Letters

To the Editor: We read with interest the article by Geelhoed and de Klerk1 regarding the mortality benefits of a policy that ensures high numbers of patients are admitted to hospital within 4 hours of arrival at an emergency department (ED). The proof of improved performance following service intervention within a complex institution requires careful consideration. ...

Dylan J Toh · Campbell H Thompson · Josephine S Thomas · Jeffrey Faunt

In reply: We thank Mitra and Cameron, and Toh and colleagues for their remarks. Comments from some physicians that the 4-hour rule might increase mortality provided the initial stimulus for us to look at data related to its introduction in Western Australia. Given our results, their hypothesis seems unlikely to be true. Mitra and Cameron point ...

Gary C Geelhoed · Nicholas H de Klerk

To the Editor: Extensive rainfall in Queensland from December 2010 to January 2011 led to much of the state being declared a disaster zone. We report on a cluster of patients requiring hospitalisation with an acute febrile illness after exposure to floodwater in Central Queensland. During the height of the flood emergency, four adults (23–56 years of age) from ...

Hugh Wright · Katie Goot · Benjamin Rogers

To the Editor: The HIV epidemic in Australia is changing. The number of new infections attributed to heterosexual contact has increased, and people from culturally and linguistically diverse (CALD) backgrounds account for a significant proportion of these diagnoses. In the period 2005–2009, 41% of new HIV diagnoses linked to heterosexual transmission were in people from ...

Augustine D Asante · Henrike Körner

To the Editor: Two aspects of developing or renewing medical curricula that were highlighted recently by Goulston and Oates1 deserve further qualification: the dynamic nature of a medical curriculum; and wide consultation with a broad range of academics. Because medical curricula are continually evolving, it is crucial to appoint and support the right people to lead ...

David A Kandiah

To the Editor: The recent letter by McLaren1 focuses attention on conflicts of interest which can arise from public, rather than private, relationships. We, as authors of a recent article on developing guidelines about conflicts ...

Dev A S Kevat · Michael J Williams · Bebe Loff

To the Editor: Clinical training opportunities are a vital component of medical student education.1 The yearly intake of medical students into Australian universities has more than doubled since 2000.2 There is a need for increased ...

Mark K D Tiong · Michele R Levinson · John C Oldroyd

To the Editor: Vertical transmission of Toxoplasma gondii can result in significant morbidity in the fetus and newborn, although it is rare in Australia.1 Antenatal testing has shown seroprevalence of 23%–35%,2,3 which is possibly lower ...

Jude C Jayamaha · Peter Robertson · William D Rawlinson

To the Editor: Strongyloidosis in Australia has been reported in Indigenous Australians, war veterans who have served in South-East Asia and travellers and immigrants from regions in which strongyloidosis is endemic.1,2 The condition is caused by ...

Hannah M Soulsby · Saliya Hewagama · Stephen Brady

To the Editor: From 2007 to 2009 in Australia, a three-dose course of quadrivalent human papillomavirus (HPV) vaccine was offered to all females aged 12–26 years through school and primary health care settings, with coverage recorded on the ...

Bianca Barbaro · Julia M L Brotherton · Dorota M Gertig

To the Editor: The possible extension of the Australian preadolescent female vaccination program against human papillomavirus (HPV) to preadolescent males is not a sensible use of public health resources. In Australia, 71% of 15-year-old girls completed ...

Peter D Massey · David N Durrheim

To the Editor: A “real world” study of smoking abstinence caught the attention of Australian media recently, who primarily focused on the commentary that “cold turkey” was the most successful approach for quitting smoking. Alpert and colleagues1 assessed the effects of nicotine replacement therapy (NRT) alone and/or in combination with behaviour counselling in 787 adult smokers from Massachusetts who had recently quit smoking. The participation rates at baseline and waves 2 and 3 were 46%, 56% and 68%, respectively. At each follow-up, almost one-third of participants reported that they had relapsed. Relapse rates were similar, regardless of NRT participation. This contradicted the higher quit rates seen with groups given NRT compared with the placebo or control groups reported in meta-analyses.2-4 Among previously heavy smokers, the lowest relapse rate was in those who received NRT and counselling; and among previously light smokers, the relapse rate was the lowest among those who did not receive NRT or counselling. In both groups, those who received only NRT had the worst relapse rates, a finding which reinforces the importance of adjunct counselling. Participants in the Alpert et al study1 self-reported NRT use. Quit status was not validated biochemically, which fails the Russell Standard5 of criteria applied to smoking cessation trials. Information on NRT dose, adherence, administration technique and reasons for shorter courses (eg, side effects, cost or perceived lack of benefit) were lacking. The longer term impact of NRT cannot be deduced from this study. The quality and quantity of psychological support received by each participant group was also unknown. It is unclear whether the study was adequately powered, given the small numbers of patients who completed a recommended course of NRT. Moreover, differential loss to follow-up threatens the study’s internal validity. Multiple attempts are often necessary before a smoker can successfully quit. Repeated yearly access to courses of NRT, as allowed under the Pharmaceutical Benefits Scheme (a 12-week supply of patches is allowed each year for clients entering a comprehensive smoking cessation support program), may confer a benefit in the longer term. There is no evidence for the effectiveness of cold turkey cessation, especially in moderate to heavy smokers. Nevertheless, those determined to quit without pharmacotherapy or additional support should be encouraged to try cold turkey cessation.

