Letters

To the Editor: We identified a geographic and temporal cluster of four patients with drug poisoning occurring within one week in February 2020 from two addresses less than 1 km apart. All patients presented with typical features of opiate poisoning but had no history of opiate use. There was one death, with the three other cases having significant morbidity, which required escalating bolus doses of naloxone. Rapid sample analysis by the New South Wales Pathology Forensic and Analytical Science Service (FASS) using liquid chromatography quadrupole time‐of‐flight mass spectrometry (LC‐Q‐TOF‐MS) found acetyl fentanyl — a synthetic fentanyl non‐pharmaceutical designer drug — in all cases within 3 days. The identification and subsequent response were coordinated by the Prescription, Recreational and Illicit Substance Evaluation (PRISE) program, a collaboration between the NSW Ministry of Health, the NSW Poisons Information Centre and FASS. The analytical confirmation and public health response, involving data collection, risk assessment with a health expert committee and customised clinical and public health response, occurred within 15 days of notification to PRISE. Two further cases were identified by the NSW Ministry of Health in other hospitals in the 2 months prior and 2 months subsequent to our cases. In October 2020, a further cluster of five cases occurred in regional NSW. Ethics approval was granted by the Sydney Local Health District Research Ethics and Governance Office, HREC 2020/ETH01380. The presence of fentanyl analogues as an adulterant in recreational drugs has become common globally but only one case of poisoning by acetyl fentanyl has been reported in the literature in Australia.1,2 This poses a significant risk to unassuming users, particularly users whose primary recreational use is stimulants, as they are likely to be opioid naïve and have worse clinical outcomes. Cases of toxicity from fentanyl and its analogues are often under‐reported because of issues with detection. Synthetic opioids do not test positive on urine drug screen immunoassays; mass spectrometry is required to confirm the diagnosis.3 Acetyl fentanyl is a non‐pharmaceutical designer analogue of fentanyl first described in 2013 after an outbreak with reported mortality in Rhode Island.4 Pharmacokinetic data for acetyl fentanyl are limited, but the drug is 15 times more potent than heroin and has an ED50 (median effective dose) and LD50 (median lethal dose) ten times narrower than morphine.5 The purpose of PRISE is to detect atypical substances in the community, focusing on presentations that are unexpected, severe and/or clusters, and coordinate an appropriate response. Rapid detection and toxicosurveillance allowed for prompt dissemination of information to clinicians and the public. Information directed to user groups is a particularly important harm minimisation strategy. Rapid detection and early dissemination of information may have limited further outbreaks. Clinicians should be informed that atypical presentations in recreational drug use may be due to substitution or contamination by other substances. Notification of cases to Poisons Information Centres can provide treatment advice and facilitate rapid identification and response by providing an access pathway, such as the NSW Ministry of Health PRISE Program.

Varan Perananthan · Chris Tremonti · Emily Nash · Thanjira Jiranantakan · Andrew H Dawson

To the Editor: There is a new player in the treatment of opioid use disorder: extended‐release depot buprenorphine. This has been hailed “a game changer”1 and has proven to be of great benefit, particularly during the current coronavirus disease 2019 (COVID‐19) pandemic. Depot buprenorphine has an impact on presentations to hospital and health services, meaning that all clinicians must be familiar with the advantages and disadvantages (Box) as well as the formulations. Opioid use disorder is a complex, chronic, relapsing health condition that requires lengthy management and is over‐represented in incarcerated people. Opioid treatment successfully reduces illicit use, overdose deaths, and costs. In Australia, there are opioid treatment programs for incarcerated persons, improving individual and community wellbeing and social functioning following release. However, until recently, the treatment perpetuated a daily drug pattern and risks, such as diversion to others, injecting opioid treatments, overdose risks and violent behaviour.2 What changed the game and model of care in Australia is the development of extended‐release depot buprenorphine. The Australian game has two products: one is available as weekly and monthly injection options and the other as a monthly injection. Depot buprenorphine is a subcutaneous injection and must be administered by a health care professional, as inadvertent injection into other structures forms a depot gel that will not provide slow release of the medication and depot gels in a vein may cause serious, life‐threatening health problems.3 Weekly or monthly doses of depot buprenorphine are provided following stabilisation using sublingual buprenorphine, most often for 7 days, and may be started the day after the last daily sublingual buprenorphine. Dose conversion tables exist to match depot buprenorphine to the sublingual buprenorphine dose. Steady state equilibrium is achieved after three to four doses.3 Hospital and health service clinicians must be aware that all buprenorphine formulations complicate routine opioid analgesia for acute pain management, and consideration of other non‐opioid‐adjuvant analgesics is needed (Box).3 Uptake of depot buprenorphine has been welcomed by patients, the community and correctional programs, with many who have transitioned reporting positive outcomes, including reduction in cravings, anxiety, improved attitude, relationships, and general mood.4 The timing of this game changing depot buprenorphine has enabled remote health care and ongoing availability of opioid therapy in the context of the COVID‐19 pandemic.5 Box – Advantages and disadvantages of depot buprenorphine Advantages of depot buprenorphine: it provides greater convenience and does not require attendance for daily dosing it reduces the treatment cost for clients and service providers it has less risk of diversion and non-medical use of the medication it has greater medication adherence and enhanced treatment outcomes it opens opportunities for normal life and to consider employment, study and travel it removes risks related to takeaway opioid treatment doses it reduces stigma and discrimination and has a positive impact on the way that people with opioid use problems are perceived Disadvantages of depot buprenorphine: ul#arrow { position: relative; list-style: none; } ul#arrow li::before { content: '▶ '; position: relative; left: 0; } it complicates routine opioid analgesia in the management of severe acute pain: it may require the use of higher doses of traditional opioids such as morphine; and it may require the use of a mu opioid receptor super agonist such as fentanyl and/or the use of non-opioid analgesic approaches (eg, ketamine infusions or regional analgesia) it provides reduced patient health care, social interactions and support opportunities it results in a loss of control over how the patient manages their dose (especially takeaways)

