Letters

To the Editor: The recent editorial by Macrae1 outlined the potential issues facing the rollout of the National Bowel Cancer Screening Program. It is estimated there will be about 5000 additional colonoscopies performed in New South Wales in the first year.2 To ascertain how the NSW public health system might absorb this increased demand, the Greater Metropolitan Clinical Taskforce (GMCT) Gastroenterology Network conducted a survey in 2006, featuring structured interviews with clinicians. Our aims were to estimate the current capacity of NSW public hospitals to perform colonoscopies and to identify perceived impediments to meeting future demand. From a total of 113 public hospitals where colonoscopies had been performed in the period 2001–2004,3 we selected a purposive sample of 32 where there had been at least 500 procedures, or which were regarded as major providers in their area health service. Responses were received from 26 hospitals, which represented 54% of colonoscopies performed in all public hospitals in NSW in 2001–20043 and included both metropolitan and rural hospitals. No information was collected from the private sector. Fifteen hospitals had dedicated endoscopy suites, 10 used operating theatres, and one unit used a day surgery centre. We found that for the majority of these hospitals (23/26), colonoscopy activity is currently at or near maximal capacity, with limited potential for expansion of services. The additional number of colonoscopies that could be accommodated ranged from one to four per week in six hospitals, up to a maximum of eight per week in a single hospital. Reasons for unbooked hours included insufficient funds, and a lack of nurses and anaesthetists. The Box summarises other key findings, which emphasise that the three major factors limiting activity are insufficient endoscopy nurses, insufficient nursing applicants, and the need for more equipment. Importantly, an absolute shortage of proceduralists was not found to be a restricting factor. Rather, insufficient available colonoscopy time for existing proceduralists was identified as a limitation. While our survey was successful in clarifying factors that impede optimal performance, the small number of participating hospitals is a relative limitation. Nevertheless, the survey suggests a requirement for additional nursing staff and equipment, and for the establishment of uniform data collection and reporting systems. Areas requiring further exploration include greater unit efficiency, opportunities for workplace redesign, and consideration of inequities in access to anaesthetic cover for patients in public hospitals. The GMCT Gastroenterology Network is currently working on these issues in collaboration with the NSW Department of Health. Factors affecting colonoscopy capacity in selected New South Wales public hospitals* Most responding units (22/26) regarded additional nursing staff as a medium to high priority requirement Increasing time available to existing proceduralists (18/25) and allocating time for new proceduralists (16/25) were regarded as medium to high priorities 11/15 hospitals with dedicated endoscopy suites had an unused endoscopy room. Most common reasons were: insufficient funds (5); lack of nurses (5); insufficient equipment, including anaesthetic machines (3); and lack of anaesthetists (2) No unit cited a shortage of proceduralists as a reason for the unit not running at full capacity “For” (11/24) and “against” (13/24) responses for the addition of procedure rooms were evenly spread across responding facilities Prioritisation of colonoscopies over other procedures was not favoured (14/24 ranked this of low importance, 5 as neither low nor high, 5 as medium to high) Most important factors impeding capacity were: Lack of approval to recruit nursing staff (18/23) Shortage of nursing staff applicants (16/25) Budgetary limitations (19/25) Insufficient endoscopy time for existing proceduralists (17/25) Insufficient budget to recruit new proceduralists (16/23) Only 2/26 units (both using operating theatres) had a data manager recording data and compiling statistics; others (13/26) in dedicated endoscopy suites used commercial reporting systems, such as Endoscribe, however the survey did not determine how systematically and completely data were compiled and reported from these systems * Some respondents did not answer all questions.

Shelanah A Fernando · Anne E Duggan · Owen F Dent · Maeve C Eikli

To the Editor: I note with interest the results of the study by Morris and colleagues comparing survival outcomes for patients with colorectal cancer treated in public and private hospitals.1 Stage of disease is a major determinant of survival in colorectal cancer, yet, as stated in their article, stage of disease was derived solely from pathology reports. I believe that this method would have very limited accuracy in diagnosing stage IV disease. Determining stage IV disease requires additional investigations such as computed tomography, which may either not have been performed before surgery, or the results of which may not have been noted on the pathology request form. Underdiagnosis of stage IV disease appears likely, as the incidence of stage IV disease of about 10% noted in this study is substantially less than the 20%–25% incidence observed in other epidemiological studies.2 Moreover, the limitations associated with the use of pathology reports to determine stage IV disease have been observed by other investigators.3 Although this study evaluates an interesting question in relation to the management of colorectal cancer, the significant possibility of an imbalance of important prognostic factors (such as tumour stage) between public and private patients creates major doubt about its conclusions.

