Letters

To the Editor: Harms related to the inappropriate use of prescription drugs include fatal and non‐fatal overdose and are a significant public health concern in Australia.1 In response, Victoria recently introduced SafeScript (https://www2.health.vic.gov.au/safescript) — a system similar to the widely implemented real time prescription monitoring (RTPM) systems in the United States.2 The Victorian RTPM system is designed to help health professionals make safer decisions when supplying high risk medicines.3 RTPM systems have been associated with unintended consequences, such as a transition from pharmaceutical opioid use to illicit opioid use, which has been associated with an increased risk of overdose and spread of blood‐borne viruses.2,4 Indeed, a 2019 American study suggests that lowering prescription opioid supply through initiatives such as RTPM use will only have a modest effect on opioid‐related deaths, unless supported with a multipronged approach including increased access to pharmacotherapy and harm‐reduction services.5 In Victoria, the implementation of an RTPM system may be of more benefit than seen in the US since these services are widely available. We have begun to explore effects of the introduction of SafeScript through analysis of data collected through the Burnet Institute's SuperMIX study — a prospective cohort study of about 1300 people who inject drugs (https://www.burnet.edu.au/projects/89_supermix_the_melbourne_injecting_drug_user_cohort_study). We introduced questions related to RTPM use in March 2019, with a total of 387 interviews conducted since the implementation of SafeScript in Victoria. We found that 20% of participants (48/242) who used a medicine monitored by SafeScript reported being refused a prescription by a general practitioner. One‐third (16/44) of those who have been refused were requesting the prescriptions for the treatment of anxiety and 45% were refused two or more times by doctors. Three per cent of participants (8/245) reported having a prescription they had already been receiving withdrawn. In addition, six out of 241 participants were refused dispensing of a prescribed medicine by a pharmacist. One‐third of participants (15/47) who had been refused a prescription were told this was due to a risky combination of medicines or having multiple providers. A third of participants (14/45) who had been refused a prescription reported an intention to not seek medication from their doctors in the future. Most had moderate to severe anxiety (33/41) and depression (36/41) disorders measured through a self‐administered Patient Health Questionnaire (PHQ). In the case of refused prescriptions requested for the treatment of anxiety, ten out of 13 patients had moderate to severe anxiety disorder and 11/13 patients had severe depression disorder, suggesting unmet treatment needs in patients denied prescriptions. RTPM systems such as SafeScript may help prevent the inappropriate use of prescription medications. Our initial analysis provides early insights on the impacts of SafeScript on this cohort, indicating careful implementation is required, particularly for people who inject drugs living with concurrent mental illnesses. The use of RTPM systems may reduce medicine‐related harm if integrated mental health and drug treatment services are adequate. It is not clear whether this is the case in Victoria. It is important to understand what happens when people are refused prescriptions — what care they receive and whether this care is appropriate for their needs. Increased mortality following restrictions to prescribed medicines is reported elsewhere.2 Rigorous research should evaluate the impact of RTPM use in Australia to understand if similar outcomes are observed.

Dagnachew M Fetene · Peter Higgs · Suzanne Nielsen · Filip Djordjevic · Paul Dietze

