Letters

David B Preen,* Belinda E S Bailey,† Alan Wright‡ * Research Associate, School of Population Health, University of Western Australia, 35 Stirling Highway, Crawley, WA 6009; † State Manager, Royal Australian College of General Practitioners — Western Australian Faculty, Perth, WA; ‡ Hospital Liaison General Practitioner, Department of General Medicine, Fremantle Hospital and Health Services, Perth, WA. davidpATsph.uwa.edu.au To the Editor: The care of patients at the time of hospital discharge and on returning home is often neglected, and has implications for those needing multidisciplinary care. Research has shown that discharge planning can produce better health outcomes, facilitate the patient’s and the general practitioner’s involvement with discharge care, and improve communication between hospital and general practice services.1-3 To encourage GPs to be involved in discharge care planning for patients with chronic diseases, there are Enhanced Primary Care (EPC)-specific Medicare Benefits Schedule (MBS) Items for contributing as a team member to EPC discharge care planning (Item 728), and for review at 3 months post-discharge (Item 724).4 However, the fact that < 1% of claims for EPC care plans are for discharge-related items has been attributed to barriers to GPs’ involvement in discharge planning, or their unwillingness or inability to initiate such a process rather than simply participate.5 Further, little evidence exists that, given the opportunity, GPs are willing to be involved as a team member in this process. In a recent study of ours investigating EPC discharge care planning for chronically ill patients,3 we required GPs to comprehensively review and comment (in writing) on discharge plans developed by the hospital. GPs also performed a follow-up consultation within 7 days of discharge and completed a questionnaire. We found that 90.1% of 91 GPs in the intervention arm of the study willingly contributed to discharge care planning for their patients, indicating that, when offered input into planning discharge and post-discharge care, GPs are willing to fulfil such a role. Further, this finding, in addition to the high questionnaire response rate of trial GPs (80.6%), indicates the importance of this issue to GPs and the belief that GPs are not sufficiently included in discharge processes. Additional results from a follow-up survey, at 28 days post-discharge, of those GPs who participated in discharge planning (n = 91, 70.3% response) showed that only 42% of GPs claimed the MBS Item 728 ($39.80 in 2002, at the time of the study). Results from a subsequent survey (n = 91, 45.1% response) suggested that even fewer (about 15% of respondents) claimed reimbursement for a 3-month care plan review (Item 724, $98.20), although we do not have data on the number of 3-month reviews performed. The reasons given for not claiming these Items included poor understanding of the Item and claiming procedures, and a belief that excessive administration was required to claim the increasing number of MBS items. In the light of sanctions for administrative claiming errors, this may explain the low claim counts for these Items. However, the most common response was that input into the discharge care plan was, in their opinion, not sufficient to justify reimbursement, even with the extra time required for care plan review and post-discharge follow-up. This suggests that GPs do not simply view EPC discharge care planning as a revenue raising exercise, but rather as quality patient care. Further, it may indicate an undervaluation by some GPs of their role in hospital-driven processes. Considering the evidence in support of discharge care planning for improving quality of care, focus should be directed towards ways of encouraging this process, other than simply providing a financial incentive.

