Volume 216 Issue 9

Supporting improved general practice is urgent, and quality improvement collaboratives are an effective Australian strategy

Andrew W Knight · John Fraser · C Dimity Pond

COVID-19 has challenged and tested Australian general practice while reinforcing its centrality and potential

Claire L Jackson

The continuation of chronic disease management in primary care remains essential during the COVID-19 pandemic

Anne Parkinson · Sethunya Matenge · Jane Desborough · Sally Hall Dykgraaf · Lauren Ball · Michael Wright · Elizabeth A Sturgiss · Michael Kidd

A 35-year-old South Asian man with mild asthma had SARS-CoV-2 infection in August 2021

Jamma Li · Kathryn Sutton · Lawrence Ong · Oliver Flower · Jonathan J Gatward · Helena Jang · Nicholas Wood · Bernard Hudson · Sanaz Tehrani · Suran L Fernando

An81-year-old man presented to his GP with a shallow, red ulcer on the dorsum of his left index finger over the distal interphalangeal joint, progressive over the previous 3 weeks

Rachel W Xu · Timothy P Stinear · Paul DR Johnson · Daniel P O’Brien

A 6-year-old girl presented with a 24-hour history of sudden onset, non-tender periorbital rash

Yi‐Teng Hung · Chun‐Bing Chen

COVID-19 vaccination seems to be precisely the sort of decision that young people should be able to make along the road to becoming independent decision makers as adults

John Massie · Georgia A Paxton · Nigel Crawford · Margie H Danchin

Overcoming problems that impede the delivery of evidence-based care is needed to bridge gaps between science and improving health

Sher May Ng · Jiliu Pan · Ajay K Gupta

The search for a cost-effective Australian model of comprehensive, coordinated patient-centred care that improves outcomes continues

Mark F Harris · Joel Rhee

Clinicians should be mindful of the importance of post-abortion contraception counselling for preventing further unintended pregnancies

Andrew F Pesce · Gayathri Jayasinghe

Optimising lipid control could include more intensive therapy and combinations of medications, including novel agents

Noor Alsadat · Karice Hyun · Farzaneh Boroumand · Craig Juergens · Leonard Kritharides · David B Brieger

Our multicomponent intervention did not improve self-rated health, health service use, or health literacy

Richard L Reed · Leigh Roeger · Yuen H Kwok · Billingsley Kaambwa · Stephen Allison · Richard H Osborne

Understanding of the benefits of early, reliable contraception after an abortion needs improving among health care practitioners and women

Luke E Grzeskowiak · Alice R Rumbold · Asvini Subasinghe · Danielle Mazza · Kirsten I Black · Helen Calabretto · Jenni Ilomäki

This statement provides guidance to managing hepatitis B, recognising groups at increased risk of HBV infection and appropriate, timely screening strategies

John S Lubel · Simone I Strasser · Alexander J Thompson · Benjamin C Cowie · Jennifer MacLachlan · Nicole L Allard · Jacinta Holmes · William W Kemp · Avik Majumdar · David Iser · Jess Howell · Gail V Matthews

To the Editor: We congratulate Schutte and colleagues1 for their call to action for improved management of blood pressure in Australia, highlighting that 68% of people have uncontrolled high blood pressure. The burden of high blood pressure is unevenly distributed, with Aboriginal and Torres Strait Islander (hereafter referred to respectfully as Indigenous) people reportedly having a higher rate of high blood pressure than non‐Indigenous Australians in every age group.2 Reducing the prevalence of high blood pressure is one of the most important means of reducing serious circulatory diseases, which are among the leading causes of death for Indigenous Australians.3 Hence, we want to extend the call to action and report on what is happening in primary health care settings with the control of blood pressure for Indigenous people. During 2012–13, we analysed blood pressure screening and follow‐up for patients diagnosed with hypertension (n = 6523) from 123 primary health care centres across Australia using continuous quality improvement data from audits of adherence to best practice chronic illness care.4 Given there are no recently available data on follow‐up actions after an abnormal blood pressure reading at this geographic scale, and as blood pressure continues to be relatively uncontrolled, these data continue to provide unique insight. The data, aggregated at primary health care centre level (Box), tells a story of clinical inertia. Regular blood pressure screening was done well — centres on average completed blood pressure screening for about 90% of patients within the past 6 and 12 months. In this cohort, about 65% of patients recorded abnormal blood pressure (n = 4240). Most primary health care centres had documentation of a follow‐up plan for more than 70% of patients, but there was wide variation (range, 0–100%; Box). Dealing with the low levels of medication reviews and adjustments (mean, ~15%; range, 0–100%) is a vital early step in limiting the contribution of uncontrolled blood pressure to adverse health outcomes for Indigenous people. These data support the need for training on strategies to overcome clinical inertia, which was identified as a top priority by over 200 Indigenous primary health care practitioners, managers and policymakers.5 We add to the call for more attention on prevention of cardiovascular disease and suggest additional investment in evidence‐based interventions appropriate to Indigenous Australian culture and needs. The time for system‐wide action has come. Box – Boxplots showing a record of scheduled services received by patients with hypertension and follow‐up of abnormal findings within the last 12 months of audit (unless otherwise indicated) at primary health centres during 2012–13 x = mean value. More information on how to interpret box plots is available in Matthews et al.4

