Volume 183 Issue 10

The Western Australian Audit of Surgical Mortality is a prototype for a national scheme Most surgical care is conducted to a high standard; when a death occurs under surgical care, the patient is usually elderly, with comorbid disease, and a gathering momentum of events leads towards death. However, this does not abrogate the need for accountability in the safety and quality of surgical care. Across the world, established programs promote a culture of reflective practice in surgery and anaesthesia1,2 which have been used as the basis for developing guidelines for perioperative care.3 For sustained accountability, programs require a high degree of perceived clinical ownership, confidentiality, safeguards for the process and participants (such as legal privilege), transparency, and a health care system oriented towards system improvement. Other requirements are robust quality assurance and safeguards to prevent suppression of process or practice failures, as well as full participation and complete data collection, with protected time for individual clinicians, if improvements in health care are to be facilitated. . . . the WA audit model is a promising advance and is likely to contribute to improving surgical care in Australia and New Zealand In this issue of the Journal, Semmens and colleagues report the successful transfer of an established program of auditing deaths after surgery from a public health care system in Scotland4 to a mix of public and private practice in Western Australia.5 While the long-term impact on surgical practice of the Western Australian Audit of Surgical Mortality remains to be determined, its reported early success merits reflection. Although the WA audit was voluntary, participation was high (96%), as occurred in the Scottish Audit of Surgical Mortality.6 The proportion of patient reviews completed in WA (54%) should improve with time, towards the 91% achieved by the Scottish audit,6 although only 100% completion can give the assurance the public deserves. The finding of the WA audit that 6% of the people who died were patients of surgeons who opted out of the audit reveals another aspect requiring improvement if significant outliers are to be identified. The “headline” finding in WA that 20% of surgery-related deaths were associated with deficiencies of care, with 5% caused by these deficiencies, and 2% considered preventable, exhibits a refreshing honesty on the part of participating surgeons. Technical errors featured prominently, in contrast to the process deficiencies identified in the Scottish audit.6 Of particular concern were the 24% of deaths that occurred after elective admissions (compared with 9% in Scotland), with a nearly twofold greater risk of having a deficiency of care in elective compared with emergency surgical patients. Furthermore, the finding that a consultant was the operating surgeon in 50% of cases, regardless of whether it was the patient’s first, second or third operation during the admission, is worrying, as subsequent operations are likely to be unplanned and to present complex challenges. Surgical audits are not new to Australia — they can be traced back to the 1950s.7 Despite this history and the increasing audit requirements of the Royal Australasian College of Surgeons, a recent national survey of medium-to-large hospitals revealed that over two-thirds of Australian surgical units did not conduct an audit according to College requirements.8 This failure was attributed to resource constraints. A method to measure the audit process itself, focusing on system issues as well as individual accountability, has recently been described.9 Although the surgical audit process has been slow to mature and progress in Australia, the WA audit model is a promising advance and is likely to contribute to improving surgical care in Australia and New Zealand, as it has done in Scotland.6 Involving other health professionals, such as anaesthetists and nurses,6 and using data from incident reporting systems,10 would further enhance the process. Implementing an integrated national audit in individual states is a challenge. Meanwhile, the many doctors who have instigated, piloted and participated in the WA audit should be congratulated. So, too, should the Royal Australasian College of Surgeons for endorsing in principle the introduction of a surgical mortality audit based on the WA model across Australia and New Zealand.

Alastair Thompson MD, FRCs(Ed) · Peter A Stonebridge FRCS(Ed) · Allan D Spigelman FRACS, FRCS, MD

One in 25 Australians carries a cystic fibrosis gene mutation, but most do not know it until they have an affected child The technology for safe, cheap screening for the principal gene mutations responsible for cystic fibrosis has long been available. Nearly 10 years ago, the US National Institutes of Health recommended “testing for gene mutations that cause [cystic fibrosis] be offered as an option to all pregnant couples and those planning a pregnancy”.1 A similar recommendation has been made by a joint committee of the American College of Obstetricians and Gynaecologists and the American College of Medical Genetics.2 In 1998, this Journal published an editorial emphasising the need for Australia to follow suit in promoting carrier screening for cystic fibrosis.3 There has been little response despite the fact that each year 70 babies are born in Australia with cystic fibrosis, almost all to parents with no family history.4 Cystic fibrosis is the most common severe autosomal recessive disease of childhood, with an incidence of 1 in 2500 and carrier frequency of 1 in 25. Clinical manifestations include progressive, irreversible suppurative lung disease and pancreatic exocrine insufficiency. Although most children with cystic fibrosis can expect to survive into adulthood, the daily therapies are rigorous, and there are many years of ill health. The median life expectancy is in the mid-30s, with end-stage lung disease the major cause of death. There is still no cure. Most patients with cystic fibrosis are detected by newborn screening, using a biochemical test (for immunoreactive trypsinogen [IRT]) for all babies, followed by cystic fibrosis gene mutation analysis for those with a raised IRT level. Newborn screening facilitates the early diagnosis of cystic fibrosis and genetic counselling for affected families. Couples identified with an affected infant can choose prenatal testing using gene mutation analysis from a chorionic villus sample for subsequent pregnancies to ascertain the status of the fetus. The genetic test used for diagnosis of cystic fibrosis and prenatal testing can also be used to identify carriers of a cystic fibrosis gene mutation. Testing for cystic fibrosis gene mutations is reliable, and, with a 12-mutation panel, nearly 85% of possible severe mutations can be detected. It can be performed using a painless cheek swab. However, testing for carrier status is generally not offered in Australia to couples without a family history, and most of those who carry a mutation do not know until an affected child is born. While we acknowledge the benefits of newborn screening, we believe it would be better to offer cystic fibrosis gene mutation screening to all couples, before they had their first baby with cystic fibrosis. Prenatal screening for a variety of conditions is routine in Australia. All women have a full blood count early in pregnancy, and those who are iron replete with a low mean cell volume are tested for thalassaemia carrier status. The outcome is that it is now uncommon for babies to be born with thalassaemia. Prenatal screening for Down syndrome (using a combination of ultrasound examination and measurement of serum markers) has been offered since 1996, and more than two-thirds of pregnant women in Victoria participate in this screening. Populations with a high frequency of genetic conditions such as Tay–Sachs disease are also offered prenatal or preconceptual screening. Paradoxically, the carrier frequency of cystic fibrosis in the general Australian population is almost the same as the carrier frequency of Tay–Sachs disease in the Ashkenazi Jewish population.5 Lack of awareness about cystic fibrosis no doubt contributes to the lack of community pressure to screen. A successful prenatal screening program for cystic fibrosis has been pursued in Edinburgh for many years.6 This program uses a model of couple testing for carrier status with the offer of prenatal genetic testing of the fetus when both partners are carriers and has halved the incidence of cystic fibrosis in that community.7 Uptake of the service is 80%,6 similar to the uptake in a smaller Dutch study.8 In Victoria, 67% of couples with an infant with cystic fibrosis have used prenatal testing for subsequent pregnancies.9 Some families have opted for pre-implantation genetic diagnosis (with in-vitro fertilisation technology) to avoid pregnancy termination. We advocate a cystic fibrosis screening program in which both parents are encouraged to be screened at the same time, which will give the most accurate risk assessment of the couple having a baby with cystic fibrosis (Box). Ideally, screening would be performed before conception, to allow the couple time to decide on the best reproductive option. In reality, many women do not present for pre-pregnancy assessment, so a screening model that allows prenatal testing of the couple should remain available. Furthermore, we advocate that both parents receive their individual carrier result to maximise the opportunities for cascade family testing. Any program offering carrier screening needs to include genetic counselling for carrier couples, individual carriers and relatives of carriers who may also wish to be tested. Extensive data clearly demonstrate the cost effectiveness of cystic fibrosis screening. The lifetime cost of care for a patient with the condition outweighs the cost of screening women of child-bearing age.10,11 Cystic fibrosis carrier screening should be a federal initiative. Currently, the care of patients with cystic fibrosis and the newborn screening programs are state funded, and there is little incentive for a national program. A Medicare-rebatable test would allow universal access and encourage uptake. Surely, it is time to fund carrier screening for cystic fibrosis in Australia. Screening for cystic fibrosis gene mutations

