Health occupations

A rigorous and well supported primary care response to COVID‐19 is essential to protect the most vulnerable people in Australia In late December 2019, a pneumonia caused by a novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS‐CoV‐2]) was reported to the World Health Organization following identification in Wuhan, China. The outbreak was declared a public health emergency of international concern on 30 January 2020 and a pandemic on 11 March 2020. The respiratory disease complex was officially renamed coronavirus disease 2019 (COVID‐19) on 11 February 2020. On 27 February 2020, the Prime Minister of Australia announced the activation of the Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID‐19).1 Australia has a strong system of primary care provided by doctors, nurses and other health care workers, including allied health professionals, midwives, community pharmacists, dentists, and Aboriginal health workers. Comprehensive primary care services are available to all members of the community through general practice and Aboriginal community‐controlled health services, provided by general practitioners, primary care nurses, allied health and other health care professionals working at the forefront of the health system. Many of the nation's most vulnerable people also access services through aged care, home care and disability care services. Australia's primary care response to COVID‐19 acknowledges the need to protect vulnerable populations,2 to continue the provision of regular primary care services to the whole community for acute and chronic conditions, preventive care and mental health concerns,3 and the need to support and protect health care workers in community settings4,5 as well as in the nation's hospitals.6 In early March 2020, a targeted action plan was initiated by the Australian Government Department of Health to develop and refine the national COVID‐19 primary care response (Box 1). This action plan acknowledged the essential, first‐contact role of general practice in the nation's pandemic response,7 and was informed by lessons from previous epidemics and pandemics where primary care had limited involvement in both planning and response8,9 and by focused consultation with primary care stakeholder organisations. Consultation included a Primary Care COVID‐19 Preparedness Forum, led by Australia's Chief Medical Officer and held on 6 March 2020 with representatives from general practice and other medical specialties, nursing, allied health, pathology, pharmacy, practice management, rural workforce, Aboriginal and Torres Strait Islander health, the disability sector, Primary Health Networks, and federal, state and territory governments. The Australian Government also established the National Aboriginal and Torres Strait Islander Advisory Group on COVID‐19, co‐chaired by the Department of Health and the National Aboriginal Community Controlled Health Organisation (NACCHO). Issues considered in the framing of the primary care response included measures required to protect both the public and the primary care workforce from infection, the management of people presenting to general practice with fever and/or respiratory symptoms, the continued health care management of vulnerable people at increased risk of COVID‐19, concerns about seasonal influenza in winter, arrangements for pathology testing in the community, and the impacts on business continuity for community‐based health services. The primary care response was supported by a funding package of $2.4 billion announced by the Australian Government on 11 March 2020, which included $1.1 billion specifically allocated to support the COVID‐19 response in primary care.10 Key components of the primary care response included: funding of a whole of population model of telehealth (using telephone or video consultations); establishment of call centres to triage people with fever or respiratory symptoms, provide advice and direct them to the most appropriate health services; establishment of a nationwide network of respiratory clinics based in the community to complement state‐ and territory‐run fever clinics; development and delivery of online infection prevention and control training for all care workers; measures to safeguard the health of the members of remote Aboriginal and Torres Strait Islander communities across the continent; and ensuring consistent messaging to members of the nation's primary care workforce. Telehealth New funding provided through Australia's Medicare Benefits Schedule (MBS) enabled a shift to the use of telehealth modalities for all appropriate consultations between patients and their health care providers. Telehealth initiatives were rolled out in a rapid, staged approach: beginning with support for the use of telehealth for members of the nation's most vulnerable populations; followed by items specific to obstetrics and midwifery, nurse practitioner care, and mental health care provision; then measures to enable vulnerable health care providers to continue providing care through telehealth; and then moving to whole of population telehealth consultations for all patients by all health care providers funded under the MBS (Box 2). On 30 March 2020, bulk‐billing incentives for people with concession cards and children aged under 16 years being seen in general practice were doubled to ensure there were no barriers for the population needing to access health care services and advice, and additional payments were introduced to support the ongoing viability of the nation's general practices.11 At the time of writing (2 June 2020), over 11 million telehealth services had been delivered to the people of Australia. National call centre People with fever or respiratory symptoms, or with concerns about possible exposure to COVID‐19, were encouraged to call Healthdirect — the Australian Government‐funded national call centre that provides free health information and advice. Healthdirect activity peaked at around 37 000 calls from members of the public per week in mid‐March 2020. The Healthdirect website also provided an online COVID‐19 symptom checker, which can be downloaded as an application for mobile phones and other devices (www.healthdirect.gov.au). Since 25 March 2020, up to 370 000 people per day have used the symptom checker. General practice‐led respiratory clinics Evidence from prior epidemics has demonstrated that neglect of usual care can be an unintended consequence of prioritising the emergency response, resulting in increased morbidity and mortality related to other causes.3,12 The establishment of a network of more than 120 general practice‐led respiratory clinics has redirected people with fever and/or respiratory presentations away from general practices and emergency departments. Primary Health Networks have had a crucial role in supporting general practices and Aboriginal community‐controlled health services, working with their local hospital networks to identify and help establish respiratory clinics. In addition to protecting other patients and health care staff from potential infection, the respiratory clinics allowed other general practices across the country to continue providing regular essential primary care services to their patients. Online infection prevention and control training A series of online education modules was created to provide consistent, evidence‐based information to health care workers and others working in community settings with vulnerable people. This series included eight modules targeting residential aged care workers and a 30‐minute online course, targeting all care workers, including those working in hospitals, primary care, aged care and disability care.13 It provided education on aspects of infection prevention and control for COVID‐19 and has been completed by over 800 000 health care workers at the time of writing. Protection of remote Aboriginal and Torres Strait Islander communities The primary care response recognised that Aboriginal and Torres Strait Islander people, as well as other people living in remote communities, are at increased risk of COVID‐19, due to pre‐existing health issues, difficulties with service access and high population mobility. Building on the strength of Aboriginal and Torres Strait Islander leadership and on measures initiated by many communities themselves, on 26 March 2020, the Australian Government enacted biosecurity restrictions on entry and travel to remote communities. Grants were provided to support remote communities in self‐determining appropriate planning and preparedness activities, adapting national plans and protocols for local use to enable early retrieval and evacuation of suspected cases, and establishing the mechanisms to support responses to any outbreak, including the deployment of appropriate health care workers. Communication with members of the primary care workforce Regular webinars with primary care doctors, nurses, mental health and allied health professionals were initiated, along with regular teleconferences with the representatives of national primary care professional organisations, with the aim of providing consistent and ongoing two‐way communication with the nation's primary care workforce.14 Since 19 March 2020, there have been over 100 000 live views of online webinars and over 130 000 accesses of online newsletters, along with use of the content by medical media outlets and reproduction by national professional organisations in their own newsletters and emails to their membership. The primary care response was supported by a series of government fact sheets and other COVID‐19‐specific resources developed to assist the primary care workforce in knowing how to protect their patients and themselves from COVID‐19. These have been made publicly available at www.health.gov.au. Primary Health Networks supported these initiatives through the provision of updates about the management of people with suspected or diagnosed COVID‐19. Conclusion Lessons from previous epidemics and pandemics have emphasised the critical importance of engaging early and effectively with primary care4 and the need for a single source of trusted information from health authorities for both clinicians and members of the public.5,15 Australia's primary care response has sought to achieve this, through early collaborative planning and ongoing two‐way communication with the nation's primary care workers. The Australian Government's investment in primary care during the COVID‐19 pandemic is an investment in essential elements of the nation's health system, enabling optimal frontline care while mitigating spread and protecting the ongoing health of the nation's most vulnerable citizens. Box 1 – Aligning Australia's coronavirus disease 2019 (COVID‐19) response with existing knowledge The known: Lessons learnt from previous epidemics and pandemics emphasise the frontline role of primary care and the need for strong, consistent communication with the primary care workforce and the wider community The new: Australia's primary care response to COVID‐19 has seen rapid implementation of initiatives to protect the nation's most vulnerable citizens, preserve existing health system function, support and treat people with COVID‐19, and optimise workforce capacity The implications: Australia's investment in the primary care response to COVID‐19 is enabling effective frontline care while mitigating spread, and protecting the ongoing health of the nation's most vulnerable people Box 2 – Staged introduction of Australia's coronavirus disease 2019 (COVID‐19) telehealth response Stage/date Description Stage 1 (13 March 2020) General practitioner consultations using telehealth for patients aged at least 70 years, Indigenous people aged at least 50 years, pregnant women, parents of children under 12 months of age, and those who are immunocompromised or have a chronic medical condition resulting in increased risk from coronavirus infection Stage 2 (16 March 2020) Supporting telehealth consultations by obstetricians, midwives, nurse practitioners, and some mental health providers Stage 3 (23 March 2020) Enabling vulnerable GPs and other medical specialists (in the same categories as in Stage 1) and providers authorised to use telehealth item numbers to provide care for their patients using telehealth Stage 4 (30 March 2020) Extending existing telehealth items to all Australians. This included a substantial investment in mental health support, with specific commitments to children and young people, older Australians, and health care workers Stage 5 (6–20 April 2020) Supporting expanded telehealth for many specialist medical services and allied health services, including consultant physicians, psychiatrists, geriatricians, public health physicians, neurosurgery, chronic disease management by nurses and Indigenous health workers, and group psychotherapy

