Letters

Gavin Turrell,* Brian F Oldenburg,† Elizabeth Harris,‡ Damien J Jolley,§ Merel L Kimman¶ * Senior Research Fellow, † Head of School, ¶ Student, School of Public Health, Queensland University of Technology, Victoria Park Road, Kelvin Grove, QLD 4059; ‡ Director, South West Sydney Area Health Service, Centre for Health Equity Research, Training and Evaluation, Liverpool, NSW; § Director, School of Health Sciences, Biostatistics and Epidemiology Unit, Deakin University, Burwood, VIC. g.turrellATqut.edu.au To the Editor: Studies investigating the relationship between socioeconomic status (SES) and use of healthcare services suggest that, in metropolitan regions, low-SES groups consult general practitioners more frequently than high-SES groups.1 The primary reason is their poorer health and hence greater medical need (however, distributional, operational and financial factors associated with the provision of general practice services are also important). Is a similar relationship found between SES and GP use in non-metropolitan areas? We investigated this issue using data from the Social health atlas of Australia project.2 We defined “GP use” as unreferred services3 provided by general and vocationally registered practitioners (not specialist medical practitioners), delivered at a surgery or clinic, a patient’s home, or an institution such as a hostel or nursing home. Specifically, 952 statistical local areas (SLAs), comprising 98.6% of all SLAs for the six Australian states, were classified into four geographic remoteness categories (see Box) using the Accessibility/Remoteness Index of Australia (ARIA).4 Within each ARIA category, we grouped SLAs into tertiles of socioeconomic disadvantage based on their Australian Bureau of Statistics’ Socio-Economic Indexes for Areas (SEIFA) score. We then compared the average rates of GP use between tertiles for the 2-year period 1996–1997. Our analysis included a measure of the number of full-time equivalent (FTE) GPs per 10 000 population in each SLA as a test of equity: similar or higher rates of GP use in disadvantaged SLAs independent of GP availability suggest equity of access. In areas classified as “highly accessible”, rates of GP use were significantly (10%) higher in disadvantaged SLAs after adjusting for GP availability (Box). The reverse was found in “remote/very remote” areas, where rates of GP use were about 36% lower in disadvantaged SLAs. Also, the strength of the relationship between GP availability and GP use differed across the ARIA categories. In “highly accessible” areas, a unit increase in the number of FTE GPs per 10 000 population was associated with a 1% increase in GP use, whereas in “remote/very remote” areas it was associated with a 15% increase (data not shown). This suggests that disadvantaged groups in rural and remote areas experience disproportionate difficulty accessing GP services. These areas are underserved by GPs, who charge more for their services and are less likely to bulk-bill.5 It seems that in metropolitan regions the Medicare principle of equity of access to GP services is being realised (ie, people with higher levels of morbidity are making greater use of GP services), whereas in remote and very remote areas this is not the case. The findings might also reflect the fact that disadvantaged groups (especially in rural and remote areas) make greater use of emergency departments of local hospitals or other community-based or primary care outreach services — these services are not covered by Medicare and, therefore, are not taken into account in the rates of GP use presented here. Association between socioeconomic disadvantage and use of general practitioners within ARIA* categories† * ARIA (Accessibility/Remoteness Index of Australia) categories:4 Highly accessible: areas with relatively unrestricted access to a wide range of goods and services and opportunities for social interaction. Accessible: areas with some restrictions to accessibility of some goods, services and opportunities for social interaction. Moderately accessible: areas with significantly restricted accessibility of goods, services and opportunities for social interaction. Remote/very remote: areas with very restricted or very little accessibility of goods, services and opportunities for social interaction. † Relationship between area disadvantage and GP use is adjusted for number of full-time equivalent GPs per 10 000 population. ‡ Each tertile comprises approximately a third of the statistical local areas (SLAs) in the six Australian states. The high and low tertiles comprise the 33% least and most socioeconomically disadvantaged SLAs, respectively.

Gavin Turrell · Brian F Oldenburg · Elizabeth Harris · Damien J Jolley · Merel L Kimman

Lynne Hillier,* Richard De Visser,† Anne M Kavanagh,‡ Ruth P McNair§ *,† Research Fellows, ‡ Senior Research Fellow, Australian Research Centre in Sex Health and Society, La Trobe University, Level 1, 215 Franklin Street, Melbourne, VIC 3000; § Senior Lecturer, Department of General Practice, Melbourne University, Carlton, VIC. l.hillierATlatrobe.edu.au To the Editor: Studies of non-representative population samples show that recreational drug use is more prevalent among non-heterosexual women than heterosexual women.1 The Australian Longitudinal Study of Women’s Health2 allowed an examination of the links between sexuality and recreational drug use in a representative sample of 9260 women aged 22–27 years in 2000. Respondents reported their history of tobacco, alcohol and illicit drug use. Reported frequency and volume of alcohol consumption were recorded according to National Health and Medical Research Council guidelines.3 Use of illicit drugs in the last year was dichotomised between marijuana and other illicit drugs (see Box). Respondents also indicated whether they had ever injected illicit drugs. Analyses compared exclusively heterosexual women with all other women. Data were weighted to correct for over-sampling in non-metropolitan areas. Odds ratios were adjusted for age, region of residence, and father’s occupation (as a measure of social class). Younger women were significantly more likely to report risky drinking and illicit drug use. Women from urban areas were significantly more likely to be non-heterosexual and to use illicit drugs, but less likely to report risky levels of alcohol consumption. Women whose fathers were professionals or managers were significantly more likely to be non-heterosexual and more likely to use illicit drugs, but less likely to smoke or report risky drinking. Details are available from the authors. Non-heterosexual women were significantly more likely than heterosexual women to have ever smoked, to be current smokers, to report risky levels of alcohol consumption, to have used marijuana and other illicit drugs in the last year, and to have ever injected drugs (Box). Although these relative differences are important, so too are the absolute values — 45.6% of non-heterosexual women were smokers, and 45.6% reported alcohol consumption of concern. In the last year, 58.2% used marijuana and 40.7% used other illicit drugs. One in 10 had ever injected illicit drugs. Although women are generally less likely than men to use drugs, and may not be a high-priority target for drug education, non-heterosexual young women’s rates of illicit drug use are at least as high as those of young men.4 Higher levels of drug use among young non-heterosexual women may be the result of individual experiences of homophobic discrimination, where drugs are used as an — albeit, short lived — panacea.1 Greater drug use may also be the result of normalisation of recreational drug use within lesbian communities.5 There is a need for specific interventions in young non-heterosexual women, and for further research to determine the reasons for their high levels of recreational drug use. Frequencies and adjusted odds ratios for drug use among 9260 heterosexual and non-heterosexual Australian women aged 22–27 years, 2000 Drug use Exclusively heterosexual Bisexual and lesbian Adjusted odds ratio* (95% CI) Smoking status (n = 8284) (n = 755) Never smoked 60.8% 37.0% 1.00 Former smoker 14.2% 17.4% 2.15 (1.65–2.79) Current smoker 25.0% 45.6% 3.18 (2.61–3.89) Alcohol consumption† (n = 8419) (n = 796) No risk 36.7% 23.9% 1.00 Low risk (no bingeing) 31.5% 30.6% 1.33 (1.05–1.69) Low risk (with bingeing) 27.9% 38.6% 2.01 (1.60–2.52) Risky 3.9% 7.0% 2.50 (1.68–3.72) Illicit drugs (n = 8409) (n = 797) Marijuana (in the last year) 21.5% 58.2% 4.68 (3.91–5.61) Other illicit drugs‡ (in the last year) 10.2% 40.7% 5.50 (4.51–6.71) Injected drugs (ever) 1.2% 10.8% 12.26 (8.53–17.63) * Adjusted for age, region of residence, and father’s occupation. † According to National Health and Medical Research Council guidelines.3 ‡ Amphetamines, LSD (d-lysergic acid diethylamide), ecstasy/designer drugs, tranquillisers, natural hallucinogens, cocaine, inhalants, heroin, barbiturates.

