Volume 189 Issue 9

Early identification of outbreaks allows carers and public health agencies to reduce the burden of this disease Recently, serious outbreaks of foodborne gastroenteritis occurring in aged-care facilities (ACFs) have captured public and media attention. Gastroenteritis will occur in settings where people gather, even when standards of care and food hygiene are very high. Some infections are inevitable due to the susceptibility of the population and the highly infectious and persistent nature of enteric pathogens. Early recognition of an outbreak and identification of the responsible organism enable interventions that can reduce the impact of disease. While gastroenteritis normally has a mild clinical course, hospitalisation and death as a result of gastroenteritis are more common among elderly people, particularly those who live in ACFs.1 The relative contribution of gastroenteritis to deaths among elderly residents of ACFs is difficult to establish. Death certificates rarely record this common condition as a contributing cause, and many residents have severe underlying illnesses that are more directly related to their death. In May 2007, the deaths of five elderly residents of a Victorian ACF were referred to the state coroner for investigation as to whether an outbreak of Salmonella Typhimurium 44 was related to their deaths. Recently, similarly serious outbreaks of Salmonella Typhimurium 135 and Clostridium perfringens have occurred among ACF residents in South Australia and New South Wales, respectively. Reassuringly, the incidence of gastroenteritis in elderly people is considerably lower than the incidence in younger people.2 Each year in Australia, an estimated 17.2 million cases of gastroenteritis (0.9 episodes per person per year) affect all age groups.2 While most episodes are mild, more severe cases result in an estimated 3.4 million visits to general practitioners annually.2 People over the age of 65 years who live in the community have the lowest incidence of gastroenteritis of any age group, and are five times less likely to experience gastroenteritis than children aged 0–4 years.2 A recent study of residents of six Australian ACFs found that the incidence of gastroenteritis was about 0.1 episodes per resident per year, making it less common than respiratory infections, urinary tract infections, and skin and soft tissue infections (Judy Forrest, Managing Director, Bug Control (Aust) Pty Ltd, personal communication). These findings are consistent with surveillance of nosocomial infections in long-term care settings internationally.3 When it does occur in ACFs, gastroenteritis commonly manifests as outbreaks in which two or more residents, along with facility staff, may be affected. In Australia, recorded outbreaks in ACFs comprise about 50% of all outbreaks of gastroenteritis (Katie Fullerton, Coordinating Epidemiologist, OzFoodNet, personal communication). A single case of gastroenteritis in an elderly resident of an ACF may signal the beginning of an outbreak, making it important for clinicians to have a low threshold for testing faecal specimens. Although testing to identify specific causes rarely benefits the individual patient, early recognition of the pathogen can guide public health investigations and infection control measures in the facility to minimise the spread and consequences of a potential outbreak. The spread of gastroenteritis in ACFs may be from person to person, foodborne, or a combination of both. The identification of some pathogens may require specialised laboratory testing, so it is important that clinicians seek advice from a laboratory microbiologist on optimal specimen collection procedures and appropriate tests. Once a diagnosis is made in two epidemiologically linked cases, further diagnostic testing is rarely required. If a foodborne pathogen such as Salmonella, C. perfringens, or shiga toxin-producing Escherichia coli is isolated from the faeces of an elderly resident of an ACF, there is an urgent need for public health authorities to search for other related cases and investigate food sources. If norovirus is identified, the focus should be on strict and heightened infection control within the facility. Norovirus is a challenge to control.4 The global spread of novel strains of the virus resulted in many gastroenteritis outbreaks in Australia in 2006 and 2007.5,6 More outbreaks than normal were observed in a wide range of settings, particularly ACFs, hospitals and childcare centres. Norovirus is highly infectious7 and difficult to control, even when intensive infection control measures are implemented.4 Outbreaks of infection with the virus cause major difficulties not only for the aged-care sector, but also for acute health care, tourism and the international cruise ship industries.4,8 Each year, Australian health departments issue advice to ACFs regarding prevention of common infections, such as gastrointestinal and respiratory infections, in addition to the numerous state and territory and national guidelines for the sector. Australia has a robust system of aged care, including provision of a safe food supply. Of the reported gastroenteritis outbreaks in these facilities, only a small number are the result of contaminated food.9 As of 5 October 2008, a new national food standard (Standard 3.3.1) requires organisations that prepare food for vulnerable populations (including elderly people) to implement risk-based food safety plans (http://www.foodstandards.gov.au/thecode). These changes need to be incorporated into state and territory food laws in order to take effect. The proportion of Australia’s population that may be considered elderly will dramatically increase in coming decades, resulting in more people requiring the services of ACFs.10 It is clear that gastroenteritis is an important issue for elderly people and ACF managers. To minimise the risk to residents, facility managers and clinicians need to be aware that organisms causing gastroenteritis often result in outbreaks and that faecal specimens of ill residents should be tested. Early identification of outbreaks allows carers and public health agencies to reduce the burden of this disease.

Martyn D Kirk BAppSci, MAppEpid · Leslee Roberts BMed, MAppEpid, PhD · John Horvath MB BS, FRACP, AO

The draft Good Medical Practice code of professional conduct is now available for public comment and consultation Over the past few years, all medical boards in Australia have issued guidance to doctors about expected standards of medical practice. Most of these documents were adapted from Good Medical Practice, a code of conduct first issued by the General Medical Council of the United Kingdom in 1995.1 Given their shared origin, the various medical board guidelines have much in common, but they are not identical. On behalf of state and territory medical boards, the Australian Medical Council (AMC), through an expert working group, is developing good practice guidelines for the entire nation. This project is now well developed, and a draft Australian Good Medical Practice code2 is currently the subject of a consultation process with the medical profession and the community. The project deserves the attention of the medical profession. Indeed, the profession’s input is critical, principally to ensure that the proposed standards are realistic and consistent with current good practice. In addition, experience tells us that codes of practice are more likely to be followed when those affected have contributed to their development. A number of questions are likely to cross the minds of doctors. Why do we need a code of practice? Doesn’t the Australian Medical Association (AMA) issue a Code of Ethics?3 Who is drafting the new Code? Why is the community involved? Is this project related to the Council of Australian Governments (COAG) decision to introduce uniform national registration for all health professionals? Is the new Code to be enforceable, and by whom? The project began before the COAG decision, but the timing now makes it highly likely that the Australian Good Medical Practice code will be adopted as a starting point by the proposed national medical board. A national registration system will need national standards. These standards must reflect the considered views of both the medical profession and the community served by the profession. In effect, the national Code will amount to a declaration to the new national board from the profession and the community about the standards of medical practice expected in Australia. It is not intended to supplant the AMA Code of Ethics. Rather, it extends the principle-based AMA Code into an explicit statement to the community and the profession about standards of practice. The draft Code covers issues in detail, including providing good care, working with patients, working with other health professionals, minimising patient risk, ensuring the health of doctors, and doctors’ performance in teaching, supervising and conducting research (Box). The Code aims to define clear, nationally consistent standards of practice. To develop these, the AMC established an expert working group with strong clinical representation, and including the perspectives of junior doctors and medical students, medical regulators and educators, medical and health administrators, consumers and community groups, medical profession advocates, rural and Indigenous practitioners, and international medical graduates. This working group reviewed the codes of each of the state and territory medical boards, comparable initiatives in the UK, New Zealand, Canada and the United States, the professional standards documents of the specialist colleges, guidelines from the National Health and Medical Research Council (NHMRC) and the AMA Code of Ethics. How will the Australian Good Medical Practice code be used? Firstly, it will give all doctors and the broader community a clear understanding of what is expected of medical practitioners in Australia. Secondly, it is expected to be used in the assessment of complaints about doctors and allegations of unprofessional conduct. Currently, the legislation establishing state medical boards and defining their powers gives the existing codes slightly different status in different states, but in all cases the boards use their codes in assessing practitioners’ conduct. Practitioners who depart from the standards set out in these codes may need to justify their conduct. Serious or persistent failures to meet the standards may have consequences for a doctor’s registration. The legislation governing the new national medical board has not yet been written. However, as a number of boards currently have the power to regulate standards of medical practice and issue codes of practice to guide practitioners, it is likely that the national board will have these powers, and that the national Code will be applied in the same way. This Code is important for all practitioners, so please have your say. The Australian Government Department of Health and Ageing has funded a comprehensive national process, seeking involvement and feedback from the profession and the community across Australia through face-to-face meetings, an online survey and written submissions. The consultation process is open until 28 November. More information is available at <http://goodmedicalpractice.org.au>. Outline of the draft Australian Good Medical Practice code of professional conduct, August 2008 Providing good patient care is the core of good medical practice requires doctors to maintain high levels of competence and professional conduct includes assessment, planning of management and ensuring effective care involves shared decision making between patient and doctor Working with patients requires relationships based on openness, trust and good communication Working with other health care professionals requires respect for colleagues, teamwork and willingness to share information and resources Working within the health care system doctors have a responsibility to contribute to the effectiveness and efficiency of the health care system Minimising patient risk requires doctors to understand what to do if patient care is compromised and the importance of reporting and responding to adverse events Maintaining good standards of medical practice requires doctors to participate in relevant continuing professional development and credentialling, and to practise within their accepted scope of practice Professional behaviour doctors’ standard of behaviour must justify the respect and trust of the community Ensuring doctors’ health maintain own health and wellbeing and look after the health of colleagues Teaching, supervising and assessing important to the care of patients now and in the future Undertaking research vital in improving health of individuals and the population researchers carry particular responsibilities.

on behalf of the Australian Medical Council Code of Professional Conduct Working Group

Objectives: To examine self-reported patterns of alcohol consumption and experience of alcohol-related harms among professional Australian Football League (AFL) players.Design, setting and participants: Cross-sectional survey of player alcohol consumption and self-reported alcohol-related harms among members of all 16 professional AFL clubs. Data relating to the 2006 football year were collected between 25 July and 30 August 2006 at regular football training sessions using a self-administered structured questionnaire.Main outcome measures: Risky/high-risk drinking for long- and short-term harm at different times of the year; Alcohol Use Disorders Identification Test (AUDIT) score.Results: 582 AFL players completed the questionnaire (an 83% response rate). Alcohol consumption varied at different times of the year. During the playing season (approximately 22 weeks), the level of risky/high-risk consumption for long-term harm in AFL players (11/564 [2%]) was typically lower than in age-matched Australian men in the general population (15%). However, risky/high-risk consumption for long-term harm was higher in AFL players during the end-of-season period (approximately 2 weeks) (303/561 [54%]) and vacation period (6–8 weeks) (231/559 [41%]) than in age-matched Australian men. Risky/high-risk drinking for short-term harm on a monthly basis was frequent at all times of the year (eg, 395/560 [71%] in the pre-season period). The mean AUDIT score was 8.8 (95% CI, 8.4 to 9.1; range, 0 to 36). Reports of harmful effects of drinking and negative consequences, such as getting involved in a fight (physical or verbal) while drinking (146/556 [26%]), were common. Risky/high-risk consumption for short-term harm on a monthly basis was associated with a variety of player characteristics, such as usually drinking in public locations (odds ratio, 1.55 [95% CI, 1.02 to 2.35]). AUDIT score was associated with variables such as marital status, with married players scoring more than two points lower (95% CI, – 3.58 to – 0.58) than single players. Formal club rules on alcohol consumption had little effect on outcome measures.Conclusions: Drinking among AFL players is intricately related to time of year. This seasonal drinking pattern requires the development of specific club and league strategies to minimise drinking-related harms to players.

