Topics

The pandemic is a vast, expanding disaster with no end in sight, producing chronic stress, disruption, and multiple losses

The coronavirus disease 2019 (COVID‐19) pandemic has been a once‐in‐100‐years event. The scale of the disaster overshadows all others in living memory. Most disasters are focal and time‐limited. This one will span a considerable period of time and the economic impact will last years. This means the mental health effects will be deeper and more sustained than in other disasters. A survey during the first month of the pandemic in Australia assessed the nation's “temperature” early, as reported in this issue of the Journal.1 This survey and other information2,3 confirm that the initial mental health impact has been severe, and worse may be coming. Scientific models predicted that Australia would face a second curve of mental ill health and suicide,4,5 and this has now clearly arrived. We have been willing to turn our society and lives upside down to flatten the COVID‐19 curve. The same commitment is now required to flatten the mental health curve.

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1 Orygen, Melbourne, VIC
2 Centre for Youth Mental Health, the University of Melbourne, Melbourne, VIC

Correspondence: pmcgorry@unimelb.edu.au

Acknowledgements:

I am supported by a National Health and Medical Research Council Senior Principal Research Fellowship (1155508).

Competing interests:

No relevant disclosures.

1. Fisher JRW, Tran TD, Hammarberg K, et al. Psychological symptoms during the first month of COVID‐19 restrictions in Australia: a national survey. Med J Aust 2020; 213: 458–464.
2. Iob E, Steptoe A, Fancourt D. Abuse, self‐harm and suicidal ideation in the UK during the COVID‐19 pandemic. Br J Psychiatry. 217: 543–546
3. Wang C, Pan R, Wan X, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID‐19) epidemic among the general population in China. Int J Environ Res Public Health 2020; 17: 1729.
4. Brain and Mind Centre (University of Sydney). Sounding the alarm: a post‐COVID‐19 curve for suicide. Preliminary results from systems modelling: North Coast Primary Health Network. 2020. https://www.sydney.edu.au/content/dam/corporate/documents/brain-and-mind-centre/mental-wealth/sounding_the_alarm_usyd_ncphn.pdf (viewed Sept 2020).
5. Orygen. COVID19 second wave: modelling mental health impacts Victoria. 2020. https://croakey.org/wp-content/uploads/2020/06/Orygen-COVID19-second-wave-briefing_FINAL.pdf (viewed Oct 2020).
6. Frasquilho D, Matos MG, Salonna F, et al. Mental health outcomes in times of economic recession: a systematic literature review. BMC Public Health 2016; 16: 115.
7. Wilkinson R, Pickett K. The spirit level: why more equal societies almost always do better. London: Penguin, 2009.
8. Productivity Commission. Mental health: draft report. Oct 2019. https://www.pc.gov.au/inquiries/completed/mental-health/draft (viewed Sept 2020).
9. Armytage P, Cockram A, Fels A, McSherry B. Royal Commission into Victoria's Mental Health System: interim report, part paper no. 87 (2018–2019). Nov 2019. https://rcvmhs.vic.gov.au/download_file/view_inline/2198 (viewed Sept 2020).
10. Andrews K (Minister for Industry, Science and Technology). Industry consortium to manufacture 2000 ventilators [media release]. 9 Apr 2020. https://www.minister.industry.gov.au/ministers/karenandrews/media-releases/industry-consortium-manufacture-2000-ventilators (viewed Oct 2020).
11. Australian Institute of Health and Welfare. Suicide and intentional self‐harm (Australia's health 2020). 23 July 2020. https://www.aihw.gov.au/reports/australias-health/suicide-and-intentional-self-harm (viewed Oct 2020).
12. Stene‐Larsen K, Reneflot A. Contact with primary and mental health care prior to suicide: a systematic review of the literature from 2000 to 2017. Scand J Public Health 2019; 47: 9–17.
13. Moreno C, Wykes T, Galderisi S, et al. How mental health care should change as a consequence of the COVID‐19 pandemic. Lancet Psychiatry 2020; 7: 813–824.
14. Australian Department of Health. Potential service model for adult mental health centres. Consultation paper, July 2020. https://consultations.health.gov.au/mental-health-services/adult-mental-health-centres (viewed Aug 2020).
15. Australian Bureau of Statistics. 4364.0.55.001. National Health Survey: first results, 2017–18. Dec 2018. https://www.abs.gov.au/statistics/health/health-conditions-and-risks/national-health-survey-first-results/latest-release (viewed Sept 2020).

