Letters

To the Editor: As a geriatrician in the subacute sector with hospital medical officers (HMOs) rotating from a major teaching hospital, I am acutely aware of the cost to all concerned of inappropriate diagnostic testing. Discussion stimulated by Stuart et al1 and the editorial by Hammett and Harris2 may help elevate this issue into its rightful arena — quality care and clinical accountability. Donabedian,3 in looking at the assessment of quality care, describes "elements in the performance of practitioners", with technical performance defined as "knowledge and judgement used in arriving at the appropriate strategies of care". I believe that both these quality elements are deficient and that it is the responsibility of the senior clinicians to provide the necessary leadership in ensuring their acquisition. While I agree with Hammett and Harris that there are systems failures and that, as an example, improved feedback of results (particularly given changing HMO work practices and shorter length of patient stays) will provide some of the answers, there appears little doubt that a significant knowledge deficit exists among junior doctors regarding the use and interpretation of common tests and how often they should be ordered. The unfortunate fact is that we have known about these issues for many years and have yet to develop a sustained response. At our hospital we have attempted to modify the use of diagnostic tests by HMOs during their geriatrics rotation, with tutorials from biochemists and haematologists which are reinforced during consultant ward rounds and meetings. This is, however, doomed to failure unless the process is continued by all other clinicians who supervise HMOs. Emanuel and Emanuel4 define accountability in a number of domains. The least controversial of these, I suggest, is professional competence. It is incumbent on us as senior clinicians to "invoke, affirm and enforce professional standards",4 being accountable for the practices of those HMOs under our supervision. Appropriate use and understanding of diagnostic testing will reduce unnecessary patient discomfort while also reducing costs. As any geriatrician will tell you, additional years without insight simply provide grey hair, not improved clinical practice.

Michael J Murray

Letters The mystery of GP research output? MJA 2001; 175: 667 To the Editor: Askew et al ask why there is not more general practice research.1I think they would have come close to the answer had their analysis of publication rates by workforce sector included the relative rates of government salaried employment. The proportions of each group in salaried work are approximately: General practitioners, 18% (of whom only 2% are government employees); Physicians, 56%; Surgeons, 26%; and Public health physicians, 90%.2 While the Primary Health Care Research, Evaluation and Development (PHC-RED) program is a laudable and exciting strategy, it is hard to imagine that it will achieve much change in the rate of general practice research until research activity becomes part of the formal "job description" for a large proportion of GPs, as it is for many of our specialist colleagues. Of course, the incursion of corporatisation into Australian general practice will introduce important issues in regard to the amount of research undertaken and the nature of the research performed, as it has for Australian universities. As yet, PHC-RED has not developed a view as to how it might handle such influences. Phillip Gray General Practitioner, Central Queanbeyan Medical Centre, Focal Point Arcade, 25 Monaro Street, Queanbeyan, NSW 2620. gray.qbnATeffect.net.au Askew DA, Glasziou PP, Del Mar CB. Research output of Australian general practice: a comparison with medicine, surgery and public health. Med J Aust 2001; 175: 77-80. Medical masterfile [database]. Sydney: Australasian Medical Publishing Company, 2001.

