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    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: 4 April 2025

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

      Neville D Yeomans, Jillian R Sewell, Philip Pigou and Stuart Macintyre
      Med J Aust 2021; 214 (2): . || doi: 10.5694/mja2.50800
      Published online: 5 October 2020

      Australia has relied, for most of its history, on international medical graduates (IMGs) to supplement its workforce. Since 1978, IMGs applying for general registration to practise in Australia have usually needed to pass the examinations of the Australian Medical Examining Council, or since 1986, its successor, the Australian Medical Council (AMC). The AMC provides several pathways to registration by the Australian Health Practitioner Regulation Agency (AHPRA). The route now termed “the standard pathway” consists of a two‐part assessment including a multiple choice question (MCQ) examination followed by a clinical examination. While most IMGs are required to pass both examinations, since 2007, IMGs who qualified in the so‐called competent authority countries (the United Kingdom, Ireland, the United States and Canada) have usually not been required to sit these examinations.1


      • 1 University of Melbourne, Melbourne, VIC
      • 2 Centre for Community Child Health, Melbourne, VIC
      • 3 Australian Medical Council, Canberra, ACT


      Correspondence: nyeomans@unimelb.edu.au
      Acknowledgements: 

      We acknowledge the assistance of Kevin Ng and Prathyusha Sama, Senior Computer Programmer and Software Developer at the AMC, for programming to extract the de‐identified data analysed in this article.

      Competing interests:

      No relevant disclosures.

      • 1. Medical Board of Australia. Competent authority pathway [website]. AHPRA, 2019. https://www.medicalboard.gov.au/Registration/International-Medical-Graduates/Competent-Authority-Pathway.aspx (viewed July 2020).
      • 2. Australian Government Publishing Service. Human Rights and Equal Opportunity Commission — annual report 1990–91. Canberra: Commonwealth of Australia; 1991. https://humanrights.gov.au/sites/default/files/Annual_Report_90-91.pdf (viewed July 2020).
      • 3. Australian Competition and Consumer Commission and Australian Health Workforce Officials’ Committee. Review of Australian specialist medical colleges: report to Australian Health Ministers. Canberra: Commonwealth of Australia, 2005.
      • 4. House of Representatives Standing Committee on Health and Ageing. Lost in the labyrinth: report on the inquiry into registration processes and support for overseas trained doctors. Canberra: Commonwealth of Australia, 2012. https://www.aph.gov.au/Parliamentary_Business/Committees/House_of_Representatives_Committees?url=haa/overseasdoctors/report.htm (viewed July 2020).
      • 5. Geffen L. Assuring medical standards: the Australian Medical Council 1985–2010. Canberra, ACT: Australian Medical Council, 2010.
      • 6. Australian Medical Council Limited. IMG guides. https://www.amc.org.au/publications/img-guides/ (viewed July 2020).
      • 7. United Nations Statistics Division. Geographical regions 1999. https://unstats.un.org/unsd/methodology/m49 (viewed July 2020).
      • 8. Australian Bureau of Statistics. Migration, Australia, 1993–2018 [Cat. No. 3412.0]. Canberra, ACT: ABS, 2018. https://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/3412.02017-18?OpenDocument (viewed July 2020).
      • 9. Breen K, Frank I, Walters T. Australian Medical Council: a view from the inside. Intern Med J 2001; 31: 243–248.
      • 10. McCoubrie P. Improving the fairness of multiple‐choice questions: a literature review. Med Teach 2004; 26: 709–712.
      • 11. Yeomans ND. They came to heal: Australia's medical immigrants, 1960 to the present [dissertation]. Melbourne: University of Melbourne, 2018: 120.
      • 12. Dewhurst NG, McManus C, Mollon J, et al. Performance in the MRCP (UK) examination 2003–4: analysis of pass rates of UK graduates in relation to self‐declared ethnicity and gender. BMC Med 2007; 5: 8.
      • 13. Shellito JL, Osland JS, Helmer SD, Chang FC. American Board of Surgery examinations: can we identify surgery residency applicants and residents who will pass the examinations on the first attempt? Am J Surg 2010; 199: 216–222.
      • 14. Rubright JD, Jodoin M, Barone MA. Examining demographics, prior academic performance, and United States Medical Licensing Examination scores. Acad Med 2019; 94: 364–370.
      • 15. Unwin E, Potts HWW, Dacre J, et al. Passing MRCP (UK) PACES: a cross‐sectional study examining the performance of doctors by sex and country. BMC Med Educ 2018; 18: 1–9.
      • 16. Sandhu H, Adams A, Singleton L, et al. The impact of gender dyads on doctor–patient communication: A systematic review. Patient Educ Couns 2009; 76: 348–355.
      • 17. Menzies L, Minson S, Brightwell A, et al. An evaluation of demographic factors affecting performance in a paediatric membership multiple‐choice examination. Postgrad Med J 2015; 91: 72–76.
      • 18. Lipner R, Song H, Biester T, et al. Factors that influence general internists’ and surgeons’ performance on maintenance of certification exams. Acad Med 2011; 86: 53–58.
      • 19. McGrail MR, Russell DJ. Australia's rural medical workforce: supply from its medical schools against career stage, gender and rural‐origin. Aust J Rural Health 2016; 25: 298–305.
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        Implementing cardiovascular disease preventive care guidelines in general practice: an opportunity missed

