Volume 213 Issue 11

The MJA–Lancet Countdown on health and climate change was established in 2017, and produced its first Australian national assessment in 2018 and its first annual update in 2019. It examines indicators across five broad domains: climate change impacts, exposures and vulnerability; adaptation, planning and resilience for health; mitigation actions and health co‐benefits; economics and finance; and public and political engagement. In the wake of the unprecedented and catastrophic 2019–20 Australian bushfire season, in this special report we present the 2020 update, with a focus on the relationship between health, climate change and bushfires, highlighting indicators that explore these linkages. In an environment of continuing increases in summer maximum temperatures and heatwave intensity, substantial increases in both fire risk and population exposure to bushfires are having an impact on Australia’s health and economy. As a result of the “Black Summer” bushfires, the monthly airborne particulate matter less than 2.5 μm in diameter (PM2.5) concentrations in New South Wales and the Australian Capital Territory in December 2019 were the highest of any month in any state or territory over the period 2000–2019 at 26.0 μg/m3 and 71.6 μg/m3 respectively, and insured economic losses were $2.2 billion. We also found growing awareness of and engagement with the links between health and climate change, with a 50% increase in scientific publications and a doubling of newspaper articles on the topic in Australia in 2019 compared with 2018. However, despite clear and present need, Australia still lacks a nationwide adaptation plan for health. As Australia recovers from the compounded effects of the bushfires and the coronavirus disease 2019 (COVID‐19) pandemic, the health profession has a pivotal role to play. It is uniquely suited to integrate the response to these short term threats with the longer term public health implications of climate change, and to argue for the economic recovery from COVID‐19 to align with and strengthen Australia’s commitments under the Paris Agreement.

Ying Zhang · Paul J Beggs · Alice McGushin · Hilary Bambrick · Stefan Trueck · Ivan C Hanigan · Geoffrey G Morgan · Helen L Berry · Martina K Linnenluecke · Fay H Johnston · Anthony G Capon · Nick Watts

Stage 3 lockdown measures in Victoria reduced COVID-19 transmission, but more was required to control the epidemic

Allan Saul · Nick Scott · Brendan S Crabb · Suman S Majumdar · Benjamin Coghlan · Margaret E Hellard

