Volume 211 Issue 2

Atrial fibrillation linked to increased dementia risk, even in stroke‐free patients Atrial fibrillation (AF) is linked with an increased risk of dementia, including in people who have not had a stroke, according to a Korean study published in the European Heart Journal. The study also found that patients with AF who took oral anticoagulants to prevent blood clots had a reduced risk of dementia. AF is the most common heart rhythm problem among older people, and more than half the people with AF are aged 80 years or more. It increases the risks of stroke, other medical problems, and death. As populations age, the incidence of AF is expected to increase, and there is some evidence that AF may contribute to the development of cognitive problems and dementia. The investigators analysed data for 262 611 people in the Korea National Health Insurance Service – Senior cohort aged 60 years or more and without AF and dementia in 2004. By the end of 2013, AF had been diagnosed in 10 435 people, of whom 2522 (24.4%) had developed dementia during the follow‐up period; 36 322 (14.4%) AF‐free people had developed dementia. “We found that the people who developed AF had a 50% increased risk of developing dementia compared to those who did not develop the condition; this increased risk remained even after we removed those who suffered a stroke from our calculations. This means that, among the general population, an extra 1.4 people per 100 of the population would develop dementia if they were diagnosed with AF. We also found that AF increased the risk of Alzheimer's disease by 30% and more than doubled the risk of vascular dementia. However, among people who developed AF who took oral anticoagulants… the risk of subsequently developing dementia reduced by 40% compared to patients who did not take anticoagulants.” https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehz386/5520105 Children with high functioning autism may not get help they need Autism researchers from the Telethon Kids Institute have called for the term “high functioning autism” to be abandoned because of the misleading and potentially harmful expectations about the abilities of children on the autism spectrum it causes. In research published in Autism, the researchers noted that the term was coined in the 1980s as a descriptor for people who had autism but not an intellectual disability. The Telethon Kids researchers reviewed data for 2225 children and young people (1–18 years old) diagnosed with autism, about half of whom had an intellectual disability. They found that those with an intellectual disability had functional skills that closely matched their reported IQ level. However, the adaptive functional abilities of those typically deemed “high functioning” because of their average or higher IQ level were well below what would be expected on the basis of their IQ score. “The implication of this study is that children given this ‘high functioning autism’ label are not just presumed to have better functioning than they really do, but they actually have far greater challenges with everyday skills than the label would suggest.” They said regarding someone as “high functioning” based on IQ alone not only raised false expectations about their abilities, but also exposed them to disadvantage. “It might be used, for example, to argue that a child should be able to go to a mainstream school without support when in fact, while they may perform well on cognitive assessments, they still struggle with skills like understanding instructions, note‐taking, self‐care, changes to routine, or interacting with their peers. By continuing to use this term, we may be inadvertently perpetuating a cycle that denies people access to services and support that they need based solely on their IQ.” https://journals.sagepub.com/doi/10.1177/1362361319852831

The PBS urgently needs to update anti-epileptic drug prescribing restrictions that put patients and prescribers at risk

Christian A Gericke · Terence J O'Brien

Training doctors through regional teaching health service networks may help deliver sustainable high quality health care closer to home for rural Australians

Paul S Worley · Belinda O'Sullivan · Rose Ellis

The strengths of primary care should be harnessed to address complexities of the ageing population

C Dimity Pond · Catherine Regan

A 63- year- old man with a history of multinodular goitre presented with a sudden enlargement of the neck associated with dysphagia and dysphonia for 3 weeks

Lucien Marchand

Medicare criteria may hinder timely diagnosis and treatment of patients

David R Hillman

A flexible balance between sensitivity and specificity can be achieved with a combination of screening tools

Chamara V Senaratna · Jennifer L Perret · Adrian Lowe · Gayan Bowatte · Michael J Abramson · Bruce Thompson · Caroline Lodge · Melissa Russell · Garun S Hamilton · Shyamali C Dharmage

The prevalence of polypharmacy among older Australians is relatively high and increasing as the population ages

Amy T Page · Michael O Falster · Melisa Litchfield · Sallie‐Anne Pearson · Christopher Etherton‐Beer

New Australian clinical practice guideline recommendations to assist GPs with the diagnosis and management of work-related mental health conditions

Danielle Mazza · Samantha P Chakraborty · Bianca Brijnath · Heather Nowak · Cate Howell · Trevor Brott · Michelle Atchison · David Gras · Justin Kenardy · Richard Buchanan · Seyram Tawia