Lynne Hillier · Richard De Visser · Anne M Kavanagh · Ruth P McNair

Andrew B Black,* Sam F Berkovic† * Neurologist, The Queen Elizabeth Hospital, Woodville, SA; and Chair, Driving Committee, Epilepsy Society of Australia. † Neurologist, Austin and Repatriation Medical Centre, West Heidelberg, VIC; and President, Epilepsy Society of Australia. Correspondence: Dr A B Black, Ashford Specialist Centre, 57–59 Anzac Highway, Ashford, SA 5035. abblackATchariot.net.au To the Editor: Seizure disorders are often the most scrutinised medical conditions in relation to road accidents.1 Epileptologists internationally have reached some consensus on the role best played by treating doctors: ensuring patients receive proper medical care; advising on assessed risk and its minimisation; and reporting (if necessary, without patient consent) when a patient becomes a risk yet continues to drive.2 In a recent editorial on sleep disorders and driving,3 McEvoy also emphasises the essential role of first establishing the therapeutic relationship, and refers to the impending release by the National Road Transport Commission of new medical standards for all vehicle types.4 Australian neurologists and the Epilepsy Society of Australia find that the new guidelines are imprecise in defining the role played by doctors and Driver Licensing Authorities (DLAs), and are excessively detailed with cumbersome processes that are open to confusion. The instructions for using four separate forms (3.3) are complex and imprecise, giving no indication about discretion in their use or non-use. Moreover, it is not the role of doctors to define specific restrictions for holders of conditional licences (3.3.1), but that of the DLA. Demands on doctors for surveillance and enforcement are excessive, and by interfering with the maintenance of proper rapport may prove counter-productive. The roles for consultants are not clearly defined. A more desirable model is one in which the DLA takes responsibility for all legally enforceable decisions and does not expect treating doctors to decide on fitness-to-drive. A treating doctor may provide factual information, but is not expected to give an opinion on licensing questions. This model, used in the United Kingdom,5 is simple, well understood and respected. The DLA there obtains independent medical advice in deciding borderline cases, an optional mechanism given little attention in the Australian review. Doctors in the UK are well aware of their common law duty to report patients if their actions are endangering. We are drifting away from this simpler and ethically and medicolegally more satisfactory model at our peril. We should re-engage our DLA colleagues to establish a more effective relationship, in which they ensure their licence holders are well informed of their obligations, while we provide the expert care and management of our patients which will best encourage a safer driving environment.

Andrew B Black · Sam F Berkovic

Keith V Woollard Cardiologist, 34 Murdoch Drive, Murdoch, WA 6015. KeithWoollardATwacardiology.com.au To the Editor: The recent review of digoxin by Campbell and MacDonald1 pointed out that a serum digoxin level of over 1.0 ng/mL is associated with excess mortality. Indeed, higher blood levels (≥ 1.2 ng/mL) are associated with higher crude rates for all-cause hospitalisation, and for increased hospitalisation for worsening heart failure or suspected digoxin toxicity.2 The post hoc analysis of the DIG trial2 suggests that the optimal range is 0.5–0.8 ng/mL. I recently surveyed 31 private pathology laboratories across Australia to determine their recommendations about the therapeutic range of serum levels of digoxin. In summary, their recommendations ranged from a lower limit between 0.5 ng/mL and 1.0 ng/mL, and an upper limit between 1.6 ng/mL and 2.1 ng/mL. Twenty-six of the 31 suggested that values below 0.8 ng/mL were subtherapeutic. It is likely that many doctors will heed such advice and inappropriately increase the dose of digoxin in patients being treated for heart failure. It is possible that adverse effects will flow from current laboratory industry recommendations, and these should be revised.

Keith V Woollard

Abdullah Demirkol,* Jan Ritchie,† Pippa Craig,‡ on behalf of nine co-researching patients * PhD Candidate, † Associate Professor in Public Health, ‡ Conjoint Lecturer, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2051 j.ritchieATunsw.edu.au To the Editor: Oldroyd et al provide some revealing views of general practitioners on the many difficulties and few rewards arising from their care of chronic disease patients.1 As co-researchers in a participatory action research inquiry, exploring how nine of us living with Type 2 diabetes can better manage our condition, we read the article with interest and wish to give our perspective, as patients, on the issues addressed. Oldroyd et al report that many GPs describe chronic disease management as a “burden”. We are only too aware of this negative response when we present with our chronic conditions. GPs are usually our first, and often only, regular contact with the healthcare system. Although we would like to rely heavily on them, we rarely find they have enough time for us. The standard consultation is barely long enough for renewal of our prescriptions. Yet, for a couple of us who have recently wanted extended assistance, the situation has been exacerbated when our GPs have resisted specialist referral, on the assumption that their care is sufficient. The article reports the conflict felt by many GPs concerning implementation of clinical management guidelines, many of which they felt were not feasible in their everyday practice. Again, we share the discomfort this brings when we are informed of the guidelines, yet know that they do not fit with our own personal situation. We would dearly love more collaboration and negotiation in developing workable solutions best suited to our own unique circumstances. As one of us states, “none of those clinical, scientific studies can possibly be as long, complex and complicated as real life”. We believe we have accumulated a considerable amount of experience and knowledge about living with diabetes, and feel disappointed that our experience is not considered of value. It is apparent that we share the same goals as GPs in seeking effective chronic disease management, but the different knowledge bases and perspectives of doctors and patients have not coalesced. Involvement in this current participatory inquiry has given us the confidence to speak out and to propose that, as patients, we should become legitimate members of the treatment team. We await an invitation to be part of the process in implementing initiatives.

Abdullah Demirkol · Jan Ritchie · Pippa Craig

Christopher M Doran,* Julia E Fawcett,† Anthony P Shakeshaft,‡ Marian D Shanahan,§ Richard P Mattick¶ * Health Economist, † Research Officer, ‡ NHMRC Fellow and Senior Investigator, § Health Economist, ¶ Director, National Drug and Alcohol Research Centre, University of New South Wales, NSW 2052. C. DoranATunsw.edu.au To the Editor: An estimated 512 935 Australian adults satisfy criteria for alcohol dependence (3.5% of the population aged 18 years and over).1 Pharmacotherapy for this condition typically comprises a benzodiazepine, such as diazepam, for withdrawal and disulfiram for relapse prevention.2 Acamprosate and naltrexone have also recently become available for treating alcohol dependence in Australia, but little is known about their uptake or cost. One indicator of uptake is the proportion of alcohol-dependent individuals who have a script filled. Based on the number of scripts for these drugs filled in Australia in 2001, and assuming 50% compliance with the recommended treatment periods, we estimated that 4602 people took acamprosate and 8899 naltrexone in that year (Box). This is equivalent to a maximum of about 3% of alcohol-dependent individuals taking either drug (13 501 individuals using either drug/512 935 alcohol-dependent individuals). We also estimated the cost of visits to medical practitioners for scripts for these drugs, assuming that most were written by general practitioners, and the costs of the drugs themselves to the Australian government and to individual patients (Box). Total treatment and medication cost of the two drugs in 2001 was $7 420 741. These estimates are based on assumptions about the relevant population sub-group (age >18 years), rate of compliance with the recommended regimen (50%), source of scripts (GPs), and GP fees (first visit, $25.05; subsequent visits, $11.14). Varying these assumptions makes little difference to the likely uptake of either acamprosate or naltrexone; applying more conservative assumptions suggests that either medication is unlikely to have been used by more than 5% of alcohol-dependent individuals in Australia. Although use of these medications is not necessarily appropriate for all dependent individuals, their low uptake raises serious concerns about why they are being under-utilised: it may be because they are poorly marketed, or it may be that they are of limited effectiveness in Australia outside the context of clinical trials. The latter possibility is exacerbated by the nebulous nature of the comprehensive treatment programs recommended for their use.5 Without methodologically rigorous Australian data, it is difficult to confidently allay such concerns. However, these results indicate a considerable amount of resources are being devoted to acamprosate and naltrexone as treatments for alcohol dependence, with little Australian evidence as to whether this investment represents value for money. Use and cost of new medications for alcohol dependence in Australia in 2001 Acamprosate Naltrexone Number of scripts filled3 27 613 13 349 Estimated number of users* 4602 8899 General practitioner visits Estimated number† 13 807 8899 Estimated cost§ $251 129 $240 794 Medication cost3,5 Cost to government $4 442 204 $2 115 315 Estimated cost to patients¶ $252 407 $118 892 Total cost $4 945 740 $2 475 001 * Number of scripts filled/number of scripts needed for recommended treatment period (12 months for acamprosate and 3 months for naltrexone,4 with each script providing one month’s supply5)/compliance (assumed to be 50%). † Based on 6 visits per year for acamprosate prescription (12 scripts; 1 repeat per script), and 2 visits per year for naltrexone prescription (3 scripts; 1 repeat per script), but assuming 50% compliance with recommended treatment period. § Based on 2001 Medicare rates (85% of MBS code 23 [$25.05] for first visit, and 85% of MBS code 3 [$11.14] for subsequent visits) plus mean patient cost per GP/vocationally registered GP visit for 2001 of $2.62.6 ¶ Taking into account variation in patient Medicare classification (general, concessional or safety net), which varied over the year.3,5