Paul M Dietze PhD · John L Fitzgerald PhD · Rebecca A Jenkinson MEpid, GradDipEpiBiostat

Objective: To evaluate the immune status and vaccination needs of first-year medical students in relation to bloodborne viruses and common vaccine-preventable diseases.Design, setting and participants: Survey of first-year medical students at the University of New South Wales, Sydney, NSW, attending a mandatory screening and vaccination clinic, 2002–2005.Main outcome measures: Self-reported history of vaccination or natural infection; serological evidence of immunity to measles, mumps, rubella and varicella (presence of specific IgG) and hepatitis B (presence of hepatitis B virus surface antibodies) or infection with hepatitis B and C viruses and HIV; and Mantoux test results.Results: 733 students attended the clinic (85% of those enrolled). Four students were positive for HBsAg and four had hepatitis C antibodies. None were HIV-positive. Twenty-nine per cent (216/733) were not immune to hepatitis B, 33% (238/724) to mumps, 26% (190/724) to measles, 13% (91/724) to rubella and 10% (75/724) to varicella. About 23% (91/237) needed further testing for tuberculosis. Immunity corresponded poorly with self-reported history of vaccination. More students reported vaccination against rubella (96%), measles (81%) and mumps (80%) than were immune, and fewer reported vaccination against hepatitis B (44%).Conclusions: Many students were not immune to vaccine-preventable diseases, and a small number had a previously undiagnosed bloodborne virus infection (hepatitis B or C). The level of immunity to vaccine-preventable infections was unacceptable and justified the provision of an easily accessible program for screening and vaccination.

Adrienne J Torda FRACP, GradDipBioethics, PhD

Objective: To describe the steps taken by health professionals to diagnose dementia and the timeframes for these steps, as reported by carers.Design, setting and participants: A cross-sectional, anonymous survey was mailed or distributed by Alzheimer’s Australia New South Wales, six Sydney residential aged care facilities and 13 Sydney general practitioners to 415 carers or family members of patients with dementia between May and August 2007.Main outcome measures: First symptoms noticed and actions taken; time to first health professional consultation and diagnosis; reported actions of first health professional; satisfaction with first consultation; and use of dementia and chronic illness resources.Results: 209 surveys were returned. Family members noticed the first symptoms of dementia at a mean of 1.9 years before the first health professional consultation about dementia, and 3.1 years before a firm diagnosis. Resource use first occurred 2.8 years after the first symptoms. Most carers (72%) were satisfied with the first consultation, which was usually with a GP (84%). Two-thirds of carers (64%) reported that the first health professional had performed a memory test.Conclusions: Delays in presentation, diagnosis and resource use may have clinical and social implications for people with dementia and their families, in addition to the challenges of the process of obtaining a firm diagnosis.

Catherine M Speechly BMedSc, FRACGP · Charles Bridges-Webb MD, FRACGP · Erin Passmore BA(Hons)

Objective: To estimate the percentage of preterm (< 37 weeks) and full-term low-birthweight (37–41 weeks, < 2500 g) babies born to mothers who smoke, stratified by Indigenous status and statistically adjusted for the potential confounding effects of social and demographic factors, medical conditions and pregnancy complications.Design, setting and participants: Population-based study of singleton babies born to mothers resident in Queensland who gave birth in Queensland from 1 July 2005 to 31 December 2006.Main outcome measures: Adjusted percentages of preterm birth and full-term low birthweight for babies born to Indigenous and non-Indigenous mothers.Results: Of the 79 803 babies studied, 4228 (5.3%) were born to Indigenous mothers and 16 395 (20.5%) were born to mothers who smoked during pregnancy. The percentage of Indigenous mothers who smoked (54%) was almost triple that for non-Indigenous mothers (risk ratio, 2.90; 95% CI, 2.81–2.99). The adjusted outcomes for babies born to Indigenous non-smokers were similar to those for non-Indigenous non-smokers (preterm, 7.1% v 6.1%; full-term low birthweight, 1.6% v 1.1%). The adjusted percentages for smokers were high regardless of Indigenous status (preterm, Indigenous v non-Indigenous, 8.3% v 7.8%; full-term low birthweight, Indigenous v non-Indigenous, 5.3% v 3.7%).Conclusions: Antenatal smoking remains an important cause of poor health among both Indigenous and non-Indigenous newborn babies. Most pregnant smokers receive their antenatal care in the public sector. State and federal governments, who directly fund this sector, have a particular responsibility to ensure that interventions are offered to all pregnant smokers to help them quit smoking.

Rachael-Anne Wills BAppSc(Hons) · Michael D Coory PhD, FAFPHM, AStat

Objectives: To explore the role of socioeconomic status and Aboriginality on birthweight at an urban hospital.Design, participants and setting: Extraction of data on the demographic characteristics (socioeconomic status, mothers’ single-parent status, age and smoking status) and infants’ birthweight from a clinical record system. Infants delivered at an outer urban hospital to mothers residing in the local government area during 2002 were included. Infants were identified and results interpreted in consultation with Indigenous health workers.Main outcome measure: Infant birthweight.Results: Indigenous infants had a lower mean birthweight than non-Indigenous infants (difference, 127 g), and were more likely to weigh < 2500 g. Mothers of Indigenous infants were more likely to be single, aged < 20 years and to smoke during pregnancy. Lower birthweight was associated with lower socioeconomic status for Indigenous and non-Indigenous infants. Indigenous infants in the most socioeconomically disadvantaged quintile in this study were at higher risk and had a mean birthweight 204 g less than non-Indigenous infants in the same quintile. In multivariate analysis, differences in birthweight were associated with socioeconomic status and smoking during pregnancy.Conclusions: For both Indigenous and non-Indigenous infants, birthweights were associated with socioeconomic status. Differences between Indigenous and non-Indigenous infants were largely explained by low socioeconomic status and smoking during pregnancy.

Angela T Titmuss BSci(Med)(Hons), MB BS, MPH · Elizabeth Harris BA, DipSocWork, MPH · Elizabeth J Comino BVSc, MPH, PhD

Objectives: To explore the understanding of both Indigenous and non-Indigenous Australians with end-stage kidney disease (ESKD) about the cause of their disease, and how this understanding could affect patients’ engagement with their treatment.Design, setting and participants: Qualitative study conducted in 2005–2006 in nine hospital renal units and 17 associated dialysis centres in four states and the Northern Territory as part of the IMPAKT (Improving Access to Kidney Transplants) study. In-depth interviews were conducted with 146 Indigenous and 95 non-Indigenous Australians with ESKD, covering personal history of illness, social and psychosocial context, attitudes to treatments including transplantation, adequacy of information and communication, and satisfaction with services.Results: Indigenous Australians were less certain about the cause of their illness and reported feeling uninformed but eager for information. They commonly reported lifestyle factors as potentially causal, with profound confusion about the role of alcohol. Indigenous Australians had considerable ambivalence towards biomedical explanations.Conclusions: Indigenous Australians are confused, frustrated and feel poorly informed about their illness. This study confirms the need to develop shared understandings about chronic kidney disease and to put in place the high-quality and appropriate educational resources that patients need.

Kate Anderson BSc(Psych)(Hons), BA · Jeannie Devitt PhD · Joan Cunningham ScD · Cilla Preece BAppSci(IPHC) · Alan Cass MB BS, FRACP, PhD

Routine thromboprophylaxis in hospitalised medical patients is based on trials that predominantly use asymptomatic deep vein thrombosis (DVT) as the endpoint. As asymptomatic DVT is 10–30-fold more common than symptomatic DVT, this exaggerates estimates of benefit and cost-effectiveness. Based on symptomatic disease, the number needed to treat per venous thromboembolism (VTE) prevented is high (150–1600), and the true cost-effectiveness of thromboprophylaxis for symptomatic event reduction is uncertain. The incidence of major bleeding among patients receiving prophylaxis is at least equal to the reduction in clinical VTE. Routine thromboprophylaxis in hospitalised medical patients is not warranted, and better patient selection is needed.

J Alasdair Millar PhD, FRACP, FRCP

Case management is inferior to a multidisciplinary team approach, where people can operate and be accountable within their specific areas of expertise Child and adolescent mental health has been identified as an area of critical concern for the future wellbeing of our society.1,2 However, it remains questionable whether mentally ill patients and their families are receiving high-quality medical care consistent with modern practice standards and published guidelines. Throughout Australia, the current public model of mental health care for children and adolescents uses generic mental health workers (case managers) who learn “on the job” rather than being required to receive specific psychiatric training and certification before they are employed. This case-management model permits young graduates from various courses (social work, occupational therapy, a bachelor of arts with a psychology major) to enter the mental health workforce and assume the role of an independent mental health professional. While such an approach may work in major metropolitan areas where sufficiently experienced senior allied health staff can provide supervision and on-the-job training to new graduates, it does not necessarily work in rural and regional areas where there may be few or no senior staff. Under the current model, allied health professionals are expected to make diagnoses and to provide counselling and other therapies for which they may not have had any specific academic training. Such an approach is a far cry from holistic scientific psychiatric treatment based on a specialised skill set, and is superficial at best and potentially harmful at worst. Given the lack of prevocational training in specific child and youth diagnoses and treatments, supervision by a qualified child and adolescent psychiatrist is essential. However, under the child and adolescent/youth mental health service model in use, all case managers are expected to work independently and interchangeably with each other, including doctors, whose only unique role would appear to be writing prescriptions, ordering investigations, and excluding organic causes. Not all clients will be seen by a doctor, and not all recommendations made by a case manager to a general practitioner or patient will have originated from or be known to the psychiatrist. Yet it is the doctor (for example, the GP who writes the prescription) who bears the overall medicolegal responsibility. Task transfer and substitutionA brief survey of the literature will indicate that doctors are not opposed to delegating to others tasks that were previously only carried out by medical staff.3-6 It is a practice that has been evolving over decades and centuries as skills and knowledge increase, and it will inevitably continue. However, “Poor economic outcomes arise when scarce resources are misallocated. To push the envelope on task substitution is to invite poor resource allocation. It is not a good use of resources to use health professionals in roles for which they are not trained and not expert.”3 Training and competenceCase management has been accepted in mental health service delivery in Australia now for over 20 years, although there is still no requirement to hold (or be training for) a postgraduate mental health qualification at the time of employment as a generic mental health worker. Instead, training is provided “on the job” (although without an apprenticeship), where knowledge and aptitude is never tested in any examination or formal assessment process. However, such an experiential approach to learning does not expose all workers to a set curriculum that ensures that all aspects of psychiatry will be considered in any one given case. No diagnosis can be accurate or trusted if the full range of differential diagnoses has not been considered, and no differential diagnoses can be considered without a comprehensive history taking and mental state examination. Without appropriate training, many aspects of a patient’s case history may not be recognised as important (or even elicited), and thus not be presented (or considered) at case conference. If the diagnosis is not correct, then any treatment plans based on it are useless. “The tragedy is that as our knowledge grows, our approaches to treatment seem to become simplistic, with psychiatric practice sadly becoming dumbed down . . . with a tendency to adopt a cookbook approach to our treatments and a lack of sophistication in the way we understand patient problems.”7 Workers operating beyond their level of competence will be appropriately anxious, but propped up by systemic reassurance. They will be unaware of what they do not know, ultimately lulled into a state of false overconfidence (a denial of the overwhelming reality of anxiety). “People tend to hold overly favourable views of their abilities . . . this overestimation occurs, in part, because people who are unskilled in these domains suffer a dual burden: not only do these people reach erroneous conclusions and make unfortunate choices, but their incompetence robs them of the metacognitive ability to realize it”.8 ConclusionThe case management model currently in use in mental health is now widely used and accepted throughout Australia. In some parts of the country, an attitude that all “mental health workers” are equivalent and interchangeable has developed, particularly among mental health administrative managers, but clearly this is not so in the eyes of the law and the public. I would argue that a multidisciplinary team approach provides a much safer and more efficient method of service delivery. Such an approach optimises the collection of information necessary for an accurate diagnosis, from which a high-quality integrated treatment plan can then be formulated. In reality, the current case management model tends to devalue the expertise of individual team members by forcing them into generic skills that do not necessarily utilise their specialist skills. However, individual team members have much to contribute from their own specialties. A well functioning multidisciplinary team will provide comprehensive assessment and consultation, together with a forum for learning more about the strategies, resources, and approaches used by other disciplines, without the need for a case manager to play all of these roles. I believe we need less of a managerial approach in teams, with a greater focus on individual clinical input and accountability, through integration and coordination (rather than management) of expertise.

