Letters

To the Editor: Panton–Valentine leukocidin (PVL) is a potent necrotising toxin, which, although produced by less than 5% of all Staphylococcus aureus strains, is strongly associated with pathogenic isolates that cause recurrent furunculosis and severe necrotising pneumonia.1 The virulence of PVL-positive community-associated methicillin-resistant S. aureus (CA-MRSA) causing necrotising pneumonia was recently highlighted in the Journal.2 Conversely, PVL produced by methicillin-sensitive S. aureus (MSSA) is uncommon.1 Here, we describe a case of fulminant necrotising pneumonia caused by PVL-positive MSSA, which, to our knowledge, is the first reported case in Australia. A previously well 33-year-old man presented to the emergency department with a 48-hour history of pleuritic chest pain, fever and productive cough. On presentation, the patient was hypotensive, and in acute renal failure and hypoxemic respiratory failure (type I). Chest x-ray showed bilateral widespread air space consolidation. Despite treatment with intravenous fluid resuscitation and early broad-spectrum antibiotics (ceftriaxone, azithromycin, vancomycin and co-trimoxazole), the patient’s condition rapidly deteriorated, requiring intubation and inotropic support. Multiple blood and sputum cultures isolated MSSA. Bronchoscopy revealed widespread airway haemorrhage. A trans-oesophageal echocardiogram excluded endocarditis. Progressive leukopenia developed. Septic shock and respiratory failure worsened, despite treatment with flucloxacillin as well as maximal inotropic and ventilatory support. The patient died 72 hours after presentation from fulminant pneumonia. Polymerase chain reaction testing subsequently identified the PVL gene in the isolated MSSA. Rising rates of CA-MRSA causing recurrent furunculosis and severe necrotising pneumonia have been reported worldwide.3 Necrotising pneumonia often affects children and young adults,1 and, despite current treatments, mortality rates are over 50%.4 Our patient exhibited two major factors predictive of increased lethality: leukopenia and airway bleeding.4 PVL has been well described in CA-MRSA; it is present in at least 96% of the two predominant strains in south-east Australia.3 There is some evidence that PVL is the major pathogenic factor of CA-MRSA, although this remains controversial.5 The precise pathogenesis of PVL has not yet been discovered; however, a severe inflammatory response secondary to PVL’s cytolytic effects on polymorphonuclear leukocytes, as well as the induction of other bacterial virulence factors, are possibilities.1 Therapies directed against the PVL toxin, including antibiotics such as clindamycin that target the bacterial ribosome, or intravenous immunoglobulin, have been suggested but have little supportive data.2,3,6,7 In contrast to CA-MRSA, the PVL gene is found much less frequently in MSSA, being present in only 2% of isolates in one French study.1 Specific Australian prevalence data are lacking, but PVL-positive MSSA isolates have similar potential to cause severe invasive disease.1,6 Most cases of severe necrotising staphylococcal pneumonia and recurrent furunculosis are caused by CA-MRSA, and empirical therapy for these conditions should cover this organism. This case involving MSSA highlights the role that PVL may play in the pathogenicity of these conditions, and shows that the development of novel therapeutics directed at PVL may be of value.

Ada S-Z Cheung · Craig A Aboltins · John R Daffy · Peter A Stanley

To the Editor: Predicting research quality on the basis of past research publications is clearly imprecise, as noted by Nicol et al in their recent article on National Health and Medical Research Council (NHMRC) grant applications.1 They note that assessor ratings of applicants’ “track records” correspond poorly with the bibliometric data for authors, and that there is vast variability between discipline panels. For immunology, the correlation between track record scores and journal impact or citations was high, at over 0.7. For public health, the correlation was actually negative. The authors consider some possible reasons for the wide discrepancies, such as poor coverage of public health publications in the journals captured by Institute for Scientific Information citation indexes. Nevertheless, they are at a loss to explain why the variation is quite so great, and conclude by suggesting that the time is right for an automated approach to assessing quality. We need to consider the implications of this suggestion carefully. Track record within NHMRC project grants is assessed relative to opportunity, with regard to factors such as legitimate career interruptions, administrative and teaching load, and typical publication rates for the field in question. In the fellowship or program grants schemes, there appears to be less emphasis on relativity, which may explain some of the closer correspondence between actual and expected citation rates. We need to be clear that the use of an “automated” system that uses surrogate measures of research quality will disadvantage individuals who experience a period of illness, take maternity leave, change their research area, or carry a period of heavy administrative or teaching load, as well as those who publish books, book chapters or government publications. It will also disadvantage teams in which feasibility requires fieldwork collaborators whose applied work does not readily translate into peer-reviewed journal publications. For instance, much public health research is based in the community or takes advantage of data collections in the public health system. Collaborators working in this context often have relatively limited opportunities for peer-reviewed publication. Nevertheless, their active collaboration is often critical for achieving a feasible research plan. Also disadvantaged would be teams with a new or junior investigator, particularly if the new team member was the first named investigator. On the other hand, a move to an automated system of quality assessment would further advantage grant applicants who work in research-dedicated institutes, those engaged in basic research, and those who do not require external collaboration. Given these reservations, I suggest further investigation, by discipline, of what makes a “good” track record, before recommending a single assessment formula.

