Volume 217 Issue 5

Breast cancer commonly causes significant physical and psychological sequelae; guidelines and models of care exist to ameliorate these

Christobel M Saunders · Lesley Stafford · Martha Hickey

The obesity epidemic has been escalating for over 30 years, but little attention has been paid to delivery of effective treatments in the public system

Ahmad Aly · Michael L Talbot · Wendy A Brown

A 58-year-old man presented with 4–6 weeks of lower limb muscle weakness, an elevated serum creatine kinase level of 344 U/L, painful paraesthesia, and weight loss

Laura Bywater · Anthea C Gist · Rahul G Muthalaly · Joanna Loh · Ian Simpson · Anthony J White · Andy KH Lim

Translating guidelines into practice is required to maintain the balance between practitioner autonomy and accountability

Peter FM Choong

Many patients with gallstone pancreatitis were not receiving timely, surgical care even before the pandemic

Robert J Aitken · David AK Watters

Prioritisation for unloading, once obvious cardiac emergencies have been excluded, disadvantages women and older people

Gao Jing Ong · John D Horowitz

Surgeons should take care with the information they publish online, and professional advertising guidelines should be more strictly enforced

Hannah Y Ryan · Geoffrey Y Sun · Masiath Monuja · Michael Gillespie · Alexander Burns · Michael Solomon · Sam Adie

Index cholecystectomy should be routinely provided to people over 50 with mild gallstone pancreatitis unless clinically contraindicated

Jian D Blundell · Robert C Gandy · Jacqueline Close · Lara Harvey

Longer ambulance offload times are associated with greater 30-day risks of death and ambulance re-attendance

Luke P Dawson · Emily Andrew · Michael Stephenson · Ziad Nehme · Jason Bloom · Shelley Cox · David Anderson · Jeffrey Lefkovits · Andrew J Taylor · David Kaye · Karen Smith · Dion Stub

The long term consequences of myocardial injury with vaccine-associated myocarditis warrant further investigation

Suraj K Varma · Ari E Horton · Anna L Taylor · Michael R Ditchfield · Sarah A Hope · Srinidhi JV Rao

Increased understanding of how to predict who is most at risk of breast cancer is leading to the possibility of risk-based screening, allowing better and more targeted early detection and treatment for women at high risk

Christobel M Saunders

To the Editor: Khatri’s and Stuckey’s1 article, Vertebral fractures after denosumab discontinuation for dental procedures: a consequence of distorted perceptions of risk, sums up the authors’ knowledge and experience of medication‐related osteonecrosis of the jaws (MRONJ) in the latter part of the title. They quote the risk of MRONJ as being very low and equal for denosumab and oral bisphosphonates. This is incorrect. The risk of MRONJ is 0.3%.2 In our study we found the risk following extractions at 1.8%.3 The recent 2022 update of the position paper on MRONJ4 found that the risk with denosumab is an order of magnitude higher than for bisphosphonates. There is no discussion in Khatri’s and Stuckey’s article1 of the effect of MRONJ on patients. A patient with stage 3 or end‐stage MRONJ has months of severe pain and requires jaw resection with or without microvascular reconstruction similar to that required for advanced jaw cancer.4,5 The impact of this is similar to vertebral collapse, both largely avoidable disasters. The current Australian recommendations for dental extractions for patients taking denosumab for osteoporosis are to delay extractions to 6 months after the last injection of denosumab and then to allow 4weeks for initial socket healing before the next injection.6 The risk is greater if the patient has been taking antiresorptives for more than 4years and if they are immunocompromised.4,7 We would agree that education and communication between prescribers, patients and dentists are key. This can only be achieved by close, mutually respectful communication and understanding between medical, dental, oral and maxillofacial surgeons and patients. However, this is easier to say than put into meaningful practice. Most definitive articles on MRONJ are in oral and maxillofacial surgery journals, which are not commonly read by physicians who prescribe antiresorptives. The most likely reason that the patient was taken off denosumab for 5 months was that the dental plan was not only to extract the teeth but to replace them with dental implants. Implants require time for osseointegration.8 Hopefully, this letter helps correct the distorted precepts expressed by Khatri and Stuckey for prescribers of this, otherwise, useful drug.

Alastair Goss

In reply

Bronwyn GA Stuckey · Nely Shrestha Khatri

To the Editor: We write in response to Reid and colleagues’1 article on congenital cytomegalovirus (CMV). While many countries worldwide have established congenital CMV screening programs, Australia urgently needs to recognise the importance of targeted congenital CMV screening and tracking its outcomes. Our 2019–2020 study tested the feasibility and acceptability of a parent‐completed targeted congenital CMV saliva polymerase chain reaction (PCR) screening program in Victoria.2 Parents of infants who did not pass their newborn hearing screening at four Victorian maternity hospitals completed their infants’ saliva swabs in the hospital or at home. The program was feasible with a 76% participation rate, and all 96 swabs (100%) were completed within the required 21days from birth, despite the majority being completed at home. Furthermore, more than 90% of families found the screen easy to do, thought it was a good idea, and were glad their baby had congenital CMV screening. However, there were challenges: false positive screens due to CMV contamination in breast milk, and excessive time taken from completing the screen to return of results due to reliance on the only laboratory in the state accredited to process saliva CMV PCR. We now have the means to overcome these challenges, determine whether universal congenital CMV screening in Australia is warranted, and systematically track outcomes of targeted congenital CMV screening. For 2years from October 2021, Murdoch Children’s Research Institute’s Generation Victoria (GenV) is recruiting a whole‐of‐state infant–parent cohort, collecting over 110000 saliva swabs from newborns to test for CMV using novel CRISPR technology at the Walter and Eliza Hall Institute of Medical Research.3 Our study, funded by the National Health and Medical Research Council, will determine the population prevalence of congenital CMV, develop a rapid bedside point‐of‐care test for congenital CMV screening, and establish whether universal congenital CMV screening is cost‐effective. In addition, the Australasian Congenital CMV Registry has been recently established to track outcomes of congenital CMV.4 These initiatives will pave the way for Australia to emerge as a leader in congenital CMV screening, better recognise this undetected condition of public health importance, and provide personalised care to affected children.

Emma Webb · Cheryl A Jones · Valerie Sung