Volume 216 Issue 4

Australia lacks a comprehensive approach to CMV screening, and most infected infants go undiagnosed

Allison Reid · Asha C Bowen · Christopher G Brennan‐Jones · Jafri B Kuthubutheen

Aducanumab, a controversial Alzheimer disease therapeutic with questionable efficacy, is under Therapeutic Goods Administration review

Andrew Gleason · Scott Ayton · Ashley I Bush

Clinicians, the experts in care delivery, are well placed to drive health system improvements

Sabe Sabesan · Lynden Roberts

The general practitioner supervisor is a key element of the apprenticeship model, ensuring the development of a strong and capable GP workforce

Gerard Ingham · Caroline Johnson

A 73-year-old woman presented to her GP with visual hallucinations

Harry Birrell · Kong‐Chan Tang

A 77-year-old never-smoker presented with an abnormal screening chest x- ray

Clare Wood · Elizabeth J Silverstone · Deborah H Yates

Noise reduction, in conjunction with counselling and night-time broadband sound therapy, reduces the distress associated with tinnitus

Melville J Da Cruz

Suicide prevention requires ensuring that social media are responsible and accountable, and that poisoning surveillance systems are adequately supported

Bridin P Murnion · Darren M Roberts

Workers at particular risk of tinnitus need targeted interventions that reduce its impact on their quality of life

Kate Lewkowski · Jane Heyworth · Elinor Ytterstad · Warwick Williams · Helen Goulios · Lin Fritschi

The major concern regarding barbiturate-related harm has shifted from accidental overdoses to their use in suicide

Shane Darke · Agata Chrzanowska · Gabrielle Campbell · Emma Zahra · Julia Lappin

Awareness of the possibility of reinfection should be promoted to encourage vaccination, testing, and protective behaviours

The Victorian SARS‐CoV‐2 Reinfection Study Group

A patient register and control program could help reduce the considerable morbidity and mortality caused by ARF and RHD

Jane Oliver · Myra Hardy · Joshua Osowicki · Daniel Engelman · Andrew C Steer · Katherine Gibney

The Care of Older People and Palliative Care Panel developed two clinical flow charts with practice points providing guidance on the delivery of quality geriatric and palliative care during the COVID-19 pandemic

for the National COVID‐19 Clinical Evidence Taskforce

To the Editor: We write regarding the study by Wilmott and colleagues1 and the accompanying editorial by McLaren and Mewett.2 There are data of interest in the study that are not found in the limited Victorian voluntary assisted dying (VAD) review reports. Notable is that four doctor participants had assessed more than 25 people each in the first year of VAD in Victoria. Given that 124 people died by VAD in the first year, the high caseload of a handful of participants highlights that few doctors choose to be VAD assessors. With a large proportion of assessments being carried out by only a strongly supportive few, this raises potential concerns about the independence of assessments, when the doctors who are the gatekeepers of VAD work together in small groups to determine eligibility. There is an association between clinicians willing to provide a hastened death (where this is legal) and advanced cancer patients in palliative care wanting just that.3 Some participants in the study acknowledged that VAD consultations via telehealth are a “second rate solution”.1 However, the legislative push for VAD telehealth assessments continues with an amendment currently before the Victorian parliament, even though this puts access ahead of safety, making it harder to exclude depression or coercion.4 It was useful to be reminded that Victorian guidelines prohibit the use of telehealth for VAD consultations due to federal criminal laws that ban suicide discussions on carriage services. However, it is known that some Victorian VAD consultations have already been conducted via telehealth.5 The editorialists state that evidence is needed to guide VAD practice that to date has been based on opinion and personal viewpoint.2 The evidence base to support the need for VAD should have been identified before and not after legalisation. Stories of distressing deaths reported by relatives can be misleading, especially when these conflict with published palliative care research that suggests excellent symptom control in dying Australians who can access and who accept specialist palliative care.6 While VAD as a new practice receives much attention, its availability does nothing to help the many thousands of Victorians each year who do not want assisted suicide but who struggle with unmet palliative care needs. Despite the time and money spent on VAD access, the palliative care needs of most Victorians at the end of life still remain largely unmet.7 Other Australian states and territories should be aware of this.