Vicki A Degotardi MB BS, FRANZCP

Inappropriate intravenous fluid therapy is a significant cause of patient morbidity and mortality and may result from either incorrect volume (too much or too little) or incorrect type of fluid. Fluid overload has no precise definition, but complications usually arise in the context of pre-existing cardiorespiratory disease and severe acute illness. Insufficient fluid administration is readily identified by signs and symptoms of inadequate circulation and decreased organ perfusion. Administration of the wrong type of fluid results in derangement of serum sodium concentration, which, if severe enough, leads to changes in cell volume and function, and may result in serious neurological injury. In patients whose condition is uncomplicated, we recommend a restrictive approach to perioperative intravenous fluid replacement, with initial avoidance of hypotonic fluids, and regular measurement of serum concentration of electrolytes, especially sodium.

Andrew K Hilton FANZCA, FJFICM · Vincent A Pellegrino FRACP, FJFICM · Carlos D Scheinkestel FRACP, FJFICM, DipDHM

Domestic medical graduate numbers will almost double between 2005 and 2012, necessitating substantial increases in supervision at prevocational and vocational levels. New approaches to resourcing and governance of training are needed to expand the capacity of the health system to deliver quality training; new settings will also be required to expand training capacity, while ensuring that trainees are exposed to a broad range of clinical experiences. With increasing demand for training placements, entry to specialty training is likely to become highly competitive; new vocational training positions must be created to ensure that bottlenecks in training do not occur and that training is not unnecessarily prolonged. Substantial increases in government funding will be required to employ the new prevocational workforce. The recent Modernising Medical Careers Inquiry in the United Kingdom offers important lessons for the workforce changes facing Australia, such as a “ring-fenced” budget that quarantines funding for medical education and training. Planning for the increasing cohorts must cover the training spectrum — from medical student to specialist. Students and trainees must be prospectively informed about how workforce changes will affect their career advancement.

Gregory J Fox MB BS(Hons), MIPH · Stephanie J Arnold BSc(Hons), MB BS(Hons)

Clinical record A previously healthy 11-year-old boy presented to the Royal Children’s Hospital (RCH) with a 20 × 12 cm necrotising wound of the left popliteal fossa (Figure A). A further inflammatory lesion was evident on the anteromedial left thigh, extending into the groin. The boy was febrile and cachectic, weighing 30 kg. The patient had a history of a suspected insect bite in the area of the popliteal fossa 5 months earlier. The suspected bite wound had developed into an 8 cm necrotic lesion over several months. The patient had initially presented to a regional centre (a few days after the suspected bite), where he was treated with oral twice-daily Augmentin Duo Forte (amoxycillin–clavulanate) (GlaxoSmithKline Australia) 750 mg, excisional debridement and split-skin grafting, with 90% graft take. The wound was treated topically with dressings. The patient then emigrated with his family to Dubai. The wound subsequently broke down and was serially debrided, with further skin grafting and antibiotic coverage with amoxycillin and ciprofloxacin. Despite 4 weeks of treatment, the wound progressed and the family was referred by a doctor in Dubai to the RCH. Investigations at our hospital revealed a white cell count of 27.4 × 109/L (reference range [RR], 4.5–13.5 × 109/L), a C-reactive protein level of 29 mg/L (RR, < 8 mg/L) and an albumin level of 26 g/L (RR, 33–47 g/L). An ultrasound scan confirmed the presence of a necrotic lymph nodal mass in the left groin. Antibiotic therapy with 6-hourly intravenous Timentin (ticarcillin–clavulanate) (GlaxoSmithKline Australia) 1.5 g was commenced. Wound and tissue cultures revealed the presence of Staphylococcus aureus and Prevotella species. Although fungal cultures were requested, no fungal pathogen was isolated. The popliteal fossa wound and necrotic inguinal nodes were surgically debrided over the following 2 weeks. This revealed extensive necrosis of the biceps femoris and semimembranosus muscle, with undermining subcutaneous fat necrosis immediately adjacent to the wound. Ten centimetres of sciatic nerve and the popliteal vessels were exposed. Both wounds were treated by topical negative pressure (vacuum) dressing (VAC Therapy System, Kinetic Concepts Inc, San Antonio, Tex, USA). When the patient failed to improve after 5 days of intravenous antibiotic treatment, clinical suspicion of an atypical disease was heightened. Multidisciplinary discussions led to a specific request to the microbiology department to attempt to identify fungal disease. Further tissue cultures under specific conditions (see below) showed growth of the fungus Saksenaea vasiformis. Histopathological analysis of resected tissue revealed extensive subcutaneous fat necrosis with calcification and many non-septate hyphae with irregular diameters and branching — features consistent with zygomycosis (mucormycosis).1 These features were not seen on Gram stain. Antifungal therapy was initiated with amphotericin B 45 mg given via central venous line over 24 hours initially and then intravenous liposomal amphotericin B 150 mg daily. Major predisposing factors to zygomycosis were excluded: specifically, hyperglycaemia, ketoacidosis and immunosuppressive disorders.1 Notable findings included a raised IgE level. Although this can be associated with hyper-IgE syndrome, the patient had no other signs of this disease. After 5 weeks of treatment with amphotericin B, the patient became unwell, with a high fever and moderate renal impairment. His creatinine level had increased from 0.06 to 0.17 mmol/L (RR, 0.03–0.08 mmol/L); his urea level was 18.7 mmol/L (RR, 2.1–6.5 mmol/L), and the glomerular filtration rate was 29 mL/min (RR, 100–140 mL/min). A renal ultrasound scan revealed parenchymal fungal spores (Figure B). Amphotericin B treatment was ceased and twice daily oral posaconazole 400 mg commenced. Renal function normalised within about 7 days. Follow-up imaging 6 weeks later revealed resolution of renal fungal disease. After 6 weeks of antifungal treatment and no growth evident on serial tissue cultures, the wounds were surgically closed. The popliteal fossa wound was treated with a pedicled medial gastrocnemius muscle flap and skin graft to cover the exposed neurovascular structures. The groin wound was closed with a sartorius muscle turnover flap and skin graft. Both the wound and donor sites fully healed without complication (Figure C). A: Necrotising wound of the left popliteal fossa on presentation. B: Renal fungal spores (arrow). C: Healed wound after 6 weeks of antifungal treatment. Since it was first isolated in 1953,2 Saksenaea vasiformis has been reported to cause human infection in about 30 cases. In only two cases has disseminated disease been reported, both occurring in immunocompetent patients and having fatal outcomes.3,4 S. vasiformis belongs to the class Zygomycetes and order Mucorales. The usual manifestation of disease is reported to be skin and soft-tissue infections, most commonly occurring secondary to trauma,1 but can also follow haematogenous dissemination. Lessons from practice Multidisciplinary care is fundamental in dealing with complex or unusual conditions. Always consider atypical pathogens, particularly fungi, when a condition fails to respond to the perceived ideal treatment. If considering a fungal pathogen, consult microbiological opinion to aid identification of the species. Posaconazole can be used safely and successfully in children to treat disseminated fungal disease. Although the two previously reported cases of disseminated S. vasiformis infection were fatal, our report details the successful treatment of disseminated disease by a combination of surgery and systemic antifungal therapy. This case thus highlights several important issues in the treatment of zygomycosis. A multidisciplinary team approach is essential for a successful outcome. Exclusion of underlying immunodeficiency is paramount, as its presence often leads to a fatal outcome.1 Surgical treatment combined with appropriate antifungal therapy is the mainstay of treatment. In the case we describe, the patient required serial debridements and the use of vacuum dressings until microbiological evidence of eradication of fungi was achieved. Vacuum dressings were a good alternative to more labour-intensive and painful forms of dressing. The dressings were changed in theatre every 3–5 days. Negative pressure dressings have been shown to improve wound healing by increasing tissue oxygenation via a reduction of interstitial fluid5,6 and reducing bacterial counts in the wound.7 Diagnosis and identification of the fungus is important. Zygomycosis must be suspected in any wound that is worsening despite appropriate treatment. Tissue culture, rather than routine wound swabs, provides the most appropriate specimen. It is important to inform the microbiology laboratory of clinical suspicion of zygomycosis. The tissue should be cultured intact to preserve the viability of the irregularly septate zygomycete hyphae. This also ensures that cultures are incubated for the extended period necessary for fungal isolation. S. vasiformis is a fast-growing organism and can usually be isolated from culture within 72 hours.1,8 Once isolated, full identification for fungi may require extended time and specialist media in a reference laboratory. Antifungal therapy is essential to the treatment of this organism, and amphotericin B has traditionally been the agent of choice. However, its significant side effects, notably nephrotoxicity, often affect treatment, as seen in this case. Our patient’s renal impairment resolved after cessation of amphotericin treatment, confirming its nephrotoxicity. Treatment with posaconazole, a new generation triazole antifungal, was initiated after withdrawal of amphotericin treatment, without leading to any complication or relapse of the disease. There is little information on the treatment of zygomycosis with posaconazole. To our knowledge, ours is the first reported case of successful salvage treatment of disseminated zygomycosis with this drug. Posaconazole has been shown to be effective against zygomycosis when other therapy has been ineffective or complications have occurred due to the therapy.9 As posaconazole is not generally used in children under the age of 13 years, its safety profile in children is unknown. The drug is available as an oral suspension and is generally administered at a dose of 800 mg daily in divided doses. The patient described here received 400 mg twice daily without complication. The duration of therapy is dictated by the presence of disease. Minor common side effects include nausea and headache. Serious side effects are rare, but hepatic impairment may occur, so liver function should be monitored every 2–3 weeks during therapy. Posaconazole interacts with several immunosuppressive agents and has few contraindications. In conclusion, this report shows that disseminated zygomycosis, specifically S. vasiformis infection, may occur in immunocompetent individuals. It also shows how, with multidisciplinary care, mortality may be avoided.