Christopher M Doran · Julia E Fawcett · Anthony P Shakeshaft · Marian D Shanahan · Richard P Mattick

Robert G Moses,* Alison J Webb,† Christine D Comber‡ * Clinical Director, † Nurse, Diabetes Service; ‡ Nurse, Department of Obstetrics and Gynaecology, Illawarra Area Health Service, PO Box W58, Wollongong West, NSW, 2500. mosesrATiahs.nsw.gov.au To the Editor: Gestational diabetes mellitus (GDM) is glucose intolerance of variable severity with onset or first recognition during the current pregnancy.1 GDM is one of the conditions requiring an entry on the New South Wales Midwives Data Form. Effective healthcare planning is dependent on accurate data collection. To our knowledge, the verity of the midwives data with respect to GDM, or indeed other entities, has not been checked for many years. A previous article has demonstrated that the accuracy of GDM data collection is poor, with the incidence of GDM being under-reported.2 Recently, an article from Victoria also showed a recorded rate of GDM about half that of the acknowledged incidence.3 We have recently completed a review of compliance with GDM testing in our area and, knowing the true incidence of GDM, this has allowed us to revisit the accuracy of the data being recorded on the Midwives Data Collection Form. In the city of Wollongong, NSW, with a population of around 280 000 and about 3000 births each year, all deliveries take place at two public hospitals (Wollongong and Shellharbour) and a private hospital (Illawarra Private Hospital). It is the policy of both the Obstetric Department and the Division of General Practice that all pregnant women should be tested for GDM in accord with the ADIPS guidelines.4 All women who delivered at the three hospitals over the 6-month period from January 2002 to June 2002 were identified from the Labour Ward records. A hospital-based delivery is used by 99.3% of women in the area.5 The results of testing for GDM were determined for all of these women. There were 1655 deliveries at the three hospitals over the 6-month period. Seven women with known type 1 or type 2 diabetes were excluded, leaving 1648 women whose data could be examined. Women were considered to have been tested for GDM (n = 1518) if they had had either a glucose tolerance test (n = 1502) or a glucose challenge test (n = 16). There were 101 women diagnosed with GDM, giving an overall incidence rate of 6.6% (prenatal clinic, 7.1%; shared-care, 6.6%; private patients, 6.3%). The most recent midwives data indicate an incidence of 5.7% at the public hospitals and 3.1% at the private hospital. It is thus apparent that the official statistics still underestimate the incidence of GDM. A similar degree of error may also be found for other entries, and hence data should be extrapolated with caution. A redesign of the collection form may help remove some of the errors and omissions. For the question regarding GDM, we feel accuracy could be enhanced if there were separate “Yes” and “No” boxes, rather than a single check box. This might encourage further consideration of the problem. Accuracy could be further enhanced by allowing space for the glucose tolerance test results at 0 and 2 hours — these would also be useful data in their own right.

Robert G Moses · Alison J Webb · Christine D Comber

Lee K Taylor Manager, Surveillance Methods, Centre for Epidemiology and Research, NSW Department of Health, Locked Bag 961, North Sydney, NSW 2059. ltaylATdoh.health.nsw.gov.au In reply: Moses et al are correct in noting that gestational diabetes mellitus (GDM) is under-reported to the New South Wales Midwives Data Collection (MDC). The most recent validation study of the MDC was carried out in 1998. We reviewed a random sample of 1680 medical records from NSW public and private hospitals, representing 1.9% of births reported in 1998. The sensitivity and specificity of reporting of GDM to the MDC were 86.7% and 99.6%, respectively.1 In this sample, the incidence rate of GDM was 3.5% according to the MDC, and 4.0% according to the medical record review. These population rates are lower than the rates reported by Moses et al among women attending hospitals in Wollongong. In addition to incomplete recording of diagnosed GDM on the MDC, the low rate of recording of GDM in medical records in our sample suggests that GDM was also under-ascertained at a population level. This is probably due to variations in the implementation of pregnancy screening for GDM between clinicians and across NSW hospitals. In February 2003, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists endorsed the Australian Diabetes in Pregnancy Society GDM Management Guidelines.2 The guidelines recommend universal screening for GDM, noting that selective screening may be appropriate because of limited resources or known low GDM incidence. The suggestions for trying to improve reporting of GDM by redesigning the MDC form are welcome, and we will certainly consider them at the next review. We are also considering using the hospital Inpatient Statistics Collection (ISC), in which discharge diagnoses are classified according to the International Classification of Diseases, as an alternative source of information on maternal morbidity. We are currently reviewing a random sample of 500 medical records of mothers who gave birth in hospitals throughout NSW. The information obtained will be compared with matched ISC records provided to the NSW Department of Health to determine whether the ISC is a more reliable source of information on maternal morbidity than the MDC. In the longer term, I anticipate that the integration of the MDC with computerised medical records in hospitals will also contribute to improved reporting. Under-reporting of maternal morbidity, including GDM, is an issue for all state and territory perinatal data collections in Australia. The information is used for planning and evaluation of healthcare services, so it is important that we get it right. I would like to thank Moses et al for raising this issue.

Lee K Taylor

David Simmons,* Amanda Fieldhouse,† Leslie E Bolitho,‡ Grant J Phelps,§ Rob Ziffer,¶ Gary J Disher** * Professorial Fellow, Department of Rural Health, University of Melbourne, Shepparton; and Professor of Medicine, University of Auckland Waikato Clinical School, Waikato Hospital, Hamilton, New Zealand; † Health Care Consultant, South Yarra, VIC; ‡ Physician, Wangaratta, VIC; § Physician, St John of God Hospital, Ballarat, VIC; ¶ Physician, Sale, VIC; ** Deputy Director – Health Policy, Royal Australasian College of Physicians, Sydney, NSW. simmonsdATwaikatodhb.govt.nz To the Editor: Rural Australia has a substantial shortage of specialist physicians. In 1999, Victoria had 52 specialist physicians for 1.3 million people (a physician to population ratio of 1:25 000).1 The Australian Medical Workforce Advisory Committee recommendation is 1:10 000.2 Although much has been written about the shortage of rural general practitioners, there is little about rural specialist physicians. However, evidence from Western Australia showed that advanced trainee physicians interested in rural practice were diverted to city-based practice during their training.3 Here, we outline a state-wide approach to encourage advanced trainee physicians to complete their training in rural Victoria. The University of Melbourne Department of Rural Health in Shepparton provided support for rural Victorian physicians to develop a state-wide network, the Victorian Rural Physicians Network, under the Victorian State Committee of the Royal Australasian College of Physicians (RACP). A pilot survey in the 14 major rural Victorian centres demonstrated capacity for at least nine Advanced Physician Trainee positions across rural Victoria. The RACP accredited five positions initially, with others to be reviewed for accreditation if required. These positions were funded largely by the joint Federal–State Government Advanced Specialist Training Program in Rural Australia. Four trainees completed 12 months of rural training in 1999–2000, and three are now working as rural physicians. These trainees were recruited through advertisements in the RACP newsletter and personal contacts. The trainees provided substantial benefits, both in service delivery, as their presence reduced the load on other doctors in the same hospital, and in medical education, as they provided more education and supervision for junior doctors and doctors from overseas. In 2001, a similar approach to recruitment identified eight potential applicants, but none came to interview. In 2002, three new strategies were therefore introduced: Flexible, joint rural–metropolitan positions were created; A rural physicians’ conference was organised;4,5 and A management consultant was employed to contact personally all 99 Victorian basic physician trainees expected to enter advanced training. The response to the new approach is shown in the Box. A third of contactable trainees indicated an interest in rural practice at the end of their basic training. Ten applications were received for the rural training positions, and seven trainees were appointed (three withdrew). We believe that our new strategies have merit, and that the personal touch has created goodwill which may improve the response for 2004. Recruiting for the 2003 Advanced Physician Training Programme for Rural Victoria

