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A 38‐year‐old woman with longstanding Crohn’s disease presented with 7 months of a non‐healing widespread rash. Examination revealed indurated and ulcerated papulonodular lesions on the abdomen and extremities (Box 1). Medications included adalimumab, 6‐mercaptopurine, allopurinol and an oral contraceptive pill. There were no other significant medical conditions. The main differentials considered were cutaneous/metastatic Crohn’s disease or a disseminated atypical infection such as atypical mycobacterium or deep fungal. The lesions were too numerous for a skin malignancy.

1 Princess Alexandra Hospital, Brisbane, QLD
2 Mater Hospital, Brisbane, QLD
3 Sullivan Nicolaides Pathology, Brisbane, QLD
4 University of Queensland, Brisbane, QLD

Correspondence: fleur.kong@health.qld.gov.au

Competing interests:

No relevant disclosures.

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Guideline summary

Care for adults with COVID‐19: living guidelines from the National COVID‐19 Clinical Evidence Taskforce

Heath White, Steve J McDonald, Bridget Barber, Joshua Davis, Lucy Burr, Priya Nair, Sutapa Mukherjee, Britta Tendal, Julian Elliott, Steven McGloughlin and Tari Turner

Med J Aust 2022; 217 (7): . || doi: 10.5694/mja2.51718
Published online: 3 October 2022

Topics

Environment and public health

Health services administration

Infectious diseases

Pharmaceutical preparations

Statistics, epidemiology and research design

Abstract

Introduction: The Australian National COVID‐19 Clinical Evidence Taskforce was established in March 2020 to maintain up‐to‐date recommendations for the treatment of people with coronavirus disease 2019 (COVID‐19). The original guideline (April 2020) has been continuously updated and expanded from nine to 176 recommendations, facilitated by the rapid identification, appraisal, and analysis of clinical trial findings and subsequent review by expert panels.

Main recommendations: In this article, we describe the recommendations for treating non‐pregnant adults with COVID‐19, as current on 1 August 2022 (version 61.0). The Taskforce has made specific recommendations for adults with severe/critical or mild disease, including definitions of disease severity, recommendations for therapy, COVID‐19 prophylaxis, respiratory support, and supportive care.

Changes in management as a result of the guideline: The Taskforce currently recommends eight drug treatments for people with COVID‐19 who do not require supplemental oxygen (inhaled corticosteroids, casirivimab/imdevimab, molnupiravir, nirmatrelvir/ritonavir, regdanvimab, remdesivir, sotrovimab, tixagevimab/cilgavimab) and six for those who require supplemental oxygen (systemic corticosteroids, remdesivir, tocilizumab, sarilumab, baricitinib, casirivimab/imdevimab). Based on evidence of their achieving no or only limited benefit, ten drug treatments or treatment combinations are not recommended; an additional 42 drug treatments should only be used in the context of randomised trials. Additional recommendations include support for the use of continuous positive airway pressure, prone positioning, and endotracheal intubation in patients whose condition is deteriorating, and prophylactic anticoagulation for preventing venous thromboembolism. The latest updates and full recommendations are available at www.covid19evidence.net.au.

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1 Cochrane Australia, Monash University, Melbourne, VIC
2 QIMR Berghofer Medical Research Institute, Brisbane, QLD
3 John Hunter Hospital, Newcastle, NSW
4 The University of Newcastle, Newcastle, NSW
5 Mater Hospital Brisbane, Brisbane, QLD
6 Mater Research Institute, University of Queensland, Brisbane, QLD
7 St Vincent's Hospital Sydney, Sydney, NSW
8 Adelaide Institute for Sleep Health, Adelaide, SA
9 The Alfred Hospital, Melbourne, VIC
10 Monash University, Melbourne, VIC

Correspondence: heath.white@monash.edu

Open access

Open access publishing facilitated by Monash University, as part of the Wiley–Monash University agreement via the Council of Australian University Librarians.

Acknowledgements:

The National COVID‐19 Clinical Evidence Taskforce is funded by the Australian Department of Health, the Victorian Department of Health and Human Services, the Ian Potter Foundation and the Walter Cottman Endowment Fund (managed by Equity Trustees), and the Lord Mayors’ Charitable Foundation. We thank all members of the National COVID‐19 Clinical Evidence Taskforce for their magnificent contributions to the work described in this article, and acknowledge the Taskforce member organisations and our partners (complete list included in the Supporting Information).

Competing interests:

No relevant disclosures.

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Editorials

Practice and system improvements for better physical health and longer lives for people living with serious mental illness

Rosemary V Calder, James A Dunbar and Maximilian P Courten

Med J Aust 2022; 217 (7): . || doi: 10.5694/mja2.51713
Published online: 3 October 2022

Topics

General medicine

Health services administration

Mental disorders

Health occupations

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

People living with serious mental illness die up to 20 years prematurely from chronic physical health conditions.1 Most of these early deaths are from preventable health conditions including cardiovascular disease, smoking‐related respiratory illness, diabetes, and cancer.2 Primary care is not organised to provide this group with screening for cardiometabolic risk factors.

