Volume 213 Issue 10

There is more to female sexual function than circulating testosterone, and symptomatic women require a thorough clinical evaluation The 2019 global consensus position statement on the use of testosterone therapy for women1 aims to provide guidance for clinicians managing women with female sexual dysfunction. The recommendations, graded according to levels of evidence, have been developed by an international taskforce with representatives from a range of organisations and societies, headed by Australian endocrinologist Professor Susan Davis, the current President of the International Menopause Society. The position statement bases many of its recommendations on a systematic review and meta‐analysis of randomised controlled trials.2 The meta‐analysis includes data from 36 randomised controlled trials with 8480 participants and includes studies with a testosterone treatment duration of at least 12 weeks. The primary outcome indicates an improvement in satisfying sexual events, measured as a mean increase of one event over 4 weeks with the use of testosterone. There were also improvements in other parameters associated with sexual function, including sexual desire, arousal and self‐image. There were no cognitive, psychological, wellbeing or musculoskeletal (including bone mineral density) benefits. In doses that approximate physiological levels, the main adverse effects of testosterone therapy are significant increases in acne and hair growth but no difference in alopecia, clitoromegaly or voice change. The position statement provides recommendations covering the assessment of women with female sexual dysfunction, laboratory measurement of testosterone, indications for treatment, and ongoing monitoring once treatment is commenced. It emphasises that the only evidence‐based indication for the use of testosterone in women is the treatment of post‐menopausal women who have been diagnosed with hypoactive sexual dysfunction disorder (HSDD) after formal biopsychosocial assessment. Doses that approximate physiological testosterone concentrations in pre‐menopausal women are recommended. At these doses, testosterone therapy is not associated with serious adverse events. Notably there are no safety data for beyond 24 months of treatment. There are insufficient data regarding the use of testosterone therapy in pre‐menopausal women. The position statement does not comment regarding women with premature ovarian insufficiency and recommends caution in women with a breast cancer diagnosis, reflecting the lack of data.3,4 The classification of female sexual disorders has been a source of controversy and debate. In the Diagnostic and Statistical Manual of Mental Health Disorders, 5th Edition, HSDD and female sexual arousal disorder (FSAD) have been amalgamated and classified as a single entity: female sexual interest/arousal disorder. The writing group for the position statement regards HSDD and FSAD to be distinct conditions, a view shared by experts in the field.5,6 Diagnostic criteria for both conditions are outlined in Box 1.7 It is important to understand this clinical distinction as the position statement does not consider FSAD to be an indication for testosterone therapy. Serum testosterone levels decline during the reproductive years and are significantly reduced in women post‐oophorectomy.8 There was no reported correlation between androgen levels and reported sexual function in one study,9 and there is no serum testosterone cut‐off below which women are more likely to experience HSDD. The authors of the position statement comment that the relationship between endogenous androgen concentrations and sexual function remains uncertain because of issues related to androgen assays in some studies. Notwithstanding these factors, it is recommended that a baseline measurement of testosterone be taken to avoid overtreatment.1 Serum total testosterone rather than free testosterone is the recommended biomarker. The significance of free testosterone in the context of female sexual dysfunction has not been evaluated. Most commercial assays in Australia use immunoassays to measure testosterone, while free testosterone and free androgen index are calculated from total testosterone and sex hormone‐binding globulin. However, immunoassays are considered unreliable, particularly for low levels in the female reference range. Liquid and gas chromatography and mass spectrometry, while not yet in common use, are considered far more accurate and efforts are being made to increase availability.10 The position statement does not comment on whether menopausal hormone therapy should be used concurrently with testosterone therapy. However, a biopsychosocial model of treatment of female sexual dysfunction is recommended, which may include menopausal hormone therapy. Multiple studies have looked at the effect of oestrogen therapy alone, testosterone alone and a combination of the two on female sexual function, with variable outcomes. One of the main criticisms of studies demonstrating no improvement with oestrogen (alone or combined with testosterone) is that low therapeutic doses of oestrogen were used and circulating oestradiol levels were either not measured or were low and did not reach pre‐ovulatory levels consistent with those seen in pre‐menopausal women.11 Only one of eight studies included in the meta‐analysis did not include concomitant menopausal hormone therapy.2 Systemic oestrogen therapy is known to improve hot flushes, urogenital symptoms and mood disturbance, while topical vaginal oestrogen is effective in managing vulvovaginal atrophy.12 Both improve wellbeing in menopausal women and may enhance libido such that other therapies are not required,13 although an improvement in absolute terms has not been described. Our view is that menopausal hormone therapy with oestrogen with or without progestogen should be considered initially in all post‐menopausal women who present with low libido before the initiation of testosterone. A significant issue is the clinical meaningfulness of the finding of a mean increase of one satisfying sexual event per month. Many will argue that such an outcome does not justify the use of testosterone therapy in clinical practice. In context, however, the meaningfulness will depend on the individual woman. For example, for a woman experiencing no satisfying sexual events, an extra one per month would equate to twelve extra events per year and could represent a significant improvement in her quality of life. Consumer involvement in the development of the position statement may have provided