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    E‐cigarette or vaping product use‐associated lung injury (EVALI): a cautionary tale

    Maitri Munsif, Mark Hew and Eli Dabscheck
    Med J Aust 2020; 213 (3): . || doi: 10.5694/mja2.50691
    Published online: 13 July 2020

    Tetrahydrocannabinol‐containing (THC) products with vitamin E additives are implicated in the pathogenesis of EVALI

    Electronic cigarettes, or e‐cigarettes, are battery‐powered devices that heat liquids containing nicotine and other chemicals in order to produce vapour.1 “Vaping” is the act of inhaling the vapour produced by an e‐cigarette.1 First marketed in 2005, e‐cigarette use is viewed by many as less harmful than traditional cigarette smoking, and championed as a strategy for smoking cessation.1,2,3 A detailed discussion of e‐cigarette use in smoking cessation is available in the United States Surgeon General's 2020 report, and is beyond the scope of this article; however, the report states that “there is presently inadequate evidence to conclude that e‐cigarettes, in general, increase smoking cessation”.2 Thus far, no e‐cigarette product for the therapeutic purpose of smoking cessation has been submitted to Australia's Therapeutic Goods Administration for safety evaluation or approval.

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    • Alfred Health, Melbourne, VIC


    Correspondence: e.dabscheck@alfred.org.au
    Competing interests:

    No relevant disclosures.

    • 1. National Academies of Sciences, Engineering, and Medicine. Public health consequences of e‐cigarettes. Washington (DC): National Academies Press, 2018. https://www.nap.edu/read/24952 (viewed Feb 2020).
    • 2. US Department of Health and Human Services. Smoking cessation: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2020. https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf (viewed Feb 2020).
    • 3. Eissenberg T, Bhatnagar A, Chapman S, et al. Invalidity of an oft‐cited estimate of the relative harms of electronic cigarettes. Am J Public Health 2020; 110: 161–162.
    • 4. Pearson JL, Villanti AC. It is past time to consider cannabis in vaping research. Nicotine Tob Res 2020; 22: 597–598.
    • 5. Hartnett KP, Kite‐Powell A, Patel MT, et al. Syndromic surveillance for e‐cigarette, or vaping, product use — associated lung injury. N Engl J Med 2019; 382: 766–772.
    • 6. Lozier M, Wallace B, Anderson K, et al. Update: demographic, product, and substance‐use characteristics of hospitalized patients in a nationwide outbreak of e‐cigarette, or vaping, product use — associated lung injuries — United States, December 2019. MMWR Morb Mortal Wkly Rep 2019; 68: 1142–1148.
    • 7. Cullen KA, Gentzke AS, Sawdey MD, et al. e‐Cigarette use among youth in the United States, 2019. JAMA 2019; 322: 2095–2103.
    • 8. Miech RA, Patrick ME, O'Malley PM, Johnston LD, Bachman JG. Trends in reported marijuana vaping among US adolescents, 2017–2019. JAMA 2020; 323: 475–476.
    • 9. Gentzke AS, Creamer M, Cullen KA, et al. Vital signs: tobacco product use among middle and high school students — United States, 2011–2018. MMWR Morb Mortal Wkly Rep 2019; 68: 157–164.
    • 10. King BA, Jones CM, Baldwin GT, et al. The EVALI and youth vaping epidemics — implications for public health. N Engl J Med 2020; 382: 689–691.
    • 11. Morgan J, Breitbarth AK, Jones AL. Risk versus regulation: an update on the state of e‐cigarette control in Australia. Intern Med J 2019; 49: 110–113.
    • 12. Wolfenden L, Stockings E, Yoong SL. Regulating e‐cigarettes in Australia: implications for tobacco use by young people. Med J Aust 2018; 208: 89. https://www.mja.com.au/journal/2018/208/1/regulating-e-cigarettes-australia-implications-tobacco-use-young-people.
    • 13. Dunlop S, Dessaix A, Currow D. How are tobacco smokers using e‐cigarettes? Patterns of use, reasons for use and places of purchase in New South Wales [letter]. Med J Aust 2016; 205: 336. https://www.mja.com.au/journal/2016/205/7/how-are-tobacco-smokers-using-e-cigarettes-patterns-use-reasons-use-and-places-0.
    • 14. Guerin N, White V. ASSAD 2017 Statistics and Trends: Australian secondary school students’ use of tobacco, alcohol, over‐the‐counter drugs, and illicit substances. Melbourne: Cancer Council Victoria, 2018. https://www.cancervic.org.au/downloads/cbrc/R18_NG_ASSAD_2017_National_Report.pdf (viewed Feb 2020).
    • 15. Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e‐cigarette use in Illinois and Wisconsin — final report. N Engl J Med 2020; 382: 903–916.
    • 16. Centers for Disease Control and Prevention. Outbreak of lung injury associated with e‐cigarette use, or vaping products [website]. Atlanta, GA: CDC, 2020. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html (viewed June 2020).
    • 17. Siegel DA, Jatlaoui TC, Koumans EH, et al. Update: interim guidance for health care providers evaluating and caring for patients with suspected e‐cigarette, or vaping, product use associated lung injury — United States. MMWR Morb Mortal Wkly Rep 2019; 68: 919–927.
    • 18. Schier JG, Meiman JG, Layden J, et al. Severe pulmonary disease associated with electronic‐cigarette‐product use — interim guidance. MMWR Morb Mortal Wkly Rep 2019; 68: 787–790.
    • 19. Blount BC, Karwowski MP, Shields PG, et al. Vitamin E acetate in bronchoalveolar‐lavage fluid associated with EVALI. N Engl J Med 2019; 382: 697–705.
    • 20. Kalininskiy A, Bach CT, Nacca NE, et al. E‐cigarette, or vaping, product use associated lung injury (EVALI): case series and diagnostic approach. Lancet Respir Med 2019; 7: 1017–1026.
    • 21. Butt YM, Smith ML, Tazelaar HD, et al. Pathology of vaping‐associated lung injury. N Engl J Med 2019; 381: 1780–1781.
    • 22. Chivers E, Janka M, Franklin P, et al. Nicotine and other potentially harmful compounds in “nicotine‐free” e‐cigarette liquids in Australia. Med J Aust 2019; 210: 127–128. https://www.mja.com.au/journal/2019/210/3/nicotine-and-other-potentially-harmful-compounds-nicotine-free-e-cigarette.

