Letters

Biswadev Mitra,* Peter A Cameron† * Registrar in Emergency Medicine, Emergency and Trauma Centre, The Alfred Hospital, Commercial Road, Melbourne, VIC 3004. † Professor of Emergency Medicine, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC. b.mitraATalfred.org.au To the Editor: We congratulate Kaye and colleagues on their efforts to educate and influence prescribing practice in reducing the use of pethidine.1 The adverse effects of pethidine and its lack of efficacy over other opiates have been known and taught since the early 1990s.2 A decade on, we are still seeing significant use of this drug,3 which has multiple disadvantages when compared with other opioid analgesics. The difficulty lies in doctors’ attitudes to quality improvement and change in health care. It has been noted that doctors’ responses to concern about the quality of health care range widely, from opposition to whole-heartedly embracing legitimate opportunities for improvement.4 While there is such variance, the implementation of evidence-based medicine into practice will lag, sometimes by decades, resulting in unnecessary adverse effects in patients. With clinical guidelines in place, a rigorous education campaign and many hours of research time and resources, Kaye and colleagues have significantly reduced, but not eradicated, pethidine prescribing in New South Wales. In comparison, O’Connor et al report combining a similar educational program with formulary restrictions to effectively eliminate the use of meperidine (pethidine) in their single centre study.5 We can only conclude that clinical evidence, even when combined with quality improvement campaigns, remains less effective than policy changes which restrict doctors’ behaviour. From available evidence, the liberal use of pethidine may cause adverse effects which are preventable by a simple system-oriented approach — in this case, the appropriate risk-management step is restricting pethidine use to very limited situations. We cannot continue to justify use of a drug with poor efficacy, toxicity and serious drug interactions. Pethidine prescribing as a percentage of total narcotics in Launceston General Hospital emergency department, 1992–2004 Note: data not available for some quarters.

Biswadev Mitra · Peter A Cameron

Paul Pielage Director of Emergency Medicine, Launceston General Hospital, Charles Street, Launceston, TAS 7250. paul.pielageATdchs.tas.gov.au To the Editor: I was interested to read the article by Kaye and colleagues about reducing pethidine use in the emergency department by means of evidence-based prescribing.1 In view of published reports describing the disadvantages of pethidine, it was decided in late 1996 to attempt to reduce the amount of pethidine prescribed in the emergency department of Launceston General Hospital. Narcotics were supplied as ampoules of 100 mg pethidine, 10 mg morphine, 15 mg papaveretum (the use of which was trivial) and fentanyl, which was used mainly for anaesthetic induction. Before mid-1996, 50%–72% of all ampoules of narcotics used in the emergency department were of pethidine. Of narcotics used for acute pain management, pethidine would have been much higher as a proportion because it was not used for acute pulmonary oedema, ischaemic myocardial pain, anaesthetic induction and in patients being ventilated. The use of narcotics was monitored by quarterly reports from the pharmacy department of the quantities of the various parenteral narcotics supplied to the emergency department. Papaveretum was removed from the pharmacopoeia in 1999. In 1996, an informal education program was instituted within the emergency department, strongly supported by the nurses, with the aim of convincing junior medical staff on rotation from other areas within the hospital to prescribe morphine rather than pethidine. It had long been observed that such staff prescribed pethidine almost exclusively for acute pain management, and a cultural change was required. As shown in the Box, the percentage of narcotics dispensed as pethidine was steadily reduced over the following years, reaching 5% in 2002. After 2 years at this level it was decided to remove pethidine from the pharmacopoeia. In February of 2005, hydromorphone was introduced and pethidine removed. There have been no complaints or problems as a result, and the whole process was unexpectedly painless and successful.

