Letters

To the Editor: In their recent article and media release, Schilling and colleagues1 concluded that after total knee replacement (TKR) “some inpatient rehabilitation is low value care”. The research was funded by Medibank Private. The article comes at a time of increasing interest in rehabilitation in the home (RITH) for TKR and other rehabilitation problems. Despite widely proclaimed opinions, there is limited high level evidence regarding outcomes for inpatient rehabilitation versus ambulatory rehabilitation. In research examining the benefits of RITH, higher complexity patients are often excluded from the studies.2 One of the limitations of this article is that important “patient‐related factors … including obesity, pre‐operative physical and mental health … functional performance” and others, “were not available”. A significant gap in the current debate is an almost total absence of nuanced thinking regarding which patients are clinically indicated and safe to have RITH. The authors’ conclusion is only a relatively minor aspect of the real problem, which is to ensure the best outcome for the patient. That is, we must confidently identify the right rehabilitation program, at the right time and in the right place. The Australasian Faculty of Rehabilitation Medicine3 is committed to ensuring high quality rehabilitation medicine services. We believe that: while many patients with uncomplicated TKR may be appropriate for RITH, there are many others for whom RITH is inappropriate or unsafe; the appropriate setting for TKR rehabilitation should be determined on evidence‐based clinical indicators and minimum safety standards;4 all patients with TKR (apart from the most uncomplicated cases) require referral to and assessment by or on behalf of a rehabilitation medicine physician (or other appropriately trained physician); and some ambulatory rehabilitation programs may be appropriate for TKR and other rehabilitation, but they must be evidence‐based, interdisciplinary, led by a rehabilitation medicine physician and adequately resourced, and not simply seen as a cheaper panacea for a struggling system. To achieve the best outcome for patients, decisions must be individualised and patient‐centred and they should start with a referral to a rehabilitation medicine physician, who can determine the right rehabilitation program, at the right time and in the right place. There are circumstances in which RITH is an alternative to inpatient rehabilitation for appropriately selected patients.4 Let's ensure, however, that we do not throw the baby out with the bathwater.

Timothy J Geraghty · Andrew M D Cole · Gregory Bowring

In reply

Chris Schilling · Anna Barker · Stephen F Wilson

To the Editor: We write to express our concerns regarding the Clinical Oncology Society of Australia (COSA) position statement on exercise in cancer care published in the MJA1 and promoted in media outlets as a “world‐first” position statement that calls for exercise to be prescribed for all patients with cancer.2 The guideline replicates those first published in Australia in 20093 and in the United States in 20104 as well as by other organisations,5 and are the same as public health recommendations for healthy adults.6 Given the array of cancers, disease stages and treatments and their combinations, it is somewhat surprising that the same general guideline is being prescribed for all patients with cancer and is not differentiated from that for healthy adults — especially, given patient health and comorbidity status and the challenges that a cancer diagnosis and treatment entail. Research in exercise oncology has progressed over the past 9 years, and more targeted and tailored guidelines reflecting the developing evidence base are now required for implementation in this population. Moreover, the majority of patients with cancer are unable to meet the COSA recommendation of at least 150 minutes of aerobic exercise and two to three resistance exercise sessions due to time availability and physical, psychological and financial capacity as well as access, let alone the level of care required for those with advanced disease. It is significant that the COSA recommendation has not been refined through clinical trials in patients with cancer and has the potential to create considerable angst for the patient and raise concerns for clinicians, who know that their patients may not be able to achieve such goals. Moreover, we highlight that there is minimal financial support for patients with cancer to undertake ongoing exercise, making the COSA recommendation somewhat superfluous. When exercise is prescribed, it must be evidenced‐based and tailored to specifically ameliorate adverse health problems, while recognising that certain modes and dosages of exercise may be detrimental. We agree that there is considerable potential for exercise medicine in the management of cancer; however, a more considered approach needs to be implemented rather than the generic exercise recommendations of the COSA statement.

