Volume 218 Issue 3

Action to incorporate evidence- based nutrition concepts in medical education is essential

Eleanor J Beck · Lauren Ball · Breanna M Lepre · Rachael McLean · Clare Wall · Melissa Adamski · Helen McCarthy · Jennifer Crowley

Data on the expected effectiveness of a formal cardiovascular risk screening are needed

Ellie Paige · Natalie Raffoul · Emma Lonsdale · Emily Banks

Environmentally sustainable equitable digital transformation is central to delivering low carbon health care models

Zerina Lokmic‐Tomkins · Ann Borda · Kimberly Humphrey

Careful clinical assessment is indicated in migraineurs to differentiate between migraine and more serious neurological pathologies

Alanna Rottler · Yew Li Dang · Wai Foong Hooi · David Burrows · Hong Kuan Kok · Douglas Crompton

A previously healthy 27-year-old woman presented to the dermatology department following a 3-month history of an itchy erythema

Li Chai · Ze‐Hu Liu

From fearing death as a paediatric patient to confronting it as a training doctor

Dominique S Schell

Health system leaders should integrate alternative models of emergency care that proved useful during the pandemic into care pathways

Amith Shetty · Jean‐Frederic Levesque

E- cigarettes are not predominantly used as smoking cessation tools for older smokers

Alexander Larcombe

Effective modulator treatments now available for most people will probably add years to their lives

John Massie

Restrictions should be accompanied by advice about appropriate locations for seeking medical care, by condition severity and type

Amy L Sweeny · Gerben Keijzers · Andrea Marshall · Emma J Hall · Jamie Ranse · Ping Zhang · Gary Grant · Ya‐Ling Huang · Dinesh Palipana · Yang D Teng · Benjamin Gerhardy · Jaimi H Greenslade · Philip Jones · Julia L Crilly

Health care professionals caring for men with prostate cancer starting ADT should ensure that their bone health is routinely assessed

Mariya F Hamid · Amy Hayden · Tania Moujaber · Sandra Turner · Howard Gurney · Mathis Grossmann · Peter Wong

The increase in e-cigarette use by younger people who smoke or have recently quit reflects their presentation and marketing

Becky Freeman · Katherine Owen · Sandra Rickards · Alecia Brooks · Philip J Clare · Anita Dessaix

CF diagnosed in adults can manifest with milder symptoms across a range of organ systems than classical CF

Amelia Lin · Keith Wong · Simone K Visser · Helen Jo · Yasmeen Al‐Hindawi · Katrin Kosbab‐Jackson · Molly Cocks · Anastasia Volovets · Paul Haber · Kirsten Hammond · Nicole Taylor · Veronica Yozghatlian · Edmund MT Lau · Nathaniel S Marshall · Tara Aquino‐Salomon · Sheila Sivam

To the Editor: In a recent Editorial,1 Grimwood and Chang cited a review of long COVID in children and adolescents,2 and wrote that symptoms are similar for those with and without evidence of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection. But this is an inaccurate description of the review's findings. Cases were more likely to experience persistent symptoms than controls in the majority of studies reviewed.2 The difference in prevalence might be even greater than reported owing to the well documented underdetection of coronavirus disease 2019 (COVID‐19) in children,3 resulting in misclassification of cases as controls. A growing body of evidence indicates children are more affected by COVID‐19 than initially thought. A recent US Centers for Disease Control and Prevention (CDC) analysis of 1.4 million children aged under 12 years and 1.7 million adolescents aged 12–17 years found increased rates of asthma, myocarditis and cardiomyopathy, cardiac dysrhythmias, diabetes, renal failure, venous thromboembolism, and coagulation disorders in children with laboratory‐confirmed COVID‐19 compared with children without COVID‐19. These increased risks (excluding asthma) were also experienced by adolescents with COVID‐19, who were additionally at increased risk of pulmonary embolism.4 Although uncommon or rare, such outcomes suggest children are not spared the cardiovascular and metabolic sequelae of COVID‐19. Recent research using low field magnetic resonance imaging (MRI) revealed persistent pulmonary dysfunction in non‐hospitalised children and adolescents (mean age, 11±3 years) who had recovered from COVID‐19 (n = 29) or had long COVID (n = 25). Despite all children having morphologically normal lungs (except for one recovered child), ventilation and perfusion (V/Q) matching was markedly lower in the recovered group (62±19%) and the long COVID group (60±20%) compared with nine healthy controls (81±6%; mean age, 10±3 years).5 Although the MRI study may be limited by selection bias (ie, children with greater symptomatology being more likely to participate), this and similar research indicate the health impact of paediatric COVID‐19 is greater than generally acknowledged. We do not know what the long term impact of SARS‐CoV‐2 infection might be, but the accumulating data are not encouraging. Reinfection is common and SARS‐CoV‐2 spreads readily in schools in the absence of mitigation measures, such as the use of masks, portable HEPA air cleaners, and improved ventilation. Notably, better ventilation has wider benefits, including improved academic performance. A poorly ventilated classroom can be equivalent to a student skipping breakfast.6 The COVID‐19 pandemic is not over. Ongoing commitment to a public health strategy informed by the precautionary principle is required. This will deliver wide‐ranging social, economic and health benefits.