Paul Pielage

Karen I Kaye,* Susan A Welch,† Linda V Graudins,‡ Andis Graudins,§ Tai Rotem,¶ Sharon R Davis,** Richard O Day†† * Executive Officer, ** Research and Liaison Officer, NSW Therapeutic Advisory Group, PO Box 766, Darlinghurst, NSW 2010. † Senior Pharmacist, †† Director, Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW. ‡ Medication Safety and Quality use of Medicines Pharmacist, Sydney Children's Hospital, Sydney, NSW. § Emergency Physician and Director, Clinical and Experimental Toxicology Unit, Prince of Wales Hospital, Sydney, NSW; and Senior Lecturer (Conjoint), University of New South Wales. ¶ Statistician, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW. nswtagATstvincents.com.au In reply: As Mitra and Cameron point out, policy change can be effective in influencing prescribing practice. Indeed, use of a restrictive formulary is a strategy used by drug and therapeutics committees in most Australian hospitals. However, where support among clinicians for policy change is lacking, significant time and effort is required by those responsible for policy implementation. Confrontation and lack of interdisciplinary cooperation can be expected. Quality use of medicines (QUM) means selecting management options wisely, choosing suitable medicines if a medicine is considered necessary, and using medicines safely and effectively. Australia is fortunate in having a National Medicines Policy1 and a national strategy for QUM.2 This strategy recognises the importance of active and respectful partnerships, and of consultative, collaborative, multidisciplinary activity to improve the quality use of medicines. To attain QUM, “. . . key partners must be involved at all stages in designing, implementing and evaluating QUM programs . . . Multiple activities and strategies are needed to raise awareness about issues related to QUM. Attitudes, knowledge, skills and behaviours that support QUM need to be developed and maintained”.2 Our approach was based on these principles. Pielage provides another example of the successful use of this approach to limit pethidine prescribing in a large teaching hospital, which should be applauded. Doctors, pharmacists, nurses and consumers are important partners in QUM. An educative, multidisciplinary approach that respects each partner is the most appropriate way to ensure sustained practice change and promote QUM in hospitals and the wider community.

Karen I Kaye · Susan A Welch · Linda V Graudins · Andis Graudins · Tai Rotem · Sharon R Davis · Richard O Day

Susan F Hurley Associate Professor, School of Population Health, University of Melbourne; and Health Economics Consultant, Bainbridge Consultants, 532 Brunswick St, North Fitzroy, VIC 3068. susanhurleyATbainbridgeconsultants.com To the Editor: Previous analyses of costs to the Pharmaceutical Benefits Scheme and costs for stroke and acute myocardial infarction hospitalisations suggest that tobacco control programs are a good investment.1,2 To further highlight the economic benefits of reducing smoking rates, I estimated the hospitalisation costs attributable to cigarette smoking in Australia for 2001–2002 by applying aetiological fractions to hospitalisation data.3 Aetiological fractions were calculated using 2001 National Health Survey smoking prevalence data and relative risks of hospitalisation for current and former smokers, as previously calculated by English and colleagues through linkage of data from the Busselton health survey and the Western Australian Hospital Morbidity Data system.4 Counts of separations (hospitalisations), bed-days, and average costs for hospitalisations in Australia in 2001–2002, by sex and 5-year age category, were obtained from the Australian Institute of Health and Welfare. They had been sourced from the National Hospital Morbidity Database (http://www.aihw.gov.au/hospitals/nhm_database.cfm) and the National Hospital Cost Data Collection (http://www.health.gov.au/casemix), linked by the common variable “DRG4.2”. The results (Box) show that, in 2001–2002, almost 300 000 hospitalisations, costing $682 million, were attributable to cigarette smoking. English and colleagues estimated previously that, in 1992, 129 000 hospital separations and over 1.1 million bed-days were attributable to cigarette smoking.4 Although the proportion of the Australian population who are smokers has decreased since then, from 26% to 23% in 2001,5 cigarette smoking is still associated with substantial health care utilisation and costs. The actual costs are even greater than the $682 million per annum estimated by my analysis, as the following were not considered: hospitalisation costs for those aged 80 years and over; pharmaceutical costs (estimated at $126 million for cardiovascular drugs on the Pharmaceutical Benefits Scheme1); community care costs (such as general practitioner visits); and patient contributions to hospitalisation costs. In stark contrast to the $682 million spent on hospitalisations attributable to smoking, the Australian Government has committed an average of only $2 million per year over the last 10 years to tobacco harm minimisation programs.6 Hospitalisations, bed-days and costs attributable to cigarette smoking in Australia in 2001–2002* Hospitalisations Bed-days Costs† Proportion Number Proportion Number Proportion $ (millions) Men 7.6% 138 000 14.6% 891 000 7.6% $339 Women 8.6% 153 000 9.8% 581 000 8.6% $342 Total 8.1% 291 000 12.2% 1 472 000 8.1% $682 * For people aged 40–79 years. † Estimated costs are conservative, as they are based on average cost per hospitalisation for the total population. However, the higher proportion of bed-days than hospitalisations attributable to smoking suggests smokers tend to have longer stays and thus higher than average costs.

