Letters

Letters Setting the (medical) record straight MJA 2000; 173: 670 To the Editor: The electronic health record is a concept which has been receiving growing community support. The recommendations of the National Electronic Health Records Taskforce were endorsed at the Australian Health Ministers Conference in July 2000. The Taskforce proposes establishing a national health information network (Health Connect). Healthcare providers would enter event summaries into patient records. The data could then be exchanged online. The report recommends that patients (or "health consumers") have access to their own records and control who can view them. This technology has the potential to improve patient care, but requires careful planning. A recent patient encounter highlighted a problem with our present medical records. A 31-year-old woman was admitted to a nearby hospital with fever, a productive cough, and pleuritic chest pain. A chest x-ray confirmed right lower-lobe consolidation. Blood cultures revealed Streptococcus pneumoniae with intermediate penicillin sensitivity. Her condition responded well to intravenous penicillin and a week of intravenous ceftriaxone with the "hospital in the home" (HIH) program. The discharge diagnosis was pneumococcal lobar pneumonia complicated by bacteraemia. Two days after discharge, she presented with the same symptoms, this time to our hospital, giving a history of her previous illness and admission. She was again febrile, but, interestingly, her chest x-ray was now clear. Her sputum cultured Streptococcus pneumoniae with an intermediate sensitivity to penicillin. An extensive septic work-up was otherwise unremarkable. Given the relapsing course, she was again treated with intravenous ceftriaxone with the HIH program. We found this recurrent febrile illness puzzling. The answer became apparent when she wasn't recognised by the HIH staff who had treated her previously. A sister visiting from overseas had become ill and used our patient's Medicare card to receive free treatment at the neighbouring hospital. The sister made a complete recovery. The real card owner then developed similar symptoms. To avoid detection she chose our hospital and used her sister's recent history as her own, not realising that the two hospitals shared the same HIH program. Thus, there had been two different patients with separate illnesses using the same Medicare card! For the second user of the card, this precipitated a prolonged inpatient stay with unnecessary investigations and treatment. This case highlights one vulnerability of our data recording system. There are few safeguards to verify patient identity on admission and, once recorded, data are filed permanently. Are more rigorous checks, such as a photo ID on Medicare cards, warranted? Is the loss of patient privacy outweighed by savings to the taxpayer, given that ultimately the cost of such exploitation of our system is borne by us all? Alan C Young Respiratory Registrar Peter W Holmes Deputy Director Department of Respiratory Medicine, Monash Medical Centre 246 Clayton Road, Clayton, VIC 3168

Alan C Young · Peter W Holmes

Letters Incongruous infants: facial features in old paintings MJA 2000; 173: 670 To the Editor: The following quote is from Sinclair's Human growth after birth: The head of the new-born baby is relatively large. This is reflected in the finding that in the infant the ratio of vertical head height to total height is 1:4, whereas in the adult it is 1:7.5. This difference was not appreciated by many well-known early European painters, and it is common to find representations of the Virgin and Child in which the baby has the chubby outline typical of his age but the proportions typical of an adult.1 I thought it would be interesting to test this statement. Most paintings of the Virgin and Child show the Virgin seated and the Child in various postures, making it impossible to measure their total height. However, we do know that the ratio of head length (vertex to chin) to forearm length (elbow to wrist) is 2:1 in the newborn, 7:4 at the age of two, and 1:1 in adults. Also, the ratio of upper head length (vertex to eyes) to face length (eyes to chin) is 4:3 in the newborn and 4:5 in adults.1 Using paintings reproduced on postcards and in the Time-Life series of art books,2 I made the appropriate body measurements of the Virgin and Child from 41 works painted between 1225 and 1619 CE. Allowing for about 10% variation in the normal ratios I obtained the following results: The head : forearm ratio for the Virgin was normal in 29 of 40 measurements; less than normal in 9; and greater than normal in 2. This ratio for the Child was normal in 12 of 41 measurements; less than normal in 25; and greater than normal in 4. The upper head : face ratio for the Virgin was normal in 18 of 43 measurements; less than normal in 15; and greater than normal in 10. This ratio for the Child was normal in 11 of 43 measurements; less than normal in 30; and greater than normal in 2. However inaccurate my measurements may be, measuring from a picture with the figures at various angles, the results do show a consistent pattern over the centuries. The artist tends to underestimate both the head : forearm ratio and upper head : face ratio in the Child. The ratios for the Virgin were also outside the normal range in many of the examples measured. Artists down the ages have always distorted the anatomical shape of their figures if they felt a better image would result. Artists who lived during the period surveyed would have had the example of the stylised and distorted forms of Byzantine art constantly before them, in the churches and monasteries in which they painted their works. When all is said and done, how important is anatomical accuracy in the production of an otherwise wonderful work of art? John E Gault Physician 203 View Street, Bendigo, VIC 3550 Sinclair D. Human growth after birth. 2nd ed. Oxford: Oxford University Press, 1973: 102-105. Time-Life Library of Art series. Time-Life International (Nederland) b.v.

John E Gault

Letters The cough that packed a punch: is boxing a risk for tuberculosis transmission? MJA 2000; 173: 671 To the Editor: The medical community is spearheading the movement for the banning of boxing as a health risk.1-3 Chronic traumatic encephalopathy, or dementia pugilistica, which is attributed to boxing is one of the associated hazards. We report a possible additional and hitherto undescribed health hazard of boxing. A 34-year-old male prison inmate identified himself as having been in close contact with someone with sputum-smear-positive, culture-positive, pulmonary tuberculosis. The inmate provided a detailed account of his contact with the index case, stating that they had sparred and boxed almost daily for three months. This involved close contact, to the point where they were cheek-to-cheek. The boxing ring was in a well-ventilated area in the prison-yard. The exposure took place between February and May 2000. The inmate underwent Mantoux testing by the two-step technique4 in May and June 2000. He tested Mantoux negative at the time. However, when Mantoux testing was repeated in August, he responded with a 10 mm lesion. His chest x-ray was normal. As he had a cough, his sputum was examined for acid-fast bacilli, but findings were negative. Preventive therapy with isoniazid was initiated. The inmate had been in the same prison since August 1999. There were no other inmates with infectious tuberculosis, apart from the index case, during the period under review. We believe that the mode of transmission of Mycobacterium tuberculosis was during boxing sessions, and propose hyperventilation and forced expiration as the direct mechanisms. One other Mantoux conversion was identified, but the mode of transmission was presumed to be shared air-space during transportation in a van with recirculated air in a confined cabin for over six hours. It should be noted that the affected inmate did not travel with the index case, at any time. This case only came to light because the exposure was so specific, and because the index case and the Mantoux conversion both occurred during periods of incarceration. Anyone acquiring a similar infection in the community would have had multiple contacts, and therefore several probable transmission modes -- this may be why this mode of transmission has not previously been proposed among community contacts of people known to have tuberculosis. Boxing is unlikely to be a major cause of tuberculosis transmission, but may make a small contribution to tuberculosis notifications among young male adults.5 Michael H Levy Director, Population Health Corrections Health Service, PO Box 150, Matraville, NSW 2036 Craig Gater Health Services Manager Australian Correctional Management, Junee, NSW mhlATcmed.wsahs.nsw.gov.au Brain damage in boxers [comment]. Med J Aust 1970; 2: 709-710. Bowden SC, Walsh KW. Boxing: time for action. Med J Aust 1985;142: 282. Moxon J. Boxing injuries. BMJ 1992; 305:1438. Wang PD. Two-step tuberculin testing of passengers and crew on a commercial airplane. Am J Infect Control 2000; 28: 233-238. Global tuberculosis control -- WHO report 2000. Geneva: Communicable diseases, World Health Organization, 2000.

