Letters

To the Editor: I was not surprised by the results published by Fassett et al1 regarding clinical handover. Despite being a crucial part of health care, clinical handover has only recently become a topical issue in the clinical governance arena. In May 2007, the World Health Organization launched the “Nine patient safety solutions” to “help reduce the toll of health care-related harm affecting millions of patients worldwide”.2 Solution number three relates to “communication during patient hand-overs”. Australia is in fact leading the international collaboration on clinical handover through the National Clinical Handover Initiative. This was recently launched by the Australian Commission on Safety and Quality in Health Care to develop and implement standardised solutions to patient safety problems associated with clinical handover.3 At a state level, the Victorian Quality Council conducted a clinical handover survey of Victorian health services in May 2006 to provide an overview of areas of concern relating to clinical handover.4 The Council launched a pilot project in 2007 to look at morning handover processes between junior doctors. Despite these efforts, hospitals are still struggling with the issue of clinical handover at the local level. All health professionals know that clinical handover is good clinical practice, but they need to be provided with the tools to carry it out properly. Clinical handover, depending on your definition, includes referral letters from general practitioners, discharge summaries from hospitals, as well as handover of clinical information between different shifts, treating teams, wards, health professionals and health services. It makes sense that the process of handover of clinical information be carried out in a standardised format, as the minimum dataset required is consistent for most circumstances. While there is a need for standardisation, health organisations must also be able to devise local innovative solutions that work for them. Information technology can assist in developing a solution to this issue. For example, different local health services have already developed in-house systems for electronic discharge summaries that are integrated with an electronic health record. While national quality bodies endeavour to develop national standards and tools for clinical handover, local health services must not sit idly and wait for these, but must continue to innovate and provide workable local solutions for their own health professionals. Otherwise, future surveys of clinical handover will continue to show that a problem still exists in relation to this issue.

Erwin Loh

In reply: Our national survey was specifically confined to medical morning handover report, one of many forms of clinical handover.1 The clinical governance area may have only recently recognised the importance of clinical handover, but it has been a topical issue for many years in the clinical arena, particularly in the United States.2 While Australia may be leading the way in international collaborations, our survey suggests that this is not translating into clinical practice. Rather than commissions and councils providing tools and guidelines to carry out clinical handover, clinical leaders need to participate and conduct clinical handover themselves at the local level. From our previous experience with morning report, we provided simple tips on how to implement clinical handover at the local level,3 and these have been incorporated into Australian Medical Association guidelines.4 Information technology can be employed to help with the clinical handover process. However, when using the all-inclusive definition of clinical handover suggested by Loh, this task is complex, as research has shown that information management needs vary significantly between different clinical environments and would require multiple end-user-defined outputs from a standardised data repository.5,6 Clinical handover needs to be implemented from the bottom up (by clinicians) rather than from the top down (by commissions).

Matthew J Fassett · Terry J Hannan · Iain K Robertson · Steven J Bollipo · Robert G Fassett

To the Editor: I was part of a review of the Therapeutic Goods Administration (TGA)-approved product information (PI) monographs contained in MIMS (Monthly index of medical specialties) annual with respect to their poisoning management advice.1 We looked at the 10 most common poisonings presenting to Westmead Hospital and another 15 clinically important poisonings as determined by two of the authors, and compared the poisoning management advice given in MIMS to a “gold standard” derived from a consensus of five pharmacological resources. For the 25 drugs examined, 14 monographs contained inaccurate information, one contained a recommendation for ineffective treatments, and 14 omitted specific treatments or antidotes. Many of these errors could delay or even prevent patients receiving currently accepted and effective therapies for life-threatening poisonings if MIMS were used as the primary resource. The omission of sodium bicarbonate for ventricular conduction delay and hypotension in amitriptyline, quinine and thioridazine poisonings is particularly problematic. Ventricular conduction delay and hypotension is often refractory to other therapies, and delay in bicarbonate administration could result in avoidable deaths. The recommendation of sodium bicarbonate for ventricular conduction delay and hypotension was included in the TGA-approved monograph for amitriptyline in 1984, but was subsequently removed without qualification in 1990 and remains absent. Cyproheptadine, an important therapy for serotonin syndrome, is not included in the TGA-approved monograph for sertraline, and its delay could result in avoidable morbidity. Atropine for verapamil-induced bradycardia is a simple and intuitive therapy; however, its omission from the TGA-approved monograph could again result in avoidable morbidity and mortality. We also found potentially dangerous treatments recommended in the TGA-approved monographs not covered by the consensus opinion. These included intravenous amphetamine or intramuscular ephedrine to counter the sedative effects of promethazine poisoning, administration of enteric-coated ammonium chloride tablets to increase urinary excretion in chloroquine poisoning, and forced osmotic diuresis using a urea or mannitol infusion for lithium poisoning. These treatments are out of the Dark Ages, and their use should be considered negligent. Based on this and other reports in previous editions of the Journal, the TGA-approved PI monographs contain inaccurate, inadequate, out-of-date or potentially dangerous information relating to poisoning management advice, paediatric drug dosages,2 drug interactions,3 breastfeeding mothers,4 and various thyroid medications.5 How can we use MIMS for anything other than simple drug formulation information? Surely, to anyone who wishes to practise up-to-date, safe, evidence-based medicine, the answer must be that we cannot. It is time for the TGA to take up its role as regulator and insist on updated and accurate PI monographs from the pharmaceutical companies.

