Letters

In reply

Anthony C Catalano · Noel E Cranswick · Joanne Grindlay · Mick Creati · Margie H Danchin · Jeff Robinson · Nicola Williams · Amanda Gwee

To the Editor: Patients presenting to an emergency department (ED) may be unable to communicate with treating clinicians. Immediate access to emergency medical information is essential to providing optimal care and avoiding harm. Smartphone medical alert apps, such as those pre‐installed on the two major operating systems (iOS [Apple], Android [Google]), allow patients to store emergency medical information that is accessible to clinicians when a patient is incapacitated and the smartphone is locked. Similar to medical alert bracelets, these apps are designed to store basic emergency medical information. Via a self‐administered app, patients can record as much emergency medical information as they feel comfortable sharing. This information can be rapidly accessed from the smartphone's locked screen, bypassing default security features. We recently asked a convenience sample of 250 adult ED patients, well enough to complete a survey, to complete a questionnaire assessing their smartphone usage, familiarity, attitudes and barriers towards storing emergency medical information on smartphone apps. Ethics approval was obtained through the St Vincent's Hospital Melbourne Human Research Ethics Committee. Two hundred patients completed the survey. The mean age of respondents was 39 years (95% CI, 37–41 years). Most owned a smartphone and had it with them in the ED. Only 15% (31/200) currently used an emergency medical information app, with most using the default pre‐installed app. The commonest barrier to use was a lack of awareness or familiarity with the app. Once informed, most patients (97%; 194/200) were willing to use such an app in the future (Box). Patients who have privacy and security concerns about the government‐controlled My Health Record may view storing emergency medical information on smartphones as a safer option. The depth of information on a smartphone would be considerably less than that accessible via My Health Record, but in an emergency, some information is better than none. Using smartphones to store emergency medical information may lead to better emergency care for incapacitated patients. There is enthusiasm from patients to embrace this technology. General practitioners and other clinicians are well placed to inform patients and facilitate its adoption. ED clinicians should be encouraged to check the phones of incapacitated patients in the initial assessment and triage phase for the presence of potentially lifesaving information. Box – Number of patients currently storing or prepared to store emergency medical information on a smartphone app, by type of information Currently storing (n = 31) Prepared to store (n = 194) Number 95% CI Number 95% CI Name 27 (87%) 74–97% 171 (88%) 84–93% Date of birth 26 (84%) 71–94% 148 (76%) 70–82% Emergency contact 21 (68%) 48–84% 179 (92%) 88–96% Medical conditions 16 (52%) 36–68% 168 (87%) 81–91% Medications 11 (36%) 19–52% 162 (84%) 78–89% Allergies 9 (29%) 14–48% 177 (91%) 87–95% Organ donor status 11 (36%) 19–52% 173 (89%) 85–94% Blood type 13 (42%) 26–58% 184 (95%) 92–98%

Weiyu Fang · Rachel Zordan · Stuart J Dilley

To the Editor: Writing recently in The Lancet, Byng and colleagues1 argue that our clinical guidelines on care of transgender children that appeared in the MJA2 use imprecise language, do not consider long term effects, and lack robust evidence. Several points the authors raise are valid and indeed align with what we and others have written about the state of evidence and need for high quality research in the field.3,4 However, it is important to provide additional clarification. First, the phrase “sex assigned at birth” is not intended to mislead as Byng and colleagues have claimed5 but is standard terminology for clinicians who work in transgender health (the guidelines’ primary intended audience).6 Second, the authors fail to acknowledge not only our direct call for more research on the guidelines’ opening page but also the detailed description of the long term effects of hormonal treatment, which is a key component of the guidelines.2 Moreover, in calling for more research, they ignore existing efforts to improve evidence in this field.7 Third, the authors raise the issue of de‐transition, which refers to the observation that some individuals who identify as transgender may eventually return to living as a member of their birth‐assigned sex. This subject has gained attention in mainstream media, which appears to be the authors’ source of information on this topic.5 While more research is needed, existing studies show true de‐transition is uncommon. For example, only 0.4% of 27 715 transgender people surveyed in the United States de‐transitioned because they felt transition was not right for them; more often, de‐transition occurred due to outside pressures (eg, parents, family, religion) and discrimination.8 In summary, Byng and colleagues’ call for more high quality research is not novel and has long been acknowledged by those of us in the field. Moreover, withholding gender‐affirming treatment via wait‐and‐see strategies mentioned by the authors is not without harm,9 and development and ongoing revision of guidelines such as ours will ensure that transgender individuals receive the best care based on up‐to‐date empirical evidence.

