Letters

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

To the Editor: There has been recent important discourse about the adverse impact of coronavirus disease 2019 (COVID‐19) on mental health, with modelling from the Brain and Mind Centre predicting increases in suicide in the wake of the pandemic.1 Links with the economic downturn have been emphasised, with financial stressors and loss of productivity among the youth and working adults playing a large part, leading to a call for proactive investment in mental health services.1 This is of undisputed, urgent importance. However, there has been relative silence about the effects of the pandemic on suicide risk in older adults, especially men aged 85 years or over, who have the highest rate of suicide of all age groups in Australia.2 Older adults are particularly vulnerable to the social ramifications of the pandemic, including social distancing, if not frank social exclusion by quarantine, exacerbating pre‐existing loneliness,3 particularly for those in residential care. Management of older people with pre‐existing mental illness as well as the expected increases in depression and anxiety3,4 have been confounded by changes in service provision and access to mental health services.3 Similarly, delays in presentation and management of physical illness combined with the suspension of elective procedures4 may contribute to untreated pain and other distressing physical symptoms, also identified as risk factors for suicide.5 Furthermore, calls to reopen the economy knowing the risk this poses to older people — seen by some as “expendable” — reflects societal ageism and adds to older people's own internalised ageism.6 Perceptions of disconnection from society and feeling burdensome and devalued are already known associations with late‐life self‐harm and suicide.5 In addition to fuelling active self‐harm, there has been speculation regarding links between the pandemic and increased requests for voluntary assisted dying.7,8 These reports suggest that such requests have been driven by anxiety about dying, fears of loss of control, and inability to access help for distressing symptoms. This is not unfounded, given the complexity of providing appropriate palliative care to older patients who are dying, particularly to those in nursing homes, ever more so during the COVID‐19 pandemic.4 We add to the call to act urgently and flatten the mental illness and suicide curve1 for Australians of all ages.

Anne P F Wand · Carmelle Peisah

To the Editor: In Australia, gestational diabetes mellitus is diagnosed by 75 g oral glucose tolerance test (OGTT). The diagnostic criteria are fasting plasma glucose (FPG) ≥ 5.1 mmol/L, one‐hour glucose level ≥ 10.0 mmol/L, and/or 2‐hour glucose level ≥ 8.5 mmol/L.1,2 International consensus favours OGTT over single measures of glucose because, in the pivotal Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) study, hyperglycaemia at each time point was independently associated with adverse outcomes, individual measures were not well correlated with one another, and no single measure was clearly superior in predicting adverse outcomes, such as birthweight above the 90th percentile, shoulder dystocia and pre‐eclampsia.2,3 To reduce contact time at pathology collection centres during the coronavirus disease 2019 (COVID‐19) pandemic, measurement of FPG alone has been advocated.4,5 One guideline advised that a result below 4.7 mmol/L may not merit a follow‐up OGTT.4 Another advised diagnosing gestational diabetes mellitus by stand‐alone FPG greater than 5.1 mmol/L.5 To determine the proportion and characteristics of gestational diabetes mellitus cases that would be missed by using alternative criteria, we extracted the results of all obstetrician‐referred OGTTs performed by our private community‐based laboratory between January 2017 and April 2020. The analysis, including determination of Wilson score confidence intervals (CIs), was performed with SAS 9.4 (SAS Institute). Of 16 169 patients, 1790 (11.1%) were diagnosed with gestational diabetes mellitus by OGTT. A rule‐out threshold of FPG below 5.1 mmol/L would have resulted in 1202 cases (67%; 95% CI, 65–69%) being missed, and a threshold below 4.7 mmol/L would have resulted in 831 cases (46%; 95% CI, 44–49%) being missed (Box). Women with gestational diabetes mellitus and normal fasting glucose did not have significantly lower one‐ or 2‐hour concentrations than those with increased fasting glucose (data not shown). Missing the diagnosis of gestational diabetes mellitus exposes women and their newborns to significant risks, including birth weight above the 90th percentile, primary caesarean delivery, neonatal hypoglycaemia, premature delivery, shoulder dystocia or birth injury, intensive neonatal care, hyperbilirubinaemia and pre‐eclampsia. Use of fasting glucose to screen for gestational diabetes mellitus would miss a large proportion of cases, with the potential for significant harm to mothers and their offspring. Clinicians must recognise the substantial limitations of stand‐alone FPG so that pregnant women can be adequately counselled and, if opting out of OGTT, considered for careful monitoring for consequences of undiagnosed gestational diabetes mellitus, such as accelerated growth or polyhydramnios. In regions without significant community spread of COVID‐19, modifying sample collection procedures to ensure strict physical distancing and having dedicated collection centres for vulnerable populations may be better than using deficient diagnostic criteria. Box – Distribution of fasting glucose results at 24–28 weeks’ gestation in patients with (n = 1790) and without (n = 14 379) gestational diabetes mellitus* (GDM) The vertical grey lines denote thresholds below which new guidelines propose that oral glucose tolerance testing is not required during the coronavirus disease 2019 (COVID‐19) pandemic. * Diagnosed using oral glucose tolerance test.

