Volume 210 Issue 10

Evidence suggests that appropriate hepatitis B virus (HBV) screening before B cell-depleting therapy is frequently not performed

Sanjivan Mudaliar · Ken Liu · Simone I Strasser

National reporting for all age groups is needed to accurately determine the full burden of disease

Hannah C Moore · Christopher C Blyth

Pertussis and influenza vaccinations should be incorporated into antenatal care and accurately documented

Helen S Marshall · Gayatri Amirthalingam

National population-level analysis provides valuable insights into severe RSV-associated disease

Gemma L Saravanos · Meru Sheel · Nusrat Homaira · Aditi Dey · Edward Brown · Han Wang · Kristine Macartney · Nicholas J Wood

Pertussis vaccination of pregnant women in Victoria has increased, but influenza vaccination rates remain moderate and variable

Stacey L Rowe · Kirsten P Perrett · Rosemary Morey · Nicola Stephens · Benjamin C Cowie · Terry M Nolan · Karin Leder · Helen Pitcher · Brett Sutton · Allen C Cheng

Testing for hepatitis B in all patients with haematological and solid tumour malignancies, and prophylactic treatment in for people with chronic HBV or past exposure to HBV, is recommended to avoid HBV reactivation during cancer therapy

Joseph Doyle · Michelle Raggatt · Monica Slavin · Sue‐Anne McLachlan · Simone I Strasser · Joseph J Sasadeusz · Jessica Howell · Krispin Hajkowicz · Harshal Nandurkar · Anna Johnston · Narin Bak · Alexander J Thompson

Treatment of erectile dysfunction with pharmacotherapy alone or in combination with graded psychosexual therapy is effective in improving and/or restoring sexual function in most men

Christopher G McMahon

To the Editor: I commend the Medical Journal of Australia for supporting high quality qualitative research with clear criteria for acceptance for publication1 on the background of increasing concerns these manuscripts are being rejected for reasons not based on the quality of the article submitted.2 However, I am concerned about the article by Chanchlani and colleagues,3 which involves randomised controlled evaluation of a peer mentoring program for new medical interns using qualitative interview‐based methodology.3 The Journal's Editor‐in‐Chief hoped this methodology would “encourage others to use comparable approaches when investigating similar topics”.4 A well conducted randomised controlled trial is considered among the highest level of evidence base for clinical practice; randomisation minimises bias from known and unknown confounders. However, other biases (selection, recall, measurement etc) also need to be controlled for randomised controlled trials to provide valid results and conclusions. Chanchlani and colleagues3 suggested their primary outcome was to assess psychosocial wellbeing and job satisfaction using inductive thematic analysis of data collected in semi‐structured interviews and focus groups at 12 months. This is different from the Australian New Zealand Clinical Trials Registry (ACTRN12618000455268, retrospectively registered) description which is “to determine the perception of the effectiveness of peer support on anxiety and depression;” the psychiatric training of the interviewers and the formal screening or post hoc assessment of the participants’ mental health are unknown. Qualitative research in randomised controlled trials is increasingly common, with new innovative purposes.5 Chanchlani et al3 reported a novel approach to qualitative research incorporating randomised controlled methodology; no quantitative data are apparent in outcome analysis, even though such measurement can be obtained from a post‐program feedback survey for both groups. Interview questions published in the online appendix cannot properly compare satisfaction rate nor assess the state of mental health. More is needed to justify comparative comments such as “participants with mentors reported high satisfaction with the program and a positive impact on stress levels, morale, sense of support, job satisfaction, and psychosocial wellbeing compared with participants without mentors”. It is desirable that the MJA supports innovative qualitative research. Important information may be omitted due to editorial requirements. Nevertheless, vigorous peer review and academic integrity are still needed. Care should be taken when comparative conclusions are made without adequate explanation.

