Letters

Alison J Ritter,* Alex D Wodak,† J Nick Crofts‡ * Head of Research and Deputy Director, Turning Point Alcohol & Drug Centre, 54-62 Gertrude Street, Fitzroy, VIC 3065; † Director, Alcohol & Drug Service, St Vincent’s Hospital, Sydney, NSW; ‡ Deputy Director, and Director, The Centre for Harm Reduction, Macfarlane Burnet Institute for Medical Research and Public Health, Melbourne, VIC. alisonrATturningpoint.org.au In reply: Caldicott and Duff raise a very important question: is the federal government intending to soon terminate Australia’s national drug policy of harm minimisation? This view can be supported by numerous and recent unambiguous speeches by senior government ministers, including the Prime Minister. The government would like Australians to believe that it is implacably opposed to a harm-minimisation approach to illicit drugs. However, a different view appears when federal government funding allocations are examined. For example, the government allocated $215 million to the Illicit Drug Diversion Initiative over 4 years (in addition to a previous allocation of $221 million).1 The intention of this Initiative is to divert selected drug offenders from the criminal justice system to drug treatment. These efforts are, in our view, highly commendable, reducing the use of expensive and largely ineffective custodial punishment and increasing the use of less expensive and more effective drug treatment. They are, however, irreconcilable with a “zero tolerance” or “Tough on drugs” approach to illicit drugs. Another example is AusAID’s recent leadership in the introduction of harm-reduction measures to control HIV epidemics among injecting drug users in Asia. It is also worth noting that the Ministerial Council on Drug Strategy (Australia’s paramount official drug policy-making body since 1985) has repeatedly and recently endorsed a national drug policy of harm minimisation. The present federal government, unlike its predecessor, frequently and stridently attacks emotionally charged symbols of harm reduction, such as the proposed prescription heroin trial or the Medically Supervised Injecting Centre in Sydney. However, as the allocation of substantial funding to the Illicit Drug Diversion Initiative demonstrates, in most respects it is very much a case of business as usual.

Alison J Ritter · Alex D Wodak · J Nick Crofts

Barry N J Walters,* Sivanthi Senaratne† * Physician in Obstetric Medicine, University of Western Australia, Subiaco, WA; † Registrar in Obstetric Medicine, Sir Charles Gairdner Hospital, Perth, WA. banjowATiinet.net.au To the Editor: The “Consensus statement on diabetes control in preparation for pregnancy”1 presents a counsel of perfection that is, regrettably, a cry in the wilderness in this most imperfect of all imperfect worlds. None will deny that the glycaemic target specified would represent a wonderful achievement in a woman attending in early pregnancy. Unfortunately, we are far from achieving this goal, for a variety of reasons. Firstly, and most importantly, “preparation for pregnancy” is unusual. At our clinic (King Edward Memorial Hospital, Perth), where we see up to 90 women each year whose diabetes (types 1 and 2) antedated pregnancy, fewer than 15% have been seen for preconceptional counselling, and a similar proportion have an HbA1c level below 7%. Moreover, at the same hospital, the rate of unplanned pregnancy in the general antenatal clinic exceeds 50%. Studies elsewhere have shown that the rate of unplanned pregnancy in women with diabetes is the same or greater,2 and this figure accords with our own observations. Finally, in many women of reproductive age with diabetes, glycaemic targets as recommended by the Diabetes Control and Complications Trial Research Group3 and the recent consensus statement1 are infrequently met. One study of young adults in a type 1 diabetes clinic4 revealed that “. . . only 3.4% . . . achieved an average HbA1c of less than 7% during 11 years of study . . . despite regular specialist physician, specialist diabetes nurse and dietitian input and repeatedly following up failed appointments”. Australian findings are probably not substantially better in this group. Unfortunately, levels espoused by the above authorities are difficult to attain outside the sequestered environment of a clinical trial. Thus, the realisation of the St Vincent declaration,5 which sought to normalise obstetric outcome for women with diabetes, has proven elusive. Statements that recommend ideal levels of glycaemic control before pregnancy, while laudable, are unlikely to improve the high rates of miscarriage, congenital abnormality, preterm birth and perinatal mortality that we observe. What, then, can we do? The most important intervention in the care of fertile women with diabetes is effective contraception, with the aim of preventing pregnancy until adequate control of diabetes has been achieved. Numerous studies have shown that women who plan their pregnancy and attend for preconceptional care demonstrate better periconceptional glycaemic control and, accordingly, lower rates of adverse events in pregnancy.6 Only by raising the matter of family planning repeatedly with all our younger female patients can we hope to avoid the disappointing observation of an unplanned pregnancy, with all its adverse consequences for the woman with diabetes and her baby.

Barry N J Walters · Sivanthi Senaratne

H David McIntyre,* Jeff R Flack† * Director, Endocrinology and Obstetric Medicine, Mater Health Services, South Brisbane, QLD; † Director, Diabetes Centre, Bankstown–Lidcombe Hospital, Bankstown, NSW. David. McIntyreATmater.org.au In reply: Walters and Senaratne raise two important points — that specific preparation for pregnancy is the exception rather than the rule, and that many people with diabetes (including women of childbearing age) demonstrate poor glycaemic control. As a first step to improving this situation, we believe it is reasonable to set a goal. We sought to alert clinicians, especially those with limited experience in this area, to the importance of optimal glycaemic control in preparation for pregnancy. We hope that the consensus statement represents a “signpost” rather than a forlorn “cry in the wilderness”. Many opinions were sought in developing the consensus statement. Some, for reasons similar to those given by Walters and Senaratne, thought the “HbA1c < 7%” goal too strict, while others believed it to be far too lax. In the end, we agreed to include this figure, with the proviso that the level of glycaemia should be the best achievable for each individual patient. We must educate women of childbearing potential with diabetes and their caring health professionals about the need for preconceptional diabetes control as part of their care. In some clinical circumstances, such as assisted reproduction, the timing of conception is actually determined by the treating doctor. In this setting, optimal glycaemic control should be a prerequisite for active treatment. Rather than taking a nihilistic view, clinicians should devote their combined talents and energy to providing optimal pre-pregnancy care to those women with diabetes who do plan their pregnancies, to promoting pre-pregnancy care (including contraception) for those who currently do not, and to assuming an advocacy role in promoting access to and funding for intensive treatment programs for all people with diabetes.