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      The risks of medical complacency towards poliomyelitis

      Meryta May, David Durrheim, Jason A Roberts and Rhonda Owen
      Med J Aust 2020; 213 (2): . || doi: 10.5694/mja2.50681
      Published online: 6 July 2020

      Australia needs to improve vigilance in the global endeavour to eradicate poliomyelitis

      In 1988, there were over 350 000 cases of paralytic poliomyelitis globally.1 In 2018, there were 29 cases and in 2019 there were 112 cases2 — all in the only two remaining countries in the world where wild poliovirus (WPV) is endemic (Afghanistan and Pakistan). We are tantalisingly close to global eradication.


      • 1 Sullivan Nicolaides Pathology, Brisbane, QLD
      • 2 Children's Health Queensland Hospital and Health Service, Brisbane, QLD
      • 3 Hunter New England Health, Newcastle, NSW
      • 4 Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW
      • 5 Victorian Infectious Diseases Reference Laboratory, Melbourne, VIC
      • 6 Australian Government Department of Health, Canberra, ACT


      Correspondence: meryta_may@snp.com.au
      Acknowledgements: 

      We thank David Isaacs and Bruce Thorley for their assistance in providing relevant information for this manuscript.

      Competing interests:

      No relevant disclosures.

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        COVID‐19: planning for the aftermath to manage the aftershocks

        Steven G Faux, Kathy Eagar, Ian D Cameron and Christopher J Poulos
        Med J Aust 2020; 213 (2): . || doi: 10.5694/mja2.50685
        Published online: 6 July 2020

        Australia has managed the crisis well so far but we should now also plan for future waves and the recovery phase

        Coronavirus disease 2019 (COVID‐19) pandemic management is focused on prevention, case finding and survival. Australia and New Zealand have done well and the numbers in our intensive care units (ICUs) are currently manageable.

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        • 1 St Vincent's Hospital, Sydney, NSW
        • 2 Australian Health Services Research Institute, University of Wollongong, Wollongong, NSW
        • 3 John Walsh Centre for Rehabilitation Research, University of Sydney, Sydney, NSW
        • 4 Centre for Positive Ageing, HammondCare, Sydney, NSW
        • 5 UNSW, Sydney, NSW


        Correspondence: sfaux@stvincents.com.au
        Competing interests:

        No relevant disclosures.

