Volume 210 Issue 3

Intersectoral collaboration is needed to engage communities and design effective culturally and age‐appropriate interventions

Angela Titmuss · Elizabeth A Davis · Alex Brown · Louise J Maple‐Brown

Biases and assumptions often arise from past experiences and, when unquestioned, can negatively influence the development of effective educational strategies

Ruth M Sladek · Sue McAllister · Kieran M Walsh

When doctors become patients, they shouldn't be surprised that the experience is frightening, undignified and disempowering

Meagan E Brennan

The importance of packaging, storage, and product design must be reflected by legislation

Ryan D Kennedy · Vanya C Jones

Governments must ensure that purportedly nicotine‐free e‐liquids do not contain any nicotine

Sarah L White · Claire Grace · Michelle M Scollo

The known: Iodine deficiency re‐emerged in Australia in the 1990s, motivating mandatory fortification of bread with iodised salt in 2009.

Gurmeet R Singh · Belinda Davison · Gary Y Ma · Creswell J Eastman · Dorothy EM Mackerras

The popularity of e‐cigarettes has increased in Australia since they first became available as smoking cessation tools; an estimated 1.3% of the New South Wales population used them in 2015, and as many as 8.4% had experimented with them.1 E‐cigarettes have been recommended by Public Health England and the Royal College of Physicians as safe smoking cessation tools.2,3 In Australia, a prescription is required for legally importing nicotine‐containing e‐cigarettes.4 The safety of these products for users and the risks for members of their households have not been established. Imported products may not conform to Australian standards, including having child‐resistant closures and appropriate labelling, and refill bottles containing highly concentrated nicotine solutions — one millilitre of which can be lethal if ingested by a child — can be purchased online. Podcast with Ms Carol Wylie We undertook a retrospective analysis of calls to Australian Poisons Information Centres (PICs) during 2009–2016. PICs play a valuable role as health care sentinels when new products such as e‐cigarettes are introduced. Our study was exempted from formal ethics approval by the Children's Health Queensland Hospital and Health Service Human Research Ethics Committee. The numbers of calls about e‐cigarette exposures increased considerably across the study period (Box), although the overall PIC call volume was stable at about 164 000 cases per year. Of 202 sequential e‐cigarette‐related cases, 38% were from relatives of children worried about their exposure to the liquid component of an e‐cigarette after children were found with uncapped vials, sucking the mouthpiece, drinking from separated liquid containers, inhaling the liquid, eating the cartridge, or having splashed liquid in their eyes. Adults and adolescents were the subjects of calls in 126 cases (62%), including calls about the potential side effects of routine use or accidental ingestion, or about skin or eye splash exposures. Twelve calls followed deliberate administration for self‐harm, ten by oral ingestion and two by injection. The reported median concentration of the 43 commercial nicotine solutions involved was 20.2 mg/mL, (range, 0.06–200 mg/mL), but confirmatory testing was not performed and actual concentrations may be higher than labelled, as noted recently.5 Most patients had only mild symptoms at the time of the call to the PIC, mainly gastrointestinal disturbances; twelve had moderate symptoms, usually a gastrointestinal disturbance combined with sedation. The potential risks, however, should not be underestimated; we are aware that an infant recently died in Australia after ingesting a concentrated nicotine solution. Almost all exposures of children to nicotine‐containing e‐cigarette liquid require their hospitalisation for monitoring of possible toxic effects. Australian PIC data refer to calls about exposures to e‐cigarette liquid but may not reflect the prevalence of such exposures. These data nevertheless provide insights into patterns of exposure, usage, and the side effects of e‐cigarettes. Our study can assist health care practitioners when advising patients about the use of e‐cigarettes, and our findings indicate that nicotine‐containing products should be stored where children cannot access them. We would welcome any move to improve the safety of electronic cigarettes, including changes to their labelling, storage, and packaging. Box – Numbers of cases related to e‐cigarette exposures reported to Australian Poisons Information Centres, by calendar year and state* No calls were received about cases in the Northern Territory.