Johnson George

To the Editor: The editorial by Seibel1 was timely, given the promotion in February last year by the New South Wales Agency for Clinical Innovation of an osteoporotic refracture prevention model of care. The evidence presented by Seibel is compelling — osteoporosis is a serious, undermanaged and preventable problem, and there are no more excuses for not instituting refracture prevention protocols in major teaching hospitals. Not only do these programs work to prevent further patient morbidity and mortality, but they are cost-effective in reducing the burgeoning public hospital costs associated with recurrent fractures and hospital admissions. We question the delay in implementing such programs. One cost analysis showed that treating 214 patients saved $156 713 and reduced hospital stays by 270 bed-days over a 2-year period (John Van der Kallen, Rheumatologist, Hunter New England Local Health District, personal communication). More than 10 years ago, we demonstrated that minimal trauma fractures were inadequately managed and preventable, and outlined a cost-effective clinical pathway for monitoring and treating these patients when they presented through the emergency department.2-5 Had this program been instituted by the medical administration at that time, there would have been a saving over a 10-year period of more than $2 million by one major Sydney teaching hospital alone. Despite much talk and “hype” on the part of medical and allied health professionals, medical administrators and government agencies, nothing has eventuated. Unless there is an injection of funds from health departments and a willingness from hospital administrators to implement such programs, we believe that “nothing” will be what continues to happen.

