Letters

To the Editor: I read with interest the consensus statement on hepatocellular carcinoma (HCC)1 and wonder why it overlooked that smoking is a major cause. Smoking is an independent and dose‐related contributing factor for HCC (relative risk, 1.51; 95% CI, 1.37–1.67) around the world.2,3 In a large European cohort, the population‐attributable fraction — the proportional reduction in population disease or mortality that would occur if exposure to a risk factor were reduced to an alternative ideal exposure scenario — for tobacco use in HCC was 48 %, more than twice the population‐attributable fraction of the second most common risk factor: hepatitis C (21%).4 In France, where smoking prevalence is high and roughly twice that in Australia, tobacco, viral hepatitis and alcohol contribute to 33%, 31% and 26% respectively of HCC cases.5 The issue is not only about prevention but also about care, as smoking cessation is an important factor in cancer outcomes (ie, treatment effectiveness, overall survival, risk of second primary malignancies, and quality of life). Lastly, only nine out of 31 recommendations in the consensus statement are graded “A1” and none are among the four related to surveillance.

Alain Braillon

To the Editor: The extension of alcohol brands to non‐alcohol products has been part of the marketing strategy of some alcohol companies on several occasions.1 Recent examples highlight that this marketing tactic warrants further research and policy attention in Australia. Following the release of a limited‐edition Bundaberg Rum‐branded Ice Break (iced coffee) in Queensland in 2019, the product was rolled out nationally in supermarkets and petrol stations in October 2020. This follows similar examples of alcohol‐branded chocolates, zero‐alcohol beverages, and fragrances. The alcohol advertising code of practice in Australia, administered by the industry‐managed Alcohol Beverages Advertising Code (ABAC) Scheme, applies to alcohol brand extensions; however, determinations suggest that the code does not restrict alcohol companies from applying their brands to a variety of non‐alcohol products. In 2019 and 2020, the ABAC Panel reviewed nine complaints about brand extensions, including the rum‐branded iced coffee (Box).2 A common theme raised by complainants was concern about children and young people’s exposure. In almost all cases, the ABAC Panel determined that the alcohol‐branded products or associated marketing would not have strong or evident appeal to minors. Most of the complaints were dismissed. Extending well known alcohol brands to non‐alcohol products provides companies with the opportunity to expose new audiences to their brands, including children and adolescents. While some extensions may not have overt appeal to children, the display of alcohol‐branded products in supermarkets and other retail outlets means children will be exposed to the marketing and may develop connections with the brands.3 The use of brand extensions has also been a strategy of the tobacco industry.1Based on the available determinations, the ABAC Scheme permits alcohol brands to be used on a wide variety of products that are not typically related to alcohol. The inadequate controls on brand extensions are consistent with reviews that have concluded that the ABAC Scheme does little to protect young people from exposure to alcohol marketing.4,5 Efforts to encourage governments to hold the alcohol industry to a higher standard in their marketing would be aided by further attention, including research attention, to the use of brand extensions by alcohol companies. Box – Alcohol Beverages Advertising Code (ABAC) Scheme determinations about alcohol brand extensions published in 2019 and 20202 Product Summary of complaint Outcome and summary of ABAC Panel comments VB‐branded Volleys (ABAC determination No. 185/20) Alcohol promotion via a shoe brand will expose children to the marketing and glorify alcohol use. Upheld in part. The VB‐branded shoes are not merchandise primarily used by young people so the product itself does not breach the ABAC Code. However, one of the associated online promotions featuring a person skateboarding while wearing the VB‐branded shoes would have strong appeal to young people. VB‐branded fragrance sold by the national chemist chain Chemist Warehouse (ABAC determination No. 124/20) The VB‐branded fragrance was marketed as an appropriate gift for Father’s Day, appealing to children and young people. The promotion seen outside a chemist included an image of a child hugging a man next to the words “#1 for Father’s Day”. Children and young people visiting the chemist would be exposed to the VB brand. Dismissed. The VB branding on the fragrance and the poster seen outside the chemist would not strongly appeal to young people, and there are no rules restricting the placement of alcohol ads in shopping centres. Heineken 0.0 television ad (ABAC determination No. 99/20) The ad promoted the product as alcohol‐free when it may not be completely alcohol‐free, and children may drink the product believing it is not alcoholic. Dismissed. The ad shows adults in an adult situation, and would not have particular attractiveness to minors beyond the appeal it has for adults. Bundaberg Rum‐branded Paul’s egg nog (ABAC determination No. 118/19) Egg nog is a flavoured milk, which is a soft drink that appeals to young people. The placement of Bundaberg Rum’s brand on the egg nog could be seen by young people. Dismissed. While flavoured milk such as chocolate milk might appeal to young people, egg nog is not considered a drink which would particularly appeal to young people. The packaging is mature and traditional and does not have features that would appeal to young people. Bundaberg Rum‐branded Ice Break drink (ABAC determination No. 82/19) The iced coffee promoted Bundaberg Rum and encouraged young people’s exposure to alcohol products and brands. Dismissed. Iced coffee as a product does not strongly or evidently appeal to young people. The product label is mature and does not contain images likely to appeal to young people. Heineken 0.0 bus stop ad (ABAC determination No. 67/19) It was not clear from the ad that the product was alcohol‐free, and it suggested that people can drink Heineken beer before driving, conflicting with anti‐drink‐driving education. Upheld. The overall impression created by the ad was positioning a Heineken product, which would be assumed to be a type of alcoholic beer, with the consumption of the product by a driver of a motor vehicle. Jack Daniels‐branded barbeque sauce and barbeque tools sold at the department store Big W (ABAC determination No. 59/19) Children would be exposed to the alcohol‐branded products being promoted in connection with Father’s Day. Dismissed. The branded barbeque products do not feature any eye‐catching designs or themes that would appeal to children or young people. Carlton Zero radio ad (ABAC determination No. 44/19) The ad referred to a “beer you can drink anywhere” and provided examples of places where it is inappropriate or irresponsible to consume alcohol, and the ad was broadcast at 12 pm on a Sunday, when children and young people are likely to be listening to the radio. Dismissed. A reasonable person would not take the ad as promoting the use of alcohol in unsafe circumstances. The timing of the broadcast was consistent with the requirements of the ABAC placement rules. Carlton Zero television ad (ABAC determination No. 35/19) Carlton Zero was marketed as a light lunch drink and could easily be misinterpreted as a soft drink. Dismissed. The ABAC definition of “strong and evident appeal to minors” refers to “confusion with a soft drink” as part of an example of how the standard might be breached. The ad taken as a whole did not create a message which could be said to be appealing to minors.