Katerina Lagios

To the Editor: Doctors’ wellbeing is an important agenda for reducing doctors’ burnout and its consequences. It is often confused with wellbeing related to personal lives that is not controlled by workplaces. My observation is that systems are implementing symbolic solutions, which undermine the efforts of advocacy for system solutions. I see wellness through my experience during teenage years, growing up in the middle of a war. I suffered emotional trauma; more than that, moral injury that was inflicted by the hypocrisy of the system that violated my human rights. Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs.1 All I wanted was for someone to stop the war; I was not expecting to be sent to a wellness officer or to wellness and resilience training workshops. In the past 22 years as a doctor, I am seeing the emergence of the term “moral injury” in health care settings and is linked to doctors’ wellbeing.1 I feel that moral injury within health care settings occurs when workers’ rights, expectations of doctors, and the organisational values and purpose are met with contradictions at workplaces.1 The literature is clear that doctors’ wellness is related to the culture and environment of the workplace rather than issues with the individuals’ resilience (Box).2 Of course, training to fine‐tune skills to manage emotionally challenging clinical situations and self‐care is important, but resilience training should not be about how to tolerate situations that cause moral injury. It will be difficult for systems to address workload‐related stress driven by doctors’ own choices. While some of the system’s problems can only be solved through organisational alignment of values and purpose, medical leaders of all levels need to take ownership of the doctors’ wellness agenda. They need to advocate for removing situations that cause moral injury and focus on cultural and structural solutions within their work teams and units, fostering a sense of belonging, cohesion and autonomy among colleagues, promoting self‐care and minimising burnout. This may create psychologically safe and joyful work teams. Box – Examples of contradictions that may cause moral injury at workplaces Expectations Contradictions Accreditation standards call for better workload and fatigue management Vacancies are not filled in a timely manner to manage the workload Front‐line staff are keen to help patients and colleagues Not enough personal protective equipment sourced Clinicians are keen to adopt Choosing Wisely and patient‐centred models Efficiency not rewarded by enhancing clinicians’ capabilities or supporting their initiatives Research as core business of organisations Prohibitive and time‐consuming regulatory processes for research Clinical directors are expected to lead change Clinical directors are not given necessary support or time to drive change Organisational values call for consultation and engagement with staff Decisions are made unilaterally by colleagues and leaders Nurses and doctors ask for help when patients with violent behaviours pose a threat to their safety Nurses and doctors get told to sort it out themselves

Sabe Sabesan

To the Editor: The article by Giuseppin,1 Chair of the Australian Medical Association Council of Rural Doctors, published in MJA InSight+, on ending geographic narcissism, overcoming metro‐based policy making, and instituting health self‐determination by rural practitioners and communities echoes the feedback we have received from health practitioners and consumers attending our workshops throughout northern Australia. The HOT NORTH (Improving Health Outcomes in the Tropical North) program (Box), funded by the National Health and Medical Research Council, aims to address inequitable health coverage across northern Australia through more widespread implementation of locally designed research and practice. Epidemiological and health service data indicate a higher disease burden and risk profile in northern Australia compared with the rest of the country, with health disparity increasing with age and remoteness and Indigenous Australians living in the north having worse health outcomes than the non‐Indigenous population.2 At 15 HOT NORTH forums held over the past 3 years, attended by over 1600 participants in locations from South Hedland to Thursday Island, we provided an opportunity for communities and local health staff to take control over the agenda, presentations and input to discussions. Participation increased, discussions became more interactive, and pride in the achievements of local health practitioners and researchers replaced the deficit data and focus of many previous presentations. The wider benefits of a consultative, locally designed and led health research and capacity‐building program are captured in the recent HOT NORTH impact report.3 While several initiatives have addressed regional and remote health care (eg, the Centre for Research Excellence in Rural and Remote Primary Healthcare, the Advanced Health Research and Translation Centre in Alice Springs, and Centres for Innovation in Regional Health in north Queensland and in regional New South Wales), we agree with Giuseppin that fundamental shifts in the rusted‐on core–periphery relationships are required to address the inequity of health coverage across Australia. However, in Australia (and its universities), this requires recognition of the pervasive dogma of “winner‐takes‐all” urbanism of “superstar cities”4 with their “creative class”,5 which arguably militates against an appetite and capacity for sustainably reshaping the service delivery and research landscape in response to the remoteness, cultures, power relations, social ties and other dynamics in rural and remote settings. Box – HOT NORTH capacity building, collaborations and regional engagement activities 2017–2019

Kevin Williams · Sean Rung · Bart J Currie

To the Editor: In the retrospective study by te Marvelde and colleagues,1 the proportions of men in public and private health services receiving radical prostatectomy and curative external beam radiation therapy were examined in a multivariable logistic regression analysis. However, only age, International Society of Urological Pathology (ISUP) tumour grade, and comorbidity were studied. Prostate‐specific antigen (PSA) level and T stage are two of the strongest determinants of choice of treatment modality in clinical practice and have not been considered or discussed by the authors. We consider this to be a major flaw in this study and a failure of the peer‐review process to highlight this deficiency, which has a significant impact on the results and subsequent conclusions reached by the authors. Furthermore, patient comorbidities have not been adequately accounted for. The authors identify comorbidity as a factor influencing treatment, but they fail to assess and account for this variable in a reliable way. Victorian Admitted Episodes Dataset (VAED) data for the year preceding the prostate cancer diagnosis and up to 30 days after diagnosis were assessed to identify comorbid conditions other than cancer according to the Charlson Comorbidity Index, categorised as 0 or at least 1. This variable provided little discriminatory power (3% v 6%), and yet it was the only surrogate variable that accounted for comorbidity in the study’s key multivariable analyses. Additionally, the odds ratios for this variable in these analyses were not reported. It should be noted that 38% of the study population were men older than 70 years, but only 3.8% scored 1 or more on the VAED‐derived Charlson Comorbidity Index. We believe that the method used in this study to account for comorbidity is not adequately robust to provide an accurate picture of the patients’ general health status. The authors also cite the ProTect trial2 to suggest no major differences between active treatment options exist; however, they did not identify the vast differences in the disease characteristics of men in the ProTect trial compared with those included in their study (77% ISUP 1 and 2% ISUP 4/5 v 35% ISUP 1 and 18% ISUP 4/5). Moreover, te Marvelde and colleagues did not address clinical outcomes and have not presented evidence that the variation in treatment modalities between public and private services has had a negative impact on the final clinical outcome. Outcomes data can be helpful in identifying systematic shortcomings, inequities and barriers to just health care, but the authors missed the opportunity to highlight these issues. They concluded that the treatment of people with cancer should be consistent, safe, of high quality and evidence‐based, but did not provide evidence that the current practice is to the contrary.