Susan F Hurley

Huy A Tran Director, Hunter Area Pathology Service; and Associate Professor, Department of Clinical Chemistry, University of Newcastle, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Centre, NSW 2310. huy.tranAThnehealth.nsw.gov.au To the Editor: The recent article by Roberts et al1 requires further comment. In anorexia nervosa, hypercalcaemia is extremely unusual because patients are likely to be under- or malnourished, with consequent hypocalcaemia and hypovitaminosis D, rather than the opposite, as implied by the authors. In one of their references,2 hypercalcaemia is only briefly included, and the mechanism is not discussed or substantiated. Another of their references3 does not include hypercalcaemia at all as a metabolic disturbance. In addition, hypercalcaemia in itself is not a diagnosis, and indicates a significant underlying pathophysiological disturbance whose differential diagnoses need to be carefully dissected. Where there are problems with the interpretation of calcium homoeostasis, such as renal impairment and hypoalbuminaemia, ionised calcium should be measured because it is the physiologically active agent. In the first patient described by Roberts et al, although the investigations are incomplete, primary hyperparathyroidism (PHPT) needs to be carefully considered, as the parathyroid hormone (PTH) level is not normal in the setting of hypercalcaemia. The normal physiological response would dictate that the PTH level should be low to suppressed. Nephrocalcinosis and renal impairment then fit snugly into the diagnosis of PHPT.4 Phosphate level, expected to be low in this condition, might have been masked by exogenous phosphate supplement. For Patient 2, stool electrolyte analysis could further support the presence of laxative misuse and aid in the interpretation of urinary results. Faecal fluid in this situation should be high in sodium, potassium and calcium concentrations. The low urinary sodium and calcium levels are therefore appropriate, and indicate relatively intact tubular function. The diagnosis of hypercalcaemia is thus difficult without a PTH measurement and in the presence of gastrointestinal confounders, even if all investigations were available. Nevertheless, familial benign hypocalciuric hypercalcaemia (FBHH) is a strong probability given the low urinary calcium excretion, especially before iatrogenic manipulation of calcium and phosphate homoeostasis. Nephrocalcinosis can theoretically occur in FBHH.5 It is important that the diagnosis is made in both cases, so that a familial study can be carried out if indicated given the patients’ age. One may also wonder if the intermittent hypercalcaemia contributed to or aggravated the psychiatric disturbance in both patients.

Huy A Tran

Matthew A Roberts,* Campbell R Thorpe,† Duncan P MacGregor,‡ Nick Paoletti,§ Francesco L Ierino¶ * Nephrologist, ‡ Director of Anatomical Pathology, § Psychiatrist, ¶ Deputy Director of Nephrology, Austin Health, Studley Road, Heidelberg, VIC 3084; † Psychiatrist, Child and Adolescent Mental Health Service, The Alfred Hospital, Melbourne, VIC. frank.ierinoATaustin.org.au In reply: Disturbances of calcium metabolism in anorexia nervosa are complex, particularly with associated renal insufficiency. Although hypocalcaemia is observed in patients with anorexia nervosa, our article attempted to highlight nephrocalcinosis and hypercalcaemia. We agree that hypercalcaemia is not in itself a diagnosis, and identifying the underlying pathology is essential. Ingestion of vitamin D preparation remains a likely explanation for the hypercalcaemia observed in Patient 1; however, primary hyperparathyroidism was considered as a possible differential diagnosis. Patient 1 had two normal parathyroid hormone tests in the setting of hypercalcaemia and renal impairment. This is consistent with secondary hyperparathyroidism and vitamin D ingestion as documented. The coexistence of primary hyperparathyroidism cannot be excluded. Ionised calcium may be a useful measure if the patient had hypoalbuminaemia, and this would be our normal practice. Patient 2 had ionised calcium measured twice (one result high, one low), but these added little to the case description and message of the article. Faecal electrolytes were not measured in Patient 2. However, we acknowledge the potential utility of this investigation when interpreting electrolyte disorders. We also agree that familial or genetic conditions should be considered if clinically appropriate.

