Letters

To the Editor:Emanuel1 enjoins readers to focus on the data concerning euthanasia and physician-assisted suicide (PAS), and to aim at improving the care of dying patients, but advances straw arguments on the basis of three claims in the end-of-life debates that are disputed by neither advocates nor opponents of assisted dying. From the fact that euthanasia and PAS are rarely requested and rarely cause death, Emanuel argues that legalising them will not help solve the problem of inadequate symptom management or improve palliative care. But he adduces no evidence that supporters of legalisation make this claim. Describing legalisation as “really a sideshow in end-of-life care — championed by the few for the few” minimises the plight of those who would avail themselves of euthanasia and PAS, and is belied by the consistent majority support in Western communities for legalisation.2 Pain is recognised, by both advocates and opponents of legalisation, to not be the primary reason why people seek euthanasia and PAS. To claim that the real motivators of requests for assistance (eg, depression, loss of control and loss of dignity) “are not relieved by increasing the dose of morphine, but by antidepressants and therapy”, perpetuates the myth that medicine can, and should, always provide therapeutic answers to such personal dilemmas.3 Emanuel describes requests for euthanasia and PAS as amounting to “traditional suicide condoned and assisted by the medical community”, on the grounds that they are motivated by psychological factors. This statement begs the question about the ethical and legal propriety of euthanasia and PAS by equating PAS with other categories of suicide, without adequate analysis. No one would be surprised at the data supporting Emanuel’s claim that all medical procedures have problems and complications, and that euthanasia and PAS are no exceptions. But to conclude from this that “the common view of euthanasia and PAS as quick, flawless, and painless ways to die is unrealistic” introduces an alleged “common view” that is also unsupported. These are all examples that seem to advance evidence-based arguments in support of a particular ethical and policy position, but one that has been decided ahead of the evidence.

Malcolm H Parker

In reply

Ezekiel Emanuel

To the Editor:I read with interest the call by Menzies and colleagues1 for revitalised efforts to vaccinate a higher proportion of the adult Australian population against common infectious diseases. At present, the aim of the adult component of the National Immunisation Program is to protect against Streptococcus pneumoniae and the two viruses that cause influenza and herpes zoster — all prevalent pathogens in our environment. In addition to infections derived in Australia, adults are more likely than children to be the focus of imported cases of infection. Exposure of adults to, for instance, tropical infectious diseases, including those transmitted by biting insects (ie, dengue, yellow fever, chikungunya and Zika viruses, malaria, etc), will be far greater than that of juveniles. This is because adults have more reason to travel overseas and typically undertake more trips than children do.2 Vaccine uptake among travellers is mixed, and there are groups that are not sufficiently vaccinated, including people who travel overseas to visit friends and relatives (VFR). These so-called VFR travellers are more likely to consider themselves at low personal risk or threat when travelling to their country of origin, stemming from a sense of familiarity with the destination country and its infectious disease risks.3 Cultural beliefs and language barriers are also important factors associated with suboptimal uptake of pre-travel advice among VFR travellers. While infants accompany their parents for holidays and to visit family abroad, intercontinental travel for business and educational opportunities is largely restricted to adults.4 For typical short stay business trips, rather than for holidays lasting an extended period, it is tempting to neglect being up to date with vaccinations.2 In this instance, for the busy business flyer — often a last-minute traveller — the risk aversion to illness may be suppressed by avoidance of the perceived hassle of immunisation. Travel acts as a vector for spread of infection and many outbreaks are imported into Australia through overseas trips; nevertheless, travellers frequently neglect to seek pre-travel health advice.5 Improving rates of travel vaccination, especially in adults, is one area of focus that may help infectious disease control efforts nationally.

