Letters

In reply: We appreciate Craig and colleagues’ comments regarding the importance of reporting general HbA1c targets for children and adolescents with type 1 and type 2 diabetes. In our position statement, the headings of Box 2 and Box 3 indicated that the targets listed were for adults with type 1 diabetes and adults with type 2 diabetes, respectively.1 While it is not possible to highlight every clinical situation, we agree that providing general HbA1c targets for children and adolescents will add value to our article, and we have updated it accordingly,1 recognising the differences in these targets for type 1 diabetes (≤ 58 mmol/mol, ≤ 7.5%) and type 2 diabetes (≤ 53 mmol/mol, ≤ 7.0%).2-4 In the interests of uniformity and simplicity, the paediatric targets expressed as “<”2-4 have been adjusted to “≤”, which represents differences of less than 1.5% of the target values. Addendum p 524

Graham R D Jones · George Barker · Ian Goodall · Hans-Gerhard Schneider · Mark D S Shephard · Stephen M Twigg

To the Editor: My observations over the past 10 years as an ambulance paramedic are consistent with the growth in demand for emergency and non-emergency ambulance services in Melbourne.1 Strong demand has been forecast to continue because 60% of patients who are eligible for emergency transport do not currently use ambulance services.2 The increasing demand for ambulance services — an essential component of the Australian health care network — necessitates the development of valid, reliable indicators of quality and safety in prehospital health care, to maintain and improve the quality of that care. As part of the Australian Commission on Safety and Quality in Health Care’s National Indicators Project, the Australian Institute of Health and Welfare (AIHW) has proposed 55 indicators of quality and safety in health care that represent a whole-of-system approach.3 However, this cannot be achieved without the inclusion of ambulance indicators. The AIHW indicators focus mainly on facility-based services (eg, hospitals) and underestimate the interdependence of the health care network. Ambulance services routinely collect information from the wider health care community, representing transported and non-transported patients, including clinical intervention and outcome parameters. These data can be used to identify interventions and outcomes attributable to prehospital health care practice. Improvements in patient sequence management,4 based on Ambulance Victoria research and data from specialised trauma and cardiac arrest registries,5 suggest that ambulance interventions can result in tangible benefits. Ambulance-specific process and outcome indicators would enable more precise attribution of outcomes to prehospital care and assist in apportioning health outcomes across the wider health network. This would directly benefit hospitals because pressure for increased public accountability currently ascribes performance based on risk factors that hospitals cannot influence. Enhanced prehospital indicators could supplement and expand the range of risk parameters that hospitals currently use to adjust hospital performance indicators; this would help mitigate the limitations inherent in comparative public reporting.6 Longer-term benefits include the implementation of alternative models of evidence-based practice, encompassing “treat-and-leave protocols”, and identification of non-hospital referral avenues. Safety is a crucial aspect of alternative practices, and protocols must be formulated and monitored in the light of valid and reliable indicators. Inclusion of ambulance indicators in the National Indicators Project would place ambulance services in a key position to ensure that timely access to safe, high-quality health care is maintained and improved.

Paul A De Vincentis

To the Editor: The potential upper gastrointestinal morbidity associated with non-steroidal anti-inflammatory drug (NSAID) misuse is well known.1,2 Recently, Frei and colleagues3 provided an overview of the morbidity and patient characteristics relating to opioid–NSAID misuse; however, they did not identify those patients with NSAID enteropathy (NE). NE is thought to occur via NSAID-induced reduction of endogenous prostaglandin via inhibition of both cyclooxygenase (COX)-1 and COX-2. The result is altered mucosal integrity, which thereby allows exposure to noxious luminal contents leading to inflammation, erosion and ulcers.1 We underscore the importance of identifying this group of patients presenting with anaemia, hypoalbuminaemia, weight loss or abdominal pain that relates to NE. The clinical presentation and small-bowel ulceration that is noted on investigations can often mimic Crohn’s disease.4 As the patient’s drug misuse is not immediately apparent, the diagnosis eludes the treating physician for some time, potentially at the expense of further morbidity from both ongoing medication misuse and the iatrogenic consequences of repeated presentations, investigations and medications that have been initiated to manage Crohn’s disease. Within the Townsville Hospital v(a 460-bed tertiary referral centre for North Queensland), we have observed an increasing number of cases where patients covertly self-medicate with large doses (up to 20 tablets per day) of codeine–ibuprofen analgesics, taken mainly for codeine addiction, subsequently developing small-bowel abnormalities. We present three cases that highlight this problem (Box). In each of these cases, the NSAID use was not immediately apparent. A recent search on the Adverse Drug Reactions Advisory Committee database did not identify any reports of such patients. This may represent significant underreporting of the issue due to lack of physician awareness. In mid-2010, the National Drugs and Poisons Schedule Committee implemented changes to how over-the-counter combination analgesics containing codeine can be accessed.5 Such medications must be accompanied by product and consumer medicine information, and a pharmacist must be involved at every sale to record the customer’s details. Despite these changes, there are still potential pitfalls, as there is no mechanism in place to stop patients from “pharmacy hopping”. It may be necessary to reschedule codeine as a prescription-only substance, and to create real-time databases of over-the-counter sales. While these drugs remain accessible over the counter, patients will continue to use them. Clinicians should therefore be vigilant for evidence of NSAID impact on the gastrointestinal tract. Three patients who self-medicated with large doses of a codeine–ibuprofen analgesic with small-bowel abnormalities consistent with NSAID enteropathy Patient characteristics Presentation Medications Investigations NSAID self-medication 42-year-old man with chronic ankle pain; hypogonadotrophic hypogonadism; diverticulitis with paracolic abscess; cholecystectomy; appendicectomy; excessive alcohol use; depression Recurrent severe hypokalaemia; vomiting, abdominal pain and weight loss; iron deficiency and hypoalbuminaemia; vitamin B12 deficiency Omeprazole 40 mg/day; mirtazapine 15 mg/day; oxycodone 5 mg 4–6 hourly as needed Gastroscopy: antral ulcers; colonoscopy: normal; capsule endoscopy: multiple jejunal ulcers with early structuring consistent with NE; CRP level within RI Ibuprofen 200 mg/codeine phosphate 12.8 mg: 10 tablets/day 41-year-old woman with previous diagnosis of Crohn’s disease elsewhere, not supported by small-bowel resection Abdominal pain, diarrhoea and vomiting; iron deficiency anaemia; hypoalbuminaemia Iron supplement Gastroscopy and colonoscopy: normal; capsule endoscopy: multiple web-like strictures with circumferential ulceration throughout the small bowel consistent with NE; CRP level within RI Ibuprofen 200 mg/codeine phosphate 12.8 mg: 20 tablets/day for 5 years 41-year-old man with Scheuermann’s disease; chronic back pain; melanoma; depression; excessive alcohol use Iron deficiency anaemia; hypoalbuminaemia Omeprazole 40 mg/day; amitriptyline 25 mg/day; as needed: buscopan 20 mg; paracetamol 500 mg/codeine 8 mg; paracetamol 500 mg/codeine 30 mg; tramadol 50 mg Upper endoscopy: small gastric ulcer; push enteroscopy: multiple jejunal ulcers consistent with NE; CRP level within RI Ibuprofen 200 mg/codeine phosphate 12.8 mg: 10–12 tablets/day for more than 5 years CRP = C-reactive protein. NE = NSAID enteropathy. NSAID = non-steroidal anti-inflammatory drug. RI = reference interval, < 5 mg/L.

