Volume 196 Issue 11

The fine line between therapeutic benefit and toxicity. In this issue of the Journal, Ahmed and colleagues1 focus our attention on the very real problem of gentamicin-induced ototoxicity, and especially on the frequently unrecognised problem of severe vestibulotoxicity. Their retrospective analysis of gentamicin-treated patients presenting to a balance disorders clinic found delayed clinical detection of vestibulotoxicity and an apparent lack of a relationship between toxicity and ...

John D Turnidge FRACP, FRCPA, FASM · John A Waterston MB BS, MD, FRACP

What is in our food should be on the labelTrans fatty acids (TFAs) are produced by the food industry during partial hydrogenation of edible vegetable oils, such as soybean oil, canola oil and cottonseed oil. This industrial process leads to oils that are more solid at room temperature and have better physical properties for food processing, including increased shelf life. Low levels of TFAs are ...

Gunveen Kaur PhD · David Cameron-Smith PhD · Andrew J Sinclair PhD

The full content of this article is available by downloading the PDF.

The full content of this article is available by downloading the PDF.

Drug industry report reveals strained relations with medical “thought leaders”One of the hottest topics in the business of medicine is how the new sunshine of disclosure is affecting relations between drug companies and so-called key opinion leaders, or KOLs. In the United States, growing public scrutiny of company payments is now causing many doctors to shy away from corporate invitations to consult, speak or advise. ...

Ray N Moynihan BA

Key performance indicators for medical research do not always indicate the long-term success of a treatmentTranslation into reduced morbidity and mortality is the ultimate measure of success for medical research. However, this may take decades and often researchers are dead before the full impact of their research is realised. Gregor Mendel’s research is an excellent example, with the most important publication in genetics remaining uncited ...

David A Mackey MD, FRANZCO

Applying a generic form of activity-based funding to mental health risks perpetuating an inappropriate hospital-centric model of psychiatric care. The upcoming implementation of activity-based funding (ABF) should drive unprecedented levels of transparency and has the potential to deliver vital funding increases to mental health services. However, current plans to apply a generic form of ABF based on diagnosis-related groups (DRGs) to mental health risk a continuation ...

Alan Rosen FRANZCP, MRCPsych, DPM · Patrick D McGorry AO, MD, PhD, FRANZCP · Hamish R M Hill BA(Psych)Hons, GradDipCouns, AssocMAPS · Sebastian P Rosenberg BA, MPA

Is now the time to send a signal that poor-quality care should not be rewarded in activity-based funding?Public hospitals in Australia are in for a shake-up over the next few years, with boards being reintroduced in many states and activity-based funding (ABF) being rolled out nationally.1 ABF will replace global or historic budgets for hospitals in most states. National casemix classifications will be agreed, and ...

Stephen J Duckett PhD, DSc, FASSA

To the Editor: A 24-year-old Sudanese woman presented to her general practitioner in 2011 with one month of fatigue, dizziness, abdominal distension and facial oedema. Hypocortisolaemia was present: morning cortisol, 13 nmol/L (reference interval [RI], 240–620 nmol/L), afternoon cortisol, 9 nmol/L (RI, 100–280 nmol/L). In contrast to this profile, she appeared cushingoid (moon facies, central obesity, skin fragility and striae) with skin depigmentation on her face, back and hands (Box, A). ...

Rebecca F Goldstein · Helena J Teede · Carolyn A Allan

To the Editor: Coiera and colleagues’ call for national e-health clinical safety governance1 is timely, given that the proposed rules and regulations for the personally controlled electronic health record (PCEHR) from the Department of Health and Ageing2 neglect this crucial component. The Royal Australasian College of Surgeons (RACS) has called on the Australian Government to provide better clinical governance arrangements for the PCEHR. In a letter ...

