Volume 199 Issue 11

Australia’s treatment of asylum seekers in closed detention causes ongoing mental health issues

Gillian Triggs LLB, LLM, PhD

Beyond the medical boundaries of clinic and hospital to the fields of public health and welfare

John D Hamilton MB BS, FRCP(UK), FRCP(Can)

New recommendations will hopefully help standardise care of people bitten by snakes in Australia

Mark Little FACEM, MPH

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

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

The organ transplant community are urged to pressure China into banning the harvesting of organs from executed prisoners

Jeremy R Chapman MD, FRACP, FRCP

What we do for asylum seekers while they are in detention has the potential to prevent future loss of life

Nicholas G Procter PhD, MBA, RN · Diego De Leo AO, DSc, PhD · Louise Newman AM, MB BS(Hons), PhD, FRANZCP

Investment in women is central to future global development

Catherine R Bateman-Steel MB ChB, BSc, MSc

Infection control data as presented on the MyHospitals website should not be used to rank hospitalsUpdated indicators of safety and quality for the 2011–12 financial year were released earlier this year by the National Health Performance Authority (NHPA) on the MyHospitals website (http://www.myhospitals.gov.au). These detail the reports received by the NHPA on a single outcome measure, Staphylococcus aureus bacteraemia (SAB), and a process measure, compliance with ...

Allen C Cheng FRACP, MPH, PhD · Emily Woolnough MB BS · Leon J Worth MB BS, FRACP, PhD · David V Pilcher MB BS, FRACP, FCICM

Major changes in health services are needed to redress health disparitiesTwo recently released reports from the Australian Institute of Health and Welfare (AIHW) make it clear that there must be major changes in the way health services for Indigenous Australians are delivered and funded if we are to improve Indigenous health and health care and ensure real returns on the substantial investments that are being ...

Lesley M Russell BSc(Hons), BA, PhD

Hi-tech selfies may save lives

Monika Janda · H Peter Soyer

Children at clandestine drug laboratories are at risk of physical injury as well as exposure to methamphetamine and toxic chemicals

Sharon L Hawkrigg · Peter M Winterton

What is the ideal smoking reduction strategy and who should be targeted

Simon Chapman

In reply: We thank Chapman for his comments and note that our article1 offers support for his proposal for a smartcard smokers licence for retail tobacco sales.2 Recent data from the Australian Health Survey indicate that nearly 6% of 15–17-year-olds are current smokers, and over 4% smoke daily.3 This figure is likely an underestimate.3 Given these statistics, tobacco control policy must continue to embrace adolescents. ...

Roger S Magnusson · David C Currow

The safety and benefits of homebirth remain contentious

Susan Ieraci · Amy B Tuteur

To the Editor: The recent article by Catling-Paull and colleagues1 documents the apparently very low perinatal mortality associated with state-funded homebirth, mostly among women in Western Australia. However, the 2007 triennial report of the WA Government Perinatal and Infant Mortality Committee (PIMC) stated that, for homebirth: The term perinatal mortality rate was 6.7 per 1000 total births, compared with a term perinatal mortality rate of 2.1 per 1000 total births in the ...

Donald M Clark

In reply: We agree that our retrospective review1 did not provide all the details about neonatal morbidity and mortality. There were limited data available on the reasons for hospital transfer and neonatal death. We explained these limitations in the article and have hence embarked on a wider study of birthplace in Australia.2 It was interesting to us that even in this low-risk population, there were 10 breech ...

Christine Catling-Paull · Rebecca L Coddington · Maralyn J Foureur · Caroline S E Homer

Managing birthweight potentially reduces the risk of diabetes, but lifestyle factors are also important

Katherine A Thurber

In reply: We agree with Thurber that analyses were conducted within the framework of the developmental origins of health and disease hypothesis; however, we did not conclude that “interventions to ‘improve’ birthweight would be ineffective in reducing the prevalence of diabetes”. In line with the hypothesis, we included adolescent as well as birth factors, and suggested that strategies to improve lifestyle factors in childhood and ...

