Letters

In reply

Luregn J Schlapbach · Justyna A Ostrowski · Graeme MacLaren

n/a

Robyn Hopkins · Kate A Dolan

To the Editor:We commend Milner and colleagues on their most important and timely study, which investigated the age-standardised rates and methods of suicide by health professionals compared with other occupational groups.1 They established that suicide rates for female health professionals, including medical professionals, were higher than for women in other occupations. While suicide rates were higher for male nurses and midwives, those for male medical practitioners were not significantly higher compared with other occupational groups.1 Milner and colleagues considered sex-related stressors in their discussion, in an attempt to understand the gender differences in suicide rates among medical professionals. The authors considered that women working in male-dominated areas face “considerable gender role stress” and may feel pressure to undertake traditional household roles and family responsibilities.1 It is highly conceivable that the abovementioned sex-related stressors may contribute to the sex differential in suicide rates. However, sexual harassment is an important sex-related stressor2 that was not included in their discussion or in Goldney’s accompanying editorial on this topic.3 There is overwhelming evidence to suggest that sexual harassment disproportionately affects women and is an entrenched problem in the medical profession.4,5 Indeed, sexual harassment has been demonstrated to be associated with suicide attempts among female doctors.5 Goldney argues that “ensuring good workplace relationships and equal opportunity, eliminating bullying [and] reducing access to means of suicide” are important pragmatic approaches to overcoming the problem of suicide among health care professionals.3 We propose that redressing sexual inequalities in medicine and eliminating sexual harassment might represent some additional approaches.

Nikki R Adler · Kimberley A Adler

In reply:In their comment on our article,1 Adler and Adler are correct in noting that sexual harassment is a significant issue facing female doctors, as it is for women in many occupations.2 Those who experience sexual harassment are also more likely to experience bullying and other forms of workplace incivility.3 Workplace bullying has also been found to be related to higher risk of suicidality.4 In view of this, we agree that these would be worthwhile targets for prevention initiatives. But the question remains as to whether sexual harassment and the problems regarding gender role stress discussed in our article1 all stem from the same set of causes. A meta-analysis3 noted two systematic sources of sexual harassment: (i) organisational context, including a climate that permits sexual harassment, and policies that do not support the reporting of and action against perpetrators; and (ii) the context of gender in the workplace — for example, the extent to which traditional gender roles are able to be maintained, such as through gender differences in the organisation of work, and the overall proportion of women employed in the job. In our article, we specifically highlighted the maintenance of gender-normative behaviour in medicine as potential stressors for suicide. While we agree that sexual harassment is a significant issue that needs to be addressed, we suggest that this be incorporated into a wider and overall strategy to overcome gender inequality in medicine. This strategy should target the negative personal and organisational (eg, organisation commitment, work withdrawal, job satisfaction) outcomes of harassment,3 and include measures to allow both male and female doctors to care for their families. In addition, to align with best practice in workplace suicide prevention,5 we would also support a stigma reduction campaign, access to treatment for health practitioners who experience poor mental health and suicidal ideation, and support for colleagues and families following bereavement from suicide within the medical profession.

Allison J Milner · Matthew J Spittal · Marie M Bismark

In reply:I thank Adler and Adler for their comment on my editorial on suicide by health care professionals.1 Their proposal of “redressing sexual inequalities in medicine and eliminating sexual harassment” appears to be encompassed in my statement about “ensuring good workplace relationships and equal opportunity [and] eliminating bullying”,1 which they quote in their letter. Regrettably, sexual harassment is common and not unique to medicine, with an estimated prevalence in the workplace of 35–50%.2 Although Adler and Adler refer to the work of Frank and colleagues3 in demonstrating an association between sexual harassment and suicide attempts in female doctors, they do not mention the caveats that the study authors noted. These include that it was “a relationship we cannot determine”; that earlier studies were “based on small numbers and the subject of considerable controversy”; and that “these problems are not unique to women physicians”. Bearing in mind the low base rate discussed in my article, ensuring that equal opportunity, good workplace relations and anti-bullying approaches are standard for health practitioners, and that health practitioners can access general and mental health care, are more realistic and achievable goals that are more likely to return dividends.