Phillip Gray

Letters Australian general practice at a fork in the road: which way forward? MJA 2001; 175: 667 To the Editor: There are a number of deceptions current in the debate over doctors in Australia. Unfortunately, some of these are expressed in your editorial of 16 July 2001.1You fail to acknowledge there are two classes of doctors, as has been the case in Australia for decades — consultants (the princes), doing very well, and general practitioners (the paupers), struggling to survive. You comment that there is "a new phenomenon . . . dispirited doctors". In Australia, consultants are certainly not dispirited (they have never had it so good). However, there are dispirited GPs, who are grouping together in corporations to solve their economic and social problems. Where, Dr Van Der Weyden, have you been hiding? All of a sudden you would have us believe there is a fork in the road for GPs. In reality, there is no fork — just the steady downhill journey that has gone on for years. Instead of supporting and fighting for an increase in the insulting rates of rebate paid to GPs, you are critical of the very reasons GPs are entering the corporate structure. The statement in your editorial that received the greatest hoots of laughter from my fellow GPs was the classic remark "second, there is the challenge of general practice research and education, which has received little attention in the corporatisation debate". Research has never received attention in general practice, and was certainly not a concern before the move to corporatisation. As you yourself have stated, GPs received a mere 1.6% of the National Health and Medical Research Council's research projects over the years 1996 to 2000. Certainly, such lack of funding has stifled what should have been a rich and flourishing research culture, but what has been done about it? Percy S Rodgers General Practitioner, 2/133 Wilson Street, Brunswick, VIC 3056 Van Der Weyden MB. Australian general practice at a fork in the road: which way forward? [editorial]. Med J Aust 2001; 175: 62-63.

Percy S Rogers

Letter Australian general practice at a fork in the road: which way forward? (In reply) MJA 2001; 175: 667 In reply: Despite Rogers' views to the contrary, disillusionment and disenchantment are pan-profession phenomena. Like general practitioners, consultants are unhappy with the deteriorating hospital conditions and working environment1 that are their lot. Further, I am not moved by Rogers' worn view of the profession as "them" (specialists) and "us" (GPs). Most modern GPs consider general practice a specialty. To qualify as a specialty, a branch of medicine needs to have a unique body of knowledge and techniques which are sustained and expanded by its members. Unfortunately, general practice lags behind other specialties in these requirements.2,3 It is depressing that the call for general practice to develop and enhance its educational and research programs occasioned "the greatest hoots of laughter" from Rogers and his fellow GPs. This destructive ethos persists in general practice, to its own detriment. In my editorial,4 I suggested that the trend to corporatisation in general practice presents an opportunity to address the lack of time, lack of critical mass and lack of recognition that are barriers to effective research in this field.5 If GP corporatisation simply replicates the current culture and barriers to research on a larger scale, what is the gain? Rogers' question "what has been done about it [research]?" reflects a passive approach — "important, but not my problem", "someone should do it, but not me". Unless research and education become the business of every GP, general practice as a specialty is in danger of disintegrating into multiple craft groups, not necesarily medically based. Such a development is certainly not a cause for hoots of laughter. Martin B Van Der Weyden Editor, The Medical Journal of Australia, Private Bag 901, North Sydney, NSW 2059. Perkins RJ, Petrie KJ, Alley PG, et al. Health service reform: the perceptions of medical specialists in Australia (NSW), the United Kingdom and New Zealand. Med J Aust 1977; 167: 201-204. Van Der Weyden MB. Promoting an evidence base for general practice [editorial]. Med J Aust 1999; 171: 60-61. McAvoy B. General practice research. Aust Fam Physician 2001; 30: 175-176. Van Der Weyden MB. Australian general practice at a fork in the road: which way forward? [editorial]. Med J Aust 2001; 175: 62-63. Kljakovic M. Flourishing research in academic general practice. NZ Fam Physician 1998; 25: 35-40. Make a comment