H David McIntyre · Jeff R Flack

Edzard Ernst Director, Department of Complementary Medicine, Peninsula Medical School, Universities of Exeter and Plymouth, 25 Victoria Park Road, Exeter, Devon EX2 4NT, UK. Edzard. ErnstATpms.ac.uk To the Editor: The article by Myers and Cheras1 is a good attempt to evaluate the safety of complementary therapies. However, I have one problem with it, which may be significant. The authors rightly state at the outset that “the critical issue in assessing any therapy is its risk to benefit”. At the end of their article they consider the “wider public safety issues” and point out that the risks of complementary and alternative medicine (CAM) are minimal compared with those of conventional therapies. I think this is not quite logical. Comparing risks of therapies does not make sense, because the “critical issue” is the risk–benefit profile. Comparing the risks and benefits of, for instance, acupuncture for severe pain versus opioids for the same type of pain would, I think, favour the latter over the former, even though the risks of acupuncture are minimal compared with those of opioids. In other words, comparing absolute risks of treatments is tempting, but meaningless.

Edzard Ernst

Stephen P Myers,* Phillip A Cheras† * Director, Australian Centre for Complementary Medicine Education and Research, Southern Cross University, PO Box 157, Lismore, NSW 2480; † Deputy Director, Australian Centre for Complementary Medicine Education and Research, University of Queensland, QLD. smyersATscu.edu.au In reply: We stand by our statement that “the critical issue in assessing any therapy is its risk to benefit”. 1 Ernst appears to miss the point made in the subsequent two sentences — that this assessment is available for conventional medicine, but not yet for complementary and alternative medicine (CAM) therapies and products. In the absence of such data, society must be able to make an assessment of health practices and medicines based on their overall risk. Ernst himself has made significant contributions to this literature, and in fact three of his articles2-4 were cited in our review. The second criterion of the Australian Health Ministers’ Advisory Council Criteria for Assessing the Need for Statutory Regulation of Unregulated Health Occupations asks the question: Do the activities of the occupation pose a significant risk of harm to the health and safety of the public? Answering this question for the currently unregulated CAM professions involves consideration of the “wider public safety issues”. This forms part of the determination about the appropriateness of occupational regulation. The two comments juxtaposed by Ernst to make his point are not mutually exclusive. While awaiting the risk–benefit analysis, society will need to make decisions about the absolute risks.

Stephen P Myers · Phillip A Cheras

Norman Shum Psychologist and Physician, Psychological Medicine, Eastwood, SA. menciusATsenet.com.au To the Editor: Patient arrogance definitely does exist and can complicate the process, described by Ellard, of “diagnosis, prognosis and therapeutics”.1 I believe this state of affairs has arisen for two reasons. Firstly, from the evolution of “informed consent” linked to “patients’ rights” — principles that need no elucidation. Secondly, as a consequence of the explosion of media and technology. Television has given us a surge of medical programs, especially of the so-called “reality” type, and technology has made information easily available on the Internet. Unfortunately, patients become Internet surfers and surfers become patients. When they then present with symptoms, it is often armed with some knowledge — albeit of dubious quality and veracity. If the doctor does not provide a very accepting ear to these proffered “medical data”, the patient often stops listening, becomes intransigent, and tends to prefer the media- or technology-generated opinion, including the suggested treatment for the semi-self-diagnosed disorder or illness. I am reminded of one of Groves’ subtypes of “hateful patients”, namely “entitled demanders”. He wrote, “. . . they use intimidation, devaluation and guilt induction. . . . The patient may try to control the physician. . . . Such patients often exude a repulsive sense of innate deservedness as if they were far superior to the physician.”2 In my own practice, I had one such patient who would arrive and immediately intimidate my secretary by literally throwing his Medicare card on the desk in front of her and ordering her to turn off the radio that was tuned quietly to ABC FM. She has now retired, but, even 2 years later, says she will always remember him! It takes considerable tact and skill to deflect and reduce the hostility of an arrogant patient so that he or she can ultimately benefit from the consultation. Perhaps it is best done by keeping in mind the fundamental principle primum non nocere.

Norman Shum

Zelman Freeman Retired Physician, 1/43 New South Head Road, Vaucluse, Sydney, NSW 2030. zelfreeATbigpond.net.au To the Editor: You recently commented on the closure of public hospital common medical dining rooms in the 1960s and 1970s.1 Traditionally, these common rooms were a place where residents and senior medical staff met. The closure of these facilities had more serious consequences than the loss of “breaking bread”, as you quaintly put it. The daily meeting between residents ending their shifts and those starting work allowed discussion about the sickest patients — after the dining room closure, such discussions became much less effective. Helpful comments and advice from senior staff were no longer available. New medical advances and the strengths and weaknesses of the system were previously subjected to keen analysis, but all this medical “shop talk” was lost. More importantly, the closure of medical dining rooms contributed greatly to the loss of hospital esprit de corps, which included a sense of belonging to a worthwhile institution to which most of the medical staff were sincerely dedicated. Medical dining rooms had a century-old history in the main state hospitals. I suspect that their closure had more to do with a Jacobin ideological mindset in health departments rather than being an “efficiency” move. Medical staff were not allowed to put tables together in the new refectory, as to do so might appear elitist. I remember going into the small staff room of my hospital at that time to have afternoon tea — a service provided to both lay and medical staff — only to be told by the medical administrator that “non-recoupable foodstuffs were no longer to be served to the medical staff”. Meanwhile, the cleaners in their room next door were enjoying their hospital biscuits! This was the beginning of the “doctor-bashing” era that only the older members of the public remember, and it is not unreasonable to claim that many of the public hospital problems in patient management stem from the actions of perverse individuals who undermined the cohesive and dedicated work of the medical staff, just as they did when they abolished the distinctive hospital uniforms and badges of the nurses, who had always taken pride in their own hospital traditions. A bland coloured gown was substituted to remind them that they were “health workers”. No wonder there is difficulty in recruiting new staff and building a sense of dedication to such an amorphous service. Administrators need to be reminded that good traditions should not be abolished without mature reflection on the consequences.