Julian A Smith

To the Editor: Although both sides of the debate about screening mammography1,2 acknowledge the mortality benefit due to screening and the risk of overdiagnosis, the magnitude and relative value of these need further clarification and reflection. In calculating the number of breast cancer deaths averted using a relative risk reduction of 35%, Roder and Olver overstate the benefit. Other estimates of effect are lower (eg, ...

Alexandra L Barratt · Paul P Glasziou

To the Editor: Recent studies have highlighted the safety of administering influenza vaccine derived from embryonated chicken eggs to egg-allergic individuals,1-3 as long as the vaccine contains no more than 1 g of egg ovalbumin per dose. This is reflected in recommendations by expert advisory groups including the Australasian Society of Clinical Immunology and Allergy.4 These recommendations have been strengthened by further evidence of the safety ...

Raymond J Mullins · Michael S Gold

To the Editor: Complementary medicines may lack evidence of safety and efficacy, but conventional medicine lacks evidence of efficacy in 30%–40% of cases,1 and the breast implant and hip replacement debates demonstrate safety concerns. The debates about conventional versus complementary medicine expose how out of touch the medical profession is with the views of government and the people about complementary medicine. The medical profession was ...

Simon J Spedding

To the Editor: The article by Wilson and colleagues concludes with the words: “... to ensure that only those applicants most likely to succeed are selected for medical training”.1 What does the word “succeed” really mean? Success is not only measured by the award of the MB BS (or MD). Academic brilliance and commitment to lifelong learning are not sufficient either. Compassion, kindness, respect for ...

Jeffrey V Rosenfeld

To the Editor: Wilson and colleagues thoughtfully summarise medical school selection procedures, highlighting the need for greater social accountability.1 We would strengthen the aim of choosing applicants with “the characteristics required to be competent medical practitioners”1 by arguing they should also be responsive to community needs. What are the “outcomes” of interest in selecting medical students? Methodological problems abound, and studies mostly consider outcomes that are ...

Tarun K Sen Gupta · Richard B Murray · Robin A Ray

In reply: We agree with Rosenfeld that success in medical training means more than graduating with knowledge, technical brilliance and commitment to lifelong learning. Admission interviews are designed to assess non-academic features, such as empathy, communication, working in teams and professionalism. We acknowledge that current selection processes are unable to identify students with major personality disorders or those who are likely to develop physical or mental ...

Ian G Wilson · Christopher Roberts · Eleanor M Flynn · Barbara N Griffin

To the Editor: At first, Thacker and Moseley appear to do an about-turn on much of their published work by de-emphasising the role of the brain and nervous system in the human pain experience.1 However, on closer scrutiny, their reflection encapsulates key messages for health professionals about pain not being located in the tissues, while exposing the inadequacy of non-person-centred approaches to their practice and ...

Lester E Jones · Laura Y Whitburn

The prevalence of vitamin D deficiency varies, with the groups at greatest risk including housebound, community-dwelling older and/or disabled people, those in residential care, dark-skinned people (particularly those modestly dressed), and other people who regularly avoid sun exposure or work indoors. Most adults are unlikely to obtain more than 5%–10% of their vitamin D requirement from dietary sources. The main source of vitamin D ...

Caryl A Nowson PhD, DipNutDiet · John J McGrath AM, MB BS, MD, PhD · Peter R Ebeling MB BS, MD · Anjali Haikerwal BSc, MB BS, MPH · Robin M Daly PhD · Kerrie M Sanders BSc, GradDipDiet, PhD · Markus J Seibel MD, PhD · Rebecca S Mason MB BS, PhD

Objectives: To estimate the incidence of metastatic breast cancer (MBC) in Australian women with an initial diagnosis of non-metastatic breast cancer.Design, setting and participants: A population-based cohort study of all women with non-metastatic breast cancer registered on the New South Wales Central Cancer Register (CCR) in 2001 and 2002 who received care in a NSW hospital.Main outcome measures: 5-year cumulative incidence ...