Ranita Siru · Johan H Conradie · Melissa J Gillett · Emily Gianatti · Michael M Page

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has required rapid adjustments in health service delivery.1 The Victorian COVID‐19 Cancer Network (VCCN) is a joint initiative of the Victorian Comprehensive Cancer Centre and Monash Partners Comprehensive Cancer Consortium. Through expert groups, the VCCN aims to provide support and advice to clinicians and health care services treating cancer patients during the pandemic. The VCCN Telehealth Expert Working Group conducted a survey to understand the barriers and enablers to the rapid adoption of telehealth in health services during the first week of April 2020. Seventeen cancer services from across metropolitan and regional Victoria and Tasmania responded. Notably, all respondent cancer services had implemented some form of telehealth since the pandemic. Healthdirect, the Victorian Department of Health and Human Services’ supported telehealth platform, was used in 40% of services, with 25% using phone only and others using platforms such as Skype, FaceTime and doxy.me. With the unprecedented increase in the uptake of telehealth,2 there is a tremendous opportunity to integrate telehealth into routine practice, potentially improving inequities and inefficiencies in the delivery of cancer care for suitably selected patients. Our survey results suggest several areas for attention to support telehealth, including the need for further investment in information technology infrastructure across health services and administrative support to facilitate changes in practice and workflow (Box). The survey results also highlight the educational and training needs of consumers and health professionals during telehealth implementation. Aboriginal and Torres Strait Islanders, people from culturally and linguistically diverse backgrounds and of lower socio‐economic status, and older patients may have greater needs and will require additional support from both government and relevant organisations to ensure equity of access to cancer care via telehealth. We strongly advocate the need to establish evidence‐based, patient‐centred and sustainable telehealth in cancer management. Research into the experience of patients and clinicians should be prioritised to ensure the consistent quality of telehealth consultation with face‐to‐face consultation in appropriate clinical circumstances. Box – Barriers to implementing telehealth: survey results

Zee Wan Wong · Hannah L Cross

To the Editor: In their recent article, Ioannidis and Boyack focused on the misuse of author‐ and journal‐based metrics.1 The “predatory and other easy journals” they allude to are becoming increasingly difficult to distinguish2 in a widening continuum of journal quality that is seeing some overlap between predatory journals and indexed (eg, in Web of Science, Scopus or PubMed) journals that are traditionally perceived to be of peer‐review quality and whose scholarly content has been editorially authenticated.3 This increasing overlap between predatory and indexed journals is accentuated by an increasing lack of reproducibility, often revealed through post‐publication peer review of indexed journals.4 Predatory journals may also seek scholarly validation by allowing citation of their papers to infiltrate supposedly reputable databases.5 However, the continued inability to identify such journals invalidates calls to ban such entities or to not cite papers from currently blacklisted predatory journals, as was recently suggested by the International Committee of Medical Journal Editors.6 Increasing retractions in the biomedical literature as a result of post‐publication peer review — which identifies errors and misuses such as the manipulation of citations discussed by Ioannidis and Boyack, including inflated and coercive self‐citation— affect author‐based metrics and journal‐based metrics differently. It is incumbent upon authors, editors and publishers to correct inflated, skewed or distorted author‐ and journal‐based metrics. To achieve this, retractions need to be destigmatised. Moreover, inflated author‐ and journal‐based metrics (eg, H‐index, Journal Impact Factor [Web of Science Group], CiteScore [Elsevier]) need to be adjusted with corrective, but not punitive, measures, to correct for imbalances and unfair rewards that may be associated with the attribution of citations of retracted (and thus potentially invalid) literature.7 Self‐citations that support stated claims are valid, independent of their number, and involve no ethical breaches. However, the misuse of self‐citations to manipulate author‐ and journal‐based metrics, such as citation cartels,8 raises ethical red flags. Independent of the possible ethical parameters of inflated or coercive self‐citation, such metrics can also be adjusted downwards to reflect the more balanced perspective of an author‐ or journal‐based metric.9 If the identity of predatory journals can be clearly determined and unanimously agreed upon, then the journal‐based metrics of valid, indexed scholarly journals that cite such journals should be adjusted accordingly.