Rozemary Karamatic · John Croese · Enrico Roche

To the Editor: We agree with Smith and colleagues1 that it is important to raise awareness among health professionals — and consumers — about recently revised dosing recommendations for colchicine. Software decision-support tools have an important role in ensuring safe prescribing of such drugs. However, we have questions about whether this software uses information that is up-to-date with current evidence, particularly in relation to colchicine. We believe that the clinical software systems used by clinicians and pharmacists could better support them in relation to medicines safety issues like this one. First, they could provide up-to-date, evidence-based dosing information. Second, they could warn the user when potentially harmful drug doses are being prescribed or dispensed, or when there are new recommendations about drug therapy. In this case, the situation is not straightforward because there are inconsistencies in the dosing recommendations for colchicine. In 2010, an article in NPS RADAR highlighted new evidence to support the use of low-dose colchicine in acute gout.2 This new dosage regimen was also recommended in the Australian medicines handbook in 2010.3 Nevertheless, higher doses are currently recommended in the Australian approved product information (PI), the consumer medicines information leaflet, and other commonly used medicine reference sources (this raises other issues, including the fact that there is currently no process to ensure that the PI is regularly reviewed, and the role of the Therapeutic Goods Administration4; however, these are beyond the scope of this letter). There is no guidance for clinical software vendors regarding which information to provide, and, at present, drug dosage information in these systems is frequently based on the PI as provided by the manufacturer or sponsor. We examined colchicine dosing information provided at (or accessible from) the point of prescribing or dispensing in a number of commonly used systems, and none showed the recent low-dose recommendations. Nor were any alerts or warnings displayed about potential toxicity specifically related to the dosage regimen for colchicine. Our previous research has shown that, in general, there is little of this type of decision support available in general practice software.5 Guidance for software vendors and high-quality, up-to-date knowledge bases are required to support this functionality. Currently, there is no overarching governance mechanism in Australia to guide the development of decision support, or to ensure that the inclusion of clinical information in software is up-to-date or based on the latest evidence. A coordinated approach to ensure that these systems support safety and quality is long overdue.6

Michelle Sweidan · James F Reeve · Kitty Yu

To the Editor: The letter from Smith and colleagues in the 6 June 2011 issue of the Journal1 highlights the potential toxicity of colchicine, even when used in the therapeutic doses recommended in the current product information (PI).2 This in turn highlights how important it is that all medicines have PI that continues to be maintained with the most clinically accurate and up-to-date information. The current system for maintaining PI seems to break down most significantly with out-of-patent, “grandfathered” and “orphan” medicines.3 During 2009, we identified an important change in the recommended dose in the American PI for colchicine through our usual processes of scanning the medical literature (including the websites of drug regulatory agencies). Colchicine is an out-of-patent medicine. The American study underpinning the American PI changes was sponsored by a different company and used a strength of colchicine tablet (600 μg) not available in Australia.4 The local sponsor companies were contacted at the time, but did not plan to update their Australian PI. Amending a PI is a costly and lengthy process, and the expense is hard to justify for an inexpensive and relatively low-use product. We updated the Australian medicines handbook dosing information5 and then wrote to the Therapeutic Goods Administration (TGA) suggesting the PI change could be initiated by them in the public interest. As yet, we have not received a response from the TGA and the dose in the PI remains unchanged. Despite its limitations in cases such as these,3 the PI forms the backbone of default dosing and drug interaction data in electronic prescribing software in Australia.6 We hope that Smith and colleagues’ letter might not only help prompt a change to the Australian PI for colchicine, but also a reconsideration of whether a more proactive approach is warranted for updating PI dosing and safety information for orphan drugs.

Nicholas A Buckley · Simone O P Rossi

To the Editor: Since 2008, the Australian Capital Territory’s public acute health care system has successfully been using multiple-parameter and single-parameter track, trigger and response (TTR) systems in parallel for the recognition of and response to clinical deterioration in patients. Jenkins and colleagues correctly identify that there is a general lack of agreement on the use of TTR systems around Australia, although they note that the most commonly used rapid response system is the medical emergency team (MET) alert which is triggered by a single parameter, a vital sign derangement, or a concern for the patient.1 As Jenkins et al suggest, a multiple-parameter TTR system may trigger a response earlier than might occur with MET parameters. In 2007 at Canberra Hospital, a multifaceted before-and-after intervention study of the recognition of and response to patients’ deteriorating conditions found improvements in both patient outcomes and measures of processes of care for patients whose condition was deteriorating.2 The intervention included the installation of a multiple-parameter TTR system, using a modified early warning score3 generated from the degree of derangement of all vital signs and end organ function. Individual vital sign early warning scores were then colour-coded and embedded within newly formatted, human-factors-designed observation charts. Further, before the new system commenced, about 90% of all health care workers (210/234) participated in an education program.4 This program comprised both an e-learning package and a 3-hour, face-to-face, low-fidelity simulation package. It aimed to promote the understanding of the physiological principles of vital signs, and reasons for their measurement and their derangement; it also provided a structure for succinct communication and initial resuscitation. The multiple-parameter TTR system has now been successfully rolled out to all areas of the hospital, including the emergency medical unit, emergency department and medical assessment and planning unit, alongside our MET system. The multiple-parameter TTR system has been a useful tool to engage parent medical teams in reviewing patients at risk of critical illness, and has empowered nurses to call for a MET review, given that the modified early warning score provides further evidence that the patient’s condition is deteriorating. With the use of the systems in parallel and the mandatory training package, MET use has doubled and delays in calling for a MET review have decreased. We would welcome further investigation of the multiple-parameter TTR system that we have adopted, particularly in a multicentre setting.