Susan M Sayers · Gurmeet R Singh

To the Editor: Despite evidence supporting the safety and benefits of influenza vaccination during pregnancy,1,2 half of pregnant women believe the influenza vaccine to be unsafe or are uncertain about its safety in pregnancy.3 Other studies report confusion among antenatal care providers about the safety of influenza vaccination during pregnancy, and cite the need for more professional education.4 To help address these safety concerns, the Western ...

Annette K Regan · Christopher C Blyth · Paul V Effler

To the Editor: I would like to thank Rintoul and colleagues for bringing together data from varied sources to highlight an important public health issue.1 The 1426% increase in supply of alprazolam they identified over the 20-year period from 1990 to 2010 was particularly striking. Alprazolam is indicated as a second-line treatment for panic disorder where other therapies are ineffective, or for short-term treatment of anxiety disorder. As ...

Tracy W Soh

To the Editor: Rintoul and colleagues showed that alprazolam is being increasingly detected in heroin-related deaths.1 One explanation provided is increased rates of alprazolam misuse among people who inject drugs. My colleagues and I recently reviewed the role of alprazolam in Australian clinical practice,2 focusing on the sole supported Pharmaceutical Benefits Scheme (PBS) indication: treatment of “panic disorder where other treatments have failed or are inappropriate”. ...

Steven Moylan

In reply: We thank Soh for her letter providing further evidence of harm relating to alprazolam misuse, which highlights deficiencies in postmarketing surveillance systems for pharmaceutical drugs. Reports of adverse drug reactions typically originate from therapeutic use; they seldom identify problems arising from misuse. Detection of misuse-related harm currently relies on ad-hoc epidemiological studies such as ours and that of Frei and colleagues, who documented ...

Angela C Rintoul · Malcolm D H Dobbin

To the Editor: Ondansetron is a 5-HT3 receptor antagonist and an effective antiemetic in the treatment of acute chemotherapy- or radiotherapy-induced nausea and vomiting1 and postoperative nausea and vomiting.2 However, there is no evidence to support the superiority of ondansetron in the empirical management of undifferentiated nausea and vomiting,1 although this appears to have become common practice. Trials comparing ondansetron and other antiemetics (such as ...

Penelope J Cotton · Samer Q Noaman

the Editor: In August 2012, a 43-year-old woman presented to her general practitioner with extensive spontaneous bruising. Her only medications were Coversyl (perindopril) 5 mg daily for hypertension and Rhodiola rosea extract. Laboratory testing revealed prolonged coagulation times (Box 1). Mixing studies (50 : 50 patient and normal plasma) showed complete correction of the activated partial thromboplastin time and international normalised ratio (INR) and no evidence of a ...

Duncan P Carradice · Ellen L Maxwell

To the Editor: Peripheral intravenous catheters (PIVCs) frequently cause Staphylococcus aureus bacteraemia, and a disproportionate number of episodes involve catheters that have been left in place for ≥ 4 days or have been inserted in emergencies.1 Other studies have shown similar results with catheters left in place for > 48 hours or not routinely replaced after emergency placements.2-4 At Canberra Hospital, we have followed all bloodstream infections (BSIs).5 Since 2002, ...

Peter J Collignon · Fiona J Kimber · Wendy D Beckingham · Jan L Roberts

In reply: We thank Collignon and colleagues for their letter regarding our study on peripheral intravenous catheter (PIVC)-associated Staphylococcus aureus bacteraemia.1 We agree with their comments. Both their data and ours support the potential importance of establishing a national standard for the insertion and management of PIVCs in Australia. Such a standard needs to address the basics of PIVC management: not inserting PIVCs unless required;2 ...

Rhonda L Stuart · M Lindsay Grayson · Paul D R Johnson

In reply: It is untrue that new recommendations for clinically indicated peripheral intravenous catheter (PIVC) replacement are based on phlebitis alone. A Cochrane systematic review considered catheter-related bloodstream infection (BSI) data from five randomised controlled trials (4806 patients) and found no evidence for the effectiveness of routine replacement (P = 0.64).1 The largest trial (3283 patients) studied both catheter-related BSIs and all-cause BSIs, finding no disadvantage to clinically ...

Claire M Rickard · Joan Webster · E Geoffrey Playford

To the Editor: In their review, Harris and Buchbinder call for a ban on all spinal injections of steroids.1 These injections are not a singular procedure; they differ by indications, technique, and the evidence that serves each. For the treatment of low back pain, no evidence supports the use of epidural steroids, and intra-articular injections of steroids are clearly no more effective than sham therapy.2 Disavowing ...

