Volume 214 Issue 5

A 1-year-old boy presented with a 6-month history of a brown plaque on his left forearm

Samuel A Der Sarkissian · Deshan F Sebaratnam

There is little legal recourse in Australia for someone who is denied care on resource grounds, particularly in the context of a pandemic

Michelle A Gunn · Fiona J McDonald

Let us move our focus to building health care relationships and partnerships that optimise care for every Indigenous patient

Talila Milroy · Lilon G Bandler

Integrating pharmacists into general practice, aged care, and hospital services will enhance the quality use of medicines

Justin Beilby

Objective: To investigate whether integrating pharmacists into general practices reduces the number of unplanned re‐admissions of patients recently discharged from hospital. Design, setting: Stepped wedge, cluster randomised trial in 14 general practices in southeast Queensland. Participants: Adults discharged from one of seven study hospitals during the seven days preceding recruitment (22 May 2017 ‒ 14 March 2018) and prescribed five or more long term medicines, or having a primary discharge diagnosis of congestive heart failure or exacerbation of chronic obstructive pulmonary disease. Intervention: Comprehensive face‐to‐face medicine management consultation with an integrated practice pharmacist within seven days of discharge, followed by a consultation with their general practitioner and further pharmacist consultations as needed. Major outcomes: Rates of unplanned, all‐cause hospital re‐admissions and emergency department (ED) presentations 12 months after hospital discharge; incremental net difference in overall costs. Results: By 12 months, there had been 282 re‐admissions among 177 control patients (incidence rate [IR], 1.65 per person‐year) and 136 among 129 intervention patients (IR, 1.09 per person‐year; fully adjusted IR ratio [IRR], 0.79; 95% CI, 0.52‒1.18). ED presentation incidence (fully adjusted IRR, 0.46; 95% CI, 0.22‒0.94) and combined re‐admission and ED presentation incidence (fully adjusted IRR, 0.69; 95% CI, 0.48‒0.99) were significantly lower for intervention patients. The estimated incremental net cost benefit of the intervention was $5072 per patient, with a benefit‒cost ratio of 31:1. Conclusion: A collaborative pharmacist‒GP model of post‐hospital discharge medicines management can reduce the incidence of hospital re‐admissions and ED presentations, achieving substantial cost savings to the health system. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12616001627448 (prospective).

Christopher R Freeman · Ian A Scott · Karla Hemming · Luke B Connelly · Carl M Kirkpatrick · Ian Coombes · Jennifer Whitty · James Martin · Neil Cottrell · Nancy Sturman · Grant M Russell · Ian Williams · Caroline Nicholson · Sue Kirsa · Holly Foot

