Letters

To the Editor: In their article on the decline of infectious syphilis in the Australian Indigenous population from 2005 to 2009,1 Ward and colleagues conclude that it “might be the right time to move toward the elimination of infectious syphilis from remote Indigenous communities”. They note that another previously endemic sexually transmitted infection, donovanosis, has almost completely disappeared from Australia as a result of an elimination program.2 I strongly support their call to action and believe that syphilis can, and should, be next. It is likely that, outside of the small number of communities who have been able to implement a coordinated screening program, the decrease in syphilis in remote areas is an unintended benefit of the use of azithromycin for genital chlamydia and trachoma, and amoxicillin for gonorrhoea. Syphilis is only transmissible to sexual partners for a few weeks during the primary phase (when a chancre is present) and during the secondary phase (when mucocutaneous lesions may be present). Although syphilis is highly infectious during these stages, the relatively short duration of infectiousness partly explains why it is less common than other bacterial sexually transmitted infections. Because the painless ulceration of syphilis is easily ignored by men, or may go unnoticed by women with genital lesions, the diagnosis and treatment of latent (ie, subclinical) disease has been the main focus of syphilis control in remote areas. This approach has had only a limited effect on reducing the incidence of infectious syphilis. Indeed, as latent disease detection and treatment improves, there may be a paradoxical increase in the incidence of infectious cases because latently infected individuals become susceptible to new infection again after treatment.3 Therefore, detection and treatment of all cases of early, infectious syphilis must be the aim of an elimination program, but it will be extremely difficult to achieve this in a remote or rural setting using current diagnostic strategies that almost exclusively rely on serological testing. Serology is still the mainstay of syphilis diagnosis, despite the development of sensitive and specific polymerase chain reaction (PCR) tests for Treponema pallidum. Multiplex PCR tests that can also detect herpes simplex and donovanosis have been used to diagnose genital ulcerative disease in remote areas of Australia,4 but not to screen asymptomatic individuals. The validation of a syphilis PCR test that can be used to identify early, infectious syphilis should be a research priority — one that could be carried out as part of an Australian Government-funded, centrally coordinated but locally implemented, targeted syphilis elimination program.

Francis J Bowden

To the Editor: Recently, Professor Hoy argued for the full inclusion of Aboriginal and Torres Strait Islander people in the Australian Health Survey (AHS), including the measurement of clinical variables and the proposed sample repository.1 Although much of the argument is plausible, several points were overlooked that make it untenable overall. First, the current study design arose with input from at least five Indigenous representative bodies, including the National Aboriginal Community Controlled Health Organisation.2 They identified social and cultural issues as priority areas to be addressed — correctly so, as the underlying causes of health disparity are located in these domains, not primarily in the clinical and biomedical aspects of the AHS. The input from these major national bodies cannot be ignored. Second, yes — there are concerns that “the stored samples and their results might be somehow misused”.1 These concerns are legitimate and well founded in historical and contemporary experiences of Indigenous people. The argument for applying “current scientific and epidemiological knowledge, methods and safeguards”1 to the use of information held in the AHS is correct as far as it goes, but ignores equally important Indigenous knowledge and methodologies, Indigenous intellectual property issues, the principles of “ownership, control, access and possession” of Indigenous information,3 and certain aspects of the United Nations Declaration on the Rights of Indigenous Peoples. This position is therefore inconsistent with the National Health and Medical Research Council guidelines on values and ethics in Aboriginal and Torres Strait Islander health research, particularly as they relate to “survival and protection”.4 Third, denying Indigenous people control over how their health information is used by mainstream research institutions prevents accountability of researchers to communities. Using and publishing this information requires review by relevant experts, in this case Aboriginal and Torres Strait Islander community representatives. Biomedical expertise alone is insufficient to enable effective peer review and, at worst, it risks promoting destructive policies that ignore social, cultural and political realities for Aboriginal people and Torres Strait Islanders. Aboriginal people and Torres Strait Islanders rightly feel that they have been one of the most researched groups in history. And yet, even with this background of decades of being constantly studied, researched and examined, it seems that there is still not enough information being collected. Wellbeing is “grounded in the respect given to people, and the control afforded to them, in their daily lives”.5 Sometimes it’s up to Aboriginal and Torres Strait Islander people to identify what is important in Aboriginal and Torres Strait Islander health: it’s our health!

Kevin G Rowley · Alister H Thorpe

In reply: I thank Dr Rowley and Mr Thorpe for their response.1 It is hard to justify exclusion of any Australian from opportunities to participate fully in important initiatives on the recommendation of bodies whose membership sometimes has no direct link to the persons affected. There is no other population group in Australia to whom this applies. Medical and clinical approaches should complement initiatives to address critical social and cultural issues; they are not in competition nor mutually exclusive. The inclusion of health measures in the adult (but not youth) components of the Australian Health Survey (AHS) acknowledges that there is much to be learned and remediated clinically. Any interpretation of the deliberate exclusion of Indigenous youth from the “measures” elements of the survey is unsettling. There is more, not less, to be learned from this group. Their exclusion deprives policymakers of robust evidence that could improve health status. It condemns enquiry to the current sidestream method of short-term research projects on small pockets of people. These sometimes yield results of dubious generalisability and cause ongoing competition for the impossibly stretched research dollar. Alternatively, is it implied that Indigenous parents are less able to make sound decisions on their child’s participation or that the minors are less likely to cooperate? I suggest that the matter of participation in the AHS be aired through general media channels, as well as those with an Indigenous focus, such as “Living Black” (SBS television) and Imparja television, and through local Indigenous radio stations and community networks. With a developed sampling frame for Indigenous people, dialogue about elements of the examination should at least be conducted with the specific individual tribal groups or communities, if not with the targeted individuals (the preferred option). Subsequently, the whole issue of representation to policymakers in Indigenous health matters might be re-examined on a national basis.