Ken C Pang · Carmen C Pace · Michelle A Tollit · Michelle M Telfer

To the Editor: Infective endocarditis with Staphylococcus aureus is associated with a high mortality despite optimal antibiotic therapy.1 The synergy between bacteriophages and antibiotics has been shown in vitro and in animal studies,2 and bacteriophages have demonstrated their value in severe bacterial infections.3 AB‐SA01 (AmpliPhi Biosciences) is a bacterial DNA‐free and protein‐free highly purified preparation of three obligately lytic Myoviridae, each at 109 plaque‐forming units per dose.4 This preparation has been recently used successfully for staphylococcal sinusitis by local irrigation.5 A protocol was established for bacteriophage therapy as an adjunct to standard care of severe staphylococcal infections under the auspices of the Therapeutic Goods Administration Special Access Scheme. Here, we report the first intravenous use of AB‐SA01 in a case of severe staphylococcal sepsis with prosthetic valve endocarditis. A 65‐year‐old man with a 30‐year‐old mechanical aortic valve presented with a week of malaise, severe exertional dyspnoea, and central pleuritic chest pain. He had been successfully treated for Haemophilus aphrophilus aortic valve endocarditis 8 years earlier with antibiotics alone. Examination revealed fever, tachypnoea, tachycardia and borderline hypotension (90–100 mmHg systolic), with a praecordial systolic murmur and click. There was no cardiac, renal or hepatic failure or any evident peripheral embolic sequelae of endocarditis (haematuria, splinter haemorrhages) at this stage. Blood cultures repeatedly grew an identical methicillin‐sensitive S. aureus determined by whole genome sequencing, and the patient received high dose intravenous flucloxacillin, ciprofloxacin and rifampicin (Box). Transoesophageal echocardiography confirmed vegetations on prosthetic aortic and native mitral valves, and the aortic root was thickened with possible paravalvular root abscess. Scheduled cardiopulmonary bypass for operative source control was postponed after a haemorrhagic infarction in the distribution of the left anterior cerebral artery on day −7 (ie, a week before starting bacteriophage therapy), despite concerns regarding development of an aortic root abscess, ongoing fevers and hypotension. Intravenous AB‐SA01 was administered twice a day for 14 days in conjunction with the patient's prescribed antibiotics, commencing (Day 1) 9 days after his first positive blood culture. Blood cultures were negative at onset of bacteriophage therapy, and the C‐reactive protein, temperature, and white cell count results showed downward trends within 24 hours (Box). This trajectory was only interrupted by splenic infarction and occlusion of the superior mesenteric artery 48 hours after commencement, which was proven on computed tomography scan (not shown). No fevers, tachycardia, hypotension or rashes were detected after bacteriophage infusions and no adverse sequelae were attributable to the therapy. The patient recovered after 40 days of antibiotic therapy and returned to his home state for follow‐up. A positron emission tomography scan on Day 80 showed no fluorodeoxyglucose‐avid lesions, including intracardiac lesions. Repeat echocardiogram on Day 98 for progressive heart failure showed severely dilated left ventricle with moderate mitral and trivial aortic regurgitation. A possible mechanical aortic valve vegetation and paravalvular phlegmon were again demonstrated. Blood cultures were negative. He declined surgical intervention and died on Day 103. To our knowledge, this was the first case of staphylococcal prosthetic valve endocarditis treated with intravenous bacteriophage (AB‐SA01), which complies with good manufacturing practice standards.4 Bacteriophage infusions were well tolerated. Future controlled trials are needed to evaluate adjunctive bacteriophage therapy, especially when surgical intervention is not feasible. Box – Graphical representation of antimicrobial treatment, bacteriophage therapy and inflammatory markers − = negative blood cultures; + = positive blood cultures; CRP = C‐reactive protein; SMA = superior mesenteric artery; WCC = white cell count. ◆

Timothy Gilbey · Josephine Ho · Louise A Cooley · Aleksandra Petrovic Fabijan · Jonathan R Iredell

