Volume 213 Issue 7

Telehealth offers an opportunity to address limited access to early medical abortion during COVID‐19 and beyond Access to early medical abortion (EMA), using mifepristone followed by misoprostol to end an early pregnancy, remains a challenge in Australia, especially for women from vulnerable groups and those living in rural and regional areas.1 Low numbers of general practitioner providers, lack of peer networks to support the establishment and ongoing provision of EMA services, and stigma are real barriers as is a broader lack of knowledge regarding medical abortion among health professionals.2,3 Many women are also unaware of the availability of EMA and the current gestational limit of 63 days.4 They also face difficulties navigating the health system to find an EMA provider, particularly when they encounter conscientious objections.4,5 Women can also face other barriers such as needing to travel to access services, take time off work or find childcare, and many need to source financial support to meet the costs.5 The current coronavirus disease 2019 (COVID‐19) pandemic has further highlighted existing barriers to accessing EMA services in Australia. During the pandemic, there has been an increase in the demand for abortion because of a rise in unplanned pregnancies and domestic violence.6 Financial insecurity and delays in accessing abortion services, due to travel restrictions or other pandemic‐related stressors, means that women are often presenting for an abortion at a later gestational age.6 In addition, flight restrictions may have curtailed the ability of clinicians to travel to rural areas to provide surgical abortion services. Delivering EMA through telehealth has been shown to be safe, effective and acceptable to women, both internationally and in Australia.7,8,9 Originally championed by Women on Web (www.womenonweb.org), telehealth delivery of EMA was used to provide abortions clandestinely in countries where they were illegal, such as in Ireland prior to decriminalisation.10 It has now, however, been implemented in many countries worldwide, irrespective of whether restrictive or non‐restrictive abortion laws exist, to provide abortion care to women and improve access to women geographically isolated from EMA services.9 Using telehealth to deliver EMA offers an opportunity to address many of the barriers to EMA provision in Australia. It removes the necessity for proximity between the provider and patient, an issue of particular importance for women living in rural and regional areas where there are fewer abortion providers.5,7 The need to travel to appointments far from home, especially when more than one appointment might be required, can result in women moving past the 9‐week gestational limit and preclude them from being able to undergo an EMA.5,7 Not only does the telehealth delivery of EMA reduce the need for patients to travel but it also increases the capacity of existing providers to deliver services to women from a larger geographical area.5,8 The availability of Medicare Benefits Schedule (MBS) telehealth item numbers, introduced as part of the government's response to the pandemic, has meant that, for the first time, telehealth EMA can be delivered through Medicare to eligible patients.11 With these item numbers in place, all EMA providers are able to use telehealth to deliver this service at a potentially reduced cost to women. Before COVID‐19, telehealth item numbers had very restrictive criteria and could only be billed if the patient lived in a very rural area (Modified Monash Model 6 or 7 location), had an existing clinical relationship with a GP telehealth provider (defined as three face‐to‐face consultations in the previous 12 months) and lived at least 15 km by road from the GP.12 These restrictions unfairly excluded many women in metropolitan or regional areas, particularly young women (who comprise the largest demographic using abortion services), as this demographic does not necessarily attend GPs on a regular basis. It is imperative therefore that MBS‐funded telehealth remains implementable by all GPs so that women are not disadvantaged, and that telehealth abortion can remain accessible via Medicare. Recent restrictions to the temporary MBS item numbers for telehealth GP consultations, which came into effect on 20 July 2020 — namely restricting eligibility to only those who have