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    Living through a pandemic as an MJA editor and a general practitioner

    Aajuli Shukla
    Med J Aust 2021; 215 (11): . || doi: 10.5694/mja2.51338
    Published online: 13 December 2021

    The end of 2021 offers many opportunities to look back on the year that was and make predictions about what is to come. At the time of writing, modelling based on vaccination rates and plans for reopening the country are the trends du jour. Yet, in approaching the end of another year in which coronavirus disease 2019 (COVID‐19) has dominated medical, public health and media agendas, it is vital we take an opportunity to reflect on the impacts that the pandemic has had on Australia’s health system, including the way in which the crisis has spurred valuable innovation and reform. For me personally, experiencing this year as an MJA editor and a general practitioner working in Western Sydney, alongside being an expectant mother from a migrant background, has given me intersecting lenses through which to view the impact of the pandemic on medical publishing, clinical practice, and learning to “live with COVID”.

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      Goodbye, 2021: a year of triumphs and failures

      Nicholas J Talley
      Med J Aust 2021; 215 (11): . || doi: 10.5694/mja2.51345
      Published online: 13 December 2021

      Australians have been challenged in many ways over the past two years: some more than others

      Welcome to the December issue of the MJA. It has not been a very jolly year, but I hope that reflecting on what has been and where we are (or should be) going is therapeutic. And I remain optimistic that, despite the challenges, the future is brighter.

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      • Editor‐in‐Chief


      Correspondence: ntalley@mja.com.au
      Acknowledgements: 

      I thank the tireless efforts of the editorial team throughout 2021, without which the quality and timely publication of our Journal would not be possible: deputy medical editors Alisha Dorrigan, Francis Geronimo, Robyn Godding, Tania Janusic, Wendy Morgan, Aajuli Shukla, and Elizabeth Zuccala; our scientific and structural editors, Paul Foley, Graeme Prince, and Laura Teruel; our consultant biostatistician, Elmer Villanueva; our news and online editor, Cate Swannell; our graphic designer, Leilani Widya; our head of publishing content, Ben Dawe; and our senior publishing coordinator, Kerrie Harding.

      Competing interests:

      A complete list of disclosures is available at https://www.mja.com.au/journal/staff/editor‐chief‐professor‐nick‐talley

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        Care of older people and people requiring palliative care with COVID‐19: guidance from the Australian National COVID‐19 Clinical Evidence Taskforce

        Saskia Cheyne, Richard I Lindley, Natasha Smallwood, Britta Tendal, Michael Chapman, David Fraile Navarro, Phillip D Good, Peter Jenkin, Steve McDonald, Deidre Morgan, Melissa Murano, Tanya Millard, Vasi Naganathan, Velandai Srikanth, Penelope Tuffin, Joshua Vogel, Heath White, Samantha P Chakraborty, Elizabeth Whiting, Leeroy William, Patsy M Yates, Mandy Callary, Julian Elliott and Meera R Agar, for the National COVID‐19 Clinical Evidence Taskforce
        Med J Aust 2022; 216 (4): . || doi: 10.5694/mja2.51353
        Published online: 6 December 2021

        Abstract

        Introduction: Older people living with frailty and/or cognitive impairment who have coronavirus disease 2019 (COVID‐19) experience higher rates of critical illness. There are also people who become critically ill with COVID‐19 for whom a decision is made to take a palliative approach to their care. The need for clinical guidance in these two populations resulted in the formation of the Care of Older People and Palliative Care Panel of the National COVID‐19 Clinical Evidence Taskforce in June 2020. This specialist panel consists of nursing, medical, pharmacy and allied health experts in geriatrics and palliative care from across Australia.

        Main recommendations: The panel was tasked with developing two clinical flow charts for the management of people with COVID‐19 who are i) older and living with frailty and/or cognitive impairment, and ii) receiving palliative care for COVID‐19 or other underlying illnesses. The flow charts focus on goals of care, communication, medication management, escalation of care, active disease‐directed care, and managing symptoms such as delirium, anxiety, agitation, breathlessness or cough. The Taskforce also developed living guideline recommendations for the care of adults with COVID‐19, including a commentary to discuss special considerations when caring for older people and those requiring palliative care.

