Letters

To the Editor:With the release of the 2017 Australia’s Health Tracker by Socio-economic Status1 comes the latest evidence of an unjust health divide in Australia. With few exceptions, people who are more socially disadvantaged have worse health than their advantaged counterparts — a paradigm known as the social gradient of health.1 Despite increased need, socially disadvantaged individuals are less likely to access health care compared with advantaged people.2 It was refreshing, therefore, to read that the federal Shadow Minister for Health and Medicare Catherine King has placed health inequities front and centre of the Australian Labor Party health strategy, highlighting the importance of equitable prevention and public health and pledging to reduce the inequities in access to health care.3 Only 1.3% of the total Australian health expenditure is dedicated to the prevention of non-communicable diseases, much of which is directed at behavioural factors, including physical inactivity, poor diet and smoking1 — all of which are known to influence non-communicable diseases, such as diabetes, cardiovascular disease and osteoporosis.4 However, focusing primarily on behaviour ignores the wider context of health problems: the social, economic and cultural factors influencing that behaviour.5 The mounting costs of living and insecure employment increase vulnerability to non-communicable diseases. Improving the availability of affordable housing, quality employment and educational opportunities may better serve individuals at the economic margins, thereby addressing the stark inequities observed between advantaged and disadvantaged people. Dealing with these inequities would achieve discrete sectoral and health goals, providing cost-effective intersectoral cobenefits. What then is the role, for example, of the employment or educational sectors in driving the policies that address the socio-economic conditions which ultimately contribute to a healthy Australia? What is role for the health sector? The Department of Health could play a stewardship role, supporting and enabling other government agencies to manage their own sectoral goals while positively influencing health outcomes. Dealing with health inequities requires an intersectoral approach, a long term view, courageous leadership at the highest executive level, and support by an empowered public sector based on principles of fairness. Australia must act on social determinants of health and address this major problem for the health of our society.

Sharon L Brennan-Olsen · Sharon Friel

To the Editor:We read with interest the recent position statement on the management of non-neurogenic overactive bladder (OAB) published in the Journal.1 This considered statement reflects recent guidelines from national and international urological societies, including the American Urological Association, the European Association of Urology, the International Continence Society, the Urological Society of Australia and New Zealand and the UroGynaecological Society of Australasia. In recognition of the often repeated phrase in urological research “the bladder is an unreliable witness”, there has been an increasing emphasis on addressing factors beyond the bladder when managing patients with OAB and lower urinary tract symptoms (LUTS).2 The authors of the MJA statement deal with this issue more than most by encouraging their readers to be mindful of known OAB risk factors and comorbid conditions. However, one condition in particular, obstructive sleep apnea (OSA), continues to be overlooked in the diagnosis and management of OAB and LUTS. Our group has previously shown a substantial burden of undiagnosed OSA in a large sample of community-based men aged 40 years and over, with 53% of men without prior diagnosis shown to have some degree of OSA, of which 14% and 12% were found to have moderate and severe OSA, respectively.3 We also demonstrated an independent association between nocturia — the most frequent and bothersome of the OAB symptoms2 — and the presence of moderate to severe OSA, with such men showing a 52% adjusted risk increase for the presence of nocturia.3 Recent systematic reviews of continuous positive airway pressure in the treatment of nocturia indicated a mean standardised difference of −2.28 episodes per night (95% confidence interval, −2.42 to −2.15) between treatment groups in patients with nocturia.4 This difference is comparable to the efficacy observed with frontline treatments for this condition. Nocturia and other OAB symptoms are also known to be sentinel markers of cardiovascular disease,5 providing further motivation for dealing with known risk factors, such as OSA, in the management of OAB. We believe that it would be helpful to include recommendations to assess for the presence of OSA in patients presenting with nocturia, either alone or in combination with other OAB-related symptoms.