David Spencer · Graydon Howe · Nicholas Manolios

To the Editor: In Australia, when melatonin is requested in doses higher than those available in preprepared formulations, in different dosage forms, or for people under 55 years of age, private prescriptions and extempora-neous preparations are often used. There is evidence of efficacy of melatonin in shiftwork-related sleep disorders, jet lag, circadian rhythm disorders, and for older people with chronic insomnia, but not for insomnia generally.1-3 There is concern over increasing use of melatonin in children, but no current data exist for actual melatonin usage patterns in Australia. In September 2010, we conducted a 2-week prospective drug use audit of melatonin prescriptions dispensed to patients by Australian compounding pharmacies. All pharmacies of the Professional Compounding Chemists of Australia (PCCA) (n = 153) received audit forms and explanatory information sheets, followed up by two telephone calls. The audit form requested patient details, the melatonin prescription, prescriber, dose amount and formulation prescribed, directions on prescription, and purpose of medication. This study was approved by the Human Research Ethics Committee of the University of Sydney. Forty-one pharmacies completed 228 audits, a response rate similar to recent pharmacy-based surveys.4 Also, 42 pharmacies estimated melatonin prescriptions in the audit period without completing patient details. The demographic details of respondents (Box) were similar to those in a previous survey of Australian compounding pharmacies.5 A total of 1463 melatonin prescriptions were reported as dispensed in the 2 weeks by 83 pharmacies (17.63 per pharmacy). In the detailed audit, the median age of people for whom melatonin was prescribed was 12 years; 56.4% (128/227) were male; the average dose prescribed was 4.3 mg ± 2.5 mg (range, 0.5 mg–20 mg); the most common reason for prescribing melatonin was to help sleep in cases of attention deficit hyperactivity disorder (ADHD); and paediatricians were the most common prescriber (43.0%; 96/223). Analysis of the non-responders showed that responders were not different to non-responders in age, sex, years of experience or pharmacy prescription volume. Extrapolating the results, 70 132 prescriptions (17.63 × 26 × 153) are estimated to be compounded in the 153 compounding pharmacies annually. This staggering figure does not include non-PCCA pharmacies, compounding hospital pharmacies, melatonin purchases without prescription (generally via the internet), or Circadin (Neurim Pharmaceuticals) prescriptions. Circadin was not included in our study as it was introduced in mid 2010 and there had been only a few sales by September 2010, and it is approved only for people over 55 years of age with primary insomnia. In conclusion, we found that melatonin was frequently dispensed, with many cases of off-label use, to both adults and children, particularly for insomnia in children with ADHD and autism. Melatonin has limited long-term safety data, and the long-term effect on gonadal development, particularly with high doses, is unclear. The efficacy and safety of melatonin in children will only be established through well designed trials of high methodological quality and sufficient sample size. Melatonin prescription details for 227 patients Demographic details of patients and prescribers Proportion or mean ± SD (range) (n = 227) Details of patients for whom melatonin was prescribed Age (years) 22.8 ± 20.9 (1–83) Age bracket 0–2 years 1.4% 3–5 years 10.1% 6–10 years 32.0% 11–18 years 19.6% 19–34 years 8.7% 34–55 years 19.6% > 55 years 8.2% Male 56.7% New prescription 29.1% (42.3% using > 6 months) Details of prescribers (from 227 audit forms*) Type of prescriber General practitioner 41.4% Paediatrician 43.2% Sleep specialist 5.7% Psychiatrist 4.8% Other specialist 3.5% Reason for prescription† Primary insomnia 26.4% Secondary insomnia 14.5% Jet lag, travelling, shift worker, CRD 12.8% Help sleep in children with ADHD 24.2% Help sleep in children with autism and behaviour problems other than ADHD 19.4% Anxiety, trauma, stress and sleep problems 3.5% Sleep problems related to pain and cancer 0.8% Sleep problems related to other comorbidities (gastro-oesophageal reflux disease, Grave’s disease) 0.8% Unsure of reason 0.8% Dose (mg) (n = 213) 4.3 ± 2.5 (0.5–20) Total amount prescribed for liquid formulations (mL) (n = 99) 55.2 ± 53.2 (5–300) Total amount prescribed for solid formulations (number of capsules, tablets, troches) (n = 123) 72.9 ± 37.9 (15–300) Repeats authorised (n = 221) 2.3 ± 2.1 (0–10) Prescription duration (months) (n = 200) 7.9 ± 9.7 (0–60) Formulation prescribed† Tablets 3.5% Capsules, slow release capsules 49.7% Liquids (suspension, oral, sublingual drops) 43.5% Troches 2.6% CRD = circadian rhythm disorder. ADHD = attention deficit hyperactivity disorder. * Some data missing on one record of 228, so 227 used for tabulation. † Percentages may not add to 100% because of some missing data, and some patients may have reported two reasons.

Jane Nikles · Victor Lo · Jennifer A Giam · Bandana Saini

To the Editor: I have read two recent reports on neurocysticercosis in the Journal.1,2 After performing a literature search for Australian cases of neurocysticercosis (PubMed search, using the terms “cysticercosis”, “neurocysticercosis” and “Australia”), I found reports of 39 patients, and the reports of 33 of these patients were published in the past two decades. This suggests that the prevalence of neurocysticercosis in Australia is rising, or that it has been increasingly recognised and reported in recent years. As expected in a developed country, more than three-quarters of the patients were immigrants from neurocysticercosis endemic areas, and the remainder were Australian residents who had travelled to endemic regions. So, although it appears that Australia is free of locally acquired neurocysticercosis, it is possible that some immigrants who developed the disease while living in Australia were not infected overseas, because some of them developed the disease more than 10 years after they migrated from their home countries. The occurrence of neurocysticercosis among people returning from endemic areas to cysticercosis-free countries shows that cysticerci may remain asymptomatic for a long time in the nervous system or may become symptomatic years (or even decades) after infection.3 Indeed, certain forms of neurocysticercosis, including calcifications, chronic arachnoiditis, subarachnoid cysts and even spinal cysticerci may manifest a long time after infection. However, the single cysticercus granuloma causes symptomatic disease in the first few months after infection;4 this form of the disease occurs mainly in people who have not had previous infection and involves an acute inflammatory reaction to the implantation of one cysticercus in the brain parenchyma. At least seven of the immigrants to Australia with neurocysticercosis had this form of the disease, and some of them developed symptoms up to 3 years after arrival, suggesting local acquisition of the disease from a contact infected with Taenia solium. Unfortunately, case reports and case series of neurocysticercosis diagnosed in Australia do not include information on whether household contacts of diagnosed patients had been tested for carriage of Taenia. Increased awareness of the mechanisms of disease transmission for neurocysticercosis will help to reduce further spread of this zoonosis.