Robert U Newton · Dennis R Taaffe · Daniel A Galvao

In reply

COSA Exercise and Cancer Group Executive Committee

To the Editor: It was a pleasure reading the 20 August 2018 issue of the Medical Journal of Australia, containing many informative, broad‐ranging articles. However, the absence of the authors’ qualifications, which ultimately establish who the authors actually are — possibly reflecting their credibility — may render an article potentially less valid for the readership. This contrasts with the detailed and impressive qualifications of the MJA staff members, faithfully and appropriately listed in each issue, transparently demonstrating their expertise. No MJA author is awarded such recognition. The perspective by Munk and colleagues1 highlighted the threat posed by predatory journals to researchers and academic literature. The MJA lists only their affiliations; therefore, the readership is unable to establish a frame of reference for their opinions. Cursory investigation reveals lead author, Peter Munk, to be a Canadian radiologist, thereby impressing also as an authority on predatory journals. Rochwerg and colleagues2 discuss clinical decision making with network meta‐analysis. Without their qualifications, the reader is unable to determine whether they are physicians, statisticians, health economists or politicians. In their helpful Editorial, Shorthouse and Stone3 examine the need for additional mental health care training for rural medical practitioners. It turns out that both authors are Australian general practitioners — Molly being a rural generalist, and Louise a professorial medical educator. Interestingly, neither is a specialist psychiatrist. Professor Olver4 discusses B‐cell non‐Hodgkin lymphoma in Queensland. Despite his fame, his Editorial would potentially have been augmented had the readership been presented with his impressive research and clinical credentials. It seems reasonable to raise the notion that the absence of authors’ postgraduate and other qualifications could diminish their contribution to the medical literature. Our group has previously documented the importance of journals publishing authors’ qualifications.5 We published that “if the author qualifications are designated, the reader may be quite sure that the article was not written by the medical records librarian, let alone the hospital trolley boy in a moment of inspiration”.5 This is not to say the hospital trolley boy is not entitled to offer his thoughts on a medical subject. Rather, it provides the readership with perspective concerning authors’ expertise and opinions.

Damien L Ling · Anna M Waldie · Ian C Francis

In reply

Nicholas J Talley AC

To the Editor: Doctors for the Environment Australia welcomed MJA’s recent planetary health issue.1 It could not come at a more crucial time. Human health and the environment are inextricably linked, and medical professionals have a vital role in actively protecting health through care of the environment. However, it was disappointing that little emphasis was given to the need to significantly mitigate greenhouse gas emissions, and to the important advocacy role that medical professionals share to raise awareness of the urgency of delivering Australia’s Paris Agreement commitment. Global temperature rises greater than 1.5–2°C will adversely affect planetary health, sustainable development and nearly all future health goals.2 Further temperature increases will be catastrophic to sea level rises and the food and ecosystems on which human life depends. While countries such as France and China move ahead on mitigation measures, Australia is, at best, slow to understand the urgency or, at worst, an active global laggard. Australia is one of the OECD countries most vulnerable to climate change;3 it is among the top seven countries contributing to 60% of the world’s biodiversity loss,4 and yet it is not transitioning jobs or future wealth towards sustainable energy. All while human-induced environmental threats to the global riches of the Great Barrier Reef, the Northern Territory and the Pilliga and Tarkine forests are fast becoming this generation’s environmental legacy. Doctors should urgently raise awareness of the threats to health from climate change, advocate to mitigate the threats, and show in practice that transitioning to low carbon societies in energy, diet and transport have health co-benefits. The greatest global health threat of the 21st century posed by climate change is also health’s greatest opportunity.5 Australian medical staff can systematically push the planetary health agenda into university training, specialist colleges, hospitals, clinics and communities. We are well placed to do so.