David Simmons · Amanda Fieldhouse · Leslie E Bolitho · Grant J Phelps · Rob Ziffer · Gary J Disher

Nicholas A Tonti-Filippini Consultant Ethicist, 15 Alburnum Crescent, Lower Templestowe, VIC 3107. ntfATcyberspace.net.au. To the Editor: Jansen’s study1 of the effect of maternal age on IVF outcome yields information that has not been available. However, the presentation of the data raises two questions. Firstly, are the births reported all attributable to IVF intervention? A couple is considered infertile if they are unable to achieve conception after a year of unprotected intercourse, or the mother is unable to carry a pregnancy to a live birth.2 In reports of infertility, there is a natural conception rate of about 25%–30% per annum,3-6 and Jansen’s study, in effect, covers a 3-year period (or 4 years if you include the period for assessing the outcome of the pregnancies). We need to know whether natural conception has contributed; whether the couples continued to have unprotected intercourse during the course of the study; and what means was used to identify a pregnancy as an IVF pregnancy (as distinct from a natural conception, if that distinction was made). Jansen notes that there was a group of women who dropped out after treatments were initiated and before egg retrieval, and a further group for whom eggs could not be retrieved. It is unclear whether the former included those who had a natural conception. In terms of evaluating the success of IVF, more information on these groups would be valuable. The second question relates to comparative embryo survival rates. Jansen gives the number of live births per egg retrieval procedure, and fresh and frozen embryo transfer is combined in the live-birth result. Separating live embryo transfer from frozen embryo transfer, which is done in the Victorian Infertility Treatment Authority annual reports 1998–2001, would indicate that the transfer of a fresh embryo has about a 9.5% chance of resulting in a live birth, and the transfer of a frozen embryo has about a 3.1% chance of resulting in a live birth. In the current discussion of embryos being available for research, this information about embryo survival rates would be informative.

Nicholas A Tonti-Filippini

Robert P S Jansen Medical Director, Sydney IVF, 4 O’Connell Street, Sydney, NSW 2000. robert.jansenATsivf.com.au In reply: The pregnancies and live births I reported are all attributable to IVF intervention. The physiological and pharmacological reasons for this certainty follow. Firstly, neither an egg-retrieval treatment nor an embryo-transfer treatment (both of which require hormone administration from the start of menstruation) can be embarked on if a woman is pregnant. This is established not just by the fact of menstrual bleeding, but by showing low levels of oestradiol and progesterone. Thus, no treatment cancellations or retrieval failures were for reasons of pregnancy. In an egg-retrieval treatment cycle, preovulatory eggs are removed from mature follicles with high efficiency, and so are not available to be ovulated, which virtually precludes natural conception in the retrieval cycle. As described in my article, transfer of cryostored embryos occurs during a month in which the ovaries are suppressed by the cyclical regimen of ethinyl oestradiol and a progestin (used to develop the endometrium predictably). The effect is that of the sequential oral contraceptive regimens of the 1960s,1 and ovulation is reliably inhibited. Tonti-Filippini’s estimate of a 25%–30% annual natural pregnancy likelihood with just 12 months’ infertility would be more or less correct for couples in their 20s, but does not pertain to our population (median age, 36 years; median duration of infertility, 3.5 years). The arithmetic that predicts an expected, approximately 5% annual natural conception for such a population is given in Jansen.2 The time during which natural pregnancy could have occurred began with the month after the egg-retrieval cycle and ended, as reported, with the month before either (a) an embryo transfer resulted in a live birth, or (b) the last stored embryo from that retrieval was transferred. There were no natural conceptions that we know of, but, even if there were, such pregnancies would not and could not have been attributed to IVF treatment. Thus, the published figures are reliable. I reported the implantation rate per embryo for women under the age of 35 as 24.7%. Subtracting the reported 10.5% miscarriage risk yields a live-birth rate of 24.7% minus (24.7% × 0.105), or about 22% per embryo transferred, which is indistinguishable from the expected 20% natural monthly fertility rates among normal couples of this age group.3 Similar calculations yield 11% live births per embryo for those 35–39 years, and 4% live births for those over 40 years. With present practices at Sydney IVF (Day 5 blastocyst transfers, generally single embryos), the chance of a baby per embryo transferred is 41% (< 35 years), 24% (35–39 years) and 12% (> 40 years). The embryo implantation and live birth data Tonti-Filippini reveals for live births per embryo in Victoria are therefore very low compared with the IVF results I report.

Robert P S Jansen

Corrine R Balit,* Geoffrey K Isbister,† Andrew H Dawson,‡ Frank F Daly,§ Ian M Whyte‡ * Research Pharmacist, NSW Poisons Information Centre, The Children's Hospital, Locked Bag 4001, Westmead, NSW 2145; † Lecturer and Clinical Toxicologist, ‡ Associate Professor, Newcastle Mater Misericordiae Hospital and the University of Newcastle, Newcastle, NSW; § Clinical Toxicologist, Royal Perth Hospital and University of Western Australia, Perth, WA. corrinebalitATaol.com To the Editor: Paracetamol availability is an important public health issue. Kisely et al have further investigated the impact of two paracetamol recall periods on analgesic poisoning using a dataset derived from hospital admissions.1 We are concerned about the robustness of data that uses ICD codes, because of significant coding problems that occur with poisoning admissions. The aim of their study was as a follow-up to our own,2 to look at the impact of removing paracetamol tablets from the shelf during a recall period. Availability is reported to be the most common reason for patients choosing to take paracetamol in overdose3 and, as such, has the potential to affect acute deliberate self-poisoning. However, Kisely et al recognised that it was difficult for them to distinguish between intentional and unintentional ingestions because of the limitations of their dataset1 and hence they considered both of these together. This is inappropriate if the aim is to assess the effect of availability on paracetamol deliberate self-poisoning. For example, there is no evidence that presentations with therapeutic errors in dosing are related to availability and these should be excluded. This is not possible by using ICD codes and was therefore not done by Kisely et al.1 In addition, it is only relevant to include accidental ingestions of tablet formulations of paracetamol, because only these were affected by the recall. There are significant numbers of presentations of children, who accidentally ingest liquid formulations of paracetamol (hence not related to the recall period), that are coded as paracetamol admissions. This introduces a further significant potential bias in the Kisely study. A more concerning problem is the reliability of ICD coding in separating out different analgesics. Poisoning with prescription products such as paracetamol-codeine combination analgesics, which were not affected by the recall period, are also likely to be included in the study being coded as T39.1 (paracetamol overdoses).1 There are significant limitations in using ICD codes, resulting in the dataset analysed not being a true reflection of the impact of the recall of paracetamol tablets. Our study took into account only tablet formulations of the paracetamol alone compounds.2 Paracetamol ingestions following therapeutic error were excluded and accidental ingestions of only tablet formulations were included. While the numbers in the study were small for the hospital presentations, the data set for the NSW Poisons Information Centre was much larger and showed significant increases in intentional and accidental ingestions of ibuprofen, the next most available analgesic.2 In an environment where paracetamol restriction is a hotly debated topic, particularly in light of recent coroners’ cases, it is vital to consider the impact of paracetamol restriction on all types of deliberate self-poisoning by using an appropriate dataset that reflects the measures taken to reduce availability. The challenge for state and federal health departments is to fund appropriate postmarketing toxicovigilance for accidental and intentional self-poisoning in order to clarify these important public health issues.

