Letters

In reply

David J Brewster · Christopher J Groombridge · Jonathan J Gatward

To the Editor: One evening in February 1974, my fellow endocrinologist Don Gutteridge phoned me to tell me about an ABC television program that I had missed. It had featured an interview in Perth with Sir Richard Kirby, recently retired as Australia’s chief judge in industrial relations. He was showing typical signs of advanced thyroid deficiency. He had slow, coarse speech, periorbital oedema, sparse scalp hair, and was “not as sharp as a chief judge should be”. Don had phoned him at his hotel to discuss the diagnosis. The judge’s response was that he did indeed have symptoms including marked cold intolerance and he had coronary artery disease. Don firmly advised him to have his thyroid tested as soon as possible and in addition he wrote to Sir Richard’s Melbourne physician pointing out that caution was needed when starting thyroxine therapy if the patient had heart disease. Later a Christmas card arrived: “Sincere thanks for a timely telephone call and advice to an old stager who was in need and did not know it … I’m on the treatment and ever since have been a younger, newer and better man.” The before‐and‐after photographs in Blanche d’Alpuget’s biography of Sir Richard1 show a marked improvement in his appearance (Box). He had been unwell for years. Two cardiologists had advised him to retire in 1969. By 1971, he was spending most of his time at his home in Berrara, NSW, feeling ill and sluggish despite a rigorous diet, no cigarettes and almost no alcohol. The story did not end there. In 1979, Don was invited to Sydney to appear on Channel 7’s This is your life television program featuring Sir Richard (https://www.fwc.gov.au>file>your‐life‐sir‐richard‐kirby). “I always saw you with a halo” enthused Sir Richard, sizing up the tall and rangy dark‐haired young doctor, “but I thought you must be an old bloke like me.” Others on the show included Bob Hawke, then President of the ACTU, past Prime Minister Gough Whitlam, and many legal colleagues. Kirby served on three Royal Commissions. He assisted in the mediation of Indonesian Independence from Dutch rule for the United Nations, and he negotiated equal pay for Aboriginal stockmen. His passion to achieve equal pay for women could have been his greatest legacy had bad health not intervened. An undiscovered thyroid deficiency may well have altered the course of Australian industrial relations. Within a month of being treated with thyroxine, Kirby looked and felt better than for almost a decade. He died 27 years later in 2001 at the age of 97. The insidious and subtle onset of hypothyroidism can easily be overlooked by patients, relatives and doctors. Screening for thyroid‐stimulating hormone levels will ensure that an important diagnosis is not missed. Any suspicious symptoms should lead to a careful examination to identify the end‐organ signs of thyroid deficiency, including the slow relaxation phase of tendon reflexes, coarse dry skin, cool extremities and a hoarse voice.2 Box – Sir Richard Kirby before (A) and after (B) treatment for hypothyroidism