insight into this question. In the meta‐analysis, testosterone therapy compared with placebo was found to reduce personal distress, a key component of HSDD, in all studies of post‐menopausal women. Perhaps more relevant to the discussion is whether a satisfying sexual event is adequate as the primary measure of efficacy for treatment. The authors address this in the final part of the position statement. Appropriately, recommendations are made for the design of future clinical trials, including the development of a validated instrument for the screening and diagnosis of HSDD that can also be used as a marker of efficacy of treatment. Australian perspective Sexual dysfunction is common among Australian women. The prevalence of low sexual desire and HSDD was 69.3% and 32.2%, respectively, among a sample of community‐based women aged 40–65 years in one study.14 In older women, the prevalence of HSDD was reported to be one in seven women in a population of women aged 65–79 years living in the community.15 The use of testosterone for therapeutic purposes in women has been controversial. Despite this, clinicians in many countries including Australia have been prescribing testosterone off‐label primarily for low sexual desire in women for several years.16 Various formulations have been used, including subcutaneous pellets, transdermal gels and intramuscular injections that are designed for men, with dosing then adjusted for the female population. In this setting, there is greater potential for treatment to result in supraphysiological testosterone levels. The position statement suggests that ‘‘where approved female preparations are unavailable, off‐label prescribing of an approved male formulation is reasonable”.1 Bio‐identical and compounded products are not recommended. In Australia, a 1% transdermal testosterone cream is available, designed specifically for women and indicated for symptoms caused by testosterone deficiency. Although the product is unlicensed in Australia, it has been available on prescription from pharmacies within Western Australia since 1999 due to an exemption under section 6 of the Therapeutic Goods Act 1989 (Cth). Women prescribed this treatment in other states are required to access it by mail order along with a prescription from their clinician. It was submitted for Therapeutic Goods Administration evaluation and inclusion on the Australian Register of Therapeutic Goods as a registered product in 2019 for the proposed indication of treatment of hypoactive sexual desire dysfunction in post‐menopausal women, and a response is expected by the end of 2020 (Michael Buckley, Medical Director, Lawley Pharmaceuticals, personal communications). Although limited by small sample sizes, pharmacokinetic and clinical studies of the recommended 5–10 mg daily dose of this cream demonstrated total and free testosterone levels within or above the pre‐menopausal range.17,18,19 Its availability in Australia overcomes the need to consider male preparations or compounded and bio‐identical products. The publication of the position statement will increase awareness of female sexual dysfunction in the medical community. Clinicians managing these patients will require education in practical terms about assessing such patients for HSDD and safely prescribing and monitoring testosterone therapy when indicated. Based on the authors’ expertise and experience, we propose an algorithm for the assessment of women presenting with female sexual dysfunction and use of testosterone (Box 2), with women initially undergoing a biopsychosocial assessment.6 We recommend information sheets for clinicians and patients written by local experts be made available on the websites of the Australasian Menopause Society, the Endocrine Society of Australia and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Conclusion The position statement is a timely addition to the literature regarding testosterone therapy for women. What is clear is that there is more to female sexual function than circulating testosterone and that symptomatic women require a thorough clinical evaluation, assessing for other factors which may be contributing to their presentation. Testosterone therapy is a small piece of the puzzle in the management of female sexual dysfunction. This position statement provides clarification regarding the indication, adverse effects and knowledge gaps. The availability in Australia of a transdermal testosterone preparation designed for women obviates the need to use male preparations, but further research regarding efficacy and safety is necessary. Future studies should address the safety of long term use of testosterone in women, particularly with respect to cardiovascular disease and breast cancer. Box 1 – Definition of hypoactive sexual desire disorder and female sexual arousal disorder7 Disorder Definition Hypoactive sexual desire disorder Any of the following for a minimum of 6 months: lack of motivation for sexual activity as manifest by reduced or absent spontaneous desire (sexual thoughts or fantasies); or reduced or absent responsive desire to erotic cues and stimulation or inability to maintain desire or interest through sexual activity loss of desire to initiate or participate in sexual activity, including behavioural responses such as avoidance of situations that could lead to sexual activity that is not secondary to sexual pain disorder AND is combined with clinically significant personal distress that includes frustration, grief, guilt, incompetence, loss, sadness, sorrow or worry Female sexual arousal disorder* Female cognitive arousal disorder Distressing difficulty or inability to attain or maintain adequate mental excitement associated with sexual activity as manifest by problems with feeling engaged, or mentally turned on or sexually aroused for a minimum of 6 months Female genital arousal disorder Distressing difficulty or inability to attain or maintain adequate genital response associated with sexual activity for a minimum of 6 months, including: vulvovaginal lubrication engorgement of the genitalia sensitivity of the genitalia associated with sexual activity Disorders related to: vascular injury or dysfunction, or neurological injury or dysfunction * Encompasses female cognitive arousal disorder and female genital arousal disorder Box 2 – Testosterone therapy for post‐menopausal women: proposed algorithm CNS = central nervous system; CVD = cardiovascular disease; HSDD = hypoactive sexual desire disorder; IMS = International Menopause Society; VTE = venous thromboembolism. * Simon et al.6 † Jane and Davis.20