Sarah J Lord MB BS, MS, FRACGP · M Luke Marinovich BA, MPH · Jillian A Patterson BSc, MBiostats · Nicholas Wilcken MB BS, PhD, FRACP · Belinda E Kiely MB BS, FRACP · Val Gebski BA, MStats, FRANZCR(Hons) · Sally Crossing AM, BEc · David M Roder AM, MPH, DDSc · Melina Gattellari PhD, MPH, BSc(Psychol) · Nehmat Houssami MB BS, PhD, FAFPHM

Objectives: To quantify the effect of previous false-positive mammogram results on rescreening rates in a population of women participating in the BreastScreen WA (BSWA) program.Design and participants: Retrospective cohort study of women aged 50–69 years who received free screening mammograms at BSWA between 1 January 1995 and 31 December 2007.Main outcome measures: Percentages of women attending rescreening, and risk ratios for rescreening.Results: ...

Marcus J H Sim · Siva Prema Siva · Intan S Ramli · Lin Fritschi MB BS, PhD, FAFPHM · Janette Tresham BSc(Agric) · Elizabeth J Wylie MB BS, FRANZCR

Objective: To determine the nutrient intakes and status of preschool children from a representative population sample in Adelaide.Design, setting and participants: Cross-sectional survey of children aged 1–5 years, using a stratified random sampling method and a doorknocking strategy, between September 2005 and July 2007.Main outcome measures: Dietary intake, assessed using a 3-day weighed-food diary; anthropometrics, biomarkers of iron, zinc and vitamin ...

Shao J Zhou PhD · Robert A Gibson BSc, PhD · Rosalind S Gibson PhD · Maria Makrides BSc, PhD

Objective: To review patients with severe bilateral vestibular loss associated with gentamicin treatment in hospital. Design and setting: A retrospective case series of presentations to a balance disorders clinic between 1988 and 2010. Main outcome measures: Relationship between vestibulotoxicity and gentamicin dose or dosing profile; indications for prescribing gentamicin. Results: 103 patients (age, 18–84 years; mean, 64 years) presented with imbalance, oscillopsia or both, but none had vertigo. Only three noted some hearing impairment after having gentamicin, but audiometric thresholds for all patients were consistent with their age. In all patients, the following tests gave positive results: a bilateral clinical head-impulse test, a vertical head-shaking test for vertical oscillopsia, and a foam Romberg test. In 21 patients, imbalance occurred during gentamicin treatment (ignored or dismissed by prescribers in 20) and in 66 after treatment; the remaining 16 could not recall when symptoms were first noticed, except that it was after gentamicin treatment in hospital. Total gentamicin dose range was 2–318 mg/kg (mean, 52 mg/kg), daily dose range was 1.5–5.6 mg/kg (mean, 3.5 mg/kg), and duration was 1–80 days (mean, 17 days). Six patients had only a single dose; 26 had five or fewer doses. Serum gentamicin levels, measured in 82 patients, were in the recommended range in 59. Time to diagnosis ranged from 4 days to 15 years. Nephrotoxicity developed in 43 patients. Gentamicin dosage complied with contemporary or current Australian antibiotic guidelines in under half the patients. Conclusions: Gentamicin ototoxicity is vestibular, not cochlear, producing permanent loss of balance, but not of hearing. Gentamicin can be vestibulotoxic in any dose, in any regimen, at any serum level.

Rebekah M Ahmed MB BS, FRACP · Imelda P Hannigan RN · Hamish G MacDougall PhD · Raymond C Chan MB BS, FRACP, FRCPA · G Michael Halmagyi MD, FRACP

Imported pathogens are increasingly recognised as potential biosecurity concerns, but may be overlooked when the clinical syndrome and causative organism are unexpected. This case highlights the need to consider an infectious aetiology in an older migrant with a chronic inflammatory monoarthritis. It emphasises the need for good communication between laboratory disciplines, and demonstrates preliminary success with a combined surgical–medical–pathology–pharmacological approach. Coccidioidomycosis (“pseudotuberculosis”) is an invasive fungal ...