Michael H Levy · Craig Gater

Letters Ulcerative "nintendinitis": a new kind of repetitive strain injury MJA 2000; 173: 671 To the Editor: A previously well 9-year-old girl presented to our clinic with a punched-out lesion in the centre of her right palm. There was no history suggestive of other systemic infection, vasculitis or ischaemia. Clinical examination was unremarkable, except for a 6 mm ulcerated area with a surrounding thin rim of erythema in the centre of her right palm (see Figure (a)). On questioning, the girl revealed that two cousins were visiting for the summer vacation, and had brought with them a Nintendo 64 (Nintendo Co Ltd, Kyoto, Japan) game, Mario Party. She had never played this game before. On the evening of the day when she had played her first game, lasting two hours, the girl complained to her mother of the hand blister. When asked, the girl admitted that she was so engrossed in the game that she used her palm to press the joystick repeatedly and enthusiastically (see Figure (b)). Treatment consisted of abstinence from playing the game and applying an antiseptic cream twice daily. The lesion took 14 days to heal, and left a scar. The Nintendo company has sold more than a billion video games worldwide to date, and since its launch in 1996 Nintendo 64 has proved one of the most popular interactive software games.1 The realistic images and three-dimensional graphics are so captivating that players often spend many hours glued to the game. There have been reports of Nintendo playing causing daytime enuresis (three boys aged 3.5, 5 and 7 years),2 faecal incontinence (a 6-year-old),3 epilepsy (a 13-year-old)4 and soreness of the right thumb ("nintendinitis" in a 35-year-old).5 All these patients were noted to be deeply engrossed in the interactive games and their pathologies all resolved following abstinence from playing. We believe that this is the first reported case of hand ulceration caused by playing Nintendo 64. The multilingual consumer information booklet for Nintendo 64 carries a warning of the risks of epilepsy, repetitive strain injury and motion sickness. The parents of our patient had not read the leaflet and were unaware of these potential complications. Parents should warn their children not to use too much force during games and should limit duration of play. We recommend that any medical practitioner who sees a patient with an unusual hand injury, epilepsy or motion sickness should ask, "Do you play any interactive computer games?". Indeed, we recently encountered a child with diabetes who spent so much time playing these interactive games that lack of exercise resulted in abnormally raised blood glucose levels. T H H Guan Koh Senior Neonatal Paediatrician, Department of Neonatology Kirwan Hospital for Women PO Box 187, Thuringowa, QLD 4817 kohtAThealth.qld.gov.au Nintendo home page <http://www.nintendo.com/corp/ history.html (accessed October 1999). Schink JC. Nintendo enuresis. Am J Dis Child 1991; 145: 1094. Corkery JC. Nintendo power. Am J Dis Child 1990; 144: 95-99. Hart EL. Nintendo epilepsy [letter]. N Engl J Med 1990; 322: 1473. Brasington R. Nintendinitis [letter]. N Engl J Med 1990; 322: 1473-1474. (a) Ulceration of the right palmBack to text (b) Hand position when playing Nintendo 64 gamesBack to text

Letter Rethinking the early childcare agenda MJA 1999; 171: 166-167 To the Editor: We are concerned that Cook's article1 lacks a balanced review of the literature on childcare, being biased in its portrayal of the possible negative effects without consideration of the likely positive ones. This could have detrimental consequences for the many children in formal childcare in Australia, their parents, and the staff and others involved in what is now an integral and vital component of Australian society. Cook's article also draws strongly on overseas studies, although childcare systems in Australia are likely to be different from those in other countries. Positive health outcomes for children attending childcare include the detection of vision and hearing problems, higher vaccination rates, appropriate nutrition, the detection of child abuse and neglect, primary health and dental care, psychosocial benefits, and opportunities for health promotion.2 The issue of socioemotional development, including attachment theory, has been debated in the literature. Cook cites Belsky, but Belsky has been noted as often citing research that did not take into account the specific characteristics and quality of care.3 It is probable that social and cognitive development are related to quality of care, and Caldwell's study suggests that childcare may provide better quality of care, at least for cognitive development, than home care.4 Thus, childcare does not appear to be consistently detrimental to cognitive and language development and may have a positive influence.4 The investigation of the influence of childcare on children's development is complex and should be considered in interpreting such research. Harvey,5 in an extensive longitudinal study, found that parental employment had "minimal effects on children's later functioning", and that increased early parental income could positively affect childhood development. We do agree with Cook that increased flexibility for working parents should be encouraged. Flexible options, such as parental leave and part-time work for parents of young children, are often advantageous. In addition to increasing work options for parents, it is important that we strive for high quality childcare, subsidised if necessary, so that all families have the choice of providing such care for their children. Linda M Slack-Smith Senior Lecturer, School of Oral Health Sciences 179 Wellington Street, Perth, WA 6000 lindasATcyllene.uwa.edu.au Anne W Read Senior Research Officer, Division of Psychosocial Research TVW Telethon Institute for Child Health Research, Perth Stephen R Zubrick Associate Professor, and Head, Division of Psychosocial Research TVW Telethon Institute for Child Health Research, Perth Cook P. Rethinking the early childcare agenda. Med J Aust 1999; 170: 29-31. Andersson B. Children's development related to day-care, type of family and other home factors. Eur Child Adolesc Psychiatry 1996; 5: 73-75. Melhuish E, Moss P. Current and future issues in policy and research. In: Melhuish E, Moss P, editors. Day care for young children. London: Tavistock/Routledge, 1991: 225. Caldwell B. Impact of day care on the child. Pediatrics 1993; 91(1 Pt 2): 225-228. Harvey E. Short-term and long-term effects of early parental employment on children of the National Longitudinal Survey of Youth. Dev Psychol 1999; 35: 445-459. In reply: A literature review was beyond my purpose, but I summarised findings of a major meta-analysis, and explained why psychological outcomes are of most concern. Benefits of childcare are often publicised, but risks, proven or probable, should not be concealed from parents and policy-makers.1 Notwithstanding the 1971 New South Wales child psychiatrists' memorandum,2 it became politically incorrect to express concerns about childcare. In social sciences, the now-discredited ideology of cultural determinism prevailed, denying the relevance of evolutionary biology to human behaviour, even mothering. A pro-childcare "spin" has pervaded research reports. Slack-Smith and colleagues' statement that "childcare does not appear to be consistently detrimental to cognitive and language development . . ." is a typical childcare-advocacy "straw man". The reply is: nobody said it was! Ochiltree's review3 seemed to me to have eight such statements within five paragraphs, and was so "unbalanced" that I wrote a book,1 to which I refer readers. It covers the points made by Slack-Smith et al, which cannot be answered in a few words. Childcare advocates seldom acknowledge that "high quality childcare" is not reliably achievable. They quote overseas studies when favourable, but, when not, they claim Australian childcare is of higher quality.3 But one carer to five infants is "nobody's definition of quality".4 I argue that the early childcare agenda is misconceived and needs rethinking. Qualitatively better outcomes should be achievable without the associated risks.1,5,6 Peter S Cook Child Psychiatrist (retired) PO Box 84, Repton, NSW 2454 Cook PS. Early child care -- infants and nations at risk. Melbourne: News Weekly Books, 1997. New South Wales Branch of the Child Psychiatry Section of the Australian and New Zealand College of Psychiatrists. Memorandum on some aspects of the welfare of children aged under three years whose mothers are in full-time employment. Med J Aust 1971; 1: 446-448. Ochiltree G. Effects of child care on young children: forty years of research. Melbourne: Australian Institute of Family Studies, 1994: 65-66. (Early Childhood Study Paper No. 5.) Hope D. Spare the non-maternal care and nurture the child. The Australian 1998; June 4. Cook PS. Home truths absent in early childcare debate: we need parent-friendly options [opinion]. The Australian 1999; March 24. Cook PS. The role of myth in childcare policy [letter]. The Australian 1999; April 14. ª 1999 Medical Journal of Australia.

