Letters

To the Editor: We report the case of a 71-year-old woman who presented with a 3-week history of lethargy, subacute confusion and drowsiness. She was known to have a seizure disorder for which she had been taking lamotrigine 100 mg and sodium valproate 500 mg twice a day for 2 years. On examination, the woman was disoriented with regard to person and time, and had constructional apraxia and asterixis. The rest of the physical examination was unremarkable. A full blood count, electrolyte levels, coagulation parameters, arterial blood gas measurements and hepatitis serology were normal. Tests for immunological markers of autoimmune liver disease were negative. Liver function tests showed longstanding raised levels of alkaline phosphatase (158 U/L [reference range (RR), 30–110 U/L]) and γ-glutamyl transferase (434 U/L [RR, < 40 U/L]). Serum drug levels were sodium valproate 51.0 mg/L (therapeutic range, 50–100 mg/L) and lamotrigine 9.5 mg/L (therapeutic range, 3–14 mg/L). The venous blood ammonia level was 109 μmol/L (RR, < 50 μmol/L). A liver ultrasound scan was normal. Computed tomography of the brain showed microvascular changes and an old cortical infarct. An electroencephalogram (EEG) showed diffuse slowing, with a predominance of rhythmical theta activity and some delta activity, suggestive of encephalopathy. As hyperammonaemic encephalopathy secondary to sodium valproate therapy (VHE) was considered a possible diagnosis, sodium valproate treatment was discontinued. The patient’s confusion resolved completely and the asterixis disappeared within a week. At the same time, her blood ammonia level fell to 19 μmol/L and her EEG normalised. Eight months after discontinuing sodium valproate treatment, the woman was still asymptomatic. A subsequent percutaneous liver biopsy, to investigate her persistently abnormal liver function, showed features consistent with primary biliary cirrhosis. Sodium valproate is used not only for management of epileptic disorders but also for migraine prophylaxis and treatment of several psychiatric conditions. Although a generally well tolerated drug, it has a few well known side effects, including hyperammonaemia and, rarely, VHE.1-3 The possible pathophysiology of VHE has been described elsewhere.2 Gerstner et al reported on a series of 19 patients with VHE between 1994 and 2003.4 Review of the literature suggests that VHE is under-recognised, leading to considerable delay in the diagnosis of this potentially reversible condition.3,5 In our patient, it is reasonable to presume that sodium valproate precipitated the encephalopathy on a background of evolving unrecognised liver disease. The marked improvement in her clinical manifestations after discontinuation of valproate further supports this presumption. We have drawn attention to this case to highlight that VHE should be considered in patients presenting with confusion. Prompt measurement of the ammonia level and cessation of valproate treatment should be considered if clinically appropriate. Patients with previously unrecognised liver disease may be at particular risk. Acknowledgement: We thank Professor Peter Roberts-Thomson, Director of the Department of Immunology at Flinders Medical Centre, for his expert opinion and advice.

H S Subhash · Robert J Heddle · David W Schultz · John Ring · Campbell H Thompson

To the Editor: The timely article by Healy and colleagues1 should provoke debate within the profession. The authors’ decision to not consider “the relative merits of national versus regional registration boards” should not stifle discussion in the Journal. In particular, Australian doctors and the public should be aware that the medical board system to which we are accustomed is not operational in most countries. In much of the English-speaking world, boards comprise mainly doctors and have considerable independence from government; medical boards in non-English-speaking countries are generally part of the health bureaucracy.2 The fundamental danger of having a Council of Australian Governments-inspired national registration “body” lies in the potential for a switch from the “English” system of self-regulation under common law to the “European” model of bureaucratic rule under administrative law. Public and professional suspicion of self-regulation lay behind the 1987 amendments to the Medical Practitioners Act 1938 (NSW), which removed the power of deregistration from the New South Wales Medical Board, handing it instead to the Medical Tribunal chaired by a District Court Judge. This move avoided both the “Scylla” of public distrust of the profession and the “Charybdis” of criticism, such as have afflicted the boards in Victoria and elsewhere, where boards retained that power. No less important problems with a national board lie in the assessment of local problems and surveillance of doctors whose registration is conditional. This is already difficult in the larger states, such as Queensland, NSW and Western Australia. The continued failure of the centralised Health Insurance Commission to prevent and prosecute the abuse of Medicare by doctors, despite repeated ineffectual changes to the legislation,3 does not encourage optimism that a national medical board could effectively manage impaired doctors or those performing below standard. Having served on Commonwealth working parties on both mutual recognition of medical qualifications and Medicare “overservicing” and “inappropriate practice”, I would opt for an independent, publicly accessible national database containing a “uniform set of items that are allowable under existing privacy legislation”.1 The elements of such a database are already operational in the safe hands of the Australian Medical Council (AMC). It should not be too difficult, and certainly less cumbersome, for state and territory governments and medical boards to agree on that uniform set, on the foundations already laid by the AMC, and to continue the AMC’s ownership of the database.

Peter C Arnold

In reply: Arnold makes some interesting points about the balance of state and professional involvement in medical registration arrangements. Wherever the balance is struck, politicians, bureaucrats and medical professionals all derive their power in some measure from the public whom they serve. Our point is that variations in registration information and public access to multiple registers make it difficult for members of the public to access and use the information, especially given the mobility of the medical workforce between jurisdictions. A public national medical register should be seen as a practical measure to improve public accountability, rather than as a battleground between the profession and the bureaucrats. We did not express a view in our article1 on how national access to medical registration details should be arranged. As Arnold suggests, the Australian Medical Council is one candidate for maintaining a national database. It is well placed to publicly call on the existing state medical registration boards to cooperate speedily to make national access a reality, pending the negotiations underway regarding a national medical board.