Michael J Davies

To the Editor: Abdulla and Ward’s excellent article on tako-tsubo cardiomyopathy (TTC)1 raises two important issues. The first issue is the diagnostic dilemma faced by emergency physicians and cardiologists in differentiating TTC from ST-elevation myocardial infarction (STEMI) in centres that lack coronary angiogram capabilities. In patients presenting with chest pain and ST elevation on electrocardiography, the diagnosis of TTC might be suspected on recognition of risk factors and the common psychological, physical and emotional stressors that precipitate TTC.1 Supporting evidence can be obtained by demonstration of basal hyperkinesis and apical or midventricular hypokinesis on transthoracic echocardiography. This modality is now available in many centres without coronary angiography. However, if the diagnosis is incorrectly made as STEMI rather than TTC, the patient runs the risk of unnecessary thrombolysis. Alternatively, after risk–benefit analysis, the clinicians may transfer the patient to a facility with coronary angiography to confirm TTC. The second issue is the therapeutic dilemma facing intensivists treating TTC-related shock with adrenergic inotropes. Although cardiogenic shock in TTC is uncommon, it can still occur (4.2%).2 As increased endogenous catecholamines are thought to be central to the pathophysiology of TTC,3 treating shock with inotropes puts the clinician in a quandary. Agents such as adrenaline, dobutamine, dopamine, milrinone and noradrenaline increase cyclic AMP within the myocardial cell, and are commonly used to restore blood pressure and cardiac output. However, in TTC, inotropes may theoretically delay resolution of the apical ballooning. A recent echocardiographic study showed no improvement in apical and midventricular akinesis with the use of low-dose dobutamine.4 Levosimendan is a calcium sensitiser that has been used successfully to stabilise shock secondary to TTC (with and without use of an intra-aortic balloon pump).5 Levosimendan is non-adrenergic and allows earlier introduction of β-blockers than would be possible with adrenergic inotropes. I agree that prospective trials are needed to guide management in this intriguing condition.

Laven Padayachee

In reply: I thank Padayachee for his interest in our review.1 We read Padayachee’s published case series of the use of levosimendan to help recovery of left ventricular dysfunction in tako-tsubo cardiomyopathy (TTC)2 after our review was published. I agree that levosimendan is the inotropic agent of choice in this situation, and this approach has been used successfully in my hospital on two occasions. This is, in fact, what we meant by “In our experience, β-blockade in conjunction with non-adrenergic inotropes can prevent this vicious cycle and allow the ventricle to recover (unpublished data)”. As Padayachee rightly points out, definitive evidence on this point would require a proper randomised trial, which would be very difficult to organise, given the low incidence of tako-tsubo cardiomyopathy and the small fraction of patients who develop cardiogenic shock requiring inotropic support. I think that it is probably better to simply state that levosimendan therapy works and makes scientific sense, so “just do it”. However, Padayachee also surmises that, if the patient has a typical wall-motion abnormality and a typical history, it might be possible to avoid unnecessary thrombolytic therapy in cases of TTC. Unfortunately, my understanding is that this is not the case. Occlusion of the left anterior descending artery (LAD) may result in the classic TTC wall-motion abnormality if the LAD extends far beyond the apex (usually with a non-dominant right coronary). As myocardial infarction can be precipitated by stressful events, and the evolution of electrocardiographic changes in TTC is similar to that seen with an anterior infarct after thrombolysis, there is still no clear way to discriminate between the two diagnoses apart from immediate coronary angiography. Whether computed tomography (CT) angiography can accurately discriminate remains to be seen — this might be useful in centres that have CT but not a cardiac catheterisation laboratory. Until then, I believe it is probably less harmful to give TTC patients thrombolysis than to withhold thrombolysis from patients with large anterior infarcts. Lastly, I invite Padayachee and other interested clinicians who frequently manage these patients to participate in an ongoing study of genetic predisposition to TTC for which we are currently enrolling participants.

Michael R Ward

To the Editor: It is a worthy aspiration for Australia to become the world’s healthiest country, but it will take revolutionary leadership to prevent and manage the effects of obesity that will reverse the previous gains in reducing heart disease.1 In addition, we have to overcome the adverse impact on the health of young people caused by fundamental changes in Australia, highlighted by Eckersley.2 He also identifies medical practitioners as a potential obstacle in that we are overfocused, with government approval, “on an individual, biomedical, disease-centred approach to health at the expense of a more social, preventative model”. He also calls for an increase from the current investment in prevention and public health programs, 1% of health expenditure — but that will only occur if his more radical suggestion is adopted: that governments change their focus from wealth to health creation. It was Japan that embraced this concept, with a health creation policy developed in 1978. It led to a law ensuring that at least 5% of their compulsory health insurance expenditure is allocated to preventive activities. If we are going to achieve Ring and O’Brien’s vision, we are going to have to do more than adopt Japan’s healthy diet. Other keys to their success are: good antenatal care; reinforcement of high breastfeeding rates by provision of small incentive payments; routine home visits to women during pregnancy and during the postpartum period by maternal and child health care workers; and all parents having their own maternal child health record. While these and other measures have probably contributed to Japan having the lowest infant mortality in the world, these interventions are also likely to have influenced their longevity by preventing the Barker hypothesis from being applied. This hypothesis, or developmental origins theory, was derived from observations of infants who are small at birth being at higher risk of increased blood pressure and other adverse cardiovascular endpoints later in life.3 It is interventions during the early years that have evidence of high returns on investment — whereas attempts to influence adult behaviour are difficult, and can fail.4,5

Bret Hart

In reply: Our paper demonstrates the considerable potential for improving Australia’s already competitive international mortality ranking by focusing on several selected conditions and inequalities in their distribution among Australians.1 Hart recognises the aspirational nature of the paper and proposes several challenges and opportunities to improve the health of the mothers, babies and young children of Australia. We agree. As shown by our evidence, Australia’s performance on mortality in infancy and early childhood is less than stellar. We acknowledge that our ranking on some childhood risk factors, such as obesity (which can confer lifelong health disadvantage and may affect future mortality), may well be similar or even worse. A critique of these was beyond the scope of our paper, as we confined our analysis to measures of past mortality. There is ample evidence of effective interventions for infants, children, adolescents, adults and older people, and for various population groups. The interventions include preventive or clinical services — as the Journal’s own repository of guidelines shows.2 We contend that rather than being alternatives, childhood and adulthood interventions are complementary (as are biomedical and social interventions), and we have to advance simultaneously on many fronts. Australia has accelerated to be among the world’s leaders on mortality and life expectancy, but, as Hart presages, this will not remain the case merely through a continuation of current trends. It may take a revolution, but we can at least be clear about how we compare in these areas and what we need to achieve.

