Health occupations

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

From fearing death as a paediatric patient to confronting it as a training doctor

Dominique S Schell

Health system leaders should integrate alternative models of emergency care that proved useful during the pandemic into care pathways

Amith Shetty · Jean‐Frederic Levesque

Improving knowledge about distress in medical and surgical specialties could assist with averting and mitigating physician burnout

Carrie Kollias · Chris Conyard · Melissa Frances Formosa · Richard Page · Ian Incoll

The gender balance of guideline panels should be improved to ensure high quality and equitable health care for all

Anna Shalit · Lauren Vallely · Renae Nguyen · Meghan Bohren · Agnes Wilson · Caroline SE Homer · Joshua Vogel

Future threats require an integrated approach to the health of humans, animals and the environment

Sandra G Steele · Jenny‐Ann LML Toribio · Siobhan M Mor

Decisions about late abortion and care for women and their families are supported by sensitive and professional care

Caroline M Costa

The Being Equally Well policy roadmap seeks to end the neglect of physical health for people living with serious mental illness

Rosemary V Calder · James A Dunbar · Maximilian P Courten

A 21-year-old man who migrated to Australia from Nepal 4 years previously was referred to a dermatologist

Akshay Flora · Priya Garg · Karen Cheung · Deshan F Sebaratnam · Monisha Gupta

Safe late termination services are essential for equitable reproductive health care for women

Shannyn Rosser · Renuka Sekar · Johanna Laporte · Gregory J Duncombe · Alexa Bendall · Christoph Lehner · Carol Portmann · Pauline McGrath · Karin Lust · Peter Ganter · Sailesh Kumar

Early detection remains an important strategy to reduce melanoma mortality and improve survival, and novel precision medicine technologies for melanoma diagnosis are rapidly changing this field

Rashidul A Mahumud · Monika Janda · H Peter Soyer · Pablo Fernández‐Peñas · Victoria J Mar · Rachael L Morton

To the Editor: Khatri’s and Stuckey’s1 article, Vertebral fractures after denosumab discontinuation for dental procedures: a consequence of distorted perceptions of risk, sums up the authors’ knowledge and experience of medication‐related osteonecrosis of the jaws (MRONJ) in the latter part of the title. They quote the risk of MRONJ as being very low and equal for denosumab and oral bisphosphonates. This is incorrect. The risk of MRONJ is 0.3%.2 In our study we found the risk following extractions at 1.8%.3 The recent 2022 update of the position paper on MRONJ4 found that the risk with denosumab is an order of magnitude higher than for bisphosphonates. There is no discussion in Khatri’s and Stuckey’s article1 of the effect of MRONJ on patients. A patient with stage 3 or end‐stage MRONJ has months of severe pain and requires jaw resection with or without microvascular reconstruction similar to that required for advanced jaw cancer.4,5 The impact of this is similar to vertebral collapse, both largely avoidable disasters. The current Australian recommendations for dental extractions for patients taking denosumab for osteoporosis are to delay extractions to 6 months after the last injection of denosumab and then to allow 4weeks for initial socket healing before the next injection.6 The risk is greater if the patient has been taking antiresorptives for more than 4years and if they are immunocompromised.4,7 We would agree that education and communication between prescribers, patients and dentists are key. This can only be achieved by close, mutually respectful communication and understanding between medical, dental, oral and maxillofacial surgeons and patients. However, this is easier to say than put into meaningful practice. Most definitive articles on MRONJ are in oral and maxillofacial surgery journals, which are not commonly read by physicians who prescribe antiresorptives. The most likely reason that the patient was taken off denosumab for 5 months was that the dental plan was not only to extract the teeth but to replace them with dental implants. Implants require time for osseointegration.8 Hopefully, this letter helps correct the distorted precepts expressed by Khatri and Stuckey for prescribers of this, otherwise, useful drug.

Alastair Goss

Many technical and regulatory hurdles have been overcome, but the field has a long way to go

Gabrielle O'Sullivan · Joshua G Philips · John EJ Rasko

A 48-year-old female health care worker of European descent, who was otherwise well and on no regular medications, developed cough symptoms the day before testing positive for coronavirus disease 2019

Nicole Seebacher · Julie Kirkham · Saxon D Smith

It is important to provide options for obtaining both oral fluid- and blood-based HIV self-tests

Dana YL Lee · Jason J Ong · Kirsty Smith · Muhammad S Jamil · Ruthy McIver · Rebecca Wigan · Kate Maddaford · Anna McNulty · John M Kaldor · Christopher K Fairley · Benjamin Bavinton · Marcus Chen · Eric PF Chow · Andrew E Grulich · Martin Holt · Damian P Conway · Mark Stoove · Handan Wand · Rebecca J Guy

First Nations Yol?u women are speaking up to reclaim control and return of childbirth services

Sarah Ireland · Yvette Roe · Suzanne Moore · Elaine Ḻäwurrpa Maypilama · Dorothy Yuŋgirrŋa Bukulatjpi · Evelyn Djota Bukulatjpi · Sue Kildea