Dean J Trotter MB BS · Gena Gonis BSc(Hons), FASM · Erin Cottrill BAppSc(Lab Med) · Christopher Coombs MB BS(Hons), FRACS(Plast)

An immunocompetent patient developed a necrotising soft tissue infection after being pecked by a magpie. The infection was caused by the fungus Saksenaea vasiformis, an uncommon human pathogen. Special culture techniques are required to induce sporulation to enable identification of the organism. Clinical recordAn 84-year-old woman presented to our hospital emergency department with cellulitis of the left lower leg. There was a small, dry eschar and some adjacent purplish discolouration (Box 1, A). Eleven days previously, she had been pecked above the left ankle by a magpie (Gymnorhina tibicen), which her daughter kept as a pet. The woman reported that within a week of the pecking incident she had experienced pain, swelling and redness on the lower leg near the injury site. Worsening symptoms had led her to present to hospital. She had a history of acute myocardial infarction many years previously and mild chronic obstructive pulmonary disease. Surgical history included a hysterectomy and varicose vein ligation. She was an ex-smoker. At the time of admission, capillary refill in the foot was sluggish and the patient was unable to bear weight on the affected leg. There was no fever, and the white cell count (8.9 × 109/L) was within the normal range. Treatment with intravenous dicloxacillin was commenced. The patient’s leg failed to improve during the first week of treatment (Box 1, B), despite the addition of metronidazole on Day 5 after admission and gentamicin on Day 6. The antibiotics were changed to ticarcillin–clavulanic acid on Day 9. The patient had low-grade fevers from Day 7 and her white cell count progressively rose to 31.1 × 109/L. A Doppler ultrasound scan of the thigh on Day 11 showed occlusion of the superficial femoral artery with reperfusion by collateral vessels, consistent with atherosclerotic peripheral vascular disease. Surgical exploration was performed on the same day, with wide resection of necrotic skin and subcutaneous tissue. Operative findings were of occluded vessels with absent blood flow in the areas of necrosis. Bacterial culture of the necrotic tissue showed profuse growth of Escherichia coli and Klebsiella pneumoniae, which led to a change in antibiotic treatment to ceftriaxone. Histopathological examination of the debrided tissue showed coagulative necrosis with scattered fungal hyphae, especially within blood vessels. The hyphae had occasional septa and branched at variable angles. The more viable areas contained acute inflammatory cells. A white downy fungus grew in culture from a tissue specimen after 5 days, but the fungus was difficult to identify as it failed to sporulate in culture. When subsequently grown on Czapek Dox agar, the isolate eventually produced vase-shaped sporangia typical of Saksenaea vasiformis (Box 2). Treatment with intravenous amphotericin B was commenced on receipt of the histopathology results. However, the patient’s foot became progressively more ischaemic, with development of frank gangrene by Day 16 after admission. Above-knee amputation was performed on Day 17. A computed tomography scan of the chest showed no evidence of pulmonary fungal infection. The antimicrobial agents were ceased 6 days after surgery, and the patient was eventually discharged to a nursing home on Day 44. DiscussionFungi of the class Zygomycetes are ubiquitous in nature, being found in soil and decaying organic matter. However, they are uncommon human pathogens. Zygomycosis in humans is usually seen either in immunosuppressed patients or in immunocompetent people after cutaneous inoculation from trauma or surgery. S. vasiformis was first described in 1953 by Saksena as a new zygomycete isolated from forest soil in India.1 Infection due to S. vasiformis was first observed in 1977 in a young man who had sustained severe cranial trauma in a motor vehicle accident. The infection involved the eye and brain.2 A total of 29 cases of human infection due to S. vasiformis have since been reported in the English language literature.3,4 Most cases occurred as cutaneous zygomycosis in immunocompetent patients after traumatic inoculation. S. vasiformis typically requires special culture techniques to induce sporulation and enable definitive identification. It shares these characteristics with Apophysomyces elegans, another zygomycete.5 Reports in the literature of skin or soft tissue infections following bird pecking injuries are sparse. These include a Pseudomonas aeruginosa infection of the finger after a swan bite6 and a Bacteroides scalp infection after an owl attack.7 More serious infections relating to trauma involving a bird have included septic arthritis of the knee after a chicken bite8 and a fatal brain abscess in a child caused by a rooster peck.9 Zygomycoses have been transmitted by insect or spider bites, with the pathogens reported as Rhizopus spp,10,11 Apophysomyces elegans12 and Mucor hiemalis.13 The infection in our patient was in some ways typical of infection with S. vasiformis, in that it occurred in an immunocompetent patient after trauma, albeit of an unusual nature. The presence of pre-existing peripheral vascular disease may have contributed to the aggressive course of the infection in this patient. Zygomycetes are rapidly growing fungi with a tendency to invade blood vessels, causing occlusion and infarction. An unusual infective agent must be considered in the setting of worsening soft tissue infection despite broad-spectrum antibiotic therapy, and early debridement accompanied by fungal culture may enable diagnosis. Trauma related to a bird-pecking injury should be added to the list of predisposing risk factors for zygomycosis, as exemplified by this case. 1 Appearance of patient’s left leg 2 Microscopic appearance of the fungus, showing typical vase-shaped sporangium

Paul A Wilson BSc, BMed(Hons)

It is with deep sadness that we mourn the passing of Sarah Mitchell after a long battle with breast cancer. Sarah was a Consultant Paediatrician at King Edward Memorial Hospital and Princess Margaret Hospital (KEMH/PMH) in Perth, Western Australia. Sarah was born in England on 15 March 1966. She studied medicine at the University of London, graduating in 1991, and subsequently undertook postgraduate paediatric and neonatal training in London, Sydney and Perth. She developed her interest in neonatal retrievals while working for the Neonatal Emergency Transport Service in New South Wales. She returned to Australia in 2002 as a Senior Registrar in neonatal and paediatric intensive care at KEMH/PMH, where her excellent clinical acumen, compassion and commitment led to her promotion to Consultant status in 2006. Sarah and her husband Steve loved to travel, and visited 35 countries during their 17 years together. It was probably her love of travel and adventure that attracted Sarah to specialise in neonatal retrievals. This ultimately led to her appointment as Director of the WA Neonatal Transport Service, which was perhaps her greatest professional achievement. She had a clear vision for neonatal retrievals in WA, and the innovations she was developing are destined to transform the way the service functions for many years to come. Sarah has always been held in high esteem by all her colleagues. Despite the ever increasing intrusion of her illness and its treatment on her life, she carried on working, always remaining her usual calm, caring, competent and professional self. She also continued to participate in triathlons. She was optimistic despite adversity, and led by example with her dedication and commitment to neonatal practice in WA. Sarah was still working right up until 2 weeks before her death on 22 May 2008, providing support and mentorship to others. Her strength, resilience and determination were an inspiration to her colleagues. Sarah will be remembered as someone who lived life to the full, and was totally committed to life with her husband Steve and to the young patients in her professional care.

Karen N Simmer · Katharine Gardiner

The community of Belmont, Victoria, lost a respected member with the death of Clifford Warmbrunn on 21 June 2008. His life was directed by his two passions: general practice and the Christian church. Cliff was born on 15 November 1933 in Melbourne. He attended Carey Baptist Grammar School and studied medicine at the University of Melbourne, graduating in 1959. In 1963, he joined the Belmont Medical Clinic in Geelong as a general practitioner. For 35 years, Cliff conscientiously cared for patients in the Belmont community. His work as a GP was also an avenue for expressing his Christian faith. As the Belmont practice expanded and took on GP trainees, so did his responsibilities, and he became the senior partner. He also became involved in Clockwork, a service to adolescents established under the auspices of the Geelong Division of General Practice. This enabled him to meet the needs of young people in a more informal setting than structured general practice. During his time at Belmont he served a term as Chairman of the Geelong Subdivision of the Australian Medical Association. After retirement from full-time medical practice in 1998, Cliff continued to do locum work in the district and to be involved with Clockwork. His special interest in retirement was his Chairmanship of Encompass, a support service for people with disabilities — a position he reluctantly relinquished as his health deteriorated. Always a committed Christian, Cliff managed to fit Christian leadership into his busy life. At Belmont Church of Christ, where he took up membership on arrival in Geelong, he was soon a member of the Congregational Council and then Chairman. His broader interests led to him serving on state and national committees of Churches of Christ. In particular, he was Chairman of the Department of Home Missions and Evangelism for a number of years and President of Churches of Christ in Victoria and Tasmania in 1985–1986. Early in 2008, Cliff’s prostatic malignancy escaped control and he was cared for lovingly at home by his wife, Helen. He is survived by Helen, their children John, Anne and Andrew, and six grandchildren.

Trevor A Banks

The mark, especially the “high mark” and “spectacular grab”, distinguishes Australian Rules football from more earthbound varieties.1 Photographs taken at a recent South Australian National Football League match revealed a high mark where hyperextension of the proximal interphalangeal joint of the right index finger occurred. Interview with the player and examination of the affected digit 4 days after the match revealed no injury to the finger, although some bruising of the right thenar web space and mild tenderness of the first metacarpophalangeal joint were evident. A previous report concluded that virtually all pure hyperextension injuries of the proximal interphalangeal joint result in rupture of the distal end of the volar plate,2 but fracture dislocation appears to depend on joint angle at the time of injury.3 A review of published literature and photographic libraries failed to reveal a similar incident. Further research is required to characterise the biomechanical forces necessary to cause digital injury in sports requiring barehanded capture of a travelling ball.

Robert J Douglas

Men surviving cancer. Barry Leigh. Sydney: Jane Curry Publications, 2007 (viii + 255 pp). ISBN 978 1 920727 31 4. This account of men’s stories provides a lesson in the power of interaction and how what we say as health professionals can change people’s perceptions. A single “throw away” statement or sentence can be etched into a patient’s mind forever. It can shape the way a person diagnosed with a life-threatening illness views both their prognosis and their future. Most of the accounts in Men surviving cancer are about Australian men who have had above average difficulties. It could be confronting for those who have been recently diagnosed, as the path ahead may seem horrendous. Those in the course of challenging treatment, however, may be encouraged by the ultimate success of such treatment. The accounts in this book, as well as those in numerous other books on the cancer journey, suggest that men experience the same physical, emotional and sociological problems as do women. Men cry too. Men feel isolated too. Men change their priorities too: focusing on the importance of family, of friends and of nature. This account of men’s experiences may help others in a similar situation recognise that emotions are normal in the abnormal situation of having cancer. These individual inspiring stories help us recognise that fear of death is at the heart of much of our day-to-day anxiety when faced with a cancer diagnosis. Perhaps the title will attract men who would not normally consider reading a book about cancer, and the upbeat nature of the accounts will help them cope better. As health providers, we can be inspired to communicate more deeply with our patients and appreciate more keenly their willingness to appreciate the power of the spoken word.