Nikolai Bogduk

To the Editor: We thank Harris and Buchbinder for their focus on interventional pain procedures.1 However, their description of the procedure they discuss has not been standard practice in pain medicine in Australia for many years. They misrepresent the Medicare Benefits Schedule (MBS) number 39013 to solely include facet joint injections, whereas it includes local anaesthetic medial branch blocks, which are an evidence-based diagnostic test for posterior elements as a source of spinal pain, and can be therapeutic in their own right.2 The number needed to treat (NNT) is the number of patients that need to be treated for one to benefit compared with a placebo or sham in a clinical trial. The ideal NNT is one. After a positive medial branch block response, radiofrequency medial branch neurotomies — a procedure with an NNT ranging from two patients3 to 4.4 patients4 treated for one patient to receive effective relief of spinal pain — creates a “therapeutic window” in which ongoing spinal rehabilitation can occur. From the 35 000 MBS number 39013 procedures performed in 2012, we can infer that fewer than 0.5% of Australians with spinal pain have facet joint injections and medial branch blocks in a 12-month period. Contrary to the comments of Harris and Buchbinder, lumbar transforaminal epidural steroid injections are effective for the treatment of radicular pain associated with disc protrusion, with an NNT of 2.7,5 and in conjunction with active pain strategies may forestall spinal surgery. Before impeaching facet joint injections and medial branch blocks, and thereby medial branch neurotomies, as well as lumbar transforaminal epidural steroid injections, Harris and Buchbinder should consider: interprofessional patient-centred approaches are key; pharmacological management is often ineffective; their view does not reflect the current practice of Australian pain medicine physicians; these procedures help people struggling to continue in social roles and maintain quality of life, so they help to reduce the economic impact of spinal pain on Australian society. We support education to improve evidence-based practice of interventional procedures.

Stephanie J Davies · Malcolm N Hogg · Eric J Visser

In reply: We thank Bogduk for his comments, but, based on previous reviews and some comparative studies,1-4 do not consider the transforaminal route to be clearly and consistently superior to the interlaminar route for radiculopathy. Further, we note that when the evidence for transforaminal injections is isolated to placebo-controlled trials, the evidence is based on very few studies. The largest of these showed marginal short-term (2-week) improvement in the steroid and local anaesthetic group over the saline group for the primary outcome (leg pain), an effect that was not sustained by 4 weeks.5 Short-term relief is a common finding in studies that use local anaesthetic in the active group. We consider the evidence for the effectiveness of transforaminal steroids over placebo to be neither strong nor consistent (within or between studies). We suggest that the gem in the bathwater be subject to more scrutiny and weighed against the risks and costs. We thank Davies and colleagues for their comments about medial branch blocks and transforaminal epidural steroid injections. We have addressed the latter in our response above. Our article does not extend beyond the use of steroids to procedures such as neurotomy, so we have not commented on this procedure here. Regarding medial branch blocks, we note that in a systematic review mentioned by Davies and colleagues, each of the randomised trials showed no significant difference in the response between groups treated with steroid and those treated with local anaesthetic alone.6 This reinforces our point that steroid injections in the spine have no specific therapeutic effect beyond natural history, the effect of any concomitant treatment or any placebo effect.

Ian A Harris · Rachelle Buchbinder

To the Editor: Silbert and colleagues highlight the benefits of peer-assisted learning (PAL).1 They allude to the number of overseas medical schools that provide tutor training programs, and to the possibility that Australian medical students are missing out on this opportunity. We agree that PAL is useful, but not all Australian medical students have been deprived. Since 2008, Monash University has been running VESPA (Vertical ...

Joanna H-M Tai · Sumudu P Cooray · Jonathan K Kam

To the Editor: Silbert and colleagues propose that teaching skills training should be compulsory for all medical students, to be used in peer-assisted learning programs and later in postgraduate roles.1 As the quality of student training will have an enduring impact on the provision of quality care and patient safety, the responsibility for this important role should be entrusted to a select group rather than ...