        Changes in management as result of the guideline: The practice points in the flow charts emphasise quality clinical care, with a focus on addressing the most important challenges when caring for older individuals and people with COVID‐19 requiring palliative care. The adult recommendations contain additional considerations for the care of older people and those requiring palliative care.

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        • 1 NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW
        • 2 Cochrane Australia, Monash University, Melbourne, VIC
        • 3 Westmead Applied Research Centre, University of Sydney, Sydney, NSW
        • 4 George Institute for Global Health, Sydney, NSW
        • 5 Alfred Hospital, Melbourne, VIC
        • 6 Monash University, Melbourne, VIC
        • 7 Canberra Hospital, Canberra, ACT
        • 8 Australian Institute of Health Innovation, Macquarie University, Sydney, NSW
        • 9 St Vincent’s Private Hospital, Brisbane, Brisbane, QLD
        • 10 Resthaven, Adelaide, SA
        • 11 Research Centre for Palliative Care, Death and Dying, Flinders University, Adelaide, SA
        • 12 Flinders University, Adelaide, SA
        • 13 Centre for Education and Research on Ageing (CRGH), University of Sydney, Sydney, NSW
        • 14 Royal Perth Hospital, Perth, WA
        • 15 Fiona Stanley Hospital, Perth, WA
        • 16 Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC
        • 17 Prince Charles Hospital, Brisbane, QLD
        • 18 Eastern Health, Melbourne, VIC
        • 19 Centre for Cancer and Palliative Care Outcomes, Queensland University of Technology, Brisbane, QLD
        • 20 Royal Adelaide Hospital, Adelaide, SA
        • 21 IMPACCT Centre, University of Technology Sydney, Sydney, NSW


        Correspondence: saskia.cheyne@monash.edu
        Acknowledgements: 

        We acknowledge all members of the National COVID‐19 Clinical Evidence Taskforce, the member organisations, partners, governments and funders that support the initiative (online Supporting Information). These guidelines have received funding from the Australian Government Department of Health; the Victorian Government Department of Health and Human Services; the Ian Potter Foundation; the Walter Cottman Endowment Fund, managed by Equity Trustees; and the Lord Mayor’s Charitable Foundation.

        Competing interests:

        No relevant disclosures.

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          Increasing ICU capacity to accommodate higher demand during the COVID‐19 pandemic

          Edward Litton, Sue Huckson, Shaila Chavan, Tamara Bucci, Anthony Holley, Evan Everest, Sean Kelly, Steven McGloughlin, Johnny Millar, Nhi Nguyen, Mark Nicholls, Paule Secombe and David Pilcher
          Med J Aust 2021; 215 (11): . || doi: 10.5694/mja2.51318
          Published online: 15 November 2021

          Abstract

          Objectives: To describe the short term ability of Australian intensive care units (ICUs) to increase capacity in response to heightened demand caused by the COVID‐19 pandemic.

          Design: Survey of ICU directors or delegated senior clinicians (disseminated 30 August 2021), supplemented by Australian and New Zealand Intensive Care Society (ANZICS) registry data.

          Setting: All 194 public and private Australian ICUs.

          Main outcome measures: Numbers of currently available and potentially available ICU beds in case of a surge; available levels of ICU‐relevant equipment and staff.

          Results: All 194 ICUs responded to the survey. The total number of currently open staffed ICU beds was 2183. This was 195 fewer (8.2%) than in 2020; the decline was greater for rural/regional (18%) and private ICUs (18%). The reported maximal ICU bed capacity (5623) included 813 additional physical ICU bed spaces and 2627 in surge areas outside ICUs. The number of available ventilators (7196) exceeded the maximum number of ICU beds. The reported number of available additional nursing staff would facilitate the immediate opening of 383 additional physical ICU beds (47%), but not the additional bed spaces outside ICUs.