To the Editor: The coronavirus disease 2019 (COVID‐19) outbreak has become a public health emergency globally.1,2 Until 26 May 2020, there were 7126 confirmed cases reported in Australia (https://coronavirus.jhu.edu/map.html). However, specimens of the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) independently isolated in Australia (in Sydney, the Gold Coast and Melbourne)3 exhibited very unusual mutations, which have not been identified in other countries (Box, A). Up to 29 April, 1319 sequences of the Australian SARS‐CoV‐2 isolates are available in the website of the Global Initiative on Sharing All Influenza Data (GISAID).3 Except for the NSW03 and NSW01 isolates, viral mutations are located at the stem‐loop II motif (s2m), an extremely conserved RNA element in the 3’ untranslated region (3’‐UTR) (Box, A). The NSW02 and VIC01 isolates have deletion of 41 and ten nucleotides respectively. All Queensland cases have single G‐to‐A substitution (nucleotides 29714/QLD01, 29736/QLD02, 29736/QLD04, and 29737/QLD03). Moreover, patients with NSW05, NSW06, NSW07, NSW15, NSW18, NSW19, NSW21, NSW24, NSW26, NSW28, or NSW31 (nucleotide 29696) have single G‐to‐U substitution at the same nucleotide. This substitution is only present in Australian patients and has not been found in SARS‐CoV‐2 isolates from other countries. Phylogenetic analysis showed that SARS and 30 other coronaviruses and astroviruses all possess the genetic element s2m, suggesting that this motif is conserved in both nucleotide sequence and secondary structure folding during evolution in an otherwise rapidly mutable RNA genome.3,5 The three‐dimensional crystal structure of the s2m RNA element of the SARS virus shows that guanosine (19), which is mutated in Australian isolates, is critical for tertiary contacts to form an RNA base quartet involving two adjacent G–C pairs (G19, C20, G28, and C31)4 (Box, B). Because s2m plays an essential role for the viral RNA to substitute host protein synthesis, we hypothesise that the disruption of s2m could alter the viral viability or infectivity dramatically. The s2m sequence of coronaviruses is highly conserved, and spontaneous mutations in this motif were not expected to have occurred during the apparent short period when SARS‐CoV‐2 has been present; therefore, it is highly likely that the changes are due to recombination.5 Because a high frequency of recombination events in coronaviruses occurs, RNA recombination could either enhance the adaptation process to its new host like humans or cause unpredictable changes in virulence during infection. Box – Mutations, deletions and recombination breakpoints in the stem‐loop II motif (s2m) of Australian severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) isolates Panel A: Deletions and mutations in the primary, secondary and tertiary structures of the coronavirus disease 2019 (COVID‐19) s2m RNA genetic element based on the three‐dimensional crystal structure of the SARS virus. Conventional RNA helical base pairings are indicated in italics. Sequence complements are indicated using colour‐coded brackets. The G19 mutation (arrowhead) of the Australian SARS‐CoV‐2 is shown with purple colour. Asterisks label the RNA recombination breakpoints based on analysis of 1319 Australia SARS‐CoV‐2 sequences using Recco algorithm (https://recco.bioinf.mpi-inf.mpg.de/) (P < 0.002). Panel B: Schematic representation of the s2m RNA secondary structure of the SARS virus, with tertiary structural interactions indicated as long range contacts.4

Ting‐Yu Yeh · Gregory P Contreras

To the Editor: On 11 March 2020, the World Health Organization declared COVID‐19 a pandemic. Australia has enacted public health measures to reduce the number and severity of cases.1 These measures, alongside disease burden, profoundly impact the health care system. However, the place of medical students in the COVID‐19 response is unclear. The gravity of the COVID‐19 crisis has led governments to take drastic measures. The graduation of over 10 000 Italian final year students has been expedited to supplement the overburdened workforce.2 In the United Kingdom, the Medical Schools Council has encouraged prioritising qualification of final year students to support the over‐encumbered National Health Service.2 Medical Deans Australia and New Zealand recognises the value of final year medical students, releasing a statement outlining appropriate roles.3 These involve routine aspects of care independent of the COVID‐19 response, in various clinical settings with which students are already familiar. Moreover, with clinical placements being disrupted, senior students may gain valuable practical exposure aligned with course requirements. Considering the noted mental health effects of COVID‐19,4 student contributions may relieve the burden on professional staff while alleviating any sense of helplessness, improving the mental wellbeing of students and staff alike. Importantly, medicine embodies altruism and humanity, with many students undertaking the vocation for this reason. As imminent doctors, senior medical students may therefore feel impassioned to contribute to the COVID‐19 response. Involving students, however, is not without risk. With the reported asymptomatic infectious period, expanding the workforce elevates infection risk. Exposure to patients with COVID‐19 should therefore be minimal. Further, the risk of litigation is pertinent as students are less experienced than professional staff. Responsibilities should be within capabilities, under supervision and institutional medico‐legal protection. Lastly, additional work hours may impede formal medical education; academic penalties should not be levied, on‐the‐job learning should be duly acknowledged, and accessibility of course materials should be maximised. Indeed, medical student involvement should be implemented following principles developed by key stakeholders.3,5 Extraordinary times call for extraordinary measures. With appropriate legal, operational and training safeguards, senior medical students have a role in the COVD‐19 response if they desire.