Judith M Healy · Paul Dugdale

To the Editor: With the World Health Organization’s annual World No Tobacco Day to be held on 31 May, it is timely to encourage all patients who smoke to reconsider their actions. During my registrar training in the 1970s, I developed a simple and effective method of helping smokers consider some consequences of their tobacco habit. I offer this in the hope that others may find it useful too, as a more meaningful exercise than the concept of “pack-years”.1-3 First, enquire when the patient began to smoke regularly. I call this the “tobacco-arche” (analogous to menarche and coitarche). Next, determine how many years the patient has smoked regularly, remembering to subtract any years he or she may have suspended the habit. Then, have the patient estimate overall daily usage, relying, if possible, on prompting from an accompanying person to determine a realistic rather than idealised figure. Finally, multiply the number of years by the daily usage and by the number of days in a year. A reasonable approximation is to multiply by 400 rather than the more cumbersome 365.25. For example: a 65-year-old person who has smoked 20 cigarettes per day since his or her mid teens (ie, for 50 years) yields 20 × 50 × 400 = 400 000 — approaching half a million cigarettes lifelong. In my three decades of experience as a general physician, I have noted that an accumulated intake of a quarter of a million cigarettes usually results in at least some cough, breathlessness and end-expiratory wheeze on forced expiration, and decreased exercise tolerance; half a million cigarettes generally causes chronic smoker’s bronchitis, with or without some degree of emphysema, and other harmful effects on the body; while three-quarters of a million cigarettes makes cancer a distinct possibility.4 A further inducement for patients to confront the effects of their harmful habit is to calculate the amount of their lifetime tobacco intake in terms of the dollar cost. In the case of cigarettes, 500 000 at 60 cents each yields the impressive figure of $300 000. This usually comes as a sobering revelation to the smoker and their “significant others”. The above method can thus contribute to the desirable effect of reducing or eliminating tobacco consumption, with flow-on benefits to patients’ health, finances, and personal and occupational relationships.

C Ross Philpot

To the Editor: In his article on medical specialist education and training in Australia, Phelan1 raises two major issues: financial and educational. On the financial front, Phelan asks about the advantages and disadvantages of the new funding model for specialist (pre-Fellowship) training. One of the advantages of the model is that it makes the funding process more explicit. We believe that all who benefit from this educational exercise — trainees, supervisors, private hospitals and society — should contribute financially in some way. On the educational front, Phelan is disappointed that we did not provide evidence that university education will enhance the educational experience of trainees. However, undertaking educational studies that meet the standards required of reductionist experiments has proven to be difficult, and we have to make do with a more ecological approach. We have no doubt that our Macquarie University scholars will derive lasting benefit from working in an environment in which learning is one of the primary goals of their existence, rather than an add-on, after-hours, activity. Learning arises not from watching, but from doing. Modern concepts of neurobiology and learning suggest that learning results in structural changes in the brain, and these will be enhanced for the learner by full participation in all processes of care. We shall ensure that learning is maximised by an appropriate balance between scholars’ clinical experience and the educational opportunities that their clinical experience will provide. The Canadian contracting model, which Phelan mentions, is not dissimilar to the arrangement that will flow from the Memorandum of Understanding between Macquarie University and the Royal Australasian College of Surgeons and the Neurosurgical Society of Australasia, in that College trainees will substitute experience at Macquarie University for time spent in public hospitals in the College’s Surgical Education and Training Program. In Australia, we do not share the Canadians’ advantage of having only two postgraduate colleges. Given the current fragmented state of postgraduate medical education in Australia, we believe that it is better to experiment with and to evaluate new models than slavishly to copy what appears to work in a different setting. One of the flavours of the decade is competition, and we believe that competing models should be set up and should be rigorously evaluated from both educational and financial viewpoints. If history shows that the Macquarie lighthouse has illuminated the way to improved health for the Australian people, we shall be well satisfied.

Rufus M Clarke · Michael K Morgan

To the Editor: I recently received written advice from the Australian Safety and Compensation Council (a division of the Department of Employment and Workplace Relations) that the records of the Australian Mesothelioma Surveillance Program (AMSP) have been lost. As some of your readers would be aware, the AMSP, which ran between 1980 and 1985, was one of the most comprehensive medical surveys of mesothelioma undertaken anywhere in the world.1 The records of the program contain full occupational and environmental histories of about 1000 mesothelioma cases reported in the early 1980s. The program has played a significant role in helping to understand the epidemiology of mesothelioma in Australia. The level of detail of data in the AMSP has not been repeated by the Australian Mesothelioma Register, which succeeded the AMSP in 1985. This less detailed reporting scheme is the current basis for mesothelioma reporting to cancer registries in the country. I am a geologist with an interest in medical geology currently studying to obtain a doctorate on naturally occurring asbestos and mesothelioma risk in Australia. I had hoped to use the detailed environmental and occupational data of the AMSP to help determine the possible influence of naturally occurring asbestos on mesothelioma in Australia, in particular in the eastern states and South Australia, but without the records this is no longer possible. Data from the Australian Mesothelioma Register are not sufficiently detailed for this purpose. My intention in writing this letter is not to embarrass staff from the Australian Safety and Compensation Council, who have done their best to find the records and have been supportive of the project, but to create awareness of the loss, in the hope that the publicity may jog someone’s memory and result in the records being located. The potential permanent loss of these records would be a great loss to mesothelioma research in Australia and raises questions about the federal government’s policies surrounding long-term storage and archiving of nationally significant scientific research datasets that may be of benefit to future researchers.

Marc Hendrickx

Comment: The Australian Mesothelioma Surveillance Program (AMSP) operated between 1980 and 1985 and was maintained by the Commonwealth School of Public Health and Tropical Medicine at the University of Sydney. These files were transferred to the National Occupational Health and Safety Commission (NOHSC) on its establishment in 1985. The NOHSC was relocated from Sydney to Canberra in 2001, and AMSP records went into storage at that time. In February 2005, the NOHSC was succeeded by the Australian Safety and Compensation Council. We attempted to locate the records over several months in 2007. This involved manually searching through all files and boxes held by our contracted storage company marked as relating to either the AMSP or the Australian Mesothelioma Register. In addition, we had a staff member of the storage facility manually search the warehouse for these records in case they were in unmarked boxes or filing cabinets. In November 2007, having been unable to locate the records, we informed Mr Hendrickx that we would be unable to assist him with access to the AMSP records for his doctoral studies. It is certainly not our policy to discard records such as these and we were disappointed when they could not be easily located. We regret the potential loss of these important records to the research community and are still attempting to locate them.