James L Mallows

In reply: An article by Stockigt1 and follow-up correspondence from Mallows raised concerns about the limitations of approved product information (PI). The purpose of PI needs to be realised. The document is not intended to act as a textbook of medicine or general management of patients, but is intended to contain sufficient information to allow a health professional, in average circumstances, to use the specified medicine safely and to refer to other sources of information and expertise should they be required. The PI covers uses of the medicine evaluated and approved by the Therapeutic Goods Administration (TGA). The sponsor of the medicine is responsible for maintaining the PI, and the TGA has procedures in place to support their timely updating. On occasions, the TGA initiates reviews of PI when a need is identified. Health professionals, especially specialists, are important in identifying possible improvements in PI, based on their experience, knowledge or awareness of current medical practice. The TGA encourages physicians who have suggestions to approach the sponsor of the medicine or the TGA. It is not possible to address in detail the article by Stockigt1 or the letter by Mallows. The thyroid PI documents have been reviewed by the sponsor companies, and changes have been made where evidence supports this. However, as indicated above, there are limitations on the role of PI. Mallows raises the issue of complex management instructions on overdosage, including the specifics of bicarbonate administration for potential metabolic acidosis. The PI documents for the named products do mention that overdose patients are likely to develop such complications, and that they require admission to hospital and management by appropriate specialists; intensive care admission is recommended in several of the documents. It is arguable how much further detail is required. The PI cannot replace careful consideration of the individual circumstances of the patient combined with expert knowledge of patient management. PIs are complex documents. The TGA is currently considering the format of the PI and whether it can be rearranged to better balance provision of basic messages and more complex material in separate presentations.

David T Graham

To the Editor: The recent conference report by Knight and Taruscio highlights the need for a coordinated effort to fill knowledge gaps and improve service provision for Australians with rare diseases.1 Although, by definition, individual rare diseases occur infrequently, there are about 6000 rare diseases affecting 6%–10% of the population.2,3 This equates to 1.2 million Australians, 30 million people in Europe and 25 million in the United States. By comparison, diabetes affects 1.4 million Australians.4 It is increasingly acknowledged that low prevalence does not equate to low impact. Rare diseases often have their onset in childhood, continue throughout life, are difficult to diagnose, are disabling, and have significant impact on patients, their families, the community and health services.2,5 However, rare diseases receive such scant attention that they have been dubbed “orphan” diseases. Lack of epidemiological and scientific data has hindered development of evidence-based practice, policy and services. To tackle the problem of rare diseases, the European Union, the US, Canada and New Zealand have established policies and agencies to foster research, and develop resources for clinicians, community information services, and appropriate health facilities. The National Institutes of Health in the US established the Office of Rare Diseases because: . . . rare disease research requires the collaboration of scientists from multiple disciplines and the capacity to share access to geographically distributed national research resources and patient populations . . . knowledge about rare diseases may offer leads for scientific advancement in other rare diseases and in more common diseases.6 There is no coordinated national effort or policy in Australia. Currently, there are 14 national paediatric surveillance units, including the Australian Paediatric Surveillance Unit (APSU), to which paediatricians contribute epi-demiological, clinical and outcome data on rare conditions of childhood.7 These data inform development of health policy and improved diagnosis and clinical management, and result in the establishment of cohorts, thereby enabling further research.7 The APSU is developing information resources for clinicians and the community on rare infections, genetic disorders, mental health conditions and injuries in children. In Australia, the APSU is the only provider of prospective national data on up to 16 rare childhood diseases concurrently, but it receives no ongoing core funding. Sound evidence is needed to underpin development of policy and services. Sound evidence requires sound research into the causes, management and effects of rare diseases. Australian clinicians, researchers and, most importantly, patients and their families deserve the benefits of a coordinated national plan to address the common burden of rare diseases.

Yvonne A Zurynski · Katie N Reeve · Elizabeth J Elliott

To the Editor: In recent years, there has been an increase in the use of highly mobile three-wheel strollers that facilitate parental activities such as jogging. Unfortunately, the very design feature that enables fast transit over uneven ground also makes it possible for unsupervised strollers to move rapidly into situations that may be highly dangerous. Within the past year in South Australia there have been two separate incidents where infants, one aged 5 months and the other aged 10 months, died after being immersed in the Torrens River. They had both been strapped into three-wheel strollers. In both instances, carers, who had been walking or jogging in the park along the banks of the river, were momentarily distracted — one by a mobile phone call and the other while attempting to use a plastic bag dispenser. The strollers had not had their front wheels locked or their brakes engaged, or been attached to the carers by wrist straps and so were unrestrained, enabling them to roll rapidly forwards into the water. Police re-enactments confirmed the scenarios described by the carers. While three-wheel strollers have safety features, such as brakes and sometimes wrist straps, these are not always used. Although consumer organisations have listed a series of recommendations for users of these strollers, this advice is not always being followed. The recommendations include never leaving a child unattended in one of these strollers, always using a wrist safety strap, always engaging the brake when stationary, and locking the front wheel when jogging to prevent swivelling. In addition, specific warnings are issued about stopping on slopes, being distracted by mobile phone calls, and being particularly careful near water, roads and railway lines.1 Drowning of infants and toddlers in rivers is an uncommon event, with only two cases documented of a total 32 drowning deaths of children under the age of 2 years in South Australia over the 35 years from 1963 to 1998 (rate, 6.25%).2 Thus, the occurrence of two drowning deaths within 4 months associated with three-wheel stroller use in parks next to a river is of concern. While mandatory requirements for safety devices such as parking brakes and tether straps will take effect on 1 July 2008,3 this legislation will have little effect if the devices are not used. Parents and carers must be made aware that infants or toddlers in three-wheel strollers near water are at risk of immersion and drowning. Such warnings should be clearly specified on these products.

