Volume 214 Issue 7

Junior doctors face uncertain career progression and futures as a consequence of the pandemic

Kate Johnston · Chloe Tyson · Indra Danny · Lois Meyer

CHRIS supported the Victorian ICU response during the COVID‐19 pandemic The coronavirus disease 2019 (COVID‐19) pandemic put an unprecedented strain on intensive care resources throughout the world. Initially in Wuhan (China)1 and then in Lombardy (Italy),2 London (United Kingdom) and New York (United States),3 demand exceeded capacity, with 10–15% of the patients admitted to hospital developing critical illness. Australia has 191 adult and paediatric intensive care units (ICUs), with over 2300 ICU beds.4 This is equivalent to 8.9 ICU beds per 100 000 population, more than the UK but fewer than Italy and the US.5,6 In late March 2020, rising numbers of COVID‐19‐related admissions to ICUs were observed throughout Australia.7 The Australian and New Zealand Intensive Care Society (ANZICS) and the Australian Government Department of Health recognised that ICU demand was unlikely to be uniform, that capacity might be exceeded in one region but not in another, and that matching ICU resources to areas of greatest need might be required. A single sentence encapsulated the approach: “Why would we let a patient die in Western Australia if we can see a spare ventilator in Sydney?” A nationwide system to monitor ICU demand and capacity in Australia A nationwide dashboard of ICU activity, the Critical Health Resources Information System (CHRIS), was rapidly developed as a collaboration between Telstra Purple, Ambulance Victoria, ANZICS and the Australian Government Department of Health. All adult and paediatric ICUs (public and private) in Australia were instructed to enter data twice daily. This manual data entry typically took 5 minutes. Each ICU was immediately able to see patient numbers and resources available within every ICU in their region and also see an aggregate summary of all ICUs in Australia. CHRIS was available to all state and territory health departments, to all patient transport and retrieval agencies, and also to ICUs in New Zealand. The system went live on 1 May 2020, after 26 days of development. Three weeks later, 184 out of 188 eligible ICUs (98%) in Australia were contributing data. The ICU response to the second wave of COVID‐19 in Victoria After a decline in severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infections throughout Australia, notifications rose again in Melbourne at the end of June 2020.8 In response, ICU directors from the lead hospitals of the nine designated Victorian health care clusters commenced a daily morning meeting with representatives from Ambulance Victoria, Safer Care Victoria and the Victorian Department of Health and Human Services. The group committed to maintaining standards of care expected under normal (non‐pandemic) conditions and to achieving this by proactively transferring patients (with or without COVID‐19) to another ICU if delivery of care was compromised by high local demand. Decisions to transfer patients were informed by data from CHRIS. Pre‐existing critical care transfer systems run by Ambulance Victoria were used. From the beginning of July to the end of September 2020, there were 237 ICU admissions with COVID‐19 pneumonitis, of which 210 (88%) occurred in July and August. Admissions were predominantly to public hospitals in north‐western Melbourne.9 The rapid and localised nature of presentations meant that it was faster to transfer patients to ICUs with vacant capacity than to open and staff additional beds, despite physical ICU bed spaces being available. Transfers from the emergency department or ICU at the four north‐western metropolitan hospitals alone accounted for 35% (46/133) of all critical care transfers in Victoria during July and August. Spare ventilators were available at all sites on all days. On six occasions in August, there were more than 140 ventilated patients (with or without COVID‐19) in Victoria. On each of these days, there were more than 500 spare ICU ventilators available (Box 1 and Supporting Information, graphic 1 in the video). Despite individual hospitals indicating transient increases in ICU bed numbers, there was no overall increase in open staffed ICU beds. As COVID‐19 cases rose, so too did numbers of critical care staff unavailable due to COVID‐19 exposure or illness, with 15 consecutive days when there were more than 60 staff unavailable (Box 2). Lessons learned CHRIS provided real‐time data on ICU activity and capacity. In addition to facilitating the transfer of critically ill patients, CHRIS also enabled early diversion of ambulance presentations to emergency departments at hospitals where ICUs had capacity. These approaches were integral to ensuring standards of care were maintained by clinicians, retrieval agencies and the Victorian health department. At the same time, there was visibility to the Australian Government Department of Health, which would, if required, coordinate a national response to overwhelmed ICU services. Although several individual ICUs came under strain, retrieval and critical care systems in metropolitan Melbourne were not overwhelmed. Strategies to redistribute critical care demand are likely to have contributed to high survival rates for ventilated patients with COVID‐19 in Victoria.9 Timely transfers to ICUs with open available beds could be facilitated. Availability of staff was more important in determining capacity to deliver care than availability of ventilators. The role for CHRIS in the future The local application of a national tool (CHRIS) for real‐time display of ICU activity and resources was a key component of the response to the COVID‐19 pandemic in Victoria. CHRIS has the potential to augment existing ICU monitoring systems. The tool may also assist in the response to local and national public health emergencies, such as mass casualty events, bushfires10 or thunderstorm asthma.11 Automated linkage of CHRIS to existing state‐based and national systems should be investigated. In addition, it may have potential use in monitoring health policy impacts more broadly. Box 1 – Snapshot of the Critical Health Resources Information System (CHRIS) summary page for Victoria during August 2020 ACT = Australian Capital Territory; COVID‐19 = coronavirus disease 2019; ECMO = extracorporeal membrane oxygenation; HDU = high dependency unit; ICU = intensive care unit; NSW = New South Wales; NT = Northern Territory; NZ = New Zealand; QLD = Queensland; SA = South Australia; TAS = Tasmania; VIC = Victoria; WA = Western Australia. Box 2 – Number of ventilated (dark blue) and non‐ventilated (light blue) patients in Victorian intensive care units and the number of critical care staff unavailable to work due to coronavirus disease 2019 (COVID‐19) exposure or illness (green dots), listed each morning in the Critical Health Resources Information System (CHRIS) LOWESS = locally weighted scatterplot smoothing.