Julie Hill

To the Editor: There are two fundamental flaws in the case for reform of youth mental health services outlined recently by McGorry and colleagues.1,2 They argued that 18 years is an unnatural and inappropriate transition point between adolescent and adult services, and that Child and Adolescent Mental Health Services (CAMHSs) are somehow inherently ill equipped to deal with serious mental illness. McGorry has long advocated a “youth model” catering for adolescents and young adults together. I believe this would be a disaster, particularly for adolescents. Adolescents and young adults need very different models of care, because of the differing degrees of responsibility and autonomy they can handle, the legal and moral responsibilities of families, carers, schools and health professionals, and the effectiveness of treatments. McGorry’s well deserved reputation and influence mean there is a real risk his opinions will be accepted as fact, especially as the opposing view is seldom heard. People aged under 18 years (on average) are not expected, or permitted, to take full responsibility for their lives or their mistakes. Legally, they cannot vote, drink or buy cigarettes. They are generally still at school and living in the family home. Those aged under 16 years are not automatically entitled to grant or withhold consent to treatment. Families thus have a central role in the management of illness in adolescents, in a way that is neither possible nor appropriate for adult patients. Adolescent inpatient units need to be highly structured environments where adults would be out of place, with school-like rules, and careful control of group process and peer interactions. Otherwise, there is bullying, sexual exploitation, epidemics of self-harm, and the kind of competitive rebelliousness that leads to riots and fires. In adult units, adolescents are unacceptably vulnerable, not only from exploitative older patients, but from a lack of boundaries to their own behaviour. McGorry made several perplexingly dismissive comments about CAMHSs. Two cannot go unanswered: that CAMHSs “struggle operationally and clinically with . . . mood, psychotic, substance use, and borderline personality disorders”;1 and that “the capacity to skilfully and safely manage highly disturbed behaviour, and the more sophisticated psychopharmacological skills, are often lacking in . . . CAMHSs”.1 The disorders described are, in fact, “bread-and-butter” work for CAMHSs. Further, there is powerful anecdotal evidence that CAMHSs manage them better, not worse, than others. Examination of data held by the Victorian Department of Human Services and the Office of the Chief Psychiatrist on seclusion (sole confinement) rates, consumer satisfaction and suicide rates will bear this out. Child psychiatrists all train as adult psychiatrists first and, in my experience, do not lack psychopharmaceutical sophistication. It is hard to see what adolescents and their families have to gain from being incorporated into young adult services, nor why 30-year-olds should be excluded from specialist early psychosis services. We need greater integration between the current tiers of service, and a more flexible approach to transition between them, not another separate tier of service.

David A Sholl

In reply: Sholl asserts that our case for reform of youth mental health services is based largely on personal opinion. In fact, as detailed in the Journal supplement,1 it is based on hard epidemiological facts, the latest developmental perspectives and a growing evidence base. Consequently, it has been widely supported by young people, families, governments and the community. The youth model ensures that developmental approaches appropriate to all stages of the process of transition from childhood to adulthood continue until the young person is genuinely independent. To design a health system around the transition age of 18 years, based on legal and educational precedents, is outmoded. Many more young people now pursue postsecondary education and are financially and socially dependent on their families well into young adulthood.2 The youth mental health paradigm involves families in a developmentally appropriate way from puberty to the mid-20s, and also recognises the increasing value of peer relationships. The key difference is that young people have increasing choice about the level and pattern of family engagement. Similarly, brain development continues actively up until the mid-20s. We believe Sholl has misunderstood the fundamental issue of youth mental health reform. It is not a binary choice between current child–adolescent and adult service models. A new stream of care is required to respond to these “transition age youth” or “emerging adults”, as they were recently termed.2 This stream borrows many of the features of adolescent psychiatry and extends these to around 25 years of age, complementing them with new evidence-based approaches, which have been difficult to create and nurture within a constrained and under-resourced Child and Adolescent Mental Health Services system. This step is crucial for the “graduates” of state care, who have appalling outcomes when care is withdrawn at 18 years (even though they can vote).3 We have successfully developed and provided such an adolescent–young adult service to a quarter of Melbourne for over a decade. Recently, we extended this to Sydney. The real-world impact of this approach has helped greatly to convince the community, including federal and state government leaders, of its wider value. We want to see genuine reform, restructure and substantial investment in a new stream of care. How well this links, not only with existing child and adult specialist systems, but equally importantly with other key systems — notably education and employment, primary care, housing, justice and drug and alcohol services — will be critical to its success.

Patrick D McGorry · Ian B Hickie · Anthony F Jorm · Rosemary Purcell

To the Editor: Singh and Castle recently commented on the assumptions made in relation to the National Mental Health Policy.1 One such assumption was that the cost of the community care service model could be constrained by limiting services to the “severely” mentally ill. The authors went on to describe the realities associated with making this and other assumptions on current mental health care delivery. Many public wards have become the province of treatment-resistant consumers with limited insight who do not welcome the interventions provided by mental health workers. It may be that this type of inpatient population is influencing medical students’ views of psychiatry and contributing to low numbers in psychiatry training across the country. Students’ perceptions that psychiatry is a difficult and pressured work environment have been reported.2 Public services for consumers who have mental illnesses that do not involve psychosis are under severe pressure in the current paradigm. Despite the availability of effective treatments, anxiety and depressive disorders remain the principal cause of the disability produced by mental disorders, and half the people with such a disorder do not seek help, not realising how well they can become.3 However, the public system appears to be retreating from providing services for such patients. There seems to be a view that all Australians with anxiety and depression can be treated in private practice or by general practitioners. Does targeting low-prevalence disorders for treatment represent an acknowledgement by those in government of the power of mental health stigma? Is there misguided thinking that spending money on patients with psychotic disorders will keep mental illness and violence off the streets? Doctors have an obligation to inform those in power that effective treatments need to be made available to the broadest range of Australians, not just those who are obviously mentally ill. The difficulty of retaining psychiatrists in the public sector has been noted in many countries.4 Health services need to provide variety in the work of clinicians to keep them within the public sector — a diet of chronic psychosis tends not to attract or sustain staff. I believe fostering specialist units dealing with high-prevalence disorders like anxiety and depression, and high-morbidity conditions like eating disorders, would encourage the training of new staff, contribute to research, and strengthen the future of psychiatry. Revitalising public treatment services for high-prevalence psychiatric disorders could provide both symptom relief and a return to productivity for many thousands of Australians, and a more sustaining work environment for mental health clinicians. It is time for our governments to hear the call to provide mental health care for the many, not just the few.