Ian T Ring · John F O’Brien

To the Editor: In their report of a child with peanut allergy who developed sunflower seed allergy, Hsu and Katelaris caution against marketing claims of “safe alternatives” in allergic children.1 Their report also raises practical issues for those advising the parents of a child with food allergy: what is the risk of a new allergy developing; should a child with peanut or tree nut allergy avoid similar foods as well; and will food avoidance prevent new allergy from developing? The natural history of peanut and tree nut allergy is for polysensitisation to develop over time. One study demonstrated that, in children younger than 2 years with peanut or tree nut allergy, 19% were sensitised and 2% were clinically reactive to more than one nut.2 By the age of 14 years, the percentages had risen to 72% and 47%, respectively. This has led to people with peanut or tree nut allergy being advised to avoid all nuts and seeds.2 Strategies commonly advised to reduce the risk of allergy developing are to avoid food allergens and to delay the introduction of allergenic foods until the age of 2 years, but evidence to support their effectiveness is limited,3 particularly for preventing food allergy.4 While studies in infants at high risk of allergic disease have reported an increased risk of eczema with early introduction of solids (before the age of 3–4 months),3 and a protective effect against asthma and eczema with the avoidance of environmental and food allergens in the first 6 months of life,4 a recent systematic review found “no strong evidence to support the association between early solid feeding and the development of persistent asthma, persistent food allergy, allergic rhinitis, or animal dander”.5 Furthermore, there is currently no evidence that avoidance strategies applied beyond 6 months of age are effective for allergy prevention, and provisional evidence that such strategies might actually promote sensitisation and food allergy rather than tolerance.6 So how should we advise patients? The peanut and tree nut avoidance strategies advised will be largely dictated by: choking hazards in infants; the risks of cross-contamination in commercially prepared foods; and the potential for confusion in young children (and caregivers) trying to differentiate one “nut” product from another. Regarding the risk of developing new food allergy, we should advise patients that: new allergies may develop with time; this risk is unpredictable; we have little evidence to recommend avoidance beyond the age of 6 months as an effective preventive strategy; and parents should not be optimistic (given the current state of knowledge) that such strategies will prevent new sensitisation once food allergy has developed.

Mimi Tang · Raymond J Mullins

To the Editor: The case reports presented by Gunja et al1 are a serious concern from many perspectives. The health authorities should be commended for their rapid risk assessment and alerting the community, which led to the immediate withdrawal and recall of the toy beads from the marketplace. However, the question needs to be asked: Could this situation have been prevented, and if so, how? There are many toys in Australia that potentially pose risks to children. These can include physical dangers, such as the size of toys, with risk of choking, to toxicological dangers, as we have seen with Bindeez toy beads (containing 1,4-butanediol), and psychological and social concerns, such as the effects of sexually provocative toys on young girls and “aggressive” toys (which may encourage violence) on young boys. More research is required to test the psychological influence of such toys on children. The evidence should be used in the development of guidelines for safer toys. At present, toy manufacturers in Australia must adhere to the Australian Toy Standard (AS/NZ 8124), established by Standards Australia.2 Toys are monitored and regulated mostly by the state governments. While the manufacturers are expected to adhere to these standards, they are in fact voluntary standards and self-regulated, and many toys can enter and be sold in Australia without meeting these standards. When a consumer or state government inspector is concerned about the safety of a toy, or if it violates the regulation, they may contact one of the state offices of fair trading, which have the power to remove the toy from the marketplace. This is essentially a post-hoc auditing system and plays an important role in safety, but action is essentially taken after a problem is detected, such as is the case with the Bindeez toys. In view of potential concerns, I believe what we need in Australia are stronger regulations and guidelines that we can provide to manufacturers to help produce safer toys. Our efforts should be towards preventing any potential harm by strengthening existing regulations, establishing consistent national and international standards for all imported toys, providing more resources for the verification and testing procedures and more expertise and wider consumer input into the safety and suitability of the types of toys permissible in Australia. We have a duty to protect and safeguard our children from both psychological and physical dangers.

Vicki Kotsirilos

To the Editor: Australia, like many other nations, is experiencing an epidemic of overweight and obesity. The most recent National Health Survey reported that 62% of men and 45% of women were overweight or obese.1 Among numerous associated concerns is the cost burden of obesity-related illnesses on individuals, the community and the health system. Among the 45–54-years age group (the stage at which osteoarthritis becomes a significant health problem), we calculated the population attributable risk (PAR) for osteoarthritis associated with obesity to be 25% for men and 22% for women, using a relative risk (RR) of 2.4 and obesity estimates of 23.3% for men and 20.1% for women. In terms of major health sequelae of the epidemic, this is second only to obesity-related type 2 diabetes (RR, 3.2; PAR, 34% for men, 31% for women). Some obese patients will have multiple obesity-related comorbidities. In 2005 in Australia, 2551 national hospital separations among people aged 45–54 years were for obesity-related osteoarthritis.2 Using data from the three most recent National Health Surveys, we projected the likely prevalence of obesity among 45–54-year-old Australians in 20251,3,4 and then estimated future hospital separations and direct health system expenditure, using costing information supplied by the Australian Institute of Health and Welfare.2 We project that in 2025, if Australians born between 1971 and 1980 maintain their current rate of weight gain, the proportion of obese 45–54-year olds will rise to 38.8% of men and 32.2% of women. The estimated number of hospital separations for obesity-related osteoarthritis will increase to 4216. The direct health system cost (in current dollars) will rise to $44.4 million, from an estimated $25.5 million in 2005. The 45–54-year-old population comprises a considerable proportion of the workforce, and obesity-related illness impacts on absenteeism5 as well as individuals’ and families’ quality of life. As the current generation of young adults ages, a trend toward increasing illness arising from high levels of obesity is likely, unless health and government policy initiatives to prevent weight gain are given higher priority.

