Volume 215 Issue 4

Community- based studies in five countries show consistent strong benefits from early rollouts of COVID-19 vaccines

David A Henry · Mark A Jones · Paulina Stehlik · Paul P Glasziou

Our current approaches to limiting transmission of respiratory viruses, including SARS-CoV-2, are inadequate

Peter AB Wark · C Raina MacIntyre · Scott Bell · Brian Oliver · Guy B Marks

A shared language will promote climate change and health research and underpin a sustainable future Climate change requires collective action across many government, non‐government and private sectors.1 The development of a shared terminology to conduct, share and use research will be critical to the effective communication and collaboration needed to achieve this collective action.2 At the same time, climate change mitigation and adaptation is an exponentially growing field of multidisciplinary research and practice, augmenting the scale of the challenge.3,4 It will be vital that this cross‐disciplinary research effort is supported, but currently, there is poor alignment in the use of relevant terms across different research and policy fields, with little standardisation of terminology in the national and international literature. This article builds on other international efforts to address the need for shared terminology. A 2018 article provides definitions for the fields linking human health to ecosystems and environments and highlights planetary health.5 Another publication defines key terms that focus on vulnerability assessments and health equity implications.6 Leading international organisations, including the Intergovernmental Panel on Climate Change (IPCC)7 and the World Health Organization,8 have developed glossaries relevant to climate change and health. However, many terms require refinement for the Australian context. In an Australian collaborative endeavour, we developed an Australia-specific glossary of 55 terms that we believe are key to enhancing local intersectoral communication and collaboration on climate change and health.9 The methods included a systematic search and review of existing glossaries relevant to climate change and health, plus three rounds of stakeholder engagement including an online survey, a workshop and further discussion via a shared online document (Supporting Information). The glossary’s target audiences are researchers from various disciplines needing to collaborate to address health and climate change, and partners who need to understand and use that research to drive change (eg, government, policy, private sector, and otherdecision makers). We acknowledge that the language and priority issues in health and climate change will continue to evolve, and welcome contributions from other stakeholders to further develop and refine the terminology in the glossary. The need for multidisciplinary collaboration on health and climate change issues in Australia is reflected in the recent National Health and Medical Research Council’s Special Initiative in Human Health and Environmental Change.10 This initiative will support a multidisciplinary, collaborative network of researchers across Australia. It is hoped that this glossary could assist multisectoral collaborations. Key terms This section outlines and discusses some of the essential principles, considerations and challenges identified in developing the glossary and illustrates these with some of the most debated key terms. Notably, several definitions integrated Aboriginal and Torres Strait Islander perspectives. We included the term “Indigenous knowledges” for its Australian relevance and its importance in sustaining and caring for the land on which we live. Furthermore, we applied an eco‐social interpretation of health and climate change relationships, recognising that human and environmental health are inextricably linked. We amended several pre‐existing definitions to include considerations of other sentient beings and ecosystems. Components of climate change Challenges in defining climate‐related terms are illustrated by the definitions of climate change from the IPCC and the United Nations Framework Convention on Climate Change (UNFCCC).7,11 Despite both being derived for United Nations processes, there are stark differences. Both refer to two components of the changing climate: anthropogenic climate change (human component) and natural variability in the Earth’s climate. While the IPCC distinguishes between these in their climate change definition, the UNFCCC has split them into separate terms: “climate change” (anthropogenic causes) and “climate variability” (natural causes). Our stakeholders recommended distinguishing between the two components and explicitly stating the existential threat of climate change to create a greater sense of urgency, and also chose “health emergency” to urge immediate action as many Australian health and medical professional organisations (eg, the Australian Medical Association12 and the Royal Australasian College of Physicians13) have declared climate change a health emergency. Equity and justice Previous definitions for “climate equity” and “climate justice” appear to be human‐centric. Our proposed definitions for climate justice and climate equity are broader, to capture the links between human health and other species and ecological systems. In Australia, the destruction of biodiversity, wetlands, mangrove swamps, and rainforests is an indiscriminate loss of sensitive ecological systems and a form of injustice. There is an even more expansive notion of climate justice which includes attention to inequity in impacts, to participation and procedural justice, and to the functioning and provision of basic needs of vulnerable communities.14 Related to climate justice is “just transition”. A policy report by the Australian Council of Trade Unions15 notes that a just transition should ensure that communities facing transitions can flourish rather than simply survive. We amended a pre‐existing definition to explicitly state that transition should be towards sustainable economic systems that promote social justice. It is also important to acknowledge Aboriginal and Torres Strait Islander perspectives for just transitions, and that Aboriginal and Torres Strait Islander peoples be at the centre of decision making to ensure that environmental stewardship is promoted.16 Anxiety, grief and solastalgia Climate change is adversely affecting mental health, with visible impacts and increasing trauma from extreme weather events (eg, Australia’s unprecedented 2019–20 bushfire season). Terms that acknowledge and highlight the psychosocial and emotional harms of climate change include “climate anxiety/grief” and “solastalgia”, coined by Australian environmental philosopher Glenn Albrecht.17 This is especially relevant to Aboriginal and Torres Strait Islander peoples.18 Our climate anxiety/grief definition explicitly states the anxiety felt around losses for future generations. We also recognise that different generations may have varying baselines for how they think of climate change. Fires There are many variations in terminology used around fires, particularly international definitions, which may cause misunderstanding and inappropriate use of some terms in the context of climate change. In Australia, the term “bushfire” is very widely used and is therefore the term included in our glossary. The management of fires in Australia involves burning, often referred to as “hazard reduction burning”, which itself carries fire‐related health risks and consequences. In Australia, “cultural burning” describes burning practices developed by Aboriginal and Torres Strait Islander peoples to enhance the health of the land and its people.19 A commonly confused fire‐related term is “fire disasters”, which is often misused when discussing fires in Australia integral to ecosystem functioning and not classified as disasters; for example, annual savanna fires, which are part of the seasonal cycle of those ecosystems involved. A bushfire is classified as a disaster when it is uncontrollable and adversely affects lives, properties or the environment. Heat In Australia, extreme heat events have claimed more lives than all other extreme weather events combined.20 Many ways of defining “heatwave” exist in global and Australian contexts, with variations across sectors and regions. It is generally agreed that heatwaves are prolonged periods of excessive heat, with “prolonged” usually defined as multiple consecutive days and “excessive” being the exceedance of an extreme threshold. Our stakeholders decided to include a detailed definition from the Bureau of Meteorology21 which also considers overnight temperatures. High night‐time temperatures affect health and wellbeing by limiting respite from heat and reducing sleep quality, with relevance for a health‐focused glossary. Responses Actions, strategies and interventions to address the health impacts of climate change fall into either adaptation or mitigation categories.6 Mitigation aims to reduce the human contribution to climate change, and adaptation is a process or strategy to manage the inevitable changes that are already beginning to occur.7 The IPCC definition of maladaptation was selected and adapted for our glossary because it allows for flexible interpretations across sectors. Our version of the IPCC definition recognises that “maladaptation” refers to the situation where an adaptation strategy causes unintended consequences. For example, one proposed strategy for bushfires is to remove bush, but this was based on a flawed argument that less bush equates to fewer bushfires. The resulting loss of biodiversity from this strategy would be an unintended consequence and thus a maladaptation. Resilience Although not commonly used in Australia at present, the term “climate resilience” is widely used internationally and has growing relevance here. Climate resilience in the Australian context involves considering how communities have responded to and recovered from past natural disasters to improve their resilience for future events. Hence, our glossary’s definition builds on the IPCC’s definition to focus on strengthening for future events7 and explicitly mentions political and governance systems’ capacity to cope with future perilous events. Indigenous knowledges The United Nations Educational, Scientific and Cultural Organization (UNESCO) and IPCC definitions of Indigenous knowledges7,22 refer broadly to all First Nations peoples’ knowledge systems. We could not identify an existing definition of Indigenous knowledges for the Australian context, an important topic for further development. When referring to Indigenous knowledges in Australia, it is appropriate to refer to these knowledge systems as Aboriginal and Torres Strait Islander knowledges.23 The international definition also lacks the important spiritual and cultural aspects of Indigenous knowledges and the fact that these knowledge systems have been passed down over many thousands of years and underpin Indigenous peoples’ understandings today. Aboriginal and Torres Strait Islander knowledges include an intricate understanding and connection to Country, developed over thousands of years to care for the environment sustainably. Caring for Country, which embodies set stewardship values for land and sea environments, describes these sustainable land management practices, as well as being a key aspect in the continuation of Aboriginal and Torres Strait Islander cultures.19 Conclusion The glossary is now publicly available. We hope that policymakers, researchers and stakeholders from different sectors will refer to the glossary to facilitate their discussions and help translate research into policies and practices. Given that language is continuously evolving, as are health and climate change issues, we acknowledge the limitations in the perspectives presented in the glossary and invite contributions from various stakeholders to make this glossary a dynamic and useful tool. By doing this, we can build a shared language to underpin a just transition to a sustainable future for our country.