James D Hundertmark

To the Editor: A 20-year-old sub-elite Australian Rules football player presented with pain and tenderness in the lower third of the sternum. He had been involved in a moderate body collision with an opposing player about 3 weeks before presentation, and had continued to train and play despite sternal discomfort. He described no other symptoms. On examination, there was no obvious sternal deformity. There was mild to moderate tenderness over the lower third of the sternum, and minimal sternal discomfort on lateral chest compression. Chest auscultation was clear. Plain chest and sternal x-rays were normal. A technetium-99m HDP bone scan showed increased tracer uptake in the lower sternum, consistent with an undisplaced oblique sternal fracture (Box). Management of the player’s injury and his fitness to train and play were discussed informally with medical and paramedical practitioners. Their opinions ranged from an immediate return to competition to 12 weeks of complete rest. After discussions within the player’s club, he was placed on a training regimen that avoided all upper body clashes and stresses, and he was rested from match play. He was regularly reassessed for symptoms and made an uneventful return to full competition 6 weeks after his initial injury. He remained asymptomatic and competitive for the remainder of the season and at 1-year review. The usual cause of sternal fracture is blunt anterior chest trauma, with about 90% of sternal fractures caused by trauma resulting from the forces associated with motor vehicle accidents.1 Sternal fracture is rarely encountered in Australian Rules football and such a case has not previously been described in the literature. The Australian Football League Injury Report database revealed only four cases of sternal fracture over the period 1992–2006, accounting for a total of 18 missed games (range, 1–11 games) (John Orchard, Conjoint Senior Lecturer, Sports Medicine Program, University of New South Wales, personal communication, May 2007). Patients suspected of suffering a sternal fracture should be investigated with appropriate chest x-rays. If these are inconclusive, it is now suggested the patient should be further investigated with sternal ultrasound, which has recently been demonstrated to be superior to bone scan in identifying sternal fractures,2 and without the associated radiation exposure. Patients with an acute suspected sternal fracture should also undergo electrocardiography. If the electrocardiogram is normal and there is no evidence of intrathoracic injury on radiological investigation, the patient can safely be discharged.3 Chest pain is the predominant persisting symptom after sternal fracture.4 Conservative management with rest, analgesia and/or anti-inflammatories, and, if required, appropriate padding and taping5 should result in full recovery and an uneventful return to competition. Bone delay views from dynamic localised technetium-99m HDP bone scan There is a band of low to moderate tracer uptake running in a slightly oblique line across the lower sternum (arrow), suggesting a sternal fracture.

Robert J Douglas

To the Editor: According to a recent article in the Journal, the pervasive nature of under-age drinking underscores the need to develop prevention strategies to delay the onset of alcohol use and its adverse consequences.1 In the United States, school-based prevention programs have played a prominent role in the alcohol-use prevention scene. Drug Abuse Resistance Education (DARE), the most widely recognised school-based alcohol-use prevention effort, is an elementary school curriculum that focuses on the adverse effects of substances of misuse, and the development of skills to resist peer pressure to use. Despite its nationwide appeal, attempts to empirically evaluate the efficacy of DARE have failed to yield positive results.2 Subsequently, Mothers Against Drunk Driving developed a school-based alcohol-use prevention program called “Protecting You/Protecting Me” (PY/PM). PY/PM centres on instructing children about central nervous system development and the importance of protecting developing brains from substances of misuse. PY/PM appears to be effective in enhancing knowledge of alcohol toxicity and changing attitudes toward binge drinking,3 but its efficacy in decreasing alcohol use remains to be established. Although the efficacy of school-based alcohol-use prevention strategies has been the subject of controversy, such programs have proliferated. School-based multicomponent approaches have also emerged. Project Northland integrated school, neighbourhood, and family components in an effort to decrease alcohol use.4 Project Northland consisted of classroom curricula, extracurricular activities, and parental involvement. Twenty-four school districts were randomly allocated to receive some or all of the prevention package or a control. At the end of 3 years, significantly fewer students in the intervention school districts reported the onset of alcohol use than students in control districts. Efforts to disentangle the impact of its various components show differential effects. While the classroom curricula proved moderately effective, the strongest effects in decreasing drinking were seen for those who participated in the extracurricular activities and parent program components.4 The robust benefits noted from the parent program in Project Northland parallel effects of some other studies suggesting the utility of family-based approaches to alcohol-use prevention. In one study, the Iowa Strengthening Families Program significantly delayed the initiation of alcohol use.4 This program, which is geared towards optimising parenting skills, showed persistence of positive effects on alcohol outcomes 4 years after the intervention.4 These data suggest that parenting and family skills training may play a part in school-based alcohol-use prevention packages. Further evaluation of these programs in other countries is necessary, and may help to reduce the widespread adverse effects of early alcohol use among children.

Vania Modesto-Lowe · Nancy M Petry · Melissa McCartney

To the Editor: We read with interest the recent editorial and articles on health technology assessment.1-4 We are pleased that the Journal highlighted this important policy process that attempts to ensure that technologies that improve health gain or health care are supported and those that do not contribute to an improved outcome are not supported. The description of HealthPACT in the editorial1 is not quite accurate in that HealthPACT is a subcommittee of the Medical Services Advisory Committee (MSAC). Its funding comes through MSAC with some supplementation from the Australian Health Ministers’ Advisory Committee. The techniques of early detection and horizon scanning have been developed, and the results of this work are available to the health community of Australia, be it jurisdictional, public, private or specialised. In particular, if promising health care technologies are identified through this process, they are referred to MSAC for a full health technology assessment, thus ensuring that appropriate technologies are identified as early as possible in the technology cycle and are assessed by MSAC for introduction into the health care system. This horizon-scanning activity does not currently involve drugs or vaccines, and the Australian health care system could benefit from this process, just as the National Institute for Health and Clinical Excellence in the United Kingdom and the Canadian Agency for Drugs and Technologies in Health undertake comprehensive horizon scanning. With respect to conflicts of interest, MSAC is very specific at all levels of its operation. At the commencement of every advisory panel and MSAC meeting, the Chair requests declaration of conflicts of interest. These are recorded in the minutes and appropriate decisions are made on the participation of the person declaring a conflict based on an assessment of the issue. This is formal and explicit, and is on the public record. It is important to state this, as the article by Petherick and colleagues implies that MSAC does not record conflicts of interest.4 In fact, MSAC places great importance on declaration of conflicts of interest.