Niall C Tebbutt

To the Editor: We suggest that marked differences in comorbidities could be one explanation for the superior outcomes for patients with colorectal cancer treated in private hospitals as reported in the study by Morris et al.1 We also have concerns about the quality of the data used in their study. We used a comprehensive prospective database to examine a cohort of Victorian patients treated at the Royal Melbourne Hospital (n = 260) and the adjacent Melbourne Private Hospital (n = 118) between 2003 and 2006. Specifically, we included data on important patient variables that were not considered in the Western Australian series (Box). These data showed a clear bias towards improved postoperative and long-term survival outcomes for patients in the private system, independent of cancer treatment. Significantly, diabetes, which affected a much larger proportion of public than private hospital patients, is also associated with inferior cancer-specific outcomes.2 Together, these results could explain the differences reported by Morris et al. In support of this, the 5-year cancer-specific survival rates they report for stage I cancer in the two hospital groups is similar (89% public versus 92% private), but the overall survival rates are markedly different (74% public versus 85% private) — consistent, we contend, with an excess of non-cancer deaths in public patients. Morris et al also report an imbalance in the receipt of adjuvant chemotherapy between public and private patients, possibly a marker of inequality of care. We analysed prospectively collected data for our patients with stage III colon cancer, where adjuvant chemotherapy has a proven impact on survival. As shown in the Box, a similar percentage were offered, accepted and completed adjuvant chemotherapy, suggesting, in Victoria at least, similar access to care and support for public and private patients. The pathology-based staging used by Morris et al may also be inaccurate, as recording of stage IV disease relies on the surgeon noting this on the pathology request form and patients having been fully evaluated before surgery (we contend that preoperative computed tomography scanning would not have been routine). This may explain the relatively low percentage of patients recorded as having stage IV disease (12% public; 9% private) compared with 17% in our combined series in which prospective clinicopathological staging was used. Finally, inaccurate data are suggested by the reported 5-year overall survival figures for patients with stage IV cancer (17% in private care).1 That this is superior to figures reported in recent clinical trials is an unexpected finding, particularly as clinical trials enrol only a select subset of patients and provide access to novel combination chemotherapy, and presentation with metastatic disease is an adverse prognostic factor. Comparison of public and private hospital patients with colorectal cancer Public hospital Private hospital P Number of patients 277 122 Smoker 141 (51%) 16 (13%) < 0.001 Diabetes 57 (21%) 8 (7%) 0.002 Emergency presentation 22 (8%) 2 (2%) 0.02 ASA score* 1 28 (10%) 36 (30%) 2 131 (47%) 32 (26%) 3 89 (32%) 22 (18%) 4 15 (5%) 0 Unknown 14 (5%) 32 (26%) Stage III colon cancer 64 38 Chemotherapy advised 50 (78%) 30 (79%) 0.22 Patient followed advice 44 (88%) 29 (97%) 0.12 Chemotherapy completed 28 (64%) 21 (72%) Chemotherapy not completed 16 (36%) 8 (28%) Toxicity 7 (44%) 3 (38%) Patient request 4 (25%) 0 Ongoing computed tomography 3 (19%) 4 (50%) Other 2 (12%) 1 (12%) * American Society of Anesthesiologists physical status score.

