Letters

Debra J Rickwood · Jason Trethowan · Patrick D McGorry

Brendan Harney · Michael Curtis · Peter Higgs

To the Editor: The impact of the coronavirus disease 2019 (COVID‐19) pandemic continues to affect institutional care, both acute and aged care services. More hidden is the impact on community care, especially community palliative care. Community palliative care aims to enable people to die where they wish. About 70% of the population seek to die at home, but between 4% and 12% actually do.1 During the COVID‐19 pandemic, however, data from three Melbourne community palliative care services indicated a rise in deaths at home of between 30% and 50% (personal communication, John Doran, Manager, Melbourne City Mission Palliative Care; Janet Phillips, Chief Executive Officer, Peninsula Home Hospice; and Kelly Rogerson, Chief Executive Officer, Palliative Care South East; December 2022). This increase has not been recently reported in Australia. One factor may be family reticence to admit their family member for inpatient care because of continued visitor restrictions2 — also reflected in international literature.3,4 Consequentially, the client profile has changed as more people present with complex needs and a higher number need terminal care. This requires lengthier visits from clinical staff — one service employed a registrar to support general practitioners (personal communication, Janet Phillips, December 2022). More emphasis is placed on telehealth, now routine, often substituting every second scheduled visit; and many staff work from home (personal communication, John Doran, Janet Phillips, and Kelly Rogerson, December 2022). The use of in‐home overnight respite has markedly increased, providing additional support to family carers (personal communication, Janet Phillips, December 2022). Perhaps because of increased workload, locum doctors are less available, meaning that palliative care staff are increasingly called on to support terminal care, including complex symptom management, and to verify death (personal communication, John Doran, Janet Phillips, and Kelly Rogerson, December 2022). Staff are still required to do regular risk assessment, including COVID‐19 testing, and to wear personal protective equipment, aligned with Department of Health guidelines for health care workers.5 A significant number of inpatient bed‐days are saved when people are supported to die at home, which may reduce the burden of care in institutional settings.6 Further work is required to measure the impact of home‐based care on outcomes for terminally ill people and their families and to understand the value of that care to the health care system.

Margaret O'Connor

To the Editor: Haining and colleagues discuss compensation for medical practitioners in supporting patients through the voluntary assisted dying process, which requires much time and effort.1 We want to inform you how the Netherlands, where euthanasia has been performed since 2002, has dealt with this challenge. A Dutch physician who performs euthanasia must evaluate whether a patient is suffering hopelessly and unbearably, is adequately informed, has no reasonable alternatives available, and is making a voluntary and well considered request. A second independent physician also needs to evaluate the patient, which often requires multiple house visits. Six weeks after the procedure, a review committee establishes whether all due diligence requirements were fulfilled. In 2021, 7666 people underwent euthanasia in the Netherlands, mostly performed by general practitioners for patients suffering from a malignancy.2 Everyone who lives or works in the Netherlands is legally required to have health insurance. Insurance companies finance the health costs through premiums and an income‐related contribution, collected through the government's tax on wages. On a side note: for religious reasons, it is possible to choose an insurance company that does not reimburse the costs of euthanasia or abortion. Every patient needs to be registered with a specific GP, who receives a registration payment every three months from the health insurer of between €18.76 and €51.86 (AU$30.37 and AU$83.96 at 3 April 2023), depending on age. When the patient visits the physician, an additional €11.51 (AU$18.63) is paid.3 However, as euthanasia is a time and effort consuming trajectory, the physician is entitled to additional compensation. Several home visits are required to investigate and explore the euthanasia request, for which the physician receives €88.85 (AU$143.84) per visit. On the day euthanasia is performed, the GP receives €269.99 (AU$437.09) from the health insurer. The second, independent physician receives €602.27 (AU$975.01) for their efforts. The pharmacist who prepares and processes the return delivery of the euthanasia drugs can invoice €274.00 (AU$443.58). Here, we have provided some insight into the compensations for physicians and pharmacists who facilitate euthanasia in the Netherlands, and we hope this can contribute to the discussion on the remuneration of this important work in Australia.

Stefan Leus · Jan Bollen

To the Editor: We thank Gibney and Steer for their editorial1 in response to our research letter,2 supporting further public health action and research into invasive group A streptococcal (iGAS) disease. However, we are concerned about the statement that the 30‐day risk of iGAS disease for contacts of someone with an index infection is about 2000‐fold higher than background risk. This figure is derived from an English population‐based study3 and cannot be universally applied across circumstances varying in background incidence of GAS‐related disease, which is driven predominantly by socio‐environmental factors. Applying this 30‐day secondary attack rate of iGAS infection in Northern Territory household contacts would translate to about 177 cases per 1000 population (18%) in Indigenous Australian contacts and 2738 per 1000 population (274%) in people receiving haemodialysis.2 In contrast, rates of iGAS infection in household contacts were 3.2 per 1000 population in Canada4 and 0.7 per 1000 population in the United States.5 As described in the NT public health guidelines for iGAS, previous NT and Queensland studies have demonstrated large diversity of iGAS genotypes,6 with less clonality and a greater proportion of sporadic cases rather than transmission directly from another case of iGAS infection. This reflects the stark contrasts in iGAS and other consequences of GAS infection between central and northern Australia and southern states, as seen with so many other health issues linked to socio‐economic disadvantage. Gibney and Steer also note that some authorities recommend antibiotic prophylaxis for close contacts, and others do not.1 We wish to highlight that the NT guidelines for the public health response to iGAS include specific guidance around antibiotic prophylaxis for close contacts (for mother–neonatal pairs, contacts of severe iGAS disease cases, and in other special circumstances), informed by a literature review in the Appendix.6 National guidelines for iGAS are currently being developed and these need to include advice tailored for the vastly different epidemiology seen across Australia, reflecting a contrasting diversity of endemicity of GAS‐related disease. This has also been necessary for the Australian guidelines for diagnosing acute rheumatic fever, with low risk and high risk populations defined.7