          Conclusions: The number of currently available staffed ICU beds is lower than in 2020. Equipment shortfalls have been remediated, with sufficient ventilators to equip every ICU bed. ICU capacity can be increased in response to demand, but is constrained by the availability of appropriately trained staff. Fewer than half the potentially additional physical ICU beds could be opened with currently available staff numbers while maintaining pre‐pandemic models of care.

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          • 1 Fiona Stanley Hospital, Perth, WA
          • 2 The University of Western Australia, Perth, WA
          • 3 Centre for Outcome and Resource Evaluation (CORE), Australian and New Zealand Intensive Care Society (ANZICS), Melbourne, VIC
          • 4 Royal Brisbane and Women's Hospital, Brisbane, QLD
          • 5 Flinders Medical Centre, Adelaide, SA
          • 6 Central Coast Local Health District, Charmhaven, NSW
          • 7 The Alfred Hospital, Melbourne, VIC
          • 8 Royal Children’s Hospital, Melbourne, VIC
          • 9 NSW Agency for Clinical Innovation, Sydney, NSW
          • 10 Nepean Hospital, Penrith, NSW
          • 11 St Vincent's Hospital Sydney, Sydney, NSW
          • 12 Alice Springs Hospital, Alice Springs, NT


          Correspondence: ed.litton@health.wa.gov.au
          Acknowledgements: 

          We thank all data collectors and clinicians, particularly the directors and nurse unit managers of all 194 Australian ICUs who contributed to this study.

          Competing interests:

          No relevant disclosures.

          • 1. Litton E, Bucci T, Chavan S, et al. Surge capacity of intensive care units in case of acute increase in demand caused by COVID‐19 in Australia. Med J Aust 2020; 212: 463–467. https://www.mja.com.au/journal/2020/212/10/surge‐capacity‐intensive‐care‐units‐case‐acute‐increase‐demand‐caused‐covid‐19
          • 2. Kadri SS, Sun J, Lawandi A, et al. Association between caseload surge and COVID‐19 survival in 558 US hospitals, March to August 2020. Ann Intern Med 2021; 174: 1240–1251.
          • 3. Toth AT, Tatem KS, Hosseinipour N, et al. Surge and mortality in ICUs in New York City’s public healthcare system. Crit Care Med 2021; 49: 1439–1450.
          • 4. Bravata DM, Perkins AJ, Myers LJ, et al. Association of intensive care unit patient load and demand with mortality rates in US Department of Veterans Affairs hospitals during the COVID‐19 pandemic. JAMA Netw Open 2021; 4: e2034266.
          • 5. Gupta S, Hayek SS, Wang W, et al; STOP‐COVID Investigators. Factors associated with death in critically ill patients with coronavirus disease 2019 in the US. JAMA Intern Med 2020; 180: 1436–1447.
          • 6. Taccone FS, Van Goethem N, De Pauw R, et al. The role of organizational characteristics on the outcome of COVID‐19 patients admitted to the ICU in Belgium [letter]. Lancet Reg Health Eur 2021; 2: 100019.
          • 7. Australian Government. National plan to transition Australia’s national COVID‐19 response. 30 July 2021. https://www.pm.gov.au/sites/default/files/media/national‐plan‐to‐transition‐australias‐national‐covid‐19‐response‐30‐july‐2021.pdf (viewed Sept 2021).
          • 8. ANZICS Centre for Outcome and Resource Evaluation. 2020 report. https://www.anzics.com.au/annual‐reports (viewed Oct 2021).
          • 9. Australian Bureau of Statistic. National, state and territory population. Reference period: December 2020. 17 June 2021. https://www.abs.gov.au/statistics/people/population/national‐state‐and‐territory‐population/dec‐2020 (viewed Sept 2021).
          • 10. Dobson H, Malpas CB, Burrell AJ, et al. Burnout and psychological distress amongst Australian healthcare workers during the COVID‐19 pandemic. Australas Psychiatry 2021; 29: 26–30.
          • 11. Painvin B, Messet H, Rodriguez M, et al. Inter‐hospital transport of critically ill patients to manage the intensive care unit surge during the COVID‐19 pandemic in France. Ann Intensive Care 2021; 11: 54.
          • 12. Pilcher D, Coatsworth NR, Rosenow M, McClure J. A national system for monitoring intensive care unit demand and capacity: the Critical Health Resources Information System (CHRIS). Med J Aust 2021; 214: 297–298.e1. https://www.mja.com.au/journal/2021/214/7/national‐system‐monitoring‐intensive‐care‐unit‐demand‐and‐capacity‐critical
          • 13. Pilcher D, Duke G, Rosenow M, et al. Assessment of a novel marker of ICU strain, the ICU Activity Index, during the COVID‐19 pandemic in Victoria, Australia. Crit Care Resusc 2021; 23: 300–307.
          • 14. Secombe P, Brown A, Bailey M, et al. Characteristics and outcomes of patients admitted to regional and rural intensive care units in Australia. Crit Care Resusc 2020; 22: 335–343.
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            Is it time to abandon clinical breast examination?