Robert Goldney

To the Editor:Advance care planning (ACP) promotes conversations about future health care, in case a person should lose capacity for decision making. Advance care directives (ACDs) provide written documentation of these conversations. Yet, although the Australian Medical Association advocates ACP within routine clinical practice,1 ACD completion rates remain low.2 While recognising numerous barriers to ACP, including patient, practitioner and health care system factors,3 a dedicated ACP Medicare Benefits Schedule (MBS) item number was mentioned in a number of general discussions at the 2016 Advance Care Planning Australia national conference (Melbourne, 15–17 November) as a potential incentive to increase the use of ACDs in primary care. In general, we support this recommendation. Health economics tells us that where there is a shortage of a specific service, as could be argued for ACP, the supply of this service will increase under fee-for-service payment.4 Patients are less knowledgeable about prices, services and associated benefit than providers; however, the existence of an agency relationship5 (where the patient assigns decisional authority on the basis that they have less information) between general practitioners and patients would facilitate ACDs from which patients are most likely to benefit. On the other hand, there is some risk that financial incentives will motivate GPs to do more than is optimal or desired, especially if the service is priced above standard consultation fees. There is also an opportunity cost; if GPs are providing more ACP services they will have less time to provide other primary care services. However, the risk of financial incentives may be mitigated by the non-financial barriers to ACP (fear or reluctance of patients, insufficient GP skills or organisational factors). Therefore, in designing policies to increase uptake, especially where financial incentives are the driver, a multifaceted approach should be considered. Service reimbursement mechanisms and potential barriers should also be balanced against maintenance of ACP values such as patient autonomy and informed decision making. As a starting point, a two-tiered MBS item number could be beneficial, the first item billable for initiation of ACP and the second used for revisitation of ACDs after a given time period (eg, annual review). Subsequent review of policy responses, including patient and medical practitioner input, will be needed to ensure appropriate directions surrounding MBS billing. Further accompanying strategies may be required to address non-financial barriers to ACP uptake.

Amanda Pereira-Salgado · Jennifer J Watts

To the Editor:The well researched narrative review by Bourke and colleagues1 offers a comprehensive overview of immune-related adverse events (irAEs) in cancer immunotherapy and their management. However, care needs to be taken in adopting too broad an approach, particularly in relation to dermatological irAEs. In the article, “rash” is described as an irAE. However, a rash is a clinical sign, not a diagnosis. The cutaneous irAEs reported in association with immune checkpoint inhibitor therapy span a spectrum of dermatoses including (but not limited to) vitiligo, eczema, lichenoid reactions, morbilliform eruptions, prurigo nodularis, bullous pemphigoid, papulopustular eruptions, rosacea, and cutaneous fungal, bacterial and viral infections.2,3 Categorising every cutaneous irAE as a rash precludes patients from obtaining an accurate diagnosis, which in turn encumbers treatment. Topical corticosteroids are a reasonable first-line treatment option for most pathologies (unless the cutaneous irAE is an infection or papulopustular eruption). However, there is a range of corticosteroid molecules, potencies and vehicles, as well as off-formulary preparations available,4 and physicians should be familiar with this class of drugs before prescribing them. Where accurate diagnosis of a cutaneous irAE becomes particularly important is when topical corticosteroids fail. Systemic corticosteroids, while helpful in containing an acute disease process, are seldom the second-line treatment employed by dermatologists. Dermatologists have an arsenal of topical, physical and systemic therapies at their disposal, and the choice of second-line treatment is determined according to diagnosis. We would therefore offer that a multidisciplinary approach is important in the management of the cutaneous toxicities of the new generation of oncological treatments; not only the moderate and severe as suggested, but also the mild and life-threatening. We commend the rapid rate at which our colleagues in medical oncology have become versed in the fundamentals of dermatological care and recognise only too well the limitations in access to dermatology, even in many of the larger teaching hospitals across Australia.5 However, in many respects, this new era of immunotherapy is uncharted territory, and managing the cutaneous toxicities of these medications necessitates an appreciation of the nuances of managing skin disease.