        Charlotte M Hespe, Anna Campain, Ruth Webster, Anushka Patel, Lucie Rychetnik, Mark F Harris and David P Peiris
        Med J Aust 2020; 213 (7): . || doi: 10.5694/mja2.50756
        Published online: 5 October 2020

        Cardiovascular disease (CVD) is the leading cause of death in Australia.1 New treatment guidelines based on absolute CVD risk estimates were adopted in 2012.2 General practitioners are central to implementing these guidelines, as about 90% of people in Australia consult GPs each year,3 but large evidence–practice gaps in the management of people with CVD in general practice have been reported.4

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        • 1 The University of Notre Dame Australia, Sydney, NSW
        • 2 The George Institute for Global Health, Sydney, NSW
        • 3 University of New South Wales, Sydney, NSW
        • 4 The Australian Health Prevention Partnership, Sax Institute, Sydney, NSW
        • 5 Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW
        • 6 Office of the Chief Scientist, The George Institute for Global Health, Sydney, NSW


        Correspondence: charlotte.hespe@nd.edu.au
        Acknowledgements: 

        The University of Notre Dame received a Bupa Health Foundation grant for research into cardiovascular disease and diabetes that funded the Q Pulse study and a quality improvement project in 46 practices in the Central and Eastern Sydney Primary Health Network. Ruth Webster is supported by a National Health and Medical Research Council (NHMRC) Early Career Fellowship (APP1125044), Anushka Patel by an NHMRC Principal Research Fellowship (APP1136898), and David Peiris by a Heart Foundation Future Leader Fellowship (101890) and NHMRC Career Development Fellowship (APP1143904).

        Competing interests:

        George Health Enterprises, the social enterprise arm of the George Institute for Global Health, has received funding for the development of fixed dose combination therapy, and has commercial relationships involving digital innovations similar to the interventions in the INTEGRATE study.

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          Frailty in older adults: moving from measurement to management

          Emily H Gordon and Ruth E Hubbard
          Med J Aust 2020; 213 (7): . || doi: 10.5694/mja2.50778
          Published online: 5 October 2020

          Incorporating routine assessment of frailty into health care would benefit both older people and the health system

          The past two decades have seen a tremendous research effort dedicated to defining, measuring and validating the frailty construct. Large cohort studies of older adults living in the community have consistently found that frail people are at risk of a range of adverse outcomes, including death, disability, and institutionalisation.1 More recently, there has been a move from population‐based cohort studies of frailty to analyses of data collected during routine clinical encounters. In this issue of the MJA, Khadka and colleagues2 contribute to this body of translational research with a large retrospective cohort study of community‐dwelling Australians undergoing Aged Care Assessment Program (ACAP) eligibility assessment.


          • 1 Centre for Health Services Research, University of Queensland, Brisbane, QLD
          • 2 The University of Queensland, Brisbane, QLD


          Correspondence: r.hubbard1@uq.edu.au
          Competing interests:

          No relevant disclosures.

