Letters

To the Editor: Thank you to McVeagh1 for highlighting some more of the amazing scientific evidence regarding the benefits of breastfeeding. It is extremely important to continue to emphasise the benefits to mother and child in order to strengthen the individual's resolve and the community's support for breastfeeding. However, my concern is whether the question "Is breastfeeding best practice?" should ever be posed in the first place. Do our natural physiological processes now need to be supported by an evidence base and scrutinised in terms of whether they conform to notions of "best practice"? And should the question about choice between breastfeeding and artificial feeding continue to be asked? McVeagh also posed the question, "Is there justification in the argument that women are being pushed too hard to breastfeed?". Can there ever be too much encouragement given to women to provide nutrition and nurturing hand-in-hand to their baby? We must keep emphasising that breastfeeding is not only about good nutrition, reduction in childhood obesity and other measurable health outcomes. Surely there must remain some areas in our lives that do not require evidence and scientific support. Breastfeeding is about loving and nurturing a baby. It is about human relationships. When one experiences a newborn latching on to feed, the clearly felt surge of hormones from breast to brain, the physical expression of these hormones as a palpable "let-down" reflex and the incredible sight of milk rushing from the breast on demand, we do not need science to tell us that this is one of life's most amazing and wonderful experiences, nor to confirm what breastfeeding mothers innately know to be best practice.

Sandra L Neate

In reply: I thank Neate for her comments and for challenging the need to ask "Is breastfeeding best practice?". I appreciate her sentiment that there is more to infant feeding than nutrition and health. However, while there are mothers who don't find breastfeeding pleasurable or easy and are deciding how long to persist; while there are mothers who opt not to exclusively breastfeed for six months or to wean before a year of age; while mothers' advisors prescribe solids or complementary feeds or weaning for myriad problems without evidence for effectiveness beyond a placebo effect; while some believe that the disadvantages of not breastfeeding only apply to infants in developing countries; while there are commercial interests promoting products that undermine exclusive breastfeeding; while the Australian government has not fully implemented the recommendations of the World Health Organization Code and subsequent resolutions;1 while health professionals are receiving "educational material" implying that a new additive makes commercial infant formula more like human milk; and while the scientifically minded among us just need to satisfy our curiosity, we need to know to what extent it matters if an infant is breastfed at all, breastfed exclusively, or breastfed for longer periods. Thank you for challenging the question. The weight of the evidence is such that the real question is not "Is breastfeeding best practice" but "By how much?".

Patricia McVeagh

To the Editor: The working group responsible for the recent chronic fatigue syndrome (CFS) guidelines needs to be congratulated for producing a sensible and well balanced document in a most controversial area.1 Larkins and Molesworth have contributed a somewhat predictable response.2 Some sufferers of CFS can be characterised by their capacity to react strongly to the suggestion that psychological factors may be involved in the pathogenesis of their condition.3 From the perspective of the consultation-liaison psychiatrist, their response can be written with the comments on physical and psychological issues substituted for one another. Hence it can read (1) there is no current evidence that the syndrome has a specific physical origin, and (2) there is evidence that a range of psychological issues occur in people with CFS, although it remains unclear whether these changes are primary or secondary. The mental health movement has worked hard in recent times to reduce the stigma associated with psychiatric conditions. The sufferers of chronic physical illness now accept the importance of looking after their emotional health as well as their physical well-being. Enlightened CFS sufferers and support groups accept the links between physical and psychological morbidity and do not mindlessly exclude the latter. There is ample evidence that cognitive–behavioural strategies and graded exercise programs assist those with CFS, and psychiatrists are skilled in providing these treatments.4

James D Hundertmark

To the Editor: The process of destigmatising chronic fatigue syndrome (CFS) is not advanced by either limiting enquiry to "acceptable" sciences or increasing the stigma already experienced by people with other neuropsychiatric disorders. Contrary to its intent, and in contrast to the recently published Royal Australasian College of Physicians (RACP) guidelines,1 the recent statement by the immediate past president of the RACP and the Chairman of the ME/Chronic Fatigue Syndrome Association of Australia2 is in danger of increasing the stigma for both people with CFS and people with other common mental disorders. Unfortunately, key propositions in their letter ("There is no evidence that the illness is primarily psychological in origin") are clearly at variance with the tone of the guidelines (see Box 1.5, p. S31; Box 1.7, p. S32; and, "Management" summary, p. S38). Their letter reinforces the classical "dualistic" and rather simplistic "biological" approach (eg, "There is significant evidence of a range of biological abnormalities occurring in people with CFS"). Unwittingly, it colludes with community-based beliefs that mental health problems are "not health",3 and often imaginary or under the voluntary control of the patient.4 There is no doubt that people with CFS share many experiences with people with other neuropsychiatric disorders. They both have daily experiences where their credibility is challenged, their disability is minimised and their needs for appropriate medical management are not met. Australian research and best practice have been recognised internationally for emphasising the integration of psychological, psychiatric and biological factors and respect for the experiences of persons with these debilitating disorders.5 Unfortunately, the major advances captured in the guidelines may now be undermined if the RACP is perceived to be backing away from supporting appropriate psychological assessment and provision of effective "psychological" treatments (such as cognitive–behavioural therapy and physical rehabilitation approaches). Similar equivocation has left clinical guideline processes in the United Kingdom in disarray.6 As demonstrated recently, prolonged fatigue syndromes are common in the Australian community, and the vast majority of those who seek healthcare services have concurrent depression or anxiety.7 Real progress towards destigmatisation, meaningful research progress and improved health services for people with CFS will only occur when the field is mature enough to deal with the clear relevance of psychological factors. Instead of rejecting "psychological factors" and associated treatments, relevant professional and consumer bodies should now join with the broader community movement towards increased community awareness of common neuropsychiatric disorders, genuine understanding of their (genetic, "biological", psychosocial and personal) causes and provision of effective (pharmacological and psychological) treatments.8