Margaret A Allman-Farinelli · Robert J Aitken · Lesley A King · Adrian E Bauman

To the Editor: I write in response to two articles published recently in the Journal.1,2 Both propose that substitution of doctors with paramedical professionals is reasonable. I disagree. I think it is imperative that before doctors decide to only see the “fun” patients, we had better be sure we want to surrender our status in the health care system. In the report by Oldmeadow and colleagues,1 as a result of workload constraints, the proposition is made to have physiotherapists run and manage an orthopaedic clinic. By the patient-to-doctor ratio in the study, the average load per week for each doctor was four new and five old patients in a 3-hour clinic. Perhaps readers will compare that load with their own. The study’s outcomes are a cause for concern. Recommendations for management and treatment by two physiotherapists were compared with those of an orthopaedic surgeon. If the surgeon’s opinion is deemed to be correct, then over 25% of the patients who attended these clinics would have been treated incorrectly. In addition, 13% of the physiotherapists’ assessments were not only wrong, but the management plans did not include referral to the surgeon. Remember, this was a highly artificial, simplified clinic treating a limited range of conditions. Consider what the error rate would be in an open clinic with no restrictions on the patients to be seen. In the same issue of the Journal, Smith and Baird proposed that radiographers are qualified in some way to read images.2 While radiographers are skilled technicians, in no way would their interpretive skill be equal to that of a general practitioner, radiologist, or consultant in any other specialty. We should not lower standards for the sole reason of speed of access. I would advocate focusing on consolidating the education of GPs, and so empower them as a group. GPs with special interests could equally act as the gatekeepers to clinics. It is unfair to foist the decisions on care, which are our duty, onto other professionals who are not as extensively trained as we. The job of a surgeon is not to operate on patients. It is rather to organise the care of patients who have a problem in the area of our specialty.

Jeffery M Peereboom

In reply: Peereboom appears to ignore reality. Recent news media1 gave an insight into the state of radiological services at some Sydney teaching hospitals. Thousands of images have never been seen by a radiologist. Yet, all of those images were seen by radiographers, who also saw the patients. I am frequently asked by doctors for my opinion about radiographs. At times, I volunteer my opinion to junior doctors and general practitoners. Thirty years of experience tells me that, if I don’t, they miss abnormalities, delaying treatment and decreasing the quality of care. Peereboom will have worked with radiographers capable of accurately interpreting radiographs. Today, many Australian radiography students have tertiary entrance scores in the 90s. Arguably, the only reason we cannot teach them to formally give their opinion on radiographs is because of a professional boundary drawn in the sand in the 1920s.2 However, the sand is shifting under the health care system. I have the greatest respect for radiologists’ knowledge, skills and intellectual capacity. However, an advanced practice role for radiographers is not just about respect. It is a human resource issue. Knowing that the current service model is antiquated, do we wish to limit the potential of both radiographers and radiologists in the future?

Tony N Smith

To the Editor: We read with interest the recent article by Oldmeadow and colleagues.1 Patients on waiting lists have long waits and poor quality of life,2 and we are currently piloting a similar model for assessment of patients referred for orthopaedic opinion for hip and knee arthroplasty.3 In keeping with other authors, the article by Oldmeadow and colleagues provides encouraging data to support role substitution. However, we suggest that important issues need to be addressed before wide-scale adoption and expansion of the model. More information is needed about the proportion of all referred patients eligible for the physiotherapist assessment, and the cost–benefit figures for “avoided” orthopaedic consultations. It is quite difficult to evaluate the outcomes given the exclusion criteria, which are common comorbidities in these settings. While the κ statistic implies concordance between two physiotherapists and one surgeon, the disagreement was still about one patient in four. Of course, this level of disagreement may also be found between surgeons. However, for a new health intervention, such discordance needs to be understood within an appropriate evaluation framework. What level of diagnostic error are consumers prepared to accept from any health care provider? The article reports five episodes of disagreement between the physiotherapists and the surgeon, where the need for surgery, medical treatment or further imaging was missed; this represents 13.2% of patient assessments (were there multiple missed opinions in individual cases?). The fact that a patient refused surgery is irrelevant if that decision was not identified a priori before surgical referral. Every consumer has the right to accept or reject recommendations about care based on the best available information about potential benefits and harms. An important role of specialist medical providers is that of diagnostician, particularly when there are multiple or complex conditions. Changes to the management of common musculoskeletal conditions should not reduce opportunities for expert input when required. Waiting times for many patients are clinically and ethically unacceptable and we agree new service delivery models are necessary. We suggest that: professional groups work together to develop agreed evidence-based protocols for triage, assessment, investigation and management of common musculoskeletal conditions; funding providers and health care organisations develop and evaluate new models of care, including their cost-effectiveness, and provide appropriate training and monitoring to ensure role redefinition is associated with maintenance of equal or better quality and safety of care; and a musculoskeletal clinical network be developed to support these objectives.