Wendy E Hoy

To the Editor: Although Indigenous males are twice as likely and Indigenous females are half as likely to report being diagnosed with osteoporosis compared with their non-Indigenous counterparts,1 data on the interracial differences in osteoporotic risk factors are limited. Our study of 276 patients attending a tertiary hip fracture unit in Western Australia over a 5-year period is the first to report differences in common risk factors for hip fracture between Indigenous and non-Indigenous patients. Our data showed a lower likelihood of vitamin D deficiency and polypharmacy but higher likelihood of diabetes mellitus, renal disease and alcohol use among Indigenous patients with hip fracture compared with non-Indigenous patients. Using the local orthogeriatric database, we identified 46 Indigenous and 230 randomly selected non-Indigenous patients aged ≥ 45 years who were transferred to a hip fracture unit following surgery for a minimal-trauma fracture at Royal Perth Hospital from July 2005 to June 2010. High alcohol use was defined as alcohol intake exceeding guideline recommendations,2 and polypharmacy as the use of more than five medications. We used a laboratory cut-off of 25-hydroxyvitamin D (25-OHD) < 50 nmol/L to indicate a low vitamin D level. Indigenous status was self-reported during admission. We compared data for Indigenous and non-Indigenous patients using the Mann–Whitney U and Pearson χ2 tests. We used logistic regression (SPSS version 17; SPSS Inc, Chicago, Ill, USA) to examine the association between Indigenous status and the predictor variables. Our study was exempted as a quality assurance activity from formal ethics review by the Royal Perth Hospital Ethics Review Committee and the Western Australian Aboriginal Health Information and Ethics Committee. Risk factors among the two groups are shown in the Box. The most common risk factors among Indigenous patients were antihypertensive use, high alcohol use and diabetes. In the final multivariate model, Indigenous patients with hip fracture were significantly more likely to have diabetes and renal disease and to report high alcohol use, but significantly less likely to have a low vitamin D level and polypharmacy, after adjustment for age, sex and rural residency. These well described risk factors contribute to fracture risk through two mechanisms: falls and secondary osteoporosis. Diabetes-related complications such as visual impairment, stroke and peripheral neuropathy can increase fracture risk.3 In renal dysfunction, osteoporosis is related to cortical thinning and uraemic osteodystrophy.4 Excessive alcohol intake at a young age among Indigenous people may affect peak bone mass.5 The effect of alcohol on liver cirrhosis, cognition, falls due to intoxication and peripheral neuropathy may contribute to fracture risk. Risk stratification will be more robust if these results can be cross-validated in other institutions. Associations between hip fracture and risk factors in Indigenous patients compared with non-Indigenous patients at Royal Perth hospital, July 2005 – June 2010 Variable Indigenous (n = 46) Non-Indigenous (n = 230) P* Crude OR Adjusted† OR (95% CI) Continuous (mean [SD]) Age at hip fracture‡ (years) 81.4 (9.1) 82.3 (9.4) 0.58 0.99 1.03 (0.96–1.10) 25-OHD level (nmol/L) 59.9 (30.2) 40.9 (18.6) < 0.001 – – Categorical (no. [%]) Women 29 (63%) 161 (70%) 0.35 1.11 2.52 (0.51–12.31) Non-metropolitan 42 (93.3%) 38 (16.6%) < 0.001 70.37 70.32 (14.43–342.59) Low vitamin D level§ 15 (38.5%) 142 (69.6%) < 0.001 0.27 0.26 (0.07–0.91) Prior fracture 9 (19.6%) 52 (22.6%) 0.65 0.83 0.42 (0.09–1.90) High alcohol use¶ 19 (41.3%) 10 (4.3%) < 0.001 15.5 13.25 (1.89–92.92) Diabetes mellitus 21 (45.7%) 41 (17.8%) < 0.001 3.87 8.19 (2.02–33.18) Renal disease 16 (34.8%) 21 (9.1%) < 0.001 5.31 6.12 (1.29–29.05) Polypharmacy** 18 (39.1%) 137 (59.6%) 0.01 0.44 0.17 (0.04–0.72) Antihypertensive use 26 (56.5%) 118 (51.3%) 0.52 1.23 2.75 (0.70–10.76) 25-OHD = 25-hydroxyvitamin D. OR = odds ratio. * Mann-Whitney U or Pearson χ2 test. Level of significance: P < 0.05. † Multivariate logistic regression. ‡ Minimal-trauma fracture. § 25-OHD level < 50 nmol/L. ¶ Alcohol intake exceeding guideline recommendations.2 ** > 5 drugs.

Michelle M Y Lai · Nicholas G Waldron

To the Editor: The number of vulvoplasty or labioplasty procedures rebated by Medicare Australia has more than doubled over the past 10 years;1 in the United Kingdom, a similar trend was observed in the National Health Service (NHS) (Box).2 Recent media debate in Australia highlights this as a concerning problem.3 The community assumes that surgical operations are clinically effective treatments performed for identifiable pathological features. In the context of female genital cosmetic surgery (FGCS), there is a blurring between disease and dissatisfaction, the latter being at least partly informed by cultural pressure about physical appearances. In addition, there is an absence of evidence on clinical effectiveness,4 and an apparent lack of commitment to monitor adverse events. This raises the question of how clinicians justify referring women for FGCS. A recent audit of referral letters for labioplasty in an NHS gynaecology clinic in the UK (University College London Hospitals project no. 03/0173) offers interesting insights. Of the 48 letters reviewed, the mean age of the women referred was 25 years (range, 9–50 years). Complaints about genital appearance were identified in 34/48 (71%) of letters (eg, embarrassment about undressing in public changing rooms). Physical discomfort was mentioned in 23/48 (48%) letters (eg, difficulty with activities such as cycling). Sexual problems were mentioned in 21/48 (44%) letters (eg, a reluctance to engage in sexual relationships). In two of the letters, the referrers mentioned disparaging comments by previous sexual partners, and one mentioned harassment by other girls at school. Alarmingly, a further seven letters (15%) alluded to concerns being flagged by the girls’ mothers. Only 77% of referrers reported examining the patient. A third of referrers judged the labia to be “normal”, yet nevertheless requested surgery for their patients. Pejorative language such as “leathery in appearance” or “pendulous and elongated” was used in 12 (25%) of the letters. Medical training may cover basic vulval anatomy, but detailed study of morphology is not included. This knowledge gap would have been less problematic in the past. However, in recent years, where intense marketing of FGCS5 is contributing to soaring demand, medical practitioners may not be sufficiently informed about female genital anatomy to assess and advise women about their concerns. Reasons for the increasing prevalence of female distress about genital appearance are likely to be complex and rooted in social and cultural changes. In the absence of identifiable diseases, referral for operations may not be the most appropriate way of managing women’s body insecurities. Labioplasty and vulvoplasty operations rebated by Medicare Australia1 and covered by the United Kingdom National Health Service2 over the past 10 years* INR = international normalised ratio. * Graph shows abbreviated, not daily, data. Intervals are weekly up to Week 9, then vary according to when INR was measured.