Selina N Lo · Kaiya Ferguson · Eugenie Kayak · Kingsley Faulkner

To the Editor: In 2007 and again in 2012, we highlighted in the Medical Journal of Australia1,2 the limited access Australian prisoners had to essential health protection measures. Six years on, we can only report that progress has been minimal (Box). In August 2012, the Australian Capital Territory Chief Minister announced the implementation of a needle exchange program for prisoners in the ACT; 6 years later, the ACT government retracted its commitment. Canada has recently agreed to a pilot prison-based needle exchange, with a commitment to national implementation in 2019. Human immunodeficiency virus (HIV) is still not a concern in Australian prisons, although bleach provision and condoms are still severely restricted in Queensland and the Northern Territory, and effectively not available in Victoria and Tasmania. Hepatitis B immunisation coverage continues to improve, and chronic hepatitis B infection is not increasing among Aboriginal and Torres Strait Islander prisoners.3 The availability of direct-acting antiviral treatments for hepatitis C infection for all Australians, including prisoners, has some Australian prisons already reporting treatment achievements commensurate to international treatment targets for 20304 — the term “micro-elimination” has been applied to facility by facility reduction of burden of this infection. However, despite reductions in hepatitis C in Australian prisons, the risk of transmission is ever present.5 The predictors of successful return to the community include housing, employment and maintenance of relationships;6 yet, private family (conjugal) visits are only allowed in some Victorian prisons and in one South Australian prison farm. Visits are definitely not available to ACT prisoners, since previous enabling policy was repealed in 2014. Safer sex is still an elusive aspiration for the majority of Australian prisoners and their families. Tattoo and body piercing programs are being implemented in prisons in Luxembourg and Catalonia, Spain. Despite this activity being successfully regulated in the community, there are still no verifiable reports of sanctioned programs in Australian prisons. In 2012, we questioned Australia’s commitment to protecting the health of prisoners.2 With changes in prison harm reduction programs internationally (notably, Canada) underpinned by legal challenges, we foresee that similar proceedings could have a place in finally driving reform in Australia. Box – Progress in Australian prisoners’ access to essential health protection measures Jurisdiction Changes since 2012 Australian Capital Territory Bleach available in single unit sachets; micro-elimination of hepatitis C from the only prison; private family visits ceased; support for a prison needle exchange program withdrawn New South Wales Micro-elimination of hepatitis C from several prisons Northern Territory No notable changes Queensland Still considering opiate replacement therapy; micro-elimination of hepatitis C from one prison South Australia Private visits available at one prison farm Tasmania Micro-elimination of hepatitis C from one prison Victoria Micro-elimination of hepatitis C from several prisons Western Australia Poor uptake of hepatitis C treatment

Michael H Levy · Carla J Treloar

To the Editor:Legislation mandates that all adult medical records be retained for a minimum of 7 years from the time of last patient contact, after which they can be destroyed. Exceptions to this requirement exist for young patients, and there are state-by-state variations, but there is no legislative requirement to retain records of patients who have implantable, high-risk devices. This is disturbing because many of these devices have an in vivo lifespan that exceeds 7 years. Of particular concern are patients with breast implants whose records may have been destroyed before a diagnosis of breast implant-associated anaplastic large cell lymphoma, which has an average latency period from implant to diagnosis of 9 years.1 Later presentations of this lymphoma are not uncommon, with latency intervals up to 23 years;2 therefore, it is imperative that implant details are retained to enable us to better understand the pathophysiology of this potentially fatal disease, which has been strongly associated with deeply textured surface implants. While the Australian Breast Device Registry (ABDR) is a safe repository for secure information on patients who are registered, those patients who are not may be at risk of losing important information about their implants. Furthermore, the expected lifespan of in vivo breast implants is at least a decade,3 so records may have been discarded at the time of patients presenting with serious implant-related problems. In our efforts to improve the safety of patients with breast implants, 30% of whom are breast reconstruction cases for cancer or congenital deformities, we encourage all practitioners to ensure that their patients are registered with the ABDR so their implant details are securely stored.4 In an effort to preserve the details of all Australian patients with breast implants, the ABDR can also store patient implant details retrospectively and will accept information from Australian patients having cosmetic tourism surgery overseas, after which significant complications can arise.5 It may be time, however, for legislation to be enacted to lengthen the mandatory retention period for patients with high-risk devices or to make it legally compulsory for practitioners inserting high-risk devices to enrol all patients into a clinical quality registry such as the ABDR.