Roger W Byard · Neil Matthews

To the Editor: A 30-year-old man presented with pain, swelling and discharge from lesions on his left arm. He had undergone extensive tattooing on the arm 3 days earlier at a commercial tattoo operation, where single-use needles were used, with initial drawing of lines followed by additional shading. The patient complained of severe neuropathic pain in the arm, which was greater than would be expected from uncomplicated bacterial cellulitis. He did not give a history of oral or genital herpes and had previously been tattooed without complication. On presentation, the patient had a low-grade fever (37.9°C), a heart rate of 80 beats/min and blood pressure of 130/80 mmHg. He had no neurological deficit. Vesicular lesions were visible in the region of the tattoo marks, predominantly affecting areas of shading and with minimal spread outside tattooed areas (Box). A bacterial swab of the lesions grew methicillin-sensitive Staphylococcus aureus, and a polymerase chain reaction test of vesicular fluid was positive for herpes simplex virus type 1 (HSV-1). The patient was commenced on intravenous flucloxacillin (1 g four times daily) and oral famciclovir (250 mg three times daily). He required ongoing inpatient management for pain relief. Five days after development of the lesions, HSV-1 serology demonstrated positive results for IgM and IgG. An HIV test was negative. The patient’s lesions slowly resolved, and he was discharged 7 days after admission. Most concerns regarding infectious complications of tattooing have focused on transmission of blood-borne viruses, but superficial infections with other pathogens have also been described.1 The personal care and body art industries are regulated in Australia to minimise the transmission of blood-borne infection,2 and most state and territory authorities also publish infection control guidelines. Herpes dermatitis is often confused with bacterial infection, although co-infection may occur. This distinction is clinically important, as antibiotics and surgical debridement are not usually required for herpetic infections, and herpetic lesions may recur. Secondary herpetic infection complicating skin disease is most commonly associated with eczema (eczema herpeticum) or other skin diseases (Kaposi’s varicelliform eruption), and minor skin trauma, such as in herpetic whitlow or herpes gladiatorum.3,4 We are not aware of any previous reports of herpetic infection complicating tattoo placement. The distribution of herpetic lesions in our patient suggested that the needle used for tattoo shading became contaminated with HSV-1 during the course of tattoo placement, but it is also possible that superinfection occurred through damaged skin after the procedure. We propose the term “herpes compunctorum” to describe this condition. Vesicular lesions on patient’s tattooed forearm

Catherine S Marshall · Felicity Murphy · Shannon E McCarthy · Allen C Cheng

To the Editor: Helping patients who have had a stroke return to driving when possible should be an important focus in rehabilitation wards. The National Stroke Foundation supports a three-stage approach to assessing ability to drive, comprising physical and cognitive assessment, an off-road driving test and an on-road driving test.1 Austroads is the association of Australian and New Zealand road transport and traffic authorities, which aims to improve road and road transport outcomes. It provides clear guidelines on criteria for licence and assessment after stroke, but the implementation of these guidelines varies in practice.2 We conducted a review of 53 consecutive patients with a primary diagnosis of stroke admitted to a specialised rehabilitation ward over a 6-month period between January and July 2007. The mean age of the sample population was 77.0 years (SD, 10.7 years), and cognition score (Functional Independence Measure) on discharge was 28.3 (SD, 7.1) (maximum possible score, 35). Each patient completed a survey on driving history. Case notes were reviewed for medical factors associated with admission, any notations about driving, and actions taken regarding driving. Patients were telephoned 6 months after the date of the stroke to determine whether they had resumed driving and, if not, to explore the reasons. At the time of admission, 26 of the 53 patients held a current drivers licence, a proportion higher than the South Australian state rate of less than 10% for people aged 75 years and over. At the time of discharge, 12 of the 26 patients had their licences cancelled, 11 were referred for medical review after discharge without formal suspension, two were referred for occupational therapy driving assessment, and one was advised not to drive for 6 weeks. At 6 months, only five of the 26 patients (19%) had resumed driving, with one having regained a cancelled licence; six patients cited “lack of confidence” as the reason for not resuming driving. Reasons for the doctors’ decisions regarding driving were poorly documented in the case notes, and the time frame proposed for medical review ranged from 1 to 4 months. Austroads requires a minimum time of 4 weeks post-stroke before patients can resume driving, but does not specify a time frame for medical or on-road reassessment. Commonly, patients undergoing acute rehabilitation are still within the 4-week period, and assessments regarding return to driving are premature. The low rate of referral to available occupational therapy on-road driving assessment may reflect poor awareness of available hospital resources and online guidelines. While overseas studies of post-stroke populations indicate a return-to-driving rate between 30% and 58%,3-5 our rate was 19%. This low rate may represent a lack of formal assessment and driver rehabilitation opportunities. The benefits of formal driving assessment and training are supported by recent studies which found that licensed drivers post-stroke did not have an increased incidence of either car accidents or driving violations.6 While most doctors in the rehabilitation ward seemed to have understood the need to address the issue of driving, more formal training in this field is required for doctors.