Martin Van Der Weyden

Letter Economy class syndrome: a forgotten lesson MJA 2001; 175: 669-670 To the Editor: The editorial by Gallus and Baker,1 and subsequent correspondence which speculated about prolonged calf pressure contributing to causing deep vein thrombosis,2 reminded me of an undergraduate lecture in 1948 about pulmonary embolism in people who slept in deck chairs in London air raid shelters during World War II. This lecture was given by Simpson, then a lecturer in forensic medicine (and later a respected authority in this specialty), who reported a significant increase in deaths from pulmonary embolism (to 24) in September and October 1940, soon after serious night air-attacks on London began.3 This compared with only four in September and October 1939. Twenty-one of these 24 deaths occurred in, or soon after leaving, air raid shelters. The pople who died were mostly elderly, obese and often had varicosities of the leg veins. A typical case was that of an overweight, 60-year-old woman who complained of numb legs and swollen ankles after sitting for 10 hours in a deck chair — she dropped dead in the street while walking home, eight minutes after leaving the shelter. Autopsy showed multiple small pulmonary embolisms and small tags of very fresh antemortem clot in the tibial veins. Simpson concluded that the process was mainly mechanical (calf compression causing obstruction, stasis, oedema and thrombosis), as sleeping in deck chairs causes compression of calf veins against the front edge of the chair for many hours. He proposed that people in air raid shelters should therefore be given provision for lying down. Indeed, by the time his letter was published, in December 1940, he noted that the number of cases of fatal pulmonary embolism were already decreasing, coinciding with the provision of bunks in the shelters. Stasis remains the precipitating factor in Virchow's triad of thrombus formation (abnormal blood flow [stasis], endothelial injury and hypercoagulability). Venous flow rate while lying down slows to half on standing and a third on sitting,4 even before calf compression is added. In 1940, civil authorities acknowledged the cause of an excess of cases of fatal pulmonary embolism and preventive measures were implemented, with documented success within two months. In 1954, Homans reported venous thromboembolism "probably due to sitting travel" by air and car.5 In 1988, calf pressure in cramped seating was blamed by the originators of the popular but restrictive term "economy class syndrome".6 In the 1990s, and in relation to the 2000 Olympic Games, a host of cases of flight-related pulmonary embolism were reported.1 But, in 2001, it seems the evidence for a causative effect must still be considered "circumstantial".1 Lloyd K Morgan Retired General Practitioner, PO Box 150, Lorne, VIC 3232 Gallus AS, Baker RI. Economy class syndrome [editorial]. Med J Aust 2001; 174: 264-265. Slonim L. Economy class syndrome Med J Aust 2001; 175: 176 Simpson K. Shelter deaths from pulmonary embolism. Lancet 1940; 2: 744. Ferrari E, Chevallier T, Chapelier A, Baudouy M. Travel as a risk factor for thromboembolic disease: a case-control study. Chest 1999; 115: 440-444. Homans J. Thrombosis of the deep leg veins due to prolonged sitting. N Engl J Med 1954; 250: 148-149. Cruickshank JM, Gorlin R, Jannett B. Economy class syndrome. Lancet 1988; 2: 497-498. Make a comment