Illustration: Multiple incisions of recent cupping procedure To the Editor: For six months a Bedouin patient had suffered from terrible headaches. Doctors at San'a' hospital performed blood tests and scans, but the tablets they prescribed did not stop the headaches, so he sought the help of a matowa, or holy man, from a nearby village. The matowa performed readings from the Holy Koran, but the headaches continued unabated, so the patient left San'a' to seek the help of a traditional healer in the desert. The healer recommended cautery and cupping. Cautery is used throughout the Arab world and parts of Africa in the treatment of pain, paralysis and a variety of other illnesses.1,2 The instrument of cauterisation is usually a metal rod, fashioned at one end into a disc. Small deep burns are inflicted close to the site of the pain or at distant points believed to influence the affected organ.3 Cupping, on the other hand, is usually used in the treatment of metaphysical conditions, such as the extraction of malicious spells, harmful medicines, and the effects of the evil eye,3 although in some parts of the world it is also used for treating physical ailments. For example, in less law-abiding parts of Africa, it is used in the treatment of shotgun wounds, and is popular among taxi drivers, who are occupationally predisposed to firearm attack.3 The skin is incised with a razor blade or knife in a series of parallel incisions about 5 mm apart and 5 cm long in an area about the size of a large coin. Then, the wide end of a goat horn is placed over the incisions and the healer sucks out the air through a hole in the tip to create a vacuum. A piece of beeswax is placed over the hole in the horn to maintain the pressure for up to half an hour.3 "The edge of the desert", wrote T E Lawrence, "is littered with the debris of great civilisations and thoughts".4 Lawrence was honouring the resistance of the desert Bedouin to cultural incursion, but in the last four decades even the Bedouin have succumbed to change from outside, and the role of the healer has also changed. In earlier times the healer functioned as a teacher, judge and religious leader, but, with the advent of schools, courts and hospitals, his traditional role has been curtailed. Today, against this trend of acculturation, the healer survives and continues to play an important role in treating difficult ailments for which Western medicine has no cure.1,5 This case is characteristic of the management of medical problems in the region. Western medicine is the treatment of first choice. This is followed by incantations from the Koran. Failing these methods, the treatments of last resort are the pre-Islamic practices of cupping and cautery. Although the specifics of management vary, the trend is always the same: towards earlier cultural modes of treatment and cure.1,3 Social policy planners around the world have long despaired at indigenous people resorting to traditional healers. There is no evidence for the efficacy of traditional cures, it is argued, and the treatments are at times harmful or disfiguring. But Western medicine fails to understand the role of the traditional healer as a familiar and trusted repository of culture in a time of uncertainty and change.3,6 The world over, traditional medicine persists in otherwise acculturated societies because it provides the sanction of an old and trusted belief system during times of crisis.3,6 The Bedouin, surrounded by ways of life they do not fully understand or even like, return to the healer who understands them, a person they know and trust, who will guide them back to health in a perplexing and unsettling world. The patient has returned for treatment of his hypertension. He nervously fingers his prayer beads as he gazes out the door of the outpatient clinic into the blazing sunshine. There is no contradiction in this. Hypertension is an invisible Western disease which requires a Western cure. But, even so, the Western diagnosis may not be accepted as complete. Should overt complications arise which are unresponsive to treatment, he may believe that there are metaphysical or other causes at work and seek the skills of the matowa or even the Bedouin healer. Chris Cooper Lecturer, Department of General Practice University of Sydney, Sydney, NSW (Dr Cooper worked for eight years as a general practitioner in Middle Eastern countries.) Ghazanfar SA. Wasm: a traditional method of healing by cauterization. J Ethnopharmacology 1995; 47: 125-128. Mohamed A, Neilson B, Hawash F, et al. Skin cauterisation marks on patients in Saudi Arabia. Lancet 1983; 1: 714. Reminick RA. The evil eye belief among the Amahra of Ethiopia. In: Landy D, editor. Culture, disease and healing. Studies in medical anthropology. New York: Macmillan, 1977: 218-225. Lawrence TE. The seven pillars of wisdom. London: Penguin, 1965. Rosenberg RA, Sagi A, Stahl N, et al. Maqua (therapeutic burn) as an indicator of underlying disease. Plast Reconstruct Surg 1988; 82: 277-280. Romanucci-Ross L. The hierarchy of resort in curative practices: the Admiralty Islands, Melanesia. In: Landy D, editor. Culture, disease and healing. Studies in medical anthropology. New York: Macmillan, 1977: 481-486.

Chris Cooper

To the Editor: My first reaction to reading "On dry land" (in In this Issue, in the 5 April issue of the Journal1) was to ask myself, "hang on, isn't the Australian Medical Association (AMA) based in Canberra now, and surely Canberra wouldn't be crowing about the superiority of its winters over Melbourne's?". Then, of course, a quick look at the first page of that issue revealed that the Journal is published in . . . surprise, surprise ... Sydney! It seems that The Medical Journal of Australia is as Sydneycentric as the ABC: "Most of us [my italics] have long suspected that Aussie Rules football should not be played outside of Melbourne". Most Sydneysiders, perhaps (although you may want to look at the number of people attending matches played by the Swans compared with those at rugby league games before you get too confident), but, in any case, Australian Rules has completely dominated football south and west of the Murray River. This is an area which contains nearly half of Australia's population, and, more importantly, nearly half of the members of the AMA. You then proffer the gratuitous insult that knee injuries could be reduced if "grounds were prepared with constant watering and little exposure to the sun -- simulating the conditions of a typical Melbourne winter!". I wonder if the same terms would have been used if the In this Issue item had been written more recently, in light of Sydney's weather in the last few months compared with Melbourne's glorious autumn and mild early winter. A David Grounds Physician Richmond, VIC 1. On dry land [In this Issue]. Med J Aust 1999; 170: 191. In reply: We stand castigated for our Sydneycentricity. Grounds' observations about the weather in the two cities during the 1999 football season aroused some curiosity in our editorial office, so we obtained the recent weather statistics (derived from Bureau of Meteorology data) from a very helpful Western Australian website.1 As the Figure shows, Sydney, although slightly warmer, had a much wetter six months in 1999. Further, the statistics for average rainfall between 1840 and 1989 show that Sydney's football season is always wetter than Melbourne's. So, it seems the answer to where we would rather spend winter, and which football code we would rather support, lies not in the weather... Whether the weather be fine, Or whether the weather be not, Whether the weather be cold, Or whether the weather be hot, We'll weather the weather, Whatever the weather, Whether we like it or not! Anon Comparison of (a) average temperatures (minimum/maximum) and (b) total monthly rainfall for Melbourne and Sydney in the 1999 football season. Ruth M Armstrong Assistant Editor The Medical Journal of Australia 1. Australian Weather Statistics. <http://cygnus.uwa.edu.au/~cloader/weather//>

To the Editor: Recent articles in the Journal on spider bites and skin ulceration1,2 made little of the importance of excluding microbial causes before diagnosing necrotising arachnidism. We report a case which illustrates this point. A 31-year-old woman was picking mandarins near Bindoon, Western Australia, when she felt something bite her wrist. When she looked, she saw a large hairy spider. A red lesion developed immediately and failed to resolve after a week, so she attended her general practitioner (A R N), who prescribed roxithromycin. After a further week she developed a 30 mm diameter, full-thickness ulcer on her wrist with some lymphangitis (Figure, above). At this point she attended an after-hours clinic, where wound care and an occlusive dressing were provided. After another three weeks she returned to her GP with no improvement, and nodular lymphangitis. Pus was aspirated from a fluctuant nodule and sent for culture. Therapy with doxycycline was started. The gram stain of the aspirate showed numerous pus cells, but no organisms. The culture showed no growth after two days, but was kept for extended incubation. The working diagnosis was necrotising arachnidism. After a further week the patient was referred to plastic surgeons at a public teaching hospital, where she was admitted and treated with intravenous clindamycin. She was discharged home with little improvement. Meanwhile, after 10 days' incubation, the aspirate culture plates grew a yeast-like organism, which was subcultured onto cornmeal agar for slide culture at 25°C. Microscopy showed a mould form of the organism, with clusters of ovoid, denticulate conidia produced sympodially on short conidiophores. With time at 25°C, the colony became blackened, glabrous and developed a wrinkled surface. This characteristic microscopy and thermal dimorphism confirmed the organism's identity as Sporothrix schenckii -- the agent of sporotrichosis. The patient has since been prescribed itraconazole and her condition is rapidly improving. Although our patient had lymphocutaneous sporotrichosis, there is also a fixed cutaneous form without lymphangitis.3 While there are reports of sporotrichosis associated with a variety of bites, including insects,4,5 we believe that this is the first report associated with a possible spider bite. We think it is important that in cases like this good quality specimens be sent for microbiological analysis and that they be specifically cultured for mycobacteria and fungi, or at least incubated for an extended period, before necrotising arachnidism -- the diagnosis of exclusion -- is diagnosed. Len D Moaven Clinical Microbiologist, St John of God Pathology Wembley, WA (moavenATbigpond.com.au) Shelley A Altman Senior Scientist, St John of God Pathology Wembley, WA A Richard Newnham General Practitioner Bindoon, WA Pincus SJ, Winkel KD, Hawdon GM, et al. Acute and recurrent skin ulceration after spider bite. Med J Aust 1999; 171: 99-102. White J. Necrotising arachnidism. Med J Aust 1999; 171: 98. Auld JC, Beardmore GL. Sporotrichosis in Queensland: a review of 137 cases at the Royal Brisbane Hospital. Aust J Dermatol 1979; 20: 14-22. Vismer HF, Hull PR. Prevalence, epidemiology and geographical distribution of Sporothrix schenckii infections in Gauteng, South Africa. Mycopathologia 1997; 137: 137-143. Lober C, Kaplan R, Herron C. Sporothrix schenckii inoculation on the abdomen. South Med J 1980; 73: 1637-1638.

