Volume 212 Issue 2

Beard FH, Hendry AJ, Macartney K. Early success with room for improvement: influenza vaccination of young Australian children. Med J Aust 2019; 210: 484–486. https://doi.org/10.5694/mja2.50141 In this Perspective article, the Box title should read: “Australian cumulative coverage estimates* of at least one dose of influenza vaccine from the Australian Immunisation Register in 2018 (1 April to 30 September) for children aged 6 months to less than 5 years, by age group, for all children (A) and Indigenous children (B) and by jurisdiction (inserts), assessed at 30 September 2018”.

A 59-year-old woman attended a spasticity clinic with treatment-resistant atypical pressure ulcer in the right hand caused by focal spasticity secondary to upper motor neuron lesion

Anupam Datta Gupta · David H Wilson

Section 8 is an unwarranted infringement on communication between health practitioners and their patients

Bryanna Moore · Courtney Hempton · Evie Kendal

Tiered universal screening systems that save lives are cost- effective

Megan Hitchins

The change from vaginal births to operative births may entail unforeseen longer term consequences

David A Ellwood

Universal tumour testing strategies for guiding germline genetic testing are likely to be cost-effective compared with no testing

Yoon‐Jung Kang · James Killen · Michael Caruana · Kate Simms · Natalie Taylor · Ian M Frayling · Tristan Snowsill · Nicola Huxley · Veerle MH Coupe · Suzanne Hughes · Victoria Freeman · Alex Boussioutas · Alison H Trainer · Robyn L Ward · Gillian Mitchell · Finlay A Macrae · Karen Canfell

Changes in the modes of twin birth in Victoria, 1983–2015

Yizhen (Amy) Liu · Mary‐Ann Davey · Rilka Lee · Kirsten R Palmer · Euan M Wallace

Evidence for implementing the first funded meningococcal B vaccine program in infants, children and adolescents

Helen S Marshall · Noel Lally · Louise Flood · Paddy Phillips

To the Editor: Uncontrolled before‐and‐after studies are highly prone to bias. Wabe and colleagues report on the impact of rapid influenza testing on outcomes for emergency department (ED) patients.1 They compared outcomes across four hospitals between the 2016 influenza season, when standard testing was used, and 2017, when rapid testing was used. Rapid testing was associated with shorter test turnaround times, more patients receiving results, and lower admission rates. Before‐and‐after studies use historical controls, in this case the prior influenza season, to evaluate the impact of interventions. This may be adequate for comparing simple indicators, such as test turnaround time, or for generating hypotheses. However, uncontrolled before‐and‐after studies are not useful for assessing more complex outcomes, such as admission rates, which are highly vulnerable to bias from other factors that may impact the observed results. For this reason, they are discouraged by some publishing groups.2 Frequent genetic drift in influenza virus strains causes variations in the burden and severity of illness each year, which influences ED presentations, testing and admission rates. The 2017 influenza season saw unprecedented numbers of influenza cases and ED presentations in NSW,3 which likely influenced admission practices. Teasing out the effect of rapid testing on admission rates is therefore not possible using an uncontrolled comparison between two disparate influenza seasons, in the manner of Wabe and colleagues. The steps taken to attempt to reduce seasonal effects cannot address this. It is also not possible to determine the net direction of biases in this study. Given the higher cost of rapid tests, it is important to have good estimates of their impact to inform economic evaluations. There are stronger methodologies that still allow timely evaluation using routinely collected data. At minimum, a comparison could be made to hospitals that did not implement rapid testing. When data from more seasons are available, an interrupted time series analysis may be appropriate.4 Interventions that mitigate the burden of seasonal influenza on health services are critical. Rapid testing is likely one such intervention, and therefore warrants careful evaluation with robust methodologies to inform its use.