To the Editor: I refer to the opinion piece by Brewster and Waxman.1 The authors defined collegiality as “a work environment where responsibility and accountability are shared by colleagues, with mutual respect”. However, in a health care setting, professional competency and patient safety are paramount; medical collegiality is desirable, but should not trump these goals. Collegial courtesy can compromise good patient care, despite concerns of competency in clinical judgement or skills. Poor communication contributes to most sentinel events,2 particularly during clinical handover. SBAR (Situation, Background, Assessment and Recommendation), which was what ISBAR (Introduction, Situation, Background, Assessment and Recommendation) was known as in 2009, was promoted to reduce dangerous transitions in the patient's journey in health care.3 Unfortunately, when first introduced in Australia, unnecessary local adaptations were applied to this simple tool — at least seven versions of SBAR existed across six states between 2009 and 2011.4,5,6,7,8,9,10,11 In 2002, SBAR was introduced by retired United States Navy Captain Doug Bonacum, while working at Kaiser Permanente on patient safety, to address the lack of effective communication in sentinel events similar to nuclear submarine incidents and airplane crashes. A quality and safety expert, he drew on his handoff experience from nuclear submarine crews needing to discuss strategies quickly during shifts changeover, thus improving communication, reducing unnecessary narratives and assisting decision making. SBAR improves communication both within the craft group and in interdisciplinary interaction as it flattens the hierarchy.12 ISBAR can fail when the giver (person providing ISBAR) neglects to prepare or perform ISBAR effectively; this is often due to inadequate training, preparation or consideration of what the receiver requires before initiating the handover. Hence, the success of ISBAR rests more on the giver rather than the receiver of the handover. Kindness should be part of ISBAR, but it starts with the giver initiating the handover. Adequate consideration should be made by ensuring thoughtful preparation and organisation to deliver relevant information professionally and competently.13 Less experienced givers should be ready to furnish any specific details upon request. Such reflections enhance communication, reduce errors and improve confidence and morale. Few can perform ISBAR properly “on the run”; formal re‐accredited requirements involving ISBAR should be mandatory for all health care professionals to ensure this critical clinical handover is done well. Slavish adherence to collegiality should not blur the fundamental issues of professional competency and patient safety.

Shyan Lii Goh

To the Editor: We read with interest the article by Brewster and Waxman1 published in the Medical Journal of Australia. Building kindness and collegiality into regular handover practice is an obligation of increasing urgency in contemporary medical settings. Clinical handover is often led by junior medical staff and can be perceived as a stressful time for them. Junior doctors have expressed fears regarding public approbation as a contributory factor for stress and burnout.2 Obstetric junior doctors within our own tertiary maternity hospital responding to the Australian Medical Association of Western Australia Hospital Health Check survey reported high levels of stress.3 Ultimately, handover is likely to be a precipitating event for stress and anxiety in this group, and addressing psychological wellbeing during this time will have benefits to both staff and patients.4 In 2018, we built kindness into our labour ward handover process, as part of a formal junior doctor wellbeing initiative. The existing handover structure commenced with individual staff introductions for all members of staff in attendance, including name and role for each staff member. We incorporated a specific staff member to handover, whose sole role, stated during introduction, is “I am here to provide emotional support to the team”. This explicit statement places emotional wellbeing of all staff members at the heart of the priorities for the handover session. Induction to the roles and responsibilities of the profession has been identified as part of the purpose of handover.5 By building kindness and support into our organisation on a daily basis, we hope to improve the wellbeing of all staff members involved in this small but vital daily interaction and embed kindness and support in the broader workplace culture. A post‐intervention survey of the response to our emotional wellbeing initiative will be available in July 2019, at which point, we will learn the effectiveness of the added focus on kindness in handover meetings. Preliminary feedback from our junior doctors has been positive.

Alarna Thomas · Katrina L Calvert · Brendan Jansen

In reply

David J Brewster · Bruce P Waxman

To the Editor: We refer to Liaw and colleagues’1 recently published study in the Journal. We acknowledge the positive intentions and rigour of this trial, and empathically concur with Thompson and Thackrah’s2 comment that the results of this research “[do] not mean that efforts to improve cultural competence in health care settings should be abandoned”. To the contrary, this study demonstrates the urgent need for more research to improve cultural competence in the health care setting; in particular, the use of culturally safe research methods that truly benefit Aboriginal and Torres Strait Islander peoples and communities.3 Like Thompson and Thackrah,2 we question the authors’ choice of the cultural quotient questionnaire.4 This generic tool is not designed for assessing cultural competence of health professionals when working with Aboriginal and Torres Strait Islander peoples in Australia. Importantly, it lacks recognition of the unique colonial experiences of Aboriginal and Torres Strait Islander peoples and, therefore, it cannot measure health professionals’ understandings or attitudes about such a key part of any cultural training, where we would hope to see change. We suggest the use of a scale that has been designed and validated by Aboriginal and Torres Strait Islander peoples, such as the Cultural Capability Measurement Tool.5 We fear that, if not carefully interpreted, the study findings have the potential to further complicate and undermine the substantial work — endorsed by the National Aboriginal Community Controlled Health Organisation and the Department of Health — being undertaken to develop the cultural safety of Australia’s health system.6 It is crucial that in all areas of Australia’s health system, including Aboriginal and Torres Strait Islander health, we present a reliable, strategically aligned approach consistent with the vision of an Australian health system free of racism and inequality.6 It is important that we continue to work together to harness the energy and commitment of the workforce towards our shared goals. We look forward to the qualitative findings of the research study.

