Letters

To the Editor: It is truly difficult to understand by what standard the University of Melbourne defines its MD degree, which it commenced in 2011 to replace its previous MB BS degree. Several things are abundantly clear, however. The educational standard is distinctly short of the traditional British and Australasian higher doctorate degree. The University of Melbourne clearly recognises this itself, as it has renamed its own ...

Richard M Hanney

In reply: The Melbourne Medical School is celebrating its 150th anniversary this year. However, the University of Melbourne awarded medical degrees as early as 1856, including the award of the MD degree ad eundem gradum to the acknowledged founder of the Medical School, Anthony Colling Brownless, on the basis of his MD from St Andrews University, Scotland, obtained by examination in 1847. The MD is ...

James D Best · Geoffrey J McColl

To the Editor: In their recent article on emergency department (ED) waiting time performance data, Greene and Hall1 proposed that “assigning patients to a less urgent triage category than is appropriate” is a possible explanation for observed variations in waiting time performance. In Australia, triage decisions are made on the basis of clinical urgency. The Australasian Triage Scale is underpinned by a robust body of research ...

Julie Considine · Ramon Z Shaban · Marie F Gerdtz · Dianne Crellin

In reply: We thank Considine and colleagues for their interest in our recent article. Our research documented a relationship between the reported urgency mix of patients in emergency departments and waiting time performance, and we discussed possible explanations for the relationship, including “undertriaging”.1 We were explicit that the study did not provide evidence of undertriaging, but argued that it was a possibility worthy of consideration, ...

Jessica Greene · Jane Hall

To the Editor: The recent Australian Institute of Health and Welfare (AIHW) statistics on emergency department (ED) care show that 38% of attendances from 1 July 2011 to 30 June 2012 were potential general practice presentations.1 This indicator is reported under the National Healthcare Agreement. Both the AIHW and Council of Australian Governments acknowledge that this method is flawed and have agreed to review this indicator.2 To date, this ...

Yusuf Nagree · Andrew D Gosbell · Daniel M Fatovich · Peter A Cameron · Sally M McCarthy · David Mountain

To the Editor: Harrison and colleagues present data which confirm that inequitable distribution of mental health care is increasing under the Better Access program.1 They discount our promotion of the central role of general practitioners in the more restricted Better Outcomes program2 and our advocacy for GPs to resume those key activities despite lack of support under the Better Access program.3 The fatal decision that accompanied ...

Sebastian P Rosenberg · Ian B Hickie

In reply: We share Rosenberg and Hickie’s belief that general practitioners should play a central role in mental health care. We showed with Bettering the Evaluation and Care of Health (BEACH) data that GPs have played this role in both Better Outcomes and Better Access.1 Rosenberg and Hickie rely on administrative data to make inferences about clinical practice. They assume that GPs not claiming review items ...

Christopher M Harrison · Graeme C Miller · Helena C Britt

To the Editor: Beatson and Rao’s article1 appeared in the MJA Open supplement subtitled “A guide to management in primary care”. Despite acknowledging that it “can be difficult to distinguish between [borderline personality disorder] and [major depressive disorder]”, the authors offer no specific guidance for general practitioners on how to do this. Beatson and Rao cite no primary care research, although admittedly there is a dearth ...

Darryl L Lacey

In reply: Lacey suggests that the Dimensional Assessment of Personality Pathology – Basic Questionnaire (DAPP-BQ)1 can be a useful tool for the assessment of personality problems by academic general practitioners. We agree. Significant elevations on the DAPP-BQ’s affective lability, identity problems, insecure attachment, and self-harm scores would alert the practitioner to the probable — if not certain — presence of borderline personality disorder (BPD). However, the ...

Josephine A Beatson · Sathya Rao

To the Editor: We congratulate Kwan and colleagues on their evaluation of an online chlamydia testing program (OLC) in Western Australia. However, their study does not demonstrate OLC to be a “highly effective means of increasing access to testing among young people at risk of STIs [sexually transmitted infections]”.1 Adolescents account for 30% of chlamydia notifications in WA,2 yet only 37 of the 377 people (10%) who were ...

Peter S Azzopardi · Elissa C Kennedy · Alex D Brown

In reply: Azzopardi and colleagues seem to equate “young” with “adolescent”. We defined “young” as less than 30 years of age; 84% of chlamydia notifications in Western Australia occur in this age group,1 and they comprised 71% of online chlamydia testing program (OLC) users.2 This group accesses the internet frequently, with about 90% of Australians under 35 years of age using the internet at least once a ...

Lewis J Marshall · Edwina A Jachimowicz · Lisa Bastian · Donna B Mak

As the debate about older drivers continues, an observant reader notes another danger for car occupants lurking in an MJA illustration.