visited the GP or practice in the previous 12 months or those who have been referred by a specialist except for where there is a current lockdown in place13 — will greatly reduce women's access to EMA. Placing restrictions on the eligibility criteria for MBS‐subsidised telehealth services severely affects women's access to GPs who can provide EMA, and discriminates against women who have not recently engaged with a GP due to various forms of disadvantage, such as family violence and unemployment. Exemptions to the restrictions have already been identified for people who are homeless and for children aged less than 12 months. Therefore, a further exemption should also be issued so that registered prescribers of medical abortion are able to use MBS telehealth item numbers for the benefit of Australian women. In addition, other measures are required to optimise the ability of telehealth to improve access to EMA for all Australian women. Firstly, a national hotline or online platform, similar to the 1800 My Options service (www.1800myoptions.org.au) in Victoria, which directs women to local abortion service providers, is required to assist women to identify an appropriate provider. Secondly, as outlined in a consensus statement on EMA developed by a coalition of key stakeholders (ie, the National Health and Medical Research Council's Centre of Research Excellence in Sexual and Reproductive Health for Women in Primary Care [SPHERE]) and clinician experts,14 changes are required to current Therapeutic Goods Administration (TGA) and Pharmaceutical Benefits Scheme (PBS) provisions restricting the prescription of MS‐2 Step (mifepristone and misoprostol) to up to 63 days’ gestation.15 These criteria are outdated and discordant with current evidence demonstrating that EMA up to 70 days’ gestation is comparable in safety and efficacy to 63 days’ gestation or less.16 Guidance from the United States, Canada and the United Kingdom all concur.17,18,19 Increasing gestational limits for prescribing EMA will not only align Australia with international guidance but will also provide a greater window of opportunity for women to access this service. However, this change requires an application to be made to the TGA, and if TGA approval of the extended indication is successful, a subsequent application to the Pharmaceutical Benefits Advisory Committee for subsidy of the extended indication would be required. This is a costly and time‐consuming exercise. Thirdly, modifications are required to EMA protocols, particularly during the COVID‐19 pandemic. Internationally, “no‐touch/no‐test” protocols have been devised and endorsed to minimise the risk of COVID‐19 transmission between patients and providers and circumvent delays created by closed health services (ie, sonography).19,20 In the Australian context, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists has already advised that a clinician may appropriately decide not to administer anti‐D IgG before 10 weeks for the medical management of abortion, particularly when an additional visit may increase exposure of women and staff.21 The SPHERE coalition has additionally recommended that, during the COVID‐19 pandemic, while ultrasound is highly desirable for all women having a telehealth EMA, in situations where obtaining an ultrasound is a significant barrier or poses a significant risk during the COVID‐19 pandemic, EMA may proceed without the necessity of ultrasound assessment.14 However, the consensus statement emphasises that women should be carefully screened for risk factors for ectopic pregnancy. This requires an assessment as to whether an accurate gestational age can be estimated from the woman's history; a discussion regarding the risks of foregoing a pre‐procedure ultrasound as part of the consent process and supported by written information; and a robust follow‐up pathway.14 If the gestation is unable to be accurately identified, or there are red flags for ectopic pregnancy, then an ultrasound assessment must be arranged.14 Finally, abortion has been decriminalised in every state and territory in Australia except South Australia,1 where mifepristone can only be supplied in a hospital setting. This precludes South Australian women from being able to access EMA through community‐based providers such as GPs or via telehealth. The relevant South Australian legislation therefore requires a change.