Sophie Hickey · Roianne West

In reply

Siaw‐Teng Liaw · Vicki Wade

To the Editor: We strongly agree with St Clair and colleagues1 that telehealth is a “game changer” for the provision of health services to Aboriginal and Torres Strait Islander communities in Australia. For more than 15 years, we have been engaging with Indigenous communities throughout Queensland, to plan and establish telehealth services for a range of clinical disciplines, including diabetes, ear, nose and throat, and aged care. Telehealth is contributing to positive changes in our health system and this is evidenced in our recent studies highlighting the value of telehealth for Aboriginal and Torres Strait Islander people. A systematic review of the outcomes of using telehealth for the provision of care to Aboriginal and Torres Strait Islander people reported improved social and emotional wellbeing, clinical outcomes and access to health services.2 Other benefits included improved screening rates and reduced need for travel.3 This review reinforced the importance of partnerships between Aboriginal community controlled health services (ACCHSs) and public hospitals. Telehealth also helps with the delivery of culturally appropriate care. In a qualitative investigative study,4 we found that telehealth allowed specialist care to be delivered from Aboriginal medical services which were familiar to the patient and local care providers. According to this study, a telehealth consultation with a specialist held in the ACCHS resulted in less stress and greater convenience; and also meant that an Indigenous health worker could be present during the telehealth appointment to provide advocacy and support for the patient.4 Telehealth also reduced out‐of‐pocket expense for the patient. These factors contributed to the interpretation of culturally appropriate services. Telehealth is already benefiting Indigenous people throughout Australia. All studies recognise the pivotal role of ACCHSs as advocates for telehealth. While telehealth applications are predominantly reported in rural and remote areas, we believe that telehealth is just as important for the delivery of specialist health care services to metropolitan ACCHSs, in lieu of community members attending mainstream health services. Telehealth is one mechanism to help close the gap. Telehealth empowers community health services and can improve equity of access to health services in rural and remote — and urban — settings.

Anthony C Smith · Nigel R Armfield · Liam J Caffery

To the Editor: In the recently published article by Morgan and colleagues1 and associated podcast, the authors raised the issue of future research into the outcomes of identification of Aboriginal and Torres Strait Islander peoples in hospital. The implementation of a visual identification methodology has previously been described2 and was put in place in partnership with the hospital department of Aboriginal health. The purpose of this identification initiative was to encourage all medical professionals who care for Aboriginal and Torres Strait Islander patients to question what they can do to assist them while they are in hospital. We describe here the positive outcomes of this process. In addition to hospital pharmacists,2 the visual alert system is also used by other departments and professionals within the hospital, such as cardiothoracic care, the emergency department (ED), Aboriginal health, and speech pathology, as well as ward‐based nursing and medical staff. The Aboriginal and Torres Strait Islander patients’ identification system is used by health care providers within the hospital to easily identify the patients they need to visit, to provide culturally appropriate resources and services and links to other services, and to enhance the care patients receive and enable them to remain in a caring hospital environment. At ward level, nursing and medical staff use the identification system to highlight the referral process needed to link with Aboriginal health workers — connecting the right resources to the right people. Because of the visual alert,2 staff feel more aware of the cultural needs of the patient before they meet them. Specifically in the ED, there is a system‐wide approach that firstly identifies Aboriginal and Torres Strait Islander patients presenting to the ED using the visual alert at triage, and then implementing initiatives that aim to reduce the level of “did not wait for treatment” episodes. The Heart and Lung Stream at St Vincent's Hospital uses the system to identify Aboriginal and Torres Strait Islander patients early during their admission in order to provide culturally specific education, resources and follow‐up after hospital discharge. We encourage others to explore this initiative in their hospital, together with cultural responsiveness training, to enhance the care of Aboriginal and Torres Strait Islander peoples during and after their hospital visit.