Paul Gerber

Deaths from hypothermia are not limited to colder climates or to the winter months. Older people who live alone without adequate heating are especially vulnerable.

Fiona Bright · Calle Winskog · Roger W Byard

To the Editor: We describe a case of unilateral central retinal vein occlusion (CRVO) in a 29-year-old woman during exposure to high altitude. She complained of blurred vision in her left eye, first noted when trekking to a maximum altitude of 6189 metres in Nepal 2 months earlier. She was not hypertensive and was not taking any medication, and had no previous history of thrombosis. Examination using a ...

Holly L Hutton · Randev Mendis · Lyndell L Lim

To the Editor: In London in the late 1960s, one of my chiefs regularly used a diathermy clamp (Med J Aust 2012; 197: 193) for the management of third and fourth degree piles. The patient was anaesthetised, placed in the lithotomy position, and draped. Meanwhile, the clamp was brought to red heat on a Bunsen burner in a side room and fetched into theatre by ...

William E M Renton-Power

The risks to the future child of morbidity associated with birth outside a hospital setting — largely ignored to date — need to be better quantified and communicated.

Lachlan J de Crespigny · Susan P Walker · Julian Savulescu

To the Editor: A major achievement of the National Immunisation Program is the progress towards elimination of congenital rubella syndrome and interruption of endemic rubella transmission in Australia.1 However, some population subgroups remain at risk of rubella infection. We describe a workplace outbreak in Perth in 2011. Between 30 June and 6 July 2011, three employees of the same organisation working in an open area on a single ...

Teresa M Ballestas · Suzanne P McEvoy

Some facilities in the United States have enforced a mandatory influenza vaccination policy with punitive action for noncompliance, resulting in sustained vaccination rates of above 97%.

Vivian K Y Leung · Susan E Harper · Monica A Slavin

To the Editor: Refugee health is an emerging area of clinical care. Over 200 000 humanitarian entrants have settled in Australia over the past 15 years, and the annual humanitarian intake has recently increased to 20 000 people.1 While there is (delayed) information on post-arrival refugee health screening, little is known about the longitudinal outcomes or use of health services in refugee-background Australians, and they remain invisible in existing population ...

Georgia A Paxton · Margaret P Kay · Ignacio Correa-Velez

To the Editor: Our scepticism about the value of many of the burgeoning number of clinical guidelines is reinforced by the position statement on vitamin D and health for adults.1 It was surprising not to find an explicit statement that there is Level I evidence that vitamin D monotherapy does not prevent falls2 or fractures3 or reduce mortality.4 Instead, Nowson and colleagues conclude that “there ...

Mark J Bolland · Andrew Grey · Tim Cundy

In reply: Our position statement summarised findings from the most relevant peer-reviewed literature.1 We clearly acknowledged that there are inconsistencies in the literature, as is often the case in many fields of medicine. Most Level I evidence indicates that vitamin D (combined with adequate calcium) reduces falls and fractures in older people. Mortality is also reduced.2 The combination of vitamin D supplementation with adequate calcium does ...

On behalf of the Working Group of the Australian and New Zealand Bone and Mineral Society, Endocrine Society of Australia and Osteoporosis Australia

To the Editor: Duckett makes a compelling argument for introducing non-pay for non-performance.1 However, such a scheme will not produce discernible results, for two reasons. First, interventions such as “time out” and surgical checklists have proven successful in reducing rare but clearly defined events, such as wrong-site surgery and retained foreign bodies.2 Not paying when these errors occur will have no impact on efforts to reduce ...

Sue M Evans · Peter A Cameron · John J McNeil

In reply: Evans and colleagues present their critique of my proposition1 to use incentives based on adverse events recorded in routine data as an alternative — it is not. Routine data, audits and registries all have a place in the quest to improve safety of care in hospitals. The financial impact of non-pay for non-performance may be small. However, early evidence from the United States suggests ...

Stephen J Duckett

Joyce contends in her recent article that “medical workforce supply levels follow a predictable, if lengthy, cycle between phases of shortage and surplus”. If this is the case, the scramble by the Australian Health Ministers’ Advisory Council to find internships for graduating medical students represents a stunning lapse in workforce planning. Marked growth in student numbers has occurred since the early 2000s, ...

Michael A Bonning · William J Milford · Rob D Mitchell

We read with interest the report by Handelsman describing an increase in Australian testosterone prescriptions, including a particular increase in prescribing of topical testosterone gel. The topically applied formulation of testosterone has a unique adverse-effect profile because of inadvertent exposure to it via direct skin contact. We report progressive virilisation in a 2-year-old girl who presented in 2011 with an 18-month history of body ...

Jacqueline K Hewitt · Margaret R Zacharin