Volume 215 Issue 5

What now for the regulation of complementary, unconventional and emerging treatments following the Medical Board of Australia’s decision not to revise its guidelines?

Miriam Wiersma · Ian H Kerridge · Cameron L Stewart · Wendy L Lipworth

Whether the U=U message is received with scepticism or not, it is clear it is radically challenging the stigma associated with HIV

James H McMahon · Brent Allan · Daniel Grace · Nic Holas

Fragmented patient care can lead to missed diagnoses, inappropriate prescribing and failure of preventive medicine

Jack Marjot · Georgie Haysom · Penny Browne

The “ABCD of CGA” concept presents varying models of CGA depending on the setting and needs of the patient

Paven Kaur · Jeffrey Rowland · Elizabeth Whiting

A 31-year-old Caucasian woman presented to the emergency department with a 1-day history of vomiting and lethargy, but no other symptoms

Nardeen S Habashy · Hwang Tan · Emily J Hibbert

An 86-year-old man presented with multiple, asymptomatic tense, white bullae over bilateral toes one week after a resolved episode of acute gouty arthritis

Hsi Yen · Hsing‐Jou Su · Wei‐Ti Chen

Wealthy nations must do much more, much faster

Lukoye Atwoli · Abdullah H Baqui · Thomas Benfield · Raffaella Bosurgi · Fiona Godlee · Stephen Hancocks · Richard C Horton · Laurie Laybourn‐Langton · Carlos A Monteiro · Ian Norman · Kirsten Patrick · Nigel Praities · Marcel GM Olde Rikkert · Eric J Rubin · Peush Sahni · Richard SW Smith · Nicholas J Talley · Sue Turale · Damián Vázquez

We need to consider offering vaccination to adolescents and young adults

Mary‐Louise McLaws

Patient survival is more likely when general practitioners and their staff are trained in resuscitation and equipped with defibrillators

Siobhán Masterson · Tomás Barry

The time for actively recommending the screening of asymptomatic men has passed

Justin J Coleman

Ambulatory monitoring or hospital in the home may reduce presentations and admissions to hospital of children with COVID-19

Laila F Ibrahim · Doris Tham · Vimuthi Chong · Mark Corden · Simon Craig · Paul Buntine · Shefali Jani · Michael Zhang · Shane George · Amit Kochar · Sharon O’Brien · Karen Robins‐Browne · Shidan Tosif · Andrew Daley · Sarah McNab · Nigel W Crawford · Catherine Wilson · Franz E Babl

Objective: To compare the frequency and outcomes of cardiac arrests in general practice clinics with those of paramedic‐witnessed cardiac arrests. Design, setting: Retrospective study; analysis of Victorian Ambulance Cardiac Arrest Registry data, 1 January 2000 – 30 December 2019. Participants: Patients with non‐traumatic cardiac arrests whom emergency medical services staff attempted to resuscitate. Main outcome measures: Survival to hospital discharge. Results: 6363 cases of cardiac arrest were identified: 216 in general practice clinics (3.4%) and 6147 witnessed by paramedics (96.6%). The proportion of patients presenting with initial shockable rhythms was larger in clinic (126 patients, 58.3%) than paramedic‐witnessed cases (1929, 31.4%). The proportion of general practice clinic cases in which defibrillation was provided in the clinic increased from 2 of 37 in 2000–2003 (5%) to 19 of 57 patients in 2016–2019 (33%); survival increased from 7 of 37 (19%) to 23 of 57 patients (40%). For patients with initial shockable rhythms, 57 of 126 in clinic cases (45%) and 1221 of 1929 people in paramedic‐witnessed cases (63.3%) survived to hospital discharge; of 47 general practice patients defibrillated by clinic staff, 27 survived (57%). For patients with initial shockable rhythms, the odds of survival were greater following paramedic‐witnessed events (adjusted odds ratio [aOR], 3.39; 95% CI, 2.08–5.54) or general clinic arrests with defibrillation by clinic staff (aOR, 2.23; 95% CI, 1.03–4.83) than for general practice clinic arrests in which arriving paramedics provided defibrillation. Conclusion: Emergency medical services should be alerted as soon as possible after people experience heart attack warning symptoms. Automated external defibrillators should be standard equipment in general practice clinics, enabling prompt defibrillation, which may substantially reduce the risk of death for people in cardiac arrest.