Lloyd K Morgan

Letter Taenia solium and neurocysticercosis MJA 2001; 175: 670-671 To the Editor: A 37-year-old Australian-born white woman presented on Christmas eve with a focal seizure with secondary generalisation. This had developed on a background of bifrontal headaches for which she had been taking ibuprofen. She was in otherwise good health, with no previous history of seizures, head injury or meningitis. On examination there were no focal neurological signs. Fundoscopy findings were normal. Computed tomography (CT) of the brain showed a small contrast-enhancing lesion, radiologically suggestive of a brain tumour. Therapy with phenytoin and dexamethasone was started, and she was referred for neurosurgical assessment. A magnetic resonance imaging (MRI) scan showed an 8 x 12 mm-enhancing nodule in the right posterior frontal cortex with surrounding oedema (Figure). She underwent excisional biopsy of the lesion, and histopathological examination showed a cysticercus cyst, the encysted larval form of Taenia solium, associated with an intense surrounding inflammatory reaction. Further questioning of the patient revealed that she was a frequent visitor to South-East Asia, where this organism is endemic in some areas.1,2 She remains well and seizure-free at follow-up. T. solium (pork tapeworm) is associated with two distinct infective states in humans: asymptomatic intestinal infection by an adult tapeworm, and cysticercosis, which is associated with clinical disease. Ingestion of eggs in contaminated food or water by an intermediate host, typically pigs but sometimes humans, leads to the development of cysticercosis, as seen in our patient. Humans acquire intestinal infection with the adult tapeworm by ingesting encysted larvae (cysticerci) in undercooked meat.1-3 Epilepsy is the most common presentation.1,2,4 The findings of cysticerci outside the central nervous system (such as in the posterior chamber of the eye, palpable within subcutaneous tissues, or as calcified nodules on plain x-rays) and the detection of anticysticercal antibodies in plasma or cerebrospinal fluid may assist in diagnosis of neurocysticercosis, and subsequently prevent unnecessary neurosurgery. However, patients with a single cerebral lesion or those with only calcified lesions are commonly seronegative.1-3 Stool examination for tapeworm eggs is insensitive, but may identify patients with intestinal infection.2 Whether treatment with praziquantel or albendazole improves long term outcome remains controversial.2,5 In cases of encephalitis, subarachnoid, spinal or ocular involvement, symptoms may worsen secondary to an inflammatory reaction around degenerating cysts. Co-administration of corticosteroids ameliorates some of this effect. Surgical treatment is reserved for patients with hydrocephalus.1-3 Neurocysticercosis is uncommon in Australia.5 Our case reminds us of the risks of infective diseases posed to travellers and migrants. It also highlights the importance of considering infective causes such as cysticerci, bacterial abscesses, toxoplasmosis and cryptococcomas in the differential diagnosis of space-occupying lesions seen on central nervous system imaging. Anthony T Zimmermann,* William S Jeffries † * General Medicine Advanced Trainee, Repatriation General Hospital, Daws Road, Daw Park, SA, 5041 † General Physician, Lyell McEwin Hospital, Elizabeth, SA atzimmATausdoctors.net Garcia HH, Del Brutto OH. Taenia solium cysticercosis. Infect Dis Clin North Am 2000; 14: 97-119. Garg RK. Neurocysticercosis. Postgrad Med J 1998; 74: 321-326. Pluschke M, Bennett G. Orbital cysticercosis. Aust N Z J Ophthalmol 1998; 26: 333-336. White AC Jr. Neurocysticercosis: a major cause of neurological disease worldwide. Clin Infect Dis 1997; 24: 101-115. Hellard ME, Street AC, Johnson PDR, et al. Detection of an aberrant motile larval form in the brain of a patient with neurocysticercosis. Clin Infect Dis 1998; 27: 391-393. Make a comment Magnetic resonance imaging (MRI) scan of the patient's brain MRI scan: axial section, T1-weighted image with intravenous contrast. Lesion clearly visible. Back to text

Anthony T Zimmermann · William S Jeffries

Letter Eye exposure to squashed spiders MJA 2001; 175: 671 To the Editor: I read with great interest the letter from Isbister and Balit describing ocular reactions to squashed daddy longlegs spiders.1 As an arachnophile, I think it is a great pity that people go around squashing these harmless beasts that are very efficient at catching and eating real pests such as mosquitoes and flies. Living in a house that is well populated with daddy longlegs, I would like to enlighten readers on my own method of removing these harmless spiders from the house without harming either myself or the spider. This is the "open fist" method. The spider can be easily caught by placing the hand over and around the spider, leaving a small amount of space in the "open fist". It can then be removed from the house and released into the garden. I have used this method successfully on at least 20 occasions without suffering any bite or reaction. Long live daddy longlegs! John E Stuart Paediatrician, John Hunter Children's Hospital, Locked Bag 1, Hunter Mail Centre, NSW 2310. jstuartATdoh.health.nsw.gov.au Isbister GK, Balit C. Eye exposure to squashed spiders [letter]. Med J Aust 2001; 175: 391-392. Make a comment