Sean A Martin · Nicholas R Brook · Gary A Wittert

In reply

Eric Chung

To the Editor: I write to comment on the Perspective by Wolfenden and colleagues1 on e-cigarette use by young people. In the article, the authors make regulatory recommendations for e-cigarettes based on the assertion that vaping causes young people to take up smoking — the so-called gateway theory. However, while many studies have found that adolescents who try vaping are more likely to try smoking, there is no evidence of cause and effect. The longitudinal studies described only show an association and are unable to demonstrate causality.2 An alternative explanation is common liability; that is, that young people who are more attracted to experimentation are more likely to try both products. In fact, international reviews suggest that vaping is diverting adolescents away from smoking and reducing smoking rates.3 As vaping rates have been increasing in young people, smoking rates are rapidly declining — a finding inconsistent with a gateway effect. Real world studies show that most vaping by young people is experimental and short lived and only a minority use nicotine. Regular vaping among teens is almost exclusively confined to those who already smoke. A recent analysis of five national surveys in the United Kingdom of 60 000 adolescents found that regular vaping by never-smoking 11–16-year-olds was 0.1–0.5%.4 Perhaps most important of all, Wolfenden and colleagues1 dismiss the substantial public health benefit that could result from vaping. Population studies have indicated that millions of smokers have quit using e-cigarettes and modelling studies have found a substantial net public health benefit, even using pessimistic scenarios.5 Banning wider access to e-cigarettes on the basis of an unproven risk to adolescents would prevent access to a life-saving quitting aid for millions of smokers. A better solution is to employ strategies to minimise youth access and make vaping available for adult smokers who are otherwise unable to quit smoking with conventional therapies.

Colin P Mendelsohn

To the Editor: Wolfenden and colleagues1 fail to justify the ban on the sale of nicotine-containing e-cigarettes in Australia and do not address the supporting arguments for allowing smokers to access these products.2,3 The concern that e-cigarettes may recruit young smokers justifies a regulatory response but not a ban on sales of nicotine-containing e-cigarettes to adults,3 who are thereby prevented from using these products. The authors cite a meta-analysis of studies that showed an association between the past 30-day use of e-cigarettes and combustible cigarettes;4 however, they ignore the weaknesses in the studies. First, most studies defined an adolescent e-cigarette user or cigarette smoker as one who had used either product in the past 30 days. These studies do not show that adolescents who used e-cigarettes were more likely to become daily smokers than their peers who did not use them. Second, the studies had substantial subject attrition (more than 30% in four out of nine studies) and they often poorly controlled for a shared liability to use drugs. The association was weakest in the largest and best controlled study.5 In addition, Wolfenden and colleagues make no mention of the steep decline in youth smoking rates that has occurred in both the United Kingdom and the United Sates while vaping has increased among young people.5,6 Nor do they mention that the UK’s smoking prevalence is now the same as Australia’s, in the absence of plain packaging or high tobacco tax.6 The authors’ claim that a relaxation of the ban on e-cigarette sales in Australia “has the potential for unintended harm” ignores the direct harms caused by the current ban; for example, the unregulated use of e-cigarettes, a black market, and the criminalisation of e-cigarettes users.6 Finally, even if the evidence for a gateway effect were accepted, it would, at most, justify a tighter regulation of e-cigarettes; it does not justify a prohibition on adult e-cigarette use. If it did, we would be morally obliged to prohibit the sale of cigarettes to smokers because on their argument this would be the most effective way of preventing adolescents from smoking cigarettes.