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1 Mitchell Institute, Victoria University, Melbourne, VIC
2 Deakin University, Warrnambool, VIC

Correspondence: rosemary.calder@vu.edu.au

Acknowledgements:

The Being Equally Well project has been partially supported by grant funding from the Australian Government Department of Health and Aged Care to the Mitchell Institute at Victoria University for the Australian Health Policy Collaboration, a network of chronic disease and population health academics, clinicians, experts, and advocates who have participated in this project. The supplement accompanying this issue of the MJA was financially supported by the Mitchell Institute, Victoria University, and by grant funding from the Australian Government Department of Health and Aged Care for the Australian Health Policy Collaboration. The authors acknowledge and thank all participants in and contributors to the Being Equally Well project for their expert commitment to the project and its potential impacts on health care for people living with serious mental illness.

Competing interests:

No relevant disclosures.

1. Australian Institute of Health Welfare. Physical health of people with mental illness. Canberra: AIHW, 2020. https://www.aihw.gov.au/reports/australias‐health/physical‐health‐of‐people‐with‐mental‐illness (viewed July 2022).
2. Roberts R. The physical health of people living with mental illness: a narrative literature review. Charles Sturt University, 2019. https://www.equallywell.org.au/wp‐content/uploads/2019/06/Literature‐review‐EquallyWell.pdf (viewed July 2022).
3. Morgan M, Peters D, Hopwood M, et al. Being Equally Well: a national policy roadmap to better physical health care and longer lives for people living with serious mental illness. Melbourne: Mitchell Institute, Victoria University, 2021. https://www.vu.edu.au/sites/default/files/being‐equally‐well‐policy‐roadmap‐mitchell‐institute.pdf (viewed July 2022).
4. Nelson EC, Batalden PB, Godfrey MM. Quality by design: a clinical microsystems approach. San Francisco: Jossey‐Bass, 2007.
5. Morgan M, Hopwood M, Dunbar JA. Shared guidelines and protocols to achieve better health outcomes for people living with serious mental illness. Med J Aust 2022; 217 (7 Suppl): S34‐S35.
6. Mc Namara K, Rosenbaum S, Rocks T, et al. Workforce development for better management of physical comorbidities among people with severe mental illness. Med J Aust 2022; 217 (7 Suppl): S39‐S42.
7. Coles AS, Maksyutynska K, Knezevic D, et al. Peer‐facilitated interventions for physical health outcomes in individuals with schizophrenia spectrum disorders. Med J Aust 2022; 217 (7 Suppl): S22‐S28.
8. Mc Namara K, Jamza AZ, Murry M, et al. Should antidiabetic medicines be considered to reduce cardiometabolic risk in patients with serious mental illness? Med J Aust 2022; 217 (7 Suppl): S29‐S33.
9. Sharma S, Buckhalter S, Siskind S, Castle D. Clozapine shared care: mental health services and GPs working together for better outcomes for people with schizophrenia. Med J Aust 2022; 217 (7 Suppl): S36‐S38.
10. Rocks T, Teasdale SB, Fehily C, et al. The role of dietary intervention for the management of physical health conditions in individuals with serious mental illness: a systematic review and meta‐analysis. Med J Aust 2022; 217 (7 Suppl): S7‐S21.

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Perspectives

Australia needs to implement a national health strategy for doctors

Chanaka Wijeratne, Margaret P Kay, Mark H Arnold and Jeffrey CL Looi

Med J Aust 2022; 217 (7): . || doi: 10.5694/mja2.51714
Published online: 3 October 2022

Topics

General medicine

Health services administration

Medical education

Coordinated systemic change and enhanced access to care are needed to improve doctors’ wellbeing

Over the past decade, there has been growing recognition of the prevalence of psychological distress across the medical profession and that practitioner wellbeing has significant implications for patient safety. The fact that burnout, anxiety, depression, suicidal ideation, and completed suicide are higher in doctors than in the general population1,2 is a problem requiring urgent and novel interventions.

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1 University of Notre Dame Australia, Sydney, NSW
2 UNSW Sydney, Sydney, NSW
3 University of Queensland, Brisbane, QLD
4 School of Rural Health, University of Sydney, Dubbo, NSW
5 University of Sydney, Sydney, NSW
6 Australian National University, Canberra, ACT

Correspondence: chanaka.wijeratne@health.nsw.gov.au

Open access

Open access publishing facilitated by University of New South Wales, as part of the Wiley ‐ University of New South Wales agreement via the Council of Australian University Librarians.

Competing interests:

Chanaka Wijeratne is a Medical Council of New South Wales Directed Health Assessor. Margaret Kay is a member of the Management Committee, Queensland Doctors’ Health Advisory Service. Mark Arnold is a member of the Medical Council of New South Wales.