            Belinda E Kiely and Annabel Goodwin
            Med J Aust 2021; 215 (10): . || doi: 10.5694/mja2.51285
            Published online: 15 November 2021

            Despite limits to its clinical value, the potential benefits for women should not be overlooked

            Women with mutations in breast cancer predisposition genes have a very high risk of developing breast cancer and are offered risk‐reducing strategies and intensified surveillance; many are referred to specialist risk management clinics. Because magnetic resonance imaging (MRI) is more sensitive for detecting breast cancer at an early stage than mammography, it is part of most high risk breast cancer screening programs, and in Australia is covered by Medicare for women at high risk under 50 years of age.


            • 1 NHMRC Clinical Trials Centre, the University of Sydney, Sydney, NSW
            • 2 Concord Repatriation General Hospital, Sydney, NSW


            Correspondence: belinda.kiely@sydney.edu.au
            Competing interests:

            Belinda Kiely has received honoraria from Roche for sitting on an advisory board (2018, 2019), and Annabel Goodwin has received honoraria from AstraZeneca and Pfizer for sitting on advisory boards (2018, 2019).

            • 1. Warner E, Messersmith H, Causer P, et al. Systematic review: using magnetic resonance imaging to screen women at high risk for breast cancer. Ann Intern Med 2008; 148: 671–679.
            • 2. Australian Department of Health. Medicare Benefits Schedule: item 63464. MBS Online. http://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=63464&qt=item&criteria=breast%20MRI (viewed Sept 2021).
            • 3. Hettipathirana T, Macdonald C, Xie J, et al. The value of clinical breast examination in a breast cancer surveillance program for women with germline BRCA1 or BRCA2 mutations. Med J Aust 2021; 215: 460–464.
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            • 5. Ngan TT, Nguyen NTQ, Van Minh H, et al. Effectiveness of clinical breast examination as a ‘‘stand‐alone’’ screening modality: an overview of systematic reviews. BMC Cancer 2020; 20: 1070.
            • 6. Mittra I, Mishra GA, Dikshit RP, et al. Effect of screening by clinical breast examination on breast cancer incidence and mortality after 20 years: prospective, cluster randomised controlled trial in Mumbai. BMJ 2021; 372: n256.
            • 7. Nelson HD, Tyne K, Naik A, et al. Screening for breast cancer: an update for the US Preventive Services Task Force. Ann Intern Med 2009; 151: 727–737.
            • 8. Rijnsburger AJ, Obdeijn IM, Kaas R, et al. BRCA1‐associated breast cancers present differently from BRCA2‐associated and familial cases: long‐term follow‐up of the Dutch MRISC Screening Study. J Clin Oncol 2010; 28: 5265–5273.
            • 9. MARIBS Study Group. Screening with magnetic resonance imaging and mammography of a UK population at high familial risk of breast cancer: a prospective multicentre cohort study (MARIBS). Lancet 2005; 365: 1769–1778.
            • 10. Guindalini RSC, Zheng Y, Abe H, et al. Intensive surveillance with biannual dynamic contrast‐enhanced magnetic resonance imaging downstages breast cancer in BRCA1 mutation carriers. Clin Cancer Res 2019; 25: 1786–1794.
            • 11. Spiegel TN, Hill KA, Warner E. The attitudes of women with BRCA1 and BRCA2 mutations toward clinical breast examinations and breast self‐examinations. J Womens Health (Larchmt) 2009; 18: 1019–1024.
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              Universal genetic testing of patients with newly diagnosed breast cancer — ready for prime time?