Brian Haskins · Ziad Nehme · Peter A Cameron · Karen Smith

Measuring prostate‐specific antigen (PSA) levels is widely used for screening for the early diagnosis of prostate cancer.1 However, the value of PSA testing for reducing prostate cancer‐specific or all‐cause mortality in asymptomatic men is uncertain.2 The Prostate Cancer Foundation of Australia and the Cancer Council of Australia recommend that men aged 50–69 years be offered biennial PSA testing if they make an informed decision to be tested.1 We investigated age‐specific patterns of PSA testing and PSA levels in men aged 40 years or more without symptoms of prostate cancer. We analysed routinely collected data from 180 Victorian general practices, pooled by the data custodian, Outcome Health.3 We included all men who had attended the same practice at least three times during October 2016 – September 2018. We identified tested men and testing frequency from recorded PSA test results. PSA testing prevalence was defined as the number of men tested at least once divided by the total number of men in an age group. We evaluated the relationship between log‐transformed PSA levels and age as a continuous variable in a linear regression model. The Royal Australian College of General Practitioners National Research and Evaluation Ethics Committee (17‐008) and the Macquarie University Human Research Ethics Committee (5201700872) approved our study. A total of 142 016 male patients were identified. The proportion who underwent PSA testing at least once (prevalence) or at least twice during the study period increased with age: prevalence peaked with the 65–69 year age group (8132 men tested, 54% of age group), and the proportion of men tested at least twice with the 70–74 year age group (3159 men, 46% of age group) (Box 1). A total of 78 818 PSA test results were recorded during the study period; about one‐third were for men aged 60–69 years (25 496 tests, 32%). The median PSA level increased from 0.7 ng/mL (interquartile range [IQR], 0.5–0.9 ng/mL; 95th percentile, 1.7 ng/mL) for men aged 40–44 years to 1.9 ng/mL (IQR, 0.8–4.5 ng/mL; 95th percentile, 11.7 ng/mL) for men aged 85 years or more (Box 2). The median PSA level increased by 3.2% per year of age (95% confidence interval, 3.1–3.3%). We found that PSA testing prevalence, the proportion of men tested more than once within 24 months, and median PSA levels each increased with age. For men over 69 years of age, this could lead to further invasive tests and treatments, some of which may be unnecessary or cause harm. The high PSA testing prevalence among older men was similar to previous Australian reports (48% of men aged 70 years or more reported they had PSA tests in the preceding two years4), and the PSA levels matched current age‐specific 95th percentile reference ranges.5 Why patterns of testing are different to those recommended (ie, more frequently than biennial and beyond 69 years of age) cannot be explained by general practice data, but reasons may include patient expectations, fragmentation of care, and the persistence of old guideline recommendations. We have reported the most comprehensive snapshot of PSA testing in Australia based on electronic general practice data since the release of the current guidelines for PSA testing of asymptomatic men. Our study also showed that such data can be used to establish benchmarks for designing quality improvement activities and to promote evidence‐based decision‐making in general practice. Box 1 – Prostate‐specific antigen (PSA) testing for 180 Victorian general practices, October 2016 – September 2018, by age group* * Proportion of male patients in age group who were tested. It is recommended that men aged 50–69 years be tested once every two years. Numbers of patients in each age group are provided in the online Supporting Information. Box 2 – Number of prostate‐specific antigen (PSA) tests and median PSA test result levels, by age group table#t2 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Age group (years) Number of tests PSA level (ng/mL) Median (IQR) 95th percentile 40–44 2685 (3.4%) 0.7 (0.5–0.9) 1.7 45–49 5894 (7.5%) 0.7 (0.5–1.0) 2.1 50–54 9544 (12.1%) 0.8 (0.5–1.2) 2.6 55–59 12 359 (15.7%) 0.9 (0.6–1.5) 3.7 60–64 12 944 (16.4%) 1.1 (0.6–2.0) 4.7 65–69 12 551 (15.9%) 1.3 (0.7–2.4) 5.5 70–74 10 999 (14.0%) 1.5 (0.8–2.8) 6.4 75–79 6440 (8.2%) 1.6 (0.8–3.3) 8.0 80–84 3327 (4.2%) 1.8 (0.8–3.6) 9.2 ≥ 85 2075 (2.6%) 1.9 (0.8–4.5) 11.7 All ages groups 78 818 1.0 (0.6–2.0) 5.4 IQR = interquartile range.