Rebecca Deans · Lih-Mei Liao · Naomi S Crouch · Sarah M Creighton

To the Editor: Animal and human studies confirm the view that colonisation by non-typeable Haemophilus influenzae (NTHi) of airways already damaged by inhaled toxins initiates a second major pathway of damage in chronic obstructive pulmonary disease (COPD). This provides a framework for novel and effective management strategies for this condition, which has previously been considered to be a self-induced disease of elderly people for which nothing can be done.1 Acute exacerbations of COPD are recognised as critical determinants of acute and long-term outcomes. They represent a shift within the bronchus of the balance between two pressures — colonising NTHi and protective recruitment of phagocytic cells — that favours the bacteria and results in an inappropriate and excessive inflammatory response. A novel oral vaccine that reduces acute exacerbations in COPD is currently undergoing an advanced clinical trial in 21 centres across Australia. Oral immunotherapy with enteric-coated inactivated NTHi enhances the efficiency of mucosal immune protection (Box). In a rodent model, specific T cells, derived from stimulation of Peyer’s patches by orally administered NTHi, enhanced clearance of bacteria from the bronchus by recruiting and activating phagocytes.2 In mice co-infected with NTHi and influenza virus, oral administration of NTHi abrogated the increase in levels of both bacteria and virus, suggesting NTHi is a final common pathway for both viral and bacterial infections.2 In humans who smoke, seasonal increase in circulating specific T cells was significantly augmented after oral immunotherapy with NTHi, blocking access of inhaled NTHi into peripheral airways.3 These data support a mechanism whereby NTHi increases physiological protection based on aspiration of bronchus content into the gut. Qualitative2-4 and quantitative2,3 sputum analysis showed that protection was correlated with a reduction of all pathogens and a significant 3-log fall in NTHi, as expected from specific activation of a non-specific clearance mechanism (phagocytosis). In COPD, T cell-recruited neutrophils within sputum undergo a phenotypic change characterised by longevity and enhanced phagocytosis, maintained by autocrine loops.2 Early clinical trials4 of oral immunotherapy showed reductions in the frequency and severity of exacerbations, with consistent decreases in antibiotic usage of more than 50%. A potent and well characterised NTHi isolate with broad cross-protection in screening assays has now been developed for use as the vaccine HI-164OV (unpublished data). Phase II clinical studies of the vaccine have shown it is safe and effective3 and resulted in significant reductions in exacerbations treated with systemic corticosteroids (63%) and hospital admissions (90%)5 among patients with severe COPD taking best-practice treatment. Phase IIb trials are now underway. Evidence of IgE antibody to NTHi in both COPD and treatment-resistant asthma predicts broader clinical value for oral therapy with HI-164OV, through its capacity to prevent inhaled bacteria (allergens) penetrating into small airways.3 Enhancement of mucosal immune protection by oral immunotherapy with enteric-coated inactivated non-typeable Haemophilus influenzae1 Aspiration of bronchus content (including bacteria) into the gut (1) stimulates Peyer’s patches (3) to release T lymphocytes that “home” to the bronchus (4). T lymphocytes — directly or indirectly — secrete cytokines and chemokines that augment recruitment and activation of phagocytes (5). Phagocytes reduce the colonising load of bacteria in the damaged bronchus mucosa. Ingestion of inactivated non-typeable Haemophilus influenzae (2), as a vaccine, augments this protective loop.

Robert L Clancy · Margaret Dunkley

To the Editor: The Australian state of Queensland has one of the highest rates of melanoma and non-melanoma skin cancer in the world.1,2 Solar ultraviolet (UV) radiation is the most important environmental risk factor,3 highlighting the need for sun safety education and skin cancer screening among outdoor workers in Queensland. Many such programs are currently in place, including the Sunsafe Workplace Program developed by the University of Queensland in collaboration with the Queensland Skin and Cancer Foundation in 2007. In August 2010, we attended an outdoor workplace in Brisbane, with extensive sun safety policies already in place, to perform free voluntary skin checks on employees. Of 55 people invited to participate, 39 accepted. Of these, 36 were male, the median age was 35 years (range, 19–62 years), and 28 were of British and/or Irish ancestry. Eighteen participants reported spending 5–8 hours a day outdoors mid week and 20 reported the same at weekends. Six reported that at the start of summer, they never tanned and always burned, and 31 reported burning first, then tanning. Nearly half reported having had more than five painful sunburns in their lifetime. Despite these results, only a third of participants (13) reported wearing sunscreen, less than half (17) reported wearing a hat, and two-thirds (26) reported wearing sunglasses more than 50% of the time. Of the 39 participants, we referred one to his general practitioner for management of two non-melanoma skin cancers. About half of the participants reported having had formal skin checks before. Of these, one had previously had melanoma and five had non-melanoma skin cancers, and 10 had one or more suspicious naevi removed in their lifetimes. The main reasons given for not having had a previous skin examination were fear of skin cancer diagnosis and difficulty attending appointments during working hours. We found that providing easy access to free on-site skin examinations reduced interference to the work day, made appointments more accessible (both physically and financially), and enabled us to provide personalised information about participants’ skin and skin cancer risks and reassure those who had been anxious about receiving skin cancer diagnoses. We found that workers were relieved when told they had nothing suspicious presenting on the day, and that they seemed less anxious about seeking skin checks in the future. Despite many public awareness campaigns on skin cancer and the establishment of sun safety programs in the workplace, we found there is still room for improvement. Although clinical guidelines do not currently recommend routine skin cancer screening for the general population,4 the success of our visit leads us to encourage workplaces that are exposed to solar UV radiation to consider providing on-site skin examinations for employees, as well as ongoing sun safety education. We believe such services can help to break down barriers that prevent people from seeking medical assessment and management, and can help to spread the safety-in-the-sun message.

Nicola C Douglas · Laura Baillie · H Peter Soyer

To the Editor: In their report on the findings in Hope v Hunter and New England Area Health Service,1 Mahar and Burke suggest that some of the judge’s reasoning “may reasonably cause apprehension for clinicians relying on the peer professional practice defence”.2 In her Editor’s Choice, Katelaris mirrors this apprehension.3 But the judge’s findings are not nearly so troubling. Mahar and Burke state that “the court considered ... that because the defendant had completed much of his training in the United Kingdom and the United States, the evidence that he gave was not necessarily indicative of professional practice in Australia”. However, the judge had said: Without at all intending any criticism of Associate Professor Haertsch [expert witness for the defendant] ... his practice was in accordance with what he had learnt in his training in Edinburgh, Scotland and in Michigan, USA which was not, of itself, evidence as to peer practice in this country.1 The judge’s point was not about the defendant having trained overseas — the judge made no mention of where the defendant had trained. The judge was concerned about the expert witness who was testifying as to what extent the technique used by the defendant was peer practice in Australia. In doing this, the expert witness described how he conducted this sort of procedure, drawing on his overseas training. Quite reasonably, the judge regarded this as “not, of itself, evidence as to peer practice in this country”. Also, Mahar and Burke state that because the same expert witness had consulted a colleague about her practice concerning ganglion excision, the “court noted that this witness ... was in sufficient doubt to consult another practitioner” and “this may have partly informed the court’s decision to reject the expert’s evidence for the purposes of the defence”. However, the judge had said: I also consider it telling that Associate Professor Haertsch appeared to be in sufficient doubt about the matter that he thought it was necessary to consult Dr Gschwind for her views and for details of her practice concerning ganglion excision. I infer from the fact of such consultation, together with the fact that Associate Professor Haertsch has only operated on little rice grain sized ganglia ... that he has not had the same breadth of experience as Associate Professor Connolly [expert witness for the plaintiff] as to what constituted widely accepted professional practice ... concerning the excision of a half centimetre sized ganglia of the type that the plaintiff had presented for removal. In this regard I prefer the evidence of Associate Professor Connolly to that of Associate Professor Haertsch.1 Seen in context, it is hard to draw the conclusion that the testimony of the expert witness “was discounted because ... he consulted a colleague about her views on the case”.3 If the consultation with a colleague discounted the testimony, it was a very minor factor.