1. Beyond Blue. National Mental Health Survey of Doctors and Medical Students, 2013. https://www.beyondblue.org.au/about‐us/our‐work‐in‐improving‐workplace‐mental‐health/health‐services‐program/national‐mental‐health‐survey‐of‐doctors‐and‐medical‐students (viewed Jan 2022).
2. Milner AJ, Maheen H, Bismark MM, Spittal MA. Suicide by health professionals: a retrospective mortality study in Australia, 2001–2012. Med J Aust 2016; 205: 260‐265. https://www.mja.com.au/journal/2016/205/6/suicide‐health‐professionals‐retrospective‐mortality‐study‐australia‐2001‐2012
3. Everymind. Every Doctor, Every Setting: a national framework to guide coordinated action on the mental health of doctors and medical students, 2019 [website]. https://lifeinmind.org.au/every‐doctor‐every‐setting (viewed Feb 2022).
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5. Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta‐analysis. JAMA 2016; 316: 2214‐2236.
6. Royal Australian and New Zealand College of Psychiatrists. Discussion paper: gender equity and the College: why does it matter? RANZCP, 2022. https://www.ranzcp.org/files/membership/wellbeing/ranzcp‐discussion‐paper‐gender‐equity.aspx (viewed Feb 2022).
7. Panagioti M, Panagopoulou E, Bower P et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta‐analysis. JAMA Int Med 2017; 177: 195‐205.
8. Guille C, Frank, E, Zhao Z, et al. Work–family conflict and the sex difference in depression among training physicians. JAMA Intern Med 2017; 177: 1766‐1772.
9. Milner A, Witt K, Spittal MJ, et al. The relationship between working conditions and self‐rated health among medical doctors: evidence from seven waves of the Medicine in Australia Balancing Employment and Life (Mabel) survey. BMC Health Serv Res 2017; 17: 609.
10. Arnold MH. Teasing out artificial intelligence in medicine: an ethical critique of artificial intelligence and machine learning in medicine. J Bioeth Inq 2021; 18: 121‐139.
11. Wijeratne C, Johnco C, Draper B, Earl J. Doctors’ reporting of mental health stigma and barriers to help‐seeking. Occupat Med 2021; 71: 366‐374.
12. Bridson TL, Jenkins K, Allen KG, McDermott BM. PPE for your mind: a peer support initiative for health care workers. Med J Aust 2021; 214: 8‐11. https://www.mja.com.au/journal/2021/214/1/ppe‐your‐mind‐peer‐support‐initiative‐health‐care‐workers
13. Nash L, Karageorge A, Lancaster, Prager S. How peer review groups support learning and wellbeing in psychiatrists. Australas Psychiatry 2022; 30: 556‐563.
14. Black Dog Institute. TEN: The Essential Network for health professionals [website]. https://www.blackdoginstitute.org.au/the‐essential‐network (viewed Feb 2022).
15. AHPRA and Medical Board. Guidelines: mandatory notifications about registered health practitioners, March 2020. https://www.medicalboard.gov.au/Codes‐Guidelines‐Policies/Guidelines‐for‐mandatory‐notifications.aspx (viewed May 2022).
16. Seselja E. Mandatory reporting discourages doctors from seeking help, puts patients in harm’s way, GP body says. ABC News 2020; 15 Dec. https://www.abc.net.au/news/2020‐12‐15/mandatory‐reporting‐laws‐discourage‐doctors‐from‐seeking‐help/12982380 (viewed Jan 2022).
17. Health Practitioner Regulation National Law. https://www.ahpra.gov.au/About‐Ahpra/What‐We‐Do/Legislation.aspx (viewed Aug 2022).

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Guidelines

Urological Society of Australia and New Zealand (USANZ) and Australasian Chapter of Sexual Health Medicine (AChSHM) for the Royal Australasian College of Physicians (RACP) clinical guidelines on the management of erectile dysfunction

Eric Chung, Michael Lowy, Michael Gillman, Chris Love, Darren Katz and Graham Neilsen

Med J Aust 2022; 217 (6): . || doi: 10.5694/mja2.51694
Published online: 19 September 2022

Correction(s) for this article:

Erratum | Published online: 16 April 2025

Topics

Men's health

Sexual health

Urologic diseases

Abstract

Introduction: These clinical practice recommendations by the Urological Society of Australia and New Zealand (USANZ) and the Australasian Chapter of Sexual Health Medicine (AChSHM) for the Royal Australasian College of Physicians (RACP) provide evidence‐based clinical guidelines on the management of erectile dysfunction (ED) in Australia.

Main recommendations:

A comprehensive clinical history and a tailored physical examination are essential (Level of evidence [LoE] 3; GRADE B).
Laboratory testing should include fasting glucose, lipid profile and total testosterone level (LoE 3; GRADE A).
Specialised diagnostic tests are recommended in selected cases and the patient should be counselled accordingly (LoE 4; GRADE B).
Lifestyle changes and optimisation of existing medical conditions should accompany all ED treatment regimens (LoE 1; GRADE A).
Oral phosphodiesterase type 5 inhibitor (PDE5i) is an effective first line medical therapy (LoE 1; GRADE A).
Intracavernosal injections and vacuum erection devices are recommended as second line therapy (LoE 1; GRADE B).
A penile prosthesis implant can be considered in men who are medically refractory or unable to tolerate the side effects of medical therapy (LoE 4; GRADE B).
Pro‐erectile regenerative therapy remains largely experimental (LoE 3; GRADE B).

Changes in management as a result of these guidelines: Modification of lifestyle behaviour, management of reversible risk factors and optimisation of existing medical conditions remain pivotal, and existing standard ED therapies are often effective and safe following cardiovascular risk stratification. Caution should be exercised on the use of regenerative technology in ED due to unknown long term outcomes.

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1 Princess Alexandra Hospital, Brisbane, QLD
2 University of Queensland, Brisbane, QLD
3 AndroUrology Centre, Brisbane, QLD
4 Male Clinic, Sydney, NSW
5 Men’s Health Doctor, Brisbane, QLD
6 Urology South, Melbourne, VIC
7 Men’s Health Melbourne, Melbourne, VIC
8 Stonewall Medical Centre, Brisbane, QLD

Correspondence: ericchg@hotmail.com

Competing interests:

No relevant disclosures.