Zelman Freeman

William B Molloy Gynaecologist, Suite 10, Level 7, William Bland Centre, 229-231 Macquarie Street, Sydney, NSW 2000. drmolloyATbigpond.com To the Editor: I congratulate you on your column in the 1 November 2004 issue.1 For years, I have stated that it is a problem, not only in the public hospitals, but now creeping into the private hospitals, that there is no private room available for doctors to talk among themselves. This also includes the theatres, where only one room is available for both nurses and doctors, and I think this is a giant mistake. I remember that when I was a young doctor, consultations were arranged over lunch. Doctors talked to each other and everyone knew about the important cases in the hospital. It was a teaching and learning experience. In addition, in the afternoon, after one had finished work and was relaxing over the newspaper, again there was contact between doctors. At St Margaret’s Hospital, where I was the Medical Superintendent for fourteen-and-a-half years, between 1969 and 1984, I fought until the day I left to maintain these rooms. The dining room was lost, but at least there was a room where doctors could gather after they did their morning ward rounds. There was an enormous amount of work done and many opinions proffered in that room, and to this day many doctors tell me how much they miss that experience in the hospital they now attend. Isn’t there someone who can point out that, although the public health system is a shambles at present, we should not allow the private system to go down the same track? Sadly, it appears to be doing just that.

William B Molloy

Peter F Burke Surgeon, PO Box 84, Newborough, VIC 3825. burkeATvic.australis.com.au To the Editor: Somerset Maugham noted, “At a dinner party one should eat wisely but not too well, and talk well but not too wisely”.1 Your recent column lamenting the disappearance of doctors’ dining and common rooms2 precipitated a flood of warm memories of, in my case, St Vincent’s Hospital in Melbourne in the 1960s, 1970s and early 1980s. Now based in the Latrobe Valley, Victoria, I have witnessed first-hand, over almost 20 years, much grievous political and social engineering — the abject failure of the first “privatisation” of a public hospital in Victoria and, in the custom-designed “greenfields” hospital, the near-complete lack of provision of facilities for consultant medical staff, leading to their fleeting meeting in corridors and carparks. It is unlikely that C P Snow had this in mind when he wrote of “corridors of power”.3 Contemporary medical staff are indeed an amorphous lot. The clinical white coat is but a memory, and often the only way to recognise a doctor, usually dressed in a manner that would suggest forthcoming involvement in a “Clean up Australia” gathering, is the fashionably appropriate half-noose stethoscope, which, akin to a saint’s halo, confers immediate status on the bearer. Laennec, who invented the stethoscope in 1819, had surely not foreseen the commercial potential of his epochal invention.

Peter F Burke

Bruce P Waxman Medical Program Director, Surgery Program, Southern Health, PO Box 478, Dandenong, VIC 3125. b.waxmanATsouthernhealth.org.au To the Editor: Your recent experience in a staff cafeteria1 is clearly anecdotal, as are my own. I believe, however, the balance needs to be redressed. There is little point in campaigning for “return of the doctors’ common dining room”, as, at least in the public sector, there are no funds available for this campaign. I have been very impressed with the camaraderie that exists in the staff cafeteria at Dandenong Hospital, Southern Health, because medical care is now a team approach and I have the opportunity to meet with medical students, interns, house medical officers, registrars, nurses and administrators, either over a cup of coffee provided free by the Health Service, or a meal. The staff cafeteria has been a meeting place for the team, engendering a team approach to medical care which, I believe, is appropriate to champion for the future of healthcare delivery in Australia.

Bruce P Waxman

To the Editor: A recent editorial in the British Medical Journal reported advice from the UK Committee on Safety of Medicines that most types of selective serotonin-reuptake inhibitors (SSRIs) should not be used in the treatment of major depression in children.1 The editorial sparked interest in the Australian media, resulting in articles in large metropolitan newspapers with titles such as “Army of kids on antidepressants”.2 General practitioners were targeted as the cause of reported “over-prescribing”. Unfortunately, while the media drew data from the national BEACH program (Bettering the Evaluation and Care of Health; a continuing study of general practice activity3), the data presented were inflated: a “child” was defined as someone aged under 20 years (while the UK advice related to children under 18 years), and national figures were extrapolated from the upper confidence limit. Reliable estimates of GP prescribing of antidepressants to children in Australia are needed. We derived age-specific rates of antidepressants prescribed per encounter in Australian general practice for the period April 2001 to March 2004 from the BEACH data (Box 1). The data showed that children were prescribed antidepressants far less often than adults. Those aged under 12 years were rarely prescribed antidepressants. Most of those prescribed were tricyclics, which are more commonly used in management of enuresis than of depression. The media’s inclusion of 18–19-year-olds as “children” greatly increased the reported rate.2 The prescribing rate of antidepressants in children aged under 18 years was 0.47 per 100 encounters (5 per 1000 encounters), but was six times higher for 18–19-year-olds (2.82 per 100 encounters). Most antidepressants prescribed for 12–17-year-olds were SSRIs. Fluoxetine is the only SSRI currently approved for use in children in the UK.4 In Australia, caution is advised when prescribing any antidepressant to children, but venlafaxine and the SSRI paroxetine are specifically advised against.5 Nevertheless, venlafaxine and paroxetine were more often prescribed (accounting for 10% and 8%, respectively, of total antidepressants for children) than fluoxetine (5%). However, GPs provided concomitant counselling at almost 20% of contacts with children aged under 12 years where an antidepressant was prescribed, and at 40% with 12–18-year-olds (Box 2). GPs were also more likely to refer the children to a specialist than when prescribing antidepressants for adults. We do not know how many of these children have been referred to a specialist at a previous encounter, nor how often antidepressant medication is initiated by a specialist. However, it will be interesting to see whether the new advice reduces the current level of prescribing of antidepressants (SSRIs in particular) in children. 1 Antidepressant prescribing in Australian general practice, April 2001 to March 2004 Age-specific rate per 100 encounters (95% CI) Variable (ATC group)† <12 years (n = 31 869) 12–17 years (n = 11 576) 18–19 years (n = 5823) ≥ 20 years (n = 247 231) All antidepressants 0.11 (0.07–0.14) 1.48 (1.18–1.77) 2.82 (2.35–3.28) 4.18 (4.05–4.31) SSRIs (N06AB) 0.03 (0.01–0.05) 1.08 (0.82–1.34) 1.84 (1.49–2.19) 2.38 (2.29–2.46) Fluoxetine (N06AB03) 0.003 (–)* 0.08 (0.00–0.13) 0.07 (0.00–0.14) 0.28 (0.25–0.30) Paroxetine (N06AB05) 0.003 (–)* 0.13 (0.06–0.20) 0.22 (0.10–0.34) 0.48 (0.45–0.52) Other SSRIs 0.02 (0.01–0.04) 0.87 (0.63–1.12) 1.55 (1.22–1.87) 1.62 (1.55–1.69) Tricyclics (N06AA) 0.07 (0.04–0.10) 0.14 (0.07–0.21) 0.22 (0.09–0.35) 0.92 (0.87–0.97) Other antidepressants 0.006 (–)* 0.26 (0.16–0.36) 0.76 (0.49–1.02) 0.89 (0.83–0.94) Venlafaxine (N06AX16) 0 0.17 (0.09–0.25) 0.52 (0.29–0.74) 0.47 (0.43–0.51) * Insufficient observations for calculating 95% confidence intervals. † Drug group according to the World Health Organization Anatomic Therapeutic Chemical (ATC) classification. SSRIs = selective serotonin reuptake inhibitors. 2 Concomitant management provided at encounters where an antidepressant was prescribed in Australian general practice, April 2001 to March 2004 Concomitant management (% of encounters where at least one antidepressant was prescribed [95% CI]) Management <12 years (n = 34) 12–17 years (n = 171) 18–19 years (n = 164) ≥ 20 years (n = 10 137) Counselling 17.6% (4.8%–30.5%) 40.4% (32.8%–47.9%) 44.1% (36.1%–52.1%) 30.4% (29.0%–31.8%) Referral to specialist 5.9% (–)* 6.4% (2.7%–10.2%) 6.8% (2.7%–10.9%) 2.7% (2.4%–3.1%) * Insufficient observations for calculating 95% confidence intervals.