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Narrative review

Understanding the diagnosis of prostate cancer

Xuan Rui S Ong, Dominic Bagguley, John W Yaxley, Arun A Azad, Declan G Murphy and Nathan Lawrentschuk

Med J Aust 2020; 213 (9): . || doi: 10.5694/mja2.50820
Published online: 2 November 2020

ARTICLE
AUTHORS
REFERENCES

Topics

Urologic diseases

Neoplasms

Diagnostic techniques and procedures

Surgical procedures, operative

Summary

Prostate cancer continues to be the most commonly diagnosed cancer, and the second leading cause of cancer death among Australian men.
Prostate‐specific antigen testing is personalised (not dichotomous in nature) and its interpretation should take into account the patient's age, symptoms, previous results and medication (eg, 5‐α reductase inhibitors such as dutasteride).
Multiparametric magnetic resonance imaging of the prostate has been proven to have a 93% sensitivity for detecting clinically significant prostate cancer. It has the potential to decrease unnecessary prostate biopsies by around 27%.
International Society of Urological Pathology (ISUP) grade 1 (Gleason score 6) has been shown to have very little, if any, risk of metastasis
ISUP grade 1 (Gleason score 3 +3 = 6) and low percentage ISUP grade 2 (Gleason score 3 + 4 [< 10%] = 7) can be offered active surveillance. The goal of active surveillance is to defer treatment but is still curative when required.
With better imaging (magnetic resonance imaging and emerging prostate‐specific membrane antigen positron emission tomography–computed tomography) and transperineal prostate biopsy, more men can be offered screening after discussion of risks and benefits, knowing that overdiagnosis has been minimised and radical treatment is reserved for only the most aggressive disease.

1 EJ Whitten Prostate Cancer Research Centre at Epworth, Melbourne, VIC
2 University of Melbourne, Melbourne, VIC
3 University of Queensland, Brisbane, QLD
4 Royal Brisbane and Women's Hospital, Brisbane, QLD
5 Peter MacCallum Cancer Centre, Melbourne, VIC

Correspondence: lawrentschuk@gmail.com

Competing interests:

No relevant disclosures.