Ian B Hickie

To the Editor: In the recent letter from Larkins and Molesworth1 various statements are made on which I would like to comment. From time to time everyone becomes physically or mentally exhausted, whether or not it is related to activity. For some people this exhaustion becomes disabling. They deserve understanding and sympathy. We must do everything we possibly can to assist them to recover and to try to find possible causes. Larkins and Molesworth acknowledge that chronic fatigue syndrome is a serious, disabling illness. When does ordinary exhaustion become disabling? I would agree that at this stage there is no clinical evidence that the condition is primarily psychological. Nor is there evidence that it is primarily physical. There may be a mixture. What is the "significant evidence" of a range of biological abnormalities occurring in people with CFS? What are these biological abnormalities and what physiological evidence is there for each one of these abnormalities to produce fatigue? Larkins and Molesworth state that treatment plans should be "within the capabilities of the patient": is there evidence to indicate that stimulating each patient to do just that little more each day will do harm? It was stated that scientific evidence of the aetiology, pathology and treatment is grossly deficient. It is in fact absent. There is no evidence at all. Research is certainly required. One of the problems is that, as soon as a medical advisor informs a patient that investigations have shown no serious abnormality, the patient often goes away and says to himself or herself or family that the "doctor said there is nothing the matter with me and that it is all in my head". Nothing could be further from the truth. Something is the matter and it is up to us to find it out.

Donald D Beard

In reply: We thank the writers for their comments on the CFS guidelines1 and our joint letter about these guidelines.2 Hundertmark remarks on the interplay between physical and psychological factors in morbidity associated with CFS. We trust that our letter in no way contradicts this. Similarly, the inferences that Hickie drew from our letter are not supported by the text of the letter. Far from undermining the guidelines, our letter had the full support of the convenor of the working party responsible for the guidelines. As clearly discussed in the guidelines, in the absence of specific diagnostic tests it is likely that a range of factors may contribute to the pathogenesis of CFS. Assumption of a primarily "psychological" pathogenesis is as unjustified as assumption of a primary "physical" basis. There are "abnormal" test results in many people with CFS, including abnormalities of the hypothalamic–pituitary–adrenal axis and some abnormalities of immune function. As stated, it is controversial whether such abnormalities are primary or secondary. While cognitive–behavioural therapy with graded exercise is effective in some patients, the guidelines outline the deficiencies of the evidence which "significantly limit the generalisability of the findings". As the guidelines indicate, and as is supported by our letter, treatment should be designed in partnership with the patient, and tailored according to the patient's capacity and response. Finally, as implied by Beard's letter, we restate the need for further research into the aetiology, pathology and treatment of CFS. We believe that effective progress in the management of this complex and mysterious illness will be best achieved by positive and cooperative rather than adversarial relationships between those suffering from the condition and the doctors and researchers attempting to help them.

Richard G Larkins · Simon R Molesworth

To the Editor: Bolin et al,1 in their editorial accompanying articles by Yusoff et al2 and Bampton et al,3 took the opportunity to make their case for endoscopic screening for colorectal cancer. We believe that their editorial is seriously misleading. 1: It is misleading to suggest that the 27 case–control and cohort studies in the meta-analysis by Johns and Houston4 stratified the index case by age at diagnosis. The 2.25 risk quoted by Bolin et al refers to the overall risk of first-degree relatives in families with one affected relative. In those studies in which age was stratified in the meta-analysis, there is a spectrum of risk, with families with onset of bowel cancer at an older age having lifetime relative risks much less than the average. A subanalysis of seven studies with age stratification showed the risk to be 1.82 (95% CI, 1.47–2.25), where the index case was over 59 years at diagnosis. Whether a 1.8-fold risk elevation warrants colonoscopic surveillance could be debated. "First do no harm" is an important axiom in well-patient screening, so one should aim for an order of magnitude of benefit over risk, which in this situation is not secured until the patient being screened is older than the suggested 40 years of age. 2: The recommendation that colonoscopic follow-up of patients with only small, tubular, distal adenomas can be at less frequent intervals is not based on the US National Polyp Study,5 as suggested in the editorial. It is based on the large cohort study of Atkin et al,6 who reported that patients with this finding were actually at below-average risk (relative risk, 0.5) for subsequent colorectal cancer after prolonged follow-up. This occurred despite the inevitable "miss rates". The editorial by Bolin et al handles this issue unconvincingly. The main message of the US National Polyp Study5 was that follow-up (except in exceptional circumstances of numerous polyps, or incomplete removal of malignant polyps) is not needed at 12 months — after 3 years is adequate. The National Health and Medical Research Council guidelines extend this to 4–6 years in the low risk groups, as defined by Atkin et al.6 The Atkin et al data, however, are only Level 3 evidence. 3: Bolin et al1 completely miss the point about pilot programs of screening with faecal occult blood testing (FOBT). There is no intention to confirm evidence of mortality reduction. The pilot studies are neither designed to, nor capable of, doing this. Mortality reduction from FOBT is well established on Level 1 evidence. The pilot studies are in place to answer the very practical questions of how to implement large-scale screening programs in Australia; what logistic and resource issues are involved; how compliance and acceptance will best be secured; and how to approach difficult-to-access populations (perhaps with low health insurance rates as distinct from populations well supplied by colonoscopy services). The central issue in advocating a menu of options to individuals versus more prescriptive screening (based on FOBT) is whether the height of the scientific bar should be at Level 1 evidence or modestly robust Level 3 evidence (flexible sigmoidoscopy) or the less robust Level 3 evidence (colonoscopy), complemented by certain appeals to logic (carefully crafted in the editorial). Medical initiatives based on less than Level 1 evidence have a history of being shown to be wrong, and the concept of colonoscopic surveillance is not immune from this outcome. Where a significant outlay from the public purse is involved, the Federal Government is being appropriately prudent in acting on Level 1 evidence.

