Volume 212 Issue 3

A 39-year-old woman was referred for colposcopy with a positive human papillomavirus (HPV) type 16 infection result on a self-collected HPV vaginal swab

Monica FG McGauran · Adam Pendlebury

A 79-year-old Indian man who immigrated to Australia in 1976 presented with a 15- year history of left wrist swelling and forearm sinus tracts

Lakshana Kalatharan · Peter Kelley

A 72-year-old immunocompromised woman presented with a 6-month history of a rapidly growing right pretibial lesion and a palpable right groin lump

Phillip Cantwell

Huyen A Tran, Harry Gibbs, Eileen Merriman, 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 In this Guideline summary, the Competing interests section should read: “Huyen Tran, Harry Gibbs, Jennifer Curnow, Chee Wee Tan, Sanjeev Chunilal, Ross Baker, Chris Ward and Harshal Nandurkar have received study grants and/or personal fees from Bayer Health, Boehringer Ingelheim, Pfizer, Sanofi and Aspen and have served on advisory boards for these companies. However, no financial or other support was sought from or provided by these or other commercial bodies for the preparation of the guidelines or this guideline summary”.

As the incidence of childhood cancer rises, challenges include delivering personalised precision medicine and minimising the late effects of disease and treatment

Neevika Manoharan · Tracey O'Brien

The long term benefits and risks of gluten avoidance for people without coeliac disease are unknown

Amanda Cartee · Joseph A Murray

The causes of childhood cancers must be understood before interventions to reduce their incidence can be developed

Danny R Youlden · Peter D Baade · Adèle C Green · Patricia C Valery · Andrew S Moore · Joanne F Aitken

Survivors of childhood cancer remain at increased risk of a second primary cancer well into adulthood

Danny R Youlden · Peter D Baade · Adèle C Green · Patricia C Valery · Andrew S Moore · Joanne F Aitken

Self-reported wheat sensitivity was reported by 14% of respondents in both 2015 and 2018

Michael DE Potter · Michael P Jones · Marjorie M Walker · Natasha A Koloski · Simon Keely · Gerald Holtmann · Nicholas J Talley AC

Essential oil exposures are frequent in Australia, and more than half involve children

Kristenbella AYR Lee · Joanna E Harnett · Rose Cairns

The treatment options for type 2 diabetes have expanded significantly in the past decade, with new classes of agents demonstrating superiority for cardiovascular outcomes

Renata Libianto · Timothy ME Davis · Elif I Ekinci

To the Editor: In their Perspective article, Mitchell and colleagues1 discuss the problems for patients resulting from overcautious attitudes in prescribing opioids within the constraints of the doctrine of double effect. In doing so, they also highlight how problems may be compounded by the inappropriate use of language in respect to voluntary assisted dying. Victoria has passed and is now implementing the Voluntary Assisted Dying Act 2017, not “assisted suicide” legislation. Like so much of the language we use, there are underlying, negative connotations to certain words. The use of the term “suicide” in the context of a person living with a terminal or serious and incurable condition that can only be relieved through death conflates two very different realities. One is the understandable or rational desire to avoid the trajectory of escalating suffering at the end of life, while the other is the tragedy of suicide resulting from social, financial or mental health conditions that culminate in feelings of abjection and of hopelessness towards the future. The focus of the authors of this article is both positive and welcome; assuring practitioners that they can adopt a proactive and patient‐centred approach towards pain relief. However, the use of language in this instance is unfortunate, as it has often been employed cynically to undermine the iterations of voluntary assisted dying Bills across Australia. Other common documented examples are referring to voluntary assisted dying as killing, murder, or state‐sanctioned murder — actions involving violence and malicious intent. Voluntary assisted dying is a managed and documented pathway embarked on by a person with decision making capacity to achieve a peaceful death on their own terms. Suicide, on the contrary, is a tragedy, usually undertaken alone as a violent and desperate act, including by people who have no legal recourse to voluntary assisted dying. It leaves a legacy of complicated grief for loved ones. Language is important. Without careful reflection, it can easily be used to subvert good intentions, including legal reforms. It can thereby thwart the will of the people — a perfect storm indeed.

Julia M Anaf

To the Editor: Mitchell and colleagues1 state, “Victoria has passed assisted suicide legislation, Western Australia plans to follow suit in 2019”. This statement is not accurate. Victoria passed voluntary assisted dying legislation, titled the Voluntary Assisted Dying Act 2017. There is no reference to suicide in this legislation. It is important to understand and acknowledge the substantial differences between suicide and voluntary assisted dying: Voluntary assisted dying involves a choice about the manner of death for a person with a terminal illness, whereas the suicidal person usually is not otherwise dying. Voluntary assisted dying mandates two independent medical assessments by specially trained doctors to advise on the person's decision making capacity, diagnosis, prognosis, suffering, and possible treatments, whereas suicide has no such pathway of medical scrutiny and support. The request for voluntary assisted dying must be from a person with decision making capacity, who does not have a mental illness or major depression underlying their request, whereas suicide frequently involves mental disorders, including depression, bipolar disorder, schizophrenia, and substance misuse. Suicide is usually undertaken alone, as an act of desperation, sometimes impulsively, and often violently, whereas voluntary assisted dying involves an enduring decision and a gentle peaceful death, with the person usually surrounded by loved ones. Suicide incurs awful bereavement for loved ones, whereas the family and friends of those who had voluntary assisted dying cope better than when a natural death occurs (less grief symptoms and post‐traumatic stress reactions).2 Suicide is tragic and every effort should be made to prevent it, whereas most of the Australian community want legislative reform for voluntary assisted dying.3 The conflation of suicide with voluntary assisted dying is often a tactic used to denigrate legislative reform. The use of such misleading language should be rejected because it is counterproductive to essential discussions about both voluntary assisted dying and suicide prevention.