Wayne D Hall

In reply

Sze Lin Yoong · Emily Stockings · Luke Wolfenden

To the Editor:There are some populations for whom unequal health cannot be overcome and a preoccupation with preserving health detrimentally affects their quality of life.1 Imagine you live in residential aged care, your health is irreversibly poor and you have days left to live. You want to go for a walk in the sunshine, but are prevented from doing so in case you fall and harm yourself. Your health cannot improve; yet, you are denied the opportunity to enjoy life. Quality of life is influenced by health, as well as social support, autonomy and spiritual fulfilment.2 Society encourages younger people to take risks to fulfil their potential and enjoy life; however, we prevent older people from doing the same. By denying this population the “dignity of risk”,3 we are denying them an opportunity to optimise their quality of life. This optimisation requires recognising that focusing on inequality in health will not always overcome an unequal quality of life, especially for vulnerable older people. Most residents of aged care facilities have multiple comorbidities contributing to poorer health, but this need not equate to a suboptimal quality of life. The goal should be to enable older people to enjoy their life by supporting them to fulfil their potential. People with a similar stage of dementia who live at home report a higher quality of life than those in residential aged care.4 Living at home provides greater independence, illustrating the importance of considering a multifaceted quality of life. If professionals focus only on improving health and not all factors contributing to quality of life, then inadvertently, neither health nor quality of life will improve. Enabling individuals to make choices, even those with a risk of harm, is a pathway to improving quality of life for everyone, including people with irreversible poor health.

Alice L Holmes · Marta H Woolford · Joseph E Ibrahim

To the Editor:A 49-year-old man, with a history of occasional red eye self-treated with over-the-counter naphazoline eye drops, accidentally self-administered a drop of “fibreglass resin catalyst”, containing concentrated (approximately 33%) methyl ethyl ketone peroxide (MEKP), to his left eye. The MEKP bottle was purchased at a local hardware store. The patient had previously placed the MEKP bottle on his bedside table and mistook it for his regular eye drops the following morning. Upon instillation, he felt immediate pain and irrigated his eye with water at home before presenting to the emergency department (ED). After appropriate ED irrigation and treatment, he was managed in the hospital’s ophthalmology department. After 13 days, his cornea had healed and his vision had returned to normal. However, there was residual evidence of limbal ischaemia — a poor prognostic sign in ocular chemical injuries.1,2 Ocular chemical injuries are a major source of preventable morbidity and blindness. Strongly oxidative compounds, such as MEKP, especially at high concentrations, cause rapid oxidative damage to corneal epithelium leading to cell death.3 MEKP in particular has been associated with long term symptoms and ocular surface dysfunction in patients who delay primary irrigation.4 The injury reported herein was particularly deleterious as it involved the direct administration of MEKP to the eye, because the patient mistook it for his regular eye drops (Box). This confusion was due to the similar packaging of MEKP to many common eye drops used in ophthalmology. Similar injuries have been reported previously in the literature4 in patients who mistook MEKP for their regular eye drops. Often, patients’ underlying vision is poor, making it difficult for them to differentiate the products without careful inspection.4,5 Packaging MEKP in this medically familiar format poses a significant danger to the general public. We urge manufacturers to reconsider the presentation of this product by obvious colouring of the entire bottle (eg, bright orange with a black lid) so it is impossible to mistake MEKP for regular eye drops. Such a change could significantly reduce the number of preventable vision-threatening injuries sustained in this manner. Box – Package similarity between naphazoline eye drops (left) and methyl ethyl ketone peroxide (right) bottles

Richard T Parker · Dominic P McCall · Chameen Samarawickrama

To the Editor: Carey and colleagues are to be applauded for drawing attention to the potential impacts of extreme hot weather on the health of vulnerable groups in the community, particularly older people.1 However, in addition to the public health effects they covered, it is important to highlight the health impacts of high ambient temperature on Australian workers. The working population, ranging widely in age, is subject to many of the factors described in the article that influence vulnerability to heat illness, including chronic diseases and medications used to manage these. In addition, workers are often exposed to other heat stress factors, such as requirements to wear restrictive, impermeable personal protective clothing or to operate heavy machinery. Occupational circumstances may limit opportunity for acclimatisation, rest breaks, maintenance of adequate hydration or access to assistance if heat illness arises. A growing body of evidence shows associations between high ambient temperature and the risk of work-related injury.2,3 Importantly, this increased risk is not just observed among outdoor workers. Studies set in Adelaide2 and Melbourne3 have identified young workers (< 25 years of age) and male workers as being at increased risk of injury in association with increasing ambient daytime temperatures. Associations have also been observed between daily maximum temperature and risk of injury for workers engaged in occupations with the heaviest physical strength requirements (such as plumbers, paramedics and bricklayers).3 Moreover, a relationship has been observed between overnight temperatures and risk of injury for younger workers and female workers.3 In spite of climate projections for more frequent hot days and more severe heatwaves, there is currently a lack of specific and consistent policy and guidance targeting the work-related health impacts of hot weather.4 It is important that the health of workers and factors that influence their vulnerability to injury and illness are included in heat health discussions and are considered in the development of adaptive strategies.