Zoë Hyde

In reply

Keith Grimwood · Anne B Chang

To the Editor: Lord and colleagues’ article1 provides a much‐needed snapshot of breast cancer distant recurrence and metastatic survival. As one of Australia's leading breast cancer advocacy organisations, Breast Cancer Network Australia (BCNA) has long been calling for reporting of recurrence data. Although we can justifiably celebrate a 5‐year survival rate of 92%,2 the long term data on distant recurrence reported by Lord and colleagues demonstrate the importance of looking beyond 5 years to understand the full burden of disease. In addition, Lord and colleagues’ survival data after distant recurrence is a critical first step in understanding the survival experience of this important but neglected group. In the associated Editorial, Redfern and Martin3 highlight that Australia's cancer registries do not systematically collect or report recurrence. The same applies for stage at diagnosis. Consequently, the number of Australians living with metastatic breast cancer is unknown. This is a fundamental problem. Without information to quantify this group of people we cannot adequately plan or deliver services. The problem extends beyond breast cancer to cancers such as prostate, melanoma, colorectal and lung, where targeted therapies, immunotherapies, and antibody drug conjugates are driving improvements in survival for patients with metastatic disease.4 These patients often have long term, complex supportive care needs yet have little visibility in our health care system. BCNA's 2017 national survey of 10318 people with breast cancer identified higher information and support needs among patients with metastatic compared with non‐metastatic breast cancer.5 These information and support needs were also less likely to be met by services for people with metastatic compared with non‐metastatic breast cancer.5 On 13 October 2022, which was Metastatic Breast Cancer Awareness Day, BCNA launched its Making metastatic breast cancer count Issues Paper to draw much‐needed attention to these issues.6 In the absence of cancer registry data, we applied Australian modelling from 2008 to current breast cancer mortality data.2,7 We estimate that in 2020 there were at least 10553 Australians living with metastatic breast cancer. Data from the United States suggest this number will continue to grow.8 Collection of recurrence and stage at diagnosis data will require national leadership and accountability, including continued investment in Cancer Australia's Stage, Treatment and Recurrence Project. Critically, it will also require input from key stakeholders including data‐management experts, cancer epidemiologists, cancer registries, clinicians and consumers. The time for action is now.

Andrea Smith · Vicki Durston · Sam Mills

To the Editor: We applaud the authors for comparing ambulance offload times with mortality and re‐presentation rates for patients presenting with chest pain.1 However, the model employed by the authors fails to account for the independent impacts of access block and emergency department (ED) overcrowding on poor outcomes and thus risks overemphasising the influence of ramping. There is clear evidence that ED overcrowding and access block are associated with worse patient outcomes, including increased mortality, re‐presentation rates and ambulance offload times.2,3,4,5 This could explain many of the study's findings: ramping is the symptom, ED overcrowding and access block are the disease. Secondly, there are fundamental differences between tertiles 1 and 3 that have not been addressed. The patients in tertile 1 are more likely to have been offloaded straight into the waiting room, a common procedure in most EDs, whereas patients in tertile 3 would not, potentially due to poor mobility, dementia, or being assessed as requiring significant cardiorespiratory monitoring. For this reason, patients in tertile 1 would be expected to have better outcomes than those in tertile 3. The article adjusts for the presence of eight comorbid conditions but not their severity. Furthermore, the incidence of each individual comorbid condition was marginally higher in tertile 3, and although individually not statistically significant, the cumulative impact of multiple comorbid conditions would be higher in tertile 3, which could confound the results. The study's use of the Charlson index is limited, as it only uses the identified eight comorbid conditions. The Charlson index also includes dementia, hemiplegia, heart failure, liver disease, and cancer; these are not measured in the study and would all contribute to offload delays and worsened outcomes. Lastly, without including patients presenting via private transport with chest pain, and in the absence of any measures of ED overcrowding and access block, the analysis of patients presenting with chest pain remains incomplete. That ED overcrowding and access block, evidenced by ambulance offload delays, is associated with worsened outcomes is well known. Unfortunately, focusing on the symptom of ambulance ramping, rather than the disease of ED overcrowding and access block, risks leading to ill‐informed policy decisions and ineffective solutions.

James L Mallows · Bridget Honan · Sierra Beck

In reply

Luke P Dawson · Emily Nehme · Ziad Nehme · Karen Smith · Dion Stub