Hannah Pierce · Julia Stafford

To the Editor: A significant driver of research waste is the incentive to do research for career progression, rather than for its relevance and patient impact, especially when volume is rewarded over quality.1 We previously found that most specialty training colleges mandate that trainees conduct research, often without requiring research training and appropriate supervision. The focus tends to be on completing projects and leading research, rather than on learning fundamental research principles.2 We also wanted to understand how these incentives are built into the selection process for specialty training programs before the training even begins. In 2020, we reviewed the research‐related selection criteria on publicly available documents and websites for the training programs of 63 Australian and New Zealand specialty colleges and their subspecialty divisions. These were categorised as mandatory or encouraged; for those that used a points‐based system to grade the application, we extracted the proportion that research was worth to the overall application. While no colleges stated that research was a mandatory requirement to apply to a training program, 46 encouraged research on the prospective trainee’s application and 12 used a points‐based system to quantify their research activities (Box). Only five did not mention research. Of the 12 colleges using a points‐based system, 11 allocated points only to leading research — where the application specifically states that the applicant must be first or second author on journal articles, primary presenter at conferences, or take a leadership role in research — nine of which required this research to be conducted in the previous 4–5 years. Ten made some reference to quality, although these were often vague or generic (Box). Research was worth a median of 25% of the curriculum vitae (CV), and 7% of the overall application. This represents a numerically small but critical proportion of the overall application, since research is often used to differentiate candidates, despite number of publications at training entry being negatively correlated with clinical performance.3 As put by Doug Altman, “The length of a list of publications is a dubious indicator of ability to do good research; its relevance to the ability to be a good doctor is even more obscure”.4 No colleges allocated points for research utilisation, research training, or participation in large research teams. It appears to be far more advantageous for applicants to complete several small, low impact projects within a short time frame as first author than a single well designed randomised controlled trial as middle author. This focus on leading research leaves junior doctors vulnerable to poor quality research experiences and outputs without structured guidance and supervision.5 The current selection criteria for college training programs encourage high volume, CV‐padding research with little regard for quality or value‐adding to their field. The value of using or participating in research is apparently ignored, reducing incentives for doctors to learn good research practices and progressively acquire research skills. We posit that this is contributing to research waste. Box – Research selection criteria for applications to Australian and New Zealand medical specialty college training programs Research selection criteria Colleges n (%) Total number of colleges 63 Colleges with publicly available application documents 61/63 (97%) Mandatory 0/63 (0%) Encouraged 46/63 (73%) Encouraged with points 12/63 (19%) Authorship priority* 11/12 (92%) Research topic must be specialty‐specific 5/12 (42%) Time limit (median) 9/12 (75%)† Quality 10/12‡ (83%) Not mentioned 5/63 (8%) * First or second authorship on journal articles or primary presenter at conferences. † One college had a limit of 4 years; all others had a limit of 5 years. ‡ Quality — any mention, including peer‐reviewed, impact factor of journals, and fewer points for case reports.