Caroline A Brand · Richard H Osborne · Ian P Wicks · Richard N de Steiger

In reply: The proportion of patients who, after being referred to specialist orthopaedic surgeons by general practitioners, are then listed for surgery, is around 20%–30%.1-3 In our trial, the diagnostic and management concordance between the physiotherapists and surgeon for this group was very high. It was also high for the 63% for whom evidence-based physiotherapy was appropriate. Management discordance occurred when surgical treatments that are controversial, and variously used by surgeons (as noted by Brand and colleagues), were recommended. It is important to note that the 74% agreement between the surgeon and physiotherapists in our trial was achieved under research conditions, with the physiotherapists screening independently. We suggest that the physiotherapist clinic be co-located with that of the surgeons, to facilitate further investigations, enhance the pathway to surgery and manage safety concerns. The advantages of a physiotherapist screening clinic are in (i) triaging out from waiting to see a surgeon, patients predicted to benefit from non-surgical interventions (including those not willing to consider surgery at the time) and (ii) triaging patients in to the appropriate non-surgical care. We agree that patients with degenerative, osteoarthritic conditions, for whom joint replacement surgery may be the eventual treatment, will be best managed through multidisciplinary care.

Leonie B Oldmeadow · Harvinda S Bedi · Hugh T Burch · Jenni S Smith · Edmund S Leahy · Miron Goldwasser

To the Editor: The concerns expressed by Byard and colleagues about “safe-sleeping messages”1 are based on the assumption that bed-sharing (mother and baby sleeping on the same bed surface) is intrinsically dangerous. While some case–control studies have shown increased mortality for young (but not older) bed-sharing babies of non-smoking mothers, more detailed studies have found excess risk only among parents affected by alcohol, extreme overtiredness, overcrowded housing, or where the sleeping environment was unsuitable, including prone or side sleeping, heavy bedding, waterbeds and sofas.2 Epidemiological studies support the safety of bed-sharing. For example, in Hong Kong and mainland China, bed-sharing is very common, but rates of unexpected infant death are extremely low. This implicates aspects of Western lifestyle and sleeping practices — including the V-shaped pillows (tri-pillows) highlighted by Byard et al, other suffocation and entrapment hazards, and maternal smoking — rather than bed-sharing per se. Bed-sharing is also the evolutionary norm, providing many opportunities for “mutual regulation” of maternal–infant physiology, including body temperature, sleep cycle and breastfeeding.3 Modern bed-sharing mothers may appreciate the more restful sleep and easier breastfeeding. Overnight sleep laboratory studies of bed-sharing and solitary-sleeping mother–baby pairs show that bed-sharing mothers are very aware of their baby’s presence, even in deep sleep, and move to avoid overlaying. Bed-sharing babies breastfeed more frequently, but with equivalent total sleep for mother and baby.3 Researchers note the rarity of unsafe prone positions among breastfeeding, bed-sharing infants.3 Other studies have shown increased rates and duration of breastfeeding among bed-sharing mothers and infants.4 For these reasons, bed-sharing has become more popular in Western cultures, with an Australian survey in 2000 finding around 40% of young babies bed-sharing for at least part of the night.5 As with other aspects of care, it is our duty as health professionals to discuss the risks, benefits and practicalities of bed-sharing so that parents can make an informed and safe choice. The Royal Australasian College of Physicians comments, “Co-sleeping or bed-sharing is common and associated with increased breastfeeding rates, longer and more restful sleep, and a protective posture and synchrony of mother with baby . . . All parents should be informed about how to safely co-sleep with their infants”.6 Safe bed-sharing recommendations are available from websites such as the UNICEF UK Baby Friendly Initiative.7

Sarah J Buckley

In reply: Our position on bed-sharing was not based on the assumption that it is intrinsically dangerous, but that there is an increased risk of mortality for bed-sharing babies of “parents affected by alcohol, extreme overtiredness, overcrowded housing, or where the sleeping environment was unsuitable” (to quote Buckley). These risk factors were not mentioned by the telephone health advice line quoted in our letter,1 which rather commented that mortality in bed-sharing babies was such a rare event that the caller should not worry about it — little consolation if a fatality occurred. We agree completely that parents need to be able to “make an informed and safe choice”, but this also requires informing them of potential dangers — which did not happen. Also, we do not agree that mothers are always aware of the presence of their babies, as reports of accidental suffocation during breastfeeding in bed clearly demonstrate.2,3 An informed decision is made when all the information has been provided, not just information that supports a particular point of view. Curiously, Buckley’s final point is to recommend a website for safe bed-sharing advice4 that states quite clearly (with italics): “the safest place for a baby to sleep is in a cot by your bed”. We concur.

Roger W Byard · Glenda Cains · Helen Noblet · Maxine Weber

To the Editor: Since graduating from medical school in 2004, I have dutifully read the Medical Journal of Australia. I was initially intrigued to read sporadic letters to the Editor in which authors, when commenting on current issues in medical education and clinical practice, referred to what happened “in our day”. Topics have included anatomy (eg, dissections), Latin and Greek lessons, teaching methods and hours worked. At times, I feel that the new generation of doctors, of which I am a part, must justify how we can work as medical professionals given our presumed inadequate knowledge. I believe that the skills I learned while at university have enabled me to successfully manage patients who not only have complex medical problems treated with numerous medications, but often require more support to be provided when at home. My training has taught me to solve problems and resource answers using multiple modalities and resources, at the same time keeping abreast of rapidly evolving medical theories and treatments. I do so while also facing the current economic challenges of rising insurance premiums, housing costs, and concerns about global warming. I did not learn Greek or Latin at school, but I did learn to touch type, design a database and formulate a spreadsheet. In my day, when electronic interfaces involved with patient care are changing rapidly, these skills have greatly enabled me for work in the 21st century.