Danielle Mazza · Seema Deb · Asvini Subasinghe

A live‐streamed teaching strategy that can be applied to all areas of medicine and many clinical scenarios The emergence of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) has resulted in unprecedented challenges to hospitals, the community and society. Although the necessary focus has been to care for patients and communities, the profound effects of coronavirus disease 2019 (COVID‐19) have disrupted medical education and required intense and prompt attention from medical educators. COVID‐19 poses unique challenges to the clinical clerkship model that is fundamental to medical students’ education and has the potential to change forever how future physicians are educated.1 For more than a decade, medical schools have been working to transform pedagogy by reducing live face‐to‐face didactic lectures; using technology and simulation; implementing team‐facilitated, active and self‐directed learning; and promoting individualised and interprofessional education.2,3 However, as described by Sir William Osler, clinical teaching of medical students at the bedside remains vitally important: “to study the phenomena of disease without books is to sail an uncharted sea, while to study without patients is not to go to sea at all”.4 Medical graduates must function in a team‐based, collaborative work environment, have sound knowledge and clinical skills, and have a capacity for lifelong learning.5 In response to COVID‐19, there has been rapid development of the “boot camp” model of accelerated learning for final year medical students to support their swift transition to assistants in medicine. However, it is unclear how medical schools will manage students from the middle years of medical school, where clinical exposure is a vital part of clinical education. Typically, during years 3 and 4 of the Doctor of Medicine degree at the University of Newcastle, students spend about 50% of their time attached to wards, clinics, operating theatres and other clinical exposure opportunities. How can this clinical education continue while medical students are omitted from the clinical environment due to the COVID‐19 pandemic? Further, given that social distancing is anticipated to last many months, clinical teaching rounds with multiple medical students are unlikely to be able to recommence soon. The clinical teaching team from the University of Newcastle at John Hunter Hospital have developed the concept of “live‐streamed ward rounds”. The initiative addresses the challenge of maintaining the clinical clerkship model of education while students are excluded from the hospital for several months during the vital early years of clerkship training. This model of education has three phases (Box 1), which broadly align to advanced cognitive levels of learning expected of medical students. The Hunter New England Local Health District Ethics Committee confirmed that ethics approval was not required for this project. Phase 1: student remote observation (assess and analyse) Clinicians undertake routine ward rounds with medical students in attendance as part of routine inpatient care. During live‐streamed ward rounds, a medical student is engaged securely (password‐protected) via mobile phone to participate in the ward round, including discussion before and after a patient visit. In addition to participating in discussions, similar to face‐to‐face teaching, the student can be shown clinical records (eg, pathology results, observation charts, medical imaging, intraoperative photographs) on video via platform‐agnostic streaming software (eg, Skype for Business, Pexip, Zoom) to broaden engagement with the clinical interaction. When the patient is visited, the patient provides verbal consent for student involvement in the live‐streamed round before the consultation. This is documented in the clinical record of each patient. After obtaining verbal consent, student introduction occurs by turning the phone around so the patient can see the student and vice versa. After the introduction, the phone is turned back to the clinician so the student can see the clinician holding the phone to observe non‐verbal cues. No streaming of the clinical examination occurs during the patient encounter. When the consultation is complete, the phone is turned briefly to the patient to facilitate eye contact when the student thanks them for permission to participate in the encounter. This process is repeated with each patient on the ward round, after which the student is involved in the post‐round clinical discussion that occurs routinely as part of multidisciplinary patient care. The phone is muted or disconnected during the patient encounter if the patient declines student involvement. Phase 2: student preparation (evaluate and synthesise) During the live‐streamed ward round, the student is directed to take detailed notes so they can formulate a series of case presentations for the subsequent student case‐based ward round. The medical student obtains any missing medical information from the junior medical officer at the completion of Phase 1. Clinical records are not available electronically for the students. The aim is to prepare the student for the role of a junior medical officer in the ward environment. Phase 3: student remote case‐based ward round presentation (construct and justify) This element of the learning cycle is typically held later in the week of the live‐streamed clinical round at a time when three to 40 students can be engaged simultaneously for 60–90 minutes through videoconferencing software. The student who attended the live‐streamed clinical round presents each patient to the group as if they were a junior medical officer performing clinical handover. A clinician educator is present to facilitate case‐based discussion. After each patient is discussed, the student presents what actually occurred on the clinical round and presents the plan for ongoing care with justification. This element of the interaction is designed to emphasise patient‐centred care. We have conducted live‐streamed rounds at John Hunter Hospital in obstetrics, gynaecology and birth suite handover rounds. Approval was provided by the hospital executive after review by the local