Jim H‐S Wang · Sarah Tan · Kyle Raubenheimer

To the Editor: The advent of coronavirus disease 2019 (COVID‐19) has generated an unparalleled level of interest from the medical and non‐medical community. As clinician‐scientists, we watch in astonishment at the exponential growth of academic publications in journals. In January 2020, PubMed saw a sharp rise in the number of publications related to COVID‐19, which continues to grow (Box). We could not help but wonder if this has generated a race to publish. Of course, publishing is crucial to help confront one of the most devastating global health issues of the century. However, it is well recognised that external pressures to publish can muddle the intrinsic pursuit for scientific curiosity and excellence,1 and COVID‐19 has certainly provided the incentive for many clinicians and scientists alike to seek rapid publication. This may, unfortunately, fuel competition in the research/publishing field, which was exemplified by the concerning lack of research collaborations when humans were faced with natural disasters,2 including the 2003 severe acute respiratory syndrome coronavirus (SARS‐CoV) outbreak.3 The urgent nature of this situation means a number of preliminary studies and publications on COVID‐19 are fast‐tracked through the peer review process — or not at all — in the hope of rapidly publicising important findings, opinions and experiences. However, hastily penned observations may mislead and do more harm than good. A recent non‐peer‐reviewed publication on a preprint server likening SARS‐CoV‐2 structurally to the human immunodeficiency virus (HIV) was quickly retracted after the scientific community highlighted serious flaws in the study.4 Furthermore, a preliminary study5 supporting the use of hydroxychloroquine as a COVID‐19 treatment prompted a flurry of off‐label use and media attention. The study was later criticised as being too small and biased, and provided insufficient evidence to recommend its use.6 In summary, rapid publishing allows extensive dissemination of knowledge and sharing of experiences; yet the astute clinician needs to keep an open mind and analyse what is being published, for this cannot take the place of rigorous scientific evaluation and best clinical practice. This is a challenging time in the academic world and COVID‐19 will, no doubt, test our abilities to untangle the vast range of literature available. Box – Monthly and cumulative published articles on coronavirus disease 2019 (COVID‐19)* * We conducted an online search in PubMed and included all articles with the terms “coronavirus”, “COVID‐19”, “COVID” and/or “SARS‐CoV‐2”. The information is correct as of 30 April 2020.

Adrian YS Lee · Ming‐Wei Lin

In reply: Lee and Lin raise an important point about the need for caution in interpreting rapidly published articles in the era of coronavirus disease 2019 (COVID‐19). At the Medical Journal of Australia, we are acutely aware of the need to balance rapid dissemination of key data with the need to maintain our usual high standards of quality and accuracy. We have taken the view that in these unprecedented times, rapid sharing of information is critical, but we recognise the risk of errors this infers. In response, we have implemented a preprint and rapid review process for selected manuscripts of an urgent nature (Box). In order to minimise the risk of errors, all manuscripts are carefully reviewed by myself, our team of experienced and medically qualified editors and, where appropriate, our consultant biostatistician, before being selected for preprint in the MJA. Only where the editorial team have a high level of confidence in the validity and importance of the article will it be selected for rapid preprint publication. Before full acceptance of the manuscript to be published online and in print and, in selected cases, before we accept an article for preprint, we organise a rapid double blind peer review followed by revision in line with our usual stringent processes. In these circumstances, we endeavour to have this process completed within 7 days of preprint publication so that any errors can be quickly identified and corrected. We are very grateful to our reviewers who have been very generous in their assistance with this new process. One final check in our process on full publication is review and editing by our experienced scientific and structural editors, who meticulously check all articles for consistency, accuracy and referencing, while finessing them for readability and clarity of presentation — their expertise is invaluable in ensuring published manuscripts are presented accurately and in the best possible light. We acknowledge that contradiction and error may be inevitable during this rapidly evolving situation but would like to assure our readers that at the MJA, when errors occur, they will be rectified in a timely manner and with full transparency. While we are living in a world of rapid change, our commitment to providing Australian health and medical researchers, clinicians and policy makers with the world‐leading general medical journal they deserve stands strong. Box – MJA process for rapid publication of selected coronavirus disease 2019 (COVID‐19)‐related manuscripts* * Timing is indicative and may vary according to the complexity of the manuscript.