Finlay A Macrae · Geoffrey S Hebbard

In reply: Macrae and Hebbard fail to grasp the concept that colorectal cancer is the only potentially preventable cancer in men and one of the two preventable cancers in women. In any discussion about screening options, this fact must be kept clearly in focus. In terms of surveillance of first-degree relatives, we doubt the available evidence is of sufficient quality to be certain whether the absolute risk is 1.82 or 2.25. In either event, we would advocate colonoscopic surveillance. We would, however, agree with Macrae and Hebbard on the importance of safety issues. Elsewhere we have advocated confining the performance of colonoscopies to endoscopists with Conjoint Committee Accreditation, and ensuring that the procedures are undertaken in accredited, suitably equipped facilities.1 We find it difficult to understand why Macrae and Hebbard believe that "the main message of the US National Polyp Study2 was that follow-up . . . is not needed at 12 months". Showing a reduction in expected cancers of 90% seems to us a far more important finding. We would, however, point out that our editorial does not advocate routine colonoscopic follow-up at 12 months. In relation to the pilot faecal occult blood testing (FOBT) studies, we believe that Macrae and Hebbard have missed the point. They advocate delaying colorectal cancer screening for a further five years to await the results of studies which, many believe, will be both outdated and probably inconclusive. Their continued inflexible stand is one that is being rejected by a rapidly increasing number of countries, including the United States, Germany, Italy and the recently formed Global Alliance for the Prevention of Digestive Cancer. Colorectal cancer is the commonest cause of mortality in both non-smoking men and women, with a death from this disease every two hours in Australia. We suggest that introducing screening is far more urgent than Macrae and Hebbard advocate. We re-emphasise the point that individuals should, if they wish, be provided with the opportunity of selecting a screening program from a menu of options chosen after discussion with their primary medical carer.

Terry Bolin · Alistair E Cowen · Melvyn G Korman

To the Editor: I am writing in response to the letter from Zardawi in the 19 August 2002 issue of the Journal.1 Zardawi suggests that radiologists and pathologists should not talk to patients, and that their contract is with the referring doctor, not with the patient. On both counts he is mistaken. Patients who are worried and anxious are certainly in need of some communication with the doctors carrying out their investigations. Most doctors of experience will know what is appropriate by way of conveying any results and what should be left to the patient's own doctor. Only those in bondage to corporate medicine will require a formula to instruct them in correct behaviour. That there is a contract with the patient is attested by the many cases of litigation against radiologists and pathologists. Of course, it is more efficient if the doctor does not speak to the patient, as valuable time is saved, and even more efficient if the doctor's staff do not speak to the patient either. This is common practice, as reported daily by patients and confirmed by my own recent experience. Nothing was communicated to me except that if I wished to rewrite my physician's referral to indicate that I had a palpable lump (which I did not) there would be a Medicare rebate, and that otherwise there would not, and I would thus have to pay the full amount. I declined the offer. I then waited two weeks to know that my results were normal. Some patients report that they will travel 20 km across the city to visit a practice where the staff look up and speak when patients enter, and where the doctor is not too busy to speak to them. No doubt such "inefficient" practices will disappear in time. The case of nuclear medicine differs in that the Health Insurance Commission schedule of fees requires the physician to see and assess the patient and to supervise the procedure in order for a benefit to be legally payable. The nuclear medicine physician is therefore in a position to know what is appropriate to communicate to the patient. Most patients are grateful for the opportunity to discuss the findings and to understand the implications of what has been found. In the case of serious abnormalities, such as pulmonary embolism, it is imperative that the patient be made aware of the importance of the findings and the need for immediate treatment.