R John Massie PhD, FRACP · Martin B Delatycki FRACP, PhD · Agnes Bankier FRACP

Specific priority actions and screening programs should target sexually active young people The incidence of sexually transmitted infections (STIs) is increasing in many parts of the world including Australia,1 and the release of the first Australian National Sexually Transmissible Infections Strategy to deal with STIs is timely.2 Three very appropriate priority areas have been identified: Aboriginal and Torres Strait Islander sexual health, STIs in men who have sex with men, and control and prevention of infection with Chlamydia trachomatis among young people. Given that an implementation plan is under development, it is timely to comment on the Strategy, pointing out its strengths and weaknesses, so as to ensure that an effective, comprehensive approach is implemented. Experience from the United Kingdom, where a national STI strategy was developed in 2001,3 suggests that this is the first stage of a long, difficult and contentious process to improve sexual health within the community. The control of STIs involves a range of activities. As well as research, surveillance, and adequate training and support of professional staff, it is essential that we not only increase access to health care (including screening, treatment and contact tracing), but that we also promote health and educate the young about sex. While the Strategy satisfactorily covers surveillance, service provision and research, sex education and behavioural prevention are not adequately addressed, except with reference to gay and other homosexually active men. There are no specific priority actions focusing on sexually active young people, and a lack of clarity with regard to the targeting of screening programs for young people. The Australian Study of Health and Relationships, a recent survey of the sexual relationships and practices of 19 307 people aged between 16 and 59 years, showed that the median age of first intercourse among Australians aged between 16 and 19 was 16 years, and that the reporting of multiple sex partners was significantly associated with younger age and with identifying as bisexual or homosexual.4,5 As the authors noted: “This early onset of sexual activity indicates that it is important to ensure that all young people have information about contraception and disease prevention before they begin their sexual careers and not simply in their final years of schooling.”5 Health promotion, including mandatory sex education, is essential for all young people, male as well as female, and those under as well as those over 16 years of age. A study comparing sexual health outcomes in young people in the context of sex educational policies in the Netherlands, the United States, France and Australia found that in France and the Netherlands, where there is mandatory secondary school sex education, there are fewer STIs than in Australia and far fewer than in the US, where sex education is patchy.6 Increasing access to health care is not enough. There is also evidence that school-based education is likely to be more effective if it is sex positive, that is, if education does not focus solely on delaying or abstaining from sex.6 In the UK, where STI rates are at an all-time high, a survey of young people’s experience of sex education came to the conclusion that such education was “too little, too late and too biological.”7 We should learn from such experience. The Strategy refers to raising awareness of STIs among sexually active young people and recommends that there be a national health promotion campaign. However, the approach is coy. Although safer sex is mentioned, the only mention of condoms occurs under the action plan for gay men, where the Strategy mentions “reinforcing safer sex and condom use.” The consistent use of condoms is a highly effective method of reducing the risk of acquiring STIs, in particular the bacterial infections (gonorrhoea, chlamydia and syphilis) and HIV.8 Condoms have been and continue to be a major factor in the reduction in the incidence of HIV in homosexually active men in Australia. Widespread condom use is also the single most important factor in the continued low incidence of all STIs in commercial sex workers in Australia.9 Young sexually active people need to be aware of the risk of STIs and use condoms to prevent their transmission. The continued promotion and widespread availability of condoms must be one of the key elements of any successful STI strategy. The incidence of chlamydia infection in Australia is increasing and has more than doubled between 2000 and 2004 with over 35 000 notifications, with the largest increases noted in women aged 15–19 and 20–29 years.1,10 In the Minister for Health’s press release, which accompanied the launch of the Strategy, funding of $12.5 million over 4 years was announced for increased awareness, improved surveillance and a pilot testing program for chlamydia infection,11 and this is very welcome. However, while the Strategy highlights the need to develop “a chlamydia screening pilot targeting sexually active young adults”, the Minister’s press release had a different spin, suggesting that the pilot testing program for chlamydia will target women aged 18–30 years. However, younger women and men, particularly young men, who seldom seek health care, should also be the target for the pilot.12,13 In the US and Sweden, where national chlamydia screening policies based largely on opportunistic screening of women have been in place for several years, rates of chlamydia infection remain high.14 There are many long-term physical consequences of STIs, in particular, pelvic inflammatory diseases and consequent infertility, and cervical and other genital tract tumours. In addition, STIs are often associated with psychological morbidity. The release of the Strategy provides a unique opportunity to reduce the prevalence of STIs and their consequences. We must ensure that we make the most of this opportunity.

Adrian Mindel MD, FRACP, FRCP · Susan Kippax BA(Hons), PhD, FASSA

Objective: To describe the peer review process of the Western Australian Audit of Surgical Mortality (WAASM), selected outcomes and recommendations.Study design: Prospective audit using peer review of all cases of patients who died while under the care of a Western Australian surgeon between 1 January 2002 and 30 June 2004. Audit reviews were current to 30 September 2004.Participants and setting: 194 of 202 surgeons participated after a patient died under their care.Main outcome measures: Surgeon participation, deficiencies of care, deep vein thrombosis (DVT) prophylaxis, futile surgery, postmortem reviews, proportion of operations performed by consultant surgeons.Results: The audit process was complete for 896 of 1647 reported deaths (54%), while a further 503 (31%) were still under review at 30 September 2004. Twenty deaths associated with terminal care were excluded from analysis. Median patient age was 80 years, and 799 of the 876 patients who died (91%) had significant comorbidities that increased the risk of death. Deficiencies of care were reported in 179/876 (20%). In 45/876 deaths (5%) the deficiency of care was assessed to have caused the death, and 15 deaths were considered preventable. The risk of a deficiency of care was 1.9 times higher in elective admissions than emergency admissions. Autopsy was undertaken in 83/768 (11%) deaths with complete data. Changes in practice were noted in some areas targeted by WAASM, such as improved DVT prophylaxis. A problem with fluid management was recorded.Conclusion: Most patients who died were elderly, had complex comorbidities and were treated appropriately. The WAASM has helped to change surgical practice and emphasises the importance of ongoing systematic audit. The participation of surgeons demonstrates their commitment to accountability and supports the intention of the Royal Australasian College of Surgeons to extend the process throughout Australia and New Zealand.

James B Semmens MSc, PhD · Frank M Sanfilippo BPharm, PGradDipPharm, PhD · S Aqif Mukhtar MSc, GradDipPH, MEMIM · Natasha S Haynes BA(Hons) · Jenny A Mountain BA, MBA · R James Aitken FCS(SA), FRACS

Objective: To assess the effect of a multifaceted hand hygiene culture-change program on health care worker behaviour, and to reduce the burden of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infections.Design and setting: Timetabled introduction of interventions (alcohol/chlorhexidine hand hygiene solution [ACHRS], improved cleaning of shared ward equipment, targeted patient decolonisation, comprehensive “culture change” package) to five clinical areas of a large university teaching hospital that had high levels of MRSA.Main outcome measures: Health care worker hand hygiene compliance; volume of ACHRS used; prevalence of patient and health care worker MRSA colonisation; environmental MRSA contamination; rates of clinical MRSA infection; and rates of laboratory detection of ESBL-producing Escherichia coli and Klebsiella spp.Results: In study wards, health care worker hand hygiene compliance improved from a pre-intervention mean of 21% (95% CI, 20.3%–22.9%) to 42% (95% CI, 40.2%–43.8%) 12 months post-intervention (P < 0.001). ACHRS use increased from 5.7 to 28.6 L/1000 bed-days. No change was observed in patient MRSA colonisation or environmental colonisation/contamination, and, except in the intensive care unit, colonisation of health care workers was unchanged. Thirty-six months post-intervention, there had been significant reductions in hospital-wide rates of total clinical MRSA isolates (40% reduction; P < 0.001), patient-episodes of MRSA bacteraemia (57% reduction; P = 0.01), and clinical isolates of ESBL-producing E. coli and Klebsiella spp (90% reduction; P < 0.001).Conclusions: Introduction of ACHRS and a detailed culture-change program was effective in improving hand hygiene compliance and reducing nosocomial MRSA infections, despite high-level MRSA endemicity.

Paul D R Johnson MB BS, PhD, FRACP · Rhea Martin RN, MPH, CSIC · Laurelle J Burrell RN, BAppSc · Elizabeth A Grabsch BSc, MPH, GradDipClinEpi, GradDipHAdmin · Susan W Kirsa BPharm, GradDipHospPharm · Jason O’Keeffe RN, BN, CSIC · Barrie C Mayall FRACP, FRCPA, BSc, DipEpid · Deidre Edmonds RN, CSIC · Wendy Barr RN · Christopher Bolger RN · Humsha Naidoo MB BChB, FRACMA · M Lindsay Grayson MD, MSc, FRACP, FAFPHM

Objective: To estimate the risks of maternal and perinatal morbidity and mortality in a second pregnancy, attributable to caesarean section in a first pregnancy.Design and setting: Cross-sectional analytic study of hospital births in New South Wales, based on linked population databases.Participants: 136 101 women with one previous birth who gave birth to a singleton infant in NSW in 1998–2002.Main outcome measures: Crude and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) for maternal and perinatal morbidity and mortality.Results: 19% of mothers had a caesarean section in their first pregnancy. Compared with mothers who had had primary vaginal births, mothers who had had primary caesarean section and undewent labour in the second birth were at increased risk of uterine rupture (aOR, 12.3; 95% CI, 5.0–30.1; P < 0.0001), hysterectomy (3.5; 1.5–8.4; P < 0.01), postpartum haemorrhage (PPH) following vaginal delivery (1.6; 1.4–1.7; P < 0.0001), manual removal of placenta (1.3; 1.1–1.6; P < 0.01), infection (6.2; 4.7–8.2; P < 0.0001) and intensive care unit (ICU) admission (3.1; 2.1–4.7; P < 0.0001); among mothers who did not undergo labour (ie, had an elective caesarean section), there was a lower risk of PPH (0.6; 0.5–0.7; P < 0.0001) and ICU admission (0.4; 0.3–0.5; P < 0.0001). For infants there was increased risk of preterm delivery (1.2; 1.1–1.3; P < 0.0001) and neonatal intensive care unit admission following labour (1.6; 1.4–1.9; P < 0.0001) in the birth after primary caesarean section. The occurrence of stillbirth was not modified by labour.Conclusions: Caesarean section in a first pregnancy confers additional risks on the second pregnancy, primarily associated with labour. These should be considered at the time caesarean section in the first pregnancy is being considered, particularly for elective caesarean section for non-medical reasons.

Lee K Taylor DRANZCOG, FAFPHM · Judy M Simpson PhD, CStat · Christine L Roberts DrPH, FAFPHM · Emily C Olive FRANZCOG, DDU · David J Henderson-Smart FRACP, PhD

Objective: To describe empiric community-acquired pneumonia (CAP) management in Australian hospital emergency departments (EDs) and evaluate this against national guidelines, including use of the pneumonia severity index and antibiotic selection.Design: A multicentre, cross-sectional, retrospective audit, April 2003 to February 2005.Setting: 37 Australian hospitals: 22 principal referral hospitals, six large major city hospitals, four large regional hospitals, four medium hospitals and one private hospital.Participants: Adult patients with a diagnosis of CAP made in the ED. Data on 20 consecutive CAP ED presentations were collected in participating hospitals.Outcome measures: Documented use of the pneumonia severity index, initial antibiotic therapy prescribed in the ED, average length of stay, inpatient mortality, and concordance with national guidelines.Results: 691 CAP presentations were included. Pneumonia severity index use was documented in 5% of cases. Antibiotic therapy covering common bacterial causes of CAP was prescribed in 67% of presentations, although overall concordance with national guidelines was 18%. Antibiotic prescribing was discordant due to inadequate empiric antimicrobial cover, allergy status (including contraindication to penicillin), inappropriate route of administration and/or inappropriate antibiotic choice according to recommendations. There was no significant difference between concordant and discordant antibiotic prescribing episodes in average length of stay (5.0 v 5.7 days; P = 0.22) or inpatient mortality (1.6% v 4.1%; χ2 = 1.82; P = 0.18).Conclusions: Antibiotic therapy for CAP prescribed in Australian EDs varied. Concordance with national CAP guidelines was generally low. Targeted interventions are required to improve concordance.

for the CAPTION Study Group*

After “unprotected” sexual encounters, sexual history guides risk assessment and testing for sexually transmissible infections (STIs). Chlamydia trachomatis infection is the most prevalent bacterial STI. Sexually active young people (aged < 25 years) should have annual chlamydia testing. Opportunistic STI testing is indicated for population groups at increased risk of STI, including young people, gay and other homosexually active men, and Indigenous people. Gay and other homosexually active men should be regularly tested for HIV, syphilis, chlamydia and gonorrhoea. Indigenous people should be regularly tested for syphilis, chlamydia and gonorrhoea. Postexposure antiretroviral prophylaxis may be indicated after high-risk sexual encounters.