Judith A McInnes · Peter Smith · Malcolm R Sim

In reply

Marion G Carey · Mark P Monaghan

To the Editor:Ahern and colleagues1 explore the potential benefits and pitfalls of benchmarked reporting in the Australian context. As a binational registry of patients on renal replacement therapy in Australia and New Zealand, the Australia and New Zealand Dialysis and Transplant Registry has been producing and distributing centre-specific performance reports to renal units for over 20 years; these share many of the challenges faced by clinician-level reporting. In the past few years, this has extended to provision of an abridged version of the report on our website, containing unit-specific risk-adjusted outcome data for each dialysis and transplant unit (http://www.anzdata.org.au/v1/hospitalreport.html). The authors highlight the challenges of low case numbers resulting in statistical models that are underpowered to detect poor performance and require long observation periods that will limit timely detection of outliers and opportunities for remedial action. Co-opting statistical techniques used for quality control in other industries may present an opportunity to address these issues in the health care sector. Cumulative sum control charts2 provide a method for sequentially monitoring cumulative performance over time, which may permit early detection of poor performance and account for varying activity levels by including the number of procedures performed, rather than just a fixed time frame. Similarly, Bayesian approaches that involve updating prior probability distributions within a dynamic model may address these concerns3 and offer the conceptual advantage of explicitly testing not just the statistical difference from average but the likelihood of performance falling into a defined poor performance category. Finally, there are systems that use differing criteria for smaller and larger units.4 Ahern and colleagues discuss the potential consequences of poor performance, but omit any reference to exactly who should oversee this process. We assert that the relevant specialty or subspecialty body has a crucial role in overseeing the interpretation of reports. The detection of an outlier is dependent on the nature of the boundaries set for acceptable performance, and the vulnerability of the statistical adjustment model to bias and unmeasured confounders. Such interpretation requires detailed knowledge of the relevant field, an appreciation of the variation between centres, and substantial epidemiological knowledge.

Matthew P Sypek · Matthew D Jose · Stephen P McDonald

In reply

Susannah Ahern · Sue M Evans · Ingrid Hopper · Arul Earnest

To the Editor:We thank Rakhra and colleagues,1 whose report highlighted a group of potential donors yet to be fully exploited for organ transplantation. While this untapped potential appears to largely affect kidney and lung donor pools, we must not exclude the effect that relaxing donor suitability criteria may have on the heart. While not largely emphasised, the data collected for the heart are compelling, particularly for an organ so susceptible to ischaemic injury. Similar to the kidney and lungs, the data show that when including ideal and expanded criteria, potential donors more than doubled the number of donor hearts available for heart transplantation.1 This is an important finding, particularly if the authors have conservatively underestimated the actual potential for organ donation. In Australia, donation after circulatory death (DCD) kidney and lung donors comprise 25–30% of the total donor pool for these organs.2,3 Since 2014, the number of national and international hospitals now investigating DCD heart donation has increased, and we anticipate that DCD heart transplantation will follow the same trend as DCD lung and kidney transplant over time. The Critical Care Research Group at the Prince Charles Hospital has developed a clinically relevant 24-hour ovine model of brain stem death,4 and these donor hearts are being used to transplant into recipient animals. Transplant clinicians and researchers from the Prince Charles Hospital, the Alfred Hospital and St Vincent’s Hospital will collaboratively employ an ex vivo hypothermic perfusion system, capable of safely storing animal hearts up to 24 hours,5 together with novel cardioprotective therapeutics to increase the allowable ischaemic times for donor hearts without impairing graft function. This technology will hopefully extend to DCD donors in the future, which are currently only preserved using a warm blood perfusion system. By relaxing donor heart suitability criteria, and using novel machine perfusion technology to increase the storage time of the donor heart,5 thus eliminating time and travel distance constraints in Australia, the donor heart pool could be greatly increased. While the numbers may ultimately be modest, the positive effect on those recipients would be substantial.

