Volume 208 Issue 4

We need to improve bureaucratic behaviour in health services research

Robyn Clay-Williams · Natalie Taylor · Jeffrey Braithwaite

Oral health cannot be isolated from physical or mental health and should form part of comprehensive care

Steve Kisely · Ratilal Lalloo · Pauline Ford

Insulinoma is a rare cause of hypoglycaemia but should be considered in the differential diagnosis of persistent hypoglycaemia

Hui Yi Ng · Alexia Pape

A 37-year-old woman admitted for elective reduction mammoplasty developed stridor after extubation

Clarissa Susanto

Medical education is a rapidly developing field requiring specific research approaches to provide evidence that can effectively translate into clinical practice

Lambert WT Schuwirth · Steven J Durning

Choosing the right statistical test or model can be baffling for researchers

Alissa Beath · Michael P Jones

The evidence that reducing trading hours reduces alcohol-related violence is compelling

Diana Egerton-Warburton

Helping the homeless is a social imperative that benefits the homeless — and the community as a whole

Adam Steen

High rates of substance use and mental disorder among homeless people in inner Sydney confirms the need for increased access to treatment for these conditions in this setting

Olav B Nielssen · William Stone · Naidene M Jones · Sarah Challis · Amelia Nielssen · Gordon Elliott · Nicholas Burns · Astrid Rogoz · Lucy E Cooper · Matthew M Large

Numbers of violence-related orbital fractures and fractures requiring surgery are lower, saving an estimated $464 000

Ryan F Holmes · Thomas Lung · Gordian WO Fulde · Clare L Fraser

New guidelines promote a broader approach to the diagnosis and management of depression

Gin S Malhi · Tim Outhred · Amber Hamilton · Philip M Boyce · Richard Bryant · Paul B Fitzgerald · Bill Lyndon · Roger Mulder · Greg Murray · Richard J Porter · Ajeet B Singh · Kristina Fritz

Early identification of GBS patients at risk of respiratory failure could reduce the rates of adverse outcomes associated with delayed intubation

Cameron Green · Tess Baker · Ashwin Subramaniam

To the Editor: We read the article by Newby and Andrews1 with great interest and wholeheartedly agree with both the prevalence of health anxiety and the effectiveness of cognitive behaviour therapy. We would add that, firstly, the scope of this problem is not confined to the primary care practitioner, and secondly, cognitive behaviour therapy can also be used to treat psychosomatic symptoms not just health anxiety.2 A proportion of medically unexplained symptoms are psychosomatic or functional in origin.3 Functional symptoms are those experienced by patients due to a problem in the nervous system or other organs not functioning appropriately, in the absence of structural abnormalities or pathological changes. Studies estimate that 15% of patients seen in a standard neurology practice are diagnosed with a functional disorder.4,5 These symptoms and syndromes are also common in other specialties; for example, irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, idiopathic chronic cough, idiopathic chronic pelvic pain and globus pharyngeus, to name a few.6 The successful management of functional neurological disorders requires careful assessment of the patient’s history, presentation and investigation findings, followed by an honest clear discussion of the diagnosis and treatment options.7,8 A good explanation of the symptoms to a patient with a functional disorder — while reassuring them of the validity of their symptoms — is vital to ensure successful treatment.7,8 Metaphorical descriptions are often used in the neurological explanation of functional disorders (eg, “the hardware is fine, but there is a software problem”).7 We find that emphasising to the patient that functional symptoms are common and often reversible and that self-help is a key part of getting better also assist in empowering the patient. We direct the reader to well written articles about components of a good explanation.5-8 Finally, we often educate the patient about basic cognitive behaviour therapy concepts, including challenging negative thoughts, distraction techniques and mindfulness, as strategies to deal with or terminate the symptoms. Once this is done, patients are often more receptive to psychology or psychiatry referrals for further work. Our experience with educating and empowering patients with these strategies is that they often lead to successful treatments and grateful patients.

Benjamin Nham · Anna Williard

To the Editor: We commend Cohen and colleagues1 on their recently published study, which is the largest randomised controlled trial (RCT) of acupuncture in the emergency department (ED). We recently completed a systematic review and meta-analysis on the role of acupuncture for analgesia in the emergency setting.2 Our meta-analysis incorporated 19 RCTs and included non-English language publications. The trial by Cohen and colleagues1 was not published at the time of our review; however, it strengthens our main conclusion that acupuncture was non-inferior to standard analgesia in the emergency setting. We also found similar evidence of improved patient satisfaction. It was interesting that the authors reported an adverse effects rate of 51% for acupuncture, whereas our study found an overall rate of 5%, with significant adverse effects being 1%. Our figures are consistent with other reviews3 and almost certainly highlight the difficulties in developing agreed definitions on adverse effects in acupuncture. Our review found that acupuncture in two out of four RCTs decreased pain medication requirements, whereas Cohen and colleagues’ study had the potential to inform this outcome, but did not report such data. The study by Cohen and colleagues1 illustrates many of the challenges in acupuncture trials, including having no sham comparator group. Some acutely painful conditions might resolve simply because of time or careful patient attention. Sham acupuncture is difficult to deliver as a control4 and needs to be plausible, realistic and, if possible, blinded. Our meta-analysis showed acupuncture to be superior, with clinically significant reductions in acute pain scores compared with sham. This latest significant RCT gives further impetus to carefully designed research on acupuncture in the emergency setting, which will require acupuncture techniques applicable to the time-constrained ED environment (eg, ear acupuncture), provision of a suitable sham acupuncture technique, and minimisation of assessment bias. We suggest that the specific outcomes to be assessed should include the impact of acupuncture as an adjunct to standard analgesia, side effects recorded using standard definitions, and reductions in medication use. Most importantly, the analgesic effect of acupuncture is unlikely to be equal for all pain presentations in the emergency setting and, therefore, the conditions for which its role is most beneficial need to be delineated.