Johanna M Birrell · Bart J Currie · Vicki L Krause

To the Editor: Paradoxically, both vitamin B6 deficiency and excess are associated with peripheral neuropathy. Increasingly, patients are presenting with peripheral neuropathy associated with elevated vitamin B6 whole blood levels, as previously presented by our laboratory.1 With a societal push towards wellness, there has been a greater uptake of over‐the‐counter vitamins in recent years. Magnesium is taken by patients for muscle, nerve and digestive issues, as well as for stress, anxiety and overall wellness. For some of these listed indications, the evidence is dubious. Vitamin B6 (as pyridoxine hydrochloride) is common among magnesium supplements based on the theory that the cellular uptake of magnesium is enhanced.2 These supplements are readily available in pharmacies, supermarkets and online, and contain up to 60mg of vitamin B6 per tablet. When purchasing magnesium supplements, patients may be unaware that they are also getting vitamin B6 and the quantity included could be hazardous to health. A patient taking two magnesium tablets per day could be unintentionally consuming 120mg of vitamin B6, now considered a large dose. This is far greater than the recommended dietary intake of vitamin B6 for adults in Australia and New Zealand of 1.3–2.0mg/day with a maximum of 50mg/day.3 The pharmacokinetics of pyridoxine hydrochloride are complex. Despite being water soluble, it has a half‐life of up to 30 days. Repetitive small doses taken over a period of months can accumulate, resulting in high blood concentrations. Vitamin B6 is associated with peripheral neuropathy when whole blood levels exceed 250nmol/L.4 Our laboratory recently presented a study showing that about 39% of our patients had elevated vitamin B6 whole blood levels (>190mol/L, the upper limit of our reference interval). The study included data from 88655 samples.1 A recent regulatory change from the Therapeutic Goods Administration mandated that products containing vitamin B6 in daily doses above 10mg now require a label warning.5 This previously applied to products containing over 50mg per daily dose. The Therapeutic Goods Administration has also reduced the maximum permitted daily dose from 200mg to 100mg for adults. It also noted cases where peripheral neuropathy developed in patients taking less than 50mg daily.5 This change applies to products produced after 1 March 2023 and therefore does not apply to products purchased before this date. In addition to being present in magnesium supplements, vitamin B6 (as pyridoxine hydrochloride) is contained in many multivitamins and energy drinks. Community awareness is key.

Gemma M Daley · David Kanowski · Lee Price

To the Editor: O'Shea and colleagues1 have highlighted the importance of precision medicine and recognised that health care systems are struggling to adapt to new genomic innovations. New technologies are frequently distributed unevenly and follow socio‐economic gradients, and health care systems have a responsibility to ensure equitable access.2 In South Western Sydney, there is a significant population of culturally and linguistically diverse people whose genetic risk factors for cancer development and treatment are different to those of the greater Sydney population. Consequently, the Department of Anatomical Pathology at Liverpool Hospital has offered next generation sequencing (NGS), using the 50‐gene Oncomine Precision Assay (ThermoFisher Scientific) for multiple tumour streams, including non‐small cell lung cancer (NSCLC) and colorectal cancer. A nine‐month internal audit of 400 patients has found that 77% of patients with stage IV NSCLC and 82% of patients with stage IV colorectal cancer had at least one gene mutation identified using this panel. Currently, the European Society of Medical Oncology has put forward a clinical scale of actionability of molecular targets, ESCAT, to help clinicians understand the utility of genetic variations in cancer.3 The guidelines define mutations from tier I to tier X based on degree of actionability. The NGS results found that 56% of patients with colorectal cancer and 50% of patients with NSCLC had tier I mutations, defined as those with clear evidence of clinical actionability. Twenty‐one per cent of patients with colorectal cancer and 28% of patients with NSCLC had tier II or III mutations with potential actionability. In addition to providing access to standard of care treatments, NGS provides a means for patients to access novel clinical trials. In our cohort, about 45% of both NSCLC and colorectal cancer patients had additional mutations on the 50‐gene panel that are currently being investigated in early phase clinical trials. Standardisation and funding of testing across Australia is critical to prevent inequities of access to testing, especially in patients in South Western Sydney with lower rates of private health insurance, high rates of socio‐economic disadvantage and low rates of health literacy. Currently, there are a limited number of centres available in New South Wales to provide NGS testing and, thus, now is the right time to get it right for all Australians.