Josephine C Wiseman

To the Editor: A 63-year-old woman presented with polyuria, polydipsia, lethargy and vomiting. Two weeks previously, she had been diagnosed as having diffuse scleroderma with possible interstitial lung disease, and had started taking 50 mg prednisolone daily. Her past history included diabetes, hypertension, hypercholesterolaemia and β-thalassemia trait, and her other medications were metformin, glibenclamide, quinapril and amlodipine. Examination revealed blood pressure 150/60 mmHg, a loud second heart sound with no murmurs, and late inspiratory crepitations at lung bases. Her serum creatinine concentration was 270 μmol/L (compared with 100 μmol/L two weeks previously) and serum glucose concentration was 26.5 mmol/L. Treatment by the admitting doctor included insulin, rehydration, and cessation of prednisolone (given hyperglycaemia) and quinapril (secondary to acute renal impairment). She developed a fever and cough, with bilateral pneumonia, which was treated with intravenous ceftriaxone. Despite normotension, concern regarding scleroderma renal crisis (SRC) was raised. On Day 12 of admission, when renal failure had developed to the dialysis-dependent level (serum creatinine level, 690 μmol/L), quinapril was recommenced for its proposed renoprotective effect and haemodialysis was initiated. Microangiopathic haemolytic anaemia (haemoglobin, 7.2 g/L) was diagnosed, with fragmented red blood cells (Box). Several months later, she continues on haemodialysis three times a week. Renal biopsy was not performed given the clinical picture of diffuse scleroderma and recent corticosteroid use with rapid development of renal failure — consistent with SRC. SRC is defined as rapidly progressive renal failure and/or new onset of malignant hypertension during the course of scleroderma, occurring in 15%–20% of patients with the diffuse variety.1 Risk factors include male sex, black race, and early diffuse scleroderma with rapidly progressive skin thickening.2 Precipitation of SRC by corticosteroid use, especially in normotensive patients, is well described, particularly with high-dose (>15 mg/day) treatment.2 Early diagnosis is critical because treatment may preserve renal function.3 Outcomes have improved with use of angiotensin-converting enzyme (ACE) inhibitors,2 which are thought to improve renal function by controlling the high renin levels seen in patients with SRC. About 61% of patients have a good outcome, with no or temporary dialysis.3 Predictors of poor outcome, despite ACE inhibitor use, include older age, male sex, higher initial serum creatinine level, and scleroderma myocardial disease.1 Eleven per cent of SRC patients remain normotensive and have significantly reduced 12-month survival rates.4 This may relate to delay in diagnosis of SRC. The use of high dose corticosteroids in patients with early diffuse scleroderma should be strongly discouraged, and intensive monitoring for SRC is recommended if low dose corticosteroids are required. Peripheral blood film, magnification x40 Changes of thalassaemia (microcytosis and hypochromasia) and microangiopathic haemolysis (fragmented red cells and spherocytes). 1. Spherocytes. 2. Fragmented red blood cells.

Anita T Y Lee · Simon Burnet

To the Editor: Comprehensive care has been shown to improve outcome in asthma management when it has four components — asthma education, self-monitoring, written self-management plans, and regular medical review.1,2 A recent Cochrane Review has explored the role of one of these components — written self-management plans — and concluded that there is "no consistent evidence that written plans produced better patient outcomes".3 Should this cause us to change our management strategies in Australian general practice? Does this mean that our patients are not able to care for their own asthma without our intensive assistance? These findings update a 1998 review of the role of written asthma management plans as part of comprehensive care in 1998: "In five studies which compared subjects who managed their asthma by self-adjustment according to individualised written plan with those whose medications were adjusted by the doctor, lung function data (FEV1 [forced expiratory volume in one second] and PEF [peak expiratory flow]) were significantly higher in the self-managed group."1 In Australian general practice, between 30% and 50% of patients are given a written asthma management plan.4 These plans form part of known beneficial comprehensive asthma care plans, such as the Six-Step Asthma Management Plan5 or the Asthma 3+ Visit Plan.4 The small number of available high quality trials for this most recent review led the authors to say, "Available trials are too small and the results too inconsistent to form any firm conclusions", and suggests that more trials are needed to produce a conclusive result.3 We should be careful not to lose the positive effects of improved chronic disease management in asthma by over-responding to this one review of one component of comprehensive care.

Andrew M Thornett · Jonathan W Newbury · Andre J Duszynski

Comment: A Cochrane systematic review identified the beneficial effects of planned asthma management and education that includes a written action plan.1 These findings have now been adapted for primary care and implemented as the Asthma 3+ Visit Plan. This involves a systematic assessment of asthma symptoms, lung function, and current treatment at each visit. Treatment and management skills are optimised and the patient is given written instructions on how and when to increase treatment when asthma deteriorates (a written action plan). A recent Cochrane review asked whether one can get the same benefits by doing less — by simply supplying a patient with a written action plan.2 The review found that the literature was inconclusive. This doesn't mean that written action plans are not effective; it means that there is not enough evidence to be able to answer the question. The result of "no evidence of effect" is completely different to "evidence of no effect".3,4 This is a crucial distinction, as many systematic reviews find insufficient evidence to be able to assess a treatment. This is a statement about our ignorance rather than a statement about whether a treatment works or not. The review also highlights the need to carefully evaluate the control intervention. For example, the control groups in two studies in the systematic review2 received regular medical review, with assessment of severity and optimisation of inhaled steroid therapy. It is not surprising that these studies found it difficult to identify any additional effect of an action plan. Cochrane systematic reviews conclude with recommendations for clinical practice that highlight effective treatments,1 and with recommendations for research that indicate where more information is needed.2 The review looking at just supplying patients with written action plans2 exemplifies the latter.