Shyan Lii Goh

In reply

Sonia Chanchlani · Jeremy SL Ong

To the Editor: Pharyngitis, a common childhood illness, accounts for around 3% of presentations to general practice in Australia.1 Although usually benign and self‐limiting, group A streptococcus (GAS) pharyngitis, isolated in up to 20% of symptomatic children,2 can lead to infectious and autoimmune sequelae. Despite Australia being a high income country, acute rheumatic fever (ARF) and rheumatic heart disease (RHD) still cause significant morbidity and mortality in Aboriginal and Torres Strait Islander people.3 Prompt treatment of GAS pharyngitis has been shown to reduce the incidence of ARF by two‐thirds in high risk individuals.4 Low risk individuals require supportive management only.5 Clinical diagnosis of GAS pharyngitis is unreliable4 and culture results take time. As such, clinicians must balance the competing priorities of appropriate treatment of patients at high risk of ARF or RHD with prudent antimicrobial stewardship. Clinical practice guidelines play an important role in decision making at both a population and individual level. We undertook a search to identify Australian and New Zealand pharyngitis guidelines and compared these with previously published criteria.6 Nine guidelines were identified. Inconsistences in diagnosis, definition of high risk groups, analgesia, antibiotic rationale, agent, therapy duration, and tonsillectomy indications were observed (Box). Australia's multitude of heterogenic guidelines coupled with the transient workforce in remote Australia, where ARF burden is the highest,7 predispose to management confusion and potential poor patient outcomes, including higher rates of ARF and RHD, and also fail to address the growing worldwide problem of antimicrobial resistance. Australia needs a single national pharyngitis guideline to assist in providing rational, consistent and timely antibiotic treatment to patients at high risk of ARF, while minimising inappropriate antibiotic usage and resistance in individuals at low risk of sequelae. We call for an evidence‐based guideline that includes the following: a clear, succinct approach to diagnosis and management; a definition of individuals at high risk of ARF, and rationale for antibiotic treatment; clear guidance regarding throat culture and point‐of‐care testing for GAS; rationale for first‐ and second‐line empirical antibiotics, with alternatives for penicillin allergy; capacity to adapt management in different clinical settings; and supportive care recommendation including analgesia, tonsillectomy and school exclusion. Box – Summary of selected criteria:6 are criteria addressed by each sore throat guideline? Guidelines NZ HF BPAC NZ CH QLD NSW ICCPG CARPA RHD Aust PCH RCH eTG Number of criteria addressed 6/12 7/12 2/12 10/12 7/12 6/12 10/12 9/12 10/12 Diagnostic criteria × × × ✓ ✓ × ✓ × ✓ Routine throat culture/rapid antigen detection testing ✓ ✓ × ✓ × ✓ ✓ ✓ × Antibiotics to reduce symptoms × ✓ × ✓ × × ✓ × ✓ Antibiotics to prevent complications ✓ ✓ × ✓ ✓ ✓ ✓ ✓ ✓ NZHF = New Zealand Heart Foundation (http://www.heartfoundation.org.nz/shop/heart-healthcare/non-stock-resources/sore-throat-algorithm.pdf); BPAC = Best Practice Advocacy Centre (https://bpac.org.nz/antibiotics/guide.aspx#sore-throat); CH QLD = Children's Health Queensland Hospital and Health Service guidelines (http://www.childrens.health.qld.gov.au/chq/health-professionals/antimicrobial-stewardship/guidelines/ent-infections); NSW ICCPG = New South Wales infants and children clinical practice guidelines (http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2014_021.pdf); CARPA = Central Australian Rural Practitioners Association's standard treatment manual (https://docs.remotephcmanuals.com.au/review/g/manuals2017-manuals/d/20321.html?page=115); RHD Aust = rheumatic heart disease Australian guidelines (https://www.rhdaustralia.org.au/arf-rhd-guideline); PCH = Perth Children's Hospital emergency department guidelines (https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Tonsillitis); RCH = Royal Children's Hospital Melbourne guidelines (with support of the Victorian Paediatric Clinical Network) (www.rch.org.au/clinicalguide/guideline_index/Sore_throat); eTG = electronic therapeutic guidelines (https://tgldcdp.tg.org.au/searchAction?appendedInputButtons=sore%20throat). ◆

Adrian J Tarca · Robert M Hand · Rosemary Wyber

Dr Andrew Browning AM is the third generation of his family doing good works and the second to dedicate his life to improving the lives of African women and children

Cate Swannell