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          Screening, assessment and management of type 2 diabetes mellitus in children and adolescents: Australasian Paediatric Endocrine Group guidelines

          Alexia S Peña, Jacqueline A Curran, Michelle Fuery, Catherine George, Craig A Jefferies, Kristine Lobley, Karissa Ludwig, Ann M Maguire, Emily Papadimos, Aimee Peters, Fiona Sellars, Jane Speight, Angela Titmuss, Dyanne Wilson, Jencia Wong, Caroline Worth and Rachana Dahiya
          Med J Aust 2020; 213 (1): . || doi: 10.5694/mja2.50666
          Published online: 6 July 2020

          Abstract

          Introduction: The incidence of type 2 diabetes mellitus has increased in children and adolescents due largely to the obesity epidemic, particularly in high risk ethnic groups. β‐Cell function declines faster and diabetes complications develop earlier in paediatric type 2 diabetes compared with adult‐onset type 2 diabetes. There are no consensus guidelines in Australasia for assessment and management of type 2 diabetes in paediatric populations and health professionals have had to refer to adult guidelines. Recent international paediatric guidelines did not address adaptations to care for patients from Indigenous backgrounds.

          Main recommendations: This guideline provides advice on paediatric type 2 diabetes in relation to screening, diagnosis, diabetes education, monitoring including targets, multicomponent healthy lifestyle, pharmacotherapy, assessment and management of complications and comorbidities, and transition. There is also a dedicated section on considerations of care for children and adolescents from Indigenous background in Australia and New Zealand.

          Changes in management as a result of the guidelines: Published international guidelines currently exist, but the challenges and specifics to care for children and adolescents with type 2 diabetes which should apply to Australasia have not been addressed to date. These include:

          • recommendations regarding care of children and adolescents from Indigenous backgrounds in Australia and New Zealand including screening and management;
          • tighter diabetes targets (glycated haemoglobin, ≤ 48 mmol/mol [≤ 6.5%]) for all children and adolescents;
          • considering the use of newer medications approved for adults with type 2 diabetes under the guidance of a paediatric endocrinologist; and
          • the need to transition adolescents with type 2 diabetes to a diabetes multidisciplinary care team including an adult endocrinologist for their ongoing care.

          • 1 Robinson Research Institute, University of Adelaide, Adelaide, SA
          • 2 Women's and Children's Hospital, Adelaide, SA
          • 3 Perth Children's Hospital, Perth, WA
          • 4 Queensland Children's Hospital, Brisbane, QLD
          • 5 Starship Children's Health, Auckland, New Zealand
          • 6 Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, NSW
          • 7 Sydney Children's Hospital, Randwick, Sydney, NSW
          • 8 University of Sydney, Sydney, NSW
          • 9 Menzies School of Health Research, Darwin, NT
          • 10 Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, VIC
          • 11 Deakin University, Geelong, VIC
          • 12 Royal Darwin Hospital, Darwin, NT
          • 13 Cairns Hospital, Cairns, QLD
          • 14 Diabetes Centre, Royal Prince Alfred Hospital, Sydney, NSW
          • 15 University of Queensland, Brisbane, QLD


          Correspondence: alexia.pena@adelaide.edu.au
          Acknowledgements: 

          We thank the Australasian Paediatric Endocrine Group (APEG) for facilitating the creation of the guideline‐developing group, teleconference and meetings required for producing this manuscript. We also thank APEG, the New Zealand Society for the Study of Diabetes, and the Australian Diabetes Educators Association for reviewing and providing comments to the manuscript before endorsement.

          Competing interests:

          No relevant disclosures.