Timothy A Welborn

To the Editor: Cardiac injury has been reported in about 20% of patients with coronavirus disease 2019 (COVID‐19) admitted to hospital.1 Elevated troponin is associated with higher complications and death rates.2,3 We report our experience in managing the cardiovascular care of all patients with COVID‐19 admitted to our 783‐bed quarternary hospital in Perth between 1 February and 1 May 2020. The hospital approved the data collection for a clinical quality improvement audit and provided an exemption from ethics review and approval to publish the results. Patients with COVID‐19 with an abnormal electrocardiogram (ECG) showed markers of increased disease severity, had a longer hospital stay and intensive care unit (ICU) admission. Eighteen patients (11 males), with a mean age 59 years (standard deviation [SD], 18), were admitted for a mean 14 days (SD, 15) with symptoms of cough (78%), fever (72%), dyspnoea (61%), fatigue (44%), chest pain (22%), and presyncope (5%). The mean presentation was 6 days (SD, 4) from onset of symptoms. Eight patients required admission to the ICU, and we recorded no deaths. The comorbidities included obesity (four patients), ischaemic heart disease (two patients), diabetes mellitus (four patients), and hypertension (six patients). Cardiac investigations included ECGs (72%), high sensitivity troponin (67%), brain natriuretic peptide (7%), and echocardiogram (6%). Upon admission, eight patients (63%) had an abnormal ECG, which included PR depression, biphasic T waves, PR prolongation, Q waves, ST elevation, atrial flutter, right bundle branch block, and atrial trigeminy. Two patients had elevated troponin. All brain natriuretic peptide and echocardiogram results were normal. Patients who did not have an ECG had low risk markers for disease severity. Patients with a normal ECG had a mean heart rate 84 beats/min (SD, 11), mean QRS duration 92 milliseconds (SD, 9), and mean QTc interval 414 milliseconds (SD, 59) compared with patients with abnormal ECGs, who had a mean heart rate 93 beats/min (SD, 11), mean QRS 96 milliseconds (SD, 18), and mean QTc 400 milliseconds (SD, 110). Seven patients had repeat ECG during their admission. Five patients developed new abnormalities on follow‐up ECGs, including transient ST elevation, sinus bradycardia, junctional rhythm, atrial fibrillation, and complete heart block. Our data show a consistent trend of increased disease severity in patients with abnormal admission ECG (Box). Patients with abnormal ECG required longer hospital admission (61% longer), double the incidence of documented arrhythmias, and double the requirement for oxygen, ventilation and inotropic support. Measures of significant inflammatory response (ferritin, C‐reactive protein, D‐dimer) were markedly higher in patients with abnormal ECG. Half of the patients developed an abnormal rhythm during admission: complete heart block (one patient), supraventricular tachycardia (one patient), atrial fibrillation (three patients), sinus tachycardia (three patients), and sinus bradycardia (one patient). Cardiac procedures performed were transesophageal echocardiogram/cardioversion (one patient), and pacemaker implantation (one patient). Our limited experience suggests an ECG may be helpful in prognostication and triaging of all patients with COVID‐19. An abnormal rhythm may arise from cardiac stress due to cytokine response, direct myocardial viral injury, or physiological strain from multi‐organ injury. Pulmonary injury from pneumonia, acute respiratory distress syndrome and pulmonary emboli can lead to significant right ventricular strain that predisposes to arrhythmia. Sepsis, and related cytokine response, is associated with atrial fibrillation. Myocardial inflammation and subsequent scarring can lead to ventricular arrhythmia and conduction disorders. ECG is a low cost test that can be performed easily and rapidly with minimal risk of viral exposure to staff. ECG should be an essential test in the COVID‐19 pandemic. Box – Characteristics of patients with coronavirus disease 2019 (COVID‐19) admitted to hospital Total Abnormal ECG Normal ECG No ECG Total number of patients 18 8 5 5 Age (years), mean (SD) 59 ± 19 67 ± 14 52 ± 15 53 ± 24 Admission (days), mean (SD) 14 ± 15 21 ± 19 13 ± 11 3 ± 2 Ferritin (μg/L), mean (SD) 1594 ± 1658 2328 ± 2141 1089 ± 620 970 ± 1206 Creatinine (μmol/L), mean (SD) 103 ± 64 110 ± 71 86 ± 33 110 ± 82 CRP (mg/L), mean (SD) 166 ± 165 255 ± 198 124 ± 108 39 ± 42 D‐dimer (mg/L), mean (SD) 4.17 ± 6.23 7.03 ± 8.29 1.99 ± 1.39 0.64 ± 0.42 Arrhythmias 9 7 < 5 na Number of patients requiring oxygen 10 6 < 5 < 5 Oxygen use (days), mean (SD) 19 ± 14 23 ± 15 15 ± 11 4 ICU admission (days), mean (SD) 19 ± 11 23 ± 11 12 ± 9 Nil Ventilation (days), mean (SD) 14 ± 10 18 ± 10 7 ± 5 Nil Inotropic support (days) mean (SD) 13 ± 12 18 ± 12 5 ± 6 Nil CRP = C‐reactive protein; ECG = electrogardiogram; ICU = intensive care unit; na = not applicable; SD = standard deviation.