Rose Liu · Pablo Fernandez-Peñas · Deshan F Sebaratnam

To the Editor:With reference to Batterham and colleagues,1 we applaud the call to better align research funding to disease burden. We also address this shortfall in the leading killer: cardiovascular disease (CVD). The federal government deserves praise for establishing the Medical Research Future Fund (MRFF), doubling funding by 2023. This augurs well for the future, but right now, we face an interregnum while the MRFF builds and the National Health and Medical Research Council funding flatlines. Every year, CVD claims the lives of 45 093 Australians,1 accounting for more than one in three deaths. The direct cost of caring for people with CVD in 2008–09 was $7.7 billion per year (or 12% of the total health budget),2 making it the costliest disease group of all. With the current budget at over $120 billion per annum,3 and assuming that CVD continues to cost 10–12% of the health budget, it is likely that the current cost is well over $12 billion per annum.3 The most recent data show that CVD deaths increased for the first time in 4 decades in men aged 55–64 years,3 an increase associated with the rising rates of obesity and diabetes.3 This reflects the unanswered questions related to heart health, which are ripe for exploration. Meanwhile CVD research is funded substantially less than the equivalent disease burden of cancer, receiving about 13.5% — cumulative frequency of about 22% — of the National Health and Medical Research Council total funding between 2008 and 2014.4 A clear consequence is that CVD research suffers from brain drain, as emerging researchers seek sectors where funding is more available. This workforce crisis was highlighted by a recent Australian Cardiovascular Alliance survey, where 65% of CVD researchers say they would leave the sector if funding is not secured. Australian CVD research is of international standing, providing the highest returns of any disease group on research investment, an extraordinary $8 in health benefits for every $1 spent.4,5 The need for a committed workforce skilled in heart research is clear. Funds from the MRFF must be invested in research that reflects the health priorities and disease burden facing the nation, particularly where the market is failing. Such research is an investment not a cost. In 2017, the Heart Foundation will boost research investment by an additional $9.3 million. While substantial for the only major health charity supporting heart research, this is a drop in the ocean to what is needed. Proportionate investment will ensure that the great legacy of cardiovascular research in Australia is retained.

Garry LR Jennings · Jaye Chin-Dusting

To the Editor:In their article, Chen and Jepson1 discussed the advances in coronary artery stent technology. However, the review did not outline the indications for the newer and more expensive technologies mentioned, and did not indicate how stenting compares with the established practice of coronary artery bypass grafting (CABG) for patients with coronary artery disease. How does percutaneous coronary intervention (PCI) compare with CABG based on current evidence? The SYNTAX2 trial is a multinational trial investigating PCI versus CABG. At 5 years, the number of major adverse cardiovascular and cerebrovascular events in the CABG group was 26.9% compared with 37.3% in the PCI group. The 5-year myocardial infarction rate was 3.8% in the CABG group compared with 9.7% for PCI. Moreover, registry data showed that the cardiac death rate was 3.6% for CABG compared with 9.5% for PCI. Therefore, the group concluded that CABG should remain the standard of care for patients with multivessel coronary artery disease.2 A 2014 meta-analysis in JAMA3 comparing PCI with CABG indicated a reduction in mortality (relative risk [RR], 0.73; 95% confidence interval [CI], 0.62–0.86), myocardial infarction (RR, 0.58; 95% CI, 0.48–0.72) and revascularisation (RR, 0.29; 95% CI, 0.21–0.41), with CABG compared with PCI at a follow-up of 4.1 years. The subgroup analysis showed benefits in patients with and without diabetes. The BEST trial4 compares second generation everolimus-eluting stents with CABG. This trial enrolled 880 patients with more than 70% stenosis of two or more coronary arteries, and followed them up to 4.6 years. At 2 years, the primary endpoint of death, myocardial infarction or revascularisation occurred in 11% of patients in the PCI group and in only 7.9% of patients in the CABG group. During long term follow-up, it occurred in 15.3% of patients in the PCI group compared with 10.6% of patients in the CABG group.4 When reviewing the available evidence in the literature, several articles support CABG over PCI.5 The benefits of CABG persist, despite the development of second generation drug-eluting stents. CABG provides superior long term results in patients with multivessel coronary disease in regard to mortality, myocardial infarction and need for revascularisation. Therefore, CABG remains the gold standard of treatment for these patients.