Christopher J Ryan

To the Editor: The Journal recently drew attention to circumstances in which courts have not accepted professional opinions on standard of care required in negligence cases.1,2 These include opinions formed after consulting colleagues, from doctors trained overseas or unrepresentative of national peer professional practice. In a veterans’ entitlements case in 2004 (Linton and Repatriation Commission3), in which I was an expert witness for the Department of Veterans’ Affairs, the Administrative Appeals Tribunal did not accept an opinion on appropriate clinical management in the past from an expert whose memory of peer professional practice was contradicted by documents that were in use at the time in question, preferring the latter. However, contrary to the circumstances described by Mahar and Burke, the Tribunal did accept opinions from a doctor who consulted others and from me, even though I trained overseas. The Repatriation Medical Authority produces “statements of principles” that enumerate factors which connect veterans’ health to service under the Veterans’ Entitlements Act 1986 [Cwlth].4 Inability to obtain appropriate clinical management is a factor in many of these statements. Tribunals have relied on professional opinion to determine the appropriateness of clinical management received by veterans. In Linton and Repatriation Commission, a veteran claimed in 2004 that withholding corticosteroids during the 1970s constituted inappropriate management of asymptomatic hilar lymphadenopathy due to sarcoidosis.3 There was disagreement between expert witnesses. One expert, a graduate of 12 years and a newly qualified Fellow of the Royal Australasian College of Physicians (FRACP) in the early 1970s, believed that the veteran should have been offered corticosteroids. Another FRACP, who was 15 years younger and graduated in the mid 1970s, after consulting colleagues who had practised at the time in question, believed corticosteroids would reasonably have been withheld. Despite being trained in the United Kingdom, the Tribunal accepted evidence from me on three important issues.3 First, the Tribunal accepted that textbooks used in the 1970s may contain statements of what should have been done at that time to manage sarcoidosis. Second, the Tribunal accepted that, based on the textbook on which Australian physicians probably relied during the 1970s, patients with the veteran’s condition were unlikely to have been treated with corticosteroids owing to an expectation that the condition would resolve spontaneously. Third, the Tribunal accepted that early clinical trials of corticosteroids in the treatment of pulmonary sarcoidosis between 1967 and 1976 were inconclusive and gave doctors no reason to believe that steroids would alter the long-term outcome of the condition. In addition, a 2000 Cochrane review found that the long-term effect of steroids was still unclear.5 The Tribunal, therefore, found that the veteran’s condition was managed appropriately. Comparing the circumstances under which civil courts and the Administrative Appeals Tribunal have not accepted opinions on standard of care would reveal any systematic differences between the jurisdictions.

Hedley G Peach

To the Editor: By focusing on the observed low correlations between the Undergraduate Medicine and Health Sciences Admission Test (UMAT) and academic scores at the University of Queensland (UQ), Wilkinson and colleagues1 conclude that the UMAT is a poor predictor of medical student performance. Alternatively, one could focus on the very high mean and low variance grade point average (GPA) scores of the UQ student cohort and conclude that the use of UMAT scores was clearly very successful in identifying a high-performing group of students. However, before making any conclusions based on these data, we should draw on the vast literature that highlights common problems that significantly affect validity coefficients.2 Range restriction is one such problem, and Wilkinson and colleagues rightly used Thorndyke case 2 to correct for this in their UMAT scores. Although they achieved little change in observed correlation values, a recalculation using the mean standard deviation of the entire UMAT cohort for the period 2005–2009 actually takes the 0.14 correlation between Section 1 and Year 1 GPA to 0.27. Despite this considerable increase, Thorndyke case 2 only accounts for direct range restriction of the predictor (UMAT scores). However, in the context of medical student selection, there are other important sources of error that need to be accounted for in order to better appreciate predictive validity. First, use of a high cut-off on the high school examination score is very likely to add indirect range restriction on the UQ UMAT scores. This may be further attenuated by not including measures of non-cognitive ability (interviews). Second, selection on cognitive ability tests (UMAT and high school results) also creates range restriction on the largely cognitive criterion (GPA) that would further reduce observed validity correlations. The UQ study illustrates such restriction. Third, the unreliability of the criterion itself needs to be accounted for, especially when more subjective ratings are included, such as ratings of clinical performance. The problem of relatively small samples in selection studies is well documented.2 Given the evidence of extreme range restriction of predictor and criterion variables used in medical school selection research, more primary studies (followed by meta-analysis) are necessary before accurate conclusions can be made about the use of the UMAT, or of any other predictor used in this high-stakes selection context.

Barbara N Griffin

To the Editor: I spent my fifth-year medical student elective at Alice Springs Hospital and a remote Aboriginal settlement in the north-west of South Australia in the early 1980s. I organised this myself and came away with a fairly firm belief that the health of the Indigenous population in remote areas was unlikely to improve. Between 1995 and 2009, I visited remote Aboriginal settlements and hospitals in Darwin and Alice Springs as a specialist physician. Nothing I have seen in that time has changed the view I formed as a student. During my time in these settings, I have seen in the Indigenous population extreme examples of poverty, severe neglect of children and adults with disability, and examples of physical and sexual abuse. On occasions I have been threatened, and at times I have needed to be escorted for my safety. When staying overnight on settlements, I have been provided with secured accommodation. I have walked in fear of feral and diseased camp dogs and have been hurried along in my work to avoid cultural incidents. The article by Patel and colleagues explores some of the issues in this area as they affect medical student training.1 I think it is good that they have done so, but to dress it up with quasi-scientific methodology is unnecessary. My view is that it is not possible to provide or sustain health services of any reasonable standard in small and remote communities that have no economic basis for development and where the population is poor, poorly educated and has little prospect to share in this country’s fortune. There is a reason that we are failing to improve the health of the Indigenous population in remote areas, and that is that we cannot. It is an unrealistic expectation. This needs to be acknowledged, and we all need to move on.

Adrian N Winsor

To the Editor: In their editorial about risks to medical students in rural and remote placements, Peachey and McBain-Rigg stated: But there is a danger that, in focusing only on possible harms, we underestimate the power of difficult circumstances to enhance the very attributes that are required for the long haul in rural and remote practice.1 They referred to such issues as a “philosophical quandary” and went on to use a metaphor about a breaking bungee rope. The editorial conflated two important issues: safety and character-building experiences. The safety of visiting medical students and workers is not a philosophical quandary. Requirements of occupational safety are a practicable matter and a matter of law. Employers are required to assess and manage risks. The editorial’s authors are from Queensland, where the current relevant legislation is the Workplace Health and Safety Act 1995. Assistance is available from state workplace safety bodies, such as Workplace Health and Safety Queensland. Patel and colleagues made a good empirical assessment of adverse events that have happened to medical students in remote areas.2 Such an assessment could contribute to a safety management plan and system. Patel et al stated that “a ‘distressing’ incident does not necessarily lead to an overall negative placement and may in fact be a powerful learning experience”. They gave the example of a female student who was not met when she got off a bus at a remote community at 3 am, which concluded with the student’s words that the placement was a “good placement medically”. A worker might implicitly or explicitly approve of any risk that he or she is exposed to, but this does not relieve the employer of its obligations to the worker’s safety. Inviting readers to look on the bright side of safety shortcomings is not in the best interests of medical students, the permanent workforce or the population of rural and remote areas.