Susan A Welch · Sonia Robinson · Tamra Langley · Pauline Deweerd

In reply

David JR Morgan · Martin Whitely · Tania Harris

To the Editor: Moynihan and colleagues1 make a good case for Australia responding to the complex challenge of reducing the overdiagnosis of clinical disease. However, this challenge should not lead to confusion with the early diagnosis of and the early intervention in preclinical disease, which are the mainstay of secondary prevention. While reducing diagnosis creep and expanding disease definitions are predominantly the realm of the specialist disciplines, primary care is uniquely placed to embrace preclinical disease diagnosis, increasing early detection and intervention, while specialists endorse reducing overdiagnosis, both collaborating in lowering long term costs to the health system. Preclinical disease and its impact are emerging as the logical next challenge. Prediabetes, for example, is almost always present before the onset of diabetes.2,3 Both the American Diabetes Association3 and Diabetes Australia4 have published recommendations on the diagnosis and screening for diabetes and prediabetes. The American Diabetes Association also leads the way in recommending that screening should be considered in children and adolescents who are overweight or obese and who have additional risk factors for diabetes.3 In 2015, the most comprehensive undertaking since Medicare's inception in the 1980s was established to consider how the more than 5700 items on the Medicare Benefits Schedule (MBS) could be aligned with contemporary clinical evidence and practice and improve health outcomes for patients with clinical disease (tertiary prevention).5 Although, the evidence base around early diagnosis and intervention is relatively recent, it is now opportune for the federal government to initiate a second tier to the MBS Review to consider new MBS items, where appropriate, for the early diagnosis of and early intervention in preclinical disease (secondary prevention). Further, this would align well with the new global awareness and endorsement of lifestyle medicine.6 Reversing the underdiagnosis of preclinical disease would be the perfect partner to reversing the overdiagnosis of clinical disease in delivering better health outcomes for patients, while reducing long term costs to the health system.

Eugen Molodysky

To the Editor: I read with interest the article by Moynihan and colleagues1 and commend the authors on their timely review of this important topic. While the article referred to research that had highlighted concerns about overdiagnosis in relation to several medical and surgical conditions, the only psychiatric condition mentioned was attention deficit/hyperactivity disorder. The authors referred to the problem of medicalisation as one of the possible drivers of overdiagnosis in one of the figures within the article, but not in the text of the article — medicalisation is the process by which non‐medical problems become defined and treated as disorders. In 2005, the medical expenditure on identified medicalised conditions in the United States was estimated to be about US$77 billion.2 Medicalisation in psychiatry has been a particular concern because of the problem created by ever‐expanding definitions of mental disorders and lowering of diagnostic thresholds.3 This has been well illustrated by the changes in the diagnostic criteria within the successive editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association, now in its fifth edition (DSM‐5). The effect of a change in the DSM diagnostic criteria was reported in 2001: changes from the third edition (DSM‐III) to the fourth edition (DSM‐IV), with an increase of the variety of stressors (events) considered capable of leading to post‐traumatic stress disorder (PTSD), led to a finding that 38% of DSM‐IV PTSD cases resulted from its wider definition.4 In the DSM‐5 the diagnostic criteria for PTSD have been further relaxed, so that “emotional reactions to the traumatic event” are no longer part of the diagnostic criteria. Another example of overdiagnosis in psychiatry is that of adjustment disorder. A 2008 article stated that there are “huge [numbers] of false‐positives for depressive and anxiety disorders because the context of symptoms is not taken into account,” and that the diagnosis of adjustment disorder “seems, by definition, ideally suited to apply to healthy people in dangerous and uncertain circumstances”.5 It is to be hoped that the 7th international Preventing Overdiagnosis conference in 2019 will include a session on overdiagnosis also in psychiatry.

George Mendelson

In reply

Raymond Moynihan · Alexandra L Barratt · Paul P Glasziou

To the Editor: I commend the Medical Journal of Australia for supporting high quality qualitative research with clear criteria for acceptance for publication1 on the background of increasing concerns these manuscripts are being rejected for reasons not based on the quality of the article submitted.2 However, I am concerned about the article by Chanchlani and colleagues,3 which involves randomised controlled evaluation of a peer mentoring program for new medical interns using qualitative interview‐based methodology.3 The Journal's Editor‐in‐Chief hoped this methodology would “encourage others to use comparable approaches when investigating similar topics”.4 A well conducted randomised controlled trial is considered among the highest level of evidence base for clinical practice; randomisation minimises bias from known and unknown confounders. However, other biases (selection, recall, measurement etc) also need to be controlled for randomised controlled trials to provide valid results and conclusions. Chanchlani and colleagues3 suggested their primary outcome was to assess psychosocial wellbeing and job satisfaction using inductive thematic analysis of data collected in semi‐structured interviews and focus groups at 12 months. This is different from the Australian New Zealand Clinical Trials Registry (ACTRN12618000455268, retrospectively registered) description which is “to determine the perception of the effectiveness of peer support on anxiety and depression;” the psychiatric training of the interviewers and the formal screening or post hoc assessment of the participants’ mental health are unknown. Qualitative research in randomised controlled trials is increasingly common, with new innovative purposes.5 Chanchlani et al3 reported a novel approach to qualitative research incorporating randomised controlled methodology; no quantitative data are apparent in outcome analysis, even though such measurement can be obtained from a post‐program feedback survey for both groups. Interview questions published in the online appendix cannot properly compare satisfaction rate nor assess the state of mental health. More is needed to justify comparative comments such as “participants with mentors reported high satisfaction with the program and a positive impact on stress levels, morale, sense of support, job satisfaction, and psychosocial wellbeing compared with participants without mentors”. It is desirable that the MJA supports innovative qualitative research. Important information may be omitted due to editorial requirements. Nevertheless, vigorous peer review and academic integrity are still needed. Care should be taken when comparative conclusions are made without adequate explanation.