Christina Jang · Jacqueline A Boyle · Amanda Vincent

A 65-year-old man from a rural town presented with severe left- hand pain on a background of previously diagnosed Buerger disease

Warren Clements · Heather K Moriarty

The pandemic is a vast, expanding disaster with no end in sight, producing chronic stress, disruption, and multiple losses The coronavirus disease 2019 (COVID‐19) pandemic has been a once‐in‐100‐years event. The scale of the disaster overshadows all others in living memory. Most disasters are focal and time‐limited. This one will span a considerable period of time and the economic impact will last years. This means the mental health effects will be deeper and more sustained than in other disasters. A survey during the first month of the pandemic in Australia assessed the nation's “temperature” early, as reported in this issue of the Journal.1 This survey and other information2,3 confirm that the initial mental health impact has been severe, and worse may be coming. Scientific models predicted that Australia would face a second curve of mental ill health and suicide,4,5 and this has now clearly arrived. We have been willing to turn our society and lives upside down to flatten the COVID‐19 curve. The same commitment is now required to flatten the mental health curve. After acute disasters, most people experience a transitory wave of distress that is considered normal and they do not generally require professional care. COVID‐19 is fundamentally different. It is not a single shock, but a vast, expanding disaster with no end in sight, producing chronic stress, disruption, and multiple losses, and many of the usual mitigation strategies are banned or unavailable. Modelling and earlier recessions show that it is the economic consequences, especially financial stress, unemployment, and educational failure, that fuel mental ill health and suicide risk.4,6 This impact is anything but short lived, and will produce a long, deep second wave of mental ill health and suicide. The impact is not uniform and there are groups at especial risk: notably, the already marginalised and disadvantaged, young people, women, those living alone and those already unemployed. Young people are especially disproportionately affected, and face a generation‐defining disruption that will have a multifaceted, long term impact on their lives. Socio‐economic inequality is a major risk factor for an array of negative health and social outcomes, including mental illness,7 and the potency of this risk factor will be magnified by a pandemic followed by a recession. We may all be in this together, but some are further in than others. The response so far has been based upon thinking from earlier crises and disasters. The focus is on the general public and aims to stress the normative aspect, that “it is OK to not be OK”, that simple coping mechanisms will get people through the crisis, and wishful thinking that professional help is available if needed. Crisis lines have been bolstered, but there has been no major effort to increase the capacity of the system, although the pivot to telehealth has sought to maintain access. These steps are welcome, but they will be inadequate on their own. The scale and sustained nature of the stress, the undermining effect of the containment measures, especially second lockdowns, and economic collapse mean that a much larger proportion of the population may need mental health care and be at risk for suicide than in more focal disasters. The capacity of the mental health system, even before COVID‐19, had been inadequate for responding to the demand.8,9 The system is now expected to respond to the surge in need for mental health care. It has been admirable how single‐mindedly governments and the health system have responded with public health measures and a boost to intensive care capacity10 in order to flatten the infection curve and to treat infected patients. At the time of writing, 886 people have died of COVID‐19 in Australia. During the same time period (February to October), more than 2000 Australians will have died from suicide,11 let down by an inadequate health and social system response. Most suffered from clear‐cut mental ill health, although only a minority had accessed mental health care.12 It is predicted that the number of suicides will rise in parallel with the COVID‐19 crisis and associated recession.4 These lives are surely just as precious as the ones directly lost to and threatened by COVID‐19. They have not yet been lost, and many, if not all, can be saved. What can be done? Firstly, policymakers must accept that this is not a routine disaster and that the times call for a very different approach. I believe the Prime Minister and some premiers are engaged with resolving this problem. Economic measures to soften the impact of the recession are the paramount preventive strategy, and the federal government has acted promptly with the JobKeeper and JobSeeker schemes, which have been partially extended while being reduced in stages. The global financial crisis showed how destructive austerity policies are, increasing inequality and social determinants of mental ill health, as well as weakening the social fabric and democracy itself. Secondly, the crisis provides a unique opportunity to create the “new mental health care” by dramatically reforming and strengthening the current system. An international position paper13 has been published, but Australia is ahead of the curve with key innovations, such as home‐based care and hospital in the home, assertive outreach models, and a national youth mental health platform (headspace), supported by digital and telehealth, which not only suit the times but are evidence‐based and strongly preferred by patients and families to emergency and inpatient care. Shifting the centre of gravity of mental health care to local communities via integrated care hubs linked closely with primary care is an innovation strongly supported by the federal government and Health Minister Hunt, not only through headspace, but also through the adult mental health hub model announced in 2019.14 Integrated care hubs with deeper capacity and expertise in helping people (young and older) with more complex needs could easily be fast tracked in the shadow of COVID‐19, initially as pop‐ups boosted by digital technology and outreach. State governments should consider releasing the governance of community mental health care from large hospital‐centric health networks so that it is embraced and can be accessed by local communities. And federal commissioning of community mental health care should be more coherent, guided by national evidence‐based standards, with the goal of regional integration of services, reversing the fragmentation produced by the competitive tendering policies of the excessively devolved primary health network model. The coming months will reveal whether we are really all in this together or whether the 5 million15 Australians (and rapidly growing) who confront mental ill health each year will continue to be treated as second class citizens.