Stephen Mark · Prem Rashid · Peter Heathcote · Kamran Zargar Shoshtari

To the Editor: Improving our understanding of the place of computed tomography (CT) coronary calcium scoring in the assessment of cardiovascular disease risk is critical. However, we disagree with the conclusions in the article by Venkataraman and colleagues1 that the results of their study support the use of CT coronary calcium scoring in individuals with intermediate risk using the Australian cardiovascular disease risk (ACVDR) calculator. Unfortunately, the study has significant flaws in its outcome measures — CT coronary artery calcium scoring and Multi‐Ethnic Study of Atherosclerosis (MESA) — which result in misleading conclusions. The authors examined the predictive power of the ACVDR to detect individuals having a calcium score greater than zero or greater than 100. However, since CT coronary calcium scoring is not a reference standard for cardiovascular disease, this is an invalid outcome for estimating the comparative accuracy of the various cardiovascular disease risk scores. This study also used the MESA risk score as an outcome measure, although this is a risk calculator that has not been validated in the Australian population. As the MESA score was developed to include CT coronary calcium scoring, any risk calculator that also includes this score is likely to appear to perform better than risk calculators that do not. The authors state that their “findings suggest that Australian patients are undertreated by international standards”. The threshold recommended by the current guidelines for cholesterol‐lowering medication in the United States — used by the authors as the international standard — would more than triple the proportion of the Australian population recommended to take medication.2 Primary prevention of cardiovascular disease involves individuals who have not yet had a cardiovascular event, making it particularly incumbent on medical professionals that recommendations consider benefits and harms. The information gained from CT coronary calcium scoring needs to demonstrate that benefits outweigh risks, such as radiation exposure, costs, and incidental findings. Trials to date have shown no improvements in health outcomes. Overall, patients are more likely to be reclassified in a higher risk category, some correctly, but higher absolute numbers may be incorrectly reclassified as high risk.3 Individuals with a calcium score of zero are still at risk of cardiovascular disease, about 0.5% per year. The notion that images seen on CT coronary calcium scoring demonstrate the presence or absence of disease is appealing, but it is a gross simplification.4 While CT coronary calcium scoring may have a place in risk assessment, the findings from this study do not support its use.

Andrew Hayen · Paul P Glasziou · Jenny A Doust

To the Editor: Modelling commissioned by the federal government estimates that the fertility rate in Australia will drop to an all‐time low of 1.59 babies per woman in 2020–21.1 However, anecdotal observation suggests this projection does not reflect the apparent increase in current bookings for antenatal appointments in our (public) practice. Therefore, we reviewed the use of the five Medicare Benefits Schedule (MBS) item numbers for “microbiological serology during a pregnancy” (ie, 69405, 69408, 69411, 69413 and 69415), as one of these numbers is usually billed at the first antenatal visit. In June 2020, the use of these item numbers increased by 25.4% and later declined to a 9.6% increase in September 2020 compared with September 2019 (Box).2 In the period from 2018 up to the start of the coronavirus disease 2019 (COVID‐19) pandemic, the mean fluctuation in billing volume in the same months over different years was about 3% less or more.2 Therefore, the larger than expected surge in antenatal serology orders since the start of the COVID‐19 pandemic likely represents a significant change in behaviour. Furthermore, this increase in serology testing is on the background of an approximate 3% decline in services for pathology tests not related to COVID‐19 from June to September 2020 compared with the same period in 2019.2 Using MBS item numbers as a surrogate for pregnancy‐related appointment bookings has limitations. In general, women accessing public hospital care may have serology tests done as part of state government funding schemes whereby no MBS item is generated. We cannot exclude the possibility that, in the context of changes related to the COVID‐19 pandemic and a move to telehealth, a higher proportion of women may have had pathology tests done via Medicare. However, it would be expected that if fertility were declining, there would have been a reduction in testing. Furthermore, we were unable to exclude repeat testing, although our experience indicates this would account for an insignificant number of tests. This historical trend, and its context in the timing of an apparent “baby boom” (ie, antenatal serology testing is usually done at around 6–10 weeks’ pregnancy), correlates with an increase in conception starting in late March to early April 2020, during the so‐called first wave of COVID‐19 in Australia. Requests for antenatal serology testing increased by 12 869 from June to September 2020 compared with the same period in 2019 (Box). Factoring in miscarriages, this may mean there will be an additional 11 000 Australian babies born in the third quarter of the financial year 2020–21 compared with the same period in the previous financial year. We believe it is unlikely that fertility rates will drop in 2020–21. Box – Combined Medicare Benefits Schedule (MBS) services for item numbers 69405, 69408, 69411, 69413 and 69415 Month Number of MBS services Variation 2019 2020 June 21 883 27 441 +25.4% July 23 867 26 935 +12.9% August 25 118 27 055 +7.7% September 23 929 26 235 +9.6% Total 94 797 107 666 +13.6%

