers

Susan Ieraci

The doctor–patient relationship can benefit from discussing health-related internet searches by adult patients

Anthony M Cocco · Rachel Zordan · David McD Taylor · Tracey J Weiland · Stuart J Dilley · Joyce Kant · Mahesha Dombagolla · Andreas Hendarto · Fiona Lai · Jennie Hutton

Survival may be improved by surveillance, as it enables curative therapies to be initiated

Thai P Hong · Paul J Gow · Michael Fink · Anouk Dev · Stuart K Roberts · Amanda Nicoll · John S Lubel · Ian Kronborg · Niranjan Arachchi · Marno Ryan · William W Kemp · Virginia Knight · Vijaya Sundararajan · Paul Desmond · Alexander JV Thompson · Sally J Bell

MoST is an innovative approach for translating molecular opportunities into clinical care

Subotheni Thavaneswaran · Lucille Sebastian · Mandy Ballinger · Megan Best · Dominique Hess · Chee K Lee · Katrin M Sjoquist · Wendy E Hague · Phyllis N Butow · R John Simes · David Thomas

Atrial fibrillation is increasing in prevalence and associated with significant morbidity and mortality

David Brieger · John Amerena · John R Attia · Beata Bajorek · Kim H Chan · Cia Connell · Ben Freedman · Caleb Ferguson · Tanya Hall · Haris M Haqqani · Jeroen Hendriks · Charlotte M Hespe · Joseph Hung · Jonathan M Kalman · Prashanthan Sanders · John Worthington · Tristan Yan · Nicholas A Zwar

Heart failure (HF) is a clinical syndrome that is secondary to an abnormality of cardiac structure or function

John J Atherton · Andrew Sindone · Carmine G De Pasquale · Andrea Driscoll · Peter S MacDonald · Ingrid Hopper · Peter Kistler · Tom G Briffa · James Wong · Walter P Abhayaratna · Liza Thomas · Ralph Audehm · Phillip J Newton · Joan O'Loughlin · Cia Connell · Maree Branagan

To the Editor:Calabria and colleagues1 report that, overall, 9.8% of Aboriginal and Torres Strait Islander adults are at high absolute cardiovascular disease (CVD) risk, reflecting how poorly Australia supports the social and cultural determinants of health for the First Australians. However, this is a different nuance from their statement: “Absolute CVD risk is high among Aboriginal and Torres Strait Islander people”. Aboriginal and Torres Strait Islander people have median age of 23 years,2 and only 1.1% of those in the 18–24 age group are at high risk. The authors note undertreatment with lipid-lowering therapies of Aboriginal and Torres Strait Islander people at high CVD risk; many Aboriginal and Torres Strait Islander people who would benefit are not offered best practice care. However, 13% of people at low CVD risk are on lipid-lowering medication,1 which may be unnecessary treatment, with costs and side effects. As health professionals we need to beware of tendencies to emphasise pathology and risk among Aboriginal people.3 Many health professionals hold ideas of “the passivity, dependency, and non-compliant nature of [the Aboriginal] mob … The perception of Aboriginality as … a health risk, and predictor of unhealthy behaviours … reinforces stereotypical ideas of Aboriginality… and disconnects Aboriginal people from their own identities … [and] stories of strength and survival”.3 There is a tension between our desires to prescribe behaviour to reduce risk and enabling and empowering people to make decisions for themselves. Well intentioned efforts to manage Aboriginal and Torres Strait Islander people may have iatrogenic side effects. For example, health professionals may develop assumptions about people’s behaviour and worthiness to receive treatment,4 while Aboriginal and Torres Strait Islander people themselves may be disconnected from their sense of self-efficacy and community and cultural strengths and identity, contributing to disengagement from health care.3 Like other procedures in health care, absolute CVD risk assessment has costs as well as benefits. Educating community members about absolute CVD risk would promote health literacy and enable people to give informed consent to assessment of this statistic. Numbers hold both face and cultural values, so it is important that Aboriginal and Torres Strait Islander people have control of their statistics.5

Rosalie Schultz

In reply

Raymond W Lovett

To the Editor: Primary meningococcal conjunctivitis (PMC) is a rare presentation of Neisseria meningitidis.1 Before antibiotics, N. meningitidis conjunctivitis was a recognised harbinger of cerebrospinal meningitis due to systemic infection.1-3 Secondary N. meningitidis conjunctivitis is now uncommon.1 PMC seeds exogenously from mucosal secretions, causing a primary infection of the ocular surface without systemic infection,4 and it is characterised by purulent conjunctivitis and periorbital oedema.3,4 Untreated PMC spreads systemically in 10–18% of cases,1,3,5 and early diagnosis is essential to prevent visual loss and life-threatening complications.1,3,5 In September 2017, the Northern Territory experienced an outbreak of N. meningitidis serogroup W strain. Presentations were atypical and, consequently, the threshold was low for empirical treatment. We report the case of a 4-year-old girl who presented to a remote clinic with a 24-hour history of rapidly progressive pain, erythema and discharge from both eyes. Her medical history was unremarkable. She had bilateral conjunctival injection with profuse yellow mucopurulent discharge (Box, A). Systemic examination was unremarkable. Considering the meningococcal outbreak, conjunctival swabs were sent for urgent Gram stain, which showed gram-negative diplococci with characteristic N. meningitidis appearance (Box, B). Ceftriaxone and topical ofloxacin were commenced as empirical meningococcal treatment. Ocular culture and polymerase chain reaction (PCR) were positive for N. meningitidis-W. Three blood cultures and serum PCR were negative. After 48 hours, the purulent discharge and eye pain resolved. On Day 4 of treatment, her conjunctivae normalised and she was asymptomatic (Box, C). Her family members received prophylactic treatment with ciprofloxacin. She was discharged from hospital on Day 6 and had an unremarkable follow-up. To our knowledge, this is the first reported case of N. meningitidis-W PMC. Since presentations of PMC in contemporary society are rare,1,3,4 clinicians may overlook PMC as a differential diagnosis to the patient’s detriment. Given the highly virulent nature of the N. meningitidis-W, the importance of early treatment and contact tracing is paramount, so that antimicrobial prophylaxis can be offered to close patient contacts, especially direct household members. To preserve vision and prevent systemic infection, a high suspicion of atypical microorganisms must be entertained, especially during an outbreak. Box – Primary meningococcal conjunctivitis due to Neisseria meningitidis: bilateral conjunctival injection with profuse yellow mucopurulent discharge (A), gram-negative diplococci with characteristic Neisseria appearance (B), and normalised conjunctivae (C)

James Sterrey · Farshad Abedi · Tim RM Henderson

From Formby to Oxford University, Borneo, Tanzania, Hong Kong and Australia, Dr Deborah Bateson’s career has been about following her passions

Cate Swannell