Patrick McGorry

The increasing use of split livers for in children has effectively increased the donor organ supply

James Neuberger

A public mental health response that includes universal, selective and indicated clinical interventions is needed

Jane RW Fisher · Thach D Tran · Karin Hammarberg · Jayagowri Sastry · Hau Nguyen · Heather Rowe · Sally Popplestone · Ruby Stocker · Claire Stubber · Maggie Kirkman

Objective: To assess long term graft and patient survival after donor liver retransplantation in children in Australia and New Zealand during 1986–2017; to determine the factors that influence survival. Design: Retrospective cohort analysis (registry data). Setting, participants: Australia and New Zealand Liver Transplant Registry data for all liver retransplantations in children (under 18 years of age), 1986–2017, in all four paediatric and six adult liver transplantation centres in the two countries. Main outcome measures: Graft and patient survival at one, 5, 10 and 15 years. Results: 142 liver retransplantations were undertaken in children (59 during 1986–2000, 83 during 2001–2017). Kaplan–Meier survival analysis indicated that survival was significantly greater during 2001–2017 than 1986–2000 (P < 0.001). During 2001–2017, graft survival one year after retransplantation was 84%, at 5 years 75%, at 10 years 70%, and at 15 years 54%; patient survival was 89% at one year, 87% at 5 years, 87% at 10 years, and 71% at 15 years. Median time between transplantations was 0.2 years (IQR, 0.03–1.4 years) during 1986–2000, and 1.8 years (IQR, 0.1–6.8 years) during 2001–2017 (P = 0.002). The proportion of graft failures that involved split grafts was larger during 2001–2017 (35 of 83, 42%) than 1986–2000 (10 of 59, 17%). Graft type, cause of graft failure, and number of transplants did not influence survival following retransplantation. Conclusion: Survival for children following retransplantation is excellent. Graft survival is similar for split and whole grafts. Children on the liver waiting list requiring retransplantation should have the same access to donor grafts as children requiring a first transplant.

Angus W Jeffrey · Gary P Jeffrey · Michael Stormon · Gordon Thomas · Edward O'Loughlin · Albert Shun · Winita Hardikar · Robert Jones · John McCall · Helen Evans · Graham Starkey · Peter Hodgkinson · Looi C Ee · David Moore · Catherine Mews · Geoff W McCaughan · Peter W Angus · Alan J Wigg · Michael Crawford · Jonathan Fawcett

Social restrictions reduced the spread of COVID-19 within 14 days of measurable changes in public mobility

Tu Hao Tran · Suraj N Sasikumar · Annemarie Hennessy · Aiden O'Loughlin · Lucy Morgan