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          • 2. Sjardin N, Reed P, Albert B, et al. Increasing incidence of type 2 diabetes in New Zealand children < 15 years of age in a regional‐based diabetes service, Auckland, New Zealand. J Paediatr Child Health 2018; 54: 1005–1010.
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          • 24. Gow ML, Baur LA, Johnson NA, et al. Reversal of type 2 diabetes in youth who adhere to a very‐low‐energy diet: a pilot study. Diabetologia 2017; 60: 406–415.
          • 25. Gow ML, Garnett SP, Baur LA, Lister NB. The effectiveness of different diet strategies to reduce type 2 diabetes risk in youth. Nutrients 2016; 8: 486.
          • 26. Minister of Health. Sit less, move more, sleep well: physical activity guidelines for children and young people. New Zealand Government. 2017. https://www.health.govt.nz/our-work/preventative-health-wellness/physical-activity#kids (viewed Jan 2019).
          • 27. Department of Health. Australian 24‐hour movement guidelines for children and young people (5–17 years): an integration of physical activity, sedentary behaviour and sleep — research report. Canberra: Commonwealth of Australia, 2018. https://www1.health.gov.au/internet/main/publishing.nsf/Content/ti-5-17years (viewed Jan 2019).
          • 28. Costigan SA, Eather N, Plotnikoff RC, et al. High‐intensity interval training for improving health‐related fitness in adolescents: a systematic review and meta‐analysis. Br J Sports Med 2015; 49: 1253–1261.
          • 29. Gohil A, Hannon TS. Poor sleep and obesity: concurrent epidemics in adolescent youth. Front Endocrinol 2018; 9: 364.
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          • 31. Titmuss A, Davis EA, Brown A, Maple‐Brown LJ. Emerging diabetes and metabolic conditions among Aboriginal and Torres Strait Islander young people. Med J Aust 2019; 210: 111–113. https://www.mja.com.au/journal/2019/210/3/emerging-diabetes-and-metabolic-conditions-among-aboriginal-and-torres-strait
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          • 45. Levitt Katz LE, Bacha F, Gidding SS, et al. Lipid profiles, inflammatory markers, and insulin therapy in youth with type 2 diabetes. J Pediatr 2018; 196: 208–216.
          • 46. Inge TH, Laffel LM, Jenkins TM, et al. Comparison of surgical and medical therapy for type 2 diabetes in severely obese adolescents. JAMA Pediatr 2018; 172: 452–460.
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            Hospital in the home: needed now more than ever

            Hugh G Dickson
            Med J Aust 2020; 213 (1): . || doi: 10.5694/mja2.50662
            Published online: 6 July 2020

            Changes in models of care elicited by COVID‐19 may improve the quality of at‐home care for patients

            As the coronavirus disease 2019 (COVID‐19) epidemic continues, attention in Australian hospitals has rapidly become more focused on methods for safely caring for patients while avoiding, when possible, admitting them to hospital or having them visit a hospital outpatient clinic. Diversion from hospitals reduces the risks for both patients and staff of cross‐infection or new infection with the COVID‐19 virus (SARS‐CoV‐2). Telehealth1 and hospital in the home2 (HITH) are two approaches for removing or reducing the need to attend a hospital while maintaining access to its clinical services. Neither system of care is novel, but each is experiencing a predictable surge in activity as the epidemic advances, and the two methods can be combined.


            • Livepool Hospital, South Western Sydney Local Health District, Sydney, NSW


            Competing interests:

            No relevant disclosures.

            • 1. Vimalananda VG, Orlander JD, Afable MK, et al. Electronic consultations (E‐consults) and their outcomes: a systematic review. J Am Med Infor Assoc 2020; 27: 471–479.
            • 2. Shepperd S, Iliffe S, Doll HA, et al. Admission avoidance hospital at home. Cochrane Database Syst Rev 2016; 9: CD007491.
            • 3. NSW Health. COVID‐19 (Coronavirus) statistics. 27 March 2020. https://www.health.nsw.gov.au/news/Pages/20200327_00.aspx (viewed Apr 2020).
            • 4. Montalto M, Leff B. “Hospital in the home”: a lot's in a name. Med J Aust 2012; 197: 479–480. https://www.mja.com.au/journal/2012/197/9/hospital-home-lots-name.
            • 5. Montalto M, McElduff P, Hardy K. Home ward bound: features of hospital in the home use by major Australian hospitals, 2011–2017. Med J Aust 2020; 213: 22–27.
            • 6. Scott IA. Public hospital bed crisis: too few or too misused? Aust Health Rev 2010; 34: 317–324.
            • 7. Varney J, Weiland TJ, Jelinek G. Efficacy of hospital in the home services providing care for patients admitted from emergency departments: an integrative review. Int J Evid Based Healthc 2014; 12: 128–141.