Len Moaven · James Brown

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has created an unprecedented need for real‐time surveillance data to inform decisions and action by public health responders and primary health care practitioners. Early in the pandemic, many countries swiftly produced interactive national dashboards with mapping capabilities.1,2 A dashboard is an online tool for data management which optimises information access and data visualisation.3 Dashboards provide benefits compared with standard reporting, including sharing near real‐time data during rapidly evolving situations, and providing users with the opportunity to interact with the data. If designed appropriately, users can also interrogate data and ask questions based on their specific informational needs. Many dashboards also provide mapping capabilities, allowing for visualisation of spatial distribution of information, and monitoring trends geographically over time.2 Australia does not yet have an official and publicly accessible national interactive dashboard for COVID‐19. Some states and territories have developed publicly available COVID‐19 dashboards, but data are generally aggregated, making it difficult to answer specific questions that include time and location and source of infection. An interactive near real‐time dashboard could improve access to and comprehension of data for primary health care providers and public health responders. Researchers from the Australian National University, Menzies School of Health Research and the University of Queensland are developing a COVID‐19 Real‐time Information System for Preparedness and Epidemic Response (CRISPER) (https://crisper-graphc.hub.arcgis.com/) as a nationwide information and visualisation system for Australia. CRISPER aims to become the principal source of accurate, reliable and spatially explicit real‐time information for COVID‐19 (Box). The system currently uses publicly available postcode‐level data, primarily from state and territory health department websites. Gaining access to nationwide line‐listed data is underway, which will allow additional functionality, including a clinical dashboard detailing clinical outcomes (eg, hospital and intensive care unit admissions, deaths) stratified by demographics, comorbidities, time and place. Also under development is an automatic alert system providing registered users with daily or weekly email alerts on new cases, contract tracing alerts and/or testing rates based on user‐defined geographical areas of interest. We believe that CRISPER will improve accessibility of information for primary health care practitioners and public health responders and will enable them to make more timely and informed decisions. This system may serve as a prototype platform for rapid information sharing for other epidemic‐prone diseases. Box – Features of the Coronavirus Disease 2019 (COVID‐19) Real‐time Information System for Preparedness and Epidemic Response (CRISPER) CRISPER aims to optimise information access and visualisation for COVID‐19 through: a national summaries dashboard detailing cases, deaths and testing — information can be filtered or summarised by states and territories, time periods, and 7‐ or 14‐day rolling averages (https://graphc.maps.arcgis.com/apps/opsdashboard/index.html#/465d9e0cd44247b488b8431a56691417); and an interactive mapping tool of cases, testing and contact tracing alerts by location (postcode, local government areas, public health units) — information can be filtered by time periods and source of infection (currently available for New South Wales). A key feature distinguishing this tool from other dashboards is that the data in the different components are linked; for example, the epidemic curve is dynamic based on cases in the map window (https://graphc.maps.arcgis.com/apps/opsdashboard/index.html#/74e69c2ab40f41c892a652e95373622c)

Emma Field · Amalie Dyda · Colleen L Lau

To the Editor: We thank the MJA for highlighting the fit testing of N95 or P2 respirators in Australian health care workers. Regli and colleagues1 make a compelling case that mandatory fit testing should be implemented in Australian hospitals for frontline staff, in line with South Australian guidelines.2 We note that NSW Health has recently implemented mandatory fit testing in high risk areas.3 We commend these efforts, but they may have important implications that would need planning and consideration in implementation. First, it is clear that anatomical variation of the nasal and malar regions means that some health care workers will only pass the fit tests with particular N95 or P2 respirators.4 This means that along with the implementation of a fit testing program, inventory management systems are also required to facilitate hospital tracking of stocks of particular respirator types and to ensure that sufficient stock is available in high risk areas for individual health care workers. At the Southern Adelaide Local Health Network, we have implemented such a system, which tracks stock levels of all available respirators within the hospital so that key workers who can use only specific types of N95 or P2 respirators will have access to the right type of mask when needed. Second, the coronavirus disease 2019 (COVID‐19) pandemic has disrupted global supply chains, affecting the availability of N95 and P2 respirators. Moreover, fit testing is not a one‐off process, but must be conducted as a rolling program to ensure that all workers have access to appropriately fitting N95 or P2 respirators. Finally, even with an efficient fit testing program, due to anatomical variations, there will always be a proportion of health care workers for whom no masks will be suitable. Along with fit testing, health departments should prioritise health care worker redeployment policies and the development of new technologies to address the needs of the proportion of the workforce with ongoing fit test failure.

Anand Ganesan · Jane Parker · Darius Chapman

To the Editor: In an article on the Human Rights Act 2019 passed by the Parliament of Queensland, Brolan1 noted the Act was “historic but not without challenge”. This challenge is manifest in the case of prisoners. In 2007, the Queensland Coroner recommended prisoners have access to clean injecting equipment.2 We described in 2009 the threat to prisoners’ health of ongoing breaches in infection control,3 which was later evident in the cluster of coronavirus disease 2019 (COVID‐19) cases in the Wacol Youth Detention Centre in Brisbane. In 2018, The Medical Journal of Australia documented the precarious state of harm minimisation in Australia’s prisons. With reference to Queensland, there was only mention to the elimination of hepatitis C infection from one prison and the fact that opiate replacement therapy was not available to all prisoners.4 Furthermore, despite some initial success to improve hepatitis C infection rates among Queensland prisoners,5 they have gone backwards, with reportedly high rates of post‐treatment reinfection in Queensland prisons. How is it possible that Queensland continues to stand out as a model of health service deprivation? Evidence that opiate replacement therapy can be life‐saving for prisoners is conclusive.6 Human rights are universal. The right to health provision and health protection cannot be, and in fact has not yet been, effectively negotiated for or by the community’s most disempowered individuals. Despite human rights protections since 2004, the Australian Capital Territory’s dismal experience7 challenges not just Queensland but all Australians.