Flesh made new: the unnatural history and broken promise of stem cells

Megan Munsie

Supporting improved general practice is urgent, and quality improvement collaboratives are an effective Australian strategy

Andrew W Knight · John Fraser · C Dimity Pond

A 6-year-old girl presented with a 24-hour history of sudden onset, non-tender periorbital rash

Yi‐Teng Hung · Chun‐Bing Chen

To the Editor: Fraile Navarro and colleagues1 recently published 20 recommendations for the treatment of coronavirus disease 2019 (COVID‐19) in children and adolescents from the National COVID‐19 Clinical Evidence Taskforce. For the paediatric inflammatory multisystem syndrome (PIMS‐TS) recommendations, the Taskforce convened an expert advisory group.1 In the absence of clinical trials, the panel considered peer‐reviewed guidelines and cohort studies to formulate consensus recommendations.1 However, they deferred providing any guidance to help clinicians prevent thromboembolism. We suggest the Taskforce consider the same approach for paediatric anticoagulation guidance. COVID‐19 is associated with marked coagulation activation and hypercoagulability in children.2,3 Life‐threatening pulmonary embolus requiring thrombolysis has been encountered in Australian adolescents hospitalised with COVID‐19. A retrospective cohort study published in 2021 found that 2.1% of children hospitalised with symptomatic COVID‐19 infection and 6.5% of those with PIMS‐TS developed thrombosis.4 Thrombosis occurred more frequently in children aged 12years and over who had central lines, PIMS‐TS, or an underlying oncological diagnosis. A D‐dimer of more than five times the upper limit of normal was significantly associated with thrombosis.4 The authors refer to “paediatric guidelines published in the US”, which are published on behalf of the Pediatric/Neonatal Hemostasis and Thrombosis Subcommittee of the International Society of Thrombosis and Haemostasis; these adapt current consensus prophylaxis guidelines to include COVID‐19‐specific features.5 In deferring making specific recommendations, the authors suggested using existing local thromboprophylaxis guidelines. The Royal Children’s Hospital, Melbourne and the Sydney Children’s Hospital, Randwick have both independently developed COVID‐19‐specific thromboprophylaxis guidelines (that are very closely aligned),6,7 as have many other centres globally because previous local thromboprophylaxis guidelines are inadequate for COVID‐19‐associated thrombotic coagulopathy. The Melbourne/Sydney guidelines advise baseline coagulation testing in hospitalised children with COVID‐19, incorporating D‐dimer to assist risk assessment, twice‐daily enoxaparin and anti‐Xa monitoring/dose titration.6,7 These could be provided as supplemental material in these living guidelines. The COVID‐19 anticoagulation in Children–Thromboprophylaxis (COVAC‐TP) trial — a phase 2 single‐arm study looking at 40 children who will receive monitored, low dose, twice‐daily enoxaparin (ClinicalTrials.gov Identifier NCT04354155) — will not change the level of evidence, so waiting for completion of this trial does not seem appropriate.

Gemma L Crighton · Anthea Greenway · Susan Russell

To the editor: Clinicians are faced with requests for mask exemptions but guidance remains limited. In keeping with the Australasian College of Dermatologists’ guidelines,1 we believe skin problems are rarely severe enough to warrant exemption. The Department of Health and Human Services states people with “a serious skin condition of the face” are eligible for mask exemption,2 but this statement is open to interpretation. Mask exemptions for skin conditions are provided by numerous clinicians and not limited to dermatologists. Regardless of immunisation status, cases that may warrant exemption include severe dermatitis with crusting or weeping; severe infections such as impetigo or eczema herpeticum; bullous dermatoses, ectodermal dysplasias and other rare conditions featuring facial skin fragility; and post‐surgical procedures involving grafts or flaps where masks may impede healing. In addition, treatments for actinic damage such as 5‐fluorouracil, imiquimod or photodynamic therapy may cause severe inflammation.3 We suggest if exemptions are warranted, duration should be minimised, which may be before resolution of the dermatoses (eg, 2weeks followed by a review). This is essential given masks have been key in reducing severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) transmission.4 The development of an assessment pathway for facial dermatoses impeding mask use may be beneficial and should differentiate between health care workers, who wear fit‐tested masks, and the general public, guiding prompt treatment and follow‐up to facilitate a return to mask use. From our experience, facial masks may irritate the skin from pressure, sweating and humidity, and commonly aggravate underlying dermatoses, such as seborrheic dermatitis, acne or rosacea. Facial masks may rarely cause allergic contact dermatitis,5 and these cases should involve a contact dermatitis expert. Education regarding skin care is vital, in particular regular cleansing and reducing the number of products used which may aggravate acne. When utilising reusable masks, it is important to opt for an appropriate material such as light‐coloured cotton and maintain mask hygiene, which includes daily mask changes, regular washing, not sharing masks, and taking regular breaks from mask wearing. In summary, clinicians should remain vigilant when writing mask exemptions, aiming to minimise the duration by treating underlying skin problems and providing patient education.

Kajal Patel · Rosemary L Nixon

A 25-year-old woman presented via ambulance following a jellyfish sting

Anthony C Rengel · Sue Davel · Sarah O’Connor · Nicholas Medcraft