David Pilcher · Nicholas R Coatsworth · Melissa Rosenow · Jason McClure

An emergency imaging pathway based on local and international guidance tailored to the Australian health care setting Imaging in coronavirus disease 2019 (COVID‐19) is primarily helpful in diagnosing COVID‐19‐related complications and identifying alternative diagnoses that may explain a patient’s presentation. It can also be useful in the risk stratification of patients by identifying the presence and severity of comorbidities.1,2 Imaging is of limited use in screening for COVID‐19 in asymptomatic individuals, and in many cases where COVID‐19 symptoms are mild.1,3 Indiscriminate use of imaging in patients with confirmed or suspected COVID‐19 not only exposes the patient to unnecessary radiation but also represents an unnecessary infection risk and logistic demand for medical imaging departments. Existing international COVID‐19 imaging pathways have been derived in clinical environments significantly different from Australia, often where there is high COVID‐19 prevalence and constrained resource availability. Some centres preferentially use chest x‐ray, whereas others perform various types of computed tomography (CT) imaging of the chest. There is also inconsistency in the reporting of imaging studies in suspected or confirmed COVID‐19, with some reports following traditional didactic format, and others using synoptic template reports as recommended by a variety of medical bodies.4,5 Here we describe an imaging pathway developed at the Royal Adelaide Hospital, the designated COVID‐19 hospital in South Australia. This pathway aims to outline the imaging indications, technique and reporting of chest imaging in an emergency setting, at a time of low COVID‐19 prevalence. We incorporate current available international pathways and best practice guidelines for emergency imaging of COVID‐19 patients into a simple pathway relevant to Australian practice. Imaging pathway development We reviewed consensus and position statements from the Royal Australian and New Zealand College of Radiologists, the Australian and New Zealand Society of Thoracic Radiology, the Fleischner Society and the British Society of Thoracic Imaging. Recommendations pertaining to high COVID‐19 prevalence environments and resource‐constrained environments were modified to suit a scenario of low prevalence. When local guidelines conflicted with international organisations, priority was given to local recommendations on the basis of relevance. Recommendations were subsequently integrated into a clinical imaging pathway in consultation with local specialists in radiology, emergency medicine, general medicine, respiratory medicine and infectious diseases (Box). Reporting terminology The pathway incorporates standardised reporting terminology for patients with COVID‐19 as recommended by the Australian and New Zealand Society of Thoracic Radiology.5 Categorisation of study findings as “normal,” “indeterminate,” “typical” or “other diagnosis favoured” improves report clarity and creates actionable imaging outcomes. Appropriate use of CT The main role of CT in this pathway is to exclude complications and alternative diagnoses in patients with confirmed or suspected COVID‐19. The pathway prompts clinicians to consider CT for patients who are hypoxic (or have an oxygen requirement) and who have a chest x‐ray that is either “normal” or “indeterminate for COVID‐19”. In this instance there is a clinicoradiological discrepancy, and either a complication (such as a pulmonary embolus) or an alternative diagnosis is suspected. In keeping with British Society of Thoracic Imaging guidance, a low‐dose unenhanced CT of the chest is the CT scan of choice, with strong consideration given to an additional CT pulmonary angiogram.4 There is accumulating evidence that patients with COVID‐19 are abnormally prothrombotic, and conventional clinical decision rules and blood tests (especially D‐dimer) may not be applicable.3 Clinicians should have a lower threshold than usual for performing a CT pulmonary angiogram. The unenhanced CT functions primarily as a baseline, as the presence of intravenous contrast can artifactually simulate ground glass. Whenever possible, the non‐contrast CT scan and the CT pulmonary angiogram should be performed on the same occasion to minimise infection control risk and operational demands on medical imaging departments. Baseline imaging for patients at risk of deterioration Patients with comorbidities are recognised as being at higher risk of deterioration. Defined risk factors vary between institutions but include older patients, requirement for oxygen supplementation, significant comorbidities (especially cardiac or respiratory) and immunosuppression. The consensus statement from the Fleischner Society supports imaging in patients who have a positive test result for COVID‐19 and risk factors for disease progression, regardless of their clinical status. The use of imaging in this situation is to establish a baseline for future comparison and determine the extent of comorbidities. Imaging may also inform the intensity of follow‐up monitoring, either in the community or an inpatient setting.1 Incidental findings suspicious for COVID‐19 Although there are no radiological findings pathognomonic for COVID‐19, there are radiological findings commonly associated with infection.5 When imaging findings typical for COVID‐19 are seen in a patient who is not suspected of having infection, the pathway prompts the radiologist to discuss the findings with the referring emergency physician. Patient isolation and COVID‐19 testing may be required. This is intended as a safety net for patients who may not be identified by current clinical screening processes, acknowledging that patients with COVID‐19 may be asymptomatic, may present with atypical symptoms and do not necessarily have knowledge of close contact with an infected individual. Ultrasound There is some evidence that point‐of‐care ultrasound can be used in the imaging of patients with COVID‐19; however, given variability in specialist expertise and availability, this has not been incorporated in this pathway.1 Conclusion Chest imaging in suspected or confirmed COVID‐19 in a low prevalence environment is best used to detect complications and rule out alternative diagnoses. The pathway described here aims to clarify imaging indications, technique and reporting of studies performed on patients with suspected or confirmed COVID‐19 in an acute care setting. Box – COVID‐19 emergency imaging guidelines AP = anteroposterior; ANZSTR = Australian and New Zealand Society of Thoracic Radiology; COVID‐19 and COVID = coronavirus disease 2019; CT = computed tomography; CTPA = computed tomography pulmonary angiogram; CXR = chest x‐ray; ED = emergency department.