Rohen Skiba · Chris Merry

In reply

Nigel Jepson · Daniel Chen

To the Editor: Since 1 October 2016, under changes in the Medicines Australia code of conduct,1 the names of all doctors receiving payments from pharmaceutical companies are being published online, together with the dollar amount received; the data will remain available for 3 years. Up until now, this information could only be published with the doctor’s consent. This change — part of the latest edition of the code of conduct — is the industry’s response to attempt to legislate for greater transparency. It represents a significant step forward in the transparency of the relationships between doctors and pharmaceutical companies. In 2015, pharmaceutical company-funded educational expenses for doctors included a $70 000 trip to Sweden for six oncologists and a $176 000 trip to Vancouver for nine dermatologists.2 With the new changes, it is likely that doctors will think twice before accepting large pharmaceutical company funding for educational events, given this information will be available to the public. Despite a considerable body of evidence showing that receipt of meals and sponsorship is associated with altered prescribing patterns,3,4 many doctors continue to incorrectly believe that they can effectively manage the influence of pharmaceutical company promotion on their decision making.4 The challenge for the profession is to foster doctor–pharmaceutical company relationships that benefit patients, while maintaining freedom from undue influence on prescribing habits. This requires system and individual change. Medicines Australia should be commended for its efforts to improve transparency; its measures are a lesson for other companies with financial interests relating to the practice and preferences of doctors, including medical devices companies. However, to fully realise the benefit of the code of conduct changes, all information on doctor payments must be accessible via a centralised repository that allows patients and third parties to search for an individual doctor. Regarding individual change, doctors must take heed of the evidence above and eschew gifts and education funding provided by pharmaceutical companies. Moreover, up to date and freely accessible evidence-based information is available via independent organisations such as NPS MedicineWise. Greater transparency in the relationships between doctors and pharmaceutical companies is a positive step to maintaining high levels of accountability and public trust in the medical profession.

Jessica Dean · Malcolm P Forbes · Richard Di Natale

To the Editor:In her MJA article, Murphy poses the question “who are we talking about when we discuss voluntary euthanasia laws?” and presents two hypothetical scenarios.1 The South Australian Voluntary Euthanasia Bill 2016 defines an eligible person as a competent adult, subject to unbearable and hopeless suffering, with no impaired decision-making capacity, and who has lived in the state for no less than 6 months.2 The degree to which the suffering is unbearable is determined subjectively. A person’s suffering is considered hopeless if medical treatment cannot reduce or relieve the suffering to a level that is bearable to the person. The nature, availability and potential effectiveness of such treatment are determined objectively under the provisions of the Bill. As Murphy observes: “Every person’s story is different and we must be careful not to lump them together”.1 It is also true that aged care and mental health systems need much greater government investment. However, this alone will be unable to deal with the highly particularised needs of people whose lives have become unbearable despite the best medical or palliative care. The 2016 Victorian inquiry into end of life choices stated: “Under the existing legal framework, Victorians with serious and incurable conditions and irremediable suffering are exposed to the possibility of a traumatic death. Some are driven to suicide.”3 The inquiry recommended a legal framework to allow assisted dying for the small number of people who seek help to end their suffering. Such legal reform would surely provide great reassurance by ending the fear of enforced protracted suffering, which leads to pre-emptive and often violent suicides. Examples of the tragic circumstances triggering these actions were compellingly recounted by Coroner John Olle before the Victorian inquiry4 and alluded to in Murphy’s own account of reading “emotionally draining” case files of suicides in nursing homes. The legal status quo is an indictment of a civilised society.

Julia M Anaf

In reply

Briony J Murphy

To the Editor:We commend Kahn and colleagues1 for publishing their data on the pre-hospital use of fibrinolysis and showing that the outcomes were similar to those treated by primary percutaneous coronary intervention (PCI). However, we noted that the median first medical contact to device time for those receiving primary PCI was 130 minutes, and indeed > 75% of patients had longer than the 90 minutes recommended in the recent National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand guidelines.2 Although there is still some uncertainty about acceptable time delays to PCI, these data suggest that even more individuals should be receiving pre-hospital thrombolysis. As an alternative, perhaps patients should be randomised in clinical trials that address the relative usefulness of these two reperfusion strategies in circumstances of likely moderately prolonged times to primary PCI. Moreover, among those patients undergoing pharmaco-invasive PCI, the dose of the fibrinolytic drugs used requires definition.3