Peter G Gibson

To the Editor: I read with great interest the article by Byard et al,1 as well as the previous work by these authors on paramethoxyamphetamine (PMA)-related fatalities in South Australia.2 In 2001, I encountered a similar fatal "outbreak" in Belgium: six fatal cases, four of them in the Antwerp metropolitan area.3,4 Striking similarities between the Belgian and Australian fatalities include the clinical symptoms, the autopsy findings and the history of alleged "ecstasy" intake. Pure PMA tablets were found on a victim with an "xTc" logo pressed onto the surface of the tablets.3 I agree with Byard et al1 that the sudden "outbreaks" of death from PMA intoxication probably do not result from contamination during the synthesis of 3,4-methylene-dioxymethamphetamine (MDMA). In Belgium, there are strong indications that the resurgence of PMA resulted from a legal loophole. Early in 2001, PMA was encountered for the first time in the blood sample of a young girl who presented to an emergency department for alleged ecstasy intoxication. A few weeks later, the first fatal case was reported, and over a period of a few months five other fatal cases were seen. After the first two deaths, PMA captured a lot of media attention and even evoked some political disturbance. By the end of 2001, PMA and its precursor molecule, p-methoxyphenylacetone, were placed on the list of regulated and restricted substances (and hence the unauthorised possession of these products became a criminal offence). Afterwards, no more fatalities were reported. I therefore hypothesise that illicit amphetamine manufacturers were aware of the (temporary) legal vacuum in Belgian law before the deaths occurred and substituted PMA for MDMA because PMA precursors were easier to obtain and less strictly controlled by legislation. It has been suggested in the Australian illicit drug report 1994,5 as well as by Byard et al,1 that manufacturers of PMA may have been deliberately marketing it as another drug (eg, MDMA) or may have promoted it specifically as a drug to augment the effects of MDMA. If this is the case, there may be serious implications for criminal liability, as we now know that PMA intoxication has a significantly worse clinical outcome than MDMA intoxication (including a greater likelihood of QRS-interval prolongation, extreme hyperthermia, seizures and a significantly lower score on the Glasgow Coma Scale).6

Werner Jacobs

To the Editor: I read with interest the MJA supplement The student and junior doctor in distress — "our duty of care".1 It is encouraging to see the time, effort and research currently being devoted to the health and mental wellbeing of our colleagues. One aspect of the medical workforce that was not discussed is that of locum doctors, who, in metropolitan and rural New South Wales, are increasingly called upon to staff public hospitals. Under this system, a doctor registers with a locum agency, hospitals advise the agency (often multiple agencies) of the shifts they need filled, and the agency then sends to all the doctors on their books a list of shifts available. Doctors then choose which shift(s) they would like to work and the agencies supply their names to the hospitals. They are paid by the hospital — the current rate for all doctors, Post Graduate Year (PGY) 1 and upwards, being a minimum of $70–$80 an hour — and the agency receives a 10%–15% commission. In contrast, the base hourly rate for a full-time PGY 1 doctor is $23.11, with a loading of 75% on Sundays and 100% for any hours worked beyond a 10-hour shift. The only barrier to locum work is that a doctor is unable to have two rates of pay within the one Area Health Service. There is thus a strong incentive for full-time employees to refuse extra overtime work at their own hospital and do locum work at other hospitals. The number of shifts needing to be filled by hospitals increases as Junior Medical Officers choose this option. The current restrictions on access to provider numbers, rather than serving as an incentive to remain in the hospital system, have encouraged many junior doctors to seek locum work. It is also relevant that, as more graduate students come through the system, more doctors are older and have financial obligations. Many have had good incomes prior to studying medicine and wish to maximise their earnings once they graduate. Wilhelm2 and Mouret3 both observe that financial concerns are a major stressor for Junior Medical Officers. There are significant disadvantages for the locum doctor (eg, lack of ongoing education from patient follow-up, feedback about mistakes, mentor and peer support; inadequate supervision of "safe working hours") and for the healthcare system (eg, lack of continuity of care; locums' unfamiliarity with the hospital and its procedures; variable skill levels of locums; resentment by regular staff of pay rate discrepancies; cost). While there is no doubt a role for locum doctors within the healthcare system, there is no overall control of the situation. Locum agencies are businesses that exist to make money for their owners. The hospitals see themselves as paying top dollar for locum doctors and therefore see no obligation to provide training and counselling. The doctors are in the middle. To protect the doctors and also the hospitals, changes must be considered. Representatives of the NSW Medical Board, Postgraduate Medical Council and Area Health Services need to discuss this issue.

