Volume 216 Issue 6

There is a lack of data relating to all-cause concussion in Aboriginal and Torres Strait Islander peoples

Jonathan Bullen · Trish Hill‐Wall · Elizabeth Thomas · Richard Norman · Gill Cowen

Broader use of clinical quality registry infrastructure will enhance research- driven improvements in health care

Susannah Ahern · Belinda J Gabbe · Sally Green · Carol L Hodgson · Erica M Wood · John R Zalcberg OAM · Tsharni Zazryn

Australia to take a world-first step towards offering preventive DNA screening through the public health care system

For the DNA Screen Investigator Group†

A 63-year-old man presented with headache, fever and decreased conscious state

Claudine Banal · Steve Lau · Sonalmeet Nagra · David AK Watters

A 68-year-old woman presented for a medical consultation

Nely Shrestha Khatri · Bronwyn GA Stuckey

A 45-year-old Sudanese man who was an ex-smoker with no past medical or family history presented with a painful, swollen left lower limb of uncertain duration

Mitra Rahmatzadeh · Jonathan Clarke · Joseph Jaya · Limi Lee · Sam Farah · Roger Bell · Ming Yii

A 7-year-old girl presented to the emergency department with fever and right forearm redness

Yu‐Lin Tai · Chien‐Yu Lin

Blood donation programs must change in response to population ageing and becoming more ethnically diverse

Chris J Hogan · Alison Street

More than ever, we must remain vigilant about ensuring equitable access to new diagnostic tools and therapeutic options

Zhi Han Yeoh · Andrew W Roberts

The distribution of blood groups has changed since 1993‒94, reflecting changes in the demographic characteristics of Australia

Rena Hirani · Natalie Weinert · David O Irving

More effective therapies are needed for acute leukaemia, particularly for people over 50 years of age at diagnosis

Kerri Beckmann · Brendon J Kearney · David Yeung · Devendra Hiwase · Ming Li · David M Roder

Increasing same-day procedure rates will involve a complex interplay of pre-and post-operative decisions by hospitals, surgeons, and patients

Joanna MZ Mills · Georgina M Luscombe · Thomas J Hugh

Opioid medications may provide very small benefits for people with osteoarthritis, but also increase the risk of adverse events

Christina Abdel Shaheed · Wasim Awal · Geoffrey Zhang · Stephen E Gilbert · Daniel Gallacher · Andrew McLachlan · Richard O Day · Giovanni E Ferreira · Caitlin MP Jones · Harbeer Ahedi · Mamata Tamrakar · Fiona M Blyth · Fiona Stanaway · Christopher G Maher

Recommendations are based on evidence-based knowledge of safety, immunogenicity and efficacy of the vaccines in the general population, plus emerging data regarding COVID-19 vaccination in immunocompromised individuals

Eliska Furlong · Rishi S Kotecha · Rachel Conyers · Tracey A O'Brien · Jordan R Hansford · Leanne Super · Peter Downie · David D Eisenstat · Gabrielle Haeusler · Brendan McMullan · Marianne B Phillips · Bhavna Padhye · Luciano Dalla‐Pozza · Frank Alvaro · Christopher J Fraser · Wayne Nicholls · Julia E Clark · Matthew O'Connor · Benjamin R Saxon · Heather Tapp · John Heath · Sarah E Hunter · Karen Tsui · Mark Winstanley · Amanda Lyver · Emma J Best · Ushma Wadia · Daniel Yeoh · Christopher C Blyth · Nicholas G Gottardo