David B Preen · Belinda E S Bailey · Alan Wright

Alan R Clough,* Bart J Currie,† Maymuna W Yunupingu,‡ Katherine M Conigrave§ * Postdoctoral Fellow, Institute of Advanced Studies, Menzies School of Health Research, Charles Darwin University, PO Box 1479, Nhulunbuy, NT 0881; † Professor, and Head, Tropical and Emerging Infectious Diseases Division, Menzies School of Health Research, Charles Darwin University, and Northern Territory Clinical School, Flinders University, Royal Darwin Hospital, Darwin, NT; ‡ Senior Aboriginal Health Worker, NT Department of Health and Community Services, Yirrkala, NT; § Specialist in Drug Health Services, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW. Alan. CloughATbigpond.com To the Editor: We are concerned that the Northern Territory’s regulations on kava have not succeeded in controlling its availability in Arnhem Land (the north-eastern region of the NT). Under the Kava Management Act 1998 (NT), one wholesaler is licensed to supply kava (Piper methysticum Forst. f.) to four licensed retailers in Arnhem Land Aboriginal communities.1 “Kava Management Plans” in “Kava Licence Areas” permit retailers to supply 600–800 g per week of kava powder to each purchaser1 — more than double the known harmful consumption levels (240–440 g per week).2 Legal kava supplied will reach 26 tonnes in 2005 (worth $3.6 million), with a persistent illegal trade adding 8 tonnes, worth perhaps $2 million (Box). Two proposed additional retail licences1 will increase kava’s availability. Kava’s social and economic effects remain an ongoing concern. The region’s community-controlled health service attributes to kava abuse an accelerated decline in participation in traditional ceremonies and mortuary rites in some localities. Kava is the psychoactive substance with greatest impact on the financial resources of communities and individuals in Arnhem Land.2 Kava’s health effects include seizures and extreme weight loss in heavy users (up to 20% of body mass), similar to that seen in anorexia nervosa.4 Extreme weight loss, evident during the 1980s, has re-emerged in the region’s kava users (M W Yunupingu, unpublished observations). Raised total and low-density lipoprotein (LDL) cholesterol levels4 add to unresolved concerns that heavy kava use may be a risk factor for cardiovascular disease and sudden cardiac deaths. Potential immunosuppressive effects are suggested by relative lymphocytopenia in heavy kava users4 and by increased risk of melioidosis.5 Raised levels of liver enzymes (alkaline phosphatase and γ-glutamyltransferase), which reverse after ceasing moderate kava use, should be monitored because of fatal hepatotoxicity documented in users of manufactured kava products available as natural therapies.6 Given the scarcity of substance misuse treatment services in the region, with no effective treatments for kava misuse, controlling supply is the only practical measure to reduce kava-related harms. Tighter controls on kava supply are urgently required while licensees implement promised demand-reduction and harm-minimisation strategies.1 We recommend that: no further retail licences be granted until kava supply is reduced; retail licensees supply no more than 440 g per week to individual kava consumers; quantities permitted to be imported by the wholesaler and supplied to retailers be limited; kava selling prices be reviewed in the light of trade-offs between higher prices to reduce demand and minimal financial drains on communities; rigorous enforcement be continued to eliminate illegal kava dealing; and the Kava Management Act be reviewed to facilitate these changes. History of kava use and retail value ($ million) on the legal and black markets in Arnhem Land, Northern Territory, since 1982, extrapolated to the end of 2005* * Data on kava supplied were obtained from d'Abbs (for 1982–1993);3 were estimated from population surveys of kava use (for 1994–1997); were estimated from kava seized by Police and Licensing Inspectors (for illegal use, 1998–2005) (seizures were estimated to account for 14% of the illegal kava supplied, based on correlation with population surveys in 1999 and 2000); and were based on the licensed wholesaler’s monthly figures, extrapolated to the end of 2005 (for legal use from May 2002). Retail value was calculated from data on kava supplied and regulated values of $100 per kg (1990–1993), $140 per kg (2002–2004) and $150 per kg (2005), or a black market value of $250 per kg.2 † Approval required from Minister for communities to supply kava. pa = per annum.