health district privacy team — student involvement by phone using a secure application (Skype for Business) was thought to be similar to student involvement with telehealth consultations in outpatient clinics. The benefits and challenges experienced with live‐streamed ward rounds are summarised in Box 2. After completion of 50 live‐streamed rounds, an informal evaluation was conducted via an anonymous voluntary Qualtrics online survey. Most of the 25 student respondents and clinicians provided positive feedback. Key findings from this survey are presented in the Supporting information. Clinical teaching is a fundamental component of medical education, particularly for developing tangible and intangible skills of medical students.6 Bedside teaching is a key opportunity for medical students, with the presence of the medical teacher, to develop medical knowledge, history taking and physical examination skills, clinical data gathering and clinical decision making.7 While students cannot participate in the clinical examination component of the patient interaction during live‐streamed ward rounds, they can hear the relevant history taking. Evidence indicates that physicians can collect 60–80% of the information relevant for a diagnosis just by taking a medical history, leading to a final diagnosis in more than 70% of cases.8 Previous studies investigating factors that are most important in creating an effective learning environment for medical students found that the level of participation students are afforded in the workplace is vital in clinical practice learning.9 Greater participation in the workplace facilitates greater confidence and competency, especially in clinical practice.9,10 A recent Australian study11 of final year medical students found the top six responses as to why students found clinical venues the most educationally useful include: the amount of patient contact; various patient presentations; being part of the clinical team; the opportunity to ask questions and receive useful information; the high level of supervision in training; and the amount of formal bedside teaching. Tutorials in a clinical setting also allow for professional development to be taught, such as communication, teamwork and ethics.12 Students require teaching in real clinical settings to develop skills for success in the real clinical environment. The structured live‐streamed ward round stimulates student participation and effectively develops clinical knowledge, enhances depth and permanency of learning, and enriches the stability and dependability of the knowledge attained. Being able to follow up patients to discharge is the ideal ending to these scenarios, where the student can see how effective the management plan was, as well as its implementation and results.11 We identified quality supervision as a key factor for maximising the educational value of clinical learning in live‐streamed ward rounds. Supervisors who are experienced and engaging make students more motivated to critically analyse patients’ clinical conditions, encourage their learning about these presentations, and formulate management plans.13,14 Live‐streamed clinical encounters should inspire us to revisit and prioritise the development of virtual clinical encounters, involving detailed scenarios that can be delivered flexibly, are always accessible and adaptive, and prioritise individualised learning. There are many advantages to live‐streamed clinical encounters, including their cost‐effectiveness in both set‐up and maintenance, the possibility of increasing access and usability of streaming technology, and allowing for the nuance of expertise and immediate feedback. As demonstrated by the COVID‐19 pandemic, they can be rapidly implemented and use principles of adult learning. The live‐streamed teaching strategy can be applied to all areas of medicine and many clinical scenarios, including ward rounds and clinical handover rounds. Recommendations on how to introduce this innovative teaching method are summarised in Box 3. This strategy is one of the many that the University of Newcastle plans to use to provide ongoing clinical teaching during the COVID‐19 pandemic. Being adaptable and flexible, cognisant of costs and driven by evidence are critical features of delivering medical education and contemporary medical practice.15 Box 1 – The three phases of the live‐streamed ward round Box 2 – Benefits and challenges of live‐streamed ward rounds Benefits The program is able to continue while students are not allowed in hospital The program is able to run while social distancing rules severely limit the number of students physically able to attend face‐to-face ward rounds The program facilitated discussions in Phase 3 which can go into greater depth than is possible in a ward environment The program provided the ability to engage larger number of students than possible in physical ward rounds The program creates more opportunity to simulate the role of a junior medical officer The program moderates clinical team variability for capacity to provide equivalent learning focus each week Challenges The program may potentially slow down ward round There is risk of technological limitations (eg, dependent on mobile phone signal and teleconferencing software) There are timetabling challenges in an unpredictable clinical environment There is inability to observe or participate in physical examination There is a loss of some of the valuable elements of the informal curriculum on ward round (eg, exemplary professional values, behaviour and collegiality via positive role modelling) Box 3 – Recommendations for introducing live‐streamed ward rounds into teaching Step 1 Design a live‐streamed round and a follow‐up reflective simulation round. This should include addressing the process for privacy, consent and technology (ie, preferred mobile videoconference platform) Step 2 Include discipline and departmental consultants running the live‐streamed round and follow‐up round in reviewing the design Step 3 Include technology support officers in reviewing the design Step 4 Seek written approval from relevant senior local health district and hospital staff (eg, medical and clinical directors) Step 5 Pilot, refine, implement