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35. Chung E. Penile prosthesis implant: Scientific advances and technological innovations over the last four decades. Transl Androl Urol 2017; 6: 37‐45.
36. Chung E, Lee J, Liu CC, et al. Clinical practice guideline recommendation on the use of low intensity extracorporeal shock wave therapy and low intensity pulsed ultrasound shock wave therapy to treat erectile dysfunction: the Asia‐Pacific Society for Sexual Medicine position statement. World J Mens Health 2021; 39: 1‐8.
37. Chung E, Wang J. A state‐of‐art review of low intensity extracorporeal shock wave therapy and lithotripter machines for the treatment of erectile dysfunction. Expert Rev Med Device 2017; 14: 929‐934.
38. Chung E. Stem‐cell‐based therapy in the file of urology: A review of stem cell basic science, clinical applications and future directions in the treatment of various sexual and urinary conditions. Expert Opin Biol Ther 2015; 15: 1623‐1632.
39. Scott S, Roberts M, Chung E. Platelet‐rich plasma and treatment of erectile dysfunction: Critical review of literature and global trends in platelet‐rich plasma clinics. Sex Med Rev 2019; 7: 306‐312.

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Medical education
Lessons from practice

A polymorphic rash from across the seas

Akshay Flora, Priya Garg, Karen Cheung, Deshan F Sebaratnam and Monisha Gupta

Med J Aust 2022; 217 (6): . || doi: 10.5694/mja2.51690
Published online: 19 September 2022

Topics

Infectious diseases

Health occupations

Environment and public health

Global health

A 21‐year‐old man who migrated to Australia from Nepal 4 years previously was referred to a dermatologist. He had a 12‐month history of a polymorphic eruption consisting of widespread macules, plaques, papules, and nodules. As these were asymptomatic, he had not previously sought medical attention.

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1 Liverpool Hospital, Sydney, NSW
2 UNSW Sydney, Sydney, NSW
3 Concord Repatriation General Hospital, Sydney, NSW
4 Douglass Hanly Moir Pathology, Sydney, NSW

Correspondence: a.flora@unsw.edu.au

Open access

Open access publishing facilitated by University of New South Wales, as part of the Wiley ‐ University of New South Wales agreement via the Council of Australian University Librarians.

Acknowledgements:

We thank Timothy Gray, Staff Specialist in Microbiology and Infectious Diseases at Concord General Repatriation Hospital, for his contribution to this article.

Competing interests:

No relevant disclosures.

1. World Health Organization. Leprosy. 2022. https://www.who.int/news‐room/fact‐sheets/detail/leprosy (viewed Jan 2022),
2. Australian Government Department of Health and Aged Care. National Notifiable Diseases Surveillance System (NNDSS) fortnightly reports – 11 July to 24 July 2022. https://www.health.gov.au/resources/publications/national‐notifiable‐diseases‐surveillance‐system‐nndss‐fortnightly‐reports‐11‐july‐to‐24‐july‐2022 (viewed Aug 2022).
3. World Health Organization. Guidelines for the diagnosis, treatment and prevention of leprosy. 2018. https://www.who.int/publications/i/item/9789290226383 (viewed Jan 2022).
4. Blok DJ, de Vlas SJ, Fischer EAJ, Richardus JH. Mathematical modelling of leprosy and its control. In: Anderson RM, Basáñez MG, editors. Advances in parasitology. Academic Press, 2015.
5. NSW Health. Control guidelines. Leprosy. https://www.health.nsw.gov.au/Infectious/controlguideline/Pages/leprosy.aspx (viewed Mar 2022).
6. Hempenstall A, Smith S, Hanson J. Leprosy in Far North Queensland: almost gone, but not to be forgotten. Med J Aust 2019; 211: 182‐183. https://www.mja.com.au/journal/2019/211/4/leprosy‐far‐north‐queensland‐almost‐gone‐not‐be‐forgotten
7. Northern Territory Government Department of Health. Guidelines for the control of leprosy in the Northern Territory, 2018. https://digitallibrary.health.nt.gov.au/prodjspui/bitstream/10137/526/3/Control%20of%20Leprosy%20in%20the%20Northern%20Territory%20Guidelines.pdf (viewed Mar 2022).
8. Government of Western Australia North Metropolitan Health Service. Guidelines for the diagnosis, management and prevention of leprosy. Feb 2019. https://ww2.health.wa.gov.au/~/media/Files/Corporate/general‐documents/Leprosy/PDF/WATBCP‐WA‐Leprosy‐Guideline.pdf (viewed March 2022).

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Perspectives

Roadmap to incorporating group A Streptococcus molecular point‐of‐care testing for remote Australia: a key activity to eliminate rheumatic heart disease

Dylan D Barth, Gelsa Cinanni, Jonathan R Carapetis, Rosemary Wyber, Louise Causer, Caroline Watts, Belinda Hengel, Susan Matthews, Anna P Ralph, Janessa Pickering, Jeffrey W Cannon, Lorraine Anderson, Vicki Wade, Rebecca J Guy and Asha C Bowen

Med J Aust 2022; 217 (6): . || doi: 10.5694/mja2.51692
Published online: 19 September 2022

Topics

General medicine

Statistics, epidemiology and research design

Infectious diseases

Indigenous health

Strep A POCT is a critical element in preventing acute rheumatic fever and will contribute to the elimination of rheumatic heart disease in Australia