Zoe A Allen · Julie Halbert · Lydia Huang

To the Editor: The Australian Pharmaceutical Benefits Scheme records 35 657 prescriptions (for either one or two devices) for EpiPen autoinjectors (CSL Limited, Melbourne, VIC), the self-injectable form of adrenaline, in 2006. This is a 650% increase on the 4758 prescriptions for EpiPens in 1998. The increase is much greater than the increase in the rate of food allergy. It is not enough to merely prescribe an EpiPen. It is vital that carers (of children), patients and prescribers understand its use. A previous South Australian study of children who had been prescribed an EpiPen at an allergy clinic found that, in 71% of severe reactions, the parents failed to use the device appropriately. Another study found that only two of 100 doctors in a major Australian paediatric teaching hospital could correctly demonstrate EpiPen use. In 2006, we surveyed EpiPen use by 120 parents of children attending the allergy clinic at the Children’s Hospital at Westmead. Children with egg allergy who were aged under 5 years when seen in 2003 were selected. Seventy per cent (84/120) of the children were prescribed an EpiPen. Half of the children had additional food allergies. Of those prescribed an EpiPen, 69% always carried it, 13% often carried it, 13% sometimes carried it and 5% never carried it. Ten per cent of parents had ever used the device, and 86% stated they were confident that they knew how and when to use it. Despite this, almost 40% stated they had concerns about using the EpiPen in an emergency. These included doubting their ability to correctly administer the EpiPen, whether they would have enough time and would inject correctly, concerns they may hurt their child, concern for the child in the event they needed it, doubt about the effectiveness of the EpiPen, and concern about appropriate timing. In the United Kingdom, 69% of parents were found to have problems using the EpiPen.4 Where, when and how to use the EpiPen was recently identified as one of 12 core parental information needs in our clinic.5 The findings that, even for parents of children attending a specialist allergy clinic where education strategies for EpiPen use are in place, 30% did not always carry the EpiPen, and 40% had concerns about its use in an emergency situation highlight the facts that just providing the device is an inadequate measure and that education and reinforcement, both in EpiPen use and in avoiding relevant allergens, are critical.

Clare W Allen · Dianne E Campbell · Andrew S Kemp

To the Editor: A 5-year-old girl with known peanut allergy presented with an acute allergic reaction after ingesting “nut-free” butter containing sunflower seeds (85%), sugar, emulsifier and antioxidant. The label on this product stated that it was processed in a peanut-free facility, and that each batch was tested for traces of nuts and peanut protein. The child had a history of atopic eczema, asthma, allergic rhinitis and egg allergy. At age 17 months, after eating a small amount of Thai satay containing peanut, coconut and chicken, she developed generalised urticaria, vomiting and marked angioedema. Skin prick tests at the time showed a negative reaction to sunflower seed (Box). The patient continued to avoid all nuts and egg. At the age of 5 years, within minutes of first eating a few mouthfuls of sunflower seed butter on toast, she developed generalised urticaria and angioedema of the lips. (The toast was made from the bread she usually ate, both before and after the reaction.) Skin prick tests at this time showed a strong positive reaction to sunflower seed (Box). She was thus diagnosed with generalised allergic reaction secondary to sunflower seed ingestion. Allergic reactions to sunflower seed are rare, with fewer than 30 published cases.1 Here, we report a child with peanut allergy who developed an allergic reaction after eating “nut-free” sunflower seed butter. The marketing by online and specialty shops of sunflower seed butter as a safe alternative to peanut butter for those with peanut allergy raises concerns, because allergic reactions can still occur, possibly through the development of new sensitisation. Our patient may have been sensitised through eating foods containing sunflower seeds, such as muesli bars and breads. There was no evidence of sensitisation through inhalation — for example, of seeds in bird feeds — although this has been reported.2 Another potential cause of allergic reaction is a previously unknown co-allergy to sunflower seed. This co-allergy was reported by 9.5% of patients with peanut allergy in one study.3 Yet patients with peanut allergy are often not tested for sunflower seed allergy because of its rarity. The promotion of sunflower seed butter as a safe alternative for those with peanut allergy raises concerns. As medical practitioners, we should carefully consider the safety of sunflower seed butter in individuals with peanut allergy. Skin prick test results,* by patient age Weal diameter (mm) Test extract 18 months 5 years Histamine (10 mg/mL) 3 8 Glycerosaline Negative Negative Dermatophagoides pteronyssimus 4 10 Cat Not done 13 Dog dander 4 Negative Egg white 6 15 Egg yolk Not done 10 Peanut 6 21 Almond Not done 6 Hazelnut Not done Negative Cashew Not done Negative Coconut 2 6 Sunflower seed Negative 16 * Skin prick tests were performed with a Microlance lancet using HollisterStier allergen extracts (HollisterStier Laboratories, Spokane, Wash, USA). Weal size was expressed as the average of two diameters. Average diameter ≥ 3 mm (with negative glycerosaline control) was considered positive.

Denise C Hsu · Constance H Katelaris

To the Editor: I refer to the recent letter by De Costa and Calcutt1 about diagnosis and management of possible Down syndrome pregnancies in remote areas of Queensland, and more specifically the lack of abortion facilities and cost of travel to larger centres for this service. Nowhere in the letter was impartial counselling mentioned. The following anecdote may be anathema to an academic journal, but I think it is relevant. Thirty years ago I took my 7-year-old son, who has Down syndrome, to a hospital cricket match. He had enormous fun trying to play cricket, as kids do. Watching was a young doctor whose wife fell pregnant not long after. The tests of those days suggested that the child might have Down syndrome. With memories of our son, they decided to go ahead with the pregnancy. As it happened, the child did not have trisomy 21. Children with Down syndrome, given a normal family life and lots of stimulation and love, may be able to achieve normal school levels and even work outside sheltered workshops. And they give lots in return. At a World Down Syndrome Conference in Sydney some years ago, adults with Down syndrome took part in the presentations, and notably present were a number of babies with Down syndrome whose mothers seemed quite happy with their lot. I am not against free choice, but people making that choice should be fully informed of the positive side of having a child with Down syndrome.