Andrew W Nielsen

In reply: It saddens us that Winsor’s experiences as a remote visiting specialist are so depressingly familiar, but his nihilism is even more disturbing. There has in fact been improvement in the health of the Indigenous population in remote communities; examples of this include the evidence provided by articles in the very same issue of the Journal, by Margolis and colleagues (falling rates of serious injury retrieval) and Ward and colleagues (declining syphilis rates).1,2 An understanding of the social determinants of health is essential to accepting that we can indeed work towards improving health, perhaps not through focusing on specialist medical services but rather in the broader primary health care context. Our students and patients deserve clinicians and mentors who might inspire and look for solutions, rather than retreat into despair. Progress in closing the gap will be far slower than many imagine, but it is not impossible, as we have already seen. We totally refute that we used a “quasi-scientific methodology”. Our study is a simple retrospective audit with not a P value in sight,3 and it has no pretensions to be otherwise. It aims to present a clear story from a defined group, and to add to the many individual anecdotes, such as Winsor’s, that on their own do not gain the attention of employers, policymakers, or government. By building a body of evidence, surely we will be able to more effectively advocate for systemic changes. Collaborating with interested colleagues such as remote area nurses who have published more widely on their own adverse experiences4 is another key strategy in influencing change. We agree wholeheartedly with Nielsen’s viewpoint that obligations to workplace health and safety legislation and to company policy and procedures should be paramount. However, this breaks down when individuals employed or contracted in various capacities are incompetent, ignorant, stupid or just have a sheer disregard for the rules. In addition, there appears to be a lack of scrutiny in remote areas where lower standards are somehow acceptable, and legal frameworks somewhat more fluid. The romanticisation of the bush and the culture of “making do” is partly responsible for the laissez-faire attitude to occupational health and safety. Perhaps our metropolitan colleagues could assist in challenging the status quo and the deeply entrenched beliefs, attitudes and systems that collude in silencing questioners and burnt-out staff.

Ameeta Patel · Margaret Vigants

To the Editor: Young children are at increased risk of severe influenza compared with the general population. Routine vaccination of children using trivalent influenza vaccine (TIV) is recommended in the United States and Canada. The Western Australian government, with support from vaccine manufacturers, has been providing TIV free of charge to all children aged 6–59 months since 2008.1 In 2010, high fevers and an increased incidence of convulsions were observed in children aged < 5 years after administration of TIV. Most reports of adverse events were from WA, owing to higher uptake of vaccination associated with the free vaccination program. The national influenza vaccination program for children aged < 5 years was subsequently suspended,2 and high rates of fever and convulsions were confirmed.2,3 The majority of adverse events occurred after administration of Fluvax or Fluvax Junior (CSL Biotherapies). More than 50% of parents of children who were administered Fluvax or Fluvax Junior reported high fever after vaccination. The incidence of febrile convulsions after vaccination with Fluvax and Fluvax Junior was 4.4 per 1000 doses, significantly higher than expected.3,4 Fluvax and Fluvax Junior are not recommended for children aged < 5 years in the Australian 2011 influenza vaccination program.5 In response to these events, WA Health established an online registry for vaccine-associated adverse events — the Western Australian Vaccine Safety Surveillance (WAVSS). Health professionals are required and members of the public encouraged to report adverse events. In addition, a prospective safety study of the 2011 TIV in children aged < 5 years has commenced at Princess Margaret Hospital for Children and the WA Central Immunisation Clinic. From 15 March to 29 April 2011, 2227 doses of TIV were administered to children aged < 5 years in WA (2130 doses of Vaxigrip [Sanofi Pasteur]; 97 doses of Influvac [Solvay]). Adverse events in four children aged < 5 years have been reported via WAVSS: two with elevated temperature (≥38°C yet < 39.5°C) within 24 hours of vaccination, one with vomiting and diarrhoea after vaccination, and one with fever (not specified) and convulsions 4 days after vaccination (this child had a respiratory tract infection at the time of vaccination). All four children were administered other vaccines with TIV. In the safety study, 144 children were enrolled between 15 March and 29 April 2011. Adverse events after vaccination were reported in 10 children (7%), two of whom received other vaccines in addition to TIV. All 10 children had fever reported, and one child had a temperature > 39.5°C. Two children developed vomiting. No convulsions were reported and none of the children who had adverse events required assistance from a health care professional. These data demonstrate that the significant adverse events that occurred after administration of TIV in 2010 have not been observed in WA during early 2011. Ongoing surveillance is underway and will continue. Poor uptake of influenza vaccination in Australian children is likely to result in increased influenza-related hospitalisation, morbidity and mortality. Data such as those reported here are required to reassure the community of the safety of this vaccination program before the expected start of the 2011 influenza season.

Christopher C Blyth · Tracy Y Markus · Paul V Effler · Peter C Richmond

To the Editor: Australian influenza notification and hospitalisation rates are highest in children aged under 5 years,1 the group most commonly affected by egg allergy (estimated to affect 8.9% of infants aged 12 months in a recent Melbourne study).2 The ability to safely vaccinate egg-allergic individuals is thus an important public health issue, particularly in the context of potentially pandemic influenza. More than 98% of over 4000 egg-allergic individuals have tolerated vaccination under direct medical supervision in published studies.3-6 As a result, Australian and several international guidelines3,5,6 recommend that influenza vaccination of the egg-allergic individual may be undertaken using a two-step protocol (10%–90% vaccine dose, 30 minutes apart with a final 30-minute waiting period), as long as vaccines contain less than 1 μg egg ovalbumin/dose. Prior allergy testing with the vaccine is not recommended. All currently available influenza vaccines for the 2011 season in Australia have less than 1 μg ovalbumin/dose, specifically Influvac (Abbott Pharmaceuticals, < 1 μg/dose), Intanza (Sanofi Pasteur, < 0.05 μg), Vaxigrip and Vaxigrip Junior (Sanofi Pasteur, < 0.05 and < 0.025 μg, respectively), Fluvax (CSL, < 1 μg), Agrippal (Novartis, < 0.20 μg) and Fluarix (GlaxoSmithKline Australia, < 0.05 μg). Based on current evidence, we suggest that the 2011 seasonal influenza trivalent vaccines can be safely administered in a medically supervised primary care setting as a single dose with a 30-minute observation period (rather than the standard 15 minutes) in those with non-anaphylactic reactions to egg. In those with a history of egg anaphylaxis (or positive allergy tests without a history of ingestion), we recommend a split-dose protocol after discussion with an allergy specialist. We acknowledge that these guidelines are at variance with those in the Australian immunisation handbook,7 but they are consistent with more recent evidence and international recommendations. Whether it is also safe to administer vaccines containing more than 1 μg ovalbumin/dose8 awaits confirmation in a larger patient population and is not currently recommended.