Group A β‐haemolytic Streptococcus pyogenes (Strep A) most commonly causes superficial infections of the throat (pharyngitis) and skin (impetigo). In Australia, one‐third of primary school aged children have an episode of pharyngitis each year,1 with Strep A identified in about 20% of children with symptomatic pharyngitis and 10% of asymptomatic children.2,3,4 Superficial Strep A infections are the sole precursor of acute rheumatic fever (ARF) and rheumatic heart disease (RHD),5 with risk likely to be driven by both pharyngitis and impetigo.6 These autoimmune sequelae are a major cause of morbidity and mortality in developing countries and among Indigenous people living in high income countries.7 The burden of ARF and RHD in remote Australian communities is high and disproportionately affects Aboriginal and Torres Strait Islander people.8 The reported mortality rates of RHD in Aboriginal populations are among the highest worldwide (28.4 per 100 000 population; 95% CI, 24.1–32.7).9 This is despite ARF and RHD being preventable through the early treatment of Strep A pharyngitis and impetigo.10 In this article, we focus on the use of molecular point‐of‐care testing (POCT) in the diagnosis of pharyngitis, which is the dominant superficial infection leading to ARF.

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1 University of Western Australia, Perth, WA
2 Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, WA
3 The George Institute for Global Health, Sydney, NSW
4 Kirby Institute, UNSW Sydney, Sydney, NSW
5 Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA
6 Menzies School of Health Research, Charles Darwin University, Darwin, NT
7 Royal Darwin Hospital, Darwin, NT
8 Kimberley Aboriginal Medical Services Limited, Broome, WA

Correspondence: dylan.barth@telethonkids.org.au

Open access

Open access publishing facilitated by The University of Western Australia, as part of the Wiley ‐ The University of Western Australia agreement via the Council of Australian University Librarians.

Competing interests:

No relevant disclosures.

1. Danchin MH, Rogers S, Kelpie L, et al. Burden of acute sore throat and group A streptococcal pharyngitis in school‐aged children and their families in Australia. Pediatrics 2007; 120: 950‐957.
2. Oliver J, Malliya Wadu E, Pierse N, et al. Group A Streptococcus pharyngitis and pharyngeal carriage: a meta‐analysis. PLoS Negl Trop Dis 2018; 12: e0006335.
3. Shaikh N, Leonard E, Martin JM. Prevalence of streptococcal pharyngitis and streptococcal carriage in children: a meta‐analysis. Pediatrics 2010; 126: e557‐e564.
4. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012; 55: 1279‐1282.
5. Haffejee I. Rheumatic fever and rheumatic heart disease: the current status of its immunology, diagnostic criteria, and prophylaxis. Q J Med 1992; 84: 641‐658.
6. RHD Australia. The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3.2 edition, March 2022). https://www.rhdaustralia.org.au/arf‐rhd‐guideline (viewed Aug 2022)
7. Steer AC, Danchin MH, Carapetis JR. Group A streptococcal infections in children. J Paediatr Child Health 2007; 43: 203‐213.
8. Katzenellenbogen JM, Bond‐Smith D, Seth RJ, et al. Contemporary incidence and prevalence of rheumatic fever and rheumatic heart disease in Australia using linked data: the case for policy change. J Am Heart Assoc 2020; 9: e016851.
9. Colquhoun SM, Condon JR, Steer AC, et al. Disparity in mortality from rheumatic heart disease in Indigenous Australians. J Am Heart Assoc 2015; 4: e001282.
10. American Academy of Pediatrics Committee on Infectious Diseases. Severe invasive group A streptococcal infections: a subject review. Pediatrics 1998; 101(1 Pt 1): 136‐140.
11. Tarca AJ, Hand RM, Wyber R. Call for a national sore throat guideline. Med J Aust 2019; 210: 477. https://www.mja.com.au/journal/2019/210/10/call‐national‐sore‐throat‐guideline
12. Fine AM, Nizet V, Mandl KD. Large‐scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med 2012; 172: 847‐852.
13. Guy RJ, Ward J, Causer LM, et al. Molecular point‐of‐care testing for chlamydia and gonorrhoea in Indigenous Australians attending remote primary health services (TTANGO): a cluster‐randomised, controlled, crossover trial. Lancet Infect Dis 2018; 18: 1117‐1126.
14. Hengel B, Causer L, Matthews S, et al. A decentralised point‐of‐care testing model to address inequities in the COVID‐19 response. Lancet Infect Dis 2021: 21: e183‐e190.
15. National Pathology Accreditation Advisory Council. Requirements for point of care testing (second edition 2021). Canberra: Commonwealth of Australia, 2021. https://www1.health.gov.au/internet/main/publishing.nsf/Content/Requirements‐for‐Point‐of‐Care‐Testing‐(Second‐Edition‐2021) (viewed June 2022).
16. Yang S, Rothman RE. PCR‐based diagnostics for infectious diseases: uses, limitations, and future applications in acute‐care settings. Lancet Infect Dis 2004; 4: 337‐348.
17. Pickering JL, Barth DD, Bowen AC. Performance and practicality of a rapid molecular test for the diagnosis of strep A pharyngitis in a remote Australian setting. Am J Trop Med Hygiene 2020; 103: 2530‐2532.
18. Causer LM, Guy RJ, Tabrizi SN, et al. Molecular test for chlamydia and gonorrhoea used at point of care in remote primary healthcare settings: a diagnostic test evaluation. Sex Transm Infect 2018; 94: 340‐345.
19. Ferrieri P, Thonen‐Kerr E, Nelson K, Arbefeville S. Prospective evaluation of Xpert® Xpress Strep A automated PCR assay vs Solana® group A streptococcal nucleic acid amplification testing vs conventional throat cultu re. Curr Microbiol 2021; 78: 2956‐2960.
20. Tran J, Danchin M, Pirotta M, C Steer A. Sore throat in primary care. Aust J Gen Pract 2018; 47: 485‐489.
21. Wyber R, Kelly A, Lee AM, et al. Formative evaluation of a community‐based approach to reduce the incidence of Strep A infections and acute rheumatic fever. Aust N Z J Public Health 2021; 45: 449‐454.
22. Ralph AP, Holt DC, Islam S, et al. Potential for molecular testing for group A streptococcus to improve diagnosis and management in a high‐risk population: a prospective study. Open Forum Infect Dis 2019; 6: ofz097.
23. Tong SYC, Davis JS, Eichenberger E, et al. Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management. Clin Microbiol Rev 2015; 28: 603‐661.
24. Beck E, Ross P, Clow A, et al. Evaluation of three rapid molecular assays for the detection of group A streptococcus. Open Forum Infect Dis 2018; 5 (Suppl 1): S679‐S680.
25. Barth DD, Mullane MJ, Sampson C, et al. Missing Piece Study protocol: prospective surveillance to determine the epidemiology of group A streptococcal pharyngitis and impetigo in remote Western Australia. BMJ Open 2022; 12: e057296.
26. Gunnarsson RK, Orda U, Elliott B, et al. Improving antibiotics targeting using PCR point‐of‐care testing for group A streptococci in patients with uncomplicated acute sore throat. Aust J Gen Pract 2021; 50: 76‐83.
27. Cannon J, Bessarab DC, Wyber R, Katzenellenbogen JM. Public health and economic perspectives on acute rheumatic fever and rheumatic heart disease. Med J Aust 2019; 211: 250‐252. https://www.mja.com.au/journal/2019/211/6/public‐health‐and‐economic‐perspectives‐acute‐rheumatic‐fever‐and‐rheumatic
28. Grant BD, Anderson CE, Williford JR, et al. SARS‐CoV‐2 coronavirus nucleocapsid antigen‐detecting half‐strip lateral flow assay toward the development of point of care tests using commercially available reagents. Anal Chem 2020; 92: 11305‐11309.
29. Thompson TZ, McMullen AR. Group A streptococcus testing in pediatrics: the move to point‐of‐care molecular testing. J Clin Microbiol 2020; 58: e01494‐19.
30. Wyber R NK, Halkon C, Enkel S, et al. The RHD Endgame Strategy: a snapshot. The blueprint to eliminate rheumatic heart disease in Australia by 2031. Perth: END RHD Centre of Research Excellence, Telethon Kids Institute, 2020. https://endrhd.telethonkids.org.au/siteassets/media‐docs‐‐‐end‐rhd/end‐rhd‐cre‐‐‐endgame‐snapshot.pdf (viewed June 2022).
31. Medical Services Advisory Committee. About MSAC. http://www.msac.gov.au/internet/msac/publishing.nsf/Content/about‐msac (viewed June 2022).
32. Natoli L, Guy RJ, Shephard M, et al. “I Do Feel Like a Scientist at Times”: a qualitative study of the acceptability of molecular point‐of‐care testing for chlamydia and gonorrhoea to primary care professionals in a remote high STI burden setting. PLoS One 2015; 10: e0145993.
33. Guy RJ, Natoli L, Ward J, et al. A randomised trial of point‐of‐care tests for chlamydia and gonorrhoea infections in remote Aboriginal communities: Test, Treat ANd GO ‐ the “TTANGO” trial protocol. BMC Infect Dis 2013; 13: 485.

