Volume 218 Issue 1

The DANGER acronym is a simple, evidence-based aid to identify high risk squamous cell carcinoma

Richard Tjahjono · Hubert TH Low · Jenny Lee · Deshan F Sebaratnam · Ruta Gupta · Michael J Veness · Jonathan Clark · Carsten E Palme

A 38-year-old woman presented to the emergency department with a 2-week history of fever, headache and mild dry cough

Arvind Yerramilli · Michelle Sam · Aadith Ashok · Eugene Athan

Paracentesis is a low bleeding risk procedure which can be carried out safely even in patients with advanced cirrhosis

John J Harvey · Ralley Prentice · Jacob George

It has been a privilege to lead the Journal through challenging times, but it is time to pass the baton

Nicholas J Talley

What the future holds is unclear

Douglas Johnson · Megan Anne Rees

AF self-screening in general practice waiting rooms is feasible, and could reduce the number of AF-related strokes

Katrina Giskes · Nicole Lowres · Jessica Orchard · JiaLin Li · Kirsty McKenzie · Charlotte Mary Hespe · Ben Freedman

SARS-CoV-2 infection is associated with higher incidence of hospitalisation with several respiratory and non-respiratory conditions

Stacey L Rowe · Karin Leder · Kylie Dyson · Lalitha Sundaresan · Dennis Wollersheim · Brigid Lynch · Ifrah Abdullahi · Benjamin C Cowie · Nicola Stephens · Terence M Nolan · Sheena G Sullivan · Brett Sutton · Allen C Cheng

The role of spinal surgery in the management of degenerative low back pain is not supported by the studies currently available

Lachlan Evans · Thomas O’Donohoe · Andrew Morokoff · Katharine Drummond

To the Editor: The metaverse is a virtual environment merging physical and digital realities.1 Once the thing of movies, metaverses are tipped to be worth $800 billion by 2024.2 They have potential to revolutionise digital health care delivery, access, education, and patient outcomes.3 Artificial intelligence (AI)‐enabled health care, with metaverse enhancement, could create virtual hospitals,4 transform clinical workflows and accelerate the diagnosis and treatment of conditions relating to mental health,5 cardiology,6,7 ophthalmology,8 and oral health,9 for example. AI‐enabled technology demonstrated potential during the pandemic by predicting the incidence of coronavirus disease 2019 (COVID‐19)10 and helping to identify sites for vaccine trials.11 Yet in the absence of strong national and global health governance and accountability mechanisms, digital health ecosystems create risk for medical confidentiality and privacy breaches12 resulting in data sharing13 and use/reuse by corporations or governments outside its intended purpose and the bounds of patient consent.14 For example, a National Health Service (NHS) Foundation Trust in the United Kingdom established patient data sharing with the international technology company DeepMind to develop machine learning‐based management tools,15 but British patient data moved to the United States when Google acquired DeepMind.14 Repurposing health‐related biometric and genomic data that cannot be altered is similarly concerning, and can result in racial profiling16 and privacy violations in the absence of appropriate legislation. Metaverses also have potential to accelerate discriminatory practices. Bias may be embedded in data used to train AI models through lack of community representation or participation.17 Structural inequalities may be reflected in health care datasets, creating risk for discriminatory outcomes.18 For instance, racial bias in a health care therapy algorithm resulted in the discriminatory underestimation of health risk for millions of American citizens, precluding access to vital treatments.19 Prioritising protections for underserved populations and their right to access safe virtual health care is crucial,20 especially for Australians at the intersection of inequities driven by poverty, disability, gender, homelessness, Indigeneity, and for the 11% highly excluded from accessing digital technologies.21 We recommend that the Department of Health and the Australian Digital Health Agency partner with the Australian eSafety Commissioner's work examining metaverse deployment,2 to ensure the highest ethical standards are upheld as planning moves forward and regulatory frameworks are developed.

Caitlin Curtis · Claire E Brolan

To the Editor: With the increasing interoperability of electronic medical records across health services, smoking and e‐cigarette use need to be systematically collected on hospital admission, and advice to quit smoking should be automatically included on hospital discharge summaries. Including information on smoking status in the discharge summary, and ultimately on My Health Record, presents an opportunity to address the use of tobacco and e‐cigarette products — the first being Australia's leading cause of preventable death and disease and the second an emerging exposure of increasing concern.1 Evidence from the United States Surgeon General reports that smoking cessation after cancer diagnosis lowers the risk of dying by 30–40%.2 For some patients with cancer, cessation benefits are equal to or exceed the value of state‐of‐the‐art cancer therapies. In addition, the Surgeon General report shows most patients admitted to hospital wish to quit smoking,2 and there are proven, workable but underused interventions to cease smoking. Peak medical bodies such as the Australian National Health and Medical Research Council and the Australian Commission on Safety and Quality in Health Care3 advise that adherence to post‐hospital referral practice guidelines leads to better outcomes, fewer readmissions, and improved patient survival. Australia's National Preventive Health Strategy has a goal of reducing the adult smoking prevalence from 14% to 5% over the next 8years.4 The newly released draft National Tobacco Strategy includes key policy actions to increase the use of cessation services and to support people who use tobacco and e‐cigarettes to quit.5 Around 1.2 million Australian adults are admitted to hospital at least once each year, and it is estimated that about one in five of them would benefit from smoking cessation services.6 Given most hospitalised patients want to quit smoking, providing this recommendation in a discharge summary for appropriate referral to a Quitline (www.quit.org.au) or a general practitioner is a practical solution to provide best practice care to patients, reduce the risk of readmission to hospital, and increase their survival.

Freddy Sitas · Ben Harris‐Roxas · Sarah L White · Fiona A Haigh · Margo L Barr · Mark F Harris

To the Editor: When statutes govern clinical activity, doctors need to know exactly what those legislative provisions mean. Nahm and colleagues1 address this in their article on eligibility for Australia's voluntary assisted dying (VAD) laws.1 However, in our opinion, the authors misinterpreted the relevant provisions, risking reduced access for eligible patients. Generally, a statutory provision should be given its “ordinary and natural meaning”;2 in other words, a plain English interpretation. As the authors note, each of the VAD Acts uses a particular form of words to set eligibility around a terminally ill person's life expectancy. In Victoria, for example, a coordinating medical practitioner must conclude their patient has been “diagnosed with a disease, illness or medical condition that … is expected to cause death within weeks or months, not exceeding 6 months”.3 Nothing in that wording refers to a probabilistic estimation of the percentage chance that the patient will die within 6 months nor any estimation of the best‐case scenario, as Nahm and colleagues suggest. If the Victorian Parliament had wanted this type of estimation, wording reflecting it could have been inserted into the Voluntary Assisted Dying Act 2017 (Vic). Instead, what is needed is that doctors have an expectation, based on the patient's clinical condition, that the illness will result in death within weeks or months, with the proviso that the number of months that the expectation of death will occur within is 6 or fewer. That clinical judgement is the beginning and end of this criterion. Although that judgement might be informed by knowledge about survival times and even by knowledge about doctors’ accuracy judging survival times, doctors need only certify that they expect that the patient's illness will cause death within 6 months. Nahm and colleagues are wrong to conclude that this wording might mean that people eligible for VAD would be “those with an expected survival time of 2 months”. That is not what the legislation says, and it is a mistake to introduce elements that are not there. Such an interpretation could, in practice, convert the 6 months test to 2 months for some patients, with the risk of narrowing access to VAD for patients the Parliament intended to be eligible.

Christopher J Ryan · Ben P White · Cameron L Stewart

In reply

Sharon H Nahm · Martin R Stockler · Belinda E Kiely