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Summary A 41-year-old male presented to the Emergency Department with a 6-month history of back and hip pain. Skeletal survey revealed bilateral pubic rami fractures and MRI of the spine demonstrated multiple thoracic and lumbar fractures. Secondary work up for osteoporosis was undertaken. There was no evidence of hyperparathyroidism and the patient was vitamin D replete. Testosterone (T) was low at 1.7 nmol/L (8.6–29.0) and gonadotrophins were undetectable. The patient failed a 1 mg dexamethasone suppression test (DST) with a morning cortisol of 570 nmol/L ( Learning points Unexplained osteoporosis requires thorough investigation and the workup for secondary causes is not complete without excluding glucocorticoid excess. MTC should be considered when searching for sources of ectopic ACTH secretion. Resistance to tyrosine kinase inhibitors is well described with MTC and clinicians should have a low threshold for screening for recurrent disease.

Background The MindSpot Clinic provides services to Australians with anxiety and depression. Routine data collection means that MindSpot has been able to monitor trends in mental health symptoms and service use prior to and during the COVID-19 pandemic, and these have been reported in two earlier studies. This third study describes user characteristics and volumes in the first 8 months of COVID-19, including a comparison between users from states and territories with significantly different COVID-19 infection rates. Methods We examined trends in demographics and symptoms for participants starting an online assessment during the COVID-19 pandemic, from March to October 2020. Participants from the state of Victoria (n = 4203), which experienced a significantly larger rate of COVID-19 infections relative to the rest of Australia, were compared to participants from the rest of Australia (n = 10,500). Results were also compared to a baseline “comparison period” prior to the COVID-19 pandemic. Results A total of 14,703 people started a mental health assessment with MindSpot between 19th March and 28th October 2020. We observed two peaks in service demand, one in the early weeks of the pandemic, and the second in August–September when COVID-19 transmission was high in Victoria. Mean symptom scores on standardised measures of distress (K-10), depression (PHQ-9) and anxiety (GAD-7) were lower during this second peak in service demand, but there were significantly higher levels of concern about COVID-19 in participants from Victoria, and a higher proportion of Victorian respondents reported that they had made significant changes in response to the pandemic. Many respondents reported changes to their mental health, such as increased feelings of worry. Most respondents reported implementing strategies to help manage the psychological impact of COVID-19, such as maintaining social connections and limiting exposure to news or social media. Conclusions We did not observe increased levels of clinical anxiety or depression on standardised symptom measures. However, there were increases in service demand, and increased levels of concern and difficulties related to COVID-19, particularly in Victoria. Encouragingly, a significant proportion of participants have implemented coping strategies. These results continue to suggest that the mental health impacts of COVID-19 represent a normal response to an abnormal situation rather than an emerging mental health crisis. This distinction is important as we develop individually appropriate and proportional mental health system responses., Highlights • We describe patient characteristics and regional variation for users of a digital mental health service in Australia. • In Australia from July to October, the state of Victoria was disproportionally affected by COVID-19. • Service demand and concern about COVID-19 were high in Victoria compared to the rest of Australia. • Encouragingly, a significant proportion of participants implemented coping strategies.

Background The MindSpot Clinic, funded by the Australian Government, is a national digital mental health service (DMHS) providing services to people experiencing anxiety and depression. We recently reported increased service use in the early weeks of the COVID-19 pandemic (19 March to 15 April 2020), and a small increase in anxiety symptoms. This follow-up paper examines trends in service use and symptoms, over 12 weeks from 19 March to 10 June 2020. Methods Demographics, symptoms, and psychosocial stressors were compared for participants starting an online assessment over four time-periods: A baseline “Comparison period” prior to the COVID-19 pandemic (1 to 28 September 2019), “Weeks 1–4” of the COVID-19 pandemic in Australia (19 March–15 April 2020), “Weeks 5–8” (16 April–13 May 2020) and “Weeks 9–12” (14 May–10 June). Responses to questions about the impact of COVID-19 and strategies used by participants to improve their mental wellbeing are also reported. Results A total of 5455 people started a mental health assessment with MindSpot from 19 March to 10 June 2020. The number of assessments per week rose steadily from 303 in week 1 to a peak of 578 in week 5. Symptoms of anxiety were highest in Weeks 1–4, declining steadily over subsequent weeks. Psychological distress and depression, as measured by the K-10 and PHQ-9 respectively, remained stable. Concern about COVID-19 was highest in the first week then steadily declined during the following weeks. The proportions of participants reporting changes to routine were consistent across the 12 weeks, and most participants reported adopting helpful strategies to improve their mental wellbeing. Conclusions We observed an initial increase in service use, which reduced over the 12 weeks. The initial rise in anxiety symptoms returned to baseline. Reported concern about the effect of COVID-19 declined steadily over 12 weeks. Symptoms of psychological distress and depression measured by the K-10 and PHQ-9, and the proportion reporting suicidal thoughts and plans did not change, and to date we have not identified indications of a mental health crisis. However, the long-term effects of COVID-19 on the economy and large sections of society are yet to be fully realised, indicating the importance of ongoing monitoring and reporting of trends as indicators of the mental health of the nation., Highlights • Demand for digital mental health services (DMHS) has increased during COVID-19. • Ongoing reports from DMHS can track changes in mental health during the pandemic. • We found an initial increase in service demand, anxiety, and concern about COVID-19. • We have also observed a high level of resilience in the community.

Background Trends in contact with a high volume national digital mental health service (DMHS), the MindSpot Clinic, provide a unique opportunity to assess the mental health effects of the COVID-19 pandemic. Methods Three methods were used to assess changes in responses to COVID-19. First, website visits and call centre traffic were compared across two time periods: the “comparison period” (1 to 28 September 2019), and during the early weeks of the “COVID-19 pandemic” (19 March to 15 April 2020). Second, demographic and symptom data were compared across all patients who started an assessment during the comparison (n = 1650) and the COVID-19 period (n = 1668). Third, responses to questions about the impact of COVID-19 introduced to the assessment from 19 March 2020, and reports from treating therapists were examined. Results There was an 89% increase in website visits and a 90% increase in telephone calls to the clinic in the early COVID-19 period compared to the comparison period. There was a higher proportion of females in the COVID-19 sample (76.9% vs. 72.9%), and a lower proportion reported being in employment (52.8% vs. 60.8%). There was a small but significant increase in the severity of anxiety symptoms, and an increase in the number of people reporting recent onset of anxiety and depression. However, there were no differences between groups in severity of symptoms of distress or depression. Most people (94%) reported concern about the impact of COVID-19, and 88% reported making changes in lifestyle. Older adults had higher levels of concern about COVID-19. Therapists reported that patients were concerned about how to access testing, manage quarantine, financial security and the effect of social isolation. Conclusions COVID-19 has resulted in a significant increase in contact with an established DMHS, but we have not yet detected increases in baseline symptom severity. With the prospect of prolonged restriction of movement, DMHS such as MindSpot could play an important role in both providing clinical services and monitoring the mental health of the population., Highlights • Demand for service contact has increased in response to COVID-19 • Anxiety increased, and more patients reported recent onset of symptoms • High volume DMHS can provide real time data on changes in psychological symptoms in the community

Stress fractures occurring within the lower limbs are relatively common in athletes and military personnel. The specific bones affected are often predictable when the patient's activities are considered. We present an unusual case of bilateral distal tibial stress fractures sustained while playing as a goalkeeper in field hockey, in an otherwise healthy 46-year-old woman.