Kaitlyn Lam · Sarah McClelland · Michael J Dallo

To the Editor: The recently published article by McAlister and colleagues1 highlights the importance of health care organisations becoming aware of their environmental impact. However, there are several misconceptions inherent in the analysis. The first misconception is that pathology organisations may not be aware of their environmental responsibility. The available literature describes how laboratories can reduce their impact2 and, in addition, some laboratories have ISO 14001 certification, which demonstrates their compliance with international standards of environmental performance, efficient use of resources and reduction of waste. The second misconception in the analysis is that pathology testing produces a significant carbon footprint compared with other health care activities. Data from the British National Health Service show that indicative carbon emissions from inpatient admission, additional bed‐day stay, and outpatient appointments are about 380, 80 and 50 kg carbon dioxide equivalent (CO2e) emissions respectively, compared with 82 g CO2e for a haematology test.3 The highest emissions were associated with the consumables used in the collection process or the transport of the reagents from the overseas manufacturer to the laboratory. The third error is that there is significant overutilisation of pathology tests. While there is some overtesting,4 considerable evidence also shows widespread underutilisation of testing.4,5 A 15‐year meta‐analysis identified that, on average, the rate of pathology testing overuse was 20.6%, but the underuse was 44.8%.4 It is noteworthy that a 2018 systematic review and meta‐analysis found significant overutilisation in diagnostic imaging.5 It is essential that all organisations reduce their environmental footprint. Health care organisations must ensure they achieve this goal without compromising patient care. Focusing on carbon emissions for phlebotomy without understanding the role pathology testing plays in early diagnosis and monitoring of disease may lead to more expensive interventions, poor patient outcomes, and a greater impact on the environment.

Tina Yen · Tony Badrick

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has highlighted the need for accessible information for people with disability during public health crises. Accessible information — including Easy Read, Auslan, large print, Braille and audiovisual formats — is a human right.1 Such information is critical for people with disability to understand public health crises and know how to remain safe and access support. These needs are important, particularly given that people with disability commonly have underlying health conditions that may make them vulnerable to public health risks,2 are subject to service systems that may enhance their exposure to infection,3 and often face entrenched system‐driven inequalities, such as being excluded from health prevention and response actions.4 In Australia, accessible information is provided by governments, specialist information access agencies, disability advocacy groups, and service providers. As these groups have provided information about COVID‐19, lessons have emerged for informing better practice during future crises.5 To be appropriate for a public health crisis, accessible information must be: Accurate and of high quality — the information needs to be correct and sufficiently accessible. This requires collaboration between medical professionals and information specialists. Timely — delays in producing accessible information are common, but dangerous. Kept up‐to-date — producing accessible information that is never revised is inappropriate when the details of a crisis are constantly changing. Provided in sufficient detail and breadth — just as the rest of the population needs to know about many different aspects of a crisis, so do people with disability. Resources with a range of subtopics are required. Produced with people with disability — including people with disability in producing the information will ensure it is useful to and accepted by them. Disseminated appropriately — people with disability need to be able to access information through agencies they trust, as well as news media and governments. Where applicable, hard copies should be available, not only online.

Ariella Meltzer

To the Editor: The MJA and Madden and colleagues1 display foresight and leadership in advocating for a transition to environmentally sustainable health care. The current coronavirus disease 2019 (COVID‐19) pandemic exposes dual sustainability challenges: uncertain provision of personal protective equipment (PPE) in the face of a fractured global supply chain and burgeoning waste from single‐use materials. Australia has an opportunity to respond to both challenges by accessing local capability and switching to reusable PPE as appropriate. An apt place to begin is PPE gowns. Personal experience at an Australian hospital in March 2020 saw intensive care of one patient with COVID‐19 requiring more than 50 single‐use gowns during a 24‐hour period. This quantum highlights the need to reconsider the source and composition of PPE materials. The National Health and Medical Research Council (NHMRC) guidelines2 state that gowns should be impervious to fluid, with no standards or levels applied. The oft‐used system from the American Association for the Advancement of Medical Instrumentation (AAMI) grades gowns, single‐use or reusable, within a range: level 1 being splash‐resistant, and levels 2–4 being impervious to water columns placed upon them of 20, 50 and 100 cm respectively.3 Application of these levels is at the discretion of Australian health care providers, rather than mandated in the NHMRC guidelines. Fluid impervious level 2 provides an ample barrier to respiratory‐borne pathogens. A transition to reusable level 2 gowns, when appropriate, provides an opportunity to reduce waste because they can be repeatedly sanitised by clinical laundry practice (detergent and > 60°C hot water). One reusable gown has been estimated to replace 50 disposable gowns.4 By way of reducing reliance on distant supply chains, Australia currently has capacity to mill the fabric and manufacture reusable fluid impervious level 2 gowns today, and these gowns could be registered by the Therapeutic Goods Administration. Current experience suggests policy makers and clinicians are unaware of this possibility. The perception that single‐use is the best choice indicates education is needed to assure clinicians that reusable gowns can provide at least equal protection for many clinical and intensive care unit tasks (severe acute respiratory syndrome coronavirus 2 [SARS‐CoV‐2] endures less on cloth than plastic).5 Activating local manufacture of reusable gowns would assure availability and potentially provide more environmentally and financially sustainable health care, while maintaining patient care and staff PPE supply.