          • 1. Kojima G, Iliffe S, Walters K. Frailty index as a predictor of mortality: a systematic review and meta‐analysis. Age Ageing 2018; 47: 193–200.
          • 2. Khadka J, Visvanathan R, Theou O, et al. Development and validation of a frailty index based on Australian Aged Care Assessment Program data. Med J Aust 2020; 213: 321–326.
          • 3. Mitnitski A, Mogilner A, Rockwood K. Accumulation of deficits as a proxy measure of aging. ScientificWorldJournal 2001; 1: 323–336.
          • 4. Rockwood K, Mitnitski A. Limits to deficit accumulation in elderly people. Mech Ageing Dev 2006; 127: 494–496.
          • 5. Clegg A, Bates C, Young J, et al. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age Ageing 2016; 45: 353–360.
          • 6. Ludwig C, Busnel C. Derivation of a frailty index from the resident assessment instrument – home care adapted for Switzerland: a study based on retrospective data analysis. BMC Geriatr 2017; 17: 205.
          • 7. Burn R, Hubbard R, Scrase R, et al. A frailty index derived from a standardized comprehensive geriatric assessment predicts mortality and aged residential care admission. BMC Geriatr 2018; 18: 319.
          • 8. National Institute for Health and Care Excellence. Multimorbidity: clinical assessment and management (NICE guideline NG56). Sept 2016. https://www.nice.org.uk/guidance/ng56/resources/multimorbidity-clinical-assessment-and-management-pdf-1837516654789 (viewed Aug 2020).
          • 9. NHS England. Supporting routine frailty identification and frailty through the GP Contract 2017/2018. Apr 2017; updated June 2019. https://www.england.nhs.uk/publication/supporting-routine-frailty-identification-and-frailty-through-the-gp-contract-20172018 (viewed Aug 2020).
          • 10. Ellis G, Whitehead M, Robinson D, et al. Comprehensive geriatric assessment for older adults admitted to hospital: meta‐analysis of randomised controlled trials. BMJ 2011; 343: d6553.
          • 11. Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post‐operative outcomes in older surgical patients: a systematic review. BMC Geriatr 2016; 16: 157.
          • 12. Poudel A, Peel N, Nissen L, et al. Adverse outcomes in relation to polypharmacy in robust and frail older hospital patients. J Am Med Dir Assoc 2016; 17: 767.e9–767.e13.
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            Red‐flagging the prescribing of oral corticosteroids for people with asthma

            Christine F McDonald and Christopher J Worsnop
            Med J Aust 2020; 213 (7): . || doi: 10.5694/mja2.50777
            Published online: 5 October 2020

            High cumulative doses are often unnecessary and can have major adverse effects

            The isolation of compound E, later known as cortisone, from the adrenal gland in 1949 led to its use for treating many medical conditions; the first randomised controlled trial of its benefit for people with asthma was published in 1956.1 However, adverse effects are associated with cumulative corticosteroid doses, both with long term continuous use of low dose preparations and with repeated short courses of high dose preparations. The introduction in 1970 of inhaled corticosteroids (ICS) revolutionised asthma management, providing anti‐inflammatory benefits with a markedly reduced side effect profile. Yet many people with asthma are less adherent to ICS use as preventive treatment than their health care professionals would wish. As many as 80% of patients do not adhere to preventive therapy as prescribed,2 and both practical and perceptual barriers to adherence have been described.3


            • Austin Hospital, Melbournne, VIC


            Competing interests:

            Christine McDonald has received speaker’s fees (paid to her organisation) from Menarini and Astra Zeneca. Christopher Worsnop has received speaker’s fees from HealthEd, GlaxoSmithKline, AstraZeneca, Cipla, Boehringer Ingelheim, Mundipharma, and Menarini.