Elizabeth Swinburn

To the Editor: It was most enlightening to read the articles on cosmetic surgery in the 17 June 2002 issue of the Journal. In particular, the Clinical Update by Castle et al on psychosocial wellbeing and cosmetic surgery1 is pertinent to everyday practice. The warning given that cosmetic specialists should be concerned about patients who have had numerous procedures, in particular patients who have previously sued physicians, is a poignant one. Psychological testing of patients who wish to have plastic and cosmetic surgery is not routine, and plastic or cosmetic surgeons cannot be expected to carry out such testing. Liaison with psychologists and psychiatrists can be conducted on a case-specific basis, but not routinely. The aim is to screen for body dysmorphic disorder, but this can be quite difficult, as the presentation is often obscure.2 In reality we live in a world where appearance is very important, and self-esteem is related to appearance. Age discrimination is a reality, and cosmetic surgery has been shown to improve a patient's psychosocial wellbeing.3 The issue of advertising of cosmetic surgery services is a vexed one, as is the issue of where cosmetic surgery should be performed. As it is usually not performed in public hospitals, it has been relegated to the private sector in Australia, and private hospital appointments that might include cosmetic surgery have been vigorously protected by special-interest craft groups in Australia. Misconceptions by the general medical community are rife, due to both the lack of exposure to cosmetic surgical procedures and the lack of information on the subject. The assistance of the general practitioner, together with a thorough patient history, is very valuable in determining whether cosmetic surgery is likely to have a positive psychosocial outcome. Unfortunately, the generally poor attitude of the Australian medical community towards cosmetic surgery has led to patients being afraid of a negative response when asking their GPs about cosmetic surgery. Often referrals are either not made or are made by an anonymous practitioner, which is not an ideal situation. Liaison with surgeons who have previously treated a patient is ideal, but cooperation in this area is not always forthcoming, as some surgeons fear litigation from former patients. With most cosmetic surgeons being shut out of the medical mainstream, access to potential patients comes through normal commercial means, such as advertising in the Yellow Pages and in magazines. It is to be hoped that in future there will be more contact between cosmetic surgeons and other medical practitioners so that the true benefits and risks of the procedures can be understood by the general medical community, who, in turn, can counsel their patients in a sympathetic manner as to whether cosmetic surgery is advisable.

Darryl J Hodgkinson

To the Editor: According to the article by Kennedy in the Journal,1 we failed to address the objections to the RARE SALAMI trial (the Royal North Shore and Ambulance Regional Study of a Stenting Strategy as an Alternative to Lytic/Medical Therapy in Acute Myocardial Infarction) in our account of the fate of this trial.2 Allegedly, we contravened standard advice regarding emergency cardiac care ("to attend the nearest hospital emergency department as quickly as possible").1 However, the standard advice is to call an ambulance,3 not to go to hospital by private transport. Kennedy also claimed that the trial would interfere with " . . . established therapeutic networks and ongoing therapeutic relationships, including relationships with hospitals".1 The reason we ignored such objections was that the wellbeing of networks seemed unimportant in comparison with the welfare of patients with life-threatening illness. The issue of the risk to patients of transport time and treatment delays with the new strategy was also raised,1 but Kennedy did not challenge the actual measured delays or other published evidence we referred to.2 These suggested that mortality was likely to be reduced with the RARE SALAMI strategy. Without reference to published data, he quoted the opinions of clinicians and a municipal council to support the opposite conclusion. The northern suburbs of Sydney are not so remote or exotic that opinion based on knowledge of the "local practicalities" he referred to1 would outweigh the evidence of published data. We argued that complexities of treatments, patients' condition and the pressure of time precluded fully informed consent.2 Allegedly, established guidelines were breached.1 However, the ethics committee, well aware of these, waived conventional informed consent after careful deliberation. A new area ethics committee, constituted subsequently,2 concurred with this decision. Now, in the light of new evidence, the RARE SALAMI trial, as originally proposed five years ago, can no longer be done. The recently presented DANAMI II study4 randomised 1129 patients to treatment with fibrinolysis at local hospitals or to transportation to angioplasty centres up to 153 km away. Transport was found to be safe, and angioplasty was associated with a 40% reduction in adverse outcomes. Field triage was not tested. However, we believe the results of the DANAMI II study now preclude randomisation of 50% of patients with suspected acute myocardial infarction presenting to the Ambulance Service (and eligible for the RARE SALAMI trial) to treatment at district hospitals. Ironically, in northern Sydney, status quo reigns and 100% of trial-eligible patients are taken to district hospitals and delays in achieving reperfusion persist! Thiemann, in a recent editorial, concluded that accrued evidence now favours treatment of patients with acute myocardial infarction in a few high-volume centralised angioplasty centres,5 and that field triage and direct transport to such centres holds great promise. He also deplored the lack of research into system changes and the economic self-interest that, he believed, had stymied change in the United States. Opposition to the RARE SALAMI trial was altruistic.6 However, it nevertheless stopped much needed research and hence may have compromised patients' rights to optimal care.

Helge H Rasmussen · Peter S Hansen · Gregory I C Nelson

In reply: Rasmussen, Hansen and Nelson have missed the entire thrust of my article.1 When an individual calls a health professional for help, we can assume he or she agrees to standard treatment, but not to be placed into an experiment. Failure to inform patients that they are being placed into an experiment is a denial of basic human rights. I outlined a mechanism by which it would be possible to conduct an experiment such as RARE SALAMI that would comply with the appropriate guidelines and avoid denial of informed consent. It is worth noting that failure to inform patients that they have been placed in a clinical experiment could also worsen our present medical indemnity crisis and lower the standing of medical research. It has been shown how institutional ethics committees can be subjected to local pressures.2 As a result, it is possible some may adopt pseudolegalistic interpretations of accepted guidelines and approve studies that would be rejected elsewhere. This is another reason why informed consent is so important. Without it some studies simply can't be done.