Letter John Thomas sign: common distraction or useful pointer? MJA 1998; 169: 670 To the Editor: Anthropomorphic studies of the penis have largely centred on comparisons of length and girth and have not always grasped the substance of a more important companion feature, namely direction. The "John Thomas" (JT) sign refers to the position of the penis in relation to unilateral disease on routine x-ray, with a positive sign being implied when inclined to the side of the disorder (eg, a fractured hip). Although readily recognised, it has attracted little scholarly attention, being confined to darkroom banter or to impressing humourless medical students. While some degree of prudishness may have been responsible for curbing potential applications of the JT sign in the past, we believe that the position of the penis now needs to be set straight. We identified 65 consecutive male patients with a fractured right hip and 65 with a fractured left hip. The penile position was graded as positive (illustrated in the Figure), negative or equivocal (part of the glans below the symphysis). The penile bent was similarly defined in a further 65 patients in whom fracture was suspected but not identified. The JT sign was positive (ie, the penis inclined toward the fracture) in 70% of patients with hip fracture (91/130), negative in 11% (14/130) and equivocal in 19% (25/130). Consequently, the sensitivity (70%; 95% CI, 62%-78%) and specificity (67%; 95% CI, 60%-75%) for the JT sign are low. The genital disposition did not correlate with length of stay (r = 0.14). Demonstration of the JT sign before x-ray may be as useful as demonstrating leg shortening and external rotation -- synonymous but in no way diagnostic. And, if all patients with suspected hip fractures are routinely x-rayed, the prognostic significance of the pointer is minimised. Nonetheless, while the clinical utility of the JT sign may be limited, it appears to be real and reproducible. Thirty-one per cent of patients (20/65) presenting with a hip injury without fracture inclined to the injured side. If at least half of x-rays for hip fracture confirm the diagnosis, the predictive value of a positive JT sign is over 69%. Similar eponymous signs, such as Homan's, are widely flaunted. By comparison, the JT has been underexposed. Genital asymmetry is common and varies with handedness,1 although most incline leftward. That equal proportions of right (46/65) and left (45/65) hip fractures had positive signs in our study would reinforce the belief that somatic sensations can override higher cerebral control. Recent data suggest that genital inclination may be related to, among other things, different patterns of cognitive function and certain malignancies.2 The findings in our study, like those of the recent United States Starr Report,3 point to at least one more discriminating relationship. Merlin C Thomas Senior Registrar and corresponding author Brett D Lyons Associate Professor, Department of Nephrology Robert J Walker Senior Registrar, Department of Radiology Dunedin Department of Medicine, Dunedin Clinical School of Medicine University of Otago, Dunedin, New Zealand Bogaert AE. Genital asymmetry in men. Human Reprod 1997; 12: 68-72. Chang RH, Hsu FK, Chan ST, et al. Scrotal asymmetry and handedness. J Anat 1960; 94: 543-548. Starr KW. Referral to the United States House of Representatives pursuant to Title 28, United States Code, ¤595(c). Submitted by the Office of the Independent Counsel, September 9, 1998. [Monica Lewinsky v. President Clinton]. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Merlin C Thomas · Brett D Lyons · Robert J Walker

Letter Removing rectal foreign bodies: is the ventouse gender specific? MJA 1998; 169: 670-671 To the Editor: A man presented in an Australian provincial town with a foreign body in his rectum that would not pass. He stated that he thought it was a bottle top. Arrangements were made for the resident surgeon to retrieve the object by sigmoidoscopy under general anaesthesia. After an uneventful induction of anaesthesia, the surgeon proceeded to try to remove the "bottle top". However, it was soon obvious to him that he was not looking at a bottle top, but rather at the bottom of a glass bottle approximately 5 cm in diameter. Attempts to remove it with fingers, assisted by abdominal pressure, very similar to bimanual pelvic examination of the female pelvis, were unsuccessful. The surgeon was considering proceeding to laparotomy, with the aim of pushing the bottle up into the sigmoid colon and then opening the abdomen and retrieving it. However, the general practitioner anaesthetist, also trained in advanced obstetrics, suggested the possible use of the ventouse. The surgeon agreed, but, having no experience in the use of the ventouse, invited the GP to perform the procedure. The management of the anaesthesia was handed over. A small disposable plastic ventouse cup (Mityvac 0044M) was gently inserted through the already lax anus and manipulated onto the bottle. The rim was checked for trapped rectal mucosa. After three attempts to seal, suction was successfully applied. The rim was then checked again for mucosa and gentle traction applied. The bottle descended easily and delivered per rectum with no obvious trauma to the anus. The surgeon then checked for mucosal tears by sigmoidoscopy. There were none, and the patient was discharged the following day. I describe this case to illustrate two points. Firstly, that general surgeons may find a use for, and possibly adapt, the well-tried ventouse cup for delivery of foreign bodies per rectum. It would be advisable to have some obstetric training to learn how to avoid the dangers of mucosal entrapment. The advantages of the suction cup are that it will mould to the object and that it doesn't increase the diameter of the foreign body. Secondly, that the multiskilled rural GP still has a place in medicine, and can occasionally bring expertise from one area to another to benefit the patient. Richard P G Mackinnon Rural General Practitioner, Crystal Brook, SA 5523 Email: rmackinnATpirie.mtx.net.au Comment: The above tale of clinical cunning is an excellent illustration of the need for lateral thinking in certain situations. The particular clinical problem described has been with us for some time and is seen all over the world. It is relatively common, and requires a sensitive, meticulous and skilfully taken history, a professional physical examination, and diagnostic imaging (usually x-rays, occasionally ultrasound or computed tomography) before a careful plan based on knowledge and experience is formulated. However, a marked degree of modification or even innovation, depending on the particular object to be removed and the clinical circumstances, is often used. Not infrequently, careful trial and error (and luck) are factors in the outcome. A quick scan of the literature confirms the diverse and international nature of the problem and of its solutions. A German report tells of an apple wrapped in cellophane, unable to be retrieved until coagulated intermittently by argon laser. The Indian gastroenterology journal tell us of screwing out carrots, removing needles and whisky bottles.1 A series from Athens reports success with obstetric forceps in 40% of cases, while highlighting the importance of negating the proximal vacuum suction effect caused by traction on the foreign body, especially smooth, round ones like bottles (see Figure 1). This is commonly done by gently passing a well-lubricated Foley-type urinary catheter up past the object to break the air seal.2 An overview of cases from California and London reminds us that, although foreign bodies can be removed in the emergency department in about two out of three cases, some 10% still require a laparotomy and a diverting colostomy to remove the object or to treat bowel perforation. Only one case report (which claimed to be a world's first) described the use of an obstetric vacuum extractor.3 As in the case described above, this report also emphasised the practical issues of ensuring that no mucosa is trapped and the need for follow-up sigmoidoscopy to check for mucosal damage or perforation. The case described above also illustrates the element of surprise when what we are led to expect from the history is nothing like what we really have to deal with (see Figures 2 and 3). As 80% of these events occur for sexual stimulation and 10% involve sexual assault,4 it is understandable that there may be an initial reluctance to tell the truth. At all times, before and after the extraction, extra effort must be made by all staff to show a confidential, sensitive and caring attitude to a patient who is deeply embarrassed and often in great discomfort. Gordian Fulde Director, Emergency Department, St Vincent's Hospital Victoria Street, Darlinghurst, NSW 2010 Vashist MG, Arora AL, Salil. Screwing a carrot out of the rectum [letter]. Ind J Gastroenterol 1997; 16: 120. Kouraklis G, Misiakos E, Dovas N, et al. Management of foreign bodies of the rectum: report of 21 cases. J Roy Coll Surg Edin 1997; 42: 246-247. Johnson SO, Hartranft TH. Nonsurgical removal of a rectal foreign body using a vacuum extractor. Report of a case. Dis Colon Rectum 1996; 39: 935-937. Cohen JS, Sackier JM. Management of colorectal foreign bodies. J Roy Coll Surg Edin 1996; 41: 312-315. Acknowledgment: Figures 2 and 3 were kindly provided by Dr T O'Connor, Colorectal Surgeon, St Vincent's Hospital, Sydney. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Letter Faith healing or Russian roulette? MJA 1998; 169: 671 To the Editor: In response to the letter on faith healing in the Christmas 1997 issue of the Journal,1 it is extremely important to recognise that there is another side to the picture of the deliberately fraudulent "faith healer". In July 1976, in the company of another physician and two psychologists, I visited seven healers in the Philippines and collected 22 samples of "blood". All of the samples proved to be human blood. In 1977, one of those healers came to my clinic in the United States, and in the presence of four scientific observers, and with three cameras trained on the proceedings, performed "surgery" on two patients. The healer had no prior knowledge of these patients, who were local volunteers. Blood seemed to appear on the surface of the skin of both patients, although there was no opening of the body that I could see. I collected that blood, and took whole blood samples from both patients and the healer. The report from the laboratory is summarised in the Table. In each case, the blood that seemed to be removed from the patient was indeed that patient's blood type. The laboratory reported that the probability of choosing two random blood samples to match two people selected at random is 0.14. While I do not recommend that people rush off to the Philippines for treatment, what I observed was a very closely monitored scientific observation which I cannot explain. C Norman Shealy Director, The Shealy Institute, 1328 East Evergreen Street Springfield, MO 65803-4400, USA Roffey PE, Freney LC, Ansford AJ. Faith healing and Russian roulette [letter]. Med J Aust 1997; 167: 649. Make a comment Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Public health and politics: the demise of the ACT heroin trial To the Editor: Wodak cites the support of the Australian Medical Association for the proposed ACT heroin trial in his editorial.1 The Federal Executive of the AMA supported the trial but the Queensland Branch (AMAQ) opposed it. The basic premise of Wodak's editorial is that stopping the trial showed lack of support for evidence-based medicine. AMAQ opposed the trial on the grounds that there was little scientific evidence, and what evidence there was came only from Switzerland and much of it was dubious at best. A view was expressed at AMAQ Council that the proposed stages of the trial were an unpleasant experiment on Australian society. The reason for Wodak's response lies in the second paragraph of his editorial, where he refers to the lucrative profits from trafficking of illicit drugs. Wodak and the trial's supporters appear to believe that liberal use of free heroin would threaten the profits of drug traffickers, but for that to be so heroin would have to be widely available in the community. Thus, the purpose of the trial was not to determine efficacy, as the authors of the trial, like Wodak, knew the outcome -- the introduction of free heroin throughout Australia. Christopher J Alroe Member, Australian Medical Association Queensland Branch Council; and Senior Consultant, Rockhampton District Mental Health Service, PO Box 4055, Rockhampton, QLD 4700 Wodak AD. Public health and politics: the demise of the ACT heroin trial [editorial]. Med J Aust 1997; 167: 348-349. Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia ".