Imogen A Mitchell · Mary-Ann Kulh · Heather McKay

To the Editor: We would like to congratulate the Central Line Associated Bacteraemia in NSW Intensive Care Units Collaborative for reducing central line-associated bacteraemia (CLAB), and showing that this reduction was associated with compliance with evidence-based aseptic central venous line (CVL) insertion, which included a patient bundle and a clinician bundle, as reported by Burrell and colleagues.1 As part of a quality improvement program in Western Australia, we conducted a collaborative cohort study (unpublished) in two major Perth teaching hospitals with adult intensive care units (ICUs), from April 2007 to September 2008, covering 36 ICU-months and 15 459 catheter-days. Both ICUs implemented the WA Safety and Quality Investment for Reform central line bundle.2 Compliance was monitored by an observer with a checklist. Adherence to all components of the central line bundle was required for compliance to be recorded. This measure was reported monthly. CLAB and catheter-days were monitored by the hospitals’ infection control practitioners. Compliance with the bundle increased from a mean of 10% to greater than 90%. Infection rates declined over the study period from more than six infections per 1000 catheter-days to zero (P = 0.019 for Hospital 1 and P = 0.10 for Hospital 2). In the final 8 ICU-months (4 months in both hospitals), there was no CLAB. The New South Wales study demonstrated the importance of the clinician bundle components over the patient bundle components, which should inform future quality improvement initiatives. We note the comment that the hat, mask and eyewear components of the bundle were unpopular with clinicians. However, there is a risk of recontaminating disinfected skin with aerosolised organisms from the clinician’s hair and upper respiratory tract, whereas eyewear is principally intended to protect the clinician from splash injury and potential blood-borne virus infection. Maximal sterile barrier precautions are endorsed by the 2010 National Health and Medical Research Council guidelines,3 the 2011 Centers for Disease Control and Prevention guidelines,4 and the epic2 study in the National Health Service in England.5

Chantal S Ferguson · Victoria C D’Abrera · Helen J Van Gessel · Dorothy Jones

To the Editor: The article by Ramsey-Stewart and colleagues1 reports a welcome addition to supplemental anatomy education in graduate-entry medical courses in Australia. Increasing medical student numbers are increasing pressure on teaching resources, further propagating the nationally recognised deficiency in anatomy teaching.2,3 In 2010, the University of Queensland Discipline of Surgery developed an extracurricular applied anatomy course to meet the needs of clinical students (Years 3 and 4) with varying foundations in anatomy.4 The course is based on a clinically oriented anatomy education model, using prosected specimens and computer resources, which has been shown to deliver learning outcomes.5 Student representatives were involved in all facets of curriculum development and evaluation. The course was taught by surgeons and provided an overview of whole-body applied anatomy in an interesting and engaging way. As the course had no seed funding, a modest course fee of $90, which was intended to be easily affordable but enough to encourage committed attendance, was charged. Class size was restricted to 44 students, with selections from the 150 applicants (from about 800 students across both years) made on a first-come, first-served basis. Over seven Saturday mornings, the students received 2-hour tutorials from surgeons with expertise in specific fields of regional anatomy. This scheduling minimised disruption for both surgeons and students. Various educational resources, including three-dimensional virtual modelling and potted pathology specimens, were used. Participants completed a short multiple choice test before each week’s tutorial. The course concluded with a wet laboratory session, staffed by surgeons using prosected cadaveric specimens at multiple stations, with a one-to-five surgeon–student ratio. Students completed a post-course exam of collated pre-tutorial multiple choice questions, as well as five-point Likert-scale evaluation forms. The students evaluated the course well (mean Likert score: 4.6 at 4 weeks, 4.8 at 8 weeks). Post-course exam scores demonstrated a small but significant improvement (mean ± SD: pre-course, 43% ± 16.7% v post-course, 50% ± 10.6%; P = 0.004). Scores were correlated with attendance. The course was highly valued by students and surgeons, effectively improved students’ knowledge and satisfied their desire for further anatomy education. The course structure is time-efficient and cost-effective. However, this course, like that of Ramsey-Stewart et al,1 is extracurricular and does not deliver educational benefit to an entire cohort of students. Further development and evaluation are required to extrapolate the benefits of these extracurricular courses into the wider medical curriculum within the constraints of graduate MB BS programs. Our model has expanded to two courses in 2011.

Matthew J Roberts · Bavahuna Manoharan · Marianne Vonau · Russell W Stitz · Owen A Ung

To the Editor: We read with interest the article by Patel and colleagues,1 which suggests a high rate of critical adverse events occurring for medical students undertaking remote placements in the Northern Territory. We note also that there is significant potential for over- or under-reporting because of the incompleteness of useable documentation in their sample. Regardless, the reported figure of one-sixth of students experiencing a “critical incident” during their placement is concerning. In answer to the question in the title of Patel et al’s article — “Safeguard or mollycoddle?” — the answer is surely neither. There is obvious benefit for students in being removed from their personal, cultural, geographical and clinical comfort zones. After all, challenging and evaluating one’s preconceptions and personal boundaries is essential for personal and professional development. However, it is vital that this is done in a safe and well supported manner, such that both the student and the community into which he or she is placed benefit from the experience. As noted by Patel et al, there is evidence from the United Kingdom that structured placements that are regularly evaluated, adequately planned and firmly grounded in clinical ethics are able to maximise the placement experience for both students and communities.2 In our minds, the key to quality in clinical placements is excellent administrative support and clinical supervision that is appropriate for the level of the student. Recently, there has been a concerted push in medical training to encourage students to gain experience in rural and Aboriginal communities. This is generally well received by Australian medical students. In light of increasing student numbers, it is likely that these alternative clinical training environments will see an increase in student traffic in the coming years. The article by Patel et al1 has highlighted that not all experiences in these settings are positive. Due to persisting rural workforce shortages, we are concerned that students who are unwilling and potentially unsuitable to undertake remote placements may be forced to do so through their medical programs or bonded medical places. We strongly urge the providers of placements and those who fund them to critically evaluate their current practices surrounding clinical placement planning and support. Most importantly, adequate supervision, matched to the individual attributes of the student, should be an absolute requisite for any placement.

