Volume 210 Issue 4

New technologies and collaborative care are improving the quality of life of patients with glaucoma

Yu Xiang George Kong · Annie Gibbins · Anne Brooks

A 64-year-old woman was referred to the glaucoma clinic at a tertiary eye hospital with elevated intraocular pressures

Helen HL Chan · John F Salmon

A 12-year-old boy was at a family gathering when he threw a deodorant can on a barbecue with exposed flames

Varun Chandra · Lei Liu · Jonathan B Ruddle

Cluster randomised trials randomise groups of individuals rather than individuals themselves to interventions. The groups might be communities, schools, workplaces, hospitals, or patients treated by a particular doctor. There are a number of reasons for the use of cluster trials as opposed to individually randomised trials. They may be the only available choice, as when a city is randomised to a mass intervention.

Michael J Campbell

Emeritus Professor Beverley Raphael was an academic, psychiatrist, general practitioner and leader in the mental health field for over 50 years

Penelope L Burns · Patricia Delaney AM

Risk stratification is the best strategy for deciding who needs medication for primary prevention of cardiovascular events

Mark R Nelson · Mark Woodward

A clinical research network would facilitate routinely including primary care patients in large clinical trials

James P Sheppard · Chris Butler

The known: Clinicians need accurate and reliable tools to help identify people at increased risk of a cardiovascular event.

Loai Albarqouni · Jennifer A Doust · Dianna Magliano · Elizabeth LM Barr · Jonathan E Shaw · Paul P Glasziou

General practice can be a rich environment for research when barriers to recruitment are overcome

Jessica E Lockery · Taya A Collyer · Walter P Abhayaratna · Sharyn M Fitzgerald · John J McNeil · Mark R Nelson · Suzanne G Orchard · Christopher Reid · Nigel P Stocks · Ruth E Trevaks · Robyn Woods

New guidelines recommend shared decision making to reduce adverse drug reactions and medication burden, leading to improved quality of life in people with dementia

Emily Reeve · Barbara Farrell · Wade Thompson · Nathan Herrmann · Ingrid Sketris · Parker J Magin · Lynn Chenoweth · Mary Gorman · Lyntara Quirke · Graeme Bethune · Sarah N Hilmer

Glaucoma management varies depending on the underlying causative mechanism, with options trending towards earlier surgical intervention for both open‐angle and angle closure glaucoma. While the increased acceptance of SLT and the introduction of MIGS devices have started to change the face of glaucoma management, IOP‐lowering eye drops remain the foundation of treatment. Adherence is an ongoing treatment limitation and future therapies are being designed to diminish this.

Jed Lusthaus · Ivan Goldberg

TO THE EDITOR: We commend Heldens and colleagues1 for publishing their data on the incidence and in‐hospital mortality of sepsis and septic shock among patients admitted to Australian intensive care units (ICUs). The incidence of sepsis and septic shock in ICUs is estimated to be 101.8 and 19.3 per 100 000 patient‐years, respectively, at an attributable cost of $32 421.2 We concur that sepsis cases captured using the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation database criteria, compared with prospective clinical diagnoses,3 has poor sensitivity for sepsis case ascertainment. Notwithstanding, we propose that the application of a third surveillance metric using coded discharge data could be a viable alternative for sepsis case ascertainment and monitoring in ICUs. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD‐10‐AM) diagnostic coding data are feasible to collect with a reduced risk of sampling bias and minimal loss to follow‐up. Using tandem dataset comparison following the implementation of a hospital‐wide sepsis pathway,4 we explored the utility of coding data for sepsis surveillance. We noted that 78% and 74% of ICU cases were designated an ICD‐10‐AM code denoting sepsis at admission and patient level, respectively (Box). Alarmingly, the concordance rate between coded administrative data and clinically verified sepsis diagnoses was even lower in non‐ICU settings. These data are in keeping with international reports.2 Robust and reproducible data are required to evaluate quality improvement regarding sepsis management. Given the poor sensitivity of research criteria and coding data, used in isolation for sepsis identification, a multifaceted approach is required. We hypothesise that the combination of administrative coding data and electronic medical record data, augmented with sepsis screening algorithms, may improve the sensitivity for sepsis case ascertainment in both cancer and non‐cancer settings.5 We encourage Heldens and colleagues to consider these suggestions as an alternative reproducible method needed to elucidate the incidence of sepsis and septic shock in Australian ICUs. Box – Relationship between sepsis cases satisfying clinical criteria and designated coded discharge data in intensive care unit (ICU) and non‐ICU settings, 2012–2014 Year Admission level ICU Non‐ICU All new admissions* ICD‐10‐AM captured cases Concordance All new admissions* ICD‐10‐AM captured cases Concordance 2012 38 27 71% 70 62 89% 2013 39 34 87% 175 103 59% 2014 81 61 75% 331 149 45% Mean (± SD) – – 78% (± 8.3%) – – 64% (± 22%) ICD‐10‐AM = International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification; SD = standard deviation. * Clinically diagnosed sepsis cases according to consensus diagnostic criteria.◆