Jane Desborough · Sally Hall Dykgraaf · Lucas Toca · Stephanie Davis · Leslee Roberts · Catherine Kelaher · Michael Kidd

Meeting the need for culturally appropriate discussions regarding patient values and preferences at end of life Advance care directives are pre‐emptive discussions that anticipate a future loss of ability to make or communicate decisions. There is no uniformity in advance care directives in Australia, with each state or territory having differing terminologies and requirements.1 The Northern Territory has the lowest population density but the highest proportion of Aboriginal people of any Australian jurisdiction.2 In the NT, an individual can make a common law or statutory advance care directive,3 referred to as an advance personal plan (APP).4 The NT APP enables documentation of legally binding directives in reference to resuscitation and life support, as well as the appointment of substitute decision maker(s).5 We have previously documented the utility of the NT APP for Aboriginal people but highlighted the need for a more culturally appropriate document.6 For patients with life‐limiting diagnoses reviewed at Top End Health Service (TEHS) hospitals, the APP could previously be used in conjunction with a not‐for‐resuscitation form. TEHS and community‐based clinicians noted clear patient care imperatives for a move away from decisions targeted solely towards cardiac arrest. Expanding capacity based on a more patient‐focused goals of care (GOC) framework also aligned with expanding evidence in the literature in support of such a focus.7 In the NT, there has been growing recognition of the need for improved discussions regarding patient values and preferences regarding end of life, informed specifically by cultural understandings.6,8 An important example of this includes determination of the site of death; for many Aboriginal people from rural and remote regions, the land holds particular spiritual and cultural significance.8 For such patients, the need to “finish up” (a culturally appropriate term for death and dying) “on country” (ancestral lands) may be paramount and may take precedence over life‐prolonging treatments in tertiary centres.8 Exploring cultural requirements The TEHS GOC committee was formed in March 2017. This group had wide stakeholder engagement across three TEHS hospitals and included medical, allied health, administrative, nursing, primary health care and Aboriginal practitioner representation. Through the committee, the NT Department of the Attorney‐General and Justice was enlisted to assist in updating the APP (governed under the Advance Personal Planning Act 2013 (NT)). Officers representing the Attorney‐General worked with the GOC committee to explore the core cultural values to be reflected in an updated APP. A Palliative Care Australia document was used as reference material for these discussions.9 The APP is a territory‐wide document (unlike the GOC) and the Attorney‐General's office additionally undertook consultation in Central Australia. An updated APP was released in June of 2018.4 New questions asked in the section concerning values and preferences (Section B) include: Where would you like to die/finish up? If nearing death, what is unacceptable to you? If nearing death, what are your goals/priorities? After death, what is important to you? People completing the APP are now able to specify cultural rituals such as ceremonial smoking, or to make a request for their body to be returned to their birth country. The capability to provide advance directives concerning cardiopulmonary resuscitation (CPR) if appropriate and other life‐sustaining treatments, as well as to nominate substitute decision makers, was retained. The ability to nominate a substitute decision maker in the event of future impairment of capacity is of utmost importance in the NT, as unlike other Australian jurisdictions, the NT does not recognise default decision makers (next of kin or responsible person in other states and territories).3 An educational video was produced with involvement of rural Aboriginal APP champions to illustrate the method and advantages of completing an APP. The new GOC form (Supporting Information) was progressively released throughout the TEHS in 2018. The trigger for commencing GOC discussions is if the treating clinician feels that their patient may be in their last year of life (the “surprise question”). This includes patients with advanced malignancy, end‐stage organ failure, dementia or other progressive neurodegenerative conditions. It also includes specific reference to GOC in neonatal and paediatric patients. Uptake of the form in this patient population remains small but important. The resuscitation component of the GOC form documents the appropriateness of rapid response/code blue calls as well as ceilings of care (possible options range from full intensive care unit care to supportive and palliative care). This allows staff caring for dying patients outside the hospice setting to obtain immediate clinical support as required, irrespective of whether CPR is to be performed. The GOC form also allows people to document their wish to remain in their regional hospital for end‐of‐life care. The implications of this and inherent ceilings of care require detailed discussion with patients and family. The TEHS GOC form also requires the documentation of barriers to understanding, cultural responsibility and patient wishes. For some Aboriginal people, in certain instances, the patient may not be the key decision maker (despite having decision‐making capacity). The appropriate clinical information — the “right story” — needs to be provided to the appropriate person, usually referred to as the “right person”.6 The GOC form provides structured assistance to the completing clinician, to consider the involvement of Aboriginal liaison officers, interpreters and the culturally defined right people. Finally, it requires the completing clinician to consider whether the patient wishes to finish up on country. The revised NT APP and the GOC form were significant steps towards improved and patient‐focused end‐of‐life care. The working group also recognised that improved documentation required a more comprehensive strategy informed by data collection and research, and enriched by communications training for clinicians in order to be robust and capable of developing over time. Data collection and research In February 2019, Royal Darwin Hospital participated in a Commonwealth‐funded national study, led by Advance Care Planning Australia, which captured the prevalence of advance care directives and other types of advance care planning documentation in Australian health and residential aged care facilities.10 These data were useful to Top End clinicians regarding the impact of the recently introduced GOC framework. Health records of people aged 65 years and older who had been admitted for 48 hours were reviewed for advance care directives and medical orders or clinical care plans. The GOC forms are non‐statutory (not based in legislation) and were classified as medical orders. The prevalence of medical orders in audited health records at Royal Darwin Hospital was 46%. By comparison, the average prevalence of medical orders across all participating hospitals was 49%. The majority of these reflected either some limitation of treatments or were aimed at symptom control. A small number of patients (eight out of 50) had both an APP and a GOC plan. Only one document showed an incongruence between the APP wishes and the GOC wishes. This was related to the documentation of CPR provision in a patient who had stated in their APP that they did not wish to have CPR. Despite being only a single example, this discrepancy is consistent with findings elsewhere indicating that clinicians have a tendency to provide more care or more interventions than patients would choose were their wishes specifically discussed and followed.11 Communications training As part of the strategy to enhance the concept of shared decision making, which underpins patient‐centred care, the TEHS provided the first set of communications training workshops in March 2019. The workshops were iValidate (developed and delivered by Barwon Health) and Paediatric SimCom training (developed by Deakin University). Over 40 clinicians including nurses, doctors, allied health workers, Aboriginal health practitioners from hospital and community as well as primary health care practitioners attended the training. Additional Aboriginal and non‐Aboriginal participants were trained “on the run” as actors and helped to develop scenarios alongside experienced iValidate simulation actors. This enhanced the cultural context and the clinical authenticity of the scenarios used. Further workshops were held in June and a workshop was held in a regional hospital in November 2019. Facilitator training has also commenced in parallel to the communications courses in order to develop a local facilitator faculty enhancing the sustainability of the program. Next steps The development of a GOC framework and a culture of shared decision making is an evolving process. The next step is specific research on the effectiveness of GOC frameworks from the patient's perspective and the development of communications training that is increasingly informed by the concept of shared decision making. Significant areas that remain to be addressed include an improvement of the end‐of‐life experience on wards outside of the hospice, bereavement services within the hospital, mortuary services, and services to those who wish to die in regional hospitals, at home or on country.