Rapid dissemination of information should not come at the expense of quality, ethical standards or oversight The coronavirus disease 2019 (COVID‐19) pandemic has resulted in wide‐ranging health, social and economic impacts. By October 2020, global cases exceeded 41 million, with 1.1 million deaths.1 Urgent requirements for information were met with data on epidemiology, clinical features and recommended management being circulated on social media and pre‐publication servers. While this has allowed timely sharing of data, it has also brought risk of misinformation, with consequent changes to medical practice and misdirection of scarce resources based on flawed evidence. Medical publishing uses peer review to provide independent and critical assessment to verify data integrity, validity of interpretations, and confidence in conclusions. This process can take many weeks; however, in a rapidly spreading pandemic, speed is a competing priority. We hypothesised that these considerations may have altered the nature of medical publication. Accordingly, we characterised various aspects of COVID‐19‐related articles published in the five leading general medical journals with the highest impact factors (Web of Science) compared with an equivalent period in the preceding year. Procedures for identifying, classifying and comparing publications were specified a priori. Research ethics approval was not required. Publications were identified in the United States National Library of Medicine PubMed database. All articles published between 1 January and 31 May (inclusive) in 2019 and 2020 in The New England Journal of Medicine, The Lancet, JAMA, The BMJ and Annals of Internal Medicine were included. The sampling timeframe was defined by the first public health notification of COVID‐19 in China on 31 December 2019, ending at the time of the conduct of the literature search (Box 1). Within the 2019 search results, 60 articles were randomly selected using a random number generator in Stata 15.1. Publications without abstracts were excluded. Journal websites for each study period were searched for retracted articles. Three reviewers independently abstracted the variables contained in Box 2 and Box 3. The h‐index (a measure of publication productivity and citation impact) of the first and last author was taken from Web of Science. A fourth investigator reviewed all data, harmonising interpretations and resolving any errors. Data were analysed using Stata 15.1. Skewed continuous data were described using medians with interquartile ranges (IQRs) and compared using the Wilcoxon–Mann–Whitney test. Categorical data were compared using the Fisher exact test or χ2 test as appropriate. Exact P values are reported and those less than 0.05 deemed significant. During January to May 2020, PubMed listed 4001 articles, of which 1120 (28%) were related to COVID‐19. There were 134 articles with PubMed‐coded abstracts which were included for full review (Box 4). One additional COVID‐19 article was identified in the search for retracted articles but excluded from quantitative comparisons because it lacked an abstract. During the same period in 2019, 54 articles were ultimately identified as eligible for comparison (Box 4). Compared with 2019, among the COVID‐19‐related publications in 2020, there were more case reports or case series, cohort studies, editorials and commentaries and fewer randomised controlled trials (7/134 [5.2%] v 19/54 [35.2%]) (Box 2). A similar proportion (37/52 [68.5%] non‐COVID‐19‐related articles v 74/134 [55.2%] COVID‐19‐related articles; P = 0.09) reported primary data. Of the 2019 articles, only two of 54 (3.7%) originated in China, whereas 32 of 134 (23.9%) of the COVID‐19 articles published in 2020 were from China. The proportion of COVID‐19 articles in 2020 for which a correction was published was higher than for non‐COVID‐19 articles published in 2019 (28/124 [20.9%] v 4/54 [7.4%] respectively; P = 0.03). Time to the first publication of a correction was no different (median, 6 days [IQR, 4–14] v 7.5 days [IQR, 5–18] respectively; P = 0.53). Three 2020 COVID‐19 articles,2,3,4 but none of the 2019 articles, were retracted after publication. Only one journal, JAMA, routinely reported when a manuscript was submitted. In this journal, the median time from submission to publication fell from 139 days (IQR, 130–144) in 2019 to 23 days (IQR, 12–30) in 2020 (P < 0.001). The median number of authors and their publication productivity and impact, as quantified by their median h‐indices, were similar. There was no statistically significant difference in the number of studies willing to share data under appropriate circumstances (P = 0.19), or those receiving commercial funding (P = 0.97). The measured characteristics of randomised trials related to COVID‐19 were not statistically different to studies of an equivalent type published in the preceding year; however, numerically fewer subjects (median, 199 [IQR, 127–397] v 424 [IQR, 225–1076]; P = 0.07) and centres (median, 10 [IQR, 1–55] v 30 [IQR, 4–168; P = 0.15) participated (Box 3). Similarly, the observational study sample size was significantly smaller (median, 152.5 [IQR, 15–3481] v 191 972.5 [IQR, 1407.5–756 444]; P < 0.001), and the number of participating centres was numerically lower in the 2020 COVID‐19 group (median, 1 [IQR, 1–7] v 26 [IQR, 1–49]; P = 0.07). While not significantly different between groups due to the low numbers, 11 (16.7%) observational studies among the COVID‐19 publications did not report oversight by an ethics committee or institutional review board, and only nine (56.3%) case reports and case series with ten patients or fewer stated that patient consent had been obtained or that an exemption from this requirement had been granted. In the first 5 months of the COVID‐19 pandemic, the five leading medical journals published a substantial number of articles that differed in many respects from their usual material. The journals examined were the clinically focused general medical journals with the top five Web of Science 2019 impact factors, ranging from 21.3 to 74.6, representing the medical literature with the greatest international influence on health policy and clinical practice. As reasonably expected, there was a seven‐fold reduction in the proportion of articles reporting randomised controlled trials, and a compensatory increase in small case series, opinions and editorials. While there were few (n = 2) articles in the random selection of 2019 papers that were published from China, nearly one‐quarter of the COVID‐19 publications came from this country, as anticipated given the location of the earliest cases. There was no difference in the median h‐indices of authors, suggesting experienced academics pivoted rapidly to COVID‐19 research. In circumstances which usually require consent, just under half of the COVID‐19 studies did not explicitly state consent was obtained, despite clear recommendations by the International Committee of Medical Journal Editors.5 The proportion of articles that referenced appropriate ethics committee or institutional review oversight was statistically unchanged; however, it is still a concern that 11 (16.7%) observational COVID‐19 studies lacked any statement to this effect. In addition, several