Craig E Pennell · Hannah Kluckow · Shirley Q Chen · Kerrie M Wisely · Ben LD Walker

A recent High Court decision directs and reassures medical and other practitioners in clinical and community settings that no parent or individual can compel this unlawful procedure

Ben Mathews · Elizabeth Dallaston

Depression as a systemic illness

Gin S Malhi

Brewster DJ, Chrimes N, Do TBT, et al. Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID‐19 adult patient group. Med J Aust 2020; 212: 472–481. https://doi.org/10.5694/mja2.50598. In this Consensus statement, on page 474, on the first paragraph, where it says: “All recommendations were debated extensively. Some of the endorsing societies — ANZICS and the Australian Society of Anaesthetists — were consulted during the development of the document to allow external opinion”, it should read: “All recommendations were debated extensively. They have been recommended by the COVID‐19 Critical Care Coordination Collaborative (5Cs), and have been widely endorsed by relevant specialty colleges and societies (Supporting Information). Some of the endorsing societies — ANZICS and the Australian Society of Anaesthetists — were consulted during the development of the document to allow external opinion”.

High cumulative doses are often unnecessary and can have major adverse effects

Christine F McDonald · Christopher J Worsnop

Incorporating routine assessment of frailty into health care would benefit both older people and the health system

Emily H Gordon · Ruth E Hubbard

Objective: To estimate the level of dispensing of oral corticosteroids (OCS) for managing asthma in Australia, with a particular focus on the cumulative dispensing of doses associated with long term toxicity (≥ 1000 mg prednisolone‐equivalent). Design: Retrospective cohort study; analysis of 10% random sample of Pharmaceutical Benefits Scheme (PBS) dispensing data. Participants, setting: People aged 12 years or more treated for asthma during 2014–2018, according to dispensing of controller inhaled corticosteroids (ICS). Main outcome measures: Number of people dispensed OCS for managing asthma during 2014–2018; proportion who were cumulatively dispensed at least 1000 mg prednisolone‐equivalent. The secondary outcome was the number of people dispensed at least 1000 mg prednisolone‐equivalent during 2018, stratified by inhaler controller dose and use. Results: 124 011 people had been dispensed at least two prescriptions of ICS during 2014–2018 and met the study definition for asthma, of whom 64 112 (51.7%) had also been dispensed OCS, including 34 580 (27.9% of the asthma group) cumulatively dispensed 1000 mg prednisolone‐equivalent or more. Of 138 073 people dispensed OCS at this level, 68 077 (49%) were patients with airway diseases. Dispensing of diabetes and osteoporosis medications was more common for people cumulatively dispensed 1000 mg prednisolone‐equivalent or more. During 2018, 4633 people with asthma using high dose ICS controllers were dispensed 1000 mg prednisolone‐equivalent or more, for 2316 of whom (50%) controller use was inadequate. Conclusions: Cumulative exposure to OCS in Australia reaches levels associated with toxicity in one‐quarter of patients with asthma using ICS. Cumulative dispensing of potentially toxic OCS amounts often accompanies inadequate inhaler controller dispensing. Better approaches are needed to improve adherence to controller therapy, improve outcomes for people with asthma, and to minimise the use and toxicity of OCS.

Mark Hew · Vanessa M McDonald · Phil G Bardin · Li Ping Chung · Claude S Farah · Amanda Barnard · Mark S Cooper · Peter G Gibson · John W Upham