Alan R Clough · Bart J Currie · Maymuna W Yunupingu · Katherine M Conigrave

John W Orchard Visiting Fellow, South Sydney Sports Medicine, University of New South Wales, 111 Anzac Parade, Kensington, NSW 2033. johnorchardATmsn.com.au To the Editor: I congratulate Harris et al1 on conducting a survey that identified aspects of specialty training that are difficult for female doctors and doctors with partners and/or children. However, there are some omissions in their article, which, although small, illustrate further ways in which “specialty” training is unfriendly to the aforementioned groups. The authors purported to survey all medical graduates registered in 2002 “with a clinical college training program”. It appears that registrars on the Australasian College of Sports Physicians (ACSP) training program were not included. This training program has been in place since 1992, has been recognised by the Health Insurance Commission since 1999, and is most definitely a “clinical college training program”. Although similar in structure, there are two major differences between the sports physician training program and most other “specialty” training programs; namely, that the training is almost entirely non-hospital based and that the resulting qualification (the FACSP) is not recognised as a “specialty” in Australia. In 2002, I believe that the Australasian College of Sexual Health Physicians was in a similar position to the ACSP, administering a “non-specialty” clinical college training program (which is now under the auspices of the Royal Australasian College of Physicians). The recognised specialties in Australia, with the major exception of general practice, almost all conduct most of their training in hospitals. Not only are these hospital-based positions relatively “female-unfriendly” and “parent-unfriendly”, they don’t adequately train specialists for the majority of doctor–patient interactions, which do not actually take place in hospitals. They also contribute to the reality that our “health” system is focused on treatment of disease rather than prevention.2 Areas such as women’s and men’s health, travel medicine and dietary medicine also exist within our health system.3 Ideally, if we want a health system that is better at actually promoting health, these areas should also have formally recognised training programs. The conservatism of both the Australian Government and the medical profession is reflected in the process for recognising new specialties, which has severely discouraged community-based specialties from being developed. The “choice” of specialty training that Harris et al examined in their study was limited by what was officially sanctioned in 2002. If it were accepted that there should be more recognised specialty postgraduate training positions in community-based fields of medicine, then not only would our medical system start to address its deficiencies in health promotion, but there would be far more attractive training opportunities for doctors who don’t wish to pursue full-time hospital-based positions.

John W Orchard

Ami Schattner,* Noa Ben-Baruch† * Associate Professor of Medicine, † Head, Breast Cancer Unit, Hebrew University Hadassah Medical School, Kaplan Medical Centre, Bilu Junction, Rehovot, 76100, Israel. amiMDATclalit.org.il To the Editor: We describe a patient with malignant ascites and bacterial peritonitis, with no apparent intra-abdominal source of infection. A 56-year-old woman with advanced breast cancer was admitted to hospital with a 10-day history of diffuse abdominal pain, umbilical tenderness, and increasing abdominal girth. Breast cancer had been diagnosed 13 years before admission (T2 N0 M0) and treated with radical mastectomy and adjuvant chemotherapy. Five years before admission, disease had recurred at the chest wall, and 2 years before, liver metastases were found. Chemotherapy had failed, and her only current treatment comprised capecitabine and analgesics. On admission, the patient had tachycardia (110 beats per min), tachypnoea (26 breaths per min), blood pressure of 115/80 mmHg, and no fever or signs of sepsis. Examination showed evidence of local recurrence around the left mastectomy scar, and marked ascites with discoloration, warmth, tenderness and a diffuse infiltration over the umbilicus. There were no signs of peritoneal irritation, nor leg oedema. Blood test results were in the normal range, except for mild leukocytosis (10.6 × 109 cells/L; reference range [RR], 3.8–9.8 × 109 cells/L), with left shift (86% neutrophils, and 6% lymphocytes; RR, up to 67% neutrophils, and at least 32% lymphocytes). X-ray did not show abdominal free air. Abdominal computed tomography revealed ascites, retroperitoneal lymph nodes, omental and umbilical infiltration, and the known liver metastases without signs of portal hypertension. Peritoneal tap removed 2800 mL of fluid. Examination of the fluid revealed a white blood cell count of 2 × 109 cells/L (80% neutrophils), glucose concentration of 790 g/L, and albumin concentration of 22 g/L (serum–ascites albumin gradient, 0.7; a gradient < 1.1 indicates that the patient does not have portal hypertension). Gram stain of the ascitic fluid revealed gram-positive cocci, and culture identified Staphylococcus aureus. Cytological examination showed sheets of atypical enlarged epithelial cells highly suggestive of malignancy. Therapy was begun with parenteral cloxacillin and ciprofloxacin, but the patient died shortly after. This patient’s condition is unlikely to have been spontaneous (“primary”) bacterial peritonitis, which usually occurs in patients with liver cirrhosis, portal hypertension and ascites with high serum–ascites albumin gradient,1 and occasionally in patients with malignant ascites.2 However, in our patient, infection may have originated from the umbilical metastasis. The umbilicus has a direct connection with the intra-abdominal cavity and is also connected to a number of intra-abdominal organs via embryological remnants, such as the umbilical vein and the urachus. Both routes may be involved in the spread of malignant tumour to the umbilicus,3 but spread may also be in the opposite direction, causing peritonitis. This diagnosis may be missed by physicians who may not notice anything new in a patient with longstanding malignant ascites, and may fail to consider bacterial peritonitis, a treatable condition.