            • 1. Subcommittee on clinical trials in asthma. Controlled trial of effects of cortisone acetate in status asthmaticus: report to the Medical Research Council. Lancet 1956; 271: 803–806.
            • 2. Bårnes CB, Ulrik CS. Asthma and adherence to inhaled corticosteroids: current status and future perspectives. Respir Care 2015; 60: 455–468.
            • 3. Lindsay JT, Heaney LG. Nonadherence in difficult asthma: facts, myths, and a time to act. Patient Prefer Adherence 2013; 7: 329–336.
            • 4. Hew M, McDonald VM, Bardin PG, et al. Cumulative dispensing of high oral corticosteroid doses for treating asthma in Australia. Med J Aust 2020; 213: 316–320.
            • 5. Aaron SD, Vandemheen KL, FitzGerald JM, et al. Re‐evaluation of diagnosis in adults with physician‐diagnosed asthma. JAMA 2017; 317: 269–279.
            • 6. Bateman ED, Boushey HA, Bousquet J, et al. Can guideline‐defined asthma control be achieved? Am J Respir Crit Care Med 2004; 170: 836–844.
            • 7. Eger KAB, Amelink M, Hekking PP, Bel E. Overuse of oral corticosteroids in asthma‐modifiable factors and potential role of biologics. Eur Respir J 2019; 54 (Suppl 63): OA5334.
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              Female genital mutilation or cutting: an updated medico‐legal analysis

              Ben Mathews and Elizabeth Dallaston
              Med J Aust 2020; 213 (7): . || doi: 10.5694/mja2.50768
              Published online: 5 October 2020

              A recent landmark High Court decision both directs and reassures medical and other practitioners in clinical and community settings that no parent or individual can compel this unlawful procedure

              Many people from countries where female genital mutilation or cutting (FGM/C) is customary have migrated to Australia and other nations. Legislation in many of these nations prohibits any person, including medical practitioners, from conducting FGM/C.1 Important questions exist about the nature of the prohibition, and lawful and ethical practice in dealing with requested FGM/C. Medical practitioners, community practitioners and religious leaders deserve sound guidance about legal responsibilities and optimal clinical practice.


              • 1 Queensland University of Technology, Brisbane, QLD
              • 2 Johns Hopkins University, Baltimore, MD, USA


              Correspondence: b.mathews@qut.edu.au
              Competing interests:

              No relevant disclosures.

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                Impact of antivaccination campaigns on health worldwide: lessons for Australia and the global community

                Helen Petousis‐Harris and Lisbeth Alley
                Med J Aust 2020; 213 (7): . || doi: 10.5694/mja2.50779
                Published online: 5 October 2020

                The arrival of social media coincides with the point at which the antivaccination movement became globally coordinated

                The antivaccination movement has roots in the first vaccine, smallpox, although opposition to the practice of artificially inducing immunity reaches back to the practice of variolation. Despite over two centuries of vaccination practice and all the advances in medical science and societal changes that have occurred over this time, the objections still follow the same themes. These have been eloquently described as: vaccines cause idiopathic illness, unholy alliance for profit, vaccines as poisonous chemical cocktails, cover‐up, towards totalitarianism, vaccine immunity is temporary, vaccines are ineffective, and health lifestyle alternative.1 For over two centuries, antivaccination activities, distribution of literature, membership and scientific establishment responses remained unchanged.2


                • 1 University of Auckland, Auckland, New Zealand
                • 2 Immunisation Advisory Centre, University of Auckland, Auckland, New Zealand


                Competing interests:

                No relevant disclosures.