Emma Spencer · Eswaran Waran

Differences between general practice and hospital settings have ethical and legal implications for teachers and learners

Michaela Kelly · Nancy Sturman · David Pakchung

Clinical record A 42‐year‐old woman presented to the Sunshine Coast University Hospital, Queensland, with a 5‐day history of odynophagia, orthopnoea and rapid onset of neck swelling over 12 hours. She had returned one week prior from a year‐long trip to Central America, Sri Lanka and Indonesia. Relevant past medical history included nephrotic syndrome due to minimal change disease, use of prednisolone 2.5 mg daily and previous treatment with rituximab. Childhood vaccinations were reported, but she had no booster travel vaccinations. On examination, she had right‐sided neck swelling, consistent with “bull neck” (Box, A), and an exudative right tonsil with a haemorrhagic component (Box, B). The patient had several healed skin lesions and a 2 cm non‐healing ulcer on her buttock. Flexible nasendoscopy showed supraglottic oedema with a patent airway. The diagnosis of diphtheria was strongly considered, with differentials including peritonsillar abscess and tonsillitis. Computed tomography scan of the neck demonstrated peritonsillar phlegmon and oedema in the parapharyngeal space, pre‐vertebral fat and subcutaneous neck tissues. She was commenced on intravenous benzylpenicillin, lincomycin and dexamethasone, was placed on contact and droplet precautions, and was admitted to the intensive care unit. Multiple tissue and swab samples were taken from the pharyngeal membrane and the buttock wound and urgently sent to the laboratory for culture into selective media. She underwent elective intubation 24 hours later due to worsening laryngeal oedema. Tissue and swabs from the pharyngeal membrane and sacral wound grew Corynebacterium diphtheriae. Diphtheria antitoxin (DAT) 100 000 IU was administered 36 hours into her admission. The isolates were confirmed to be toxigenic by polymerase chain reaction.1,2 The patient was discharged from the intensive care unit on Day 6. On Day 7, she developed anterior T wave inversions on her electrocardiogram, with an elevated troponin value (0.39 μg/L; reference range, < 0.040 μg/L). Her cardiac enzymes showed serial improvement. She developed a moderate glossopharyngeal and vagal palsy, which resolved after 3 weeks, and peripheral neuropathy, which resolved after 4 months. The cardiac and neurological sequelae were thought to be complications of pharyngeal diphtheria. The local Public Health Unit and the infection management service identified 12 staff and seven close community contacts. All contacts had nasal and throat swabs taken, were treated with oral erythromycin and were vaccinated where appropriate.3 Staff were excluded from work until returning negative throat and nasal cultures at 48–72 hours. Discussion Diphtheria is an acute pharyngeal or cutaneous infection caused by toxigenic strains of C. diphtheriae — a gram‐positive, non‐motile, non‐encapsulated bacillus.4 The infection spreads by respiratory droplets or direct contact with nasopharyngeal secretions or skin lesions. The incubation period of diphtheria is commonly 2–5 days. Data from the World Health Organization show that diphtheria is endemic to South‐East Asia, including Indonesia, Malaysia and the Philippines.5 Our case illustrates the need for a thorough travel history and administration of timely antitoxin therapy in suspected diphtheria cases to limit diphtheria‐related neurological and cardiovascular consequences. Diphtheria is rare in Australia after the widespread use of the effective vaccine following World War II, with most cases associated with sporadic importations. There have been seven cases of diphtheria reported since 2001, including one that was fatal in 2011.6 Diphtheria affects the upper respiratory tract, presenting with sore throat and cervical lymphadenopathy; a coating membrane forms in about a third of cases. Simultaneous infection of the skin and respiratory tract is uncommon. Accumulation of the C. diphtheriae organism within the membrane along with fibrin debris result in the appearance of a white pseudomembrane.4 The pathognomonic bull neck is caused by superficial oedema of neck tissues and is associated with a more severe course and higher mortality. The diphtheria toxin is produced by toxigenic strains of the bacterium and affects the cardiovascular, renal and nervous systems via haematogenous spread. The toxin is bound on cell surface receptors and acts to arrest protein synthesis.7 Toxin‐producing infections have a mortality rate between 5% and 10%.8 Diphtheritic myocarditis occurs in 10–20% of patients with pharyngeal diphtheria manifesting as ST disturbance, corrected QT interval (QTc) prolongation, or heart block.9 Cardiac abnormalities are associated with extensive respiratory tract involvement and bull neck appearance as well as neurological sequelae, which occur in 75% of patients with severe respiratory disease.4 Cranial nerve neuropathy develops first; often presenting as swallowing difficulties and resulting in aspiration. DAT and antibiotics should be administered promptly upon clinical suspicion. Early administration of DAT reduces circulating toxin load and reduces clinical sequelae.3 Our patient received DAT at 36 hours, yet significant neurological sequelae were observed up to 4 months later. Penicillin and/or erythromycin are the antimicrobials of choice; however, resistance has been described.10 Lessons from practice Diphtheria should be suspected in patients presenting with pseudomembranous tonsillitis, significant neck swelling and relevant travel history. It is important for clinicians to liaise with their local laboratory and Public Health Unit in suspicious cases so appropriate investigations and follow‐up can be established. Timely administration of diphtheria antitoxin is imperative and should not be delayed awaiting laboratory confirmation. Booster vaccinations should be considered before travel, particularly in patients who may have waning immunity. Box – “Bull neck” characteristic of diffuse cervical lymphadenopathy with tracheal deviation (A). Pseudomembrane coating right tonsil, soft palate and uvula on presentation (B)

