Letters

First-line monoclonal antibody therapy to prevent bone loss in bone-metastatic breast and prostate cancers is delivered subcutaneously, often by general practitioners who need to be aware that this treatment in patients with low vitamin D levels, impaired renal function and poor calcium absorption (all often seen in older patients) can lead to serious hypocalcaemia.

Jennifer M McLachlan · Gavin M Marx · Margaret Bridgman

To the Editor: Guidelines for the management of absolute cardiovascular disease risk, published recently by the National Vascular Disease Prevention Alliance, contain the following evidence-based recommendations (EBRs) for choice of blood pressure-lowering therapy: EBR 11: Treatment should begin with any one of the following agents: · ACE [angiotensin-converting enzyme] inhibitor · Angiotensin receptor blocker · Calcium channel blocker · Low dose thiazide or thiazide-like diuretic. EBR 12: If monotherapy does not ...

Timothy Usherwood

In reply: On behalf of the National Vascular Disease Prevention Alliance, I thank Usherwood for raising concerns about the evidence-based recommendations (EBRs) within the Guidelines for the management of absolute cardiovascular disease risk.1 These guidelines inform a comprehensive, absolute risk approach to prevention of cardiovascular disease, and were approved by the National Health and Medical Research Council in 2012. Usherwood’s concerns are specific to treatment recommendations ...

Robert D Grenfell

To the Editor: Increased numbers of medical graduates in Australia over recent years are causing great concern about the capacity of current prevocational training systems to effectively absorb extra trainees.1 For example, in the Australian Capital Territory, 42 intern positions in 2007 increased to 96 in 2013 — an increase of 130%. ACT Health has seen this increase in intern and junior doctor numbers as an opportunity to improve current ...

Melanie Angstmann · Tobias J Angstmann · Tim McDonald

Lead is toxic at picomolar concentrations, but what is the best basis for determining the intervention level for its concentration in blood?

Ian H Wilson · Simon B Wilson

In reply: In epidemiology, the weight-of-evidence approach is useful for reaching general conclusions, whereas details from selected studies are useful for understanding nuances. This is particularly important when evidence from human and experimental research is consistent across multiple studies and in populations with different characteristics, including Australia.1-3 There will always be limitations and unmeasured confounders, but, ultimately, we can rely on controlled laboratory studies which ...

Mark P Taylor · Bruce P Lanphear · Chris Winder

To the Editor: BCG is an effective vaccine to prevent tuberculosis (TB) in young children travelling to countries with a high prevalence of TB.1 Although it does not completely mitigate the risk of developing TB, nor the need for preventive therapy after a significant TB exposure, it provides about 80% protection against the severe forms of TB that affect infants and young children.2 In Australia, ...

Amanda Gwee · Ranmali Rodrigo · Dan Casalaz · Nicole Ritz · Nigel Curtis

To the Editor: I commend de Costa and Rane1 for highlighting a matter that has been causing me increasing concern over the past few years; namely, the decline in undergraduate education in obstetrics and gynaecology. Coincidentally, a couple of weeks before their article was published, I was the consultant on call at a rural hospital and was asked to see a young woman who turned out ...

Graeme J Dennerstein

To the Editor: In his article on the German Medical Association’s apology for medical crimes under Nazism, Weisz states “One can but hope that it will be soon followed by an apology from the Austrian Medical Association”.1 Having been in Vienna on the 75th anniversary of the Anschluss (the annexation of Austria by Germany in March 1938), I would like to comment as to why ...

Peter M Winterton

In reply: I thank Winterton for providing important information about Austria’s attitude towards its participation in Nazi atrocities. Nazi crimes perpetrated in Austria include those at the Mauthausen-Gusen concentration camp, where over a quarter of a million inmates perished. The Austrian government has acknowledged this by establishing the Mauthausen Memorial. However, the Austrian Medical Association remains silent. Recall Irmfried Eberl, the Austrian doctor who was the ...

George M Weisz

Twitter is being used to promote alcohol, and this includes promoting it to people who are underage; putting an end to this practice requires political will and international cooperation.