Michael Levy · Daniel Mogg

To the Editor: In their observational study, Kimmel and colleagues1 examined the impact of inpatient rehabilitation (IPR) for isolated lower limb injuries on functional outcomes in working‐aged people using inverse probability of treatment weighting (IPTW) propensity score analysis. It concerns us that the study lacks real clinical perspectives in disability management. Firstly, the authors assumed exchangeability in the baseline characteristics of patients discharged home and patients admitted to IPR. Exchangeability of the samples is a prerequisite for IPTW propensity score analysis.2,3 However, this is a flawed assumption in the Australasian context, where patients discharged home are medically stable, have minimal physical disability and have sufficient psychological coping skills. In contrast, patients admitted to IPR are deemed unsafe to be discharged home, with greater disability, home hazards, or inadequate support. IPR addresses complex therapy and care needs while alleviating pressure on acute beds. Secondly, the study examined disability and returning to work without considering all relevant determinants of health and functioning as listed in the World Health Organization’s International Classification of Functioning, Disability and Health. Rather than IPR resulting in a poorer functional outcome through hospital‐related complications, it is our experience that persons who require IPR will have a higher physical, functional, psychological, personal and social complexity or vulnerability, which may result in the observed long term disability. Thirdly, the study identified adverse 12‐month outcomes in patients discharged home. This control group were physically and functionally fit for discharge home, but 67% reported suboptimal recovery on the extended Glasgow Outcomes Scale (GOS‐E) and 16% failed to return to work at 12‐month follow‐up. Given that return to previous jobs plateaus by 6–12 months,4 gaps in care may aggravate problems by preventing timely access to multidisciplinary interventions to address the medical, psychological, physical, occupational and social impact of a traumatic injury. Finally, we encourage the authors to present the 12‐month follow‐up data in the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) for pain scores, anxiety and/or depression, and other domains of the EuroQol EQ‐5D‐3L Scale.4 Pain perception and depressive symptoms are known predictors for functioning and returning to work following an orthopaedic trauma and likely confounded the results.5

Pearl Chung · Mark Haran

To the Editor: In a recent letter published in the MJA, Muhi and colleagues1 reviewed the source of acquisition by 11 health care workers with coronavirus disease 2019 (COVID‐19) who presented for symptomatic screening at a single clinic. Travel and transmission outside the workplace were considered the likely source of infection for most of them. Data on COVID‐19 cases collected for public health purposes in Western Australia up to 1 June 2020 were reviewed to inform local public health strategies to protect health care workers. Fifty‐seven cases of COVID‐19 among health care workers or workers in health care settings with direct patient contact were identified. Fifty‐six cases were confirmed by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) polymerase chain reaction (PCR) test, and one case had positive SARS‐CoV‐2 IgG serology indicating past infection. Thirty‐one health care workers acquired their infection from a cruise ship or overseas, and 26 health care workers acquired COVID‐19 within Australia. The likely source of the 26 locally acquired cases is shown in the Box. Ten health care workers acquired the infection in the workplace. A further eight had no known contact with a COVID‐19 case but worked during their incubation period. These health care workers may have acquired the infection from an unidentified patient with COVID‐19, from another health care worker, or via fomite transmission at work. Extensive contact tracing did not reveal an alternate source in a setting of limited community transmission. Where possible, whole genome sequencing was used to substantiate epidemiological findings. Transmission of COVID‐19 occurred between health care workers, emphasising the need for staff to recognise not only the risk from patients but also from colleagues, where use of personal protective equipment and physical distancing may be relaxed. There were no cases among staff in COVID‐19 clinics, suggesting that the use of personal protective equipment does mitigate risk. Workplace fomite transmission was the putative source on three occasions, which reinforces the importance of regular environmental cleaning, rigorous cleaning of shared equipment, and good cough etiquette and hand hygiene practices within health care facilities. Our review describes a larger cohort of COVID‐19 cases among health care workers, encompassing metropolitan and regional settings. With international travel restrictions, an increasing proportion of locally acquired infections among health care workers may be expected. From this analysis and others,2 colleagues and fomites should be recognised as potential workplace sources of infection, in addition to direct patient contact. Box – Likely source of coronavirus disease 2019 (COVID‐19) infection for locally acquired cases by Western Australian health care workers (HCWs) Source of infection Cases Direct HCW to HCW transmission 7 Likely fomite transmission 3 Unknown, but worked during incubation period* 8 From a close contact outside of work 5 Contact not identified, but interstate travel 3 Total 26 * No alternate source of infection identified in the context of limited community transmission.

Rebecca J Hogan · Suzanne McEvoy

To the Editor: The clinical trial landscape has arguably progressed more in the past 6 months than in the previous 10 years. The needs of humanity in the global pandemic catalysed the necessity to evaluate study design, implementation, governance, technology and collaboration. The race for effective therapies and a vaccine highlighted the need to expedite drug development and approval. While clinical trials in oncology have used master protocols for many years, with clear guidance from regulatory authorities1 and a gradual adoption in other therapeutic areas,2 these have become the blueprint for coronavirus disease 2019 (COVID‐19) clinical trials developed by the World Health Organization, ensuring the ability to test a broad range of therapies. COVID‐19 has also triggered the adoption of technology to support trials, accelerating the move to a digital age of clinical trials.3 Platforms to deliver online recruitment, electronic consent, wearable devices, artificial intelligence and electronic systems for source data and regulatory documents now provide the solution to maintaining clinical trials activity, at a time when restrictions challenge the viability of face to face trial operations. The need for comprehensive, integrated electronic medical records is evident, with enduring access for parties for data verification, but raises issues of access, privacy and cybersecurity. Out of necessity, clinical trials have also adopted teletrials, like the need in medical practices to adopt telemedicine,4 resulting in a dispersed, decentralised model of operation. The pressure to adapt clinical trial delivery has seen previously perceived barriers fall away. By focusing on common goals, collaboration, technology, and building solid foundations to evaluate our progress to ensure research integrity and safety, a new era of clinical trials will unfold. The clinical trials team of the future will evolve, incorporating a core team with information and communication technology capabilities to support training, management and development of trial systems in a networked model of delivery. While this is a welcome push into a new technological era, with an opportunity to retain new elements and abandon outdated models, we must proceed with thoughtful consideration and evaluation of our progress.

