Volume 216 Issue 3

Different booster to original COVID‐19 vaccine may boost antibody response The antibody response after a COVID‐19 booster (third dose) vaccine appears to be stronger if the booster is a different vaccine to the first and second dose, according to international research, published in the New England Journal of Medicine. The researchers tested three booster shots, Pfizer (153 recipients), Moderna (154 recipients) and Johnson & Johnson (150 recipients). For all combinations, antibody neutralising titres against a SARS‐CoV‐2 D614G pseudovirus increased by a factor of 4 to 73, and binding titres increased by a factor of 5 to 55. Homologous boosters increased neutralising antibody titres by a factor of 4 to 20, whereas heterologous boosters increased titres by a factor of 6 to 73. T cell responses increased in all but the homologous Johnson & Johnson‐boosted subgroup. “These data suggest that an immune response will be generated for each of these vaccines used as a booster regardless of the primary COVID‐19 vaccination regimen,” the researchers reported. https://www.nejm.org/doi/10.1056/NEJMoa2116414 Make‐up of gut microbiome may be linked to long COVID risk The make‐up of the gut microbiome may be linked to a person’s risk of developing long COVID many months after initial infection with SARS‐CoV‐2, suggests research published in Gut. Researchers from the Chinese University of Hong Kong tracked changes in the gut microbiome of 106 patients with varying degrees of COVID‐19 severity, treated at three different hospitals between February and August 2020, and in a comparison group of 68 people who did not have COVID‐19, over the same period. Among those with COVID‐19, stool samples were collected on admission (68), and again after 1 month (64) and after 6 months (68). Stool samples were also collected from 11 patients 9 months later. The researchers checked for the presence of the 30 most commonly reported long COVID symptoms 3 and 6 months after initial COVID‐19 infection. Aerobic capacity and endurance, an indicator of long COVID, was also measured in a 6‐minute distance walk test. Long COVID was reported in 86 (81%) patients at 3 months and in 81 (76.5%) at 6 months. Although initial viral load was not associated with long COVID, their gut microbiome differed from that of patients without long COVID and those who had not had COVID‐19 infection. These patients had a less diverse and abundant microbiome; the gut microbiome of patients who did not develop long COVID was similar to that of those who had not had COVID‐19. Among the bacteria species found in patients with long COVID, 28 were reduced and 14 were enriched both at hospital admission and at 3 and 6 months after hospital discharge. At 6 months, patients with long COVID had significantly fewer “friendly” Faecalibacterium prausnitzii and Blautia obeum and a greater abundance of “unfriendly” Ruminococcus gnavus and Bacteroides vulgatus than people who had not had COVID‐19. On the other hand, the gut microbiome of those who did not develop long COVID showed only 25 changes in bacteria species at hospital admission, with complete recovery after 6 months. https://gut.bmj.com/content/early/2022/01/05/gutjnl‐2021‐325989

A new trial validates the ongoing concerns regarding the introduction of the one-step approach to the diagnosis of gestational diabetes mellitus

Jenny A Doust · Paul P Glasziou · Michael C dʼEmden

Smarter measures for general medicine are needed to improve hospital access

Harvey H Newnham

Australia has the clinical and scientific expertise to introduce mitochondrial donation in a highly regulated environment, but requires changes in legislation to adopt this innovative technology

Marie A Dziadek · Carolyn M Sue

COVID-19 mRNA vaccine-related myocarditis is an extremely rare and mild complication, and is much less frequent than myocarditis secondary to COVID-19 infection

Joshua Wong · Sameer Sharma · Jessica V Yao · Anuradha Aggarwal · Leeanne Grigg

A 21-year-old white man presented with a 3-day history of central blurry vision in his right eye in the context of 3 weeks of right frontotemporal headaches and earaches, fevers, and drenching night sweats

Peter ZX Cui · Elaine Chong · Thomas G Campbell

Peripheral nerve entrapment (entrapment neuropathy) can affect any peripheral nerve in the body

Gavin A Davis · Timothy J Day

Medical providers who learn physical examination techniques early in medical training can spend years honing the craft of observation, palpation and auscultation

Stephen W Russell · Maja K Artandi

Women with non-ST-elevation acute coronary syndromes remain understudied and undertreated

Carlo Andrea Pivato · Birgit Vogel · Roxana Mehran

Older patients may never need kidney replacement therapy, but their other medical conditions require attention

Kevan R Polkinghorne · Peter G Kerr

Women with symptomatic macromastia need relief from a condition that can seriously impair their quality of life