                • 1. Leask JA, Chapman S. An attempt to swindle nature: press anti‐immunisation reportage 1993–1997. Aust N Z J Public Health 1998; 22: 17–26.
                • 2. Wolfe RM, Sharp LK. Anti‐vaccinationists past and present. BMJ 2002; 325: 430–432.
                • 3. Ryan J. A history of the internet and the digital future. Reaktion Books 2013.
                • 4. Brügger N. A brief history of Facebook as a media text: the development of an empty structure. First Monday 2015; 20: https://doi.org/10.5210/fm.v20i5.5423.
                • 5. Markowitz LE, Tsu V, Deeks SL, et al. Human papillomavirus vaccine introduction — the first five years. Vaccine 2012; 30 (Suppl): F139–F148.
                • 6. Smith N, Graham T. Mapping the anti‐vaccination movement on Facebook. Inf Commun Soc 2019; 22: 1310–1327.
                • 7. Jamison AM, Broniatowski DA, Dredze M, et al. Vaccine‐related advertising in the Facebook Ad Archive. Vaccine 2020; 38: 512–520.
                • 8. Global Advisory Committee on Vaccine Safety. Global Advisory Committee on Vaccine Safety, 4–5 December 2019. Review of case studies of vaccine safety communications and lessons learnt. Wkly Epidemiol Rec 2020; 4: 25–36.
                • 9. Simms KT, Hanley SJB, Smith MA, et al. Impact of HPV vaccine hesitancy on cervical cancer in Japan: a modelling study. Lancet Public Health 2020; 5: e223–e234.
                • 10. Hansen PR, Schmidtblaicher M, Brewer NT. Resilience of HPV vaccine uptake in Denmark: decline and recovery. Vaccine 2020; 38: 1842–1848.
                • 11. World Health Organization. Ten threats to global health in 2019. Geneva: WHO, 2019. https://www.who.int/vietnam/news/feature-stories/detail/ten-threats-to-global-health-in-2019 (viewed Aug 2020).
                • 12. World Health Organization. Urgent health challenges for the next decade. Geneva: WHO, 2020. https://www.who.int/news-room/photo-story/photo-story-detail/urgent-health-challenges-for-the-next-decade (viewed Aug 2020).
                • 13. Lane S, MacDonald NE, Marti M, Dumolard L. Vaccine hesitancy around the globe: analysis of three years of WHO/UNICEF Joint Reporting Form data — 2015–2017. Vaccine 2018; 36: 3861–3867.
                • 14. Lo NC, Hotez PJ. Public health and economic consequences of vaccine hesitancy for measles in the United States. JAMA Pediatr 2017; 171: 887–892.
                • 15. Hanley SJ, Yoshioka E, Ito Y, Kishi R. HPV vaccination crisis in Japan. Lancet 2015; 385: 2571.
                • 16. World Health Organization; UNICEF. Samoa: WHO and UNICEF estimates of national immunization coverage: 2019 revision. https://www.who.int/immunization/monitoring_surveillance/data/wsm.pdf (viewed Aug 2020).
                • 17. Guarino Ben, Satija N, Sun LH. Deadly measles outbreak hits children in Samoa after anti‐vaccine fears. Washington Post 2019; 28: . Nov. https://www.washingtonpost.com/health/2019/11/26/deadly-measles-outbreak-hits-children-samoa-after-anti-vaccine-fears/ (viewed Aug 2020).
                • 18. Samoa arrests vaccination critic amid deadly measles crisis. BBC News 2019; 6 Dec. https://www.bbc.com/news/world-asia-50682881 (viewed Aug 2020).
                • 19. Duckor‐Jones A. Tragedy in paradise: how Samoa is faring after the measles epidemic. New Zealand Listener 2020; 5 Feb. https://www.noted.co.nz/currently/currently-world/samoa-measles-how-its-faring-after-the-epidemic (viewed Aug 2020).
                • 20. Greenberg J, Dubé E, Driedger M. Vaccine hesitancy: in search of the risk communication comfort zone. PLoS Curr 2017; 9: ecurrents.outbreaks.0561a011117a1d1f9596e24949e8690b.
                • 21. Corcoran B, Clarke A, Barrett T. Rapid response to HPV vaccination crisis in Ireland. Lancet 20186; 391: 2103.
                • 22. Berry NJ, Danchin M, Trevena L, et al. Sharing knowledge about immunisation (SKAI): an exploration of parents’ communication needs to inform development of a clinical communication support intervention. Vaccine 2018; 36: 6480–6490.
                • 23. Chung Y, Schamel J, Fisher A, Frew PM. Influences on immunization decision‐making among US parents of young children. Matern Child Health J 2017; 21: 2178–2187.
                • 24. Dubé E, Gagnon D, Vivion M. Best practices for addressing vaccine hesitancy. Can Commun Dis Rep 2020; 46: 48–51.
                • 25. Gesualdo F, Zamperini N, Tozzi AE. To talk better about vaccines, we should talk less about vaccines. Vaccine 2018; 36: 5107.
                • 26. Fagerlin A, Wang C, Ubel PA. Reducing the influence of anecdotal reasoning on people's health care decisions: is a picture worth a thousand statistics? Med Decis Making 2005; 25: 398–405.
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                  Ethical issues in reproductive genetic carrier screening