Andrew D Webster · Robert D Marshall · Lee J Fairhead · Trent Little · Falk Reinholz

To the Editor: The commissioned article by Pirotta, dealing with the ethics of prescribing alternative complementary treatments that may lack an evidence base,1 contains a number of statements which, if the article had been subjected to peer review, might well have finished up on the cutting-room floor. For example, the statement “it is estimated that as little as a quarter of conventional medicine is based on level-1 evidence” is not backed up by the only monograph cited in support of it.2 Whatever relevance a lack of level-1 evidence may have to the practice of dermatology (for which it is claimed), it plays little part in either modern medicine or the revolutionary advances in surgery, few being the result of a systematic review of multiple well controlled randomised trials. Having said that, the reference to complementary or alternative treatments that lack any evidence base as “medicine” gives a misleading legitimacy to practices that may be — and frequently are — based on cultural, historical or spiritual beliefs, or even just plain wacky approaches to healing. Regrettably, Pirotta adds nothing new to the (uncited) definitive 2004 article by Kerridge and McPhee.3 How times have changed. Not only are doctors now expected to have sufficient knowledge of complementary and alternative medicine to be able to advise their patients of therapeutic alternatives, but we may well have reached the stage where a failure to alert patients of such alternative treatment options may constitute negligence at common law. The New South Wales case of McGroder v Maguire4 is instructive. In that case, the plaintiff, a truck driver, had suffered a neck injury in the course of his employment. Despite a lengthy period of treatment, he continued to suffer from tingling in his arm. The defendant, a general practitioner retained by the plaintiff’s employer, although not having examined the patient, nevertheless referred him to a chiropractor. This referral was held to have been negligent, not because of the referral per se, but because of the patient’s condition. This came to light in the evidence given by a neurosurgeon and orthopaedic surgeon at the trial of the action, both of whom agreed that this case was not one for chiropractic manipulation of the plaintiff’s neck and back. Despite subsequent neurosurgery, the plaintiff became totally incapacitated for work. In the result, both the referring GP and the chiropractor were held to be liable in negligence.

Paul Gerber

To the Editor: We read with interest the commentaries by Pirotta and Dwyer on complementary and alternative medicines (CAMs).1,2 This debate has a long history, spanning more than two decades,3 and the pessimism continues to ignore good science.2 Firstly, integrative medicine (IM), which combines alternative and conventional medical practices, is not and never has been synonymous with CAMs. IM is a global paradigm shift that expands the conventional model of medical care with evidence-based laboratory and clinical research. IM embraces the foundations of medicine, such as (i) the critical role of the doctor–patient relationship, (ii) the importance of lifestyle, and (iii) improving the wellbeing and promoting the natural healing potential of people afflicted with disease.4 Secondly, a thinly disguised commentary on the ineffectiveness of CAMs,2 while dismissing a large body of scientific clinical evidence, is broadly misleading. This is significantly remiss, failing to cite the value of prebiotics and probiotics in digestive diseases,5 the effect of omega-3 essential fatty acids on endothelial function,6 the efficacy of acupuncture for some forms of pain,4 mindfulness-based stress reduction and mindfulness-based cognitive therapy for mental health,7 and emerging modalities such as yoga for menopausal symptoms4 and tai chi for fibromyalgia,4 and many more.4 Moreover, such deliberate carelessness serves only to confuse researchers and clinicians, as well as the public. Evidence-based medicine is critical in expanding the medical model of care; of this there can be no doubt. Adhering to biologically plausible mechanisms of action is the key foundation that will always guide scientific evidence, including that for CAMs. As an example, we have recently scientifically challenged the validity of the antioxidant effect to abrogate free radicals that are purported to contribute to the development of chronic diseases.8 Therapies that deviate from the conventional medical model still elicit an unhealthy cynical response2 that hinders the progress of scientific and medical investigations. If Florey and Fleming had adopted such cynicism and dismissed the biologically far-fetched notion of an antimicrobial mould in a Petri dish (Penicillium notatum), they most probably would not have pursued and contributed to the discovery of the antibiotic penicillin. Thus there is no place in science and medicine for the imprimatur of distrust and scepticism that is levelled without respite at novel concepts, even those with scientific plausibility.

Luis Vitetta · Shoshannah L Beck · Samantha Coulson · Avni Sali

To the Editor: I am concerned that the viewpoints by Dwyer1 and Pirotta2 were published without establishing a clear definition of “complementary and alternative medicine” (CAM). The term CAM is not ideal as it groups many non-evidence-based therapies that have little in common, such as iridology and homoeopathy, with more evidence-based complementary therapies such as acupuncture, nutritional medicine, meditation and some herbal medicines that have demonstrated efficacy. To date there is a growing body of research, including Cochrane reviews, to support the use of some complementary therapies (Box). The fact that many complementary therapies have not been tested and subjected to high-quality research does not necessarily mean they do not work.3 For other complementary therapies, there are mixed findings (negative trials balanced by positive trials, as seen in Cochrane reviews), so one needs to ask why the differences in results? Were there differences in dosage, the quality of the substance or method of the therapy tested? Would you argue with patients who find symptomatic relief for troublesome symptoms of menopause from herbs when they are intolerant to hormone replacement therapy, or relief from osteoarthritic pain from complementary medicines and acupuncture if non-steroidal anti-inflammatory medications are contraindicated because of a peptic ulcer? Demand for complementary therapies in Australia is actually coming from consumers. If they found the therapies unhelpful, why would they continue with them? A better term for complementary and alternative medicine is integrative medicine (IM), defined as: the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing.4 The aim of IM is to find common ground and respect for the patients who choose to use complementary therapies and to understand their use. General practitioners have been shown to be very interested in learning about complementary therapies, with one study finding that about 30% of Australian GPs identified themselves as practising IM and most (more than 80%) requesting more education and research in complementary therapies.5 It is important that doctors balance clinical decisions between the risks associated with any therapy, the evidence and the therapeutic clinical outcome (effectiveness) to inform patients appropriately.