other articles stated that they had been exempted from the requirement for ethical review due to the nature of the pandemic. Respect for personal autonomy and the value of independent oversight have always imposed additional workload on those seeking broader public health benefits. If COVID‐19 has created challenges in adhering to the usual practices of obtaining ethics approval and consent, consideration should be given to whether these processes could be amended to improve speed and accessibility, particularly during global health emergencies. There was a near three‐fold increase in the proportion of studies that published corrections, perhaps reflecting the observed reduction in time from submission to publication observed in the one journal for which these data were available. It is likely this figure is an underestimation, given that corrections and retractions would be expected to continue over time. Three COVID‐19 studies were retracted. The publication of one of these articles4 had important implications, resulting in the temporary cessation of the World Health Organization's trial of hydroxychloroquine.6 While the corrections and retractions may be an artefact of increased speed to publication, it is also possible that their higher number might be the effect of enhanced focus on research related to COVID‐19. Nonetheless, journals must retain the integrity of review processes if they are to offer value beyond alternative online means of information dissemination. This review has found similar results to bibliometric studies relating to the COVID‐19 pandemic, which have identified higher numbers of case series and reviews and fewer randomised clinical trials.7,8,9 We did not examine other articles from 2020 to understand the effect of COVID‐19 on contemporaneous publications, or to be able to comment on whether observed changes were specific to COVID‐19 or true of all 2020 articles. We note the convenience sampling of two similar periods may overestimate the magnitude of our findings. The cohort of 2019 studies for comparison was selected at random, rather than being matched by study type or size. When identifying h‐indices, we had difficulty identifying some Chinese authors, highlighting a bias against researchers without a name that can be distinctively rendered in the English language alphabet. Further implementation of unique author identifiers, such as the Open Research and Contributor ID (ORCID; www.orcid.org) or ResearcherID (Clarivate Analytics) would address this problem. We did not assess the quality of published studies or adherence to reporting guidelines. As part of their early response to the worldwide problem presented by the COVID‐19 pandemic, there was a significant change in the characteristics of articles published by leading medical journals, with some evidence of a tendency towards publishing articles prematurely and those with lower internal validity. While these unique circumstances no doubt warranted such a change, rapid dissemination of information should not need to come at the expense of quality, ethical standards or oversight. Others have suggested several solutions to this challenge, including a two‐track review process for pandemic and non‐pandemic research, rapid preliminary assessment of research methodology by skilled in‐house reviewers before deciding whether to send for peer review, sharing of peer‐reviews between reviewers and journals, and mentored peer reviewing by research trainees.10 As part of pandemic preparedness, planning to facilitate augmentation of resources available to medical publishers, allowing maintenance of standards of review, should occur. Box 1 – Search strategy ((“JAMA”[Journal]) or (“The New England Journal of Medicine”[Journal]) or (“Annals of Internal Medicine”[Journal]) or (“BMJ”[Journal]) or (“Lancet”[Journal])) and (2020/1/1:2020/5/31[Date — Entry]) or and (2019/1/1:2019/5/31[Date — Entry]) Articles related to COVID‐19 were identified by adding and ((“covid”[All fields]) or (“coronavirus”[MeSH Terms]) or (“coronavirus”[All fields]) or (“coronaviruses”[All fields])) Box 2 – Characteristics of publications 2019 non‐COVID‐19 2020 COVID‐19 P Total number of articles 54 134 Article type Systematic review/meta‐analysis/narrative review 8 (14.8%) 16 (11.9%) < 0.001 Randomised controlled trial 19 (35.2%) 7 (5.2%) Cohort study 11 (20.4%) 25 (18.7%) Cross‐sectional study 5 (9.3%) 8 (6.0%) Case–control study 1 (1.9%) 2 (1.5%) Case series 2 (3.7%) 30 (22.4%) Case report 0 (0.0%) 4 (3.0%) Diagnostic evaluation 0 (0.0%) 1 (0.7%) Opinion 7 (13.0%) 33 (24.6%) Other 1 (1.9%) 8 (6.0%) Reported primary data 37 (68.5%) 74 (55.2%) 0.09 Correction published 4 (7.4%) 28 (20.9%) 0.03 Days from publication to correction, median (IQR) 6 (4–14) 7.5 (5–18) 0.53 Retracted 0 (0.0%) 3 (2.2%) 0.56 h‐index of first author, median (IQR) 13.5 (3–36) 11.5 (6–30) 0.54 h‐index of last author, median (IQR) 26 (14–38) 21 (10–38) 0.14 Associated editorial of eligible articles 21 (38.9%) 44 (32.9%) 0.43 Number of masthead authors, median (IQR) 8 (5–19) 7 (4–18) 0.52 Number of total authors, median (IQR) 8 (5–23) 7 (4–19) 0.23 Region of origin China 2 (3.7%) 32 (23.9%) < 0.001 United States 24 (44.4%) 67 (50.0%) Europe 20 (37.0%) 24 (17.9%) Rest of world (high income countries) 3 (5.6%) 11 (8.2%) Rest of world (low income countries) 5 (9.3%) 0 (0.0%) COVID-19 = coronavirus disease 2019; IQR = interquartile range. Box 3 – Characteristics of studies reported table#t3 tbody td:nth-child(n+2) P. Pleft { text-align: center; } 2019 non‐COVID‐19 2020 COVID‐19 P Randomised controlled trials 19 7 Number of subjects, median (IQR) 424 (225–1076) 199 (127–397) 0.07 Participating centres, median (IQR) 30 (4–168) 10 (1–55) 0.15 Studies that received funding of any type from a commercial source 8 (42.1%) 3 (42.9%) 0.97 Studies in which a commercial entity had influence over any aspect of study conduct or reporting 7 (36.8%) 2 (28.6%) 0.69 Studies stating willingness to share data under appropriate circumstances 15 (78.9%) 7 (100.0%) 0.19 Studies stating individual patient consent or waiver was granted 19 (100.0%) 7 (100.0%) 1.0 Studies noting review by ethics committee 19 (100.0%) 7 (100.0%) 1.0 Observational studies* 19 66 Number of subjects, median (IQR) 191 972.5 (1407.5–756 444) 152.5 (15–3481) < 0.001 Participating centres, median (IQR) 26 (1–49) 1 (1–7) 0.07 Studies that received funding of any type from a commercial source 0 (0.0%) 4 (6.1%) 0.27 Studies in which a commercial entity had influence over any aspect of study conduct or reporting 0 (0.0%) 3 (4.5%) 0.34 Studies stating willingness to share data under appropriate circumstances 8 (42.1%) 15 (22.7%) 0.09 Studies not stating individual patient consent was obtained or a waiver was granted 3 (15.8%) 17 (25.8%) 0.37 Studies not noting review by ethics committee 0 (0.0%) 11 (16.7%) 0.06 Case reports/case series (≤ 10 patients) 1 16 Studies stating individual patient consent was obtained 1 (100.0%) 9 (56.3%) 0.40 COVID-19 = coronavirus disease 2019; IQR = interquartile range. * Observational studies included cross-sectional studies, case–control studies, cohort studies and case series reporting data from one patient or more. Box 4 – Publication identification flow diagram COVID‐19 = coronavirus disease 2019.