Sarah Grigg · David Hogan · F Shaun Hosein · Dean Johns · Amy Jennison · Shradha Subedi

Technology is revolutionising medicine, and telemedicine is having a measurable impact on stroke care

Richard I Lindley

Opportunities to recognise and invest in general practice research need to be realised General practice research is essential to quality general practice, building an evidence base for over 27 000 general practitioners working within the specialty who provide medical care to the majority of Australians.1 Over eight in ten Australians consult with their GP at least once per year, and two million people are seen each week in general practice.2,3 General practice, a medical specialty, is the first point of access to the health system, providing longitudinal care for all. It is essential for the delivery of efficient, equitable and effective health care services.4 General practice is unique, complex and continuing to evolve. A GP must have a good working knowledge of 167 problems to cover 85% of the conditions that they see most frequently,5 and management of multimorbidity has become the norm. The number of general practices appears to be declining, practices are becoming larger, and the proportion of GPs who are practice owners is decreasing.6 General practice research is key to optimising health care in this evolving context, but needs to be supported by the profession, funders and our professional colleges. Current challenges General practice has traditionally been seen as an applied discipline, rather than one with an academic underpinning, and research has therefore been undervalued. The undervaluing of general practice research is reflected in current research funding and a paucity of opportunities during specialty training. The proportion of National Health and Medical Research Council funding to primary care research has been consistently low,7 and this has continued in the current Medical Research Future Fund budget, with only $5 million of $392.5 million for the 2019–20 financial year specifically allocated to primary care,8 despite primary care being noted as a medical research and innovation priority for 2018–2020.9 The Medical Research Future Fund 2019 investigator grant opportunity for early to mid career researchers included primary care research as one of its 11 research priority areas, but it will not be known if general practice research specifically has been supported until the results of that round are released. In the context of this undervaluing, GPs who have completed PhDs have expressed concerns about insecure academic career pathways,10 and the current ageing GP research workforce may not be replaced.11 Additional barriers to general practice research include lack of funding for Australia and New Zealand's academic primary care peak body (the Australasian Association for Academic Primary Care), general practice research networks, and payments to adequately compensate practices for the time and resources required to participate in research. Recent achievements Despite the challenges, general practice has a long tradition of rigorous, detailed and credible scientific research. This work covers a broad range of research questions, utilising a range of methodologies and frameworks (Box). However, general practice research outcomes are often less visible as hospital admissions avoided, diseases prevented, complications averted and health services redirected are key outcomes.4 The generalist nature of primary care means that research must deal with heterogeneous populations, multimorbidity and complex health service delivery. What would health care look like without general practice research? Primary care is the most efficient, equitable and effective place to deliver health care for most of the population,4 and is underpinned by a growing scientific knowledge base as research in and about general practice has evolved and grown over the past 50 years.12 Research in this setting is required as never before, with an ageing population, increasing rates of multimorbidity, and management continuing to move out of the hospital and into the community setting.13 There is no other academic specialty that will focus on generalist care in the community, and general practice is integral to research translation. Without general practice, the health outcomes of the population will be poorer and less equitable, and associated with increased health costs.4 Contextual knowledge of primary care is essential for credible and relevant general practice research. It is hard to imagine research into cardiology, for example, without the involvement of cardiologists. However, it is not uncommon for research in health services and primary care to not involve GPs, or to involve them at a late stage in development. Without GP involvement, research outcomes are unlikely to be fit for the general practice environment or appropriate for patients attending primary care. Academic GPs play important roles in both research and teaching, including training academic GP registrars and supervision of primary care researchers and students more broadly. They contribute to shaping the policy and practice environment through representing general practice on guideline development groups and engaging with international colleagues to develop and implement research methodologies suitable for the primary care environment. Without support of general practice research and training, this expertise would be lost. GPs and practice staff work with academic GPs and play a critical role in the development and implementation of interventions, recruitment and data collection and interpretation. Without compensation for their time (participation in research often results in loss of income) and without the infrastructure of practice‐based research networks, this practice knowledge cannot be harnessed. Data collected from general practice that is not interpreted through a generalist lens with an understanding of the context in which general practice operates can result in conclusions that do not reflect practice. A lack of focus on general practice research and academic opportunities will have a flow‐on effect to the recruitment of new GPs. To build interest in general practice more broadly, attention needs to be paid to medical students who often believe there is little intellectual challenge in the profession and a lack of academic opportunities.14 The national General Practice Student Network, a network for medical students interested in general practice supported by General Practice Registrars Australia, provides an opportunity for academic GPs and the Royal Australian College of General Practitioners (RACGP) to link with medical students to showcase opportunities for GP research, teaching and academic training. Towards the future Vocational training will be transitioned to the RACGP and the Australian College of Rural and Remote Medicine from the federal Department of Health in January 2022. This presents a real opportunity for shaping the future of general practice training by acknowledging the importance of research to the discipline, expanding current academic registrar programs and encompassing key Australian Medical Council accreditation recommendations, including that appropriate candidates can enter research training during specialist medical training with opportunities to undertake intercalated research degrees.15 This would provide a foundation for a supported path in GP academia. The RACGP Expert Committee – Research is currently developing a research strategy that will address these issues. Advanced Health Research Translation Centres and Centres for Innovation in Regional Health exist around Australia, and are partnerships of hospitals, research institutes and universities developed to accelerate translation of research into clinical care. As these structures currently stand, primary care is often lost among the multitude of hospital partners and clinicians and researchers who have little experience of, or interaction with, general practice. The Centres work together as the Australian Health Research Alliance, which currently does not include primary care as one of its system level initiatives. A focus on primary care would provide a more meaningful option for engaging with community general practice and primary care, working collaboratively with properly funded and sustainable practice‐based research networks that have led to successful innovations in other parts of the world. The GP academic community would welcome closer collaboration with both the Medical Research Future Fund and the Australian Health Research Alliance. The promise of big data has huge implications for general practice, with many heralding this as the beginning of a new era, but big data without appropriate expert interpretation is likely to lead to misunderstanding. General practice has a long history of working with data, starting with Charles Bridges‐Webb developing the first general practice survey in 1961, laying the groundwork for the Bettering the Evaluation and Care of Health (BEACH) program.2 Large general practice datasets are now held by NPS MedicineInsight, Primary Health Networks, and departments of general practice (for example, the UNSW electronic Practice Based Research Network and the Data for Decisions program at the University of Melbourne). The ability to track the patient journey between primary care and hospitals is being realised through linked datasets. The National Primary Health Care Data Asset is now under development, and it is critical that this includes oversight and input of GP clinician‐scientists to ensure that data are not misinterpreted. General practice is an academic specialty based on an international body of literature and decades of research. However, in Australia we still have a way to go to understand why primary care works in our context, how to best implement change, and how to teach best practice to new clinicians. Recognising and investing in the value of general practice research will require a systems approach that includes medical student training, vocational training, and support of research infrastructure and GP clinician‐scientists to enable research and research training in general practice and translation into practice and policy. This investment in general practice research and infrastructure should reflect the size of general practice in Australia, the population it serves, and the proportion of the associated Medicare spend. Box – Examples of general practice research informing clinical practice and health service design Research Key findings and implications for general practice General practice research involvement ASPirin in Reducing Event in the Elderly (ASPREE)12 Higher all‐cause mortality was found in healthy older adults in Australia aged over 70 years of age who received daily aspirin. This suggests that aspirin may not be of benefit for primary prevention of cardiovascular disease in this age group Mark Nelson (principal investigator) and Nigel Stocks were authors on this randomised controlled trial. Australian GP Associate Investigators in clinical practice recruited 87% of the 19 114 patient participants What treatments are effective for common colds in adults and children? Decongestants alone, or with antihistamines or analgesics, can be helpful for adults with nasal symptoms, but other commonly recommended treatments such as echinacea, vapour rub and heated, humidified air have no evidence of effect Systematic review led by Mieke van Driel13 Comparing non‐sterile to sterile gloves for minor surgery: a prospective randomised controlled non‐inferiority trial14 Non‐sterile gloves are not inferior to sterile gloves in regard to wound infection for minor skin excisions in general practice Trial led by Clare Heal, conducted in a single private general practice in Mackay, Queensland How to increase uptake of long acting reversible contraception (LARC) through general practice15 Online GP training in effectiveness‐based contraceptive counselling, together with GP access to rapid referral to a LARC insertion clinic increases LARC uptake by women Cluster randomised controlled trial in 57 general practices in Melbourne led by Danielle Mazza Bettering the Evaluation and Care of Health (BEACH)2 The BEACH dataset, consisting of almost 1.8 million GP–patient encounters recorded between 1998 and 2016, has been used to inform general practice research, education and policy Each year, about 1000 GPs recorded data about 100 consecutive patient encounters, contributing to the development of the BEACH dataset. Graeme Miller was the Medical Director of BEACH Clinical outcomes of an integrated primary–secondary model of care for individuals with complex type 2 diabetes: a non‐inferiority randomised controlled trial16 GPs with special interests working with a Beacon model of integrated care for diabetes achieved clinical outcomes that were not inferior to hospital‐based specialist clinics, with greater patient satisfaction Claire Jackson co‐led the development and evaluation of the Beacon model, which has now also been adapted and utilised in Western Australia Composite Abuse Scale17 The Composite Abuse Scale was developed as a research tool to classify women according to type and severity of abuse. It has been translated into eight languages and is considered the standard for assessing women's self‐reported experiences of abuse The Composite Abuse Scale was developed by Kelsey Hegarty and used in a cluster randomised controlled trial to identify women who screened positive to intimate partner violence and who may benefit from brief counselling from their GP