Kevin B Orr

To the Editor: Coory and colleagues revealed a disturbing attitude to children with Down syndrome in their recent report in the Journal on trends in Down syndrome birth rates in Queensland.1 The authors inform us that, of the 70 children with Down syndrome who would have been born without a particular form of “antenatal care” (selective termination), 21 were aborted, but another 22 could (and, by implication, should) have been aborted, had the recommended “antenatal care” by private obstetricians been replicated across the whole of Queensland. The United Nations Committee on the Rights of the Child has condemned selective termination as discrimination against children and “a serious violation of their rights, affecting their survival”.2 The Committee’s recent General comment on the rights of children with disabilities affirmed that these children have a right to positive antenatal care.3 The concluding comment of Coory et al that “When the costs of screening are offset against the life-time costs of caring for a person with Down syndrome, screening is less costly . . .” is deeply disturbing. Surely a person with Down syndrome is entitled to the same recognition of inherent dignity and worth as are all other members of the human family. The authors acknowledge that their view may be regarded by some as “distasteful”, but offer the defence that they are merely advocating that “. . . all expectant parents should be provided with the same information and have the same access to services so that they all have the same choices”. But termination is not a value-free choice. By suggesting that the best outcome of screening is a reduction in the births of children with Down syndrome by cutting these children’s lives short, the authors make a moral judgement that steps outside medicine and contravenes universal human values. The human rights of children have been recognised by the international community since the 1924 Geneva declaration of the rights of the child4 and continuously re-affirmed to the present day. It is frightening to see how much progress we have still to make when authors such as Coory and colleagues can argue that reducing the births of children with Down syndrome by the practice of selective termination is a positive thing.

Mary C Joseph

In reply: The aim of our article was to assess trends in Down syndrome births by rurality and type of antenatal care provider.1 Whether to have prenatal screening is a decision for expectant parents. It has been argued that the availability of screening for Down syndrome means that expectant parents are confronted with unprecedented ethical dilemmas and responsibilities.2 However, the available evidence shows that expectant parents do not take decisions about Down syndrome screening lightly and, in particular, do not take the implications of a positive result lightly.3 We cited three analyses of the cost-effectiveness of Down syndrome screening, but could have cited several more, all of which use essentially the same methods. Our calculation of the absolute number of Down syndrome births (the number which might have occurred if screening rates had been lower) was a statistical analysis and carries no intrinsic ethical judgement. Others may choose to apply their own moral evaluation to it. Our only intention was to report the data as clearly as possible. Several expert groups, including the Royal Australian and New Zealand College of Obstetricians and Gynaecologists,4 recommend a population-based approach to Down syndrome screening. An important aspect of such population-based screening is to provide equal access for all expectant parents, regardless of where they live or who provides their antenatal care. Another is to provide clear information so that expectant parents can make their own well informed decisions.

Michael D Coory

To the Editor: The recent editorial by Ring and Wenitong1 about interventions to prevent child abuse in the Northern Territory highlights the importance of treating the causes as well as the symptoms. This is true not only for children in remote Aboriginal communities, but for all children across Australia. Child abuse and neglect is not a “new” national emergency. In 1966, Bialestock2 wrote in the Journal: This situation should be considered as a national emergency as lethal to the lives of potential Australians as is a war. Immediate allocations of revenue to prevent this situation should be made if the[se children] . . . are to be allowed to grow into adults able to live in dignity and to work to contribute to our economy. We must not sentence these children to a lifelong need for State support. There are no reliable prevalence data, but Australian Institute of Health and Welfare data indicate that there were 266 745 notifications of suspected child abuse and neglect in Australia last year, double the number 6 years ago. About one in five of these notifications were “substantiated”. Over 25 000 children are in state care at any one time, an 82% increase in the past decade.3 Our child protection systems are at risk of imploding under the strain. These systems are also potentially dangerous, with high levels of multiple placements contributing to the very high prevalence of mental health problems among children in care.4 The contributory factors are well known. Children with disabilities, chronic health problems, difficult temperaments and externalising behaviours, families where there is domestic violence and parental mental health or substance misuse, and communities characterised by poverty, unemployment, higher residential mobility, and a low adult to child ratio are at much greater risk. We must close the gap between what we know and what we do. A public health approach is needed to reduce the risk factors, using population-based measures of child abuse and neglect, and tapping the potential of universal health, welfare and education services as platforms for primary and secondary prevention. In relation to health services, the adequate provision of universal maternal and child health services, including sustained nurse home-visiting programs, is vital. General practitioners and mental health and drug treatment services using child-sensitive and family-centred approaches also have a major role to play. These interventions have also been shown to improve overall outcomes for children in education, health, and social and economic participation. Hence, economists have suggested that they are the most cost-effective intervention for a nation.5 Now is the time to ask whether governments are really serious about preventing child abuse and neglect.

Fiona J Stanley · Dorothy A Scott · Melissa O’Donnell

To the Editor: I congratulate the Journal for publishing the article by Smith and Baird on the radiographer’s role in radiological reporting.1 It demonstrates the Journal’s objectivity by providing an opportunity to examine a health service model that, if carefully implemented and evaluated, may enhance outcomes in diagnostic imaging within a clinically useful timeframe. It is quite understandable that the Royal Australian and New Zealand College of Radiologists (RANZCR) would move quickly to defend its professional jurisdiction. However, in their editorial published in the same issue of the Journal,2 Kenny and Andrews, representing the RANZCR, seem to have overlooked the contribution of the Smith and Baird article to the development of new models of health care delivery. Further, their defence ignores the reality that, in the Queensland public hospital system, for example, diagnostic imaging is conducted in 108 centres but radiologists are only present at eight of those centres. The past three decades have seen rapid technological change, resulting in an array of diagnostic and interventional imaging modalities and providing a challenge to 21st century radiologists. However, plain radiographic images were being interpreted by non-radiologists for two or more decades before the medical specialty evolved.3 Alerting rural general practitioners and junior medical officers in emergency departments to abnormal features on plain films is a work practice that radiographers have always performed. Image interpretation in plain radiography is a skill they are exposed to every day of their working lives. Formal postgraduate training would develop that skill and formalise the practice. The nurse practitioner model developed because of identifiable health care service deficiencies, particularly in vulnerable, underserved communities.4 Similar service gaps exist in diagnostic imaging. The maldistribution of radiologists in Australia will never change, for economic and lifestyle reasons. There will never be a radiologist to supervise, advise, report findings and communicate results of plain radiographs at 3 am in a provincial hospital — nor in a metropolitan emergency department, for that matter. The radiographer will be there, however. It is time that due recognition be given to radiographers and enhanced training provided. The RANZCR, as the responsible body of medical professionals, owes it to the communities that they are unable to serve.