Vicki Kotsirilos

To the Editor: The Journal is to be commended for this important discussion on quality improvement (QI) by Millar1 and Runciman.2 It is important to understand that if doctors are not engaged in changes to health service provision, including QI, such changes will be ineffective.3 Not surprisingly, unengaged doctors can “prove” the lack of an effect of a QI initiative and return to doing what they have always done. Millar comments on the “division between QI and clinicians”.1 Why this division? Why is there a lack of engagement, and a lack of common purpose, values, and beliefs? Professional responsibilities as defined by the American College of Physicians (ACP) in 2002 include “commitments” to, among others, “improving quality of care”, “improving access to care”, and “a just distribution of finite resources”.4 The 2009 Royal Australasian College of Physicians Professional Qualities Curriculum provides a very similar list of responsibilities for all physicians.5 It may be time for many doctors to step onto the common ground and out of the ivory tower. It is time that doctors become able to view themselves as only one part of a larger system that exists solely to provide health care for patients and the population. Teamwork and collaboration with non-medical health professionals (including managers) may often be undervalued from a “doctor-centric”, and often “hospital-centric”, perspective. It is also high time that health organisations and many managers become serious about involving clinicians, initiating “true” clinical leadership, and engaging and communicating in a meaningful way. Clinical leadership, clinical governance and “teamwork” have unfortunately become almost slogan-like, stale entities that appear in health policy plans and strategy documents without much meaning or consequence. One day, clinical care may be better and have more resources because of better implementation of QI that actually engages clinicians.

Roland J Meyer

To the Editor: I would have thought that, in 2011, any debate pitting fee-for-service against salary models of remuneration was both stale and futile. These debates, such as the one entered into by Peat1 and Travis,2 have been around since Bismarck introduced health insurance for workers in Germany. Surely we have come to realise, after more than a century of varied health insurance schemes and health services around the world, that it is a matter of horses for courses. A single payment system, whatever it is, will be inappropriate if applied universally in any country. There is a place for fee-for-service delivery, accompanied by insurance; there is a place for salaried service; and there is even (heresy for some!) a place for that form of salary called “capitation”. Each system has its merits and its faults, which have been discussed ad nauseam by health economists too numerous to refer to (two publications serve as examples3,4); there is nothing new under the sun. Debates such as this generalise the behaviour of a few miscreants to all salaried or fee-for-service practitioners. This is clearly unfair to both groups. Australia is fortunate that, back in the 1970s, our profession was able to stave off a Canadian-style, single-payer system. Our graduates can choose their method of remuneration — and, however they have been paid, we have distinguished colleagues who have achieved much and, regrettably, a few rogues. In the latter respect, we are no different from any other profession or trade. Why not abandon the ideologies underlying both sides of the debate, face these facts and have both systems in place, where each is appropriate, rather than trying to apply a single solution everywhere? I am reminded of the wisdom of Anthony Ashley Cooper, third Earl of Shaftesbury; “The most ingenious way of becoming foolish is by a System”.5

Peter C Arnold

To the Editor: The recent article by Hebden and colleagues on the frequency and content of fast-food advertising on Australian television concluded that the industry self-regulatory initiatives currently in place are ineffective in reducing children’s exposure to advertising of non-core foods.1 As the managers of these self-regulatory initiatives, we consider this conclusion to be misleading to your readers. The Australian food and beverage industry recognises the level of community concern in relation to food and beverage advertising to children. There are currently two self-regulatory initiatives in place to moderate advertising of non-core foods and beverages to children: the Responsible Children’s Marketing Initiative, that covers products found in retail outlets; and the Australian Quick Service Restaurant Industry Initiative for Responsible Advertising and Marketing to Children, that covers foods sold in quick-service restaurants. These initiatives are designed to restrict advertisements aimed at children by means of the nature of the advertisement and/or the medium by which it is delivered. Hebden et al base their conclusion on a broad definition of “advertising to children” that captures all advertisements screened between 5.30 pm and 10.30 pm on weekdays, and between 7.30 am and 11 am and 4.30 pm and 11 pm on weekends. Specific time periods are not, in fact, covered in the industry initiatives as these periods capture programs that are watched primarily by adults. If children are watching these programs, they are likely to be doing so accompanied by an adult who can provide guidance on appropriate food consumption. However, industry does recognise that times when children are watching television alone and advertisements that are designed particularly to target children are a different matter, and that it must act responsibly in these areas. The success of the initiatives should not be measured by advertising frequencies during certain time periods, as implied by Hebden and colleagues. Nevertheless, the data presented by Hebden et al actually suggest a significant reduction in the frequency of non-core-food advertisements (excluding fast food) in just the first year of operation of the initiatives, which, in terms of what the authors perceive to be “advertising to children”, should be viewed as a positive finding. The Australian Food and Grocery Council is committed to monitoring the self-regulatory initiatives and makes the results available to all stakeholders to help evaluate the effectiveness of what the initiatives set out to achieve.

Peta E Craig · Geoffrey Annison

In reply: Children’s exposure to advertising of unhealthy foods is of concern because children are exposed to a large volume of such advertisements. The World Health Organization has clearly stated that any efforts to address this issue must reduce children’s exposure to unhealthy food advertising.1 Our research article2 was based on such measures. The viewing times applied in our research were specifically those when the highest numbers of children aged 5–12 years watch commercial television, according to Australian audience data for Sydney commercial television stations, and thus are exposed to advertising. Craig and Annison refer to a decrease in the relative proportion of advertisements for unhealthy fast foods over the first year of the industry initiatives. However, readers should be aware that our research showed that the total amount of fast-food advertising increased over this period, so that the frequency of unhealthy fast-food advertisements that children were exposed to remained the same. To make meaningful changes to what advertising children see, time-based restrictions would form a more responsible approach for regulation than the current industry specifications.