Christopher J Alroe

Letter A study of 100 anabolic-androgenic steroid users MJA 1998; 168: 311-312 To the Editor: We report the findings of a study of 100 current anabolic-androgenic steroid (AAS) users in New South Wales which aimed to explore the patterns and correlates of AAS use (motivations for use, ways of identifying harms, and knowledge, attitudes and behaviours concerning harm reduction strategies, as well as appropriate public health strategies). We recruited the sample through media and gymnasia advertising and conducted interviews in 1996-1997. Thirty-eight subjects were from inner-city areas, 50 from suburban metropolitan areas and 12 from non-metropolitan areas. Our AAS users were different from other Australian samples of injecting drug users.1 They were more likely to be men (94), homosexual (27), in a stable relationship (37 were married or in a de-facto relationship; of the 85 non-married subjects, 55 were in a relationship that had lasted a mean of 22.5 months), well educated (68 post-secondary school), and employed (86). Their median age was 27 years (range, 18-50) and they had been using AASs for a median of four years (range, 1 month - 21 years). General practitioners (GPs) were the reported source of AASs for 42 subjects and, for 21, their usual supply source. Fifty-four were being monitored (32 by a GP, 2 by a medical student, and the rest by a friend, trainer or partner). The most common source of education on injection technique was a GP (30). In common with other illicit drug users, AAS users experienced negative health and psychological effects; those most commonly self-reported included fluid retention (64), painful injection sites (57), acne (54), and hypertension (18). Men reported testicular atrophy (52/94) and gynaecomastia (32/94), and all of the women reported clitoral hypertrophy and voice changes (which are irreversible2), and four of the six women reported menstrual irregularities. Nearly half of the sample (42) reported more aggressive behaviour when using AASs. Thirteen met DSM-IV3 criteria for dependence on AASs, including symptoms of tolerance and withdrawal, and a further 24 met criteria for AAS abuse. Subjects reported that health concerns were the most likely deterrent to AAS use. Several potentially harmful activities engaged in included self-taught injection procedures, injecting specific muscle groups for localised growth (calves, biceps), concurrent use of several AASs ("stacking"), use of high doses and/or long cycles, and use of other drugs such as clenbuterol, diuretics, thyroxine, insulin, and human growth hormone. AAS users actively seek out information relevant to their AAS use. Friends (63), non-medical handbooks (60) and fitness magazines (53) are the most common sources, making the quality of the information highly questionable. Almost three-quarters (73) of the sample claimed that their preferred AAS information source would be their family medical practitioner (provided she or he were well informed and approachable), giving scope for improving the harm reduction information available to this eager group by educating medical practitioners. Medical education could highlight the legal and ethical obligations of medical practitioners as well as provide harm reduction information to pass on to their patients. Jan Copeland Lecturer Richard Peters Research Assistant Paul Dillon Information Officer National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052 Darke S, Ross J, Hall W. Overdose among heroin users in Sydney, Australia. 1. Prevalence and correlates of non-fatal overdose. Addict 1994; 91: 405-411. Bierly JR. Use of anabolic steroids by athletes: do the risks outweigh the benefits? Postgrad Med 1987; 82: 67-74. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edition. Washington, DC: American Psychiatric Association, 1994. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Jan Copeland · Richard Peters · Paul Dillon

Faith healing or Russian roulette? MJA 1997; 167: 649 To the Editor: In 1995, a Brisbane woman visited a renowned faith healer in Manila for treatment of chronic tinnitus. The treatment involved the removal of what appeared to be a clot of blood from below her left ear and also one from her abdomen. The operation was performed seemingly by way of incisions at those sites without instruments or anaesthetic and using bare hands. During both procedures, blood was released which spilled onto her skin and stained her clothing. The woman's husband and brother-in-law, who witnessed and photographed the proceedings in close proximity, were convinced that what they had seen was genuine. However, following treatment her condition remained unchanged. To explore the facts more closely, the woman brought her bloodstained clothing to the Forensic Biology Laboratory in Brisbane. Examination of the clothing confirmed the presence of splashes and stains of human blood, but most appeared diluted. These findings were corroborated by photographs which showed the blood to be far less viscous than usual (Figure). Blood samples taken from her clothing were examined using three independent genetic tests: HLA DQA1, D1S80, and HUMTH01. These tests are commonly used in forensic practice to identify the origins of biological materials and stains such as blood, hair, saliva and semen; they distinguish individuals based on their genetic make-up. The results unequivocally showed that the blood on her clothing was not her own but a mixture of blood from at least two other individuals. As a precaution, she was tested for HIV and hepatitis B antibodies, both of which were negative after three months. Hundreds of people are treated by this faith healer every day. He is revered in the Philippines and people travel from all over the world to attend his "clinic". He also claims to travel frequently to other countries to perform his services. His healing power appears to be based on illusion. No doubt, the wellbeing of patients can be influenced by their confidence in their physician ("the placebo effect"). Judging by this man's reputation, it would seem that many have felt that they benefited from his treatment. However, it is a serious health concern that he uses blood to "convince" people that his practice is authentic, considering the number of people that he treats and the diversity of their backgrounds. The possible transmission of diseases such as hepatitis B and HIV to Australian citizens during these procedures would be of interest to Australian health authorities. Paul E Roffey Formerly, Forensic Scientist, Queensland Health Department; now Lecturer, School of Biomedical Sciences, Charles Sturt University, PO Box 588, Wagga Wagga, NSW 2678 E-mail: proffey AT csu.edu.au Leo C Freney Supervising Scientist Anthony J Ansford Director, John Tonge Centre for Forensic Sciences, Queensland Health Scientific Services, Brisbane, QLD - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Paul E Roffey · Leo C Freney · Anthony J Ansford