Hospitals in the Northern Territory often operate beyond capacity and serve a sparsely distributed population with rates of chronic disease and household overcrowding that are higher than in many other parts of Australia. The NT consequently adopted particularly strict public health measures to avert the potentially catastrophic consequences of community transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), including supervised isolation until viral clearance of all people with confirmed SARS‐CoV‐2 infections (Supporting Information 1). This measure provided a unique opportunity to study the duration and trajectory of viral shedding in relation to clinical illness. In this article, we describe epidemiologic, clinical, and virological aspects of the first 28 cases of coronavirus disease 2019 (COVID‐19) in the NT. The Top End and Central Australian Human Research Ethics Committees approved the study (reference, 2020‐3737). Between 4 March and 4 April 2020, 28 cases of COVID‐19 were diagnosed in the NT, all linked to overseas or interstate travel. The median age of patients was 45.0 years (range, 1.5–75 years); 16 were women (Supporting Information 1, table). Two patients required supplemental oxygen, one of whom also required intubation. There were no deaths. Symptoms had been present for a median 3 days (range, 0–16 days) before oro‐nasopharyngeal swab collection and lasted a median 9.5 days (range, 4–18 days). Viral RNA could be detected by multiplex tandem real‐time polymerase chain reaction (PCR) assay (AusDiagnostics; Supporting Information 1) for a median 25 days after symptom onset (range, 14–41 days; interquartile range [IQR], 21–32 days), and in most patients for more than two weeks after symptom resolution (median, 17.5 days; range, 2–31 days; IQR, 14.5–22.5 days) (Box 1). Within‐patient variability in viral target cycle threshold values during follow‐up was considerable (Box 2; Supporting Information 1, figure), despite adequate and consistent amounts of human biologic material in test samples (data not shown). Prolonged compulsory isolation was distressing for several patients. The phylogeny of the 27 available NT viral genomes was consistent with acquisition in locations on all inhabited continents (Box 3). Five genetic clusters were evident (maximum of one single nucleotide polymorphism within each cluster) that were also epidemiologically linked by shared travel or household contact. The SARS‐CoV‐2 genomes from two independent travellers without epidemiologic connections were identical, but matched other publicly available genomes, highlighting the importance of interpreting genomic analyses in their epidemiologic context. The priority of the strict NT isolation requirements for patients with COVID‐19 was viral containment at a time when data on the duration of viral transmissibility were sparse. More recent evidence suggests that viable SARS‐CoV‐2 is rarely isolated more than 10 days after symptom onset,1,2,3 and requirements have consequently been eased, while maintaining supervised isolation with health management during the period of greatest infectivity. The high degree of temporal variability in viral shedding during follow‐up indicates that a single assay is not adequate for excluding infection in patients at epidemiologic risk of COVID‐19. The NT implemented particularly aggressive public health measures to contain SARS‐CoV‐2 transmission. Epidemiologic and genomic analyses suggest that this response has successfully prevented local community transmission of the virus. Box 1 – Time course of 28 cases of coronavirus disease 2019 (COVID‐19) diagnosed in the Northern Territory, 4 March – 4 April 2020 Each line represents a single patient. Day zero is the day of collection of the first SARS‐CoV‐2‐positive specimen; thickened sections indicate the period of COVID‐19 symptoms. Closed circles indicate positive SARS‐CoV‐2 assay results, hollow circles negative assay results. Patients 13 and 15 (lighter marking) required supplemental oxygen. The bottom line summarises the median duration of symptoms prior to diagnosis, the median duration of symptoms, and the median time to viral clearance. Box 2 – Multiplex tandem polymerase chain reaction cycle threshold values for detection of the SARS‐CoV‐2 open reading frame 1a gene (ORF1a) Box 3 – Maximum likelihood phylogenetic tree, depicting SARS‐CoV‐2 genomes from the Northern Territory and elsewhere SARS‐CoV‐2 = severe acute respiratory syndrome coronavirus 2. The phylogenetic tree shows that SARS‐CoV‐2 genomes in the Northern Territory (on the inner side of the outer ring) were drawn from across the range of genomes reported elsewhere (outer ring). NT travel‐related cases with epidemiologic links formed genomic clusters. Two cases without epidemiologic links also comprised a cluster, but the genomes were identical with overseas genomes. The context genomes were obtained from GISAID (https://www.gisaid.org), with region based on location of the submitting laboratory; the Wuhan‐Hu‐1 genome was used as an outgroup, and the scale bar indicates substitutions per site.

for the Northern Territory COVID‐19 Response Group

Introduction: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) cause significant morbidity and premature mortality among Australian Aboriginal and Torres Strait Islander peoples. RHDAustralia has produced a fully updated clinical guideline in response to new knowledge gained since the 2012 edition. The guideline aligns with major international ARF and RHD practice guidelines from the American Heart Association and World Heart Federation to ensure best practice. The GRADE system was used to assess the quality and strength of evidence where appropriate.Main recommendations: The 2020 Australian guideline details best practice care for people with or at risk of ARF and RHD. It provides up‐to‐date guidance on primordial, primary and secondary prevention, diagnosis and management, preconception and perinatal management of women with RHD, culturally safe practice, provision of a trained and supported Aboriginal and Torres Strait Islander workforce, disease burden, RHD screening, control programs and new technologies.Changes in management as a result of the guideline: Key changes include updating of ARF and RHD diagnostic criteria; change in secondary prophylaxis duration; improved pain management for intramuscular injections; and changes to antibiotic regimens for primary prevention. Other changes include an emphasis on provision of culturally appropriate care; updated burden of disease data using linked register and hospitalisations data; primordial prevention strategies to reduce streptococcal infection addressing household overcrowding and personal hygiene; recommendations for population‐based echocardiographic screening for RHD in select populations; expanded management guidance for women with RHD or ARF to cover contraception, antenatal, delivery and postnatal care, and to stratify pregnancy risks according to RHD severity; and a priority classification system for presence and severity of RHD to align with appropriate timing of follow‐up.