John E Stuart

MJA 2001; 175: 672 To the Editor: In these days of increasing globalisation of medicine, it is refreshing to realise that there are some uniquely antipodean case scenarios. I wish to report two patients who presented to the emergency department with multiple injuries caused by a single kangaroo. Although there have been previous reports of kangaroos causing injury, this is usually in the passive capacity as an immovable obstruction to a moving vehicle.1 I do not believe there have been any reports of a single kangaroo causing injury to two people at the same time by actively inflicting injury, resulting in a need for hospital treatment. Patient 1: A 32-year-old man intervened in a fight between his dog and a grey kangaroo. The dog escaped, but the kangaroo then turned on the man, inflicting several deep abrasions to his chest, trunk and back, and a bite to his left forearm. X-rays revealed no underlying fractures, and the skin abrasions were treated conservatively. Prophylactic antibiotics and a tetanus booster were administered, and the patient was discharged. Patient 2: While driving past, a 50-year-old man saw the attack described above. He stopped to assist, and grabbed the tail of the kangaroo to distract its attention. The man was thrown to the ground, and sustained bruising to the right shoulder and upper arm. X-rays revealed no fracture, but the arm was immobilised in a sling for symptomatic relief of pain. The kangaroo escaped without injury. These two cases should serve as a warning that intervening in fights between animals poses the risk of injury, and that one kangaroo is easily capable of injuring two humans at the same time. Caution is required if approaching these animals in the wild. Alan E O'Connor Emergency Physician, Emergency Department, The Canberra Hospital, Yamba Drive, Woden, ACT 2606 Alan. O'ConnorATact.gov.au Whittle IR. Beware of boomerangs and kangaroos. Med J Aust 1980; 2: 347. Make a comment

Alan E O'Connor

Letter Improving the treatment of leg ulcers MJA 2001; 175: 670 To the Editor: The article by McMullin emphasises the importance of compression in the treatment of ulcers.1 External pressure equal to that inside the veins will collapse varicosities, which can easily be seen by standing in a swimming pool with water up to the chest. As one cannot spend one's life standing in a pool, it seemed to me that there should be some way of duplicating this in a more convenient form. After some experimentation, I have found a reasonably easy way is to use two sphygmomanometer cuffs, with the tubes connected by suitable plastic tubing, and containing enough water to about 3/4 fill one of the bladders. An insert is put in the canvas of one, to enable it to be worn around the waist (theoretically it should be at the height of the heart, but in practice there seems little difference if it is worn at waist height), and the other is wrapped around the ankle with the ulcer (see Box). The leg cuff is applied first, while still empty, over whatever dressing is preferred on the ulcer, and maybe a layer of cotton wool, as the cuff material can be rather coarse. Then the waist cuff is put on; this contains the water, which can be felt running down and expanding the lower cuff. The importance is that the pressure exerted will balance that in the veins, cannot exceed this, and will vary according to whether one is standing, sitting, or lying down, when water will run back into the upper cuff. As an ophthalmologist I don't get to treat many people with leg ulcers, but I have had vein problems myself for a number of years, with periodic small ulcers, none of which have ever grown to any size, and have healed in four weeks, most in rather less time, with the above management. Obviously, I don't claim it will cure everyone, but it does provide a more scientific pressure which is equal all round the leg, and balances the venous pressure at all times. In my case the pressure, when standing, works out at 66 mm Hg. Even if there is arterial insufficiency, the pressure is only that which is in the veins. No doubt, a purpose-made appliance which is easier to apply and covers a larger area could be produced. Graeme W Johnson Ophthalmologist, 4th Floor, 39 East Esplanade, Manly, NSW 2095. grapamATnsw.bigpond.net.au McMullin GM. Improving the treatment of leg ulcers. Med J Aust 2001; 175: 375-378. Make a comment Device for applying appropriate and even pressure in the management of leg ulcers A: The two connected sphygmomanometer cuffs, one extended to allow it to fit around the waist. B: The device as it is worn. Back to text