"Irukandji" syndrome: a risk for divers in tropical waters MJA 1997; 167: 649 To the Editor: Envenomation by the cubozoan jellyfish Carukia barnesi causes "Irukandji" syndrome (named by Dr Hugo Flecker after an Aboriginal tribe near Cairns).1 I report a case of Irukandji syndrome in a scuba diver for whom appropriate therapy was delayed because it was not initially considered as a possible cause of the patient's symptoms. A 28-year-old experienced diver was diving off Brampton Island in Queensland. During his second dive, at a depth of 6 m, he had a feeling of disequilibrium and so made a controlled ascent and removed his gear. His vague malaise was accompanied by aching pain in the groin and thighs, with numbness in the fingers and toes. This rapidly progressed to severe pain in the skin, muscles, face, jaw, testes and lumbar region, with profuse sweating and agitation. By the time he presented to the emergency department (after a delay of six hours because of transport difficulties), he was in great pain, with tachycardia (90 beats/min) and hypertension (170/100 mmHg). He was treated with 100% oxygen and pethidine (intramuscular and intravenous). At this stage, there were no diagnostic clues, except that symptoms had developed rapidly within minutes of his ascent. Decompression sickness was therefore considered, but after two conversations with the consultant at the Townsville General Hospital Hyperbaric Unit, an interview with the dive buddy, and in view of the patient's diving experience and the dive history, this diagnosis was dismissed. Irukandji syndrome was suggested and, when prompted, the patient recalled seeing a small jellyfish while descending and feeling a slight irritation on his right arm. A 3 cm x 4 cm oval inflamed area was evident on his right antecubital fossa and the patient provided a sketch of the jellyfish (Figure). He was commenced on an intravenous morphine infusion over 10 hours. Although a dull chest pain and lower-limb pain persisted, he did not require further analgesia. His serum creatine phosphokinase level peaked at 7317 IU/L (normal range, 10-60 IU/L) and his serum lactate dehydrogenase level reached 349 IU/L (normal range, 120-300 IU/L). Echocardiography after two days showed mild mitral valve regurgitation. Fortunately, the patient escaped the more sinister complications of Carukia envenomation (myocardial failure and pulmonary oedema).2-4 This is the first reported case where a patient with Irukandji syndrome identified the jellyfish. It has been reported that the syndrome may be mistaken for decompression sickness,5,6 thus evading rapid diagnosis and triggering costly evacuation and recompression procedures (J Williamson, Director of Hyperbaric Medicine, Royal Adelaide Hospital, personal communication). This case is a reminder that Irukandji syndrome can be a "diving-related illness", and should always be considered in the differential diagnoses of an ill diver in tropical waters. John C Hadok Senior Medical Officer, Emergency Department, Mackay Base Hospital PO Box 5580, Mackay, QLD 4740 E-mail: jchadokAThealth.qld.gov.au Fenner PJ, Williamson J, Callanan VI, Anderley I. Further understanding of, and a new treatment for, "Irukandji" (Carukia barnesi) stings. Med J Aust 1986; 145: 569-574. Fenner PJ, Williamson JA, Burnett JW, et al. The "Irukandji syndrome" and acute pulmonary oedema. Med J Aust 1988; 149: 150-156. Martin JC, Audley I. Cardiac failure following Irukandji envenomation. Med J Aust 1990; 153: 164-166. Herceg I. Pulmonary oedema following an Irukandji sting. SPUMS J (South Pacific Underwater Medicine Society Journal) 1987; 17: 95-97. Williamson J. Scuba diving perspective. In: Williamson JA, Fenner PJ, Burnett JW, Rifkin JF, editors. Venomous and poisonous marine animals. Sydney: University of New South Wales Press, 1996: 423-427. Williamson J. "Irukandji" syndrome or decompression sickness or cerebral arterial gas embolism? A differential diagnostic trap for practitioners of diving medicine in north Queensland. SPUMS J 1985; 15: 38-39. My thanks to Drs Bruce Todd, Bert Sadleir and Associate Professor John Williamson. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

John C Hadok

Papilloedema and coma in a child: undescribed symptoms of the "Irukandji" syndrome MJA 1997; 167: 650 To the Editor: The "Irukandji" syndrome, so named in 1952,1 refers to the severe systemic symptoms that follow envenomation by the jellyfish Carukia barnesi,2,3 named by Dr Jack Barnes in 1964.4 Here, we report papilloedema and coma in a seven-year-old child who developed Irukandji syndrome after a jellyfish sting in the tropical waters of Cairns, in far north Queensland. The child was treated by one of us (R J H) in 1981, but not reported at the time and only recently described to colleagues. The boy was admitted to hospital with the severe systemic symptoms of Irukandji syndrome, including generalised muscle cramps, anxiety and sweating. Ten hours later, he was confused, disoriented, tachycardic and tachypnoeic, and had several episodes of profound sweating, cyanosis and agitation. Bilateral crepitations (more marked on the left) were heard on chest auscultation, and a chest x-ray showed increased interstitial markings consistent with pulmonary oedema. He had 4+ glycosuria, Dextrostix of 130 mg/100 mL (normal range, 80-120 mg/100 mL), and periodic auditory and visual hallucinations. The boy was pale and in obvious respiratory distress, requiring oxygen 6 L/min via facemask to maintain his central colour. Examination of his fundi showed blurring of the disc margins. Initial management consisted of an intravenous dexamethasone infusion and intermittent intravenous frusemide (exact doses not known). His symptoms persisted through the first 24 hours of admission, and by the second evening he was more disoriented and unresponsive to commands. He was given 100 mL of 20% mannitol intravenously and within two hours had a huge diuresis with a wet bed. Three hours later, he was answering questions with a grunt, and shortly after was obeying commands and was easily rousable. Ten hours later, he was talking freely and answering questions, and subsequently made a complete recovery with no neurological sequelae. To our knowledge, this is the first reported case of papilloedema and unconsciousness associated with the Irukandji syndrome. We believe this indicates cerebral oedema, but no cerebral scan was done to confirm this. Recently, a case of cerebral oedema was reported after a chirodropid (multitentacled box jellyfish) sting.5 We suggest that the patient's level of consciousness be carefully monitored in all serious jellyfish envenomations, and that any deterioration of consciousness be appropriately investigated. Peter J Fenner Honorary Medical Officer, Surf Life Saving Association, PO Box 3080, Mackay, QLD 4740 RJ Heazlewood Visiting Medical Officer, Cairns Base Hospital, QLD Flecker H. "Irukandji" sting to north Queensland bathers without production of wheals but with severe general symptoms. Med J Aust 1952; 1: 89-91. Fenner PJ, Williamson JAM, Callanan V, Audley I. Further understanding of, and a new treatment for, "Irukandji" (Carukia barnesi) stings. Med J Aust 1986; 145: 569-574. Fenner PJ, Williamson JA. World wide deaths and severe envenomation from jellyfish stings. Med J Aust 1996; 165: 658-661. Barnes JH. Cause and effect in Irukandji stingings. Med J Aust 1964; 1: 897-904. Fenner PJ, Williamson JA, Burnett JW, et al. The "Irukandji syndrome" and acute pulmonary oedema. Med J Aust 1988; 149: 150-156. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Peter J Fenner · RJ Heazlewood