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Editorials

Ambulance ramping and patients with cardiac‐type symptoms: understanding the unloading queue

Gao Jing Ong and John D Horowitz

Med J Aust 2022; 217 (5): . || doi: 10.5694/mja2.51677
Published online: 5 September 2022

Prioritisation for unloading, once obvious cardiac emergencies have been excluded, disadvantages women and older people

About 10–20% of people transported by emergency ambulance to hospital have (presumptively cardiac) chest pain.1 Our management of these patients is inevitably geared to the possibility of evolving myocardial infarction, in which case any delay in initiating definitive treatment to restore coronary perfusion will increase the short and long term risks of death.2 The three major sources of delay after the ambulance collects the patient are the time taken to deliver the patient to a suitable hospital, the waiting period outside the emergency department before unloading the patient, and within‐hospital barriers to treatment initiation, such as delays in definite diagnosis and the availability of suitably trained staff for delivering definitive treatment. For most purposes, it is best to consider barriers to treatment as a “series resistance model”: what ultimately matters is to ensure that treatment is delivered as expeditiously as possible.

1 Central Adelaide Local Health Network, Adelaide, SA
2 Basil Hetzel Institute for Translational Health Research, Adelaide, SA
3 The University of Adelaide, Adelaide, SA

Correspondence: john.horowitz@adelaide.edu.au

Competing interests:

No relevant disclosures.