Udit Nindra · Abhijit Pal · C Soon Lee

To the Editor: The article by Williams and colleagues1 is a narrative review of prostate cancer care from a urological perspective. However, developing recommendations for prostate cancer screening requires complementary perspectives, including population health, general practice, and the wider community. Population‐based prostate‐specific antigen (PSA) testing to screen asymptomatic men for prostate cancer is not supported by the references cited by Williams and colleagues or by systematic reviews, which identify and account for bias.2 The Royal Australian College of General Practitioners (RACGP) has assessed the current evidence and has advised against prostate cancer screening.3 The RACGP guidelines specifically state that GPs have no obligation to offer prostate cancer screening, and advise against adding PSA to a battery of pathology tests. The RACGP and the National Health and Medical Research Council have developed information sheets drawing attention to the numbers of men with screen‐detected prostate cancers who would never know they had cancer if they had not undergone screening, as well as to the impotence, incontinence and bowel problems that prostate cancer diagnosis and treatment can cause, whether necessary or not.3,4 Between 42% and 66% of screen‐detected prostate cancers would not have been diagnosed without screening. Prostate cancer is discovered at autopsy in 36% of men of European ancestry and in 21% of Asian men aged 70–79 years.5 As Williams and colleagues note, prostate cancer screening can lead to earlier diagnosis of aggressive cancers, and modern techniques enable individualised patient‐centred treatment.1 However, for the men whose cancers would never have been detected without screening, any treatment is unnecessary and potentially harmful.5 Prostate cancer screening does not meet the aim of reducing overall mortality.2 After 11 years of annual screening, four of 1000 screened men compared with five of 1000 unscreened men have died of prostate cancer. Among the screened men are 87 cases with a false positive PSA test result, of whom 28 have complications of biopsy, including 0.5 extra heart attacks. Both groups have lost 190 men from all causes.3 Australia's GPs manage a growing demand for evidence‐based primary health care, and the RACGP supports them by developing standards and guidelines. These are based on unbiased approaches and, with the current evidence, they cannot recommend prostate cancer screening.3

Rosalie Schultz

To the Editor: Kamini Vidrawan Ras (Kamini) is an opiate‐containing Ayurvedic preparation with multiple purported functions.1 Kamini comes in the form of handmade tablets or balls, with varying quantities of opium within the tablets ranging from 2mg to 20mg.2 Chemical analysis of Kamini tablets revealed a variety of opioid alkaloids and heavy metals such as lead, mercury and arsenic.2 There are reports of patients suffering significant harms from heavy metal poisoning after ingestion of Ayurvedic medicines.3 Evident risks of the use of Kamini include the development of de novo opioid use disorder, use of the preparation as an additional opioid source by current opioid users, and contribution to potential harms including overdose, particularly when combined with other opioids or drugs. In Australia, Kamini poses a public health concern as an unregulated opiate‐containing medication available in certain Indian grocery stores.4 Australia is trying to curb the harms associated with opioid medications through real‐time prescription monitoring and various other interventions. As opioid medications are being increasingly scrutinised and rationalised, importation of Kamini into Western countries could increase. In 2016, the Therapeutic Goods Administration prohibited the importation of Kamini, but patients are still presenting with opioid use disorder‐associated with this Ayurvedic preparation.1,2,4 The limited evidence regarding treatment and management of opioid dependence related to Kamini shows that the majority of patients can be stabilised with opioid substitution therapy, remain engaged in treatment, and cease Kamini use.1,4 Most patients (22/24) in the two largest case series on Kamini use were of Indian background and a large proportion were of Punjabi origin.1,4 Some sociological studies about Punjabi men and the cultural norms within this community state that it is appropriate to use substances to deal with stress and to increase productivity.5 Traditional views on the role of medications can be precipitating and perpetuating factors for ongoing substance use and could lead to poorer health outcomes. Treatment for patients with Kamini dependence should include culturally appropriate and specific education.

Thileepan Naren · Jon Cook

To the Editor: Nursing homes need enough qualified, skilled staff to care for residents with diverse clinical needs and preferences. Even though most staff are personal care workers, registered nurses and enrolled nurses represent the majority of registered health care professionals. The Royal Commission into Aged Care Quality and Safety heard that, by 2050, best practice nursing home care will require about 7170 more enrolled nurses.1,2 Despite this, the importance of enrolled nurses in the sector is overlooked. Newly legislated minimum time standards and requirements for registered nurses’ presence 24/7 do not explicitly include enrolled nurses.3 This means employers are incentivised to use other staff, particularly personal care workers. There are already reports of providers making enrolled nurses redundant despite staff shortages, risking further workforce deprofessionalisation and possible worse outcomes for both residents and staff.4 Although evidence specific to enrolled nurses is limited and must increase,5 they are valuable, regulated staff members in nursing homes and their role represents an important step in career progression between personal care workers and registered nurses. If Australia is to develop a world‐class aged care sector that prioritises the best possible resident outcomes and experiences and matches staffing levels and skills to the needs of residents, then enrolled nurses must be valued multidisciplinary team members. Necessary legislative change should mandate a minimum time standard for direct care staff that includes clear specification of the enrolled nurses’ role and contribution.