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              Critically ill Indigenous Australians and mortality: a complex story

              Paul J Secombe, Alex Brown, Michael J Bailey and David Pilcher
              Med J Aust 2020; 213 (1): . || doi: 10.5694/mja2.50661
              Published online: 6 July 2020

              For most patients, life continues beyond the intensive care unit, and this is where action is needed

              Aboriginal and Torres Strait Islander (Indigenous Australian) cultures thrived for thousands of years before European colonisation.1 The colonists brought disease, and displaced and marginalised the first peoples, the consequences of which are now seen as inequalities in life expectancy, social determinants of health, and interrupted access to health care.2 Indigenous people fare worse than non‐Indigenous Australians on a range of measures.3 They are over‐represented in acute hospital admissions, particularly to intensive care.4,5,6,7,8 In the critical care literature a consistent story emerges: critically ill Indigenous Australian patients are typically younger and more likely to be mechanically ventilated than non‐Indigenous patients, but their in‐hospital mortality, after adjusting for illness severity, is similar.

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              • 1 Alice Springs Hospital, Alice Springs, NT
              • 2 Flinders University, Adelaide, SA
              • 3 Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC
              • 4 South Australian Health and Medical Research Institute, Adelaide, SA
              • 5 University of South Australia, Adelaide, SA
              • 6 Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC
              • 7 The Alfred Hospital, Melbourne, VIC


              Correspondence: paul.secombe@nt.gov.au
              Acknowledgements: 

              We acknowledge the wisdom and careful proof reading of Greg McAnulty.

              Competing interests:

              No relevant disclosures.

              • 1. Pascoe B. Dark emu. Black seeds: agriculture or accident? Broome: Magabala Books, 2014.
              • 2. Mackean T, Withall E, Dwyer J, Wilson A. Role of Aboriginal Health Workers and Liaison Officers in quality care in the Australian acute care setting: a systematic review. Aust Health Rev 2020; 44: 427–433.
              • 3. Australian Department of the Prime Minister and Cabinet. Closing the gap: Prime Minister's report 2018. https://www.pmc.gov.au/sites/default/files/reports/closing-the-gap-2018/sites/default/files/ctg-report-20183872.pdf?a=1 (viewed Apr 2018).
              • 4. Ho KM, Finn J, Dobb GJ, Webb SA. The outcome of critically ill Indigenous patients. Med J Aust 2006; 184: 496–499. https://www.mja.com.au/journal/2006/184/10/outcome-critically-ill-indigenous-patients.
              • 5. Trout MI, Henson G, Senthuran S. Characteristics and outcomes of critically ill Aboriginal and/or Torres Strait Islander patients in North Queensland. Anaesth Intensive Care 2015; 43: 216–223.
              • 6. Australian Institute of Health and Welfare. Admitted patient care 2016–17: Australian hospital statistics (Cat. No. HSA 201; Health services series no. 84). Canberra: AIHW, 2018.
              • 7. Magee F, Wilson A, Bailey MJ, et al. Trauma‐related admissions to intensive care units in Australia: the influence of Indigenous status on outcomes. Med J Aust 2019; 210: 493–498. https://www.mja.com.au/journal/2019/210/11/trauma-related-admissions-intensive-care-units-australia-influence-indigenous.
              • 8. Secombe P, Brown A, McAnulty G, Pilcher D. Aboriginal and Torres Strait Islander patients requiring critical care: characteristics, resource use, and outcomes. Crit Care Resusc 2019; 21: 200–211.
              • 9. Mitchell WG, Deane A, Brown A, et al. Long term outcomes for Aboriginal and Torres Strait Islander Australians after hospital intensive care. Med J Aust 2020; 213: 16–21.
              • 10. Secombe P, Moynihan G, McAnulty G; Alice Springs Hospital Renal–ICU research group. Long term outcomes of dialysis dependent chronic kidney disease patients requiring critical care: an observational matched cohort study. Intern Med J 2020; https://doi.org/10.1111/imj.14764 [Epub ahead of print].
              • 11. Australian Institute of Health and Welfare. Indigenous identification in hospital separations data: quality report (Cat. no. IHW 90). Canberra: AIHW, 2013.
              • 12. Secombe PJ, Brown A, Bailey MJ, Pilcher D. Equity for Indigenous Australians in intensive care. Med J Aust 2019; 211: 297–299.e1. https://www.mja.com.au/journal/2019/211/7/equity-indigenous-australians-intensive-care.
              • 13. Katzenellenbogen JM, Sanfilippo FM, Hobbs MST, et al. Voting with their feet – predictors of discharge against medical advice in Aboriginal and non‐Aboriginal ischaemic heart disease inpatients in Western Australia: an analytic study using data linkage. BMC Health Serv Res 2013; 13: 330.
              • 14. Ni Cheallaigh C, Cullivan S, Sears J, et al. Usage of unscheduled hospital care by homeless individuals in Dublin, Ireland: a cross‐sectional study. BMJ Open 2017; 7: e016420.