Andrew W Taylor-Robinson

In reply

Robert I Menzies · Jenny Royle · C Raina MacIntyre

To the Editor:While vaccine refusal is but one contributor among several to failures of vaccine-preventable disease control, as stated by Beard and colleagues,1 there are important ethical aspects of vaccine refusal. Intentionally opting out of vaccination imposes risks on others, and policies allowing some to opt out weigh their freedom to do so against the rights of others not to be harmed by vaccine-preventable diseases.2 In particular, people who cannot be safely vaccinated (eg, infants) or maintain immunity (eg, the immunosuppressed) are at increased risk of severe disease — including death — and depend on the immunity of others.2 It is true that herd immunity has no “magic threshold”:1 even with high population vaccination levels, severe harm may be caused when just one unvaccinated person has contact with an infectious person and then a vulnerable person. The death of an immunosuppressed woman from measles pneumonitis in the state of Washington, United States, in 2015 is a case in point.3 Tighter legislation on universal vaccination does not unfairly target vaccine refusal. Indeed, Victorian No Jab, No Play legislation has a general objective: “to increase immunisation rates for young children,”4 which applies equally to people who have unintentionally failed to vaccinate and those who intentionally opt out due to hesitancy or refusal. Policy should make vaccination the norm and aim for the highest possible coverage. Moreover, while we should revise financial penalties if they unfairly burden poor families (while the wealthy may pay to opt out), policy should, in some way, recognise that conscientious objection to vaccination has consequences for others.5 Measles outbreaks are correlated with vaccine refusal6 and lead to significant social costs, which Australia may avoid if high levels of vaccination are maintained. Though the true epidemiology is certainly more complex, if measles vaccination leads to immunity in 99% of vaccine recipients, and 95% of people are vaccinated,1 the population level of immunity would be 94.05%. Threshold concepts have limitations, but whether this is “comfortably exceeding” 94%,1 or perilously close to recurrent measles outbreaks — which impose avoidable risks of harm on others — is a matter for debate.

Euzebiusz Jamrozik

In reply

Frank H Beard · Julie Leask · Peter B McIntyre

To the Editor:While highlighting the benefits of endovascular clot retrieval (ECR), Hwang and Gawarikar1 identified Victoria as establishing the first statewide 24/7 ECR service in Australia. We agree with the authors’ caution against focusing on a singular therapy for a few patients at the cost of delivering basic, high quality stroke care to all. As they note in the article, offering ECR requires capacity to appropriately assess patients with advanced imaging and to treat or transfer patients if ECR is indicated.1 We want to provide some background to the ECR service and the role of telemedicine for delivering evidence-based stroke care across regional Victoria, including ECR access. In Victoria, stroke telemedicine has been an important linchpin for overcoming clinical practice variation. The Victorian Stroke Telemedicine (VST) program (www.vst.org.au), operational since 2011, is a statewide service providing 16 regional hospitals with remote access to stroke specialists 24/7.2 The first VST patient eligible for ECR was identified in May 2015, with 78 identified to date. The Victorian Government statewide ECR protocol3 was released in May 2016, with VST being pivotal in identifying and transferring suitable patients from regional areas. Working with regional colleagues through telemedicine has led to numerous benefits,4 including capacity building and incorporating the latest evidence into local stroke protocols. So far, 1600 patients have received a VST consultation, the thrombolysis rate for ischaemic stroke under 4.5 hours is 38% (nationally, 24%),5 some hospitals have provided thrombolysis therapy for the first time, more patients are receiving thrombolysis in under 60 minutes and haemorrhagic complications rates are comparable with those of metropolitan hospitals. Moreover, VST delivers a broader neurological service: 38% of VST consultations receive a “not stroke” diagnosis. We agree that attention to guideline adherence (ie, stroke unit access, care plans and preventive medication) is required.1 Telemedicine may improve access to both basic and specialised care, and in our experience, it provides important infrastructure to incorporate new evidence rapidly. If systems of care could be improved to support rapid uptake of evidence, then geographical boundaries may be overcome: a national acute stroke telemedicine service may be one solution. Commensurate with the need to ensure value, we are undertaking a comprehensive cost effectiveness analysis to support optimal stroke care policy and practice decisions.

