Letters

To the Editor: Patients who survive subarachnoid haemorrhage (SAH) are at significant risk of visual impairment, further complicating their recovery. This may arise as a result of Terson syndrome,1 which is the phenomenon of intraocular haemorrhage associated with any intracranial bleed and raised intracranial pressure. We report a case of missed Terson syndrome at a tertiary referral centre. A 36-year-old previously well woman presented with a ...

Akbar N Ashrafi · Rahul Chakrabarti · John Laidlaw

To the Editor: The United States medical education system is not a valid comparator in arguing for the shortening of training times for specialist doctors in Australia,1 whose training experience is already less than desirable. I was recently a medical observer at a major US training hospital, and there are significant differences in specialist training between the two countries. The Australian Medical Association Safe Hours campaign ...

David Ku

To the Editor: There are challenging ethical, legal and clinical issues associated with resuscitation and end-of-life care for older people. When an elderly patient with comorbidities and limited independence deteriorates, and is unable to participate in decision making, is it good medical practice to subject that person to invasive and traumatic resuscitation when the survival rate is less than 3.4%?1 Currently, many older patients will be ...

Campbell H Thompson · Margaret Brown

To the Editor: A rising awareness of the prevalence of 25-hydroxyvitamin D (25OHD) deficiency over the past decade is likely to have led to a surge in the number of individuals who undergo 25OHD testing.1 United States data indicate that testing for 25OHD has increased by 80%–90% annually,2 yet there are no reports that investigate the cost of 25OHD testing in Australia. We analysed the ...

Kellie L Bilinski · Steven C Boyages

To the Editor: The South Australian Institute of Medical Education and Training (SA IMET) recently conducted a review of internships in South Australia and proposed three potential changes.1 First, new prevocational training networks would rotate individual interns between more than one major teaching hospital. Under the existing system, most interns remain exclusively at one location, although there is an established southern network incorporating the Flinders ...

Thomas D Crowhurst · John Floridis · Lisa M Raven

To the Editor: A 23-year-old woman presented to the emergency department with bilateral pain, swelling and loss of power in her upper arms, which had started that morning. She had no history of significant trauma. Her medical history was significant for Wolff–Parkinson–White syndrome, diagnosed 3 weeks earlier at the same institution, and mild depression, diagnosed 8 months earlier, for which she had been taking desvenlafaxine (50 mg daily ...

Maximilian Stephens · Jeffrey T J Rowland · Anis Zand Irani

To the Editor: A 38-year-old HIV-positive Somalian refugee with a past history of pulmonary tuberculosis (TB) and poor compliance with antiretroviral therapy (ART) presented with fever, lethargy and mediastinal lymphadenopathy. He was diagnosed with fully drug-sensitive lymph node TB. The CD4 lymphocyte count at TB diagnosis was 20/µL (reference interval, 350–2630/µL), and the HIV RNA viral load was 99 000 copies/µL. Standard anti-TB treatment was commenced, and ART ...

Sarah L McGuinness · Joseph S Doyle · Alan C Street

To the Editor: Monshat and Castle have summarised the current state of play of mindfulness as an important component of the integrated management of chronic disease. So too medical students experience significant acute and chronic psychological disturbance, which impacts on their professional performance and personal life, as well as increasing their risk of substance misuse and suicidality.2 Strangely, in this respect, students and doctors have much ...

Jonathan P Page

Comment: In the 4 June issue of the Journal, I responded1 to an enquiry from McBryde2 as to why the Medical Journal of Australia decided not to publish an article by Haines and Lowenthal regarding the importance of a histological diagnosis when managing advanced cancer. I would like to clarify that the prime reason for rejecting the manuscript was that the patient in the case it reported ...

Annette G Katelaris

To the Editor: It has been estimated that “levelling the playing field” in terms of cardiovascular health alone could narrow the life-expectancy gap between Indigenous and non-Indigenous Australians by 6.5 years.1 While there has been a particular (and important) focus on risk factor modification, and prevention and management of chronic disease, it is worth noting that, compared with other Australians, Aboriginal and Torres Strait Islander people have: three ...

Robert D Grenfell · Vicki Wade · Eleanor Clune · Kelley O’Donohue · Prue Power

To the Editor: Woods and colleagues provide a timely and descriptive reminder of cyclone Yasi and the 2010–2011 summer.1 The evacuation of the hospitals on the Cairns foreshore, a decision made by the Queensland Premier, was the largest hospital evacuation in Australian history. The capability to successfully aeromedically transport 297 patients 1800 km, in a window of 22 hours, without loss of life or reported adverse clinical incident, was ...

Jeannette R Young · Mark S Elcock · Peter J Aitken

To the Editor: George,1 who has received a research grant from Pfizer on smoking cessation, makes the manifestly incorrect statement that “there is no evidence for the effectiveness of cold turkey cessation, especially in moderate to heavy smokers”. In fact, it has always been the case that the most common method used by ex-smokers in their final successful attempt to quit is cold turkey.2 Those promoting ...

Simon Chapman

In reply: The response of Chapman to my article is not surprising, given his involvement in the Alpert article.1 The recommendations of Alpert and colleagues have already been criticised internationally, and debate on the effectiveness of pharmacological smoking cessation therapies is not new. Meta-analyses have shown 50% to 70% greater quit rates for nicotine replacement therapy (NRT) compared with placebo or in controls.2,3 Advocates of ...