Caitlyn Withers · Christy Noble · Caitlin Brandenburg · Paul P Glasziou · Paulina Stehlik

To the Editor: We congratulate Buising and colleagues1 on their article published in the MJA and agree that the approach needs to be multidimensional and iterative. To expand upon the multidimensional theme of their article, we would like to emphasise the need for the approach to be multidisciplinary and to include the whole of the health service workforce. The article highlighted the ubiquitous nature of coronavirus disease 2019 (COVID‐19) transmission in health care settings, with 18.3% (or almost one in five) of health care workers infected, and that these workers are traditionally regarded as non‐clinical staff (food services, environmental services, administrative and security staff). The non‐clinician workforce has been overlooked in other research investigating COVID‐19 transmission risk factors.2 At Monash Health, we used multidisciplinary shift briefings to ensure all health service team members were included in the information and safety messages.3 Human factor‐designed briefing cards, based on the airline industry pre‐flight safety cards, were used to ensure consistent messaging (Box and online Supporting Information). The early involvement of a design team, from the Design Health Collab at Monash University, ensured clear and unambiguous messaging to health care workers. The images were designed to represent diversity in gender, race and role to ensure all health care workers would see themselves reflected in the briefing card and that the safety messages were relevant and directed towards them. Providing information that is timely and accessible as well as readable and visually clear is important.4 Commentaries have emphasised the need for clear and concise communication to ensure the safety and wellbeing of health care workers during the COVID‐19 pandemic.5 However, we believe that involving all workers, not just clinicians, in the safety messages and interventions is paramount to the health and safety of non‐clinical health care workers and to the ongoing operation of health care services. COVID‐19 does not recognise the individual worker role in the health care service and the pandemic has offered us a unique and powerful opportunity to bring together the whole health care workforce and break down traditional barriers. We believe that a multidisciplinary approach is just as vital as a multidimensional one. Box – Card used to ensure consistent messaging during shift briefings Permission to reproduce this image was obtained from the American Journal of Infection Control.

Diana Egerton-Warburton · Lisa Kuhn · Daphne Flynn

To the Editor: Low and colleagues1 highlight the long‐standing issue that the provision of residential aged care in Australia remains grossly inadequate. This is particularly egregious given that these deficits and remedial actions have been known for decades from numerous inquiries commissioned by successive federal governments and reiterated by the Royal Commission. This vacuum is being filled by initiatives undertaken by the Victorian Government in public sector residential aged care services to develop better ways to conceptualise aged care. We acknowledge there is no single ideal model2 for the provision of residential aged care, as there is such wide variation in residential aged care services profiles (eg, number and type of residents, geographic location, physical environment, staffing). However, our recently proposed conceptual model for the provision of residential aged care3 includes many of the necessary aspects recommended by the NHMRC National Institute for Dementia Research Special Interest Group in Rehabilitation and Dementia. Our conceptual model takes as its purpose the provision of person‐centred care to older people with complex health issues, especially those living with dementia. It consists of five domains relevant to the experience of older people living in residential aged care: health care, social inclusion, individual rights, personal care and reablement, and dementia management. The model also supports the dignity of risk and quality of life beyond clinical care to enable older people to thrive. The development of our model involved several stages using a similar approach to model development described in 20104 which comprised: initial conceptualisation and development based on a review of the literature to document and map the key domains of residents’ needs in aged care; brainstorming using the expertise and experience of the research team to refine and categorise the domains and subdomains; extensive consultation with key stakeholders (n = 382) to test the model for feasibility and acceptability (field testing) for the sector; and testing against a range of theoretical organisational failure scenarios (validity checks against coroners’ cases). The model has been presented to the Royal Commission into Aged Care Quality and Safety and published in a peer‐reviewed journal.3 Uptake of this model would allow the Commonwealth government, which finances and regulates this sector, and individual service providers to have a common understanding of aged care. This is an important step towards improving aged care services.