              Dilanka L De Silva, Paul A James, G Bruce Mann and Geoffrey J Lindeman
              Med J Aust 2021; 215 (10): . || doi: 10.5694/mja2.51317
              Published online: 15 November 2021

              Current genetic testing guidelines may overlook patients with actionable mutations in high risk breast and ovarian cancer predisposition genes

              The discovery of the BRCA1 and BRCA2 genes just over 25 years ago ushered in a new era of genetic testing for patients diagnosed with breast and/or ovarian cancer. A new field of practice in familial cancer emerged that has continued to evolve at an accelerating pace over the intervening years. With improvements in technology, changing patient attitudes and striking new clinical data, genetic testing may have now arrived at another defining moment — as a routine investigation for virtually all patients with newly diagnosed breast cancer (universal testing), a notion that was unimaginable a quarter of a century ago.


              • 1 Familial Cancer Centre, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC
              • 2 Memorial Sloan Kettering Cancer Center, New York, USA
              • 3 University of Melbourne, Melbourne, VIC
              • 4 Royal Melbourne and Royal Women's Hospitals, Melbourne, VIC
              • 5 Peter MacCallum Cancer Centre, Melbourne, VIC
              • 6 Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC


              Correspondence: lindeman@wehi.edu.au
              Acknowledgements: 

              Geoffrey Lindeman is supported by a National Health and Medical Research Council (NHMRC) Leadership Fellowship (1175960). The NHMRC played no role in the planning, writing or publication of this work.

              Competing interests:

              No relevant disclosures.