Jaime A Teixeira da Silva

To the Editor: A recent article highlighted a case where self‐collection enabled detection of an early cervical adenocarcinoma and curative treatment in a previously underscreened woman.1 This case underlines the important benefits from self‐collection making cervical screening more accessible and acceptable to women who have previously declined or delayed screening. Unfortunately, self‐collection is currently very underutilised in Australia. Although it is currently restricted to women aged 30 years and over who are 2 or more years overdue for cervical screening, potentially around a million women are eligible.2 In contrast, data from Medicare, VCS Pathology, and the National Cancer Screening Register suggest that fewer than 6000 self‐collected tests were processed over 2018 and 2019, indicating that less than 1% of eligible women have had a self‐collected test. What drives this discrepancy? Self‐collection is highly acceptable to underscreened Australian women, and very high uptake can be achieved with appropriate clinical support.3 A recent survey reported that many practitioners, especially outside Victoria, do not yet feel comfortable discussing or recommending self‐collection, and lack confidence that self‐collection is a reliable test.4 Potentially, this is due to an initial delay in self‐collection being available, confusion about eligibility, and current restrictions giving the false impression that self‐collection is less sensitive. Self‐collection is now available to eligible women nationally (provided samples are sent to one of two accredited laboratories, which accept samples from anywhere in Australia), and updated evidence demonstrates that polymerase chain reaction‐based human papillomavirus (HPV) testing is equally sensitive for detecting pre‐cancer in self‐collected and clinician‐collected samples.5 Another barrier may be difficulties for providers in checking whether women are eligible. The rollout of the provider portal into the National Cancer Screening Register, allowing providers to view a woman's screening history at the point of care, will be important in addressing this issue. Many screening‐eligible women who have not had their first HPV test are now overdue and could be eligible for self‐collection. Self‐collection is a reliable test now available nationally to eligible women, which can have a transformative effect in the lives of underscreened women, as shown in the recent case study.

Megan Smith · Marion Saville · Karen Canfell

To the Editor: The recent article by Akram and Sadashiv1 presents a timely and most welcome opportunity to enhance awareness, in the medical community at large, of the investigation and treatment options for proximal deep vein thrombosis (DVT) of the lower extremity. Diagnosis of lower extremity DVT is generally made or confirmed with duplex ultrasound assessment. Standards in Australia and New Zealand state that duplex ultrasound for DVT should determine the proximal extent of the thrombus, as well as identify structures causing extrinsic compression that may have contributed to the thrombosis.2 This information assists the clinician in determining the need to consider specific treatments, such as venous stenting for May–Thurner syndrome or placement of a caval filter in cases where there is a free‐floating thrombus in the inferior vena cava. Duplex ultrasound can play a key role in the diagnosis of May–Thurner syndrome.3 Technical factors, such as the presence of bowel gas, may inhibit ultrasonographic views of the abdominal and pelvic vasculature, and may therefore prevent attainment of the required information. Further, clinical experience in vascular surgery services in Australia and overseas has shown that, despite the above‐mentioned standards, it is common for there to be no attempt to obtain adequate proximal views during ultrasound DVT scans. Clinicians should therefore be wary of the limitations of ultrasound DVT scans and consider alternate imaging modalities such as computed tomography venography in cases where ultrasound has yielded inadequate information. Clinicians should also be aware of the potential of clot removal therapies such as catheter‐directed thrombolysis to improve long term outcomes for patients with proximal lower extremity DVT, whether or not May–Thurner syndrome is identified as a predisposing factor. Recent studies have reported improvements in the incidence and/or severity of post‐thrombotic syndrome in patients receiving catheter‐directed thrombolysis compared with those treated with anticoagulation alone.4,5 The appropriateness of catheter‐directed thrombolysis for some patients is acknowledged in the relevant guidelines,6 although patient selection remains a topic of debate. Lower extremity DVT is a common condition encountered in both inpatient and community settings. Due to technical considerations and quality variations, ultrasound DVT scans do not always yield adequate information to determine the optimal therapeutic approach. In such situations, consultation with a vascular specialist is strongly encouraged.