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27. Catalona WJ, Partin AW, Sanda MG, et al. A multicenter study of [‐2] pro‐prostate specific antigen combined with prostate specific antigen and free prostate specific antigen for prostate cancer detection in the 2.0 to 10.0 ng/ml prostate specific antigen range. J Urol 2011; 185: 1650–1655.
28. Vickers AJ, Cronin AM, Aus G, et al. A panel of kallikrein markers can reduce unnecessary biopsy for prostate cancer: data from the European Randomized Study of Prostate Cancer Screening in Göteborg, Sweden. BMC Med 2008; 6: 19.
29. Russo GI, Regis F, Castelli T, et al. A systematic review and meta‐analysis of the diagnostic accuracy of Prostate Health Index and 4‐kallikrein panel score in predicting overall and high‐grade prostate cancer. Clin Genitourin Cancer 2017; 15: 429–439.e1.
30. Mottet N, van den Bergh R, Briers E. EAU‐EANM-ESTRO‐ESUR-SIOG guidelines on prostate cancer. Eur Urol 2019; 75: 889–890.
31. Grossman DC, Curry SJ, Owens DK, et al. Screening for prostate cancer: US Preventive Services Task Force recommendation statement. JAMA 2018; 319: 1901–1913.
32. Prostate Cancer Foundation of Australia and Cancer Council Australia. Clinical practice guidelines for PSA testing and early management of test‐detected prostate cancer. 2015. https://wiki.cancer.org.au/australia/Guidelines:PSA_Testing (viewed Aug 2020).
33. Catalona WJ, Richie JP, Ahmann FR, et al. Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicenter clinical trial of 6,630 men. J Urol 2017; 197 (2 Suppl): S200–S207.
34. Patel MI, Kakala B, Beattie K. Teaching medical students digital rectal examination: a randomized study of simulated model vs rectal examination volunteers. BJU Int 2019; 124 (Suppl 1): 14–18.
35. Schröder FH, Kruger AB, Rietbergen J, et al. Evaluation of the digital rectal examination as a screening test for prostate cancer. J Natl Cancer Inst 1998; 90: 1817–1823.
36. Carvalhal GF, Smith DS, Mager DE, et al. Digital rectal examination for detecting prostate cancer at prostate specific antigen levels of 4 ng/ml or less. J Urol 1999; 161: 835–839.
37. Thompson J, Van Leeuwen P, Moses D, et al. The diagnostic performance of multiparametric magnetic resonance imaging to detect significant prostate cancer. J Urol 2016; 195: 1428–1435.
38. Ahmed HU, El‐Shater Bosaily A, Brown LC, et al. Diagnostic accuracy of multi‐parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. Lancet 2017; 389: 815–822.
39. Hu Y, Ahmed HU, Carter T, et al. A biopsy simulation study to assess the accuracy of several transrectal ultrasonography (TRUS)‐biopsy strategies compared with template prostate mapping biopsies in patients who have undergone radical prostatectomy. BJU Int 2012; 110: 812–820.
40. Norberg M, Egevad L, Holmberg L, et al. The sextant protocol for ultrasound‐guided core biopsies of the prostate underestimates the presence of cancer. Urology 1997; 50: 562–566.
41. Kasivisvanathan V, Rannikko AS, Borghi M, et al. MRI‐targeted or standard biopsy for prostate‐cancer diagnosis. N Engl J Med 2018; 378: 1767–1777.
42. Weinreb JC, Barentsz JO, Choyke PL, et al. PI‐RADS prostate imaging ‐ reporting and data system: 2015, version 2. Eur Urol 2016; 69: 16–40.
43. Park SY, Jung DC, Oh YT, et al. Prostate cancer: PI‐RADS version 2 helps preoperatively predict clinically significant cancers. Radiology 2016; 280: 108–116.
44. Padhani AR, Weinreb J, Rosenkrantz AB, et al. Prostate Imaging‐Reporting and Data System Steering Committee: PI‐RADS v2 status update and future directions. Eur Urol 2019; 75: 385–396.
45. Woo S, Kim SY, Lee J, et al. PI‐RADS version 2 for prediction of pathological downgrading after radical prostatectomy: a preliminary study in patients with biopsy‐proven Gleason Score 7 (3+4) prostate cancer. Eur Radiol 2016; 26: 3580–3587.
46. Hansen NL, Barrett T, Kesch C, et al. Multicentre evaluation of magnetic resonance imaging supported transperineal prostate biopsy in biopsy‐naïve men with suspicion of prostate cancer. BJU Int 2018; 122: 40–49.
47. Wei TC, Lin TP, Chang YH, et al. Transrectal ultrasound‐guided prostate biopsy in Taiwan: A nationwide database study. J Chin Med Assoc 2015; 78: 662–665.
48. Grummet JP, Weerakoon M, Huang S, et al. Sepsis and ‘superbugs’: should we favour the transperineal over the transrectal approach for prostate biopsy? BJU Int 2014; 114: 384–388.
49. Symons JL, Huo A, Yuen CL, et al. Outcomes of transperineal template‐guided prostate biopsy in 409 patients. BJU Int 2013; 112: 585–593.
50. Yaxley AJ, Yaxley JW, Thangasamy IA, et al. Comparison between target magnetic resonance imaging (MRI) in‐gantry and cognitively directed transperineal or transrectal‐guided prostate biopsies for Prostate Imaging‐Reporting and Data System (PI‐RADS) 3‐5 MRI lesions. BJU Int 2017; 120 (Suppl 3): 43–50.
51. Stefanova V, Buckley R, Flax S, et al. Transperineal prostate biopsies using local anesthesia: experience with 1,287 patients. prostate cancer detection rate, complications and patient tolerability. J Urol 2019; 201: 1121–1126.
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53. Gleason DF, Mellinger GT. Prediction of prognosis for prostatic adenocarcinoma by combined histological grading and clinical staging. J Urol 2017; 197 (2 Suppl): S134–S139.
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55. Epstein JI, Egevad L, Amin MB, et al. The 2014 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading of Prostatic Carcinoma: definition of grading patterns and proposal for a new grading system. Am J Surg Pathol 2016; 40: 244–252.
56. Epstein JI, Zelefsky MJ, Sjoberg DD, et al. A contemporary prostate cancer grading system: a validated alternative to the Gleason score. Eur Urol 2016; 69: 428–435.
57. Ross AE, Marchionni L, Vuica‐Ross M, et al. Gene expression pathways of high grade localized prostate cancer. Prostate 2011; 71: 1568–1577.
58. Ross HM, Kryvenko ON, Cowan JE, et al. Do adenocarcinomas of the prostate with Gleason score (GS) ≤6 have the potential to metastasize to lymph nodes? Am J Surg Pathol 2012; 36: 1346–1352.
59. Amin A, Scheltema MJ, Shnier R, et al. The Magnetic Resonance Imaging in Active Surveillance (MRIAS) trial: use of baseline multiparametric magnetic resonance imaging and saturation biopsy to reduce the frequency of surveillance prostate biopsies. J Urol 2020; 203: 910–917.
60. Hofman MS, Lawrentschuk N, Francis RJ, et al. Prostate‐specific membrane antigen PET‐CT in patients with high‐risk prostate cancer before curative‐intent surgery or radiotherapy (proPSMA): a prospective, randomised, multicentre study. Lancet 2020; 395: 1208–1216.
61. Kalapara AA, Nzenza T, Pan HYC, et al. Detection and localisation of primary prostate cancer using (68) gallium prostate‐specific membrane antigen positron emission tomography/computed tomography compared with multiparametric magnetic resonance imaging and radical prostatectomy specimen pathology. BJU Int 2020; 126: 83–90.
62. Scheltema MJ, Chang JI, Stricker PD, et al. Diagnostic accuracy of 68Ga‐prostate‐specific membrane antigen (PSMA) positron‐emission tomography (PET) and multiparametric (mp) MRI to detect intermediate‐grade intra‐prostatic prostate cancer using whole‐mount pathology: impact of the addition of 68Ga‐PSMA PET to mp MRI. BJU Int 2019; 124: 42–49.
63. Donato P, Morton A, Yaxley J, et al. (68)Ga‐PSMA PET/CT better characterises localised prostate cancer after MRI and transperineal prostate biopsy: is (68)Ga‐PSMA PET/CT guided biopsy the future? Eur J Nucl Med Mol Imaging 2020; 47: 1843–1851.
64. Amin A, Blazevski A, Thompson J, et al. Protocol for the PRIMARY clinical trial, a prospective, multicentre, cross‐sectional study of the additive diagnostic value of gallium‐68 prostate‐specific membrane antigen positron‐emission tomography/computed tomography to multiparametric magnetic resonance imaging in the diagnostic setting for men being investigated for prostate cancer. BJU Int 2020; 125: 515–524.
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Editorials