Matilde Breth‐Petersen · Lucie Rychetnik · Alexandra L Barratt · Ying Zhang

Stillbirth and cancer rates are significantly elevated among Aboriginal people living near the Ranger uranium mine Stillbirth and cancer incidence rates are significantly higher among Aboriginal people living near the Ranger uranium mine than among Aboriginal people elsewhere in the Top End of the Northern Territory, with a stillbirth rate over twice as high and cancer incidence almost 50% higher.1 The NT Chief Health Officer commissioned an investigation into the excess stillbirths and cancers in 2014, but a November 2020 report found no explanatory cause.1 The Ranger uranium mine ceased operations as planned in January 2021.2 Communities expect health departments to respond to reports of clusters of adverse health outcomes such as the excess stillbirths and cancers among Aboriginal people living near the Ranger uranium mine.3 However, investigating clusters of health outcomes which have complex aetiologies rarely provides definitive answers.3 Even when associations are identified, cluster investigations cannot demonstrate that these associations are responsible for the disease cluster. Nonetheless, important environmental, public health and social problems may be identified through cluster investigations, enabling health education and promotion, and potentially, mitigation of contributing causes.3 The Ranger mine cluster investigation focused on ionising radiation as a potential cause of the excess stillbirths and cancers because this was considered the worst‐case scenario.1 There are well established causative associations between ionising radiation and increased rates of some cancers, particularly lung, head and neck, thyroid cancer in childhood and leukaemia, and fetal malformations that lead to stillbirth.1 Tobacco and alcohol consumption likewise contribute to stillbirths and cancers, and these were also examined in the cluster investigation, together with markers of poor nutrition.1 High levels of alcohol consumption by Aboriginal people in the Ranger mine region have long been a concern.4,5 The Ranger uranium mine in Kakadu National Park Uranium mining began at a location labelled “Ranger” in 1980 on land excised from the Kakadu National Park World Heritage site.6 Aboriginal rights to veto mining were overridden in legislation, and detrimental impacts on Aboriginal people were anticipated, but market prospects for uranium appeared strong and the mine was considered to be in the national interest. Mining was allowed to proceed, with recommendations to monitor and reduce harmful impacts on the region’s Aboriginal people.4,7 Health, social and ecological aspects of the Ranger uranium mine were explored in a 1984 report, whose authors recognised that their immersion into Aboriginal communities gave them deep concern about how uranium mining could affect Aboriginal people.5 They recommended that uranium mining not expand without interventions to mitigate harmful and strengthen positive effects of mining on Aboriginal people.5 Mining continued for 40 years, and the Ranger uranium mine contributed up to $388 million annually to the NT economy before its 2021 closure.2,8 During the period of mine operation, more than 200 leaks, spills and other incidents were documented.9 Five major incidents are outlined in Box 1, highlighting threats to ecosystems and employees more than radiation exposure among Aboriginal community residents.9,10 The Gundjeihmi Aboriginal Corporation represents the Mirarr people of the region and for decades has expressed grave concerns about continuing incidents and the lack of effective government response.7 While the Mirarr people maintain the right to live on their lands, their lives are disrupted by mining operations and incidents that threaten biodiversity, landscapes and livelihoods.7,9 In 2014, the mine operators lodged a proposal to expand. A submission on the proposal by the NT Department of Health noted that rates of stillbirth and cancer among Aboriginal people in the region were elevated.1 NT Department of Health investigation In 2014, the NT Chief Health Officer commissioned an investigation into stillbirth and cancer rates in long term Aboriginal residents around the Ranger mine. The investigation aimed to quantify rates and identify exposures that may have contributed to the excess stillbirths and cancers. Stakeholders including Aboriginal health and land corporations and public health and politics experts oversaw the investigation to ensure transparency, while independent epidemiologists scrutinised the investigation’s scope, design and conduct. The investigation report was released publicly in November 2020.1 The investigation identified all Aboriginal people who had spent more than half of their lives in the mine region during the 1991–2014 study period, with an exposed cohort of about 2200 people. The focus was ionising radiation because this exposure was considered the worst‐case scenario.1 The mine employed few local Aboriginal people, so occupational exposures were not considered.1,2 The comparison group comprised all other Aboriginal people in the Top End.1 Elevated stillbirth and cancer incidence rates among Aboriginal people living near the Ranger mine compared with other Aboriginal people in the Top End were confirmed. Stillbirth was over twice as common (odds ratio, 2.17; 95% CI, 1.13–3.82) and cancer about 50% more common (total cancer incidence ratio, 1.48; 95% CI, 1.17‐1.85).1 Examination of the cancer types showed that no specific cancer was responsible for the excess of total cancers. Cancers of the lip, mouth and pharynx together were the most common cancers and made up 42% of the excess: 16 cases, compared with 5.5 expected. These cancers are not considered to be caused by ionising radiation, but they are associated with tobacco smoking and alcohol consumption.1 The Aboriginal people living near the mine had higher prevalence of tobacco smoking (prevalence ratio, 1.08; 95% CI, 1.04–1.13), alcohol use (prevalence ratio, 1.21; 95% CI, 1.13–1.31) and infrequent intake of vegetables indicating poor nutrition (prevalence ratio, 1.08; 95% CI, 1.02–1.24) compared with other Aboriginal people in the Top End. Other risk factors were not statistically different between the groups. Multivariable analysis