Matthew A Roberts · Campbell R Thorpe · Duncan P MacGregor · Nick Paoletti · Francesco L Ierino

Alan Rodger Professor of Clinical Oncology, Beatson Oncology Centre, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, United Kingdom. alan.rodgerATnorthglasgow.scot.nhs.uk To the Editor: I note with concern that one of the authors of the article on aromatase inhibitors in early breast cancer (Nordman)1 declares under competing interests that she received an honorarium (in the form of financial support to attend a conference) “for writing this article” from a manufacturer of one of the current licensed aromatase inhibitors. It is reassuring to be informed that the company concerned had no role in the content of the article. However, is it wise and reasonable and, indeed, necessary for a medical oncology registrar to be financially rewarded by a pharmaceutical company for writing an article published in The Medical Journal of Australia about therapeutic products, one of which was developed and is now marketed by that company? Two other authors and reviewers and editorial staff were involved in this otherwise excellent article. I commend Nordman for her openness and declaration. However, I question the role of the pharmaceutical industry in rewarding medical authors in this way.

Alan Rodger

Glen Pater Director, Medical and Regulatory Affairs, AstraZeneca Australia, PO Box 131, North Ryde, NSW 1670. Glen. PaterATASTRAZENECA. COM In reply: In response to Rodger, AstraZeneca would like to reiterate that the company had no role in the content of the article published by Nordman and colleagues in the 4 July issue of The Medical Journal of Australia.1 AstraZeneca has provided Sydney Cancer Centre with an unrestricted educational grant. Along with Rodger, we commend the authors on their transparency about how this grant was applied.

Glen Pater

Duncan A Howard,* Sue D Waygood,* Sharon L Desmond† * General Practitioner, † Registered Nurse and Practice Manager, Brunswick Community Medical Centre, St Vincents Health, 11 Glenlyon Road, Brunswick, VIC 3056. duncan.howardATsvhm.org.au To the Editor: It is well known that people with serious mental health problems are more likely to suffer substantial physical health problems, or die younger, than those in the general population.1,2 We would like to report some early results from a program that is aiming to improve primary health care for people with serious mental health problems. The Stewart Lodge program was developed through cooperation between the local Moreland Community Health Service, two general practitioners and one registered nurse from the medical clinic collocated with the Community Health Service, the local area mental health service, and the managers of the Victorian Government Supported Residential Services program. The Stewart Lodge program includes a regular non-appointment doctor’s session, complete health assessments for all residents, and regular case conferences involving all carers and clinicians. Initial establishment was funded through a Victorian Government Department of Human Services GPs in Community Health Services strategy grant, which focused on improving integration and service coordination. There are around 85 people living in this community, most of whom have chronic schizophrenia or another serious mental health problem. We plan to report the findings from our program in more detail when we have completed the assessments of most Stewart Lodge residents. However, we would like to report our interim findings on vitamin D levels, which are likely to be relevant to many others in similar circumstances. Of the 30 residents tested so far, three have had vitamin D levels in the normal range (> 50 nmol/L), 20 in the deficient range, (25–50 nmol/L) and seven in the severely depleted range (< 25 nmol/L). An increased risk of low vitamin D levels has been previously reported in populations of older institutionalised people,3 and a recent position statement in the Journal on accepted levels of 25-hydroxyvitamin D (25-OHD) warned of risks of vitamin D deficiencyfor various groups in the community.4 We suggest that people with serious mental illness are another group that should be included in those at risk. The people we work with are at risk because of decreased exposure to the sun through inactivity, and because of their illness and medication. Of note, the median age of our residents is 49 years. We aim to tackle this issue by giving Vitamin D supplementation (although this is currently problematic because there is no suitable vitamin D supplement supported by the Pharmaceutical Benefits Scheme). We will be encouraging more physical activity, particularly outdoors, as this is most likely to be of overall benefit to our residents’ general health.