Christopher M Harrison BPsych(Hons), MSocHlth · Helena C Britt BA, PhD

To the Editor: I report a patient with splenic infarction associated with group A streptococcal sepsis that occurred post partum. Although spontaneous splenic infarcts have been associated with many types of infections, to my knowledge this is the first published report of an association with this organism. A 29-year-old woman had an unremarkable term labour and vaginal delivery of her third child. On Day 2, she felt feverish, but no abnormalities were detected on clinical examination or pelvic ultrasound examination. Over the next 24 hours, she developed abdominal pain and sweats, and appeared flushed. On Day 3, her temperature was 37.6°C, and she developed nausea and diarrhoea. Empirical treatment was begun with intravenous ampicillin and metronidazole. She developed hypotension (blood pressure, 90/60 mmHg) and an erythematous rash of the legs and diffuse erythema of the trunk, anterior thighs and face. Relevant results of laboratory investigations are summarised in Box 1. On Day 4, a vaginal swab was taken, and antibiotic therapy changed to ticarcillin–clavulanate and clindamycin on the basis of presumed toxic shock syndrome. The next day, the patient developed oedema of the hands and feet, a sore throat and sore ankles. Group A streptococcus grew from the vaginal swab. Blood cultures showed no growth, but the samples had been taken after antibiotic therapy was begun. Over the next few days, the patient’s condition improved, but on Day 9 again deteriorated, with recurrence of low-grade fever and the development of sharp, retrosternal chest pain. Computed tomography (CT) of the chest with a pulmonary angiogram revealed a small right lower-lobe opacity, suggestive of a pulmonary infarct. The CT scan also revealed multiple splenic infarcts (Box 2). Screening for thrombophilia gave normal results. She was treated initially with intravenous heparin, followed by oral warfarin for 3 months. Her clinical recovery was slow but complete. This patient had probable toxic shock syndrome caused by group A streptococcus.1 She had the non-specific features of toxic shock syndrome2 (fever, nausea, diarrhoea, rash, abnormal hepatic and renal function) and disproportionate abdominal pain as the initial symptom. The only criterion lacking for “definite” toxic shock syndrome was the isolation of group A streptococcus from a normally sterile site (it was isolated only from the vagina). Puerperal toxic shock syndrome caused by group A streptococcus is well reported,1,2 with mortality of 25%–50%.2 The patient’s clinical course was complicated by multiple splenic infarcts and a possible pulmonary infarct, thought to have developed in situ with no identifiable prothrombotic diathesis. Splenic infarction is not common and is usually associated with a haematological or rheumatological disorder.3,4 Spontaneous splenic infarcts have been associated with infections, but there is only one report of these infarcts in association with toxic shock syndrome, in that case caused by Staphylococcus aureus.5 The infarcts have been postulated to be caused by circulating endotoxin.5 1 Abnormal laboratory results Investigation Result RR White cell count (x 109/L) 11.07* 3.50–11.00 Platelet count (cells x 109/L) 63 150–450 Prothrombin time (s) 15.3 12–5 ESR (mm/h) 22 0–12 C-reactive protein (mg/L) 56 < 3 INR 1.2 0.8–1.1 Alkaline phosphatase (U/L) 298 38–126 γ-Glutamyltransferase (U/L) 95 0–30 Albumin (g/L) 18 33–48 Creatinine (μmol/L) 111 60–110 * 63% band forms. ESR = erythrocyte sedimentation rate. INR = international normalised ratio. RR = reference range. 2 Computed tomography of the abdomen Scan shows one of multiple splenic infarcts — in the lateral third of the spleen.

Adrienne Torda

To the Editor: Cokis and Faris describe an intraoperative complication detected by transoesophageal echocardiography (TOE).1 Their letter is interesting in that it describes a rare complication during aortic valve surgery, and it is provocative in that it is critical of the Department of Health and Ageing decision not to rebate TOE (except in valve repair or replacement) to anaesthetists. A rare complication is not an argument for routine monitoring. Justification for monitoring requires detailed analysis of complication rates. The number needed to monitor for this and other complications is not known. Cokis and Faris do not discuss the rate of complications from TOE, which could be similar to that of the rare complication they describe. That there is a link between efficacy and the likelihood of a Medicare rebate is yet to be shown, and the authors themselves allude to this. TOE can be performed without a rebate. This is good for patients and also for a healthcare service which is strapped for funds. There are arguably other pressing needs for Medicare funds in the healthcare system. Presumably, both doctors were remunerated for their presence at the operation. Eligibility for a Medicare rebate can be a “perverse incentive” leading to overservicing. I have seen this with monitoring with TOE. Procedures have a clinical and financial cost as well as perceived benefit. I have seen other diagnoses missed or misinterpreted because of routine use of TOE, and it has occasionally led to prolonged intensive care unit stays and other complications. None of my arguments should deny TOE a place as a useful monitoring tool. It may become as routine during cardiac surgery as central venous pressure and arterial pressure monitoring is now. Whether that happens should not depend on whether TOE is eligible for a Medicare rebate. The use of TOE during surgery should depend on whether there is evidence of a meaningful benefit, and it is well to remember that the routine use of any procedure is hard to justify and can sometimes be dangerous. Early in Australian cardiac surgery, it was argued that the rebate for coronary bypass surgery should be related to the number of grafts. This argument was rightly not accepted. Similarly, the rebates for cardiac anaesthesia should not be related to the number of monitors used. Cokis and Faris should be commended on their excellent care of the patient. However, their argument for a rebate is not compelling.