did not show that these risk factors contributed to the excess cancer incidence in the people living near the mine (Box 2). However, this analysis had low statistical power because of a lack of risk factor data.1 The investigation found “little evidence that the risk factors investigated … were associated with increased risk of cancer in study participants” in the period for which risk factor data were available.1 Despite this statistical conclusion, higher rates of tobacco smoking and alcohol use and poor diets among Aboriginal people in the mine region were highlighted in relation to the excess stillbirths and cancers. The investigation concluded by recommending that Aboriginal people follow advice about smoking, alcohol and diet.1 Discussion The Ranger uranium mine has had an impact on surrounding Aboriginal communities for over 40 years. The investigation by the NT Department of Health into the rates of stillbirths and cancers among people in the region invested significant resources and expertise in gathering data on stillbirths, cancers, ionising radiation and behavioural risk factors. It focused on cause–effect relationships between possible exposure to ionising radiation and behavioural risk factors, and the increased stillbirth and cancer rates. The investigation was not designed to consider the impact of the imposition of uranium mining on Aboriginal lands, as was recommended when the mine was proposed and developed.4,5 Development of the Ranger mine entailed nullification of veto rights, disempowering Aboriginal communities and threatening their livelihoods.7 With mining came royalty money, expensive commodities, money‐hunger and alcohol.5 Economic development from the mine has increased inequity among Aboriginal people in the region.5 Inequity may contribute to both stillbirths and cancer, although this would not be detected in a cluster investigation.3,11,12 Employment and educational opportunities associated with the Ranger mine did not promote socio‐economic development of the Aboriginal community; rather, Aboriginal wellbeing deteriorated through people relying on royalty income.2,7 Aboriginal people’s rights were ignored, and their expertise, authority and lifeways were devalued by the mine.7 Aboriginal community perspectives, knowledge and research methodologies may offer important insights into adverse Aboriginal health outcomes, while marginalising Aboriginal expertise perpetuates the impacts of colonisation.13 Excess stillbirths and cancers may be associated with a web of interrelationships between individuals, communities and wider ecological, sociological and political environments, which a biomedically focused investigation may overlook.14 Further research is needed to unravel this web, and explain the disparity in stillbirth and cancer rates between Aboriginal people in the region of the mine and the other Aboriginal people in the Top End. The NT Department of Health stillbirth and cancer cluster investigation recommended that Aboriginal people in the region reduce their tobacco and excessive alcohol consumption, although these were not considered the causes of the raised stillbirth and cancer rates.1 This response could be strengthened by a foundational approach to improve understanding and relationships between government, mining companies and Aboriginal community members.2 Conclusion The investigation by the NT Department of Health into the excess stillbirths and cancers among Aboriginal people living near the Ranger uranium mine was transparent, detailed and publicly available. High level expertise was engaged, although stronger Aboriginal contribution to the investigation’s grounding and methodology may have enhanced two‐way intercultural learning.13 Research from Aboriginal community perspectives that focuses on improving health and wellbeing may lead to possible interventions. While the mine is now closed and undergoing rehabilitation, there is an opportunity for further research to better understand and close the gap in health risk exposures and outcomes between Aboriginal people in the region of the mine and other Aboriginal people in the Top End. Box 1 – Major incidents at the Ranger uranium mine, 1979–20139,10 Date Location Incident Outcome Risk minimisation December 1995 Retention pond 2 at power station 12 000 litres of diesel fuel spilled World’s richest tropical waterbird breeding ground threatened; 40 identified waterbirds perished Office of Supervising Scientist designated this as unacceptable environmental impact. Increases in monitoring not implemented due to mine operator’s other commitments January–April 2002 Headwaters of Corridor Creek, southern side of mine Incorrect stockpiling of low grade uranium ore Water contaminated by leakage of uranium Remedial works undertaken in February 2002. No source found for ongoing run‐off identified in April March 2004 Ranger mine utility site Process water connected to drinking water, leading to water uranium levels 400 times Australian standards 159 workers potentially exposed to contaminated water for drinking and washing Mine operator prosecuted and fined $150 000 January–June 2011 Region wide Extreme wet season Risk of overflow from tailings dam Uranium mill was shut for duration of wet season December 2013 Ranger mine site Collapse of acid leach tank 1 million litres of radioactive ore slurry spilled Area was evacuated until spill contained Box 2 – Total cancer incidence rate ratios for Aboriginal people living near the mine compared with other Aboriginal people in the Top End of the Northern Territory, by selected risk factors*,1 Risk factor Cancer incidence rate ratio (95% CI) Tobacco smoking 1.53 (0.75–3.12) Alcohol use 1.54 (0.76–3.15) Infrequent vegetable intake 1.49 (0.73–3.06) * Poisson regression model adjusted for age and sex.

Rosalie Schultz

Australian public hospitals’ energy choices are at odds with “first, do no harm”

Hayden Burch · Matthew H Anstey · Forbes McGain

A previously well, 42-year-old man presented with a 4-day history of sudden onset, bilateral, occipital headache, 4 weeks after returning from a holiday in Thailand

Simon Smith · Ian Wilson · Lea Starck · Enzo Binotto · Jennifer Ho · Joshua Hanson

A 77-year-old woman with a long term urinary catheter on haemodialysis complained of suprapubic discomfort