Duncan A Howard · Sue D Waygood · Sharon L Desmond

Biji T Kurien Senior Research Scientist, Arthritis and Immunology, Oklahoma Medical Research Foundation, 825 NE 13th Street, Oklahoma City, OK 73104, USA. biji-kurienATomrf.ouhsc.edu To the Editor: The smiley icon “ :) ” has been widely used to convey amusement, mirth or jollity in casual email communications. However, there seems to be a lack of simple icons for use by health professionals as email shorthand in different scenarios. I therefore submit the symbols shown in the Box for use by doctors and others involved in health care. All are derived by typing a combination of characters of various font sizes and other features (colour, superscript, subscript, italics, and bold), and all are in Times New Roman font except when stated otherwise. Note that it would be highly inadvisable to use a spell check feature in conjunction with these icons.1 Email icons (“emoticons”) for the health profession Symbol Meaning Bearded doctor with stethoscope around neck Curly-haired (red-haired) doctor/scientist with big moustache Nurse (face) [Characters: { in red, ital, f12; space; colon in black, bold, ital, Sp, f12; space; ” in red, bold, f8;) in red, bold, ital, f8.] Nurse (whole body) [Characters: { in red, ital, f12; space; colon in black, bold, ital, Sp, f12; space; ” in red, bold, f8;) in red, bold, ital, f8; = in yellow, f8; { in red bold f12; 3 in red f9; two colons in red, bold, f10; \ in red, ital, f8; = in green, f28; \ in green, bold, Sb, f8; = in dark red, Sb, f16; / in red, bold, Sb, f8.] Bearded doctor/scientist awestruck on having article accepted in MJA Bearded doctor/scientist awestruck on learning of receipt of Nobel Prize Mouth-to-mouth resuscitation [Characters for lips: “ in Sb, f11.] Identical twins Whole body x-ray [Characters: 8 in f9; space; O in f10; hyphen in f12; { in f12; | in f12; | in f11; | in f10; | in f8; () in f8; five colons in f12; full stop in f12; / in Sp, f12; / in f12. All in bold; convert font to white and highlight characters in black.] Acromegaly and gigantism (same as for twins, but use Courier New) Smoking [Characters for cigarette: [ and ] in bold, ital, f10; ~ in f24.] Obesity Healthy laboratory mice (Courier font) Dead laboratory mice Concerned doctors/scientists discussing experimental failure ital = italics. Sp = superscript. Sb = subscript. f = font.

Biji T Kurien

Allen E Gale Physician (Allergy), Adelaide Aerobiology Laboratory, PO Box 401, Hindmarsh, SA 5007. agaleATagale.com.au To the Editor: I have had increasing pain in my right hip over recent years, which now appears to have been caused by pressure from the lateral wing of the bucket seat in my car. The use of the right leg for both the brake and accelerator (my car is an automatic) explains why the pain is unilateral. The discomfort, which became intolerable recently when I was on holidays and driving an automatic hire-car with stiff bucket seats, was relieved by sitting on a roll of towelling! The diagnosis was finally confirmed by ultrasound. The report revealed that “a small amount of fluid was present in the greater trochanteric bursa. Pain was accurately localised to the bursa over the greater trochanter . . .”. My wife has suggested an appropriate name for the condition — “bucket seat bursitis”. She has already discovered that only three modern car manufacturers offer a flat seat as an alternative to bucket seats. I have now had the offending bucket seat wings removed at modest cost without disfiguring the seats. I wonder how commonly this condition occurs and why the old bench-type seats were replaced by bucket seats?