Kirsty A Whitmore · Kevin B Laupland · Clare M Vincent · Felicity A Edwards · Michael C Reade

Name badges are a simple additional method of communicating doctors’ names to patients and their families, but uptake remains poor Most new relationships begin with an exchange of names and most existing relationships are reinforced using names. Except in health care. Despite campaigns such as #hellomynameis (https://www.hellomynameis.org.uk/), clinicians’ names remain absent from many health care experiences and environments. Patients meet many people during an illness journey, particularly when that takes place in a public hospital. There are nurses rotating through different shifts, the specialist under whom the patient is admitted, a registrar, resident or intern, plus maybe a medical student or two. There are also teams of allied health providers. One study found that 75% of inpatients were unable to name anyone when asked to recall the name of the physician in charge of their care.1 Limited recall of doctors’ names is part of a broader pattern. Only 42% of patients can name their diagnosis at discharge,2 and in a study of older patients, only 18% of patients could recall a single message one hour after the ward round, falling to 9% four hours after the ward round.3 The very basic components of effective health care communication, particularly in hospitals, are lagging. Barriers to effective communication are complex and structural.4 Let's for a moment focus on the most fundamental information transfer in any patient–doctor encounter: names. Patients’ names are documented from the moment of admission, printed on sticky labels, placed on wrist bands, attached to meal trays, printed on patient lists, and displayed and discussed in ward and team meetings. In contrast, doctors’ names usually appear only on faded ID swipe cards attached at the hip, or on crowded lanyards around the neck. This asymmetry in identification is just one symptom of the enormous information gulf separating patients and their doctors. Studies consistently show that the majority of patients believe doctors should wear name badges,5 with a preferred site being the breast pocket.6 In 2019, our hospital introduced voluntary name badges for all interns and residents. Something as simple as a name badge, which nearly every other service‐oriented industry employs without question, required careful navigation in the hospital. What name should appear on the badge? Should surnames be included? Should “Intern” or “Resident” or just “Doctor” appear on the badge? Badges were rolled out to interns and residents at the start of the clinical year with a mixed response. Anecdotally, senior doctors commented favourably on the badges, and nurses and allied health workers found it helpful for learning and remembering the names of doctors rotating through their wards. Mid‐year, we collected data on how many interns and residents were wearing badges. During two compulsory teaching sessions, we quietly counted the number of interns and residents wearing name badges: adherence was a lowly 25%. To determine why three‐quarters of interns and residents were not wearing badges, we circulated a voluntary, anonymous and electronic survey to all 108 interns and residents. Our aim was to identify levers or incentives that we could incorporate into a series of behavioural nudges to improve name badge adherence. Around one‐third (34%) of the cohort took part in the survey, 80% of whom did not wear their name badge. Half of respondents reported that their ID swipe card contained their name and was sufficient. About one‐fifth (22%) did not see a need to wear a name badge and a similar number mentioned that senior doctors not wearing badges discouraged them from wearing one. Not wanting members of the public or patients to know their name was a reason indicated by 16% of respondents. Free text responses mainly centred on forgetting to, or being annoyed by, attaching it each day. In response, we have developed new strategies to increase name badge adherence. For example, a brief lecture will be given on the evidence‐base underpinning good communication, coffee vouchers will be provided to doctors seen wearing their badges, badges will be provided to new interns during orientation, and name badges will soon be rolled out across the hospital for all medical staff. Making name badges available to senior doctors is important as they can influence the cultures within units and teams, and our cohort identified a lack of badges among seniors as a barrier to adherence. An informal poll of intern and resident representatives across New South Wales suggests a similar pattern of poor name badge adherence. Five networks with name badges reported that adoption by junior doctors was low. Four networks did not provide name badges. Only three networks provided name badges and have good adherence among junior doctors. As pressure on hospitals, and our clinical interactions, continues to grow, we must look for ways to support effective communication. Alongside a clear introduction, easy‐to‐read name badges reinforce familiarity and contribute to rapport between patients and our (increasingly) busy workforce.