Wayne J Nuss

To the Editor: On the basis of the recent traumas experienced by the United Kingdom in rolling out its Modernising Medical Careers program, you warn the Royal Colleges to “resist political pressure to solve medical manpower problems created by governments”.1 Kenny and Andrew,2 representing the Royal Australian and New Zealand College of Radiologists (RANZCR), clearly link the need to cope with increasing demand for diagnostic imaging with the drive to allow non-medical staff to develop roles previously reserved for the medically qualified — and they oppose much of this. Meanwhile, Smith and Baird3 argue cogently — and supported by evidence, rather than conjecture — that there is a place for allied health professionals with appropriate training and education to take on some of the more traditional medical roles. Each group could be arguing from a position of self-interest. The representatives of the RANZCR (surprisingly) do not mention reimbursement of radiologists,2 while university teachers advocate a wider role for their institutions.3 The arguments are further mired by the assumption that role development or delegation is and should only be driven by unmet service demand. That need not be. Smith and Baird,3 in describing many of the UK developments, correctly assume that service demand is a driver, but that is not always the case. In diagnostic and therapeutic radiography in many parts of the UK, such as Scotland, the process of role development is seen as a natural progression in training and work practice that allows individuals to develop the skills they are capable of using. This is not merely a process reserved for areas of understaffing. In fact, medical staff have extra roles — in training, mentoring and supervising. They are also able to free up time for more demanding medical work. Notably, resistance to such change (of which I see very little in therapeutic radiography) is not confined to medical staff: major opposition is often expressed by radiographers and their managers. Thus, the process of role development of all clinical staff requires close cooperation between all professional and educational bodies. That is a proper role for a medical college — rather than that of a trade group protecting its patch or resisting change. Personally, I find it highly enjoyable to practise with experienced, motivated nursing and allied health colleagues who have been trained to perform these enhanced tasks.

Alan Rodger

To the Editor: The views of Mendelson and Murray1 regarding inappropriate use of diagnostic imaging and how it might be reduced are timely and important. Unless governments, doctors, the medical imaging industry and consumers acknowledge the significant barriers to Mendelson and Murray’s proposed changes, the number of inappropriate tests will grow. The authors argue that radiologists need to be more active in vetting requests. This is often hindered by the lack of relevant clinical information from referrers about the indications for tests. Broadhurst et al2 found that 34% of unselected Australian requests for shoulder ultrasound contained “no tangible information to assist the radiological examination”. Surveys of doctors in the United Kingdom found that their knowledge of the radiation delivered by various imaging tests, relative to that of a chest x-ray, was poor.3 This lack of knowledge makes it difficult, if not impossible, for doctors to inform patients about the risks and benefits of an imaging test. The Quality Use of Diagnostic Imaging (QUDI) Program of the Royal Australian and New Zealand College of Radiologists was set up in 2004 to develop a knowledge base of evidence-based best practice in radiology. To date, it has commissioned over 25 quality-related projects in areas such as development of information for consumers, best practice standards for radiology requests, and audit–feedback analysis of radiation dosage in paediatric computed tomography. The QUDI Program and the National Institute of Clinical Studies have sponsored fellowships in evidence implementation, training radiologists in the art and science of supporting clinicians’ use of evidence-based, appropriate diagnostic imaging. The results of QUDI projects are used in strategies to improve the use of radiology. The Australian Medical Association is advocating that general practitioners have access to magnetic resonance imaging, arguing that it would reduce costs and radiation exposure.4 However, this does not address the issue of appropriate consultative referral, and has the potential to simply add to the burgeoning diagnostic imaging budget rather than directly benefiting patients. A multifaceted approach to change is required, involving the referrer, the consumer and the entire radiology industry. This must be based on best-practice, patient-focused use of radiology. Radi-ologists are central to providing advice on the most appropriate imaging procedures and reducing the burden of inappropriate imaging. This is likely to require changes to practice and to legislation.

Lizbeth M Kenny · Stacy K Goergen · Catherine J Mandel

To the Editor: The authors of the editorial “Towards the appropriate use of diagnostic imaging”1 canvass possible strategies to improve the appropriateness of requests for diagnostic imaging. One strategy that research suggests may be effective is feedback provided by the providers of diagnostic services.2,3 Discussion of the feedback could, and should, be supported by federal government funding, perhaps via Divisions of General Practice, and should attract continuing professional development points for the general practitioners involved.

