Volume 210 Issue 2

Well designed and accessible electronic health records, national registries of verified drug reactions, and validated medical alerting devices may assist in the effective communication of drug allergy information

Michaela Lucas · Richard KS Loh · William B Smith

Individualised dosing is important in cancer treatment in real‐world settings and may require departure from trial‐based protocols

Angelina Tjokrowidjaja · Elizabeth Hovey · Craig R Lewis

Although hand transplantation has the potential to transform lives, the procedure is not without risk

Karen M Dwyer · James D Burt · Tim Bennett

ANA by indirect immunofluorescence remains the method of choice for screening patients suspected of having SARDs. A positive ANA test should be followed by further testing for ENA and dsDNA antibody testing for defining the ANA specificities and disease associations. The presence of anti‐DFS70 antibody in absence of ENA and dsDNA antibodies effectively excludes a diagnosis of SARD.

Pravin Hissaria · Andrew Broadfoot · Karl W Baumgart

Overseas experience need not portend the future of prescription drug misuse in Australia

Bridin Murnion · Katherine M Conigrave

Effective therapies are available, but too few patients are receiving them

Karam Kostner

The known: Pregabalin misuse is increasing worldwide, and is associated with acute psychiatric and medical harms, but patterns of pregabalin misuse in Australia have not been reported. The new: The rate of pregabalin‐related ambulance attendances has increased tenfold since 2012, associated with an increase in the national prescription rate. Patients frequently misused pregabalin with other sedatives, particularly benzodiazepines, and almost 40% of misuse‐related events requiring paramedic attendance were suicide attempts. The implications: Caution is required when prescribing pregabalin for patients using other sedatives. Misuse might be reduced by restricting dispensing of the drug.

Rose Crossin · Debbie Scott · Shalini Arunogiri · Karen Smith · Paul M Dietze · Dan I Lubman

The known: People who have experienced an acute coronary syndrome (ACS) are at high risk of further events. High blood cholesterol is an important modifiable factor that increases the risks of both initial and subsequent ACS events. The new: Only 55% of patients treated in Australia for ACS were undergoing intensive lipid‐lowering therapy 6 or 12 months after their hospitalisation. The major predictor of not receiving such therapy at follow‐up was its not being prescribed at hospital discharge. The implications: Improving oral lipid‐lowering therapy for people who have had an ACS should prevent recurrent coronary events.

David Brieger · Mario D'Souza · Karice Hyun · James C Weaver · Leonard Kritharides

Colonoscopy should also be considered in cases of infective endocarditis with an unclear source of infection

Eugene Athan · Ivana Cabiltes · Sarah Coghill · Steven J Bowe

Characterising the isolates responsible for infection would help identify virulence factors and the relatedness of isolates

Nabeel Imam · Simone Tempone · Paul K Armstrong · Rebecca McCann · Sandra Johnson · Leon J Worth · Michael J Richards

Food allergy has been increasing in incidence worldwide, with rates in Australia the highest in the world

Preeti A Joshi · Jill Smith · Sandra Vale · Dianne E Campbell

Recent international consensus guidelines provide a more rigorous approach to diagnosis, introducing a system of major and minor criteria to facilitate early and accurate diagnosis and to guide diagnostic food challenge. They highlight the need for rapid fluid resuscitation in emergency presentations and the increasing evidence for the use of ondansetron in acute management. Diagnostic challenges should be performed in settings with suitable resuscitation facilities. Action plans and dietary information consistent with this guideline are available via ASCIA.10It is likely that improved understanding of the immunological basis of FPIES will, in the future, facilitate the development of a sensitive and specific biomarker. Until that time, use of standardised diagnostic criteria, improved recognition, timely fluid resuscitation, avoidance of trigger foods, and education form current best practice.

Sam Mehr · Dianne E Campbell

To the Editor: Schilling and colleagues1 state that the Australasian Rehabilitation Outcomes Centre (AROC) — the national rehabilitation clinical quality registry for Australia and New Zealand — does not routinely collect data on post‐surgery outcomes for private total knee replacement (TKR) recipients. This statement is factually incorrect. All private inpatient rehabilitation services in Australia are members of AROC and routinely submit data (including functional outcomes as assessed by a functional independence measure) describing all episodes of rehabilitation they provide. More specifically, over the period described by Schilling and colleagues,1 AROC received data on outcomes for 93 278 TKRs receiving private rehabilitation. If we restrict the AROC data to match the study data (patients aged 40–89, single TKR, first admission), AROC received data describing 76 847 privately rehabilitated TKRs. In rehabilitation, the Australian National Subacute and Non‐Acute Patient Classification2 is routinely used to classify episodes into resource‐homogeneous groups. In interrogating the AROC TKR data, we concur with Schilling et al1 that the average length of stay in rehabilitation has been declining, with this decline accelerating over the past 5 years. Concurrent with the decline in length of stay, the functional change achieved (both absolute and relative) during rehabilitation has been increasing, and has in fact accelerated over the past 5 years. Achieving more functional change in a shorter length of stay shows that services are becoming more efficient while also continuing to produce positive outcomes for their patients. Moreover, it is also factually incorrect that AROC does not collect data outside of the inpatient setting. In fact, AROC also runs an ambulatory benchmarking initiative, and while coverage is not 100%, it is growing. There are currently 35 private ambulatory rehabilitation services that participate and routinely provide data describing their ambulatory rehabilitation outcomes. In conclusion, we suggest that while the authors provide an interesting analysis, it is incomplete, given that they did not include function — the key driver of cost and outcomes in rehabilitation — as one of the variables they used.