John K French · Derek P Chew · Richard W Harper · Philip EG Aylward

In reply

Arshad A Khan · Peter J Fletcher · Andrew J Boyle

To the Editor:Acute stroke management has undergone major transformations with the advent of endovascular thrombectomy, but there remains a large gap in care between metropolitan and rural Australia. While metropolitan stroke centres are currently redesigning their services to expedite intervention for patients eligible for endovascular thrombectomy, rural and remote areas are still lagging behind with basic stroke therapies. Alteplase therapy for acute stroke within 4.5 hours remains the bedrock of treatment. Nevertheless, presenting to a hospital that has the capability to facilitate this treatment is not as simple for a rural patient as for a metropolitan patient. Distance and isolation are major factors in preventing access to treatment, as is lack of local expertise. In addition, there is a paucity of neurologists working in rural Australia. Where Melbourne and Sydney boast one neurologist for every 25 000 persons, rural Australia ranges from one in 100 000–200 000 people (Costello, C. Australian and New Zealand Association of Neurologists Workforce Survey. Sydney: ANZAN; 2016 [unpublished internal report]). There are rural physicians who are skilled in the management of acute stroke, but there remain barriers and reluctance to use thrombolysis within this group.1 The impact of stroke also significantly burdens the rural Indigenous community. In the Northern Territory, the Indigenous population have a three times higher incidence (307 per 100 000 people) of stroke, a younger age of onset (10 years earlier), higher case fatality, higher stroke recurrence and higher cost of lifetime stroke compared with non-Indigenous and metropolitan patients.2,3 Due to remoteness and delays in transfer, Indigenous people often miss the opportunity for acute therapy. Telestroke services are currently being used in certain parts of regional Australia; they are an effective, safe and efficient method of bringing the metropolitan neurologist to the rural patient’s bedside.4 However, more resources must be invested to make this a service that covers all corners of the country. In addition, it is necessary to implement better recruitment strategies for neurologists to rural centres and stroke-specific public health campaigns that are culturally appropriate, and to increase funding for research to design innovative and creative ways to provide comprehensive care to remote patients. Urgent action is required now; otherwise, an isolated part of our country and community will only face greater challenges over time.

Prashanth Ramachandran · James Burrow

To the Editor:Hepatitis E virus (HEV) genotype 3, the most common genotype in high income countries, is transmitted by ingestion of high risk food — including pork, deer and shellfish — and by blood transfusion. Rural residence, travel to hyperendemic areas (eg, southern Europe) and animal exposure are other risk factors.1 Both de novo and reactivated HEV infection can lead to chronic infection in up to 60% of immunocompromised patients, particularly in solid organ transplant (SOT) recipients.1,2 Moreover, 10% of patients who are chronically infected develop cirrhosis.1 In a 2013 study, the seroprevalence of HEV in Australian blood donors was 5.99%.3 Autochthonous transmission in Australia, including one patient who was a liver transplant recipient, is well documented.4,5 However, the seroprevalence and rate of chronic HEV infection in SOT recipients in Australia are unknown. We carried out a study to investigate this in an Australian tertiary hospital. In phase 1 of our study, we recruited renal transplant recipients attending routine outpatient follow-up in 2014–15; phase 2 was limited to seropositive participants from phase 1. The study was approved by the Northern Sydney Local Health District Human Research Ethics Committee (LNR/14/HAWKE/300). Seventy-four patients consented to participate in phase 1, and post-transplant stored serum was tested for HEV IgG. Six participants were HEV IgG positive. One seropositive participant died of invasive fungal infection before phase 2. The remaining five participants who were seropositive consented to phase 2, of whom one was HEV IgM positive. We tested plasma for HEV RNA and no phase 2 participants had evidence of ongoing chronic infection. While our study had limitations and we did not identify any participant with chronic infection, it is important to note that Australian SOT recipients are exposed to HEV and are at risk of chronic infection. Effective therapy for chronic HEV is available; therefore, we recommend that SOT recipients who have abnormal liver function tests should be tested for HEV RNA in blood to maximise early diagnosis. In addition, with respect to risk mitigation, previous Australian research supports a link between local pork consumption and HEV infection,4 and French guidelines suggest that SOT recipients should avoid consuming food containing pork liver.6 We believe that similar advice should be given to SOT recipients in Australia. Moreover, consideration should be given to screening donated blood in Australia for HEV RNA, as done in France and the United Kingdom, with experts calling for such screening across the European Union.7,8 The Australian Red Cross Blood Service has undertaken a large scale screening study of donated plasma for HEV RNA to estimate the local risk of HEV transmission by blood transfusion, with results currently pending.9