Nicholas J Talley

To the Editor: Rising obesity rates in high income countries have resulted in a growing demand for weight‐loss products.1 Unfortunately, drugs that increase energy expenditure often have severe adverse effects. 2,4‐Dinitrophenol (DNP) uncouples oxidative phosphorylation, inducing a hyper‐metabolic state. It was first used for weight loss in the 1930s but was banned due to deaths.2 It has recently had a resurgence in popularity in the body building/body sculpting arena as a “fat burner” and “pre‐event shredder”, and is available online and as an undeclared ingredient in supplements.1 DNP was up‐scheduled in Australia in 2017 to Schedule 10 (“substances of such danger to health as to warrant prohibition of sale, supply and use”).3 We used data from the New South Wales Poisons Information Centre (NSWPIC) and the National Coronial Information System (NCIS) to evaluate effects of up‐scheduling. Ethics approval was granted from the Sydney Children's Hospitals Network (LNR/16/SCHN/44) and from the Victorian Department of Justice (CF/15/18367) human research ethics committees. There were 24 DNP exposures reported to NSWPIC between 2004 and 2018, with an increasing trend (Box). Most patients (71%, n = 17) were male, 83% (n = 20) were adults aged 20–74 years, and 92% (n = 22) were in hospital or were referred to hospital by NSWPIC. The NSWPIC database showed one death — an adult man who had a cardiac arrest after taking four DNP capsules — and NCIS recorded three more deaths from DNP. All deaths occurred since 2015, with two occurring since the 2017 rescheduling. Despite up‐scheduling, we have identified rapidly increasing harms from DNP, which suggest a resurgence of DNP use. Increasing use and deaths have also been reported in the United Kingdom4 and the United States.5 This highlights the need for urgent action by state and federal law enforcement agencies and awareness campaigns targeting high risk groups. It is important to note that the Therapeutic Goods Administration makes scheduling changes but does not enforce non‐medicinal product restrictions, which is the role of police and Fair Trading. It is likely that DNP is frequently obtained online and often disguised for shipping (eg, labelled as turmeric), thus complicating detection.1 Increased incoming mail screening and awareness and education at gyms may be an option to restrain the use of DNP. Medical practitioners should warn patients of the dangers of illicit weight‐loss supplements. Box – Time trends in 2,4‐dinitrophenol exposures reported to the New South Wales Poisons Information Centre (NSWPIC) in 2004–2018. Up‐scheduling to Schedule 10 was announced in September 2016 and implemented in February 2017. The timing of deaths is censored due to low numbers; however, all deaths occurred since 2015, including two since the 2017 scheduling

Rose Cairns · Jacques Raubenheimer · Jared A Brown · Kylie McArdle · Nicholas A Buckley

To the Editor: The narrative review of diverticular disease by You and colleagues1 is most welcome. While highlighting the ubiquity of the problem and factors that facilitate the development of the disease and outlining an evidence‐based strategy to assess and manage the condition, it is also important to note patient factors, such as comorbidities treated with certain medications, which may facilitate uncomplicated disease becoming complicated. Further, commencing certain medications in patients with diverticular disease may often have unappreciated risks.2,3,4,5 Patients in the prevalent age group often have comorbidities, many of which may be treated with non‐steroidal anti‐inflammatory drugs, corticosteroids, opioids2 and, occasionally, with immunosuppressive therapy. Of these medications, the risk of perforations is highest with corticosteroids.4,5 Specifically, corticosteroids used in the management of rheumatic disease may increase the risk of diverticular abscess perforation 30‐fold.5 The association between complications of diverticular disease and the administration of various medications, particularly corticosteroids, must be emphasised,2,3,4,5 as both uncomplicated and complicated disease may present with non‐specific symptoms, suggesting a broad differential diagnosis.1 Medications must not be overlooked as an iatrogenic risk for complications for both existing and new users.

