Volume 216 Issue 11

Dynamic consent has the potential to facilitate personalised medicine delivering on its goals

Liza Goncharov · Hanna Suominen · Matthew Cook

As the number of requests for raw genomic data increases, policies and protocols reflecting the perspectives of clinicians, patients, researchers and research participants are required

Jane L Nielsen · Carolyn Johnston · Tracey O'Brien · Vanessa J Tyrrell

Australia owes a debt to its IMGs; we need to improve how we manage the transition of an immigrant doctor to Australian practice

Neville D Yeomans · Ayaz Chowdhury · Alan Roberts

Nations need to come together to plan and execute urgent actions to break through the obstacles to sharing essential intellectual property

Martin Hensher · Sithara Wanni Arachchige Dona

A 32-year-old man with 15 years of intermittent bloody diarrhoea was diagnosed with ulcerative proctosigmoiditis

Kenneth K Cho · Yanna Ko · Kelly Nilsen · Christine Verdon · Giuseppe Femia

A 70-year-old man of non-English speaking background migrated from Vietnam to Melbourne, Victoria, in 2007.

Robert G Stolz · Mark R Dowling · Belinda B Lin · Kylie Mason · Stephen Muhi

A previously well 9-year-old boy presented to the outpatients’ clinic with a tender, swollen occipital scalp lesion progressing over one month’s duration

Abhinav Rajkumar · Philip N Britton

Healthcare technology in context: lessons for telehealth in the age of COVID-19

Bodil Rasmussen

Cradle-to-grave regional programs featuring immersive community engaged education are needed to ensure a sustainable rural medical workforce

Roger P Strasser

International medical graduates still face significant obstacles to registration 10 years after the Lost in the labyrinth inquiry

Susan Douglas

Recruitment to and retention in rural practice were higher among graduates with extended RCS experience

Alexa N Seal · Denese Playford · Matthew R McGrail · Lara Fuller · Penny L Allen · Julie M Burrows · Julian R Wright · Suzanne Bain‐Donohue · David Garne · Laura G Major · Georgina M Luscombe

The estimated prevalence of hereditary pancreatitis in South Australia is higher than in Europe, particularly among Indigenous young people

Denghao Wu · Tristan J Bampton · Hamish S Scott · Alex Brown · Karin Kassahn · Christopher Drogemuller · Sunita MC De Sousa · David Moore · Thuong Ha · John WC Chen · Sanjeev Khurana · David J Torpy · Toni Radford · Richard Couper · Lyle Palmer · P Toby Coates

The COVID-19 border closures delayed cardiac interventions for young patients by at least 18 months

Elizabeth Paratz · Joaquina Maurays · Ricardo Flavio · Alan Appelbe · Noel Bayley

General practitioners view health and medical research positively, but their participation in postal surveys is typically low

Alison C Zucca · Mariko Carey · Rob W Sanson‐Fisher · Joel Rhee · Balakrishnan (Kichu) R Nair · Christopher Oldmeadow · Tiffany‐Jane Evans · Simon Chiu

Ongoing elucidation of genetic and inflammatory pathways responsible for atopic dermatitis holds promise for new targeted treatments and increasingly personalised atopic dermatitis therapy

Michelle SY Goh · Jenny SW Yun · John C Su

To the Editor: We read with interest the letter by Withers and colleagues1 highlighting the research waste generated by the inclusion of research in the selection criteria for specialist training in Australia and Aotearoa New Zealand. We agree the inclusion of research for selection or completion of specialty training produces unintended incentives that contribute to poor quality studies and research waste. We also support the notion that “research utilisation, research training, or participation in large research teams” should be prioritised by colleges. Selection criteria for medical specialty training should incentivise contribution to high quality projects and the development of research literacy and skills, rather than publishing many small, low impact articles. Student‐ and trainee‐led collaborative research groups, such as the TASMAN (Trials and Audit in Surgery by Medical Students in Australia and New Zealand) Collaborative, provide a promising solution to this research waste.2,3 Similar groups have emerged locally and internationally and have successfully delivered large randomised controlled trials and cohort studies.2,3,4 These high impact publications have provided practice‐changing results4 as well as training and opportunities for collaborators to develop research skills. Locally, medical students, junior doctors and surgical trainees have contributed to the recent SUNRRiSE (Single Use Negative Pressure Dressing for Reduction in Surgical Site Infection Following Emergency Laparotomy) randomised controlled trial,5 and POSTVenTT (Postoperative Variations in Anaemia Treatment and Transfusions) prospective audit,6 the results of which are eagerly awaited. Despite this, the contribution to collaborative research studies is not currently recognised for selection into most specialty training programs in Australia or Aotearoa New Zealand. We echo the calls of our international counterparts for participation in collaborative research to be accounted for in applications for postgraduate training.7 We applaud the Royal Australasian College of Surgeons and General Surgeons Australia for incorporating collaborative research as part of the selection criteria and the points‐based research requirements during General Surgical Education and Training in 2022,8,9 and hope that other specialties follow suit. We look forward to the emergence of student‐ and trainee‐led collaborative groups from other medical specialties in Australia and Aotearoa New Zealand. Further recognition of collaborative research will improve research skills in medical graduates, reduce research waste and, most importantly, generate meaningful data to improve patient outcomes.