Alana Sarah · Olivia Dean · Michael Berk

To the Editor: Despite death being common in aged care, bereavement support for family and others is not part of care.1 In contrast, palliative care inherently extends to the patient’s family members, including after death.2 Coronavirus disease 2019 (COVID‐19)‐related deaths in aged care have left many families bereft. This is a consequence of forced separation in the final stage of life, the family member being transferred to an acute hospital, the question of whether the patient died alone, and limitations on traditional rituals and practices surrounding funerals.3,4 Like many community palliative care services, Melbourne City Mission’s Palliative Care (MCMPC) services have a well established aged care consultative team that provides advice on complex end‐of‐life issues. At the beginning of the COVID‐19 pandemic, MCMPC started to receive referrals for bereavement support — rapid referrals for residents in aged care facilities in the terminal phase of illness to speak with their families both before and after the patient’s death. Examples of catastrophic grief resulting from the COVID‐19‐related deaths in aged care facilities overseas prompted MCMPC’s preparation to respond to traumatised relatives.5 This work simply involved a phone call to families after the patient’s death. What was heard was sobering, summed up by one family member as “it was not meant to be this way”. Families expressed disappointment that the resident had contracted COVID‐19, stating they should have been safe in their home. The bereaved spoke of their enormous loss, having not been able to be with their loved one, in some cases, for a period of over 7 months. While most families were realistic about the frailty of their family member, they also said that “it was not their time,” that COVID‐19 unfairly changed the trajectory of how they expected their last days or months to go. Palliative care has much in common with aged care, notably the care of patients who are facing the final stage of their life. For staff it has been important to give each bereaved person a chance to capture their individual story, to give identity to the person who died, so they are not just another of the many deaths in aged care. In validating family members’ experiences, this simple phone intervention may mitigate poor bereavement outcomes5 by providing a space to honour their loss.

Margaret O’Connor · Bronwyn Wilson

To the Editor: Public health strategies to control coronavirus disease 2019 (COVID‐19) in Australia aim to test, identify and isolate all cases including those among children.1 We investigated the intended actions of parents if their child developed COVID‐19 symptoms, such as a runny nose, sore throat, cough, fever, chills, loss of smell, diarrhoea, and/or nausea and vomiting.1 We collected data during 15–23 June 2020 via an online survey of 1834 Australian parents of children aged 3–17 years who attended childcare, kindergarten and/or school.2 The sample was limited to these respondents as one of our objectives was to test if children would be kept home from childcare and/or school (isolate). The questionnaire was administered by a private vendor as part of the Royal Children’s Hospital National Child Health Poll, a recurring periodic online survey. Participants were randomly selected from a representative consumer panel of over 350 000 Australian adults — who were recruited onto the panel via online and offline methods such as door knocking, phone calls, letters etc — using quotas to achieve a nationally representative sample reflective of age, sex and state populations. The sample size was justified based on the commonly used margin of error of 3% for estimating a proportion. Only one parent per household could complete the questionnaire and households were not permitted to participate in more than one poll. Participants had no direct contact with the research team. Responses were voluntary and anonymous. Respondents were incentivised for participation in the form of points towards shopping gift cards. The study protocol was approved by the Royal Children’s Hospital Human Research Ethics Committee (RCH HREC 35254). Intended actions of parents if their child developed possible COVID‐19 symptoms are presented in the Box. We classified parents as “seeking COVID‐19 test or medical advice” or not. The sample characteristics are presented in the Supporting Information. We found that 1458 of 1834 parents (78.95%, weighted) of children with symptoms compatible with COVID‐19 intended to seek a COVID‐19 test for their child. There is little published research exploring why some parents may not present children for COVID‐19 testing. A recent Australian study has identified barriers to testing among adults, including a belief that testing is painful, a lack of knowledge about how to get tested, and worry about getting infected at the testing centre.3 These barriers may also apply to parents in relation to testing for children. Additional barriers may include financial implications of time off work to take a child for testing and fear of the social stigma associated with a diagnosis of COVID‐19.4 As upper respiratory tract infections are common among children and often present with similar symptoms to COVID‐19,1 parents may misattribute possible COVID‐19 symptoms to the common cold. Messages from governments may be unclear and parents may not believe that general directives apply to children.5 Timely testing is a critical aspect of containing the pandemic in Australia. With one in five parents indicating they would not present their symptomatic child for COVID‐19 testing, further research is urgently needed to identify and understand barriers to testing in order to inform targeted strategies and messaging to enhance testing uptake in children. Box – Intentions of parents if child developed symptoms compatible with coronavirus disease 2019 (COVID‐19), Australia, 2020 Number (%)*† Keep child home from school or child care until all their symptoms have gone 991 (53.22%) Take child to a doctor (GP or hospital) for a COVID‐19 test 810 (44.66%) Keep child home from school or child care for a couple of days 672 (36.34%) Call the GP for advice 618 (33.62%) Take child to a COVID‐19 testing centre 452 (23.33%) Call the COVID‐19 hotline for advice 415 (22.69%) Send child to school or childcare if they seem well enough 47 (2.66%) Not sure what to do 34 (1.73%) Take child for test‡* 1458 (78.95%) GP = general practitioner. * The cumulative percentage is greater than 100% as respondents could select more than one option. † The sample was nationally representative in terms of the distribution of national resident population by state; however, the distribution of parent sex by state and socio‐economic status was slightly over‐representative of female and more advantaged residents (Supporting Information). Hence, the data were weighted by state, sex and the Index of Relative Socio‐economic Advantage and Disadvantage (IRSAD). ‡ “Take child for test” was defined as at least one of the following options: take child to doctor or testing centre for a test, call GP for advice or call the COVID‐19 testing centre.