David Ngan · Suzanne McKeen · Meegan Gun · Daniel Haustead · Andrew Low · Brett Lorraine · James Bewes

The large number of long term hydroxychloroquine users in Australia necessitates clear guidelines on hydroxychloroquine retinopathy screening Hydroxychloroquine retinopathy, which causes permanent visual loss, is a well documented adverse effect in long term users of both hydroxychloroquine and chloroquine. However, it can be difficult to detect as visual acuity is often well preserved until the disease is severe.1 Because of this, it was once thought to be a rare adverse effect, with only 0.5–2.0% of long term hydroxychloroquine users estimated to suffer from the condition.2 However, a 2014 epidemiological study of 2361 patients using hydroxychloroquine long term in the United States found that this was a large underestimation.2 The investigators found an overall prevalence of 7.5% in patients who had taken the drug for at least 5 years, but this risk increased with length of use and dosage.2 Owing to its efficacy in treating a variety of inflammatory and dermatological conditions (eg, systemic lupus erythematosus), cost‐effectiveness and relatively good safety profile, hydroxychloroquine is widely used by many Australians long term.3 In 2015, there were about 28 300 individuals (0.12% of all Australians) using the drug daily.4 Given this estimated number of users and the 7.5% prevalence rate,2 there could be more than 2000 potential cases of hydroxychloroquine retinopathy in Australia. However, there is no recommended consensus on screening for this condition in Australia, which may lead to inconsistent screening and missed cases.5 Existing screening guidelines Currently, two main guidelines on hydroxychloroquine retinopathy screening exist and are used by practitioners in Australia: the American Academy of Ophthalmology 2016 guidelines and the United Kingdom Royal College of Ophthalmologists 2020 guidelines.1,6 While both are very similar, small but significant differences exist between them. For example, both guidelines recommend that patients who fall within the high risk category should commence screening earlier than the general population, who are screened starting from 5 years of taking hydroxychloroquine.1,6 However, there is some disagreement on which risk factors warrant classification into the high risk category (Box 1). Recommendations also vary regarding the frequency of screening in high risk patients.1,6 There are also small differences in the investigations recommended by each set of guidelines. For example, the UK guidelines6 recommend fundus autofluorescence as an additional standard screening investigation (Box 2). The need for Australian guidelines There are currently no studies discussing the prevalence of hydroxychloroquine retinopathy in Australia, which makes it difficult to determine whether current screening practices are sufficient. However, the differences in the US and UK guidelines may have practical consequences for the consistency of hydroxychloroquine detection rates in the Australian population.5 As these guidelines were developed in non‐Australian settings, they may also need to be modified to better suit Australia’s unique context. For example, compared with the US and the UK, Australia has a significantly larger proportion of residents identifying as Asian in ancestry. In 2016, about 13% identified as having Asian ancestry,7 compared with 5.9% of Americans who identified as Asian in 2019.8 Due to the more peripheral pattern of damage from hydroxychloroquine sometimes seen in Asian populations, there are recommendations that a wider 24‐2 or 30‐2 visual field test should be performed for such patients, in addition to the recommended 10‐2 visual field test in the US and UK guidelines.9 Another factor to consider is whether Australia’s public health system can support ophthalmology screening at the frequency recommended by the US and UK guidelines. Already, waiting times for non‐urgent appointments for ophthalmologists in the public system can reach years. In South Australia, the median waiting time for an outpatient ophthalmologist appointment ranges from 4.8 to 17.6 months at metropolitan hospitals,10 which makes annual screening impossible for many patients without private care. The costs to the health system also warrant consideration. Under the current Medicare Benefits Schedule, a standard specialist consultation (item 104) and visual field test (item 11224) would cost $131.65, totalling more than $1.5 million to test 50% of the individuals taking hydroxychloroquine annually in the public setting.11 Australia‐specific screening guidelines could better account for these practical considerations, although further studies would be necessary to determine how successfully the system already supports hydroxychloroquine retinopathy screening based on existing guidelines. Conclusion Given its potential to cause permanent vision loss and the number of Australians taking hydroxychloroquine long term, developing Australian screening guidelines for hydroxychloroquine retinopathy would be beneficial in promoting consistent screening practices tailored to the Australian population. Before these can be established, however, more research needs to be conducted on the prevalence and current detection rates of hydroxychloroquine retinopathy in Australia. Box 1 – Risk factors and recommendations in the United States1 and United Kingdom6 hydroxychloroquine retinopathy screening guidelines Risk factor US UK Hydroxychloroquine dose > 5 mg/kg Yes Yes Renal disease Yes Yes Tamoxifen use Yes Yes Pre‐existing retinal and macular conditions Yes No Equivalent chloroquine dose > 2.3 mg/kg No Yes Box 2 – Screening investigations for hydroxychloroquine retinopathy recommended by the United States1 and United Kingdom6 guidelines Investigations US UK Baseline (for patients with no known pathology) Fundus evaluation of the macula Fundus evaluation of the macula Spectral domain optical coherence tomography Screening 10‐2 visual field test Spectral domain optical coherence tomography 10‐2 visual field test Spectral domain optical coherence tomography Fundus autofluorescence