Suzanne Kosmider · Ian T Jones · Ian P Hayes · Peter Gibbs

In reply: The first issue is whether we accurately identified patients with stage IV disease, as the incidence in our study was only 11% and the anticipated incidence is normally 20%–25%. We agree that simply reviewing pathology reports would tend to underdiagnose stage IV disease. However, all patients were crosschecked to the linked database to see if they had had a computed tomography scan or ultrasound image showing metastatic disease. In addition, we only reviewed patients whose primary cancer was resected. This excluded about a third of all the patients with stage IV disease. In my (C P) own surgical prospective colorectal cancer database of 781 patients, (1996 to 2007), 24% of the 185 referred with colorectal cancer had stage IV disease (private hospital patients, 21% v public hospital patients, 25%). Resection of the primary cancer was only undertaken in 126 of the 185 patients with stage IV disease (68%). Therefore, only 16% of all patients with colorectal cancer who had resections had stage IV disease (126/781). Tebbutt argues that there could be a possibility of some imbalance between public and private patients based on this observation. We argue that the difficulty in diagnosing stage IV disease applies equally to public and private patients. Similarly, my own database does not show a significant difference in the incidence of stage IV disease between public and private hospital patients. Kosmider et al report that, at their own institution, completion rates for chemotherapy for stage III colon cancers are the same for public and private patients, “. . . suggesting, in Victoria at least, similar access to care and support for public and private patients”. These results are hardly comparable with our study. Their observations are limited to a select subgroup and only relevant to a small section of the Victorian population, where there is a collocated public and private hospital. In contrast, our study included the entire population of Western Australia, and all public and private hospital patients. Interestingly, we noted wide variations in the rates at which chemotherapy was used, not only between public and private hospitals, but also between individual hospitals. We also noted that there are few collocated public and private hospitals within WA. The fact remains that, at a population level, public hospital patients in WA were less likely to receive chemotherapy. Finally, Kosmider et al raise the issue that comorbidities can influence overall and cancer-specific survival (especially in relation to diabetes). We recognise this as a weakness of our study, and highlighted it in the discussion. Nonetheless, we did include a number of measures of social disadvantage in the analysis. Such measures can act as surrogate markers of common comorbidities. For example, there is a fairly clear association between type 2 diabetes and disadvantage.1 We therefore do not believe that comorbidities can account for all of the observations seen in our study. Our conclusion therefore remains — that patients with colon and rectal cancer treated in private hospitals in WA had superior outcomes. In reality, given the inequities between the two systems, is this really so surprising?

Cameron Platell · Melinda Morris · Barry Iacopetta

To the Editor: Menzies’ recent editorial1 highlights the clear benefits of dermoscopy in the assessment of pigmented lesions. This is well appreciated by anyone who uses this inexpensive handheld tool on a day-to-day basis (its retail price ranges from A$380 to A$1840). Although the potential value of the device has been documented in both specialist and general practice settings, it would seem that most Australian general practitioners aren’t using this valuable technology. We recently surveyed 223 predominantly Victorian GPs (at a dermatology symposium for GPs, Melbourne, August 2006) and a cross-section of 179 Australian dermatologists (at the 39th Annual Scientific Meeting of the Australasian College of Dermatologists, Melbourne, May 2006) on their use and perceptions of the value of dermoscopy (Box). The surveys were conducted at the end of dermoscopy seminars using electronic keypads that generated live feedback to questions posed. The sample of dermatologists represented about 56% of all practising fellows of the Australasian College of Dermatologists and should thus be reasonably representative. On the other hand, we acknowledge that the sample of GPs may have been biased towards those with a particular interest (and more experience) in the area of skin cancer and dermatology — or, alternatively, biased towards novice GPs seeking more experience in the area. Participation rates in each survey were over 90%. The majority of both groups of clinicians who reported using dermoscopy felt that it influenced their clinical diagnosis. However, only a third of GPs reported using dermoscopy as a diagnostic aid, in contrast with the vast majority of dermatologists (95%), who were regular users. While there was a difference between the instrument preferred by GPs (the Welch Allyn EpiScope [Welch Allyn Inc, Skaneateles Falls, NY, USA]) and by dermatologists (the Heine Delta 20 Dermatoscope [Heine Optotechnik, Herrsching, Germany]), any one of the commercially available dermoscopes would be suitable for the novice user. The popularity of the Heine system is mostly due to its brighter light-emitting-diode illumination and adaptability to compact digital cameras. Although there is a general perception that non-polarised immersion contact dermoscopes offer superior imaging (this was reflected in the most popular choices from our survey), newer polarised non-contact dermoscopes are increasingly popular, and some of the earlier models are inexpensive. Polarised dermoscopes, such as the DermLite range of instruments (3Gen, LLC [San Juan Capistrano, Calif, USA]), offer the advantages of creating less mess (immersion fluid is not required) and better resolution of vascular structures. However, certain features critical for diagnosis of melanoma may be harder to appreciate with polarised systems (eg, the presence of regression structures or blue–white veil).2 The use of dermoscopy is fairly mainstream among dermatologists in continental Europe (Giuseppe Argenziano, Assistant Professor, Department of Dermatology, Second University of Naples, personal communication), where the technology was first established in the 1980s. However, dermatologists in the United States have been slow to embrace the technology: only 17% of dermatologists surveyed in a 2001 study were using the tool.3 In our personal experience, there is an increasing demand from Australian GPs for dermoscopic educational seminars. Given the high incidence of skin cancer in Australia, and the important role that Australian GPs play in managing the disease, we support Menzies’ assertion that training and familiarity with dermoscopy should be a priority.1 Survey of use and value of dermoscopy among Australian general practitioners and dermatologists GPs (n = 223) Dermatologists (n = 179) Never use dermoscopy 66% 5% Favoured instrument Welch Allyn EpiScope (41%) Heine Delta 20 Dermatoscope (32%) Use computer-assisted dermoscopy 5% 3% Claim that dermoscopy influences diagnosis 75% 97%