Opioid stewardship can reduce inappropriate prescribing of opioids at hospital discharge

Stephan A Schug

Med J Aust 2020; 213 (9): . || doi: 10.5694/mja2.50818
Published online: 2 November 2020

ARTICLE
AUTHORS
REFERENCES

Topics

Pharmaceutical preparations

Health services administration

The associated risks, particularly that of long term use, are underestimated, and appropriate measures are needed

Before 1990, opioids were primarily used to treat severe acute and cancer pain. In the subsequent 30 years, opioids have been increasingly used for treating chronic non‐malignant pain; prescribing has increased exponentially in the developed world, particularly in the United States, but also in Canada and Australia.1 Regrettably, this has not only resulted in poor outcomes for patients living with chronic pain; the analgesic efficacy of opioids for this indication are limited, and they do not improve, and often reduce, function and quality of life.2 Further, diversion of prescribed opioids and their misuse have risen in parallel with increased prescribing, leading to higher numbers of overdoses deaths. In Australia, about 1100 people died following opioid overdoses during 2018, and 75% of cases involved prescription opioids (similar to the number of deaths from car accidents in that year).3

University of Western Australia, Perth, WA

Correspondence: stephan.schug@uwa.edu.au

Competing interests:

The Anaesthesiology Unit of the University of Western Australia and Stephan Schug personally (since his retirement in October 2019) have received research and travel funding and speaking and consulting honoraria from Grünenthal, Indivior, Mundipharma, Pfizer, iX Biopharma, Seqirus, Xgene, Biogen, Luye Pharma and Foundry during the past 36 months.

1. Häuser W, Schug S, Furlan AD. The opioid epidemic and national guidelines for opioid therapy for chronic noncancer pain: a perspective from different continents. Pain Rep 2017; 2: e599.
2. Busse JW, Wang L, Kamaleldin M, et al. Opioids for chronic noncancer pain: a systematic review and meta‐analysis. JAMA 2018; 320: 2448–2460.
3. Man N, Chrzanowska A, Dobbins T, et al. Trends in drug‐induced deaths in Australia, 1997–2018 (Drug Trends Bulletin Series). Sydney: National Drug and Alcohol Research Centre, UNSW Sydney, 2019. https://ndarc.med.unsw.edu.au/resource/trends-drug-induced-deaths-australia-1997-2018 (viewed Sept 2020).
4. Roughead EE, Lim R, Ramsay E, et al. Persistence with opioids post discharge from hospitalisation for surgery in Australian adults: a retrospective cohort study. BMJ Open 2019; 9: e023990.
5. Schug SA, Palmer GM, Scott DA, et al, editors. Acute pain management: scientific evidence. 4th edition. Melbourne: Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine, 2015; here: pp. 365–368.
6. Macintyre PE, Huxtable CA, Flint SL, Dobbin MD. Costs and consequences: a review of discharge opioid prescribing for ongoing management of acute pain. Anaesth Intensive Care 2014; 42: 558–574.
7. Stewart JE, Tuffin PH, Kay J, et al. The effect of guideline implementation on discharge analgesia prescribing (two years on). Anaesth Intensive Care 2019; 47: 40–44.
8. McAnally H. Rationale for and approach to preoperative opioid weaning: a preoperative optimization protocol. Perioper Med (Lond) 2017; 6: 19.
9. Stark N, Kerr S, Stevens J. Prevalence and predictors of persistent post‐surgical opioid use: a prospective observational cohort study. Anaesth Intensive Care 2017; 45: 700–706.
10. Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long‐term opioid use: United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017; 66: 265–269.
11. Australian and New Zealand College of Anaesthetists, Faculty of Pain Medicine. Position statement on the use of slow‐release opioid preparations in the treatment of acute pain. Mar 2018. https://www.anzca.edu.au/getattachment/d9e2a7c5-0f17-42d3-bda7-c6dae7e55ced/Position-statement-on-the-use-of-slow-release-opioid-preparations-in-the-treatmentofacute-pain (viewed Oct 2020).
12. Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ 2018; 360: j5790.
13. Therapeutic Goods Administration. Return your unused opioids: resource kit. July 2019. https://www.tga.gov.au/publication/return-your-unused-opioids-resource-kit (viewed Sept 2020).
14. Hopkins R, Bui T, Konstantatos AH, et al. Educating junior doctors and pharmacists to reduce discharge prescribing of opioids for surgical patients: a cluster randomised controlled trial. Med J Aust 2020; 213: 417–423.
15. Stevens J, Trimboli A, Samios P, et al. A sustainable method to reduce postoperative oxycodone discharge prescribing in a metropolitan tertiary referral hospital. Anaesthesia 2019; 74: 292–299.
16. Allen ML, Leslie K, Parker AV, et al. Post‐surgical opioid stewardship programs across Australia and New Zealand: current situation and future directions. Anaesth Intensive Care 2019; 47: 548–552.