Lana Hebden · Lesley King · Anne Grunseit · Bridget Kelly · Kathy Chapman

To the Editor: Outpatient non-attendance remains a major problem that significantly drains the ability of hospitals to provide efficient and effective outpatient services.1,2 Our earlier pilot study demonstrated the effectiveness of short message service (SMS) text message reminders in improving attendance at the outpatient department in Melbourne’s Royal Children’s Hospital (a 250-bed tertiary referral hospital).3,4 We present the results of a follow-up retrospective cohort study that examined the effect of the following eight factors on failure to attend (FTA): sex, native language, distance lived from hospital, day of appointment, time of appointment, wait time (days from scheduling to appointment), socioeconomic status (SES), and SMS reminders. Data included all outpatient appointments (65 535) in the period July 2005 to January 2006. Incomplete data meant that 44 appointments were excluded, leaving 65 491 episodes for the analyses. The patients were classified into three SES groups: low (G1), middle (G2) and high (G3). This classification was based on the Jarman score (a proxy for SES) derived from the patient’s residential postcode.5 Similarly, patients were classified into three groups based on distance between the patient’s residence and the hospital: < 25 km, 25–50 km and > 50 km. Univariate and multiple logistic regression analyses confirmed that all factors other than sex were significantly associated with FTA. We also found that the two populations with and without SMS reminders were significantly different. We conducted a stratified analysis for the two groups and the summary results are presented in the Box. Our analysis shows that FTA rates improve by 5.34% (from 14.85% to 9.51%), and confirms the effectiveness of SMS reminders in lowering FTA. It shows that native language, distance lived from hospital, SES and wait time are significantly associated with FTA across both groups. Although SMS reminders resulted in higher improvement in attendance for non-English speaking patients compared with English speakers (8.33% versus 4.1%), those patients still had higher odds of missing an appointment. Lower SES was associated with an increased likelihood of defaulting. Longer waits until the appointment resulted in lower odds of attending, and odds of attending improved with increased distance from the clinic. Together these results suggest that in addition to SMS reminders, interventions targeted at specific groups may improve attendance rates and cost effectiveness. Stratified analysis of factors contributing to outpatient failure-to-attend rates, by SMS reminder No SMS reminder (n = 20 871) SMS reminder sent (n = 44 620) Factor FTA OR FTA OR Aggregate 14.85% 9.51% Native language English 13.04% 1* 8.94% 1* Non-English 21.35% 1.62† 13.02% 1.30† Distance lived from hospital < 25 km 15.89% 1.36† 10.28% 1.51† 25–50 km 13.77% 1.20†† 8.71% 1.28† > 50 km 11.36% 1* 7.16% 1* Socioeconomic status Low (G1) 17.51% 1.37† 12.28% 1.57† Middle (G2) 14.84% 1.34† 9.26% 1.22† High (G3) 12.11% 1* 8.26% 1* Wait time (from scheduling to actual appointment) < 15 days 8.40% 0.42† 5.94% 0.45† 15–30 days 16.40% 0.90‡ 9.48% 0.74† > 30 days 18.13% 1* 12.40% 1* SMS = short message service. FTA = failure to attend. OR = odds ratio. * Baseline comparison group: OR = 1. † OR significant at P < 0.001. ‡ OR significant at P < 0.05.

Sean R Downer · Kannan Sethuraman · Devanath Tirupati

To the Editor: Kinner and colleagues described the high proportion of deaths among recently released prisoners in Australia.1 I had a patient with a history of intravenous drug use who, after a prolonged stay in hospital for osteomyelitis complicating a diabetic foot ulcer, including extensive inpatient rehabilitation, died due to drug overdose on the first weekend after discharge. This tragic death suggests a mortality risk for people with a history of drug misuse who are released from any long-stay institution, including hospitals. It may be appropriate for medical practitioners to discuss this risk frankly with such patients at discharge.

Emma L Duncan

To the Editor: We wish to report Queensland data regarding vitamin D levels during pregnancy, to contribute to the debate on screening during pregnancy raised in Lau and colleagues’ article1 and Ebeling’s accompanying editorial.2 In 2009, we measured serum 25-hydroxyvitamin D (25[OH]D) levels, using a DiaSorin radioimmunoassay (DiaSorin, Stillwater, Minn, USA), in 75 women who attended general antenatal clinics at the Royal Brisbane and Women’s Hospital (RBWH) and Mater Mothers’ Hospital. Both institutions’ Human Research Ethics Committees approved the study. Participants gave written consent. The RBWH Private Practice Fund covered pathology expenses. Fifty-seven of the 75 women were white; the remainder were Asian (five), Indian Subcontinental (seven), Polynesian (four), Middle Eastern (one) and black African (one). Mean age was 28.6 years (SD, 5.4 years), mean gestational age was 28.7 weeks (SD, 2.7 weeks) and mean body mass index was 26.4 kg/m2 (SD, 5.5 kg/m2). Median serum 25(OH)D level was 92 nmol/L (interquartile range, 74–118 nmol/L). Using cut-offs of < 25 nmol/L for deficiency and < 50 nmol/L for insufficiency, two women were vitamin D deficient (one was Middle Eastern and one was South-East Asian) and five women were vitamin D insufficient (three were white, with lowest serum 25[OH]D level of 40 nmol/L, and two were Indian Subcontinental). The result of a Fisher exact test suggested an association with ethnicity (P = 0.01). A χ2 value of 21.36 (P < 0.001) confirmed that the proportions of deficiency and insufficiency in our study population were significantly different to those of Lau et al’s study population. The majority of serum samples (40) were obtained in winter, followed by spring (21), summer (10) and autumn (three). Six of the seven results of deficiency and insufficiency were from samples obtained in winter; the other was from a sample obtained in September. Excluding autumn, categorical and continuous analyses showed borderline significant variation of 25(OH)D level by season (Mann–Whitney U test [P = 0.08] and Kruskal–Wallis test [P = 0.08], respectively). Several factors may account for the difference in vitamin D deficiency and insufficiency prevalence between our study and that of Lau et al. The most obvious is the “Sunshine State” factor, because several studies in southern states have reported higher prevalence of vitamin D insufficiency than in our study.3-5 In Lau et al’s study, a large proportion of women were at high risk of vitamin D deficiency (only 19% were white) and the women were recruited from a gestational diabetes mellitus clinic. Care should be taken in extrapolating such findings to the wider population. Although our study was not population based, it included a majority white and healthy general obstetric population, rather than sampling at a clinic where women are at high risk of vitamin D insufficiency. We are not asserting that gestational vitamin D levels are unimportant. The increasing incidence of rickets in Australia,2 along with other potential hazards, dictate that increased awareness is mandatory. However, as opposed to routine screening in all pregnancies, our data suggest that local assessment of vitamin D status and demographic risk factors (in gestational diabetes mellitus and general obstetric populations) should be the priority.