Kathleen L Bagot · Dominique A Cadilhac · Chris Bladin

In reply

Yun Tae Hwang · Yash Gawarikar

To the Editor:High technology solutions to the difficult task of selecting and monitoring moles (pigmented skin naevi) may be useful to keep accurate records of people’s skin. Adopting military surveillance and warfare technology,1 there are computer algorithms that search for changes in moles’ appearance over time. Deep convolutional neural networks analysis can group them into benign or malignant lesions with high accuracy.2 In a study by Esteva and colleagues,2 the convolutional neural networks algorithm differentiated between benign, malignant or non-neoplastic lesions with about 72% accuracy compared with about 66% accuracy by two dermatologists; for melanocytic lesions, the algorithm had a better sensitivity and specificity performance compared with the average of 21 dermatologists, although these findings still need to be replicated in independent datasets. Despite recent advances, there are still questions about how Australians can benefit from this technology and how it is best integrated into clinical practice. Cancer agencies worldwide do not recommend screening for melanoma, but instead ask people to make skin self-examinations a habit and present to a doctor with moles of concern — although informal screening is widespread in Australia. Apps that provide easy access to personalised risk estimation may alert people to engage in such exams more frequently. Moreover, apps that guide people through the skin self-examination process may also be useful, as most people find this task complex.3 Once people notice a spot or mole, they may seek a clinical skin examination. Evidence that clinical skin exams are beneficial comes from the Queensland melanoma case control study4 and other similar studies that show that they lead to the detection of thinner melanomas. There are many apps that allow people to take and send photos of moles, but these are highly variable in sophistication and costs. Whether such technology is best placed in front of (for filtering out clearly benign lesions) or after a clinician’s diagnosis (for additional validation) is also matter of debate. Apps should not distract from the patient–doctor relationship, as the final decision about excision requires face-to-face consultations. While technology solutions are promising, validation studies have mostly been small, have lacked a control group or have not been replicated in clinical practice. Independent big research initiatives, such as the International Skin Imaging Collaboration Challenge on Skin Lesion Analysis towards Melanoma Detection,5 are underway to take the momentum further. This healthy competition may be just what is needed to take the last steps to eradicate melanoma.

Monika Janda · H Peter Soyer

To the Editor:I congratulate Isbister and colleagues1 for performing a first aid randomised controlled trial on box jellyfish stings (a rarity in toxinology). The result is at variance with other studies on this topic (although they mainly involved North American jellyfish stings).2 I agree with the authors and the accompanying editorial3 that the major weakness in the study was the up to 4-hour delay for treatment with hot water. Unlike the earlier bluebottle stings first aid study performed on the beach,4 this study is performed in the emergency department of the Royal Darwin Hospital, when the pain severity was lessening. Pain severity was the primary study outcome: 25% of the study group had pain scores of less than 26 (hot water) or 20 (ice), which is minimal pain. Only 10% of the study group received opioid analgesia, compared with the results obtained by Currie and Jacups5 in a 14-year prospective observational study of box jellyfish stings in Darwin, where 48% of patients received analgesia, including 30% of patients receiving narcotic analgesia. The article by Currie and Jacups5 also reported that 71% of patients received ice. The current trial1 does not detail if ice (or heat) was applied to patients before enrolling in the study. Moreover, Currie and Jacups5 also reported that 84% of stings occurred in less than 1 m of water and most of the stings occurred on the legs. I am not sure how the temperature of the water in the bucket used for distal limb stings was controlled to maintain a temperature of 45°C. If not well regulated, then this would lessen the benefits of the heat. In addition, I am surprised that the authors have not attempted to use their findings to push for a standardised approach to jellyfish stings in Australia. The Australian Resuscitation Council currently has different first aid advice for stings in the tropics compared with southern Australia.3,6 These results would suggest that heat is equally effective as ice for box jellyfish stings. The authors were concerned about the difficulty in providing hot water as first aid, which is the same problem for southern Australia, where hot water is recommended. Surely, it is time to standardise first aid for jellyfish stings in Australia.