Jo‐Anne Rayner · Deirdre Fetherstonhaugh · Joseph E Ibrahim

To the Editor: Despite the rapid uptake of telemedicine during the coronavirus disease 2019 (COVID‐19) pandemic,1 it is important to identify the barriers that hinder the delivery of alternate modes of care among specific populations. We share our reflections on the challenges of implementing telemedicine in a tertiary addiction medical clinic in Melbourne, providing treatment for about 105 patients each month. At the start of the COVID‐19 pandemic in February 2020, videoconferencing appointments were encouraged, supported by technical assistance from a clinician. During the Stage 4 lockdown period (August to September 2020 inclusive), appointments were switched to videoconferencing, with face‐to‐face only offered where clinically necessary (eg, for long‐acting injectable opioid agonist treatment). For patients unable to access videoconferencing, telephone appointments were offered. The uptake of videoconferencing was low, comprising 21% (n = 47) of appointments conducted during lockdown versus 57% (n = 128) via telephone (Box). After the lockdown (November 2020 to February 2021), there was a gradual return to face‐to‐face appointments. Seven per cent (n = 28) of appointments were done via videoconferencing while 40% (n = 155) remained via telephone. Difficulties in connecting to the videoconferencing platform, poor audiovisual quality and time spent troubleshooting contributed to the low uptake of videoconferencing. While telemedicine has been a convenient mode of health care delivery during the COVID‐19 pandemic,3 not all patients benefit from it. People accessing specialist addiction treatment are often from sociodemographic groups that are digitally excluded, such as the unemployed and people with low income or with disabilities.4 We found several barriers to telemedicine in our patient cohort. Many patients did not own a computer, had poor digital literacy, could not afford internet access or did not have privacy for consultations. Telephone appointments raise clinical gaps, with physical signs, mental state and visual cues unable to be assessed. Digital inequality further marginalises an already vulnerable population. Access, affordability and digital ability issues need to be managed for telemedicine to be a viable option.4 Examples of how this might be achieved include the establishment of hubs with telemedicine facilities, technical support and private spaces, located at local community health centres for practicality and accessibility, along with providers offering more affordable internet plans for health care card holders. Box – Modality of clinic appointments by month during the coronavirus disease 2019 (COVID‐19)‐related restrictions in Melbourne, Victoria (total monthly COVID‐19 Victorian cases also shown2)

Anthony Hew · Shalini Arunogiri · Dan I Lubman

To the Editor: Published evidence recognises that the recreational misuse of nitrous oxide (N2O) can be associated with vitamin B12 deficiency and subacute combined degeneration of the spinal cord.1 Misuse of N2O is increasing,2 with canisters (known as “nangs” or “whippits”) readily available for legal purchase in convenience stores and online ostensibly for the purpose of whipping cream. In recent years, an increase in the number of emergency presentations and acute hospital admissions related to N2O misuse has been recorded in Australia.3,4 We have also seen an increase in the number of patients requiring specialist multidisciplinary rehabilitation for severe impairments, including proprioceptive deficits, ataxia, disabling lower limb weakness and persistent gait abnormalities. Over recent years, a growing number of patients have been admitted to our inpatient metropolitan Sydney rehabilitation unit with serious disabilities related to N2O misuse. In line with published reports, our experience confirmed that patients are often university students (typically aged < 30 years).3,4 As acute medical specialties recognise the significance of these presentations,3,4 we highlight that the resulting disabilities can remain for months or years at functional, vocational and emotional levels, and many will be lifelong. This will impose a significant disability burden that will require ongoing management by specialist rehabilitation and disability services and will have an impact on the wider health care utilisation and cost. As long as N2O remains legal and accessible and is perceived by many as seemingly innocuous, users will remain largely unaware of the severity and risk presented by its long term use. Compared with messaging surrounding other “hard drugs”, most of the literature and the public health messaging in Australia do not appear to emphasise the potential for catastrophic, permanent injury associated with the misuse of N2O. Given the emerging disability burden resulting from recreational N2O misuse, we recommend enhancing existing public awareness campaigns.5 We suggest that educational resources place greater emphasis on the potential for serious, long term impairments and that education campaigns be targeted to most susceptible people via tertiary and/or secondary education establishments. Widespread restrictions on N2O purchase should also be considered. Such measures may help prevent permanent and devastating disabilities resulting from the misuse of this easily accessible substance.