John Wing Li · Kamal Sud

Medical students continue to be involved in legally and ethically concerning intimate examination practices Terra pericolosa was the cartographical term used to denote dangerous land — regions likely to put travellers in jeopardy. Despite the degree of governance and regulation in modern health care,1,2,3 medical literature,4 student‐authored ethics reports5,6 and the media7 continue to document medical students being involved in legally and ethically concerning intimate examination practices. This article summarises the ethico‐legal aspects of medical student involvement in patient care, and reviews international best practice and the factors which influence why medical students continue to find themselves in terra pericolosa situations. Ethico‐legal and governance issues Through most of its history, medical ethics maintained a utilitarian focus, usually demonstrating scant regard for patient autonomy, with non‐disclosure being the norm; it was not until the 1950s that the term “informed consent” was coined.8 The 1980s and 90s saw the first publications questioning the ethics and legality of medical students performing examinations without consent, with students often raising their concerns about the status quo.5,9 The legal implications of performing an examination without consent are significant. Each state and territory’s criminal codes define the elements that constitute an assault, as well as various categories, including sexual assault. In general, the term “assault” refers to both “common assault” and “battery”, even though the two offences remain distinct entities. Common assault typically involves intentionally or recklessly causing a person to apprehend the imminent infliction of unlawful force, while battery refers to the actual infliction of force. The legal classifications all include lack of consent as part of their wording. Consent to medical treatment is defined by Australian common law as having three conditions: it must be voluntary, be informed, and the individual must have capacity to provide consent.10 Consent may be given in writing, orally or be implied.3 An Australian Law Reform Commission report states: “If consent is not established, there may be legal consequences for health professionals. Under the law of trespass, patients have a right not [to] be subjected to an invasive procedure without consent or other lawful justification, such as an emergency or necessity.”10 Although there is no legal mandate for written consent to be obtained for medical student involvement in intimate examinations or procedures, the principles for consent are that the riskier or more potentially litigious the procedure, the higher the standard should be to ensure that the person fully understands the nature of the procedure and that their consent can be attested to in writing.3 The Australian Charter of Healthcare Rights11 notes that a health care recipient should “be treated as an individual, and with dignity and respect” and have “clear information about [their] condition, the possible benefits and risks of different tests and treatments, so [they] can give [their] informed consent”. There is no information about health professional student involvement in their care. The Medical Board of Australia code of conduct2 defines the standards of conduct for medical doctors in Australia. The code states that regarding medical students, good medical practice involves “Making the scope of the student’s role in patient care clear to the student, to patients and to other members of the health care team” and “Informing your patients about the involvement of medical students and obtaining their consent for student participation, while respecting their right to choose not to consent”. The Australian Medical Council provides a core curriculum for both medical students and all medical doctors in Australia.3 It states: “Access to patients and their cooperation is a privilege that must not be taken for granted. … Before approaching any patient, students should generally first seek permission from those responsible for the immediate care of the patient.” Regarding physical examination, the authors note that: … when conducting a physical examination, it may be appropriate to have a nurse or medical student present who is of the same gender as the patient. Under no circumstances should medical students conduct intimate examinations — including breast, genital or rectal examinations — without supervision or an accompanying nurse of the same gender as the patient. Students need to be specifically aware of the medical school policy in regard to intimate examinations.3 In 2018, the Medical Board of Australia published guidelines on sexual boundaries in the doctor–patient relationship.1 These guidelines recognise that a patient’s cultural values and beliefs may influence what they perceive to be an intimate examination, and that before conducting a physical examination, good medical practice involves “obtaining the patient’s permission if medical students or anyone else is to be present during an examination or consultation” and that an “unwarranted physical examination may constitute sexual assault. This includes conducting or allowing others, such as students, to conduct examinations on anaesthetised patients, when the patient has not given explicit consent for the examination”.1 In summary, although Australian law is clear on the importance of consent and the implications of this regarding assault, current Australian medical governance makes some assumptions about medical school policies for intimate examinations and allows discretion regarding the requirements for written consent. What we can learn from other countries The recognition that medical students may be involved in unconsented intimate examinations4,9,12 has resulted in the introduction of specific ethical codes and guidance in many jurisdictions. The United Kingdom and New Zealand have similar ethical codes to Australia.2,12,13 The UK also provides detailed guidance on good medical practice for students.13 NZ is the most prescriptive, with specific information regarding medical student involvement in patient care documented in a national consensus statement and their Code of Rights.6,12 The NZ experience provides useful insights into the challenges of protecting patient rights during intimate examinations or procedures. Malpas and colleagues6 demonstrated that despite the national consensus statement’s introduction and related legislation, students continue to be involved in unconsented intimate examinations. In response, the authors recommended the following system changes in NZ: review consent processes to include information for patients about health professional student involvement in their care, and include specific sections in procedural consent forms for student involvement; provide the public with more information about patients’ rights and consent processes; and change the culture through increased emphasis on ethical leadership by senior health professionals in modelling best practice, and ensure zero tolerance/disciplinary processes for those who commit serious ethical breaches.6 Future directions The UK General Medical Council states that “Professionalism is not about doing the minimum — it is about doing what is necessary to protect patients”.13 When judged against this standard, most health care systems appear to have gaps. An individual’s likelihood of engaging in a behaviour is influenced by three factors: their attitudes towards the behaviour, their perceptions of the social norms, and their perceived ability to perform the behaviour.14 Although contemporary medical education and ethics actively promote patient autonomy and informed consent, students can unfortunately find themselves working in what has been described as the “weak ethical climate within the clinical workplace”.4 Most medical education and psychological research indicates that students are strongly influenced by the cultural norms of their workplace and their supervisory relationships.4,6,14,15 Fifteen years after a landmark paper by Coldicott and colleagues,9 Malpas and colleagues6 and an accompanying student‐authored editorial5 reaffirmed that the most common problems with medical student involvement in intimate examinations and procedures are not aspects of rogue student behaviour, but continue to be students struggling with the “the incongruence of what is taught … and the reality and expectations of clinical practice”,5 with students narrating specific instances of being asked by their supervisors to conduct or remain present during intimate examinations without clear and/or adequately informed patient consent. The NZ recommendations6 should positively influence students, health professionals and public attitudes and behaviours. However, unless resources are embedded in health professional educational and clinical environments to promote and facilitate speaking up for patient safety, the evidence suggests that those at the bottom of the hierarchy rarely feel safe in speaking truth to power;4,5,6,14,15 students will continue to be led into jeopardy. The UK experience with the Francis enquiry16 and other patient safety system failures provided the impetus to promote patient safety at national, local and medical school levels through General Medical Council guidance and initiatives such as “Speaking up”.13,17 To assist and empower students, some medical schools have developed web portals for their students to raise concerns.18 The lessons from the NZ work in this area and the UK initiatives indicate that although policies, processes and pedagogy are important, Australian health care and medical education providers should also critically examine their clinical workplace cultures and consider whether they adequately protect both patients and students.