Mark Little

In reply

Geoffrey K Isbister · Bart J Currie

To the Editor:Cadilhac and colleagues1 explore an important issue in the measurement and reporting of stroke outcomes. We agree that appropriate risk-adjustment methods are essential to compare hospital outcomes. We also agree that stroke severity is an important predictor of mortality for individual patients. However, we do not agree that determining stroke severity is essential for robust risk-adjustment approaches. The Bureau of Health Information has recently published its second report on 30-day mortality.2 Our approach includes adjustment for comorbidity, and we developed separate models for ischaemic and haemorrhagic stroke, given the significant differences in outcomes and risk factors. The approach of Cadilhac and colleagues does neither, which means that we do not know the impact of including comorbidity adjustment and severity in the same model. Further, our method is applicable to small hospitals with as few as 50 patients in a 3-year period. In settings such as Australia, where many patients reside outside major cities, it is important to assess outcomes in both small and large hospitals. The results of Cadhilac et al show that adjusting for stroke severity affected hospital rankings, and across the two models, hospital rates changed on average by 0.01 (range, 0.001–0.026). The impact on outlier status is not described. In our view, it is the outlier status that is the most salient element of public reporting, and indirect standardisation should not be used to rank hospitals.3 Measurement approaches in the United States and Canada do not adjust for severity, and it is not currently possible to do so using administrative records in Australia. While Cadhilac et al have shown that including severity information can affect rankings, such rankings are not appropriate to assess hospital performance when they are based on indirect standardisation and do not take account of hospital size.

Kim Sutherland · Jean-Frederic Levesque · Julia Chessman

In reply

Monique Kilkenny · Leonid Churilov · Dominique A Cadilhac

To the Editor:We thank Tong and colleagues1 for their report on a patient with schizophrenia and clozapine-induced maculopathy, and for highlighting this under-recognised condition. Both typical2 and atypical3 antipsychotic drugs have been reported to cause widespread retinopathy; more recently, there have been reports of rare cases of retinal damage localised to the macula (maculopathy) due to both typical4 and atypical1,5 antipsychotics. The classical hypothesis for widespread pigmentary retinopathy is that drugs are absorbed by melanin in the retinal pigment epithelium (RPE) and act as photosensitisers to damage the RPE. This results in loss of RPE support functions of overlying photoreceptors, which secondarily degenerate. An alternative hypothesis,2 supported by histological and animal studies, is that the problem begins in photoreceptors, with drug-induced blockade of retinal dopamine receptors followed by photoreceptor and subsequent RPE cell loss. Neuroleptic retinal drug toxicity typically involves pigment disruption in the RPE, but the dopamine hypothesis allows for broader combinations of RPE and/or photoreceptor damage. The reasons for the development of maculopathy in some patients, rather than a widespread retinopathy, are not known. This phenomenon is seen in other ocular drug toxicities, particularly hydroxychloroquine. Most drug-induced retinal toxicities are bilateral and symmetrical; asymmetrical cases have rarely been reported. The patient reported by Tong and colleagues is atypical with apparently unilateral macular changes.1 Significant differential diagnoses for unilateral macular pigment and photoreceptor changes include age-related and secondary to retinal conditions, such as central serous chorioretinopathy, inflammatory retinopathies and trauma. Maculopathy limited to the outer neuroretina may occur with the use of other drugs (eg, poppers maculopathy).6 Also, schizophrenia is known to cause illness-related retinal changes in the neuroretina but not in the RPE.7 We agree that patients taking psychotropic medications benefit from a multidisciplinary approach when ocular symptoms and signs develop.