Oscar H Del Brutto

To the Editor: Le and Chapman’s article1 on capacity at the end of life raises a number of timely issues, given our ageing population and the autonomous rights of individuals in end-of-life decision making.2 The authors made a best-interests decision, based on the patient’s humanity and their responsibility not to let him die “alone, cold and probably in pain”, contrary to his “decision” to die what would not be “a good death”. This stance can be problematic because best interests or good death are entirely subjective, and doctors who provide treatment to a competent patient may be committing trespass.3 Thus, the question of whether he was capable of making a decision to die “a bad death” is possibly more crucial. Structured capacity assessment is beneficial for the peace of mind of clinicians, patients and family. This patient lay on the floor “because he wished to do so” — a “limited realistic choice”. He was delirious and therefore deemed incompetent. Did the delirium affect his ability to weigh the pros and cons of staying on the floor and refusing hospital admission? Assessment of capacity to consent to medical treatment involves determining whether the patient is capable of understanding the ramifications of treatment and its alternatives (including no treatment). His premorbid choices (precedent autonomy)4 of living a squalid, isolated existence and refusing treatment for some time must also be noted. Yet capacity is dynamic and can change over time. Careful capacity assessment can justify decisions made on behalf of patients.

Sharon G Reutens · Carmelle Peisah

In reply: We thank Reutens and Peisah for their response to our article.1 We agree that careful capacity assessment is of critical importance — a patient’s capacity should be assessed rather than assumed. Delirium can often affect capacity due to the impact of attentional deficit on the process of decision making.2 In our case, the patient could neither reason through the ramifications of his decision to stay on the floor nor be involved in a logical discussion as to why we had concerns about his choice. Indeed, he had not chosen to be on the floor but was there because of his fall, his delirium and his inability to rise. However, we do caution that clinicians should trust their own clinical decisions when these are based on sound assessment. Choosing not to make hard decisions for fear of litigation (eg, committing trespass) does neither the patient, the community nor our profession any favours.

Brian H Le · Michael D Chapman

To the Editor: Kapur and colleagues correctly assert that the Declaration of Montréal states that “access to pain management is a fundamental human right”.1 The Declaration was proposed by International Association for the Study of Pain (IASP) delegates to the International Pain Summit and was approved by the IASP Council. However, Kapur et al incorrectly assert that the Declaration leaves the position of diagnosis uncertain, and that “the only specific treatment modality mentioned is opioid therapy”. Article 3 of the Declaration recognises: The right of all people with pain to have access to appropriate assessment and treatment of the pain by adequately trained health care professionals.2 Footnote 6 includes the need for “educational programs regarding pain assessment and treatment in all of the health care professions”. Thus, a label of “chronic pain” does not lead to a right to opioid treatment without proper assessment and consideration of treatment options. Footnote 6 refers to a range of treatment options, such as pain medications, including opioids and other essential medications for pain, and best-practice interdisciplinary and integrative nonpharmacological therapies, with access to professionals skilled in [their] safe and effective use ...2 It would be hard to describe the carefully worded articles, obligations and footnotes of the Declaration as “dogma, moral coercion or forays into jurisprudence”.1 At its General Assembly in 2011, the World Medical Association (WMA) supported measures to improve access to pain management. Dr Mukesh Haikerwal, Chair of the WMA, said: Physicians and other health care professionals have an ethical duty to offer proper clinical assessments to patients with pain and to offer appropriate treatment.3 Further, a WMA resolution asserted that people facing pain had a right to appropriate pain management, including effective medications such as morphine. Denial of pain treatment violated the right to health and might be medically unethical.3 It is puzzling that Awerbuch feels that describing chronic pain as a disease means that “the patient becomes the sole arbiter of whether he or she is ill. The prescribing doctor has no means by which to objectively determine treatment outcomes”.4 In the article to which he refers,5 and in other reports including Australia’s National Pain Strategy,6 the “disease” of chronic pain is described in terms of physical, psychological and environmental factors that require assessment by health professionals with adequate knowledge and training. This is not just a labelling exercise.