Dawn Hooper · Mark Tweeddale

To the Editor: There is an established link between salt intake and blood pressure. The public health impact of a 1–3 mmHg reduction in blood pressure by lowering salt intake could be substantial. An American study found that a projected reduction in diastolic blood pressure of 2 mmHg would result in a 17% decrease in the prevalence of hypertension, a 6% reduction in the risk of coronary artery disease events, and a 15% reduction in risk of stroke and transient ischaemic attacks.1 In Finland, a one-third decrease in average salt intake achieved over 30 years was accompanied by a fall of more than 10 mmHg in the population averages of systolic and diastolic blood pressure.2 However, in the absence of active measures to reduce salt in the food supply, public health messages to reduce salt intake have largely been unsuccessful. The National Health and Medical Research Council (NHMRC) has recently revised its recommendations and now states that an adequate sodium intake for adults is 460–920 mg/day (20–40 mmol/day), with a suggested dietary target for chronic disease prevention of 1600 mg/day (70 mmol/day).3 The most recent Australian sodium intake data are from the 1995 Hobart Salt Study, in which the then national target of 6 g/day was achieved by only 6% of men and 36% of women, with an average salt intake of 7–10 g/day.4 Volunteers in weight-loss studies at the Commonwealth Scientific and Industrial Research Organisation (CSIRO) Human Nutrition unit over the past 5 years continue to have a high salt intake of 8–11 g/day (urinary sodium/24 h: men [n = 85], 181 ± 95 mmol; women [n = 189], 136 ± 61 mmol; reference range, 40–100 mmol).5 Recent data from another Australian study report similar urinary sodium concentrations.6 The average salt intake of Australian adults appears to be 7–12 g/day, which is little changed from 10 years ago. Achieving a low salt intake in the present food supply is difficult, as more than 80% of intake is from salt added to food during processing. As well as the more obvious foods in which salt is a preservative, staple foods such as bread also contain salt. The variety of foods has increased considerably, and many of the numerous processed foods now available contain very high salt levels. Processed and convenience foods frequently have salt added that the consumer cannot avoid. It is clear that large changes to the food supply are needed to reduce salt intake. We believe that salt reduction in the food supply should be the first line of attack to reduce the risk of cardiovascular disease in the population.

Jennifer B Keogh · Peter M Clifton

To the Editor: It’s all very difficult isn’t it? Teasing out the issues around impartiality, weighing evidence and competing interests? Wain wrote a recent editorial for the Journal, and included a list of his “competing interests”: Chair of the CSL Gardasil Advisory Board; speaker fees, travel assistance and consultancy fees from CSL Biotherapies and from Merck and its affiliates in relation to Gardasil; and shares in CSL Limited.1 He helpfully advises that Gardasil (Merck) “is available at no cost to Australian girls and women between the ages of 12 and 26 as part of the National Immunisation Program. The bivalent vaccine, Cervarix (GlaxoSmithKline), has to date not been included in the program, having initially been rejected by the Pharmaceutical Benefits Advisory Committee (PBAC) on the basis of uncertain cost-effectiveness, but subsequently recommended for inclusion.”1 This is disingenuous at best. Initially, the PBAC also “rejected the application for [Gardasil] . . . based on unacceptable and uncertain cost-effectiveness at the price requested.”2 At the request of the then Health Minister, the PBAC reviewed its decision after the company made some small changes to its submission, including a change in pricing. At about the time Wain’s editorial was published, a hard copy of the previous Medical Journal of Australia article on human papillomavirus (HPV) arrived on my desk,3 courtesy of GlaxoSmithKline. That article on HPV vaccination listed the “competing interests” at the end. Clearly, all the authors have received some sort of funding through GlaxoSmithKline, CSL and/or Merck. I am not impressed by authors who receive funding from pharmaceutical companies that market the drugs they are discussing. It seems to me that the problem lies with interests not competing, or at least not competing with the author’s intent. Perhaps a little healthy competition would bring out some more thoughtful, articulate articles, unaffected by any commercial pressures. “A plague o’ both your houses.” Let’s consider where we could best spend our money without the help of the competing interests of various pharmaceutical marketing mechanisms. “HPV vaccination will not prevent all cases of cervical cancer, therefore vaccinated women should continue to have two yearly Pap smears.”4 Given that HPV vaccination (in this country) will not change the rate of cervical screening required in the near future, perhaps the money would be better spent on ensuring that all Australian women are screened in a timely manner. That is, ensuring that poor women, Indigenous women, rural women, and immigrant women are part of “Cervical screening in Australia . . . one of the great public health success stories, as witnessed by a continuing dramatic fall in the incidence of carcinoma of the cervix and mortality from this disease since the introduction of the National Cervical Screening Program (NCSP).”5

Lilon G Bandler

To the Editor: We would like to express our disappointment with the Journal’s decision to publish an editorial on human papillomavirus (HPV) vaccines that demonstrated significant bias.1 It seems that simply documenting an author’s conflicts of interest exonerates the author and relieves the Journal of the responsibility of considering whether or not the article is biased. In his article, Wain states that the bivalent vaccine, Cervarix (GlaxoSmithKline), has not been included in the National Immunisation Program, having initially been rejected by the Pharmaceutical Benefits Advisory Committee (PBAC) on the grounds of uncertain cost-effectiveness. He omits to mention that Gardasil (Merck), was initially also rejected, and only funded after political intervention, an emergency meeting of the PBAC and further price negotiations with CSL.2 Wain claims that Cervarix is being promoted to older women despite the absence of efficacy data and the uncertain population benefits in this age group. Surely a balanced argument would include the fact that Gardasil is licensed for boys aged from 9–15 years based on immunogenicity data only, and that efficacy has not been established in this population. Why does the author consider this to be acceptable, but that licensing the vaccine for older women where the indication is to prevent cervical cancer is unacceptable? Many vaccines are licensed on the basis of immunogenicity data provided these have been shown to predict efficacy. While the efficacy of HPV vaccines in older women is being established, there are good data to show that an immune response to HPV vaccine is predictive of efficacy.3 Women aged over 26 years produce a robust immune response to HPV vaccines, similar to levels achieved in women aged 15–25 years, for whom efficacy has already been demonstrated. The Therapeutic Goods Administration has licensed Cervarix for women aged 26–45 years, before efficacy data became available, based on the assumption that efficacy will be demonstrated in seronegative older women. Women of all ages have shown interest in benefiting from a vaccine to protect against cervical cancer.4 Women of any age have the right to be informed, and to have the opportunity to discuss with their treating physician the relative benefits and risks of receiving the HPV vaccine for prevention of cervical cancer. Many vaccines are initially available only if purchased by individuals and, although this may result in inequity, ultimately, this is a decision of priority (individual financial and public health funding priorities) and not a reason to withhold licensing a vaccine with proven benefit.

Helen S Marshall · David Isaacs

To the Editor: Wain’s criticism of the Australian Therapeutic Goods Administration (TGA) approval of the bivalent vaccine, Cervarix (GlaxoSmithKline), suggesting it did not adhere to World Health Organization guidelines,1 should not detract from the potential benefits of human papillomavirus (HPV) vaccination in women over 26 years of age. An immunogenicity study showed all women up to the age of 55 years seroconverted to both HPV types and, while mean antibody concentrations at Month 7 were lower than in the younger age group, they were still three to four times higher than those observed in 15–25-year-old women in the long-term follow-up study (up to 4.5 years after vaccination), where continued efficacy was demonstrated.2 HPV infection is most prevalent in younger age groups, with one study showing a prevalence of 44.8% in women aged 20–24 years.3 As indicated by Wain, the vaccine has diminished efficacy in populations with high rates of previous exposure. Thus, 20–24-year-olds would benefit least, and if we extrapolate his argument, should not be included in any catch-up vaccination program. The United Kingdom has, in fact, recommended a catch-up campaign for girls aged up to 18 years only. The prevalence of HPV infection decreases after 26 years of age, and these “older” women should benefit from vaccination as supported by preliminary efficacy data of the quadrivalent vaccine Gardasil (Merck) in an older population.4 This vaccine may also be protective for women who have been previously exposed to the same subtypes of HPV as the vaccines, as shown by 100% efficacy against cervical intraepithelial neoplasia (CIN) grade 2/3 or adenocarcinoma in situ (AIS) among people who are seropositive but HPV-DNA-negative to the relevant HPV type.5 The Pharmaceutical Benefits Advisory Committee initially did not recommend funding for Gardasil on the basis of cost-effectiveness until after an extraordinary meeting to consider a revised submission, following an “unusual” request from the Health Minister.6,7 CSL agreed to reduce the price, undertook to make a substantial contribution to any booster program if it became necessary in the next 20 years, and also to the costs of setting up a national register to link vaccination data to later cervical screening records. It is obvious that the efficacy of HPV vaccines will inevitably be lower after commencement of sexual activity, but we believe that it is the medical practitioner’s responsibility to offer women aged over 26 years the current, albeit incomplete, information on vaccine efficacy, and allow women to make the choice.

Jeffrey H J Tan · Michael A Quinn

To the Editor: Recent articles in the Journal describing endeavours to measure and classify the tasks of doctors are indicative of the re-emergence of work analysis and time and motion studies.1,2 While commending the authors on their endeavours, it is concerning that the articles state almost contradictory findings. Westbrook and colleagues reported that professional communication, social activities and meal breaks represented the greatest proportion of observed time.1 Zhu and colleagues reported that direct patient-related tasks accounted for 86% of intern time.2 Acknowledging the different contexts of the individual studies, the collective picture is one of confusion and may lead to misrepresentation of the work of doctors. We have also analysed the work of doctors using observational techniques.3 We built on work done in the United States4 that is underpinned by functional job analysis (FJA)5 to produce a list of tasks (task taxonomy) that describe the work in the acute-care setting, and coordination of roles between hospitals and the community.3,6 The task is the fundamental unit of work, and FJA describes each task in terms of behaviours and interdependencies between people, data and things for the achievement of the task. The method seeks to achieve quality information through adopting precise language descriptions and benchmarks for levels of tasks required for jobs.5 Data are recorded by means of a simple electronic tool.6 Our method captures contextual information about the service (eg, location of work) and rigid details about the observed tasks. We have presented our findings at the 5th Health Services and Policy Research Conference of the Health Services Research Association of Australia and New Zealand,6 and the Change Champions Skill Mix and Workforce Development conference, both in 2007. We found that doctors in the units studied spent about 11% of time on education and training, between 50% and 60% on direct clinical activities (depending on context and role), and less than 10% of time on non-clinical administration. We suggest that if observations are recorded according to the purpose of the output, what may appear to be “socialising” may, in fact, be waiting for something or someone. It is far more important to measure what the impediment to getting on with the job is, rather than inferring that socialising is the main activity. There is a need for a consistent task classification system that can be used across units and across professions to describe the work that is being performed. A common unit of measure would provide a strong foundation for collaboration and learning in work redesign projects across the nation. Without such a system, planning for the future and evaluation of new roles will continue to be hindered. To this end, we are happy to share the task taxonomy that we have developed, and welcome contact via email.