Jo‐Anne E Manski‐Nankervis · Elizabeth A Sturgiss · Siaw‐Teng Liaw · Geoffrey K Spurling · Danielle Mazza

Primary care is the single most significant contributor to positive health outcomes,1,2 but the number of general practitioners in Australia has been falling, a situation previously described for nations with poorer health outcomes.2 The reasons for the decline are many,3 but this phenomenon has not been described in detail in the peer‐reviewed literature. We have therefore examined the registration categories, as recorded by the Australian Health Practitioner Regulation Agency (AHPRA), of people who graduated from the University of Western Australia (UWA) medical school during 1985–2007. Our study was approved by the UWA Human Research Ethics Committee (reference, RA 4/1/1627). We included all active medical practitioners who graduated (MBBS) from UWA during 1985–2007 and were registered with AHPRA in December 2019. We included all doctors listed by AHPRA as practising GPs, whether vocationally registered or with college membership, in our GP category; 65 of the 93 1985–1987 graduates registered by AHPRA as GPs did not have postgraduate qualifications, but only five of the 56 2004–2007 graduates. AHPRA registration as a GP was about half as likely for 2004–2007 graduates as for 1985–1987 graduates (relative risk [RR], 0.46; 95% confidence interval, 0.35–0.60). This decline in entry into general practice was accompanied by an increase in the proportion of graduates with general registration status alone (in 2004–2007 v 1985–1987: RR, 3.01; 95% CI, 1.97–4.61) (Box). These findings are consistent with the recently reported drop in the proportion of medical graduates who intend to enter general practice,5 which may lead to a further decline in the number of AHPRA GP registrations. We also found an equally concerning increase in the number of doctors practising as generally registered practitioners alone during 2007–2019, presumably waiting for the opportunity to enter their preferred medical specialty. This problem, first discussed without data in the MJA in 2012,6 has not attracted the attention of policymakers. The reduction in size of the primary care workforce is felt most keenly in rural communities, where dependence on primary health care is more pronounced, but urban practices also struggle to recruit new fellows.2 The causes of this problem include the perceived lower status of general practice, the generally lower income provided by Medicare fees, the burden of practice accreditation, and specialist‐focused teaching in medical schools. Further challenges for rural practice include problems of work–life balance and the focus on fly‐in/fly‐out specialist services instead of developing extended scope primary care models for regional and remote communities. One limitation of our study is that the AHPRA general registration data need to be compared with college registries for accuracy. Our findings nevertheless suggest that solutions for the general practice problem are urgently needed if Australia is to continue enjoying some of the best health outcomes in the world. Box – Category of registration for University of Western Australia medical graduates, 1985–2007, as recorded by the Australian Health Practitioner Regulation Agency (AHPRA)* * Data as at 28 November 2019; data shown for categories with at least 25 graduates during 1985–2007. Total number of practising graduates registered with AHPRA, by graduation year: 1985–1987: 237; 1988–1991: 355; 1992–1995: 355; 1996–1999: 370; 2000–2003: 426; 2004–2007: 419. † Includes all medical graduates who have completed an accredited internship in Australia or New Zealand and are not required to complete any additional supervised practice to become eligible for general registration; those who completed a recognised internship elsewhere and have additionally satisfactorily completed 47 weeks of full‐time approved supervised practice in Australia; those who have previously held general registration in Australia; those who have completed the competent authority pathway; and Australian Medical Council certificate holders in the standard pathway who have completed a period of approved supervised practice in Australia.4