Graeme W Johnson

Letters What a louse! MJA 2000; 173: 603

Paul Prociv

Letter A possible case of intestinal myiasis due to Eristalis tenax MJA 2000; 173: 652 To the Editor: A 42-year-old woman living in rural South Australia presented with a history of passing actively swimming "fish-like creatures" with her stool. There were no other symptoms (apart from a sense of revulsion). Specimens brought in by the patient were cylindrical larvae about 2.5 cm long with a "tail". Based on the characteristic morphology, they were identified by our local pathologist as "rat-tailed maggots", or larvae of the introduced drone fly (Eristalis tenax). The patient saw one to three of the larvae on about five occasions over a 2-week period, whereupon they spontaneously ceased to occur. She remained asymptomatic. There was nothing to suggest that the patient had a low standard of hygiene. The specimen, apparently passed with stool, was identified as a "rat-tailed maggot", or larva of the introduced drone fly (Eristalis tenax). Infestation of live humans or vertebrate animals with larvae of Diptera (fly) species is known as myiasis -- for part of their life cycle, the larvae feed on dead or living tissue or the ingested food of the host.1 Pseudomyiasis is the term used for deposition of maggots on faeces immediately after they are passed. Recognition of dead larvae in stool also comes into this category, as host infestation has not been established. A few patients with intestinal myiasis with drone fly larvae have been described previously, with the mode of infestation presumed to be consumption of water or food contaminated with fly larvae or eggs.2,3,5 Life stages of Eristalis tenax: (a) larva; (b) pupa; and (c) adult fly. The rat-tailed maggot usually breeds in drains, sewage pools, and other stagnant water. Although the larvae live on decaying organic matter, they must breathe air. For this, the breathing tube (the tail) is extended or contracted depending on the depth of the liquid in which they are feeding. Our patient had a septic toilet system. It is possible that the maggots could have bred in the tank and travelled upstream to the toilet bowl. The tank, however, was 10 metres away and appeared normal when opened and inspected, and no other family members noted the maggots in their stool. Doubts have been expressed about the theory that accidentally ingested fly larvae could survive in the environment of the gastrointestinal tract. Zumpt proposed an alternative kind of intestinal myiasis due to Eristalis tenax called "rectal myiasis".1 Flies, attracted to faeces, may deposit their eggs or larvae near or into the anus, and the larvae then penetrate further into the rectum. The larvae may then feed on faeces at this site, as long as the breathing tube reaches towards the anus. Although our patient had no symptoms, anal pruritus or discomfort has been described in other reports.4,5 Phillip B Whish-Wilson General practitioner PO Box 1118 Mount Barker, SA 5251 Zumpt F. The problem of intestinal myiasis in humans. S Afr Med J 1963; 37: 305-307. Lakshminarayana CS, Kanchana MV, Janakavalli R, Mallika M. Intestinal myiasis due to Eristalis tenax. J Indian Med Assoc 1975; 65: 234-235. Aguilera A, Cid A, Regueiro JM, et al. Intestinal myiasis caused by Eristalis tenax (letter). J Clin Microbiol 1999; 37: 3082. Hall MC. A note regarding myiasis, especially that due to syrphid larvae. Arch Intern Med 1918; 21: 309-312. Cookson HA, Oldroyd H. Intestinal infestation by larvae of a drone fly. Lancet 1937; 2: 804.