Forbes McGain · Meriel Chamberlin · Jane Milburn

To the Editor: Health care workers are at occupational risk of contracting coronavirus disease 2019 (COVID‐19) and may act as vectors of transmission. The guidelines from the Department of Health prioritise health care workers as a risk group for diagnostic testing.1,2 After confirmation of diagnosis, in addition to resolution of symptoms, polymerase chain reaction (PCR) negativity on at least two consecutive respiratory specimens collected 24 hours apart and at least 7 days after symptom onset was required before health care workers were permitted to return to work.1,2 Since 10 March 2020, there have been 11 health care workers managed at our hospital diagnosed with mild COVID‐19 not requiring hospitalisation, with repeated specimens tested by PCR (Box). All patients with COVID‐19 assessed and managed at the Austin Hospital were prospectively included in a clinical database approved by the Austin Health Human Research Ethics Committee (database reference number: CD 20002). The median time from PCR positivity to the second negative swab was 32.5 days (range, 11–53 days). None of these health care workers received any specific antiviral or immunomodulatory treatment. Our current understanding of the viral kinetics in COVID‐19 is incomplete. Pharyngeal viral shedding is very high early in the course of illness3 and may be prolonged.4 However, nucleic acid detection cannot differentiate between infectious and non‐infectious virus. In a study of nine patients with mild COVID‐19, severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) was not recoverable by culture after day 8 of illness despite high viral loads by PCR.3 In another contact tracing study, there were no secondary cases in the group that was exposed after 6 days.5 These findings suggest that infectivity and transmissibility is low after the initial illness. In Australia, although there was allowance for the return to work of health care workers with prolonged PCR positivity, this was predicated on rounds of testing in what was assumed to be a “small proportion of people”.1,2 Culture for viable virus is not readily available. The findings in our cohort indicate that persistent positivity is the norm and is in line with international studies.4 Current guidelines for health care workers’ return to work appear conservative, with significant workforce implications if outbreaks were to occur in health care settings. Further studies are urgently required to determine the infectivity in patients with prolonged SARS‐CoV‐2 viral shedding to find a balance in policy that benefits health care workers, hospitals and patients. Box – Health care workers with mild coronavirus disease 2019 (COVID‐19) Patient number Age (years) Sex Duration of symptoms (days) Number of swabs collected after first positive swab Days between first PCR positive swab and second negative swab* 1† 62 Male 10 5 42 2 20 Female 5 5 34 3 24 Female 1 5 32 4 32 Female Patient asymptomatic 5 33 5 56 Male 23 3 na‡ 6 26 Female 8 6 43 7§ 62 Female 28 7 53 8 50 Female 12 2 11 9 35 Female 11 2 13 10¶ 52 Female 14 3 21 11 55 Female Unable to ascertain 2 23 na = not applicable; PCR = polymerase chain reaction. * Of two consecutive negative swabs. † Patient with asthma. ‡ The last collected specimen from patient 5 was PCR positive 11 days after initial positive specimen. The nucleic acid detection assay used was the AusDiagnostics Coronavirus Typing (8‐well) assay. This is a multiplex‐tandem PCR assay that employs two rounds of amplification. The cycle take‐off value for the last positive specimen on patient 5 was 23 cycles in the second round of amplification. § Patient with hypertension. ¶ Patient with rheumatoid arthritis.

