Volume 215 Issue 11

The benefits gained by vaccination mandates must be greater than the harms they may cause

Julie Leask · Holly Seale · Jane H Williams · Jessica Kaufman · Kerrie Wiley · Abela Mahimbo · Katrina K Clark · Margie H Danchin · Katie Attwell

A 34-year-old man presented seeking treatment for opioid use disorder in Melbourne

Shalini Arunogiri · Rowan Dowling · Vicky Phan · Michelle Sharkey · Temika Mu · Dan I Lubman

An 85-year-old man with a history of type 2 diabetes, vascular disease and chronic kidney disease awoke with central sharp pleuritic pain radiating through to his back

Elliot T Bowden · Paul Smith · Karen M Dwyer

The end of 2021 offers many opportunities to look back on the year that was and make predictions about what is to come

Aajuli Shukla

We cannot let complacency encumber how we live with the virus: vigilance and a planned recovery are essential

Stephen J Duckett · Brett Sutton

Given the limitations of our resources, we need well planned processes for optimising health care should demand exceed capacity

Raymond Raper

Maximising the availability of trained staff and coordinated matching of ICU capacity with demand are urgently needed

Edward Litton · Sue Huckson · Shaila Chavan · Tamara Bucci · Anthony Holley · Evan Everest · Sean Kelly · Steven McGloughlin · Johnny Millar · Nhi Nguyen · Mark Nicholls · Paule Secombe · David Pilcher

These revised guidelines have three key recommendations which provide evidence-based advice on how to reduce the health risks from alcohol consumption

Katherine M Conigrave · Robert L Ali · Rebecca Armstrong · Tanya N Chikritzhs · Peter d’Abbs · Mark F Harris · Nicole Hewlett · Michael Livingston · Dan I Lubman · Anne McKenzie · Colleen O’Leary · Alison Ritter · Scott Wilson · Melanie Grimmond · Emily Banks

To the Editor: As systematic reviews in the health literature increase,1 there is an emerging theme of reporting the geographic location of included studies.2,3,4,5,6,7 Approaches to classifying the geographic location of studies have varied. In the cases of Jennings and colleagues5 and Beks and colleagues,6 the authors captured information on study location and then assigned a geographic category. Jennings and colleagues5 followed the classification used by Eades and colleagues8 and combined RA1 and RA2 (originally based on the Australian Statistical Geographical Classification – Remoteness Area)9 to form an urban category. Although these two categories are both urban areas, the Remoteness Areas (RA) imply varying access to services. Beks et al6 opted to report on all five Australian Statistical Geography Standard (ASGS‐RA) categories. Acknowledging the different research questions — the commonality being a better understanding of Aboriginal health activity — Jennings et al5 concluded that urban areas (reported as a combination of RA1‐Major Cities of Australia and RA2‐Inner Regional Australia) were under‐represented, whereas Beks et al6 concluded that RA2‐Inner Regional Australia, RA3‐Outer Regional Australia and RA4‐Remote Australia were under‐represented. When reporting systematic reviews, we recommend that results be presented using all available categories (eg, the five categories of the ASGS‐RA). Authors can then combine categories as required to address their specific research question. Of the reviews identified,2,3,4,5,6,7 the Modified Monash Model (MMM) is yet to be applied.10 With seven categories, the MMM builds upon the five categories of the ASGS‐RA and uses population and road distance to add further granularity. Given the large number of studies that are typically included in a review, it is likely there will be examples across multiple categories. There is direct contemporary policy relevance in adopting the MMM, which spans workforce (eg, Department of Health programs are transitioning to MMM), research translation (eg, 2020 Rapid Applied Research Translation Grant Opportunity), and service delivery (eg, Medicare rebates on telehealth psychology consults).11 A uniform approach to the geographic classification of included studies in systematic reviews would enable greater comparability of findings across reviews. Consistent reporting using the MMM will likely enhance the uptake of health research, and subsequent systematic reviews, by policymakers and funding agencies. This will assist the objective allocation of resources and evaluation of activity of geographically focused programs.