Mary‐Anne Measey · Monsurul Hoq · Anthea L Rhodes

To the Editor: The Coroners Court of Victoria made several recommendations in 2020 after a 38‐year‐old man died alone at home.1 The cause of death was determined to be sepsis in the setting of an adrenal crisis. The key coronial recommendations1 were to emphasise to the general medical community the non‐specific nature of symptoms of impending adrenal crisis (eg, fatigue, nausea, loss of appetite, vomiting),2 to record the diagnosis of adrenal insufficiency prominently as an alert in medical records,3 and to encourage endocrinologists to provide sick day or steroid stress dosing letters to patients, general practitioners, and family members and carers. The Endocrine Society of Australia (ESA) endorses these recommendations. A standard patient letter has been developed and is now available on the ESA’s Hormones Australia website.4 We strongly support medical record alerts for the diagnosis of cortisol deficiency due to Addison disease or hypopituitarism. It is crucial for doctors to have a high index of suspicion for the possibility of impending adrenal crisis in a patient with known adrenal insufficiency. The clinical syndrome evolves from acute adrenal insufficiency with symptoms of malaise, nausea and lethargy — all of which are non‐specific and may be considered part of another pathological process — to adrenal crisis, which is associated with hypotension initially manifest by postural blood pressure falls greater than 20 mmHg.2,3 Prevention involves advice on stress dosing:1 triple glucocorticoid dosing for 3 days (ie, the 3 × 3 rule),2 parenteral hydrocortisone at home (SOLU‐CORTEF Act‐O‐Vial, Pfizer) when unable to take tablets,3 and the availability of personal alerts (eg, a MedicAlert bracelet [MedicAlert Foundation], a steroid card) when the person is delirious or very unwell (Box). The incidence of adrenal crises is increasing in Australia.3 Missed cases or failure to treat them because of overestimation of the risks of glucocorticoid therapy are unfortunately too common. Box – Practical steps to reduce the risk of adrenal crisis Ensure that others are aware of the diagnosis of established adrenal insufficiency Prominent medical alert in GP and hospital medical records Patient carries either a steroid card, which lists diagnosis and glucocorticoid therapy, or uses a MedicAlert bracelet (MedicAlert Foundation) A sick day or steroid stress dosing letter should be provided by the endocrinologist to the patient with adrenal insufficiency, with a copy to their GP Encourage the patient with adrenal insufficiency to provide copies of the letter to their next of kin, close relatives or carer Have a high index of suspicion for an impending adrenal crisis Beware of non-specific symptoms of nausea, vomiting or lethargy in a patient with established adrenal insufficiency Prevent an adrenal crisis in patients with established adrenal insufficiency When unwell, follow the 3 × 3 rule (ie, three times the usual glucocorticoid dose for 3 days) and seek urgent medical attention if not improving Promptly treat an impending adrenal crisis The patient and/or carer should be trained to administer 100 mg SOLU‐CORTEF Act‐O‐Vial (Pfizer) intramuscularly* if vomiting occurs or the patient is unable to swallow tablets GP = general practitioner. * Some authorities recommend the off‐label use of a subcutaneous injection as this is easier for patient and/or carer to administer.

Peter S Hamblin · Bu B Yeap · David J Torpy

To the Editor: Hereditary cancer predisposition syndromes (HCPS) account for at least 10% of paediatric cancers.1 Li‐Fraumeni syndrome (LFS) is a dominant HCPS caused by mutations in the TP53 gene and is associated with an 80–90% lifetime risk of cancer, commencing in infancy.2 Children of affected individuals are at 50% risk of inheriting the family mutation. Surveillance programs, involving clinical review and medical imaging, are being used in paediatric populations with HCPS, as significantly higher overall survival is reported with early tumour detection.3 In 2018, the Paediatric Surveillance Clinic was established at Perth Children’s Hospital to provide surveillance for asymptomatic children with, or at 50% risk of developing, LFS and with other HCPS, and to address the needs of their families. Families with at‐risk children can choose to attend the clinic, allowing them to receive information, support and sufficient time to make a decision regarding genetic testing. The quarterly clinic is in a general paediatric setting and offers surveillance for mutation‐positive children in line with eviQ guidelines — a free resource of evidence‐based, consensus‐driven cancer treatment and genetic testing protocols hosted by Cancer Institute NSW.4 Children at 50% risk of LFS, who have not had genetic testing, receive a six‐monthly clinical review and prompt assessment of any concerning symptoms during the interim period. Over an 18‐month period, the Paediatric Surveillance Clinic has seen 11 children from five families, aged from 3 months to 14 years. Most of these children are at risk of or have a TP53 mutation and one child has a VHL (Von‐Hippel‐Lindau) mutation. The Paediatric Surveillance Clinic offers a holistic service with a multidisciplinary team consisting of a general paediatrician, a paediatric nurse, a paediatric oncologist, a genetic counsellor and a clinical geneticist. The clinic has highlighted the specific and unmet needs of families dealing with HCPS and has allowed for essential integration of genetic, paediatric and oncology services for these families.5 As the number of identified HCPS grows, the Paediatric Surveillance Clinic will continue to offer a flexible service that supports families, assisting with decisions around genetic testing and surveillance for malignancy during childhood and adolescence.