Ami Schattner · Noa Ben-Baruch

John C Bridgman,* William F Heddle† * Cardiology Registrar, † Cardiologist, Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042. cameronbridgmanAThotmail.com To the Editor: A 50-year-old morbidly obese woman (weight, 183 kg; body mass index, 70 kg/m2) presented after 1 month of worsening dyspnoea. Risk factors for cardiovascular disease included hypertension, smoking and previous heavy alcohol consumption. She had left ventricular failure (thought to be due to diastolic dysfunction) and atrial fibrillation with rapid ventricular response. There was no evidence of infection or pulmonary embolism. A transthoracic echocardiogram showed normal systolic function, although the images were poor. Measurement of arterial blood gases showed a compensated respiratory acidosis (Paco2, 58 mmHg; Pao2, 76 mmHg; pH, 7.39; bicarbonate, 34 mmol/L; base excess, 8 mmol/L). Administration of intravenous digoxin, frusemide and heparin led to some symptomatic improvement. Cardiac monitoring showed atrial fibrillation, with ventricular rates of 120–170 beats/minute despite the digoxin treatment. Overnight, 70 pauses in heartbeat of up to 7 seconds were recorded (Box). The constellation of the nocturnal rhythm disturbance, hypercapnia and obesity suggested sleep disordered breathing as a unifying diagnosis. Further questioning revealed symptoms indicative of obstructive sleep apnoea. Polysomnography, performed that night, showed a respiratory disturbance index (number of apnoeic or hypopnoeic episodes per hour) of 130 (normal value, < 15). The longest apnoeic episode was recorded at 34 seconds. The average minimum oxygen saturation was 84% during non-REM (rapid eye movement) sleep and 64% during REM sleep. The lowest saturations reached during non-REM and REM sleep were 64% and 61%, respectively. These results suggested severe obstructive sleep apnoea.1 The following night, her condition improved with application via mask of continuous positive airway pressure (CPAP) at a level of 12 cm H2O using room air. Cardiac monitoring continued to show atrial fibrillation with high ventricular rates, but no pauses in heartbeat occurred. This allowed treatment with atenolol and digoxin to control the ventricular rate. At 6-week review, the patient was complying with home CPAP therapy and felt well. An electrocardiogram confirmed spontaneous reversion to sinus rhythm at 70 beats/minute. There is increasing evidence to suggest a link between obstructive sleep apnoea and atrial fibrillation.2 Obstructive sleep apnoea is also a risk factor for hypertension, coronary artery disease and heart failure, all of which are known to precipitate atrial fibrillation.3,4 Transient heartblock has been found in 10% of patients with obstructive sleep apnoea. Pauses of up to 2 seconds are a predictable physiological response to inspiratory airflow obstruction and hypoxia. These pauses are exacerbated by negative chronotropes. Studies have shown that bradycardia can be effectively abolished with mask CPAP therapy.5 The dramatic response to CPAP therapy in this patient suggests that sleep apnoea caused the significant nocturnal ventricular pauses and had a role in the aetiology of the atrial fibrillation. Overnight cardiac monitor trace, showing atrial fibrillation and a 7-second pause