Rodney D Cooter · Ingrid Hopper · John J McNeil

To the Editor:The National Bowel Cancer Screening Program will reduce the burden of colorectal cancer, saving lives and money.1 The benefits of the program, however, rely on both public and private sectors to deliver colonoscopy, surgery and, if necessary, advanced cancer care. Public confidence in the whole program is likely to be affected by the affordability, ability and availability of these frontline services. Some public hospitals are unable to reliably deliver timely colonoscopy (ie, within 120 days).2,3 Private practice is an efficient and, for many, affordable option, but there is considerable variation in price. Furthermore, pricing information is often not readily available before referral and can be complicated by multiple separate fees. In contrast, the public hospital system is affordable (free), but there may be issues of availability due to waiting times. The ability of the colonoscopist is relevant to both settings, with adenoma detection rate a well validated quality indicator.4 To test the performance of a discounted, anaesthetist-assisted, private colonoscopy service for high-risk public patients, we conducted the following observational study in a metropolitan practice. Through efficiencies and cost sharing, we provided colonoscopy for a discounted out-of-pocket fee of $310 ($300 for the colonoscopy plus $10 for the bowel preparation kit). We performed 100 colonoscopies and diagnosed seven cancers, with an adenoma detection rate of 66% and a median wait of 29 days. These colonoscopies, if performed publicly, would have cost the state budget over $190 000, at approximately $1900 per colonoscopy (Margaret Clark, South Australia Health, personal communication; July 2018). In contrast, the total cost of this program was about $94 895, comprising the total patient payment of $31 000 plus the total combined bulk-billed fee for clinicopathological services of $63 895. This program did not cost-shift, it cost-saved about $95 105. Private and public services should provide current information to general practitioners, patients and government concerning their affordability (total out-of-pocket fee), ability (http://recert.gesa.org.au/recertified.php) and availability (waiting time from GP referral to colonoscopy). The $310 out-of-pocket fee is unlikely to be the equilibrium price for self-funded colonoscopy in Australia and investment in public colonoscopy remains important. Nevertheless, we suggest that patient autonomy and access would be improved by real time accurate information about their colonoscopy options to allow them to make a rational choice. This would help optimise the benefits of the National Bowel Cancer Screening Program and allow public and private sectors to work together to eradicate bowel cancer death in Australia.

Peter Bampton · Tarik Sammour · Gregor JE Brown · David G Hewett · Daniel L Worthley

To the Editor:Lichen planus is an autoimmune mucocutaneous inflammatory disorder. Diagnosis is often made clinically and confirmed on biopsy.1 Hypertrophic lichen planus is a distinct subtype characterised by pruritic, hyperkeratotic plaques. Histopathological findings may not have the typical features of lichen planus and can mimic squamous cell carcinoma (SCC).2 Distinguishing between hypertrophic lichen planus and SCC can be difficult for clinicians and pathologists. In our dermatology practice, we encountered three patients initially diagnosed with SCC, but on review, the cases were consistent with lichen planus. One patient was a 52-year-old woman presenting with asymmetrical, raised and violaceous lesions to her lower legs. She was referred to a skin cancer clinic that performed biopsies of these lesions, which were reported as well differentiated SCC. These lesions were excised, but they were recurrent and were excised again. The second patient was a 54-year-old man who presented with a one-year history of eruptive raised, violaceous lesions to his chest and legs. Biopsies were reported as SCC and multiple lesions were excised by a general surgeon. The third patient was a 77-year-old woman with a 2-year history of pruritic lesions to the lower legs (Box). Biopsies were reported as well differentiated SCC. Each of these patients underwent numerous excisions before being referred to our practice. The patients were reassessed and new biopsies taken, and the clinical picture was discussed with a dermatopathologist. Hypertrophic lichen planus was confirmed as the diagnosis in each of these patients, and they responded well to prednisone, acitretin and topical steroid treatment. SCC may arise in long-standing hypertrophic lichen planus, but it should be emphasised that cases of supposed SCC with atypical history should not be treated without consideration of the many mimics of SCC, including pseudoepitheliomatous hyperplasia, irritated seborrhoeic keratosis, coral reef granuloma, hypertrophic lupus erythematosus and hypertrophic lichen planus. Clinicians should provide clinical description and a list of potential differentials when referring to a pathologist. Adequate biopsy depth is important, as lichenoid activity may only be present at the tips of the rete ridges, which may be missed on a superficial biopsy. These cases highlight the difficulties in distinguishing hypertrophic lichen planus from SCC. In the cases we described, correct diagnosis was made after re-evaluation and clinicopathological correlation. Box – Figure showing violaceous hyperkeratotic patches on the patient’s lower leg, with original biopsies reported as squamous cell carcinoma (A). Histopathology showed a lichenoid inflammatory infiltrate confined to the tips of the rete processes (B)* * Infiltrate is composed of predominantly lymphocytes with few eosinophils and plasma cells. While these features are typical of hypertrophic lichen planus, superficial shave biopsies may not capture the lichenoid infiltrate at the rete processes.