Allen E Gale

Joseph M Rey Professor of Child and Adolescent Psychiatry, University of Sydney, Sydney, NSW. jmreyATbigpond.net.au To the Editor: Yet another report has been published highlighting the parlous state of mental health services in Australia and the plight of the mentally ill and their families.1 In the words of Mr Keith Wilson, Chairman of the Mental Health Council of Australia, they are the “untouchable and untouched”,2 the pariahs of Australian society. Summarising the findings of the report is unnecessary, as the issues (poor access to services, lack of continuity of care, and a dwindling workforce among others) have been much in the public eye and are all too familiar to most medical practitioners. More important is whether this report will succeed in generating change for the better where scores of others have failed. The difference this time is that consideration has been given to a Commonwealth Solution:2 the Commonwealth government taking over the management and funding of these services across Australia. As state governments have made such a mess of mental health services and have repeatedly failed to sort out the well known problems, that seems an attractive option. This solution would stop passing the blame between the states and the Commonwealth, would reduce cost-shifting, may standardise (if not improve) care across Australian jurisdictions, and may result in more adequate funding. There might be light at the end of the tunnel after all. The counterbalance is that having the Commonwealth in charge of mental health services will pose new problems, least of which is the creation of a parallel health bureaucracy. One of the few achievements of the past 30 years has been the “mainstreaming” of mental illness; that is, bringing psychiatric disorders out of the asylums and into the general health services and hospitals. If the Commonwealth takes over, demarcation disputes between mental health and general health services are likely to flare up, especially in emergency departments and hospital wards. Because general health services are themselves stretched and under-funded, clinicians and administrators will be tempted or even forced to push mental health patients out of the general hospitals and try to unload anyone with psychiatric problems, whether physically ill or not, into the Commonwealth-run services. “Mental illness is no longer our responsibility”, many relieved administrators and clinicians will say. Endless arguments and meetings will ensue about where these Commonwealth-run services should be located and where patients with both mental and physical illness belong. The only way to avoid this retrograde leap would be for the Commonwealth to take over all health services — too simple and rational a solution to be adopted. As the report eloquently depicts,1 mentally ill people and their families are desperate. In that context, any change can be perceived as better than nothing, certainly better than the hopelessness that currently pervades these services. Such a solution may also be tempting to a stretched and demoralised mental health workforce.3 Can the Commonwealth be more effective or enlightened than the states? The Commonwealth’s track record of compassion, of emphasising individualism, the survival of the fittest, does not augur well for its ability to care for the mentally ill. By and large, psychiatric patients are neither the “fittest” nor the best equipped people to compete in a free marketplace. The Commonwealth does have a track record of expediency. In that context, it is not too far-fetched to imagine the now empty refugee detention centres being reconditioned into outback psychiatric facilities for the severely disturbed. “This is a provisional but necessary measure to meet the urgent need for more psychiatric beds” will undoubtedly be the words used by the incumbent health minister. We may even be blessed with a “Pacific Solution” to mental illness.

Joseph M Rey

Jim Siderov Senior Pharmacist, Cancer Services, Austin Health, Studley Road, Heidelberg, VIC 3084. jim.siderovATaustin.org.au To the Editor: Acetylcysteine (Mucomyst [Bristol-Myers Squibb, Melbourne]) is a mucolytic agent commonly used as adjuvant therapy for patients with abnormal, viscid or inspissated mucous secretions in such conditions as chronic bronchopulmonary disease. It is administered as fine nebulae, and its adverse effects in this form are minimal. Patients may observe an initial slight odour, or stickiness on the face after nebulisation. When acetylcysteine is nebulised using a normal nebuliser it produces a dense mist. One of the less well known adverse effects of the medication was recently observed at a major teaching hospital, when an acetylcysteine cloud activated the hospital’s fire alarm! Medical, nursing and pharmacy staff need to be aware of this potentially embarrassing situation. To help alleviate the problem, acetylcysteine can be administered via a jet nebuliser, similar to that used to administer the antimicrobial pentamidine. The jet nebuliser uses an air or gas stream to break liquids up into smaller particles, decreasing the droplet size and thus eliminating the dense mist.

Jim Siderov

I am pleased to introduce this supplement on research in primary health care. In 2001, the Australian Government introduced the Primary Health Care Research Education and Development Program. One element of this is the Australian Primary Health Care Research Institute, which commenced in 2003 and is based at the Australian National University. The Institute aims to draw together research capacity focusing on policy questions relevant to Australia’s primary health care system with a view to establishing what works best and disseminating it to researchers, practitioners, policy makers and the community. Areas under consideration include: developments in federal/state relationships; different funding arrangements for new or existing services/models; and innovation in organisation and linkages within the primary health care sector. This supplement reports the outcomes of the first round of the Institute’s research. In particular, it addresses the important question of the long-term sustainability of primary health care. The supplement is a valuable contribution to a better understanding of primary health care in Australia. It highlights some of the important political, institutional, economic and workforce factors that need to be considered in the development of primary health care policy to deliver sustainable system improvements.