John C Bridgman · William F Heddle

John D Paull Anaesthestist, Launceston General Hospital, PO Box 200, Exeter, TAS 7275. jdpaullATintas.net.au To the Editor: A black day for the MJA, I thought, on seeing the title of the article by Crotty, “More students and less patients: the squeeze on medical teaching resources”.1 I hesitate, but only briefly, to wave the Fowler brothers’ classic work at you. The revised 3rd edition, by the brothers’ proxy, R W Burchfield, notes that “Regrettable, but prevalent among some standard as well as many non-standard speakers, is the use of less with an unprotected plural noun”.2 He goes on to give examples, among which your article title could well appear, and concludes, “The incorrect use is very widespread and seems likely to be ineradicable, however regrettable that may be”. The author of the Editorial is not discussing an amorphous pile of patients. He is writing about a countable number of people, of which, regrettably, fewer are willing to participate in the education of those they expect to look after them in later life.

John D Paull

Helen Randall Senior Assistant Editor The Medical Journal of Australia In reply: We plead guilty, but knowingly so. When this article was being proofread, there was much discussion about this “regrettable” use of less, but in this instance a catchy title was preferred to following Burchfield’s prescription.1 We take comfort from The Cambridge Australian English style guide, which notes that “using fewer rather than less is . . . a stylistic matter rather than one of correct grammar”.2

Helen Randall

Richard B Hays,* Ian Wronski,† Jan Veitch,‡ Tamara McCloskey§ * Foundation Dean, † Pro-Vice-Chancellor, ‡ Lecturer in Medical Education, § Project Officer, Faculty of Medicine, Health and Molecular Sciences, James Cook University, Townsville, QLD 4811. richard.haysATjcu.edu.au To the Editor: The School of Medicine at James Cook University (JCU) was established in 1999, based on a case that the workforce needs of northern Australia needed to be addressed.1 The model was based in part on other regional medical schools in the United States, Canada and Europe, which had demonstrated that local student recruitment and training could produce graduates who prefer to work in either local or similar regional and rural areas.2 The 6-year undergraduate curriculum at JCU has achieved considerable success in recruiting students from rural backgrounds3 and in developing and delivering a rural curriculum.4 The first cohort of students graduated at the end of 2005, and the intended locations of their internship are now known. JCU students were treated like graduates of other schools by the intern allocation systems within each state. Of 58 graduating students, 51 (88%) have chosen to remain within Queensland, with 29 (50%) in the three North Queensland intern training hospitals, occupying a majority of available intern places in the region. Twelve (21%) will work in other regional hospitals in Queensland and 10 (17%) in a hospital in Brisbane. Seven will work interstate. Furthermore, most of the 37 students of North Queensland origin are staying in North Queensland or adjacent regional centres (only two are leaving Queensland); and about half of the Brisbane-origin and interstate-origin students are staying in Queensland. Hence, while some local students have chosen to move away, some from other states have chosen to stay close to where they moved to study. Forty-two students (72%) responded to a brief survey exploring their decisions. The most popular reasons for choosing the location of their internship were proximity to family and friends, and trying somewhere different from where they had received their training. All but five respondents indicated that they were “likely” or “very likely” to work somewhere in North Queensland in the future, depending on the availability of postgraduate training opportunities. This outcome suggests that the intended workforce mission of the school may be achievable through a combination of selection and curriculum strategies. A longitudinal cohort study is in progress to address longer-term graduate career choice outcomes.

Richard B Hays · Ian Wronski · Jan Veitch · Tamara McCloskey

Robert G Batey Professor of Medicine, Faculty of Health, University of Newcastle, Locked Bag 119, Wallsend, NSW 2287. Robert. BateyAThnehealth.nsw.gov.au To the Editor: The article by Sanson-Fisher and Lynagh on problem-based learning (PBL)1 is very timely, raising important questions about the popularity and efficacy of this method. My “traditional” education included lectures involving 600 students, as well as small-group sessions on the wards and in tutorial rooms. The sessions focused on real patients. Problem-based sessions often deal with videos, at best, and, at worst, paper case histories and laboratory data. I believe the differences between PBL and the standard “curriculum” have been overstated. The quality of the teacher is a critical factor that is understated by proponents of PBL. An excellent teacher can captivate large groups with highly relevant and exciting deliveries, and there is nothing to suggest that such teaching is less effective, stimulating or encouraging than PBL-based teaching. The authors challenge the proponents of PBL to provide evidence that their methodology works. It is also time for those who teach PBL curricula to ask whether this approach is cost-effective. With the knowledge base of medical science increasing exponentially, it is hard to understand how students, without some guidance, can be expected to take on board the complexities of some of the problems that they are faced with. Taking a humane approach and communicating well with patients are commendable goals, but not if they are pursued to the point where patients fail to receive a correct diagnosis and appropriate treatment. Good teaching is provided by good teachers rather than by a particular teaching approach. The PBL system is just as fallible as any other system. I applaud the authors for raising this matter and for asking the questions they asked. I look forward to seeing answers provided in the months to years ahead.