Anthea L Katelaris · Ross M Andrews · Jeremy McAnulty

In reply

Nasir Wabe

To the Editor: Currie and colleagues highlight the important topic of animal vaccines as occupational hazards and the need for improved clinician advice to manage patients safely.1 The article title describes “high pressure” injections, yet the oil emulsion vaccine of most concern, against ovine Johne's disease, is delivered via a standard needle injection. All accidental mineral oil injections are of concern (as are all high pressure injections). Appropriate identification and advice can be obtained by contacting a Poisons Information Centre (PIC). This was not discussed by Currie and colleagues, although it was recommended in a reference they cited.2 Unlike some vaccine manufacturers, the publicly funded PIC service provides 24‐hour emergency medical advice (131 126) for the public and health professionals. PICs access the Australian National Poisons Register, which allows rapid identification of the dozens of oil‐containing vaccines. Currently in Australia, oil adjuvant vaccines lack clear labelling to identify the presence of oil on the front packaging. Increased prominence would aid recognition, similar to initiatives for active ingredients within human therapeutic products. Indeed, review of the unscheduled status of most animal vaccines is required as they possess a risk assessment profile at odds with the Scheduling Policy Framework.3 Improved pharmacovigilance of veterinary products (and agrochemicals) is urgently required, particularly regarding the risks posed to human health. Unpublished analysis of data from Australian PIC annual reports identified about 2000 cases annually of human exposures to veterinary pharmaceuticals. We recently reported on human exposures to veterinary pharmaceuticals from New South Wales PIC calls from 2014 to 2016, with 30 exposures to Johne's disease vaccine alone.4 Collectively, PICs have over 20 times the number of reports to the designated authority for post‐market surveillance; the Australian Adverse Experience Reporting Program run by the Australian Pesticides and Veterinary Medicines Authority received 91 reports for human effects from registered veterinary medicines and agricultural chemical products combined in 2015.5 There is an opportunity for PICs to be engaged more efficiently in surveillance, which would allow the collection of additional information through follow‐up calls to understand risk factors, evaluate outcomes and recommend interventions to prevent future injuries. This would facilitate improvements in management of human exposures to veterinary pharmaceuticals to protect occupational health.

Jared A Brown · Nicholas A Buckley · Rose Cairns · Claire E Wylie

To the Editor: We thoroughly enjoyed the insightful review on erectile dysfunction by McMahon.1 We offer some observations, as most of the abnormalities described in erectile dysfunction are also associated with obstructive sleep apnoea (OSA). Fortunately, OSA can be reliably diagnosed in 80% of cases by bilateral, simultaneous, lateral, passive, anterosuperior, paramarginal distraction of a patient's upper eyelids.2 Finding lax (floppy) lids clearly has a positive association with OSA. Clinical examination of patients with lax eyelids — and in their extreme manifestation, floppy eyelid syndrome — can elucidate a patient's preferred sleeping laterality. Moreover, the presence of OSA can be imputed if the lid laxity is moderate to severe.2 We were concerned that there was no mention of the pathogenetic association of OSA with erectile dysfunction; it may be prudent to exclude OSA in patients diagnosed with erectile dysfunction. As management of floppy eyelid syndrome includes weight loss, it was gratifying to see McMahon emphasising lifestyle modification to reduce the impact of vascular risk factors. Similarly, upper eyelid laxity can also be improved with weight loss.3 This also benefits the OSA‐related complications of hypertension, diabetes, myocardial infarction, stroke and depression, and the ophthalmological complications of floppy eyelid syndrome. It was pleasing to note that McMahon referred to non‐arteritic ischaemic optic neuropathy. However, this condition occurs not only in the context of utilisation of phosphodiesterase type 5 inhibitors but also as a consequence of OSA.4 We suggest that clinicians carry out lid distraction to screen for OSA and assist in the diagnosis and management of erectile dysfunction.

Kriti Agnihotri · Eugene Ting · Ian C Francis

To the Editor: Over the past decades, the incidence of type 2 diabetes, rarely diagnosed in children and adolescents before the 1990s,1 has been increasing in young people in several populations, including Australia.2,3,4 Early onset type 2 diabetes appears to have a more severe phenotype compared with adult onset type 2 diabetes, and has a high prevalence of complications already present at the time of diagnosis despite the patients’ young age and short duration of the disease.5 We aimed to describe the characteristics of Western Australian children aged less than 10 years diagnosed with type 2 diabetes between June 2000 and June 2017. Demographic and clinical data for children diagnosed with type 2 diabetes during the study period were extracted from the population‐based WA Children's Diabetes Database and via manual review of hospital clinical files. Of the 193 children aged less than 16 years diagnosed with type 2 diabetes in WA during the study period, 12 children were diagnosed at less than 10 years of age, with the youngest aged 6 years and 11 months. These 12 patients had one or both parents diagnosed with type 2 diabetes, 11 children were Aboriginal Australians, one was Māori, 11 were obese (mean body mass index z‐score, 2.38; standard deviation [SD], 0.64); nine were female, and seven had one or more comorbidities. Of the 11 children examined, ten had acanthosis nigricans present on their skin. Three children presented with polyuria and polydipsia, six were unwell with other illnesses and three were asymptomatic. Type 1 diabetes antibodies were negative in seven of eight of the children tested, and the mean glycated haemoglobin level at diagnosis was 75 mmol/mol (mean, 9.0%; SD, 2.4%). Nine patients had one or more diabetes complications present at the time of diagnosis; seven had dyslipidaemia, two had an elevated albumin creatinine ratio, and three had hypertension. Our study describes the common clinical features of early onset type 2 diabetes in young children in WA, such as history of parental type 2 diabetes, Aboriginal heritage, obesity, and female sex, and provides strong evidence for the need to screen children with these risk factors for type 2 diabetes, irrespective of their age. Moreover, the high prevalence of diabetes complications present strongly supports the need for complications screening at the time of diagnosis.

Jacqueline A Curran · Aveni Haynes · Elizabeth A Davis