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Medical education
Snapshot

Yellow nails syndrome: complete triad

Adrián López Alba and Agustín Blanco Echevarría

Med J Aust 2020; 213 (9): . || doi: 10.5694/mja2.50807
Published online: 2 November 2020

ARTICLE
AUTHORS
REFERENCES

Topics

Respiratory tract diseases

Hematologic diseases

Health occupations

An 83‐year‐old male non‐smoker presented with chronic purulent cough. On physical examination, xanthonychia (yellow discoloration), onychauxis (thickened nails), onycholisis (separation of the nail from the nail bed), enhanced transverse curvature, and scleronychia (hardening and thickening of the nails) were observed (Figure, A). He had a 5 year history of decreased longitudinal nail growth and progressive adult onset bilateral lower limb lymphoedema. Findings on computed tomography scan demonstrated severe bilateral cystic bronchiectasis (Figure, B and C). Yellow nails syndrome is a disorder characterised by the triad of yellow thickened nails, lymphoedema and respiratory manifestations, typically chronic cough, bronchiectasis or pleural effusion. All three features appear in only 27–60% of patients.1 Treatment is symptomatic and includes antibiotic prescription for bronchiectasis and oral vitamin E alone or combined with triazole antifungals for yellow nails, achieving partial to complete responses.1

Hospital Universitario 12 de Octubre, Madrid, Spain

Correspondence: alalba@salud.madrid.org

Acknowledgements:

We thank the patient who made the article possible.

Competing interests:

No relevant disclosures.

1. Vignes S, Baran R. Yellow nail syndrome: a review. Orphanet J Rare Dis 2017; 12: 42.

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Meta‐analysis

Gut microbiota‐derived trimethylamine N‐oxide is associated with poor prognosis in patients with heart failure

Wensheng Li, Anqing Huang, Hailan Zhu, Xinyue Liu, Xiaohui Huang, Yan Huang, Xiaoyan Cai, Jianhua Lu and Yuli Huang

Med J Aust 2020; 213 (8): . || doi: 10.5694/mja2.50781
Published online: 19 October 2020

ARTICLE
AUTHORS
REFERENCES

Topics

Cardiovascular diseases

Diagnostic techniques and procedures

Abstract

Objective: Gut microbiota‐produced trimethylamine N‐oxide (TMAO) is a risk factor for cardiovascular events. However, conflicting findings regarding the link between plasma TMAO level and prognosis for patients with heart failure have been reported. We examined the association of plasma TMAO concentration with risk of major adverse cardiac events (MACEs) and all‐cause mortality in patients with heart failure.

Study design: Meta‐analysis of prospective clinical studies.

Data sources: We searched electronic databases (PubMed, EMBASE) for published prospective studies examining associations between plasma TMAO level and MACEs and all‐cause mortality in adults with heart failure.

Data synthesis: Hazard ratios (HRs) with 95% confidence intervals for associations between TMAO level and outcomes were estimated in random effects models. In seven eligible studies including a total of 6879 patients (median follow‐up, 5.0 years) and adjusted for multiple risk factors, higher plasma TMAO level was associated with greater risks of MACEs (TMAO tertile 3 v tertile 1: HR, 1.68; 95% CI, 1.44–1.96; per SD increment: HR, 1.26; 95% CI, 1.18–1.36) and of all‐cause mortality (TMAO tertile 3 v tertile 1: HR, 1.67; 95% CI, 1.17–2.38; per SD increment: HR, 1.26; 95% CI, 1.07–1.48). Higher TMAO level was also associated with greater risk of MACEs after adjusting for estimated glomerular filtration rate (eGFR; six studies included); however, the heterogeneity of studies in which risk was adjusted for eGFR was significant (I² = 76%).