Objectives: To develop and validate a frailty index, derived from aged care eligibility assessment data. Design: Retrospective cohort study; analysis of the historical national cohort of the Registry of Senior Australians (ROSA). Participants: 903 996 non‐Indigenous Australians aged 65 years or more, living in the community and assessed for subsidised aged care eligibility during 2003–2013. Main outcome measures: 44‐item frailty index; summary statistics for frailty index score distribution; predictive validity with respect to mortality and entry into permanent residential aged care during the five years after assessment. Results: The mean frailty index score during 2003–2013 was 0.20 (SD, 0.07; range, 0–0.41); the proportion of assessed older people with scores exceeding 0.20 increased from 32.1% in 2003–2005 to 75.0% in 2012–2013. The risks of death and entry into permanent residential aged care at one, three and five years increased with frailty index score level (at one year, high [over 0.35] v low scores [under 0.05]: hazard ratio for death, 5.99; 95% CI, 5.69–6.31; for entry into permanent residential aged care, 8.70; 95% CI, 8.32–9.11). The predictive validity (area under the receiver operating characteristic curve) of Cox proportional hazard models including age, sex, and frailty index score was 0.64 (95% CI, 0.63–0.64) for death and 0.63 (95% CI, 0.62–0.63) for entry into permanent residential aged care within one year of assessment. Conclusions: We used Australian aged care eligibility assessment program data to construct and validate a frailty index. It can be employed in aged care research in Australia, but its application to aged care planning requires further investigation.

Jyoti Khadka · Renuka Visvanathan · Olga Theou · Max Moldovan · Azmeraw T Amare · Catherine Lang · Julie Ratcliffe · Steven L Wesselingh · Maria C Inacio

Overcoming patient, GP, and health system barriers to changes in care delivery are critical to progress

Charlotte M Hespe · Anna Campain · Ruth Webster · Anushka Patel · Lucie Rychetnik · Mark F Harris · David P Peiris

Objective: To synthesise what is known about women combining motherhood and a career in medicine by examining the published research into their experiences and perspectives. Study design: We reviewed peer‐reviewed articles published or available in English reporting original research into motherhood and medicine and published during 2008–2019. Two researchers screened each abstract and independently reviewed full text articles. Study quality was assessed. Data sources: CINAHL, MEDLINE, PsycINFO, Web of Science, and Scopus abstract databases. Data synthesis: The database search identified 4200 articles; after screening and full text assessment, we undertook an integrative review synthesis of the 35 articles that met our inclusion criteria. Conclusions: Three core themes were identified: Motherhood: the impact of being a doctor on raising children; Medicine: the impact of being a mother on a medical career; and Combining motherhood and medicine: strategies and policies. Several structural and attitudinal barriers to women pursuing both medical careers and motherhood were identified. It was often reported that women prioritise career advancement by delaying starting a family, and that female doctors believed that career progression would be slowed by motherhood. Few evaluations of policies for supporting pregnant doctors, providing maternity leave, and assisting their return to work after giving birth have been published. We did not find any relevant studies undertaken in Australia or New Zealand, nor any studies with a focus on community‐based medicine or intervention studies. Prospective investigations and rigorous evaluations of policies and support mechanisms in different medical specialties would be appropriate. Protocol registration: PROSPERO CRD42019116228.

Rebekah Hoffman · Judy Mullan · Marisa Nguyen · Andrew D Bonney

To the Editor: Torda and colleagues1 highlight the impact of the coronavirus disease 2019 (COVID‐19) pandemic on medical education, which has prompted the rapid shift to online teaching for medical students. We need to ensure that these recent changes in medical education are thoughtfully blended with the reintroduction of face‐to‐face teaching when it occurs. Before integrating these changes, it is critical we reflect and review three key elements: Preparing students: blended learning, where online learning is combined with traditional face‐to-face teaching, is likely to capture more students’ learning styles but is also often associated with increased need for self‐directed learning, which may mainly benefit high achieving students.2,3 It is critical we equip all our students to engage effectively in adult learning to maximise the benefits of blended learning and develop engaged independent learners.4 This is an opportunity to develop these skills by ensuring that staged and increasing self‐directedness is built into new material and forms of delivery.5 Preparing educators: the attitude and preparedness of educators running or engaging in online education is crucial. As vital stakeholders, lecturers should be seen as educators and be supported and developed as such, including the training in both design and delivery of online learning.6 Preparing delivery and its content: facing the option of moving material back from online learning to face‐to-face learning, each move must be critically analysed to determine what is the most effective form of delivery. Historical modes of delivery need not be the default. Indeed, we have been given a once in a lifetime opportunity for a major, if incidental, review of each part of the curriculum and the best way it can be delivered — online, face‐to-face, or maybe a mix of both. As the mode of delivery is reviewed, the content can be refined and tailored for the students’ needs. Many of us know the deafening and discouraging silence when students are quiet in response to a question, both face‐to‐face and online. However, we are at a turning point in medical education where we must take the time to reflect and move forward with excitement regarding what has worked, and have the courage to leave behind what has not.