Sara L Barnes MB BS

To the Editor: I am concerned that the Journal supplement “Early intervention in youth mental health”, published on 1 October 2007, may contravene the MJA policy on sponsored supplements. Item 9 of that policy (http://www.mja.com.au/public/information/instruc.html#Supplements) states: The supplement’s articles should not favour drugs/interventions/views/products of the supporting body to the detriment of other drugs/interventions/views/products. While many of the articles in this supplement are clearly scientific papers, a minority read more as advertorials and promote the interests of two of the supplement’s sponsors.1-3 The ORYGEN–headspace approach to adolescent mental health differs from the approach of other expert organisations, including the Faculty of Child and Adolescent Psychiatry of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and the Australian Infant, Child, Adolescent and Family Mental Health Association.4 Both these organisations support ORYGEN and headspace in seeking to enhance mental health services and transition to adult services for adolescents, but not in the proposed “specialist youth-specific (12–25 years) mental health services providing comprehensive assessment, treatment and social and vocational recovery services”2 (Dr Phill Brock, Chair, Faculty of Child and Adolescent Psychiatry, RANZCP, personal communication). This arrangement does not fit with the way in which other service providers (education, juvenile justice, medicine) are organised, or with the legislative framework that protects the rights, welfare and safety of children (0–17 years of age). Children are not young adults, and child and adolescent mental health service models differ significantly from the traditional focus of adult mental illness. Most teenagers require a family-centred, developmentally appropriate, contextually sensitive, multimodal and systemic model that is less well developed in adult mental health services, including ORYGEN. In spite of claims to the contrary in the supplement, these different approaches are in competition for resources. ORYGEN and headspace have a product to sell (to government and to the medical and lay community). The publication of this supplement has provided them with a platform without presenting an alternate view.

Jon N Jureidini

In reply: Dr Jureidini’s response to the “Early intervention in youth mental health” supplement is puzzling and idiosyncratic. He asserts some kind of impropriety on our behalf or that of the MJA — an assertion we strongly reject. All articles were peer reviewed by experts in the field, including the editorial,1 which is obviously and explicitly the authors’ point of view and therefore open to debate, which we welcome. Other articles Jureidini characterises as “advertorial” are genuine descriptions of new models of care.2,3 Far from selling a product, we are advancing legitimate clinical and scientific arguments, and describing active reforms in mental health. Our “interests” are the pursuit of better mental health care and outcomes for young Australians, pure and simple. No evidence is provided for the assertion that the models described are in competition for resources. headspace has been fully funded with a completely new allocation of federal resources, with no funding redirected from other programs to support it. Furthermore, the youth mental health reform model was selected by the Australian Government through a nationally competitive tender process, in which anyone with a different approach was free to put it forward; indeed, several other submissions were considered and rejected. Similarly, no resources have been diverted to create the ORYGEN model; it is simply a successful restructure of existing resources that is demonstrably better accepted and more effective. Evidence shows that young people and their families find services structured in this way much more user-friendly, and levels of access, engagement and retention are substantially increased over traditional models. One of us (P M) is a member of the Faculty of Child and Adolescent Psychiatry of the Royal Australian and New Zealand College of Psychiatrists (RANZCP), and neither we nor headspace are aware of any official position of the RANZCP that is inconsistent with or unsupportive of the headspace development. Most of the 30 new headspace services across the nation are being established in partnership with local child and adolescent psychiatrists and public mental health services. While many psychiatrists are supportive of and working within the headspace and ORYGEN models, a small subset have expressed a fear that strengthening the focus on adolescents and young adults will somehow disadvantage children. Where is the evidence to support this fear? We are wholly supportive of further investment and improvement in mental health services for children. Unnecessary division on this issue will hamper all progress and is against the interests of patients and families. We strongly agree that there is clearly unmet need in the 0–12-years age group, as well as a further need for preventive interventions beyond the clinical service system, which may in time reduce the surge of incident cases of adult-type disorders. We call on Dr Jureidini to put his efforts into increasing resources and developing innovative service models to improve the mental health of both children and young people, rather than engaging in sterile arguments over professional territory and distribution of existing resources that will benefit no-one.

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

In reply: I welcome Dr Jureidini’s criticisms regarding the publication of the MJA supplement “Early intervention in youth mental health”.1 Dr Jureidini has two major concerns. First, a number of articles in the supplement are deemed to unilaterally advocate concepts arising from the ORYGEN–headspace program, with the suggestion that this exclusivity contravenes the MJA policy for publishing sponsored supplements. Second, he claims that the general framework of the ORYGEN–headspace program does not have the endorsement of professional bodies such as the Faculty of Child and Adolescent Psychiatry of the Royal Australian and New Zealand College of Psychiatrists (RANZCP). Eminent mental health experts reviewed the articles in the supplement and, interestingly, not one of these authorities raised the RANZCP’s misgivings. This could mean that propagation of the Faculty’s concerns in the psychiatry fraternity may be selective, or that the rationale for its position has not convinced psychiatrists at large. Dr Jureidini’s other concern — that the supplement favoured the ORYGEN–headspace approach at the expense of other interventions, views or products — reflects the very essence of supplements. The fundamental purpose of publishing research or commentaries is to enter information into the publishing–evidence–integration cycle, wherein the dissemination of evidence or ideas is intended to promote change by influencing other researchers, health care professionals, the public and, ultimately, policymakers. Indeed, the ORYGEN–headspace program must have influenced policymakers, as the federal government recently announced grants totalling $19 million to support the national roll-out of the headspace program, especially in rural communities.2 Even if the publication of the MJA supplement played little or no part in this political endorsement, I am content that it has, at least, fostered debate and may well play a part in improving mental health services for young Australians.