Brendon J Kearney · Stephen L Blamey

To the Editor: I wish Professor Carr the very best in his attempt to eliminate the somewhat confusing term “Barrett’s oesophagus” from the literature.1 Changing well entrenched medical nomenclature is difficult, however. I tried to do this with “microscopic colitis” 10 years ago2 but was not successful. After all, I argued, we do not speak of “microscopic bronchitis” or “microscopic salpingitis” — so why should we have the term microscopic colitis? It is nonetheless pleasing to note that the definition of microscopic colitis has tightened up over the past 10 years,3 and I think this may be a more realistic aim for Professor Carr with the term Barrett’s oesophagus. Admittedly, the two entities are not perfectly analogous, as, unlike microscopic colitis, Barrett’s oesophagus is classically associated with abnormally coloured mucosa. However, in both entities, the endoscopist usually takes biopsies from endoscopically flat mucosa, specifically looking for the disease in question. I am not sure I can see myself in 10 years’ time looking down someone’s oesophagus and saying, “I think there may be some columnar metaplasia down there. I wonder if there is some intestinal metaplasia as well?” Maybe this would be a good conversation opener in the halls of the pathology department, but certainly not in the endoscopy suite! I think I will still be saying, “That looks like Barrett’s, but we will need to take biopsies to make sure”.

Andrew A Thomson

In reply: I thank Dr Thomson for his kind comments. I sympathise with his attempts to eliminate the term “microscopic colitis”1,2 and would happily join him in this campaign. I agree it is important to tighten up the definitions of ambiguous terms. For example, “indeterminate colitis” is another term that continues to be used in different ways, despite attempts to clarify its definition.3 However, in the case of Barrett’s oesophagus, there are precise definitions, but they are mutually exclusive. The British Society of Gastroenterology uses one definition (not requiring goblet cells), whereas other national bodies use another definition (requiring the demonstration of goblet cells histologically).4 Therefore, when an endoscopist says “That looks like Barrett’s”, he or she could be saying either that the mucosa appears glandular or that a pathologist will find goblet cells in it. The two are not the same and we should not confuse them. I believe we should not use “Barrett’s oesophagus” because it is defined differently by different people; confusion regarding the site of a particular biopsy can cause it to be applied inappropriately; and we have existing terminology that does the job. I accept that a few lone voices are not going to change well entrenched terminology. However, we can hope that the national and international bodies that construct guidelines in this area will take heed, accept the challenge and deal with the problem.

Norman J Carr

To the Editor: Recently, we treated a patient with fatal paramethoxyamphetamine (PMA) poisoning. We believe this is the first PMA poisoning to be reported in the Australian Capital Territory. PMA (street name, “death”) was first reported in the early 1970s during the emergence of recreational use of 3,4-methylenedioxymethamphetamine (MDMA [“ecstasy”]).1,2 Hyperthermia, coma and seizures are features of MDMA and PMA poisoning, but they are more severe with PMA ingestion; features of hypoglycaemia, hyperkalaemia and QRS interval prolongation are suggestive of PMA poisoning.3 Our patient was a 20-year-old man who was conveyed to the emergency department by ambulance after presumed MDMA ingestion. On presentation, he was unconscious (Glasgow Coma Score, 4/15) and had the following signs: temperature, 42.8°C; heart rate, 90 beats/min; QRS interval, 160 ms (reference range [RR], < 100 ms); blood pressure, 171/148 mmHg; oxygen saturation, 76% (RR, 95%–100%); and respiratory rate, 40 breaths/min. After intubation, external cardiac compressions and multiple DC shocks were required to restore circulation. The initial serum potassium level was 8.9 mmol/L (RR, 3.2–5.0 mmol/L). Hypoxaemia persisted, and a chest x-ray showed extensive bilateral airspace consolidation. The patient’s associates alleged that he habitually used equine clenbuterol and ovine androgen preparations in addition to ecstasy. The subsequent days were notable for resistant shock, rhabdomyolysis, cardiomyolysis and severe coagulopathy refractory to therapy. Oliguric renal failure necessitated extracorporeal blood purification. Hepatic failure and hypoglycaemia were pronounced. The most extreme biochemical derangements recorded in this case are listed in the Box. Five days after admission, the patient’s pupils were sluggishly reactive. Oculocephalic and oculocaloric reflexes were present but abnormal, while gag and cough reflexes were absent. A cerebral computed tomography scan showed extensive cerebral oedema. By Day 8, the patient had fixed pupils and worsening haemodynamic instability. He died 10 days after ingestion of PMA. The patient’s antemortem blood concentration of PMA was 2.3 mg/L — 2.0 mg/L above the typical fatal threshold of 0.3 mg/L previously reported.2-4 MDMA, methylenedioxyamphetamine (MDA) and methylecgonine were also detected at low levels. Since 2005, the Pharmacy Guild of Australia has instituted its “Pseudo Watch” program to reduce diversion of pseudoephedrine to illicit methamphetamine manufacture by a combination of retail restrictions and recording details of purchasers judged genuine. Supporting legislation varies by state.5 However, PMA is made from the readily available and unmonitored precursor, anethole. Further, PMA has a slower onset of action than MDMA, leading to the possibility of additional doses being ingested while awaiting effects. We believe medical practitioners should consider PMA poisoning in cases of severe reactions to ecstasy, especially those in which hypoglycaemia and hyperkalaemia are present. A “market” shift in drug use towards the more lethal PMA because of reduced availability of pseudoephedrine would be a cause for concern. Laboratory markers of multisystem organ dysfunction in a case of PMA poisoning Biochemical marker Extreme value (peak or nadir) Reference range Creatine kinase (U/L) 58 358 20–200 Troponin I (U/L) 85.83 < 0.06 Bilirubin (μmol/L) 412 2–20 ALT (U/L) 3961 < 55 Ammonia (μmol/L) 219 10–50 Platelet count (× 109/L) 18 150–400 ALT = alanine aminotransferase. PMA = paramethoxyamphetamine.