Heather G Mack · RC Andrew Symons

In reply

Jessica Y Tong · Amy Pai · Stephanie H Young

To the Editor:Whitely and colleagues1 reported that children born in June were more likely to receive treatment for attention deficit/hyperactivity disorder (ADHD) than children born in July. It is unfortunate that they did not measure the year of school intake, and rather made the assumption that all children entered school at the recommended age. The authors concluded that “there are significant concerns about the validity of ADHD as a diagnosis,” which is a large leap not substantiated by the data presented. We are conducting Australia’s first community-based longitudinal study of children with (n = 179) and without ADHD (n = 212), the Children’s Attention Project.2,3 Our design is ideal for examining this research question as children were all recruited across one year of school, enabling us to accurately categorise children as early or late starters. We rigorously assessed for ADHD (ie, via parent and teacher surveys and diagnostic interviews) and also recorded the use of ADHD medications. To investigate the same question within our cohort, we defined early starters as those children with birth months in February, March or April (age at entry, 4 years 9 months to 4 years 11 months; n = 46) and late starters as those children born in May, June or July (age at entry, 5 years 6 months to 5 years 8 months; n = 123). We found no relationship between being an early or late starter and meeting the criteria for ADHD at either age 7 years or age 10 years. Our sample size for these analyses was small because most children with ADHD were born outside the months encapsulating early and late start date definitions (n = 112; 63% of our ADHD sample). Only nine children were prescribed medication across the early and late starter definitions — one early starter and eight late starters. In conclusion, our data show that when school commencement year is considered, there is little evidence to support early versus late school starter status as a predictor of ADHD and treatment in Victoria. The overall rate of ADHD medication prescribing for children aged 6–15 years reported by Whitely and colleagues was 1.9%.1 ADHD has a prevalence of about 5%,4 thus, these data provide further reassurance that the rates of prescribing of ADHD medications in Australia remain moderate.

Emma Sciberras · Alisha Gulenc · Daryl Efron

In reply

Martin Whitely · John Phillimore · Leanne Lester · Suzanne Robinson

To the Editor: A 53-year-old woman experienced rapid onset of left eyelid pain, swelling and purulent discharge (Box 1). She presented to our eye hospital 3 days later and, on assessment, the lids were exquisitely tender, inflamed and difficult to open. There was chemosis, microcystic corneal oedema with Descemet membrane folds and moderate inflammation in the anterior chamber. Visual acuity was 6/24 in the left eye and 6/9 in the right eye. Ocular motility appeared normal. The severe inflammation and visual impairment raised concerns for post-septal orbital cellulitis. A computed tomography scan showed severe pre-septal stranding only (Box 2). A diagnosis of left pre-septal cellulitis and keratoconjunctivitis was made. She was given intravenous ceftriaxone 2 g daily, intravenous flucloxacillin 2 g four times a day, topical chloramphenicol 0.5% four times a day and regular eye washings. Microscopy found gram-negative diplococci, and polymerase chain reaction testing was positive for Neisseria gonorrhoeae. The patient denied history of sexually transmissible infection. A urine and serum sexually transmissible infection screen for N. gonorrhoeae, Chlamydia trachomatis and blood-borne viruses was negative. Treatment was rationalised to intravenous ceftriaxone 1 g daily, with a single 1 g dose of oral azithromycin. The patient had dramatic improvement over 4 days, and visual acuity improved to 6/7.5 at discharge (Box 3). One week later, the infection had predominately resolved. N. gonorrhoeae typically produces a hyperacute unilateral conjunctivitis. While the source of infection in this patient is unclear, in most cases infection is acquired via sexual transmission and reaches the conjunctiva through hand–eye auto-inoculation.1,2 The bacteria can invade the corneal epithelium, producing keratitis and corneal melting necessitating therapeutic keratoplasty.1,2 Gonococcal periorbital infection is rare, with only three cases of pre-septal cellulitis and two cases of post-septal cellulitis reported.3 All patients were successfully treated with parenteral antibiotics. N. gonorrhoeae has increasing antimicrobial resistance, creating a therapeutic challenge. The Australian Gonococcal Surveillance Programme has shown an emerging resistance to ceftriaxone — the antibiotic of choice — from 0.6% in 2006 to 5.4% in 2014.4 Azithromycin resistance occurs in 2.4% of strains.4 The Australian Therapeutic Guidelines recommend treatment of N. gonorrhoeae with parenteral ceftriaxone and oral azithromycin, for bactericidal synergy and cotreatment for C. trachomatis. When presented with pre-septal cellulitis and purulent keratoconjunctivitis, the clinician should be vigilant for a sight-threatening N. gonorrhoeae infection. Box 1 – Lid inflammation and purulent discharge at onset, 3 days before presentation Box 2 – Contrast-enhanced computed tomography scan showing significant pre-septal subcutaneous stranding (blue arrow) and severe conjunctival chemosis (yellow arrow) Box 3 – Marked improvement in periorbital inflammation after 3 days of antibiotic therapy, with residual conjunctival injection