Michael Pearson

To the Editor: The articles by Hu and colleagues1 and Silbert and colleagues2 highlight the imperatives for medical educators. The future requires the ability to teach as a distinct set of skills that need to be identified early and then encouraged throughout one’s career. Silbert et al advocate a comprehensive, vertically integrated student teaching program using peer-assisted learning (PAL).2 The Royal Australasian College of Surgeons ...

Stephen A Tobin · David J Hillis · Julian A Smith

In reply: We agree that the quality of student training and competence of those delivering it are of utmost importance. However, we disagree with Pearson’s opinion that teaching “should be an honour bestowed on a few rather than a rite or obligation for all” and that only these “honourable few” should be trained.1 Involvement in any teaching confers benefits to both tutors and tutees1-3 and, ...

Benjamin I Silbert · Stephanie J P Lam · Robert D Henderson · Fiona R Lake

To the Editor: I thank Cameron and colleagues for their timely report,1 particularly in the context of publicity for a new self-help book by economist Emily Oster, which questions advice about avoiding alcohol during pregnancy.2,3 I note with interest that Cameron et al’s study reports that proportionally more of the women who consumed alcohol beyond the first trimester were older and more highly educated. Oster has ...

Tracy W Soh

Medicinal cannabis is effective and safe, but the NSW Government remains unwilling to recognise this

Laurence E Mather PhD, FANZCA, FRCA · Evert R Rauwendaal BSW · Vivienne L Moxham-Hall BA, BSc, MHealthPol · Alex D Wodak AM, FRACP, FAChAM, FAFPHM

Guidelines with bite: managing a potentially life-threatening condition

Geoffrey K Isbister BSc, FACEM, MD · Simon G A Brown MB BS, PhD, FACEM · Colin B Page MB ChB, FACEM, MMedSci · David L McCoubrie MB BS, FACEM · Shaun L Greene MB ChB, MSc, FACEM · Nicholas A Buckley MD, FRACP

Objective: To examine comparable survey data across 10 years to assess whether rates of self-reported weapon carrying and intent to harm others have increased as suggested in reported trends in violent offences.Design, setting and participants: Population-based surveys administered to Victorian secondary school students in 1999 (8984 students) and 2009 (10 273 students) attending government, Catholic and independent schools.Main outcome measures: Student self-reports of carrying a ...

Sheryl A Hemphill BBSc(Hons), PhD · Michelle A Tollit BPsych(Hons), MEdPsych · Helena Romaniuk BSc, MSc, PhD · Joanne Williams BSc(Hons), MAppEpid, PhD · John W Toumbourou MA, PhD · Lyndal Bond PhD · George C Patton MD, MB BS, FRANZCP

Survivors of terrorism need counselling and easily accessible government support

Garry J Stevens BSc(Hons), MClinPsych · Julie C Dunsmore BSc(Psych)(Hons), MPH, MAPS · Kingsley E Agho BSc(Hons), PhD, MPH · Melanie R Taylor BSc(Hons), PhD, CPsychol · Alison L Jones MD, FRCP, FRCPE · Beverley Raphael MB BS, MD, FRANZCP

Half of asylum seekers needed ED care in 2011, suggesting primary health care in closed detention is lacking

Adrienne K Deans MB BS, FRACGP, FACEM · Clare J Boerma MB BS · James Fordyce MB BS, MPH, FACEM · Mark De Souza MB BS, FACEM · Didier J Palmer FRCP, FRCS, FACEM · Joshua S Davis MB BS, FRACP, PhD

What stops students losing interest in a rural career?

Tyler R Clark BA, MA · Saul B Freedman FCSANZ, FACC, FESC · Amanda J Croft BBus(AgrCom) · Hazel E Dalton BSc(Hons), PhD · Georgina M Luscombe BSc(Hons), PhD · Anthony M Brown MPH, FAFPHM, FAFOEM · David J Tiller MB BS, FRACP · Michael S Frommer MB BS, FAFPHM, FAFOEM

Western opera is, perhaps not surprisingly, rife with suicidal deeds and thoughts

Saxby A Pridmore MB BS, MD, FRANZCP · Stephane Auchincloss MB BS, MRCP, FRANZCP · Nerissa L Soh BMedSc, MNutrDiet, PhD · Garry J Walter MB BS, PhD, FRANZCP