European wasps: an emerging hazard in Australia MJA 1997; 167: 650 To the Editor: The Victorian Department of Natural Resources and Environment has predicted a surge in European wasp (Vespula germanica) numbers this summer (6 August 1997, press release).1 This is expected to result in an increase in serious and potentially life-threatening injuries from wasp stings.2 Since arriving in mainland Australia in 1977, the European wasp has spread dramatically,3 and is now found in all States and Norfolk Island. It has so far resisted biological and chemical control measures, and the wasp population is expected to explode.3 The toxicity of wasp venom, their multiple stinging capacity, aggressiveness and tendency to build hidden subterranean nests2,3 mean that increased morbidity from wasp stings is likely. According to the Victorian Minimum Inpatient Dataset, hospitalisations as a result of wasp stings have increased in Victoria in recent years (1992-1996),4 and wasp stings were among the top 10 poisons exposure inquiries in Victoria for 1996.4 Fatalities have been reported in other countries.5 The current paradigm is that most serious reactions to wasp stings are allergic in nature, so that only a small percentage of the population is at risk. However, as in the case of a Melbourne child who disturbed a wasp nest,2 the large number of stings sustained from an attack by a swarm of wasps (often 30 to 200 stings) can result in a massive life-threatening envenomation. Therefore, not only those with wasp allergy are at risk. Unfortunately, this issue has not been studied, despite the important implications for patient management. Allergic effects, which may be managed by immunotherapy and early administration of adrenaline, need to be distinguished from the toxic effects of envenomation, which require alternative management. We support the initiative of the Victorian Conservation Minister to develop a national European wasp strategy and recommend that it include a national surveillance system, through the Australian Venom Research Unit (AVRU), to monitor the health impact of the growing wasp population. We also encourage doctors to report serious wasp-related injuries to the AVRU: telephone (03) 9344 7753 or facsimile (03) 9348 2048. Interdisciplinary collaborative research involving entomological, toxicological, public health and emergency medicine professionals is needed to address this increasing threat to our health and enjoyment of the great outdoors. Nadine R Levick Faculty, Division Pediatric Emergency Medicine, Johns Hopkins Medical Institutions 600 North Wolfe Street, CMSC 144, Baltimore, MD, USA 21287-3144 E-mail: nlevickATwelchlink.welch.jhu.edu Ken D Winkel Deputy Director, Australian Venom Research Unit, Department of Pharmacology University of Melbourne, VIC Gordon Smith Associate Professor, Center for Injury Research and Policy, School of Hygiene and Public Health Johns Hopkins University, Baltimore, MD, USA Alexander C. Wasp plague on the way. Herald Sun 1997 Aug 8. Levick N, Braitburg G. Massive European wasp envenomation of a child. Emerg Med 1996; 8: 239-245. Spradbery JP, Maywald GF. The distribution of the European or German wasp in Australia, past, present and future. Aust J Zool 1992; 40: 495-510. Royal Children's Hospital, Pharmacy Department. Keeping tabs. Newsletter. Melbourne: Royal Children's Hospital, 1997; 3: 1. Man dies after attack by wasps. The Washington Post 1997 Aug 29: D06. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Nadine R Levick · Ken D Winkel · Gordon Smith

Choking after inhaling a foreign body through a Ventolin puffer MJA 1997; 167: 651 To the Editor: A 10-year-old boy awoke with asthma. His mother, also an asthmatic, took her salbutamol inhaler from her purse and gave the boy a puff. The boy immediately became extremely distressed and was unable to speak. He mouthed to his mother, "I cannot breathe". His mother performed the Heimlich manoeuvre, during which a white object was expelled from the boy's mouth, immediately relieving his distress. The object was a cigarette filter. His mother is a cigarette smoker and rolls her own cigarettes. Loose cigarette filters and uncapped asthma inhalers were found in the clutter at the bottom of her purse (Figure). As she had previously propelled a filter into her own airway from an inhaler, with less severe consequences, she recognised the likely cause of her son's sudden inability to breathe. This frightening and potentially lethal episode illustrates the importance of keeping caps on asthma aerosol inhalers when not in use, so preventing objects from lodging in the aerosol mouthpieces. Michael J Mackay Senior Medical Officer, Emergency Department, Mackay Base Hospital Bridge Road, Mackay, QLD 4741 - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Michael J Mackay

Out of the blue and into the pink A new litmus test for chlorine gas exposure MJA 1997; 167: 651 To the Editor: A 40-year-old man arrived at the emergency department by ambulance in respiratory distress. In his duties as a hotel maintenance worker, he had been mixing swimming pool chemicals in a dark, confined space. Inadvertently, he had mixed liquid pool "chlorine" (sodium hypochlorite) with a hydrochloric acid solution, forming an irritating yellow-green gas. Despite a brief exposure, he rapidly developed eye irritation, burning in his oropharynx, cough and chest pain. He noticed that the keys in his pocket had turned a dull colour. On arrival, about 20 minutes after the exposure, he had an irritating cough, but his vital signs were normal, oxygen saturation was 99%, and his chest was clear to auscultation. His clothing smelt of chlorine and was removed to prevent skin irritation. On removing his white overalls, it was noticed that his blue underpants had changed colour to a pink-mauve hue. Although he suffered acute embarrassment, he developed no acute clinical or radiographic signs and was discharged well after several hours' observation. Chlorine gas exposure is not an uncommon hazard of mixing household cleaners or pool chemicals. The addition of an acid to a chloride-containing base releases chlorine gas in an exothermic reaction. Chlorine gas is highly water soluble and on moist surfaces is transformed into hydrochloric acid and an oxygen radical. This mechanism explains the clinical manifestations, with the hydrochloric acid causing immediate irritation to mucosal surfaces, leading to lacrimation, burning sensations and cough. These symptoms usually serve as a warning to the victim to move away from the gas to prevent the more serious sequelae of laryngeal oedema, bronchospasm and adult respiratory distress syndrome. Presumably in this case, the elaboration of acid in the sweaty confines of his true-blue Y-fronts mimicked the classic pH indicator reaction of litmus paper. Perhaps he should have worn his underpants on the outside! Tim C Green Staff Specialist, Emergency Department, Royal Prince Alfred Hospital Missenden Road, Camperdown, NSW 2050. E-mail: timgreenATmpx.com.au Reference: Hoffman RS. Toxic inhalations. In: Rosen P, Barkin R, et al., editors. Emergency medicine -- concepts and clinical practice. 3rd ed. 1992: 2673-2682. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Tim C Green

A sad stool MJA 1997; 167: 654 To the Editor: With greater attention being given to improving communication between healthcare professionals and the public, the following incident is a simple yet worthy reminder that effective communication depends not only on the information that is transmitted but, more importantly, on the information that is received. A young woman came into my pharmacy with a prescription for Ferro-Gradumet (ferrous sulfate, Abbott), and it was obvious that she was reluctant to have it dispensed. During our conversation, she remarked that she was very concerned about becoming depressed because the doctor had told her that while taking this medicine her emotions would be black. This certainly wasn't the message that the doctor intended to transmit (viz. her motions would be black), and it could have led her to abandon the treatment. How can we ensure that the correct message is received? Failures in communication like this can be avoided if plain, straightforward words are used instead of outdated euphemisms. In this instance, the more direct word "faeces" is less likely to be misinterpreted and, if not understood, is more likely to prompt the question, "What do you mean by that?". Richard M Worrell Pharmacist, PO Box 274, Rose Bay, NSW 2029 - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Richard M Worrell