Benjamin D Bravery · Jovana Stojkov · Jeremy Brown

The dangers of modern football are often scrutinised, but has safety actually evolved over time?

Jacob L Jewson · Peter Brukner · Thomas J Gara · Lauren V Fortington

Jeffrey GP. Hepatocellular carcinoma surveillance in Australia: time to improve the diagnosis of cirrhosis and use liver ultrasound. Med J Aust 2020; 213: 432. https://doi.org/10.5694/mja2.50808 In this reply letter, the authorship details listed were incorrect. The Author details section should read: “Gary P Jeffrey,1,2 Louisa Gordon,3,4 Grant Ramm.3,4”. The affiliations list should read: “1 Sir Charles Gairdner Hospital, Perth, WA; 2 University of Western Australia, Perth, WA; 3 QIMR Berghofer Medical Research Institute, Brisbane, QLD; 4 University of Queensland, Brisbane, QLD”.

It was mid-morning, halfway through ward round

Jillian Chau

Beached by COVID‐19, orthopaedic surgeons have cooked up some new techniques to enhance skills There is a hidden danger in the enforced “shutdown” caused by COVID‐19. Bored certified orthopaedic surgeons who now have a lot of time on their hands, with very few patients to see and even less surgery to do, are stranded at home. This is a recipe for disaster. This communique outlines a superb technique designed to eliminate boredom and to enhance surgical skills. Marooned at home by the COVID‐19 isolation and because necessity is the mother of invention, rather than doing nothing, I travelled to the local store and bought a box of a Better known, do‐it‐yourself cake mix (Moist Vanilla 540 g). I had seen my mother make cakes in the past; it did not look that hard. Indeed, even the instructions were on the back of the box. This was as simple as Chemistry 101; they even specified the weights (and I had scales). So imbued with the unbridled hubris of a surgeon, I proceeded to make my first ever Moist Vanilla cake, with icing. Cake number one was perfect. I followed the instructions per the pack; added “A” to “B”, mixed, put it in a pan and cooked it for 55 minutes at 160°C. It turned out just like my mother used to bake; it was perfect. Buoyed by this success and bathed with arrogance, I became more adventuresome. I purchased another packet of the same stuff, and this time decided to make “Whisky Cake”, a self‐creation (Box 1). At a critical point of the mixing of the components, I added a very specific quantity of whisky (“specific” means a quantity greater than 25 cm3 but less than 100 cm3 or maybe a bit more). (Note spelling of “whisky” is without an “e” because it was Scotch. As my Scottish mother taught me, if the country has an “e” in it then so does the spelling of whisky. Irish whiskey can be substituted.) This creation went through the same cooking process and, once again, the “Whisky Cake” turned out to be beautifully moist and friends and acquaintances all enjoyed their sample, and even after consumption they were able to maintain verticality and appropriate social distancing measures. Praise was heaped upon me. Now, if the “Whisky Cake” was good, then, logically, a “Double Whisky Cake” must be better (please refer above for required quantity of whisky for the “Double Whisky Cake”). Sadly, the inescapable logic of arithmetic progression does not appear to have made it to the Annals of Cookery, in fact, what emerged at the end of 50 minutes of baking is what could be best described as “sludge”. Surgery training teaches you that complications occur … and physicians often joke that surgeons bury their complications. Emotionally crestfallen, the mutant, little less than successful “cake” was judiciously hidden from my friends and acquaintances and, loathing waste, the “Double Whisky Cake” sludge was offered to my four rescue dogs. They loved it and promptly slept all afternoon. However, physicians have no understanding of the logical approach that orthopaedic surgeons apply to problem solving (eg, problem: the square peg won't go into the round hole; solution: get a bigger hammer). But it takes much more than a bigger hammer, it takes sheer bloody‐mindedness and a certain strength of ego to soldier on when crestfallen. My inbred surgical fearlessness emerged, and knowing that failure is an important part of learning, I became emboldened by this “lesson”. The next experiment was a “Lemon Orange Single Whisky Cake” with added zest from the rinds of lemons and oranges. “Double Whisky” was thought to be the demon. (It emerged later that “Double Whisky Cake” was actually a Type II research error. A Type II error, as Wikipedia explains, means “the true fact is that the item is a weapon but the system keeps silent at this time”.2). The zest was boiled up together and added to the mix. Cake number four was very satisfactory. Current “scorebored”: good, good, disaster, and another good. Further emboldened by my newly discovered talent, I then went to the freezer where I had some mulberries (given to me by a patient many months ago, destalked and frozen). This time, I decided to make “Mulberry‐Apple‐Cointreau‐Single Whisky Roller Pie with Flaky Pastry”, another new creation — Cointreau was selected because (a) the whisky was nearly empty and (b) Cointreau was “on special”. The “Whisky Roller Pie” component is mentioned only because I did not have a roller and because I used the nearly empty whisky bottle to roll out the pastry. The flaky pastry was prepared exactly per selected internet recipe. About one hours’ worth of rolling, folding adding butter and folding again, all the time believing the words from the internet recipe when it wrote that, “You'll never go back to buying flaky pastry in the supermarket ever again”. One has now learnt not to believe everything one reads on the internet. Everything seemed to be going well. A specific amount of Cointreau was added per previous formula. Pie was baked and, at the end of one hour, it was removed, allowed to cool and then … it exploded. In many regards, the explosion was an epiphany, reminiscent of a major polytrauma. Mulberries are ferociously red … the smallest quantity of fluid stained everything and not only do the stains remain, the dispersed fluid clots like blood! It was just like being at work again. For the mulberry clot, see Box 2. It took me about a humbling hour and a half to clean it up. The four rescue dogs were very grateful to have this “Mulberry‐Apple‐Cointreau‐Single Whisky Roller Pie with (not so) Flaky Pastry” pie. Conclusions The COVID‐19 “shutdown” conveys hidden dangers. This research has unearthed some important facts and highlighted a number of issues: One should never underestimate the skill of your mother and her cooking ability. If this is a glimpse of what retirement might be like, then it is not going to be pretty. I recommend using the Better known brands of cake mix as they include the pre‐made icing. Pre‐made icing is important. Other brands of cake mix provide the icing sugar and “easy instructions” how to “make it yourself”. This is clearly a new definition of the word “easy”. My self‐made icing gracefully floated off the top of the cake on to the table then on to the floor. Rescue dogs to the rescue … again! Cooking and baking should be assigned CME points and should be included as an essential part of basic surgical training. Consideration should be given to creating a new specialist Royal Australasian College. Orthopaedic surgeons, who are often the butt of medical jokes, have demonstrated that we are the leading researchers into psychological support for the self‐isolated surgeon. Addition of flammable ingredients to cake mix should only be attempted by seasoned professionals who have sampled the agent in equal parts. “Double Whisky Cake” is a misnomer. The internet does not always tell the truth. Mulberries should be declared a Level 4 biohazard. This research suggests that further investigation needs to be done into “The Triple Whisky Cake”. Ethics approval from the RSPCA will be needed. Finally, this research illustrates the hidden danger that unoccupied orthopaedic surgeons pose not only to themselves but also to the wider community. This is obviously a specific concern during this COVID‐19 crisis and the MJA owes it to the general readership of this esteemed Journal to publish this article as a warning. Disclaimers The author did not receive any funds from any do‐it‐yourself cake mix company. No animals were harmed in the manufacturing and testing process. Besides the fact that the alcohol component is boiled off … any issues mentioned herein, which some might consider “controversial”, should be taken with a pinch of salt. No recipes will be available from the MJA. Box 1 – Irish whiskey cake1 Greenwood recently published “The Irish Whiskey Cake” in The Irish Times and reported, “Normally, I avoid adding alcohol to bakes that my children eat, but so far, this [Irish Whiskey Cake] doesn't seem to have resulted in any adverse effects”. My self‐created “Whisky Cake” (no “e”) appears to be a synchronous creation. Box 2 – Mulberry clot