Trevor MY Kwok

To the Editor: In Australia, 2020 began with raging bushfires, and we now confront the coronavirus disease 2019 (COVID‐19) pandemic. While health protection is currently at the top of the public policy agenda, can we rise from these huge ruptures and “build back better”? The full health costs of the bushfires, including the mental health toll, are yet to be quantified. No sooner had the bushfires abated than the battle against the COVID‐19 pandemic began. The immediate public health response has been well managed in Australia.1 Although Victoria is currently grappling with a second wave of infections, by international comparisons the number of cases and deaths around the country has remained low.2 Government leaders have listened to health experts and acted on evidence, including the need for strict physical distancing in the absence of a vaccine, supplemented by universal masking in Victoria. As governments move to revitalise the economy with financial stimulus, what guidance can health experts provide to inform this stimulus? One clear priority is that stimulus accelerates the decarbonisation of the Australian economy. Climate change is a recognised health issue. Published as the bushfires erupted, the 2019 MJA–Lancet Countdown on health and climate change report3 found that Australia is extremely vulnerable to the impacts of climate change on health. There are also health co‐benefits from action on climate change. The clearest example is the transition to renewable energy generation. Globally, in 2015 alone, more than 460 000 preventable deaths were attributable to coal burning.4 An urgent transition to renewable energy would be an evidence‐based public policy response to these deaths and assist a global green recovery from the pandemic which is called for by the World Health Organization.5 Australia is well placed to lead such a recovery as indicated in a recent report by ClimateWorks Australia,6 which provides a blueprint to achieve net zero emissions by 2050 through accelerated uptake of mature zero emission technologies and the rapid development and commercialisation of emerging zero emission technologies in harder to abate sectors (Box). Beyond stimulus for decarbonisation, investments in affordable housing, mass transit infrastructure, safe routes for walking and cycling, regeneration of degraded ecosystems and infrastructure to support working from home would also benefit health through reduced homelessness, improved levels of physical activity, and improved urban air quality. Australia has, thus far, avoided the high COVID‐19 case numbers and death rates seen in some other countries because of evidence‐based decision making. It is essential that decisions about the stimulus for economic recovery are similarly grounded in evidence. The health and wellbeing of current and future generations of Australians depend on it. Box – Summary table of key emissions‐reduction solutions by sector CCS = carbon capture and storage.

Selina N Lo · Anna Skarbek · Anthony Capon

To the Editor: Before the coronavirus disease 2019 (COVID‐19) pandemic, we had been thinking about how best to re‐imagine our university medical program to enhance student experience and learning outcomes. Globally, questions have been raised regarding the utility and format of the pre‐clinical content taught in medical programs in the junior years,1 particularly lectures, which have increasingly low attendance rates. There is emerging evidence that blended approaches to education meet the connectivity, flexibility and interactivity expectations of learners,2 and have potential to combine the best of both online and face‐to‐face teaching. Packaging content in digestible chunks, combined with active learning activities online such as adaptive tutorials, discussions and reflections, results in more meaningful educational experiences for students than didactic lectures.3,4 The COVID‐19 pandemic forced a rapid transition to entirely online teaching for junior medical students. Even components of clinical teaching (other than physical examination) had to proceed in this format. Despite the pace of this transition, both formal and informal student feedback indicated that students have an extremely high level of satisfaction and engagement with online learning activities. The clinical training components of the program have, by necessity, also become more streamlined. COVID‐19 has forced us to examine all elements of our medical program. This is an opportunity to review the curriculum for future doctors, especially its alignment with the skills and capabilities they will need in their careers. Clearly, we need to facilitate the development of teamwork and communication skills, which will prepare students for effective patient care and multidisciplinary, interprofessional practice. Additionally, we have an obligation to support medical students in developing skills in reflection, adaptive problem solving, leadership and lifelong learning, all of which are needed to adapt to a rapidly changing health care environment.5 Some important aspects of university life, such as such as friendships, personal identity development, exposure to diversity and self‐care skills, will be much harder to achieve in a solely online environment, but as we develop plans to reintroduce elements of face‐to‐face teaching, we need to ensure that these are integrated with, and informed by, the advances made in medical education during the past few months.