Jodie Bailie · Veronica Matthews · Ross S Bailie

In reply

Aletta E Schutte · Garry Jennings · Markus Schlaich

To the Editor: Fraile Navarro and colleagues1 recently published 20 recommendations for the treatment of coronavirus disease 2019 (COVID‐19) in children and adolescents from the National COVID‐19 Clinical Evidence Taskforce. For the paediatric inflammatory multisystem syndrome (PIMS‐TS) recommendations, the Taskforce convened an expert advisory group.1 In the absence of clinical trials, the panel considered peer‐reviewed guidelines and cohort studies to formulate consensus recommendations.1 However, they deferred providing any guidance to help clinicians prevent thromboembolism. We suggest the Taskforce consider the same approach for paediatric anticoagulation guidance. COVID‐19 is associated with marked coagulation activation and hypercoagulability in children.2,3 Life‐threatening pulmonary embolus requiring thrombolysis has been encountered in Australian adolescents hospitalised with COVID‐19. A retrospective cohort study published in 2021 found that 2.1% of children hospitalised with symptomatic COVID‐19 infection and 6.5% of those with PIMS‐TS developed thrombosis.4 Thrombosis occurred more frequently in children aged 12years and over who had central lines, PIMS‐TS, or an underlying oncological diagnosis. A D‐dimer of more than five times the upper limit of normal was significantly associated with thrombosis.4 The authors refer to “paediatric guidelines published in the US”, which are published on behalf of the Pediatric/Neonatal Hemostasis and Thrombosis Subcommittee of the International Society of Thrombosis and Haemostasis; these adapt current consensus prophylaxis guidelines to include COVID‐19‐specific features.5 In deferring making specific recommendations, the authors suggested using existing local thromboprophylaxis guidelines. The Royal Children’s Hospital, Melbourne and the Sydney Children’s Hospital, Randwick have both independently developed COVID‐19‐specific thromboprophylaxis guidelines (that are very closely aligned),6,7 as have many other centres globally because previous local thromboprophylaxis guidelines are inadequate for COVID‐19‐associated thrombotic coagulopathy. The Melbourne/Sydney guidelines advise baseline coagulation testing in hospitalised children with COVID‐19, incorporating D‐dimer to assist risk assessment, twice‐daily enoxaparin and anti‐Xa monitoring/dose titration.6,7 These could be provided as supplemental material in these living guidelines. The COVID‐19 anticoagulation in Children–Thromboprophylaxis (COVAC‐TP) trial — a phase 2 single‐arm study looking at 40 children who will receive monitored, low dose, twice‐daily enoxaparin (ClinicalTrials.gov Identifier NCT04354155) — will not change the level of evidence, so waiting for completion of this trial does not seem appropriate.

Gemma L Crighton · Anthea Greenway · Susan Russell

In reply

For the National COVID‐19 Clinical Evidence Taskforce

To the editor: Clinicians are faced with requests for mask exemptions but guidance remains limited. In keeping with the Australasian College of Dermatologists’ guidelines,1 we believe skin problems are rarely severe enough to warrant exemption. The Department of Health and Human Services states people with “a serious skin condition of the face” are eligible for mask exemption,2 but this statement is open to interpretation. Mask exemptions for skin conditions are provided by numerous clinicians and not limited to dermatologists. Regardless of immunisation status, cases that may warrant exemption include severe dermatitis with crusting or weeping; severe infections such as impetigo or eczema herpeticum; bullous dermatoses, ectodermal dysplasias and other rare conditions featuring facial skin fragility; and post‐surgical procedures involving grafts or flaps where masks may impede healing. In addition, treatments for actinic damage such as 5‐fluorouracil, imiquimod or photodynamic therapy may cause severe inflammation.3 We suggest if exemptions are warranted, duration should be minimised, which may be before resolution of the dermatoses (eg, 2weeks followed by a review). This is essential given masks have been key in reducing severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) transmission.4 The development of an assessment pathway for facial dermatoses impeding mask use may be beneficial and should differentiate between health care workers, who wear fit‐tested masks, and the general public, guiding prompt treatment and follow‐up to facilitate a return to mask use. From our experience, facial masks may irritate the skin from pressure, sweating and humidity, and commonly aggravate underlying dermatoses, such as seborrheic dermatitis, acne or rosacea. Facial masks may rarely cause allergic contact dermatitis,5 and these cases should involve a contact dermatitis expert. Education regarding skin care is vital, in particular regular cleansing and reducing the number of products used which may aggravate acne. When utilising reusable masks, it is important to opt for an appropriate material such as light‐coloured cotton and maintain mask hygiene, which includes daily mask changes, regular washing, not sharing masks, and taking regular breaks from mask wearing. In summary, clinicians should remain vigilant when writing mask exemptions, aiming to minimise the duration by treating underlying skin problems and providing patient education.

Kajal Patel · Rosemary L Nixon