Deborah L Couldwell MB BS, MM, FAChSHM

Recent MJA editorials assert that Australian hospitals are no safer than they were when the first hospital safety report was published in 1995. Despite many recommendations by several committees and much activity to improve safety over the past decade, we lack concrete evidence that safety and quality of health care have improved. Efforts to promote hospital safety in the United States and the United Kingdom also remain unevaluated. Incentives for safer care have been implemented locally, but not applied to entire health systems. A recent review in Australia has recommended replacing the current Australian Council for Safety and Quality in Health Care with a smaller Commission on Safety and Quality in Health Care. The Commission will link all national safety activity and report annually to Australian health ministers on hospital safety. We need a system that measures quality and safety, and provides financial incentives for safer care. Implementing the national framework for education about patient safety would develop teamwork skills and skills in techniques of continuous improvement. Linked to this, adequate financial support should be available to make safety changes in the health care environment.

George L Rubin FRACP, FACPM, FAFPHM · Stephen R Leeder AO, PhD, FRACP, FFAPHM

Clinical record A 29-year-old Vietnamese woman who had migrated to Australia 5 years previously was referred with a 2-month history of erythematous painful nodules on her thighs and left buttock, the largest of which measured 3 cm × 4 cm. There was no history of recent infections or previous exposure to tuberculosis. She denied any symptoms of inflammatory bowel disease, vasculitis or connective tissue disease. Examination disclosed no abnormalities such as lymphadenopathy, hepatosplenomegaly or synovitis. A chest x-ray was normal. Blood tests showed a total white cell count of 7.3 × 109/L, haemoglobin level of 133 g/L, platelet count of 295 × 109/L and an erythrocyte sedimentation rate of 11 mm/h. No antinuclear antibodies or antineutrophil cytoplasmic antibodies were detected. Liver and thyroid function tests and coagulation studies were all normal. A working diagnosis of erythema nodosum was made, and the patient was commenced on naproxen. When treatment with naproxen was unsuccessful after 4 weeks, she was commenced on 45 mg (1 mg/kg) of prednisolone daily. As she showed only a partial response to prednisolone, a deep incisional biopsy of a lesion was performed. It revealed a granulomatous lobular panniculitis with necrosis (Box), consistent with erythema induratum (EI). There were no visible mycobacteria or fungi on staining. A subsequent Mantoux test was strongly positive, while a polymerase chain reaction test for Mycobacterium tuberculosis DNA performed on the paraffin-embedded tissue was negative. The patient was commenced on a 6-month course of quadruple antituberculous directly observed therapy, consisting of rifampicin, isoniazid, pyrazinamide and ethambutol, together with pyridoxine, while the prednisolone dose was quickly tapered and ceased. Within 2 months, the cutaneous lesions had resolved, and had not recurred a month after the completion of antituberculous therapy. Bazin1 first described erythema induratum (EI) in 1861 to illustrate chronic, painful, violaceous, indurated and occasionally ulcerative nodules that occurred predominantly on the lower limbs of patients (mainly women) with tuberculin hypersensitivity. Its appearance can easily be confused with erythema nodosum, polyarteritis nodosa or perniosis. The diagnosis of EI could easily have been missed, as the cutaneous lesions were similar to those characteristic of erythema nodosum. In addition, there was a partial response to corticosteroids. A diagnosis of EI is based on cutaneous characteristics, a positive Mantoux test, evidence of tuberculosis and histological findings.2 The diagnosis of EI in this patient was established with three of the four criteria. Furthermore, the patient responded clinically to antituberculous therapy. The negative polymerase chain reaction (PCR) result is not surprising. In other studies, only 56%–88% of patients previously diagnosed with cutaneous tuberculosis had a positive PCR result using the IS6110 primer.2,3 Schneider et al4 found a positive PCR result in only 5 of 20 patients with EI. Shimizu et al5 failed to isolate Mycobacterium tuberculosis by either culturing cutaneous EI tissue or inoculating the tissue into guinea pigs. The association of EI with tuberculosis is still a matter of debate. Some have considered EI to be a type III or type IV hypersensitivity reaction to M. tuberculosis antigens.6 This may explain the patient’s partial response to corticosteroids. Lessons from practice Erythema induratum (EI) can easily be mistaken for erythema nodosum, perniosis or cutaneous polyarteritis nodosa. The failure to detect Mycobacterium tuberculosis on microscopy or by a polymerase chain reaction test on the biopsy specimen does not exclude the diagnosis. EI lesions can resolve with corticosteroid therapy, which may lead to a misdiagnosis of erythema nodosum. EI should be treated with antituberculous therapy. Histological section of subcutaneous tissue from one of the nodules The lower-power image shows florid inflammatory changes involving fat lobules (L) with thickening of lobular septa (S), consistent with a florid, predominantly lobular, panniculitis. The higher-power image (inset) shows a classical combination of granulomatous inflammation (G) and eosinophilic granular fat necrosis (N).

Gary Y J Chew MB BS, BSc(Med) · John W Quin PhD, FRACP, FRCPA · Christopher Henderson MB BS, FRCPA

Clinical records Patient 1 An intubated and ventilated 73-year-old woman was transferred to a tertiary referral hospital intensive care unit for investigation and management of coma after suspected drug overdose, complicated by pulmonary aspiration. Her initial 12-lead electrocardiogram showed acute changes consistent with tricyclic antidepressant-induced cardiotoxicity. She had normal international normalised ratio (INR; 1.0) and serum alanine aminotransferase (ALT) level (25 IU/L; reference range, ≤ 40 IU/L) at presentation. Her serum paracetamol concentration at 6 hours after ingestion was 2713 μmol/L (410 mg/L) (treatment level, 150 mg/L at 6 hours after ingestion) and intravenous N-acetylcysteine (NAC) was ordered. However, only 10% of the recommended intravenous NAC doses were ordered for each of the infusion bags (ie, 1200 mg loading dose instead of 12 000 mg, followed by 400 mg instead of 4000 mg in the first infusion, followed by 800 mg instead of 8000 mg in the second infusion). This error was not detected until 40 hours after presentation, by which time her serum ALT level was 4940 IU/L and INR was 2.2. The correct dose was commenced. The serum ALT level peaked at 5360 IU/L 52 hours after ingestion, and then decreased rapidly. The patient recovered fully after a prolonged stay in the intensive care unit complicated by aspiration pneumonia and sepsis. Patient 2 A 28-year-old woman presented to a regional hospital within 30 minutes of ingesting 35 g of paracetamol and 400 mL of rum, and was given activated charcoal. Her 4-hour serum paracetamol level was 2395 μmol/L (362 mg/L) (treatment level, 200 mg/L at 4 hours after ingestion) and intravenous NAC was commenced 5 hours after ingestion. Her INR (1.0) and serum ALT level (30 IU/L) were normal at presentation. The NAC infusion was ceased after the standard 20 hours. However, by 48 hours after ingestion her INR was 3.4 and serum ALT level was 9450 IU/L. She was transferred to a teaching hospital for further management. Review of the medical records on arrival 72 hours after the overdose revealed that only 10% of the recommended intravenous NAC dose had been given in each of the infusion bags (ie, 900 mg instead of 9000 mg, followed by 300 mg instead of 3000 mg, followed by 600 mg instead of 6000 mg). Intravenous NAC was recommenced at standard doses. Eighty hours after ingestion, her INR and ALT peaked at 3.5 and 11 500 IU/L, respectively, before normalising. She recovered well and was discharged to the regional hospital. Paracetamol is one of the most common agents involved in deliberate self-poisoning in Australia.1,2 N-Acetylcysteine (NAC; Parvolex, Mayne Pharma Pty Ltd, Parkville, Vic) is the specific antidote,3,4 and its administration is recommended to all patients judged to be at risk of developing hepatotoxicity following paracetamol overdose. The standard administration regimen in Australia is a dose of 300 mg/kg given by staged intra-venous infusion in 5% dextrose solution (150 mg/kg over 15–60 minutes, followed by 50 mg/kg over 4 hours, followed by 100 mg/kg over 16 hours). This is how staff in Australia routinely calculate doses of NAC for infusion. For these two patients, intravenous NAC was commenced but, because of either a miscalculation or transcription error, the final order involved a 10-fold underdosing error. In both cases, intra-venous NAC was ordered and commenced by staff who rarely initiate this therapy. N-Acetylcysteine for intravenous use is packaged as a liquid preparation in 10-mL ampoules, each containing 2000 mg. If NAC is prescribed in milligrams, the prescriber must calculate the correct dose based on the patient’s known or estimated weight. The person making up the infusion must then derive the volume of NAC required to add to the 5% dextrose solution. For an adult patient, multiple ampoules of NAC are typically required for each of the staged infusions. If a 10-fold error is made, then it is not surprising that the person preparing the infusion may not realise the volume is inappropriate. However, the Parvolex package insert and eMIMS contain a useful table that shows the volume in millilitres of NAC required for ranges of body weight (Box). This removes the need for calculations based on patient weight and conversion of milligrams to millilitres; use of this table should greatly reduce the potential for error. In our clinical toxicology service, all NAC infusion orders are prescribed in terms of NAC volumes directly derived from the package insert table. We strongly recommend that this practice be adopted elsewhere, particularly by inexperienced prescribers of NAC. Lessons from practice N-Acetylcysteine (NAC; Parvolex) is an effective antidote in the treatment of paracetamol poisoning. Prescription errors can occur when calculating the dose of NAC using the recommended milligram per kilogram dose. Using the supplied “Parvolex intravenous infusion dosage guide” allows prescribing a “dose in millilitres” of NAC to be administered and greatly reduces the potential for error. Parvolex intravenous infusion dosage guide Patient’s body weight (kg) Initial: 150 mg/kg in 200 mL of 5% glucose in 15–60 min Second: 50 mg/kg in 500 mL of 5% glucose in 4 hours Third: 100 mg/kg in 1 L of 5% glucose in 16 hours Total Parvolex (mL) Parvolex (mL) Parvolex (mL) Parvolex (mL) 50 37.5 12.5 25 75 60 45.0 15.0 30 90 70 52.5 17.5 35 105 80 60.0 20.0 40 120 90 67.5 22.5 45 135 x 0.75x 0.25x 0.5x 1.5x Consider a 60 kg patient requiring N-acetylcysteine (NAC; Parvolex). Conventionally, the first dose is calculated by: 60 kg ×150 mg/kg = 9000 mg NAC. The staff drawing up the NAC then have to ascertain what volume of NAC this is [9000 mg/200 mg/mL NAC = 45 mL, which is 4.5 ampoules of NAC]. Using this table, one can immediately see that a 60 kg person’s first dose will be 45 mL NAC, and subsequent doses are 15 mL and 30 mL. Reproduced with the permission of Mayne Pharma Pty Ltd