Anna P Ralph · Sara Noonan · Vicki Wade · Bart J Currie

Introduction: The 2001 Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Islander populations were revised in 2010. This 2020 update by the Centre of Research Excellence in Ear and Hearing Health of Aboriginal and Torres Strait Islander Children used for the first time the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Main recommendations: We performed systematic reviews of evidence across prevention, diagnosis, prognosis and management. We report ten algorithms to guide diagnosis and clinical management of all forms of otitis media. The guidelines include 14 prevention and 37 treatment strategies addressing 191 questions. Changes in management as a result of the guidelines: A GRADE approach is used. Targeted recommendations for both high and low risk children. New tympanostomy tube otorrhoea section. New Priority 5 for health services: annual and catch‐up ear health checks for at‐risk children. Antibiotics are strongly recommended for persistent otitis media with effusion in high risk children. Azithromycin is strongly recommended for acute otitis media where adherence is difficult or there is no access to refrigeration. Concurrent audiology and surgical referrals are recommended where delays are likely. Surgical referral is recommended for chronic suppurative otitis media at the time of diagnosis. The use of autoinflation devices is recommended for some children with persistent otitis media with effusion. Definitions for mild (21–30 dB) and moderate (> 30 dB) hearing impairment have been updated. New “OMapp” enables free fast access to the guidelines, plus images, animations, and multiple Aboriginal and Torres Strait Islander language audio translations to aid communication with families.

Amanda J Leach · Peter S Morris · Harvey LC Coates · Sandra Nelson · Stephen J O'Leary · Peter C Richmond · Hasantha Gunasekera · Samantha Harkus · Kelvin Kong · Christopher G Brennan‐Jones · Sam Brophy‐Williams · Kathy Currie · Sumon K Das · David Isaacs · Katherine Jarosz · Deborah Lehmann · Jarod Pak · Hemi Patel · Chris Perry · Jennifer S Reath · Jessica Sommer · Paul J Torzillo

To the Editor: Fetene and colleagues1 describe refusal to prescribe or dispense prescriptions to some of their study cohort of people who inject drugs (PWIDs) and concern that their mental health treatment needs may not be met due to SafeScript, Victoria’s real time prescription monitoring system. SafeScript is a live electronic database providing information about the prescribing and dispensing of monitored medicines to each patient, instantly available in real time on a prescriber’s or pharmacist’s desktop (https://www2.health.vic.gov.au/safescript). SafeScript alerts prescribers and pharmacists to the risk of uncoordinated treatment by multiple providers or to the overdose risk of drug–drug interactions. Prescribers and pharmacists may have responded appropriately by offering more effective treatments instead of providing a continued supply of the medication. For instance, benzodiazepines are not recommended for first line or prolonged treatment of anxiety. Many people who misuse drugs have comorbid mental health disorders and need medical support. SafeScript is helping to identify this group of at‐risk patients so they can receive the appropriate medical treatment they require. SafeScript provides a clinical decision support system for prescribers and pharmacists, enabling more informed decisions for safer prescribing or dispensing of high risk monitored medicines. By providing proactive alerts, strong real time prescription monitoring systems, such as SafeScript, reduce overdose deaths from prescription opioids2 and decrease the number of opioid prescriptions, diversion, and opioid‐related morbidity and substance use disorder outcomes.3 Since the rollout of SafeScript, the number of multiple provider episodes and the average morphine equivalent dose have both been trending gradually but consistently downwards. SafeScript was designed with the lessons learnt from the United States. The implementation of this system included several measures to encourage and support a professional response for high risk patients, such as podcasts and face to face and online training, in which more than 4500 prescribers and pharmacists have participated. Furthermore, the SafeScript implementation included upgrading the Drug and Alcohol Clinical Advisory Service, providing trained general practitioner clinical advisors to offer peer support, a consumer pharmaceutical helpline, and increased funding to support professionals and consumers manage benzodiazepine problems. In addition, $273.1 million were invested in drug treatment, support and harm reduction services in 2019–2020,4 representing a 65% increase in investment through the last five Victorian state budgets. This new initiative helps prescribers and pharmacists provide the appropriate clinical care and professional response needed by high risk patients.

