Volume 216 Issue 7

The NORDR is designed to protect workers and prevent occupational respiratory disease but will require widespread stakeholder engagement and interaction to succeed

Ryan F Hoy · Fraser J Brims

A precision medicine approach to asthma places the patient at the centre of their care

Vanessa M McDonald · Peter G Gibson

Lung cancer treatments and outcomes are changing, but survival remains a challenge

Fraser J Brims · Annette McWilliams · Susan V Harden · Ken O'Byrne

Asthma is one of the most common chronic diseases in Australia, affecting 11% of the population

Helen K Reddel

A 62-year-old man presented complaining of 3 days of abdominal discomfort on a background of a month-long history of fatigue and fevers

Angus AW Baumann · Nicholas J Montarello · Glenn D Young

A previously well 32-year-old Caucasian man with no history of smoking presented with a 6-week history of progressive exertional dyspnoea, a productive cough, and night sweats

Samantha Dean · Rachel Lennox · Clare Senko · Sagun Parakh

Supporting people with COVID-19 should look beyond medical management and take into account their social and economic situation

Joanne Flavel · Fran Baum

Proactively offering Quitline counselling and nicotine replacement therapy can reduce the prevalence of smoking

Sally Plever · Coral E Gartner

Global pandemics are inevitable, but their effects can be ameliorated by better health systems, education, and being prepared

Robert Booy · Gary Grohmann

Socio-economic factors may have contributed to the non-homogeneous incidence of SARS-CoV-2 infections across Victoria during 2020

Christine Roder · Callum Maggs · Bridgette J McNamara · Daniel O'Brien · Amanda J Wade · Catherine Bennett · Julie A Pasco · Eugene Athan

Systematically offering cessation support is a low cost means for encouraging elective surgery patients to quit

Ashley R Webb · Lisa Coward · Darshana Meanger · Samuel Leong · Sarah L White · Ron Borland

We suggest five potential strategy areas that could begin to address nequities

Sharon Goldfeld · Elodie O'Connor · Valerie Sung · Gehan Roberts · Melissa Wake · Sue West · Harriet Hiscock

To the Editor: In their recent article, Larcombe and colleagues1 describe the analysis of 65 electronic cigarette fluid samples. The gas chromatography mass spectrometry method, as described in the Supporting Information, used “the ratio between the peak area corresponding to the fragment with the highest signal‐to‐noise ratio … and the peak area of the internal standard” for quantification.1 Direct comparison of the peaks for the analyte of interest and the internal standard does not take into account differences in response factor and/or ionisation efficiency for the different molecules. For accurate quantification, individual calibration curves should be prepared for all molecules of interest. If the authors prepared calibration curves but did not include this information, then the methods section should be modified to reflect this, and additional validation should be provided for all analytes, including limits of detection, limits of quantification, and coefficients of determination for all curves. In addition, all samples should be analysed in triplicate and a standard deviation should be provided to further validate the analysis. Larcombe et al1 note in their article that the determined concentrations of benzaldehyde, menthol, 2‐chlorophenol and benzyl alcohol exceed inhalational LC50 (the median lethal concentrations that kill 50% of a test animal population) values for these compounds. This assertion, as written, is incorrect and should have been reworded to a less confident statement. As the authors themselves acknowledge, the e‐liquid concentration and the inhalational LC50 values are not comparable. Furthermore, the authors did not provide the LC50 values they were using nor a citation to their source for these values. For a more accurate comparison, the volume of e‐liquid vaporised per litre of inhaled vapour would need to be calculated. Assuming the consumption of 9.47 mg of e‐liquid per puff and a puff volume of 55 mL,2 the maximum concentration observed for both benzaldehyde (2.58 mg/m3) and menthol (30.5 mg/m3) would fall below their respective derived no‐effect level (DNEL) values of 9.8 mg/m3 and 132 mg/m3.3,4 We were unable to locate an inhalational DNEL or LC50 value for 2‐chlorophenol. The maximum concentration for benzyl alcohol (251 mg/m3) would exceed its DNEL value of 110 mg/m3 for acute exposure.5 This, along with the high prevalence of benzyl alcohol in e‐liquid samples, requires further investigation.

Jody Morgan · Alison Jones · Celine Kelso

In reply

Alexander Larcombe · Sebastien Allard · Benjamin Mullins

To the Editor: Chan and colleagues1 recently reported a case of putative e‐cigarette or vaping product use‐associated lung injury (EVALI) in a 15 year‐old girl who was a low level user of vaporised nicotine (without adulterants). We believe that, rather than EVALI, her presentation is better explained by urosepsis‐related acute lung injury. Current guidance from the United States Centers for Disease Control and Prevention (CDC)2 emphasises the role of adulterants, especially vitamin E acetate, in EVALI. In a US study completed before the widespread adoption of e‐cigarettes, the incidence of acute lung injury in 15–19‐year‐olds was 16 per 100 000 patient‐years, with many cases stemming from non‐pulmonary sepsis.3 In February 2020, only 2807 cases of vaping lung injury had been reported in the US, representing an incidence of well under one case per 100 000 patient‐years.1 Given these rates, as well as the patient’s prominent dysuria, polyuria, back pain and worsening pyrexia, we think urosepsis triggered the acute lung injury in this case. The authors say that sepsis was ruled out due to negative blood and urine cultures. However, if samples were collected after the initiation of antibiotics, false negative cultures are common in sepsis. The patient met the accepted criteria for sepsis, with suspected infection, a systemic inflammatory response syndrome and acute end‐organ failure,4 and was treated for this condition with antibiotics and corticosteroids for the acute lung injury. The CDC criteria for EVALI emphasise that the diagnosis should only be made where there is “no evidence in [the] medical record of alternative plausible diagnoses”.5 Dysuria, polyuria and back pain are not known symptoms of EVALI, and the authors have not explained how EVALI could account for this aspect of her presentation nor why these symptoms preceded the respiratory symptoms. In conclusion, the evidence to support a diagnosis of EVALI is insufficient in this case, and an alternative explanation is far more likely. Therefore, this case report should not be regarded as evidence for a case of EVALI occurring in Australia.

Cameron RL McKenzie · Joshua Davis · Adrian J Dunlop

In reply

Betty SH Chan · Vicky Sheppeard · Andrew H Dawson

Clinical Professor Lucy Morgan was the public face of COVID-19 treatment in 2021, but there’s more to her than acute care

Cate Swannell