Micah DJ Peters

To the Editor: Over 26000 Australians experience out‐of‐hospital cardiac arrest (OHCA) each year, with almost nine in ten of these patients not surviving to hospital discharge or 30 days.1 Although it is known that swift defibrillation increases the possibility of patient survival in these situations, and that initial defibrillation by first responders (regardless of training) is associated with greater survival than initial defibrillation by emergency medical services,2 in Australia, less than 2% of OHCA cases receive defibrillation by a bystander.1 It is likely that this is driven by the limits to publicly accessible automated external defibrillators (AEDs) in Australian communities.3 On 30 November 2022, South Australia took a major step to deal with this problem and reduce death from OHCA. The SA Parliament passed the Automated External Defibrillators (Public Access) Bill 2022,4 making SA the first state or territory in Australia, and one of few in the world, to mandate the public provision of AEDs. The legislation, introduced by Member of the Legislative Council, the Hon Frank Pangallo of the SA‐BEST party, had bipartisan political support and backing from various organisations, and follows a recent public health campaign to install AEDs in Adelaide. The Bill will come into effect for government and public buildings in 2025 and a variety of private buildings in 2026, with awareness campaigns, grant programs, and communication with organisations being the focus of the interim period. The expected cost to the SA government of $7.2 million across four years is weighed against the $2 billion gross domestic product loss that Australia incurs annually as a result of sudden cardiac arrest.5 The health and economic benefits of public access defibrillation to Australian society are large. For the benefit of all Australians, other states and territories should follow the example set by SA and move to implement similar laws mandating the public availability of AEDs in their communities.

Joshua G Kovoor · Gregory J Page · Pramesh Kovoor

To the Editor: Until recently, detection of locally acquired tox gene carrying diphtheria in Australia was rare. Toxigenic diphtheria had almost disappeared from the Australian landscape, with the widespread uptake of the diphtheria toxoid vaccine. Diphtheria is predominantly caused by toxigenic Corynebacterium diphtheriae and can present as both respiratory and cutaneous diphtheria disease. There have been increasing reports internationally of diphtheria outbreaks primarily in vulnerable migrant populations.1 In Australia, there were 46 diphtheria cases between 1999 and 2019 (eight respiratory diphtheria and 38 cutaneous), with C. diphtheriae accounting for 87% of these cases.2 Since 2020, a genomically linked clone of tox gene carrying diphtheria bacteria has spread across North Queensland. Cases described here are from the Queensland Health's Notifiable Conditions Register. The Townsville Hospital and Health Service Human Research and Ethics Committee provided an ethics exemption (EX/2022/HREC/88895) for this study. Of the 29 linked cases identified between 2020 and 2022, all have had epidemiological links to North Queensland and 23 were notified in 2022. Three of these cases were detected interstate. Clinically, three cases presented with classic diphtheria, four with mild respiratory diphtheria, and 22 with cutaneous diphtheria. The median age was 21 years (range, 2–59 years). Of the 29 cases, 34% (10/29) were aged 11–20 years and 45% (13/29) were older than 20 years. Further, 38% of cases (11/29) were fully vaccinated, 48% (14/29) were partially vaccinated and 10% (3/29), including two of the classic diphtheria cases, were unvaccinated for their age according to the National Immunisation Program Schedule. All were acquired in Australia, and 86% of patients (25/29) identified as Aboriginal and/or Torres Strait Islander. Isolates in the cluster are closely genomically linked, with between zero and 20 single nucleotide polymorphism differences found on whole genome sequencing. All cases were managed with penicillin or azithromycin, vaccination, and diphtheria antitoxin administered when deemed appropriate by infectious disease physician assessment. Azithromycin was given in most cases, as higher minimum inhibitory concentrations to penicillin have been observed with this clone. Household contacts were screened for symptoms, administered chemoprophylaxis with penicillin or azithromycin, and offered a diphtheria‐containing vaccine if due. A North Queensland public health working group has recently been established to develop a consensus on further public health management. This diphtheria outbreak, almost exclusively in Aboriginal and Torres Strait Islander communities, highlights the continuing impact of social determinants on disease in vulnerable populations. We recommend clinicians be aware of these cases and consider diphtheria among their differentials in patients from, or who recently travelled to, North Queensland. Classic diphtheria is characterised by a sore throat, fever, and membrane on the back of the throat, which may cause difficulty in breathing and swallowing. Cutaneous diphtheria usually presents as a non‐healing ulcerative lesion.2 The toxoid vaccine protects against the toxin effects rather than the infection itself. Unvaccinated individuals are therefore at highest risk of severe disease, including classic diphtheria, myocarditis, and neuropathies. Vaccination remains imperative and timely vaccinations are essential. The National Immunisation Program Schedule currently recommends a diphtheria‐containing vaccine for children at two, four, six and 18 months, and four years, and adolescents at 11–13 years. A diphtheria‐containing vaccine booster is recommended for adults at 50 years.3 Clinicians across the state and nation should be vigilant for future cases.