Mark Little DTM · Lindsay Murray MB BS, FACEM · David McCoubrie MB BS, FACEM · Frank F S Daly MB BS, FACEM

A 30-year-old woman with a history of bipolar disorder presented after ingestion of 4 g of carbamazepine and 40 mg of alprazolam in a suicide attempt. She became increasingly drowsy and eventually required intubation and mechanical ventilation. The patient received a total of 350 g of activated charcoal via a nasogastric tube over 25 hours. She experienced some charcoal-stained vomiting, but made an otherwise unremarkable recovery and was discharged home. The patient was hospitalised again 3 days later complaining of constant sharp abdominal pain, diagnosed on culture as a urinary tract infection. Over the next 4 days, she experienced multiple bouts of nausea, charcoal vomits and colicky central abdominal pain. A Gastrografin meal (Schering Pty Ltd, Sydney) and follow-through showed complete small bowel obstruction (Box 1). Subsequent laparotomy revealed a 2.5 × 5 cm bezoar in the distal small bowel, about 60 cm from the ileocaecal valve (Box 2). The bezoar was manually fragmented and passed through the ileocaecal valve into the caecum. The patient recovered well after the operation, and was discharged with psychiatric follow-up. Charcoal bezoars are a rare complication of activated charcoal administration. They have been associated with treatments for intoxication with carbamazepine,1 amitriptyline,2 theophylline,3 benzodiazepines and barbiturates.4,5 The parasympatholytic effects of the drugs can precipitate or contribute to paralytic ileus, allowing charcoal to accumulate (potentially with remnants of undigested tablets) and form bezoars. Additional factors that influence bowel obstruction secondary to charcoal administration include the dose and timing of activated charcoal therapy, patient age and comorbidities, and previous intra-abdominal surgery. Gastrointestinal complications should be considered whenever activated charcoal is administered. Prompt recognition and treatment at the first sign of ileus or obstruction may prevent bowel necrosis and subsequent perforation/peritonitis. Charcoal-stained vomiting, abdominal distension and ongoing pain should raise the suspicion of mechanical obstruction. We would advocate Gastrografin follow-through as both a diagnostic and potentially therapeutic tool in incomplete obstruction. However, complete obstruction may signal the need for early laparotomy. 1 Abdominal x-ray after Gastrografin meal, showing complete small bowel obstruction 2 Operative photograph of bezoar in distal small bowel

Justin C Y Chan MB BS BMedSci · Chaminda Saranasuriya MBBS · Bruce P Waxman MB BS, FRACS, BMedSci

Physical activity can significantly reduce the risk of cardiovascular disease, diabetes, some forms of cancer, osteoporosis, obesity, falls and fractures, and some mental health problems. While the benefits of physical activity are clear, there is a slightly increased risk of sudden death while exercising (compared with while sedentary), especially in untrained people undertaking unaccustomed vigorous activity. Routine exercise testing yields a significant number of false-positive results, and has not been shown to prevent exercise-related acute cardiac events. There is no convincing evidence that exercise is itself associated with osteoarthritis, but significant joint injury which occurs during sport is associated with an increased risk of subsequent development of osteoarthritis.

Peter D Brukner MB BS, FACSP · Wendy J Brown BSc(Hons), MSc, PhD

Stephen Clarke,* Justin G Oakley,† David A Neil,‡ Joseph E Ibrahim§ * Research Fellow, Centre for Applied Philosophy and Public Ethics, Charles Sturt University and the Australian National University, Canberra, ACT 2601; † Director, Centre for Human Bioethics, Monash University; ‡ Lecturer, Faculty of Arts, University of Wollongong; § Professor, Rehabilitation, Aged and Palliative Care Services, Peninsula Health, Mt Eliza, VIC. Stephen. ClarkeATanu.edu.au To the Editor: Last year, three of us made a case for the public reporting of individual surgeon performance information.1 We argued that considerations of safety and accountability strongly justify the collection of individual outcomes data, and that considerations of patient choice make it very hard to argue against the public reporting of collected data. The public trust in health care in Australia has, in the words of a recent MJA editorial, “taken a pounding” as a result of a series of scandals at the King Edward Memorial Hospital, Perth, in 1999, the Canberra Hospital, in 2000, and the Campbelltown and Camden Hospitals in NSW, in 2002.2 We noted that recent developments in public reporting of surgeon performance information in the United Kingdom were driven in large part by the Bristol Royal Infirmary Inquiry, and we warned of the danger of waiting for a scandal like Bristol to occur before acting to improve performance management. Unfortunately, a scandal, perhaps on the scale of that at the Bristol Royal Infirmary, has now occurred in Bundaberg. Although this scandal is ostensibly about the failings of one badly performing surgeon, it is widely seen as symptomatic of a failure of regulation of health care throughout Australia. The Queensland Health Systems Review, headed by Mr Peter Forster, was established in April this year as a result of public disquiet resulting from the Bundaberg scandal.3 The Premier received the report on 30 September and has recommended a wide range of reforms including increased performance monitoring of a range of health care outcomes (Recommendation 13.2), and the insistence that information on health system outcomes be made public (Recommendation 13.3). We welcome the review’s recommendations as both a necessary component of a successful system of management of the health care system and a means to begin to restore public trust in the health care system. Unfortunately, we suspect that this may not be enough to restore trust in the system. A system in which a plainly incompetent surgeon has been allowed to continue operating is one where, in the eyes of the public, the performance of all surgeons working within that system is called into question. A public reporting system that provides reliable and valid information about individual surgeons, as well as hospitals’ clinical performance, would be a significant step towards restoring the public’s confidence and ensuring transparency within that system.

Stephen Clarke · Justin G Oakley · David A Neil · Joseph E Ibrahim

Sue M Evans,* Peter A Cameron,† Paul Myles,‡ Johannes Stoelwinder,§ John J McNeil¶ * Executive Officer/Research Fellow, † Professor of Emergency Medicine, ‡ Professor and Director, Department of Anaesthesia and Perioperative Medicine, § Professor; and Chair of Health Services Management, ¶ Head, Department of Epidemiology and Preventive Medicine, Monash University, NHMRC Centre of Research Excellence in Patient Safety, Level 3, Burnet Building, Alfred Hospital, Prahran, VIC 3004. sue.evansATmed.monash.edu.au To the Editor: The article by Morton1 and the editorial by Van Der Weyden2 raised some important points. Investment in redesigning the health bureaucracy and recruiting more clinicians to work in Queensland is clearly important, but we also need to address more fundamental issues to ensure optimal quality of care. The following two matters require particular attention: lack of measurement and monitoring; and developing clinical governance. We cannot know how hospitals are performing unless we have well developed and validated markers of quality of care that can be risk-adjusted and benchmarked. Measurement and benchmarking are fundamental components of quality assurance in virtually every industry other than health care, and it is difficult to see how standards can be guaranteed and improved unless they are adopted more widely in health care. In contrast to Bristol, where data on cardiac surgery were collected but not used effectively,3 we also need systems in place to react to poorly performing individuals, units or hospitals. Effective monitoring is also currently limited by an inability to link data, such as deaths, re-admissions and complications. Clinical performance has depended too much on personal capabilities — training, experience, memory and vigilance. Although important, the avoidance of human error will necessitate change to a more system-focused approach to patient care. This will involve greater coordination of care to improve efficiency and to build layers of safety into our daily work practices. Currently, supervision of medical practice is extraordinarily diffuse. The accountability of medical practitioners must be made more explicit, and greater attention paid to ensuring that skills are gained under adequate supervision and maintained over time. Simulation offers great potential for identifying vulnerabilities in a learning environment and in the adoption of new technologies into routine practice. Doctors have traditionally been reluctant to adopt clinical pathways or decision support tools to supplement memory and record clinical information and results. However, these can help standardise clinical care and reduce human error by ensuring that uniform, evidence-based practices are adopted. These strategies will also provide the basis of effective clinical governance.

Sue M Evans · Peter A Cameron · Paul Myles · Johannes Stoelwinder · John J McNeil

Anthony P Morton Consultant, and Medical Statistician, Infection Management Services, Princess Alexandra Hospital, Woolloongabba, QLD 4102. amor5444ATbigpond.net.au To the Editor: Recent articles drawing attention to the “Bundaberg problem” and its causes1,2 have stressed the need to make hospitals safer. Queensland Health’s approach to improving quality has been the Measured Quality Hospital Reports.3 Unfortunately, this approach puts the cart before the horse. The quality of all work is a function of the systems in which it is performed.4 Therefore, it is logical to concentrate first on optimising hospital systems. When that is done, the work of the hospital should be consistent and reproducible. It is then logical to use measurement to detect any deterioration or to gauge the effect of any effort to improve a hospital’s systems. This measurement needs to be sequential, and, where random variation occurs, it should take advantage of the excellent statistical process control methods now available.5 In addition, the limitations of risk-adjustment must be applied and understood. Where possible, this is best done at a local level, as at this level risk-adjustment can be made to work better,6 and local ownership promotes efforts to learn how to improve rather than efforts to be seen to comply with a target. Putting measurement first encourages excuses (eg, demographic and classification differences), quick fixes and gaming, not solutions. Correcting hospital systems requires, for example, a focus on specific processes, use of evidence, employment of multidisciplinary teams, independent audit of surgical outcomes, proper supervision of junior staff and, above all, leadership.4 Central offices are seen to be remote, judgemental, controlling and arbitrary. It is very difficult to foster ownership and trust in such an environment. Without trust, leaders do not emerge and teamwork becomes impossible. To achieve better systems in hospitals, central offices have to change; they have to become coaches. They must help hospital staff with the difficult task of analysing and changing their systems. They must then institute programs of surveillance to ensure that this process is sustained. Central offices need to ensure that, if a hospital’s measurement system detects a possible change in the quality of its care, a search for a possible cause is undertaken and, if a cause is found, appropriate corrective action is instituted. Demands on hospitals are potentially infinite and resources are not. Determining what is best requires informed public debate. However, whatever the resources available, safe care is likely to be less costly than unsafe care, as there is much less failed work needing redoing.