Paul M McGurgan · Katrina L Calvert

We urgently need a national strategy to reduce overreliance on hospital services for functional recovery treatments

Ian D Cameron · Maria Crotty · Susan E Kurrle

If suitable mosquito vectors are present in a region, returning infected travellers can initiate local transmission

Annelies Wilder‐Smith

Objective: To identify functional performance trajectories and the characteristics of people who receive inpatient geriatric rehabilitation after hospital admissions. Design, setting, participants: REStORing health of acutely unwell adulTs (RESORT) is an observational, prospective, longitudinal inception cohort study of consecutive patients admitted to geriatric rehabilitation wards at the Royal Melbourne Hospital. Recruitment commenced on 15 October 2017. Main outcome measures: Functional performance, assessed with the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) scales two weeks before acute hospitalisation, on admission to and discharge from geriatric rehabilitation, and three months after discharge from geriatric rehabilitation. Results: A total of 618 rehabilitation patients were included in our analysis. For each of the two scales, three distinct functional performance trajectories were identified by latent class growth modelling: poor at baseline and 3‐month follow‐up (remained poor: ADL, 6.6% of patients; IADL, 42%), good at baseline but poor recovery (deteriorated: ADL, 33%; IADL, 20%), and good at baseline and good recovery (recovered: ADL, 60%; IADL, 35%). Higher Clinical Frailty Scale (CFS) score (v recovered, per point: odds ratio [OR], 2.51; 95% CI, 1.64–3.84) and cognitive impairment (OR, 6.33; 95% CI, 2.09–19.1) were associated with greater likelihood of remaining poor in ADL, and also with deterioration (CFS score: OR, 1.76; 95% CI, 1.45–2.13; cognitive impairment: OR, 1.87; 95% CI, 1.24–2.82). Higher CFS score (OR, 1.64; 95% CI, 1.37–1.97) and cognitive impairment (OR, 3.60; 95% CI, 2.31–5.61) were associated with remaining poor in IADL, and higher CFS score was also associated with deterioration (OR, 1.63; 95% CI, 1.33–1.99). Conclusions: Based on ADL assessments, most people who underwent inpatient geriatric rehabilitation regained their baseline functional performance. As higher CFS score and cognitive impairment were associated with poorer functional recovery, assessing frailty and cognition at hospital admission could assist intervention and discharge planning.

Cheng Hwee Soh · Esmee M Reijnierse · Camilla Tuttle · Celia Marston · Rose Goonan · Wen Kwang Lim · Andrea B Maier

Estimating expected background rates of hospital transfer and death can inform analyses of vaccine safety

Hazel J Clothier · Yonatan M Mesfin · Steven Strange · Jim P Buttery

On 23 May 2019, the Central Queensland Public Health Unit received a confirmed laboratory notification of a dengue virus serotype‐2 (DENV‐2) infection in a Rockhampton resident. On 5 May, a 71‐year‐old man without a history of travel overseas or to Far North Queensland had developed symptoms consistent with a zoonotic disease, and presented later that month to his general practitioner because his symptoms had not abated. Between 23 May and 7 October 2019, 21 locally acquired cases of DENV‐2 were identified in Rockhampton: 13 laboratory‐confirmed cases and eight probable cases detected by active surveillance. This was the first outbreak of locally acquired dengue in Central Queensland for 65 years.1 In 14 cases (67%), the infected persons sought medical attention; two required hospitalisation. A formal outbreak response was initiated by the Central Queensland Public Health Unit on 23 May 2019, including extensive mosquito surveillance and active and passive human surveillance within 200 metres of the residences of each identified infected person. Particular attention was directed to surveying locations that might facilitate increased dengue transmission in the community (such as schools, a plant nursery, and aged care facilities) for artificial and natural containers that could serve as breeding areas for infected mosquitoes (Aedes aegypti). Such containers were either removed or emptied of residual water and treated with pellets of the insect growth regulator (S)‐methoprene, and the premises and buildings were sprayed inside and out with the residual insecticide Temprid 75 (Bayer; includes imidacloprid and β‐cyfluthrin). In addition to the house‐to‐house human surveillance, a novel “lure and kill” approach was adopted for vector control: lethal ovitraps were deployed within 200 metres of the residence of any person with a probable or confirmed infection. Ae. aegypti was found in 105 of 1107 inspected residential premises (9.5%), or more than half of the 205 premises found to contain mosquitoes. Enhanced serological surveillance was undertaken to detect patients with viraemia early, enabling prompt public health and mosquito control interventions. The complete DENV‐2 genome sequence (GenBank accession number, MN982899.1) indicated that the implicated virus was most closely related to Southeast Asian strains of DENV‐2. Given the presence of Ae. aegypti in Central Queensland and the increasing numbers of travellers and visitors returning from countries in which dengue is endemic, it is important that Rockhampton be recognised as a dengue‐receptive area. As locally acquired cases of dengue are being reported outside Far North Queensland, the state map of dengue‐receptive areas2 should be updated; specifically, the broad geographic area from Townsville south to Rockhampton should be considered dengue‐receptive.

Jacina Walker · Alyssa Pyke · Paul Florian · Rachael M Rodney Harris · Gulam Khandaker

▪ Obesity is reaching pandemic proportions globally, with overweight or obesity affecting at least two‐thirds of Australian adults. ▪ Bariatric surgery is an effective weight loss strategy but is constrained by high resource requirements and low patient acceptance. ▪ Multiple endoscopic bariatric therapies have matured, with well established and favourable safety and efficacy profiles in multiple randomised controlled trials (RCTs), and are best used within a multidisciplinary setting as an adjuvant to lifestyle intervention. ▪ Three types of intragastric balloon are currently in use in Australia offering average total weight loss ranging from 10% to 18%, with others available internationally. ▪ Endoscopic sleeve gastroplasty produces average total weight loss of 15–20% with low rates of severe complications, with RCT data anticipated in December 2021. ▪ Bariatric and metabolic endoscopy is rapidly evolving, with many novel, promising therapies currently under investigation.

Dominic A Staudenmann · Zhixian Sui · Payal Saxena · Arthur J Kaffes · George Marinos · Vivek Kumbhari · Patrick Aepli · Adrian Sartoretto

To the Editor: The research letter by Hespe and colleagues1 on cardiovascular disease prevention is itself a missed opportunity to illuminate the complexities of person‐focused management of patients in general practice. While it provides a snapshot on cardiovascular disease prevention, it does not offer any exploration of the veracity or otherwise of these findings. Aggregate decontextualised and — as acknowledged — limited data ultimately fail to identify the true nature of the problem. Simply focusing on easily extractable data from computerised medical record systems, without linkage to the unique features and context of the person to whom these data belong, necessarily results in a distorted picture. Big data has the potential to inform only if it is appropriately interpreted and may be useful in process monitoring. Such data have a limited role in assessing general practitioner performance and outcomes of care.2 One must always remember that guidelines are nothing more than guides, which must be appropriately adapted to the unique circumstances of each patient. A more relevant research question would be: how appropriately or inappropriately are preventive treatments applied? This question addresses both overtreatment and undertreatment.3 As a binary question, however, it fails to ask more important contextual questions such as whether the patient can cope with the demands of the treatment, whether the treatment decision is a truly informed one, and whether it fits the needs and expectations of the patient given other health concerns. It ignores entirely the impact of a therapeutic alliance on actual health outcomes.4 Finally, the implied need for a hawkish attitude to prevention must take account of the fact that no intervention is risk‐free. Our obligation clearly states: primum non nocere. Research aiming to improve understanding of the interdependencies inherent in each and every consultation is urgently needed. The health and wellbeing outcomes of medical care are far less determined by biomedical interventions than by the contextual stressors in a person’s life.5 Providing general practice with the tools and resources to truly address the complexities of our patients’ needs is of utmost urgency.