Benefits go beyond the competencies achievable with adequate supervision and mentoring

Louise Young MPsychEd, PhD · Sarah L Larkins MB BS, MPH · Tarun K Sen Gupta MB BS, FACRRM, PhD · Suzanne H McKenzie MB BS, MMedSci, FRACGP · Rebecca J Evans BSptExSci(Hons), GradCertGovernancePolicy · Michael J Crowe BSc(Mgmt), MIT, PhD · Elizabeth J Ware BSc, DipEd, GradCertClinEd

A previously unknown effect of watching the State of Origin

Michael H Toon BPharm, MB BS(Hons) · Martin R Brown MB BS, MRCP, FRACP

We report the first and only known case of envenoming by the Lake Cronin snake (Paroplocephalus atriceps), which is closely related to Hoplocephalus spp. A 24-year-old man was bitten while photographing the holotype of the species. He developed venom-induced consumption coagulopathy but no neurotoxicity or myotoxicity, similar to the clinical features of Hoplocephalus envenoming. He was treated with polyvalent antivenom and made a full recovery.Clinical ...

George E Allen BSc, MB BS · Steve K Wilson · Geoffrey K Isbister BSc, FACEM, MD

We describe the case of a 35-year-old woman who presented to a remote Northern Territory hospital with severe metabolic acidosis after a 10-day solo bush walk, during which she survived on various specimens of “bush tucker” including a cane toad.Clinical recordAn otherwise fit and healthy 35-year-old woman presented to our emergency department at a remote Northern Territory hospital with vomiting and abdominal pain. An independent ...

Sarah Wongseelashote MB BS, BMedSc · Simon Quilty FRACP, MPhilPH · Malcolm Johnston-Leek FACEM

A qualified, culturally competent Aboriginal and Torres Strait Islander health workforce is vital for making a difference to Indigenous health

Romlie Mokak BSocSci, GradDipSpecEd

Medical involvement in sport and training should not focus only on the elite athlete

John Best AO, MD BS, PhD, DSc(Hon)

A fragile life opens a new dimension to family love

John S Whitehall FRACP

Medical students have been teaching their colleagues for generationsIn 2013, Silbert and colleagues have taken a “modern” look at students teaching their colleagues.1 Eighty-nine years ago, my father failed anatomy. During his repeat year, the students at his dissection table asked him, their more “experienced” colleague, for help. That year, he passed anatomy with a distinction. After gaining his Fellowship of the Royal College of Surgeons (FRCS) ...

Peter C Arnold BSc, MB BCh, BA

Stephen R Leeder

(a friend, his son) “They said I should beam protonsinto his brain fuzzy with morphine and painin the room where he hung on shadows of life, side by sidewith death waiting for me that I might see his smilea last time. Where have you gone beamsof particles or light or waves that my son could not ride youback to this world. They said I should ...

Meir Weksler PhD

Peter Thomson was born on 12 June 1940 in Esher, near London. His mother May was a highly trained registered nurse. His Australian-born father, George Macdonald Thomson, was a medical graduate from the University of Sydney who qualified and practised as a surgeon in England in the 1930s until he was conscripted into the British Army in World War II. Peter and the rest of the family ...

George Thomson

Thomas (Tom) Trauer was born in Manchester, England, on 10 November 1944. Although his Jewish parents had escaped the Holocaust, few of their wider family survived and, as an only child, Tom became the sole member of his generation. Previously qualified in Prague, Tom’s father Robert repeated his medical degree in Adelaide in order to practise in Australia, and the family settled in St Kilda. While ...

James M Trauer

Anthony Radford was the inaugural professor of primary care at Flinders University in Adelaide, South Australia. Before and after that appointment, he accumulated a total of 50 years of experience in Papua New Guinea (PNG). Radford first went to that country as a student in 1951; from 1963 to 1972, he was a public health officer there; and later, he consulted on PNG for the World Health ...

Robert B Black

As the World Health Organization regularly reminds us, neither the timing nor the severity of the next influenza pandemic can be predicted. So, when avian influenza A(H5N1) virus emerged and fatal human cases were detected in a number of countries from 2003 onwards, pandemic planning took centrestage. At that time, those tasked with writing and implementing pandemic plans had no easy reference or experience to draw ...