Louise E See Hoe · David McGiffin · John F Fraser

To the Editor:In October 2016, we achieved the eradication and control of hepatitis C virus (HCV) in a New South Wales correctional centre, which we believe to be a first of its kind in NSW. HCV prevalence in NSW prisons is 30–40 times higher than in the community, where prevalence is about 1%.1,2 Elevated risk of HCV infection is associated with the high proportion of prisoners who have injected drugs, the rate of injecting in prison, and restricted or limited access to bleach and needle and syringe programs.3 The Justice Health and Forensic Mental Health Network (the Network) is responsible for health care in the NSW forensic mental health and criminal justice systems. The availability of direct-acting antivirals on the Pharmaceutical Benefits Scheme in March 20164 created an opportunity for the Network to cure all patients with HCV infection in one prison. The Compulsory Drug Treatment Program (CDTP) is run at the Compulsory Drug Treatment Correctional Centre — a stand-alone prison with a stable sentenced inmate population, where patients with repeat drug-related charges participate in comprehensive drug treatment and rehabilitation. Patients at this correctional centre have longer sentences than those in other centres, which allowed for the full course of treatment. The Network, Corrective Services NSW and Hepatitis NSW formed a partnership to ensure that patients were able to access health centres, have their medication scripted and administered, could undertake monitoring and were supported through the Network’s established nurse-led model of care.5 All 58 patients in the CDTP were offered screening, and 54 patients with risk factors were screened; of these, 18 patients had chronic HCV infection. After further work-up, including liver elastography to measure fibrosis, all patients were concurrently commenced on treatment. Of the remaining four patients who were not screened, all had recent negative HCV pathology results. Three months after the treatment, 15 patients achieved sustained virological response equating to cure of their chronic HCV infection, and three patients were released before final assessment.6 Concurrent treatment commencement with the direct-acting antivirals was recognised as an innovative measure in reducing re-infection, in conjunction with the more common practices of harm minimisation education and use of the hospital-grade disinfectant for general cleaning purposes offered by Corrective Services NSW to all incarcerated people. Throughout the course of the project, two new patients were admitted, screened, and returned negative HCV pathology results. A proactive screening approach with patient consent was adopted to ensure that new cases were able to be identified and treated to maintain elimination. Maintaining a prison HCV-free may mean that patients have to take some responsibility with regard to sharing needles with new inmates. A peer education approach is being developed to increase patients’ ownership of a prison’s HCV-free status. The CDTP treatment model, combined with ongoing screening of new admissions, is an innovative approach for eliminating HCV, and is considered suitable for adoption in similar-sized prisons across Australia. The Network is currently rolling out this approach within NSW.