Marisse T Sonido · Kristopher Rallah-Baker · Monisha Gupta

A multilayered action plan is needed for a substantial, timely and sustained investment in dementia prevention In 2012, the Australian Government declared dementia as the ninth National Health Priority Area. Eight years later, dementia is the greatest cause of disability in Australians aged over 65 years, the second leading cause of mortality, and the highest in women.1 Today, more than 459 000 Australians live with dementia, and this number is expected to exceed one million by 2056.2 The societal, economic and health care burden of dementia is unprecedented, with significant impacts on individuals, caregivers and families. In addition to therapeutic advances, improved and timely diagnosis and coordinated person‐centred care, dementia prevention and risk‐factor management are our best chance to make a difference.3 How do we tackle dementia prevention cost‐effectively in the post‐pandemic era? Between 40% and 48% of dementia risk is considered modifiable.4,5 In Australia, the population‐attributable risk of dementia risk factors, in descending order, are physical inactivity (17.9%), mid‐life obesity (17.0%), low educational attainment in early life (14.7%), mid‐life hypertension (13.7%), depression (8.0%), smoking (4.3%), and diabetes mellitus (2.4%).5 In addition, the 2020 Lancet Commission report on dementia prevention, intervention and care4 includes hearing loss, traumatic brain injury, alcohol use, social isolation, and air pollution as risk factors. Emerging research suggests that a suboptimal diet,6 cognitive inactivity7 and sleep–wake disturbance8 also influence the modifiable dementia risk. We urge substantial, timely, and sustained investment in dementia prevention via a multilayered action plan with eight recommendations (Box). 1. Create public health and clinical practice guidelines for dementia prevention across the lifespan for the Australian setting. In 2019, the World Health Organization released dementia risk‐reduction guidelines stating that “the existence of potentially modifiable risk factors means that prevention of dementia is possible through a public health approach”.9 These guidelines focus on “interventions that delay or slow cognitive decline or dementia,” with the strongest recommendations being applied to addressing physical inactivity, tobacco cessation, hypertension and diabetes mellitus.9 Yet, in Australia, we do not have dementia prevention guidelines, with the clinical practice guidelines for dementia from the National Health and Medical Research Council (NHMRC) and the Australian Cognitive Decline Partnership Centre (CDPC) focusing on diagnosis and management.10 Since then, Australia has made significant progress by including dementia prevention guidelines for general practitioners in the CDPC’s Care guide for general practice.11 We recommend extending guidelines beyond primary care, including secondary prevention in memory clinics, prioritising educational attainment in early life, and developing occupational and environmental policy to reduce hearing loss, traumatic brain injury, and air pollution. 2. Equip and resource primary care providers to be the clinical spearheads for dementia prevention throughout life. Primary care is the usual entry point and key coordinator of care within the health care system and is well positioned to spearhead dementia prevention throughout life. The Medicare Benefits Schedule should increase focus on dementia prevention, enabling primary care, specialists, and allied health professionals more time, resources and team care. This could be achieved through new Medicare Benefits Schedule item numbers and modification of existing items, such as the 45–49‐year‐old health check for individuals at risk of chronic conditions. Private health insurers could complement this by expanding the scope of preventive health services to target dementia risk factors and rewarding individuals who participate with lower insurance premiums or greater rebates for health services. 3. Support multidisciplinary memory clinics and specialists to implement secondary prevention programs for those at high risk. Memory clinics and specialists should focus on secondary prevention for people at higher risk, such as those with mild cognitive impairment.12 The Australian Dementia Network (ADNeT) aims to unite and build the network of memory clinics, establish practice guidelines, harmonise assessments, and implement dementia prevention tools and strategies. ADNeT will also facilitate access to clinical trials, improve diagnostic accuracy to aid secondary prevention approaches and introduce a Clinical Quality Registry. 4. Fund research for evidence‐based interventions for modifiable risk factors for dementia across the life cycle to reduce the evidence‐to‐practice gap. While there has been increasing funding for dementia prevention research and the establishment of the International Research Network on Dementia Prevention as part of the Australian Government’s commitment to the World Dementia Council,13 urgent funding is still required to address critical evidence‐to‐practice gaps. The current evidence base includes observational studies and intervention trials that have generally focused on cognitive outcomes, rather than dementia incidence, given the long time frames needed. We need to strengthen the evidence base on managing risk factors across different phases of the lifespan, such as the most effective doses and forms of interventions in large‐scale trials. Rigorously evaluated multidomain prevention trials that simultaneously target multiple risk factors may present the best value for money if shown to be effective and sustainable, particularly as they address risk factors that have an established evidence base for preventing other conditions. A number of these trials are already underway in Australia. 5. Implement findings from dementia risk reduction and implementation research through translation into health promotion programs. Implementation research will be key to translating the increasing evidence base for dementia risk reduction interventions into effective health promotion programs. The science of behaviour change will be critical given the evidence‐to‐practice gap. This emphasises the importance of co‐design to empower individuals to modify their risk. For health professionals, education and training on dementia risk factors and skills in motivational interviewing and behaviour change principles should be prioritised. 6. Strengthen dementia prevention public health campaigns embracing Australians’ diversity, particularly Aboriginal and Torres Strait Islander Australians. Australian‐specific dementia prevention guidelines that inform public health campaigns need to appeal to all Australians, embracing geographic, socio‐economic, cultural, linguistic, social, ethnic, age, gender, and sexual diversity. This is particularly important for Aboriginal and Torres Strait Islander people, for whom dementia prevalence is three to five times higher than the general population. These measures need to be equitable and not disadvantage vulnerable groups that may already have reduced access to resources. 7. Resource and coordinate a whole‐of-community approach including government, public and private health care, community services and education sectors to operationalise guidelines and multifaceted dementia prevention programs throughout life. Dementia prevention is everyone’s business. Successful public health and disease prevention campaigns have required a coordinated effort across all levels of the health sector, government, policy makers, non‐government organisations, research, education, industry and the community. Yet, many Australians do not believe that dementia risk can be reduced.14 Dementia prevention is complex due to stigma, literacy, and multifactor risks throughout life. The success of widely known public health campaigns in Australia (eg, Quit for Life and Slip, Slop, Slap) is attributable to their focus on behaviour change using a single behaviour or risk factor, informed by knowledge of barriers and enablers. The Dementia Australia Your Brain Matters campaign was targeted at raising public awareness for dementia, but this was not sustained beyond the funding period (2012–2015). The report from the Lancet Commission identifies educational attainment in early life as an impactful risk factor4 and this should be prioritised given its broader socio‐economic benefits. There are specific mid‐life (hearing loss, traumatic brain injury, hypertension, alcohol intake, obesity) and late‐life factors (smoking, depression, social isolation, physical inactivity, diabetes, air pollution) which offer opportunities for risk reduction across the lifespan.4 From a practical perspective, as many dementia risk factors are shared with other chronic conditions, particularly vascular risk factors, these may present the best opportunity for greatest impact. 8. Mobilise peak health advocacy bodies to promote and coordinate public health messaging on dementia risk factors that cut across chronic conditions. How do we ensure value for money and sustainability of dementia prevention public health campaigns? A unified approach with clear messaging communicated through media, community organisations, and health professionals promoting shared responsibility is crucial. An initial focus on risk factors with the highest population‐attributable risk (physical inactivity and midlife obesity) is recommended to improve wellbeing and reduce risk for multiple chronic conditions. They are also ideal for integrated programs given their overlap with vascular risk factors and successful campaigns (eg, smoking cessation). A key step is the coordination and pooling of resources between peak advocacy bodies such as Dementia Australia, Diabetes Australia, and the Heart Foundation, with clear messaging focusing on single risk factors that have multiple benefits. In clinical practice, this facilitates approaches that are tailored to an individual’s experiences and motivation. For example, motivation for increasing physical activity for one individual may arise from receiving a result of impaired glucose tolerance, while for another it may be the experience of having a family member living with heart disease or dementia. Australia has excellent health infrastructure and an international reputation for dementia prevention due to our depth of clinical, research, and knowledge translation expertise. If we are committed to achieving the ambitious targets of reduced dementia prevalence and incidence, we must shine a spotlight on dementia prevention across all levels of society. To achieve this, the National Health and Medical Research Council National Institute for Dementia Research (NNIDR) Dementia Prevention Special Interest Group proposes this Dementia Prevention Action Plan for Australia. It is time for a call to action in the fight against dementia: dementia prevention needs to be the next international public health area of focus, with Australia playing a leading role. Box – Dementia Prevention Action Plan