Gina Samaan

Objective: Vitamin D has been proposed to have beneficial effects in a wide range of contexts. We investigate the hypothesis that vitamin D deficiency, caused by both aversion to sunlight and unwholesome diet, could also be a significant contributor to the triumph of good over evil in fantasy literature.Design: Data on the dietary habits, moral attributes and martial prowess of various inhabitants of ...

Joseph A Hopkinson · Nicholas S Hopkinson MA, PhD, FRCP

Objectives: To determine the incidence of patients presenting to a major metropolitan hospital after experiencing syncope at church, and to compare their outcomes with those of patients experiencing syncope at other locations.Design, setting and participants: A retrospective matched cohort study in which patients presenting with church syncope between July 2009 and June 2013 were compared with controls (patients presenting after syncope experienced elsewhere) matched by ...

Biswadev Mitra MB BS, PhD, FACEM · Andrew J Tagg BSc, MB BS, MRCS · Elyse Fyfe · Gerard M O’Reilly MB BS, FACEM, ASTAT

Objective: To test the popular assertion that bald men are more virile than their well thatched contemporariesDesign, participants and setting: Secondary analysis of data from a case–control study in a community setting between 1994 and 1997 among men below the age of 70 years, using in-person interviews and categorisation of baldness, with subsequent completion of a questionnaire by the participant. We analysed risk factors for baldness ...

Rodney D Sinclair MB BS, MD, FACD · Dallas R English BSc, MS, PhD · Graham G Giles PhD

Objective: To examine the effect of an education campaign based around a gold coin fine on ordering of C-reactive protein (CRP) tests.Design and setting: A retrospective analysis of CRP test ordering before and after the intervention in the emergency department (ED) of a tertiary referral hospital in metropolitan Sydney that sees about 60 000 patients per annum. The date of the intervention — 2 August 2013 — ...

James L Mallows MB BS, FACEM

Sometimes a special patient brings colour to clinicLoaded down with four volumes of medical records, I struggled into the clinic room to see the next patient. Beaming from under a bowler hat covered with silver glitter, a plump, dishevelled woman greets me enthusiastically: “Hello, I’m Harriet! Are you my new neurosurgeon?” There is clear fluid dripping from the tip of her nose, and throughout the ...

Rosalind L Jeffree MSc, FRACS, MHE

We offer an alphabetical guide into the opaque and mystical world of researchMany are called to do research, but few are chosen. How is this possible in an era of improved gender equality, educational access and global connectivity? The answer lies in the secret “Da Vinci Code” of research: the unwritten interpretation of the alphabet of research that touches us all through serial rejection of ...

Dominic A Fitzgerald MB BS, PhD, FRACP · David Isaacs MB BChir, MD, FRACP · Steve Isaacs MB BChir, MRCP, MRCPsych

A newborn child’s critical illness changes his mother’s perspective on her own medical careerOn a cold Monday night in late winter, I pulled on my scrubs, packed my lunch and crept quietly into the small, cosy room my children share. My daughter was lying rumpled and skewiff in her big bed, covers thrown back, her little nappy-clad bottom in the air. I moved to the ...

Kristin J Boyle MB BS

CorrectionIncorrect footnote: In “Australia is continuing to make progress against cancer, but the regional and remote disadvantage remains” in the 4 November 2013 issue of the Journal (Med J Aust 2013; 199: 605-608), there was an error in Box 2 (page 607). There should be two separate footnotes for Box 2A and Box 2B: the footnote to Box 2A should state “Based on age- and sex-specific rates for ...

Michael D Coory MB BS, PhD, FAFPHM · Tsun Ho BE(Hons), PhD · Susan J Jordan MB BS, PhD

It’s the holiday season again. But before packing any bags, what are the best steps to ensure continuity of care for your patients and your practice’s wellbeing while you are away?

Annabel McGilvray

MÉDECINS Sans Frontières (MSF) has released a series of films entitled See what we see, highlighting the continuing need for funding and resources directed at HIV/AIDS.1 http://see.msf.org/

Cate Swannell

Anaesthetist Dr Kevin Baker has travelled the world’s war zones, patching up broken bodies and mentoring young people to do the same. It’s rewarding, life-changing work.

Cate Swannell