Paul G Lamberth · Geoff K A Ding · Liisa A Nurmi

To the Editor: The recent editorial by Waxman1 implies that early streaming of students during medical school training is to become the norm for admission to the Royal Australasian College of Surgeons’ Surgical Education and Training (SET) program. We would like to draw attention to the disturbing nature of this development for medical students and junior doctors alike. Waxman described the imperative for students to now decide upon a career in surgery “usually as undergraduate medical students”.1 He stated that some universities have proposed early streaming of students into specific surgical modules in later years of their medical programs. While early streaming may appear to be the answer to the growing conflict between the time constraints of undergraduate medical programs and the expanding body of medical knowledge, there are a number of significant pitfalls to this approach that are yet to be explored. First, early streaming may jeopardise the quality of the generalist education offered at medical schools. International experience from McGill University in Canada, which implemented an early-streaming program in the late 1970s, supports this notion.2 The cohorts from McGill’s early-streaming program had poorer overall performance than their predecessors in the non-streamed program on the Medical Council of Canada’s national licensing examination, which was attributed in part to their reduced opportunity for generalist training. Second, the notion that well resourced university surgical departments could provide an early-streaming package for undergraduate students that “[gives] their students an advantage and an almost guaranteed pathway into SET”1 creates gross inequity in access to surgical training. This system would disproportionately disadvantage students from both graduate-entry programs, which have a shorter course duration, and newer universities, which lack the resources to provide advanced surgical training modules. Third, the program disadvantages students who have not formed firm career intentions by the later years of their medical program. With data from the United Kingdom showing that more than a quarter of junior doctors change their career intentions in the 3 years after graduation,3,4 a significant proportion of medical graduates will gain no appreciable benefit from early streaming, and may in fact be disadvantaged by it. We strongly discourage the introduction of early-streaming programs in medical schools. All schools should graduate “pluripotent” undifferentiated doctors with a strong generalist background.

Timothy J Smith · Carly M Fox · Michael A Bonning

To the Editor: The editorial by Waxman1 on the Royal Australasian College of Surgeons’ new Surgical Education and Training (SET) program contains some factual errors that have led to anxiety among potential applicants. We wish to give the formal position of the College and to correct any misunderstandings. The SET program2 is evolutionary, builds on the strengths of the previously available program, and is based on an educationally sound framework and group of principles. Registering an interest in training with the College does not in itself confer an advantage but will enable those registered to receive up-to-date information and College publications. The College website also provides up-to-date, relevant information for potential applicants. Completion of the Australian and New Zealand Surgical Skills Education and Training (ASSET) course is not compulsory before selection into SET, but it must be completed by the end of the first 2 years of the SET program. The College and the specialist surgical associations and societies involved in the delivery of the SET program will rely on robust workplace-based assessment to monitor trainees’ progress and provide career advice. New in-training assessment tools are necessary to achieve this, and their implementation requires support, including courses for surgeons who undertake this vital work. Those contemplating a career in surgery will not have to decide on their career choices at an earlier stage than previously. In the previous program, graduates could apply during their internship but now must wait until their second year after graduation. The College is committed to a broad-based period of preparation for surgical training but does not wish to deny the opportunity to those in their second year after graduation who are certain of their career aspirations. Applications will also be accepted from those who delay their career decisions for whatever reason. Streaming medical students for vocational careers is an attractive educational philosophy, provided it does not interfere with the generalist experience required for all graduates. Furthermore, streaming is predicated on the medical colleges recognising this prior learning in their programs. Until this is resolved, the question of its implementation remains some way off. The current practice of undertaking electives in an area of interest is strongly supported. The College is committed to working with the universities for a more integrated approach across the continuum of learning and seeks to build on the meaningful and collaborative partnerships already established. The key interface is the practising surgeon in an academic position who understands the requirements of the College and the university, as well as the needs of the community. Selection into surgical training is through a national merit-based process. The curriculum vitae (CV) and its components of academic achievement, other accomplishments and clinical experience will each be scored and given appropriate weighting. The lower percentage overall for CVs (15%–25%) takes into account that many candidates will apply very early in their careers.2 While we laud the suggestion of university surgery departments providing a package for potential trainees, “giving their students an advantage and an almost guaranteed pathway into SET”1 does not necessarily follow, given the competitive nature of selection.

John P Collins · Ian D Civil

To the Editor: The revised recommendations of the Australasian Creatinine Consensus Working Group1 are improved with the recognition of an age-related reduction in glomerular filtration rate (GFR), but don’t deal with a number of other significant problems associated with an estimated GFR (eGFR). When a plasma creatinine measurement is requested, an eGFR is commonly provided, increasing the sensitivity but reducing the specificity of diagnosis of kidney disease. The eGFR remains a substantially flawed estimate of GFR. It is associated with significant predictive error (up to 30% of individual eGFRs differ by more than 30% from the measured GFR at 60–90 mL/min)2 and with substantial false positive and false negative outcomes. The flaws in the eGFR are, firstly, the limitations of creatinine clearance rate as a measure of GFR, and secondly (and more importantly), the use of age, sex and race as surrogates for muscle mass (the determining factor in creatinine production and, together with creatinine clearance, plasma creatinine level). Age, sex and race are imperfect predictors of muscle mass, and this leads to underestimation of GFR in people who are fit and well muscled and overestimation in those who are wasted and disabled. While reporting eGFR values represents a worthwhile advance on using plasma creatinine levels to detect kidney disease, it could be considered, at best, the “least bad” readily available measure of GFR. When no better test is readily available, how should we handle a suboptimal measure of GFR? Educating the medical profession about the limitations of eGFR is important, but, based on personal experience and anecdotal evidence, I believe that using conventional methods of informing doctors has not been uniformly effective. Providing “just in time” information support is likely to assist this process. Thus, I support the recommendation that laboratories routinely report eGFRs, but suggest that, when they do so, they add a product warning along the following lines: The eGFR is calculated assuming a normal muscle mass for age, sex and race. It will underestimate GFR in well muscled individuals and overestimate GFR in patients with muscle wasting. A creatinine clearance test or formal GFR measurement may be helpful in patients whose muscle mass differs from the average for their age and sex. Proteinuria and haematuria are other useful indicators of kidney disease. In patients over 70 years of age, an additional product warning, consistent with the Australasian Creatinine Consensus Working Group’s revised recommendations,1 could be as follows: GFR declines with age, and, in patients over 70 years of age, an eGFR of 45–59 mL/min/1.73m2, if stable over time and unaccompanied by proteinuria or haematuria, is unlikely to have specific renal prognostic or therapeutic implications.