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                Reducing stillbirth safely in Australia

                Roshan Selvaratnam, Mary‐Ann Davey and Euan M Wallace
                Med J Aust 2020; 213 (1): . || doi: 10.5694/mja2.50658
                Published online: 22 June 2020

                Caution is needed so that population‐level reductions in the stillbirth rate are not offset by iatrogenic harm to healthy babies

                The federal Minister for Health the Honourable Greg Hunt MP recently launched the Safer Baby Bundle — a national stillbirth program that aims to reduce stillbirth in Australia by 20% by 2023.1 The program is one of the responses to recommendations arising from the federal Senate's Select Committee on Stillbirth Research and Education.2 It draws from similar bundles of care in the United Kingdom that have been associated with successful reductions in stillbirth.3,4 Undoubtedly, these whole‐of‐population level programs are important and effective. However, because late pregnancy stillbirth can be prevented simply by delivering all babies early, they have the potential for harm.


                • 1 Monash University, Melbourne, VIC
                • 2 Safer Care Victoria, Melbourne, VIC


                Correspondence: euan.wallace@monash.edu
                Acknowledgements: 

                Euan Wallace is the recipient of a National Health and Medical Research Council (NHMRC) Program Grant (APP1113902). Roshan Selvaratnam has been granted a PhD Scholarship Top‐up from the NHMRC Stillbirth Centre of Research Excellence (APP1116640).

                Competing interests:

                No relevant disclosures.

                • 1. Centre of Research Excellence Stillbirth. Safer Baby Bundle handbook and resource guide: working together to reduce stillbirth. Stillbirth CRE, 2019. https://resources.stillbirthcre.org.au/downloads/SBB+Handbook_Final.pdf (viewed Nov 2019).
                • 2. Parliament of Australia. Select Committee on Stillbirth Research and Education report. Canberra: Commonwealth of Australia, 2018. https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Stillbirth_Research_and_Education/Stillbirth/Report (viewed Nov 2019).
                • 3. NHS England. Saving Babies’ Lives: a care bundle for reducing stillbirth. London: NHS England, 2016. https://www.england.nhs.uk/wp-content/uploads/2016/03/saving-babies-lives-car-bundl.pdf (viewed Nov 2019).
                • 4. Healthcare Improvement Scotland. Scottish Patient Safety Programme Maternity and Children, end of phase report. Edinburgh: HIS, 2016. https://ihub.scot/media/2317/spsp-mc-eopr.pdf (viewed Nov 2019).
                • 5. Selvaratnam RJ, Davey MA, Anil S, et al. Does public reporting of the detection of fetal growth restriction improve clinical outcomes: a retrospective cohort study. BJOG 2019; 127: 581–589.
                • 6. Monier I, Blondel B, Ego A, et al. Poor effectiveness of antenatal detection of fetal growth restriction and consequences for obstetric management and neonatal outcomes: a French national study. BJOG 2015; 122: 518–527.
                • 7. Bentley JP, Roberts CL, Bowen JR, et al. Planned birth before 39 weeks and child development: a population‐based study. Pediatrics 2016; 138: e20162002.
                • 8. Stacey T, Thompson JMD, Mitchell EA, et al. Maternal perception of fetal activity and late stillbirth risk: findings from the Auckland Stillbirth study. Birth 2011; 38: 311–316.
                • 9. Grant A, Valentin L, Elbourne D, Alexander S. Routine formal fetal movement counting and risk of antepartum late death in normally formed singletons. Lancet 1989; 334: 345–349.
                • 10. Norman JE, Heazell AEP, Rodriguez A, et al. Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM): a stepped wedge, cluster‐randomised trial. Lancet 2018; 392: 1629–1638.
                • 11. Heazell AEP, Weir CJ, Stock SJE, et al. Can promoting awareness of fetal movements and focussing interventions reduce fetal mortality? A stepped‐wedge cluster randomised trial (AFFIRM) protocol. BMJ Open 2017; 7: e014813.
                • 12. Shah A. Using data for improvement. BMJ 2019; 364: l189.
                • 13. Sovio U, Goulding N, McBride N, et al. A maternal serum metabolite ratio predicts fetal growth restriction at term. Nature Med 2020; 26: 348–353.
                • 14. Bradford BF, Cronin RS, McCowan LME, et al. Association between maternally perceived quality and pattern of fetal movements and late stillbirth. Sci Rep 2019; 9: 9815.