Donald S A McLeod · Katherine A Scott · Karin M C Lust · H David McIntyre

To the Editor: We published a case in the Journal in 2009 titled “Spontaneous chylothorax in a 2-year-old child”.1 Subsequently, it has come to our attention that trauma is likely to have been the cause of the chylothorax. At the time of caring for the child, and submission of our article to the Journal, we had no evidence of this. We had specifically asked for a history of trauma and looked for external signs of injury. The chest x-ray and computed tomography (CT) scan had been reviewed with our radiology staff at the time and we did not detect abnormalities of the vertebrae or paravertebral tissue, and no such abnormalities were detected during surgery. However, the child presented with serious injuries 9 months later and died on arrival at hospital. At autopsy, a CT scan showed a paravertebral haematoma and vertebral injury in the lower thoracic vertebrae where the thoracic duct traverses the diaphragm and ascends on the right side (it was a right-sided chylothorax). On further review of the original chest x-ray and CT scan, it was possible to see that some of these findings were evident at the initial presentation with chylothorax. At the time of submission of our article, we speculated that vomiting could have caused injury to the thoracic duct. We now wish to highlight that apparently spontaneous chylothorax may be due to trauma. In children, non-accidental injury must be considered as a possible cause.2

Manuel E Soto-Martinez · Vanessa Clifford · Tom Clarnette · Sarath Ranganathan · R John Massie

To the Editor: A 38-year-old man with genotype 1b chronic hepatitis C infection had been treated with 48 weeks of pegylated interferon (IFN)-α and ribavirin. Autoimmune serology performed just before treatment showed positive perinuclear antineutrophil cytoplasmic antibodies (ANCA) accompanied by an elevated antimyeloperoxidase antibody level (22 U/mL; reference range [RR], < 5 U/mL). Notably, the patient was ANCA-negative 12 months previously. The treatment course was uneventful. One month after the completion of therapy, the patient presented with a subacute onset of fever, haemoptysis, breathlessness and generalised arthralgia. Laboratory investigations demonstrated raised levels of C-reactive protein (128 mg/L; RR, < 5 mg/L) and creatinine (159 μmol/L; RR, 64–104 μmol/L), low albumin concentration (28 g/L; RR, 35–46 g/L), a low haemoglobin level (64 g/L; RR, 135–180 g/L), and microcytic hypochromic anaemia. Autoimmune serology showed persistence of a positive ANCA and an elevated antimyeloperoxidase antibody level (29 U/mL). A high-resolution computed tomography scan of the chest showed features of interstitial lung disease (Figure, A) and a renal biopsy demonstrated pauci-immune necrotising glomerulonephritis (Figure, B). These findings were consistent with a diagnosis of microscopic polyangiitis. Despite treatment with intravenous cyclophosphamide and pulse methylprednisolone, the patient deteriorated and was admitted to the intensive care unit for ventilatory support, haemodialysis and plasmapheresis. This admission lasted 4 weeks and was complicated by line-related sepsis and persistent anaemia requiring multiple blood transfusions. The patient remains clinically well 14 months after discharge, with negative ANCA and negative hepatitis C virus RNA polymerase chain reaction consistent with a sustained viral response. Autoimmune disease is a well recognised complication of IFN-α therapy in chronic hepatitis C infection. The clinical manifestations of IFN-α-related autoimmune disease can be either organ-specific (thyroiditis, psoriasis) or, less commonly, systemic (rheumatoid arthritis, lupus-like disease, sarcoidosis).1 IFN-α-based treatment in chronic hepatitis C infection unmasks silent autoimmune processes, or induces de novo autoimmune diseases or autoantibodies.2 A predisposition to autoimmunity, together with the presence of baseline auto-antibodies, has been demonstrated in most instances of IFN-α-mediated autoimmune diseases,1 as observed in our case. Although rare, the diagnosis of microscopic polyangiitis needs to be considered in patients treated with IFN-α-based therapy for chronic hepatitis C infection presenting with skin rash, fevers, arthritis, an active urine sediment, renal failure or pulmonary haemorrhage. One could consider reducing the duration of therapy in patients who achieve negative RNA polymerase chain reaction at Week 4 of treatment. There is emerging evidence that 24 weeks of response-guided therapy in genotype 1b chronic hepatitis C infection is as effective as the standard-of-care treatment for 48 weeks in rapid responders.3 We also suggest that, in the presence of a positive ANCA at baseline screening, a chest x-ray and urinalysis be performed before initiating IFN-α-based treatment, and that patients be monitored clinically and with urinalysis during treatment. A chest x-ray should also be performed at the completion of treatment. The presence of auto-antibodies alone is not a contraindication to IFN-α therapy, but it does mandate careful monitoring and a high index of suspicion of an immune diathesis. A: High-resolution computed tomography scan of the patient’s chest showing patchy foci of ground glass opacification and nodules bilaterally. B: Renal biopsy showing focal crescentic necrotising glomerulonephritis (haematoxylin-eosin stain; original magnification x 400).

Stephen Y Oh · Brett E Jones · Suran L Fernando

To the Editor: In a recent article that appeared in newspapers such as Melbourne’s The Age and Sydney Morning Herald on 19 Jan 2011,1 one of us (P Z) argued that it is both ineffective and inaccurate to blame those who are overweight and obese for their health problems. It was highlighted that our social, economic, cultural and physical environments are all “obesogenic”,2 acting as barriers to achieving a healthy lifestyle. The article by Proietto in the August 2011 issue of the Journal similarly argued that the obesogenic environment, and its interaction with a person’s genetic make-up, is to blame for the increasing prevalence of overweight and obesity.3 Neglecting to address the role of environmental factors in lifestyle disease may lead to a number of unintended negative consequences. First, healthy eating and being physically active are not easy choices. If attempts are not as successful as first hoped, and if the response from health professionals is simply “try harder”, feelings of guilt and despair can result, which then make it even harder to engage in healthy behaviours. Second, a sole emphasis on individuals’ responsibility for their own health has led governments at all levels in Australia to be passive on this issue. Governments seek to protect us in other ways (eg, legislation to restrict the use and advertising of tobacco), so they now need to be encouraged to take steps towards reducing the obesogenic nature of our environment (eg, introducing policy that ensures affordable and sustainable fruit and vegetable production).4 Finally, focusing on individual health behaviours alone may create or reinforce a social stigma around obesity and related chronic conditions, such as type 2 diabetes.5 When individual behaviour change is the sole focus of prevention and management efforts, the subtext is that the individual is to blame if he or she develops the condition. The astonishing and immediate public response to the aforementioned newspaper article — almost 300 comments were posted online on The Age and Sydney Morning Herald websites alone within hours — reflected an entrenched attitude of blame towards people who are overweight or obese. Given that type 2 diabetes can only be prevented in about 60% of cases,6 these comments reveal and perpetuate a limited understanding of the multiple causes of lifestyle diseases. It remains critical to encourage people to pursue healthy lifestyle choices. However, addressing the obesogenic elements of our environment is just as important. Encouraging patients to become involved in organisations such as The Parents’ Jury, an online network dedicated to improving children’s food and physical activity environments (www.parentsjury.org.au), or to become familiar with community-based initiatives such as Victoria Walks (www.victoriawalks.org.au) may be beneficial. More broadly, it is important for health professionals and their professional bodies to make known to governments their support of policy and other initiatives that make our environ-ment conducive to healthy choices.