Kyra YL Chua · Natasha E Holmes · Jason Kwong

To the Editor: The recent discussion on chronic liver disease and ultrasonographic surveillance is welcome.1 Over two decades ago, investigators at Westmead Hospital in Sydney showed that ultrasonographic surveillance of 232 Australian patients with chronic liver disease (most of whom had cirrhosis) was superior to α‐fetoprotein in the detection of hepatocellular carcinoma (HCC).2 In this research, we detected six HCCs with ultrasound for an annual cohort incidence of 1.4%; we calculated that each HCC detected cost $US8472 (in 1998 dollar terms). Further, the superior detection of HCCs with ultrasonography did not translate into improved survival either because of tumour multicentricity, metastases at diagnosis, or patient comorbidity factors precluding surgery. Since that time, our technical expertise in liver screening with ultrasound has grown. Nevertheless, we remain concerned by the relatively poor sensitivity compared with computed tomography or magnetic resonance imaging. In addition, specialists in diagnostic imaging understand that the distorted liver architecture from cirrhosis and the presence of regenerating nodules pose significant challenges in distinguishing HCC from benign lesions. While published meta‐analyses3,4 offer some promise, they are by their very nature highly selective in the data evaluated and seldom consider the downstream costs of false positive tests. It is perhaps unsurprising that recent appropriateness criteria guidelines from the American College of Radiology sound a note of caution on the role of ultrasound in this context.5 Despite the above, there remains a need to perform a contemporary analysis of the potential benefits and costs of screening in patients with cirrhosis in Australian settings. However, as a recent Australian HCC surveillance study6 has concluded, it is difficult to interpret survival outcomes from selective retrospective studies, and conducting a randomised controlled trial may be nigh on impossible.

George Larcos

To the Editor: Travel restrictions to control the transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), the virus that causes coronavirus disease 2019 (COVID‐19), were rapidly implemented in Australia. Despite its apparent efficacy, this proactive approach has been criticised as unscientific and in breach of the International Health Regulations. A recently published comment1 claimed that travel restrictions were implemented without supporting scientific evidence and had “been challenged by public health researchers”, citing research on Ebola and influenza. However, their interpretation is not consistent with an evidence‐based approach. When managing a novel infection, evidence‐based decision making should (i) use the best available relevant information that is generalisable to the novel infection — for example, an infection with a similar route of transmission; that is, not Ebola, but rather severe acute respiratory syndrome (SARS), influenza, and Middle East respiratory syndrome (MERS) — and (ii) clearly define the outcome of interest (eg, prevention v delay). A recent review2 of travel restrictions for emerging infectious diseases, including SARS and MERS, found only one study regarding coronaviruses. The evidence identified supports the use of air travel bans to prevent the spread of coronavirus epidemics.2 Furthermore, systematic reviews,3,4,5 including the review4 cited in the comment,1 have reported that travel restrictions delayed, but did not prevent, the spread of influenza.3,4 These delays were up to 4 months,4 and up to 10 months if implemented in combination with other local strategies.5 At the start of the COVID‐19 pandemic, this reflected the best available evidence to make evidence‐based decisions regarding travel restrictions. The evidence suggests that travel restrictions may, therefore, be used to delay and attenuate the peak in case numbers to reduce the burden on the health system, allowing for preparations to be made to better manage the outbreak. The preparation measures may include upskilling the health care workforce, building new facilities, improving access to laboratory testing and ventilators, and stockpiling personal protective equipment. This is the primary goal of travel restrictions as public health interventions. We conclude that Australia's rapid introduction of travel restrictions is consistent with an evidence‐based approach that prioritises the precautionary principle and saving lives.

Jessica Stanhope · Philip Weinstein

To the Editor: Infectious diseases physicians and microbiologists are pivotal in guiding the response to the coronavirus disease 2019 (COVID‐19) pandemic. Their involvement ranges from managing cases and coordinating local responses to establishing timely and accurate diagnostic testing.1,2 We conducted a survey of infectious diseases physicians and microbiologists in Australia and New Zealand in early March 2020 to assess the impact on workload and the perspectives of infectious diseases physicians in the pre‐pandemic period. Responses were received from 214/600 infectious diseases physicians (35.6%) and 55/310 practising microbiologists (17.7%). During February 2020, infectious diseases physicians spent a median of 27 hours (interquartile range [IQR], 17–50 h) on COVID‐19‐related activities. Microbiologists worked a median of 8 hours (IQR, 2.5–8 h) overtime per week, and nearly one‐third of infectious diseases physicians (70/214) worked late hours at least 3 days a week on COVID‐19‐related activities. While many doctors have been less busy than usual lately,3 infectious diseases physicians and microbiologists have been busier than ever. At the time of the survey, only 45% (95/212) of infectious diseases physicians agreed that the government's response was well coordinated. Similarly, only 25% (11/42) of microbiologists felt that advice from laboratory regulatory bodies was of assistance. This feedback highlights the confusion and lack of clarity that many clinicians experienced at the beginning of the pandemic. To improve coordination and response, we advocate for the establishment of a national Centre for Disease Prevention and Control.4 This Centre would need to be supported politically and financially by the federal government and all jurisdictions to be effective. Reflecting the current lack of clear data about therapeutic options for patients with COVID‐19, over three‐quarters (169, 79%) of infectious diseases physicians felt they had equipoise for a clinical trial of specific antiretroviral. We advocate for investigational agents for COVID‐19 to only be used in the context of a clinical trial.5 At this time of great challenge to the Australian and New Zealand health care systems, infectious diseases physicians and microbiologists stand with all health care professionals and members of the community. The unedited version of this article was published as a preprint on mja.com.au on 20 August 2020.