Martin B Van Der Weyden

To the Editor: Little is known about the epidemiology of respiratory syncytial virus (RSV) in arid, desert regions generally, and in central Australia in particular. We performed a 5-year retrospective study from 2000 to 2004, inclusive, of children aged less than 2 years who were admitted to Alice Springs Hospital and identified as having RSV infection. RSV was detected using direct immunofluorescence (Light Diagnostics SimulFluor; Millipore, Billerica, Mass, USA) on nasopharyngeal secretions. The test has a reported sensitivity of 92%.1 We extracted demographic data from case notes and obtained population data from the Northern Territory Department of Health2 and the Australian Bureau of Statistics.3 From case notes over the 5 years, we identified 173 eligible children with RSV infection. The annual incidence rate was 21.4 per 1000 children under 2 years old. The rate in Aboriginal children was 30.9 per 1000, and the rate in non-Aboriginal children 11.6 per 1000 (P < 0.0001). The monthly distribution of cases is shown in the Box. Cases occurred throughout the year, and in every month, but there was a peak in admissions from March to August, which covers the Australian winter. Because Alice Springs Hospital is the only large hospital in the region, and almost all children needing hospital admission for RSV infection will be admitted there, our incidence rates of hospitalisation for RSV infection closely approximate population rates. However, we may have under-estimated the incidence because we only included children in hospital with proven infection, so we may have missed children who were not tested, or whose immunofluorescence test results were falsely negative. There may have been selection bias regarding admissions. Nevertheless, we found that Aboriginal children were more likely than non-Aboriginal children to be hospitalised with RSV infection, a finding in keeping with the known high incidence of pneumonia and bronchiectasis in Aboriginal children.4,5 While the incidence of RSV infection peaked in winter in central Australia, infections occurred throughout the year, and the winter predominance was less marked than is the case in temperate Australia.6 These data provide valuable information about RSV infection in an arid, desert region and can inform decisions about active or passive immunisation against RSV infection in central Australia. Monthly distribution of admissions to Alice Springs Hospital of children aged less than 2 years with respiratory syncytial virus, 2000–2004* * Inclusive.

Apakasimaka Dede · David Isaacs · Paul J Torzillo · John Wakerman · Rob Roseby · Rose Fahy · George Clothier · Andrew White · Paula Kitto

To the Editor: We report the serendipitous finding of non-Hodgkin’s lymphoma in a patient with adrenal Cushing’s syndrome. A 62-year-old previously well man (body mass index, 22 kg/m2) was referred to our institution with newly diagnosed type 2 diabetes, hypertension and dyslipidaemia. Clinical findings included oral thrush, bilateral severe pitting lower limb oedema, lower limb proximal myopathy, kyphosis, and increased abdominal girth (waist circumference, 92 cm), raising suspicion of Cushing’s syndrome (Box 1). Biochemical assessment revealed normal electrolytes, an unsuppressed early morning cortisol (following 1 mg dexamethasone), urinary free cortisol 6475 nmol/day (reference range, 0 – 250 nmol/day), and undetectable adrenocorticotropic hormone levels. Twenty-four-hour urinary catecholamine was normal. His testosterone level was 3.2 nmol/L, and dehydroepiandrosterone sulfate level was normal. Abdominal computed tomography showed a right adrenal mass that measured 3.1 × 2.8 × 3.4 cm (density, 36 Hounsfield units). Thoracic spine x-rays revealed wedge compression fractures at T-10 and T-11. Bone densitometry showed T-scores of − 3.3 at L2 – 4 and − 2.3 at the right femoral neck. Total body fat (18.5 kg; 33%) was higher than the recommended range for age and sex (13%–25%). The patient had a laparoscopic right adrenalectomy. Surgical excision was complete. Post-operatively, blood glucose and blood pressure returned to normal. Histopathology revealed an adrenal cortical tumour with atypical features, including a preponderance of eosinophilic cells, small numbers of clear cells, prominent nuclear pleomorphism, large nucleoli and occasional mitoses (Box 2A). However, the proliferation fraction (Ki67) was low and there was no necrosis. There was no large vessel invasion, although a single area of small vessel invasion was present (Box 2B). Unexpectedly, the adipose tissue adjacent to the adrenal gland was infiltrated by a diffuse large B-cell non-Hodgkin’s lymphoma (Box 2B). This was confirmed by positive CD20 immunohistochemistry. Bone marrow biopsy was normal. [18F]Fluorodeoxyglucose positron emission tomography (FDG-PET) scan showed increased uptake in the right adrenal bed only. The patient was treated with six courses of CHOP chemotherapy (cyclophosphamide, doxorubicin, vincristine and prednisolone) in combination with rituximab. A repeat FDG-PET scan 1 month after chemotherapy was clear. We speculate that lymphoma progression was suppressed by the coexistent steroid-producing adrenal tumour. The decision to treat the non-Hodgkin’s lymphoma was, in part, based on reports of progression of haematological disease following treatment of Cushing’s syndrome.1,2 Although histopathological examination of the tumour revealed some features suggestive of adrenocortical carcinoma, the distinction between adenoma and carcinoma can be difficult. In patients with recurrent or metastatic adrenocortical carcinoma, partial response has been reported using a combination of cylophosphamide, vincristine, cisplatin and teniposide.3 Two of these agents were used to treat our patient’s lymphoma. 1 Patient appearance at presentation, with obvious kyphosis and abdominal swelling 2 Immunohistochemistry A: Right adrenal tumour composed of enlarged pleomorphic cells with prominent nucleoli. B: Adrenal cortex (on right) with tumour showing focal vascular invasion (centre), plus adjacent non-Hodgkin’s lymphoma (on left).