Corrine R Balit · Geoffrey K Isbister · Andrew H Dawson · Frank F Daly · Ian M Whyte

Elizabeth A Hender,* Jeremy Raftos† * Scientific Officer, Hazardous Substances Section, Department of Human Services, PO Box 6, Rundle Mall, Adelaide, SA 5000; † Director, Paediatric Emergency Department, Women’s and Children’s Hospital, Adelaide, SA. Elizabeth. HenderATdhs.sa.gov.au To the Editor: We read with interest the study of Kisely et al,1 which showed a decrease in admissions for poisoning with paracetamol, but no coincident increase in use of other agents, as a result of the paracetamol recalls. We had noticed there was an unusually high number of presentations (18) to the Paediatric Emergency Department at the Women’s and Children’s Hospital, Adelaide (WCH), for poisoning with aspirin in 2000, compared with one presentation in 2001 and one in 2002. We wondered if the presentations in 2000 were temporally associated with the paracetamol recalls. We extracted all WCH presentations with a primary diagnosis of paracetamol poisoning (ICD-9 code 965.4), aspirin poisoning (965.1), nonsteroidal anti-inflammatory drugs (965.6) and poisoning with all other drugs (960–979.9) for the two recall periods (16 March 2000 to 21 May 2000; 6 June 2000 to 23 August 2000)2 and the same periods in 2001 and 2002. It could not be determined whether an over-the-counter preparation of a nonsteroidal anti-inflammatory drug had been taken. The results are shown in the Box. Presentations (P) and admissions (A) for poisoning with paracetamol, aspirin, NSAIDs and other drugs at the Women’s and Children’s Hospital, Adelaide 2000 restricted 2001 available 2002 available P A P A P A Aspirin 15 13 1 0 0 0 Paracetamol 23 6 34 13 34 14 NSAID 3 1 0 0 1 0 Other drugs 86 43 89 35 60 23 NSAID = non-steroidal anti-inflammatory drug. These data show that the number of paracetamol poisoning presentations and admissions was lower during the recalls than in the same period in subsequent years, but there was a higher number of presentations and admissions for poisoning with aspirin. All the aspirin poisoning presentations and admissions during the period when paracetamol was recalled were during the second recall (affecting SmithKline Beecham products). The other three aspirin poisoning presentations in 2000 occurred within 10 days of the end of the second recall. All but one of the 18 patients with aspirin poisoning who presented during 2000 were adolescents (17 females). Most of these exposures were likely to be due to intentional self-poisoning. Although it is not possible to reach any definite conclusion from these observations, we share the concerns of Balit et al2 that limiting the availability of paracetamol could result in an increase in poisonings with potentially more acutely dangerous agents such as aspirin, particularly for adolescents. There needs to be further consideration of the motivation of patients in choosing paracetamol and the source of the drug when taken for intentional self-poisoning before measures are taken to restrict access to paracetamol.

Elizabeth A Hender · Jeremy Raftos

Stephen R Kisely,* David Lawrence,† Neil J Preston‡ * Professor of Health Outcomes, Department of Psychiatry, Dalhousie University, Canada; † Post-doctoral Fellow, Institute for Child Health Research, Perth, WA; ‡ Research Psychologist, Fremantle Hospital and Health Service, Fremantle, WA. stephen.kiselyATcdha.nshealth.ca In reply: Balit et al raise the problem of distinguishing between intentional and unintentional ingestions. As stated in our article, we did look at deliberate and accidental poisonings separately, but space restrictions, not limitations of our dataset, prevented us from presenting the results.1 Of 2266 paracetamol poisonings, 1731 (76%) were coded as deliberate, 433 (19%) were accidental and in 103 (4.5%) the intention could not be determined. Restricting the analysis to the deliberate cases yields almost identical results. Our dataset may have contained poisonings with liquid or combination formulations of paracetamol that were not recalled. This factor would have operated before, during and after the recall and would only serve to reduce the magnitude of any effect, rather than accentuating it. We considered 2663 admissions for over-the-counter analgesic poisoning,1 as opposed to 143 in the NSW study.2 We did not look at telephone calls, as reliance on data from calls to a poisons information centre raises far more concerns about data quality than hospital statistics do. How reliable was the informant? How serious was the poisoning? Do telephone data contain less serious cases that do not require admission? Hender et al report the findings of an observational study restricted to a single paediatric emergency department attached to the Women’s and Children’s Hospital, Adelaide. Unfortunately, data for only three years are presented, with no information for the years before the recall. Neither do we know how many were intentional or unintentional. By definition, their data exclude adults. As they state themselves, it is not possible to reach any definite conclusions from their observations. We should not prematurely dismiss the possible benefits of restrictions on the availability of paracetamol. If there are concerns that restricting the availability of paracetamol might increase the use of other over-the-counter analgesics in poisonings, we should be investigating the effectiveness of restrictions on the availability of these as well. Who precisely benefits from continued sales of over-the-counter analgesics in catering pack sizes?

Stephen R Kisely · David Lawrence · Neil J Preston

Barbara M Miflin,* Kevin L Forbes† * Lecturer in Teaching and Learning Development, † Deputy Head, Years 3 and 4 MB BS Program, School of Medicine, University of Queensland, Herston Road, Herston, QLD 4006. barbara.miflinATuq.edu.au To the Editor: All established disciplines that have contributed to medical curricula in the past should play, as Weedon1 argued recently for pathology, a pivotal role in contemporary medical curricula. Indeed, students should be able to acquire better knowledge of a discipline through a problem-based learning (PBL) approach than through traditional teaching methods. The crux of the PBL approach is that knowledge, skills and the other professional attributes are learnt in a way that puts them into context and thus makes them meaningful and better remembered by medical students. The trouble is, as Weedon pointed out, the number of academics in the discipline of pathology is dwindling. The scarcity of academic pathologists, combined with the increased workloads of private pathologists, means that their input into designing and developing curricula and into pathology teaching may be increasingly inadequate. Pathology is not the only discipline to be underserved in today’s medical schools. In response to concerns about the medical curriculum, the Royal College of Pathologists of Australasia and other Colleges and interest groups have developed core syllabuses for use in medical programs. These developments are most welcome in view of the diminishing resources available for teaching in universities. In a PBL-oriented curriculum, teaching staff work in a multidisciplinary team in which the aspirations and limitations of each group are acknowledged, respected and acted upon in the context of realistic expectations of what is possible and what is necessary for medical graduates in the 21st century. Currently, in Queensland, a series of pathology modules for students to use during their clinical rotations would be well received. The use and interpretation of pathology tests are already built into PBL case studies, and could be extended into a module set as prerequisite learning for an attachment to a public or private pathology laboratory. Pathologists may also be able to use the syllabus to guide their teaching in mentorships for the elective components of medical programs. The needs of disciplines such as pathology will be best achieved through genuine understanding of the aims of medical schools to ensure appropriate, realistically achievable learning for students. When students are motivated to acquire knowledge of a discipline because they can see its relevance to solving patients’ problems, their enthusiasm for the discipline will be enhanced and they will learn well.

Barbara M Miflin · Kevin L Forbes

Donald D Beard Surgeon, 134 Beulah Road, Norwood, SA 5067. To the Editor: The issues raised in the editorial by Weedon1 are a sad reflection on current medical education. Weedon voiced the serious concern of the Royal College of Pathologists of Australasia regarding the downgrading and marginalising of the teaching of pathology because of the ascendancy of problem-based learning, to the detriment of the basic sciences pathology, physiology and anatomy. Weedon reminded us of Virchow’s pronouncement that applying the doctrines of pathology “helps to deepen biological knowledge, and to light up still further that region of the unknown which still envelops the intimate structure of living matter”. That statement also applies to anatomy and physiology. It could not have been said better. Some years ago, while I was on the Curriculum Committee of the University of Adelaide, the Committee agreed to recommend that the basic sciences continue to be taught throughout the medical course. Unfortunately, the recommendation was not accepted, and now the position is even worse. I find it very difficult to understand the priorities of the current medical curricula and who is making the recommendations. I feel the excitement of the study of medicine is disappearing, and hope it is not too late to reverse the current trend.

Donald D Beard

H Reginald Magee Vascular Surgeon (retired), “Alexandra”, 201 Wickham Terrace, Brisbane, QLD 4000. reginaldmATbigpond.com To the Editor: I was most interested in Weedon’s editorial on the teaching of pathology in the present medical curriculum.1 I have lamented the demise of anatomy teaching in undergraduate courses and regret that pathology is going the same way. In my view, anatomy, physiology and pathology are fundamental to understanding the disease process. They enable physical symptoms and signs to be interpreted in a logical manner so that a provisional diagnosis can be made. Once this has been done, it is reasonable to progress to ancillary aids to confirm or refute the original diagnosis. When doing operative surgery I used to ask my assistants questions, usually on anatomical features that were being exposed. Many, including some who possessed the primary surgical fellowship, could not identify simple structures such as the sartorius muscle when the popliteal artery was being exposed. Questions on structures in the neck were even less well answered. The present medical curriculum is directed towards problem-solving methods and the patient’s condition in relation to the environment and other conditions. But how much thought goes into the mechanism of disease and understanding physical findings? I consider medicine and surgery to be applied pathology, and therefore knowledge of the basic facts is essential. Future doctors may be proficient in the general and social aspects of medicine, but it would seem that their knowledge of the basic facts of anatomy, physiology and pathology and their understanding of the mechanism of disease may be no better than that of a “medicine man”.