John S Fox

In health care, we now need to be curators and disseminators of accurate and timely information, not solely producers, this includes digital sources

Rebecca A Szabo

Medicine in the pre‐antibiotic era offers lessons still relevant today, particularly regarding the prudent use of valuable medications The handwritten line on an archived envelope stored in a safe in The Children's Hospital at Westmead undercroft — “The first child in Australia to have ‘Penicillin’ therapy” (Box 1) — understates the remarkable story of how an experimental drug was requested, approved and delivered in secrecy during the Second World War for one child. The “Penicillin Papers”, rediscovered in 2018 by the Heritage Committee of The Children's Hospital at Westmead, highlight important questions of ongoing relevance. The story of the fortuitous discovery of penicillin by Alexander Fleming in 1928 has entered popular consciousness. What is less well known is how penicillin, which dramatically changed the course of medicine, came to be given to patients. The patient: a small boy in wartime Sydney On 17 June 1943, Peter, almost 7 years old, was admitted to the Royal Alexandra Hospital for Children with fever and increasing drowsiness. During the following 24 hours he reported headache, and a lumbar puncture found turbid cerebrospinal fluid (CSF) with an “uncountable number of leucocytes”, and Streptococcus pneumoniae “type 18” was cultured, a serotype that frequently caused meningitis.1 Sulfonamide drugs were manufactured in Australia in the 1940s, but between 1942 and 1945 stocks were strictly controlled, being reserved almost exclusively for military campaigns in New Guinea.2 Peter, diagnosed with pneumococcal meningitis, was treated with intravenous sulfapyridine for four days, and his fever resolved (Box 2); daily lumbar punctures showed CSF clearing. Treatment switched to oral sulfapyridine, but his fever and vomiting returned. Further intravenous sulfapyridine for one day was followed by extremely painful subcutaneous sulfadiazine infusions for 18 days, then by oral sulfathiazole for four days. Sulfadiazine was obtained from the 118th General Hospital of the United States Army, based in Herne Bay (now Riverwood) and staffed by health professionals from the Johns Hopkins University Hospital in Baltimore. Access to the restricted sulfa drugs was granted by Major McPherson Brown (1906–1989), a professor at the Johns Hopkins, suggesting early involvement of the US Army. By 10 July, however, Peter's CSF was again culture‐positive for S. pneumoniae and the outlook was “grave”. In 1943, penicillin was a highly experimental drug; clinical trials in US troops in Sicily were underway, and only two scientific articles on its clinical use had been published.3,4 In the US, the unenviable task of rationing the small supply for civilian use fell to Chester Keefer, professor of medicine at Boston University Hospital and chairman of the National Research Council Committee on Chemotherapy. Keefer personally vetted each penicillin request, restricting its use to cases in which all other treatments had failed.5 To better understand its potential and limitations, he collected detailed information on all patients given penicillin. Fortunately for Peter, his father was Lieutenant Commander Leo Harrison, a Navy surgeon working as a base medical officer in Sydney in 1943. It is likely that his father's connections with US Army doctors helped secure access to the treatment that ultimately saved his life. On the morning of Saturday, 10 July, Sir Alan Newton, chairman of the Medical Equipment Control Committee, cabled Washington to request urgent supply of penicillin for Peter. At 4:30 pm, one million units (600 mg) were despatched from Washington to San Francisco, together with documents stipulating that the penicillin was for research purposes only, and on the understanding that clinical notes would be provided to the National Research Council following treatment. The penicillin was transported by Liberator bomber from San Francisco to Hawaii, and from there via Brisbane to Sydney, arriving at the Royal Alexandra Hospital at midnight on Thursday, 15 July. The first dose was administered to Peter intramuscularly at 12:18 am on 16 July. Over ten days he received 15 000 units (9 mg) penicillin intramuscularly every four hours, and 10 000 units (6 mg) intrathecally. Today, 5 million units intravenous benzylpenicillin per day would be recommended for a boy of Peter's weight (almost 22 kg). Although Peter's condition improved dramatically, waking from “a stupor” to eat a full breakfast within 48 hours, the dose and treatment duration were inadequate. By 21 July, Peter was again febrile and CSF cultures were positive. Regretting that type‐specific pneumococcal antiserum had not also been requested, Newton had sent a second cable to Washington on 16 July. Rabbit anti‐pneumococcal (type 18) serum arrived and 100 000 units were administered intramuscularly each day from 23 July to 1 August, and oral sulfadiazine from 26 July to 8 August. On 18 September 1943, Peter was discharged home “cured”. Seventy‐five years later, he and his family (Box 3) were interviewed by ABC News reporter Tracy Bowden,6 after his case had been re‐discovered by The Children's Hospital at Westmead Heritage Committee. Research secrecy There are three references in the medical literature regarding this incredible case. The first was a report published in the Medical Journal of Australia in June 1944 by the treating physicians Donald Vickery and Lindsay Dey.7 The second, a short mention by Newton in a speech to the British Medical Association, was published in July 1944;2 the third, a letter by Dey's son in the MJA in August 1981,8 described his father's recounting of events that “would have made an excellent basis for a film”. The initial publication7 was delayed by the condition that details of the case be released only to the US National Research Council, effectively a non‐disclosure agreement. Discussions about research secrecy are as old as science itself.9 Proponents of openness argue that it promotes innovation and enhances productivity and efficiency of research. Openness is essential for testing hypotheses and fostering collaboration. Sharing information with the public fulfils moral obligations to provide evidence for shaping policy and to be accountable for the use of public funds. Conversely, research secrecy is often justified as protecting credit and intellectual property, shielding scientists and human research participants from stigmatisation or harassment, and minimising threats to national or international security. The financial interests of biotechnology and pharmaceutical companies further complicate the discussion. In 1943, arguments for secrecy about experimental penicillin treatments were compounded by the need to protect the limited supplies of the drug. It is pertinent here that the reverse of the envelope containing the Penicillin Papers was marked “Silence saves soldiers” (Box 1). Under the direction of Keefer, the Committee on Chemotherapy charged “accredited investigators” with assessing thousands of requests for penicillin.5 A strict allocation policy was adopted to ensure that decisions were made on clinical grounds. Only patients with severe infections caused by sulfonamide‐resistant, penicillin‐susceptible streptococci, gonococci and staphylococci, should receive penicillin, and only then if a cure could be expected. Access, compassionate and otherwise Equitable allocation of limited medical resources is a problem that often confronts clinicians and public authorities, particularly in resource‐constrained environments and during wartime, natural disasters,10 or epidemics.11 In 1943, Vickery and Dey did all they could to obtain the experimental drug penicillin for their patient. Wartime priorities in Australia did not include active control of therapeutic substances, although the National Health and Medical Research Council dealt with some medication access questions.12 In the US, the Food and Drug Administration (FDA) first addressed access to investigational drugs for therapeutic purposes in January 1963,13 three months after President Kennedy had approved the amendment of the Food, Drug, and Cosmetic Act that strengthened the FDA mandate to approve medications.14 The process of “expanded access”, the preferred FDA term for compassionate use — that is, of an unlicensed drug or device outside clinical trials — was formalised in 1987 in response to requests for access to investigational anti‐retroviral agents.13 In Australia, the Therapeutic Goods Administration (TGA) was established in 1989 as the national regulatory body; its Special Access Scheme, introduced in response to the 1991 Baume report,15 is the mechanism by which doctors can secure access to unlicensed drugs for selected patients. The 1962 American drug law amendments, passed in the wake of the thalidomide catastrophe, had the potential to make children “therapeutic orphans”, as many drugs have been tested only in adults.16 Paediatricians today regularly use medications off‐label, but the use of unlicensed drugs is less common and usually restricted to neonatal intensive care.17 Fortunately, the importance of including children in clinical trials is increasingly recognised internationally by research institutions and funding and regulatory agencies.18 Further, the FDA was empowered to provide financial incentives for including children in clinical trials and licensing applications by the 2007 Best Pharmaceuticals for Children and Pediatric Research Equity Acts.19 Lessons for the post‐antibiotic era from the pre‐antibiotic era Sulfonamides, the first effective antimicrobial agents, were available from the mid‐1930s, but drug resistance was widespread by the 1940s. One initial control on penicillin use was the requirement for demonstrated penicillin susceptibility and sulfonamide resistance: an early form of antimicrobial stewardship. As we approach the post‐antibiotic era because of rapidly increasing antimicrobial resistance, institutional, national and international antimicrobial stewardship programs are being implemented to protect the limited therapeutic options available for many infections. Multimodal programs incorporate pharmacokinetic and pharmacodynamic principles to avoid treatment failure through undertreatment, as experienced by Peter in 1943.20 In the future, strengthening these antimicrobial stewardship programs by integrating molecular technologies and high throughput screening methods will be critical. We also need to rediscover non‐antibiotic approaches to treating infections, including serotherapy21 and bacteriophage therapy.22 Both were widely and successfully employed in the early 20th century, and Peter's ultimate recovery in August 1943 appeared to require type‐specific anti‐pneumococcal serum treatment. However, our reliance on antibiotics over the past century has led to clinical and research neglect of alternative treatment modalities, although interest has revived in recent years, particularly in bacteriophage therapy.22 Greater investment in alternative treatment options is needed, as well as investigation of novel therapeutic and infection prevention strategies. Box 1 – The “Penicillin Papers”, retrieved from a safe in the basement of The Children's Hospital at Westmead in 2018, include letters and telegrams about the acquisition of penicillin from the United States and its use for treating Peter Harrison Source: The Penicillin Papers; courtesy of The Children's Hospital at Westmead. Box 2 – Details from transcribed observation charts for the first patient in Australia to be treated with penicillin, 1943 Source: The Penicillin Papers; courtesy of The Children's Hospital at Westmead. Box 3 – Peter Harrison (right), the first person in Australia to be treated with penicillin, pictured with his family in 2018, together with Bethany Robinson (second from right), the University of Sydney student who rediscovered the “Penicillin Papers”