Guilherme S Franco · Rae‐Anne Hardie · Ling Li · Chisato Imai · Gorkem Sezgin · Julie Li · Adam McLeod · Christopher Pearce · Andrew Georgiou

It is critical primary care clinicians dedicate specific attention to the management of both depression and insomnia when they co-occur

Alexander Sweetman · Leon Lack · Emer Van Ryswyk · Andrew Vakulin · Richard L Reed · Malcolm W Battersby · Nicole Lovato · Robert J Adams

To the Editor: Despite the rapid uptake of telemedicine during the coronavirus disease 2019 (COVID‐19) pandemic,1 it is important to identify the barriers that hinder the delivery of alternate modes of care among specific populations. We share our reflections on the challenges of implementing telemedicine in a tertiary addiction medical clinic in Melbourne, providing treatment for about 105 patients each month. At the start of the COVID‐19 pandemic in February 2020, videoconferencing appointments were encouraged, supported by technical assistance from a clinician. During the Stage 4 lockdown period (August to September 2020 inclusive), appointments were switched to videoconferencing, with face‐to‐face only offered where clinically necessary (eg, for long‐acting injectable opioid agonist treatment). For patients unable to access videoconferencing, telephone appointments were offered. The uptake of videoconferencing was low, comprising 21% (n = 47) of appointments conducted during lockdown versus 57% (n = 128) via telephone (Box). After the lockdown (November 2020 to February 2021), there was a gradual return to face‐to‐face appointments. Seven per cent (n = 28) of appointments were done via videoconferencing while 40% (n = 155) remained via telephone. Difficulties in connecting to the videoconferencing platform, poor audiovisual quality and time spent troubleshooting contributed to the low uptake of videoconferencing. While telemedicine has been a convenient mode of health care delivery during the COVID‐19 pandemic,3 not all patients benefit from it. People accessing specialist addiction treatment are often from sociodemographic groups that are digitally excluded, such as the unemployed and people with low income or with disabilities.4 We found several barriers to telemedicine in our patient cohort. Many patients did not own a computer, had poor digital literacy, could not afford internet access or did not have privacy for consultations. Telephone appointments raise clinical gaps, with physical signs, mental state and visual cues unable to be assessed. Digital inequality further marginalises an already vulnerable population. Access, affordability and digital ability issues need to be managed for telemedicine to be a viable option.4 Examples of how this might be achieved include the establishment of hubs with telemedicine facilities, technical support and private spaces, located at local community health centres for practicality and accessibility, along with providers offering more affordable internet plans for health care card holders. Box – Modality of clinic appointments by month during the coronavirus disease 2019 (COVID‐19)‐related restrictions in Melbourne, Victoria (total monthly COVID‐19 Victorian cases also shown2)

Anthony Hew · Shalini Arunogiri · Dan I Lubman

To the Editor: Published evidence recognises that the recreational misuse of nitrous oxide (N2O) can be associated with vitamin B12 deficiency and subacute combined degeneration of the spinal cord.1 Misuse of N2O is increasing,2 with canisters (known as “nangs” or “whippits”) readily available for legal purchase in convenience stores and online ostensibly for the purpose of whipping cream. In recent years, an increase in the number of emergency presentations and acute hospital admissions related to N2O misuse has been recorded in Australia.3,4 We have also seen an increase in the number of patients requiring specialist multidisciplinary rehabilitation for severe impairments, including proprioceptive deficits, ataxia, disabling lower limb weakness and persistent gait abnormalities. Over recent years, a growing number of patients have been admitted to our inpatient metropolitan Sydney rehabilitation unit with serious disabilities related to N2O misuse. In line with published reports, our experience confirmed that patients are often university students (typically aged < 30 years).3,4 As acute medical specialties recognise the significance of these presentations,3,4 we highlight that the resulting disabilities can remain for months or years at functional, vocational and emotional levels, and many will be lifelong. This will impose a significant disability burden that will require ongoing management by specialist rehabilitation and disability services and will have an impact on the wider health care utilisation and cost. As long as N2O remains legal and accessible and is perceived by many as seemingly innocuous, users will remain largely unaware of the severity and risk presented by its long term use. Compared with messaging surrounding other “hard drugs”, most of the literature and the public health messaging in Australia do not appear to emphasise the potential for catastrophic, permanent injury associated with the misuse of N2O. Given the emerging disability burden resulting from recreational N2O misuse, we recommend enhancing existing public awareness campaigns.5 We suggest that educational resources place greater emphasis on the potential for serious, long term impairments and that education campaigns be targeted to most susceptible people via tertiary and/or secondary education establishments. Widespread restrictions on N2O purchase should also be considered. Such measures may help prevent permanent and devastating disabilities resulting from the misuse of this easily accessible substance.

Simon Mosalski · Anne Tanner · Christine T Shiner

Taking opportunities as they’ve arisen has been the key to Dr Laila Ibrahim finding her vocation

Cate Swannell