Nicholas Leedman · Murray Princehorn · Nicholas Gottardo · Claire Franklin · Rebecca D'Souza · Catherine E Kiraly‐Borri

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has raised concerns of a subsequent increase in suicides,1 but limited empirical data are available on this topic.2,3 We analysed numbers of suicidal presentations (including suicidal ideation, non‐suicidal self‐injury and suicide attempts) to emergency departments (EDs) within the Gold Coast Hospital and Health Service before and since the spread of COVID‐19 in Queensland, Australia. Cases were identified from ED administrative data through relevant diagnoses, presenting problems and keywords, followed by a manual investigation of triage narratives to exclude false positive cases, such as non‐deliberate injuries or poisonings. The numbers of ED visits between January and August 2020 were compared with the projected numbers, calculated by applying an annual increase of 13.5%4 to presentations during the same period in 2019. From March 2020 onwards, a marked divergence between observed and projected numbers is noted, corresponding to the oscillations in the numbers of diagnosed COVID‐19 cases in Queensland (Box). At the peak of the pandemic, the reductions in suicidal presentations were the largest (29.8% in March and 23.6% in April 2020). Over the next 2 months, daily numbers of diagnosed COVID‐19 cases remained low and the difference between observed and projected numbers gradually narrowed (20.8% in May and 14.6% in June 2020). In July 2020, observed numbers exceeded projected numbers by 11.4%, but then declined again in August 2020, coinciding with another resurgence of COVID‐19. Between March and August 2020, the Gold Coast Hospital and Health Service had 554 less suicidal presentations than expected. The well documented negative impact of COVID‐19 on all aspects of society, including mental health,5 suggests that a substantial reduction of suicide risk during this time is unlikely. Instead, our results may reflect changes in help‐seeking behaviour, with fewer people willing to seek help for suicidality through in‐hospital consultations due to fears of contracting COVID‐19.6 Ongoing promotion of telehealth and enabling safe hospital presentations or alternatives to ED7 is therefore needed to prevent the adverse outcomes of the COVID‐19 pandemic due to delayed access to care. Limitations of this work include potential underestimations of suicidal presentations due to coding issues8 and the inability to differentiate between types of suicidal presentations. Box – Numbers of suicidal presentations to the Gold Coast Hospital and Health Service in 2019 and 2020, and numbers of daily coronavirus disease 2019 (COVID‐19) cases in Queensland, Australia Error ranges for the projected 2020 numbers are 95% confidence intervals.

Jerneja Sveticic · Nicolas JC Stapelberg · Kathryn Turner

To the Editor: Siru and colleagues have raised potential concerns about the strategy recommended by the Australian Diabetes Society (ADS) and other peak bodies to diagnose gestational diabetes (GDM) during the coronavirus disease 2019 (COVID‐19) pandemic.1 In their study, 46% of subjects diagnosed with GDM had a fasting blood glucose level (BGL) < 4.7 mmol/L but elevated post‐load blood glucose levels, and would be missed by the ADS‐recommended strategy. The authors suggested that this exposes women and their newborns to significant risks with the potential for significant harm. No outcome data were provided to justify these assertions. Evidence from the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study suggests that such women do not have increased rates of pregnancy‐associated complications.2,3,4,5 The subgroups with the highest odds ratios for newborns who were large for gestational age had an elevated fasting BGL and any elevation of post‐load BGL (odds ratio > 3), whereas subgroups having only elevated fasting or post‐load BGL had a considerably lower odds ratio, equivalent to the diagnostic threshold for GDM of 1.75.2 Further, women with a fasting BGL < 4.5 mmol/L had low rates of some complications irrespective of their post‐load BGL.3 A subsequent analysis of 6128 patients from five centres involved in the HAPO study did not observe any increase in pregnancy‐associated complications in women with a fasting BGL below the 75th centile (4.6 mmol/L).4 A recent analysis of 5974 women in the HAPO study assessed the ADS‐recommended COVID‐19 GDM strategy and reported no increase in any complication.5 There were fewer cases of pregnancy‐associated hypertension and caesarean delivery, with similar rates of large‐for‐gestational‐age newborns and neonatal hypoglycaemia. These data provide reassurance. There is no evidence of harm. When this strategy is used, women with a fasting BGL < 4.7 mmol/L are spared being labelled with GDM and do not require education, monitoring, more frequent follow‐up or transfer to specialist services, freeing up valuable health care resources. Importantly, they will not be advised to inappropriately restrict their dietary intake or commence therapy with insulin or metformin with the potential for harm. An initial fasting BGL test would eliminate the need for a pregnancy oral glucose tolerance test in the majority of women, identifying a smaller group of women at risk of pregnancy‐associated complications where management can be more appropriately targeted.

Michael C d'Emden · Jacobus PJ Ungerer · Susan J Jersey

To the Editor: We read with interest the analysis and comments by Shand and colleagues.1 The authors show a rise in the dispensing of intravenous iron agents in the period from 2013 to 2017 for women. They suggest that this may be an issue relating to the inappropriate use of this agent. However, we question whether the data can support this suggestion, and feel this should be viewed cautiously because of the study limitations. The study did not examine the reasons for the escalation in prescriptions. The rise in numbers is not surprising. Iron deficiency anaemia is common and undertreated.2 While dietary modifications and oral iron are the first line treatment, oral iron is limited by the high occurrence of side effects in up to 50% of users.3 The new intravenous agents allow a full treatment in one visit — often in primary care — which is safe and effective. The authors are rightly concerned about safety; however, it is reassuring that studies have demonstrated the relative safety of these agents.4 During the study period, ferric carboxymaltose became more widely available, with its listing on the Pharmaceutical Benefits Scheme easing a financial barrier to women who need treatment. A number of education programs and various patient blood management initiatives to detect and treat iron deficiency that occurred during the study period could influence the study findings. A noteworthy activity was the landmark Patient Blood Management Collaborative facilitated by the Australian Commission on Safety and Quality in Health Care.5 The assumption by the authors that the number of women receiving treatment is equivalent to the number of dispensing claims by pharmacy is likely incorrect, as there are situations when an individual can have multiple dispensing claims. The study is timely because it highlights a serious condition affecting a large proportion of Australian women that must be better managed. Despite the various endeavours to improve access to treatment for women, iron deficiency remains undertreated and under‐recognised.

Pradeep Jayasuriya · Toby Richards · Bernd Froessler