James P Newcombe · Stella McGinn · Bruce Wong · Archie Darbar · George Kotsiou

To the Editor:We report an extensive investigation into a cluster of five confirmed cases of Legionnaires’ disease in Sydney’s Inner West in May 2016. The patients were aged 62–89 years, four were men, all were ex-smokers, and four had significant comorbidities, such as immunosuppression. Hospitalisations lasted a median of 6 days and one patient died. All patients tested positive for Legionella pneumophila serogroup 1 urinary antigens; however, L. pneumophila was isolated by culture in only one patient. Patients were interviewed to obtain the histories of where they had been in the 2–10 days before the onset of symptoms (the incubation period), and then, to identify the focus for our environmental investigation, we mapped the locations against water source locations.1 Local councils assisted in the collection of water samples: 86 samples were obtained from cooling towers and 15 from other sites, such as fountains. At the time of sampling, requests were made for immediate cleaning of all visibly unclean air conditioning cooling towers or those with cloudy water. Only one sample tested positive for Legionella: a fountain with a low positive result of Legionella anisa. If Legionella isolates are genetically indistinguishable, the genomic sequencing of clinical and environmental samples is a useful tool that can link cases to each other and to an environmental source. In this investigation, L. pneumophila was cultured in only one case and in no environmental samples; therefore, we could not link cases to each other or to an environmental source by genotyping, leaving the possibility that cases were unrelated and sporadic. Despite this investigation, no environmental source for these infections was identified. It is uncommon in an investigation of this size to not detect L. pneumophila in any cooling towers — a routine New South Wales survey found L. pneumophila in 2% of cooling towers in a non-outbreak situation.2 Possible explanations for not detecting Legionella include low sensitivity of sampling at one point in time, incidental and possibly unrelated cleaning of the source cooling tower before sampling, or underestimating the distance that contaminated aerosols may travel, meaning that the source cooling tower was not sampled.3 No further cases with similar exposures were reported in the period immediately after the environmental investigation. This suggests that the extensive public health interventions taken at the time to remedy the problems identified may have been effective, or that incidental cleaning of cooling towers before our sampling may have eliminated the potential source.

Marianne Dowsett · Emma Quinn · Leena Gupta

To the Editor:Biobanking involves the collection, processing, storage and distribution of biospecimens and data, and, in recent years, it has rapidly evolved to become an integral component in biomedical research.1 Biobanks may range in complexity from a single researcher storing their own material to large stores of material used by multiple researchers. This diversity has complicated the standardisation of biobanking practices,2,3 sometimes compromising biospecimen quality and storage capacity4 and the security of funding. In turn, irreproducible research results, poor biospecimen access and decreased public confidence may ensue.4 Therefore, New South Wales Health Pathology — a statewide clinical diagnostic service — has adapted and launched a Biobank Certification Program in conjunction with the Canadian Office of Biobank Education and Research and the Canadian Tissue Repository Network, where the program has been operating successfully for 4 years.5 This voluntary program aims to improve the quality of biobanking practices and raise standards through the provision of education modules and document templates. To encourage participation, the program is free for NSW biobanks and associated pathology laboratories for the first year. Nominal fees will subsequently apply for non-NSW Health organisations. Certification requires the biobank or pathology leader to register details of the biobank and complete (with team members) up to nine pertinent education modules, submit a declaration of compliance to adhere to best practices and upload key documents for auditor review. Moreover, biobanks may also opt to be listed on a publically available biobank locator. The program is designed as a first step towards improving the quality of biobanks for stakeholders, including researchers, multicentre trials, ethics committees, funders and the public. Current biobank practices are diverse, making a formal accreditation system impractical for some biobanks to undertake. It is envisaged that the program — subject to evaluation and uptake of staff education modules — may provide a foundation for a future accreditation program. Further information is available at https://nsw.biobanking.org.