Shivesh Varma · Nathan Wong · Jwu Jin Khong

To the Editor:We fully support Colagiuri’s appeal to implement comprehensive, regulatory action to reduce sugar-sweetened beverage consumption.1 Excessive sugar-sweetened soft drink consumption is associated with weight gain, diabetes and dental caries.2 Strikingly, sugary drinks are the single largest contributor of added sugars in the diet of Australians aged 14–50 years.3 In recognition that environmental changes can support healthier consumer choices, the New South Wales government has pledged to remove sugary drinks for sale from all its health facilities by December 2017.4 This follows the lead of 13 health services in Victoria that have also adopted this health-promoting policy. Media coverage of these measures has been positive,4 as communities look to health centres to be leaders in supporting and protecting public health. In contrast, Australian university campuses, including those with medical schools responsible for developing future health leaders, remain saturated in soft drink promotions and sales. Detractors of policy-based approaches suggest that education efforts and offering healthy choices are preferable to “nanny state” restrictions. Health education campaigns that advise people to restrict their consumption of sugary drinks must battle against the ubiquitous advertising and availability of these products. In the United States, it is well documented that the university food environment is shaped by purveyors of unhealthy food and drink.5 “Free choice” arguments ignore the realities of sales contracts that include exclusively selling certain brands and products. Similarly, in Australia, exclusive sales contracts offered to suppliers may restrict the choices of staff and students on campus. The real issue appears to be the unfounded fear that banning the sale of soft drinks on campuses may have negative revenue implications. This fails to acknowledge that replacement beverages that are not sugar-sweetened could still be sold. Australian university campuses have readily banned smoking and the sale of tobacco without experiencing financial hardship as a consequence. Universities, especially those training future health professionals, need to flex their collective muscle and be part of the momentum towards creating healthy environments. Initiating healthy beverage policies is a significant step forward.

Becky Freeman · Kieron Rooney · Eloise Howse

To the Editor:Recent reports from the World Health Organization1 and from Australian agencies2,3 emphasise the urgency of improving health service response to family violence. Understanding the victim and survivor experience and perpetrator patterns is essential to improving health practitioners’ capacities for recognising and responding appropriately to family violence.1,3 Although there is an increasing awareness of the severity of health consequences of family violence,1,4 there is little standardisation of terminology within the national and international literature. The Royal Australian College of General Practitioners recognises physical, emotional, economic, social, sexual, psychological, verbal and spiritual abuse as forms of family violence.4 Family violence includes any violence or abuse that occurs within a family,4 including between partners, parents, children, siblings, uncles or aunts, cousins, grandparents and in-laws. Complexities arise because of the pervasive nature of violence when trying to differentiate the types of violence and individual victims. For example, studies show that 50% of children who experienced physical abuse and 40% of children who experienced sexual abuse have a mother who experienced intimate partner violence.5 “Domestic violence” emphasises the place of the violence, whereas “family violence” emphasises the relationships between the victim and the perpetrator. “Intimate partner violence” refers to the “behaviour within an intimate relationship” of current or former partners (including same-sex relationships) causing “physical, emotional, sexual, economic and social harm to those in the relationship”.4 Family violence (Box) encompasses domestic violence, intimate partner violence and sibling violence. Cases of child neglect, child abuse, child sexual abuse, sexual assault and rape may occur in the context of family violence; however, these forms of violence may also occur outside the context of the family, such as institutional abuse or stranger violence. Likewise, older people abuse, which can include sexual abuse and rape, may occur in the context of family violence and also in institutional contexts, in the context of service provision or between people who have no familial or institutional relationships. An increased understanding of the terminology used in the research literature enhances the capacity for delivering high quality care to women, children and men experiencing the health impacts of family violence. Box – Terminology for family violence Figure by Debbi Long and Serena Lee.