Joachim P Sturmberg · Carmel M Martin

In reply

Charlotte M Hespe · Mark F Harris · David P Peiris

To the Editor: The incidence of syphilis is dramatically rising in Australia. As such, previously rare sequelae like syphilitic hepatitis are occurring more frequently, supported by a growing number of case reports in the literature.1 We present a typical case of syphilitic hepatitis and review the evolving at‐risk populations, to raise awareness of this potentially fatal yet highly treatable disease. A 34‐year‐old Caucasian man presented with a maculopapular rash over the trunk and limbs associated with abdominal discomfort, anorexia and fatigue. He had been treated for early syphilis 2 years previously, with serological evidence of response. He had no history of human immunodeficiency virus infection. He was married with children and denied other sexual relationships. Aside from the aforementioned rash, his examination was unremarkable. His alkaline phosphatase level was 684 U/L (reference interval [RI], 50–130 U/L), γ‐glutamyl transpeptidase was 942 U/L (RI, < 55 U/L), alanine aminotransferase was 429 U/L (RI, < 45 U/L), and aspartate aminotransferase was 181 U/L (RI, 5–35 U/L); bilirubin was 18 μmol/L (RI, < 20 μmol/L) and C‐reactive protein (CRP) was 55 mg/L (RI, < 5 mg/L). Abdominal ultrasound and extensive liver screen results were normal. Treponema pallidum particle agglutination assay and rapid plasma reagin test results were reactive at a 1:32 titre, prompting a diagnosis of syphilitic hepatitis. He was administered 2.4 million units of benzathine benzylpenicillin intramuscularly once‐weekly for 3 weeks. His rash, symptoms and liver function tests resolved within 6 weeks. The Australian notification rate of syphilis increased from 5.0 to 18.3 per 100 000 population between 2010 and 2017. Women aged 15–19 years experienced a tenfold increase in incidence over this period. In 2017, women from remote areas were 27.3 times more likely to contract syphilis than those from major cities, while Aboriginal and Torres Strait Islander people were 6.6 times more likely to contract syphilis than non‐Indigenous Australians.2 Despite this disproportionate rise in vulnerable populations, rates remain highest among men who have sex with men and those with human immunodeficiency virus infection.3,4 Re‐infection is common, as was found in our patient. Described as the “great imitator”, secondary syphilis can be difficult to diagnose; consequently, the true incidence of syphilitic hepatitis is not known. While our case illustrates a typical presentation, cases of fulminant liver failure have been described.5 Rash (78%), anorexia (57%) and fatigue (57%) are the most common presenting symptoms.1 Marked elevation of alkaline phosphatase and γ‐glutamyl transpeptidase, coupled with milder elevation of alanine aminotransferase and aspartate aminotransferase are the most common laboratory findings, with hyperbilirubinaemia present only in severe cases. A liver biopsy is not essential for diagnosis, but may reveal inflammatory infiltration of the bile duct, hepatic granulomas or, less commonly, intrahepatic spirochetes via immunohistochemical staining.1 It is imperative that clinicians consider ordering treponemal serology in high risk patients fitting this presentation, as prompt treatment with penicillin leads to rapid disease resolution and aversion of tertiary complications, including death.

Matthew Smale · William R Connell · Julien D Schulberg

To the Editor: The explanation of inference from confidence intervals by Hemming and Taljaard is interesting but unfortunately incorrect.1 The authors may have fallen for the confidence interval variation of the P value fallacy — the mistaken idea that the P value (or confidence interval) can capture both the long term outcomes of an experiment, as commonly reflected in the phrase “a trend to significance (P = 0.06)”, and the evidential meaning of a single result.2 In a frequentist approach, the P value follows from the null hypothesis, which is either accepted or rejected. The calculation of the P value proceeds only because we have accepted the null hypothesis to be true. Are Hemming and Taljaard confusing Bayesian and frequentist inferential methods?3 The difference between Bayesian and frequentist logic is analogous to the diagnosis of measles for a hypothetical patient presenting with a fever and a rash.4 With frequentist logic, we would consult a text book (the correct textbook being a key assumption), and base our diagnostic inference on a hypothetical cohort of 100 patients presenting to us with an identical rash and fever, to state that 95 of them would have measles. We would not be able to state which of this hypothetical group of individuals had measles. Moreover, a diagnosis of “a trend to measles (P = 0.06)” does not exist in the real world. By contrast, with Bayesian logic, our hunch (the prior) that the patient in front of us has measles is firmed up (the posterior) by knowing that there is a measles outbreak in the community (the evidence). Unfortunately, the thinking commonly found in association with P values and 95% confidence intervals, and suggestions that directive conclusions from randomised trials are achievable from borderline P values, leads to terms such as “a trend to significance” for findings from studies that are underpowered.5

James C Hurley

To the Editor: In their medical education article on confidence intervals, Hemming and Taljaard1 describe an intuitively appealing but incorrect interpretation of confidence intervals, seeming to use a Bayesian interpretation in a frequentist paradigm. They state: “Directive, yet not statistically significant results, can also arise when the confidence interval mostly overlaps with the values indicative of benefit (or harm), that is, when the interval covers treatment effects mostly in one direction.” This gives a confidence interval a property it does not have — that of a probability distribution. The true value of the population parameter, for which the confidence interval is providing an interval estimate, is fixed and cannot be more likely in one region of the confidence interval than any other. It is either in it or out of it. Standard statistical texts routinely emphasise this point.2,3,4 Good and Hardin4 state: “In interpreting a confidence interval based on a test of significance, it is essential to realize that the center of the interval is no more likely than any other value.” It would thus be mistaken to be directive in either direction (benefit or harm) if a confidence interval overlaps the value of no effect. All we can say here is that our data do not enable us to reject the null hypothesis, our results are inconclusive and more research may be necessary.