Alex J Chamberlain MB BS(Hons), FACD · John W Kelly MD, FACD

To the Editor: Walker and colleagues recently reported a series of patients with interstitial pneumonitis following use of statin cholesterol-lowering drugs.1 They state that other investigators have previously reported biopsy findings resembling amiodarone-induced pulmonary toxicity in pneumonitis associated with statin therapy. We believe this observation is pivotal to understanding the authors’ findings. Amiodarone produces mitochondrial toxicity, which is recognised to be a potential initiating event in amiodarone-induced pulmonary toxicity.2 Statins also produce mitochondrial toxicity in vulnerable individuals. Adverse effects of statins on muscle have been linked to mitochondrial abnormalities,3 and other clinical manifestations of statin mitochondrial toxicity have been reported. Mitochondrial respiratory chain disease is famously protean in its manifestations, but most classically produces a mitochondrial encephalomyopathy — with muscle, brain, or both affected. Consistent with this, muscle and cognitive symptoms are the most widely reported adverse effects in our reporting database of statin adverse effects (comprising 2478 patients to date), and these symptoms frequently occur together, consistent with a common mechanism. Statin–amiodarone combinations have produced heightened toxicity relative to each agent alone. Interference with cytochrome P450 metabolism has been the presumed mechanism,4 but additive or synergistic mitochondrial toxicity may also be a factor. The occurrence of amiodarone-like interstitial pulmonary disease in statin users adds to concerns that a range of clinical presentations of mitochondrial toxicity may ultimately be reported with statins in susceptible individuals, with mitochondrial heteroplasmy and threshold effects determining the specific manifestations.5