Debbi Long · Serena Lee · Jan Y Coles

To the Editor: We note with interest the recent review of challenges in the management of maturity onset diabetes of the young associated with glucokinase gene mutations (GCK-MODY).1 In Box 2, Bishay and Greenfield reported a prevalence of gestational diabetes mellitus (GDM) of 5–10%. Indeed, in 2010 we reported an estimated prevalence of 10–11% of GDM in south-western Sydney;2 however, the prevalence is now almost double that figure (18.5% of births at Bankstown-Lidcombe hospital in 2015). Bishay and Greenfield also summarised the findings of Chakera and colleagues3 for a population of predominantly European descent: A lower body mass index (BMI, < 25 kg/m2) and a fasting glucose level greater than or equal to 5.5 mmol/L have sensitivity and specificity of 68% and 96%, respectively. It is estimated that among lean women with mild fasting hyperglycaemia, the number of women needed to test is 2.7 to detect a single case of GCK-MODY.1 In contrast, in our recent study of women with GDM, we found that at least 8.1 women would need to be tested to identify one case of GCK-MODY.4 Given our interest in the management of women with GDM, we sought to determine whether these criteria were applicable in a large multi-ethnic cohort of women with GDM. Analysing de-identified, prospectively collected data from all women with GDM in our ethnically diverse population, diagnosed using the Australasian Diabetes in Pregnancy Society (1998) criteria at our institution between 1993 and 2013, we categorised the women into two groups: those with body mass index ≤ 21 kg/m2 (group A1) and those with body mass index > 21 kg/m2 and < 25 kg/m2 (group A2). We collected complete data, including post-partum oral glucose tolerance test results, for 171 women (54, group A1; 117, group A2). The oral glucose tolerance test and post-partum glycated haemoglobin results identified few women (< 14%) in either group who still had possible GCK-MODY. Testing all 171 of these women in pregnancy would have been a costly exercise with a low yield. In testing data in different ethnic groups, we therefore recommend caution regarding the number suggested by Chakera and colleagues.

Jeff R Flack · Glynis P Ross · N Wah Cheung

In reply

Ramy H Bishay · Jerry R Greenfield

Modern digital radiological techniques include “stitching” together multiple x-ray images. This provides one overall image of the area of interest, such as the entire spine or lower limbs, for deformity assessment. Dedicated software automatically combines separate exposures and allows for overlap. Image acquisition is rapid, minimising patient motion artefact and reducing distortion.1 However, if images are inappropriately put together (digitally stitched), stitching errors may occur with this computer-driven process. If not manually corrected by the radiology technician, the supplied image may hide pathology or give the false impression of abnormality. Four cases of digital stitching error have recently occurred in our tertiary referral paediatric hospital. Digitally stitched x-rays from the lower limbs were obtained for routine assessment of a child with skeletal dysplasia, and fractures of the left tibia and fibula were apparent (Box, A). This did not correlate with the clinical findings, including the child dancing in the waiting room. The radiology department was contacted and they re-issued corrected images (Box, B). Spinal x-rays in two patients after scoliosis surgery incorrectly showed broken surgical rods. In the context of ongoing symptoms, the option of revision surgery was discussed with the family in the first case. Repeat x-rays, obtained as part of the pre-operative planning, showed the rod was in fact not broken. A stitching error was immediately recognised by the spinal surgeon when a second similar case occurred. In a fourth case, comparison of the anteroposterior and lateral views of a child’s spine showed different numbers of vertebrae in the two views (11 vertebrae on the frontal view and 12 on the lateral). Digital radiology is commonplace and allows rapid image acquisition and ease of digital measurement.2 However, technical errors — digital stitching errors — may occur. Although rarely reported, these may be relatively common, with one study identifying stitching errors in 14 out of 86 reviewed scoliosis studies.1 Despite ongoing technological refinements,3 clinicians should always carefully check digitally stitched images: look for soft tissue mismatch, correlate with source images and clinical presentation, and avoid digital stitching in certain patients, such as people with movement disorders. Box – Digitally stitched long leg images of a paediatric patient, showing the stitching error and apparent fracture (A),* and corrected image with resolution of the stitching error and no fracture (B) * Note the mismatched soft tissue shadow (A).