Raymond J Mullins · Michael S Gold

To the Editor: Amid debate about growth in the number of Disability Support Pension (DSP) recipients and the increasing percentage of recipients with mental disorders,1,2 the recent federal Budget announced further welfare reforms and significant investment in mental health services.3 There are, however, limitations in the data informing the current discussion. Administrative data are restricted to coding the primary disability of DSP recipients, and do not assess comorbidity. Further, data on the health of recipients receiving other welfare payments are lacking, precluding thorough understanding of the context of the growth in the DSP population. We recently published an analysis of the 2007 Australian Bureau of Statistics National Survey of Mental Health and Wellbeing, in which we estimated the prevalence of common mental disorders in different categories of working-age welfare recipients.4 The main results showed that just over one-third (34%) of income-support recipients had a 12-month affective, anxiety and/or substance use disorder, compared with 20% of non-recipients; that, despite a decade of reform of the welfare and mental health systems and improved economic circumstances, there had been little change in the overall prevalence of mental disorders among welfare recipients since 1997 (Box, A);5 and that most income-support recipients with mental disorders received payments other than DSP. We compared data from the 1997 and 2007 surveys, focusing on welfare recipients with a mental disorder (12-month common mental disorder assessed by the World Mental Health Composite International Diagnostic Interview). Of the 10 641 and 8841 survey respondents in 1997 and 2007, 667 and 362, respectively, were identified as working-age welfare recipients with a mental disorder.5 We estimated that 31% of income-support recipients with mental disorders were DSP recipients in 1997, but in 2007 this had increased to 45% (Box, B). The increased concentration of recipients with mental disorders receiving the DSP was significant in logistic regression models controlling for age and sex (odds ratio, 1.72; 95% CI, 1.05–2.83).5 The increased profile of mental disorders among DSP recipients may reflect shifts between payments within the welfare recipient population. Although this could be due to financial incentives to receive DSP rather than lower-paying allowances (eg, Newstart Allowance), the results may reflect that some income-support recipients with a mental disorder are unable to comply with the new activity or work requirements introduced by recent policy changes.6 Careful consideration is needed of the potential adverse unintended consequences of welfare reforms for the large number of income-support recipients with mental disorders. Changes that promote DSP as the most appropriate option for people with mental disorders risk entrenching their alienation from the workforce. Mental disorders and welfare recipients (with 95% CIs), 1997 and 20075 DSP = Disability Support Pension.

Peter Butterworth · Philip M Burgess · Harvey Whiteford

To the Editor: The Health Practitioner Regulation National Law Act 2009 (Part 8, Sections 140 and 141) enshrines mandatory notification in the new national registration framework. As registered health practitioners, clinician-researchers are bound by the notification requirements. This raises the question of whether mandatory notification has implications for observational research in health services that is conducted by clinician-researchers. In particular, how likely is it that these requirements will lead to reclassification of one’s observations from “research data” to “notification evidence”? Three initial considerations are important here. First, the Act was designed to make health care safer for patients. Its intent is to limit incidents by ensuring clinicians are more open about and address inappropriate care. Second, serious incidents are rarely isolated, instantaneous and therefore easily observable disasters. When something goes seriously wrong, problems tend to be inherent in how teams practise, communicate and support one another over time. Third, observers may encounter instances of substandard care, but these become notifiable only when the threshold of unsafety is surpassed. This threshold is pegged to relatively high levels of severity, frequency and risk.1 In all, observational research can help clinicians to identify existing risks, but it is unlikely to become a source of notification. Human research ethics committees may also feel obliged to acknowledge and consider the possibility of incident notifications arising from observational research. However, it would not be wise to regard the risk of such notification as detracting from a study’s potential for obtaining ethics approval. The situation calls for specification of: how the observers will deal with incidents if and when observed the observers’ understanding of the definition and threshold of notification how the definition of notification is likely to bear on the study how the design of the study affects the likelihood of notification (eg, does the researcher seek to identify care irregularities or track these irregularities over time?) a projection of the relevant service’s vulnerabilities to notification, and plans for addressing and resolving existing vulnerabilities. In addition, mandatory notification does not mean that observational research will be more difficult to “sell” to ethics committees and frontline clinicians. The aim is generally to stimulate learning and raise awareness of problems. Our experience is that if the research is designed with frontline clinicians, and they contribute to its implementation, analysis and publication,2 it attracts considerable interest and support.3 Frontline staff know that the best way to understand the complexities inherent in their everyday work is through observation. Such research takes seriously their specific and unique circumstances, enabling them to actively participate as analysts and improvers of their own practice. Observation encourages reflection, and this means they become aware of and can proactively resolve their own vulnerabilities. Ultimately, the priority for clinician-researchers involved in observational research in health services, as for patients, is to reduce risks and prevent incidents.

Rick A M Iedema · Donella A Piper

To the Editor: We read with interest the case by Nadeem and Khateeb of an elderly man with migratory lung lesions and the concurrent finding of mixed cryoglobulins.1 We are concerned about attributing this man’s symptoms to mixed essential cryoglobulinaemia. The clinical syndrome described in this patient is not typical of cryoglobulinaemia. The establishment of a diagnosis of essential mixed cryoglobulinaemia in this man is problematic, given a lack of cutaneous findings and no definite evidence of peripheral neuropathy and renal disease. Nerve conduction studies to establish the presence of peripheral neuropathy and renal biopsy to confirm membranoproliferative glomerulonephritis were not carried out. Given his age, the confirmation of membranoproliferative glomerulonephritis would potentially necessitate long-term and possibly intensive immunosuppression to prevent subsequent development of renal failure. The cryoglobulins reported in this case fulfil the criteria for type II cryoglobulins. However, they were of relatively low concentration (0.4 g/L of monoclonal IgM/kappa and 0.1 g/L of polyclonal IgG). As well as hepatitis C, type II cryoglobulins can be detected in association with hepatitis B and Sjögren’s syndrome.2 The absence of anti-Sjögren’s syndrome A and anti-Sjögren’s syndrome B antibodies by no means excludes the diagnosis of concurrent, subclinical Sjögren’s syndrome. In addition, hepatitis B and C have not been excluded as the cryocrit was not analysed for hepatitis B virus DNA and hepatitis C virus RNA. Furthermore, the relatively low concentration of cryoglobulin detected and the findings of chest opacities with very high levels of C-reactive protein (that fell to normal levels with antibiotic treatment) could also be due to an infective aetiology.3 We also note that the thermal amplitude of the cryoglobulins should be investigated in such cases, as it has been well described that cryoglobulins of higher thermal amplitudes are more likely to be clinically significant. In conclusion, given the long duration of this man’s admission, repeat cryoglobulin measurements after he was discharged would have helped to more clearly define the role of cryoglobulins in his disease. We therefore recommend caution when interpreting low levels of cryoglobulinaemia in patients who have a clinical syndrome that may or may not be consistent with clinical cryoglobulinaemia.

Carl A Kennedy · David Gillis · Richard C W Wong

To the Editor: Katelaris recently asserted: In our society the response to medical error is typically legal, rather than investigative and remedial. This should be deplored by both the profession and the public.1 This polarised orientation seems more political than objective. It acknowledges neither the reticence of medical professionals regarding investigative reviews, nor the costs to patients’ families. Katelaris notes that defensive approaches encourage the concealment of errors. I have long advocated clinical reviews of critical incidents. Having personally set up Queensland Health’s original Suicide Register, I released statewide patient suicide data to health services. Reactions from service providers were decidedly underwhelming, despite the gravity of the outcomes. Katelaris did not explain how clinical reviews can address the problem of income replacement or other major costs associated with catastrophic outcomes for patients’ families. In the 1990s, I reviewed all Australian litigation for failure to prevent suicidal behaviour in care, through a survey of insurers and defendant solicitors.2 Of the 13 non-fatal cases identified, paraplegia occurred in seven patients, with other serious injuries in the remaining six. These were not trivial complaints. I also reviewed what might be learnt from the international literature3 and made known my availability to assist with clinical reviews of patient suicides. Despite having been an expert witness at the Royal Commission into Aboriginal Deaths in Custody and a Royal Australian Navy inquiry into the loss of a sailor who disappeared overboard in 2002, among others, no medical services have sought my assistance over more than 20 years! I understand, from personal experience, how distressing trivial and vexatious complaints against doctors are. I have even received a complaint for providing a report to a plaintiff’s solicitor, in relation to failure to prevent suicidal behaviour, in which I asserted that reasonable care had been provided. I now run a personal-injury psychiatric practice, with alleged medical negligence featuring in about 3% of cases. Mostly I am called by the plaintiff’s side, often following devastating surgical outcomes. Referral bias operates, in that negative surgical outcomes with psychiatric consequences are likely to have been more serious than those without. The outcomes have often been both emotionally and financially devastating to those affected. I long to see a medically mature culture develop with respect to clinical reviews of critical incidents, but my experience suggests we still have a way to go. But even when or if such a medical utopia is achieved, how will the financial disadvantages to patients’ families be overcome?