To the Editor: People without Medicare coverage cannot access Pharmaceutical Benefits Scheme (PBS)‐subsidised human immunodeficiency virus (HIV) pre‐exposure prophylaxis (PrEP) or associated clinical care. Rates of HIV infection diagnosis are disproportionately higher among overseas‐born gay and bisexual men compared with Australian‐born gay and bisexual men.1 In response, in June 2020, the Alfred Hospital and the Victorian Infectious Diseases Reference Laboratory established the free PrEPMe Clinic for Medicare‐ineligible people. Data were collected using proformas after patients provided verbal consent (Alfred Health Ethics Committee approval No. 656/18). The first 100 consecutive patients were all born overseas (Box). Melbourne’s only public sexual health clinic referred 65 patients. Almost all patients were male, all patients had sex with men and reported a median of three sexual partners in 3 months at baseline; 76 patients inconsistently used condoms for anal sex. Fifty‐eight patients reported previous sexually transmissible infections (STIs); STIs were diagnosed in 12/100 patients at baseline, a rate similar to that found in Medicare‐eligible PrEP users.2 Thirty‐four patients had previously accessed HIV post‐exposure prophylaxis (PEP), and 49 patients had previously unsuccessfully attempted to obtain PrEP. The reported barriers to access mainly included costs of medical appointments and pathology, and difficulties navigating Australia’s health care system. All patients received a non‐PBS PrEP prescription. At 3‐month follow‐up, 87 patients had commenced PrEP. Local pharmacies supplied PrEP at cost price (A$40–55 per month) or free to patients with financial hardship; other patients purchased PrEP online (US$20–30 per month) or obtained free PrEP online using assistance coupons (www.pan.org.au; Box). Most patients who ordered PrEP online experienced delivery delays of 4–6 weeks, leaving them at risk of HIV infection. We report that Medicare‐ineligible gay and bisexual men and transgender women were at high risk of HIV infection, yet faced significant financial barriers to accessing PrEP. PrEP uptake has been associated with significant population‐level declines in incident HIV infection in Australia.3 Australia’s Eighth National HIV Strategy aims for virtual elimination of HIV transmissions by 2022,4 and to achieve this goal, Australia must provide universally subsidised PrEP medication and clinical services, irrespective of Medicare status.5 Medicare‐ineligible gay and bisexual men often already attend publicly funded sexual health clinics for free HIV/STI testing and treatment, as reported here. In a high income country like Australia, the additional cost of providing universally subsidised PrEP care would likely be lower than treating preventable new HIV infections, with an estimated lifetime cost of more than US$350 000 per HIV infection diagnosis.6 Box – Demographic characteristics, immunodeficiency virus (HIV) acquisition risk, and prior efforts to obtain pre‐exposure prophylaxis (PrEP) in the first 100 consecutive patients to attend the PrEPMe HIV prevention clinic at the Alfred Hospital in Melbourne, Australia* Values Total number of patients 100 Demographic characteristics Region of birth Asia 47 Latin America 31 Europe 14 Other 8 Age, years, median (IQR) 28 (26–31) Gender Cisgender male 96 Transgender female 4 Visa status Student visa 62 Working visa 34 Other 4 Referral sources Melbourne Sexual Health Centre 65 Word of mouth 16 Other† 13 Unknown 6 HIV risk at initial clinical assessment Sexual partners (3 months), median (IQR) 3 (1–5) Condom use for anal sex (3 months) Always 24 Mostly or sometimes 60 Never 13 Not applicable 1 Unknown 2 Previous STIs (ever) Yes 58 No 42 Previous STIs (ever, specific STIs) Gonorrhoea 35 Chlamydia 21 Syphilis 21 Other‡ 5 STIs diagnosed at baseline Chlamydia only 6 Other§ 6 Previous attempts at HIV risk reduction Previous use of PEP Yes 34 No 57 Unknown 9 Previous unsuccessful attempts to obtain PrEP Yes 49 No 46 Unknown 5 PrEP commencement by 3‐month follow‐up Commenced PrEP 87 Local pharmacy 65 Online 19 Online order did not arrive, then purchased at pharmacy 3 PrEP not commenced 6 Online order did not arrive 3 Other¶ 3 Lost to follow‐up 7 COVID‐19 = coronavirus disease 2019; IQR = interquartile range; PEP = post‐exposure prophylaxis; STIs = sexually transmissible infections. * Enrolment dates: 1 June 2020 to 26 October 2020. † Includes general practices, internet search, “PrEP Access Now” Facebook page, Alfred Hospital PEP program. ‡ Includes herpes simplex virus, Mycoplasma genitalium, hepatitis B virus. § Includes syphilis, hepatitis B virus, both chlamydia and gonorrhoea. ¶ Includes lost prescription, no sex due to COVID‐19.