Mark Mackay · Pamela J Castle

To the Editor: The study of intern activities in Melbourne emergency departments (EDs) highlighted gaps in the ED training of interns.1 In particular, it was shown that interns undertake a low number of procedural tasks. Most did not perform urinary catheterisation, nasogastric tube insertion or reductions of fractures and dislocations, just some of the skills highlighted as important in the Australian Curriculum Framework for Junior Doctors (ACFJD).2 Time pressure on supervisors was cited as a reason for this. New South Wales will experience a doubling in the number of medical graduates in the next few years. Increased capacity in emergency terms will be needed. The reported capacity (available supervision, clinical workload and funding) in NSW EDs indicates that a shortage of terms could develop from 2011. The NSW Institute of Medical Education and Training (IMET) recently explored the educational validity of retaining the emergency term as a mandatory requirement for general registration3 in view of the reported limited capacity. IMET-accredited emergency term descriptions were reviewed and mapped against the “Common presenting problems and conditions” listed in the ACFJD. The study found that an ED term would likely provide exposure to most of the common conditions, many of which were unlikely to be encountered in other medical or surgical hospital rotations. The acute phase of key conditions, that all medical practitioners are expected to be able to recognise and treat appropriately, were often unique to the ED term. Further, most of the “Skills and procedures” for junior doctors were likely to be learned in the ED, and around 50% were not commonly experienced elsewhere. Many of the broader competencies of the curriculum such as “Doctor and society” are also covered in an ED term. The ED provides a unique context for learning, bridging community and hospital situations. The approach to acutely ill patients, with as yet undifferentiated problems, for whom JMOs learn to initiate treatment and appropriate investigations concurrently, cannot be reliably replicated elsewhere. Emergency departments bear the brunt of the growing demand for acute care from an ageing population with multiple comorbidities, and also of the growing demand for excellent and accountable postgraduate medical training. In NSW, about 30% of directors of prevocational training are ED physicians, reflecting their commitment to education. They typically supervise numerous trainees at a time. The educator role of ED physicians and other senior doctors in EDs is essential. Resources should be directed to supporting this role and enhancing the capacity of EDs to train medical graduates.

Belinda Doherty · Mark A Brown

To the Editor: Learning in the clinical setting remains central to the development of well trained health care professionals. The issue is whether that learning should occur through formal or informal learning opportunities. Westbrook and colleagues define “supervision or education” in a way that focuses mainly on formal experiences,1 possibly because trained observers could accurately classify such experiences. As noted by Brown and Arnold, much learning in the hospital setting is largely informal in nature.2 Although learning is likely to be occurring during the many discussions that junior doctors have with consultants or during the procedures they perform in an emergency department,3 it can be difficult to describe, and may not be recognised as learning by the individuals involved.4 There is a divide between the perceptions of teachers and trainees about how much learning is occurring, whether teaching has occurred and feedback has been given. Consultants believe they are providing a great deal, but junior doctors do not recognise it. Although junior doctors perceive they have adequate informal contact with registrars, and some (but not enough) with consultants, what they want is more teaching in “formal” sessions.5 Additionally, supervisors think they give detailed feedback, but junior doctors view it as less than adequate.6 The answer might lie in upskilling both junior doctors and teachers to make teaching and learning more effective, in part by making it more explicit to all involved. At Sir Charles Gairdner Hospital in Perth, an innovation has been to create new positions known as “medical education registrars” who, as supernumerary staff at a senior registrar level, have time to advise on patient management, supervise and teach skills.7 Much of this is provided at the patient’s bedside. The very nature of their job title makes it explicit that they are there to help learning during daily activities. The staff development program, “Teaching on the Run”, developed by the Education Centre at the Faculty of Medicine and Dentistry, University of Western Australia,8 aims to make teachers more effective. More recently, we have piloted another program, “Learning on the Run”, for junior doctors and students, to provide them with the skills to recognise opportunities and drive their own learning agendas. We agree with Brown and Arnold that learning and service are not mutually exclusive.2 By providing both junior doctors and senior medical staff with the necessary skills, many tasks within a day in the life of a new doctor could become a valuable learning experience. Whether this will ultimately translate into improved teaching and learning outcomes is a question we are continuing to explore.

Lisa Caputo · Fiona R Lake · Margaret Potter · Ian Rogers

To the Editor: In his exploration of the health advocacy potential of modern clinicians, Gruen1 observes that the public first needs to be convinced that “the profession has its own house in order”. Unfortunately, one room in that house accommodates one of the serious health threats identified by the author: terrorism. Currently, over 95% of the world’s radiopharmaceuticals are generated from highly enriched (bomb-grade) uranium (HEU), an unnecessary nuclear weapons proliferation hazard.2 Prompt conversion of the global medical isotope supply chain to low enriched uranium (LEU, containing less than 20% uranium 235, so not viable for weapons production) is technically feasible.3 Clinicians are thus uniquely placed to advocate conversion to the use of LEU, while pressuring their imaging and isotope providers to end reliance on HEU, thereby blocking one of the most vulnerable pathways to producing a “terrorist bomb”. But, as Gruen suggests, we can do even more through “collective advocacy” to address the much larger nuclear threat: that is, the 26 000-plus nuclear weapons remaining in the arsenals of Russia, the United States, the United Kingdom, France, India, Pakistan, Israel, China and North Korea. While a sophisticated terrorist group armed with home-manufactured nuclear weapons could devastate a few cities, the existing nuclear-armed states have the capacity to destroy between tens and thousands of urban centres and their populations within a few short hours. Worse still, recent research indicates that 100 Hiroshima-sized (ie, “small”) nuclear weapons exploded on major cities would be capable of precipitating a “nuclear winter” that could persist for 10 years.4 The dispersal of carbonaceous material into the stratosphere from major urban firestorms could dramatically reduce terrestrial sunlight, lower surface temperatures by several degrees, shorten the growing season, reduce rainfall and trigger global famine. One billion deaths from starvation is a realistic assessment of the consequences.5 Such a catastrophic scenario is within the firepower capacity of all currently nuclear-armed nations except North Korea. A new generation of medical students and young physicians has launched several initiatives over the past few years to challenge this threat, including the Nuclear Weapons Inheritance Project and Target X (http://www.ippnw-students.org). Most recently, International Physicians for the Prevention of Nuclear War launched the International Campaign to Abolish Nuclear Weapons (http://www.icanw.org), whose goal is to establish a nuclear weapons convention to eliminate all nuclear weapons once and for all. By ending our reliance on bomb-grade HEU in medical imaging, we can certainly begin to put our own house in order. But let’s also follow Virchow’s lead: let’s “engage with the broader social concerns that cause illness and harm”,1 get active for our patients’ — and our own — wellbeing, and help prevent a global nuclear pandemic.

Bill Williams

To the Editor: We note with interest the recent commentary by Cretikos et al on the predictive value of a high respiratory rate for adverse outcomes.1 We wish to provide empirical evidence from Australian patients with pneumonia in support of their view that simple clinical parameters are good predictors of adverse outcomes. We examined data from a prospective cohort of consecutive patients presenting to the Royal Melbourne Hospital Emergency Department with radiologically confirmed, community-acquired pneumonia between 2003 and 2006.2 In an earlier study of a subset of these patients,3 we found that hypotension and tachypnoea were strongly associated with death and/or the need for respiratory/inotropic support (odds ratios, 8.0 and 3.5, respectively). In the full cohort (n = 740), we examined factors associated with either admission to the intensive care unit (ICU) or mortality (106 patients were in one of these two categories). Respiratory rate was documented in 712 patients (96%). A combination of tachypnoea (≥ 24 breaths/min) and/or hypotension (systolic blood pressure ≤ 90 mmHg) had similar predictive value for the risk of ICU admission and/or death to the recommended system of risk stratification, the Pneumonia Severity Index (PSI)4 (Box). The combination of respiratory rate and systolic blood pressure performed better than either sign alone in ruling out at-risk patients if both were normal (ie, a high negative predictive value), although almost a quarter of patients with either clinical sign had adverse outcomes. The PSI is based on 20 individual clinical and laboratory parameters, and evidence suggests that it is poorly documented in patients’ records.5 Our data relate to patients with community-acquired pneumonia from a single centre and thus have limited statistical power for making comparisons. However, they suggest that these two routinely measured clinical parameters can be used to stratify patients at risk of adverse outcomes at the time of presentation. We support efforts to incorporate simple clinical indicators into systems that can identify seriously unwell patients early in the course of illness. Summary statistics for tachypnoea, hypotension and PSI class as predictors of ICU admission and/or death from community-acquired pneumonia* Number of patients Sensitivity Specificity PPV NPV RR ≥ 24 breaths/min 712 82% (73%–89%) 48% (44%–52%) 22% (18%–26%) 94% (91%–96%) RR ≥ 27 breaths/min 712 70% (60%–78%) 67% (63%–71%) 27% (22%–32%) 93% (90%–95%) RR ≥ 24 breaths/min and/or systolic BP ≤ 90 mmHg 713 93% (86%–97%) 45% (41%–49%) 23% (19%–27%) 97% (94%–99%) PSI class IV or V† 740 90% (82%–95%) 49% (45%–53%) 22% (19%–27%) 97% (94%–98%) BP = blood pressure. ICU = intensive care unit. NPV = negative predictive value. PPV = positive predictive value. PSI = Pneumonia Severity Index. RR = respiratory rate. * Figures in parentheses represent 95% CIs calculated using the exact binomial distribution. † Severe pneumonia.