                  Lisa Dive and Ainsley J Newson
                  Med J Aust 2021; 214 (4): . || doi: 10.5694/mja2.50789
                  Published online: 28 September 2020

                  Publicly funded reproductive carrier screening programs must weigh up a number of ethical considerations

                  Reproductive genetic carrier screening (RCS) is undertaken by individuals or couples to determine their likelihood of having a child with particular autosomal recessive or X‐linked genetic conditions. It can be undertaken by anyone of reproductive age who wishes to have it, regardless of their family history or ancestry, and either before or during pregnancy.1 Some forms of RCS are currently available in Australia on a user‐pays basis, costing around $400–$500 per person. It is usually accessed via general practitioners but can also be accessed directly from testing companies.2 People who receive an increased chance result are offered genetic counselling to explore their reproductive options, which might include steps to avoid having a child with a genetic condition. Taking the test before pregnancy gives those with an increased chance result a wider range of reproductive options compared with prenatal testing.3

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                  • University of Sydney, Sydney, NSW


                  Acknowledgements: 

                  The Australian Reproductive Genetic Carrier Screening Project (Mackenzie's Mission) is funded by the Australian Government Medical Research Future Fund as part of the Australian Genomics Health Futures Mission (GHFM73390 [MRFF‐G‐MM]). The funding source had no direct role in the planning, writing or publication of this article. The authors thank Alison Archibald, Edwin Kirk, Nigel Laing and Martin Delatycki, as well as members of the Mackenzie's Mission Research and Gene Selection Committees, for helpful discussions that informed the drafting of this article.

                  Competing interests:

                  Lisa Dive's position at the University of Sydney is funded by Mackenzie's Mission. Ainsley Newson is a Chief investigator with Mackenzie's Mission.

                  • 1. Henneman L, Borry P, Chokoshvili D, et al. Responsible implementation of expanded carrier screening. Eur J Hum Genet 2016; 24: e1–e12.
                  • 2. Delatycki MB, Alkuraya F, Archibald A, et al. International perspectives on the implementation of reproductive carrier screening. Prenat Diagn 2020; 40: 301–310.
                  • 3. van der Hout S, Dondorp W, de Wert G. The aims of expanded universal carrier screening: autonomy, prevention, and responsible parenthood. Bioethics 2019; 33: 568–576.
                  • 4. Mackenzie's Mission. https://www.mackenziesmission.org.au (viewed June 2020).
                  • 5. Delatycki MB, Laing N, Kirk E. Expanded reproductive carrier screening — how can we do the most good and cause the least harm? Eur J Hum Genet 2019; 27: 669–670.
                  • 6. De Wert GM, Dondorp WJ, Knoppers BM. Preconception care and genetic risk: ethical issues. J Community Genet 2012; 3: 221–228.
                  • 7. Kater‐Kuipers A, De Beaufort ID, Galjaard R‐JH, et al. Ethics of routine: a critical analysis of the concept of ‘routinisation’ in prenatal screening. J Med Ethics 2018; 44: 626–631.
                  • 8. Asch A. Prenatal diagnosis and selective abortion: a challenge to practice and policy. Am J Public Health 1999; 89: 1649–1657.
                  • 9. Savell K, Karpin I. The meaning of “serious disability” in the legal regulation of prenatal and neonatal decision‐making. J Law Med 2008; 16: 233–245.
                  • 10. Kirk EP, Ong R, Boggs K, et al. Gene selection for the Australian Reproductive Genetic Carrier Screening Project (“Mackenzie's Mission”). Eur J Hum Genet 2020; https://doi.org/10.1038/s41431-020-0685-x.
                  • 11. Rowe CA, Wright CF. Expanded universal carrier screening and its implementation within a publicly funded healthcare service. J Commun Genet 2020; 11: 21–38.
                  • 12. Newson AJ. Ethical aspects arising from non‐invasive fetal diagnosis. Semin Fetal Neonatal Med 2008; 13: 103–108.
                  • 13. Schuurmans J, Birnie E, van den Heuvel LM, et al. Feasibility of couple‐based expanded carrier screening offered by general practitioners. Eur J Hum Genet 2019; 27: 691–700.
                  • 14. Holtkamp KC, Mathijssen IB, Lakeman P, et al. Factors for successful implementation of population‐based expanded carrier screening: learning from existing initiatives. Eur J Public Health 2017; 27: 372–377.
                  • 15. Newson AJ, Leonard SJ, Hall A, Gaff CL. Known unknowns: building an ethics of uncertainty into genomic medicine. BMC Med Genomics 2016; 9: 57.
                  • 16. Plantinga M, Birnie E, Schuurmans J, et al. Expanded carrier screening for autosomal recessive conditions in health care: arguments for a couple‐based approach and examination of couples’ views. Prenat Diagn 2019; 39: 369–378.
                  • 17. Haque IS, Lazarin GA, Kang HP, et al. Modeled fetal risk of genetic diseases identified by expanded carrier screening. JAMA 2016; 316: 734–742.
                  • 18. Bennett R. Antenatal genetic testing and the right to remain in ignorance. Theor Med Bioeth 2001; 22: 461–471.
                  • 19. Hildt E. Autonomy and freedom of choice in prenatal genetic diagnosis. Med Health Care Philos 2002; 5: 65–72.
                  • 20. Ong R, Howting D, Rea A, et al. Measuring the impact of genetic knowledge on intentions and attitudes of the community towards expanded preconception carrier screening. J Med Genet 2018; 55: 744–752.
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                    Addressing the oral health needs of Indigenous Australians through water fluoridation