Emily X Shao · Benjamin Carew · James Muir

To the Editor:Calabria and colleagues1 report that, overall, 9.8% of Aboriginal and Torres Strait Islander adults are at high absolute cardiovascular disease (CVD) risk, reflecting how poorly Australia supports the social and cultural determinants of health for the First Australians. However, this is a different nuance from their statement: “Absolute CVD risk is high among Aboriginal and Torres Strait Islander people”. Aboriginal and Torres Strait Islander people have median age of 23 years,2 and only 1.1% of those in the 18–24 age group are at high risk. The authors note undertreatment with lipid-lowering therapies of Aboriginal and Torres Strait Islander people at high CVD risk; many Aboriginal and Torres Strait Islander people who would benefit are not offered best practice care. However, 13% of people at low CVD risk are on lipid-lowering medication,1 which may be unnecessary treatment, with costs and side effects. As health professionals we need to beware of tendencies to emphasise pathology and risk among Aboriginal people.3 Many health professionals hold ideas of “the passivity, dependency, and non-compliant nature of [the Aboriginal] mob … The perception of Aboriginality as … a health risk, and predictor of unhealthy behaviours … reinforces stereotypical ideas of Aboriginality… and disconnects Aboriginal people from their own identities … [and] stories of strength and survival”.3 There is a tension between our desires to prescribe behaviour to reduce risk and enabling and empowering people to make decisions for themselves. Well intentioned efforts to manage Aboriginal and Torres Strait Islander people may have iatrogenic side effects. For example, health professionals may develop assumptions about people’s behaviour and worthiness to receive treatment,4 while Aboriginal and Torres Strait Islander people themselves may be disconnected from their sense of self-efficacy and community and cultural strengths and identity, contributing to disengagement from health care.3 Like other procedures in health care, absolute CVD risk assessment has costs as well as benefits. Educating community members about absolute CVD risk would promote health literacy and enable people to give informed consent to assessment of this statistic. Numbers hold both face and cultural values, so it is important that Aboriginal and Torres Strait Islander people have control of their statistics.5