Allen C Cheng · James F Black · Kirsty L Buising

To the Editor: Cretikos et al make a strong case for routinely recording patients’ respiratory rate (RR) in acute wards.1 In a prospective study designed to evaluate the prognostic value of RR in acutely hospitalised patients aged over 75 years, we analysed data from all admissions to a single 14-bed acute-care geriatric unit between 15 May and 15 November 2007. Clinical data were recorded on admission and blood tests were performed the next morning. The Charlson score was used to assess comorbidity.2 Features of the 195 admissions during the study period (13 patients were admitted twice) are reported in the Box. The main reasons for admission were falls (15%), left ventricular failure (11%), pneumonia (11%), cancer complications (9%), pyelonephritis (7%) and stroke (5%). Twenty-nine patients died in hospital, including six from cancer complications, five from pneumonia, four from pyelonephritis and four from left ventricular failure. Based on univariate logistic regression analysis at the 0.05 significance level, the following variables were predictive of death during hospitalisation: being male (odds ratio [OR], 2.42, Wald test P = 0.03); increased Charlson score (OR, 1.50 for each additional point between 3 and 13; P < 0.001); decreased systolic blood pressure (OR, 6.71 for systolic blood pressure < 100 mmHg; P =0.004); abnormal heart rate (< 60 beats/min or > 100 beats/min) (OR, 3.63; P = 0.003); increased RR (OR, 1.81 for each additional 5 breaths/min between 14 and 44; P < 0.001); abnormal blood sodium level (< 137 mmol/L or > 143 mmol/L) (OR, 2.82; P = 0.01) and raised C-reactive protein level (OR, 2.67 for C-reactive protein level > 45 mg/L; P = 0.02). After multivariate logistic regression analysis with stepwise backward elimination, the only remaining factors that were significant predictors of death during hospitalisation were Charlson score (OR, 1.53 for each additional point between 3 and 13; P < 0.001) and RR (OR, 1.83 for each additional 5 breaths/min between 14 and 44 breaths/min; P < 0.001). RR on admission was associated with an area under the ROC (receiver operating characteristic) curve of 0.73 (95% CI, 0.64–0.82) for the prediction of death during hospitalisation. An RR of ≥ 20 breaths/min had a sensitivity of 97% (95% CI, 80%–100%), a specificity of 28% (95% CI, 21%–35%) and a negative likelihood ratio of 0.12 (95% CI, 0.02–0.82) for prediction of death during hospitalisation. Only one patient (admitted for stroke) with an RR of < 20 breaths/min at admission died in hospital. Higher RR cut-off values increased specificity but reduced sensitivity. For instance, an RR of ≥ 30 breaths/min had a specificity of 90% (95% CI, 84%–94%), but a sensitivity of 38% (95% CI, 21%–58%), leading to a positive likelihood ratio of 3.68 (95% CI, 1.93–7.04) for prediction of death during hospitalisation. In conclusion, besides comorbidity (Charlson score), RR was the most useful predictor of death in acutely hospitalised patients aged over 75 years. Our results extend the evidence base promoting regular documentation of RR in acute-care departments.1 Features of the 195 admissions to the acute-care geriatric unit between May and November 2007 Age (years) 85 (81–91)* Women 123 (63%)† Charlson score 6 (5–8)* Dementia 88 (45%)† Body temperature (°C) 37.0 (36.8–37.5)* Systolic blood pressure (mmHg) 136 (120–152)* Heart rate (beats/min) 80 (70–92)* Respiratory rate (breaths/min) 20 (20–25)* Serum sodium level (mmol/L) 140 (137–143)* Serum creatinine level (μmol/L) 91 (76–120)* Serum protein level (g/L) 65 (59–70)* Serum C-reactive protein level (mg/L) 36 (12–108)* Blood haemoglobin level (g/L) 115 (100–125)* White blood cell count (× 109/L) 8.3 (6.3–11.5)* * Median (interquartile range). † Number of admissions (%).

Olivier Steichen · Gilles Grateau · Eric Bouvard

To the Editor: The concept that respiratory rate (RR) is a key vital sign is hardly new,1 but it is being re-emphasised.2,3 The recent article by Cretikos et al3 highlights the diagnostic relevance of a raised RR for serious adverse events. The authors make sensible recommendations regarding the need to educate hospital staff about the importance of measuring patients’ RR. However, they do not specify how this rate should be measured. Indeed, most textbooks of general medicine, and even respiratory medicine, fail to provide guidance on this or to define an abnormal rate. A widely used book on clinical examination4 suggests measuring RR while feeling the pulse, and quotes a normal (adult) resting range of 16–25 breaths/min, but no source for this information is provided. There are few reports of true normal resting RR measurements obtained by covert observation. Respiratory physiologists have long known that RR commonly increases and becomes more regular as soon as a subject becomes aware of the measurement. This is especially so if a mouthpiece is in place. Rates as low as 8 breaths/min may be seen at rest, and the normal adult range quoted by physiologists is 11–14 breaths/min.5 Bradypnoea is usually defined as a rate less than 8 breaths/min and tachypnoea as a rate greater than 18–20 breaths/min. There is no gold standard method for accurate measurement of RR in clinical practice. Of course, when patients are being monitored, particularly with a nasal cannula, it should be easy to obtain the rate. Oximetry is not a surrogate measure of RR, although it is often easier to record. Inductance bands around the chest provide a simple non-invasive way to measure RR. In addition to the absolute rate, an irregular and erratic rate is of concern. In settings in which formal monitoring is not being conducted, RR is the one “vital” sign that must be assessed when the patient is resting quietly, unaware of its measurement, and not conversing with staff. Duplicate measurements should be made over an interval of at least 1 minute. An RR of over 20 breaths/min, particularly if irregular, is noteworthy. Tachypnoea is intimately linked with the sensation of breathlessness, and hence the patient’s respiratory sensations should be assessed. In some patients with a normal RR at rest, marked tachypnoea may be precipitated by mild exertion, such as walking a few paces.

Simon C Gandevia · David K McKenzie

To the Editor: Buruli ulcer, caused by the bacterium Mycobacterium ulcerans, leads to the destruction of skin and sometimes bone. It has been reported in many tropical countries in Africa and in some temperate regions of Australia, Japan and China.1 In 2004, the World Health Organization recommended treatment with the combination of oral rifampicin and intramuscular streptomycin (or amikacin) for 8 weeks.2,3 In-vitro studies and new data from mouse models suggest that combinations of rifampicin with clarithromycin, rifampicin with moxifloxacin, or clarithromycin with moxifloxacin may be as effective as rifampicin and streptomycin.4,5 In June 2007, a woman who was 6-months pregnant with her first child and had a 7-month history of Buruli ulcer on her right upper limb (Box 1, A) was admitted to the Buruli ulcer treatment centre in Allada, Benin. She was otherwise in good health, and the fetal heart beat was normal. Routine laboratory examinations, including HIV serology tests, found no abnormalities. Swabs from the ulcer were positive for acid-fast bacilli by Ziehl–Neelsen stain, and for IS 2404 (DNA sequence specific for Mycobacterium ulcerans) by polymerase chain reaction testing, but no growth of M. ulcerans was obtained on culture. Histopathological analysis of punch biopsy specimens showed typical features of Buruli ulcer. As streptomycin is contraindicated in pregnancy, we treated the patient with a combination of oral rifampicin (600 mg daily) and oral clarithromycin (500 mg twice daily) for 56 days, beginning 2 weeks after presentation. The treatment was well tolerated. We monitored the clinical response through serial photographs (Box 1) and measurements of the circumference of the affected and unaffected limbs at defined points (Box 2). The patient gave birth to a healthy boy weighing 2.25 kg in September 2007, 2 weeks after completing antibiotic treatment. She underwent skin grafting a month later. The lesion healed without functional limitation (Box 1, D), and the patient was discharged in December 2007. At that time, the surface area affected by the lesion was reduced by 55%. To our knowledge, this is the first report of successful treatment of Buruli ulcer using fully oral treament with rifampicin and clarithromycin alone. We hope our experience will contribute to future discussion and studies to find an oral treatment for this devastating disease. 1 Serial views of Buruli ulcer in a woman treated with rifampicin and clarithromycin A: At presentation. B: After 4 weeks' antibiotic treatment. C: On completion of antibiotic treatment (8 weeks). D: At hospital discharge after skin grafting, showing full movement of the elbow joint (23 weeks). 2 Clinical response to treatment Week after treatment start 0 4 8 23 Limb circumference (cm) At wrist Affected limb 21 17.5 16.5 15 Unaffected limb 14 14 14 14 % difference 50% 25% 18% 7% At mid-arm Affected limb 36 33 30 25 Unaffected limb 22 22 22 22 % difference 64% 50% 36% 14% At elbow Affected limb 34 21 21 21 Unaffected limb 23 23 23 23 % difference 48% − 9% − 9% − 9% Lesion dimensions Diameter (cm)* 30.3 23.8 22.5 20.3 Area Estimate (cm2) 722 446 397 325 % reduction — 38% 45% 55% * Median diameter.

Ange D Dossou · Ghislain E Sopoh · Christian R Johnson · Yves T Barogui · Dissou Affolabi · Sévérin Y Anagonou · Théophile Zohoun · Françoise Portaels · Kingsley Asiedu

To the Editor: Kaposi’s varicelliform eruption (KVE) is a disseminated cutaneous infection caused by herpes simplex virus (HSV) in patients with predisposing factors such as atopic dermatitis, widespread skin injury and sun exposure.1-5 I report a patient with KVE but no apparent predisposing factors. A 54-year-old man presented with a 3-day history of a rapidly progressing vesiculopustular rash on his trunk, legs, arms and hands (Box). He reported a burning skin sensation and had a temperature of 38.2°C. He had no labial or oral erosions, and no history of skin disease, HSV infection or any systemic disease. He was not taking any medication and reported no excessive sun exposure before symptom onset. Haematological, biochemical and immunological parameters, including levels of C-reactive protein, immunoglobulins, complement components, lymphocyte blastogenesis and natural killer cell cytolytic activity were normal. An HIV test was negative. Skin swabs from the lesion were positive for HSV-1 by polymerase chain reaction (PCR) testing; HSV-1 was also isolated on culture. Cultures were negative for bacterial, fungal and mycobacterial pathogens. A diagnosis of KVE was thus established. Based on past experience treating KVE with a combination of oral valaciclovir and vidarabine ointment, which accelerated resolution of symptoms,6 I treated the patient with oral valaciclovir (1 g three times per day) and vidarabine ointment (three times per day). The lesions were completely healed after 7 days of treatment. HSV-1 antibody titres on Days 1 and 7, respectively, were: IgM, 3.1 and 5.2 (reference range, < 0.8); and IgG, < 2.0 and 4.7 (reference range, < 2.0). HSV-2 IgM and IgG antibody titres on Days 1 and 7 were within reference ranges (< 0.8 and < 2.0, respectively). This case is unusual as it occurred in an otherwise healthy patient. KVE is usually associated with healing second-degree burns, peribuccal dermabrasion and laser skin resurfacing,2-4 and sun exposure in patients with recurrent HSV infection.5 The origin of the patient’s HSV-1 infection was not identified: there was no outbreak of HSV infection in his city of residence; his wife and two children were healthy and had no systemic or skin diseases; PCR testing of their saliva for HSV-1 and HSV-2 DNA 3 days after the patient’s presentation gave negative results; and the patient had no apparent contact with HSV-infected patients before onset of symptoms. KVE has been successfully treated with intravenous aciclovir (three times per day) or oral aciclovir (five times per day).2,5 However, intravenous aciclovir requires hospital admission, and compliance with the dosage regimen of oral aciclovir is troublesome. In contrast, oral valaciclovir (three times per day) and vidarabine ointment do not require hospital admission and are easier for patients.1,3,6 Oral valaciclovir is also very effective for preventing herpes infection.7 This case highlights that KVE should be considered in otherwise healthy patients with a sudden, rapidly progressing vesiculopustular rash. Vesiculopustular lesions in a patient with Kaposi’s varicelliform eruption