It has been reported that about 60% of patients commencing chemotherapy in Australia with curative intent and 47% of those receiving radiotherapy also use complementary medicine.1,2 Ingestible products are frequently used, but are often not discussed with the medical team, which increases the risk of interactions and other undesirable effects. Opportunity costs are another problem; while complementary medicine is typically used by people with cancer for supportive care and wellbeing, some use it to help treat cancer.2 Given the frequent use of complementary medicine by people with cancer, we surveyed Australian public and private hospitals with dedicated cancer services (1 May – 15 December 2016),3,4 to assess various aspects of cancer service coverage, particularly complementary medicine services. In this report, we describe hospital policies on complementary medicine and the availability of related information for patients. The study was approved by the human research ethics committees of the University of Western Sydney (reference, H11389), the University of Wollongong and Illawarra Shoalhaven Local Health District (reference, HREC/16/WGONG/178), and Calvary Health Care, Adelaide (reference, 16‐CHREC‐E011). One staff member from the cancer service of each participating hospital (262 of 282 invited hospitals, 93%) completed a 52‐item electronic survey (online Supporting Information). Chemotherapy was provided by 207 of the participating services (79%) and supportive and allied health care by 196 (75%), including 66 (25%) that provided at least one type of complementary medicine service. Palliative care was provided by 168 hospitals (64%), surgery by 143 (55%), and radiotherapy by 143 (34%). Ninety‐three responding hospitals (36%) could not provide responses to one or more of the five policy‐related survey questions. This was despite the option to complete the survey across several log‐in sessions and 223 of the respondents (85%) having administrator or management roles. Only 89 respondents (34%) were aware of the Council of Australian Therapeutic Advisory Groups (CATAG) position statement on complementary medicines,5 and only 31 of these respondents (35%) thought that their hospital policies were aligned with this statement. A substantial proportion of hospitals did not have policies regarding complementary medicine practitioners or patient‐initiated complementary medicine use (Box). Most hospitals (229, 87%) had policies for documenting complementary medicines: 76 (33%) documented all complementary medicines (including patient‐initiated products) on medication charts, 88 (38%) documented only complementary medicines approved by medical staff, and 48 (21%) documented complementary medicine use only in the clinical history. The policy at 17 hospitals (6%) was that complementary medicines were never permitted, despite CATAG advice.5 In an adjusted backward multinominal logistic regression analysis, hospitals with cancer services without complementary medicine services were significantly less likely to have policies on complementary medicine practitioners and documenting complementary medicines (Box). Further, only 123 services (47%) provided complementary medicine information for patients, and 23 respondents (9%) did not know whether such information was available. The differences in the awareness of and the availability of hospital policies and patient information about complementary medicine are concerning. Irrespective of whether a cancer service provides complementary medicine, consistent policies across Australian hospitals, and staff and patient awareness of these policies, are important because of the widespread use of complementary medicine. Stronger leadership is needed from peak bodies, such as the Australian Commission on Safety and Quality in Health Care and CATAG, to encourage Australian cancer services and hospitals to update or review their complementary medicine policies. Box – Hospital policies regarding complementary medicine products and visiting practitioners, based on survey responses from 262 hospitals with cancer services Complementary medicine (CM) cancer services available Hospitals without v with CM service: adjusted odds ratio* (95% CI) Policy type Number Yes No Total number of hospitals 262 66 (25%) 196 (75%) Documenting CM product use Hospital policy 229 (87%) 60 (91%) 169 (86%) — No policy 24 (9%) 1 (2%) 23 (12%) 10.4 (1.3–81) Unknown 9 (3%) 5 (8%) 4 (2%) 0.29 (0.07–12) Documenting patient‐initiated CM products Hospital policy 43 (16%) 15 (23%) 28 (14%) — No policy 133 (51%) 30 (45%) 103 (53%) 1.8 (0.84–4.0) Case‐by‐case 43 (16%) 9 (14%) 34 (17%) 1.2 (0.48–3.3) Unknown 43 (16%) 12 (18%) 31 (16%) 1.8 (0.68–5.0) Referrals to CM practitioners outside the hospital Hospital policy 25 (10%) 14 (21%) 11 (6%) — No policy 145 (55%) 27 (41%) 118 (60%) 5.2 (2.1–13) Case‐by‐case 43 (16%) 15 (23%) 28 (14%) 2.8 (0.99–8.0) Unknown 49 (19%) 10 (15%) 39 (20%) 4.4 (1.5–13) Scope of practice for visiting CM practitioners Hospital policy 54 (21%) 20 (30%) 34 (17%) — No policy 113 (43%) 16 (24%) 97 (49%) 3.3 (1.5–7.3) Case‐by‐case 34 (13%) 17 (26%) 17 (9%) 0.65 (0.26–1.6) Unknown 61 (23%) 13 (20%) 48 (24%) 2.1 (0.95–5.0) Credentialing for visiting CM practitioners Hospital policy 72 (28%) 32 (48%) 40 (20%) — No policy 103 (39%) 11 (17%) 92 (47%) 6.2 (2.8–14) Case‐by‐case 28 (11%) 11 (17%) 17 (9%) 1.4 (0.56–3.5) Unknown 59 (22%) 12 (18%) 47 (24%) 2.9 (1.3–6.6) CI = confidence interval. * Reference category: hospital has policy and its cancer service provides complementary medicine services. Derived by backward multinominal logistic regression, adjusted for survey responder's role (administration/management: 46 [18%], health care professional: 70 [27%], dual role: 146 [56%]); hospital ownership (public: 132 [50%], private for‐profit: 74 [28%], private not‐for‐profit: 56 [21%]; and Australian Bureau of Statistics remoteness classification (major cities: 117 [40%], inner/outer regional: 87 [30%], remote/very remote: 91 [31%]).