Denese Playford · Jennifer A May · Hanh Ngo · Ian B Puddey

Objectives: To evaluate the impact of the Victorian Stroke Telemedicine (VST) program during its first 12 months on the quality of care provided to patients presenting with suspected stroke to hospitals in regional Victoria. Design: Historical controlled cohort study comparing outcomes during a 12‐month control period with those for the initial 12 months of full implementation of the VST program at each hospital. Setting: 16 hospitals in regional Victoria that participated in the VST program between 1 January 2010 and 30 January 2016. Participants: Adult patients with suspected stroke presenting to the emergency departments of the participating hospitals. Main outcome measures: Indicators for key processes of care, including symptom onset‐to‐arrival, door‐to‐first medical review, and door‐to‐CT times; provision and timeliness of provision of thrombolysis to patients with ischaemic stroke. Results: 2887 patients with suspected stroke presented to participating emergency departments during the control period, 3178 during the intervention period; the patient characteristics were similar for both periods. A slightly larger proportion of patients with ischaemic stroke who arrived within 4.5 hours of symptom onset received thrombolysis during the intervention than during the control period (37% v 30%). Door‐to‐CT scan time (median, 25 min [IQR, 13–49 min] v 34 min [IQR, 18–76 min]) and door‐to‐needle time for stroke thrombolysis (73 min [IQR, 56–96 min] v 102 min [IQR, 77–128 min]) were shorter during the intervention. The proportions of patients who received thrombolysis and had a symptomatic intracerebral haemorrhage (4% v 16%) or died in hospital (6% v 20%) were smaller during the intervention period. Conclusions: Telemedicine has provided Victorian regional hospitals access to expert care for emergency department patients with suspected acute stroke. Eligible patients with ischaemic stroke are now receiving stroke thrombolysis more quickly and safely.

Chris F Bladin · Joosup Kim · Kathleen L Bagot · Michelle Vu · Natasha Moloczij · Sonia Denisenko · Chris Price · Nancy Pompeani · Lauren Arthurson · Casey Hair · Justin Rabl · Mick O'Shea · Patrick Groot · Leslie Bolitho · Bruce CV Campbell · Helen M Dewey · Geoffrey A Donnan · Dominique A Cadilhac