1. Burman RA, Zakaraissen E, Hunskaar S. Acute chest pain: a prospective population‐based study of contacts to Norwegian emergency medical communications centres. BMC Emerg Med 2011; 11: 9.
2. Scholz KH, Maier SKG, Maier LS, et al. Impact of treatment delay on mortality in ST‐segment elevation myocardial infarction (STEMI) patients presenting with and without haemodynamic instability: results from the German prospective, multicentre FITT‐STEMI trial. Eur Heart J 2018; 39: 1065‐1074.
3. Woodward T, Hocking J, James L, Johnson D. Impact of an emergency department‐run clinical decision unit on access block, ambulance ramping and National Emergency Access Target. Emerg Med Australas 2019; 31: 200‐204.
4. Schull MJ, Morrison LJ, Vermeulen M, Redelmeier DA. Emergency department overcrowding and ambulance transport delays for patients with chest pain. CMAJ 2003; 168: 277‐283.
5. Dawson LP, Andrew E, Stephenson M, et al. The influence of ambulance offload time on 30‐day risks of death and re‐presentation for patients with chest pain. Med J Aust 2022; 217: 253‐259.
6. Pedersen GJ, Stengaard C, Friesgaard K, et al. Chest pain in the ambulance: prevalence, causes and outcome: a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2019; 27: 84.
7. Elbadawi A, Elgendi IY, Najvi SY, et al. Temporal trends and outcomes of hospitalisations with Prinzmetal angina: perspectives from a national database. Am J Med 2019; 132: 1053‐1061.
8. Ghadri JR, Wittstein IS, Prasad A, et al. Expert consensus document on takotsubo syndrome (part 1): clinical characteristics, diagnostic criteria, and pathophysiology. Eur Heart J 2018; 39: 2032‐2046.

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Editorials

Clearing elective surgery waiting lists after the COVID‐19 pandemic cannot be allowed to compromise emergency surgery care

Robert J Aitken and David AK Watters

Med J Aust 2022; 217 (5): . || doi: 10.5694/mja2.51672
Published online: 5 September 2022

Topics

Surgical procedures, operative

Many patients with gallstone pancreatitis were not receiving timely, surgical care even before the pandemic

Elective surgery waiting lists have long been a sensitive political issue.1 Reducing the increased backlog and waiting times caused by coronavirus disease 2019 (COVID‐19) pandemic‐related restrictions on elective surgery will be a major health priority during the next three to five years. Delaying emergency surgery is one approach used to prioritise elective surgery, but focusing on elective surgery rates may result in delayed theatre access for emergency operations,2,3 compromising emergency surgery outcomes and prolonging hospital stays and consequently increasing costs.

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1 Sir Charles Gairdner Hospital, Perth, WA
2 Deakin University, Geelong, VIC
3 Barwon Health, Geelong, VIC

Correspondence: rjaitken@me.com

Competing interests:

No relevant disclosures.

1. Curtis AJ, Russell COH, Stoelwinder JU, McNeil JJ. Waiting lists and elective surgery: ordering the queue. Med J Aust 2010; 192: 217‐220. https://www.mja.com.au/journal/2010/192/4/waiting‐lists‐and‐elective‐surgery‐ordering‐queue
2. NSW Agency for Clinical Innovation. NSW emergency surgery guidelines and principles for improvement (GL2021_007). 18 May 2021. https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2021_007.pdf (viewed Apr 2022).
3. Deane SA, MacLellan DG, Meredith GL, Cregan PC; Surgical Services Taskforce Emergency Surgery Sub‐group. Making sense of emergency surgery in New South Wales: a position statement. ANZ J Surg 2010; 80: 139‐144.
4. Blundell JD, Gandy RC, Close J, Harvey L. Cholecystectomy for people aged 50 years or more with mild gallstone pancreatitis: predictors and outcomes of index and interval procedures. Med J Aust 2022; 217: 246‐252.
5. De Mestral C, Nathens AB. Cholecystectomy in mild gallstone pancreatitis: don’t defer. Lancet 2015; 386: 1218‐1219.
6. Le Manach Y, Collins G, Bhandari M, et al. Outcomes after hip fracture surgery compared with elective total hip replacement. JAMA 2015; 314: 1159‐1166.
7. Mullen MG, Michaels AD, Mehaffey JH, et al. Risk associated with complications and mortality after urgent surgery vs elective and emergency surgery implications for defining “quality” and reporting outcomes for urgent surgery. JAMA Surg 2017; 152: 768‐774.
8. Danford NC, Logue TC, Boddapati V, et al. Debate update: surgery after 48 hours of admission for geriatric hip fracture patients is associated with increase in mortality and complication rate: a study of 27 058 patients using the National Trauma Data Bank. J Orthop Trauma 2021; 35: 535‐541.
9. Australian and New Zealand Hip Fracture Registry. Annual report 2021 (figure 23). Sept 2021. https://anzhfr.org/wp‐content/uploads/sites/1164/2021/12/ANZHFR_eReport2021‐FA.pdf (viewed May 2022).
10. Aitken RJ, Griffiths B, van Acker J, et al; ANZELA‐QI Working Party. Two‐year outcomes from the Australian and New Zealand Emergency Laparotomy Audit – Quality Improvement pilot. ANZ J Surg 2021; 91: 2575‐2582.
11. NELA Project Team. Seventh patient report of the National Emergency Laparotomy Audit. Nov 2021. https://www.nela.org.uk/Seventh‐Patient‐Report#pt (viewed Apr 2022).
12. Drysdale HRE, Ooi S, Geelong Surgical COVID‐19 Response Team, Nagra S, et al. Clinical activity and outcomes during Geelong’s general surgery response to the coronavirus disease 2019 pandemic. ANZ J Surg 2020; 90: 1573‐1579.
13. Boyd‐Carson H, Doleman B, Cromwell D, et al; National Emergency Laparotomy Audit Collaboration. Delay in source control in perforated peptic ulcer leads to 6% increased risk of death per hour: a nationwide cohort study. World J Surg 2020; 44: 869‐875.
14. Australian Government. Maximising the value of Australia’s clinical quality outcomes data. a national strategy for clinical quality registry and virtual registries 2020–2030. Updated 14 Dec 2021. https://www1.health.gov.au/internet/main/publishing.nsf/Content/national_clinical_quality_registry_and_virtual_registry_strategy_2020‐2030 (viewed Apr 2022).