Adrienne J Torda · Gary Velan · Vlado Perkovic

To the Editor: Australia's social distancing policies to contain the spread of coronavirus disease 2019 (COVID‐19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), have had social consequences. Social distancing and school disruptions have increased parental responsibilities. There has also been an increased opportunity for parents to use alcohol to cope with increased stress.1 Parents, especially mothers, have taken to social media to share “memes” about needing a drink to survive staying at home (Box). These posts are mostly shared with the aim of creating an online environment for peer support and stress relief, but they risk normalising the use of alcohol as a coping strategy and promoting the false belief that alcohol is good for mental health.2 Alcohol is a central nervous system depressant that may relieve stress in the short term, but regular drinking increases psychological distress and the risk of alcohol‐related harm.3 A review of recent advertising complaints indicated that some alcohol advertisers have been quick to capitalise on COVID‐19.4 An investigation of a social media account found an average of one alcohol advertisement every 35 seconds, with themes of easy access without leaving home (58%), buy more (35%), drink during COVID‐19 (24%), and drink to cope (16%).5 Australia has a regulation system for alcohol advertising, which most people mistakenly believe is government‐funded.6 It is in fact an industry‐funded quasi‐regulatory system that is activated by consumer complaints and lacks systematic independent monitoring.7 Further, regulations do not prevent certain social media platforms from being used by alcohol brands to post advertisements and engage with consumers.8 In light of the alcohol industry's opportunistic advertising through social media, it is questionable how well Australia's regulatory system protects parents and other targeted populations at risk from exposure to constant encouragements to drink during these challenging times. Box – Examples of parental drinking‐related memes during the coronavirus disease 2019 (COVID‐19) lockdown

Janni Leung · Jason Connor · Leanne Hides · Wayne D Hall

To the Editor: The issue of cancer overdiagnosis highlighted by Glasziou and colleagues1 is not new. The problem lies in how clinicians translate caution into the care of individual patients. In August 2019, non‐clinician epidemiologists, via the media, alarmed and confused many post‐menopausal women by reminding us that menopausal hormone therapy (MHT) mildly increases breast cancer risk.2 This was already known; breast cancer is common in post‐menopausal women, with or without a history of MHT use. Women taking MHT understandably comply with government‐recommended and funded screening mammography.3 Thyroid cancer overdiagnosis has been recognised for many years and is addressed in international evidence‐based management guidelines.4,5 The Royal Australasian College of Physicians has the EVOLVE program, endorsed by the Endocrine Society of Australia, to guide clinicians to order fewer thyroid ultrasounds.6 The adoption of thyroid ultrasound reporting systems such as TIRADS has already reduced the number of thyroid fine needle biopsies.7 Furthermore, active surveillance, rather than surgical intervention, is now advocated and supported by evidence for the management of small low risk thyroid cancers.5 Data from overseas show that older patients may accept surveillance over surgery, but younger patients demand intervention due to uncertainty about tumour behaviour. Active surveillance becomes expensive with time.8 Clinicians face anxious patients seeking guidance over mixed messages from the popular press. Genomics and better personalised medicine may eventually allow prognostication. For now, addressing clinical and family histories, physical examination, and appropriate investigations are done on a case‐by‐case basis. Thyroid cancer guidelines have already been adjusted and expanded to outline an individualised approach.

Diana L Learoyd