Chris G Dalton

In reply

Karla Hemming · Monica Taljaard

This calendar will be updated each month. If you have an event you would like to add, please include relevant details in an email to cswannell@mja.com.au. The full version of the calendar is available online at https://www.mja.com.au/conference-calendar August 2021 17 Aug ‐ 20 Aug AFAC Conference, Sydney, NSW 20 Aug ‐ 21 Aug Medico‐Legal Society of Queensland Annual Conference, Gold Coast, QLD 20 Aug ‐ 21 Aug AOA WA Branch ASM, Bunker Bay, WA 21 Aug ANZCA Tasmanian Winter Meeting, Barnbougle, TAS 26 Aug ‐ 27 Aug ACEM 2021 Research Network Symposium, Mooloolaba and online, QLD 26 Aug ‐ 29 Aug Australian Hand Therapy Association National Conference, Perth, WA 27 Aug AOA ACT Branch ASM 2021, Canberra, ACT 28 Aug ‐ 29 Aug AIDA2021 Roadshow, Noongar Country (Perth), WA 28 Aug ‐ 29 Aug General Practice Conference and Exhibition, Perth, WA September 2021 01 Sep ‐ 03 Sep 31st ASCIA Annual Conference, Online 02 Sep ‐ 04 Sep AGES XXXI Annual Scientific Meeting 2021, Gold Coast and online 03 Sep 10th National MND Conference, Online 03 Sep ‐ 05 Sep RANZCP Faculty of Consultation–Liaison Psychiatry 2021 Conference, Adelaide, SA 03 Sep ‐ 06 Sep 22nd World Congress of Epidemiology, Online 06 Sep ‐ 08 Sep Cancer Therapy Conference, Online 06 Sep ‐ 10 Sep Herston Health Precinct Symposium, Brisbane, QLD 07 Sep Oceanic Palliative Care Virtual Conference 2021, Online 07 Sep ‐ 09 Sep GPTEC 2021, Darwin, NT 07 Sep ‐ 09 Sep National Dementia & Aged Care Reform Conference, Melbourne, VIC 08 Sep ‐ 10 Sep Day Hospitals Australia National Conference, Brisbane, QLD 08 Sep ‐ 10 Sep Australasian Delirium Association DECLARED Conference, Brisbane, QLD 09 Sep ‐ 10 Sep Australian Association of Family Therapy (AAFT) Conference 2021, Perth and online 09 Sep ‐ 10 Sep 22nd Asia‐Pacific Prostate Cancer Conference, Melbourne, VIC 10 Sep ‐ 12 Sep RACGP GP21, Online and Melbourne, VIC 10 Sep ‐ 12 Sep AOA Queensland Branch ASM, Noosa, QLD 13 Sep ‐ 14 Sep High Risk Emergency Medicine Meeting, Sydney and online, NSW 13 Sep ‐ 15 Sep Workplace Mental Health Symposium, Gold Coast and online, QLD 16 Sep ‐ 19 Sep RANZCR 2021, Melbourne and online 16 Sep ‐ 21 Sep ESMO 2021, Online 17 Sep ‐ 18 Sep Australian Conference On Neurodevelopmental Disorders, Launceston and online 18 Sep ‐ 19 Sep AIDA2021 Roadshow, Larrakia Country (Darwin), NT 20 Sep ‐ 23 Sep Blood 2021, Online 23 Sep ‐ 24 Sep Australian Public Health Conference 2021, Canberra and online 24 Sep ‐ 25 Sep AIDA2021 Roadshow, Gadigal Country (Sydney), NSW 24 Sep ‐ 26 Sep 14th Annual Update in Paediatric Emergencies, Noosa, QLD 27 Sep ‐ 30 Sep 17th ISDE World Congress for Esophageal Diseases, Online 28 Sep ‐ 30 Sep AACB 58th Annual Scientific Conference, Brisbane and online, QLD 28 Sep ‐ 01 Oct SSEM 2021, Uluru, NT 28 Sep ‐ 01 Oct 9th World RETT Congress, Gold Coast, QLD October 2021 01 Oct ‐ 03 Oct 9th BioCeuticals Research Symposium, Melbourne, VIC 01 Oct ‐ 03 Oct ANZCA Combined Communication, Education, Wellbeing, Leadership and Management Special Interest Group Meeting, Cairns, QLD 01 Oct ‐ 04 Oct NSC 2021, Cairns, QLD 07 Oct ‐ 08 Oct Indigenous Wellbeing Conference, Cairns and online, QLD 08 Oct ‐ 09 Oct USANZ Northern Section Meeting, Brisbane, QLD 09 Oct Advanced Prostate Cancer Consensus Conference, Online 09 Oct ‐ 10 Oct GP Wellbeing Weekend, Daylesford, VIC 12 Oct ‐ 15 Oct 30th Anniversary Stroke Society of Australasia Conference, Perth, WA 12 Oct ‐ 15 Oct Australasian Gastro‐Intestinal Trials Group 23rd ASM, Melbourne, VIC 12 Oct ‐ 15 Oct International Continence Society 2021 Online, Online 12 Oct ‐ 15 Oct Australian and New Zealand Burn Association ASM, Perth, WA 13 Oct ‐ 15 Oct Aged Care Workforce Leaders Forum, Sydney, NSW 16 Oct ‐ 17 Oct USANZ Western Australian Section Meeting, Perth, WA 17 Oct ‐ 19 Oct ANZUP ASM 2021, Adelaide, SA 20 Oct ‐ 22 Oct 2021 NDARC Annual Research Symposium, Online and Sydney 20 Oct ‐ 22 Oct USANZ New Zealand Section Meeting, Auckland, NZ 20 Oct ‐ 23 Oct Rural Medicine Australia RMA21 Conference, TBA 20 Oct ‐ 23 Oct Australasian Society of Cataract and Refractive Surgeons Conference, Noosa, QLD 22 Oct USANZ Victorian Section Meeting, TBC 24 Oct ‐ 26 Oct 13th Cooperative Trials Group for Neuro‐Oncology ASM, Melbourne, VIC 24 Oct ‐ 29 Oct FIGO World Congress of Gynaecology and Obstetrics, Sydney, NSW 27 Oct ‐ 29 Oct Enhancing Practice 2021 Conference, Wollongong, NSW 28 Oct ‐ 29 Oct 13th World Stroke Congress, Online 28 Oct ‐ 30 Oct 41st Australian Association for Cognitive and Behaviour Therapy 41st National Conference, Fremantle, WA 30 Oct USANZ South Australian and Northern Territory Section Meeting, Adelaide, SA November 2021 03 Nov ‐ 04 Nov Justice Health Conference 2021, Online 03 Nov ‐ 05 Nov Australian Rural and Remote Mental Health Symposium, Canberra and online, ACT 04 Nov ‐ 06 Nov USANZ NSW Section Meeting, Wollongong, NSW 04 Nov ‐ 07 Nov International Hip Society