"Hale-Bopp" and "Knocking on Heaven's Gate" Hits of the Net, 1997 MJA 1997; 167: 654 "If anyone comes to Me and does not hate his father and mother and his wife and children and brothers and sisters -- and even his own life also -- he cannot be My disciple". Luke 14:261 To the Editor: This Christmas, as we renew old family quarrels, we should remember we are celebrating the birth of Christ, who, according to the Heaven's Gate cult, was the first visitor from TELAH -- The Evolutionary Level Above Human.1 On 22 March 1997, when the Hale-Bopp comet was nearest to Earth, 39 members of this cult left earth to link up with the comet's "companion spaceship" bound for TELAH,2 wearing black Nike sneakers. Their transport to TELAH began with deliberate self-poisoning. Although we previously found no relationship between self-poisoning and celestial or occult events,3 this event combined both and suggested that we might have overlooked a synergistic mechanism. We also examined the possibility that traffic was going in the opposite direction that day, with ancient astronauts escaping their spaceship to appear on earth as newborn babies. We used two databases to test our hypothesis: a register of births in the Canberra Hospital (which we felt would closely resemble the sterile environment of a spaceship) and the Hunter Area Toxicology Service database of presentations to hospital with self-poisoning in the Lower Hunter Valley of New South Wales. To examine for evidence of massive successful and attempted soul migrations, we compared the number of births and self-poisonings between 21 and 23 March with those for the rest of the month. There did not appear to be any significant surge in self-poisonings or births at this time. On those three days, there were eight self-poisonings, compared with 51 on all the other days in March (P = 0.24, Mann-Whitney test), and 13 births compared with 141 (P = 0.61). However, we did note a surprisingly strong correlation between self-poisonings and the Nike share price4 (P = 0.005, Spearman) (Figure). In the three months after the Heaven's Gate tragedy, the share price of Nike fell by 20%, despite a 15% increase in the market index and a 28% increase in sales.4 This could either be a suicide prevention strategy or evidence that people are reducing their Nike stocks to invest in futures. When surfing the Internet, it is quickly apparent that data-dredging is not confined to medicine and there is no statistical refereeing. Significance can be found everywhere on the Net: a place to publish and perish. Nicholas A Buckley Visiting Fellow,National Centre for Epidemiology and Population Health The Australian National University, Canberra, ACT 0200 E-mail: mdnabATcc.newcastle.edu.au Janelle A McDonald Obstetric Registrar, National Centre for Epidemiology and Population Health The Australian National University, Canberra, ACT 0200 Do, Ti, et al. How and when Heaven's Gate may be entered (The door to the Physical Kingdom Level Above Human). Phoenix (Ariz): TELAH Services, 1997. On the Internet: http://www5.zdnet.com/yil/higher/heavensgate/ http://www.neosoft.com/~cshramek/comet.htm Buckley NA, Whyte IM, Dawson AH. There are days . . . and moons. Self-poisoning is not lunacy. Med J Aust 1993; 159 (11/12): 786-789. http://quote.yahoo.com/ - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Nicholas A Buckley · Janelle A McDonald

Effect of postgraduate exams on putting performance MJA 1997; 167: 655 Objective: To test the hypothesis that examination stress adversely affects golf putting performance. Participant: An advanced trainee of a learned specialist college, with moderate golfing skills and about to undertake final fellowship examinations. Methods: A week before the exams, the subject was asked to perform 50 consecutive 60 cm putts on the practice putting green, under standard conditions. The hole was cut on a flat portion of the green, with negligible borrow or irregularities. The number of successful putts was recorded. Two weeks after successfully completing the exams, the subject was asked to repeat the test. The hole and the weather conditions were similar. Results: Test one. Successful putts: 40 (including three mulligans); unsuccessful putts: 10. Test two. Successful putts: 46 (including one mulligan); unsuccessful putts: 4. Mulligans were putts that, while not successfully "holed", were deemed by the subject to have been so close that they were considered "holed". Reasons included: "The wind changed direction at the last minute" and "The hole moved after I had putted". Statistical analysis: Two new techniques relevant to golfing data were used. The Norman Index of the sum of rank performances (n value) was multiplied by the Tiger Woods covariant of superior performances (t value). The resulting score was divided by the square root of the subject's handicap, giving a dubious value (d) which was statistically feasible (d < 0.05). Like all golfing data, these values need to be treated with suspicion. Discussion: The adverse affects of examination stress on putting performance could be a result of physical impairment (tremors and sleep deprivation) and psychological impairment (distraction and fear of failure). As putting is a vital component of a golfer's repertoire, it is reasonable to extrapolate that examination stress would be detrimental to overall golfing performance. It may be that poor golfing performances adversely impact upon examination performances. This requires further testing, preferably over a long period of time (several months would be fine), at a suitable golf course (perhaps Port Douglas in far north Queensland) and with appropriate funding (to cover travel expenses!). Conclusion: Examination stress adversely affects putting performance. Postgraduate examinations should be scheduled to avoid significant golfing fixtures, such as club championships. (Disclosure: Any resemblance between the author and subject is purely coincidental.) Craig T Hore Clinical Fellow, CareFlight, NSW Medical Retrieval Services PO Box 159, Westmead, NSW 2145 - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Craig T Hore

Letter Ultrarapid opiate detoxification. What's all the fuss about? MJA 1997; 167: 393 To the Editor: In the past few months, the Australian electronic and print media have hailed ultrarapid opiate detoxification (UROD) as being able to "cure" 60%-100% of heroin addicts. These claims were initially made as part of a professionally organised media campaign by CITA/ATT, a Spanish-Israeli organisation, but have been repeated by opponents of harm-minimisation addiction treatments.1 While there is no conclusive evidence as to the efficacy of UROD, CITA/ATT has attempted to patent and franchise what it considers to be "its" treatment. In UROD, opioid addicts are anaesthetised for several hours and given naltrexone to precipitate withdrawals. Naltrexone is a long-acting, opioid antagonist with little or no agonist activity that is effective orally. It has not been approved for use in Australia. While there are benefits in terms of speed and reduced suffering, there are no published reports comparing the long-term outcome after UROD with other methods of rapid opioid detoxification. UROD is expensive and has obvious risks; a patient died during treatment in the United Kingdom.2 After UROD, patients are given up to a year's maintenance treatment with naltrexone, usually 100 mg on Mondays and Wednesdays and 150 mg on Fridays. While the available evidence is contradictory, there is a suggestion that socially stable addicts with no psychiatric comorbidity may benefit from postdetoxification naltrexone treatment. In two randomised, placebo-controlled, double-blind trials the treated group tended to use less heroin, but the differences were not statistically significant.3,4 CITA claimed UROD was discovered by a Spanish psychologist, Dr Juan Legarda.5 However, rapid opiate detoxification was first described by researchers working at Vienna University in a series of papers published in the international peer-reviewed literature between 1988 and 1991.6 Dr Legarda's first and only published account dates from 1994 and refers to the work of the Vienna group and others.7 CITA/ATT sought to franchise "its" treatment (international patent application PCT/ES94/100108),5 and has threatened to sue a British and American physician who offer patients similar services. CITA/ATT has also attempted to issue national franchises for the "CITA Method". A United Kingdom version of the franchise agreement stipulated "the Method" must remain secret. A minimum 240 detoxifications had to be performed in the first six months and one-quarter of all payments were to be paid to the parent company. The British licensee would have been obliged to spend no less than US$50 000 in the first year and US$25 000 in subsequent years marketing and advertising "the Method".2 The CITA/ATT marketing campaign represents a corruption of the scientific process and is unethical. The profession should condemn this and similar attempts to use the mass media to bypass the peer-reviewed literature. However, despite the concerns raised by the CITA/ATT media campaign, a local, randomised trial of UROD versus another form of rapid, antagonist-assisted detoxification is warranted.5 Such a study should include a double-blind, placebo-controlled trial of postdetoxification naltrexone maintenance. John R M Caplehorn PhD Student, Department of Public Health and Community Medicine University of Sydney, NSW 2006 E-mail: johncATpub.health.su.oz.au Ackerman P. Aim must be abstinence when it comes to drugs. Sunday Telegraph 1997 March 23; 143. Tyaransen O. The strange and terrible saga of Brendan Woolhead. Hot Press (Dublin) 1997 May 14; 12, 13, 62. National Research Council Committee on Clinical Evaluation of Narcotic Antagonists. Clinical evaluation of naltrexone treatment of opiate-dependent individuals. Arch Gen Psychiatry 1978; 35: 335-340. Shufman EN, Porat S, Witzum E, et al. The efficacy of naltrexone in preventing reabuse of heroin after detoxification. Biol Psychiatry 1994; 35: 935-945. Brewer C. Ultra-rapid, antagonist-precipitated opiate detoxification under general anaesthesia or sedation. Addiction Biol 1997; 2: 291-302. Loimer N, Schmid R, Presslich Q, Lenz K. Continuous naloxone administration suppresses opiate withdrawal symptoms in human opiate addicts during detoxification treatment. J Psychiatr Res 1988; 23: 81-96. Legarda J, Gossop M. A 24-h inpatient detoxification treatment for heroin addicts: a preliminary investigation. Drug Alcohol Depend 1994; 35: 91-93.