John W Stokes FANZCA, FJFICM

In reply: Stokes raises a number of relevant issues, but we would like to make the following points. The case we reported occurred in a teaching hospital and neither of us undertakes routine transoesophageal echocardiography (TOE) in a private capacity. While a Medicare rebate is not directly relevant to the clinical usefulness of a medical procedure, the Medicare Benefits Schedule functions as a surrogate marker for clinical legitimacy. Stokes quotes anecdotes of occasional misuse or overuse of TOE. We agree that single cases neither justify nor give cause to reject a particular kind of monitoring. However, case reports, although lacking a denominator, are a start. The main point of our letter was, in fact, to report the complication of surgery and the vital role played by TOE in achieving a good outcome. Nevertheless, many of us who routinely use TOE consider that its advantages over other kinds of monitoring regularly benefit patients. We agree there is little “hard” evidence to support this, but detailed risk–benefit analysis for many of our routine monitoring devices is similarly non-existent. The Swan–Ganz catheter is a classic example. We suspect that if a group of cardiac anaesthetists and surgeons was asked to review the usefulness of TOE in routine cardiac surgery, the decision of the Department of Health and Ageing might be different.

Chris Cokis MB BS, FANZCA · John Faris MB ChB, DAvMed, FFOM, FANZCA

To the Editor: de Crespigny and Savulescu1 criticise legal and media attention given to the abortion of a 32-week fetus with suspected dwarfism in a case in which the expectant mother had become suicidal. At the same time, they appeal to populism to support legislative change in favour of easier access to late-term abortion. This paradox raises an intriguing point about public opinion and medical ethics. How can members of the public develop opinion unless they are told what is going on? The case was made known to the public (although the patient’s name and face were not shown) because a newspaper editor considered it to be of great interest to many people. The public rightly has an interest in this tragic case, as it relates to at least three controversial themes of significance to public and social health — disability, suicide and abortion. Unfortunately, in recent decades, balanced and informed debate about abortion has been lacking. Instead, the issue has been portrayed simplistically in terms of a woman’s “right to choose”, with little research into the desperate and often coercive circumstances and the harmful consequences of those choices. That late-term abortions are subject to unclear and complex state laws is testament to the fact that abortion is far from a closed case for the public, healthcare professionals and politicians. de Crespigny and Savulescu acknowledge that the case raises “profound and divisive ethical issues”. Yet, they later assure readers that the case “appears to be ethical”, adding to their overall implication that, if only Australia’s laws were clear, uniform and liberal, the media and the public would not have had any business in the matter. Many aspects of the doctor–patient relationship are regulated by legislation — an “intrusion” that is accepted in jurisdictions in which democracy and state-funded healthcare coexist, and necessarily so, to protect both doctor and patient. If legislative change is to occur, public consultation must be sought, and the public must be given more, not less, information about abortion.

Selena R Ewing BHSc

To the Editor: The article by de Crespigny and Savulescu is certainly thought provoking and timely. The harms they cite as caused by an uncertain legal environment are lamentable, although the outcomes were probably the result of multiple factors in addition to the justice system. To bring order, reason, compassion and justice to a clinical problem as complex as termination of pregnancy — especially late termination — requires a framework for decision-making. This should operate at the hospital level, at the national level among the professionals involved, and, as de Crespigny and Savulescu contend, in the national legal system. Most hospitals have now developed consistent guidelines to assist clinicians and patients in decisions regarding pregnancy termination (in the past, there was significant intrahospital diversity and uncertainty). More recently, clinicians involved with late termination of pregnancy for fetal abnormality in eight centres in six states and the Australian Capital Territory met in Melbourne to develop a consistent national set of guidelines. There was adequate consensus to produce a document that will soon be submitted for publication for wider community comment. Hopefully, this will facilitate better outcomes for all and perhaps even provide a stimulus for review and consistency of abortion laws.

Leslie Reti SM, FRCOG, FRANZCOG

In reply: Reti is correct that the outcomes of the late abortion case probably resulted from multiple factors in addition to the justice system. A pivotal one was the decision to divulge confidential patient information before there had been a thorough internal review. It is pleasing that hospitals are developing consistent guidelines, although, as we indicated in our article, these guidelines should not include responsibility for clinical decision-making by committee. The responsibility for clinical decision-making should reside with the doctor, and committees should have a purely advisory role. Consistent national professional guidelines are needed. These could be a stimulus for law reform. Without reform, it is only a matter of time before a single complaint about a case leads to a similar succession of adverse outcomes. Ewing writes that we “criticise legal and media attention given to the abortion”. We have no criticism of the media attention and would not presume to criticise the legal processes. Our criticism was of the “decision to expose the events to legal and media scrutiny”. That is, we criticised the decision to expose the case and those involved before a thorough internal review had been conducted. We support transparency and believe that secrecy in relation to medical procedures is contrary to public interest. We agree with Ewing that public consultation must be sought before legislative change. But one thing is clear — abortion law reform is essential. It is unacceptable that, in some cases, such as the late-abortion case we described, doctors may be charged with an indictable offence whether they agree to perform the abortion or not — under the law on abortion or child destruction if they agree to abortion, or under the law of homicide by negligence if they refuse abortion and the patient subsequently commits suicide.

Lachlan J de Crespigny MD, FRANZCOG · Julian Savulescu MB BS, BMedSci

To the Editor: In a recent article, de Costa and Robson1 suggest that Australia’s high rates of caesarean surgery — currently among the highest in the Western world — may be beneficial, and causally related to our low perinatal mortality rate. In support, they cite a single article that reports the outcomes from three large hospitals in Dublin between 1979 and 2000.2 In these hospitals, as in most of the Western world, caesarean rates increased and perinatal mortality rates declined over this 21-year period. The authors of the article ascribe a causal relationship, but admit that “. . . it was not possible to allow for the confounding effect of time”.2 The time factor also confounds the interpretation of Australian data. Furthermore, results from an earlier Dublin study “. . . do not support the contention that the expansion in cesarean birth rates has contributed significantly to reduced perinatal mortality in recent years,”3 and there are many other articles with similar conclusions.4 Moreover, de Costa and Robson do not acknowledge the significant morbidity associated with caesarean surgery, nor the risks to mother and baby in subsequent pregnancies. A recent large retrospective cohort study in Scotland found that women whose first baby had been born by caesarean section had twice the risk of unexplained stillbirth at term in the subsequent pregnancy.5 There are also well documented increased risks of placental pathology (placenta praevia, accreta and percreta) in this group. Such problems are likely to increase in Australia in proportion to the increase in caesarean rate. I note also that King et al, who discuss maternal mortality in the same issue of the Journal, specifically mention the contribution of previous caesarean surgery to severe obstetric haemorrhage and emergency hysterectomy.6 They report that maternal death from amniotic fluid embolism occurred in association with induction in five of seven cases. Australian rates of induction and augmentation are among the highest in the Western world. Finally, as regards onus of proof, I agree with the statements by Enkin et al7 that “. . . the only justification for practices that restrict a woman’s autonomy, her freedom of choice, and her access to her baby, would be clear evidence that these restrictive practices do more good than harm; and second, that any interference with the natural processes of pregnancy and childbirth should also be shown to do more good than harm”, and “. . . the onus of proof rests on those who advocate any intervention that interferes with either of these principles”.