Anthony P Morton

Bruce H Barraclough Chair, Australian Council for Safety and Quality in Health Care; and NSW Clinical Excellence Commission; Professor of Cancer Services, Northern Sydney Central Coast Health, Royal North Shore Hospital, Pacific Highway, St Leonards, NSW 2065. bbarraATozemail.com.au To the Editor: I am surprised that your recent editorial1 failed to recognise the quite dramatic changes for the better occurring in our health system and the way these changes have come about. In July, the Australian Health Ministers agreed that there had been widespread acceptance of the National Safety and Quality agenda developed by the Australian Council for Safety and Quality in Health Care, and agreed to build on the Council’s extensive platform of reforms by establishing the Australian Commission on Safety and Quality in Health Care to continue this work.2 They noted change and progress in key areas, including the development of incident management systems in all jurisdictions to fix problems in a timely way. All public hospitals are developing integrated patient safety risk management plans, a common protocol for correct site procedures has been accepted, and across the system the booklet 10 Tips for safer health care3 is being given to patients on admission to hospital to enhance their ability to ask the right questions and better control their care. The Australian Council for Safety and Quality in Health Care has commissioned preparation of the first national sentinel events report. Each state is teaching health care staff “root cause analysis” methodology and, on the back of this, there has been a massive increase in reporting across the country — 30-fold in New South Wales — because people realise that systems issues will be fixed without inappropriate blame. This supports openness about mistakes and the reporting of problems. Other national initiatives under way include an education framework for safety and quality, a single common medication chart in all public hospitals, agreed national approaches to infection control, as well as a national open disclosure standard and a national standard for credentialling and defining the scope of clinical practice. Ministers have endorsed this standard, which, if applied appropriately, could be expected to help prevent situations like that in Bundaberg. The Bundaberg scandal, however, appears to have been caused initially by a fraudulent application for registration. The safety and quality agenda does not address criminal behaviour, but puts in place opportunities for improvement. These are only some of the reforms being implemented using levers for change, which include leadership, advice, persuasion, example, and the development of tools, standards and guidelines. Commonwealth, state and territory health and human services departments, as well as organisations in the private sector, continue to be responsible and accountable for implementing these activities. Internationally, the Council’s work is held in high regard by authorities from the United Kingdom, the United States, Canada and Ireland, who are seeking advice about how coordination of these activities across the health and human services departments of nine sovereign governments has been achieved. The new Commission will continue the difficult task of taking the health system from “very good” to “even better”.

Bruce H Barraclough

Peter M Brooks Executive Dean (Health Sciences), University of Queensland, Royal Brisbane Hospital, Herston, QLD 4006. p.brooksATmailbox.uq.edu.au To the Editor: Van Der Weyden is to be congratulated on his editorial about the Bundaberg Hospital scandal.1 He rightly points out that, although these issues have surfaced now in Queensland, the whole of the Australian health system is currently like a time bomb, with other disasters waiting to happen. However, the current health workforce shortage, which underlies many of the problems facing the health system, is not going to be solved by creating more of the same. There needs to be a radical rethink of how we deliver services in different ways, with different types of health practitioners, such as physician assistants, nurse anaesthetists and a range of other health professionals — many of whom already practise in other countries. The editorial did not emphasise, however, the importance of creating “partnerships” between Queensland Health and the universities. The concept of the professor/director, so common now in the southern states of Australia, has not been embraced in Queensland. There are significant opportunities to work together to improve health worker training in the future if this partnership is embraced. There is also an urgent need for an open debate on what Australians want from their health system and how much they are willing to pay. These are difficult issues and, although other countries such as the United States (Oregon) have attempted to have this community debate in the past, no clear solutions have been forthcoming. The current issues in Queensland, the publication of the Queensland Health Systems Review by Mr Peter Forster2 and the Productivity Commission’s Position Paper on Australia’s Health Workforce3 provide a great opportunity for the government and the community to sit down and have that debate, so that we can plan an appropriate health system for the future.

Peter M Brooks

R James Aitken Surgeon, Sir Charles Gairdner Hospital, Hollywood Specialist Centre, 95 Monash Avenue, Nedlands, WA 6090. rjaitkenATcyllene.uwa.edu.au To the Editor: Van Der Weyden calls for quality and safety for all Australians accessing health care.1 Improving the quality and safety of health care requires clinical leadership and active participation by all staff. This will not occur until quality and safety activities are allocated protected time and considered by governments, hospitals, managers, health departments, health funds, clinicians and all others to be equivalent in value to clinical work. Airline pilots, to whom doctors are often compared, spend a day a month on safety training. The recently revised consultant contract in the United Kingdom provides a minimum of a half-day per week of protected non-clinical time for audit, quality and safety, governance and similar activities.2 These paid, protected sessions are equivalent to those spent in theatre, outpatients or other clinical work. There is no similar protected, non-clinical time in the Australian health service. Australia’s current trainees, the consultants of tomorrow, will expect such activities to be included within their safe working hours’ allowance. The clear message is that time allocated to quality and safety is less valuable than that spent maintaining clinical throughput. The shortage of doctors over the medium term means there will be pressure to maintain the clinical service. This will inevitably result in a further reduction in the time spent on quality and safety. A suitable start would be for every Australian hospital to stop clinical activity for one half-day per month to provide protected time within working hours for quality and safety activities. This need not be expensive. For example, many hospitals close for a prolonged period over the summer and by reducing this closure by 1 week, and spreading the days gained as quality and safety sessions over the year, hospitals will work exactly the same number of days. By rotating this half-day each month, the impact would be spread evenly. If coordinated, this would facilitate multidisciplinary, inter-hospital and even area-wide meetings. The cost of quality and safety activities is a short-term necessary inefficiency that is an investment for a long-term gain. The government’s failure to provide the paid, protected time for this necessary inefficiency clearly indicates that its interest in quality and safety ceases when a cost is involved.

R James Aitken

Megan A Bohensky,* Joseph E Ibrahim,† David L Ranson‡ * Research Officer, † Consultant and Head of Research, Clinical Liaison Service, ‡ Deputy Director, Victorian Institute of Forensic Medicine, Monash University, State Coroner's Office Victoria, 57–83 Kavanagh Street, Southbank, VIC 3006. meganbATvifm.org To the Editor: Van Der Weyden highlights the need for a health system with a focus on patient safety that is open, transparent and connected to local communities and clinicians who are able to make decisions about health care delivery.1 The editorial refers to the Bundaberg and other Australian hospital “scandals” that went undetected by medical boards, the clinical governance structures within each hospital, and sentinel event reporting processes. However, no consideration is given to the role of the Coroner’s Office, where a formal structure is already in place for reviewing particular deaths associated with health system failures. The role of the Coroner’s Office in these incidents is worth reflecting on, as the Coroner is external to the health system, has the capacity to review reported hospital deaths, and can address the concerns of doctors and nurses as well as the family members of the deceased. The case involving Dr Patel begs the question of whether this system of judicial investigation was utilised. If not, how could the system improve to encourage the disclosure of internal problems in our hospitals? One option to improve the system has been developed by the Clinical Liaison Service. This service was initiated by the State Coroner’s Office in Victoria to involve clinicians in a regular review of deaths in hospital as a means of identifying potential instances of hospital system failures.2 Through a system-based approach, issues of communication failure, unclear work protocols and a lack of supervision for junior doctors have been highlighted. These issues are fed back into the health care community through coronial findings and the service’s quarterly publication Coronial communiqué.3 Improving the clinical input into judicial investigation may, by encouraging clinicians’ trust in the system, remove barriers to identifying system issues relevant to health care. Currently, Victoria is the only state or territory in Australia where clinical input is a routine part of the Coroner’s review process. Although the Coroners’ jurisdiction only extends to instances resulting in death, their findings are often far-reaching and garner public attention and support.4 Another initiative to improve this system is the development of the National Coroners Information System (http://www.vifp.monash.edu.au/ncis/). This database provides a national repository of information about reported deaths, and has the potential to be used as a health and injury surveillance system to inform policy for death prevention. As noted by Morton, system analysis requires a process that is just and transparent.5 The coronial process inherently comprises both of these features through its legislative structure. It is conceivable that a team of clinical reviewers within the Queensland Coroner’s Office could have identified issues at Bundaberg earlier on. Our health system unquestionably requires a better strategy for preventing the patient deaths that occur every day. The Clinical Liaison Service and the National Coroners Information System are helping the legal and health care community to work towards identifying and preventing incidents that compromise patient safety.

Megan A Bohensky · Joseph E Ibrahim · David L Ranson

William Coote Chief Executive Officer, General Practice Education and Training, GPO Box 2914, Canberra, ACT 2601. billcooteATnetspeed.com.au To the Editor: Lightning can strike in the same place twice, or at least untoward medical deaths can. Today, I was looking through the Medical Journal of Australia of 7 July 1928 and was amazed to find the report of a Royal Commission entitled “The fatalities at Bundaberg”.1 It is a tragic story. On 27 January 1928, 21 children received an injection from “an india-rubber capped bottle purporting to contain diphtheria toxin-antitoxin mixture”. Eighteen of these children became ill during the night of 27 January. Eleven died on 28 January, and another child died on 29 January. The Royal Commission found that the bottle had become “contaminated with a pathogenic staphylococcus” when it was being used the previous week. The bottle had been stored at room temperature during the intervening week. The Royal Commissioners made a series of recommendations including “biological products must be distributed in bottles or ampoules of clear glass”, “antiseptics should be included in bottles that might be used on several occasions” and, if this was not possible, bottles “should be used immediately on opening and any remaining product discarded”. One similarity with the current inquiries into Dr Patel’s activities is the complicated and confused lines of responsibility and accountability. The immunisations were administered under a Bundaberg City Council program. The Council was implementing immunisation policies of the Commissioner of Health for Queensland. The injections were given on the Council’s premises by a private doctor on contract to the council. The product was manufactured by the Commonwealth Serum Laboratories in Melbourne and supplied to the council by a private firm in Brisbane.