James Blogg · James Wood · Colette McGrath · Camilla Lobo

To the Editor:Your publication of a review on global approaches to antimicrobial resistance is timely.1 We especially note that antibiotic-resistant pathogens are not limited by borders, have greater impact on disadvantaged communities, and will require coordinated, high level government commitment to minimise their threat.1 In Australia, Indigenous communities bear a disproportionate burden of infectious diseases. This burden arises on a background of overcrowding, poorly built and maintained water and sanitation infrastructure, and colonisation of companion animals by human pathogens. The delivery of biomedically oriented health services leads to frequent use of broad spectrum antibiotics, promoting the development of multiresistant pathogens.2 The prominent multiresistant pathogen methicillin-resistant Staphylococcus aureus first emerged in hospitals, but, in Australia, it was soon identified in remote Indigenous communities.2 Health services have been unable to control its development and spread. As a consequence, community-acquired methicillin-resistant S. aureus is now the dominant strain of this bacterium in Central Australia, where Indigenous people are one-quarter of the population, but bear three-quarters of the S. aureus disease burden in Alice Springs Hospital.3 Primary health care is founded on full community participation and an intersectoral approach, incorporating education, housing and other sectors to complement health services.4 Housing for Indigenous communities remains inadequate, and government responses deficient, particularly in remote regions.5 As a result, even high quality health services have limited impact on Indigenous people’s health and wellbeing. Safe, secure, functioning housing that is appropriate for its occupants is a building block to manage other areas of Indigenous disadvantage.5 The deficit in appropriate housing contributes to bacterial colonisation, infection and development of antimicrobial resistance among Indigenous Australians.2 “Illness is a weapon” was intended as a metaphor for the resistance of Indigenous people to their ongoing colonisation.6 However, the threat of antibiotic resistance evolving through the neglected conditions in which some communities find themselves could make this metaphor more real than was likely intended. The spread of antibiotic-resistant pathogens in Indigenous communities and elsewhere is a global threat, which highlights the need to transform services for Indigenous people using approaches driven by communities and focused on their strengths.

Rosalie Schultz

To the Editor: Cullen and colleagues are to be congratulated on their most recent contribution to the assessment of emergency department patients presenting with possible acute coronary syndrome.1 The ability to safely reduce length of stay for a larger proportion of patients compared with the ADAPT study, pending external validation, is promising.1 The timing of the article also presents an invaluable opportunity to remind all clinicians that despite the progressive improvements in accelerated diagnostic pathways for chest pain, not all chest pain is cardiac. Accelerated diagnostic pathways, when used incorrectly, run the risk of introducing cognitive dispositions to respond such as availability bias (where a clinician may choose a diagnosis that is more familiar, such as acute coronary syndrome), omission bias (doing something easy and omitting something hard, such as ordering serial troponins instead of a computed tomography aortogram) and Sutton’s slip (settling on the most obvious interpretation of the problem).2 The potential for error is further compounded by error-producing conditions inherent in busy emergency departments, such as overcrowding, narrow time windows for assessment, surge phenomena and multiple transitions of care (eg, movement to short stay).3 It is pleasing to see that additional features were utilised in stratifying patients compared with previous accelerated diagnostic pathways.1 High-risk features such as prolonged duration and recurrence of chest pain as well as syncope may also be present in aortic dissection.4 It is possible that a patient presenting with an aortic dissection could be deemed low risk with criteria such as those in the ADAPT accelerated diagnostic pathway.5 Troponin levels do not provide a safeguard, as evidenced in a previous case where a 75-year-old woman was discharged home after two normal troponin test results only to die later the same day from progression of a type A aortic dissection.4 Aortic dissection is a lethal cardiovascular emergency that boasts significant morbidity and mortality.4 It has been astutely described as the “subarachnoid haemorrhage of chest pain”.4 Although it is rare and sometimes difficult to diagnose compared with acute coronary syndrome, clinicians are urged to include aortic dissection in their initial assessment of chest pain before implementing an accelerated diagnostic pathway.

Joe-Anthony Rotella

To the Editor: We read with interest Mendelson and colleagues’ article regarding the underutilisation of computed tomography colonography (CTC) for colorectal cancer detection in Australia.1 The authors state that “CTC is less accurate in the diagnosis of small or diminutive polyps … However, in the context of symptomatic patients, this is not relevant”.1 This overlooks the importance of detecting small adenomas as well as flat, right-sided colonic lesions such as sessile serrated polyps. It is well established that the early detection and treatment of these lesions reduces interval colorectal cancer.2 To state that these are “not relevant” in symptomatic patients is inaccurate. High definition white light with the aid of chromoendoscopy tools such as narrow band imaging in optical colonoscopy (OC) has significantly improved the ability of endoscopists to detect diminutive and subtle lesions. CTC has a markedly limited ability to detect small and flat lesions when compared with OC.3 The authors reference phase 2 data from the National Bowel Cancer Screening Program, stating that “the great majority of OCs (about nine in ten) were normal”. However, polyps were detected in 34.9% of participants.4 The authors appear to define normality as the absence of a cancer or advanced adenoma (one in ten colonoscopies). We argue that the detection of any adenoma is important and is not “normal”, as it highlights a cohort of patients at risk of colorectal cancer and requiring ongoing polyp surveillance. We also question the authors’ suggestion that a negative CTC obviates the need for OC in lower risk patients with positive faecal immunochemical test results. OC provides the opportunity to detect and treat a range of polypoid and non-polypoid colonic pathology and although a negative CTC may help exclude a cancer, it does not address the range of other potentially morbid or precancerous causes of occult faecal blood. Given these limitations, a cautious approach should be adopted if CTC is to be used as an alternative to OC in all lower risk patients.