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                  Opening the lines of communication: towards shared decision making and improved end‐of‐life care in the Top End

                  Emma Spencer and Eswaran Waran
                  Med J Aust 2020; 213 (1): . || doi: 10.5694/mja2.50656
                  Published online: 22 June 2020

                  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

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                  • Royal Darwin Hospital, Darwin, NT


                  Correspondence: emma.spencer@nt.gov.au
                  Acknowledgements: 

                  We thank the TEHS GOC committee and the Barwon Health/Deakin University iValidate Communications Training Team.

                  Competing interests:

                  No relevant disclosures.

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                    The deleterious effects of cannabis during pregnancy on neonatal outcomes

                    Luke E Grzeskowiak, Jessica A Grieger, Prabha Andraweera, Emma J Knight, Shalem Leemaqz, Lucilla Poston, Lesley McCowan, Louise Kenny, Jenny Myers, James J Walker, Gustaaf A Dekker and Claire T Roberts
                    Med J Aust 2020; 212 (11): . || doi: 10.5694/mja2.50624
                    Published online: 15 June 2020

                    Abstract

                    Objectives: To evaluate whether cannabis use during pregnancy is associated with adverse neonatal outcomes that are independent of cigarette smoking.

                    Design: Prospective cohort study.

                    Setting: Adelaide (Australia), Auckland (New Zealand), Cork (Ireland), and Leeds, London and Manchester (United Kingdom).

                    Participants: 5610 pregnant nulliparous women with low risk pregnancies recruited for the Screening for Pregnancy Endpoints (SCOPE) study, November 2004 – February 2011. At 14–16 weeks of pregnancy, women were grouped by self‐reported cannabis use.

                    Main outcome measures: Infant birthweight, head circumference, birth length, gestational age, and severe neonatal morbidity or mortality.

                    Results: 314 women (5.6%) reported using cannabis in the 3 months before or during their pregnancy; 97 (31%) stopped using it before and 157 (50%) during the first 15 weeks of pregnancy, while 60 (19%) were still using cannabis at 15 weeks. Compared with babies of mother who had never used cannabis, infants of those who still used it at 15 weeks had lower mean values for birthweight (adjusted mean difference [aMD], –127 g; 95% CI, –238 to –17 g), head circumference (aMD, –0.5 cm; 95% CI, –0.8 to –0.1 cm), birth length (aMD, –0.8 cm; 95% CI, –1.4 to –0.2 cm), and gestational age at birth (aMD, –8.1 days; 95% CI, –12.1 to –4.0 days). The differences for all outcomes except gestational age were greater for women who used cannabis more than once a week than for those who used it less frequently.

                    Conclusions: Continuing to use cannabis during pregnancy is an independent risk factor for poorer neonatal outcomes.