William Coote

Martin B Van Der Weyden Editor,The Medical Journal of Australia, Locked Bag 3030, Strawberry Hills, NSW 2012. medjaustATampco.com.au In reply: The letters in response to my editorial1 reflect concern within the medical community about the continuing saga of safety in our hospitals. Clarke et al call again for public report cards on individual surgeons. It is difficult to see what positive outcomes such an exercise would have on systemic safety — it is likely to encourage a culture of individual blame and to detract from probing system factors, an outcome not favoured by experts in safety.2,3 Despite this, surgeons in Australia are at the forefront of performance monitoring, as exemplified by the Western Australian Audit of Surgical Mortality.4 Indeed, the Royal Australasian College of Surgeons is introducing a similar program across Australia and New Zealand,5 and its leadership in this matter is to be applauded. Evans and her colleagues and Morton reiterate the dire need for a comprehensive and continuous measurement system for clinical outcomes and the central role of clinical governance. The importance of these requirements is echoed in the use of the words “measurement” or “monitoring” 11 times and “governance” five times in the preceding letters. Aitken raises the important point that improving safety and quality comes at a cost and requires dedicated time. He also draws attention to the recently introduced protected, non-clinical time for consultants in the United Kingdom, a development that deserves serious consideration by health departments Australia-wide. That medical manpower shortage is at the root of the Bundaberg Hospital scandal is emphasised by Brooks, but he calls for a debate about the bigger picture: a radical rethink of what we want from our health system and who should be the providers. Such a debate is usually side-stepped by our politicians, but the recent Productivity Commission report on Australia’s health workforce6 may force the issue. Finally, Barraclough enumerates the achievements of the Australian Council for Safety and Quality in Health Care (ACSQHC). As acknowledged in the recent review of the ACSQHC,7 the Council’s key achievements have been in raising safety issues among clinicians and the public, producing a bevy of quality policies, and focusing on systemic causes rather than individual blame for medical mishaps. The total funding allocation to the Council over its 6-year term was $55 million.7 However, the purpose of my editorial was not to dwell on these achievements, but to draw attention to the lack of a comprehensive system for gathering data on defined clinical outcomes — a necessary tool if we are to achieve meaningful safety and quality improvement. Without these data, we have no way of knowing whether the activities of the ACSQHC have made any difference to safety. As the Royal Australasian College of Physicians noted in its submission to the ACSQHC review: “clinicians do not have ready access to meaningful information about clinical practice”.7 In short, we need to resolve what we want to know and why we want to know it, and then to measure it locally, state-wide and nationally. Measuring progress and demonstrating improvement are potent forces for change. But it all depends on the availability of robust measurements.

Martin B Van Der Weyden

Benjamin P Howden,* Elizabeth A Grabsch,† Helen King,‡ Maryza Graham,§ Paul D R Johnson,¶ Tony M Korman** M Lindsay Grayson,†† Barrie C Mayall‡‡ * Infectious Diseases Physician, § Infectious Diseases Registrar, ¶ Deputy Director, †† Director, Infectious Diseases Department, Austin Health, Studley Road, Heidelberg, VIC 3084; † Infection Control Scientist, ‡ Scientist, ‡‡ Medical Microbiologist, Microbiology Department, Austin Health, Melbourne, VIC; ** Director, Infectious Diseases Department, Southern Health, Melbourne, VIC. benjamin.howdenATaustin.org.au To the Editor: Although community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has been reported, it is not recognised as important in Victoria.1 Also, health-care acquisition of “typical CA-MRSA” strains has been reported, but is uncommon.2 Because of an apparent increase in CA-MRSA at Austin Health (a tertiary referral centre in Melbourne encompassing The Austin Hospital, The Heidelberg Repatriation Hospital and Royal Talbot Rehabilitation Centre), we undertook a retrospective survey of cases to determine the frequency of isolation, and clinical and laboratory features of non-multiresistant MRSA (nmMRSA),1 as a marker for CA-MRSA. Patients with nmMRSA isolated from blood culture between January 2000 and December 2003 or from any specimen between March 2002 and August 2003 were included. Medical records were reviewed, and the mode of acquisition was defined as described previously.3 All isolates underwent polymerase chain reaction testing for genes encoding Panton–Valentine leukocidin, and pulsed field gel electrophoresis (PFGE). The frequency of isolation of nmMRSA was also reviewed for the period 1999–2004 at two major hospitals in Victoria — Austin Health and Southern Health. We identified 53 patients with nmMRSA infection or colonisation (Box). Thirteen cases (25%) were community acquired, including one fatal case of endocarditis, nine cases of soft tissue infection, two of bacteraemia, and one of bone/joint infection. Forty cases were health-care-acquired, including 17 cases of skin or soft tissue infection and seven of bacteraemia. Ten hospital patients had nmMRSA colonisation without infection. Patients with health-care-acquired nmMRSA were commonly in the renal or spinal unit or from nursing homes. PFGE revealed that the 53 nmMRSA isolates belonged to 18 groups, including six that have been previously described (WA-1 and 2, Queensland, SWP, UK EMRSA-15 and 16) and 12 novel groups (A-L). Health-care-acquired infection or colonisation was documented for all PFGE groups, including “typical CA-MRSA” strains (WA-1, WA-2, Queensland, and SWP). Twelve isolates (23%), including four health-care-acquired isolates, were positive for Panton–Valentine leukocidin (PVL). This is of particular concern given the association of PVL-positive S. aureus strains with severe skin disease, necrotising pneumonia, and high mortality in some studies, and the increased virulence of CA-MRSA compared with typical health-care-acquired multiresistant MRSA.4,5 Ten patients with CA-MRSA (77%) received ineffective antimicrobial therapy in the first 48 hours of treatment, including patients with bacteraemia. From 1999 to 2004, there was a significant decrease in the total number of MRSA cases per hospital discharge at Austin Health and Southern Health, but the number of nmMRSA cases increased, from 0.6 to 1.1 per 1000 discharges at Austin Health (1999 to 2004; P = 0.004) and from 0.08 to 0.35 per 1000 discharges at Southern Health (2001 to 2004; P < 0.001). Multiple genotypes of CA-MRSA are increasingly causing community-acquired and, importantly, health-care-acquired infections in Victoria. Clinicians need to be alert to this problem, and further research to understand the epidemiology and risk factors is urgently required to help guide changes in therapy and infection control policy. Characteristics of patients and isolates of non-multiresistant methicillin-resistant Staphylococcus aureus at a hospital in Victoria Characteristic Total Community-acquired Health-care- acquired Number of cases* 53 13 40 Age (years): median (range) 31 (17–58) 69 (18–94) Sex (M/F) 8/5 16/24 Infection type* Skin/soft tissue 26 9 17 Bacteraemia 9 2† 7 Endocarditis 1 1‡ 0 Bone/joint 4 1 3 Pneumonia 1 0 1 Urine 1 0 1 Pelvic abscess 1 0 1 Colonisation 10 0 10 PFGE group WA-1 4 2 2 WA-2 3 1 2 Queensland 6§ 5§ 1§ SWP 5§ 3§ 2§ UK EMRSA-15 10 0 10 UK EMRSA-16 3 2 1 A-L 22¶ 0 22¶ PFGE = pulsed field gel electrophoresis. * Survey included blood culture isolates for the period 2000–2003, and isolates from any specimen for the period March 2002–August 2003. † One case was associated with pneumonia, the other with epidural abscess. ‡ Fatal case. § All isolates were Panton–Valentine leukocidin (PVL)-positive. ¶ One isolate was PVL-positive.

Benjamin P Howden · Elizabeth A Grabsch · Helen King · Maryza Graham · Paul D R Johnson · Tony M Korman · M Lindsay Grayson · Barrie C Mayall

Christopher K Fairley,* Jane Hocking,† Jane Gunn,‡ Marcus Y Chen§ * Professor, † Postdoctoral Research Fellow, School of Population Health, ‡ Associate Professor and Deputy Head, Department of General Practice, § Registrar, Melbourne Sexual Health Centre, University of Melbourne, 580 Swanston Street, Carlton, VIC 3053. cfairleyATunimelb.edu.au To the Editor: Each year, Australian general practitioners test only about 7% of women aged 16–24 years for chlamydia (according to Medicare records, 89 132 tests were performed on women in this age group in 2004). This compares with 30% of women aged 20–24 years in Sweden1 or Denmark.2 Why are Australian GPs not testing young women for chlamydia? Chlamydia screening in sexually active women is cost-effective and significantly reduces complications such as infertility.3 The Australian Government’s commitment to chlamydia control is evidenced by the $12.5 million recently provided for increased awareness, improved surveillance and a pilot testing program for chlamydia. In 2004, 81% of 15–19-year-old and 89% of 20–24-year-old women attended a GP at least once in Australia (unpublished data from Health Insurance Commission [HIC]), yet chlamydia testing was ordered for only a small fraction of these women. Possible reasons for the low testing rate include a lack of knowledge about the benefits of testing young women, inadequate support, difficulties in raising chlamydia testing during consultations not related to sexual health, or concern about violating HIC rules on screening.4 However, the Medicare Benefits Schedule does permit testing for chlamydia among young sexually active women. Benefits are payable for: health screening services . . . by the patient’s own medical practitioner . . . to ensure the patient receives any medical advice or treatment necessary to maintain his/her state of health . . . [B]enefits would be payable for the attendance and such tests which would be considered reasonably necessary according to the circumstances of the patient, such as age, physical condition, past personal and family history.5 If the HIC is concerned that “inappropriate practice” may have occurred, there is a clearly defined process for determining this.6 Part of the definition of “inappropriate practice” is “conduct in connection with rendering or initiating services that would be unacceptable to the general body of members of that profession”. A GP’s professional peers would be members of the Royal Australian College of General Practitioners. The College will soon release the latest edition of its Guidelines for preventive activities in general practice (“The Red Book”),7 which includes activities only if they are relevant to general practice and have a demonstrated benefit. The book now recommends that all sexually active women less than 25 years of age should be tested annually for chlamydia. Increasing chlamydia testing in young Australian women from the current low rate of 7% would reduce complications and save money in the long run.3