Sarah J Buckley MB ChB, DipObst

In reply: Buckley makes some important points regarding caesarean section, but overlooks the fact that our brief was to explore childbirth options from the viewpoint of the baby, not the mother. The Irish study of Matthews (a paediatrician) and colleagues took as its outcome measure deaths during pregnancy or within one week of birth of normally formed infants weighing > 2.5 kg.1 This was done because two of the main contributors to crude perinatal mortality rates (in Australia and other developed countries) are lethal abnormalities and very low birthweight — neither of which is likely to be improved by increasing caesarean section rates. More than 400 000 births over 22 years were studied retrospectively. While the time factor is acknowledged, the authors clearly show that as caesarean section rates have risen mortality among these normally formed babies of normal weight has fallen. They state that “. . . the caesarean section rate is an important part of the overall package of care delivered”, a “package” that includes the advances in antenatal surveillance and neonatal care of the past 22 years, as well as wider indications for caesarean section. The authors invite other centres to publish “similar matching caesarean section and mortality rates . . . to see whether some hospitals are capable of delivering packages of care that include low caesarean section rates (? < 15%) and perinatal mortality rates of < 1.5/1000 for normally formed babies of normal birthweight”. To date, none have done so, but there have been reports from other large maternity hospitals of similar findings to those of Matthews et al. One of these adds that “[our] low incidence of intrapartum hypoxic ischaemic encephalopathy (1.3/1000 births) . . . suggests that a policy of more liberal caesarean section may benefit babies in ways other than simply avoiding death”.2,3 In other words, this very large and careful study, and others resulting from it, strongly support the view that current caesarean section rates are good for babies.

Caroline M de Costa FRANZCOG, FRCOG

To the Editor: The article by de Costa and Robson1 is a timely reminder that the ideology and politics surrounding maternity services could have an adverse impact on Australia’s excellent record as one of the safest countries in the world in which to be born.2 de Costa and Robson highlighted continuity of care as the attribute of antenatal supervision and birthing that women value most highly, and they quote evidence of the safe care provided by a midwife or general practitioner in a “low-tech” environment. This type of care is currently provided by a diminishing number of GP obstetricians and midwives in small obstetric units throughout rural Australia, where continuity of carer ensures the continuity of care that leads to maternal satisfaction and good health outcomes. Data show a lower rate of adverse events in small rural hospitals compared with urban hospitals. Studies in diverse environments suggest communication breakdowns and handovers between multiple carers are major risk factors.3,4 These points of vulnerability are minimised in the close environment of a small rural hospital. National and international data demonstrate the safety of small rural maternity services,5 and yet rural obstetric units continue to be closed at an alarming and accelerating rate. The proponents of “de-medicalising” birth and improving maternal satisfaction through continuity of care are focused on perceived problems in the delivery of obstetric care in large urban hospitals. The evidence presented by de Costa and Robson confirms that women are most satisfied with care by a midwife and GP in a “low-tech” environment. While this option may now be unavailable in many urban areas, it is generally the model that exists in rural areas. Unfortunately, the politics of change is resulting in the application of urban- and ideology-based processes to rural maternity units, where they are often inappropriate and can lead to reduced support for rural procedural obstetricians. This is likely to result in the eventual closure of the maternity units — a situation in which women, their babies, local healthcare professionals and their communities will all lose out in the end. For rural communities, the risk in local maternity services is not to the standard of care, but to the continued existence of their services. Transferring alternative urban models of maternity care to country hospitals may be superficially attractive to budget-focused health authorities or ideologues, but it is rural people and their babies who will have to live with the consequences.