Elisabeth Elder

Clinical guidelines should include recommendations about holistic supportive care for older patients, not just dialysis and transplantation

Matthew D Jose · Rajesh Raj · Kim Jose · Alex Kitsos · Tim Saunder · Charlotte McKercher · Jan Radford

Healthcare systems in all Australian states should support access to surgery for both private and public patients

Tamara A Crittenden · Julie Ratcliffe · David I Watson · Christine Mpundu‐Kaambwa · Nicola R Dean

Adherence to guideline-based therapy for people with NSTEACS could be improved in Australia

Bianca C Bachelet · Karice Hyun · Mario D'Souza · Clara K Chow · Julie Redfern · David B Brieger

Screening by GPs for six major risk factors and brief interventions in primary care or schools may help

the Heath4Life team †

To the Editor: In March 2021, the federal Parliament introduced a bill to legalise the use of the reproductive technology known as mitochondrial donation in Australia.1 Mitochondrial donation would be offered initially at a single trial clinic and, eventually, it would be made more widely available. The aim is to provide at‐risk women with the opportunity to have a genetically related child who is unlikely to develop maternally inherited mitochondrial disease. Legalising mitochondrial donation would have meaningful benefits for such women. However, as the bill currently stands, its implementation raises unresolved ethical and legal issues. Access will predictably be mediated by geographic, financial, medical and informational considerations. These include the location of the initial trial clinic, any out‐of‐pocket costs to prospective parents, and health professionals’ awareness of mitochondrial donation. Existing barriers to genomic testing, genetic counselling, and assisted reproductive technologies will also affect access. These barriers, including long waiting times and limited Medicare coverage for some genetic services, should be minimised. Mitochondrial donation requires donor oocytes. This raises questions about how oocytes will be procured and how many should be apportioned to mitochondrial donation relative to other procedures that may require fewer eggs to achieve a live birth. One crucial issue is whether oocyte donation for mitochondrial donation should require specific consent from donors. One option is to use oocytes donated for assisted reproduction generally, without requiring consent for their use in mitochondrial donation specifically. The first study of mitochondrial donation to yield a live birth took this approach.2 However, we believe this strategy fails to acknowledge the legitimate reservations some donors may have about the use of their oocytes in this novel reproductive procedure. Securing specific informed consent would protect donors’ wellbeing and autonomy as well as protect public trust in medicine. At a minimum, specific consent should be required in the trial stage. This could also generate important data on the views of a critical group of stakeholders (the oocyte donors) and on what impact, if any, requiring specific consent would have on oocyte supply. Mitochondrial donation also prompts a reconsideration of the ethics of sex selection. The Australian Government has signalled that it may provide parents with the option of implanting only male embryos.3 Since mitochondrial DNA is inherited through the maternal line, this would minimise any effects on the descendants of children born via this technique. However, this use of sex selection sits uneasily with Australia’s legal prohibition on, and moral reservations regarding, non‐medical sex selection. Both male and female embryos would receive identical mitochondrial DNA and face the same risks from the procedure; sex selection reduces risks only to that child’s descendants. There is also a concern that offering sex selection would lead parents to believe it is medically indicated, creating a sense of pressure to select male embryos. As sex selection raises serious concerns without promising clear benefits, we think there are problems with offering it in this context. Legalising mitochondrial donation raises numerous ethical issues, including access, oocyte donor consent, and sex selection. While mitochondrial donation carries important potential benefits, these issues need careful attention to ensure that its implementation in Australia is ethically robust.

Julian Koplin · Esther Lestrell

To the Editor: We congratulate Wright and Versteeg1 for their timely article outlining Australian and international experience of patient enrolment in general practice. Missing from the debate, however, is any reflection on the Practice Incentives Program – Indigenous Health Incentive (PIP‐IHI), a voluntary general practice enrolment of Indigenous patients intended to improve chronic illness care. Here, to offer transferrable lessons for informing the rollout of the Voluntary Patient Enrolment scheme (called MyGP),2 we draw on findings from the Sentinel Sites Evaluation — based on administrative data from the Department of Health and more than 700 interviews with Aboriginal health services and general practice3 — and submissions made to the PIP‐IHI review by key stakeholders in 2019.4,5 First, the lack of existing clinical information system capacity to record if a patient was registered with the PIP‐IHI hindered its implementation. Of particular concern were the separate spreadsheets developed to manage patient registration. Short term gains from developing parallel systems did not advance systematic development and use of follow‐up and recall systems in the longer term. Thus, investment in patient registration systems that advance clinical information systems is required. Second, a perception that the PIP‐IHI rewarded paperwork but did not improve clinical outcomes was a disincentive for participation. Administrative requirements were widely considered too burdensome, particularly, annual patient registration that required practices to determine whether patients were previously registered or had duplicate registrations. This resulted in low patient re‐registrations, limiting the potential for the measure to provide longer term community benefit. Hence, to improve participation, the administration burden must be minimised, with flexible, simplified one‐off registration procedures that enable patients to change general practices. Last, given that patients registered for the PIP‐IHI were expected to have a diagnosed chronic disease, it is notable that Tier 1 or Tier 2 payments reflecting continuity of care and planned review were not triggered for about 30% of patients.6 A substantial proportion of PIP‐IHI‐registered patients were either not regularly attending general practices or the practices were not billing for care in a way that triggered payments. Practice staff attributed this to inadequacies in their recall and reminder systems and to difficulties in contacting patients for recall and in getting them to attend a follow‐up appointment. Therefore, incentives need to encourage better care, not just enrolments.