              • 1. Narod SA, Foulkes WD. BRCA1 and BRCA2: 1994 and beyond. Nat Rev Cancer 2004; 4: 665–676.
              • 2. Cancer Australia. Advice about familial aspects of breast cancer and epithelial ovarian cancer. Sydney: Cancer Australia, 2015. https://www.canceraustralia.gov.au/publications‐and‐resources/cancer‐australia‐publications/advice‐about‐familial‐aspects‐breast‐cancer‐and‐epithelial‐ovarian‐cancer (viewed Oct 2021).
              • 3. Tung NM, Garber JE. BRCA1/2 testing: therapeutic implications for breast cancer management. Br J Cancer 2018; 119: 141–152.
              • 4. Robson M, Im SA, Senkus E, et al. Olaparib for metastatic breast cancer in patients with a germline BRCA mutation. N Engl J Med 2017; 377: 523–533.
              • 5. EviQ. BRCA1 and BRCA2 genetic testing: Cancer Institute NSW. https://www.eviq.org.au/cancer‐genetics/adult/genetic‐testing‐for‐heritable‐pathogenic‐variants/620‐brca1‐and‐brca2‐genetic‐testing (viewed Oct 2021).
              • 6. Antoniou AC, Hardy R, Walker L, et al. Predicting the likelihood of carrying a BRCA1 or BRCA2 mutation: validation of BOADICEA, BRCAPRO, IBIS, Myriad and the Manchester scoring system using data from UK genetics clinics. J Med Genet 2008; 45: 425–431.
              • 7. Kirk J, Barlow‐Stewart KK, Poplawski NK, et al. Medicare‐funded cancer genetic tests: a note of caution. Med J Aust 2018; 209: 193–196. https://www.mja.com.au/journal/2018/209/5/medicare‐funded‐cancer‐genetic‐tests‐note‐caution
              • 8. Hu C, Hart SN, Gnanaolivu R, et al. A population‐based study of genes previously implicated in breast cancer. N Engl J Med 2021; 384: 440–451.
              • 9. Audeh MW, Carmichael J, Penson RT, et al. Oral poly(ADP‐ribose) polymerase inhibitor olaparib in patients with BRCA1 or BRCA2 mutations and recurrent ovarian cancer: a proof‐of‐concept trial. Lancet 2010; 376: 245–251.
              • 10. Moore K, Colombo N, Scambia G, et al. Maintenance olaparib in patients with newly diagnosed advanced ovarian cancer. N Engl J Med 2018; 379: 2495–505.
              • 11. Tutt ANJ, Garber JE, Kaufman B, et al. Adjuvant olaparib for patients with BRCA1‐ or BRCA2‐mutated breast cancer. N Engl J Med 2021; 384: 2394–2405.
              • 12. Tung NM, Zakalik D, Somerfield MR, for the Hereditary Breast Cancer Guideline Expert Panel. Adjuvant PARP inhibitors in patients with high‐risk early‐stage HER2‐negative breast cancer and germline BRCA mutations: ASCO hereditary breast cancer guideline rapid recommendation update. J Clin Oncol 2021; 39: 2959–2961.
              • 13. Kuchenbaecker KB, Hopper JL, Barnes DR, et al. Risks of breast, ovarian, and contralateral breast cancer for BRCA1 and BRCA2 mutation carriers. JAMA 2017; 317: 2402–2416.
              • 14. Fasching PA, Yadav S, Hu C, et al. Mutations in BRCA1/2 and other panel genes in patients with metastatic breast cancer ‐association with patient and disease characteristics and effect on prognosis. J Clin Oncol 2021; 39: 1619–1630.
              • 15. Plon SE, Eccles DM, Easton D, et al. Sequence variant classification and reporting: recommendations for improving the interpretation of cancer susceptibility genetic test results. Hum Mutat 2008; 29: 1282–1291.
              • 16. Robson M, Domchek S. Broad application of multigene panel testing for breast cancer susceptibility ‐ Pandora’s Box Is opening wider. JAMA Oncol 2019; 5: 1687–1688.
              • 17. Kemp Z, Turnbull A, Yost S, et al. Evaluation of cancer‐based criteria for use in mainstream BRCA1 and BRCA2 genetic testing in patients with breast cancer. JAMA Netw Open 2019; 2: e194428.
              • 18. Beard C, Monohan K, Cicciarelli L, et al. Mainstream genetic testing for breast cancer patients: early experiences from the Parkville Familial Cancer Centre. Eur J Hum Genet 2021; 29: 872–880.
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                It is time for governments to support retailers in the transition to a smoke‐free society

                Coral E Gartner, April Wright, Marita Hefler, Andrew Perusco and Janet Hoek
                Med J Aust 2021; 215 (10): . || doi: 10.5694/mja2.51312
                Published online: 15 November 2021

                Phasing out tobacco retailing is gaining traction as the natural next step in controlling the tobacco pandemic

                The commercial tobacco trade is a complex system involving multiple actors, from tobacco growers and manufacturers to the importers and wholesalers that distribute products to retailers, who onsell to consumers. Consumers who purchase and use products form the demand side. Governments can influence each actor through policy, but have historically focused on the demand‐side measures in the World Health Organization Framework Convention on Tobacco Control (WHO FCTC; Articles 6–14). These outnumber the supply‐side measures (Articles 15–17), which have primarily focused on constraining tobacco product manufacturers. Calls are growing for governments to increase attention on retail supply — the critical link in the supply chain between manufacturers and consumers.


                • 1 University of Queensland, Brisbane, QLD
                • 2 Charles Darwin University, Darwin, NT
                • 3 Australian National University, Canberra, ACT
                • 4 University of Otago, Dunedin, New Zealand


                Correspondence: c.gartner@uq.edu.au
                Acknowledgements: 

                Coral Gartner is the chief investigator in a National Health and Medical Research Council (NHMRC) grant (GNT1198301). Andrew Perusco holds an Australian Government Research Training Scholarship administered by Australian National University. The manuscript was written as part of the activities of the NHMRC‐funded Centre of Research Excellence on Achieving the Tobacco Endgame. The funder played no role in the study design, manuscript preparation, or the decision to submit it for publication.