Simon Mosalski · Anne Tanner · Christine T Shiner

To the Editor: The research letter by Hespe and colleagues1 on cardiovascular disease prevention is itself a missed opportunity to illuminate the complexities of person‐focused management of patients in general practice. While it provides a snapshot on cardiovascular disease prevention, it does not offer any exploration of the veracity or otherwise of these findings. Aggregate decontextualised and — as acknowledged — limited data ultimately fail to identify the true nature of the problem. Simply focusing on easily extractable data from computerised medical record systems, without linkage to the unique features and context of the person to whom these data belong, necessarily results in a distorted picture. Big data has the potential to inform only if it is appropriately interpreted and may be useful in process monitoring. Such data have a limited role in assessing general practitioner performance and outcomes of care.2 One must always remember that guidelines are nothing more than guides, which must be appropriately adapted to the unique circumstances of each patient. A more relevant research question would be: how appropriately or inappropriately are preventive treatments applied? This question addresses both overtreatment and undertreatment.3 As a binary question, however, it fails to ask more important contextual questions such as whether the patient can cope with the demands of the treatment, whether the treatment decision is a truly informed one, and whether it fits the needs and expectations of the patient given other health concerns. It ignores entirely the impact of a therapeutic alliance on actual health outcomes.4 Finally, the implied need for a hawkish attitude to prevention must take account of the fact that no intervention is risk‐free. Our obligation clearly states: primum non nocere. Research aiming to improve understanding of the interdependencies inherent in each and every consultation is urgently needed. The health and wellbeing outcomes of medical care are far less determined by biomedical interventions than by the contextual stressors in a person’s life.5 Providing general practice with the tools and resources to truly address the complexities of our patients’ needs is of utmost urgency.

Joachim P Sturmberg · Carmel M Martin

To the Editor: The incidence of syphilis is dramatically rising in Australia. As such, previously rare sequelae like syphilitic hepatitis are occurring more frequently, supported by a growing number of case reports in the literature.1 We present a typical case of syphilitic hepatitis and review the evolving at‐risk populations, to raise awareness of this potentially fatal yet highly treatable disease. A 34‐year‐old Caucasian man presented with a maculopapular rash over the trunk and limbs associated with abdominal discomfort, anorexia and fatigue. He had been treated for early syphilis 2 years previously, with serological evidence of response. He had no history of human immunodeficiency virus infection. He was married with children and denied other sexual relationships. Aside from the aforementioned rash, his examination was unremarkable. His alkaline phosphatase level was 684 U/L (reference interval [RI], 50–130 U/L), γ‐glutamyl transpeptidase was 942 U/L (RI, < 55 U/L), alanine aminotransferase was 429 U/L (RI, < 45 U/L), and aspartate aminotransferase was 181 U/L (RI, 5–35 U/L); bilirubin was 18 μmol/L (RI, < 20 μmol/L) and C‐reactive protein (CRP) was 55 mg/L (RI, < 5 mg/L). Abdominal ultrasound and extensive liver screen results were normal. Treponema pallidum particle agglutination assay and rapid plasma reagin test results were reactive at a 1:32 titre, prompting a diagnosis of syphilitic hepatitis. He was administered 2.4 million units of benzathine benzylpenicillin intramuscularly once‐weekly for 3 weeks. His rash, symptoms and liver function tests resolved within 6 weeks. The Australian notification rate of syphilis increased from 5.0 to 18.3 per 100 000 population between 2010 and 2017. Women aged 15–19 years experienced a tenfold increase in incidence over this period. In 2017, women from remote areas were 27.3 times more likely to contract syphilis than those from major cities, while Aboriginal and Torres Strait Islander people were 6.6 times more likely to contract syphilis than non‐Indigenous Australians.2 Despite this disproportionate rise in vulnerable populations, rates remain highest among men who have sex with men and those with human immunodeficiency virus infection.3,4 Re‐infection is common, as was found in our patient. Described as the “great imitator”, secondary syphilis can be difficult to diagnose; consequently, the true incidence of syphilitic hepatitis is not known. While our case illustrates a typical presentation, cases of fulminant liver failure have been described.5 Rash (78%), anorexia (57%) and fatigue (57%) are the most common presenting symptoms.1 Marked elevation of alkaline phosphatase and γ‐glutamyl transpeptidase, coupled with milder elevation of alanine aminotransferase and aspartate aminotransferase are the most common laboratory findings, with hyperbilirubinaemia present only in severe cases. A liver biopsy is not essential for diagnosis, but may reveal inflammatory infiltration of the bile duct, hepatic granulomas or, less commonly, intrahepatic spirochetes via immunohistochemical staining.1 It is imperative that clinicians consider ordering treponemal serology in high risk patients fitting this presentation, as prompt treatment with penicillin leads to rapid disease resolution and aversion of tertiary complications, including death.