Jennifer Hunter · Suzanne Grant · Geoff P Delaney · Caroline A Smith · Kate Templeman · Jane Ussher

To the Editor: Cardiac injury has been reported in about 20% of patients with coronavirus disease 2019 (COVID‐19) admitted to hospital.1 Elevated troponin is associated with higher complications and death rates.2,3 We report our experience in managing the cardiovascular care of all patients with COVID‐19 admitted to our 783‐bed quarternary hospital in Perth between 1 February and 1 May 2020. The hospital approved the data collection for a clinical quality improvement audit and provided an exemption from ethics review and approval to publish the results. Patients with COVID‐19 with an abnormal electrocardiogram (ECG) showed markers of increased disease severity, had a longer hospital stay and intensive care unit (ICU) admission. Eighteen patients (11 males), with a mean age 59 years (standard deviation [SD], 18), were admitted for a mean 14 days (SD, 15) with symptoms of cough (78%), fever (72%), dyspnoea (61%), fatigue (44%), chest pain (22%), and presyncope (5%). The mean presentation was 6 days (SD, 4) from onset of symptoms. Eight patients required admission to the ICU, and we recorded no deaths. The comorbidities included obesity (four patients), ischaemic heart disease (two patients), diabetes mellitus (four patients), and hypertension (six patients). Cardiac investigations included ECGs (72%), high sensitivity troponin (67%), brain natriuretic peptide (7%), and echocardiogram (6%). Upon admission, eight patients (63%) had an abnormal ECG, which included PR depression, biphasic T waves, PR prolongation, Q waves, ST elevation, atrial flutter, right bundle branch block, and atrial trigeminy. Two patients had elevated troponin. All brain natriuretic peptide and echocardiogram results were normal. Patients who did not have an ECG had low risk markers for disease severity. Patients with a normal ECG had a mean heart rate 84 beats/min (SD, 11), mean QRS duration 92 milliseconds (SD, 9), and mean QTc interval 414 milliseconds (SD, 59) compared with patients with abnormal ECGs, who had a mean heart rate 93 beats/min (SD, 11), mean QRS 96 milliseconds (SD, 18), and mean QTc 400 milliseconds (SD, 110). Seven patients had repeat ECG during their admission. Five patients developed new abnormalities on follow‐up ECGs, including transient ST elevation, sinus bradycardia, junctional rhythm, atrial fibrillation, and complete heart block. Our data show a consistent trend of increased disease severity in patients with abnormal admission ECG (Box). Patients with abnormal ECG required longer hospital admission (61% longer), double the incidence of documented arrhythmias, and double the requirement for oxygen, ventilation and inotropic support. Measures of significant inflammatory response (ferritin, C‐reactive protein, D‐dimer) were markedly higher in patients with abnormal ECG. Half of the patients developed an abnormal rhythm during admission: complete heart block (one patient), supraventricular tachycardia (one patient), atrial fibrillation (three patients), sinus tachycardia (three patients), and sinus bradycardia (one patient). Cardiac procedures performed were transesophageal echocardiogram/cardioversion (one patient), and pacemaker implantation (one patient). Our limited experience suggests an ECG may be helpful in prognostication and triaging of all patients with COVID‐19. An abnormal rhythm may arise from cardiac stress due to cytokine response, direct myocardial viral injury, or physiological strain from multi‐organ injury. Pulmonary injury from pneumonia, acute respiratory distress syndrome and pulmonary emboli can lead to significant right ventricular strain that predisposes to arrhythmia. Sepsis, and related cytokine response, is associated with atrial fibrillation. Myocardial inflammation and subsequent scarring can lead to ventricular arrhythmia and conduction disorders. ECG is a low cost test that can be performed easily and rapidly with minimal risk of viral exposure to staff. ECG should be an essential test in the COVID‐19 pandemic. Box – Characteristics of patients with coronavirus disease 2019 (COVID‐19) admitted to hospital Total Abnormal ECG Normal ECG No ECG Total number of patients 18 8 5 5 Age (years), mean (SD) 59 ± 19 67 ± 14 52 ± 15 53 ± 24 Admission (days), mean (SD) 14 ± 15 21 ± 19 13 ± 11 3 ± 2 Ferritin (μg/L), mean (SD) 1594 ± 1658 2328 ± 2141 1089 ± 620 970 ± 1206 Creatinine (μmol/L), mean (SD) 103 ± 64 110 ± 71 86 ± 33 110 ± 82 CRP (mg/L), mean (SD) 166 ± 165 255 ± 198 124 ± 108 39 ± 42 D‐dimer (mg/L), mean (SD) 4.17 ± 6.23 7.03 ± 8.29 1.99 ± 1.39 0.64 ± 0.42 Arrhythmias 9 7 < 5 na Number of patients requiring oxygen 10 6 < 5 < 5 Oxygen use (days), mean (SD) 19 ± 14 23 ± 15 15 ± 11 4 ICU admission (days), mean (SD) 19 ± 11 23 ± 11 12 ± 9 Nil Ventilation (days), mean (SD) 14 ± 10 18 ± 10 7 ± 5 Nil Inotropic support (days) mean (SD) 13 ± 12 18 ± 12 5 ± 6 Nil CRP = C‐reactive protein; ECG = electrogardiogram; ICU = intensive care unit; na = not applicable; SD = standard deviation.