For the NHMRC National Institute for Dementia Research, Dementia Prevention Special Interest Group*

A 61-year-old man was referred to our ophthalmology service 3 days after a tree branch injury to the left eye

Shivesh Varma · Yi Fan Tang · Salim Okera

An 88-year-old white woman presented with a subcutaneous mass on the left lateral brow

Tung T Hoang · Graham A Lee · Timothy J Sullivan

Patients receive similar treatment and have similar outcomes whether their initial hospital has cardiac catheterisation facilities or not

Peter L Thompson

Improving integrated care and systematically targeting major cancer and non- cancer causes of morbidity and mortality could yield major benefits

Emily Banks · Grace Joshy

Objective: To determine whether the availability of invasive coronary angiography at the hospital of presentation influences catheterisation rates for patients with acute coronary syndrome (ACS), and whether presenting to a catheterisation‐capable hospital is associated with better outcomes for patients with ACS. Design, setting: Retrospective cohort study; analysis of Cooperative National Registry of Acute Coronary Events (CONCORDANCE) data. Setting, participants: Adults admitted with ACS to 43 Australian hospitals (including 31 catheterisation‐capable hospitals), February 2009 – October 2018. Main outcome measures: Major adverse cardiovascular events (myocardial infarction, stroke, congestive heart failure, cardiogenic shock, cardiovascular death) and all‐cause deaths in hospital and by six and 12‐ or 24‐month follow‐up. Results: The proportion of women among the 5637 patients who presented to catheterisation‐capable hospitals was smaller than for the 2608 patients who presented to hospitals without catheterisation facilities (28% v 33%); the proportion of patients diagnosed with ST elevation myocardial infarction was larger (32% v 20%). The proportions of patients who underwent catheterisation (81% v 70%) or percutaneous coronary intervention (49% v 35%) were larger for those who presented to catheterisation‐capable hospitals. The baseline characteristics of patients who underwent catheterisation were similar for both presentation hospital categories, as were rates of major adverse cardiovascular events and all‐cause death in hospital and by 6‐ and 12‐ or 24‐month follow‐up. Conclusions: Although a larger proportion of patients who presented to catheterisation‐capable hospitals underwent catheterisation, patients with similar characteristics were selected for the procedure, independent of the hospital of presentation. Major outcomes for patients were also similar, suggesting equitable management of patients with ACS across Australia.

Michael Ayad · Karice Hyun · Mario D’Souza · Julie Redfern · Janice Gullick · Mark Ryan · David B Brieger

Objectives: To investigate causes of death of people with cancer alive five years after diagnosis, and to compare mortality rates for this group with those of the general population. Design, setting, participants: Retrospective cohort study; analysis of South Australian Cancer Registry data for all people diagnosed with cancer during 1990–1999 and alive five years after diagnosis, with follow‐up to 31 December 2016. Main outcome measures: All‐cause and cancer cause‐specific mortality, by cancer diagnosis; standardised mortality ratios (study group v SA general population) by sex, age at diagnosis, follow‐up period, and index cancer. Results: Of 32 646 people with cancer alive five years after diagnosis, 30 309 were of European background (93%) and 16 400 were males (50%); the mean age at diagnosis was 60.3 years (SD, 15.7 years). The median follow‐up time was 17 years (IQR, 11–21 years); 17 268 deaths were recorded (53% of patients; mean age, 80.6 years; SD, 11.4 years): 7845 attributed to cancer (45% of deaths) and 9423 attributed to non‐cancer causes (55%). Ischaemic heart disease was the leading cause of death (2393 deaths), followed by prostate cancer (1424), cerebrovascular disease (1175), and breast cancer (1118). The overall standardised mortality ratio (adjusted for age, sex, and year of diagnosis) was 1.24 (95% CI, 1.22–1.25). The cumulative number of cardiovascular deaths exceeded that of cancer cause‐specific deaths from 13 years after cancer diagnosis. Conclusions: Mortality among people with cancer who are alive at least five years after diagnosis was higher than for the general population, particularly cardiovascular disease‐related mortality. Survivorship care should include early recognition and management of risk factors for cardiovascular disease.