Vincent J Cornelisse · Jude Armishaw · Mike Catton · Dean Murphy · Edwina J Wright

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has strained health systems in New South Wales, and hospitals have rapidly adapted to care for inpatients with COVID‐19. In the 4 weeks leading up to 9 September 2021, 9330 locally acquired cases were diagnosed in Western Sydney alone.1 The management of large numbers of COVID‐19 inpatients with diabetes has been challenging. People with diabetes are a vulnerable population who are at risk of adverse outcomes from COVID‐19, with a two‐ to threefold likelihood of death compared with people without diabetes.2 Hyperglycaemia is associated with higher risk;3 hence, good glucose management is desirable. Exacerbation of diabetes by dexamethasone therapy, used to treat patients with COVID‐19, and the development of steroid‐induced hyperglycaemia in non‐diabetic patients present further challenges. Traditional models of care relying on referrals from parent teams to an endocrinologist (or registrar), who then reviews the patient daily to chart insulin, are inefficient and impractical for this situation. We have developed a virtual inpatient diabetes management service (vIDMS) as a means for a small diabetes team to manage COVID‐19 inpatients with diabetes. The success of this model has revolved around an electronic medical record, electronic inpatient prescribing, a diabetes dashboard, and videoconferencing communications. The recording of all glucose measurements (including point of care) within the electronic medical record has enabled the systematic capture and display of hospital‐wide glucose data on a diabetes dashboard (Box). This also allows viewing and filtering by any variable in the electronic medical record, such as ward, age, biochemistry (including formal laboratory glucose and glycated haemoglobin), development of hypoglycaemia, prescribed medications (including corticosteroids), and COVID‐19 status. Therefore, COVID‐19 patients with diabetes or hyperglycaemia are easily identified. The vIDMS, comprising of a consultant, a registrar and a diabetes educator, reviewed patients with COVID‐19 and hyperglycaemia on a daily basis, using the dashboard and electronic medical record, by sharing a screen on a videoconferencing platform. Remote management was undertaken through the electronic medical record, including medication and insulin dose adjustments. Communication with ward staff and patients with COVID‐19 through the electronic medical record, or by telephone or video, was undertaken when needed, including for diabetes education. Entry into the COVID‐19 wards and usage of personal protective equipment was not required. In the 6 weeks to 5 September 2021, 112 COVID‐19 patients with diabetes were thus managed in Westmead Hospital (median age, 62 years; range, 23–91 years), with up to 40 patients reviewed per day. Necessitated by COVID‐19, the future of inpatient diabetes management is now here. With one‐quarter of patients in metropolitan hospitals having self‐reported diabetes4 but insufficient specialised diabetes staff to provide individual management, the vIDMS will become a significant part of the wider model of diabetes care for large hospitals.5 While initial and intermittent face‐to‐face contact remains valuable to build a relationship and discuss relevant issues, and careful review of medical records is necessary to understand perturbations in glucose levels (eg, fasting, missed medication), the vIDMS enables daily specialist care for large numbers of patients with diabetes by a small team. The health system needs to facilitate its wider application for the management of both COVID‐19 and non‐COVID‐19 patients with diabetes in hospital. Box – Diabetes dashboard showing hospital‐wide glucose data for patients with coronavirus disease 2019 (COVID‐19)

N Wah Cheung · Amanda Hor · Tien‐Ming Hng