Kaitlyn Lam · Sarah McClelland · Michael J Dallo

To the Editor: The Royal College of Pathologists of Australasia (RCPA) is concerned with some of the conclusions drawn in the article by McAlister and colleagues.1 We support the suggestion that there are opportunities for reducing waste and carbon dioxide emissions in pathology laboratories and, with the RCPA Quality Assurance Programs, we encourage laboratories to reduce their environmental impact whenever possible. There are laboratories already active in this space.2,3 Furthermore, we unequivocally support and encourage clinicians to exercise due consideration in choosing appropriate pathology tests. However, the reduction of pathology testing purely to reduce carbon footprint brings significant public health and economic consequences to the community. Pathology is an essential health service, vital for the diagnosis of medical conditions (eg, cancer) as well as for monitoring chronic diseases (eg, diabetes). Providing quality medical testing to the Australian population of about 25.6 million4 is likely to have some environmental impacts. Despite the pathology community facilitating time‐critical testing, and often running 24 hours a day with appropriate clinical governance, the carbon footprint of pathology, as acknowledged by the authors, is small. On an individual level, delayed testing may lead to a late diagnosis, so that the disease moves past a manageable, treatable phase and into an advanced stage. This increases the chances of complications5 and produces its own environmental impacts. In the community, reducing pathology testing can also increase the risk to public health. In the current climate, we have a convenient example of this with coronavirus disease 2019 (COVID‐19). Increased testing is a strategy outlined by governments in Australia, New Zealand and across the world to manage the COVID‐19 pandemic. As treatment regimens intensify for more advanced conditions, there is an increased financial burden. When the demand grows for more costly medical care, it channels funds away from other health initiatives, including research and preventive health programs. Pathologists’ important work is often undervalued and, unfortunately, the article by McAlister and colleagues fails to acknowledge the steps laboratories have already undertaken to reduce waste and environmental impacts. The RCPA strives to encourage and educate clinicians on appropriate test requesting through activities and publications; however, we must apply caution and essential tests should not be missed for the sake of the overall pathology carbon footprint.

Michael Dray · Daman Langguth · Tony Badrick

In reply

Scott McAlister · Alexandra L Barratt · Forbes McGain

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has highlighted the need for accessible information for people with disability during public health crises. Accessible information — including Easy Read, Auslan, large print, Braille and audiovisual formats — is a human right.1 Such information is critical for people with disability to understand public health crises and know how to remain safe and access support. These needs are important, particularly given that people with disability commonly have underlying health conditions that may make them vulnerable to public health risks,2 are subject to service systems that may enhance their exposure to infection,3 and often face entrenched system‐driven inequalities, such as being excluded from health prevention and response actions.4 In Australia, accessible information is provided by governments, specialist information access agencies, disability advocacy groups, and service providers. As these groups have provided information about COVID‐19, lessons have emerged for informing better practice during future crises.5 To be appropriate for a public health crisis, accessible information must be: Accurate and of high quality — the information needs to be correct and sufficiently accessible. This requires collaboration between medical professionals and information specialists. Timely — delays in producing accessible information are common, but dangerous. Kept up‐to-date — producing accessible information that is never revised is inappropriate when the details of a crisis are constantly changing. Provided in sufficient detail and breadth — just as the rest of the population needs to know about many different aspects of a crisis, so do people with disability. Resources with a range of subtopics are required. Produced with people with disability — including people with disability in producing the information will ensure it is useful to and accepted by them. Disseminated appropriately — people with disability need to be able to access information through agencies they trust, as well as news media and governments. Where applicable, hard copies should be available, not only online.