                    Andrew McAuliffe, Chris Bourke and Lisa M Jamieson
                    Med J Aust 2020; 213 (6): . || doi: 10.5694/mja2.50744
                    Published online: 21 September 2020

                    To the Editor: Poor oral health profoundly affects a person's ability to eat, speak, socialise, work and learn.1 It has an impact on social and emotional wellbeing, productivity in the workplace, and quality of life. Pain from dental caries is a common experience. In children, dental caries may require treatment under a hospital‐based general anaesthetic — at considerable cost and itself not without risk.2 Poor oral health in childhood is the leading cause of poor adult oral health.1

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                    • 1 Australian Healthcare and Hospitals Association, Canberra, ACT
                    • 2 University of Adelaide, Adelaide, SA


                    Competing interests:

                    No relevant disclosures.

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                      Three‐dimensional printing in a pandemic: panacea or panic?

                      Michael Wagels and Dietmar W Hutmacher
                      Med J Aust 2020; 213 (6): . || doi: 10.5694/mja2.50753
                      Published online: 21 September 2020

                      Patience and well designed studies are important for balancing opportunity and risk in uncertain times

                      Even before they had to deal with the COVID‐19 pandemic, clinicians were negotiating the infiltration of three‐dimensional printing (3DP) into several aspects of medicine. This development probably began with the invention of stereolithography by Charles Hull in 1983.1 The technology has found broad application in engineering and manufacturing, particularly for computer‐aided design of machine parts. Its principles were also relevant to related aspects of clinical medicine, beginning with the production of reference biomodels from imaging data, and later in virtual surgical planning. It did not take long for the workflow that provided these services in the clinical environment to expand into other areas.

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                      • 1 The Australian Centre for Complex Integrated Surgical Solutions, Princess Alexandra Hospital, Brisbane, QLD
                      • 2 The University of Queensland, Brisbane, QLD
                      • 3 ARC Centre in Additive Biomanufacturing, Queensland University of Technology, Brisbane, QLD


                      Competing interests:

                      No relevant disclosures.

                      • 1. Jain A, Bansal KK, Tiwari A, et al. Role of polymers in 3D printing technology for drug delivery: an overview. Curr Pharm Des 2018; 24: 4979–4990.
                      • 2. Ballard DH, Trace AP, Ali S, et al. Clinical applications of 3D printing: primer for radiologists. Acad Radiol 2018; 25: 52–65.
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