Jake C Valentine · Gabrielle Haeusler · Leon Worth · Karin Thursky

TO THE EDITOR: We congratulate Heldens and colleagues1 for their work investigating the prevalence and mortality of sepsis within a tertiary hospital intensive care unit (ICU). As the authors rightly point out in their article and podcast, this requires careful screening, consistent diagnostic criteria, and considerable time and effort. The Australian and New Zealand Intensive Care Society (ANZICS) registry provides a highly specific, widely applicable, cost‐effective, timely and practical epidemiological measure of the prevalence and outcomes of sepsis and septic shock as a primary cause of ICU admissions throughout Australia and New Zealand.2 Findings from the registry appear consistent with those of Heldens and colleagues.1 However, their article confirms that there are more patients with sepsis within our ICUs than those who enter with this as an admission diagnosis. Between January 2016 and June 2018, 11.6% (43 529/374 442) of the ICU admissions reported to the ANZICS Adult Patient Database were due to sepsis as defined by the international Sepsis‐3 taskforce.3 In tertiary hospital ICUs, this was slightly higher at 12.1% (19 204/159 067), which is between 14.0% (121/864) by clinical criteria and 11.3% (98/864) by database criteria found within the first 24 hours of ICU admission by Heldens et al. With the recent addition of information about vasopressors and lactate levels, ANZICS can also now confidently identify patients with septic shock. Of 59 069 ICU admissions with available information, 3.3% (1978) had septic shock, again similar to the findings of Heldens et al. ICU admissions in the ANZICS registry due to sepsis or septic shock were associated with mortality of 15.1% and 26.7%, respectively. Heldens et al reported a similar mortality of 24% (8/33) with septic shock identified in the first 24 hours of admission (Appendix, table 4). The study by Heldens et al and the findings from the ANZICS registry are complementary. Together they highlight how the measurement of sepsis depends on the exact definition applied, and the population under consideration, which may vary between clinical practice, prospective observational and interventional studies, and widespread epidemiological comparisons.

David Pilcher · Sue Huckson · Peter Hicks

To the Editor: The Perspectives article by William1 states that medical assistance in dying may disrupt therapeutic relationships and will challenge beliefs. Concern is expressed about countertransference of feelings and attitude between doctors and patients. However, such concern must surely exist with or without the availability of assisted dying laws. What guides our practice is not just codes of medical ethics, professionalism and law, important as those are. It is also a natural and nurtured feeling of compassion and oneness with our patients. Doing no intentional harm (non‐maleficence) does not rule out, or cast doubt on, the application of voluntary assisted dying. Cutting short intolerable pain, suffering and indignity, as specifically requested by the patient, is not maleficence. The suggestion that people requesting medical assistance in dying challenge our beliefs about the meaning and value of who we are and what we do is not something that applies to all of us. Some physicians would feel that assisting a patient's firmly held wish to hasten death is among the most compassionate of acts that can be undertaken, and would experience it as such, along with the patient and family members. Changing the law to something that is better than currently exists does not present a dilemma. It does not contravene medical ethics. It has nothing to do with non‐maleficence or justice (except to introduce an element of justice to those individuals seeking such change). As for education, skills and insights, these can all be honed to a new and better balance in the future. With regards to death anxiety, it may be true that much can be achieved through human engagement, but it is also true that providing the means of assisted dying can itself significantly reduce anxiety and allow any remaining time to be better enjoyed.2 Finally, the suggestion that medical assistance in dying will have a negative influence on the development of teamwork is overly pessimistic. It fails to recognise the positive and complementary potential of assisted dying laws. Alleviation of suffering is surely a noble aim, attainable in a high proportion of cases.

Peter G Beahan

To the Editor: We commend William1 for his perceptive review of the complex issues involved in euthanasia and assisted suicide (EAS).1 In contrast to the euphemisms in the popular media, he confronts us with some uncomfortable realities: EAS is the intentional taking of a person's life (E) or facilitating suicide (AS); doctors considering EAS may be (unconsciously) demonstrating “countertransference of their helplessness onto the patient;” and relief of all suffering is a fantasy beyond the ability of doctors, politicians and lawyers. Similar concerns are expressed by seven Canadian physicians in a critique entitled “Euthanasia in Canada: a cautionary tale”.2 Contrary to the rosy predictions of its proponents, within 2 years, the Canadian experiment with EAS has left physicians aghast. “The introduction of euthanasia in Canada has caused doubt, conflict and crisis.”2 The passing of the Voluntary Assisted Dying Bill 2017 by the Victorian Parliament marked a seismic shift in medical practice, overturning 2500 years of medical ethics: the Hippocratic prohibition on killing patients. We note the increasing pressures, internal and external, on medical associations to declare neutrality on this issue. We believe that such a stance is a mistake. Equally, it is a lost opportunity to educate the public. As stated in a 2018 review, “doctors are not agents of the state and organized medicine cannot afford to be ‘neutral’ on a topic that touches medicine at its very core”.3 Furthermore, the Australian and New Zealand Society for Palliative Medicine4 and the Australian and New Zealand Society for Geriatric Medicine all have position statements that oppose EAS.5 As the peak physician organisation in Australasia, we urge the Royal Australasian College of Physicians to make an unambiguous statement to the general public, the medical profession and politicians that: EAS is not part of health care; EAS should not require involvement of doctors; and EAS creates irreconcilable conflicts with our responsibilities to our patients. If a medical association declares neutrality on this important issue, it squanders the precious role such associations have in providing guidance to the public and political sphere. That squandering comes at precisely the time this debate would be immeasurably enhanced by the expertise and wisdom of those members of the community most involved in the care of patients with serious illnesses.

Douglas T Bridge · Sinead M Donnelly · Frank P Brennan

DECADES of hard work, dedication and innovation have been rewarded with a large number of health professionals on the receiving end of Australia Day Honours.

Cate Swannell