Allison Hempenstall · Jay Short · Tonia Marquardt · Valmay Fisher · Janice Johnson

To the Editor: A recent survey found that 65% of Australians choose cremation over burial, and that, in the context of the coronavirus disease 2019 (COVID‐19) pandemic, cremations could be increased fourfold.1 It seems appropriate to look at the various roles of the medical practitioner in approving cremations. The first crematorium was built in England in 1878.2 Medical practitioners were at the forefront of the movement in Australia, and argued that cemeteries were already overcrowded and in disrepair, that a fear of being buried alive was common, and that cremation was a hygienic way to dispose of the dead when it was still believed that cemeteries were a source of disease in the living.2 The first Australian crematorium was established in Adelaide in 1903, after which progress halted due to ongoing debate;3 however, objections were overcome and many were constructed in the interwar years (Box 1). The most cogent reason for rejecting cremation was that it could be employed to hide homicides. The contrary argument was that having a medical practitioner verify the cause of death would both prevent undetected crime and advance medical knowledge.4 To provide for this verification step, each Australian state and territory introduced legislation setting out a process for the approval of cremations. Where the cause of death is suspicious or unclear, permission is withheld and referral made to a coroner. In Queensland, Tasmania and Victoria, any medical practitioner who did not complete the death certificate may issue a cremation permit (Box 2). In the Australian Capital Territory, New South Wales and Western Australia, only government‐appointed medical referees may issue a permit. Some states and territories also require assessment of cremation safety, verifying that there is no implanted battery‐operated device, which may explode and damage the cremator, and that the deceased has not received radioisotopes, which may create a public health risk during cremation. At the Public Health Unit, we manage the appointment of medical referees for the NSW Ministry of Health. As part of the review of the effectiveness of our procedures, in 2020 we developed a short questionnaire to identify reasons why medical referees may refuse permission to cremate and to seek suggestions for improvement to this administrative process. We emailed it to a 10% random sample of NSW medical referees (n = 77) and received 46 responses (60%). Of these, 29 respondents (63%) had served in the role for more than 15 years, nine (20%) for five to 15 years, and five (11%) for less than five years. The number of permits issued in the previous 12 months ranged widely: 25 had signed zero to ten, and at the other extreme, two provided estimates of 780 and 1200 permits. This large variation is most likely related to varying demands on medical referees by local funeral directors. The reasons for rejecting applications included inconsistencies in the forms (ten), incorrect or unclear cause of death (seven), a reportable death (four), uncertain identity of the deceased (one), and a retained battery‐powered device (one). No suggestions for improvement were made, but three respondents suggested we provide some medical referee training — we have undertaken to develop an online education module. Although roles differ between Australian jurisdictions, medical practitioners have an important responsibility for verifying that a body is suitable for cremation, a decision that they must make independently of the practitioner who certifies the cause of death. Box 1 – Woronora Crematorium, Sydney, constructed in 1934* * Courtesy of Woronora Memorial Park. Box 2 – Roles of medical practitioners in approval of cremation under current legislation for each Australian state and territory State or territory Legislation Final approver of cremation Name of permit Comments Who assesses cremation risk Australian Capital Territory Cemeteries and Crematoria Regulation 2003 Medical referee, a medical practitioner appointed by the Director‐General Certificate of medical referee The medical referee must view and be satisfied with the “Certificate of medical attendant” The “Certificate of medical referee” must state that there is no medical reason why the remains should not be cremated New South Wales Public Health Regulation 2022 Medical referee, a medical practitioner appointed by the Secretary Medical referee's cremation permit The medical referee must be independent of the applicant and of the medical practitioner who attended the deceased A medical practitioner must provide cremation risk advice concerning battery‐operated implanted devices and radioactive treatment Northern Territory Cemeteries Act 1952 Crematorium manager Cremation permit A permit can only be issued by the cremation manager if the certificate provided is signed by two medical practitioners stating that death was due to natural causes No reference to assessment of cremation risk Queensland Crematorium Act 2003 Independent doctor Permission to cremate (independent doctor) The independent doctor is a doctor who has not signed the cause of death certificate or the “Cremation risk certificate” Any other medical practitioner may complete the “Cremation risk certificate” South Australia Burial and Cremation Act 2013; Burial and Cremation Regulations 2014 Registrar of Births, Deaths and Marriages Cremation permit Registrar of Births, Deaths and Marriages must consider the “Death from natural causes certificate of second doctor” Second doctor certifies that there is no reason why the body of the deceased should not be cremated Tasmania Burial and Cremation Regulations 2015; Burial and Cremation Act 2019 Medical practitioner Cremation permit The medical practitioner who issues the permit must not be a partner, employee or relative of the medical practitioner who issued the medical certificate in respect of the deceased person The medical practitioner who signs the permit must be satisfied that any implanted medical device has been removed Victoria Cemeteries and Crematoria Act 2003; Cemeteries and Crematoria Regulation 2015 Registered medical practitioner Certificate of registered medical practitioner authorising cremation The registered medical practitioner is someone who is not the medical practitioner who completed the notice in respect to the death of the deceased The funeral director must take note of any battery‐operated implanted device mentioned on the “Medical certificate of cause of death” Western Australia Cremation Act 1929; Cremation Regulations 1954 Medical referee, appointed by the Governor Permit to cremate The medical referee must not issue the certificate of cause of death or be in partnership with the medical practitioner who does so The “Certificate of medical practitioner” covers battery‐operated implanted devices and radioactive treatments