Roger W Hunt

To the Editor: We thank Anaf and Hunt for their letters and accept their points about using the words “voluntary assisted dying”. Language does matter and this term, with the passing of the Voluntary Assisted Dying Act 2017 in Victoria, is now the accepted phrase in Australia. However, we consider the existing point remains that a doctor is being asked to assist a patient to take their own life. While that is acceptable to a substantial number of doctors, it is something with which many doctors have a problem, and the argument that we have put forward still stands. If doctors are concerned with the act of a person taking their own life, then they will not want to be accused of this. If a person dies at the time they have been prescribed appropriate doses of medicines (including opioids), they may feel they have promoted that person's death. If they try to avoid accelerated death by using doses of medicines that are less than effective, then they are not providing the care they should deliver. They lose either way. The choice of whether to provide voluntary assisted dying for a patient is one every Victorian doctor has to decide for themselves. But for all doctors providing end‐of‐life care, there should not be the risk of undertreatment and providing less than effective palliative care because of concerns about legal sanctions. Our study1 shows that sanctions are unlikely to be applied.

Geoffrey K Mitchell · Lindy Willmott · Ben P White · Donella Piper · David C Currow · Patsy M Yates

To the Editor: The recent perspective on antibiotic use in animals and humans in Australia1 provides an overview based on sales of antibiotics for livestock during the period 2005–2010. Unfortunately, these are the most recent data available, an important limitation that the authors highlight. Here, I provide details of significant initiatives implemented within the Australian livestock industries since 2010. Indeed, a perspective article published in the MJA in 20122 described the low level of antimicrobial resistance in bacterial isolates from food animals and food products together with work on updating prescribing guidelines and developments in infection control. A comprehensive summary of antimicrobial stewardship (AMS) activities in the pork, poultry, red meat and dairy industries published in 20183 describes the five Rs approach to AMS: taking responsibility for every decision to use antibiotics, reviewing current and ongoing antibiotic use, and reduction, refinement and replacement of antibiotics. A critical element of AMS in livestock practice is focused on removing the need for antibiotics by ensuring that there are biosecurity measures (bio‐exclusion, biocontainment, and individual animal resilience) operating to minimise the presence of pathogens and increase the immunocompetence of animals. Vaccination is a key component of AMS and new vaccine development is an ongoing area of research, with many examples of disease reduction and decreased antibiotic use following the introduction of vaccines.4 The use of antibiotics in livestock in Australia was assessed in the recent global review of antimicrobial resistance,5 and among the 29 countries included in the review, Australia ranked fifth, well below Denmark, a country considered the benchmark for antibiotic use. In addition to the quantity of use, significant attention is paid in Australia to the quality of use of antibiotics, as highlighted in a recent prescribing guideline.6 The absence of current data on antibiotic use remains an important limitation that must be reversed. Nevertheless, there are a multitude of AMS activities being actively implemented which will ensure, as reported in the 2018 article,2 that “Australia's food supply is one of the safest and cleanest in the world”.

Stephen W Page

To the Editor: Pharmacist prescribing rights in Australia have recently sparked debate between medical practitioners and pharmacists.1 While discussion on the potential role of pharmacists to prescribe is important, the debate has focused on the initiation of medications. There is a need to acknowledge that prescribing is a process, which, according to the World Health Organization's six‐step Guide to good prescribing, includes “Step 6: Monitor (and stop?) the treatment”.2 Given inappropriate polypharmacy is increasing in older people,3 collaborative deprescribing (defined as the supervised withdrawal of inappropriate medications) with pharmacists, medical practitioners, and patients should therefore be given equal priority within this debate. Expanding the pharmacists’ role to deprescribe in collaboration with the medical practitioner can be considered as an effective mechanism to enact Step 6. Pharmacists are experts in pharmacotherapy, and consistently use a collaborative approach in providing health care. There is growing evidence internationally of the effectiveness of pharmacist prescribing roles that include medication cessation. In New Zealand and the United Kingdom, recent changes in the legislation have enabled suitably trained pharmacists to prescribe, and various studies have tested the feasibility of pharmacists initiating and deprescribing medications in multiple settings, such as nursing homes and general practice.4,5 The pharmacists’ expanded deprescribing role can be achievable with a team‐based approach in which there is a clear delineation of roles and responsibilities, separating the prescribing from the dispensing pharmacist, as in New Zealand.5,6 In Australia, many health practitioners can prescribe medications. For example, nurse practitioners can initiate and deprescribe within the boundaries of legislation and scope; that is, limited by the scope of practice, requirements from the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme, and by relevant hospital formulary or prescribing arrangements. This may be a model to adopt for expanding the pharmacists’ collaborative deprescribing role. All the steps that underpin prescribing (initiation to withdrawal) are equally important to ensure patient safety, so they receive appropriate medications that are safe and effective. The proposal of expanding the pharmacists’ prescribing role needs to encompass all aspects of the prescribing process. If initiation and continuation of a medication is emphasised, in the context of pharmacists’ prescribing rights in Australia, we may lose focus on patient care and safety.

Lisa Kouladjian O'Donnell · Mouna J Sawan

Dr James Muecke, Professor John Newnham and Professor Bruce Robinson are the recipients of top-flight honours on Australia Day …

Cate Swannell