Carol Wylie · Aaron Heffernan · Jared A Brown · Rose Cairns · Ann‐Maree Lynch · Jeff Robinson

The nicotine levels in three e-liquids were comparable with those of low dose nicotine e-liquids

Emily Chivers · Maxine Janka · Peter Franklin · Benjamin Mullins · Alexander Larcombe

The incidence of cerebral palsy is decreasing and early identification is not only important for families but may help to target treatment. Early interventions with targeted therapies are showing promising results in altering the natural history of cerebral palsy as well as enhancing patient activities. There remain many challenges in the management of a child with cerebral palsy, but there exist a number of interventions with a good evidence base. A child's ability should be viewed in context of their development and current evidence used to guide treatment with what is important for the child and their family. The six Fs framework provides a guide to developing shared goals with families.

David Graham · Simon P Paget · Neil Wimalasundera

The minimum requirement for TKA must be prolonged clinically important symptoms in the presence of clinical signs that allow attribution of those symptoms to local pathology affecting articular surfaces and knee alignment. If, after reasonable attempts at non‐operative treatment, symptoms are sufficiently severe to justify the risks, a person is considered suitable for surgery. Optimisation to attenuate surgical risks should be attempted in all TKA candidates, although high level evidence is lacking for certain important factors. Pre‐operative interventional trials, with the aim of improving post‐operative TKA outcomes, are particularly needed in the areas of patient expectation, diabetes, obesity and vascular disease.

Sam Adie · Ian Harris · Alwin Chuan · Peter Lewis · Justine M Naylor

To the Editor: Many people are aware that Australia has an opt‐in system for recording organ donation decisions; and many are also aware that, historically, donation decisions were recorded on the driver's licence. What is not well known is that, in 2000, the Australian Organ Donor Register (AODR) was introduced as a register of consent (or objection), and that, between 2005 and 2012, the recording of donation decisions (except for South Australia) was transitioned from the driver's licence to registration on the national register, the AODR.1 Five years on, 53% of the people we surveyed in New South Wales (n = 802) were unaware that donation decisions were no longer recorded on the driver's licence,2 and less than a third of eligible Australians had registered their decision on the AODR.3 The implications of this are profound. Consent to donate by the next‐of‐kin in the intensive care unit is 90% when decisions are registered on the AODR, but only 44% when the decision is unknown.4 We have responded to the need to increase registration rates by developing5 an immediate registration opportunity, which combines the opportunity to discuss donation in a face to face interaction with the opportunity to register on the AODR immediately.2 Participants’ concerns, fears and questions about donation are prompted through a brief survey about organ donation beliefs, which facilitates discussion and allows misconceptions to be addressed. The participants are then asked if they would like to register on the AODR. This initiative has been successful in increasing AODR registrations among the general public at a range of locations in NSW in 2017,2 and we had even higher success rates when we rolled this out in two NSW hospital‐based settings (Box). Integral to the success of the immediate registration opportunity is the consistent finding that the public and health care staff simultaneously hold positive beliefs and negative concerns about organ donation. Addressing the tension created by these dichotomous beliefs through face to face interaction, coupled with the ease and immediacy of on‐the‐spot registration, facilitates the registration decision. We believe that offering the immediate registration opportunity nationally in hospital‐based settings and in the community has the potential to increase registrations in the AODR dramatically. Box – Percentage of participants who registered on the day at the public and private hospitals from particpants who had not yet registered and were eligible to do so

Gail Moloney · Michael Sutherland · Maddison Norton · Alison Bowling · Iain Walker