Christopher H Cantor

To the Editor: I was extremely surprised to note that there was no mention of the Australian Council on Healthcare Standards’ (ACHS) extensive national clinical database (http://www.achs.org.au/ClinicalIndicators) in the recent article by Evans and colleagues on clinical-quality registries.1 Since 1993, commencing with a small set of generic indicators that were of limited value, the ACHS has been collecting clinical data through its clinical indicator (CI) program as part of its accreditation process. Now, with over 300 CIs in use and around 670 health care organisations (HCOs), including some from New Zealand, contributing data, the scope of the ACHS national clinical database is unique in the world. Its longevity makes it one of very few national programs that can display longer term trends in processes and outcomes — both desirable and undesirable — of medical care. The clinical indicators, which form the basis of the database, were all developed in conjunction with providers of medical care, namely, the medical colleges. The validity, reliability and effectiveness of the indicators were established (and published) subsequent to introduction of the more specific indicators into the accreditation process.2 In addition to providing aggregate and peer-comparative data to the contributing HCOs, the ACHS publishes aggregate data with detailed analyses on an annual basis.3 As with similar databases, problems have arisen regarding maintenance of currency and relevance, timelines for reporting, and other issues. However, it seems extraordinary that this valuable aid to determining the quality of health care standards — envied by many countries — could be ignored by Evans et al, as it was similarly ignored by the authors of a recent special MJA supplement that reported on gathering patient-centred health care data aimed at improving care.4

Brian T Collopy, AM

To the Editor: Cancer Voices NSW, a leading organisation for health care consumers, welcomes the coverage in the 18 April issue of the Medical Journal of Australia of gaps in and barriers to research endeavours into cancer. We particularly commend Olver’s editorial which, among other things, calls for more consumer-friendly clinical trial registries to play a role in enhancing patient recruitment by making it easier for them to find suitable trials.1 Cancer Voices NSW (http://www.cancervoices.org.au), the voice of people affected by cancer in our state, has long advocated for such a resource, both centralised and reliable. We are delighted to advise Journal readers that an initiative of ours, the Australian Cancer Trials website (http://www.australiancancertrials.gov.au), is now up and running. It has been publicly available since its launch by Professor Jim Bishop, Australia’s Chief Medical Officer, in November 2010 and is hosted by Cancer Australia. In partnership with consumers, the development of the project was led by a research team that included members from the University of Sydney, the Australian New Zealand Clinical Trials Registry (ANZCTR), Cancer Voices NSW and Cancer Australia. Consumers had considerable input to the website’s development through consultation with members of Cancer Voices NSW and Cancer Australia’s National Consumer Advisory Group. The Australian Cancer Trials website was funded by Cancer Australia with partial funding from the National Health and Medical Research Council project grant (grant reference number 512380). The Australian Cancer Trials website’s consumer-friendly portal offers open access information held on both the ANZCTR and the United States ClinicalTrials.gov registers (http://clinicaltrials.gov/). It currently lists over 1000 cancer trials, and it is updated every day. Consumers can do a “simple search” by cancer type or keyword or an “advanced search” using criteria including cancer status, trial focus, phase of clinical trial, recruitment status and age category. Information about each trial is displayed in a user-friendly format. All cancer trials registered with ANZCTR in Australia for which a few consumer-friendly additional cancer fields are completed at registration will find recruitment easier. Patients with cancer and their specialists will have much easier access to up-to-date clinical trial information. This website is a successful model that can be translated to other diseases and conditions, and indeed, generically.

Sally Crossing

To the Editor: The association between poor hand hygiene of health care workers and nosocomial infection is well established.1 The National Hand Hygiene Initiative2 has been established to improve hand hygiene among health care workers, and the use of ethanol- or isopropanol-based hand sanitisers has been widely adopted in the hospital setting. To encourage their use by health care workers, many hospitals have undertaken extensive education programs and made hand sanitisers with high alcohol content readily available at all points of patient care. An unanticipated but potentially adverse outcome of this campaign is the intentional consumption of hand sanitisers by patients. We report the case of a 45-year-old man, with a history of polysubstance misuse, who was admitted to our institution with epigastric pain in the setting of acute-on-chronic alcohol intake. No evidence of pancreatic or biliary disease was found and the diagnosis of probable alcohol-related gastritis was made. On Day 3 of admission, the patient became increasingly drowsy. Clinical examination showed that he was rousable, and had a Glasgow Coma Scale score of 13. There were no other significant findings. Some hours later, six near-empty 375 mL bottles of Aqium Gel (Ego Pharmaceuticals, Melbourne, Vic), an antibacterial hand sanitiser that has an ethanol content of 66%, were found by the patient’s bedside. Excipients in this gel include thickener, dexpanthenol, dl-alpha-tocopheryl acetate, fragrance, pH neutraliser and water.3 On direct questioning, the patient admitted to intentionally consuming the contents of the hand sanitiser bottles. This was supported by a breath test performed about 40 minutes after the bottles were found, which showed a blood alcohol concentration of 0.271%. Following advice from the Poisons Information Line, supportive therapy was instigated and the patient made an uneventful recovery. Intentional consumption of ethanol- and isopropanol-based hand sanitisers by hospitalised patients has been described in overseas settings and serious adverse outcomes (including the need for intubation) have occurred.4-6 In one emergency department, all removable bottles of alcohol-based hand sanitiser in patient care areas were replaced with non-removable, self-contained dispensers.6 Experience at our institution over the past 6 months suggests that consumption of alcohol-based hand sanitisers by inpatients may be an increasing problem in Australian settings — we are aware of a further three patients who have consumed these products while at our institution. An increased awareness of this practice is required among health care workers in Australia, as it has the potential to create diagnostic dilemmas and lead to serious outcomes, and preventive measures need to be identified and implemented.

