Volume 216 Issue 1

A 76-year-old man with a history of ureteric nephrolithiasis presented with dysuria and sharp, severe right flank pain with radiation to the inguinal region

Roland Z White · Hemant Vanmali · Matthew Sampson

An 82-year-old woman presented to hospital with worsening chronic dyspnoea without fever or other specific symptoms

Michael Toolis

We need strength and courage to live with COVID-19, and still more to overcome chronic social and planetary neglect

Nicholas J Talley

Knowledge about the composition and physiological effects of e-liquids is essential for assessing their effects on health

Ira N Advani · Mario Perez · Laura E Crotty Alexander

Influenza vaccination for travellers and the resources mobilised during the COVID-19 pandemic could mitigate the effects of an influenza resurgence

Sheena G Sullivan

Australian e-liquids contain a wide variety of chemicals for which information on inhalation toxicity is not available

Alexander Larcombe · Sebastien Allard · Paul Pringle · Ryan Mead‐Hunter · Natalie Anderson · Benjamin Mullins

Our findings prompted a local health campaign promoting influenza vaccination before travelling overseas during the Australian summer

Celeste K Marsh · Vicky Sheppeard · Sean Tobin · Robin Gilmour · Ross M Andrews

An ongoing pandemic response, beyond mass vaccination, will be required of political and health systems throughout 2022

Mark J Hanly · Timothy Churches · Oisin Fitzgerald · Jeffrey J Post · C Raina MacIntyre · Louisa Jorm

The absence of high quality evidence for basic clinical dilemmas in immune thrombocytopenic purpura underlines the need for contemporary guidelines relevant to the local treatment context

Philip YI Choi · Eileen Merriman · Ashwini Bennett · Anoop K Enjeti · Chee Wee Tan · Isaac Goncalves · Danny Hsu · Robert Bird

To the Editor: As members of the Australian Rheumatology Association (ARA), we read with great interest the recent article by Russell and colleagues.1 The organisation has long been concerned that current training pathways and health care resourcing are resulting in a discordance between rheumatology health care supply in Australia and community needs. ARA believes the rheumatology workforce is in significant undersupply, ageing and largely focused in cities, and that our current training programs will not deal with these issues. A 2018 ARA survey of members found that 41% of respondents (of which 54.5% work at rural and remote clinics) plan to retire in the next 10 years.2 Our concerns are supported by Western Australian data3 reporting a critical shortfall of rheumatologists that trainee throughput will not address. However, accessing accurate national data has been difficult due to the issues outlined by Russell et al.1 For example, Australian Health Practitioner Regulation Agency (Ahpra) data suggest there are 441 practising rheumatologists in Australia, but the ARA is only able to identify 364 (including non‐members).4 In addition, understanding the community demand for care has been challenging, as this might be assessed through the surrogate of numbers of people on waiting lists, but there is heterogeneity of the referral acceptance guidelines and data collection processes. To this end, ARA has recently partnered with the Public Health Information Development Unit at Torrens University to define the rheumatology workforce in Australia, analyse interaction effects, and understand the relationships across public and private settings. This needs to be linked to disease prevalence data and geographic service area to understand supply and demand. We also need to understand the selection into the training process and pathways in order to drive policy addressing our suspected workforce problems. We strongly believe that any workforce planning research should engage and partner with specialty societies; for example, we believe that ARA is best placed to engage our members to aid understanding of their career choices and practice patterns. We encourage other specialty groups to follow suit and the Royal Australasian College of Physicians to consider their leadership role in this area.

Helen I Keen · Claire Barrett · Catherine Hill

To the Editor: In their study examining the suicide deaths of 3027 young Australians during 2006–2015, Hill and colleagues1 reported that nearly 60% of cases had experienced mental health problems during their lifetime, and around 75% of deaths were of young males. We would like to draw attention to another important statistic within these data. Specifically, 4.6% of males who died by suicide in Australia had a diagnosis of autism spectrum disorder (ASD). This is alarming, considering that the prevalence of males with ASD in Australia is estimated to be only 1.3%.2 For males in the study age range (ie, 10–24 years), the prevalence ranges from 1.2% to 3.3%, with the highest prevalence in the 10–14 year bracket. Nonetheless, the apparent high incidence of suicide by males with ASD is consistent with recent research indicating a three‐ to nine‐fold increased risk of suicide among people with ASD compared with the general population.3,4 The increased suicide risk in ASD may be explained by the high incidence of comorbid psychiatric disorders among this population.5 Indeed, in one national cohort study from Denmark, over 90% of people with ASD who attempted or died by suicide had another comorbid mental health condition.3 In addition, it is important to note the low rate of suicide reported among females with ASD (0.4%). This finding is inconsistent with large international studies that report significantly increased incidence of suicide among females with ASD compared with females in the general population, with rates similar to or exceeding that of males with and without ASD.3,4,5 Females with ASD may be underrepresented in the data presented by Hill and colleagues due to lower recognition of ASD among females or to diagnostic overshadowing, whereby ASD is overlooked in favour of other more apparent psychiatric diagnoses (eg, anxiety, borderline personality disorder, depression). Finally, we highlight the fact that there is no systematic procedure or requirement in Australia for asking about or reporting ASD diagnoses within the emergency department or hospital admission systems. Plausibly, ASD is inadequately captured in data concerning health and mental health profiles, health service system access, suicide attempts and deaths in Australia.

Darren Hedley · Mark A Stokes · Julian N Trollor

In reply

Nicole TM Hill · Patrick D McGorry · Jo Robinson

To the Editor: The incisive editorial by Dudley and Lin1 should serve as a clarion call for the development of “more robust strategies with targeted, customised approaches … evidence‐based interventions and peer‐reviewed evaluations”. Their sobering editorial highlights the immense challenges that need to be overcome to affect the growing suicide rates underscored by Hill and colleagues.2 They point out that transgenerational trauma and socio‐economic disadvantages increase suicide in Indigenous populations and call upon collaborative governmental support to address the problem. Intriguingly, although prevalence is higher in moderate to severely disadvantaged youth, the statistics among the least disadvantaged youth are not lagging far behind.2 This suggests that there are likely additional commonalities, such as mental illness, which features in at least half of all such suicide (> 55%).2 It is in light of this confronting reality that we raise the additional need for in‐depth knowledge and mechanism‐informed targeted treatment to avert suicide. It is concerning that one‐third of parents and carers are inadequately informed of mental health services available for mentally ill youth, impeding access to appropriate services,1 which clearly needs to be addressed. But simultaneously, it is important to identify more specific interventions and discern when and how to apply them effectively. This requires a reconceptualisation of suicide as a process, which involves both broad factors within the social environment and specific changes within cognitive and emotional processing networks within the brain.3 Mental illnesses, such as depression, have an impact on the latter by creating a cognitive drive that can be modelled as sequential steps that emerge from a faulty appraisal system to engender feelings of defeat and entrapment that increase hopelessness.3 It is because of these poorly understood antecedents4 and lack of rescuing factors that suicidal ideation ensues3 and is intensified to ideation or intent by additional motivational factors before being converted volitionally to planning and attempting suicide.3 The latter alters neural network connectivity, and further increases the likelihood of future suicide.5 Such deeper insights are needed to provide a framework for targeted preventive interventions. Therefore, we strongly resonate with the authors’ demand for targeted evidence‐based interventions and urge that in addition to these much‐needed initiatives, our energies should also be invested in mechanism‐based research.

Gin S Malhi · Erica Bell · Zola Mannie

In reply

Ping‐I Lin · Michael J Dudley