Bogda Koczwara · Rosie Meng · Michelle D Miller · Robyn A Clark · Billingsley Kaambwa · Tania Marin · Raechel A Damarell · David M Roder

Objective: To evaluate the efficacy and safety of paracetamol as an analgesic medication in a range of painful conditions. Study design: Systematic review of systematic reviews of the analgesic effects of paracetamol in randomised, placebo‐controlled trials. Conduct of systematic reviews was assessed with AMSTAR‐2; confidence in effect estimates (quality of evidence) was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Data sources: MEDLINE, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews; systematic reviews published 1 January 2010 – 30 April 2020. Data synthesis: We extracted pain and adverse events outcomes from 36 systematic reviews that assessed the efficacy of paracetamol in 44 painful conditions. Continuous pain outcomes were expressed as mean differences (MDs; standardised 0–10‐point scale); dichotomous outcomes were expressed as risk ratios (RRs). There is high quality evidence that paracetamol provides modest pain relief for people with knee or hip osteoarthritis (MD, –0.3 points; 95% CI, –0.6 to –0.1 points) and after craniotomy (MD, –0.8 points; 95% CI, –1.4 to –0.2 points); there is moderate quality evidence for its efficacy in tension‐type headache (pain‐free at 2 hours: RR, 1.3; 95% CI, 1.1–1.4) and perineal pain soon after childbirth (patients experiencing 50% pain relief: RR, 2.4; 95% CI, 1.5–3.8). There is high quality evidence that paracetamol is not effective for relieving acute low back pain (MD, 0.2 points; 95% CI, –0.1 to 0.4 points). Evidence regarding efficacy in other conditions was of low or very low quality. Frequency of adverse events was generally similar for people receiving placebo or paracetamol, except that transient elevation of blood liver enzyme levels was more frequent during repeated administration of paracetamol to patients with spinal pain (RR, 3.8; 95% CI, 1.9–7.4). Conclusions: For most conditions, evidence regarding the effectiveness of paracetamol is insufficient for drawing firm conclusions. Evidence for its efficacy in four conditions was moderate to strong, and there is strong evidence that paracetamol is not effective for reducing acute low back pain. Investigations that evaluate more typical dosing regimens are required. PROSPERO registration: CRD42015029282 (prospective).

Christina Abdel Shaheed · Giovanni E Ferreira · Alissa Dmitritchenko · Andrew J McLachlan · Richard O Day · Bruno Saragiotto · Christine Lin · Vicki Langendyk · Fiona Stanaway · Jane Latimer · Steven Kamper · Hanan McLachlan · Harbeer Ahedi · Christopher G Maher

To the Editor: In a recent letter published in the MJA, Muhi and colleagues1 reviewed the source of acquisition by 11 health care workers with coronavirus disease 2019 (COVID‐19) who presented for symptomatic screening at a single clinic. Travel and transmission outside the workplace were considered the likely source of infection for most of them. Data on COVID‐19 cases collected for public health purposes in Western Australia up to 1 June 2020 were reviewed to inform local public health strategies to protect health care workers. Fifty‐seven cases of COVID‐19 among health care workers or workers in health care settings with direct patient contact were identified. Fifty‐six cases were confirmed by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) polymerase chain reaction (PCR) test, and one case had positive SARS‐CoV‐2 IgG serology indicating past infection. Thirty‐one health care workers acquired their infection from a cruise ship or overseas, and 26 health care workers acquired COVID‐19 within Australia. The likely source of the 26 locally acquired cases is shown in the Box. Ten health care workers acquired the infection in the workplace. A further eight had no known contact with a COVID‐19 case but worked during their incubation period. These health care workers may have acquired the infection from an unidentified patient with COVID‐19, from another health care worker, or via fomite transmission at work. Extensive contact tracing did not reveal an alternate source in a setting of limited community transmission. Where possible, whole genome sequencing was used to substantiate epidemiological findings. Transmission of COVID‐19 occurred between health care workers, emphasising the need for staff to recognise not only the risk from patients but also from colleagues, where use of personal protective equipment and physical distancing may be relaxed. There were no cases among staff in COVID‐19 clinics, suggesting that the use of personal protective equipment does mitigate risk. Workplace fomite transmission was the putative source on three occasions, which reinforces the importance of regular environmental cleaning, rigorous cleaning of shared equipment, and good cough etiquette and hand hygiene practices within health care facilities. Our review describes a larger cohort of COVID‐19 cases among health care workers, encompassing metropolitan and regional settings. With international travel restrictions, an increasing proportion of locally acquired infections among health care workers may be expected. From this analysis and others,2 colleagues and fomites should be recognised as potential workplace sources of infection, in addition to direct patient contact. Box – Likely source of coronavirus disease 2019 (COVID‐19) infection for locally acquired cases by Western Australian health care workers (HCWs) Source of infection Cases Direct HCW to HCW transmission 7 Likely fomite transmission 3 Unknown, but worked during incubation period* 8 From a close contact outside of work 5 Contact not identified, but interstate travel 3 Total 26 * No alternate source of infection identified in the context of limited community transmission.

Rebecca J Hogan · Suzanne McEvoy

To the Editor: The clinical trial landscape has arguably progressed more in the past 6 months than in the previous 10 years. The needs of humanity in the global pandemic catalysed the necessity to evaluate study design, implementation, governance, technology and collaboration. The race for effective therapies and a vaccine highlighted the need to expedite drug development and approval. While clinical trials in oncology have used master protocols for many years, with clear guidance from regulatory authorities1 and a gradual adoption in other therapeutic areas,2 these have become the blueprint for coronavirus disease 2019 (COVID‐19) clinical trials developed by the World Health Organization, ensuring the ability to test a broad range of therapies. COVID‐19 has also triggered the adoption of technology to support trials, accelerating the move to a digital age of clinical trials.3 Platforms to deliver online recruitment, electronic consent, wearable devices, artificial intelligence and electronic systems for source data and regulatory documents now provide the solution to maintaining clinical trials activity, at a time when restrictions challenge the viability of face to face trial operations. The need for comprehensive, integrated electronic medical records is evident, with enduring access for parties for data verification, but raises issues of access, privacy and cybersecurity. Out of necessity, clinical trials have also adopted teletrials, like the need in medical practices to adopt telemedicine,4 resulting in a dispersed, decentralised model of operation. The pressure to adapt clinical trial delivery has seen previously perceived barriers fall away. By focusing on common goals, collaboration, technology, and building solid foundations to evaluate our progress to ensure research integrity and safety, a new era of clinical trials will unfold. The clinical trials team of the future will evolve, incorporating a core team with information and communication technology capabilities to support training, management and development of trial systems in a networked model of delivery. While this is a welcome push into a new technological era, with an opportunity to retain new elements and abandon outdated models, we must proceed with thoughtful consideration and evaluation of our progress.