ASM, Melbourne, VIC 05 Nov ‐ 06 Nov Australian Orthopaedic Registrars Association Annual Conference, Melbourne, VIC 05 Nov ‐ 06 Nov Global Advances and Controversies in Skin Cancer (GAC‐SC) 2021, Brisbane, QLD 07 Nov ‐ 10 Nov APSAD Conference, Brisbane, QLD 07 Nov ‐ 11 Nov ACEM 38th Annual Scientific Meeting, Christchurch, NZ 07 Nov ‐ 11 Nov Australian Orthopaedic Association 81st ASM, Melbourne, VIC 10 Nov ‐ 12 Nov 2021: The HITH Revolution conference, Canberra, ACT 10 Nov ‐ 13 Nov XIII International Congress of Dermatology, Melbourne, VIC 11 Nov ‐ 13 Nov Australian and New Zealand Association of Oral and Maxillofacial Surgeons 2021 Conference, Hobart, TAS 11 Nov ‐ 13 Nov International Conference on Stillbirth, Neonatal Death and Sudden Unexpected Death in Infancy, Brisbane, QLD 11 Nov ‐ 14 Nov ASCCP 27th Scientific Meeting, Sydney, NSW 11 Nov ‐ 14 Nov Australian Knee Society ASM, TBC, VIC 12 Nov ‐ 14 Aug General Practice Conference and Exhibition, Melbourne, VIC 13 Nov USANZ Tasmanian Section Meeting, Hobart, TAS 14 Nov ‐ 17 Nov Forensic and Clinical Toxicology Association 11th Conference, Brisbane, QLD 16 Nov ‐ 18 Nov Clinical Oncology Society of Australia 48th ASM, Melbourne, VIC 17 Nov ‐ 20 Nov International Summit on Psychedelic Therapies for Mental Illness, Melbourne, VIC 19 Nov ‐ 20 Nov Australasian Melanoma Conference 2021, Sydney, NSW 19 Nov ‐ 21 Nov Australasian Society for Ultrasound in Medicine Conference, Sydney, NSW 19 Nov ‐ 23 Nov 52nd ASC of the Royal Australian and New Zealand College of Ophthalmologists, Brisbane, QLD 20 Nov ‐ 21 Nov Rural Health West Aboriginal Health Conference, Perth, WA 25 Nov ‐ 27 Nov Medicines Management 2021, Adelaide, SA 26 Nov ‐ 28 Nov 24th Annual Australasian Menopause Society Congress, Adelaide, SA 26 Nov ‐ 28 Nov Spine Society of Australia 32nd ASM, Sydney, NSW December 2021 01 Dec ‐ 03 Dec 2021 STOP Domestic Violence Conference, Gold Coast and online, QLD February 2022 06 Feb ‐ 11 Feb 33rd International Congress on Occupational Health, Melbourne, VIC 21 Feb ‐ 24 Feb Tripartite Colorectal Meeting 2022, Auckland, NZ 24 Feb 4th Sydney Spinal Symposium, Sydney, NSW 24 Feb ‐ 26 Feb ASURA 2022, Adelaide, SA March 2022 01 Mar ‐ 05 Mar AusACPDM and IAACD 2022 Conference, Melbourne, VIC 03 Mar ‐ 05 Mar SWA2022: Trauma, critical care and emergency surgery conference, Sydney, NSW 14 Mar ‐ 15 Mar 2022 Frontline Mental Health Conference, Gold Coast and online, QLD 24 Mar ‐ 27 Mar 13th International Symposium on Paediatric Pain, Auckland, NZ 25 Mar ‐ 28 Mar 2022 World Ophthalmology Congress, Melbourne, VIC 28 Mar ‐ 30 Mar 2022 Child and Adolescent Mental Health Conference, Gold Coast and online, QLD April 2022 03 Apr ‐ 06 Apr Coda22, Melbourne, VIC 03 Apr ‐ 07 Apr International Stereotactic Radiosurgery Society Congress, Brisbane, QLD 22 Apr ‐ 25 Apr World Congress for Hair Research 2022, Melbourne, VIC May 2022 11 May ‐ 13 May TAPNA 2022, Perth, WA 25 May ‐ 28 May Arthroplasty Society of Australia 2022 Annual Scientific Meeting, Noosa, QLD June 2022 07 Jun ‐ 10 Jun 2022 Rehabilitation Medicine Society of Australia and NZ 5th ASM, Gold Coast, QLD 16 Jun ‐ 18 Jun ASPS Plastic Surgery Congress, Gold Coast, QLD 17 Jun ‐ 18 Jun Sydney Robotics Summit, TBA July 2022 02 Jul ‐ 07 Jul International Society of Posture and Gait Research World Congress 2022, Brisbane, QLD 20 Jul ‐ 21 Jul 10th Annual Victorian Healthcare Week, Melbourne, VIC 23 Jul 2022 Sydney Eye Hospital Alumni Meeting, Sydney, NSW 31 Jul ‐ 05 Aug 4th Biennial International Childhood Trauma Conference, Melbourne, VIC August 2022 19 Aug ‐ 20 Aug AOA WA Branch ASM, TBA, WA 28 Aug ‐ 31 Aug 19th International Symposium on Staphylococci and Staphylococcal Infections, Perth, WA September 2022 06 Sep ‐ 09 Sep 32nd ASCIA Annual Conference, Brisbane, QLD 21 Sep ‐ 23 Sep Population Health Congress 2022, Adelaide and online October 2022 01 Oct 16th International Symposium on Dendritic Cells, TBA 12 Oct ‐ 15 Oct Rural Medicine Australia RMA22 Conference, TBA 15 Oct ‐ 18 Oct Asia‐Pacific Federation for Clinical Biochemistry and Laboratory Medicine Congress, Sydney, NSW 20 Oct ‐ 23 Oct WONCA 2022, Sydney, NSW 30 Oct ‐ 03 Nov NZOA/AOA Combined Annual Scientific Meeting 2022, Christchurch, NZ November 2022 04 Nov ‐ 08 Nov RANZCO’s 53rd Annual Scientific Congress, Perth, WA 27 Nov ‐ 30 Nov 14th World Conference on Injury Prevention and Safety Promotion, Adelaide, SA March 2023 04 Mar RANZCO Victoria Branch Annual Scientific Meeting, TBC 17 Mar ‐ 18 Mar RANZCO NSW Branch ASM, TBC, NSW August 2023 18 Aug ‐ 19 Aug AOA WA Branch ASM, TBA, WA October 2023 25 Oct ‐ 28 Oct Rural Medicine Australia RMA23 Conference, TBA November 2023 20 Nov ‐ 23 Nov 23rd Triennial Meeting of the International Association of Forensic Sciences and the 26th Symposium of the Australian and New Zealand Forensic Science Society, Sydney, NSW October 2024 18 Oct ‐ 22 Oct 2024 World Congress on the Menopause, Melbourne, VIC

Cate Swannell