Jodie Bailie · Alison Laycock · Ross S Bailie

In reply

Michael Wright · Roald Versteeg

To the Editor: We congratulate Backholer and colleagues for their article.1 This is a timely, powerful call to action. One in six Australians live with a hearing condition, a proportion that is set to rise as our population ages. However, prevalence also increases with longer exposure to loud noise and is higher in Indigenous and lower socio‐economic status populations. As audiologists, researchers and consumer advocates, we believe that taking a social determinants approach is the best way to significantly improve health and wellbeing. Historically, approaches to hearing health in Australia have been device‐centric.2 With the Roadmap for Hearing Health,3 collaboratively created by the sector and the federal government, there is an opportunity to change direction. To date, with the notable exception of initiatives in Aboriginal communities,4 hearing health has not been approached through the lens of the social determinants of health. We are currently working to change this. Physical and digital spaces determine the experience of hearing conditions5 to such an extent that interventions for accessibility can have as much impact on wellbeing as health interventions. Across all specialties, we encourage clinicians and researchers to forge connections with the disciplines of architecture, town planning, acoustic engineering, communications, and technology, to name a few. The HearMe report,5 which combines lived experience narratives with expertise from far beyond the health sector, was a first step in this direction. The work of the Obesity Collective is to be commended for taking a similar approach to an urgent public health issue (www.obesityaustralia.org). We live in a hearing society, making a person’s hearing status itself a determinant of health. People living with hearing conditions face stigma, discrimination and access barriers, including to health care. As highlighted by Backholer and colleagues,1 the coronavirus disease 2019 (COVID‐19) pandemic was a great disruptor and accelerator, showing us that rapid, society‐wide transformation is achievable. A world that is fulfilling, accessible, inclusive and respectful for people living with hearing conditions is possible if we centre the diversity of lived experience and commit to action on the social determinants of hearing health across the life course.

Jessica Vitkovic · Caitlin Barr · Bamini Gopinath

To the Editor: With great interest we read the article by Weise and colleagues,1 which presents the results of a retrospective cohort study that found higher age‐standardised rates of potentially preventable hospitalisation in people with intellectual disability in New South Wales compared with the general NSW population. Given the great health inequality of people with intellectual disability, we acknowledge the authors’ effort to conduct this valuable study. However, after reading the article, we were left with two questions. First, to be able to interpret the results of this study, a clear description of the population characteristics of both groups is indispensable. Information about parameters such as age and sex of both populations and about the design of the database is of crucial importance. The absence of this information makes it difficult to get a good picture of the population studied and any limitations or biases that need to be taken into account. We recognise that this type of data is not always easy to collect, especially when working with large population databases. Given its importance for interpretation purposes, we see this as a crucial point of attention for future research. Second, in this study, potentially preventable hospitalisations were identified using the definition in the National Healthcare Agreement, progress indicator 18.2 However, in addition to this definition, the circumstances and the exact reason for hospital admission have not been explored, which makes it difficult to conclude whether all hospital admissions could actually have been prevented in clinical practice. Further research would therefore be of great added value to unravel the significance of the study findings by exploring the differences in the rates of potentially preventable hospitalisations to guide possible future reforms of primary and community health care. In conclusion, the article provided us with important knowledge about the rates of potentially preventable hospitalisation of people with intellectual disability. However, the questions mentioned above need to be answered and further research should be conducted to allow a good interpretation of the results.

Karel L Wel · Lydia Kleinjan · Marleen J Leeuw

In reply

Janelle C Weise · Preeyaporn Srasuebkul · Julian N Trollor