Ameneh Khatami · Philip N Britton · Glendon Farrow · Megan Phelps · Alyson Kakakios

The institute that has investigated the “common diseases of mankind” for 100 years was established by an unlikely partnership During the First World War, two young men served with distinction on opposite sides of the battlefields in France. One, William Wilson Ingram (1888–1982) was wounded in action, “mentioned in despatches”, and awarded the Military Cross by the British government. The other, Max Rudolf Lemberg (1896–1975), was awarded the Iron Cross after being wounded in the Somme offensive of March 1918. Despite being on opposing sides of this appalling conflict, they later formed a partnership in Sydney, together laying the foundations for the Kolling Institute of Medical Research at the Royal North Shore Hospital. The Kolling, which traces its origin to the Institute of Pathological Research in 1920, is the oldest medical research organisation in NSW. In this, its centenary year, it is an opportune time to explore the contributions of its two remarkable pioneers. William Wilson Ingram (1888–1982) MC, MB, ChB, MD (Aberdeen), FRACP William Wilson Ingram graduated from the University of Aberdeen in 1912. On the declaration of war, he enlisted in the Royal Medical Corps. He served in France, where he received the Military Medal in 1915; wounded, he returned to England. In 1916, Captain Ingram resumed active service, and ultimately took command of the Pathology Services at the headquarters of the British Expeditionary Force in France.1 After the War, Ingram completed a medical degree at Aberdeen. He then accepted the post of lecturer in physiology at the University of Sydney, and also established a general medical practice. In 1921, Ingram was appointed Honorary Pathologist at the Royal North Shore Hospital (RNSH), where, in addition to supervising the routine pathology service, he founded the Institute of Pathological Research. The Institute of Pathological Research of New South Wales In 1920, a group of influential NSW citizens proposed a research institute for investigating the “common diseases of mankind”, inspired by the Lister Institute of Preventive Medicine in London. They launched an appeal for establishing the Institute of Pathological Research of New South Wales (under the Royal North Shore Hospital of Sydney Act of Incorporation, 1910).2 Initial donations were disappointingly few, but after Mr Thomas Rofe (1869–1945), member of the Hospital Board, donated £5000, the Institute was ready to proceed in 1923. These funds facilitated the appointment of G. Vincent Rudd MSc, senior biochemist, as its first fulltime research scientist in 1925. Later that year, Ingram returned to London for postgraduate study, during which he observed the clinical effects of the newly discovered insulin. On his return to RNSH, he established one of the first specialist diabetes clinics in Australia. He later collaborated with Rudd on the significant and popular text, The diagnosis and treatment of diabetes, published in 1933.3 By 1928, space at the Institute was at a premium, and as it expanded in scope and personnel, more commodious, fully equipped laboratories were urgently required.4 Ingram invited Eva Kolling, the widow of American‐born merchant, Charles Kolling (1858–1926), to tour the original hospital cottage that now served as a laboratory. Mrs Kolling was suitably impressed by the standard of clinical research carried out in extremely cramped conditions. With the opportunity to commit funds to commemorate her husband — but also because “many lives will be spared and Humanity assisted generally”5 — she donated £5000, a sum matched by the NSW government. Ingram drew up plans for the “Charles Kolling Memorial Laboratory” shortly before his departure as medical officer with Douglas Mawson and the British, Australian and New Zealand Antarctic Research Expedition (BANZARE) (Box 1). Eva Kolling laid the foundation stone for the new laboratory in 1930 (Box 2) and, after Ingram returned from his second BANZARE expedition (1931), she officially opened the new facility on 12 September 1931. After the move into the new building, which provided much needed laboratory space and a library, and to re‐emphasise its focus on research into common medical conditions, the institute was renamed the Institute of Medical Research. Ingram was appointed honorary director, a position he held until his retirement in 1974. When Rudd resigned in 1934, Ingram was unable to recruit a suitably qualified Australian‐based scientist, and extended his search overseas. Max Rudolf Lemberg (1896–1975), with a 14‐year background in biochemical research and working in Cambridge after fleeing Hitler's Germany, applied for the position. Max Rudolf Lemberg (1896–1975) Max Rudolf (Rudi) Lemberg was born in Breslau (Silesia; now Wrocław, Poland), where he graduated in science in 1916. In mid‐1917, he enlisted in the German army as a private, a gunner in the field artillery. Lemberg was wounded in action during the Somme offensive of March 1918, his bravery recognised with the Iron Cross. These experiences had a profound effect on Lemberg, who became a convinced pacifist; he later (1952) joined the Society of Friends in Sydney. In 1922, he completed a doctorate in Breslau under Heinrich Blitz, an organic chemist. Blitz strongly advised him against an academic career, citing the poor prospects for a scientist of Jewish descent in any German university.6 After a period as an industrial chemist with Boehringer in Mannheim, he returned to academic life in Heidelberg in 1926. Equipped with a Rockefeller Foundation scholarship, he moved to Cambridge to study with Sir Frederick Gowland Hopkins (1861–1947) in the Institute of Biochemistry.7 He then returned to Heidelberg, but Lemberg later recalled that “the Nazi shadows began rapidly to gather”, and in 1933 his academic career came to an abrupt halt. He realised that, despite his war service and Iron Cross, he was unlikely to escape ending in a concentration camp.6 He fled Germany and returned to Cambridge, which at the time was full of highly qualified refugees from Germany, and not all could stay. Lemberg successfully applied for the position of director of the biochemical laboratories at the RNSH, going “into the wilderness, for I did not expect inspiration from my Australian colleagues at that time.”6 After a final (and risky) visit to his ageing parents in Breslau, Lemberg and his wife arrived in Sydney on 1 October 1936. Australia must have seemed remote from his academic life in Heidelberg and Cambridge, especially as “there was little space for research and hardly any equipment”.6 Nevertheless, Ingram and Lemberg established a good partnership, Ingram as the director of the Institute of Medical Research and Lemberg later as assistant director until his retirement in 1972 (Box 3). Ingram managed the administration and provided the clinical input, while Lemberg undertook fundamental scientific research, primarily into porphyrins and tetrapyrrole metabolism, research with which the Institute developed its scientific reputation. The Institute during the Second World War During the Second World War, Ingram enlisted in the Australian Army Medical Corps and served as Lieutenant‐Colonel until 1944.8 Lemberg remained in his laboratory, contributing to the war effort with research into the metabolism of trinitrotoluene (TNT) in animals, the role of sulphonamides in bacterial metabolism, and the preparation of X‐ray contrast media, among other topics.7 Eva Kolling, who remained one of the most significant supporters of the Institute, died in 1941, and left an extraordinary bequest of £25 000 to support and expand the work of the Institute and the Charles Kolling Memorial Laboratory. The Institute of Medical Research, 1945–1974 In 1948, the RNSH became a teaching hospital of the University of Sydney; in 1950, Ingram created a Unit of Clinical Investigation within the Institute of Medical Research, under the direction of Frank Rundle (1910–1993), later founding Dean and Professor of Surgery of the University of New South Wales. A new teaching block in 1963 provided additional facilities for the Institute, and a closer relationship with the clinical school developed. In 1964, routine hospital pathology moved from the Kolling laboratories into stage I of the new hospital complex, so that the Institute of Medical Research was free, for the first time, to concentrate solely on research. Lemberg continued his basic biochemical research. In 1949 he published his monograph on Hematin compounds and bile pigments, which became a standard text in the field of tetrapyrroles and confirmed his international scientific reputation.9 In 1952, he was elected a Fellow of the Royal Society and a Foundation Fellow of the Australian Academy of Science, and in 1955 was elected the first president of the Australian Biochemical Society. His scientific output was prodigious, encompassing more than 200 scientific publications.7 After Ingram and Lemberg: the Kolling Institute of Medical Research Following the retirements of Ingram and Lemberg, David Nelson (1935–1989), clinician and researcher, was appointed the first fulltime director (1974–1989). From 1971, the Institute was commonly known as the Kolling Institute of Medical Research, and, under Nelson's direction, concentrated on the emerging discipline of clinical immunology.10 Under its third director (1994–2011), Robert Baxter, the Kolling focused on endocrinology and cell biology. In 2008, the various research laboratories were all relocated to a new purpose‐built facility on the RNSH campus. With the appointment of Jonathan Morris as its fourth director in 2012, the academic research focus of the Kolling broadened to ensure that medical research findings informed clinical practice. Carolyn Sue was appointed the fifth director in 2019. The Institute now hosts numerous research teams investigating an extensive range of medical conditions. The Kolling Institute of 2020 has thereby remained true to the original charter of the Institute of Pathological Research in 1920, investigating the “common diseases of mankind”. Box 1 – William Wilson Ingram, 1929 Source: Archive and Heritage Collection, Royal North Shore Hospital, Sydney; with kind permission. Box 2 – Eva Kolling lays the foundation stone for the new laboratory of the Institute of Medical Research, 1930 Source: Archive and Heritage Collection, Royal North Shore Hospital, Sydney; with kind permission. Box 3 – Max Rudolf Lemberg and William Wilson Ingram, 1970 Source: Archive and Heritage Collection, Royal North Shore Hospital, Sydney; with kind permission.