Malcolm Dobbin

In reply

Dagnachew M Fetene · Peter Higgs · Suzanne Nielsen · Filip Djordjevic · Paul Dietze

To the Editor: Influenza vaccination of residents and staff in aged care homes is recommended by national guidelines1 and has been demonstrated to decrease transmission and burden of infection.2 During the current coronavirus disease 2019 pandemic, influenza vaccination of both groups potentially also reduces the risk of mortality associated with influenza virus and severe acute respiratory syndrome coronavirus 2 co‐infection. We sought to evaluate uptake of influenza vaccination by residents and staff in public sector residential aged care services in Victoria, where non‐mandatory vaccination programs are currently used. There are 178 public sector residential aged care services in Victoria, with the majority located in rural communities. In 2018 and 2019, infection prevention staff in public sector residential aged care services were requested to complete a point prevalence survey of all residents on a set date and a period prevalence survey of all staff employed during the influenza season, in order to estimate vaccine uptake. A standardised data collection tool was used, with online submission of summary data via a secure portal hosted by the Victorian Healthcare Associated Infections Surveillance System Coordinating Centre. Consistent with quality assurance activities defined according to National Health and Medical Research Council recommendations, non‐identifiable aggregate data were collated by participating public sector residential aged care services to support quality improvement initiatives. Ethics approval was therefore not required.3 Of surveyed residents, 87% were vaccinated in both 2018 and 2019. Small proportions of residents declined vaccination or had unknown status. In 2018, 87% of surveyed staff were vaccinated, with 8% and 6% reported as declining vaccination or having unknown status, respectively. In 2019, 88% of surveyed staff were vaccinated, with 9% and 4% declining vaccination or having unknown status, respectively (Box). Public sector residential aged care services provide services for older people with complex care needs, representing a population at high risk for poorer clinical outcomes in the setting of influenza infection. Reassuringly, we observed high uptake of vaccination among surveyed residents, comparable to recently reported uptake in New South Wales aged care homes.4 Review of successful vaccination strategies would be beneficial to improve and sustain future programs in individual aged care homes. Our findings also reflect high uptake of vaccination by aged care staff. Looking ahead, mandatory vaccination of staff employed in Victorian hospitals and public sector residential aged care services is planned,5 and this will likely result in additional uptake.6 While we observed low proportions of staff to have unknown status or to decline vaccination, implementation of the new policy will require an ethical and legal focus on these groups, including reasons for acceptable declination and required workforce planning (eg, redeployment). Box – Influenza vaccination uptake by residents and staff in Victorian public sector residential aged care services, 2018–2019 Target population Year No. of facilities surveyed No. of residents or staff surveyed Vaccinated Declined Unknown Residents 2018 177 5162 4482 (87%) 357 (7%) 323 (6%) 2019 178 5082 4427 (87%) 302 (6%) 353 (7%) Staff 2018 177 12536 10894 (87%) 948 (8%) 694 (6%) 2019 175 13844 12181 (88%) 1179 (9%) 484 (4%)