Matthew Smale · William R Connell · Julien D Schulberg

To the Editor: The explanation of inference from confidence intervals by Hemming and Taljaard is interesting but unfortunately incorrect.1 The authors may have fallen for the confidence interval variation of the P value fallacy — the mistaken idea that the P value (or confidence interval) can capture both the long term outcomes of an experiment, as commonly reflected in the phrase “a trend to significance (P = 0.06)”, and the evidential meaning of a single result.2 In a frequentist approach, the P value follows from the null hypothesis, which is either accepted or rejected. The calculation of the P value proceeds only because we have accepted the null hypothesis to be true. Are Hemming and Taljaard confusing Bayesian and frequentist inferential methods?3 The difference between Bayesian and frequentist logic is analogous to the diagnosis of measles for a hypothetical patient presenting with a fever and a rash.4 With frequentist logic, we would consult a text book (the correct textbook being a key assumption), and base our diagnostic inference on a hypothetical cohort of 100 patients presenting to us with an identical rash and fever, to state that 95 of them would have measles. We would not be able to state which of this hypothetical group of individuals had measles. Moreover, a diagnosis of “a trend to measles (P = 0.06)” does not exist in the real world. By contrast, with Bayesian logic, our hunch (the prior) that the patient in front of us has measles is firmed up (the posterior) by knowing that there is a measles outbreak in the community (the evidence). Unfortunately, the thinking commonly found in association with P values and 95% confidence intervals, and suggestions that directive conclusions from randomised trials are achievable from borderline P values, leads to terms such as “a trend to significance” for findings from studies that are underpowered.5

James C Hurley

To the Editor: A 35‐year‐old man born in Dire Dawa, Ethiopia, with childhood exposure to swimming in rivers, migrated to Australia 18 years ago. He presented with recurrent gastrointestinal bleeding. His index gastroscopy revealed portal hypertensive gastropathy and large oesophageal varices with high risk stigmata of recent bleeding requiring banding. Abdominal ultrasonography and transient elastography excluded liver cirrhosis. Six weeks later, he re‐presented with recurrent severe haematemesis associated with dark maroon rectal bleeding. Repeat urgent gastroscopy and flexi‐sigmoidoscopy revealed oesophageal varices without active bleeding. On sigmoidoscopy, a large amount of dark blood was seen, presumed to be related to rapid transit from recent oesophageal variceal bleeding. In the next 48 hours, a repeat colonoscopy was performed. Colonoscopy identified yellowish nodules throughout the colon with diffuse telangiectasia (Box, A and B). Mucosa was oedematous and friable. Aphthous ulcers were seen in the transverse colon and biopsies were obtained. No polyps or focal source of colonic bleeding were evident. Histopathology confirmed the presence of cystic ova resembling Schistosoma in the lamina propria immediately adjacent to crypts. Although classical granuloma formation was absent, aggregation of eosinophils was seen around a ruptured ovum (Box, C and D). Indirect assay via serology testing was positive for Schistosoma mansoni antibody (titre of 1:640). His eosinophil count was normal and stool microscopy was negative. He was treated with praziquantel. Four months later, a follow‐up gastroscopy revealed stable appearance of grade 1 oesophageal varices without high risk features. Routine variceal surveillance had been organised but not further colonoscopies. Schistosomiasis affects over 200 million people worldwide but is not acquired in Australia. In a national survey in Ethiopia, 37.3 million individuals were living in endemic areas.1 Schistosoma mansoni is the commonest species to cause intestinal and hepatic schistosomiasis. In the 2016 national census, there were 11 795 people in Australia who were born in Ethiopia, 64.3% (7584) of whom were Australian citizens.2 Most screening data for schistosomiasis in Australia are based on African refugees, with 37% in Newcastle, 38% in Hobart and 12% in Melbourne.3 Despite anecdotal knowledge, there are no published cases of non‐cirrhotic portal hypertension related to schistosomiasis in Australia. As a multiracial country with high immigration and tourism, increased recognition in Australia is paramount. Box – Colonoscopy showing widespread yellowish nodules (arrows) with oedematous and friable mucosa (A) and diffuse telangiectasia (B); and histopathology showing aggregation of eosinophils surrounding a Schistosoma ovum(C) and a cross‐sectional image of a Schistosoma ovum (D)