Inclusion of the right to health in Queensland's Human Rights Act is historic but not without challenge In February 2019, the Queensland Parliament passed the Human Rights Act 2019, which took effect on 1 January 2020. Its introduction makes Queensland the third Australian jurisdiction to implement human rights legislation, after the Australian Capital Territory and Victoria in 2004 and 2006, respectively. While the Queensland Act is based on a model of rights legislation broadly consistent with the Victorian and ACT models, it differs in its inclusion of the right to health services (section 37): Every person has the right to access health services without discrimination. A person must not be refused emergency medical treatment that is immediately necessary to save the person's life or to prevent serious impairment to the person.1 The inclusion of section 37 is historic. The right to health is made subject to law on Australian shores and a state/territory government is finally accountable, by law, to protect and promote the enjoyment of the highest attainable standard of physical and mental health. Rights language is part of Australia's public health vernacular, evidenced by the Australian Charter of Healthcare Rights.2 However, unless such rights are expressed in domestic law, then right to health principles and policies are important words on paper without overt legal consequence for effective monitoring and accountability.3,4 As Australia lacks a legal tradition regarding the right to health, the introduction of section 37 creates interpretive challenges for the new Queensland Human Rights Commission (QHRC). The right to health has received limited robust attention in both Australian schools of public health and law, as well as in Australian public health‐related literature.5 The QHRC, and Queensland's courts and tribunals, will likely look to United Nations (UN) commentary on the right to health, and to overseas jurisprudence and scholarship for guidance on section 37's emergent framing.3,6 With the right to health found in over 100 national constitutions and the UN Special Rapporteur on the right to health issuing annual reports, guidance is available.7,8 Health service obligations and remedies under the new Act Queensland government departments and public employees will have a responsibility to protect and promote the human rights of Queensland individuals, and in their health service delivery and decision making, act in a way consistent with their obligations under the Act.1 Health agencies that fit the Act's “public entity” criteria are also bound to comply with the Act. If an individual alleges a section 37 violation, they should make a complaint to the government agency or public entity, which must respond within 45 business days.1,6 If an inadequate or no response is received, the individual — or two or more people jointly — can lodge a complaint with the QHRC.1 Given that the Act's regulatory model favours discussion, rights awareness raising and education, the QHRC will aim to pragmatically resolve section 37 disputes. Monetary damages will not be available.6 In the case of judicial review, a person might have the original decision quashed or referred back to the original decision maker for redetermination.6 In certain circumstances, pending legal advice, a section 37 complainant might have grounds to pursue a distinctly separate medical negligence cause of action if a health professional or service provider breaches their common law duty of care and the complainant has sustained pain and suffering, loss or injury.9 Some grievances against health service providers (notably private providers) can continue to be dealt with by the Health Ombudsman under Queensland's Health Ombudsman Act 2013, and the QHRC may indeed refer complaints to the Health Ombudsman (with the complainant's consent).1,10 However, potential complainants under either Act should be aware the objectives of both Acts markedly differ. The Health Ombudsman Act emphasises that the health and safety of the public are paramount, thereby framing health through a health security lens at the population level, whereas the Human Rights Act takes an individual level approach: the enjoyment of the highest attainable standard of physical and mental health of each and every person in Queensland is paramount (Box 1). Additionally, the Health Ombudsman Act does not recognise the special importance that human rights — and by extension, health and human rights and accessible, non‐discriminatory health service provision — has for Queensland's Aboriginal peoples and Torres Strait Islander peoples.1 On this point, there is no reason why the definition of health services in section 37(1) could not be interpreted to integrate a culturally responsive meaning for Queensland's Indigenous peoples, consistent with the UN Declaration on the Rights of Indigenous Peoples (Box 2).11 Interpreting section 37 and health rights protections found elsewhere in the Act The Act takes a narrow approach to interpreting the right to health Section 37 is modelled on the right to health in article 12 of the International Covenant on Economic, Social and Cultural Rights.12 The UN Committee responsible for the Covenant stated in General Comment No. 14 that article 12 contains two elements: the right to access health services; and the right to access the underlying determinants of health, or the underlying factors that promote conditions in which people can lead a healthy life.3 Regarding the first element of what accessible, non‐discriminatory health services might look like for section 37 achievement, General Comment No. 14 provides the QHRC with instruction (Supporting Information).3 The Queensland Parliament has clarified it will only adopt the first element of article 12 of the International Covenant, which protects right to health service access; section 37 will not extend to include Queenslanders’ right to the broader health determinants. By limiting section 37 to questions of access to emergency medical treatment and non‐discriminatory health service provision, Parliament cautiously chose not to conflate the parameters of section 37. For some right to health academic specialists, this measured approach is prudent.13 Although section 37 claims are not to incorporate the determinants of health, complainants may nevertheless lodge separate or concurrent claims that capture certain health determinants, such as the right to culture (sections 27 and 28). Public health practitioners are well aware that culture is a significant health determinant.14 Housing is also a major determinant of health, and a housing rights claim (that causally impacts a claimant's health and wellbeing) might be realised under section 24 (property rights). Claims that seek to protect and promote the rights of individuals and communities to access the determinants of health relating to food and water could be sought under the right to life (section 16). This is because, per the explanatory notes to the Human Rights Bill 2018 (Qld), this right reflects the positive obligation on states “to take positive steps to protect the lives of individuals through, for example … positive measures to address other threats to life such as malnutrition and infant mortality” (emphasis added).6 With this in mind, section 16 allegations that identify a compelling food or water security nexus that threatens the right to life could be made. However, the QHRC can refuse to deal with a complaint it considers “frivolous, trivial, vexatious, misconceived or lacking in substance”.1 The protection of other health rights elsewhere in the new Act As highlighted above, the content of section 37 claims will likely raise other rights contraventions. It is foreseeable, for example, that a section 25 right to privacy breach by a health service provider could directly or indirectly create a section 37 access to health service violation (and vice versa). Further, a section 37 contravention, or its ramifications, may be so egregious that the complainant could rationally argue that they have experienced a breach of their section 17(b) right not to be treated in a cruel, inhuman or degrading way by the health service. Section 17(c) also protects and promotes an individual's health and human right to “not be … subjected to medical or scientific experimentation or treatment without the person's full, free and informed consent”.1 Certainly, in some cases, a fine line will arise between informed consent to medical treatment and health service access under section 37. The Act also covers reproductive health and rights. Section 106 clarifies that the Act “does not affect laws about termination of pregnancy”, thereby referring to and upholding the Termination of Pregnancy Act 2018 (Qld). According to Queensland Health, that Act “ensures termination of pregnancy is treated as a health issue rather than a criminal issue” and “supports a woman's right to health, including reproductive health and autonomy”.15 Final comments Queensland Health already has antidiscrimination policies and protocols for its staff and for its patients and clients. Therefore, compliance with section 37 and the Act's wider provisions should not be onerous for government and many other public health service agencies bound by the new Act. However, if international right to health experience can teach Queensland anything, it is that government response to allegations of section 37 violations should not be reactive and visible at QHRC conciliation meetings alone.4 Advancing the right to health for all Queenslanders will not occur in legal silos but in complement with planned educational and promotional activities that help build a culture in the Queensland public sector and broader community that respects and promotes health and human rights, as well as promotes a dialogue about the nature, meaning and scope of health rights for Queensland's most important asset, its human capital.1,6 This will require the engagement of both government and non‐government stakeholders, as well as community members, beyond the health sector. Box 1 – Objectives and principles of the Human Rights Act 2019 (Qld) and Health Ombudsman Act 2013 (Qld) Human Rights Act 2019 Health Ombudsman Act 2013 Main objects: section 3* Main objects: section 3 † to protect and promote human rights; and to help build a culture in the Queensland public sector that respects and promotes human rights; and to help promote a dialogue about the nature, meaning and scope of human rights. to protect the health and safety of the public; and to promote— professional, safe and competent practice by health practitioners; and high standards of service delivery by health service organisations; and to maintain public confidence in the management of complaints and other matters relating to the provision of health services. Preamble* Paramount guiding principle: section 4 † In enacting this Act, the Parliament of Queensland recognises— The inherent dignity and worth of all human beings. The equal and inalienable human rights of all human beings. Human rights are essential in a democratic and inclusive society that respects the rule of law. Human rights must be exercised in a way that respects the human rights and dignity of others. Human rights should be limited only after careful consideration, and should only be limited in a way that can be justified in a free and democratic society based on human dignity, equality, freedom and the rule of law. Although human rights belong to all individuals, human rights have a special importance for the Aboriginal peoples and Torres Strait Islander peoples of Queensland, as Australia's first people, with their distinctive and diverse spiritual, material and economic relationship with the lands, territories, waters, coastal seas and other resources with which they have a connection under Aboriginal tradition and Ailan Kastom. Of particular significance to Aboriginal peoples and Torres Strait Islander peoples of Queensland is the right to self‐determination. The main principle for administering this Act is that the health and safety of the public are paramount. Without limiting subsection (1), the health and safety of the public is the main consideration for— the health ombudsman, when deciding what relevant action to take to deal with a complaint or other matter; and the director of proceedings, when deciding whether to refer a matter to QCAT; and QCAT, when deciding a matter referred to it under this Act. QCAT = Queensland Civil and Administrative Tribunal. * Reproduced from https://www.legislation.qld.gov.au/view/html/asmade/act-2019-005;8 † Reproduced from https://www.legislation.qld.gov.au/view/html/inforce/current/act-2013-036.10 Box 2 – The right to health: article 24 of the United Nations Declaration on the Rights of Indigenous Peoples* Indigenous peoples have the right to their traditional medicines and to maintain their health practices, including the conservation of their vital medicinal plants, animals and minerals. Indigenous individuals also have the right to access, without any discrimination, to all social and health services. Indigenous individuals have an equal right to the enjoyment of the highest attainable standard of physical and mental health. States shall take the necessary steps with a view to achieving progressively the full realization of this right. * Reproduced from https://www.un.org/development/desa/indigenouspeoples/wp-content/uploads/sites/19/2018/11/UNDRIP_E_web.pdf.11 Declarations are not ratified. Adopted by the UN General Assembly on 17 September 2007. Supported by the Australian Government on 3 April 2009.