Shyan Lii Goh

In reply

Sonia Chanchlani · Jeremy SL Ong

To the Editor: Pharyngitis, a common childhood illness, accounts for around 3% of presentations to general practice in Australia.1 Although usually benign and self‐limiting, group A streptococcus (GAS) pharyngitis, isolated in up to 20% of symptomatic children,2 can lead to infectious and autoimmune sequelae. Despite Australia being a high income country, acute rheumatic fever (ARF) and rheumatic heart disease (RHD) still cause significant morbidity and mortality in Aboriginal and Torres Strait Islander people.3 Prompt treatment of GAS pharyngitis has been shown to reduce the incidence of ARF by two‐thirds in high risk individuals.4 Low risk individuals require supportive management only.5 Clinical diagnosis of GAS pharyngitis is unreliable4 and culture results take time. As such, clinicians must balance the competing priorities of appropriate treatment of patients at high risk of ARF or RHD with prudent antimicrobial stewardship. Clinical practice guidelines play an important role in decision making at both a population and individual level. We undertook a search to identify Australian and New Zealand pharyngitis guidelines and compared these with previously published criteria.6 Nine guidelines were identified. Inconsistences in diagnosis, definition of high risk groups, analgesia, antibiotic rationale, agent, therapy duration, and tonsillectomy indications were observed (Box). Australia's multitude of heterogenic guidelines coupled with the transient workforce in remote Australia, where ARF burden is the highest,7 predispose to management confusion and potential poor patient outcomes, including higher rates of ARF and RHD, and also fail to address the growing worldwide problem of antimicrobial resistance. Australia needs a single national pharyngitis guideline to assist in providing rational, consistent and timely antibiotic treatment to patients at high risk of ARF, while minimising inappropriate antibiotic usage and resistance in individuals at low risk of sequelae. We call for an evidence‐based guideline that includes the following: a clear, succinct approach to diagnosis and management; a definition of individuals at high risk of ARF, and rationale for antibiotic treatment; clear guidance regarding throat culture and point‐of‐care testing for GAS; rationale for first‐ and second‐line empirical antibiotics, with alternatives for penicillin allergy; capacity to adapt management in different clinical settings; and supportive care recommendation including analgesia, tonsillectomy and school exclusion. Box – Summary of selected criteria:6 are criteria addressed by each sore throat guideline? Guidelines NZ HF BPAC NZ CH QLD NSW ICCPG CARPA RHD Aust PCH RCH eTG Number of criteria addressed 6/12 7/12 2/12 10/12 7/12 6/12 10/12 9/12 10/12 Diagnostic criteria × × × ✓ ✓ × ✓ × ✓ Routine throat culture/rapid antigen detection testing ✓ ✓ × ✓ × ✓ ✓ ✓ × Antibiotics to reduce symptoms × ✓ × ✓ × × ✓ × ✓ Antibiotics to prevent complications ✓ ✓ × ✓ ✓ ✓ ✓ ✓ ✓ NZHF = New Zealand Heart Foundation (http://www.heartfoundation.org.nz/shop/heart-healthcare/non-stock-resources/sore-throat-algorithm.pdf); BPAC = Best Practice Advocacy Centre (https://bpac.org.nz/antibiotics/guide.aspx#sore-throat); CH QLD = Children's Health Queensland Hospital and Health Service guidelines (http://www.childrens.health.qld.gov.au/chq/health-professionals/antimicrobial-stewardship/guidelines/ent-infections); NSW ICCPG = New South Wales infants and children clinical practice guidelines (http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2014_021.pdf); CARPA = Central Australian Rural Practitioners Association's standard treatment manual (https://docs.remotephcmanuals.com.au/review/g/manuals2017-manuals/d/20321.html?page=115); RHD Aust = rheumatic heart disease Australian guidelines (https://www.rhdaustralia.org.au/arf-rhd-guideline); PCH = Perth Children's Hospital emergency department guidelines (https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Tonsillitis); RCH = Royal Children's Hospital Melbourne guidelines (with support of the Victorian Paediatric Clinical Network) (www.rch.org.au/clinicalguide/guideline_index/Sore_throat); eTG = electronic therapeutic guidelines (https://tgldcdp.tg.org.au/searchAction?appendedInputButtons=sore%20throat). ◆