Vincent L Versace · Hannah Beks · James Charles

To the Editor: We read with great interest the article by Holmwood1 which provides a new perspective on alcohol screening, brief intervention and referral to treatment (SBIRT) in primary care settings. Holmwood argues that even though addressing unhealthy alcohol consumption in clinical practice has its place, the effectiveness of SBIRT in reducing alcohol intake is supported by little evidence. The author concludes that emphasis should be placed on strategies with the strongest evidence, such as harm reduction policies. We agree with Holmwood that effective strategies to reduce alcohol consumption should be adopted, and SBIRT itself will not solve the problem entirely. As the author pointed out, the 2018 Cochrane review2 shows that the effect of SBIRT on the reduction of alcohol consumption might be limited. Yet, as stated in the review, we emphasise that while the reduction of alcohol consumption due to brief intervention is relatively small, the benefit on the population level and public health is still likely to be positive.2 With an alcohol intake of 11.9 L per capita (aged 15 years or older), the Czech Republic ranked in the third place in the world in 2019.3 In the Czech Republic, health care professionals are obliged by law to provide SBIRT to their patients.4 However, studies among Czech patients show that less than half of them are asked about their alcohol consumption by their doctor, and only 7.9% of patients are advised to lower their alcohol consumption.5 Studies among Czech doctors report that a quarter do not provide brief intervention to any of their patients.5 It would be interesting to know related information from Australia, but with respect to Czech data, we believe there should be an increased emphasis on the education and training of health care professionals in SBIRT and on supporting general practitioners in providing brief interventions (eg, adequate financial reimbursement of their time) to increase the use of SBIRT in clinical practice. That way, SBIRT can be used to its full potential and complement other strategies to address the high alcohol consumption and related harms.

Jana Malinovská · Jan Brož

In reply

Chris B Holmwood

To the Editor: Recent media reports imply there is an increased pressure on Adelaide’s metropolitan emergency medical system which has resulted in additional ambulance ramping and consequent industrial action.1,2,3 We collected a novel dataset of emergency department (ED) capacity state observations at 30‐minute intervals from the public South Australia ED Dashboard4 to investigate the claims of increased pressure. The dashboard uses a traffic light system to indicate ED busyness. The 7‐day moving average of the daily percentage of EDs in “green” status (≤ 80% of capacity) oscillated around 25% between 3 October 2019 and 16 March 2020 and then steeply increased to 80%, coinciding with the first wave of coronavirus disease 2019 (COVID‐19) cases in South Australia, which drove a major reduction in ED presentations (Box).5 The graph then shows a slow return to a baseline fluctuation of around 25% until January 2021. Since then, the moving average of EDs in “green” has been lower than 25%, showing an overall trend of increasing pressure over the subsequent months. This pattern is mirrored in the daily percentage of “red” and “white” status (ED at ≥ 95% of capacity). The 7‐day moving average of the daily percentage of EDs in “red” and “white” status exceeded 75% for the first time in February 2021. Four new record highs have been recorded since 10 May 2021, with the highest daily percentage of “red” and “white” observations at 98% on 27 May 2021. The average daily proportion of “red” and “white” observations pre‐pandemic (from 4 October 2019 to 19 March 2020) was 55% and has since increased to 64% (from 5 December 2020 to 29 June 2021), indicating that EDs are currently under significantly more strain. These issues are not new; EDs are one component of a complex interdependent health care system. EDs operating for extended periods at or near capacity is often the most conspicuous symptom of a broader system under pressure. It is doubtful that a solution to this problem can be found within the ED. Long term ED congestion relief lies in redesigning multiple aspects of the health and social care systems, which should involve health care consumer groups. Suggestions include: i) reducing hospital access block, ii) increasing social and community care, iii) adequate hospital beds, iv) alternatives to traditional care such as urgent care facilities or virtual wards, and v) cohort‐specific interventions to reduce ED presentations (eg, rehabilitation centres for alcohol and substance misuse). Box – Seven‐day moving average of the daily proportions of observations of the six metropolitan public hospitals (excluding the Women’s and Children’s Hospital) classified as alert codes “green” (0–80% occupied capacity), “amber” (80–95% occupied capacity), “red” (95–125% occupied capacity), and “white” (> 125% occupied capacity) between 4 November 2019 and 19 June 2021* * Due to problems in the data collection system, the data for the period between 14 and 31 July 2020 are missing.