Noleen J Bennett · Alex Hoskins · Leon J Worth

To the Editor: As the coronavirus disease 2019 (COVID‐19) pandemic spread across Europe, we worked in the intensive care unit (ICU) of a Swedish university hospital. We share our experiences and offer some thoughts regarding Sweden’s pandemic response. The decentralised Swedish health system works on three levels (Box). These traditional divisions may partially account for the lack of coordination between care services in the initial phases of the pandemic, where large numbers of deaths occurred in care homes. As the pandemic intensified, safety checks were implemented to protect residents of aged care facilities. This resulted in a quick containment of infections, although tragically too late for many. Our health care region received the fourth highest number of hospitalisations in Sweden.1 We were privileged to work in a system that was well organised, without political conflict and with pre‐existing disaster plans that were quickly converted to pandemic plans. A pandemic‐specific leadership established a centralised inventory and oversaw the acquisition and distribution of beds, staffing, medical equipment, essential drugs, personal protective equipment and disinfection agents. An eight‐step plan ensured a rapid escalation of regional ICU capacity. Intermediate care units were opened, reducing demand for ICU beds. Projected numbers of patients were calculated daily, based on models provided from the Public Health Agency of Sweden and local data. Anaesthesia and intensive care are a combined speciality in Sweden. This enabled the rapid deployment of a large workforce of anaesthetists and nurse anaesthetists to ICUs. Despite these resources, our tripled ICU capacity meant significant staffing challenges, with additional difficulties because of staff illnesses and quarantines. Our impression is that the Swedish response has been controlled and planned for the long term. Daily public announcements from the Public Health Agency became a regular part of our lives and Swedes were generally compliant with recommendations regarding physical distancing and hygiene routines. We are perplexed by reports in the media that life went on as usual in Sweden. In fact, life was very different. Most people worked from home, large numbers were furloughed, many institutions were closed and public events were cancelled. Travel was discouraged and fell dramatically.2 What sets the Swedish approach apart from others is that these measures were largely voluntary, with generally good public support. We avoided an overwhelming wave of patients with an undercapacity of ICU beds, as seen in many other countries. We maintained normal criteria for ICU admissions. This is notable given that Sweden has the second lowest number of ICU beds per capita in Europe.3,4 Results from intensive care are encouraging, with mortality rates generally lower than previously reported.5 Challenges included staff burnout, a shortage of usual sedatives and lack of clinical experience with this new disease, resulting in the use of futile and potentially harmful treatments. However, guidance from a national group of senior clinicians provided regular recommendations6 and there was excellent compliance with advice from regulatory authorities. Up to 70% of elective surgeries were cancelled during the first half of 2020. Cancer‐related surgeries continued to be prioritised during the pandemic, but the longer term effects of cancelled surgeries, outpatient clinics and altered illness behaviour are not known. We are heartbroken at our inability to provide enough comfort to relatives of our patients who succumbed to COVID‐19 when hospital visits were prohibited. As two Australian emigrants working in a Swedish ICU, we are humbled by our ability to contribute to the care of patients during the pandemic. Our Australian medical training instilled in us a sense of duty, tempering any feelings of helplessness. We applaud the tenacity of our Swedish colleagues. We wish our Australian colleagues well and hope that Australia will be protected from the horrors of COVID‐19. Box – Decentralised organisation of the Swedish health care system