Mark J Ferson · Reannon Johnson · Toni Cains

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has changed the doctor–patient relationship. The technological revolution that is telehealth has brought undeniable benefits to patients, including greater access and convenience, and more control and empowerment through self‐care.1 There are high satisfaction ratings for patients utilising digital health care technologies.2 Unsurprisingly, there has been an increased uptake in the use of online prescription, referral and medical certificate services where a pre‐existing doctor–patient relationship is not always present.3 In our experience, there is an increasing digital incursion on the traditional general practice consultation. General practitioners are being pressured by their patients to issue prescriptions4 and referrals outside of scheduled consultations. Presumably to preserve the doctor–patient relationship and potentially business interests, we have seen GPs acquiesce to these patient requests, often with little to no consultation. This is occurring despite previous research showing that consumer demand is a driver of unnecessary tests and treatments.5 This non‐contemporaneous doctor–patient interaction exacerbates the demand for fast, convenient health care delivered how and when patients dictate. In this instance, ensuring consumer satisfaction is potentially at odds with ensuring good and safe patient outcomes. There are risks of engaging with this type of instant medicine. Increased accessibility to, and demands made of, GPs increases their workload burden2 and precipitates cognitive overload. This emerging expectation of doctors to engage in asynchronous interactions with patients, outside of consultations, creates what we term a “digital fourth wall”. Patients can access their GP in an inherently one‐sided encounter, with doctors given little time and opportunity to reciprocate. Our concern is that the impersonal nature of this doctor–patient interaction may beget a diminution of professional responsibility towards the patient and suboptimal treatment and diagnosis. Striving for a mutually acceptable outcome through shared decision‐making processes will ensure that duty of care to the patient, based on GPs’ best clinical judgment, is not compromised. This may mean saying “no” to a patient, despite what we observe to be the natural inclination of many GP colleagues to acquiesce to increasing digital demands. The medico‐legal risk, and responsibility for patient care, ultimately rests with the GP. Despite appearances, novel innovations in technology do not always lead to health improvements.

Michael Tran · Katrina Anderson

To the Editor: In a recent Editorial,1 Grimwood and Chang cited a review of long COVID in children and adolescents,2 and wrote that symptoms are similar for those with and without evidence of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection. But this is an inaccurate description of the review's findings. Cases were more likely to experience persistent symptoms than controls in the majority of studies reviewed.2 The difference in prevalence might be even greater than reported owing to the well documented underdetection of coronavirus disease 2019 (COVID‐19) in children,3 resulting in misclassification of cases as controls. A growing body of evidence indicates children are more affected by COVID‐19 than initially thought. A recent US Centers for Disease Control and Prevention (CDC) analysis of 1.4 million children aged under 12 years and 1.7 million adolescents aged 12–17 years found increased rates of asthma, myocarditis and cardiomyopathy, cardiac dysrhythmias, diabetes, renal failure, venous thromboembolism, and coagulation disorders in children with laboratory‐confirmed COVID‐19 compared with children without COVID‐19. These increased risks (excluding asthma) were also experienced by adolescents with COVID‐19, who were additionally at increased risk of pulmonary embolism.4 Although uncommon or rare, such outcomes suggest children are not spared the cardiovascular and metabolic sequelae of COVID‐19. Recent research using low field magnetic resonance imaging (MRI) revealed persistent pulmonary dysfunction in non‐hospitalised children and adolescents (mean age, 11±3 years) who had recovered from COVID‐19 (n = 29) or had long COVID (n = 25). Despite all children having morphologically normal lungs (except for one recovered child), ventilation and perfusion (V/Q) matching was markedly lower in the recovered group (62±19%) and the long COVID group (60±20%) compared with nine healthy controls (81±6%; mean age, 10±3 years).5 Although the MRI study may be limited by selection bias (ie, children with greater symptomatology being more likely to participate), this and similar research indicate the health impact of paediatric COVID‐19 is greater than generally acknowledged. We do not know what the long term impact of SARS‐CoV‐2 infection might be, but the accumulating data are not encouraging. Reinfection is common and SARS‐CoV‐2 spreads readily in schools in the absence of mitigation measures, such as the use of masks, portable HEPA air cleaners, and improved ventilation. Notably, better ventilation has wider benefits, including improved academic performance. A poorly ventilated classroom can be equivalent to a student skipping breakfast.6 The COVID‐19 pandemic is not over. Ongoing commitment to a public health strategy informed by the precautionary principle is required. This will deliver wide‐ranging social, economic and health benefits.