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Editorials

Advertising by orthopaedic surgeons: the tension between professionalism and commercialism

Peter FM Choong

Med J Aust 2022; 217 (5): . || doi: 10.5694/mja2.51676
Published online: 5 September 2022

Topics

Ethics and law

Information science

Musculoskeletal diseases

Translating guidelines into practice is required to maintain the balance between practitioner autonomy and accountability

Medical professionals assure us that they will only provide care that limits harm (non‐maleficence) and promotes the best outcomes (beneficence) for patients. The basis of this social contract is the expectation of integrity, morality, and altruism in their business practices, making doctors trustworthy sources of good health care. A doctor’s first duty is to their patient, a dictum as relevant today as it was for Hippocrates. In our complex society, it is more important than ever that doctors are trusted by their patients. In return, doctors enjoy autonomy of practice, status in society, and self‐regulation.

The University of Melbourne, Melbourne, VIC

Correspondence: pchoong@unimelb.edu.au

Acknowledgements:

I am supported by a National Health and Medical Research Council Practitioner Fellowship.

Competing interests:

I received consultancy fees for advisory and design work from Johnson & Johnson, and from Stryker.

1. Ryan HY, Sun GY, Monuja M, et al. Adherence by orthopaedic surgeons to AHPRA and Australian Orthopaedic Association advertising guidelines. Med J Aust 2022; 217: 240‐245.
2. Hesse BW, Greenberg AJ, Rutten LJF. The role of Internet resources in clinical oncology: promises and challenges. Nat Rev Clin Oncol 2016; 13: 767‐776.
3. Schneller ES, Wilson NA. Professionalism in 21st century professional practice: autonomy and accountability in orthopaedic surgery. Clin Orthop Relat Res 2009; 467: 2561‐2569.
4. Jones JW, McCullough LB. Is medical advertising always unethical, or does it just seem to be? J Vasc Surg 2015; 61: 1635‐1636.
5. Davaris MT, Dowsey MM, Bunzli S, Choong PF. Arthroplasty information on the internet: quality or quantity? Bone Jt Open 2020; 1: 64‐73.
6. Australian Health Practitioner Regulation Agency. AHPRA and national boards annual report 2020/21. www.ahpra.gov.au/annualreport (viewed June 2022).
7. Australian Health Practitioner Regulation Agency. Guidelines for advertising a regulated health service. Reviewed 9 Feb 2021. https://www.ahpra.gov.au/Resources/Advertising‐hub/Advertising‐guidelines‐and‐other‐guidance/Advertising‐guidelines.aspx (viewed June 2022).
8. Holden A. Soon Australian doctors will be allowed to advertise with patient testimonials: but beware the hype. The Conversation (Australia) [online], 25 May 2022. https://theconversation.com/soon‐australian‐doctors‐will‐be‐allowed‐to‐advertise‐with‐patient‐testimonials‐but‐beware‐the‐hype‐183126 (viewed June 2022).
9. Fischer F, Lange K, Klose K, et al. Barriers and strategies in guideline implementation: a scoping review. Healthcare (Basel) 2016; 4: 36.

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Care for adults with COVID‐19: living guidelines from the National COVID‐19 Clinical Evidence Taskforce

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Practice and system improvements for better physical health and longer lives for people living with serious mental illness

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Australia needs to implement a national health strategy for doctors

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Urological Society of Australia and New Zealand (USANZ) and Australasian Chapter of Sexual Health Medicine (AChSHM) for the Royal Australasian College of Physicians (RACP) clinical guidelines on the management of erectile dysfunction

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A polymorphic rash from across the seas

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Roadmap to incorporating group A Streptococcus molecular point‐of‐care testing for remote Australia: a key activity to eliminate rheumatic heart disease

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Ambulance ramping and patients with cardiac‐type symptoms: understanding the unloading queue

Clearing elective surgery waiting lists after the COVID‐19 pandemic cannot be allowed to compromise emergency surgery care

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Advertising by orthopaedic surgeons: the tension between professionalism and commercialism

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Mycobacterium haemophilum in a patient with inflammatory bowel disease

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Care for adults with COVID‐19: living guidelines from the National COVID‐19 Clinical Evidence Taskforce

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Practice and system improvements for better physical health and longer lives for people living with serious mental illness

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Australia needs to implement a national health strategy for doctors

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Urological Society of Australia and New Zealand (USANZ) and Australasian Chapter of Sexual Health Medicine (AChSHM) for the Royal Australasian College of Physicians (RACP) clinical guidelines on the management of erectile dysfunction

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A polymorphic rash from across the seas

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Roadmap to incorporating group A Streptococcus molecular point‐of‐care testing for remote Australia: a key activity to eliminate rheumatic heart disease

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Ambulance ramping and patients with cardiac‐type symptoms: understanding the unloading queue

Clearing elective surgery waiting lists after the COVID‐19 pandemic cannot be allowed to compromise emergency surgery care

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Advertising by orthopaedic surgeons: the tension between professionalism and commercialism

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