Phillip B Whish-Wilson

Letters Chromomycosis MJA 2000; 173: 656 To the Editor: A 38-year-old man presented with a hyperkeratotic, crusting lesion on his right knee which had been present for 17 years and had not responded to treatment (Box 1). The lesion developed in 1983 after he knelt on wood chips while cutting wood in scrub country to the west of Mackay in Queensland. The lesion had slowly increased in size and persisted despite various attempts at therapy. When it was about 1 cm in diameter, local excision was offered, but, as the surgeon was not able to guarantee the lesion would not recur, excision was not performed. In January 1996 a biopsy was taken. The report read "pseudoepitheliomatous hyperplasia" of the epidermis. In the dermis there was a "granulomatous inflammatory reaction in which there were collections of pigmented yeast bodies". The histological diagnosis was chromomycosis (chromoblastomycosis) (Box 2). Chromomycosis organisms are round, thick-walled brown cells, 5-12 mm in diameter, usually occurring in dermal microabscesses. After one month's culture, Cladophialophora carrionii (also known as Cladosporium carrionii) was isolated. By 1999, when the patient presented, he had been treated sequentially, without success, with ketoconazole (200 mg daily for six months), fluorocytosine (dose unknown) and terbinafine (250 mg daily). In October 1999, he was given itraconazole 100 mg daily. This dose was increased to 100 mg twice daily in November 1999 and was continued until May 2000, by which time the total dose of itraconazole administered was 54 g. (The patient was 179 cm tall and weighed 114 kg.) The drug has been well tolerated, with no abnormality of blood film or liver function. There has been a slow but steady healing of the knee lesion (Box 3). Chromomycosis (chromoblastomycosis) is a chronic mycotic infection of the cutaneous and subcutaneous tissues. It is diagnosed by the presence in the tissue of phaeoid (Greek phaeios, "dusky") muriform cells and by isolation and identification of the pathogenic fungus. The muriform cells represent an intermediate vegetative fungal form arrested between yeast and hyphal development. The dusky colour of these muriform cells results from a melanin pigment.1 The lesions produced by the infection are nodulo-verrucous. The fungal genera that can cause this infection (Cladophialophora, Fonsecaea, Phialophora, Rhinocladiella) live as saprophytes in soil and in decaying wood and vegetation. Infection is caused by inoculation, but the injury may be so minor as to go unnoticed and may have occurred years before the slow-growing lesion is noticed. It occurs most commonly on the feet or legs, but, in Australia, the upper limbs are more commonly involved. Cladophialophora carrionii infection is a common cause of chromoblastomycosis and, although the infection can be contracted from many environments, it is particularly prevalent in arid and semi-arid areas, most often in tropical and subtropical zones. It has been reported from North, Central and South America, Cuba, Jamaica, Martinique and many other countries, including India, South Africa, and Madagascar, as well as Australia and Northern Europe. It has occurred as an imported infection in the United Kingdom.2 Chromoblastomycosis is frustratingly difficult to treat, but it is becoming increasingly evident that itraconazole is the treatment of choice, at least for infections with Cladophialophora spp., partly because itraconazole accumulates in the skin and subcutaneous tissues owing to its lipophilicity.3 In adults the dose of itraconazole is 200 mg or more per day for as long as required (the dose is continued for a period two to three times longer than that required to obtain negative culture results).4 George R Crowe Plenary Physician, Pioneer Valley Private Hospital PO Box 8877, Mount Pleasant, QLD 4740 Michael Martin Pathologist, Central Queensland Pathology Laboratory Mackay, QLD Acknowledgements: Dr Brian Reid, Dermatologist, Townsville; Dr Andrew O'Neill, Mackay; Mr John Atkinson, Librarian, Mackay Base Hospital; and Ann James, Janssen-Cilag Australia. Guerrant RL, Walker DH, Weller PF. Tropical infectious diseases: priciples, pathogens and practice. London: Churchill Livingstone, 1999: 621-623. Champion RH, Burton JL, Ebling FJG. Textbook of dermatology. 5th ed. Oxford: Blackwell Scientific Publications, 1992: 1205-1206. Strickland GT. Hunter's tropical medicine. 8th ed. Philadephia: WB Saunders, 1999: 573. Borelli D. A clinical trial of itraconazole in the treatment of deep mycoses and leishmaniasis. Rev Infect Dis 1987; 9 Suppl 1: S57-S63. 1: The lesion The lesion on the knee when the patient presented in 1999. The lesion first developed in 1983 after the patient knelt on wood chips. Back to text 2: Chromomycosis organisms Photomicrograph (haematoxylin-eosin, original magnification x400) of skin biopsy in 1996, showing two Cladophialophora spores in a microabscess (arrow). Back to text 3: Healing after 17 years Treatment with itraconazole in late 1999 resulted in steady healing of the lesion. Back to text

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