Zoë Hyde

To the Editor: Lord and colleagues’ article1 provides a much‐needed snapshot of breast cancer distant recurrence and metastatic survival. As one of Australia's leading breast cancer advocacy organisations, Breast Cancer Network Australia (BCNA) has long been calling for reporting of recurrence data. Although we can justifiably celebrate a 5‐year survival rate of 92%,2 the long term data on distant recurrence reported by Lord and colleagues demonstrate the importance of looking beyond 5 years to understand the full burden of disease. In addition, Lord and colleagues’ survival data after distant recurrence is a critical first step in understanding the survival experience of this important but neglected group. In the associated Editorial, Redfern and Martin3 highlight that Australia's cancer registries do not systematically collect or report recurrence. The same applies for stage at diagnosis. Consequently, the number of Australians living with metastatic breast cancer is unknown. This is a fundamental problem. Without information to quantify this group of people we cannot adequately plan or deliver services. The problem extends beyond breast cancer to cancers such as prostate, melanoma, colorectal and lung, where targeted therapies, immunotherapies, and antibody drug conjugates are driving improvements in survival for patients with metastatic disease.4 These patients often have long term, complex supportive care needs yet have little visibility in our health care system. BCNA's 2017 national survey of 10318 people with breast cancer identified higher information and support needs among patients with metastatic compared with non‐metastatic breast cancer.5 These information and support needs were also less likely to be met by services for people with metastatic compared with non‐metastatic breast cancer.5 On 13 October 2022, which was Metastatic Breast Cancer Awareness Day, BCNA launched its Making metastatic breast cancer count Issues Paper to draw much‐needed attention to these issues.6 In the absence of cancer registry data, we applied Australian modelling from 2008 to current breast cancer mortality data.2,7 We estimate that in 2020 there were at least 10553 Australians living with metastatic breast cancer. Data from the United States suggest this number will continue to grow.8 Collection of recurrence and stage at diagnosis data will require national leadership and accountability, including continued investment in Cancer Australia's Stage, Treatment and Recurrence Project. Critically, it will also require input from key stakeholders including data‐management experts, cancer epidemiologists, cancer registries, clinicians and consumers. The time for action is now.

Andrea Smith · Vicki Durston · Sam Mills

To the Editor: We applaud the authors for comparing ambulance offload times with mortality and re‐presentation rates for patients presenting with chest pain.1 However, the model employed by the authors fails to account for the independent impacts of access block and emergency department (ED) overcrowding on poor outcomes and thus risks overemphasising the influence of ramping. There is clear evidence that ED overcrowding and access block are associated with worse patient outcomes, including increased mortality, re‐presentation rates and ambulance offload times.2,3,4,5 This could explain many of the study's findings: ramping is the symptom, ED overcrowding and access block are the disease. Secondly, there are fundamental differences between tertiles 1 and 3 that have not been addressed. The patients in tertile 1 are more likely to have been offloaded straight into the waiting room, a common procedure in most EDs, whereas patients in tertile 3 would not, potentially due to poor mobility, dementia, or being assessed as requiring significant cardiorespiratory monitoring. For this reason, patients in tertile 1 would be expected to have better outcomes than those in tertile 3. The article adjusts for the presence of eight comorbid conditions but not their severity. Furthermore, the incidence of each individual comorbid condition was marginally higher in tertile 3, and although individually not statistically significant, the cumulative impact of multiple comorbid conditions would be higher in tertile 3, which could confound the results. The study's use of the Charlson index is limited, as it only uses the identified eight comorbid conditions. The Charlson index also includes dementia, hemiplegia, heart failure, liver disease, and cancer; these are not measured in the study and would all contribute to offload delays and worsened outcomes. Lastly, without including patients presenting via private transport with chest pain, and in the absence of any measures of ED overcrowding and access block, the analysis of patients presenting with chest pain remains incomplete. That ED overcrowding and access block, evidenced by ambulance offload delays, is associated with worsened outcomes is well known. Unfortunately, focusing on the symptom of ambulance ramping, rather than the disease of ED overcrowding and access block, risks leading to ill‐informed policy decisions and ineffective solutions.