Lachlan M Batty · Anna J Brischetto · Ajay C Kevat · Michael J Oldmeadow

To the Editor: A 44-year-old female nurse with a 4-year history of hand dermatitis was referred to an occupational dermatology clinic in Melbourne. In 2009, her hand dermatitis had worsened when she started working in a neonatal intensive care unit, where she used antimicrobial hand gel more frequently. Her hands improved when she spent time away from work but worsened again within 2 days of returning. Patch testing was conducted using our baseline patch test series as well as rubber accelerators (used in manufacturing rubber gloves), antiseptics and the patient’s own samples (eg, gloves, moisturiser, etc). She developed positive reactions to formaldehyde and the formaldehyde releasers quaternium 15, imidazolidinyl urea and diazolidinyl urea, as well as the hand gel she had been using — Microshield Antimicrobial Hand Gel (Johnson and Johnson Medical, Sydney, NSW) — a gel containing 30%–60% water, and diazolidinyl urea as a preservative. (Diazolidinyl urea is not listed on the safety data sheet for this product as it is in a concentration of < 1%.) A negative result for a radioallergosorbent test indicated it was unlikely the patient was allergic to latex. She was advised to use a waterless, alcohol-based hand cleaner without preservatives and was given advice about general skin care, especially use of moisturising cream.1 She complied with this advice, and her condition subsequently improved. Diazolidinyl urea is a preservative commonly used in cosmetic products. Once absorbed into the skin, it releases small amounts of formaldehyde. Individuals may become sensitised to diazolidinyl urea, formaldehyde, or both. This can occur at any stage, even if the individual has been exposed to the product for years. At our occupational dermatology clinic we have patch tested 2688 patients and diagnosed 1461 of these with allergic contact dermatitis (ACD) over the past 16 years. Nine health care workers have been diagnosed with ACD to diazolidinyl urea contained in products they used at work. Thirty other patients have had ACD caused by this preservative from other sources, usually their skin care products. Many workers will simply accept their hand dermatitis as part of the job, or begin treatment without patch testing. It is only with patch testing that an accurate diagnosis can be made. Waterless hand cleaners are an important part of hand hygiene in health care settings,2 and they minimise irritation caused by washing hands with soap and water and drying with paper towels.3 Alcohol-based liquid hand-disinfectant solutions are more efficacious than gels.4 Our report provides another reason to use these products as, generally, alcohol-based liquids do not contain preservatives such as diazolidinyl urea.

Jennifer L Cahill · Rosemary L Nixon

To the Editor: Weight fluctuations may lead to significant changes in a patient’s treatment, so it is vital that hospital scales are accurate. A literature review revealed that calibration,1 accuracy2 and centralised hospital quality control3 of hospital scales were issues that are being recognised and addressed around the world. We audited all scales at the Royal Melbourne Hospital, city campus, to assess their accuracy and identify the types of scales that are likely to be most accurate. A preliminary survey identified all scales on the wards and in outpatient departments. On a single survey day, each scale was categorised and photographed. Scales were “zeroed” and standard weights of 5 kg, 10 kg, 15 kg and 20 kg, and a person whose weight had been established elsewhere as 106 kg, were then weighed on each scale. Our primary measure of accuracy was the difference between 106 kg and the recorded weight of the person, as this most closely approximated the weight of an average patient (rather than using the 5, 10, 15 and 20 kg weights). Forty-three of 50 scales identified in the hospital were tested. Scales that were excluded were either not working or not able to be tested with the weights we used. All scales in the outpatients department were digital (22). On the wards, there was a mix of sit-on (6) and stand-on (15), and digital (9) and analogue (12) scales. The digital scales had an accuracy (range around the standard weight) of − 1 kg to +1.5 kg, compared with an accuracy of − 3.5 kg to +1 kg for the analogue scales (P = 0.006; Wilcoxon signed rank test). Interquartile ranges were − 0.45 kg to +0.07 kg for digital scales and − 2 kg to +0.5 kg for analogue scales. The mean deviation from the correct weight was 0.06 kg for digital scales and 0.55 kg for analog scales. The most accurate scales were in the renal wards, used by dialysis outpatients and inpatients. Some areas had scales that were unusable by patients, such as sit-on scales in the geriatric ward (Box 1) that were difficult to mount. A haematology ward, where decisions are often made on the basis of changes in weight, had five sets of scales, with significant inaccuracies and differences between them. In one ward, no scales could be located, and five out of 23 outpatient rooms had no scales. The digital scales were more accurate than the analogue scales (Box 2). In areas where treatment decisions are made on the basis of changes in weight, scales should regularly be checked for accuracy, and patients should be weighed on the same scales each time they are weighed. For greater accuracy and consistency in measuring patient weights, we recommend that all scales be upgraded to digital scales throughout the hospital. 1 Sit-on analogue scale at Royal Melbourne Hospital, unusable for some patients 2 Weight variations in 43 digital and analogue scales at Royal Melbourne Hospital * As measured using standard weights of 5 kg, 10 kg, 15 kg, 20 kg and a 106 kg person.

Rimma Goldberg · Geoffrey Hebbard

To the Editor: Atypical femur fractures appear to be an emerging adverse outcome of long-term use of bisphosphonates. Although analyses of epidemiological data suggest that subtrochanteric and diaphyseal fractures per se are rare,1,2 the true incidence of atypical fractures (a distinct subset of such fractures) is unknown. In a recent 5-year retrospective study, we reviewed individual radiographs of 152 patients with subtrochanteric and diaphyseal femur fractures and identified 20 atypical fractures.3 Seventeen of these 20 atypical fractures had occurred in patients treated with oral bisphosphonates. In light of these findings, we sought to calculate the incidence of atypical femur fractures in the population served by our large tertiary referral hospital in Sydney. According to the Australian Bureau of Statistics 2006 Census, the hospital’s catchment population (as defined by the New South Wales Department of Health) was 174 448. The annual incidence of atypical femur fractures in 2006 was therefore estimated to be 0.23 per 10 000 in the general population, and 1.6 per 10 000 in people aged over 65 years. These estimates, based on a stringent radiological definition of atypical femur fractures, confirm that, on a population basis, these fractures are indeed rare. We also sought to define the mean annual incidence of atypical femur fractures in patients treated with oral bisphosphonates. Thus, we obtained data on the wholesale purchase of alendronate and risedronate by pharmacies within the hospital’s catchment area over the 5 years of the original retrospective study (1 June 2003 to 30 May 2008) from IMS Health Australia (market researchers for the global pharmaceutical and health care industries). A mean number of 2860 patients per year were prescribed alendronate and 1265 patients per year were prescribed risedronate. This corresponded to a mean annual incidence of atypical femur fractures of 10 per 10 000 in patients taking alendronate and three per 10 000 in those taking risedronate. The use of a relatively small number of cases to calculate these incidences is a particular limitation of our research, and is a reflection of the rarity of these events. Furthermore, our estimates need to be considered within the wider context of the established beneficial effects of bisphosphonates in patients with osteoporosis. On the basis of randomised trials, it has been estimated that treating 1000 women with oral bisphosphonates for 3 years prevents 100 fractures.2 Also, several meta-analyses have confirmed significant reductions in the risk of osteoporotic vertebral and non-vertebral fractures in patients treated with oral bisphosphonates.4,5 In spite of two recent large database studies that showed a greater incidence of atypical fractures among long-term bisphosphonate users,6,7 atypical fractures are rare and the risks of using this class of drugs appears to be strongly outweighed by their proven efficacy in preventing fractures.

Christian M Girgis · Markus J Seibel