Marion T Harris · Maria C Cigolini

In reply

Lindy Willmott · Ben P White · Marcus Sellars

In reply

Cameron J McLaren · Greg Mewett

To the Editor: Close and colleagues raise some important issues in their article on voluntary assisted dying (VAD) and telehealth.1 For the most part, their four key considerations give good practical advice to clinicians trying to work around Commonwealth laws introduced for a substantially unrelated purpose. A scenario they do not address is where a patient has been assessed as eligible for VAD, and then needs to discuss with the doctor by telehealth the choice between having lethal medication administered to them, or taking it themself (self‐administration). This is already an issue in Western Australia, and will become an issue in Tasmania and Queensland; not so much in Victoria or South Australia, where this choice is essentially restricted by clinical criteria set out in the legislation. In the above scenario, it needs to be made clear to the patient that the doctor is not favouring self‐administration over practitioner administration, but has an open mind in talking through this choice by telehealth with the patient. Close and colleagues are right to caution against using telehealth to discuss the VAD medication protocol for self‐administration, but their advice to have such discussions in person is not particularly helpful when the doctor is remote from the patient. When self‐administration is chosen, Western Australian law requires written instructions to be provided to the patient by the doctor and the applicable pharmacist on how to prepare and take the lethal medication.2 It can be explained that these instructions will be provided as hard copy, with the doctor making clear that nothing said to the patient over telehealth should be construed as instruction on how to prepare or take the medication. When the pharmacist delivers the medication to the patient for self‐administration, as is the practice in Victoria and Western Australia, any question about the written instructions can be dealt with face to face, as part of the counselling of patients expected of pharmacists under guidelines issued by the Pharmacy Board of Australia.3

Richard SW Lugg

To the Editor: Kaur and colleagues propose the ABCD (abbreviated, brief, comprehensive, detailed) approach for older patients.1 Further to that, we propose extending the mnemonic to ABCDEF with E for efficiency and F for feasibility. This would make it more realistic. The Australian population is ageing. Older patients are often beset by numerous comorbidities. Innovative approaches to facilitate minimisation of hospitalisation and early discharge of frail older patients are urgently needed. Comprehensive geriatric assessment is advocated as the gold standard of managing older patients’ medical needs to improve quality of life. It requires specialist geriatrician assessment in geriatric evaluation and management wards. Unfortunately, a minority of older patients end up being admitted to geriatric evaluation and management units, whereas acute medical beds are mostly occupied by older patients where access to comprehensive geriatric assessment is poor.2 Further, the cost‐effectiveness of comprehensive geriatric assessment in specialised units remains unknown and its utility in reducing length of stay and avoiding readmissions is limited.3 The ABCD concept is intriguing. However, it is unlikely to resolve the dilemma of bed occupancy and length of stay of older patients unless the approach is sufficiently efficient and feasible. These elements conveniently extend the mnemonic to ABCDEF. By “efficiency” we mean efficiency in early recognition of their acute issues, establishing a multimodal approach of therapeutic interventions and discharge planning. “Feasibility” of utilising ABCD in various hospital settings must also be considered. Hospital in the home in appropriately selected patients is an example of efficient and feasible comprehensive geriatric assessment based on the ABCD approach.4 For the ABCD to be properly executed, E (efficiency) and F (feasibility) are integral to this approach. Timely access to specialist geriatric care along with improved delivery of primary care for older people are key issues that need to be concurrently addressed.5