Simon Hew · Zaid SM Ardalan

In reply

Richard M Mendelson · Tom R Sutherland · Andrew F Little

To the Editor: We commend Cohen and colleagues1 on their recently published study, which is the largest randomised controlled trial (RCT) of acupuncture in the emergency department (ED). We recently completed a systematic review and meta-analysis on the role of acupuncture for analgesia in the emergency setting.2 Our meta-analysis incorporated 19 RCTs and included non-English language publications. The trial by Cohen and colleagues1 was not published at the time of our review; however, it strengthens our main conclusion that acupuncture was non-inferior to standard analgesia in the emergency setting. We also found similar evidence of improved patient satisfaction. It was interesting that the authors reported an adverse effects rate of 51% for acupuncture, whereas our study found an overall rate of 5%, with significant adverse effects being 1%. Our figures are consistent with other reviews3 and almost certainly highlight the difficulties in developing agreed definitions on adverse effects in acupuncture. Our review found that acupuncture in two out of four RCTs decreased pain medication requirements, whereas Cohen and colleagues’ study had the potential to inform this outcome, but did not report such data. The study by Cohen and colleagues1 illustrates many of the challenges in acupuncture trials, including having no sham comparator group. Some acutely painful conditions might resolve simply because of time or careful patient attention. Sham acupuncture is difficult to deliver as a control4 and needs to be plausible, realistic and, if possible, blinded. Our meta-analysis showed acupuncture to be superior, with clinically significant reductions in acute pain scores compared with sham. This latest significant RCT gives further impetus to carefully designed research on acupuncture in the emergency setting, which will require acupuncture techniques applicable to the time-constrained ED environment (eg, ear acupuncture), provision of a suitable sham acupuncture technique, and minimisation of assessment bias. We suggest that the specific outcomes to be assessed should include the impact of acupuncture as an adjunct to standard analgesia, side effects recorded using standard definitions, and reductions in medication use. Most importantly, the analgesic effect of acupuncture is unlikely to be equal for all pain presentations in the emergency setting and, therefore, the conditions for which its role is most beneficial need to be delineated.

Andrew L Jan · Ian Rogers · Eric J Visser

To the Editor: The conclusions made by Cohen and colleagues1 can be challenged on the basis of study design and results. A significant flaw in the design is that of all patients not excluded due to additional medical problems, 38% of potential study participants declined to be included, possibly because they were not prepared to be assigned to the acupuncture-only arm. This flaw introduces a critical bias when analysing the 62% who did participate, as it is reasonable to assume that they are statistically more inclined to experience a placebo benefit from acupuncture and more likely to be positive at 48 hours about repeating this therapy. Even with this bias, however, the results of the study do not support a broad interpretation of non-inferiority, given that 39% of acupuncture-only patients required rescue therapy at or after one hour, compared with 22.5% of pharmacotherapy-only patients. In the context of an emergency department (ED) and patients with mean verbal numerical rating scale score of 8.5 at presentation, this difference in pain reduction and satisfaction with the initial therapy during the first hour of treatment should render the acupuncture-only option unacceptable. The authors have selectively and speculatively interpreted their data to support their enthusiasm for acupuncture. Results for patients with migraine are given minimum discussion or reference in the conclusions. The inferior performance of acupuncture-only patients’ willingness to repeat the therapy at one hour is dismissed as being influenced by patients’ concerns about length of stay and transport arrangements, whereas they indicate that the same parameter at 48 hours is more meaningful. I suggest that the results at one hour more accurately reflect a patient’s experience of their pain and desire for abatement, whereas the improved satisfaction at 48 hours is the result of shifted perspective following self-resolution — in a selected patient population with an existing positive bias for acupuncture. The authors’ suggestion that acupuncture use in EDs would reduce opioid addiction is an opportunistic grab at exploiting popular sentiment among people who do not understand the causes and parameters of this serious problem. This article does not support diversion of resources towards acupuncture use in EDs or a change in evidence-based treatment protocols in emergency medicine.