Christopher K Fairley · Jane Hocking · Jane Gunn · Marcus Y Chen

Simon D J Gibbs,* John O'Grady,† John F Seymour,‡ H Miles Prince§ * Haematology Registrar, † Dental Oncologist, ‡ Haematoncologist, § Head, Department of Haematology and Medical Oncology, Peter MacCallum Cancer Centre, St Andrew's Place, East Melbourne, VIC 8006. simongibbs02ATyahoo.com.au To the Editor: We read with interest the article by Carter and colleagues reporting five cases of jaw osteonecrosis associated with bisphosphonate use.1 To emphasise the association, we report a further eight cases seen at our institution between February 2004 and June 2005. After Marx’s report of the condition in 2003,2 we instituted a policy of active screening for jaw osteonecrosis in patients taking bisphosphonates. Patients were asked about suggestive symptoms, such as tooth pain or dental infection, and underwent oral examination by the treating haematologist or oncologist. Suspected cases were referred to our dental oncology unit. Bisphosphonate therapy was discontinued in established cases to prevent further bisphosphonate accumulation and possible worsening of the complication. Of the eight patients detected with jaw osteonecrosis, five had multiple myeloma, two breast cancer, and one prostate cancer. All were receiving monthly intravenous bisphosphonate therapy: zoledronic acid (4 mg) in seven patients, and pamidronate (90 mg) in the other. Median duration of bisphosphonate therapy before onset of symptoms was 22 months (range, 6–66 months). Five patients were male, and three female. Seven had undergone tooth extraction before presentation (Box), and the five with multiple myeloma had received high-dose corticosteroids. Management was conservative in all eight. No improvement was seen in any patient by 3 months, but, with continued withholding of bisphosphonates, some signs of healing were seen in all by 6 months. Four of the patients had a change in therapy from pamidronate to zoledronic acid (because of the latter’s shorter infusion time) in the 2–18 months before onset of symptoms. None had experienced osteonecrosis while taking pamidronate. It is postulated that zoledronic acid is more often associated with osteonecrosis than pamidronate.3 Appropriate management for patients who need to resume bisphosphonate therapy after osteonecrosis remains to be determined. Clodronate is an orally administered first-generation bisphosphonate which has been used widely in Europe with no reports of associated osteonecrosis.4 Unlike pamidronate and zoledronic acid, it does not contain a nitrogen ring. On this basis, we recently began clodronate therapy in a patient with complete jaw healing after osteonecrosis. Avoiding tooth extractions while taking bisphosphonates should minimise the incidence of osteonecrosis. Our active screening policy allowed earlier detection of osteonecrosis and prompt intervention, including cessation of bisphosphonates and avoidance of debridement of necrotic bone (which often exacerbates the condition), thereby limiting the extent of osteonecrosis. It is uncommon for physicians to ask about dental problems and for dentists to ask about bisphosphonate use. This new complication highlights the need for this to change. Osteononecrosis of the jaw in a patient with multiple myeloma taking zoledronic acid Necrotic maxillary bone and sequestrum formation which developed after tooth extraction. Computed tomography scan showing failure of the bone to heal at the extraction site.

Simon D J Gibbs · John O'Grady · John F Seymour · H Miles Prince

Jesia G Berry,* James E Harrison,† Raymond A Cripps,‡ Ruth Marshall§ * Research Officer, † Director and Associate Professor, ‡ Research Associate, National Injury Surveillance Unit, Flinders University, GPO Box 2100, Adelaide, SA; § Director, South Australian Spinal Cord Injury Service, Royal Adelaide Hospital, SA. Jesia. BerryATflinders.edu.au To the Editor: The authors of a recent article on football spinal injuries1 restate the case made in 1987 “for an independent registry of football-related ASCIs [acute spinal cord injuries]”2 and conclude that “the games must be made safer than they presently are, and a national registry is the first step in this direction”.1 The Australian Spinal Cord Injury Register (ASCIR) was established in 1995 by the National Injury Surveillance Unit of the Australian Institute of Health and Welfare and the directors of all six Australian spinal units. The ASCIR collects data from these units on persisting ASCI from all causes. Published reports are available at <http://www.nisu.flinders.edu.au/publications. php#hdr16>. We think that this existing register provides the basis for the function advocated by Carmody et al.1 The ASCIR can be used to identify particular types of ASCI cases, such as those due to football, and can provide basic demographic and clinical information. Indeed, The ASCIR was used to identify relevant cases when Carmody and colleagues1 asked spinal units for this information. Ideally, data for a sports injury register are obtained from injured players, witnesses and clinicians to enable detailed analysis of mechanisms and circumstances. A good example is a register of catastrophic head and neck injuries in American football which has, since 1977, collected data from each injured player’s coach, physician and athletic director, prompting rule changes and equipment improvements.3 As a register of ASCI generally, the ASCIR does not normally obtain such detailed information about cases occurring during football. There is no obvious reason why football-related cases ascertained by the ASCIR should not be flagged for supplementary information collection, perhaps by or in collaboration with interested researchers such as Carmody and colleagues.1 In addition to case data, participation numbers over time are necessary for trend analysis. The Australian Rugby Union has published comprehensive annual participation data since 1996, but the Australian Rugby League has not. The American football register is supplied with participation figures by national school and collegiate associations,3 and similar information from Australian sports-governing bodies would be beneficial. The brief statement of methods and the omission of year-specific case numbers by Carmody et al1 left us unsure how trends had been modelled (eg, Were trends based on annual rates? Were annual exposure data interpolated from their Box 1 figures?) We note that their figure of 68 179 registered rugby union players in 1996 is more than 20 000 lower than the figure published by the Australian Rugby Union.4

Jesia G Berry · James E Harrison · Raymond A Cripps · Ruth Marshall

Thomas K F Taylor,* David J Carmody,† David A Parker,‡ Myles R J Coolican,‡ Robert G Cumming§ * Emeritus Professor, † Registrar, ‡ Surgeon, Department of Orthopaedics and Traumatic Surgery, Royal North Shore Hospital, Pacific Highway, St Leonards, NSW 2065; § Professor, Centre for Education and Research on Ageing, Concord Hospital, Concord, NSW. tktaylorATmed.usyd.edu.au In reply: We welcome the opportunity to comment briefly on what we consider a registry for spinal injuries in football should actually be. The raw data collected by the Australian Spinal Cord Injury Register is valuable for governments and other statutory bodies — for example, to plan for the enormous costs of acute spinal cord injuries (ASCIs), irrespective of their causation. However, a proper registry for spinal injuries from football (all codes) is a far cry from this. In particular, hospital records are notoriously inaccurate as to the way in which injuries sustained are documented, and to rely on them ensures misleading, if not spurious, data. We established long ago that interviewing players was the only accurate way to identify the mechanisms of injury, which are the keys to possible preventive measures.1 It is entirely relevant that ASCIs are at one end of a spectrum of vertebral column injuries (eg, fractures, dislocations) sustained in all football codes. Between 1986 and 2002, 65 footballers were admitted to the Royal North Shore Hospital with vertebral column injuries but no spinal cord damage. These injuries were sustained by the same mechanisms as their more serious counterparts and differed from them in degree rather than absolute kind. We contend there should be mandatory reporting of all spinal injuries to an independent registry and that football club registration should depend upon compliance with this requirement.

Thomas K F Taylor · David J Carmody · David A Parker · Myles R J Coolican · Robert G Cumming

Roxanne L Wu General Surgeon, White Rock Surgery, 2/194 Progress Rd, White Rock, QLD 4868. rockdocsATbigpond.net.au To the Editor: May I suggest some explanations for the findings of Schofield and colleagues on the rate and reasons for surgery cancellations on the intended day of surgery.1 Patients placed on a “never-never” waiting list for relatively minor surgery, such as many ear, nose and throat operations, treat the procedure with the contempt that has been shown to them. If the problem really needed the operation, most will have turned to the private sector, and, if it did not really need an operation, it has got better by itself. Surgeons who have many “no-shows” habitually overbook to fill their lists. In this day and age, surgeons who “underutilise” their lists are punished by losing them. No surgeon who has purposely overbooked their list will put a correct time estimate on the operation. We know how to add up. Surgeons whose lists are often shortened because of lack of beds begin to double book themselves, so that they are not left with an empty day. If the list is full, the surgeon may then be unavailable because of the other commitment. Surgeons who know they have a 30% chance of not getting an elective postoperative intensive-care bed for one patient book a “stand-by” patient, which becomes a cancellation if the intensive-care bed eventuates. I suggest that, before millions of dollars are spent on management consultants, the following simple procedures be considered: Always give the patient a date for the operation, even if it is next year. It keeps everyone a lot more honest, and patients might even ring the hospital to change the date (if they can get through the unnecessarily tedious process of phoning the booking clerks.) Administrators must understand that a hospital’s load fluctuates enormously and, if elective surgery is deemed the least important activity, it will never be done. To have enough beds for elective surgery means having empty beds sometimes. If patients are given a date, the hospital can predict the number of beds required for elective surgery patients, and these should be treated as full beds in advance. Intensive-care beds can also be booked, as intensive-care stays after elective surgery are predictable. If the hospital has excessive emergency admissions, it should be possible to open reserve beds at short notice or to reschedule surgery by negotiating with patients. These simple measures might cost more to the current account, but not the millions required to engineer some high-technology process driven by management consultants.

