Letters

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

In their recent article on false-positive screening mammograms and their effect on rescreening rates within the BreastScreen WA program, Sim and colleagues posit that an absolute reduction in future rescreening of 3 percentage points can be seen among women who are recalled for assessment but do not have breast cancer. The analysis presented did not adjust for other factors known to influence rescreening ...

Nathan A M Dunn

To the Editor: The recent editorial by Kefford1 fails to mention that (i) the 5-year survival for malignant melanoma is excellent at 89% for males and 91% for females; (ii) treatment with the new melanoma drug ipilimumab for the 1279 people who died from melanoma in 2007 would cost the Australian Government $156 million based on the quoted drug cost of $120 000 for a course of four injections; and ...

Graeme W Morgan

To the Editor: Kefford’s contention that making cancer drugs affordable requires coherent policy and cannot be left to market forces1 is correct. Two new drugs, ipilimumab and vemurafenib, are now approved by the United States Food and Drug Administration and the Australian Therapeutic Goods Administration for use in metastatic melanoma. However, their efficacy in a minority of patients is low. The cost of this palliative treatment ...

Sonia Fullerton

In reply: The letters of Morgan and Fullerton correctly emphasise the importance of palliative care in the management of patients with metastatic melanoma. They also draw attention to the immense cost of new drugs for melanoma, and their limited efficacy in life extension — something I also emphasised.1 Much ignored in this debate is the rapid and dramatic improvement in quality of life experienced by ...

Richard F Kefford

To the Editor: Methylnaltrexone is a peripheral opioid antagonist registered for the treatment of opioid-induced constipation (OIC) on the basis of quality Phase III studies.1 Monitoring uptake of a new medication such as methylnaltrexone after it has been listed on the Pharmaceutical Benefits Scheme (PBS) is crucial to understanding how such medications can be best used in routine clinical practice. Compared with the whole population, higher ...

Debra S Rowett · Katherine Clark · Maxine K Robinson · David C Currow

To the Editor: In September 2012, the Australian Institute of Health and Welfare (AIHW) released its report on cancer survival and prevalence in Australia from 1982 to 2010, incorporating incidence and mortality estimates for all malignancies reported to Australian cancer registries.1 Cancer is a leading cause of morbidity and mortality in Australia, accounting for about 20% of the total disease burden and 30% of deaths.2 Liver cancer ...

Jennifer H MacLachlan · Benjamin C Cowie

To the Editor: On 5 June 2012, the forum “Eliminating childhood lead toxicity in Australia — a little is still too much” was held at Macquarie University to examine new evidence on the toxicity of lead and its implications for Australian children and communities. Presently, the National Health and Medical Research Council (NHMRC) recommends an increasingly obsolete intervention level that was established in 1993: blood lead levels ...

Mark P Taylor · Chris Winder · Bruce P Lanphear

We support the recommendation of Runciman and colleagues for national agreement on clinical standards of health care, and highlight the importance of including routine health promotion activities as a core part of quality care in clinical practice. The indicators used by Runciman et al fail to consider core aspects of preventive care, such as screening and evidence-based behavioural interventions for lifestyle risk ...

Annemarie Wright · Bruce Bolam

Tests for serum vitamin B12 and red cell folate levels are commonly requested in elderly inpatients to rule out reversible causes of cognitive impairment (eg, delirium). This imposes some cost on the community. The evidence for the association of cognitive impairment and vitamin B12 deficiency is inconclusive. It is also unclear whether other markers, such as elevated mean corpuscular volume (MCV) and ...

Celia S M Ting · John C Oldroyd · Michele R Levinson

The implication by Wilson and colleagues that selection processes might at any stage be designed “to identify students ... who are likely to develop physical or mental illness ... that will impair their ability to practise in an empathic and professional manner” raises significant ethical and legal issues. The solution suggested by Wilson et al with reference to “fitness to practise” processes in place in medical schools suggests a link ...

Patrick D Mahar

To the Editor: Most of us in the medical profession would have had encounters with colour blind doctors at some stage, perhaps unknowingly. Colour blindness, more formally known as congenital colour vision deficiency (CVD), affects 8% of males and 0.4% of females.1 For those of us who perceive the world in a different spectrum, tasks involving colour in the workplace may provoke anxiety.2 One could argue ...

Navin I Dadlani

To the Editor: The closet is a common lesbian response to prejudice, discrimination and stigma. Many rural lesbians choose to “pass” as heterosexual and keep their sexuality secret.1,2 Research shows that this secrecy is fuelled by the fear of violence, including harassment, ostracism and rejection,2 and it is unlikely that a lesbian will disclose her sexuality to a doctor unless she feels safe. Without full ...

Cathy Wheel

To the Editor: The latest guidelines for the management of absolute cardiovascular disease (CVD) risk released by the National Vascular Disease Prevention Alliance1 question the utility of conventional risk assessment methods to accurately estimate cardiovascular risk of individuals with depression. Subsequently, these guidelines advocate that individuals assessed for CVD risk be assessed for depression and other psychosocial factors. This appears to be a promising advance, ...

Adrienne E O’Neil