Lucy E Kirk · Imogen Mitchell

In reply

Adrienne J Torda · Gary Velan · Vlado Perkovic

To the Editor: There has been recent important discourse about the adverse impact of coronavirus disease 2019 (COVID‐19) on mental health, with modelling from the Brain and Mind Centre predicting increases in suicide in the wake of the pandemic.1 Links with the economic downturn have been emphasised, with financial stressors and loss of productivity among the youth and working adults playing a large part, leading to a call for proactive investment in mental health services.1 This is of undisputed, urgent importance. However, there has been relative silence about the effects of the pandemic on suicide risk in older adults, especially men aged 85 years or over, who have the highest rate of suicide of all age groups in Australia.2 Older adults are particularly vulnerable to the social ramifications of the pandemic, including social distancing, if not frank social exclusion by quarantine, exacerbating pre‐existing loneliness,3 particularly for those in residential care. Management of older people with pre‐existing mental illness as well as the expected increases in depression and anxiety3,4 have been confounded by changes in service provision and access to mental health services.3 Similarly, delays in presentation and management of physical illness combined with the suspension of elective procedures4 may contribute to untreated pain and other distressing physical symptoms, also identified as risk factors for suicide.5 Furthermore, calls to reopen the economy knowing the risk this poses to older people — seen by some as “expendable” — reflects societal ageism and adds to older people's own internalised ageism.6 Perceptions of disconnection from society and feeling burdensome and devalued are already known associations with late‐life self‐harm and suicide.5 In addition to fuelling active self‐harm, there has been speculation regarding links between the pandemic and increased requests for voluntary assisted dying.7,8 These reports suggest that such requests have been driven by anxiety about dying, fears of loss of control, and inability to access help for distressing symptoms. This is not unfounded, given the complexity of providing appropriate palliative care to older patients who are dying, particularly to those in nursing homes, ever more so during the COVID‐19 pandemic.4 We add to the call to act urgently and flatten the mental illness and suicide curve1 for Australians of all ages.