Michael C Kennedy

To the Editor: I thought it most appropriate that you juxtaposed the articles by Kilmartin et al1 and Fitzgerald2 in your General Practice issue (15 July). Missing from each article is a key aspect from the patient's point of view. As a patient, I value, above all else, continuity of care by my general practitioner. In this age of increasing sessional work (by both female and male doctors) and of increasing employment of doctors on a sessional basis by corporations, this feature of general practice is threatened. As a former GP, I am increasingly being asked to comment by lawyers (for both plaintiffs and defendants) on cases where patients have fallen through the cracks that are an inevitable aspect of sessional care. Patients are being seriously harmed because of poor communication and poor or no handover between sessional doctors. What is most disturbing is the absence of failsafe mechanisms to ensure that communication, both verbal and, more importantly, written, between the sessional GPs in a practice comes as close as possible to providing the continuity of care offered by the now nearly obsolete five- or six-day-a-week and after-hours family doctor.

Peter C Arnold

To the Editor: I offer the following additions to the growing list of favourite books with a medical flavour.1,2 The house of God, by pseudo-intern Samuel Shem, is an irreverent, bawdy, cult classic ("Catch-22 with stethoscopes"). I was particularly intrigued by the "laws of the house of God", including "placement comes first" and "if you don't take a temperature, you can't find a fever." The woman who walked into doors, by Dubliner Roddy Doyle, is a heartrending narrative of emotional and physical abuse of a woman by her partner, and of neglect by her health professionals. "A nurse . . . She'd seen me before . . . I waited to be asked. Ask me. Ask me. Ask me. I'd tell them everything. Look at the burn. Ask me about it. Ask. No. . . Her boyfriend was waiting." "The doctor never looked at me. He studied part of me but he never saw all of me." Another is The plague, by French novelist Albert Camus and translated by Stuart Gilbert. " 'Please, doctor, what is it?' 'It might be — almost anything. There's nothing definite as yet.' . . . On returning to his flat [Dr Bernard] Rieux rang his colleague Richard, one of the leading practitioners in the town. "'No,' Richard said, 'I can't say I've noticed anything exceptional.' 'No cases of fever with local inflammation?' 'Wait a bit! I have two cases with inflamed glands.' 'Abnormally so?' 'Well,' Richard said, 'that depends on what you mean by "normal".' "

C Ross Philpot

To the Editor: In their recent article, Makdissi and Brukner stated that resumption of play should follow the "30/30" rule.1 In the article, the authors cited three references, each of which relates to position statements rather than to any scientific reference that "blue skies and lack of rainfall are not adequate reason to breach the 30 minute return to play rule".2-4 Unless there are reasonable scientific explanations why lightning should strike someone in the presence of blue skies, I would think that this policy needs some reconsideration. It seems logical that if a storm is moving away, the skies should become blue, and the time between lightning and thunder should increase. I would have thought that if there was a weather watcher around, he or she could monitor the situation, and ascertain that the storm was moving away, and this would allow for earlier resumption of sport. Can you imagine a weather watcher preventing play in an AFL game, or even a minor suburban game of football, because of the threat of lightning if the skies were indeed blue? If I am to take this recommendation to my local football club, I would like to see evidence that this has some credible scientific backing.

David Vivian

In reply: The "30/30" rule is a simple and easy-to-remember rule designed to reduce the probability of lightning strikes. Two important studies over recent years have led to its development. First, in 1993, Holle et al analysed the number of casualties relative to flash rates during thunderstorms and found that most casualties occur at the beginning and end of storms.1 They concluded that individuals typically wait too long to seek safe shelter and often resume too soon. Secondly, in 1999, Lopez and Holle examined the distribution of successive flashes for large numbers of different types of storms, and found that, although most were separated by less than 8 km, a significant number of successive flashes occurred up to 13 km apart.2 This was noted to be more likely with larger, more complex storms. Given that lightning can strike kilometres forwards or backwards from the storm front, being within 10 km of lightning activity (as estimated by a "flash-to-bang" count of 30 seconds) reflects a risk that the next flash might conceivably be at the observer's location, irrespective of whether there are blue skies overhead. This is why blue sky alone is not enough reason to break the 30/30 rule.

Michael Makdissi

To the Editor: I enjoyed reading Makdissi and Brukner's "Recommendations for lightning protection in sport",1 but I feel that in addressing an audience of renowned golf hacks the authors have made a glaring omission. It is well known in golfing circles that the first rule of lightning self-protection on the golf course is to always carry a 1-iron in the bag and in appropriate conditions to reach for it — because not even God can hit a 1-iron!

Michael Gullquist

To the Editor: We write to alert policy makers and clinicians to the challenge presented by rising cannabis use in north-east Arnhem Land, in the Northern Territory, given that many current cannabis users were previously petrol sniffers. In the past five years, there has been a rise in cannabis use and evidence of expansion of supply links in the Miwatj region.1 There are concerns that rising cannabis use is associated with social effects: increased family violence, drug–alcohol psychosis, self-harm and suicide, and community disruption. Policy makers seeking to foster initiatives to minimise harmful outcomes must develop general policies that can have local effects in a varied Northern Territory population. NT police have targeted cannabis in remote communities. A Substance Abuse Select Committee and Illicit Drugs Task Force, each with Indigenous representation, will report to the NT government during 2002. We recently began collecting baseline data to allow us to evaluate the effects on patterns of use of cannabis (and related harm) of community-wide interventions. These interventions will be similar to those implemented for petrol sniffing,2 but with a focus on improved availability of appropriate drug education. We have selected a random sample of about a third of the residents (aged 13–34 years) from two communities. From this sample, current cannabis users (at least weekly) and past petrol sniffers have been identified by using health worker consensus classification, supported by data from review of the health clinic chart and self-report, if available. These data for 145 males and 141 females are presented in the Figure. Among males aged 20–34 years, 74% are current cannabis users and, of these, 60% are former petrol sniffers. To date, 57 cannabis users have agreed to interview (34 males and 23 females) and, of these, 38 met DSM-IV criteria for cannabis dependence.3 A particular health concern is that persistent cannabis use may compound any residual cognitive impairment from petrol sniffing. Current cannabis users among people aged 13–34 years in northeast Arnhem Land Results for samples from two remote communities in the Miwatj region, assessed by using health worker consensus classification, self-report data, and supporting data from health clinic chart review.