Rosalie Schultz

In reply

Raymond W Lovett

To the Editor: Primary meningococcal conjunctivitis (PMC) is a rare presentation of Neisseria meningitidis.1 Before antibiotics, N. meningitidis conjunctivitis was a recognised harbinger of cerebrospinal meningitis due to systemic infection.1-3 Secondary N. meningitidis conjunctivitis is now uncommon.1 PMC seeds exogenously from mucosal secretions, causing a primary infection of the ocular surface without systemic infection,4 and it is characterised by purulent conjunctivitis and periorbital oedema.3,4 Untreated PMC spreads systemically in 10–18% of cases,1,3,5 and early diagnosis is essential to prevent visual loss and life-threatening complications.1,3,5 In September 2017, the Northern Territory experienced an outbreak of N. meningitidis serogroup W strain. Presentations were atypical and, consequently, the threshold was low for empirical treatment. We report the case of a 4-year-old girl who presented to a remote clinic with a 24-hour history of rapidly progressive pain, erythema and discharge from both eyes. Her medical history was unremarkable. She had bilateral conjunctival injection with profuse yellow mucopurulent discharge (Box, A). Systemic examination was unremarkable. Considering the meningococcal outbreak, conjunctival swabs were sent for urgent Gram stain, which showed gram-negative diplococci with characteristic N. meningitidis appearance (Box, B). Ceftriaxone and topical ofloxacin were commenced as empirical meningococcal treatment. Ocular culture and polymerase chain reaction (PCR) were positive for N. meningitidis-W. Three blood cultures and serum PCR were negative. After 48 hours, the purulent discharge and eye pain resolved. On Day 4 of treatment, her conjunctivae normalised and she was asymptomatic (Box, C). Her family members received prophylactic treatment with ciprofloxacin. She was discharged from hospital on Day 6 and had an unremarkable follow-up. To our knowledge, this is the first reported case of N. meningitidis-W PMC. Since presentations of PMC in contemporary society are rare,1,3,4 clinicians may overlook PMC as a differential diagnosis to the patient’s detriment. Given the highly virulent nature of the N. meningitidis-W, the importance of early treatment and contact tracing is paramount, so that antimicrobial prophylaxis can be offered to close patient contacts, especially direct household members. To preserve vision and prevent systemic infection, a high suspicion of atypical microorganisms must be entertained, especially during an outbreak. Box – Primary meningococcal conjunctivitis due to Neisseria meningitidis: bilateral conjunctival injection with profuse yellow mucopurulent discharge (A), gram-negative diplococci with characteristic Neisseria appearance (B), and normalised conjunctivae (C)

James Sterrey · Farshad Abedi · Tim RM Henderson

To the Editor: Behavioural and psychological symptoms of dementia can manifest as aggression directed towards staff or other residents,1 often culminating in recourse to the local emergency department as a “permanent solution”. What does the law say? Under Division 2, User Rights Principles 2014 (section 96-1, Aged Care Act 1997), the only circumstances in which a provider may ask a care recipient to leave a residential care service are if (i) the service is closing; or (ii) the service no longer provides suitable accommodation and care (as assessed by an aged care assessment team or at least two medical or other health practitioners chosen by the recipient who are competent to assess their care needs) and the provider has not agreed to provide the care that the recipient presently needs; or (iii) the recipient no longer needs the care provided, as assessed by an aged care assessment team; or (iv) the recipient has not paid any agreed fees for a reason within their control; or (v) or the recipient has intentionally caused serious damage to the service or serious injury to staff or another care recipient; or (vi) the recipient is away continuously for 7 days or more from the service for reasons not permitted by the Aged Care Act or an emergency. The approved provider must neither imply nor take action to make the care recipient leave, unless suitable alternative accommodation is available that is affordable and meets the care recipient’s needs. Written notice must be given of the decision and reasons for it. A person cannot be asked precipitously to leave a nursing home or, in practical terms, hospital staff or family cannot be told that a bed is no longer available without adhering to the guidelines above. Intention regarding injury and behavioural and psychological symptoms of dementia is complex and cannot be used as grounds for discharge without proper assessment. An alternative is to use the Dementia Behaviour Management Advisory Service and Severe Behaviour Response Teams (24-hour helpline: 1800 699 799), which provide clinical support for carers of people with behavioural and psychological symptoms of dementia. Aged care consumers need to be aware of their rights around security of tenure, and facilities should be resourced sufficiently to fulfil their commitments under the Aged Care Act to care for residents with behavioural and psychological symptoms of dementia.