Ariella Meltzer

To the Editor: The MJA and Madden and colleagues1 display foresight and leadership in advocating for a transition to environmentally sustainable health care. The current coronavirus disease 2019 (COVID‐19) pandemic exposes dual sustainability challenges: uncertain provision of personal protective equipment (PPE) in the face of a fractured global supply chain and burgeoning waste from single‐use materials. Australia has an opportunity to respond to both challenges by accessing local capability and switching to reusable PPE as appropriate. An apt place to begin is PPE gowns. Personal experience at an Australian hospital in March 2020 saw intensive care of one patient with COVID‐19 requiring more than 50 single‐use gowns during a 24‐hour period. This quantum highlights the need to reconsider the source and composition of PPE materials. The National Health and Medical Research Council (NHMRC) guidelines2 state that gowns should be impervious to fluid, with no standards or levels applied. The oft‐used system from the American Association for the Advancement of Medical Instrumentation (AAMI) grades gowns, single‐use or reusable, within a range: level 1 being splash‐resistant, and levels 2–4 being impervious to water columns placed upon them of 20, 50 and 100 cm respectively.3 Application of these levels is at the discretion of Australian health care providers, rather than mandated in the NHMRC guidelines. Fluid impervious level 2 provides an ample barrier to respiratory‐borne pathogens. A transition to reusable level 2 gowns, when appropriate, provides an opportunity to reduce waste because they can be repeatedly sanitised by clinical laundry practice (detergent and > 60°C hot water). One reusable gown has been estimated to replace 50 disposable gowns.4 By way of reducing reliance on distant supply chains, Australia currently has capacity to mill the fabric and manufacture reusable fluid impervious level 2 gowns today, and these gowns could be registered by the Therapeutic Goods Administration. Current experience suggests policy makers and clinicians are unaware of this possibility. The perception that single‐use is the best choice indicates education is needed to assure clinicians that reusable gowns can provide at least equal protection for many clinical and intensive care unit tasks (severe acute respiratory syndrome coronavirus 2 [SARS‐CoV‐2] endures less on cloth than plastic).5 Activating local manufacture of reusable gowns would assure availability and potentially provide more environmentally and financially sustainable health care, while maintaining patient care and staff PPE supply.

Forbes McGain · Meriel Chamberlin · Jane Milburn

In reply

Anthony Capon · Diana L Madden · Philip G Truskett

To the Editor: The recently published article by McAlister and colleagues1 highlights the importance of health care organisations becoming aware of their environmental impact. However, there are several misconceptions inherent in the analysis. The first misconception is that pathology organisations may not be aware of their environmental responsibility. The available literature describes how laboratories can reduce their impact2 and, in addition, some laboratories have ISO 14001 certification, which demonstrates their compliance with international standards of environmental performance, efficient use of resources and reduction of waste. The second misconception in the analysis is that pathology testing produces a significant carbon footprint compared with other health care activities. Data from the British National Health Service show that indicative carbon emissions from inpatient admission, additional bed‐day stay, and outpatient appointments are about 380, 80 and 50 kg carbon dioxide equivalent (CO2e) emissions respectively, compared with 82 g CO2e for a haematology test.3 The highest emissions were associated with the consumables used in the collection process or the transport of the reagents from the overseas manufacturer to the laboratory. The third error is that there is significant overutilisation of pathology tests. While there is some overtesting,4 considerable evidence also shows widespread underutilisation of testing.4,5 A 15‐year meta‐analysis identified that, on average, the rate of pathology testing overuse was 20.6%, but the underuse was 44.8%.4 It is noteworthy that a 2018 systematic review and meta‐analysis found significant overutilisation in diagnostic imaging.5 It is essential that all organisations reduce their environmental footprint. Health care organisations must ensure they achieve this goal without compromising patient care. Focusing on carbon emissions for phlebotomy without understanding the role pathology testing plays in early diagnosis and monitoring of disease may lead to more expensive interventions, poor patient outcomes, and a greater impact on the environment.

Tina Yen · Tony Badrick

Med J Aust 2020; 213 (10 Suppl).