Oliver R Frank

In reply: We thank Kenny and colleagues for their comments and congratulate the members of the Quality Use of Diagnostic Imaging (QUDI) Program of the Royal Australian and New Zealand College of Radiologists on their continuing efforts. We are also grateful to Frank for his constructive suggestion. We entirely agree that a multifaceted approach is needed to improve the appropriateness of referral for diagnostic imaging. We believe that the majority of general practitioners are willing to be educated and guided with regard to their referring practices. However, to do so they require up-to-date guidelines that are easily accessible in electronic form, based on evidence and consensus, practicable and able to be integrated into their everyday desktop applications,1 much like pharmaceutical guidelines are currently. The QUDI Program has chosen to focus on producing guidelines on selected topics, while we, with our “Diagnostic Imaging Pathways”,2 have chosen to work towards a more comprehensive clinical decision support and educational application. Of course, the two approaches are entirely complementary. It also behoves radiologists, at an individual level, to interact with their referrers, to vet requests (ensuring that requests are appropriate and contain adequate clinical information, as emphasised by Kenny and colleagues) and act as the consultants they were trained to be. Sometimes this may be to their short-term economic detriment. However, one hopes that such short-term disadvantage would be countered in the longer term by greater professional satisfaction and a better relationship with referrers, who are likely to remain loyal to those radiologists on whom they can rely for advice and education in addition to trustworthy image interpretation.

Richard M Mendelson · Conor P J Murray

To the Editor: Austin et al1 bring to our attention findings from the report on maternal deaths in Australia in which 26 suicides were reported, making it one of the leading causes of indirect maternal deaths in the perinatal period — a finding consistent with the Confidential Enquiries into Maternal Deaths report from the United Kingdom.2 These reports raise the issue of the importance and risk of maternal mental illness in the perinatal period. While this high rate of suicide is unacceptable, it needs to seen in context: this is a rare event overall, representing a standardised mortality ratio of 1.14 per 100 000 women. This is considerably lower than the suicide rate for women in general, which ranges from 3.6 per 100 000 in the 15–19-year age group to 6.4 per 100 000 in the 25–29-year age group.2,3 This comparison verifies the observation made by Appleby that suicide rates are low during the perinatal period.4 Austin et al recommend that psychosocial screening, in conjunction with ongoing mental health monitoring and clear referral pathways, should be made available to women in a maternity setting as part of the solution to preventing the “relatively high” rate of early maternal suicide. But to date, antenatal screening programs have proven costly to implement, can produce large numbers of false positives, are often poorly accepted by antenatal care providers (as they add to the administrative burden), and do not result in greater uptake of services by at-risk women.5 Remarkably, 40% of the suicides reported by Austin et al occurred in the first trimester, predominantly before women had attended an antenatal clinic and before any psychosocial screening. A number of the suicide cases were already under the care of mental health services, and screening may not have prevented the tragic outcomes. We believe the answer to this problem is for appropriately resourced, accessible and publicly funded specialised perinatal psychiatric services to be put in place (including dedicated mother and baby units) so that high-risk women can be appropriately treated. In providing such services, we would need to develop appropriate strategies to engage mothers who need support from psychiatric services. This concurs with the National Institute for Health and Clinical Excellence perinatal mental illness guidelines,6 which advocate for the identification of pertinent risk factors (such as personal and familial mental health history) and assessment of current distress (through targeted interviewing). Screening is recommended to monitor outcomes but not to dictate clinical decision making.

Phillip M Boyce · Jodi Barton

In reply: Boyce and Barton raise a number of points. Firstly, with respect to their critique of the 2006 beyondblue postnatal depression report,1 there are, to date, no studies assessing the cost of antenatal screening programs. Furthermore, while false positives are a feature of all screening programs, that, in itself, is not a deterrent to using antenatal screening if the rate of false positives is considered acceptable. While midwives have concerns about undertaking routine psychosocial assessment, uptake of such a program can be done through adequate training and support of staff, as now demonstrated in a number of sites around Australia.2 With respect to the inadequate uptake of services by “high-risk” women, these are generally poor in the psychiatric clinic setting3 and would not be expected to be different perinatally. Secondly, the authors report that “a number of the suicide cases were already under the care of mental health services, and screening may not have prevented the tragic outcomes”. This overlooks one of the key attributes of routine psychosocial assessment in the primary health care setting — that it encourages communication and monitoring across the primary (eg, midwifery) and mental health sectors. Thus, while some women may be lost to psychiatric follow-up during pregnancy, most will attend antenatal appointments, thus providing their health care network with an opportunity for ongoing psychosocial review. Thirdly, while we agree with Boyce and Barton that “targeted interviewing” (as described in the UK National Institute for Health and Clinical Excellence guidelines) is important, “psychosocial assessment”, as undertaken in some Australian maternity settings, aims to assess the broad number of psychosocial risk factors that may contribute to the mental health outcomes of a woman and her infant. This point has been identified as a key issue in the 2007 beyondblue national action plan for perinatal mental health briefing document.4

Marie-Paule Austin

To the Editor: I compliment Dunbar and colleagues on their analysis of the systematic problems underlying whistleblowing “scandals” at four Australian hospitals.1 I disagree totally, however, with their major conclusion. I refer to their endorsing the recommendation from the President of the General Medical Council of the United Kingdom that “... if there’s a risk to patients ... we expect people to pipe up, but pipe up locally”. Attempting to put this recommendation into practice is itself the root cause of the problem. The many and varied obstacles to locally notifying one’s concerns about a colleague’s performance are almost insurmountable; any permutation or combination might apply in a particular location. On the part of the whistleblower, obstacles might include fear of their confidence being breached, being suspected of professional envy or of being a troublemaker, a concern for job security or about failure to be promoted, a reluctance to rock the boat in their own working environment, or fear of being victimised at work. On the part of the chief executive officer or equivalent local person to whom the report is made, obstacles might include their potential affront at a slight on their responsibility for overall management or for having appointed the person to whom the notification refers, personal friendships and even family relationships (especially in smaller centres), reluctance to have to inquire into a senior staff member’s work, or financial implications (as in the case of Bundaberg Hospital1). I suggest that, instead of trying to overcome such awkward and off-putting obstacles locally, performance concerns should be taken directly to a statutory body with responsibility for overall standards of health care and with absolutely no “conflicts of interest” in specific local situations. In New South Wales, at least, and specifically in relation to doctors, Section 86E of the Medical Practice Act 1992 provides that persons may notify the medical board of professional performance matters, namely “any matter that the person thinks indicates that the professional performance of a registered medical practitioner is unsatisfactory”. This avenue avoids all the pitfalls involved in attempting to resolve the matter locally, affords the potential whistleblower a recognised means of having their concerns given serious consideration, and reassures the whistleblower that the matter is in the hands of a responsible body with statutory authority and with tried and tested methods of dispassionately assessing the situation. The whistleblower would then have no need to “go public”, with the devastating results so well described by the authors.