Jane E Carpenter · Amanda Rush · Candace Carter

To the Editor:In our study,1 we engaged the services of a third party online panel to recruit survey participants. Pre-existing information on private health insurance status, smoking status and exercise participation for those completing the survey was provided by the third party, who has now confirmed that the data initially labelled as “private health insurance” were actually “smoking” status. All other demographic information used in our analysis was collected directly from participants completing the online survey. We initially reported a positive association between private health insurance and being bulk-billed (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.09–1.78). However, the discovery of this labelling error better explains the positive association we initially reported for those data; it is smokers who are more likely to be bulk-billed than non-smokers, not those with private health insurance being more likely to be bulk-billed than those without private health insurance. Retaining these data on smoking status in our model, and adding in the correct data for private health insurance status, we observe that those with private health insurance are less likely to be bulk-billed than those without it (OR, 0.63; 95% CI, 0.51–0.77). The remaining relationships between individuals’ characteristics and the likelihood of being bulked-billed are unchanged from those reported previously. The results from the updated multivariate logistic regression analysis are provided in the Box. Box – Odds ratios for factors associated with bulk billing (n = 2467) Multivariate regression statistic Wald χ2 = 234.63 (P = < 0.001). Bars represent 95% confidence intervals (CIs). For each category, except age, the base factor appears without a 95% CI and straddles the line at 1. The number of respondents included was reduced by ten due to six missing observations for age and four missing observations for concession card status. * P = < 0.05 compared with the base factor.

Richard De Abreu Lourenco · Patricia Kenny · Marion R Haas · Jane P Hall

To the Editor:I question that clinicians and the public may be reassured that the evidence underpinning the renewal of the National Cervical Screening Program (NCSP) is sound.1 A fundamental aspect of the sensitivity of a screening test is the definition of the disease of interest that the test seeks to detect. For cancer screening, it is disease that will progress to life-threatening cancer and not the sensitivity to detect disease that only may progress to cancer.2,3 It is a very common but profound error to consider these equivalent,2 particularly when comparing two tests that measure different aspects of the disease process. Overdiagnosis and regression biases are avoided by using the interval cancer method to estimate sensitivity.2,3 The estimates of the sensitivity of human papillomavirus (HPV) testing and cytology, used in the models of the New South Wales group to justify the NCSP renewal policy, were for the detection of cervical intraepithelial neoplasia (CIN) grade 2+ and not for the detection of progressing disease.4 Their approach is fraught because CIN 2 and CIN 3 have different rates of regression and persistence. A higher sensitivity of HPV to detect CIN 2, but lower sensitivity to detect CIN 3 or progressive disease, will produce a lower effectiveness to reduce invasive cervical cancer than cytology, despite a higher sensitivity to detect CIN 2+. There is evidence from the randomised controlled trials that this is the case, even within the regression, persistence but no progression, and progression spectrum of CIN 3. The results of the only randomised trial of the implementation of HPV testing in a screening program, published in 2013,2 found the sensitivity of HPV testing (87%) to detect disease that progresses to invasive cervical cancer to be lower than cytology screening (93%). The authors concluded that “sensitivity of HPV testing was similar to that of Pap testing but caused more overdiagnosis. Therefore, implementation of HPV testing needs to be reconsidered especially in countries with well organised programmes”. This suggests that it is mathematically impossible for HPV testing to provide greater protection from invasive cervical cancer than cytology. Assuming participation of 80%, the renewal program will increase the incidence of cervical cancer by about 39%, and the unit of economic effectiveness will be dollars saved per life prematurely lost. From the perspective of public health medicine, it would be professionally negligent not to estimate the effect of moving to 5-yearly HPV testing using the Finnish estimates of the sensitivity of HPV testing and cytology, but instead rely only on estimates with major regression and overdiagnosis bias.4