Michael J Cousins

To the Editor: Recent media reports related to Ian “Molly” Meldrum1 are a timely reminder, once again, of the risk of physical injury posed by a fall from a ladder. We carried out a survey of injuries sustained in falls from ladders among patients presenting to the Royal Prince Alfred Hospital (RPAH), an inner-Sydney major trauma centre, between January 2009 and December 2011. We linked data from the hospital trauma registry with data from the New South Wales Department of Health Centre for Epidemiology and Research. The trauma registry routinely collects data on all injury-related admissions and trauma team activations. NSW Health provided data from a free-text search for the term “ladder” within the presenting problems, triage text and diagnoses in the electronic medical records of all patients who presented to the RPAH emergency department (ED) during the period studied. For comparison, we also constructed a survey of injuries sustained by pedestrians struck by a motor vehicle. We used trauma registry data, from a previous study of patients with such injuries, for 409 consecutive patients admitted during 2008–2010. The study was approved by the Sydney Local Health District Ethics Review Committee (RPAH zone). We identified 331 ED presentations related to any ladder incident. Of these, 136 were available in the trauma registry for analysis. The mean age of patients was 54 years (SD, 17 years; 95% CI, 51–57), and a significant proportion (37; 27%) were 65 years or older. No inpatient deaths were reported. The most common body regions injured were upper limb (54; 40%) and head (41; 30%). Severe head injuries were sustained by 14 patients (10%) (Box). Although the proportion of patients with major trauma (injury severity score, > 15) was consistent with previous trauma registry reports,2,3 the proportion with head injury was much higher and may be related to the older age in this cohort. One recent study suggested that the incidence of major injury from ladder falls is increasing, particularly among older people.4 Many presentations for minor injury were not captured by the trauma registry; however, unlike previous reports, we included all patients requiring initial assessment by the trauma team. The proportions with severe head injury (head Abbreviated Injury Scale score, ≥ 3), intensive care admission and major trauma were similar between patients who fell from ladders and pedestrians who were struck by motor vehicles (10% v 12%, P = 0.50; 10% v 9%, P = 0.79; 12% v 15%, P = 0.30, respectively). Based on the significant proportion of people sustaining severe head injury, new ladder-safety initiatives are required, particularly targeting those aged 65 years and over. Demographic and injury profile of patients with injuries sustained in a fall from a ladder who were admitted to an inner-Sydney trauma centre, January 2009 – December 2011 (n = 136) Variable No. (%)* 95% CI Age, years (mean, SD) 54 (17) – Male 111 (82%) 76–89 Time of incident After hours† 30 (22%) 15–29 Weekend 37 (27%) 20–35 Height of fall < 1 m 29 (21%) 14–28 1–5 m 105 (77%) 69–83 > 5 m 2 (1%) 0–5 Hospital admission 95 (70%) 62–77 Intensive care admission 14 (10%) 5–15 Length of stay in hospital, days (mean, SD) 5.4 (8.9) – Injury severity score (mean, SD) 7 (5) – Major trauma‡ 16 (12%) 6–17 Body region injured Head 41 (30%) 22–38 Severe head injury§ 14 (10%) 5–15 Upper limb 54 (40%) 31–48 Lower limb 37 (27%) 20–35 Chest 14 (10%) 5–15 Severe chest injury¶ 7 (5%) 1–9 Abdomen 3 (2%) 0–5 Vertebral column 26 (19%) 12–26 Spinal cord injury 9 (6%) 2–11 AIS = Abbreviated Injury Scale. * Unless otherwise specified. † Any time between 18:00 and 08:00. ‡ Injury severity score > 15. § Any significant intracranial bleed, oedema and/or major skull fracture; head AIS score ≥ 3. ¶ Includes flail chest, major haemothorax or pneumothorax and mediastinal injury; chest AIS score ≥ 3.

Michael M Dinh · Helen L Stark · Kendall J Bein

To the Editor: The recent article by New and colleagues1 is an important piece in the “bed-block” picture, providing insight into perceived difficulties for patients on discharge, as a result of insufficient appropriate facilities. The authors suggested that “Redistributing proposed funding for inpatient subacute beds to measures for overcoming these barriers” may improve patient flow through the whole hospital system. This idea fits well with current federal health policy that “bed equivalents” are an important aspect of innovative and flexible models of care for rehabilitation services in Australia.2 Most states are reviewing how rehabilitation services are best designed to ensure the most effective use of limited resources, both in terms of programs and workforce. Improving the coordination of programs managed by the various levels of government, across health, disability and the aged care sectors, will help overcome the barriers identified in this study. The Australasian Faculty of Rehabilitation Medicine applauds efforts to increase research on rehabilitation and patient care, and supports federal and state initiatives providing increased resources for subacute care, both within hospitals and in the community. Investment in rehabilitation services at the community level is one of the most viable solutions and will meet the needs of an ageing population. Effective community care and the proposed National Disability Insurance Scheme (http://www.ndis.gov.au), if well executed, will reduce the burden on other parts of the health and aged care sectors and help ease the burden on hospitals.

Kathleen McCarthy