Adrian J Tarca · Robert M Hand · Rosemary Wyber

To the Editor: Patients may require long term anticoagulation for reasons that commonly include deep vein thrombosis, pulmonary embolism or atrial fibrillation.1 In these circumstances, heparin is commonly used for bridging and is discontinued after the effects of warfarin result in a therapeutic international normalisation ratio. It takes approximately 5 days for this to occur because warfarin inhibits the production of vitamin K‐dependent clotting factors II, VII, IX and X.2 The time to therapeutic anticoagulation is a reflection of the half‐lives of the circulating clotting factors and the time for them to diminish from the plasma. This has been our mindset for decades from the perspective of warfarin use. The introduction of direct‐acting oral anticoagulants (DOACs), such as apixaban, dabigatran and rivaroxaban, has resulted in important logistical and clinical benefits in patients admitted to hospital. For example, bridging with heparin is no longer needed3 because DOACs directly inhibit circulating clotting factors resulting in a relatively quick onset of anticoagulation. The maximum concentration in the plasma is achieved within a few hours, which also mirrors its anticoagulant effect.4 Unfortunately, based on internal audits at our institution, our medication safety committee has identified cases in which DOACs were combined with heparin or low molecular weight heparin. During a 38‐day audit period, there were 14 cases involving such duplication. Based on anecdotal discussions, this duplication is partly related to the prescribers’ lack of knowledge with regards to DOACs. Nurses or pharmacists usually intercepted these events such that the overlap occurred for a few doses and no patients were harmed. In the shift from warfarin to DOACs, inadvertent and unnecessary duplicate anticoagulation due to bridging increases the risk of bleeding. Although we seldom use absolutes, we can confidently endorse that there are no circumstances in which DOACs should be combined with another anticoagulant. Prescriber education and clear institutional guidelines may help deal with this issue. In addition, institutions with electronic medical records could optimise clinical decision support systems to prevent such duplication. The combination of DOACs with heparin is a bridge to nowhere.

Mark A Sheppard · Russell Levy · Asad E Patanwala

To the Editor: Recent Australian surveys of gluten content in gluten‐free labelled foods purchased from supermarkets or restaurants are reminders of the difficulties faced by patients with coeliac disease.1,2,3 Despite trying to adhere to a gluten‐free diet, significant inadvertent gluten exposure is common, leaving about 30% of patients with incomplete intestinal mucosal healing.4,5 In Australia, a “no detectable gluten” standard applies to food labelled gluten‐free. However, surveys published in the Journal reported detectable gluten in 14% of imported gluten‐free foods (0.5–1.1 parts per million [ppm]),2 in 9% of gluten‐free marketed restaurant foods in Melbourne (5.2 to > 80 ppm),3 and in 2.7% of “commonly purchased” gluten‐free foods (5–49 ppm), including foods manufactured in dedicated gluten‐free factories.1 The governance of the compliance with the gluten‐free food code is unsatisfactory; the testing of gluten‐free foods is done by the food industry. Despite a multilayered food code bureaucracy, there is no federal or state oversight of testing, and test results are not published. State authorities have not investigated the non‐compliance reported for imported gluten‐free foods in 2016.2 Local governments are responsible for implementing state food laws, yet, they cannot coordinate oversight of gluten testing nationally. The federal Department of Agriculture and Water Resources is responsible for imported foods, but there is no evidence they test gluten‐free foods imported from jurisdictions that permit up to 20 ppm gluten. The Australian Competition and Consumer Commission is responsible for the Australian Consumer Law, and Food Standards Australia and New Zealand establishes the food code standard; however, there has been no indication by either agency that they consider the problems with the gluten‐free standard or its governance a sufficient public health issue to warrant changes to current practices. Inadvertent gluten exposure may occur by cross‐contamination from known gluten‐containing foods, or from foods considered free of gluten by listed ingredients but not labelled gluten‐free. The very least that patients with coeliac disease should expect is negligible additional contamination from foods that are labelled gluten‐free. Transparent testing of gluten‐free labelled foods is therefore critical. It is unlikely that the government will implement regular testing programs in place of the current ad hoc and unreported industry‐based testing. However, mandating the regular publication of laboratory test results is a simple measure to reassure consumers with coeliac disease, and would likely be a positive initiative for local gluten‐free food exporters seeking to take international advantage of the tight Australian gluten‐free standard.