Alan R Clough · Sheree Cairney · Paul Maruff · Robert Parker

To the Editor: In Australia, an estimated 11 000 people become infected with hepatitis C virus (HCV) each year.1 Most are injecting drug users. The Early Hepatitis C Intervention Project was a collaboration between the STD Services Surveillance Unit, Drug and Alcohol Resource Unit and Infectious Diseases Unit at the Royal Adelaide Hospital, Adelaide, South Australia. Its objectives were to manage people who had seroconverted in the preceding 12 months and to provide standard treatments for drug use and dependence. Services included information and education on HCV, referral, counselling, psychosocial support and three-monthly clinical evaluation. The project was approved by the Ethics Committee of the Royal Adelaide Hospital and funded by the Department of Human Services for 18 months. The attendance rate was low. Of 88 people with HCV seroconversion who were identified as eligible for enrolment by the Surveillance Unit (from the mandatory notification scheme), 57 agreed to further contact by mail or telephone, and 12 attended for risk assessment. Of these, eight enrolled in the project (10% of those eligible). Despite demographic variation within the group, similarities included difficulties with accommodation, finances, mental health and social integration. Seven of the eight participants had injecting drug use as the risk factor for HCV infection. Most participants also used alcohol and cannabis. During the program, half decreased their risk-taking behaviour: four reduced injecting drug use, and four reduced alcohol use, reaching low risk levels. Characteristics of participants at their last interview are summarised in the Box. Two participants are maintaining regular contact with the Drug and Alcohol Resource Unit. Despite encouragement, few of the target group engaged in the program. We do not know why so few people who agreed to attend a first appointment failed to do so. We did not have their permission or the resources to contact them again. Maintaining contact with participants also proved challenging, and was in part unsuccessful because of complex, multifaceted social issues aside from HCV infection (Box). These included unstable accommodation, use of health services only when in crisis, mental health problems, financial difficulties, polydrug use and continued risk-taking behaviours despite harm-reduction information. In conclusion, the Australian epidemic of HCV infection, driven by injecting drug use, is likely to continue unless a new approach to harm minimisation is developed. Such an approach will recognise that comorbidities and social dislocation influence risk of infection. Unless treatment programs address coexisting problems, it will be futile to offer definitive treatment for HCV infection.2 Within the limited objectives and resources of this project, we were unable to support these people comprehensively. We believe that a "one-stop shop" that includes active and intensive case management by a flexible, multidisciplinary team and deals with social, economic and mental health issues may be a more effective approach to the care of people with recent HCV infection. Characteristics of participants in the Early Hepatitis C Intervention Project at last interview Place of residence Current mental illness* Attendances Age, sex Employ-ment Polydrug use At 5 nominated appointments Total† IDU change‡ Persistent viraemia‡ 19, F No Yes NFA Yes 3 6 Reduced IDU Yes 21, F Part-time Yes NFA Yes 3 5 Reduced IDU No 21, M No Yes NFA Yes 3 4 No IDU at enrolment Yes 24, M Voluntary No Rental Yes 1 1 Denied IDU ever Yes 30, M Casual Yes NFA No 2 4 No IDU Yes 36, M No Yes Parents Yes 1 4 Unknown Yes 38, M Full-time Yes NFA Yes 2 3 Reduced IDU No 43, M Full-time No Rental Unknown 1 1 Unknown No IDU = injecting drug use. NFA = no fixed abode. * Mainly depression, anxiety and personality disorder. † Includes self-initiated visits. ‡ Determined by polymerase chain reaction.

To the Editor: The recent article by Johnston et al is an important contribution to the small but growing body of literature on the health effects of particulate matter (PM) pollution derived from bush or forest fire.1 The authors studied an important wood smoke PM exposure in Australia and showed consistent associations between higher concentrations of PM and emergency department presentations for asthma. Most research on the effects of PM has focused on motor-vehicle-derived PM pollution.2,3 However, Johnston et al do not appear to have accounted for serial correlation in their data. Measurements connected in time, such as repeated measurements of the same population, are likely to be correlated and not independent.4 Further, school holidays have been shown to influence hospital admission rates.5 The major Northern Territory school holidays in June and July are in the middle of the study period. Johnston et al adjusted for some important confounders in their analysis (acute respiratory infections and weekdays/weekends).1 However, in time-series data, especially those dealing with asthma, serial correlation, as well as other potentially important confounders such as school holidays and temperature and humidity, should also be assessed. It may be that, even after appropriate adjustments for serial correlation and potential confounders, the rate ratios found by Johnston et al may not alter appreciably. However, it would have been useful for the investigators to have at least discussed any effects that controlling for serial correlation and other potential confounders might have had on their findings.

Bin B Jalaludin · Guy B Marks · Geoffrey G Morgan