To the Editor: The Australian Government's decision to uphold a restriction on Electronic Nicotine Delivery Systems (ENDS), or e‐cigarettes, is in keeping with its highly effective tobacco control framework. In its March 2017 ruling, the Therapeutic Goods Administration outlined the lack of long term safety data around ENDS and the emerging evidence suggesting that availability of these devices may be associated with an increase in cigarette smoking in young adults.1 While it remains illegal to sell ENDS products containing nicotine, an individual may import up to 3 months’ personal supply with a doctor's prescription.1 ENDS products are easily purchased online from overseas. Their attractive packaging and scent makes them appealing to children. As these products are not produced or licensed in Australia, there is no existing legislation around child‐safe packaging or labels warning of potential toxicity. The Centers for Disease Control and Prevention reported a rise in nicotine poisonings from one to 215 per month over a 5‐year period,2 the majority involving children aged under 5 years. Furthermore, a retrospective study of children aged under 6 years found that poisonings from liquid nicotine compared with traditional cigarettes were five times more likely to result in hospitalisation.3 Nicotine is both highly toxic and readily absorbable and, therefore, the potential for poisoning is high. Nicotine poisoning occurs through initial stimulation and ultimate blockade of the nicotinic acetylcholine receptor, resulting in hypotension, bradycardia and coma at high doses.4 The minimum potentially lethal dose of nicotine in humans is 60 mg.5 A review of e‐liquid products purchased online found the standard nicotine concentration to range between 0 and 36 mg/mL.6 Therefore, ingestion of even a small volume could cause serious harm or even death. We advocate for specific legislation to regulate the personal importation of these products. This legislation should include specific safety labelling highlighting the risks of poisoning in children and mandated supply in child‐proof packaging. Given the inherent difficulties in preventing and regulating the online trade of ENDS products, we strongly encourage the federal government to partner with organisations such as Quit Victoria to highlight the potential dangers of all imported nicotine products, whether they remain prohibited or not.

Christian Catalano · Noel E Cranswick · Jeff Robinson · Joanne Grindlay · Mick Creati · Margie H Danchin · Nicola Williams · Amanda Gwee

To the Editor: Within our clinical practice, we sought to establish the qualifications of a medical practitioner. In doing so, we discovered that medical practitioners are not required to practise under the name that they are listed under on the Australian Health Practitioner Regulation Agency (AHPRA) Register of Practitioners. A practitioner may register under one name, then practise under another. We see this as problematic for patients and inconsistent with the function of the register. AHPRA states that the register “has accurate, up to date information about the registration status of all registered health practitioners in Australia. It is an important way the National Registration and Accreditation Scheme helps keep the public safe”.1 The national register lists all practitioners registered with AHPRA and any conditions on their registration. Patients may access this information if they feel unable to make enquiries directly of a practitioner, or if they wish to view particulars before seeing the practitioner. AHPRA states that “if a practitioner's name does not appear on the register, they are not registered to practise in Australia”. The stated exemption to this statement is that “in a very small number of cases, the details of a registered health practitioner may not appear on the register because of personal safety issues”.1 It is under Part 10 of the Health Practitioner Regulation National Law Act 2009 that each national Board is empowered to maintain the register of all health practitioners currently registered by that Board.2 We note the current consultation paper by the COAG Health Council,3 in preparation for a second tranche of amendments to the National Law, which includes the proposal that the National Law be amended to “enable a practitioner to nominate one or more aliases or additional names to be recorded on the public register, with the register searchable using the alias”.3 We believe this relatively simple measure is consistent with the rights of the practitioner to use a favoured name and of the patient to confirm a practitioner's registration. We therefore support this change.

Katinka Morton · Grant Lester

In reply: The national online register of practitioners is a vital part of Australia's system of regulating health practitioners to assure patient safety. It makes accessible to the public and employers the names of all health practitioners who are registered to practise. It also provides important information about limits or restrictions placed on the way a registered practitioner is allowed to practise. The national online register must remain an authoritative source of trusted information on health practitioners, so consumers can rely on it for accurate and up to date information to inform their health care decision making. Through our work, we have become aware that some health practitioners practise their profession using an alias rather than their legally recognised name published on the register. The Australian Health Practitioner Regulation Agency (AHPRA) has asked governments to consider an amendment to the Health Practitioner Regulation National Law Act 2009 to enable a practitioner to nominate one or more aliases to be recorded on the public register. We are pleased that this proposal is now the subject of public consultation. AHPRA believes that recording additional names or aliases on the register would help inform and protect the public, by making it easier to identify a practitioner who may not be practising under their legal name. There are some operational and practical issues to consider. A clear definition of an alias is required so health practitioners can readily understand their obligations to inform AHPRA and the national Boards of the use of these names. Consideration would need to be given to the requirements for practitioners to provide up to date information on the use of aliases in their practice, and whether any verification of this is necessary. The validity of the register could be compromised by information that is unverified or out of date. Finally, there may be risks from unintended consequences, including whether publishing aliases could be used for commercial gain or benefits not related to public information and protection, which is the focus of the National Law. AHPRA awaits the outcomes of the current public consultation process with interest.

Martin Fletcher