                Competing interests:

                No relevant disclosures.

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                  Who cares about climate?

                  Hugh Montgomery and Fintan Hughes
                  Med J Aust 2021; 215 (9): . || doi: 10.5694/mja2.51300
                  Published online: 1 November 2021

                  The threat of climate change is immediate and grave, and now is the time to act


                  • 1 University College London, London, UK
                  • 2 Duke University, Durham, NC, USA


                  Correspondence: h.montgomery@ucl.ac.uk
                  Competing interests:

                  Hugh Montgomery chairs the Lancet Countdown on health and climate change, which is funded by the Wellcome Trust.

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                    Mucormycosis: early treatment is the key to survival

                    Timothy R Holmes, Jenny L Hepschke, Ian Jacobson and Anthony Maloof
                    Med J Aust 2021; 215 (9): . || doi: 10.5694/mja2.51290
                    Published online: 1 November 2021

                     


                    • Prince of Wales Hospital and Community Health Services, Sydney, NSW


                    Acknowledgements: 

                    We thank the patient and his wife for their insights and help in preparing this article. Their fortitude and commitment throughout his illness were remarkable. We also acknowledge the many other clinicians involved in the patient's care, without whose contributions the outcome might have been quite different.

                    Competing interests:

                    No relevant disclosures.

                    • 1. Cornely OA, Alastruey‐Izquierdo A, Arenz D, et al. Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium. Lancet Infect Dis 2019; 19: e405–e421.
                    • 2. Vaughan C, Bartolo A, Vallabh N, Leong SC. A meta‐analysis of survival factors in rhino‐orbital‐cerebral mucormycosis‐has anything changed in the past 20 years? Clin Otolaryngol 2018; 43: 1454–1464.
                    • 3. Prakash H, Ghosh AK, Rudramurthy SM, et al. A prospective multicenter study on mucormycosis in India: epidemiology, diagnosis, and treatment. Med Mycol 2019; 57: 395–402.
                    • 4. Chamilos G, Lewis RE, Kontoyiannis DP. Delaying amphotericin B‐based frontline therapy significantly increases mortality among patients with hematologic malignancy who have zygomycosis. Clin Infect Dis 2008; 47: 503–509.
                    • 5. Gamba JL, Woodruff WW, Djang WT, Yeates AE. Craniofacial mucormycosis: assessment with CT. Radiology 1986; 160: 207–212.
                    • 6. Fanos V, Cataldi L. Amphotericin B‐induced nephrotoxicity: a review. J Chemother 2000; 12: 463–470.
                    • 7. Saedi B, Sadeghi M, Seilani P. Endoscopic management of rhinocerebral mucormycosis with topical and intravenous amphotericin. Br J Laryngol Otol 2011; 125: 807–810.
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                      The 2021 report of the MJA–Lancet Countdown on health and climate change: Australia increasingly out on a limb

                      Paul J Beggs, Ying Zhang, Alice McGushin, Stefan Trueck, Martina K Linnenluecke, Hilary Bambrick, Helen L Berry, Ollie Jay, Lucie Rychetnik, Ivan C Hanigan, Geoffrey G Morgan, Yuming Guo, Arunima Malik, Mark Stevenson, Donna Green, Fay H Johnston, Celia McMichael, Ian Hamilton and Anthony G Capon
                      Med J Aust 2021; 215 (9): . || doi: 10.5694/mja2.51302
                      Published online: 21 October 2021