William R Adam

To the Editor: The revised recommendations for the use of the estimated glomerular filration rate (eGFR) in the clinical setting use the Modification of Diet in Renal Disease (MDRD) formula to adjust drug dosing in people with renal impairment (Recommendation 6).1 Although the utility of the MDRD-based eGFR as a screening tool to identify people with chronic kidney disease represents an important clinical opportunity, we, and others,2,3 remain concerned about this recommendation. Certainly, adjusting the dose of renally excreted medicines based on a patient’s serum creatinine concentration alone is not appropriate. Accordingly, many drug monographs provide explicit dosing recommendations based on the estimated creatinine clearance (calculated using the Cockcroft–Gault formula) as a rational basis for dose adjustment using sound pharmacological principles. This assumes a significant correlation between the estimated creatinine clearance and the actual clearance of a drug (or metabolite). But such a correlation has not been established for the MDRD formula. Indeed, an empirical study comparing the use of the Cockcroft–Gault formula to the MDRD formula in 1067 elderly patients found that the MDRD formula significantly overestimated renal function and would, if used, lead to significantly higher doses of two drugs in question (enoxaparin and gentamicin) being administered.2 This highlights the need for further research to rigorously characterise the relationship between MDRD estimates of renal function and drug clearance before this formula can be recommended to guide dose adjustment in the clinical setting. Recommendation 6, that the MDRD-based eGFR should be used for dosing after considering body size,1 requires further clinical information about the patient — the same information needed to use the Cockcroft–Gault formula. Even limiting Recommendation 6 to drugs that are not “critical-dose drugs”1 is confusing. Many drugs would be considered critical-dose drugs when used in frail older people with some degree of renal impairment. We reaffirm the statement, from the 2008 Australian medicines handbook, that “there is no evidence that [automatically reported eGFR] is suitable for adjusting drug doses in people with renal impairment”.4

on behalf of the Editorial Advisory Board, Australian medicines handbook

In reply: We agree with Adam’s points that: The estimated glomerular filtration rate (eGFR) represents a worthwhile advance on the plasma creatinine level for detecting kidney disease, and is currently the best readily available measure of GFR; Educating the medical profession on the limitations of eGFR is important; and Further refinements of eGFR accuracy are highly desirable. Since the advent of automated laboratory reporting of eGFR, there has been a concerted effort by the Kidney Check Australia Taskforce to educate medical professionals and other clinicians about the strengths and limitations of eGFR and about how best to approach the patient with a significantly reduced eGFR. Education has been via printed office materials, accredited workshops, medical journal articles, online education, and decision-support systems embedded in medical software. Adding statements to laboratory reports has also been considered by the Australasian Creatinine Consensus Working Group, and some laboratories do provide explanatory eGFR statements. However, many have not embarked on this because of the difficulty of providing adequately informative explanatory remarks in very limited space. Individual laboratories balance the need for such supporting information against the space requirements on reports and the diminishing effect of excessive repetition. Given that routine reports are already complex, often containing over 20 result items, and that many millions of reports with serum creatinine results are produced annually in Australia, the value of any repetitive comment needs careful consideration. The response of clinicians to the introduction of automatic reporting of eGFR together with the linked educational campaign has been strongly positive, with outcomes that have included easier identification of chronic kidney disease, better decision making for affected patients, and more appropriate referral patterns, both in Australia and overseas. Nevertheless, we agree with Adam that eGFR is only an approximation of actual GFR and is subject to error. There are ongoing attempts to further improve the accuracy and clinical utility of eGFR through such ventures as the universal standardisation of creatinine calibration (which has already taken place in Australia and New Zealand) and the Chronic Kidney Disease Epidemiology Collaboration.1 McLachlan, on behalf of the Editorial Advisory Board of the Australian medicines handbook, reaffirms the Board’s position that eGFR is not appropriate for use in dosage calculations. However, for the reasons stated in the consensus document,2 we remain convinced that eGFR is a useful tool for most drug dosing decisions. We note with interest the recent change in the position taken by the British National Formulary (BNF 54) to one of support for the Modification of Diet in Renal Disease (MDRD)-based eGFR1 being used in place of creatinine clearance rate “for most drugs and for most patients of average build and height”3 — a stance similar to ours. In particular, we re-emphasise that eGFR, because of its ready availability, increases the rate of identification of renal failure. We agree with McLachlan that prescribers should continue to follow specific published recommendations for drugs such as enoxaparin and gentamicin (these are good examples of “critical-dose drugs” in the hospital setting). We note additionally that there is increasing acceptance of the eGFR in the drug literature. In the case of enoxaparin, the MDRD equation for eGFR has been used to assess the effect of renal function on bleeding in elderly patients4 and has been found to provide the best relationship with enoxaparin clearance in this setting.5 The eGFR is now an established feature of pathology reports in Australia, and we believe it is important to integrate this information into routine practice for drug dosing decisions. We therefore offer to work with the authors of the Australian medicines handbook and other interested parties to develop guidelines for drug dosing decisions using all available information.