Michelle S Chew · Thomas Halliday

To the Editor: Palliative radiotherapy is effective for symptomatic management of bone metastases in cancer patients. However, it may take 2–4 weeks after completion of radiotherapy to achieve maximal clinical response.1 Radiotherapy can be delivered as a single fraction treatment (SFRT), or over a more protracted course of multifraction treatment (MFRT).2 Randomised trials have consistently shown that SFRT and MFRT provide equally effective symptom control,3 and SFRT is associated with lower medical and societal cost,4 allowing for better health services utilisation. Hence, in patients with poor prognosis, the use of SFRT over MFRT should be encouraged to minimise the time patients spend on treatment at the end of life without compromising efficacy. Using the population‐based Victorian Cancer Registry data linked to the Victorian Radiotherapy Minimum Data Set, we evaluated the use of SFRT for bone metastases at the end of life. The study sample included all cancer patients who received radiotherapy for bone metastases between 2013 and 2016, and died within 30 days of commencing radiotherapy. The primary outcome was SFRT use and the associated factors. The Cochrane–Armitage test for trend was used to evaluate temporal changes in SFRT use over time. Logistic regression was used to evaluate factors associated with SFRT use; variables with a P value below 0.1 in univariate analyses were included in multivariate model, which employed the robust standard error, with analyses clustered on patient identifiers to allow for clustering of patients who had multiple courses of radiotherapy. The study was approved by the Austin Health Human Research Ethics Committee (LNR/18/Austin/34). A total of 1069 patients received 1359 courses of radiotherapy for bone metastases at the end of life, of which 396 courses (29%) were SFRT, and 963 (71%) were MFRT (Box). There was no significant change in SFRT use over time: from 30% in 2013 to 32% in 2016. SFRT was more commonly used closer to death: 49%, 29% and 25% of radiotherapy courses delivered within 7 days, 8–14 days, and 15–30 days of death, respectively. There were large institutional provider variations in SFRT use: 33% and 19% of radiotherapy delivered in public and private institutions, respectively. In multivariate analyses, the site of bone metastases, time between radiotherapy and death, and treatment institution type were independently associated with SFRT use. Overall, in this large Victorian population‐based study, less than one in three courses of radiotherapy for bone metastases at the end of life were SFRT, and about one in two courses of radiotherapy delivered in the last week of life were MFRT, meaning that these cancer patients spent multiple days in their final week of life receiving radiotherapy. Acknowledging that estimation of prognosis towards the end of life can be difficult, there are models (eg, the TEACHH model)5 that can be useful in guiding clinicians in this process. Nonetheless, given the large body of evidence supporting the use of SFRT for bone metastases, there is a need to raise awareness of the recommendation to use of SFRT instead of MFRT, especially at the end of life, among radiation oncologists, other health professionals and patients. This can be achieved through health education initiatives such as the Choosing Wisely campaign (https://www.choosingwisely.org.au/). Box – Factors associated with single fraction palliative radiotherapy (SFRT) for bone metastases at the end of life in Victoria, 2013–2016 (1359 courses of radiotherapy) Variable SFRT (n = 396, 29%) MFRT (n = 963, 71%) Multivariate analysis (odds ratio [95%CI]) P Age (years) Mean (SD) 71.7 (11.9) 70.1 (12.3) < 60 62 (24%) 192 (76%) 1 60–69 95 (27%) 252 (73%) 1.04 (0.67–1.61) 0.9 70–79 149 (32%) 312 (68%) 1.29 (0.83–1.99) 0.3 ≥ 80 90 (30%) 207 (70%) 1.17 (0.73–1.88) 0.5 Sex Men 247 (28%) 622 (72%) Women 149 (30%) 341 (70%) Primary cancer type Lung 163 (30%) 373 (70%) Prostate 49 (29%) 118 (71%) Breast 32 (29%) 77 (71%) Gastrointestinal 53 (28%) 138 (72%) Melanoma 21 (25%) 62 (75%) Other 78 (29%) 195 (71%) Target site of radiotherapy Spine 202 (27%) 545 (73%) 1 Skull 9 (6%) 147 (94%) 0.15 (0.06–0.38) <0.001 Rib 35 (51%) 33 (49%) 3.82 (2.10–6.95) <0.001 Shoulder 35 (49%) 36 (51%) 2.80 (1.44–5.42) 0.002 Hip 19 (36%) 34 (64%) 1.67 (0.78–3.54) 0.2 Pelvic bone 20 (27%) 54 (73%) 1.10 (0.57–2.14) 0.8 Extremities 42 (52%) 39 (48%) 3.04 (1.74–5.29) <0.001 Multiple site 34 (31%) 75 (69%) 1.25 (0.73–2.14) 0.4 Time between radiotherapy start date and death 1–7 days 92 (49%) 97 (51%) 1 8–14 days 99 (29%) 246 (71%) 0.40 (0.25–0.65) < 0.001 15–30 days 205 (25%) 620 (75%) 0.33 (0.21–0.51) < 0.001 Socio‐economic status 1st quintile (most disadvantaged) 103 (35%) 194 (65%) 1 2nd quintile 63 (32%) 137 (69%) 0.88 (0.55–1.40) 0.6 3rd quintile 70 (26%) 203 (74%) 0.73 (0.46–1.17) 0.2 4th quintile 55 (22%) 194 (78%) 0.63 (0.39–1.02) 0.06 5th quintile (least disadvantaged) 105 (31%) 235 (69%) 1.00 (0.62–1.61) 0.9 Remoteness of area of residency Major city 262 (28%) 668 (72%) Inner regional 109 (31%) 241 (69%) Outer regional/ remote 25 (32%) 54 (68%) Treatment institution type Public 317 (33%) 633 (67%) 1 Private 79 (19%) 330 (81%) 0.44 (0.29–0.65) < 0.001 Treatment institution location Metropolitan 280 (27%) 746 (73%) 1 Regional 116 (35%) 217 (65%) 1.02 (0.71‐1.47) 0.9 Year of radiotherapy 2013 115 (30%) 262 (70%) 2014 93 (28%) 243 (72%) 2015 84 (26%) 241 (74%) 2016 104 (32%) 217 (68%) MFRT = multifraction radiotherapy.

Wee Loon Ong · Farshad Foroudi · Roger L Milne · Jeremy L Millar