Mark H Arnold

To the Editor: Thiopurines are used in oncology, immunology and inflammatory bowel disease (IBD). In the coronavirus disease 2019 (COVID‐19) pandemic, patients taking thiopurines face uncertainty as to the risk of serious complications or death if infected. Traditionally, thiopurine use has been associated with an increased risk of opportunistic viral infections.1,2,3 A large IBD registry study found that using thiopurines and having active disease were associated with a higher risk of serious viral infection.3 However, all identified causative agents were species of the Herpesviridae genus.1,2,3 The risk associated with thiopurine use can therefore not yet be generalised to other virus genera, and indeed only corticosteroid use is associated with risk of contracting influenza in patients with IBD.4 COVID‐19 is caused by a novel coronavirus — the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) — and there are no available data from previous coronavirus strains such as SARS‐CoV or Middle East respiratory syndrome coronavirus (MERS‐CoV) to allow for estimation of risk in patients taking thiopurines.3,5 Although, intuitively, immunosuppression with thiopurines may increase the risk from COVID‐19, there are in vitro and in silico data to suggest that thiopurines constrain maturation of MERS‐CoV via inhibition of a viral protease.5 Although this study has not been replicated for COVID‐19 or progressed into animal models, it does raise the possibility that thiopurines use may not necessarily increase the risk of contracting COVID‐19. Thiopurine withdrawal is associated with a 12‐month relapse rate of 17–53% in patients with Crohn's disease and 11–77% in patients with ulcerative colitis.6 This is an important consideration in COVID‐19, as disease relapse requiring steroid use has previously been associated with increased risk of viral complications.3,4 The consequences of thiopurine withdrawal due to COVID‐19 are not yet clear and this information is eagerly awaited as many centres collect prospective data. Preliminary data from SECURE‐IBD — a COVID‐19 database for IBD — report 87 COVID‐19 cases to date in patients taking thiopurines, of whom 52 were managed as outpatients and 35 were admitted to hospital, with two reported deaths.7 These evolving data provide cautious support for the relative safety of thiopurines but cannot be interpreted conclusively in the setting of the rapidly evolving situation. Perhaps the best advice we can currently offer patients is that effective control of disease may carry less risk than poorly considered withdrawal of therapy. The Gastroenterological Society of Australia has issued recommendations that the minimum level of immunosuppression should be continued to control disease although a drug holiday may be considered in some patients with long term stable disease.8 This dilemma highlights the importance of online registries to gather vital data as we work together as a profession to provide evidence‐based advice for our patients during this pandemic.

Thomas M Goodsall · Samuel P Costello · Robert V Bryant

To the Editor: Climate change is this century's greatest global health threat. As the MJA considers the role of the health care sector in climate change, we urge readers to consider hospital food environments. Australia's health care system should be promoting diets that are healthy for both humans and the planet. A growing body of evidence suggests that healthier human diets have significant environmental co‐benefits. For example, reduced consumption of processed discretionary foods and red meats and increased consumption of fruits, vegetables and legumes have been shown to reduce the risk of certain non‐communicable diseases while also reducing diet‐related greenhouse gas emissions.1,2 Hospital food environments provide a useful intervention point to model and promote healthy, sustainable diets to Australians, as millions of meals are served to patients and their families in hospitals each year. Hospital food retailer guidelines have recently been developed by state governments and health care providers.3,4 To optimise health care food environments, a first step is to remove fast food outlets, vending machines and sugar‐sweetened beverages from hospitals. Inpatient food guidelines, however, are mostly outdated and sustainability is rarely considered. Inpatient food services should prioritise the delivery of fresh, locally sourced, unrefined foods with minimal packaging. Meals should adhere to dietary guidelines, be personalised to patients’ health needs, and minimise food waste. A recent audit by the Victorian Government into inpatient food services may provide an important opportunity to initiate reform.5 The Mater Group hospitals’ “at your request” room service exemplifies a cost‐effective food service model, showing improvements in patients’ nutrient intake, clinical outcomes, food waste reduction and patient satisfaction.6 Australia can also learn from the growing number of global initiatives to improve hospital food, including the New Zealand Ministry of Health's sustainability commitments, which include recommendations to encourage plant‐based eating, sustainable food sourcing and reductions in food waste.7 We should also look to innovative programs such as hospital rooftop gardens, hospital teaching kitchens, and traffic light labelling systems. To protect the health of humans and the planet, we urge state governments and health care providers to urgently evaluate hospital food quality, inpatient food services and retail food environments and implement new mandatory standards.

Genevieve Moseley · Luke Spajic · Georgia Behrens

To the Editor: We welcome the recent article by Secombe and colleagues1 highlighting the impact of alcohol policy reforms in the Northern Territory, namely the influence of the minimum floor price on critical care admissions.1 We agree that the social costs and harms of alcohol in the NT are too high,2 and are reassured by the improved health outcomes associated with the implementation of emerging alcohol policies.3,4 There have been, however, other notable alcohol and social policy investments in the NT, including the introduction of Police Auxiliary Liquor Inspectors (PALIs). PALIs are uniformed inspectors, stationed at takeaway alcohol outlets, who seek to prevent the consumption of alcohol in restricted areas. These areas include all land defined as Aboriginal land as per the Aboriginal Land Rights (NT) Act 1976,5 within 2 km of a licensed venue, and in certain regulated public and private areas. PALIs ascertain where individuals purchasing alcohol will be consuming their purchase by requesting a form of identification, alongside questions regarding intended drinking location. If a valid (non‐restricted) address cannot be provided, purchase is not permitted. The first squad of PALIs graduated on 20 August 2018. As noted by Secombe and colleagues, the minimum floor price was introduced on 1 October 2018. Considering the time of implementation of both policies, it is imperative that we better understand the intersection between PALIs, the minimum floor price and other alcohol policy initiatives, such as the Banned Drinker Register.6 The recent analysis by Secombe et al provides a partial snapshot of the impacts of a highly complex public health issue. Given that a suite of alcohol policies has been introduced by the NT Government to combat alcohol‐related harms,6 a more sophisticated evaluation approach is required to understand these relationships. This means a broader range of data sources need to be used to evaluate the impacts of alcohol policies in the NT. This should include health, police, corrections, domestic violence, child protection, and education data. Furthermore, to advance comprehensive understandings of these alcohol reforms, it is also imperative to include qualitative approaches that explain how and why different alcohol policies work.