Julia Lim · Shweta Sharma · Damian Dowling

To the Editor: We read with interest the article by Kault,1 who carried out an analysis on superspreaders, asymptomatic cases, and coronavirus disease 2019 (COVID‐19) elimination. Although all efforts made for preventing or containing the COVID‐19 pandemic are certainly welcome, we raise doubts on some basic aspects used for constructing the prediction model and which do not seem to be evidence‐based. In the risk model of COVID‐19 re‐emergence after release of restrictive measures (eg, lockdowns), Kault made some erroneous assumptions, including the fact that asymptomatic subjects may be as infectious as symptomatic patients with COVID‐19.1 This hypothesis seems to be contradicted by several lines of evidence. First, a meta‐analysis published in 2020 concluded that the rate of asymptomatic transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection is 35% lower compared with COVID‐19 patients with symptomatic illness.2 This has also been clearly explained in a seminal study showing that the viral load is the highest in concomitance with symptoms onset, so that the infectiousness of pre‐symptomatic or asymptomatic individuals is probably low.3 Notably, the impact of pre‐symptomatic SARS‐CoV‐2 transmission seems also rather limited, whereby the secondary attack rate was found to account for only 15% of all secondary COVID‐19 cases.4 A second aspect that needs to be highlighted is that presuming that 50% of SARS‐CoV‐2‐positive patients are asymptomatic may also be formally incorrect. Beside the fact that the asymptomatic SARS‐CoV‐2‐positive rate varies greatly depending on many genetic, demographic (ie, age, sex and ethnic origin) and even clinical (eg, time course of disease, comorbidities) variables, an analysis in the official database of the Italian National Institute of Health reveals, for example, that the rate of asymptomatic subjects with SARS‐CoV‐2 infection approximates 70%.5 Combined with lower infectiousness, the high prevalence of asymptomatic subjects bearing SARS‐CoV‐2 infection after release of restrictive practices (eg, lifting of lockdowns) would persuade us to conclude that the possible impact of asymptomatic superspreaders on SARS‐CoV‐2 transmission would be low and perhaps insufficient to influence or guide future policies aimed at restricting individual freedom.

Camilla Mattiuzzi · Giuseppe Lippi

To the Editor: Recruitment and retention of a sustainable rural health workforce was one of four issues highlighted by Osborne in a recent MJA supplement.1 Chapter 4 of the Supplement describes a need for longitudinal methods to evaluate recruitment and retention of nursing and allied health professionals, noting challenges around scale and links to policy.2 Comparative efforts examining the medical workforce in Australia are more advanced (eg, the Medical Schools Outcomes Database). Chapter 5 concludes there is a need for a longitudinal, linked database to address rural workforce planning that utilises public data sources, noting medicine was covered by all primary data sources identified, yet only three covered all health professions.3 The Nursing and Allied Health Graduate Outcome Tracking (NAHGOT) study is a research collaboration between the University of Newcastle, Monash University and Deakin University that addresses issues of scale and relevance to national health workforce policy. NAHGOT links Australian Health Practitioner Regulation Agency practice location data (the outcome) with university administrative records (explanatory variables including placement location and duration), and is complemented by the national Student Experience and Graduate Outcomes Surveys. Further complementing the NAHGOT database are the publicly available Socio‐Economic Indexes for Areas at varying spatial resolutions (eg, Statistical Areas Level 1 to Level 4), a general measure of spatial access (Australian Statistical Geography Standard — Remoteness Areas), and a workforce specific model used to define Distribution Priority Areas (Modified Monash Model). Across the nursing and allied health disciplines offered by the three universities, data from a new cohort of about 2000 first year students are captured annually and securely stored in a central, de‐identified repository. Database access is currently restricted to participating institutions, with the longer term intent to permit external data extractions based upon predefined study protocols through a formal process. To our knowledge, NAHGOT is the largest tracking study of this type and growing, with three other universities soon to join the collaboration, enabling expansion into Queensland and South Australia. All participating universities are funded by the Rural Health Multidisciplinary Training Program, with the study design reflecting the objectives of the federal Department of Health. Universities are the logical choice to undertake tracking of graduate outcomes at scale. Unlike other data sources, universities hold admission and professional placement data not available elsewhere. The protocol will soon be available4 and the first peer reviewed publications from NAHGOT have now been published,5,6 and as the project expands it is anticipated it will become a major contributor to workforce planning and augment established efforts in medicine.