Catherine E Storey

To the Editor: One evening in February 1974, my fellow endocrinologist Don Gutteridge phoned me to tell me about an ABC television program that I had missed. It had featured an interview in Perth with Sir Richard Kirby, recently retired as Australia’s chief judge in industrial relations. He was showing typical signs of advanced thyroid deficiency. He had slow, coarse speech, periorbital oedema, sparse scalp hair, and was “not as sharp as a chief judge should be”. Don had phoned him at his hotel to discuss the diagnosis. The judge’s response was that he did indeed have symptoms including marked cold intolerance and he had coronary artery disease. Don firmly advised him to have his thyroid tested as soon as possible and in addition he wrote to Sir Richard’s Melbourne physician pointing out that caution was needed when starting thyroxine therapy if the patient had heart disease. Later a Christmas card arrived: “Sincere thanks for a timely telephone call and advice to an old stager who was in need and did not know it … I’m on the treatment and ever since have been a younger, newer and better man.” The before‐and‐after photographs in Blanche d’Alpuget’s biography of Sir Richard1 show a marked improvement in his appearance (Box). He had been unwell for years. Two cardiologists had advised him to retire in 1969. By 1971, he was spending most of his time at his home in Berrara, NSW, feeling ill and sluggish despite a rigorous diet, no cigarettes and almost no alcohol. The story did not end there. In 1979, Don was invited to Sydney to appear on Channel 7’s This is your life television program featuring Sir Richard (https://www.fwc.gov.au>file>your‐life‐sir‐richard‐kirby). “I always saw you with a halo” enthused Sir Richard, sizing up the tall and rangy dark‐haired young doctor, “but I thought you must be an old bloke like me.” Others on the show included Bob Hawke, then President of the ACTU, past Prime Minister Gough Whitlam, and many legal colleagues. Kirby served on three Royal Commissions. He assisted in the mediation of Indonesian Independence from Dutch rule for the United Nations, and he negotiated equal pay for Aboriginal stockmen. His passion to achieve equal pay for women could have been his greatest legacy had bad health not intervened. An undiscovered thyroid deficiency may well have altered the course of Australian industrial relations. Within a month of being treated with thyroxine, Kirby looked and felt better than for almost a decade. He died 27 years later in 2001 at the age of 97. The insidious and subtle onset of hypothyroidism can easily be overlooked by patients, relatives and doctors. Screening for thyroid‐stimulating hormone levels will ensure that an important diagnosis is not missed. Any suspicious symptoms should lead to a careful examination to identify the end‐organ signs of thyroid deficiency, including the slow relaxation phase of tendon reflexes, coarse dry skin, cool extremities and a hoarse voice.2 Box – Sir Richard Kirby before (A) and after (B) treatment for hypothyroidism

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Med J Aust 2020; 213 (11 Suppl).