On behalf of the Australasian Society for Infectious Diseases Clinical Research Network

To the Editor: Torda and colleagues1 highlight the impact of the coronavirus disease 2019 (COVID‐19) pandemic on medical education, which has prompted the rapid shift to online teaching for medical students. We need to ensure that these recent changes in medical education are thoughtfully blended with the reintroduction of face‐to‐face teaching when it occurs. Before integrating these changes, it is critical we reflect and review three key elements: Preparing students: blended learning, where online learning is combined with traditional face‐to-face teaching, is likely to capture more students’ learning styles but is also often associated with increased need for self‐directed learning, which may mainly benefit high achieving students.2,3 It is critical we equip all our students to engage effectively in adult learning to maximise the benefits of blended learning and develop engaged independent learners.4 This is an opportunity to develop these skills by ensuring that staged and increasing self‐directedness is built into new material and forms of delivery.5 Preparing educators: the attitude and preparedness of educators running or engaging in online education is crucial. As vital stakeholders, lecturers should be seen as educators and be supported and developed as such, including the training in both design and delivery of online learning.6 Preparing delivery and its content: facing the option of moving material back from online learning to face‐to-face learning, each move must be critically analysed to determine what is the most effective form of delivery. Historical modes of delivery need not be the default. Indeed, we have been given a once in a lifetime opportunity for a major, if incidental, review of each part of the curriculum and the best way it can be delivered — online, face‐to-face, or maybe a mix of both. As the mode of delivery is reviewed, the content can be refined and tailored for the students’ needs. Many of us know the deafening and discouraging silence when students are quiet in response to a question, both face‐to‐face and online. However, we are at a turning point in medical education where we must take the time to reflect and move forward with excitement regarding what has worked, and have the courage to leave behind what has not.

Lucy E Kirk · Imogen Mitchell

To the Editor: Takotsubo syndrome, also known as stress cardiomyopathy, apical ballooning syndrome, or broken heart syndrome, is a reversible cardiomyopathy frequently precipitated by a stressful event. Its clinical presentation is indistinguishable from a myocardial infarction,1 with electrocardiogram (ECG) changes and elevation in cardiac enzymes. The syndrome was first described in 1991 in Japan and named in reference to the left ventricle morphological features that resemble a pot used for trapping octopuses. Takotsubo syndrome has recently been reported in association with coronavirus disease 2019 (COVID‐19),2 but we report a case of takotsubo cardiomyopathy brought on by the stress of isolation as a result of social distancing. A 71‐year‐old woman presented to the emergency department complaining of chest pain. On arrival, an ECG demonstrated diffuse ST elevation (Box) and troponin was elevated (7800 ng/L). Coronary angiography was performed immediately which did not demonstrate any obstructive lesion and she was admitted to the intensive care unit (ICU) for ongoing haemodynamic support. Echocardiography performed in the ICU showed a dilated left ventricle with an akinetic apex and preserved contraction of the basal segments (Box) suggestive of takotsubo cardiomyopathy. On questioning regarding recent stressors, our patient, who lived alone, reported significant anxiety about not being able to visit family due to social distancing, and was particularly saddened by being unable to see her grandchildren. Public health interventions undertaken by governments around the world in an attempt to reduce the rate of transmission of COVID‐19, or to “flatten the curve”, have included measures such as social distancing.3 While being effective in the aim of lowering infections, these measures may have many unintended consequences. Social isolation is detrimental to mental health, associated with increased stress levels and anxiety, especially in older people, who may be less able to use technology to stay in contact with friends and family.4 In our patient, this stress was enough to trigger takotsubo cardiomyopathy. Box – Electrocardiogram (A) showing diffuse ST elevation. Echocardiogram (B) showing a dilated left ventricle with an akinetic apex and preserved contraction of the basal segments (arrows)