Roxanne L Wu

John P Royle Vascular Surgeon (retired), Past President, Royal Australasian College of Surgeons, and Associate Professor of Surgery, University of Melbourne, Austin Hospital, Heidelberg, VIC 3084. johnroyleATonthe.net.au Comment: The recent articles in the Journal by Schofield and colleagues1 and Cregan2 on cancellations of surgery on the scheduled day are important, as they focus attention on the management of elective surgery in the public sector. The number of on-the-day cancellations reported by Schofield et al could be reduced by continuing to compile these statistics. The consequent focus on the various problems at their hospital would reduce cancellations, although it might take several years for an effect. The statistics will vary between hospitals, depending on the amount of complex tertiary surgery undertaken and the demographic characteristics of the catchment population. Some of the problems are common to most hospitals, and more dialogue between them would be helpful. Most surgeons working in the public sector experience repeated frustrations with the management of the elective surgery waiting list. The points made by Wu are valid but of course do not cover everything in a multifactorial problem. However, her suggestions for improvement are very worthy of consideration. Giving a patient a date for an operation is sensible: both patient and staff know where they stand. If a patient had to be given a date more than 12 months in advance, then the hospital would be failing in its obligation to provide an adequate service to the community. A major reorganisation might be required. A patient who has been given a definite date can be brought into a pre-admission and pre-anaesthetic clinic (as suggested by Cregan) 3–4 weeks before the date. This would eliminate many of the reasons for cancellation listed by Schofield et al. At the pre-admission clinic, the patient could be instructed to telephone on the day before surgery to confirm arrangements (as is done at some hospitals). This does require staffing the telephone, but puts the onus back on the patient. A late cancellation could then be substituted by a “stand-by” patient, thus avoiding a vacancy on the list. Although cases of sudden illness will still occur (when 4% of staff of large hospitals are on sick leave at any one time, inevitably some patients will be sick too), only a very small number will become acutely ill after 19:00 on the previous day. Wu’s second point, concerning administrators’ views of elective surgery, is even more important. As Cregan points out, elective surgery is the easiest service for health administrators to manipulate to meet budgetary requirements.2 It is essential that, somehow, beds (and intensive care beds) for elective surgery are effectively quarantined to give certainty to patients and staff. The 23-hour model described by Ryan and colleagues3 is a method of achieving this. There is a shortage of surgeons — a fact recognised by the Royal Australasian College of Surgeons and by governments. The training of new surgeons relies heavily on the elective surgery lists of public hospitals. The governments of New South Wales and Victoria have been agitating for the accreditation of more surgical trainees. This becomes a nonsense when an adequate supply of elective surgical patients is denied by financial restrictions and hospital policies that deliberately restrict elective surgical beds. As elective surgery is at the heart of the training of future surgeons and surgical nurses, attention to this problem should be a top priority of all governments.

John P Royle

Jim R Stockigt,* Zita E Ballok,† Victor Kalff† * Endocrinologist, † Nuclear Medicine Physician, Epworth Hospital, Richmond, and Alfred Hospital, Commercial Road, Prahran, VIC 3181. jrsATnetspace.net.au To the Editor: An Australian businessman travelled to the United States by air 1 week after receiving a second therapeutic dose of 8 mCi (300 MBq) iodine-131 for thyrotoxicosis due to Graves’ disease. He carried no medical documentation, but had with him carbimazole tablets, to be recommenced 1 week after the dose. While awaiting passport clearance at Los Angeles, he noticed that an attendant from homeland security was monitoring the line of passengers with a hand-held device no larger than a mobile phone. He was approached and asked if he was a doctor, or if he was under medical treatment. He indicated that he had received radioiodine recently. The official appeared to be aware of the situation and moved him to the front of the line. He was asked whether he had a letter from his doctor or whether he had medication with him. No letter was to hand, but the medication was shown. He was escorted to collect his baggage and was taken aside for detailed questioning. His luggage and person were searched in detail and information entered into a database. The episode caused significant distress. On two occasions during the next week, he re-entered the US from Canada, by which time he had a letter that documented his medical treatment. On each occasion he was detected by the surveillance system, and questioning and search procedures were repeated. Current radiation detection devices in use at airports appear to have very high sensitivity.1 A recent detailed study that compared the sensitivity of various hand-held radiation detectors in recording various radionuclides,2 showed that therapeutic doses of I-131 could be detected for up to 95 days, F-18 FDG was detectable for 1 day, Tc-99m would trigger the alarm for 3 days, and Tl-201 or Ga-67 could be detected for up to 30 days.2 The authors of that study concluded: . . . personal radiation detectors used for Homeland Security are extremely sensitive and may detect low levels of radionuclides for long periods of time. Patients should be appropriately counselled to carry information regarding administration of diagnostic and therapeutic radiopharmaceuticals for these extended periods. Some devices are quoted as being able to detect 0.01 MBq of I-131 at 2 m —3 m,1 a level of activity that might still be present 3–4 months after treatment with 400 MBq (about 11 mCi) I-131, within the standard dose range for thyrotoxicosis. It is now a medical responsibility to make people who have received relevant radionuclides such as I-131, Tl-201 or Ga-67 aware of this travel hazard, to avoid unexpected apprehension in circumstances that cause delay and distress. Such patients should ensure that they carry appropriate medical documentation with them when they travel and should be aware that they may be interrogated and searched, even if they have documentation. To our knowledge, no similar surveillance is currently used at Australian airports.

Jim R Stockigt · Zita E Ballok · Victor Kalff

Public expectations and physicians’ responsibilities. Voices of medical humanities. John K Crellin. Abingdon: Radcliffe Publishing, 2005 (vi + 165 pp). ISBN 1 85775 642 8. John Crellin, Professor of the History of Medicine at the Memorial University of Newfoundland, explains that “underpinning this book is the perception that the values held by physicians have changed in recent years and may not be in keeping with the needs of patients today”. He and his colleagues (including students) have dipped into popular culture, literature and film to illustrate their point. The material is organised according to seven key professional roles: the doctor as expert and clinical decision-maker, communicator, collaborator, manager, health advocate, scholar and professional. These are the roles identified by the CanMEDS 2000 Project1 and widely adopted in Canada and other countries, including Australia, to guide curriculum development in postgraduate training programs. These roles provide one “axis”, with various forms of literature, the arts and popular culture providing the other. It’s a patchwork of different pieces and genres with little overall coherence, but this is not necessarily a bad thing; the book is more like a “dress-up box” than an exegesis. Excerpts vary from the memorable to the mundane, with an understandable bias towards Canadian literature. A rather more impressive literary collection appears in a new book, The moral of the story: an anthology of ethics through literature.2 This one is a knockout — a necessary quality for a book that is priced at $230.00. Here we have some of the best chapters from the best books by the best writers, arranged and annotated in “ethical clusters”. “Bedside teaching” usually occurs around the patient’s bed, but another equally important form of bedside teaching occurs when we spend a little time with books like these at the end of a hard day. Just beware: if your bedside table looks like mine, it is almost certainly an occupational health and safety hazard. Jill GordonDirector, Centre for Medical Humanities University of Sydney, NSW Frank JR, Jabbour M, Tugwell P, et al. Skills for the new millennium: report of the societal needs working group, CanMEDS 2000 Project. Ann R Coll Physicians Surg Can 1996; 29: 206-216. Singer P, Singer R, editors. The moral of the story: an anthology of ethics through literature. Oxford: Blackwell Publishing, 2005.

Jill Gordon

Inhaled insulin Inhaled insulin holds promise as a management option for patients with type 2 diabetes in whom dual oral therapy (an insulin secretagogue and an insulin sensitiser) is insufficient for glycaemic control. A North American study randomised 309 such patients to receive: inhaled insulin alone (n = 104); inhaled insulin in addition to oral therapy (n = 103); or, to maintain their oral therapy (n = 99). Patients randomised to receive inhaled insulin took it as an aerosolised powder just before meals; the dose was titrated to blood glucose levels. The combination therapy with inhaled insulin was more effective than monotherapy in reducing HbA1c levels after 12 weeks of treatment; both were more effective than usual treatment. Reported side-effects of inhaled insulin included hypoglycaemia, mild weight gain, and mild cough. Inhaled insulin has a faster onset of action than injected rapid-onset insulin, and its effect lasts for 4 to 6 hours. Ann Intern Med 2005; 143: 549-558 Marijuana and the lung Australian authors have advised clinicians to consider marijuana smoking in the differential diagnosis of extensive interstitial fibrosis and lung bullae in young patients, especially when other causes have been excluded. They reported a case with these features in a 26-year-old man who had presented with worsening dry cough and exertional dyspnoea, giving a history of only minimal tobacco use (10 cigarettes per day for 2 years) but heavy marijuana use (10 pipes per day for 5 years). Lung biopsy revealed advanced fibrosis with cystic changes, with infiltration of numerous brown pigmented macrophages. The patient responded to prednisolone 50 mg daily, in addition to cessation of marijuana smoking. This case report adds to others which have suggested a link between marijuana smoking and a variety of adverse respiratory events. Australas Radiol 2005; 49: 411-414 Mesothelioma biomarker? In people with a history of exposure to asbestos, a serum biomarker could successfully distinguish between those with pleural mesothelioma and those without cancer, according to US researchers. They used an enzyme-linked immunosorbent assay (ELISA) to detect serum osteopontin levels in 76 study subjects with mesothelioma, 69 subjects with asbestos-related benign lung disease, and 45 subjects with no history of asbestos exposure. Patients with mesothelioma had higher levels of this biomarker, including those with early, Stage 1 disease. Osteopontin, a glycoprotein, is overexpressed in various cancers including lung, breast, colorectal and ovarian cancer, and melanoma. N Engl J Med 2005; 353: 1564-1573 Beware cashew nut allergy Cashew nut allergy needs to have the same recognition in clinical practice and in the community as peanut allergy, say Australian researchers. Davoren and Peake had conducted a retrospective chart review of 213 children with a peanut or tree nut allergy seen by a single paediatric allergist in Brisbane over a 42-month period. Although peanut allergy (177 cases) was more common than cashew nut allergy (27 cases), anaphylaxis to cashew nut (20 cases; about 75%) occurred much more commonly than to peanut (54 cases; about 30%). Arch Dis Child 2005; 90: 1084-1085 Detecting depression Adding a “help” question to two more standard screening questions for depression seems to sort out the patients with major depression from those without, say Australasian researchers. They studied more than 1000 consecutive patients presenting to six general practices in New Zealand, comparing the results of their simple trio of screening questions — During the past month have you often been bothered by feeling down, depressed or hopeless? During the past month have you often been bothered by little interest or pleasure in doing things? and the “help” question: Is this something with which you would like help? — with a reference standard for detecting depression. They found that a positive response to the “help” question made it less likely that positive responses to the first two questions were false positives; and a patient with a negative response to the help question would only have a 1% chance of being depressed. BMJ 2005; 331: 884 Death after bariatric surgery Several high-profile reports of death after bariatric surgery have triggered a critical re-appraisal of the safety of bariatric surgery, say US researchers. Now, their new data add to the previous anecdotal concerns. In a nationwide study of post-surgical mortality among more than 16 000 US Medicare patients who had undergone bariatric procedures from 1997 to 2002, they found that the early risk of post-surgical death in this population — a 30-day mortality rate of 2.0% and a 1-year mortality rate of 4.6% — was higher (in this at-risk group) than that suggested by earlier series. They also found that the risk of early death was linked with advancing age, male sex, and lower surgeon volume of bariatric procedures. JAMA 2005; 294: 1903-1908

Ann Gregory

Med J Aust 2005; 183 (10 Suppl).