Graham M Slaney · Susan M Stratigos

Gwendolyn L Gilbert,* Heather F Gidding,† Josephine Backhouse,‡ Peter B McIntyre§ * Director, ‡ Serology Project Officer, Centre for Infectious Diseases and Microbiology, Institute of Clinical Pathology and Medical Research, PO Box 533, Wentworthville, NSW 2145. † Epidemiologist, § Director, National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases, University of Sydney, Westmead, NSW. LyngATicpmr.wsahs.nsw.gov.au To the Editor: Varicella vaccine was licensed in Australia in 2000. It is safe and efficacious and can prevent significant acute morbidity, significant out-of-pocket expenses for parents of affected children and, in Australia, prevents an estimated 450 admissions to hospital and one death per year.1 In September 2003, the National Health and Medical Research Council (NHMRC) recommended giving varicella vaccine to all children at 18 months of age.2 The net effect of childhood immunisation on varicella morbidity will depend on vaccination coverage. Modelling of Australian (unpublished National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases data) and UK3 seroprevalence data suggests that, for a range of vaccine efficacy estimates, 80% coverage is required before morbidity is reduced in adults. Accurate Australian coverage data are unavailable, as varicella vaccine is not funded under the National Immunisation Program.2 National serosurveillance can provide a practical alternative estimate of vaccine uptake. The first Australian national serosurvey of vaccine-preventable diseases, for which sera were collected between July 1996 and February 1999, established baseline seroprevalence for future assessment of the effects of changes in the vaccination schedule. It showed that the incidence of varicella was highest in 5–9-year-old children,4 indicating that infant vaccination would provide optimal protection. The second national serosurvey (with sera collected in 2002) is under way, with methods identical to those of the first.4 We compared varicella IgG levels in children aged 1–5 years, testing 459 sera in the first serosurvey and 380 in the second (see Box). The proportion with protective or equivocal antibody levels increased between the two serosurveys. The difference was statistically significant only in 3–4-year-olds, which is consistent with the greatest uptake when children enter childcare. Although there is some variation in varicella incidence over time, the changes are consistent with only modest vaccine uptake in the time that varicella vaccine has been available in Australia. The only other available estimates of varicella vaccine uptake are from GP consultations5 and reports to the Australian Childhood Immunisation Register (ACIR), which also indicate it is modest. For example, only 6.2% of children aged 4 years were reported to the ACIR to have received varicella vaccine (Brynley Hull, Epidemiologist, National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases, personal communication). This is probably an underestimate, as there is no incentive for notifying varicella vaccination. However, a low vaccination uptake is consistent with use only in the private sector, and could lead to an increase in adult morbidity (despite an overall reduction in infection rates) because of a higher average age of infection (unpublished National Centre for Immunisation Research data). Unless vaccine is provided in the routine immunisation program at no cost to parents, uptake is unlikely to meet the 80% target required to reduce disease burden in all ages.3 Varicella IgG seroprevalence in preschool children in the 1st and 2nd national serosurveys 1st serosurvey, July 1996 to February 1999 2nd serosurvey, 2002 Age group No. Positive Negative Equivocal* No. Positive Negative Equivocal* Increase in positive and equivocal (95% CI) P 1 to < 3 years 138 27 (19.6%) 111 (80.4%) 0 152 34 (22.4%) 118 (77.6%) 0 2.8% (−6.6 to 12.2) 0.6 3 to < 5 years 214 72 (33.6%) 140 (65.4%) 2 (0.9%) 152 73 (48.0%) 79 (52.0%) 0 13.4% (3.3 to 23.6) 0.01 5 years 107 61 (57.0%) 46 (43.0%) 0 76 43 (56.6%) 33 (43.4%) 0 −0.4% (−15.0 to 14.1) 1.0 Total 459 160 (34.9%) 297 (64.7%) 2 (0.4%) 380 150 (39.5%) 230 (60.5%) 0 4.2% (-2.4 to 10.8) 0.2 *Sera giving equivocal results by enzyme immunoassay were retested and most were resolved by immunofluorescence (IF). These results represent the few that were still equivocal by IF and are probably low-titre positive results.

Gwendolyn L Gilbert · Heather F Gidding · Josephine Backhouse · Peter B McIntyre

Angelo Labate,* Mark R Newton,† Graeme M Vernon,‡ Samuel F Berkovic§ * Research Fellow, Brain Research Institute, † Neurologist, § Director, Epilepsy Research Centre, ‡ Drug Information Pharmacist, Austin Health, Heidelberg West, VIC 3081. s.berkovicATunimelb.edu.au To the Editor: Tramadol is a synthetic, centrally acting analgesic that was approved for use in Australia in 1998. Seizures have been reported in patients receiving the drug in overdose and, rarely, at the recommended dose.1-4 Over a one-year period, we observed a number of tramadol-associated seizures in the First Seizure Clinic at Austin Health, an outpatient service for rapid evaluation and diagnosis of patients with new-onset seizures.5 We evaluated 197 patients from April 2003 to April 2004. One hundred had alternative diagnoses to epileptic seizures: syncope (n = 56), convulsive syncope (n = 27), panic attacks (n = 3) and other events (n = 14). Of 97 patients with confirmed seizures, 8 (5 male; median age, 34 years [range, 18–51 years]) were associated with tramadol (Box). Two patients who had received high doses of tramadol (600–750 mg/day [maximum recommended dose, 400 mg/day]) had developed seizures within 24–48 hours. Among the other six patients, who had received tramadol in the recommended dose range (50–300 mg/day), seizures had occurred 2–365 days after commencing therapy. Long-term psychotropic medication was taken by two patients. Seizures were generalised tonic–clonic seizures, without auras or focal features. No patient had a prior history of seizures, and none had a recurrence after they had ceased taking tramadol for a median of 9 months’ follow-up (range, 2–14 months). Electroencephalographic studies were normal in seven patients, with only one isolated sharp slow-wave in one patient. Computed tomography scans were all normal, and magnetic resonance imaging was normal in five patients. Previous US studies suggest a relatively low risk of seizures with tramadol, unless it is taken by people with epilepsy or taken with other drugs that reduce the seizure threshold.2-4 Tramadol is now widely prescribed in Australia, with 1.65 million prescriptions for oral tramadol issued under the Pharmaceutical Benefits Scheme in 2003.6 The Australian Adverse Drug Reactions Advisory Committee had received 83 reports of convulsions associated with tramadol to March 2004, although in only three cases was the association classified as “certain”. In our First Seizure Clinic, tramadol is the most frequently suspected cause of provoked seizures. We cannot calculate the exposure risk in our population, but the frequency of tramadol-related seizures suggests that they may be under-reported. It is important to consider tramadol as a possible cause of seizures — even when used at recommended doses. This may avoid inappropriate use of anti-epileptic drugs and unnecessary restrictions on driving and choice of vocation that might apply in cases of new-onset epilepsy. Details of eight patients with tramadol-related seizures at the First Seizure Clinic, Austin Health, April 2003–April 2004 Patient 1 2 3 4 5 6 7 8 Age (years) 18 35 31 33 48 51 25 45 Sex M F F M M M F F Tramadol dosage (mg/day) 750 600 100 300 100 50 100 300 Treatment duration (days) 1 2 7 365 21 90 2 180 Concomitant psychotropic drug taken No No No Yes* Yes† No No No Duration of follow-up (months) 12 9 14 9 9 3 3 2 * Chlorpromazine hydrochloride 200 mg/day. † Haloperidol 1 mg/day.