Alaa Alghamry · Joseph C Lee

In reply

Paven Kaur

To the Editor: In August 2020, the South Eastern Sydney Public Health Unit, located in New South Wales, Australia, received a statutory laboratory notification of an elevated blood lead level of 0.34 µmol/L in a preschool‐aged child recently diagnosed with autism. This was above the 0.24 µmol/L level requiring notification under the Public Health Act 2010 (NSW). The test had been requested by the child's paediatrician due to concern about the child’s recent consumption of an oral Ayurvedic medicine prescribed by a naturopath. Our environmental health officers undertook a home lead assessment, during which a soil sample and the Ayurvedic medication sample were taken for heavy metals analysis. The soil lead concentration was 160 mg/kg. The medication was labelled Manasmithra Vatika (MV), manufactured in India (Box). Analysis revealed that it comprised 0.96% lead by weight. The naturopath indicated that they had prescribed the medication to other child and adult patients, some of whom were seeking treatment for autism. Most consultations were conducted online and the prescriptions were purchased online. We were concerned about the risk of lead toxicity in the naturopath’s other patients who had been prescribed MV, and mounted a public health investigation in order to inform patients of their risk, to advise them to cease use of the medication, and to identify the extent of the problem. The naturopath provided a list of 28 patients (13 children) to whom they had prescribed the medication. We directly followed up the 12 NSW patients (other than the index case), asking whether they had taken MV, and, if so, in what dosage and over what period. We advised those who were taking MV to immediately cease its use, and to seek blood lead level testing through their own doctors. We asked patients to provide us with any remaining MV for lead analysis. Five patients provided MV samples; analysis showed lead content of 0.74–0.96% (mean, 0.81%) by weight. Four patients had an elevated blood lead level ranging from 0.30 to 0.68 µmol/L (reference interval, < 0.24 µmol/L). A fifth patient, whose blood lead level was undetectable (< 0.1 µmol/L) had ceased taking the MV at least 3 months before measurement. Based on these findings, we initiated a multi‐agency investigation involving NSW and Australian government regulatory bodies. Action taken against the naturopath by the Australian Health Practitioner Regulation Agency and NSW Health Care Complaints Commission prohibited them from treating medical conditions, such as autism. The naturopath voluntarily ceased prescribing MV and immediately contacted their patients to inform them of the lead adulteration of the preparation. The NSW distributor of the MV medication was investigated by the NSW Health Pharmaceutical Regulatory Unit and the Therapeutic Goods Administration, leading to the distributor ceasing to import the adulterated MV. The Therapeutic Goods Administration issued a public warning regarding the presence of lead in MV preparations generally, without naming an implicated brand or source.1 Lead exposure in children can be linked to reduced intelligence, and behavioural and developmental impacts.2,3 Ayurvedic medicines are formulated and prescribed based on ancient Indian texts. Although they are herbally based, Ayurevedic texts also provide for formulation with heavy metals including lead.4 Their use has been associated with elevated blood lead levels in patients.5 The public health investigation and subsequent multi‐agency intervention we have described prevented ongoing exposure of patients to a lead‐contaminated herbal product. As a result of this investigation, we suggest: ▪ health practitioner awareness be raised regarding the risks of recommending or prescribing unregistered, imported medications; ▪ clinicians consider testing for blood lead in patients who have consumed unregistered, imported Ayurvedic medications; ▪ public health professionals be engaged in the investigation of patients with elevated blood lead levels in the absence of an occupational source; ▪ community awareness be raised regarding the risk of consuming unregistered, imported Ayurvedic medications; and ▪ a multi‐agency response is required to effectively address prescribing of unsafe complementary medications by unregistered health professionals. Box – Manismithra Vatika tablets provided by a patient with an elevated blood lead level

Mark J Ferson · Sinead Flanigan · Toni Cains

To the Editor: Self‐collected vaginal samples are as effective as clinician‐collected cervical samples for detecting underlying cervical intraepithelial neoplasia grade 2 or higher (the target lesion of cervical screening) using polymerase chain reaction‐based oncogenic human papillomavirus DNA assays.1 However, the use of self‐collection within Australia’s cervical screening program is currently restricted to women who are underscreened or never screened (at least 2 years overdue, so 4 years since their last Pap test), aged ≥ 30 years and refuse a clinician‐collected sample. This is because, at the time the current policy was developed, self‐collection was believed to result in a small loss of sensitivity. Accredited laboratories are not permitted to test samples that do not meet these requirements. VCS Pathology (part of the Australian Centre for the Prevention of Cervical Cancer) was the first laboratory to receive regulatory approval to process self‐collected samples. Here we report the reasons for rejection of samples received between February 2018 and 30 June 2021, which is important given that about one‐third (34%; 2166/6234) of samples received could not be processed (37.4% in 2018; 37.9% in 2019; 34.1% in 2020; 22.8% in 2021). The three most common reasons were that the person was not sufficiently overdue (54.1% of rejected samples; 18.5% of all samples); that the wrong type of collection device was used (17.3% of rejected samples; 5.9% of all samples); or that the person was < 30 years of age (11.2% of rejected samples; 3.8% of all samples). Other reasons included delayed sample receipt (5.2% of rejected samples; 1.8% of all samples), presence of symptoms (3.0% of rejected samples; 1.0% of all samples) and multiple reasons (combination of above factors: 6.6% of rejected samples; 2.3% of all samples) (Box). The implementation of self‐collection, while known to be highly acceptable to many women who will not accept a speculum examination for screening,1,2 has been problematic in Australia to date.3,4 The eligibility restrictions and strict laboratory requirements have created unintended barriers for practitioners and potential participants, as demonstrated by both the sample rejection rate and low overall numbers compared with the eligible population (< 1%).3 The recently announced mainstreaming of self‐collection, by making it a choice for all screening participants using on‐label tests, should overcome many of these barriers5 and improve program equity and participation. Successful implementation will depend on timely education, communication and change management. Box – Proportion of 6234 self‐collected samples received that were unable to be processed, by reason and year of receipt (VCS Pathology, February 2018 to the end of June 2021) * Incorrect collection device refers to wrong swab type or media. † Other reasons include duplicate samples, and pregnancy (which was initially an exclusion criterion).

Julia ML Brotherton · David Hawkes · Marion Saville