Conclusions: Elevated plasma TMAO level in patients with heart failure is associated with poorer prognoses. This association is only partially mediated by renal dysfunction.

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1 Shunde Hospital of Southern Medical University, Foshan (Guangdong), China
2 George Institute for Global Health, Sydney, NSW

Correspondence: yhuang@georgeinstitute.org.au

Acknowledgements:

Our investigation was supported by the Science and Technology Innovation Project in Foshan, Guangdong (FS0AA‐KJ218‐1301‐0006), the Clinical Research Startup Program of Shunde Hospital, Southern Medical University (CRSP2019001, CRSP2019008), the self‐financing Science and Technology Plan Project of Foshan, Guangdong (Medical Science and Technology Research Key Project; 2018AB00208), and the Medical Science and Technology Research Foundation of Guangdong Province (A2018209).We thank Julia Jenkins (Liwen Bianji, Edanz Editing China; www.liwenbianji.cn/ac), for editing the English text of our manuscript.

Competing interests:

No relevant disclosures.

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2. Benjamin EJ, Muntner P, Alonso A, et al. American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics: 2019 update. A report from the American Heart Association. Circulation 2019; 139: e56–e528.
3. Tang W, Bäckhed F, Landmesser U, Hazen SL. Intestinal microbiota in cardiovascular health and disease. J Am Coll Cardiol 2019; 73: 2089–2105.
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Editorials

“No jab, no pay” pays off

Terence M Nolan

Med J Aust 2020; 213 (8): . || doi: 10.5694/mja2.50796
Published online: 19 October 2020

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Environment and public health

Pediatric medicine

The policy has been effective, albeit with modest closure of coverage gaps, and without substantial backlash

In April 1998, the Australian government linked the payment of childcare subsidies (Childcare Assistance and Childcare Cash Rebate) and the Maternity Immunisation Allowance to childhood vaccination status.1 To receive these benefits, families needed to show that their child was fully vaccinated according to the National Immunisation Program Schedule.2 Further, the Victorian government passed legislation in 2015 that required childcare proprietors to record and regularly update the vaccination status of each child in their care, and to restrict admission to children who were up to date (“No jab, no play”).3 Other states have since followed suit.

1 Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC
2 Murdoch Children's Research Institute, Melbourne, VIC

Correspondence: t.nolan@unimelb.edu.au

Competing interests:

No relevant disclosures.

1. Bond L, Nolan T, Lester R. Immunisation uptake, services required and government incentives for users of formal day care. Aust N Z J Public Health 1999; 23: 368–376.
2. Bond L, Davie G, Carlin JB, et al. Increases in vaccination coverage for children in child care, 1997 to 2000: an evaluation of the impact of government incentives and initiatives. Aust N Z J Public Health 2002; 26: 58–64.
3. Department of Health and Human Services (Victoria). No jab no play [website]. 2017. https://www2.health.vic.gov.au/public-health/immunisation/vaccination-children/no-jab-no-play (viewed Sept 2020).
4. Lawrence GL, MacIntyre CR, Hull BP, McIntyre PB. Effectiveness of the linkage of child care and maternity payments to childhood immunisation. Vaccine 2004; 22: 2345–2350.
5. Hull BP, Beard FH, Hendry AJ, et al. “No jab, no pay”: catch‐up vaccination activity during its first two years. Med J Aust 2020; 213: 364–369.
6. Leask J, Danchin M. Imposing penalties for vaccine rejection requires strong scrutiny. J Paediatr Child Health 2017; 53: 439–444.

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Editorials

Time for a new approach to funding residential aged care

Edward Strivens

Med J Aust 2020; 213 (8): . || doi: 10.5694/mja2.50799
Published online: 19 October 2020

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Health services administration

Gerontology

Support should be tied to the health care needs of residents, not to how eligibility for subsidies is assessed

Government support for residential aged care facilities (RACFs) in Australia has undergone major periodic shifts in the attempt to match residents’ needs and the costs of care. The money involved is considerable: during 2018–19, the Australian government provided $13.3 billion in subsidies, with more than 200 000 people living in RACFs.1

1 James Cook University, Cairns, QLD
2 Cairns and Hinterland Hospital and Health Service, Cairns, QLD

Correspondence: Edward.Strivens@health.qld.gov.au

Competing interests:

No relevant disclosures.