Pulmonary embolism is a potentially life-threatening condition, mandating urgent diagnosis and treatment

Paul C Kruger · John W Eikelboom · James D Douketis · Graeme J Hankey

A review of the legislation may be warranted to assess the balance between professional and public interests

Leon A Simons

To the Editor: I refer to the opinion piece by Brewster and Waxman.1 The authors defined collegiality as “a work environment where responsibility and accountability are shared by colleagues, with mutual respect”. However, in a health care setting, professional competency and patient safety are paramount; medical collegiality is desirable, but should not trump these goals. Collegial courtesy can compromise good patient care, despite concerns of competency in clinical judgement or skills. Poor communication contributes to most sentinel events,2 particularly during clinical handover. SBAR (Situation, Background, Assessment and Recommendation), which was what ISBAR (Introduction, Situation, Background, Assessment and Recommendation) was known as in 2009, was promoted to reduce dangerous transitions in the patient's journey in health care.3 Unfortunately, when first introduced in Australia, unnecessary local adaptations were applied to this simple tool — at least seven versions of SBAR existed across six states between 2009 and 2011.4,5,6,7,8,9,10,11 In 2002, SBAR was introduced by retired United States Navy Captain Doug Bonacum, while working at Kaiser Permanente on patient safety, to address the lack of effective communication in sentinel events similar to nuclear submarine incidents and airplane crashes. A quality and safety expert, he drew on his handoff experience from nuclear submarine crews needing to discuss strategies quickly during shifts changeover, thus improving communication, reducing unnecessary narratives and assisting decision making. SBAR improves communication both within the craft group and in interdisciplinary interaction as it flattens the hierarchy.12 ISBAR can fail when the giver (person providing ISBAR) neglects to prepare or perform ISBAR effectively; this is often due to inadequate training, preparation or consideration of what the receiver requires before initiating the handover. Hence, the success of ISBAR rests more on the giver rather than the receiver of the handover. Kindness should be part of ISBAR, but it starts with the giver initiating the handover. Adequate consideration should be made by ensuring thoughtful preparation and organisation to deliver relevant information professionally and competently.13 Less experienced givers should be ready to furnish any specific details upon request. Such reflections enhance communication, reduce errors and improve confidence and morale. Few can perform ISBAR properly “on the run”; formal re‐accredited requirements involving ISBAR should be mandatory for all health care professionals to ensure this critical clinical handover is done well. Slavish adherence to collegiality should not blur the fundamental issues of professional competency and patient safety.

Shyan Lii Goh

To the Editor: We read with interest the article by Brewster and Waxman1 published in the Medical Journal of Australia. Building kindness and collegiality into regular handover practice is an obligation of increasing urgency in contemporary medical settings. Clinical handover is often led by junior medical staff and can be perceived as a stressful time for them. Junior doctors have expressed fears regarding public approbation as a contributory factor for stress and burnout.2 Obstetric junior doctors within our own tertiary maternity hospital responding to the Australian Medical Association of Western Australia Hospital Health Check survey reported high levels of stress.3 Ultimately, handover is likely to be a precipitating event for stress and anxiety in this group, and addressing psychological wellbeing during this time will have benefits to both staff and patients.4 In 2018, we built kindness into our labour ward handover process, as part of a formal junior doctor wellbeing initiative. The existing handover structure commenced with individual staff introductions for all members of staff in attendance, including name and role for each staff member. We incorporated a specific staff member to handover, whose sole role, stated during introduction, is “I am here to provide emotional support to the team”. This explicit statement places emotional wellbeing of all staff members at the heart of the priorities for the handover session. Induction to the roles and responsibilities of the profession has been identified as part of the purpose of handover.5 By building kindness and support into our organisation on a daily basis, we hope to improve the wellbeing of all staff members involved in this small but vital daily interaction and embed kindness and support in the broader workplace culture. A post‐intervention survey of the response to our emotional wellbeing initiative will be available in July 2019, at which point, we will learn the effectiveness of the added focus on kindness in handover meetings. Preliminary feedback from our junior doctors has been positive.

Alarna Thomas · Katrina L Calvert · Brendan Jansen

In reply

David J Brewster · Bruce P Waxman

Tran HA, Gibbs H, Merriman E, et al. New guidelines from the Thrombosis and Haemostasis Society of Australia and New Zealand for the diagnosis and management of venous thromboembolism. Med J Aust 2019; 210: 227‐235. https://doi.org/10.5694/mja2.50004 The name of author Chee Wee Tan was reversed at original publication and has been corrected online. ◆