on behalf of the Australasian Creatinine Consensus Working Group

To the Editor: I read with interest the article by Morton et al, summarising their impressive results of lung transplantation in adolescents treated in an adult hospital.1 The authors state they “do not have an exclusion policy for patients suitable for LTx [lung transplantation] based on age or size criteria alone”, and refer small or very young children to overseas units. The accompanying editorial by Snell et al comments that a paediatric transplant unit would have too low a caseload (four to eight transplants per year) to ensure they deliver good results.2 I agree that large-volume units are desirable, yet of the 158 centres reporting adult lung transplantation to the International Society for Heart and Lung Transplantation, 59% averaged fewer than 10 lung transplants a year.3 While a Surgical Fellow at St Louis Children’s Hospital, Mo, USA (1996–97), I was part of the surgical team undertaking a transplantation operation on a 13-month-old ventilator-dependent infant referred from Sydney. He had an uncomplicated postoperative course, leading to early hospital discharge and early return to Australia. Over the ensuing 5 years, while I was in touch with the family, they travelled regularly to St Louis for follow-up, as local expertise in managing young lung transplant recipients was lacking. Referring families to overseas units may be a good, albeit extremely expensive, short-term solution, yet developing local expertise in the follow-up of these patients has to be part of this package, to ensure optimal management, referrals and dialogue with overseas transplantation centres. Such local expertise could provide the backbone of a future paediatric lung transplantation unit, preventing unnecessary deaths in this population. Although paediatric lung transplantation is challenging, results for isolated operations in children are similar to those in older age groups,3 so the “perception that the risk of undertaking LTx in children and adolescents does not warrant the reward”2 needs to be challenged. From 1990 to 2002, 190 children received transplants at St Louis Children’s Hospital (45% of them younger than 10 years), 30 of whom underwent living-related lung transplantation (generally reserved for patients too ill to wait for cadaveric lung transplants); although they were a higher-risk group, their survival statistics exceeded those of adult lung transplant patients.4 After all, a low case workload does not stop any of the four paediatric cardiac surgery units in this country from offering arterial switch operations. A local paediatric lung transplant follow-up service, perhaps attached to an adult unit, would be instrumental in optimising paediatric lung transplantation outcomes and could inform the debate on the pros and cons of setting up local paediatric lung transplantation services.

Monica C Robotin

In reply: We were interested to read about Robotin’s insights gained from her experience at St Louis Children’s Hospital, which has one of the largest and most successful paediatric lung transplantation units in the world. We agree that development of local expertise in paediatric lung transplantation would be a cost-efficient means of offering optimum care to young Australians. Because the experience in lung transplants at St Vincent’s Hospital, Sydney, has grown, we would like to provide this service for younger recipients, but our centre lacks specific expertise and facilities for ongoing paediatric care. A dedicated paediatric ward with experienced nursing staff in a family-friendly environment is essential to meet world’s best practice in this area. There are many complications of the underlying conditions that might benefit from paediatric specialty expertise. Our experience emphasises that a close working relationship with the patient and his or her family is crucial, and that distance from the location of care delivery and ease of access to the primary treating team are important factors. Given the tyranny of distance, a single Australian centre would be inefficient. However, analysis of outcomes in adult centres shows superior results with increasing transplantation volume, so the concept of small stand-alone centres is not supported by evidence.2 Logistics dictate that linking paediatric services to existing adult services in Australia should improve long-term outcomes. Our data show that performing adolescent lung transplantation in a centre with proven expertise in adult procedures produces excellent results. We advocate provision of adequate funding and resources in all Australian transplantation centres to achieve optimum service delivery in paediatric lung transplantation.

Judith M Morton · Allan R Glanville

In reply: We thank Robotin for her positive comments. We agree that the current successful lung transplantation outcomes for adolescents in Australia should be able to be extended to the whole paediatric population in due course.,2 The appropriate timing of the operation and peritransplantation management of young children with advanced lung diseases requires further consideration and debate.3 This should involve the existing lung transplantation services and specific committed paediatric institutions. However, we disagree that a very low caseload, with procedures performed in a number of institutions, is acceptable. On the basis of cost, training, staffing and political support, it is appropriate to concentrate the expertise. A solid case can be made for a national approach, supported by the Australian Government, with Nationally Funded Centre status. In time, this would provide solid paediatric expertise and access to lung transplantation, either in Australia, or even overseas, as appropriate, during the early evolution of such a program. The objective would be improved survival in children with severe lung disease while minimising the disruption and cost associated with young Australians and their families travelling internationally for lung transplantation care.

Gregory I Snell · Glen P Westall · Trevor J Williams

To the Editor: Applying for medical school in Australia is not an easy process. Prospective applicants must choose from 19 medical schools and multiple course options, navigate admissions processes and tests, and develop some understanding of the pathway towards full registration and vocational training. Despite this complexity, there is a paucity of information that provides a bird’s eye view of the Australian medical school admissions process. There is no single source of information that comprehensively maps the options available to those wishing to embark on a career in medicine. Existing references are often outdated1 or do not accurately identify all medical courses.2 To fill this information gap, the Australian Medical Students’ Association (AMSA) launched its inaugural Medical School Guide in 2007. The guide paves the way for informing prospective medical students about the challenges of studying medicine and the diversity of medical courses on offer in Australia. The guide contains two sections: “Essential Information” includes details about the categories of entry, admissions tests, support schemes and vocational training pathways; and “The Medical Schools” contains information about individual universities, including location, entry requirements and procedures, and contact details. AMSA produced the guide in conjunction with Medical Deans Australia New Zealand (MDANZ) and the Australian Medical Association. Information on individual courses was supplied by the universities, via MDANZ, to ensure accuracy. All but one medical school submitted enrolment information for publishing. The Medical School Guide was launched on the AMSA website (at http://www.amsa.org.au/medschoolguide.pdf), and promotional letters were sent to relevant stakeholder groups. In the 110 days immediately after its release, there were 37 555 hits on the webpage, with more than 3500 downloads of the guide. In 2008, AMSA hopes to attract the financial and in-kind support required to publish and distribute a hardcopy version of the Medical School Guide. AMSA also hopes to further develop the guide to include information for prospective international students about visa requirements and opportunities to enter the Australian health workforce. In a dynamic environment where numbers of medical students and schools are on the rise, there is a convincing case for a comprehensive, user-friendly guide to medical school admissions. The AMSA Medical School Guide aims to do this, and its effectiveness will require rigorous evaluation in years to come.

James M Hillis · Robert D Mitchell