Letters

In reply: We agree that our retrospective review1 did not provide all the details about neonatal morbidity and mortality. There were limited data available on the reasons for hospital transfer and neonatal death. We explained these limitations in the article and have hence embarked on a wider study of birthplace in Australia.2 It was interesting to us that even in this low-risk population, there were 10 breech ...

Christine Catling-Paull · Rebecca L Coddington · Maralyn J Foureur · Caroline S E Homer

Managing birthweight potentially reduces the risk of diabetes, but lifestyle factors are also important

Katherine A Thurber

In reply: We agree with Thurber that analyses were conducted within the framework of the developmental origins of health and disease hypothesis; however, we did not conclude that “interventions to ‘improve’ birthweight would be ineffective in reducing the prevalence of diabetes”. In line with the hypothesis, we included adolescent as well as birth factors, and suggested that strategies to improve lifestyle factors in childhood and ...

Susan M Sayers · Gurmeet R Singh

To the Editor: Despite evidence supporting the safety and benefits of influenza vaccination during pregnancy,1,2 half of pregnant women believe the influenza vaccine to be unsafe or are uncertain about its safety in pregnancy.3 Other studies report confusion among antenatal care providers about the safety of influenza vaccination during pregnancy, and cite the need for more professional education.4 To help address these safety concerns, the Western ...

Annette K Regan · Christopher C Blyth · Paul V Effler

To the Editor: I would like to thank Rintoul and colleagues for bringing together data from varied sources to highlight an important public health issue.1 The 1426% increase in supply of alprazolam they identified over the 20-year period from 1990 to 2010 was particularly striking. Alprazolam is indicated as a second-line treatment for panic disorder where other therapies are ineffective, or for short-term treatment of anxiety disorder. As ...

Tracy W Soh

To the Editor: Rintoul and colleagues showed that alprazolam is being increasingly detected in heroin-related deaths.1 One explanation provided is increased rates of alprazolam misuse among people who inject drugs. My colleagues and I recently reviewed the role of alprazolam in Australian clinical practice,2 focusing on the sole supported Pharmaceutical Benefits Scheme (PBS) indication: treatment of “panic disorder where other treatments have failed or are inappropriate”. ...

Steven Moylan

In reply: We thank Soh for her letter providing further evidence of harm relating to alprazolam misuse, which highlights deficiencies in postmarketing surveillance systems for pharmaceutical drugs. Reports of adverse drug reactions typically originate from therapeutic use; they seldom identify problems arising from misuse. Detection of misuse-related harm currently relies on ad-hoc epidemiological studies such as ours and that of Frei and colleagues, who documented ...

Angela C Rintoul · Malcolm D H Dobbin

To the Editor: Peripheral intravenous catheters (PIVCs) frequently cause Staphylococcus aureus bacteraemia, and a disproportionate number of episodes involve catheters that have been left in place for ≥ 4 days or have been inserted in emergencies.1 Other studies have shown similar results with catheters left in place for > 48 hours or not routinely replaced after emergency placements.2-4 At Canberra Hospital, we have followed all bloodstream infections (BSIs).5 Since 2002, ...

Peter J Collignon · Fiona J Kimber · Wendy D Beckingham · Jan L Roberts

In reply: We thank Collignon and colleagues for their letter regarding our study on peripheral intravenous catheter (PIVC)-associated Staphylococcus aureus bacteraemia.1 We agree with their comments. Both their data and ours support the potential importance of establishing a national standard for the insertion and management of PIVCs in Australia. Such a standard needs to address the basics of PIVC management: not inserting PIVCs unless required;2 ...

Rhonda L Stuart · M Lindsay Grayson · Paul D R Johnson

In reply: It is untrue that new recommendations for clinically indicated peripheral intravenous catheter (PIVC) replacement are based on phlebitis alone. A Cochrane systematic review considered catheter-related bloodstream infection (BSI) data from five randomised controlled trials (4806 patients) and found no evidence for the effectiveness of routine replacement (P = 0.64).1 The largest trial (3283 patients) studied both catheter-related BSIs and all-cause BSIs, finding no disadvantage to clinically ...

Claire M Rickard · Joan Webster · E Geoffrey Playford

To the Editor: In their review, Harris and Buchbinder call for a ban on all spinal injections of steroids.1 These injections are not a singular procedure; they differ by indications, technique, and the evidence that serves each. For the treatment of low back pain, no evidence supports the use of epidural steroids, and intra-articular injections of steroids are clearly no more effective than sham therapy.2 Disavowing ...