Frances Simmonds · John H Olver

To the Editor: In reply to Shilling and colleagues,1 the Rehabilitation Medicine Society of Australia and New Zealand refers the authors and readers to our position statement regarding referral for rehabilitation in the home after total knee replacement (TKR).2 Shilling and colleagues1 state that the most important determinant for referral to inpatient rehabilitation was the hospital where the TKR took place. Independent researchers might be more circumspect, considering there is no acknowledgement that Medibank Private did not fund rehabilitation in the home nationally during the study period nor whether their data included outpatient rehabilitation carried out as “same day rehabilitation”, usually coded as inpatient. Also, disturbingly, some of the literature is misrepresented. The unblinded Canadian randomised controlled trial3 comparing a publicly funded combination of rehabilitation in the home and hospital‐based outpatient therapy with inpatient rehabilitation is not generalisable to privately insured Australian patients. Moreover, the Australian randomised controlled trial4 showing equivalent outcomes for the same two groups excluded patients who were appropriately referred for inpatient rehabilitation on the basis of numerous patient factors. The present study included few patient factors and not clinically relevant factors, such as obesity, ability to walk after TKR, or complications.1 Finally, while no patient safety or outcome data were included, the choice to include the dollar value of the previous year's private hospital claims seems gratuitous — are those patients with higher cost to insurers more likely to use inpatient rehabilitation, or perhaps they were just sicker? It is interesting that no reference is made to the 2017 study that found that referrals to inpatient rehabilitation were directly influenced by preferences of the patient, the surgeon, therapists, discharge planners, insurers and others.5

Steven G Faux · Lee Laycock

To the Editor: In their recent article and media release, Schilling and colleagues1 concluded that after total knee replacement (TKR) “some inpatient rehabilitation is low value care”. The research was funded by Medibank Private. The article comes at a time of increasing interest in rehabilitation in the home (RITH) for TKR and other rehabilitation problems. Despite widely proclaimed opinions, there is limited high level evidence regarding outcomes for inpatient rehabilitation versus ambulatory rehabilitation. In research examining the benefits of RITH, higher complexity patients are often excluded from the studies.2 One of the limitations of this article is that important “patient‐related factors … including obesity, pre‐operative physical and mental health … functional performance” and others, “were not available”. A significant gap in the current debate is an almost total absence of nuanced thinking regarding which patients are clinically indicated and safe to have RITH. The authors’ conclusion is only a relatively minor aspect of the real problem, which is to ensure the best outcome for the patient. That is, we must confidently identify the right rehabilitation program, at the right time and in the right place. The Australasian Faculty of Rehabilitation Medicine3 is committed to ensuring high quality rehabilitation medicine services. We believe that: while many patients with uncomplicated TKR may be appropriate for RITH, there are many others for whom RITH is inappropriate or unsafe; the appropriate setting for TKR rehabilitation should be determined on evidence‐based clinical indicators and minimum safety standards;4 all patients with TKR (apart from the most uncomplicated cases) require referral to and assessment by or on behalf of a rehabilitation medicine physician (or other appropriately trained physician); and some ambulatory rehabilitation programs may be appropriate for TKR and other rehabilitation, but they must be evidence‐based, interdisciplinary, led by a rehabilitation medicine physician and adequately resourced, and not simply seen as a cheaper panacea for a struggling system. To achieve the best outcome for patients, decisions must be individualised and patient‐centred and they should start with a referral to a rehabilitation medicine physician, who can determine the right rehabilitation program, at the right time and in the right place. There are circumstances in which RITH is an alternative to inpatient rehabilitation for appropriately selected patients.4 Let's ensure, however, that we do not throw the baby out with the bathwater.

Timothy J Geraghty · Andrew M D Cole · Gregory Bowring

In reply

Chris Schilling · Anna Barker · Stephen F Wilson

“There's no career path that you can't do. Anything is possible”

Cate Swannell