1. Australian Institute of Health and Welfare. Government spending on aged care. Updated Apr 2020. https://www.gen-agedcaredata.gov.au/Topics/Government-spending-on-aged-care (viewed Sept 2020).
2. Rowe L. Preventing a COVID‐19 firestorm in residential aged care. Insight+ [online], 4 May 2020. https://insightplus.mja.com.au/2020/17/preventing-a-covid-19-firestorm-in-residential-aged-care (viewed Sept 2020).
3. Australian Institute of Health and Welfare. GEN data: People leaving aged care. June 2019. https://www.gen-agedcaredata.gov.au/Resources/Access-data/2018/June/GEN-data-People-leaving-aged-care (viewed Sept 2020).
4. Royal Commission into Aged Care Quality and Safety. Interim report, volume 1: neglect. Oct 2019. https://agedcare.royalcommission.gov.au/sites/default/files/2020-02/interim-report-volume-1.pdf (viewed Sept 2020).
5. Australian Department of Health. The Aged Care Funding Instrument (ACFI). Updated Apr 2020. https://www.health.gov.au/initiatives-and-programs/residential-aged-care/funding-for-residential-aged-care/the-aged-care-funding-instrument-acfi (viewed Sept 2020).
6. McNamee J, Poulos C, Seraji H, et al. Alternative aged care assessment, classification system and funding models: final report, volume one. Wollongong: Centre for Health Service Development, Australian Health Services Research Institute, University of Wollongong, 2017. https://www.health.gov.au/resources/publications/alternative-aged-care-assessment-classification-system-and-funding-models-report (viewed Sept 2020).
7. Eagar K, Gordon R, Snoek MF, et al. The Australian National Aged Care Classification (AN‐ACC): a new casemix classification for residential aged care. Med J Aust 2020; 213: 359–363.
8. Johnson Village Services. The case for a fixed funding model (Consultation Paper 1 submissions, WF.660.00076.003). Feb 2020. https://agedcare.royalcommission.gov.au/media/26741 (viewed Sept 2020).
9. Ratcliffe J, Chen G, Cleland J, et al; Caring Futures Institute (Flinders University). Australia's aged care system: assessing the views and preferences of the general public for quality of care and future funding (Royal Commission into Aged Care Quality and Safety, research paper 6). July 2020. https://agedcare.royalcommission.gov.au/sites/default/files/2020-07/research_paper_6_-_australias_aged_care_system_-_assessing_the_views_an._.pdf (viewed Sept 2020).

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Perspectives

Considerations for cancer immunotherapy during the COVID‐19 pandemic

Yada Kanjanapan and Desmond Yip

Med J Aust 2020; 213 (9): . || doi: 10.5694/mja2.50805
Published online: 14 October 2020

Correction(s) for this article:

Erratum | Published online: 18 January 2021

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Infectious diseases

Immune system diseases

Neoplasms

Cancer immunotherapy during the COVID‐19 pandemic presents management challenges from immune‐related toxicities, requiring careful patient selection

The coronavirus disease 2019 (COVID‐19) pandemic has led to fundamental re‐evaluation of the benefits versus risks of treatment in oncology. Immunotherapy has had an expanding presence in oncology, becoming a primary systemic treatment option in diseases such as melanoma, lung, urothelial, renal, and head and neck cancers. Immune checkpoint inhibitor (ICI) therapy, namely anti‐programmed cell death protein 1 (anti‐PD‐1), anti‐programmed cell death ligand 1 (anti‐PD‐L1) and anti‐cytotoxic T‐lymphocyte‐associated protein 4 (anti‐CTLA‐4) antibodies, halt the negative regulatory checks of T lymphocytes, thus activating the immune response against tumours. Patients with cancer receiving these treatments are faced with a unique set of treatment‐related toxicities driven by an autoimmune mechanism.

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1 Canberra Hospital, Canberra, ACT
2 Australian National University, Canberra, ACT

Correspondence: yada.kanjanapan@act.gov.au

Competing interests:

No relevant disclosures.