Lai Y Wong · John Moore · Debbie Hill · Phil Brenner · Warick Delprado · Jennifer Turner · Joanne Taylor · Lesley Campbell · Jerry R Greenfield

To the Editor: We agree wholeheartedly with Skull and Nolan’s call for a lifetime immunisation register to enhance monitoring of coverage, provide a clinical support service and provide data for program evaluation.1 An expanded register could also provide information on the vaccine coverage for childhood diseases that may increasingly affect adults (such as varicella and measles), for immigrants who may receive childhood vaccines after childhood, and for occupational groups (eg, influenza vaccine for health care workers). However, we note some policy implications that need to be addressed before such an expanded register could be implemented. In August 2007, at a La Trobe University seminar on human papillomavirus vaccination, the 180 participants (mainly students and staff of La Trobe University) were asked to fill out a survey that included a question about the acceptability of a lifetime vaccination register. Of the 154 who responded, 8.5% were not in favour of such a register and another 8.5% declined to answer that question (unpublished data). This suggests that there may be significant barriers to the implementation of a lifetime register. Principal among the concerns cited were the implications for privacy, which were also noted by consumer groups.2 As with the existing Australian Childhood Immunisation Register, people will need to be aware of what data are being collected (including policies for data retention), their choice to opt out, and a clearly defined purpose in gathering the data (in particular, that the data will not be used in a punitive manner). People will also need to be assured that there are unambiguous policies governing access to the register and penalties associated with breaches of confidentiality. These concerns have led to the suggestion that a private health record should be developed instead,2 but such a record would be unlikely to be adopted widely and could not be used for monitoring or program evaluation. Development of an expanded register could also present potentially significant logistical problems. We would suggest a staged approach, beginning with expanding the current childhood register to include adolescents of school age and elderly people. Incentives to improve vaccine coverage in these groups could be modelled on the current General Practice Immunisation Incentives Scheme, which provides service incentive payments, outcomes-based payments and immunisation infrastructure funding. Many Indigenous Australians are currently covered through Aboriginal-controlled community health organisations. With the consent of those organisations, data could be absorbed into a national register. Later stages of implementation might see the inclusion of special groups (such as post-splenectomy patients and immigrants) and people receiving occupation-related and travel-related vaccines. The register could eventually be expanded to encompass the full Australian population. The current redevelopment scoping study for the Australian Childhood Immunisation Register3 is due for completion in 2008. We support enhancing the current central register, but clearly defined policies to protect privacy are required to address public concerns.

Allen C Cheng · Carmel M Hobbs · Priscilla M Robinson

In reply: We welcome additional dialogue on the important issue of developing a whole-of-life immunisation register in Australia. As with introduction of any register, logistics and concerns about privacy must be carefully considered, and a stepwise approach may well be appropriate. However, it is important to note that a non-acceptance rate of 8.5% derived from a small and potentially non-representative survey of seminar attendees does not necessarily represent a significant barrier to implementation of such a register.

Susan A Skull · Terrence M Nolan

To the Editor: I congratulate Haslam on his excellent overview of the role of empathy in medicine.1 He rightly reminds us that empathy is not vague or ill defined; rather, its presence improves clinical outcomes, and it can be both learned and lost. I would go further and argue that empathy is not an optional extra but a clinical competence essential for sound medical practice, no matter what our specialty. All clinical practice requires a doctor–patient relationship, the core skill of which is empathy. I wish to draw readers’ attention to a time-honoured but, in Australia, somewhat neglected educational activity where empathy is the major focus — that of Balint groups. In London in the 1950s, Hungarian-born psychiatrist Michael Balint and his wife Enid developed a unique method for studying the doctor–patient relationship.2 A Balint group is an experiential, small-group educational activity in which practising clinicians meet regularly to discuss their own doctor–patient interactions. The focus is on the emotional content of the doctor–patient relationship; the group’s primary task is to describe and empathise with both the doctor’s and the patient’s experience. Participants’ learning, therefore, is based on real-life situations they have encountered in their practices. A rationale for this kind of training is that all doctors tend to have habitual responses to certain clinical situations. Although these responses can be strengths which doctors bring to the care of some patients, they can also limit their capacity to help other patients. In certain situations, limits to doctors’ capacities for empathy may be unhelpful or even harmful to patients. A growing body of research suggests Balint-group training increases: practitioner sensitivity to hidden patient cues;3 the proportion of the consultation spent listening to the patient;4 practitioners’ experience of wellbeing during the consultation;3,5 practitioners’ sense of control in their work situation;5 and practitioners’ work satisfaction.6 At the same time it decreases: practitioner burnout;3,5 and unnecessary prescriptions,3 referrals5 and tests.5,6 In many countries today, Balint-group training is used in undergraduate and postgraduate education, most often in general practice training, but also in psychiatry, paediatrics, obstetrics and gynaecology, and internal medicine. At an international level, the vibrancy and energy of Balint-group work is reflected in the 26-year-old International Balint Federation (http://www.balintinternational.com). The Balint Society of Australia (http://www.balintaustralia.org), formed in 2005, joined the Federation in 2007.

Marion Lustig

To the Editor: I note the concern expressed by Byard and Matthews about the safety of three-wheel strollers.1 Surely a safer method of control would be for the brake to be on at all times other than when the stroller is in use? This could be done by having a lever that had to be held in position by the user in order to move the stroller. Should not this be required in the safety standard?

Charles Bridges-Webb