Carmelle Peisah · Tiffany Jessop · Henry Brodaty

To the Editor:The Reflection article by Bravery1 reminded us of the disability rights movement slogan “Nothing about us without us” and prompted us to reflect on the ways in which expert patients, carers, health and patient advocates, and community members contribute to medical student teaching at the School of Medicine at the University of Notre Dame Australia, Fremantle. Their partnership is crucial to the School being able to meet the standards — (2.1.4) “the medical education provider relates its teaching, service and research activities to the health care needs of the communities it serves,” and (4.6) “learning and teaching methods in the clinical environment promote the concepts of patient centred care and collaborative engagement” — of the Australian Medical Council’s Standards for Assessment and Accreditation of Primary Medical Programs.2 From the School’s inception in 2005, academic staff and community members have worked collaboratively, in the spirit of reciprocity, to teach students. First-year students engage with teenage mothers, expert patients and their families, older people in community-based physical activity classes, and patients in general practice settings, and they live with a family in the Wheatbelt region in Western Australia to learn first-hand about the social determinants of health and the health needs and priorities of Australians in rural settings — a program undertaken in collaboration with the medical students from Curtin University.3 By the end of the pre-clinical years, students have been taught by sex workers, people of diverse sexualities, and children with cancer via panel discussions and in clinical skills sessions, and they have shadowed a patient to witness their lived journey in a community radiology clinic. A one-week Kimberley placement provides insight into health issues in remote areas by living and working in community settings such as Indigenous communities, pastoral stations, art galleries and sporting organisations. These opportunities pave the way for collaboration between the School and other professions and industries — two-way interprofessional learning in real-world settings. As stated by Bravery,1 the impact on students is palpable. They appreciate the opportunity to understand people’s personal perspectives4,5 and apply this understanding to their medical practice — “the [rural or remote placement] guides my work now … It comes back to me; it helps me understand rural people’s lives”.6

Donna B Mak · Jelena Maticevic · Brian D Power

To the Editor:In less than 12 months, voluntary assisted dying (VAD) will become a reality in Victoria. The recent past has seen much passionate debate on both sides of this issue, covering aspects of its impact on society, public health, the law, medicine and an individual’s right to self-determination. Public health interventions have provided our society with significant benefits in many areas; however, for most physicians in clinical practice, our care is focused on each individual patient. To date, little attention has been placed on the implications of VAD for each doctor–patient encounter in which a request is made. For a clinician, the most challenging aspect of VAD now is how to support our patients. How do we balance the fundamentals of our professional and personal beliefs with our clinical and therapeutic responsibilities in practice? The legislation allows doctors the choice to participate in VAD or not; yet, we wonder how we may navigate this therapeutic space. While we believe that directly ending life is a boundary we cannot cross, we also know we cannot abandon our patient at what would clearly be a time of need. Can the doctor–patient relationship survive when electing not to participate? No amount of debate in Parliament will answer this question. We believe we need to derive collective wisdom to craft our compassionate response in this setting — in a considered and thoughtful manner. We believe we must recognise our own distress and anxiety and, nevertheless, remain focused on how we best care for patients. We need to remember our critical role as scientists to learn how to accurately assess, measure and report risks and benefits, to improve care for patients requesting VAD and to inform public health policy. In Victoria, VAD will soon be available. As doctors we must consider our response to our patients and assess the resulting impact on our relationship, here and now. This is a conundrum we had hoped we would never need to face. And it is what keeps us up at night.