1. Bersanelli M. Controversies about COVID‐19 and anticancer treatment with immune checkpoint inhibitors. Immunotherapy 2020; 12: 269–273.
2. Dai M, Liu D, Liu M, et al. Patients with cancer appear more vulnerable to SARS‐COV-2: a multicenter study during the COVID‐19 outbreak. Cancer Discov 2020; 10: 783–791.
3. Qin C, Zhou L, Hu Z, et al. Dysregulation of immune response in patients with COVID‐19 in Wuhan, China. Clin Infect Dis 2020; 71: 762–768.
4. Lim SY, Lee JH, Gide TN, et al. Circulating cytokines predict immune‐related toxicity in melanoma patients receiving anti‐PD‐1-based immunotherapy. Clin Cancer Res 2019; 25: 1557–1563.
5. Robilotti EV, Babady NE, Mead PA, et al. Determinants of COVID‐19 disease severity in patients with cancer. Nat Med 2020; 26: 1218–1223.
6. Garassino MC, Whisenant JG, Huang LC, et al. COVID‐19 in patients with thoracic malignancies (TERAVOLT): first results of an international, registry‐based, cohort study. Lancet Oncol 2020; 21: 914–922.
7. Wolchok JD, Rollin L, Larkin J. Nivolumab and ipilimumab in advanced melanoma. N Engl J Med 2017; 377: 2503–2504.
8. Motzer RJ, Tannir NM, McDermott DF, et al. Nivolumab plus ipilimumab versus sunitinib in advanced renal‐cell carcinoma. N Engl J Med 2018; 378: 1277–1290.
9. RECOVERY Collaborative Group. Dexamethasone in hospitalized patients with COVID‐19 — preliminary report. N Engl J Med 2020; https://doi.org/10.1056/nejmoa2021436 [Epub ahead of print].
10. Del Castillo M, Romero FA, Argüello E, et al. The spectrum of serious infections among patients receiving immune checkpoint blockade for the treatment of melanoma. Clin Infect Dis 2016; 63: 1490–1493.
11. Schwarz M, Kocher F, Niedersuess‐Beke D, et al. Immunosuppression for immune checkpoint‐related toxicity can cause Pneumocystis jirovecii pneumonia (PJP) in Non‐small‐cell lung cancer (NSCLC): a report of 2 cases. Clin Lung Cancer 2019; 20: e247–e250.
12. Fujita K, Kim YH, Kanai O, et al. Emerging concerns of infectious diseases in lung cancer patients receiving immune checkpoint inhibitor therapy. Respir Med 2019; 146: 66–70.
13. Picchi H, Mateus C, Chouaid C, et al. Infectious complications associated with the use of immune checkpoint inhibitors in oncology: reactivation of tuberculosis after anti PD‐1 treatment. Clin Microbiol Infect 2018; 24: 216–218.
14. Läubli H, Balmelli C, Kaufmann L, et al. Influenza vaccination of cancer patients during PD‐1 blockade induces serological protection but may raise the risk for immune‐related adverse events. J Immunother Cancer 2018; 6: 40.
15. Failing JJ, Ho TP, Yadav S, et al. Safety of influenza vaccine in patients with cancer receiving pembrolizumab. JCO Oncol Pract 2020; 16: e573–e580.
16. Segelov E, Underhill C, Prenen H, et al. Practical considerations for treating patients with cancer in the COVID‐19 pandemic. JCO Oncol Pract 2020; 16: 467–482.
17. Weinkove R, McQuilten ZK, Adler J, et al. Managing haematology and oncology patients during the COVID‐19 pandemic: interim consensus guidance. Med J Aust 2020; 212: 481–489. https://www.mja.com.au/journal/2020/212/10/managing-haematology-and-oncology-patients-during-covid-19-pandemic-interim-0
18. Friedlaender A, Kim C, Addeo A. Rethinking the optimal duration of immune checkpoint inhibitors in non‐small cell lung cancer throughout the COVID‐19 pandemic. Front Oncol 2020; 10: 862.
19. Robert C, Ribas A, Hamid O, et al. Durable Complete Response After Discontinuation of Pembrolizumab in Patients With Metastatic Melanoma. J Clin Oncol 2018; 36: 1668–1674.

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Mental health and COVID‐19: are we really all in this together?

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Understanding the diagnosis of prostate cancer

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Opioid stewardship can reduce inappropriate prescribing of opioids at hospital discharge

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Yellow nails syndrome: complete triad

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Gut microbiota‐derived trimethylamine N‐oxide is associated with poor prognosis in patients with heart failure

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“No jab, no pay” pays off

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Time for a new approach to funding residential aged care

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Considerations for cancer immunotherapy during the COVID‐19 pandemic

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Demographics and performance of candidates in the examinations of the Australian Medical Council, 1978–2019

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Implementing cardiovascular disease preventive care guidelines in general practice: an opportunity missed

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Mental health and COVID‐19: are we really all in this together?

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Understanding the diagnosis of prostate cancer

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Opioid stewardship can reduce inappropriate prescribing of opioids at hospital discharge

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Yellow nails syndrome: complete triad

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Gut microbiota‐derived trimethylamine N‐oxide is associated with poor prognosis in patients with heart failure

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“No jab, no pay” pays off

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Time for a new approach to funding residential aged care

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Considerations for cancer immunotherapy during the COVID‐19 pandemic

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Demographics and performance of candidates in the examinations of the Australian Medical Council, 1978–2019

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Implementing cardiovascular disease preventive care guidelines in general practice: an opportunity missed

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