James L Mallows · Bridget Honan · Sierra Beck

To the Editor: We read the article by Wang and colleagues1 with great interest. In their study, they used linked administrative datasets from 2005 to 2018 to investigate sex differences in pre‐hospital management of patients with stroke from a single jurisdiction. Among their findings, they observed that a greater proportion of women (52.4%) than men (47.9%) arrived at hospital by ambulance. We seek to draw attention to a similar, nationally representative study on the factors associated with the use of ambulances and access to evidence‐based care among patients with stroke.2 Our study included patients with first‐ever strokes from the Australian Stroke Clinical Registry (2010–2013) linked with administrative data (emergency, hospital admissions),2 as part of the Stroke123 study3 (including 39 hospitals from New South Wales, Queensland, Victoria and Western Australia). We found that among the 6262 patients with first‐ever stroke, 4737 (76%) arrived by ambulance.2 Interestingly, we also found sex differences in arrival by ambulance before adjustment for other covariates (women, 78.8% v men, 72.9%).2 In the Stroke123 study, we adjusted for factors associated with ambulance arrival.2,3 Some of the factors most strongly associated with ambulance arrival were age, frailty and markers of stroke severity. We found that patients who were older, frailer and had more severe strokes were more likely to arrive by ambulance. Following adjustments for age and stroke severity, the sex differences were no longer statistically significant.2 In other research undertaken by our group using linked ambulance, hospital and Australian Stroke Clinical Registry data, other important factors associated with arrival by ambulance included call‐taker or paramedic identification of stroke, which was less often identified in women.4 In the investigations on sex differences by Wang and colleagues, there was no adjustment for markers of stroke severity. We are curious as to why no adjustment for Glasgow Coma Scale was made, particularly when looking at assessment for stroke by paramedics. It is possible that the sex differences observed would not be as marked after adjusting for stroke severity.

Monique Kilkenny · Amminadab L Eliakundu · Joosup Kim

To the Editor: The metaverse is a virtual environment merging physical and digital realities.1 Once the thing of movies, metaverses are tipped to be worth $800 billion by 2024.2 They have potential to revolutionise digital health care delivery, access, education, and patient outcomes.3 Artificial intelligence (AI)‐enabled health care, with metaverse enhancement, could create virtual hospitals,4 transform clinical workflows and accelerate the diagnosis and treatment of conditions relating to mental health,5 cardiology,6,7 ophthalmology,8 and oral health,9 for example. AI‐enabled technology demonstrated potential during the pandemic by predicting the incidence of coronavirus disease 2019 (COVID‐19)10 and helping to identify sites for vaccine trials.11 Yet in the absence of strong national and global health governance and accountability mechanisms, digital health ecosystems create risk for medical confidentiality and privacy breaches12 resulting in data sharing13 and use/reuse by corporations or governments outside its intended purpose and the bounds of patient consent.14 For example, a National Health Service (NHS) Foundation Trust in the United Kingdom established patient data sharing with the international technology company DeepMind to develop machine learning‐based management tools,15 but British patient data moved to the United States when Google acquired DeepMind.14 Repurposing health‐related biometric and genomic data that cannot be altered is similarly concerning, and can result in racial profiling16 and privacy violations in the absence of appropriate legislation. Metaverses also have potential to accelerate discriminatory practices. Bias may be embedded in data used to train AI models through lack of community representation or participation.17 Structural inequalities may be reflected in health care datasets, creating risk for discriminatory outcomes.18 For instance, racial bias in a health care therapy algorithm resulted in the discriminatory underestimation of health risk for millions of American citizens, precluding access to vital treatments.19 Prioritising protections for underserved populations and their right to access safe virtual health care is crucial,20 especially for Australians at the intersection of inequities driven by poverty, disability, gender, homelessness, Indigeneity, and for the 11% highly excluded from accessing digital technologies.21 We recommend that the Department of Health and the Australian Digital Health Agency partner with the Australian eSafety Commissioner's work examining metaverse deployment,2 to ensure the highest ethical standards are upheld as planning moves forward and regulatory frameworks are developed.

Caitlin Curtis · Claire E Brolan

To the Editor: With the increasing interoperability of electronic medical records across health services, smoking and e‐cigarette use need to be systematically collected on hospital admission, and advice to quit smoking should be automatically included on hospital discharge summaries. Including information on smoking status in the discharge summary, and ultimately on My Health Record, presents an opportunity to address the use of tobacco and e‐cigarette products — the first being Australia's leading cause of preventable death and disease and the second an emerging exposure of increasing concern.1 Evidence from the United States Surgeon General reports that smoking cessation after cancer diagnosis lowers the risk of dying by 30–40%.2 For some patients with cancer, cessation benefits are equal to or exceed the value of state‐of‐the‐art cancer therapies. In addition, the Surgeon General report shows most patients admitted to hospital wish to quit smoking,2 and there are proven, workable but underused interventions to cease smoking. Peak medical bodies such as the Australian National Health and Medical Research Council and the Australian Commission on Safety and Quality in Health Care3 advise that adherence to post‐hospital referral practice guidelines leads to better outcomes, fewer readmissions, and improved patient survival. Australia's National Preventive Health Strategy has a goal of reducing the adult smoking prevalence from 14% to 5% over the next 8years.4 The newly released draft National Tobacco Strategy includes key policy actions to increase the use of cessation services and to support people who use tobacco and e‐cigarettes to quit.5 Around 1.2 million Australian adults are admitted to hospital at least once each year, and it is estimated that about one in five of them would benefit from smoking cessation services.6 Given most hospitalised patients want to quit smoking, providing this recommendation in a discharge summary for appropriate referral to a Quitline (www.quit.org.au) or a general practitioner is a practical solution to provide best practice care to patients, reduce the risk of readmission to hospital, and increase their survival.

Freddy Sitas · Ben Harris‐Roxas · Sarah L White · Fiona A Haigh · Margo L Barr · Mark F Harris