Adrian T L Ong MB, BCh, BAO · Hema Mahajan MB BS, FRCPA, PhD · Sharon C-A Chen PhD, FRACP, FRCPA · Catriona Halliday BSc(Hons), PhD · Matthew R Watts MB BS, FRACP, FRCPA · Roger Brighton MB BS, FRACS(Orth) · Anna P Ralph MB BS, PhD, FRACP

Changes in health service delivery and issues of quality of care and safety are driving interprofessional practice, and interprofessional learning (IPL) is now a requirement for medical school accreditation. There is international agreement that learning outcomes frameworks are required for the objectives of IPL to be fully realised, but there is debate about the most appropriate terminology. Interprofessional skills can be gained in ...

Louise N Greenstock BSc(Hons), PGCertSS, PhD · Peter M Brooks AM, MD, FRACP, FAFRM · Gillian R Webb DipPhysio, MClinEd, DEd · Monica C Moran GradCertEd, MPhil(OT), DSocSc

Work, as well as life, can lead to surprising placesIf someone had suggested in my medical student days that I would end up working where I do, I would have laughed. But, no one knows where experiences, conversations and opportunities might lead. Like many idealistic medical students, I did electives in areas of need. My first was in north-east Arnhem Land. Returning to lectures, I remember ...

Marianne E Jauncey BMed, MPH(Hons), FAFPHM

oday, I am going to open a corpse. I’m eighteen and in my first year of university. Apprehension jars my every movement as I approach the white sheet stretched tight over a humanoid form. I stare, try to imagine, try to prepare myself. But no preparation is enough. This could be my grandfather, my grandmother, my uncle. An aunt. But it’s not. “Be respectful.” My lecturer raises his ...

Yin Lin

You wake to a doctor, sitting where your leg would be. How brave, they say, as if a body is to be endured. Through a closed window — a wind-tossed tree. You wanted to be normal, not to be reassured. What is lost? An empty room soon fills with echoes. How brave, they say. As if a body is to be endured, you keep score, sitting in the stands. Who ...

Andy Jackson

It is a pleasure to announce the winner of the MJA, MDA National Prize for Excellence in Medical Research 2011. This $10 000 award honours the authors of the best original clinical research article published in the Medical Journal of Australia in each calendar year. The Journal’s Content Review Committee has awarded the 2011 prize to a team of seven authors led by Nola Olsen and Professor Bill Musk ...

Annette Katelaris

PATIENTS WITH eating disorders are like canaries in the mines warning of some of the ills of Western society. In broader society, we have lost our way with eating. There are mixed messages on desirable weight and eating. We fret about obesity. No wonder a young person with little sense of self-worth stumbles into dieting and develops an eating disorder. The publisher’s website states that “Fast ...

Judith Fleming

GORDON PARKER describes himself as a “contrarian”. He admits that he’s difficult, combative, impatient with received wisdoms in psychiatry that he thinks don’t work, and dogged — even aggressive — in tackling problems, clinical and conceptual. And it’s clear in this intellectual autobiography that these personal qualities, combined with his enormous energy and brilliance, have been central to his enormous contributions to the field. Professor ...

Rebecca E Adams

As Australia’s population ages, demand for geriatricians is set to further increase

Sophie McNamara

Dr Anthony French, Advanced Trainee in Geriatric Medicine, Princess Alexandra Hospital, Brisbane.

Sophie McNamara

Associate Professor Michael Woodward is head of aged and residential care services at Austin Health, and a geriatrician in private practice at Donvale Rehabilitation Hospital

Sophie McNamara

When Australia’s Olympic athletes head to London next month, they will be accompanied by an entourage of doctors, nurses, psychologists, masseurs and physiotherapists.

Sophie McNamara

The much trumpeted personally controlled electronic health record (PCEHR) officially launches on 1 July, but if you’re feeling a little underprepared, you’re not alone.

Amanda Bryan