Anitra J Wenden

In reply

Marc M Cohen · Michael Ben-Meir · Nick Andrianopoulos

The following study was conducted independently of the MJA. The MJA has not verified the accuracy of the data

Yassar Alamri · Mohamud Osman

To the Editor: After reading the recent article by van Driel and colleagues,1 we want to report on hepatitis C treatment outcomes in a Sydney general practice. New direct-acting antiviral (DAA) therapy for the treatment of chronic hepatitis C became widely available in Australia on 1 March 2016 via the Pharmaceutical Benefits Scheme, and general practitioners are able to prescribe it in consultation with a specialist. We describe here the treatment outcomes from the first 60 days of DAA prescribing in a single general practice clinic. We searched the clinic database to extract demographic and clinical data for all patients prescribed DAA from 1 March to 30 April 2016. We found that 47 patients had been prescribed DAA agents by a GP, five had received DAA therapy via an early access program, 41 had genotype 1 hepatitis C virus (HCV), six patients had genotype 3 HCV, and 11 patients had co-infection with HIV. All treated patients had an assessment of liver fibrosis performed with a FibroScan. Most patients had early liver disease, with three having cirrhosis. On 1 May 2017, we assessed the outcome data: 33 patients were treated with ledipasvir and sofosbuvir (all had genotype 1 HCV), nine were treated with daclatasvir and sofosbuvir (three had genotype 1 HCV, and six had genotype 3 HCV), and five patients were treated with paritaprevir + ritonavir + ombitasvir + dasabuvir (all had genotype 1 HCV). Forty-six patients had started treatment, with sustained virological response (SVR16; ie, undetectable virus 16 weeks after the end of treatment) results available for 45 patients. One patient had treatment failure, one had not started treatment and one patient was waiting on SVR results. On-treatment SVR (cure) rate was 96%. A steadily increasing percentage of patients in Australia are receiving hepatitis C treatment prescribed by their GPs, with 19% of prescriptions provided in this setting in September 2016.2 GPs are well placed to provide care for patients living with chronic hepatitis C, with reassuringly high cure rates.

David Baker · Marilyn McMurchie · Vanessa Farr

To the Editor: I read with some concern the study by Ibrahim and colleagues1 published in the Journal. In their epidemiological study of deaths of nursing home residents reported to the coroner, the authors reported a more than quadrupling of the rate of deaths due to falls over the decade from 2002 to 2012, and deemed these deaths to be preventable and premature. In their discussion, Ibrahim and colleagues1 insinuate that this increased rate of deaths due to falls relates to some extent to a decline in the standard of care provided to nursing home residents. As this study lacks a control group, fundamentally, there is a problem in making any assumptions about preventable deaths and care provided to nursing home residents. This problem is particularly pertinent in light of data published by the Australian Institute of Health and Welfare which show an almost 40% increase in the rate of injury hospitalisations for older Australians, predominantly due to falls, over a similar 10-year period.2 A subsequent publication by the Australian Institute of Health and Welfare reports that 50% of all falls in older people resulting in hospitalisation occur in or around the home and that only 22% occur in an aged care facility.3 Therefore, one could ask whether there has been a similar increase in the rate of premature and preventable deaths due to falls of older Australians who live in their own homes. Clearly, further research on falls in general is required before any conclusions about possible causes can be made.

Henry Zeimer