H Reginald Magee

Colleen T Bruce,* Margaret M Sanger,† Paul S Thomas,‡ Jonathon R Petkus,§ Deborah H Yates¶ * Research Assistant, ‡ Senior Lecturer, Faculty of Medicine, University of New South Wales, Randwick, NSW; † Deputy Medical Director, Concord Repatriation General Hospital, Concord, NSW; § Medical Student, ¶ Senior Lecturer, Faculty of Medicine, University of Sydney. Correspondence: Dr Deborah H Yates, Department of Respiratory Medicine, St Vincent’s Hospital, Darlinghurst, NSW 2010. deborahy88AThotmail.com To the Editor: The demands of practising medicine can have significant effects on general health, work satisfaction, professional and non-professional life.1 We conducted a survey among senior medical staff in a metropolitan teaching hospital. The survey explored the pressures of work, social and family demands on consultants, and whether there was a difference between sexes. Participants completed a self-reported questionnaire on quality of life, levels of stress and feelings of work satisfaction, using previously validated questions and scoring from the General Health Questionnaire (GHQ-28, a 28-question subset of the GHQ)2 and Specialist Doctors Stress Inventory (SDSI).3 (Questionnaire available from authors on request.) Respondents answered anonymously and gave informed consent. Fifty-seven per cent of consultants (54/94) returned surveys, of whom a third (18/54) were women. The response rates were comparable to those of other physician surveys.4 On average, consultants had been employed at the hospital for 10.8 (SD, 8.0) years, had been qualified for 22.2 (SD, 9.6) years, and were working 47.7 (SD, 14.0) hours per week. Eighty-one per cent (44/54) were married, 74% (40/54) had children and 54% (29/54) lived in a double-income household. Half (27/54) reported an unreasonable ratio between work hours and leisure time, and 50% (27/54) reported feeling stressed. Despite this, 65% (35/54) believed they had or would achieve their ideal medical career. Female consultants worked fewer professional hours, but more hours in unpaid domestic work, than male consultants. Furthermore, female doctors were more likely to have had their career modified by family or social factors; more likely to use paid support to cope with their domestic workload; and, if they had children, more likely than men to have modified their careers to look after dependants (see Box). Consultants who reported feeling stressed were more likely than other consultants to report an unreasonable ratio between work hours and leisure time (74.1% [20/27] v 48.1% [13/27]; P = 0.05). Forty-one per cent (22/54) scored above 4 on the GHQ-28, indicating that a high level of stress and psychiatric “caseness” (ie, clinically significant levels of psychiatric disturbance) is experienced by senior doctors. This result is similar to that of a UK study in which 46% (30/65) of senior doctors reported experiencing high levels of stress.5 From our data there appears to be a significant relationship between stress, psychiatric “caseness” and hours worked (P < 0.001). Our study and others have identified potential reasons why women work fewer hours in medical work and have a shorter working life. These include having and caring for children, stress, dual-career marriages, personality and social expectations.6 Our survey highlights the fact that female consultants in Australia face undue pressure in balancing their medical and domestic roles compared with male consultants. There is a continuing need for flexibility in workplace and training environments for women in medicine to ensure equal career choice, balance between work and domestic commitments, and professional satisfaction. Comparison of self-reported factors between female and male consultants (n = 54) Female consultants (n = 18) Male consultants (n = 36) P value Mean age in years (SD) 45.3 (10.5) 47.7 (8.1) 0.43 Mean hours in medical work per week (95% CI) 33.4 (28.5–38.4) 54.7 (51.5–58.0) < 0.001* Mean hours in unpaid domestic work per week (95% CI) 22.9 (8.0–37.8) 10.6 (7.6–13.5) 0.02* Uses paid domestic support 14/18 (78%) 18/36 (50%) 0.05* Has children 11/18 (61%) 29/36 (81%) 0.12 Expects to achieve future medical goals 12/18 (67%) 24/36 (67%) 0.78 Has had career expectations modified by: Workplace 8/18 (44%) 22/36 (61%) 0.25 College/training 4/18 (22%) 7/36 (19%) 0.81 Family/social factors 12/18 (67%) 14/36 (39%) 0.05* Illness 1/18 (6%) 4/36 (11%) 0.51 Has had career opportunities modified by care for dependants 9/11 (82%) 10/29 (34%) 0.02* Reports partner is inconvenienced by respondent’s career goals 10/18 (56%) 9/36 (25%) 0.03* Mean score on GHQ-28 (95% CI)† 2.24 (1.81–2.68) 2.10 (1.95–2.26) 0.45 Psychiatric “caseness”‡ 8/18 (44%) 14/36 (39%) 0.30 Median job satisfaction score§ 3 (range, 3–4) 3 (range, 1–4) 0.15 Median life stress score§ 2 (range, 1–2) 1 (range, 1–3) 0.13 GHQ-28 = 28-item General Health Questionnaire. * Difference between men and women significant. † Minimum score = 0; maximum score = 28. ‡ ie, Clinically significant psychiatric disturbance (GHQ-28 score > 4). § Minimum score = 1; maximum score = 4. Data were analysed by Pearson’s χ2 test, Student’s t-test or the Mann–Whitney test and stratified by sex.

Colleen T Bruce · Margaret M Sanger · Paul S Thomas · Jonathon R Petkus · Deborah H Yates