Brian H Le · Jennifer Philip

To the Editor: Due to the adverse effects of modified release (MR)-oxycodone/naloxone in patients with moderate to severe liver impairment as a result of advanced cirrhosis or with spontaneous or artificially created portosystemic shunts (Box), its use in this patient population is contraindicated.1 In our clinician roles, we have observed both poor analgesic efficacy and opioid withdrawal in such patients, and similar observations are reported in the literature.2,3 There are clear pharmacological and physiological bases for these outcomes. MR-oxycodone/naloxone is an oral combination opioid analgesic. The naloxone component is subject to a significant first-pass metabolism, and bioavailability is less than 2%.4 The benefit of low level oral bioavailability of naloxone is reduced opioid-induced constipation due to antagonism of opioid receptors in the gut while permitting the desired analgesic opioid effects. The recommended dose of MR-oxycodone/naloxone ranges from 2.5/1.25 mg to 80/40 mg twice daily — the upper limit guiding prescribers to avoid further opioid dose escalation.1 In patients with compensated cirrhosis (mild hepatic impairment) (Box), MR-oxycodone/naloxone may cautiously be prescribed.1 Satisfactory analgesia without significant adverse effects has been observed in selected patients with compensated cirrhosis and pain from hepatocellular cancer.5 In moderate to severe liver impairment, the first-pass (hepatic) metabolism of both medications are markedly but disproportionately reduced, thereby increasing the systemic relative exposure to naloxone (Cmax > 5000% of control) compared with oxycodone (Cmax > 200%).1 The mechanisms are hepatocellular dysfunction and spontaneous portosystemic shunting.3 Artificially created surgical or transjugular intrahepatic portosystemic shunts also reduce hepatic extraction. Hepatic infiltration due to malignancy similarly reduces the liver’s ability to metabolise MR-oxycodone/naloxone effectively.2 The relative increase in exposure to naloxone reduces analgesic efficacy through increased antagonism of opioid pain receptors. Escalating doses of MR-oxycodone/naloxone (or other opioid) may not achieve improved analgesia.2 The relatively high systemic naloxone exposure may also induce opioid withdrawal symptoms.3 Switching from MR-oxycodone/naloxone to oxycodone immediate-release in a patient with hepatic impairment contributed to opioid toxicity due to the sudden loss of the high level systemic naloxone exposure.2 In patients with moderate to severe liver impairment due to advanced cirrhosis or with portosystemic shunts, clinicians should be aware of the contraindication of MR-oxycodone/naloxone. Box – Severity of liver impairment in cirrhosis Liver impairment Clinical features of portal hypertension/portosystemic shunting Biochemical signs Mild Early, compensated cirrhosis No ascites or hepatic encephalopathy Albumin ≥ 35 g/L Bilirubin < 34 μmol/L INR < 1.7 Moderate to severe Advanced, decompensated cirrhosis Portosystemic shunting Presence of: Oesophageal/gastric varices Portal vein thrombosis Ascites Hepatic encephalopathy Hepatorenal syndrome TIPSS Surgical portosystemic shunt Albumin < 35 g/L Bilirubin ≥ 34 μmol/L INR ≥ 1.7 INR = international normalised ratio. TIPSS = transjugular intrahepatic portosystemic shunt.

Venessa Pattullo · Gavin G Pattullo · Simone I Strasser

To the Editor: The recent guideline review by Almeida and colleagues1 coincides with an international call for action to address the burden of low back pain.2 Low back pain is a major societal problem and the number one cause of disability internationally. Recent guidelines prioritise advice, reassurance and self-management as first line care. Implementing these simple, high value interventions is important in populations, such as Aboriginal Australians, where there has been limited previous recognition of low back pain as a problem. A recent systematic review of musculoskeletal pain among Aboriginal Australians3 summarised that the prevalence of low back pain is higher among Aboriginal Australians and has disproportional impacts. Qualitatively, low back pain has multidimensional effects, including functional, cultural and emotional. Access to both primary and specialist level care is lower for some musculoskeletal pain conditions such as osteoarthritis, and there may be parallels for low back pain. Worryingly, there is evidence that the health care that Aboriginal people receive for low back pain is worse than that received by non-Aboriginal Australians, including care with the potential to cause iatrogenic harm. These include higher rates of opioid prescribing and unhelpful low back pain information. Low back pain is associated with a higher number of comorbid health issues, psychological stress and income poverty, and may contribute to the complex milieu of health burden and disadvantage for some Aboriginal communities. The implementation of effective, high value, first line care described by Almeida and colleagues1 is critical for Aboriginal people with low back pain; however, it needs to be adapted so that it is acceptable, accessible and appropriate. For example, advice and education to reassure patients and encourage self-management may need to be supported by culturally appropriate low back pain information. This could include visual, story-based information that has been developed with input from Aboriginal people.4 Implementing successful self-management requires doctors to develop trusting relationships with patients in services that are culturally secure for Aboriginal people. Effective communication is critical.5 The provision of evidence-informed low back pain care to Aboriginal patients requires better recognition of low back pain as a health issue affecting Aboriginal Australians, and a greater understanding of how such care can be best implemented in Aboriginal communities.

Ivan Lin · Donna B Mak · Juli Coffin · Peter O'Sullivan

In reply

Matheus Almeida · Bruno Saragiotto · Chris G Maher