Sarah C Clifford · Kalinda E Griffiths · James A Smith

Editor’s note: This is an update of a Letter to the editor originally published as a preprint on 16 March 2020 (https://www.mja.com.au/journal/2020/212/8/covid-19-precautions-easier-said-done-when-patients-are-homeless). To the Editor: Implementation of advice to the public and general practitioners on minimising the risk of COVID‐19 exposure and transmission is immensely difficult for people experiencing homelessness and for the health services working with them. Yet this is a population group more vulnerable to infection than most.1 The elevated risk factors for COVID‐19 are substantial, as people experiencing homelessness have a much higher prevalence of comorbidity and chronic disease compared with people of the same age who are housed.2 To illustrate further, among the 4000 active patients seen by Homeless Healthcare (Australia's largest specialist homelessness GP practice based in Perth), nearly all patients have comorbidities, 13% have chronic respiratory conditions, 79% smoke (associated with poorer lung health and risk) and 8% have diabetes (associated with supressed immunity). There are parallel calls in Australia and the United Kingdom for clearer government guidance as to how the precautionary measures can be applied in homeless populations. There are a myriad of challenges to this, both for people who are homeless themselves and for those providing health care to this vulnerable population group. These challenges include: Regular hand washing and hygiene (and accessing soap or sanitiser and bathrooms in order to do this) is extremely problematic if living on the street. Self‐isolation by staying at home if you feel unwell and suspect having symptoms is impossible if you do not have a home to live in. Reducing face‐to‐face health service contact is being advocated to GPs and health services in Australia and the UK. The Australian Government has just announced Medicare rebates for bulk‐billed telephone consultations,3 but this is problematic for people who are homeless without a phone. Similarly, technological solutions such as video or virtual consultations are digitally prohibitive for people without a home let alone a computer. Outreach health services are among the most effective ways of enabling people who are rough sleeping to access health care.4 Homeless Healthcare, for example, runs clinics at drop‐in centres and crisis accommodation settings and has nurses out on the streets each day and doing home visits to those recently housed. However, implementing the use of personal protective equipment is difficult in these settings, and in the absence of primary care outreach, emergency department presentations are likely to escalate. Cancelling outreach GP clinics and other outreach services for this population to reduce exposure risks would have severe unintended consequences. If risk factors for COVID‐19 or patients with COVID‐19 are untreated in this highly susceptible population, the mortality risk is high.1 Moreover, many people will not receive critical treatment for other medical conditions, such as depot medications for psychotic illness and, as articulated in a recently published article, “lockdowns and disease containment procedures might also be deleterious to the mental health of people experiencing homelessness, many of whom have fears around involuntary hospitalisation and incarceration”.1 The higher risks of COVID‐19 for people experiencing homelessness and, consequently, for those working closely with them present an enormous challenge that has no easy answers. As new precautionary measures are being announced daily, it is critical that further marginalisation for this group is not an unintended consequence.