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                    • 1 Robinson Research Institute, University of Adelaide, Adelaide, SA
                    • 2 Adelaide Medical School, University of Adelaide, Adelaide, SA
                    • 3 Women's Health Academic Centre and King's Health Partners, King's College London, London, United Kingdom
                    • 4 Auckland University, Auckland, New Zealand
                    • 5 University of Liverpool, Liverpool, United Kingdom
                    • 6 Maternal and Fetal Health Research Centre, University of Manchester, Manchester, United Kingdom
                    • 7 Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom


                    Acknowledgements: 

                    We thank all SCOPE participants and the SCOPE research midwives in each centre. The SCOPE database is provided and maintained by MedSciNet (medscinet.com). The Australian SCOPE study was funded by the Premier's Science and Research Fund (South Australian government). The New Zealand SCOPE study was funded by the New Enterprise Research Fund, the Foundation for Research Science and Technology, the Health Research Council (04/198), the Evelyn Bond Trust, and the Auckland District Health Board Charitable Trust. The Irish SCOPE study was funded by the Health Research Board of Ireland (CSA/2007/2). The United Kingdom SCOPE study was funded by a National Health Service NEAT grant (FSD025), the Biotechnology and Biological Sciences Research Council (GT084), University of Manchester Proof of Concept Funding, and the Guy's and St. Thomas’ Charity (King's College London), Tommy's Charity (King's College London and University of Manchester), and Cerebra UK (University of Leeds). Claire Roberts was supported by a National Health and Medical Research Council (NHMRC) Senior Research Fellowship (GNT1020749) and a Lloyd Cox Professorial Fellowship (University of Adelaide). Luke Grzeskowiak was supported by an NHMRC Early Career Fellowship (GNT1070421), a Robinson Research Institute Career Development Fellowship, and a Lloyd Cox Research Fellowship (University of Adelaide).

                    Competing interests:

                    No relevant disclosures.

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                      Will online symptom checkers improve health care in Australia?

                      Adam G Dunn
                      Med J Aust 2020; 212 (11): . || doi: 10.5694/mja2.50621
                      Published online: 15 June 2020

                      The available tools are largely unregulated, and do not reliably guide people to the right care at the right time

                      In times when health services are under increasing strain, digital health technologies such as online symptom checkers appear convenient and cost‐effective tools for reducing the burden on clinics, telemedicine services, and emergency departments. In practical terms, an online symptom checker is a smartphone app or web‐based form that can provide a diagnosis on the basis of a set of self‐reported symptoms. They can suggest diagnoses for a broad range of conditions with which people may present to a clinic or emergency department. When they work properly, symptom checkers should turn current practice guidelines into tools that can diagnose and triage patients at low cost.


                      • The University of Sydney, Sydney, NSW


                      Correspondence: adam.dunn@sydney.edu.au
                      Competing interests:

                      No relevant disclosures.

                      • 1. Hill MG, Sim M, Mills B. The quality of diagnosis and triage advice provided by free online symptom checkers and apps in Australia. Med J Aust 2020; 213: 514–519.
                      • 2. Fraser H, Coiera E, Wong D. Safety of patient‐facing digital symptom checkers. Lancet 2018; 392: 2263–2264.
                      • 3. Razzaki S, Baker A, Perov Y, et al. A comparative study of artificial intelligence and human doctors for the purpose of triage and diagnosis [preprint]. 27 June 2018. https://arxiv.org/abs/1806.10698v1 (viewed Apr 2020).
                      • 4. McGrath P, Blumer C, Story Carter J. Medical appointment booking app HealthEngine sharing clients’ personal information with lawyers. ABC News [online]. 24 June 2018. https://www.abc.net.au/news/2018-06-25/healthengine-sharing-patients-information-with-lawyers/9894114 (viewed Apr 2020).
                      • 5. Meyer AND, Giardina TD, Spitzmueller C, et al. Patient perspectives on the usefulness of an artificial intelligence–assisted symptom checker: cross‐sectional survey study. J Med Internet Res 2020; 22: e14679.
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                      • 7. Shuren J, Patel B, Gottlieb S. FDA regulation of mobile medical apps. JAMA 2018; 320: 337–338.
                      • 8. Semigran HL, Linder JA, Gidengil C, Mehrotra A. Evaluation of symptom checkers for self diagnosis and triage: audit study. BMJ 2015; 351: h3480.
                      • 9. Chambers D, Cantrell AJ, Johnson M, et al. Digital and online symptom checkers and health assessment/triage services for urgent health problems: systematic review. BMJ Open 2019; 9: e027743.
                      • 10. Winn AN, Somai M, Fergestrom N, Crotty BH. Associations of use of online symptom checkers with patients’ plans for seeking care. JAMA Network Open 2019; 2: e1918561.

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