Angelo Labate · Mark R Newton · Graeme M Vernon · Samuel F Berkovic

Barbara A Hawkshaw,* Yeqin Zuo† * Planning and Evaluation Officer, Health Promotion Unit, Central Sydney Area Health Service, Level 9 North, King George V Building, RPAH, Missenden Rd, Camperdown, NSW 2050; † Currently Tobacco Control Program Coordinator, Cancer Institute NSW, Sydney, NSW barbara.hawkshawATemail.cs.nsw.gov.au To the Editor: The World Health Organization recommends that hospital staff ask about the smoking status of every patient, and offer brief quit advice and pharmacotherapy.1 These effective strategies2 underlie the Central Sydney Area Health Service (CSAHS) Smoke Free Environment Policy,3 which specifies the use of nicotine replacement therapy (NRT) in managing nicotine dependence of inpatients. Recording quit advice is yet to become a regular feature of medical records, but documentation of smoking status and NRT prescribing is evidence of compliance with the policy. To monitor the implementation of this policy in CSAHS, we examined the medical records of smokers for evidence of NRT prescribing in hospital or at discharge. A small sample was chosen to provide a “snapshot” of NRT use. First, we identified 2718 patients admitted to Royal Prince Alfred Hospital and Canterbury Hospital between 1 July 2001 and 30 June 2002 who were single admissions, stayed 48 hours or longer, and were current smokers (ICD-10 code Z720).4 Current smokers were defined as those who had smoked any tobacco in the past month.4 Sixty medical and 60 surgical patients from each hospital were selected randomly by random number generation (medical/surgical status was based on the specialty of the admitting doctor). After excluding 33 patients who were either ex-smokers or smokers who died during admission, the sample included 207 patients. Records were examined for smoking history, NRT prescribing during hospitalisation, and documentation of smoking status or NRT prescribing on discharge summary. NRT was prescribed to 13 patients (6.3%) during their hospitalisation (Box). All 13 received patches. A larger proportion of medical patients than surgical patients had NRT prescribed in hospital (8.1% v 4.6%) and at discharge (7.1% v 2.8%). In 8% of records, smoking was identified on the discharge summary. Most records (80%) provided numerical information about daily cigarette consumption. Seventy per cent of our sample smoked more than 10 cigarettes per day. Other records described consumption in subjective terms only, such as “heavy”. We believe that this is the first study in Australia to estimate the NRT prescribing rate for inpatients using medical record audit. Very few patients who were smokers were prescribed NRT. It is encouraging that most patients who were prescribed NRT were given a supply of patches at discharge. The NSW Health Department’s Guide for the management of nicotine dependent inpatients is a commitment to assisting people to quit.5 Implementation of the CSAHS Smoke Free Environment Policy3 by hospital staff requires a greater knowledge of the barriers to prescribing NRT and documenting quit activities at all levels of the hospital system. Nicotine replacement therapy (NRT) prescribing and smoking history Medical* Surgical* Total NRT prescribing (n = 99) (n = 108) (n = 207) During hospital stay 8 5 13 (6%) At discharge 7 3 10 (5%) Smoking history (n = 99) (n = 108) (n = 207) Number of cigarettes recorded 76 90 166 (80%) Years of smoking recorded 26 41 67 (32%) Cigarettes per day (n = 76) (n = 90) (n = 166)† 1–10 25 24 49 (30%) > 10 51 66 117 (70%) * Admission categorised according to specialty of admitting doctor. † Only 80% of total sample indicated number of cigarettes per day.

Barbara A Hawkshaw · Yeqin Zuo

Desmond O’Brien Emeritus Honorary Anaesthetist, The Prince of Wales Hospital, Randwick, NSW 2031. hdobrienATbigpond.com.au To the Editor: Tonti-Filippini condemns denial of elective surgery to smokers as discriminatory.1 He disregards the fact that surgery requires anaesthesia, which may require serious consideration before undertaking non-urgent surgery, and in no way involves discrimination. He mistakenly regards denying elective surgery to those who continue to smoke as discrimination, in breach of the Hippocratic Oath, and the Australian Medical Association (AMA) Code of Ethics. In fact, to proceed with elective, especially cosmetic, surgery in a heavy smoker is more in breach of the Oath and the AMA Code than not proceeding, for the following reasons. Smokers are at a significantly greater risk under anaesthesia than non-smokers because, firstly, smoking reduces the capacity of the lungs to take up oxygen, thus increasing the risk of hypoxia and its consequences to heart and brain.2 It also causes coughing and breath-holding during anaesthesia,2,3 creating surgical difficulties, and the risk of error. Postoperative coughing causes additional pain (especially after thoracic and abdominal operations), and increases the risk of postoperative bleeding, infection, delayed healing and even wound breakdown.4,5 Rather than being discriminatory, delaying elective and cosmetic surgery until he or she stops smoking is very much in the patient’s interests.

Desmond O’Brien

Daniel M Fatovich Specialist in Emergency Medicine, Royal Perth Hospital, GPO Box X2213, Perth, WA 6847 daniel.fatovichAThealth.wa.gov.au To the Editor: I have read with interest the debate in the MJA on the use of tPA in acute ischaemic stroke. Most recently, Levi et al published a position statement stating that it is a major advance.1 This was probably in response to Hoffman’s critical editorial.2 At the 10th International Conference on Emergency Medicine in June 2004, a session on the use of tPA in acute ischaemic stroke clearly portrayed thrombolysis as not standard care.3 I have attended other emergency medicine conferences where thrombolysis was seen as risking more harm than good. Conversely, I expect that stroke physicians attend stroke conferences that endorse thrombolysis. In my experience, when such divergent views exist, it usually means that we don’t have enough answers. I would like to outline here some other viewpoints that are not often considered. Number needed to harm (NNH): The best results to date were from the NINDS study that reported a number needed to treat (NNT) of 8.4 With their findings of an intracranial haemorrhage rate of 6.4%, the NNH is about 16. Hence, for every 16 patients treated with tPA, two may derive much benefit, but one much harm. These odds are worse than Russian roulette. The Cleveland study reported an intracranial haemorrhage rate of 22%.5 Hence, the worst possible NNH is about 5. Other authors have expressed similar ethical concerns.6 Risk tolerance is an individual judgement, but, when faced with the above issues, my practice is to ask what I would want for myself. Knowing that the earlier thrombolysis is given the better,7 my personal choice would be to only have thrombolysis if it is administered within 90 minutes of stroke onset (ie, maximal benefit and minimal risk). Unfortunately, it is rare for patients to present early enough for this to occur. Furthermore, many of my colleagues do not know what they would want for themselves, so how can we advise our patients? Pathophysiology: Heart muscle is relatively robust, whereas the brain is a softer structure. A haemorrhagic complication is very different in the two organs. Mode of thrombolysis: Giving thrombolysis by infusion is an outdated approach. Furthermore, thrombolysis is almost a forgotten therapy for acute myocardial infarction in tertiary centres because of the use of primary angioplasty. When thrombolysis is used, the agent is given as a bolus. Uptake of this mode of administration would be rapid if it were shown to be effective and safe for acute ischaemic stroke. Obviously, consensus among care providers on the use of tPA does not exist. This means that more research needs to be done to work out the answers to these difficult questions. I believe there is much support for this, as we need to define who should be receiving thrombolysis, and, perhaps more importantly, who should not. We all want something that works! However, we need greater knowledge to overcome the safety issues. The answer to Levi’s question “Why did it take so long?” is “Because it is a complex problem”.

Daniel M Fatovich