Patricia A Figgis,* Allan R Glanville,† John L Harkness‡ * Thoracic Registrar (currently, Senior Registrar, General Intensive Care, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW, 2050); † Head of Thoracic Medicine, ‡ Director of Microbiology, St Vincent's Hospital, Darlinghurst, NSW. patriciafiggisAThotmail.com To the Editor: A previously well 57-year-old man presented to the emergency department with a 3-day history of severe dyspnoea. Six weeks earlier he had noticed coryzal symptoms with subsequent lethargy, reduced appetite with weight loss, and a non-productive cough. He then developed ankle swelling and increasing abdominal girth. He had a background of excessive alcohol consumption, but had abstained for 10 years. On examination, he was febrile and in respiratory distress, with a respiratory rate of 35 per minute, pulse rate of 130 bpm, and blood pressure of 130/85 mmHg. Chest auscultation revealed bilateral diffuse coarse crackles. The chest x-ray is shown in Box 1, and results of additional investigations in Box 2. Despite treatment with broad-spectrum antibiotics (intravenous ceftriaxone, dicloxacillin and erythromycin), the patient’s condition deteriorated rapidly, and he required intubation within 24 hours of presentation. Trap sputa contained abundant thin, partially acid-fast, beaded, branching filaments, suggesting Nocardia asteroides, which was later confirmed on culture using conventional biochemical testing. Several blood cultures taken on admission also grew N. asteroides. All cultures for mycobacteria were negative. The patient was treated with intravenous trimethoprim–sulfamethoxazole for a total of 5 weeks and oral minocycline for 14 weeks. He spent 6 weeks in hospital. Liver biopsy, performed because of persistently abnormal hepatic function at follow-up 8 weeks after hospital discharge, showed central fibrosis and non-caseating granulomatous hepatitis (Box 3). The patientn received no further treatment and remained well 18 months later, with almost normal hepatic function and a clear chest x-ray. Nocardia bacteraemia is rare, although the incidence appears to be increasing in the immunosuppressed. Nocardia spp. are seldom isolated in blood cultures, with one study finding that blood was the source of only 8% of all Nocardia isolates.1 Up to 30% of patients with Nocardia bacteraemia have coexistent infection with gram-negative bacteria.1,2 There has been one previous report of Nocardia pneumonia associated with positive blood cultures and liver disease. However, this patient had documented end-stage chronic liver disease at presentation, was taking prednisolone, and developed nocardiosis after prolonged hospitalisation with gram-negative sepsis.1 Granulomatous reactions are well described in Nocardia infection. Although granulomatous hepatitis is also described in sarcoidosis, it is rare and usually presents with itch and obstructive abnormalities of liver function.4 In our patient, acute N. asteroides infection was the most likely cause of both the pulmonary infiltrate and the granulomatous hepatitis. Not only were results of modified acid-fast stains consistent with Nocardia spp., but cultures from multiple trap sputa and blood specimens also grew N. asteroides, suggesting a large load of this organism. No other organisms were isolated despite prolonged incubation of cultures, and the patient recovered after specific treatment directed at Nocardia spp. Furthermore, he remained well with no further treatment at 18-month follow-up, with near-normal hepatic function and no new abnormalities. We conclude that N. asteroides infection can present as a fulminant community-acquired pneumonia with bacteraemia in the absence of immunosuppression or coexistent infection. Our case illustrates the potential hepatic sequelae of Nocardia bacteraemia. 1: Chest x-ray of a patient with Nocardia asteroides pneumonia Chest x-ray taken on admission to hospital, showing widespread non-symmetrical interstitial and airspace infiltrates. 2: Results of investigations Result Reference range At presentation Arterial blood gases* pH 7.37 7.35 –7.45 pCO2 (mmHg) 43 35 – 45 pO2 (mmHg) 60 75 –105 Bicarbonate (mmol/L) 24 24 – 31 Base excess 0 − 3 to 3 White cell count Total (x 109/L) 31.5† 4 –11 Neutrophils (x 109/L) 30.2 2 – 7.5 Lymphocytes (x 109/L) 0.7 2 – 4 Follow-up at 8 weeks Liver function tests‡ Bilirubin (μmol/L) 9 < 18 Alkaline phosphatase (U/L) 124 30 –100 γ-Glutamyl transferase (U/L) 153 < 35 Iron studies Serum ferritin (μg/L) 446 30 – 400 Serum iron (μmol/L) < 3 10 – 30 Transferrin (g/L) 1.9 2.0 – 3.5 Transferrin saturation < 6% 15%–50% Vitamin B12 (pmol/L) 376 > 126 Immunological tests HIV antibodies Negative Hepatitis B and C§ Negative Autoantibody screen¶ Negative Complement C3 (g/L) 1.07 0.82 –1.45 Complement C4 (g/L) 0.25 0.15–0.45 * Breathing 10 L/min oxygen. † Occasional myelocytes, toxic granulation. ‡ Levels of alanine and aspartate aminotransferase were in the reference range. § Including hepatitis B surface antigen and hepatitis C antibody. ¶ Including antinuclear, extractable nuclear antigen, double-stranded DNA and antineutrophil cytoplasmic antibodies. 3: Liver biopsy in a patient with Nocardia asteroides pneumonia Core biopsy of liver, showing a granuloma within the central portal triad (arrow); the portal ducts are expanded and fibrosed with a patchy lymphocytic infiltrate (original magnification x 40; haematoxylin and eosin stain).

Patricia A Figgis · Allan R Glanville · John L Harkness

Sam L S Yuen,* Bruce McGarity† * Medical Registrar, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050; † Physician, Bathurst Base Hospital, Bathurst, NSW. lsyuen_98ATyahoo.com To the Editor: A 71-year-old man was admitted to hospital in 2002 with nausea, abdominal discomfort and myalgia. He was dehydrated and had mild right upper quadrant tenderness. No muscle tenderness was noted. Five weeks previously, an infected right femoropopliteal gortex graft had been surgically removed. Methicillin-resistant Staphylococcus aureus was present on culture. Therapy with fusidic acid (250 mg three times daily) and rifampicin (600 mg daily) had been commenced, and the patient’s condition improved. Fusidic acid therapy was continued because of unsatisfactory wound healing. On presentation he had been taking fusidic acid for 4 weeks. He had been taking simvastatin (40 mg nightly) for 8 years. The patient had a history of generalised vascular disease and multiple bypass procedures. He had a background of paroxysmal atrial fibrillation, myocardial infarction, left ventricular failure, hypertension, hypercholesterolaemia and chronic airways limitation. His other medications were metoprolol, irbesartan, frusemide, warfarin, paracetamol and narcotic analgesics. Test results showed the following biochemical concentrations: aspartate transaminase, 1618 U/L (normal range, < 40 U/L); alanine transaminase 657 U/L (normal range [NR], < 35 U/L); alkaline phosphatase 133 U/L (NR, 25–100 U/L); total bilirubin, 29 μmol/L (NR, < 20 μmol/L); γ-glutamyltransferase, 37 U/L (NR, < 50 U/L); urea, 24.7 mmol/L (NR, 3.0–8.0 mmol/L); creatinine, 0.35 mmol/L (compared with previous creatinine concentration of 0.11 mmol/L [NR, 0.06–0.12 mmol/L]). Drug hepatitis, secondary to fusidic acid was suspected, and therapy with this drug was ceased. The following day, the patient’s clinical status declined, with generalised muscle pains and weakness, significantly impairing his mobility. The serum creatine kinase concentration was elevated at 66 710 U/L (normal range, 60–220 U/L), with a normal troponin I concentration. Myoglobinuria (567 200 ng/mL) was detected. Simvastatin therapy was ceased, and there was prompt clinical improvement, with recovery of renal function and a gradual fall in the concentration of serum creatine kinase. On discharge 14 days after admission, his serum creatine kinase concentration was 1153 U/L and creatinine concentration was 0.12 mmol/L. Transaminase concentration readings fell rapidly in line with the creatine kinase concentration, suggesting they were of muscular rather than hepatic origin. Three other cases of rhabdomyolysis have been reported as a result of interaction between an HMG CoA-reductase inhibitor and fusidic acid,1-3 but there have been no previous reports from Australia. Fusidic acid, like simvastatin, undergoes extensive first-pass metabolism in the liver (over 98%). Simvastatin is metabolised via the cytochrome P3A4 enzyme system. It is known that, if given concomitantly with inhibitors of this system (eg, macrolides and azole derivatives), statin concentrations can become elevated and lead to an increased likelihood of adverse effects.4 Fusidic acid is not known to be an inhibitor of this system (Peter Hobbs, Manager of Medical Affairs, CSL Limited [manufacturers of fucidin], personal communication), although our case is suggestive of such an interaction. This case demonstrates the interaction of fusidic acid with simvastatin resulting in rhabdomyolysis. The extensive use of statin therapy in patients with vascular disease makes it important for doctors to be aware of this interaction when prescribing fusidic acid.

Sam L S Yuen · Bruce McGarity

Andrew G Marsden Occupational Physician, Unit 6, 125 Melville Parade, Como, WA 6152. To the Editor: Modern air travel lends itself to aerosol transmission of viral infection. Infected individuals in modern aircraft represent a significant risk for other travellers during long journeys. In September 1999, a person with an influenza-like illness joined other workers returning by aircraft to an isolated mine in north-western Australia. He was identified as unwell by a mine supervisor in the airport lounge but was allowed to board the BAe 146 aircraft (a 75-seat passenger jet aircraft). The flight lasted 3 hours 20 minutes. On landing in the evening, most workers were transported to their quarters in a 10-minute bus trip, but some, including the affected worker, travelled independently. They then went to their individual rooms. The next day, the affected worker reported sick immediately on going to his work site and did not work for 4 days. The other workers undertook 12-hour shifts operating machinery or in offices, relatively isolated from other people. However, they may have mixed socially. Over the next 3–4 days, 15 other workers presented with an acute influenza-like illness, with fever, cough, nasal congestion, anorexia and prostration. No serological tests were undertaken because of the remoteness of the mine. All other workers on the flight were contacted by telephone 6 days after the flight. Five more were identified who had significant upper respiratory tract symptoms and were taking simple analgesics, but had continued to work. The airline reported that no staff from the aircraft had reported sick over the next week or so. The seating positions of the affected workers on the aircraft, which was full, are shown in the Box. The index patient sat in seat 11G. Most of the other affected workers appeared to sit in a “plume” around him. The only affected workers who sat further away were the supervisor who assessed the index patient in the airport lounge (seat 3A) and a person who conducted a raffle during the flight and walked the length of the aircraft collecting money and ticket stubs (seat 1F). In aircraft such as the BAe 146, air is circulated and filtered, entering the passenger compartment through continuous vents just beneath the overhead lockers, circulating downwards and exiting from continuous vents under the seats. Air therefore tends to flow in two contrarotating circles, from ceiling to floor on either side of the aircraft. Infection could well have been transmitted by aerosol droplets to passengers behind the index patient, as he coughed and sneezed throughout the flight. The immunisation status of the passengers was not recorded; most were aged 20–45 years. This outbreak was relatively confined, as the passengers were in an isolated community, and those affected were managed in their rooms. However, the implications for the spread of airborne infection in passenger aircraft and into the wider community are obvious. It must be stressed to the travelling public that people with this type of illness should not fly. Airport authorities at passenger check-ins should be encouraged to identify and formally assess potentially infected individuals, and should have the authority to take precautions against spread. Aircraft seat allocations of index patient and affected passengers I = index patient. F = passenger developed influenza-like illness. M = passenger developed mild upper respiratory tract illness.