Alana Sarah · Olivia Dean · Michael Berk

To the Editor: Despite death being common in aged care, bereavement support for family and others is not part of care.1 In contrast, palliative care inherently extends to the patient’s family members, including after death.2 Coronavirus disease 2019 (COVID‐19)‐related deaths in aged care have left many families bereft. This is a consequence of forced separation in the final stage of life, the family member being transferred to an acute hospital, the question of whether the patient died alone, and limitations on traditional rituals and practices surrounding funerals.3,4 Like many community palliative care services, Melbourne City Mission’s Palliative Care (MCMPC) services have a well established aged care consultative team that provides advice on complex end‐of‐life issues. At the beginning of the COVID‐19 pandemic, MCMPC started to receive referrals for bereavement support — rapid referrals for residents in aged care facilities in the terminal phase of illness to speak with their families both before and after the patient’s death. Examples of catastrophic grief resulting from the COVID‐19‐related deaths in aged care facilities overseas prompted MCMPC’s preparation to respond to traumatised relatives.5 This work simply involved a phone call to families after the patient’s death. What was heard was sobering, summed up by one family member as “it was not meant to be this way”. Families expressed disappointment that the resident had contracted COVID‐19, stating they should have been safe in their home. The bereaved spoke of their enormous loss, having not been able to be with their loved one, in some cases, for a period of over 7 months. While most families were realistic about the frailty of their family member, they also said that “it was not their time,” that COVID‐19 unfairly changed the trajectory of how they expected their last days or months to go. Palliative care has much in common with aged care, notably the care of patients who are facing the final stage of their life. For staff it has been important to give each bereaved person a chance to capture their individual story, to give identity to the person who died, so they are not just another of the many deaths in aged care. In validating family members’ experiences, this simple phone intervention may mitigate poor bereavement outcomes5 by providing a space to honour their loss.

Margaret O’Connor · Bronwyn Wilson

To the Editor: Public health strategies to control coronavirus disease 2019 (COVID‐19) in Australia aim to test, identify and isolate all cases including those among children.1 We investigated the intended actions of parents if their child developed COVID‐19 symptoms, such as a runny nose, sore throat, cough, fever, chills, loss of smell, diarrhoea, and/or nausea and vomiting.1 We collected data during 15–23 June 2020 via an online survey of 1834 Australian parents of children aged 3–17 years who attended childcare, kindergarten and/or school.2 The sample was limited to these respondents as one of our objectives was to test if children would be kept home from childcare and/or school (isolate). The questionnaire was administered by a private vendor as part of the Royal Children’s Hospital National Child Health Poll, a recurring periodic online survey. Participants were randomly selected from a representative consumer panel of over 350 000 Australian adults — who were recruited onto the panel via online and offline methods such as door knocking, phone calls, letters etc — using quotas to achieve a nationally representative sample reflective of age, sex and state populations. The sample size was justified based on the commonly used margin of error of 3% for estimating a proportion. Only one parent per household could complete the questionnaire and households were not permitted to participate in more than one poll. Participants had no direct contact with the research team. Responses were voluntary and anonymous. Respondents were incentivised for participation in the form of points towards shopping gift cards. The study protocol was approved by the Royal Children’s Hospital Human Research Ethics Committee (RCH HREC 35254). Intended actions of parents if their child developed possible COVID‐19 symptoms are presented in the Box. We classified parents as “seeking COVID‐19 test or medical advice” or not. The sample characteristics are presented in the Supporting Information. We found that 1458 of 1834 parents (78.95%, weighted) of children with symptoms compatible with COVID‐19 intended to seek a COVID‐19 test for their child. There is little published research exploring why some parents may not present children for COVID‐19 testing. A recent Australian study has identified barriers to testing among adults, including a belief that testing is painful, a lack of knowledge about how to get tested, and worry about getting infected at the testing centre.3 These barriers may also apply to parents in relation to testing for children. Additional barriers may include financial implications of time off work to take a child for testing and fear of the social stigma associated with a diagnosis of COVID‐19.4 As upper respiratory tract infections are common among children and often present with similar symptoms to COVID‐19,1 parents may misattribute possible COVID‐19 symptoms to the common cold. Messages from governments may be unclear and parents may not believe that general directives apply to children.5 Timely testing is a critical aspect of containing the pandemic in Australia. With one in five parents indicating they would not present their symptomatic child for COVID‐19 testing, further research is urgently needed to identify and understand barriers to testing in order to inform targeted strategies and messaging to enhance testing uptake in children. Box – Intentions of parents if child developed symptoms compatible with coronavirus disease 2019 (COVID‐19), Australia, 2020 Number (%)*† Keep child home from school or child care until all their symptoms have gone 991 (53.22%) Take child to a doctor (GP or hospital) for a COVID‐19 test 810 (44.66%) Keep child home from school or child care for a couple of days 672 (36.34%) Call the GP for advice 618 (33.62%) Take child to a COVID‐19 testing centre 452 (23.33%) Call the COVID‐19 hotline for advice 415 (22.69%) Send child to school or childcare if they seem well enough 47 (2.66%) Not sure what to do 34 (1.73%) Take child for test‡* 1458 (78.95%) GP = general practitioner. * The cumulative percentage is greater than 100% as respondents could select more than one option. † The sample was nationally representative in terms of the distribution of national resident population by state; however, the distribution of parent sex by state and socio‐economic status was slightly over‐representative of female and more advantaged residents (Supporting Information). Hence, the data were weighted by state, sex and the Index of Relative Socio‐economic Advantage and Disadvantage (IRSAD). ‡ “Take child for test” was defined as at least one of the following options: take child to doctor or testing centre for a test, call GP for advice or call the COVID‐19 testing centre.