Anne P F Wand · Carmelle Peisah

To the Editor: In Australia, gestational diabetes mellitus is diagnosed by 75 g oral glucose tolerance test (OGTT). The diagnostic criteria are fasting plasma glucose (FPG) ≥ 5.1 mmol/L, one‐hour glucose level ≥ 10.0 mmol/L, and/or 2‐hour glucose level ≥ 8.5 mmol/L.1,2 International consensus favours OGTT over single measures of glucose because, in the pivotal Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) study, hyperglycaemia at each time point was independently associated with adverse outcomes, individual measures were not well correlated with one another, and no single measure was clearly superior in predicting adverse outcomes, such as birthweight above the 90th percentile, shoulder dystocia and pre‐eclampsia.2,3 To reduce contact time at pathology collection centres during the coronavirus disease 2019 (COVID‐19) pandemic, measurement of FPG alone has been advocated.4,5 One guideline advised that a result below 4.7 mmol/L may not merit a follow‐up OGTT.4 Another advised diagnosing gestational diabetes mellitus by stand‐alone FPG greater than 5.1 mmol/L.5 To determine the proportion and characteristics of gestational diabetes mellitus cases that would be missed by using alternative criteria, we extracted the results of all obstetrician‐referred OGTTs performed by our private community‐based laboratory between January 2017 and April 2020. The analysis, including determination of Wilson score confidence intervals (CIs), was performed with SAS 9.4 (SAS Institute). Of 16 169 patients, 1790 (11.1%) were diagnosed with gestational diabetes mellitus by OGTT. A rule‐out threshold of FPG below 5.1 mmol/L would have resulted in 1202 cases (67%; 95% CI, 65–69%) being missed, and a threshold below 4.7 mmol/L would have resulted in 831 cases (46%; 95% CI, 44–49%) being missed (Box). Women with gestational diabetes mellitus and normal fasting glucose did not have significantly lower one‐ or 2‐hour concentrations than those with increased fasting glucose (data not shown). Missing the diagnosis of gestational diabetes mellitus exposes women and their newborns to significant risks, including birth weight above the 90th percentile, primary caesarean delivery, neonatal hypoglycaemia, premature delivery, shoulder dystocia or birth injury, intensive neonatal care, hyperbilirubinaemia and pre‐eclampsia. Use of fasting glucose to screen for gestational diabetes mellitus would miss a large proportion of cases, with the potential for significant harm to mothers and their offspring. Clinicians must recognise the substantial limitations of stand‐alone FPG so that pregnant women can be adequately counselled and, if opting out of OGTT, considered for careful monitoring for consequences of undiagnosed gestational diabetes mellitus, such as accelerated growth or polyhydramnios. In regions without significant community spread of COVID‐19, modifying sample collection procedures to ensure strict physical distancing and having dedicated collection centres for vulnerable populations may be better than using deficient diagnostic criteria. Box – Distribution of fasting glucose results at 24–28 weeks’ gestation in patients with (n = 1790) and without (n = 14 379) gestational diabetes mellitus* (GDM) The vertical grey lines denote thresholds below which new guidelines propose that oral glucose tolerance testing is not required during the coronavirus disease 2019 (COVID‐19) pandemic. * Diagnosed using oral glucose tolerance test.

Ranita Siru · Johan H Conradie · Melissa J Gillett · Emily Gianatti · Michael M Page

To the Editor: Takotsubo syndrome, also known as stress cardiomyopathy, apical ballooning syndrome, or broken heart syndrome, is a reversible cardiomyopathy frequently precipitated by a stressful event. Its clinical presentation is indistinguishable from a myocardial infarction,1 with electrocardiogram (ECG) changes and elevation in cardiac enzymes. The syndrome was first described in 1991 in Japan and named in reference to the left ventricle morphological features that resemble a pot used for trapping octopuses. Takotsubo syndrome has recently been reported in association with coronavirus disease 2019 (COVID‐19),2 but we report a case of takotsubo cardiomyopathy brought on by the stress of isolation as a result of social distancing. A 71‐year‐old woman presented to the emergency department complaining of chest pain. On arrival, an ECG demonstrated diffuse ST elevation (Box) and troponin was elevated (7800 ng/L). Coronary angiography was performed immediately which did not demonstrate any obstructive lesion and she was admitted to the intensive care unit (ICU) for ongoing haemodynamic support. Echocardiography performed in the ICU showed a dilated left ventricle with an akinetic apex and preserved contraction of the basal segments (Box) suggestive of takotsubo cardiomyopathy. On questioning regarding recent stressors, our patient, who lived alone, reported significant anxiety about not being able to visit family due to social distancing, and was particularly saddened by being unable to see her grandchildren. Public health interventions undertaken by governments around the world in an attempt to reduce the rate of transmission of COVID‐19, or to “flatten the curve”, have included measures such as social distancing.3 While being effective in the aim of lowering infections, these measures may have many unintended consequences. Social isolation is detrimental to mental health, associated with increased stress levels and anxiety, especially in older people, who may be less able to use technology to stay in contact with friends and family.4 In our patient, this stress was enough to trigger takotsubo cardiomyopathy. Box – Electrocardiogram (A) showing diffuse ST elevation. Echocardiogram (B) showing a dilated left ventricle with an akinetic apex and preserved contraction of the basal segments (arrows)

Jon Rivers · Joshua F Ihle