Andrew L Jan · Ian Rogers · Eric J Visser

To the Editor: The conclusions made by Cohen and colleagues1 can be challenged on the basis of study design and results. A significant flaw in the design is that of all patients not excluded due to additional medical problems, 38% of potential study participants declined to be included, possibly because they were not prepared to be assigned to the acupuncture-only arm. This flaw introduces a critical bias when analysing the 62% who did participate, as it is reasonable to assume that they are statistically more inclined to experience a placebo benefit from acupuncture and more likely to be positive at 48 hours about repeating this therapy. Even with this bias, however, the results of the study do not support a broad interpretation of non-inferiority, given that 39% of acupuncture-only patients required rescue therapy at or after one hour, compared with 22.5% of pharmacotherapy-only patients. In the context of an emergency department (ED) and patients with mean verbal numerical rating scale score of 8.5 at presentation, this difference in pain reduction and satisfaction with the initial therapy during the first hour of treatment should render the acupuncture-only option unacceptable. The authors have selectively and speculatively interpreted their data to support their enthusiasm for acupuncture. Results for patients with migraine are given minimum discussion or reference in the conclusions. The inferior performance of acupuncture-only patients’ willingness to repeat the therapy at one hour is dismissed as being influenced by patients’ concerns about length of stay and transport arrangements, whereas they indicate that the same parameter at 48 hours is more meaningful. I suggest that the results at one hour more accurately reflect a patient’s experience of their pain and desire for abatement, whereas the improved satisfaction at 48 hours is the result of shifted perspective following self-resolution — in a selected patient population with an existing positive bias for acupuncture. The authors’ suggestion that acupuncture use in EDs would reduce opioid addiction is an opportunistic grab at exploiting popular sentiment among people who do not understand the causes and parameters of this serious problem. This article does not support diversion of resources towards acupuncture use in EDs or a change in evidence-based treatment protocols in emergency medicine.

Anitra J Wenden

In reply

Marc M Cohen · Michael Ben-Meir · Nick Andrianopoulos

The following study was conducted independently of the MJA. The MJA has not verified the accuracy of the data

Yassar Alamri · Mohamud Osman

To the Editor: After reading the recent article by van Driel and colleagues,1 we want to report on hepatitis C treatment outcomes in a Sydney general practice. New direct-acting antiviral (DAA) therapy for the treatment of chronic hepatitis C became widely available in Australia on 1 March 2016 via the Pharmaceutical Benefits Scheme, and general practitioners are able to prescribe it in consultation with a specialist. We describe here the treatment outcomes from the first 60 days of DAA prescribing in a single general practice clinic. We searched the clinic database to extract demographic and clinical data for all patients prescribed DAA from 1 March to 30 April 2016. We found that 47 patients had been prescribed DAA agents by a GP, five had received DAA therapy via an early access program, 41 had genotype 1 hepatitis C virus (HCV), six patients had genotype 3 HCV, and 11 patients had co-infection with HIV. All treated patients had an assessment of liver fibrosis performed with a FibroScan. Most patients had early liver disease, with three having cirrhosis. On 1 May 2017, we assessed the outcome data: 33 patients were treated with ledipasvir and sofosbuvir (all had genotype 1 HCV), nine were treated with daclatasvir and sofosbuvir (three had genotype 1 HCV, and six had genotype 3 HCV), and five patients were treated with paritaprevir + ritonavir + ombitasvir + dasabuvir (all had genotype 1 HCV). Forty-six patients had started treatment, with sustained virological response (SVR16; ie, undetectable virus 16 weeks after the end of treatment) results available for 45 patients. One patient had treatment failure, one had not started treatment and one patient was waiting on SVR results. On-treatment SVR (cure) rate was 96%. A steadily increasing percentage of patients in Australia are receiving hepatitis C treatment prescribed by their GPs, with 19% of prescriptions provided in this setting in September 2016.2 GPs are well placed to provide care for patients living with chronic hepatitis C, with reassuringly high cure rates.

David Baker · Marilyn McMurchie · Vanessa Farr

Professor Marc Cohen believes in putting complementary medicine to the test and then using what works to help patients

Cate Swannell

This calendar will be updated each month. If you have an event you would like to add, please include relevant details in an email to cswannell@mja.com.au. The full version of the calendar is available online at https://www.mja.com.au/careers

Cate Swannell