Jon Rivers · Joshua F Ihle

To the Editor: The incidence of bushfires, forest fires and wildfires, is increasing globally. Epidemiology shows that individuals with chronic respiratory diseases are most affected with increased hospitalisations. However, the impacts or safe exposure levels of bushfire smoke are not well known.1 We were recently awarded the Medical Research Future Fund's Bushfire Impact Research grant 2020 and in this project we will address the following questions: How does bushfire smoke exposure affect respiratory health? How does it exacerbate chronic respiratory diseases and affect different age groups? What are the impacts on cells, tissues and molecular pathways? How can we target the effects therapeutically? Bushfire smoke is a complex mix of inspirable particles, volatile organics, aldehydes, carbon monoxide, and particulate matter (PM).2 Although extensive research evaluating the effects of bushfire smoke has not been carried out, studies utilising cigarette smoke or vehicular PM10−2.5 show that exposure to these insults induces lung inflammation and oxidative stress, and promotes the progression of chronic respiratory diseases.3,4,5 Further, in vitro studies with healthy human fibroblasts and bronchoepithelial cells show that bushfire smoke affects pathways including oxidative stress, barrier function, innate defence, and autophagy.6 Accordingly, we plan to expose mice to the different PM particles from bushfire smoke and will elucidate the acute and prolonged effects on lung inflammation, airway remodelling and lung function. In addition, by using our mouse model of chronic respiratory diseases (chronic obstructive pulmonary disease, asthma) and mice at different ages (pregnant, infant, aged), we will assess the impact of bushfire smoke on predisposition, pathogenesis and progression of chronic respiratory diseases. We will use advanced molecular and multi‐omics (single cell/tissue sequencing, proteomics, epigenetics) technology to elucidate cell and tissue responses. Furthermore, we will define therapeutic avenues for prevention and treatment (antioxidants, metabolic modulators) (Box). The outcomes of this project will inform the development of safe exposure guidelines and define preventive/treatment measures. Moreover, we will address evidence gaps related to harmful health effects of hazardous bushfire smoke exposure which we hope will aid government and health agencies to design appropriate policies, prevention measures, and treatment strategies to deal with future bushfire smoke events. Box – Methodology for evaluating the impact of bushfire smoke COPD = chronic obstructive pulmonary disease; PM = particulate matter.

Vivek Dharwal · Keshav R Paudel · Philip M Hansbro

To the Editor: We read with interest the article by Koff and Lyons1 and agree that there is a need to develop, implement and evaluate health systems around patient needs and wishes. Implementing value‐based health care is an excellent initiative to address sustainability and patient‐centred care.2 Genuine reform requires a transition away from volume‐based service contracting towards a multidisciplinary approach focused on evidence of improved outcomes.1,2 This would reward doctors and the system for keeping patients healthy and independent in their own homes, with community support, for as long as possible.2 The Leading Better Value Care initiative (2016–2020)1 may be misinterpreted as another set of top‐down policies. It may also have unintended consequences such as reinforcing the silo approach to disease states, diverting finite hospital and local health district resources, such as staff and expertise, to these 13 policy‐driven priority projects. In our work in perioperative health care, we have identified some concerns. First, the sustainability of our health systems is tested by patients who are frailer, who have chronic diseases, and who present for high risk surgery.1,3,4 Second, these patients have a higher incidence of post‐operative complications3,4 and are more likely to be discharged to a higher care facility, rather than back to their home.4 Third, performing surgery on these patients is associated with higher costs and hospital readmissions.4 Fourth, our research has found that past policy for surgical patients5 has led to today's “wicked problem”; that is, frontline perioperative clinicians and managers are dealing with lack of time, increased demand for precision, fragmentation of care, lack of coordination across an episode of care, bed block, complexity of care, and unclear patient outcome measures. In this context, work is required to empower patients and staff in shared decision making to understand the true complexity of risks and outcomes associated with high risk surgery. In conclusion, implementing statewide value‐based care is timely and can be transformational. The high risk surgical patient cohort and the staff providing their care are likely to benefit from, and should be included in, this important reform agenda.