Lisa J Wood · Andrew P Davies · Zana Khan

To the Editor: Nearly all industries profit from today's 25 million slaves and 150 million child labourers.1 The results of their work, including medical disposables, are sold worldwide. Unfortunately, there is not a comprehensive analysis identifying exactly where slaves are involved in the medical products supply chain. From the hazardous work forging surgical instruments in Pakistan to the manufacture of gloves in Malaysia,2 slavery permeates the manufacture and supply chains of medical products. Slaves are involved in the direct manufacture of medical products and in the generation of raw materials used to make medical devices, including cotton, rubber and metals.3 Some companies, have made a public effort to review their supply chains;4 however, many organisations are failing to monitor human rights abuses in their supply chains.5 As countries legislate Modern Day Slavery Acts, a few companies are moving to eliminate slavery. As an act of radical transparency in the long‐discussed issue of child labour in the cocoa industry, in 2017, Nestlé published the number of child labourers aged 5–17 years known to be working on cocoa farms that supply their cocoa.6 Nothing similar to Nestlé's effort has been done in the medical industry. However, notable efforts to regulate procurement have been demonstrated in the United Kingdom and Sweden.2 Few health professionals are responsible for the direct sourcing of medical products. Nonetheless, when speaking with managers, executives, and representatives of medical suppliers, we have the opportunity to share our concerns for the origins of the products we use. While a conversation with a medical representative on this topic may demonstrate scant knowledge of the manufacturing processes of the goods they are selling, that initial conversation is an important first step towards transparency, and we know that the influence of health professionals on industry is significant.7 Modern slaves are forced to work under threat of harm or by coercion or deception. Unable to refuse or leave, they earn little to no pay for extensive working hours in unsafe conditions, which may cause injury, sickness and, at times, death. Reports of harassment are common. In the medical industry, we must do all we can to address modern slavery because, above all, we should “first do no harm”.

Sharon Sitters

To the Editor: In August 2019, the Australian Institute of Health and Welfare (AIHW) released a report on chronic musculoskeletal conditions in Australia.1 In the report, the prevalence of gout is estimated at 0.8% (equating to 187 000 people), based on self‐reported survey data. This rate is much smaller than previously reported in Australia. Recent South Australian population‐based studies using “self‐reported doctor diagnosed gout” as the case definition reported the prevalence of gout as being between 5.2% and 6.8%.2 Thus, the rate of self‐reported gout detailed in the AIHW report is incongruous with published data and appears to be unusually low. The reported prevalence of gout in the AIHW document is based on the 2017–18 National Health Survey, in which participants were asked to self‐report doctor‐ or nurse‐diagnosed gout and whether the gout was current and expected to last for 6 months or more. Participants who did not identify as having current or long term gout did not have their condition recorded in the survey. Given that for most patients gout manifests as an intermittently flaring disease, with most flares lasting 7–10 days, respondents would likely not report their gout to be “current” or “likely to last 6 months” unless they have a clear understanding that gout is a chronic disease of monosodium urate crystal deposition. Many people with gout have not received this information from their health care providers and view the disease as present only when they are experiencing a flare.3 The chronic nature of the disease is reflected in the current definition of gout as “current or prior clinically evident disease”, as agreed by international gout experts.4 Gout is a systemic disease and an established independent risk factor for renal and cardiovascular disease. Like many chronic diseases, flares of gout and their long term consequences can be prevented with daily medication. However, both international and Australian evidence demonstrates that gout is inadequately treated, that persistence to urate‐lowering therapies is low, with suboptimal outcomes for patients.2 Under‐reporting and under‐recognition of gout and its burden on society is likely to contribute to undertreating and failure to manage it as a chronic disease — in contrast to other chronic conditions such as diabetes, in which the need for optimal disease management is well accepted. It is important that the burden of gout in Australia is understood and accurately measured to allow optimal use of limited health resources, reduce burden on society, and improve outcomes for people with this condition. Quality data are required but must be generated with appropriate definitions. We suggest that a validated case definition, such as “self‐reported gout” or “urate‐lowering therapies use”, be used in future Australian epidemiological studies.5