Peter C Arnold

In reply: Dr Arnold raises the difficulties involved in bringing poorly performing colleagues to notice and proposes that reporting doctors to a medical board is the best option. There are difficulties in relying solely on medical boards. First, doctors have a very high threshold for referral to a medical board, so poor performance may not be reported. Even serious cases of poor performance can go unreported for many years.1 Second, there are many cases of remediable poor performance2 that require a different approach. In the United Kingdom, local procedures are managed by medical directors as part of their contract. The Good Medical Practice guidelines issued by the General Medical Council make it clear that all doctors have a responsibility to report poorly performing colleagues.3 If the medical director then fails to act, the hospital’s insurance could be invalidated and the medical director would appear before the General Medical Council. A number of Australian jurisdictions, including the Australian Capital Territory, New South Wales and Queensland,4,5 have made substantial progress in developing local procedures that offer the best opportunity for remediation of doctors where possible, and for discipline by the medical board where not. With these procedures, we can assure patients of safety while maintaining as many doctors as possible in the workforce.

James A Dunbar · Prasuna Reddy · Bill Beresford · Wayne P Ramsey · Reginald S A Lord

To the Editor: The recent editorial by Penington and Mitchell1 unreservedly supports the Victorian Government’s legislation allowing “therapeutic cloning” by somatic cell nuclear transfer (SCNT) — generating an embryo by transferring an adult somatic cell nucleus (skin, muscle, etc) from an individual into a donated ovum from which the nucleus has been removed. State and federal support for therapeutic cloning has clearly been dependent upon belief in the therapeutic benefits to be obtained — a belief that the editorial does nothing to dispel. Since the licensing system for embryo research (Research Involving Human Embryos Act 2002 [Cwlth]) was introduced, there have been no discoveries in animal or human embryonic stem (ES) cell research that support an urgent need for therapeutic cloning. This includes references 3–8 in Penington and Mitchell’s editorial, all of which fall far short of providing proof of concept of efficacy of ES cells in treatment. A number of major problems need to be resolved before any remotely credible scientific case could be made for the need for therapeutic cloning. These include achieving prolonged, effective, safe therapy in an animal model of disease, and safe transplantation of ES cells in animals, without any tumour formation — a problem that occurs commonly,2,3 not on the “rare occasions” claimed in the editorial. We need to understand how stable the fully differentiated phenotype is when ES cells are used to generate specialised cells. This can be explored in animal ES cells, but also in human ES cells that do not need to be prepared by therapeutic cloning. If stability is indeed shown, these cells must die eventually — how will they then be replaced? Will this require a compromise of using less “mature” cells and incurring an even greater risk of tumour formation? If cells derived by SCNT are to be used to find “new approaches to ... hitherto unyielding diseases”, proof of this concept could readily be provided by studying animal examples. Crucially though, that will require resolution in animal studies of the effect of SCNT on genetic controls and epigenetic effects in the derived ES cells. These are all scientific requirements. Proceeding to therapeutic cloning provides no scientific advance without them — and of course it should be noted that no one anywhere in the world has ever made human ES cells by SCNT. Penington and Mitchell’s editorial provides a limited view of these matters. It acknowledges the long lead times required if there is ever to be success in ES cell therapies, but does not advance even a single compelling argument in support of SCNT now.

T John Martin

To the Editor: I read with interest the editorial by Penington and Mitchell1 in which they briefly discussed the recent legislative developments with regard to human embryonic stem cells. As a medical student, I delight at the complexity and passion that surround the stem cell debate. How is a student to proceed through this ethical minefield? At the Australian National University, we are taught that international human rights are likely to become more important in professional regulation than classical medical ethics born of the Hippocratic Oath.2 The International Covenant on Civil and Political Rights (ICCPR)3 and the Universal Declaration of Human Rights (UDHR)4 are currently used as the cornerstone for building ethical arguments and controversial legislation. However, problems with these international human rights documents include their relevance and applicability to the 21st century. The medical and technological advances made since they were introduced are mind-numbing; I doubt that stem cell research was a consideration when they were drafted. Both Article 6 of the ICCPR and Article 3 of the UDHR state that every human being has the right to life. An individual’s ethical principles must shape his or her interpretation of this statement. Moreover, ethical argument should not be confused with religious views. Australian society and its belief systems are more than ever moving further away from religion, and medical ethics should incorporate the views of the community at large. An example of religion and international human rights opposing society’s position is the termination of pregnancy. In Australian medicine there is an ethical obligation to uphold a woman’s right to autonomy and wellbeing, while the exact wording of the ICCPR and UDHR is ignored to achieve a currently socially acceptable outcome. We are seeing a similar rationale with stem cell research, in that there is an ethical responsibility to “the greater good”, regardless of the requirements of the UDHR and ICCPR. I am a strong supporter of both stem cell research and a woman’s right to choose. I am simply suggesting that we stop looking to international human rights covenants to be the cornerstone of legislation or to answer ethical dilemmas. I just don’t think current international human rights documentation incorporates all the ethical considerations required of modern medicine. A new alternative is just what the medical student ordered.

Jeffrey J Flaherty