Laura M Boyle · Mark Mackay · Keith Stockman

To the Editor: Undescended testis affects 2–4% of term male newborns.1 Clinical examination by an experienced clinician remains the most accurate method of assessing the position of the testis. It allows for the clear distinction between a retractile testis and palpable and impalpable undescended testes. In 2013, an evidence‐based statement on undescended testes was released jointly by Choosing Wisely and the American Urological Association which advocated against performing ultrasounds to investigate undescended testes due to their poor ability to localise non‐palpable testes.2 Unfortunately, this recommendation is not listed in the Australian Choosing Wisely website. Our study intended to improve awareness of the American Urological Association Choosing Wisely guidelines among Australian general practitioners and draw attention to the resources misspent due to lack of awareness. A retrospective audit was undertaken of 50 children referred in 2017 for an undescended testis to a single paediatric urologist in a private clinic. De‐identified data were extracted from the practitioner’s medical record system. The research ethics committee at the Sydney Adventist Hospital approved the publication of the audit. Of the patients referred with a diagnosis of an undescended testis, 35 testes (70%) were palpable in the scrotum on the day of consultation. However, 32 of 50 children (64%) already had an ultrasound by the time they were seen, with 51 testes (79%) labelled as undescended testis. Thus, more than two‐thirds of children had an ultrasound that was not needed, and the specificity was low at 27% (95% CI, 15–42%) (Box). About 159 379 boys were born in Australia in the study period.3 The cost of an ultrasound of the scrotum as per the Medicare Benefits Schedule was $109.50 (item 55048). Assuming an incidence of undescended testis of 2% and assuming ultrasounds were ordered in three times as many children, as happened in our study (15 undescended testes and 35 descended testes), the cost of unnecessary studies is calculated to be $1 047 120 (3 × 0.02 × birth cohort of 159 379 × $109.50). The numbers of Medicare claims for item 55048 have increased by 5% each year since 2010.4 Health budgets are finite, and expenditure should be linked to quality metrics. GPs and paediatricians are undoubtedly trying to be helpful by organising an ultrasound before the referral, but it is unnecessary. This letter is an attempt to continue the discussion with referring doctors to let them know that ultrasound is not required before referral for an undescended testis. This is a single clinic audit. We hope it will inspire larger population‐based audits to facilitate systemic change. Box – Ultrasound and examination findings Position of the testicle On examination inguinal On examination scrotal Total Inguinal ultrasound 16 35 51* Scrotal ultrasound 0 13 13 Total 16 48 64 * One testicle reported in the inguinal region on ultrasound was impalpable on examination.

Dharshini Selvarajah · Dermot McDowell · Susan Jehangir · Grahame Smith

Santa Claus is at high risk of developing atrial fibrillation. Despite this, no guidelines exist on the subject

Mark T Mills · David R Warriner

We can give and consume seasonal sweets in hospitals with a clear conscience!

Dirk Stengel · Alexander Hönning · Stephan Just · Sven Mutze · Axel Ekkernkamp · Tobias Ohmann · Hajo Haase · Patric Kröpil · Leonie Gölz

Bananas are not only healthy snacks during breaks, but also good for improving simple and vertical mattress suturing skills

Geoffrey Murphy · Muhammad A Khan · Adil Lathif · John Preddy

We recommend that individuals increase their intake of garlic as a preventive measure to minimise the risks of a “vampiregeddon” event

Evangeline Mantzioris · Philip Weinstein

What is life if you can’t go to work?

Andrew Huang