Johnson George

To the Editor: National disclosure of health care-associated infections has recently been facilitated by the launch of the MyHospitals website by the Australian Institute of Health and Welfare (http://www.myhospitals. gov.au). As high rates of Staphylococcus aureus bacteraemia (SAB) have been reported at our tertiary health care facility,1 we wish to outline the pitfalls and potential misrepresentation of generic health care infection surveillance data when used ...

Leon J Worth · Karin A Thursky · Monica A Slavin

To the Editor: Rates of health care-associated Staphylococcus aureus bacteraemia (HCA-SAB) and hand hygiene (HH) compliance are now subject to public disclosure on the MyHospitals website (http://www.myhospitals.gov.au). HH compliance and HH alcohol hand rub and liquid soap procurement have been associated with reduced methicillin-resistant (but not methicillin-sensitive) S. aureus bacteraemias, generally in the presence of other co-interventions.1,2 However, the National Hand Hygiene Initiative advocates that ...

E Geoffrey Playford · David McDougall · Mary-Louise McLaws

To the Editor: Speer and colleagues’ recent article concerning pancreatic cancer outcomes makes sobering reading.1 Notwithstanding the results of surgery being in line with other case series, they found a somewhat high rate (nearly 40%) of positive resection margins in patients undergoing surgery with curative intent. The authors also cite evidence from other studies indicating benefit from a small number of surgeons each performing a ...

Andrew A Thomson

To the Editor: A 24-year-old Sudanese woman presented to her general practitioner in 2011 with one month of fatigue, dizziness, abdominal distension and facial oedema. Hypocortisolaemia was present: morning cortisol, 13 nmol/L (reference interval [RI], 240–620 nmol/L), afternoon cortisol, 9 nmol/L (RI, 100–280 nmol/L). In contrast to this profile, she appeared cushingoid (moon facies, central obesity, skin fragility and striae) with skin depigmentation on her face, back and hands (Box, A). ...

Rebecca F Goldstein · Helena J Teede · Carolyn A Allan

To the Editor: Coiera and colleagues’ call for national e-health clinical safety governance1 is timely, given that the proposed rules and regulations for the personally controlled electronic health record (PCEHR) from the Department of Health and Ageing2 neglect this crucial component. The Royal Australasian College of Surgeons (RACS) has called on the Australian Government to provide better clinical governance arrangements for the PCEHR. In a letter ...

Julian A Smith

To the Editor: Although both sides of the debate about screening mammography1,2 acknowledge the mortality benefit due to screening and the risk of overdiagnosis, the magnitude and relative value of these need further clarification and reflection. In calculating the number of breast cancer deaths averted using a relative risk reduction of 35%, Roder and Olver overstate the benefit. Other estimates of effect are lower (eg, ...

Alexandra L Barratt · Paul P Glasziou

To the Editor: Recent studies have highlighted the safety of administering influenza vaccine derived from embryonated chicken eggs to egg-allergic individuals,1-3 as long as the vaccine contains no more than 1 g of egg ovalbumin per dose. This is reflected in recommendations by expert advisory groups including the Australasian Society of Clinical Immunology and Allergy.4 These recommendations have been strengthened by further evidence of the safety ...

Raymond J Mullins · Michael S Gold

To the Editor: Complementary medicines may lack evidence of safety and efficacy, but conventional medicine lacks evidence of efficacy in 30%–40% of cases,1 and the breast implant and hip replacement debates demonstrate safety concerns. The debates about conventional versus complementary medicine expose how out of touch the medical profession is with the views of government and the people about complementary medicine. The medical profession was ...

Simon J Spedding

To the Editor: The article by Wilson and colleagues concludes with the words: “... to ensure that only those applicants most likely to succeed are selected for medical training”.1 What does the word “succeed” really mean? Success is not only measured by the award of the MB BS (or MD). Academic brilliance and commitment to lifelong learning are not sufficient either. Compassion, kindness, respect for ...

Jeffrey V Rosenfeld

To the Editor: Wilson and colleagues thoughtfully summarise medical school selection procedures, highlighting the need for greater social accountability.1 We would strengthen the aim of choosing applicants with “the characteristics required to be competent medical practitioners”1 by arguing they should also be responsive to community needs. What are the “outcomes” of interest in selecting medical students? Methodological problems abound, and studies mostly consider outcomes that are ...

Tarun K Sen Gupta · Richard B Murray · Robin A Ray

In reply: We agree with Rosenfeld that success in medical training means more than graduating with knowledge, technical brilliance and commitment to lifelong learning. Admission interviews are designed to assess non-academic features, such as empathy, communication, working in teams and professionalism. We acknowledge that current selection processes are unable to identify students with major personality disorders or those who are likely to develop physical or mental ...

Ian G Wilson · Christopher Roberts · Eleanor M Flynn · Barbara N Griffin

To the Editor: At first, Thacker and Moseley appear to do an about-turn on much of their published work by de-emphasising the role of the brain and nervous system in the human pain experience.1 However, on closer scrutiny, their reflection encapsulates key messages for health professionals about pain not being located in the tissues, while exposing the inadequacy of non-person-centred approaches to their practice and ...

Lester E Jones · Laura Y Whitburn