Hajime Kimata

To the Editor: Serotonin toxicity is an under-recognised, potentially fatal syndrome that is becoming more common as the use of serotonergic drugs increases.1 We report a case of serotonin toxicity following the concomitant use of the antidepressant citalopram and methylene blue. A 44-year-old woman underwent elective partial parathyroidectomy for primary hyperparathyroidism. Three hours after surgery, the patient became agitated and restless while staring vaguely into space, making incomprehensible sounds (Glasgow Coma Scale: 11/15; motor response, 5; verbal response, 2; eye opening, 4). Her blood pressure (120/66 mmHg), pulse (100 beats/minute [sinus rhythm]), oxygen saturation (92% while breathing room air), and temperature (37.5°C) were not clinically significant. Neurological examination revealed bilateral pupillary dilatation with sluggish response to light, myoclonic movements of the lower limbs, brisk reflexes throughout and downgoing plantar responses. Clonus was absent and there was no focal neurological deficit. Blood tests showed a mild inflammatory response (white cell count, 12.7 × 109/L [reference range (RR), 4.0–11.0 × 109/L]; C-reactive protein, 23 mg/L [RR, < 10 mg/L]), normal serum levels of calcium (2.50 mmol/L [RR, 2.12–2.65 mmol/L]), and mildly elevated phosphate (1.5 mmol/L [RR, 0.8–1.4 mmol/L]). A computed tomography scan of the head showed no abnormalities. The patient’s medical history included ischaemic heart disease, hypertension, obesity and depression. Regular long-term medications included aspirin (75 mg daily), simvastatin (40 mg each night), atenolol (50 mg daily), isosorbide mononitrate (20 mg daily), bendroflumethiazide (a thiazide diuretic not available in Australia; 2.5 mg daily), felodipine (5 mg daily) and citalopram (20 mg daily). On the day of the operation, she received propofol, remifentanil, rocuronium, dexamethasone, morphine analgesia and a preoperative methylene blue infusion (560 mg in 500 mL of saline over 2 hours; used to stain the parathyroid glands). She had previously undergone general anaesthesia without complication. Serotonin toxicity was diagnosed, precipitated by the combination of methylene blue and citalopram. She was transferred to the intensive care unit, where she was sedated for 12 hours with propofol and alfentanil. Citalopram was withheld, and she received supportive treatment only. She was discharged to the ward 24 hours later and then home (3 days after discharge from the intensive care unit), with no long-term adverse effects. Three months after discharge, she continued to take citalopram, and serum calcium levels were in the normal range. Serotonin toxicity can be caused by a single drug or a combination of drugs with serotonergic activity. Methylene blue attenuates the metabolism of serotonin through inhibition of monoamine oxidase A.2 When used in combination with a selective serotonin reuptake inhibitor, such as citalopram, toxic accumulation of serotonin may result.3 Features include mental state changes, autonomic hyperactivity, and neuromuscular abnormalities. In mild cases, treatment is supportive, with withdrawal of serotonergic drugs and control of agitation. Moderate to severe cases require control of hyperthermia and autonomic instability, and administration of 5-HT2A (5-hydroxytryptamine2A) antagonists.1

Ali Khavandi · John Whitaker · Hanney Gonna

To the Editor: The 21 July 2008 “general practice” issue of the Journal raises a number of important issues about the future of generalist medical care, including the role of the general practitioner in the care of cancer patients. The editorial by Weller and Harris acknowledges the importance of multidisciplinary teams, including the full gamut of primary care practitioners, in meeting the diverse needs of people with cancer, from diagnosis to long-term “survivorship”.1 Jiwa et al propose a new model of an “integrated primary care hub” — with a “cancer care coordinator” — as a possible solution to the challenges of providing good team-based care.2 However, creating an entirely new disease-centred role would seem to ignore much of the debate in the rest of the general practice issue. Multiple morbidity is an emerging reality in Australia, and it is a fact that many survivors of cancer will die from other chronic conditions. Disease-specific care coordinators are currently being promoted as the new model for delivering chronic disease management to the community, but how many of these care coordinators will be needed for patients such as those described by Britt et al?3 And who will coordinate the coordinators? Gunn et al make a strong case for the generalist primary care medical practitioner as the overarching coordinator of care.4 We must stop seeing our patients through the eyes of our disease-centred hospital colleagues. Instead, we must create new mechanisms that will allow the experts in generalism — GPs — to move away from predominantly “reactive, consultation-based medicine”4 to high-quality integrated care planning in coordination with other members of the primary care team.

Jon D Emery

To the Editor: Venous thromboembolism (VTE) is frequently described among air travellers but data on VTE related to train travel are limited.1-3 We report a case of VTE in a patient after a prolonged train journey. A 35-year-old man presented with sudden onset of breathlessness, perspiration and syncope after a 14-hour train journey, during which he had limited mobility. He had no history of similar episodes, no significant comorbidities or previous periods of prolonged immobility and no family history of thromboembolic disorders, and he was vegetarian. Physical examination revealed tachycardia, tachypnoea, blood pressure of 90/60 mmHg, raised jugular venous pressure and a right ventricular third heart sound. Blood-gas analysis showed hypoxaemia with respiratory alkalosis: Pao2, 49 mmHg (reference range [RR], 95 ± 5 mmHg), pH 7.49 (RR, 7.40 ± 0.02), Paco2, 22 mmHg (RR, 40 ± 2 mmHg). A plasma D-dimer test result was positive. Electrocardiography revealed right axis deviation with an S1Q3T3 pattern. Echocardiography revealed right ventricular dilatation, a thrombus in the main pulmonary artery, and pulmonary arterial hypertension (pulmonary artery systolic pressure, 65 mmHg) (Box, A). Computed tomographic angiography of the pulmonary artery confirmed the presence of a large saddle embolus at the bifurcation of the main pulmonary artery (Box, B) and a wedge-shaped infarct in the middle lobe of the right lung. Venous Doppler imaging showed a thrombus in the left popliteal vein. The patient had fasting hyperhomocysteinaemia (plasma homocysteine level, 36.6 μmol/L; RR, 4.4–10.8 μmol/L] secondary to nutritional vitamin B12 deficiency (serum vitamin B12 level, 42 pmol/L; RR, 206–735 pmol/L]. Tests for antithrombin III, protein C, protein S, factor V Leiden mutation and antiphospholipid antibodies returned normal results. The patient was successfully treated with intravenous streptokinase followed by standard anticoagulation therapy and vitamin B12 supplementation. He was well on follow-up. The association between thrombosis and prolonged travel was first described in 1954.1 Symptoms usually develop within 1–8 weeks of travel. Any journey of more than 4 hours poses a risk of VTE. Factors involved are low humidity, hypoxia, immobilisation and cramped conditions.2,3 Individuals with underlying hypercoagulation states such as factor V Leiden mutation, prothrombin gene G20210A mutation, and protein C and protein S deficiency have increased risk of VTE.4 Recently, hyperhomocysteinaemia has also been identified as an important risk factor for VTE.5 Acquired risk factors include obesity, oral contraceptive use, pregnancy, recent trauma or surgery, malignancy and history of VTE. This case highlights the association between train travel and VTE, and the importance of considering all types of prolonged travel as potential risk factors for VTE. Echocardiogram and angiogram of a patient with venous thromboembolism after prolonged train travel A: Echocardiogram (parasternal long axis view) showing dilatation of the right ventricle (arrow) as a result of acute pulmonary arterial hypertension. B: Computed tomographic angiogram of pulmonary artery showing a saddle embolus (arrows) at the bifurcation of the main pulmonary artery (MPA).

Jeet Ram Kashyap · Sanjay D’Cruz · Sandeep Chauhan · Suman Kochhar

Sight-saving in diabetes Diabetic retinopathy is a significant cause of vision loss. In an attempt to determine how renin-angiotensin system blockers might reduce the burden of diabetic retinopathy, international researchers designed two randomised double-blind placebo-controlled trials.1 In 309 centres worldwide, normotensive participants with and without retinopathy were randomly allocated to groups receiving candesartan or placebo. The aim was to ascertain if the angiotensin II receptor antagonist could reduce the incidence of diabetic retinopathy in diabetics without the complication or slow its progression in those who already had the diagnosis. The results in over 3000 patients followed for 4 years suggested a role for candesartan in reducing the incidence of retinopathy, but no apparent beneficial effect on the progression of the disease in early cases. However, an accompanying comment by two experts from Australia and Singapore2 discusses the findings and the post-hoc statistical analysis, which suggested that treatment could increase regression of retinopathy in patients with early disease. 1, 2 Lancet 2008; 26 Sep [Epub ahead of print] Autism and urinary opiates Contrary to previous claims, children with autism do not appear to have exogenously derived opioid peptides in their urine, say British researchers. In a case-control study of 65 boys with autism and 158 controls, urine samples were examined by high-pressure liquid chromatography (HPLC) and mass spectrometry for the presence of opioid peptides. The highly sensitive mass-spectrometry method used is able to identify molecules that may appear to be peptides on initial examination with HPLC. There were no significant differences between the urinary profiles of the children with autism and the control group. The authors comment that there appears to be no evidence that opioid peptiduria serves as a biochemical marker for autism, nor that it can be used to monitor the response to certain exclusion diets. Arch Dis Child 2008; 93: 745-750 Read all about it News articles reporting on medication studies may not always give a complete picture, especially when it comes to declaring pharmaceutical company funding, according to the results of a US study. With the aim of assessing the use of generic versus brand names, and the reporting of pharmaceutical company funding, researchers reviewed news articles from print and online sources about medication studies published in five major medical journals between 2004 and 2008. Editors at 100 newspapers with a wide circulation were also surveyed. Despite the majority (88%) of newspaper editors reporting they often or always disclosed when studies received company funding, 42% of the articles reviewed did not do so. Most of the articles were found to refer to medications by their brand names, once again in contrast to the large majority of editors’ belief that this was not the case. The authors suggest further education of journalists in these areas, and propose medical journals can assist by making funding declarations more prominent. JAMA 2008; 300: 1544-1550 Suspicious fractures Identifying childhood fractures that are due to child abuse can be difficult. The authors of a recent Welsh systematic review set out to identify characteristics of injury that may distinguish fractures resulting from abuse by reviewing comparative studies of fractures in children at different skeletal sites. Researchers found that fractures resulting from abuse were more common in infants less than 1 year old and toddlers aged 1-3 years, and that multiple fractures were more common in cases of abuse. After excluding major trauma, rib fractures had the highest probability of being caused by abuse, and humeral fractures, a one in two chance. The authors comment that no one fracture in isolation is specific for physical abuse, and that assessment must rely on an evaluation of the whole clinical and social picture at the time of presentation. BMJ 2008; 337: a1518 Finding the occult Although faecal occult blood testing has become an acceptable screening tool for colorectal cancer, new methods continue to be investigated as alternatives that may prove to be more sensitive and specific. Stool DNA studies, which test for cancer-related genes, are potentially superior, as the colonic mucosa is constantly shedding cells, and the bleeding detected by occult blood tests may be intermittent. In a US multicentre, cross-sectional study, including over 4000 adults, faecal blood testing and two types of stool DNA analyses have been compared. Over 3500 adults had a screening colonoscopy, faecal occult blood testing, and a first- and second-generation stool DNA test. Researchers found that the second-generation DNA analysis appeared to be substantially more sensitive than the faecal occult blood testing. Although the authors caution that they were unable to determine whether this gain in sensitivity was offset by a loss in specificity, it appears that assay refinements in molecular testing may be promising for the development of future tests. Ann Intern Med 2008; 149: 441-450

Tanya Grassi