Jessica L Browne · Paul Zimmet · Jane Speight

To the Editor: A daunting idea for health care providers is the statistic that, for many medications, only about half of the patients given standard doses will receive the desired therapeutic benefit.1 In the past decade or so, it has been argued that some of this variation in response may be attributed to genetic differences between individuals in mechanisms responsible for the pharmacokinetics and pharmaco-dynamics of many drugs.2 The disparity in health standards among Aboriginal and Torres Strait Islander people compared with non-Indigenous groups is a cause for concern, and requires a concerted political effort to instigate adequate solutions.3,4 Some of the problems include a higher rate of diseases such as hypertension, diabetes, obesity, cardiac disease and depression.3,4 The range of medicines prescribed for these conditions is broad, and some people may not receive the full therapeutic benefit, or may have more severe side effects compared with others. Genetically determined variables contribute to the pharmacokinetics and pharmaco-dynamics of these drugs. Many medications used to treat such diseases are metabolised by the cytochrome P450 (CYP) hepatic enzyme systems, and/or their pharmacokinetics are altered by drug influx and efflux systems. Many of these mechanisms are under genetic control and their efficiency may vary between individuals. Despite this, there are few data on the pharmacogenetics of Indigenous populations generally, and the data on Aboriginal and Torres Strait Islander populations are particularly scant.5 Of the few genetic studies of Indigenous Australians, one found that CYP2C19 and CYP2D6 allele frequencies in a group from remote north-western Australia differed significantly from those for Australians of European ancestry, but were similar to those for East Asian populations.5 An altered CYP2C19 allele could mean alterations in levels of drugs such as phenytoin and clopidogrel, and an altered CYP2D6 allele could mean alterations in levels of drugs such as tricyclic antidepressants, selective serotonin reuptake inhibitors, codeine and tamoxifen. We urgently need to identify clinically relevant issues relating to the capacity of people from these groups to metabolise certain medicines. Screening for genetic variations in drug metabolism and transport mechanisms may highlight significant variations in capacity. This may influence whether people benefit from or are harmed by commonly prescribed medications for hypertension, type 2 diabetes, cardiac disease and depression. The high and increasing prevalence of these diseases among Aboriginal and Torres Strait Islander populations supports a detailed, methodical assessment of the genetics of their drug-metabolising capacity.

Joseph D Tucci

To the Editor: NSW Health’s latest initiative, www.emergencywait. com.au, is a website that presents real-time information about estimated waiting times at 58 emergency departments (EDs) in New South Wales. Similar websites have been used in other Australian states, including South Australia, Western Australia and Victoria, as well as overseas, in Ontario, Canada, and in Memphis, Tennessee. I am concerned that this initiative will be counterproductive and will add further congestion to our already overcrowded EDs. Extended waiting times are a longstanding problem at EDs. They have traditionally been attributed to staff shortages, delays in pathology and imaging tests,1 and inadequate funding. However, there is another major contributor to waiting times that rarely attracts attention in the lay media — the overwhelming number of patients who inappropriately seek medical attention in EDs and would be better served by a general practitioner. Much of the work in EDs involves treating patients with non-acute and non-urgent problems. Recent examples from my personal experience include a man requesting a prescription for antiepileptic medication, a perimenopausal woman with many months of irregular menstrual bleeding, and a young man with a common cold. All of these patients bypassed their GPs, despite their attendances being within normal business hours. A logical outcome of www. emergencywait.com.au is an increase in the number of non-acute, non-urgent presentations to EDs that are seen to be “quiet”. For alongside each hospital’s estimated waiting time, the website presents a list of nearby hospitals with the number of patients waiting at each, thereby enabling patients to compare EDs and attend the least busy one. Formal studies are scant, but crude American data indicate a 6%–10% increase in ED patient volume since waiting times were publicised.2 Although the transparency of www.emergencywait. com.au may help our EDs to share more equitably the burden of inappropriate patient attendances, I expect that it will increase the overall number of such attendances and ultimately increase waiting times. Australian EDs provide excellent, prompt care for patients who have been in accidents or emergencies, but they are neither equipped nor designed to look after individuals who meet neither of these criteria. The solution to overcrowded EDs lies not in websites that publicise waiting times, but in convincing the public that emergency rooms are for emergencies.

Alexander M Owen

To the Editor: Recently, there has been an increase in the popularity and use of baby slings to transport infants. A sling is a soft fabric carrier, worn around a parent or caregiver’s neck, in which the infant is suspended. Slings are often promoted as a secure and easy way to carry an infant, that maintains close contact with the child. An issue has arisen concerning the safety of such devices, in that infants may be placed in a position where there is excessive flexion of the neck (chin-to-chest positioning) or obstruction of the mouth and nose that may cause suffocation. Warnings have recently been issued by the Australian Competition and Consumer Commission.1 Sixteen deaths attributed to the use of slings have occurred in the United States and Canada,2,3 resulting in calls for mandatory standards by the US Consumer Product Safety Commission.2 We report a South Australian case of a 2-day-old boy, born at 38 weeks’ gestation by normal vaginal delivery, who was placed into a cloth sling worn under his mother’s shirt and jumper and was subsequently noted by his mother to be cold and not breathing. At autopsy, there were no significant abnormalities identified, with no injuries visible on x-ray or physical examination. Results of toxicological, metabolic, virological and bacteriological studies were normal. In the absence of definitive pathological findings, the cause of death was undetermined, although the baby sling was considered a risk factor. It is well recognised that infants placed in certain positions, such as in car safety seats, may be at risk of significant oxygen desaturation, and even death, due to upper airway compromise. This applies particularly to preterm and low-birthweight infants.4 It appears that a similar situation occurs with certain slings, albeit rarely, as the soft and rounded sleeping surfaces may promote a potentially dangerous posture that impedes normal respiration. Certain infants may also be quite vulnerable to airway occlusion, with deaths being reported while breastfeeding, for example.5 Given the cases of infant death associated with baby slings in North America, and this Australian case, it is important that parents and carers are made aware of potential safety issues with the use of these devices, particularly in very young infants. Constant monitoring of infants in slings is advised, to ensure that the infant’s head is facing outwards, with no covering of the face.

Roger W Byard · John D Gilbert