                      Summary

                      • The MJA–Lancet Countdown on health and climate change in Australia was established in 2017, and produced its first national assessment in 2018, its first annual update in 2019, and its second annual update in 2020. It examines indicators across five broad domains: climate change impacts, exposures and vulnerability; adaptation, planning and resilience for health; mitigation actions and health co‐benefits; economics and finance; and public and political engagement.
                      • Our special report in 2020 focused on the unprecedented and catastrophic 2019–20 Australian bushfire season, highlighting indicators that explore the relationships between health, climate change and bushfires. For 2021, we return to reporting on the full suite of indicators across each of the five domains and have added some new indicators.
                      • We find that Australians are increasingly exposed to and vulnerable to excess heat and that this is already limiting our way of life, increasing the risk of heat stress during outdoor sports, and decreasing work productivity across a range of sectors. Other weather extremes are also on the rise, resulting in escalating social, economic and health impacts. Climate change disproportionately threatens Indigenous Australians’ wellbeing in multiple and complex ways.
                      • In response to these threats, we find positive action at the individual, local, state and territory levels, with growing uptake of rooftop solar and electric vehicles, and the beginnings of appropriate adaptation planning. However, this is severely undermined by national policies and actions that are contrary and increasingly place Australia out on a limb. Australia has responded well to the COVID‐19 public health crisis (while still emerging from the bushfire crisis that preceded it) and it now needs to respond to and prepare for the health crises resulting from climate change.

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                      • 1 Macquarie University, Sydney, NSW
                      • 2 University of Sydney, Sydney, NSW
                      • 3 Institute for Global Health, University College London, London, UK
                      • 4 Queensland University of Technology, Brisbane, QLD
                      • 5 Australian Institute of Health Innovation, Macquarie University, Sydney, NSW
                      • 6 University Centre for Rural Health, University of Sydney, Sydney, NSW
                      • 7 University Centre for Rural Health, University of Sydney, Lismore, NSW
                      • 8 Monash University, Melbourne, VIC
                      • 9 Integrated Sustainability Analysis, University of Sydney, Sydney, NSW
                      • 10 University of Melbourne, Parkville, VIC
                      • 11 Climate Change Research Centre and ARC Centre of Excellence for Climate Extremes, University of New South Wales, Sydney, NSW
                      • 12 Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS
                      • 13 UCL Energy Institute, University College London, London, UK
                      • 14 Monash Sustainable Development Institute, Monash University, Melbourne, VIC


                      Correspondence: paul.beggs@mq.edu.au
                      Acknowledgements: 

                      We thank Katie Quail for assistance with indicator 1.2 Indigenous health and climate change. We thank Robert Fawcett, John Nairn (retired), Elizabeth Ebert and Bronwyn Brown (all from the Australian Bureau of Meteorology) for indicators 1.3 Health effects of heatwaves and 2.4 Climate information services for health. We thank Nathan Morris for assistance with the analysis for indicator 1.4 Heat impact on physical and sporting activities. We thank Tord Kjellstrom and Matthias Otto for providing the results for indicator 1.5 Change in labour capacity. The Bushfires indicator was generated with support from NASA Applied Sciences Program (grant no. 80NSSC21K0507) and we thank Yang Liu, Bryan Vu and Liuhua Shi (all from Emory University) for the Australian data used for this indicator (1.7), and Nicolas Borchers Arriagada (Menzies Institute for Medical Research, University of Tasmania) for assistance with analysis. Shouro Dasgupta conducted the sea level rise‐related data analysis for indicator 1.9 Migration, displacement, and environmental change. He is an author on the Lancet Countdown global report, and contributor to the sea level rise indicator. The global version of this indicator was developed in collaboration also with Ilan Kelman and Sonja Ayeb‐Karlsson. We thank Kerry Nice (University of Melbourne) who worked on indicator 2.6 Urban green space. The assistance of Zahra Borghei Ghomi (Macquarie University) in compiling the data for indicators 3.1 Carbon intensity of the energy system, 3.2 Coal phase‐out, 3.3 Zero carbon emission electricity, and 3.4 Clean household energy is acknowledged. We thank Marco Springman from the Lancet Countdown for providing the results for indicator 3.9 Diet and health co‐benefits. We thank Maddie Heenan for searching and data compilation for indicator 5.3 Government engagement in health and climate change in Australia. We thank the NHMRC for providing the data for indicator 5.4 Health and climate change research funding.

                      Competing interests:

                      No relevant disclosures.

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