TASMAN Collaborative

In reply

Paulina Stehlik · Caitlyn Withers · Caitlin Brandenburg

To the Editor: We present a case of hypotensive shock after insulin pump delivery interruption during a diabetes technology trial, and offer a systematic insulin pump troubleshooting approach.1 A 61‐year‐old woman with long‐duration type 1 diabetes using an insulin pump, coronary artery disease and hypertension presented to an emergency department with hyperglycaemia, hypotension and presyncope. She had self‐identified insulin pump delivery interruption but felt too unwell to troubleshoot independently. Initial subcutaneous insulin bolus dose administration via the pump as directed by the hospital doctor was ineffective and diabetic ketoacidosis developed. In the context of cardiovascular comorbidities and antihypertensives, including transdermal glyceryl trinitrate, the patient deteriorated rapidly progressing to hypotensive shock requiring intensive care. Insulin delivery interruption was ultimately attributed to line blockage; earlier identification and prompt administration of insulin via an alternative route may have avoided the development of ketoacidosis. Therapeutic diabetes technology is evolving, with an increasing proportion of people with type 1 diabetes now using insulin pumps to replace lost pancreatic β‐cell function.2 Insulin pumps subcutaneously infuse rapid‐acting insulin alone, providing both background basal and bolus insulin doses. These insulin preparations have peak effect at 1–2 hours and duration of action of about 4 hours. Therefore, for people with type 1 diabetes, insulin pump delivery interruption typically causes relative insulin deficiency within 2 hours and absolute insulin deficiency within 4 hours with consequent risk of rapid development of hyperglycaemia, ketosis and ketoacidosis.3 Pump users are routinely instructed on how to troubleshoot insulin delivery problems, including proactive self‐management of pump‐related issues; however, management may revert to clinicians during acute illness. All clinicians should therefore be familiar with common complications during insulin pump therapy, and when to convert to an alternative route of insulin administration to prevent rapid metabolic deterioration.4 The treatment of hyperglycaemia and ketosis is time‐critical, and decisions regarding insulin pump continuation during hospital admissions should be individualised within the acute context.4,5 Once stabilised, patients should reconnect with their diabetes management team for ongoing education. We present a systematic approach to managing rising blood glucose and/or ketones during insulin pump use (Box). As the vignette illustrates, individuals with medical comorbid conditions are at risk of rapid, life‐threatening deterioration after insulin pump delivery interruption. Box – Clinical practice flowchart of steps to troubleshoot insulin pump delivery‐related problems SGLT‐2 = sodium glucose co‐transporter 2. The potential causes of insulin delivery interruption are presented systematically from the site of insulin delivery to the insulin pump. * Hyperglycaemia generally considered to be glucose level>14mmol/L. † Ketosis generally considered to be ketone level>0.6mmol/L. Clinicians should consider the flowchart to be a general guide; always adapt treatment approach to the clinical presentation and refer to local policies and procedures. Management of hyperglycaemia and ketosis is time‐critical; refer to the Royal Australian College of General Practitioners and Australian Diabetes Society joint clinical position statement for a primary care emergency management algorithm.4 Assess whether it is clinically appropriate for hospitalised patients to continue insulin pump therapy.5 Inset: Schematic diagram of the main components of insulin pump therapy; the insulin “infusion set” comprises the cannula (inserted subcutaneously), delivery line and insulin reservoir.

Anindita Chakrabarti · Richard J MacIsaac · Sybil A McAuley

To the Editor: We thank Polkinghorne and Kerr1 for their editorial on the health care needs of people with chronic kidney disease (CKD). We write to highlight the burden of visual loss suffered by people with CKD and its effects on quality of life and mortality. The prevalence of eye diseases associated with visual impairment (combined World Health Organization definitions of blindness and low vision) in people with CKD is about 36%, rising to about 60% in people with end‐stage renal disease.2 The commonest causes of visual impairment are diabetic retinopathy (prevalence in patients with CKD, 19–46%), cataract (prevalence, 33–75%) and age‐related macular degeneration (prevalence, 8–36%).2 Increased incidence of retinal vein occlusions and hypertensive retinopathy are also associated with CKD. Patients receiving haemodialysis have increased risk of additional ocular complications. A recent study of 121 patients found at least one ocular finding in over 89% cases, including conjunctival (32%) and corneal (32%) calcification, and optic atrophy (19%).3 Ectopic calcification has been a common cause of irritated eyes in patients receiving dialysis, but this may be decreasing with modern dialysis methods. Increased risk of optic atrophy may be related to chronic anaemia and an increased risk of non‐arteritic anterior ischaemic optic neuropathy. Uraemic optic neuropathy is now an uncommon event. People with CKD are recognised to have an increased risk of dying from heart disease (up to 20 times that of age and gender matched people for people on haemodialysis).4,5 Vision impairment may incrementally contribute to increased mortality; a recent meta‐analysis demonstrated an all‐cause mortality hazard ratio of 1.43 (95% CI, 1.22–1.68) for visual acuity worse than 6/18.6 Vision‐related quality of life is potentially reduced in people with CKD, affecting their ability to complete activities of daily living and their social, emotional and economic wellbeing. Vision loss is associated with increased risk of falls and increased mental health burden, typically anxiety and depression, and may limit the ability to live independently, including self‐medicating with insulin and performing home dialysis. Multiple studies show people rate losing vision as worse than losing hearing, memory, speech or a limb.7 We agree that supportive care clinics for people electing to not receive kidney replacement therapy are important, and suggest that these clinics include regular eye care services.

Heather G Mack · Deborah J Colville · Judith A Savige