Brian Cox

In reply

Jonathan Carter · Ian Hammond · Megan Smith

To the Editor:As 2017 marks the 10-year anniversary of the Australian Scleroderma Interest Group (ASIG), we want to raise awareness of the significant morbidity and mortality associated with systemic sclerosis (SSc), a chronic multisystem autoimmune disorder characterised by vasculopathy and fibrosis, with a particular focus on SSc-related pulmonary arterial hypertension (PAH).1 SSc-PAH is the leading cause of SSc-related death with a survival, once symptomatic, of only 2–3 years without treatment.2 Survival may be improved by annual screening with algorithms incorporating transthoracic echocardiogram and pulmonary function tests — even after adjustment for lead-time bias — and with early implementation of specific PAH therapies available through the Pharmaceutical Benefits Scheme (PBS).3 Thus, annual screening is recommended4 to identify patients who should undergo right heart catheterisation to confirm the diagnosis. Despite the documented benefits of PAH screening, physician adherence in Australia is suboptimal, with over 40% not adhering to annual screening.5 Therefore, the Australian Scleroderma Cohort Study (ASCS) was established in 2007 as a web-based screening platform for the cardiorespiratory manifestations of SSc, particularly PAH. The ASCS is a nationwide project where patients with SSc are recruited from 13 participating centres across Australia. Physicians who are not part of ASIG and care for patients with SSc are invited to refer patients for the screening service. Over the past 9 years, 1636 patients with SSc have been recruited and, as a result of annual screening, 194 patients (11.9%) have been diagnosed with PAH. All patients have received a specific PAH therapy. In Australia, the PBS only subsidises monotherapy (treatment with one PAH therapy at any one time) in patients with PAH who are in the World Health Organization (WHO) functional classes III or IV. International data have shown that patients treated earlier, such as those in the WHO functional class II, before damage to the right ventricle has occurred, have an improved survival rate over those treated later and those in a worse WHO functional class. Furthermore, patients treated with combination therapy (treatment with two specific PAH agents at the same time) have a survival benefit compared with those treated with monotherapy only.6 In the coming years, ASIG will continue to campaign to optimise screening and the treatment of SSc-PAH through efforts directed at closing the evidence–practice and evidence–policy gap in Australia, with the goal of improving outcomes for patients who have this incapacitating disease.

Mandana Nikpour · Susanna Proudman · Kathleen Morrisroe · Joanne M Sahhar · Wendy Stevens

To the Editor:We present a case that illustrates the need for careful medical evaluation of pigmented lesions, and the potential risks associated with laser treatment by non-medical providers. A 56-year-old nurse presented to the Victorian Melanoma Service for management of a biopsy-proven lentigo maligna on her right cheek. The patient described an 18-month history of a growing pigmented lesion that had initially been treated by a non-medical cosmetic clinic using laser. There had been no formal clinical or dermoscopic assessment of the pigmented lesion before the laser treatment. Although initially there was complete clearance of the pigment, the lesion recurred over the following 12 months (Box), prompting the patient to seek medical advice. Relevant melanoma risk factors included a family history of melanoma and significant prior sun exposure. Pigmented lesions should only be treated by medical experts given that the diagnostic possibilities range from benign to malignant pathologies, including melanoma.1 There is an increasing tendency in the aesthetic industry to treat pigmented lesions with modalities such as laser, as if they were merely a cosmetic problem. The potentially fatal consequences of laser treatment of pigmented lesions performed by untrained providers has been described in the literature.1,2 However, causation of melanoma by laser, with resultant malignant proliferation or transformation, has not been proven.2 Nevertheless, performing laser treatments on undifferentiated pigmented lesions can delay diagnosis and lead to more devastating outcomes, including metastasis.2,3 To maintain patient safety, pigmented lesions should be assessed medically before any cosmetic treatment.2,4 There is a vast array of unregulated, non-medical cosmetic practices that may use destructive treatments, such as laser, for pigmented lesions. It is therefore essential to increase the awareness of the general public in the face of this potential danger. Box – Recurring lesion after laser therapy

Harini Rajgopal Bala · Yan Pan · Rosemary L Nixon

To the Editor:I read with interest the Medical Education article by Elder and Nair1 and I was surprised that it suggested that the assessment of the jugular vein pulsation should be done “in whatever position the patient is in”. I am often shocked by the fact that medical students are taught to look for the jugular venous pulsation with the patient positioned at 45 degrees. In a person who is asymptomatic and lying flat, without any obvious distress and who has no fluid retention clinically, the pressures in the right atrium will be in the range of 2–8 mmHg and it would be impossible to see the top of the jugular venous pulsation if the patient was elevated. In most patients, the jugular venous pulsation should be assessed by examining the patient in the supine position. Elevation should only be undertaken if there is obvious fluid retention or dyspnoea when lying flat. If there is any question after examining the patient in the supine position, then the patient may be elevated to ensure that the correct peak of the jugular venous pulsation is seen. However, if students are taught to examine the jugular venous pulsation only when the patient is sitting up, then it will seldom be seen in a person who has normal right atrial pressure. I believe this concern should be brought to the attention of all clinical educators so that they clearly explain when the jugular venous pulsation should be examined in the supine position and when it is necessary to elevate the patient to the 45 degrees position.

Stanley Peter Woodhouse