Su‐Jen Yap · Roberto Forero · David Greenfield · Kenneth M Hillman

To the Editor: Poor oral health profoundly affects a person's ability to eat, speak, socialise, work and learn.1 It has an impact on social and emotional wellbeing, productivity in the workplace, and quality of life. Pain from dental caries is a common experience. In children, dental caries may require treatment under a hospital‐based general anaesthetic — at considerable cost and itself not without risk.2 Poor oral health in childhood is the leading cause of poor adult oral health.1 A higher proportion of Australians who are socially disadvantaged have dental caries. In the 2012–2014 National Child Oral Health Survey, the mean number of deciduous teeth with dental caries in Indigenous children aged 5–10 years was 6.3 (95% CI, 5.2–7.4) compared with 2.9 (95% CI, 2.7–3.1) among non‐Indigenous children.3 In the 2004–2006 National Survey of Adult Oral Health, almost 60% of Indigenous adults had untreated dental caries compared with 25% of non‐Indigenous Australians.4 In the interests of equity, it is desirable for water fluoridation to provide a greater benefit to groups carrying the highest burden of disease. In Australia, this is the Indigenous population. Community water fluoridation is one of the most effective public health interventions of the 20th century. Its success has been attributed to wide population coverage with no concurrent behaviour change required. Evidence in Australia demonstrates that community water fluoridation has decreased both the prevalence (proportion of population) and severity (amount per person) of tooth decay by 44% in children and 27% in adults.5 However, nearly 3 million Australians (11% of the population) cannot access a fluoridated water supply.5 Access to fluoridated water in Australia varies. In Queensland before 2008, access was limited to 5% of the population.5 At that time, there were higher rates of untreated dental caries in non‐fluoridated than in fluoridated communities. In 2008, the Queensland Government mandated water fluoridation for all community water supplies that serviced communities of more than 1000 people; 134 water supplies were identified. Within 4 years, 90% of Queenslanders had access to fluoridated water and rates of dental caries declined.6 After the 2012 Queensland election, the new government overturned mandatory water fluoridation, with the decision to fluoridate community water reverting to water supply authorities. The subsequent deactivation of water fluoridation plants in 18 local government areas reduced the population coverage to around 76%. This had a disproportionate impact on Indigenous Australians, who are more likely to reside in areas where water fluoridation ceased after 2012 or in areas where it was never implemented. The consequence is that only 50% of the Indigenous population in Queensland have access to fluoridated water compared with 76% of non‐Indigenous Queenslanders.7 The denial of access to fluoridated drinking water for Indigenous Australians is of great concern. We urge the Commonwealth government, through current negotiations for funding agreements for public dental care, to mandate that all states and territories maintain a minimum standard of 90% population access to fluoridated water. Water fluoridation would then be an effective as well as socially equitable public health intervention to reduce the oral health inequalities between Indigenous and non‐Indigenous Australians.

Andrew McAuliffe · Chris Bourke · Lisa M Jamieson

To the Editor: We thank Davidson and colleagues1 for their comprehensive narrative review on skin infections in Australian Aboriginal children. A significant factor in both individual and mass drug administration therapy of scabies is the uncertainty regarding the safety of oral ivermectin in small children and during pregnancy. Australian guidelines state ivermectin should not be used in children aged under 5 years or who weigh less than 15 kg or in pregnant women.2 A retrospective cohort study of 170 children aged 1–64 months (median age, 15 months) or weighing under 15 kg treated with ivermectin (mean dose, 223 μg/kg) found only minor self‐limiting adverse effects in seven patients (4%).3 A review of previous literature found 60 children aged under 5 years or weighing less than 15 kg who had been treated with ivermectin at a dose range of 150–200 μg/kg for whom safety data were available.4 Only four of 60 children (7%) developed an adverse reaction, all of which were benign and transient, with no long term sequelae. A recent study of oral ivermectin (dose 400 μg/kg) in the treatment of head lice revealed no adverse effects in 54 children aged under 5 years.5 The Ivermectin Exposure in Small Children Study Group expected to commence the analysis in late 2019 of data collected from 2017 to 2019.6 Three studies totalling 363 women with inadvertent maternal exposure to ivermectin 150 μg/kg (76–85% in first trimester) for filariasis and onchocerciasis found no increased risk of congenital malformations, miscarriage or stillbirth.7 A study of 199 pregnancies with maternal treatment in the second trimester with ivermectin and albendazole, and 198 with ivermectin alone in the management of helminth infections, found no increased risk of adverse pregnancy outcomes.8 In France, the use of oral ivermectin is permitted during pregnancy and in children weighing less than 15 kg when topical therapy has failed.9 Further published data regarding the safety of ivermectin in these populations would be useful, particularly with respect to mass drug administration programs.

Sarah K Morton · Adam Morton