Geoffrey M Forbes

To the Editor: Bateson and Black1 do a great service in encouraging clinicians to discuss pre‐conception care with women of reproductive age.1 However, in relation to infection prevention, one area not discussed was cytomegalovirus (CMV) infection, which is the most common infectious cause and the second most common aetiology of all causes of severe congenital malformations.2 Mother to child transmission of CMV can result in prematurity, stillbirth, cerebral palsy and neurodevelopmental delay and is the most common infectious cause of hearing loss.2 Discussions about CMV prevention should ideally commence before pregnancy, as maternal CMV infection in the first trimester poses the greatest risk of harm to the fetus if mother to child transmission occurs. Such discussions should continue throughout pregnancy, as secondary maternal infection with a different strain of CMV can also result in mother to child transmission of virus,2 although the risk per infectious event is lower. Women can adopt simple hygiene strategies to reduce risk of CMV infection and thus reduce mother to child transmission of virus during pregnancy. These recommendations have been published3 and referenced in consensus recommendations2 and other sources.4 Strategies preventing women acquiring CMV (usually from children)3 are acceptable and inexpensive — handwashing, not sharing food or objects covered with children's saliva, not kissing children on the lips and wearing disposable gloves during nappy changes. These strategies reduce the risk of infection before pregnancy and of mother to child transmission during pregnancy;2 they do not affect reactivation of latent virus, although this is associated with lower mother to child transmission. Universal serological screening with CMV IgG to determine previous immunity is not recommended, as congenital CMV can still occur as a result of non‐primary maternal infection and reactivation during pregnancy. Women should be advised to use hygiene strategies regardless of their serological status.2 In Australia, only one in six women who are pregnant know about CMV,5 and only one in ten maternity clinicians routinely discuss CMV prevention with pregnant women.6 It is likely fewer discuss CMV prevention before conception. We encourage clinicians, women considering pregnancy and parents to increase their knowledge about CMV and its prevention.4

Antonia Shand · Pamela Palasanthiran · William D Rawlinson

In reply

Deborah J Bateson · Kirsten I Black

In reply

Carmelle Peisah · Tiffany Jessop · Henry Brodaty

To the Editor: We note with interest the research letter by Taft and colleagues regarding unplanned pregnancy in Australia.1 An audit of terminations of pregnancy in our Australian metropolitan hospital service (Austin Health, Melbourne) supports the findings of the national survey while highlighting additional areas of educational need. Of 309 women (aged 15–46 years) who underwent terminations for unwanted pregnancy from January 2016 to October 2018, 145 chose surgical termination and 164 women chose medical termination. Compared with the national survey, our cohort had similar rates of not using contraception (48.2% v 56.5%) and contraception failure (51.8% v 41.4%).1 Failed barrier and oral contraception respectively accounted for 52.1% and 29.3% of contraception failures. This differs from the survey findings, where the most common contraception failure was oral contraception, followed by condoms.1 There is a paucity of Australian literature reporting long‐acting reversible contraception (LARC) usage following termination; however, a Swedish study found a rate of 34%2 and a New Zealand public hospital service reported a rate of 44.5%.3 Our post‐termination LARC rate was 58.2% (72.5% following surgical termination and 43.2% following medical termination). We attribute the higher rate to our conscientious use of tiered counselling4 (ie, presenting the most efficacious method first) to enable women to make informed decisions regarding contraception. The most common choice of contraception following surgical termination was a levonorgestrel‐releasing intrauterine device (Mirena [Bayer]) (56.0%); however, oral contraception was more popular (38.8%) following medical termination, followed by Mirena (25.9%). A British study also found that women more often chose an intrauterine device or implant after surgical termination,5 suggesting that ease of insertion under anaesthetic influences choice. Of the 134 women documented as not using contraception in our audit, three had received inaccurate medical advice regarding contraception, or had been inappropriately labelled as infertile due to age, endometriosis or polycystic ovary syndrome. A further three pregnancies occurred as a result of removing LARC without arranging alternative contraception. We support the researchers’ conclusion regarding the need to explore reasons for poor contraception uptake and determine where education would be most helpful.1 In addition to increasing access to and promoting informed choice of LARC in primary health care settings,6 greater efforts to improve practitioner knowledge of contraception management, as well as common gynaecological conditions to aid appropriate diagnosis and evaluation of fertility impact, are vitally important.

Sophie L Yeates · Charlotte V Elder · Sonia R Grover