Clare Faurie · Nicole Williams · Peter J Cundy

To the Editor: Intensive care is a finite and costly resource with nine beds per 100 000 population in Australia and at a cost of $4000 per bed-day. From 1999, the demand for intensive care unit (ICU) beds has increased at an average rate of 2.5% annually.1,2 Faced with increased demand and capacity restraints, fiscal sustainability is dependent on efficient use of limited ICU resources. ICU bed availability varies significantly across countries and creates a threshold for clinicians to admit patients.3 The availability of beds may be influenced by the number of patients well enough for ward discharge but who are exit blocked. ICU access block is a significant safety concern for critically ill patients, and ICU exit block (the inability to discharge a patient who is medically fit for discharge) may contribute significantly to ICU access block.4,5 Using a single-day point prevalence study, we obtained an estimate for ICU exit block in 39 Australian and ten New Zealand adult ICUs in 2014. Across all sites, 13% (median value of exit block across the sample hospitals, 8.1%; interquartile range, 0–23%) of patients in the ICU on the study day were awaiting a ward bed. Patients in Australian ICUs were twice as likely to be exit blocked compared with patients in New Zealand ICUs (14.9% v 7.6%). Hospital and ICU size and location (rural v metropolitan) did not influence levels of exit block, but ICUs with > 80% occupancy had higher levels of exit block (Box). Our results were similar to those of the 2007–14 Australian Council on Healthcare Standards clinical indicator report, which found that about 25% of ICU discharges were delayed for more than 6 hours.5 Using an ICU bed for a patient who no longer needs it represents an inefficient use of resources and risks creating delays in admitting other acutely unwell patients. In the emergency department setting, we have seen the 4-hour rule improve hospital access and outcomes by prioritising transfer of emergency department patients to ward beds. Monitoring ICU access and exit block provides a comparable metric for understanding the effects of prohibiting ICU patient flow and for determining how to safely and efficiently allocate limited resources for critically ill patients. Box – Intensive care unit (ICU) bed occupancy and exit block Bed occupancy No. of ICUs* Median percentage of patients experiencing exit block (IQR) 0–50% 6 0 (0–28.6%) 51–80% 20 0 (0–10.8%) 81–100% 21 13.0% (5.5–25%) IQR = interquartile range. * Two sites did not provide bed occupancy rates so were not included in our analysis.

Matthew H Anstey · Kelly Thompson · Ian Seppelt

To the Editor:I thank Kritharides and colleagues1 for their review Cardiovascular disease in patients with schizophrenia. I agree with them and support their work, which seeks to improve the physical health of patients living in the community with a chronic mental illness such as schizophrenia, through an innovative, coordinated and multidisciplinary model of care. Clozapine side effects, including risks of myocarditis and cardiomyopathy, hypercholesterolaemia and weight gain, reduce years of life and require medical attention. But the management is not always straightforward. One challenge is patient compliance with often demanding allied health therapies. How do we keep our patients motivated to continue with prescribed regular exercise most days of the week? How do we encourage compliance with a weight-reducing, low salt, low glycaemic index diet? Multidisciplinary primary care and specialist teams may consider a rehabilitation approach to complement the model of care. Two essential elements are goal setting and measurement of function.2 Some patients will be motivated by their personal goals (eg, getting back to weighing 80 kg or playing a game of table tennis) and other patients will appreciate their gain in terms of function (eg, walking up the stairs without a rest or shopping for groceries independently) more so than in terms of presented data (eg, cholesterol levels or absolute cardiovascular risk reduction). For motivating patients with schizophrenia and significant cardiovascular risk, a rehabilitation approach may be worth a try.

David Skalicky