Andrew G Marsden

John M Weiner Allergist, Department of Respiratory Medicine, St Vincent’s Hospital, Fitzroy, VIC 3065. jmweinerATallergynet.com.au To the Editor: Any doubts that many Australian doctors are prescribing inhaled fluticasone for asthma at inappropriately high doses are dispelled by the three reports in the 3 March issue of the Journal.1-3 Fluticasone has a flat dose–response curve for efficacy and a steep dose–response curve for adverse effects;1 individuals with asthma are receiving high doses of inhaled fluticasone;2 and there is a potential for the effects to be lethal.3 Each of these reports restricted its advice to negative recommendations about drug treatment (DON’T overtreat, BACK-titrate), but this is the right time to also promote positive recommendations about asthma management. All individuals with persistent asthma requiring daily therapy should have either skin testing or in-vitro testing to determine the presence of specific IgE antibodies to inhalant allergens.4 This might allow the option of allergen avoidance. In some studies, dust mite reduction was found to ameliorate asthma symptoms in sensitised individuals (National Health and Medical Research Council Level II evidence), although those findings are not supported by a meta-analysis. Repeated low-dose exposure to cat allergen in cat-allergic individuals with asthma leads to increased non-specific bronchial hyperreactivity (Level II evidence).5 Allergen desensitisation in carefully selected cases with consultant supervision can lead to a significant reduction in medication requirement, and reduced specific bronchial hyperreactivity (Level I evidence).6 Treatment of concomitant rhinitis can itself lead to easier asthma control. A checklist of the “A,B,C...” of asthma triggers does not take long and often yields useful tertiary prevention strategies: Allergy (seasonality, dust, pets), Bronchial infection, Cold air/exercise, Drugs, Emotion/stress, Food and food additives, Gastro-oesophageal reflux, Hormones and pregnancy, Irritants including cigarette smoke, and the Job. Inhaled anti-inflammatory treatment using cromolyns or corticosteroids, with or without consideration of oral montelukast, remains the cornerstone of asthma control when the disease is frequent or persistent. However, the search for allergic and other triggers by healthcare workers, individuals with asthma, and their carers can instil into the entire group a culture of prevention, which naturally leads to a brake on overtreatment. Such a culture is firmly entrenched in continental Europe and the United States. In Australia, there has been outstanding research into the epidemiology and immunology of asthma, but it’s at the coalface where the individual with asthma gets advice. A diligent search for triggers, with appropriate management, should start at the first consultation, as the pen (or mouse) is poised to prescribe.

John M Weiner

Jill S Butty Quality Facilitator, Werribee Mercy Hospital, 300 Princes Highway, Werribee, VIC 3030 jbuttyATmercy.com.au To the Editor: It was refreshing to see the report by South et al, describing a simple, inexpensive intervention which resulted in a positive effect on the appropriate prescribing of antibiotics and a cost saving for the organisation.1 In the current climate, it has been much more fashionable to suggest computerised prescribing as the cure-all for medication and prescribing errors. As demonstrated by Newby et al,2 computerised prescribing has inherent problems, including an increase in repeat ordering of antibiotics. The Australian Council for Safety and Quality in Healthcare suggests computerised prescribing as one of several strategies to reduce medication critical incidents.3 However, the costs of establishing such a system in smaller hospitals and community health centres can prove prohibitive. This can lead to an attitude of “too expensive” so do nothing. Other strategies and interventions can be introduced at minimal cost to the organisation and yet prove effective in reducing both inappropriate prescribing and the number of critical incidents or errors. The provision of easily accessible standardised protocols and guidelines, the review of medication charts and their ease of use, changing the times of daily medication administration to maximise access to clinicians, and empowering patients to be more aware and responsible for their medications are just a few. In summary, other strategies need to be developed and their success or failure reported. There should also be awareness that familiarity with procedures can lead to errors and reinforcement is required for all interventions. Computerised prescribing should not be viewed as the solution to all medication adverse events, but one of several strategies that healthcare organisations can use in their battle with medication errors.

Jill S Butty · Saji S Damodaran

Saji S Damodaran Associate Professor, Department of Psychological Medicine, Monash University, and Clinical Director, Monash Medical Centre, 246 Clayton Road, Clayton, VIC 3168 saji.damodaranATmed.monash.edu.au To the Editor: Australia has a high rate of antibiotic use. Increasing antibiotic resistance, spiralling pharmaceutical cost, need for evidence-based practice, public awareness, and widespread variation in prescribing practice, which may lead to quality and safety issues, are reported as the drivers for improving antibiotic use and prescribing. South et al are to be commended for the introduction of a laminated card for doctors as a simple intervention to improve prescribing practices.1 Despite the passive nature of the intervention, they found significant improvement in the appropriateness of prescribing. The authors acknowledge that they are not claiming that their intervention “is the cause or only cause” for change in practice. Areas like antibiotic prescribing and physician behaviour are highly complex and require a series of systematic approaches. Doctors are only one of the multiple stakeholders involved in this process. The level of experience, training background, and awareness of the public health and clinical implications of such interventions vary widely among doctors. Improvement of South et al’s methodology from a passive mailout to gathering systematic baseline information about the medical staff involved, clarifying the purpose of the initiative and finding the proportions of uptake among junior and senior staff would have made the intervention more robust. One of the fundamentals of any change process is to instil a sense of urgency and develop a coalition to drive and lead it. Development and evaluation of quality initiatives need more than just passive information provision. It has been suggested that any such quality and safety initiative should have set priorities, and these priorities should be developed using a systematic evaluation process with explicit criteria.2 Various systemic strategies that involved systematic methodology and evaluation processes, such as antibiotic decision support systems (both computer and manual) and drug utilisation reviews, reported sustainable changes in prescribing practices.3 The intervention by South et al is a welcome initiative, but it is important to realise that simplifying a complex problem like drug prescribing may lead to setting up wrong priorities for action and trivialise the problem and solution. Such initiatives will suffer the fate of the many quality programs that we hear about in hospital corridors but which fail to make a sustainable change.

Stephen C Due Editor, AMPI, Geelong Hospital Library PO Box 281, Geelong, VIC dueATbarwonhealth.org.au Readers interested in medical history may like to know about the Australian Medical Pioneers Index (AMPI), which is the first major Australian medical history website, and the first published encyclopaedia of Australian medical biography. AMPI aims to provide basic personal and professional information on every doctor resident in Australia, or professionally connected with Australia, up to the year 1875. This includes medical officers on immigrant and convict ships, doctors who practised in Australia, and doctors who pursued other occupations here. Over 3000 pioneer doctors are listed. In addition to biographical data, the website provides interesting material on the medical profession in colonial times, including a picture gallery containing rare images of pioneer medical life (Box). There is also a section on sources of information about early doctors. The original compiler of AMPI was Dr David Richards (1937–1998) of Nottingham, England, whose card file was computerised at the Geelong Hospital Library. The website was developed in conjunction with the State Library of Victoria as a community service. Anyone with additional data about a particular doctor is encouraged to contribute to the project. Colonial medical transport. Dr S R Robinson adopted this modern mode of transport when most of his colleagues still kept horses and buggies. (Geelong Heritage Centre — reproduced with permission.)

Stephen C Due