Mary‐Anne Measey · Monsurul Hoq · Anthea L Rhodes

To the Editor: The Coroners Court of Victoria made several recommendations in 2020 after a 38‐year‐old man died alone at home.1 The cause of death was determined to be sepsis in the setting of an adrenal crisis. The key coronial recommendations1 were to emphasise to the general medical community the non‐specific nature of symptoms of impending adrenal crisis (eg, fatigue, nausea, loss of appetite, vomiting),2 to record the diagnosis of adrenal insufficiency prominently as an alert in medical records,3 and to encourage endocrinologists to provide sick day or steroid stress dosing letters to patients, general practitioners, and family members and carers. The Endocrine Society of Australia (ESA) endorses these recommendations. A standard patient letter has been developed and is now available on the ESA’s Hormones Australia website.4 We strongly support medical record alerts for the diagnosis of cortisol deficiency due to Addison disease or hypopituitarism. It is crucial for doctors to have a high index of suspicion for the possibility of impending adrenal crisis in a patient with known adrenal insufficiency. The clinical syndrome evolves from acute adrenal insufficiency with symptoms of malaise, nausea and lethargy — all of which are non‐specific and may be considered part of another pathological process — to adrenal crisis, which is associated with hypotension initially manifest by postural blood pressure falls greater than 20 mmHg.2,3 Prevention involves advice on stress dosing:1 triple glucocorticoid dosing for 3 days (ie, the 3 × 3 rule),2 parenteral hydrocortisone at home (SOLU‐CORTEF Act‐O‐Vial, Pfizer) when unable to take tablets,3 and the availability of personal alerts (eg, a MedicAlert bracelet [MedicAlert Foundation], a steroid card) when the person is delirious or very unwell (Box). The incidence of adrenal crises is increasing in Australia.3 Missed cases or failure to treat them because of overestimation of the risks of glucocorticoid therapy are unfortunately too common. Box – Practical steps to reduce the risk of adrenal crisis Ensure that others are aware of the diagnosis of established adrenal insufficiency Prominent medical alert in GP and hospital medical records Patient carries either a steroid card, which lists diagnosis and glucocorticoid therapy, or uses a MedicAlert bracelet (MedicAlert Foundation) A sick day or steroid stress dosing letter should be provided by the endocrinologist to the patient with adrenal insufficiency, with a copy to their GP Encourage the patient with adrenal insufficiency to provide copies of the letter to their next of kin, close relatives or carer Have a high index of suspicion for an impending adrenal crisis Beware of non-specific symptoms of nausea, vomiting or lethargy in a patient with established adrenal insufficiency Prevent an adrenal crisis in patients with established adrenal insufficiency When unwell, follow the 3 × 3 rule (ie, three times the usual glucocorticoid dose for 3 days) and seek urgent medical attention if not improving Promptly treat an impending adrenal crisis The patient and/or carer should be trained to administer 100 mg SOLU‐CORTEF Act‐O‐Vial (Pfizer) intramuscularly* if vomiting occurs or the patient is unable to swallow tablets GP = general practitioner. * Some authorities recommend the off‐label use of a subcutaneous injection as this is easier for patient and/or carer to administer.

Peter S Hamblin · Bu B Yeap · David J Torpy

To the Editor: Hereditary cancer predisposition syndromes (HCPS) account for at least 10% of paediatric cancers.1 Li‐Fraumeni syndrome (LFS) is a dominant HCPS caused by mutations in the TP53 gene and is associated with an 80–90% lifetime risk of cancer, commencing in infancy.2 Children of affected individuals are at 50% risk of inheriting the family mutation. Surveillance programs, involving clinical review and medical imaging, are being used in paediatric populations with HCPS, as significantly higher overall survival is reported with early tumour detection.3 In 2018, the Paediatric Surveillance Clinic was established at Perth Children’s Hospital to provide surveillance for asymptomatic children with, or at 50% risk of developing, LFS and with other HCPS, and to address the needs of their families. Families with at‐risk children can choose to attend the clinic, allowing them to receive information, support and sufficient time to make a decision regarding genetic testing. The quarterly clinic is in a general paediatric setting and offers surveillance for mutation‐positive children in line with eviQ guidelines — a free resource of evidence‐based, consensus‐driven cancer treatment and genetic testing protocols hosted by Cancer Institute NSW.4 Children at 50% risk of LFS, who have not had genetic testing, receive a six‐monthly clinical review and prompt assessment of any concerning symptoms during the interim period. Over an 18‐month period, the Paediatric Surveillance Clinic has seen 11 children from five families, aged from 3 months to 14 years. Most of these children are at risk of or have a TP53 mutation and one child has a VHL (Von‐Hippel‐Lindau) mutation. The Paediatric Surveillance Clinic offers a holistic service with a multidisciplinary team consisting of a general paediatrician, a paediatric nurse, a paediatric oncologist, a genetic counsellor and a clinical geneticist. The clinic has highlighted the specific and unmet needs of families dealing with HCPS and has allowed for essential integration of genetic, paediatric and oncology services for these families.5 As the number of identified HCPS grows, the Paediatric Surveillance Clinic will continue to offer a flexible service that supports families, assisting with decisions around genetic testing and surveillance for malignancy during childhood and adolescence.

Nicholas Leedman · Murray Princehorn · Nicholas Gottardo · Claire Franklin · Rebecca D'Souza · Catherine E Kiraly‐Borri