Nikolai Bogduk

To the Editor: We thank Harris and Buchbinder for their focus on interventional pain procedures.1 However, their description of the procedure they discuss has not been standard practice in pain medicine in Australia for many years. They misrepresent the Medicare Benefits Schedule (MBS) number 39013 to solely include facet joint injections, whereas it includes local anaesthetic medial branch blocks, which are an evidence-based diagnostic test for posterior elements as a source of spinal pain, and can be therapeutic in their own right.2 The number needed to treat (NNT) is the number of patients that need to be treated for one to benefit compared with a placebo or sham in a clinical trial. The ideal NNT is one. After a positive medial branch block response, radiofrequency medial branch neurotomies — a procedure with an NNT ranging from two patients3 to 4.4 patients4 treated for one patient to receive effective relief of spinal pain — creates a “therapeutic window” in which ongoing spinal rehabilitation can occur. From the 35 000 MBS number 39013 procedures performed in 2012, we can infer that fewer than 0.5% of Australians with spinal pain have facet joint injections and medial branch blocks in a 12-month period. Contrary to the comments of Harris and Buchbinder, lumbar transforaminal epidural steroid injections are effective for the treatment of radicular pain associated with disc protrusion, with an NNT of 2.7,5 and in conjunction with active pain strategies may forestall spinal surgery. Before impeaching facet joint injections and medial branch blocks, and thereby medial branch neurotomies, as well as lumbar transforaminal epidural steroid injections, Harris and Buchbinder should consider: interprofessional patient-centred approaches are key; pharmacological management is often ineffective; their view does not reflect the current practice of Australian pain medicine physicians; these procedures help people struggling to continue in social roles and maintain quality of life, so they help to reduce the economic impact of spinal pain on Australian society. We support education to improve evidence-based practice of interventional procedures.

Stephanie J Davies · Malcolm N Hogg · Eric J Visser

In reply: We thank Bogduk for his comments, but, based on previous reviews and some comparative studies,1-4 do not consider the transforaminal route to be clearly and consistently superior to the interlaminar route for radiculopathy. Further, we note that when the evidence for transforaminal injections is isolated to placebo-controlled trials, the evidence is based on very few studies. The largest of these showed marginal short-term (2-week) improvement in the steroid and local anaesthetic group over the saline group for the primary outcome (leg pain), an effect that was not sustained by 4 weeks.5 Short-term relief is a common finding in studies that use local anaesthetic in the active group. We consider the evidence for the effectiveness of transforaminal steroids over placebo to be neither strong nor consistent (within or between studies). We suggest that the gem in the bathwater be subject to more scrutiny and weighed against the risks and costs. We thank Davies and colleagues for their comments about medial branch blocks and transforaminal epidural steroid injections. We have addressed the latter in our response above. Our article does not extend beyond the use of steroids to procedures such as neurotomy, so we have not commented on this procedure here. Regarding medial branch blocks, we note that in a systematic review mentioned by Davies and colleagues, each of the randomised trials showed no significant difference in the response between groups treated with steroid and those treated with local anaesthetic alone.6 This reinforces our point that steroid injections in the spine have no specific therapeutic effect beyond natural history, the effect of any concomitant treatment or any placebo effect.

Ian A Harris · Rachelle Buchbinder

To the Editor: Silbert and colleagues highlight the benefits of peer-assisted learning (PAL).1 They allude to the number of overseas medical schools that provide tutor training programs, and to the possibility that Australian medical students are missing out on this opportunity. We agree that PAL is useful, but not all Australian medical students have been deprived. Since 2008, Monash University has been running VESPA (Vertical ...

Joanna H-M Tai · Sumudu P Cooray · Jonathan K Kam

To the Editor: Silbert and colleagues propose that teaching skills training should be compulsory for all medical students, to be used in peer-assisted learning programs and later in postgraduate roles.1 As the quality of student training will have an enduring impact on the provision of quality care and patient safety, the responsibility for this important role should be entrusted to a select group rather than ...

Michael Pearson

In reply: We agree that the quality of student training and competence of those delivering it are of utmost importance. However, we disagree with Pearson’s opinion that teaching “should be an honour bestowed on a few rather than a rite or obligation for all” and that only these “honourable few” should be trained.1 Involvement in any teaching confers benefits to both tutors and tutees1-3 and, ...

Benjamin I Silbert · Stephanie J P Lam · Robert D Henderson · Fiona R Lake

To the Editor: I thank Cameron and colleagues for their timely report,1 particularly in the context of publicity for a new self-help book by economist Emily Oster, which questions advice about avoiding alcohol during pregnancy.2,3 I note with interest that Cameron et al’s study reports that proportionally more of the women who consumed alcohol beyond the first trimester were older and more highly educated. Oster has ...

Tracy W Soh

Clinicians should sometimes just say no to the “just in case” peripheral intravenous catheter to reduce harm caused.

Claire Dendle · Rhonda L Stuart · Diana Egerton-Warburton

The coincident seasonality of active TB cases and vitamin D deficiency suggests that low vitamin D levels may increase the likelihood of reactivation of tuberculosis. Vitamin D testing and supplementation is therefore recommended for high-risk groups.

Jennifer H MacLachlan · Benjamin C Cowie

The PSA test is an important clinical tool that must be considered in its correct context.

Kenneth A Sikaris · Bronwen A Ross · Teck Y Khong