Helen I Keen · Philip C Robinson · Nicola Dalbeth · Catherine Hill

To the Editor: Amyotrophic lateral sclerosis (ALS) is a rapidly progressive and fatal neurodegenerative condition with no cure. Only two treatments with class I evidence exist — riluzole1 and edaravone2 — both with unclear mechanisms of action and modest survival benefits. In Australia, riluzole remains the only treatment approved by the Therapeutic Goods Administration. The Pharmaceutical Benefits Scheme limits initiation of riluzole to patients with at least 60% of predicted forced vital capacity, although facial weakness may make this an unreliable target. Initial and continuing treatment requires patients to be ambulant; or to have good upper limb function or to be able to swallow; and not to have respiratory failure. A recent retrospective study classified patients into different disease severity stages, ranging from 1 (one region involved) to 5 (death); patients with respiratory and nutritional failure were assigned to stage 4.3 The study identified that patients in stage 4 receiving 100 mg of riluzole daily did not progress to the next clinical stage (ie, death) as rapidly as those in milder stages. This suggests that the modest survival benefit experienced by patients taking riluzole comes about by extending the time spent at this stage. A quarter of patients present with bulbar or respiratory onset,4 making many ineligible for treatment, despite data suggesting they may benefit most.5 Mean survival in these forms of ALS is particularly short, meaning the modest survival benefit offered should be considered, as a majority of patients with advanced ALS do not wish to hasten death.6 A recent study of over 4000 trial participants confirmed benefit in both early and late stages,7 supporting use of riluzole throughout the disease. Few prospective studies on late‐stage treatments exist; patient choice in continuing treatment during advanced stages therefore remains paramount. Prospective studies are needed to establish whether the benefit of riluzole is weighted towards more advanced disease. However, recent studies, along with the recognition of the clinical spectrum of ALS, indicate that the current Pharmaceutical Benefits Scheme criteria are too stringent. As we move towards precision‐based medicine, different profiles of therapeutic response are likely. Regulators will be required to rapidly respond to emerging data to ensure the right patients can access the right medications.

Colin J Mahoney · Matthew C Kiernan

To the Editor: We applaud the astute perspective of Teede in relation to gender equity in medical leadership.1 Organisational culture that promotes male leadership styles is self‐perpetuating and this has implications for our specialty of endocrinology, which is rapidly becoming “feminised”. About 80% of physician advanced trainees in endocrinology are female and yet only 20% of heads of endocrinology departments in Australian training hospitals are women (Royal Australasian College of Physicians Advanced Training in Endocrinology Program, unpublished data). Waseem and colleagues2 documented significant under‐representation of women at higher academic levels in endocrinology societies internationally. Only 23% of full professors and 31% of board members were female. Women have fewer publications or research citations, but their skill sets are diverse and they bring value to executive boards through negotiation and problem solving skills. The historical biases around the expectations of women are perpetuated by male powerbrokers. Unconscious bias can be subtle. Duma and colleagues3 reported that when introducing female speakers at an international conference, men were more likely to use a woman's first name alone, but male speakers were introduced with full professorial title and surname. This undervalues the women who already tend to underplay their own skills. Part‐time employment may be supported in theory, but it is left up to the woman to find a solution. Women fear that part‐time work may challenge perceptions of competence. A healthy endocrinology training scheme must support our significant female workforce and serve the 70% of endocrinology outpatients who are women. We have wonderful male colleagues who are willing to support progress, but they may be deterred by the stigma attached to issues such as paternity leave. The current chair of the Royal Australasian College of Physicians Advanced Training Committee and the coordinator of the Advanced Training in Endocrinology Program are both women, so we do see a bright future ahead. This is an important issue for our patients, for women and for men.

Diana L Learoyd · Jane Holmes‐Walker

To the Editor: In their Perspective article, Mitchell and colleagues1 discuss the problems for patients resulting from overcautious attitudes in prescribing opioids within the constraints of the doctrine of double effect. In doing so, they also highlight how problems may be compounded by the inappropriate use of language in respect to voluntary assisted dying. Victoria has passed and is now implementing the Voluntary Assisted Dying Act 2017, not “assisted suicide” legislation. Like so much of the language we use, there are underlying, negative connotations to certain words. The use of the term “suicide” in the context of a person living with a terminal or serious and incurable condition that can only be relieved through death conflates two very different realities. One is the understandable or rational desire to avoid the trajectory of escalating suffering at the end of life, while the other is the tragedy of suicide resulting from social, financial or mental health conditions that culminate in feelings of abjection and of hopelessness towards the future. The focus of the authors of this article is both positive and welcome; assuring practitioners that they can adopt a proactive and patient‐centred approach towards pain relief. However, the use of language in this instance is unfortunate, as it has often been employed cynically to undermine the iterations of voluntary assisted dying Bills across Australia. Other common documented examples are referring to voluntary assisted dying as killing, murder, or state‐sanctioned murder — actions involving violence and malicious intent. Voluntary assisted dying is a managed and documented pathway embarked on by a person with decision making capacity to achieve a peaceful death on their own terms. Suicide, on the contrary, is a tragedy, usually undertaken alone as a violent and desperate act, including by people who have no legal recourse to voluntary assisted dying. It leaves a legacy of complicated grief for loved ones. Language is important. Without careful reflection, it can easily be used to subvert good intentions, including legal reforms. It can thereby thwart the will of the people — a perfect storm indeed.

Julia M Anaf