Vincent L Versace · Tony Smith · Keith Sutton

To the Editor: Victoria introduced voluntary assisted dying in June 2019, historic legislation which aimed to enable terminally ill people in limited circumstances to end their life with autonomy, compassion and support. The Voluntary Assisted Dying Act 20171 is considered the most conservative and safe legislation in the world, with 68 safeguards. We compared recent Victorian reporting data2,3 with a 12‐month period of data on Oregon’s Death with Dignity Act (1997),4 as the jurisdictions have similar population sizes and there is no comparable jurisdiction currently operating in Australia. To access voluntary assisted dying in Victoria a person must: have an incurable and advanced disease, illness or medical condition that is expected to cause death within 6 months (or within 12 months for a neurodegenerative condition); be experiencing suffering, which the person considers intolerable; have decision‐making capacity in relation to voluntary assisted dying; be an adult, aged 18 years or older; and be an Australian citizen or permanent resident who has lived in Victoria for at least the past 12 months. Eligibility requirements for Oregonians are comparable; however, there is no requirement to demonstrate intolerable suffering. Based on a total number of 46 581 deaths in Victoria during the 2019–2020 period, 0.3% of deaths can be attributed to voluntary assisted dying.5 In both Victoria and Oregon, the most frequently reported reasons for requesting voluntary assisted dying and dying with dignity were loss of autonomy and losing control of body functions; additionally, loss of dignity and being unable to engage in activities that make life enjoyable were also cited. Data show that: Victorian applicants were aged between 32 and 100 years, with an average age of 71 years.2,3 In comparison, the average age in Oregon was 74 years, with a range of applicants from 18 to over 85 years.4 In Victoria, 44% of applicants were female, 55% were male and 1% selected “self‐described” as their gender,2,3 comparable to Oregon (41% female and 59% male).4 Between 19 June 2019 and 30 June 2020, 231 permits were issued. Of these, 104 (45%) self‐administered the medication, while another 20 (9%) had the medication administered by a medical practitioner (Box).2,3 Oregon data from 2019 (population, 4.2 million) revealed that 290 applicants were prescribed medication, with 150 (59%) self‐administering;4 in Victoria (population, 6.3 million), 54% self‐administered, while another 61 (21%) did not take the medication and died of other causes. In addition to the first 12 months of Victorian data, we also included the cumulative totals to February 2021 (Box). The Victorian Act requires three requests be made to a registered medical practitioner for an individual to access voluntary assisted dying. Medical practitioners can apply for either a self‐administration or practitioner administration permit at any one time. Time from first to last request occurred within 11 days for 25% of applicants and 19 days for 50% of applicants.2 Voluntary assisted dying and dying with dignity represent an option for individuals to choose the manner and timing of their death during the terminal phase of illness. Continued community awareness and conversations about end of life options are essential to ensuring that voluntary assisted dying is available to eligible Victorians who seek access. Box – Victorian voluntary assisted dying data snapshot4,5 Total Stage Status 19 June 2019–30 June 2020 To February 2021 Eligibility First assessment by coordinating medical practitioner Eligible 341 562 Ineligible 7 19 Second assessment by consulting medical practitioner Eligible 297 483 Ineligible 4 8 Permit applications Self‐administration permit Issued 201 350 Not issued 32 44 Practitioner administration permit Issued 30 55 Not issued 9 16 Withdrawn: case withdrawn from portal by medical practitioner or upon notification of death of the applicant 134 239 Medications dispensed For self‐administration 154 281 Confirmed deaths Medication administered Self‐administered 104 184 Administered by practitioner 20 40

Kate Furness · Donna Markham · Tamica Sturgess · Margaret O’Connor

To the Editor: The Medical Research Future Fund (MRFF) should be a policy triumph for the Australian Government, tackling unmet clinical needs through transformative research that saves lives, creates jobs and strengthens the industry.1 However, to deliver these objectives, medical research findings must be translated from the laboratory and library to achieve impact on the clinic, community and companies. The capacity for efficient health research translation has been limited in Australia.2 The MRFF provided $20 million per year, finishing in 2021, to pump‐prime Australia’s ten health research translation centres designated by the National Health and Medical Research Council, in which we work. The Translation Centres bring health services and consumers together with health researchers from universities and medical research institutes. Distributed across the nation, the Centres have come together to form the Australian Health Research Alliance (AHRA), providing a “go to” destination for those seeking expertise in health research translation.3 We want to see that research‐ and translation‐trained practitioners in medicine, nursing, allied health disciplines, clinical laboratories, pharmacy, health informatics and other frontline services have time stably funded to deploy their skills in a role we describe as “research translators”.4 Alongside conventional health care duties, such staff will have dedicated time to engage consumers, recruit participants to clinical research, partner with industry, prove the relevance of research to their service, promote best evidenced practice, and champion the adoption of innovation. While overseas governments invest heavily in such roles, funding time for frontline clinical staff to deliver research and translation alongside their clinical work, Australia does not. For example, the National Institute of Health Research in the United Kingdom commits approximately $20 per citizen per year, with an impressive impact on lives saved, jobs created and industry invigorated.5 Australia should address this translational workforce gap or risk failure to achieve full beneficial impact from the MRFF. About $65 million per year (about 10% of the MRFF investment income) would support a cadre of research translators broadly proportional to the provision from comparable research budgets overseas, with AHRA’s Centres best placed to provide efficient coordination. Thus, the MRFF would be powered for success by investing in research translators through AHRA, ensuring the triumph of an exciting new policy that promises benefit to all Australians.

John Savill · Christopher Levi · Gary Geelhoed