Tony Abbott MHR

“SNAP” is a model for the general practice management of four common behavioural risk factors: smoking, nutrition, alcohol and physical activity. The SNAP program was developed for the Australian Government in 2002. In 2003 and 2004, a feasibility study was conducted in one urban and one rural division of general practice (DGP) in NSW, in partnership with their local area health services. Information technology support and referral directories were developed, based on an initial needs assessment, SNAP guidelines, a clinical summary chart, patient education materials, and general practitioner and staff training. GPs reported that the SNAP approach fitted general practice consultations well. After its implementation, they were more confident in using motivational interviewing and SNAP interventions and referred more frequently. The impact and sustainability of the SNAP program were limited by a lack of effective practice teamwork, poor linkages with referral services, and the lack of a business model to support SNAP in the practices. DGPs could play an important role in providing practice visits and resources to improve communication, education and collaboration to support SNAP programs.

Mark F Harris DRACOG, FRACGP, MD · Coletta Hobbs BSc(Psych)(Hons), PhD · Gawaine Powell Davies BA, MHP · Sarah Simpson BA(Hons), BAppSci(Health Ed), MPH · Diana Bernard BSocStud, Grad Dip Early Childhood Studies, MPH · Anthony Stubbs BA(Health Ed)

The Care and Prevention Programme (CPP) began in 1998. It is based on the philosophy of primary health care, and has improved health among homosexually active men, including about a third of HIV-positive South Australians. The CPP was assessed using financial analysis and qualitative methods. Participants wanted to access care where they could feel comfortable and safe to talk about issues of sexuality and lifestyle. The CPP model is “economically” sustainable, but not “financially” sustainable within the Medicare Benefits Schedule. It is vulnerable to changes in political environment. The financing model for the CPP has been adapted by including state funding. General practitioners have adapted by lowering their personal incomes (but not quality of care). These adaptations have achieved fragile financial viability. Facilitators of sustainability for the CPP included: It is part of the community that it serves; The creation of deeply integrated networks of diversity-competent service providers; and “Virtuous non-adaptability” of service providers in refusing to compromise care standards despite financial pressure to do so. Threats to sustainability included: Difficulty maintaining a diversity-competent workforce skilled in HIV medicine; Marginal financial viability; and Political vulnerability.

Gary D Rogers MB BS, MGPPsych, FACPsychMed · Christopher A Barton PhD, MMedSci, BSc · Ann C Lawless BA, GradDipEd · Joy M Oddy · Rebecca Hepworth MB BS · Justin J Beilby MD, MPH, FRACGP, DRCOG, DA · Brita A Pekarsky BEc(Hons), GradDipHealthEcon

The Sharing Health Care Initiative (SHCI) demonstration project, which aimed to improve management of chronic diseases, was implemented in four small remote communities in the Katherine region which are serviced by the Katherine West Health Board, a remote Aboriginal-community-controlled health organisation in the Northern Territory. We reviewed the project proposal, final report, evaluation reports and transitional funding proposal, and supplemented these with in-depth interviews with key individuals. We determined factors critical to the sustainability of the SHCI project in relation to context, community engagement, systems flexibility and adaptability, the availability and effect of information systems, and the human nature of health care and policy. The project had a significant impact on community awareness of chronic disease and an improvement in clinic processes. We found that a number of interrelated factors promoted sustainability, including: An implementation strategy sufficiently flexible to take account of local conditions; A high level of community engagement; Appropriate timeframes, timing and congruence between national policy and local readiness to implement a chronic disease project; Effective communication between participating organisations; Project champions (key individuals) in participating organisations; Effective use of monitoring and evaluation data; and Adequate and ongoing funding. The absence of a number of these factors, such as poor communication, inhibited sustainability. Other factors could both promote and inhibit. For example, the impact of key individuals was important, but could be idiosyncratic and have negative effects.

John Wakerman MTH, FAFPHM, FACRRM · Elizabeth M Chalmers MPH, FAFPHM, FACRRM · Christine L Clarence BPE, MICD, DipTeaching · John S Humphreys BA, Dip Ed, PhD · Andrew I Bell MB BS, FAFPHM, FACRRM · Ann Larson BA, MA, PhD · David Lyle MB BS, FAFPHM, PhD · Dennis R Pashen MPHTM, FRACGP, FACCRM

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

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

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

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

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

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

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

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

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

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

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

Roxanne L Wu

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

John P Royle

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

Jim R Stockigt · Zita E Ballok · Victor Kalff