Ann M Dadich · Suzan M Burton · Alena Soboleva

In Victoria, from 2001 to 2011, 115 deaths were identified with codeine and ibuprofen co-detected in postmortem toxicological analysis or with codeine–ibuprofen analgesic misuse described in the coroners’ findings.

Jennifer L Pilgrim · Malcolm Dobbin · Olaf H Drummer

A young boy’s painful encounter with a moth playing possum.

John J van Bockxmeer · Jennifer Green

To the Editor: The gluten-free (GF) diet for people with coeliac disease (CD) is complex, costly, and compliance with the diet is variable. Coeliac Australia, with the Australian Food and Grocery Council, are lobbying to increase the mandated gluten threshold for GF foods.1 The situation in Australia since 1995 has been that there must be “no detectable gluten” in foods labelled “gluten free”. The proposed new ...

Geoffrey M Forbes

To the Editor: We are concerned that recent media reports about a 17-year-old Sydney boy who died after allegedly consuming 25B- or 25I-NBOMe might lead to an increase in the incidence of NBOMe toxicity among patients presenting to emergency departments. NBOMe was reported to be available online for as little as $1.50 per tab.1 The subsequent media interest is likely to have increased public awareness of ...

David G E Caldicott · Stephen J Bright · Monica J Barratt

While it is encouraging that new, effective, anticoagulant agents have been added to the anticoagulant pharmacopoeia, specific concerns are raised about the management of intracranial haemorrhage in patients treated with dabigatran.

Piers A W Thomas · Nicholas B Schaerf · Jeffrey V Rosenfeld

To the Editor: In their editorial on stroke care in Australia, Hoffman and Lindley state “only 7% of ischaemic stroke patients received thrombolysis treatment, yet for every 100 patients who receive it, there are up to 10 extra independent survivors”,1 citing the most recent meta-analysis.2 This research also found a significant increase in the risk of early death with thrombolysis, mostly from intracranial haemorrhage. For the individual ...

Stephen P J Macdonald

To the Editor: We concur with Hoffman and Lindley that dedicated funding for implementation of a comprehensive stroke strategy is overdue.1 The importance of funding the implementation of evidence-based care has been recognised by the New South Wales Agency for Clinical Innovation (ACI). Two key projects are currently putting high-level evidence into practice in NSW. The first is the Quality in Acute Stroke Care (QASC) ...

Sandy Middleton · Nigel Lyons

In reply: In response to Macdonald’s letter, we agree there are many effective interventions for stroke that should be routinely available, including stroke units and early coordinated care for minor strokes and transient ischaemic attacks (early care is particularly neglected in Australia). However, thrombolysis is one of the interventions that should be more widely available. Australian and international guidelines (the National Health and Medical Research ...

Tammy C Hoffmann · Richard I Lindley

To the Editor: The evidence that industrially produced trans fatty acids (TFAs) increase the risk of coronary heart disease is compelling, and it is widely agreed that their use in food products should be minimised.1-3 Dietary TFAs are generally found in higher quantities in “unhealthy” food products,4 consumption of which is also found to follow predictable socio-demographic patterns.5 Thus, although the average TFA intake for ...

Kathryn Backholer · Anna Peeters

Renal infarction is a rare cause of abdominal or flank pain. This is the first reported case of an acute thrombosis in an accessory renal artery causing a renal infarction.

Elizabeth C Travis · Vicki A Quincey

Using a new assay method on an old set of samples reveals that the role of high-sensitivity troponin in the real world still requires clarification

Daniel M Fatovich · Michael R Phillips · Kelley M Hubble · Samuel D Vasikaran

To the Editor: Alcohol and other drug (AOD)-related harms are considerable,1 yet individuals with AOD disorders are reluctant to seek treatment.2,3 Barriers to help-seeking include issues of stigma and a lack of understanding of what treatment involves. One possible approach to improving access is the use of online tools that provide advice about available help options. While online screening for alcohol has shown value as ...

Ann S Wilson · David W Best · Michael Savic · Dan I Lubman

Why should authors choose to submit articles to the MJA?

Dev A S Kevat