Robert G Batey

Graham D Tracy Emeritus Professor of Surgery, University of New South Wales, PO Box 720, Port Macquarie, NSW 2444. gtracyATbigpond.net.au To the Editor: The two excellent articles in the MJA on an issue important for medical education provided too few strategies for improvement.1,2 First, there is a need for a fundamental attitude change concerning the role of student “doctors”. As long as they are viewed as inexperienced novices, intruding on hapless “guinea pigs”, barriers will always be found to reduce access. Patients should be informed that interview and examination by a student doctor adds much to the discussion of their problem, with real clinical advantage for their care program. Student doctors are usually grateful for the privilege, and should be encouraged to be part of the team, and assured of the value of discussion with nurses, residents and other team members. No additional funding should be needed for such activity. Secondly, as surgical patients are admitted on the day of operation, students should attend the preadmission clinics to help with fuller evaluation. Most teachers would welcome student doctors in their rooms, but this requires planning. It works best when there is a separate examining room for students and patients seeking the added benefit of re-examination. Thirdly, although it is difficult to conduct symptom analysis for someone without symptoms, much value can be obtained from rehearsing specific interrogation and physical examination of all systems in normal people; for example, family and friends. It is not surprising that a few students in exams cannot feel pulses, when they have never tried to feel their own! Fourthly, with modest financial compensation, an army of people with abnormal signs, not in need of treatment, could be recruited for clinical teaching. This task could be assigned to a teaching coordinator, with skills in social interaction, and would need the cooperation of clinical staff.

Graham D Tracy

To the Editor: Goldney and Fisher recently reported data on medication use in an Australian community sample and estimated the financial savings that could be made if the number of prescribed medications was reduced.1 However, the assumption that the average number of medications per patient could be reduced ignores the large body of evidence that has accumulated over recent years demonstrating under-use of beneficial medicines. Under-prescribing has been identified in the management of a broad range of chronic conditions, including heart failure, ischaemic heart disease, hypertension, atrial fibrillation, asthma, osteoporosis, pain, and depression.2,3 It has been suggested that under-use of beneficial therapies may be an even bigger problem than over-prescribing, especially in older patients.4,5 As Goldney and Fisher did not collect any clinical information about their study subjects, no conclusions can be drawn about whether medications were more frequently over-prescribed or under-prescribed. Focusing solely on reducing the number of medications prescribed may be misguided and may result in poorer health outcomes. A broader view of prescribing is required, recognising that problems result from both over- and under-prescribing, as well as inappropriate dose selection and monitoring.5

Rohan A Elliott

Robert D Goldney,* Laura J Fisher† * Professor of Psychiatry, † Research Officer, The Adelaide Clinic, Suite 13, 33 Park Terrace, Gilberton, SA 5081. robert.goldneyATadelaide.edu.au In reply: We agree that, because of our research methodology, we could not necessarily assume that any medication prescription was inappropriate, and we noted that on two occasions. However, our economic analysis addressed only those people using six or more prescribed medications (mean, 7.8), and we reported multiple use of same-class medications, and, at times, use of two different preparations of the same medication. Therefore, we believe our estimate of potential cost savings to be conservative. Nevertheless, we accept that our hypothesis needs more formal testing using clinical data.

Robert D Goldney · Laura J Fisher

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