Claire E Brolan

The evidence from real world implementation is compelling

Mike Daube · Julia Stafford

Compared with age-matched men, women tend to have poorer health status but longer life expectancy

Emily H Gordon · Ruth E Hubbard

To the Editor: In July 2019, sarcopenia — a progressive and generalised skeletal muscle condition involving loss of skeletal muscle mass and function1 — was awarded a code in the International Classification of Diseases, tenth revision, Australian modification (ICD‐10‐AM). This recognition has arrived 30 years after Irwin Rosenberg first described the condition in 1989.2 Sarcopenia is independently associated with poor quality of life, falls, fractures, institutionalisation and mortality.1 About 13–19% of community‐dwelling older adults may have this condition, and prevalence is highest among those living in residential care.1 All individuals experience declines in muscle mass and function during ageing, but only those who meet the criteria described in the Box are considered to have sarcopenia. The definition currently promoted by the Australian and New Zealand Society for Sarcopenia and Frailty Research is the initial European Working Group on Sarcopenia in Older People definition,3 which was adopted after a Delphi consensus.5 Measures of muscle strength and physical performance such as grip strength, chair stands and gait speed are cost‐effective and easy to perform in clinical practice. Obtaining measures of muscle and lean mass may be challenging outside of the research setting. Therefore, in individuals with low muscle strength or physical performance, in the absence of other potential causes (eg, osteoarthritis), sarcopenia should be suspected and safe and effective interventions can be offered. Patients with, or at risk of, sarcopenia should be recommended exercise therapy, in particular, progressive resistance training.1 This type of training prescribed by treating clinicians can be implemented by allied health professionals, including exercise physiologists and physiotherapists. Protein supplementation can prevent loss of muscle, but this is most beneficial when combined with progressive resistance training.1 A number of randomised controlled trials are underway examining different therapeutics for the treatment of sarcopenia.1 With the advent of the ICD‐10‐AM code, primary care clinicians, allied health staff, and members of the public will begin observing sarcopenia diagnoses on medical correspondence. Hospital funding models may adjust in line with the ICD‐10‐AM code and in recognition of the increased complexity and risk of complications that comes with caring for patients with sarcopenia. An understanding of this condition, its implications and treatment is key in providing evidence‐based care to patients living with sarcopenia. Box – Diagnostic tools and measurements to diagnose sarcopenia* using the initial European Working Group on Sarcopenia in Older People (EWGSOP) definition†3 Component Thresholds and equipment Low muscle strength Hand grip strength using dynamometer: Men: < 30 kg Women: < 20 kg Low physical performance Men and women over 4 m course: Gait speed: ≤ 0.8 m/s Low lean mass ALM using whole‐body DXA (adjusted for height, m2): Men: < 7.26 kg/m2 Women: < 5.50 kg/m2 ALM = appendicular lean mass; DXA = dual x‐ray absorptiometry. * Diagnosis of sarcopenia is based on low lean mass and low physical performance or muscle strength. † The EWGSOP have developed a revised definition for sarcopenia (known as EWGSOP2);4 however, this has not yet been recommended for use in Australia.

Jesse Zanker · David Scott · Sharon L Brennan‐Olsen · Gustavo Duque

A 63- year- old woman developed chills, vomiting and diarrhoea the day after returning from 2 months’ travel in South East Europe

Naomi CA Whyler · Jasmine C Teng · David J Brewster · Ruth Chin · Ian Cox · Julian Druce · Henry M Prince · David A Sheffield · Eugene Teh · Vineet Sarode

The reason I was not finding great satisfaction was that I was searching in all the wrong places

Zhenghong Liu

Glucose and HbA1c screening alone does not increase detection of previously unidentified diabetes in patients admitted from EDs

N Wah Cheung · Lesley V Campbell · Gregory R Fulcher · Patrick McElduff · Barbara Depczynski · Shamasunder Acharya · John Carter · Bernard Champion · Roger Chen · David Chipps · Jeff Flack · Jen Kinsella · Margaret Layton · Mark McLean · Robert G Moses · Kris Park · Ann M Poynten · Carol Pollock · Debbie Scadden · Katherine T Tonks · Mary Webber · Chris White · Vincent Wong · Sandy Middleton

Achieving gender equity in intensive care medicine requires specific interventions to attract and retain female trainees and support their progress to leadership roles

Lucy J Modra · Sarah A Yong

The most frequent reason for retrieval, myocardial infarction, requires early treatment and extensive long term management

Fergus W Gardiner · Alice M Richardson · Lara Bishop · Abby Harwood · Elli Gardiner · Lauren Gale · Narcissus Teoh · Robyn M Lucas · Martin Laverty

The lung will tolerate the challenges of low gravity and decompression stress during lunar exploration, but dust may be the major challenge

G Kim Prisk

To the Editor: The period from January to March marks the peak season for travellers returning to Australia, and typhoid is a key illness of concern. Since 2016, an extensively drug‐resistant (XDR) typhoid clade has emerged in Pakistan, showing resistance to all first‐line agents.1,2 Over the past 2 years, seven cases have been reported in returned travellers — mostly children — from Pakistan to England, Germany and the United States.1,3,4 We report here the first case of XDR typhoid identified in Australia. A 20‐month‐old Australian‐born girl presented to the Children's Hospital at Westmead with features of enteric fever 14 days after her return from a 3‐month trip to Karachi. Diarrhoea began in Pakistan 6 weeks before her return, and continued despite the use of oral antibiotics prescribed locally in Pakistan. Ten days of high fevers, irritability, vomiting and reduced oral intake prompted admission to our hospital. She was a previously well child and had received routine vaccines. No additional pre‐travel vaccinations had been recommended. Blood and stool cultures grew extended spectrum β‐lactamase‐producing Salmonella enterica serovar Typhi. The isolate showed microbiological features typical for the XDR clade, with resistance to chloramphenicol, ampicillin, trimethoprim–sulfamethoxazole, fluoroquinolones and third‐generation cephalosporins (Box). The isolate was susceptible to meropenem and had an azithromycin minimum inhibitory concentration of 12 mg/L. The child responded to intravenous meropenem and oral azithromycin and was discharged after an uncomplicated 8‐day admission to complete a further week of azithromycin. Notification to the local public health unit facilitated contact tracing. This case was one of 12 travel‐associated, culture‐positive enteric fever cases managed at our hospital in the first 3 months of 2019. This continues a trend toward a higher incidence of enteric fever, as previously reported at our hospital from 2003 to 2015.5 This case highlights the emerging threat of XDR typhoid and the broader global issue of escalating antimicrobial resistance, to which Australia is not immune, especially given increasing travel connectivity. Typhoid must be considered as a diagnosis for febrile returned travellers from endemic regions, including South and South‐East Asia. Typhoid vaccination is recommended from 2 years of age if travel is planned to these regions. The important role of general practitioners in providing travel‐related vaccine advice and care to returning travellers must not be underestimated. Box – European Committee on Antimicrobial Susceptibility Testing (EUCAST) disc diffusion demonstrating zones of inhibition to cefotaxime (COX), amoxicillin–clavulanate (AMC), cefepime (FEP), meropenem (MEM), ampicillin (AMP), imipenem (IMP), ciprofloxacin (CIP), amikacin (AKN), piperacillin–tazobactam (PTZ), fosfomycin (FOS); trimethoprim–sulfamethoxazole (SXT) and gentamicin (GMN)

Annaleise Howard‐Jones · Alison M Kesson · Alexander C Outhred · Philip N Britton

Mental and behavioural disorders in rural and remote communities trigger a considerable number of RFDS retrievals

Fergus W Gardiner · Mathew Coleman · Narcissus Teoh · Abby Harwood · Neil T Coffee · Lauren Gale · Lara Bishop · Martin Laverty

The strengths of primary care should be harnessed to address complexities of the ageing population

C Dimity Pond · Catherine Regan