Beatrice A Golomb · Marcella A Evans

To the Editor: While Joosten et al highlight the uncommon but serious problem of potential carbon dioxide (CO2) narcosis after emergency management of respiratory illness,1 it is important that their findings are kept in perspective and do not lead to inadequate administration of oxygen to patients with acute dyspnoea. Their findings are based on a retrospective chart review. The main claim that the administration of oxygen causes increased length of hospital stay and possibly death for those presenting to emergency departments with exacerbation of chronic obstructive pulmonary disease (COPD) can be challenged by selection bias, sample size, assessment of severity of illness, and the definition of clinically significant hypercapnia. Ninety per cent of their study patients arrived by ambulance, presumably indicating the relatively sudden onset of acute distressing symptoms — a call for urgent help, not the “killing me slowly” drowsiness and confusion of CO2 retention. Of those who received more than 4 litres of oxygen (O2) per minute, 57% (16 of 28) were in triage category 1 and 2, but only 31% (4 of 13) of those who received O2 at a lower flow rate were in triage category 1 and 2. Sixty per cent (12 of 20) of those with a high partial pressure of arterial oxygen (Pao2), when measured after arrival and treatment were in triage category 1 or 2, but only 14% (3 of 21) of those with a lower Pao2 were in triage category 1 or 2 (P = 0.002; Fisher’s exact test). Clearly the first group was a sicker group on arrival, and the increased length of stay of these patients was more likely to be the result of this, rather than of O2 therapy supervised by emergency specialists in an emergency room of a teaching hospital. The contention that oxygen therapy in emergency departments is “often uncontrolled” is not supported by any data supplied. Critical care staff, including ambulance and emergency personnel, are acutely aware of the challenges posed by patients with chronic respiratory disease. However, they are also aware of the need to achieve adequate oxygenation in patients with acute dyspnoea. Patients are observed closely for signs of clinically significant hypercapnia and respiratory support is adjusted accordingly. Some patients may require a higher fraction of inspired oxygen (Fio2), particularly in the initial phases of care, to achieve this. As the patient’s condition improves, the Fio2 is often reduced. The methods in the study by Joosten et al fail to account for this. Respiratory rate, for example, was not reported. Treating the patient, not the chart, is of most importance. It would be a pity if the article by Joosten et al resulted in the withholding of oxygen from acutely dyspnoeic patients with a rapid respiratory rate and adequate respiratory drive because of some fear that they could be retaining CO2. We agree that a better and seamless patient-centred information system with cooperation between sectors of the health system, the patient, the patient’s general practitioner, and ambulance, emergency and in-hospital services, would assist in identifying those at risk of CO2 narcosis and improve patient care.

Andrew W Dent · George A Jelinek · Sandra L Neate · Tracey J Weiland · Ann-Maree Kelly

In reply: We performed a retrospective audit as part of a quality improvement program following a number of serious adverse events in various areas of our hospital. Our article showed that carbon dioxide retention in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is common (41 of 65 patients admitted with chronic obstructive pulmonary disease [COPD] over 4 months), and that guidelines on blood gas measurement and oxygen use were not being followed. Dent and colleagues state that more patients in our study who received more than 4 litres of oxygen per minute were in a triage category that indicated a more serious condition. However, the multivariate analysis showed that triage category did not predict length of stay. In contrast, partial pressure of arterial oxygen (Pao2) did, and patients with a Pao2 of less than 74.5 mmHg (range, 36.7–74.0 mmHg) had a shorter length of stay than those with a Pao2 of 74.5 mmHg or higher (range, 74.5–452.0 mmHg). Many patients had a Pao2 much higher than neccessary to achieve a haemoglobin saturation of about 90%. Dent and colleagues state that our data did not support the claim that oxygen therapy is often uncontrolled in the emergency setting. In fact, only 68% of the patients receiving more than 4 litres of oxygen per minute had arterial blood gas measurements performed. We agree with Dent et al that the management of AECOPD may not be as simple as following guidelines. However, we hope to raise awareness of the fact that hypercapnia in COPD is common, requires careful assessment, and that oxygen therapy should be titrated to physiological endpoints.

Simon A Joosten · David Smallwood · Mariko S Koh · Louis B Irving · Xiaoning Bu

To the Editor: Cosmetic surgery has grown in appeal over the past few years, and more and more procedures are being performed. However, the literature on attitudes towards cosmetic surgery is scant. Here, we report the results of a cross-sectional study that assessed Australian university students’ attitudes towards, and experiences of, cosmetic surgery. Preclinical students from the faculty of medicine at the University of Melbourne were chosen to participate, as they formed a fairly homogeneous group and were considered at a higher risk of experiencing appearance concerns than the general population.1,2 Students from clinical years were excluded, as their greater exposure to clinical medicine could have impacted on their attitudes towards cosmetic surgery. Participants completed a questionnaire that covered their experience of and familiarity with a range of cosmetic procedures, as well as attitudes towards cosmetic procedures. About 320 students were approached for this study, and 284 agreed to participate (45% male; age [mean ± SD], 20.8 ± 3.4 years; body mass index [mean ± SD], 21.9 ± 2.7 kg/m2). Respondents noted a high degree of familiarity with cosmetic enhancement procedures (Box); only 8% were not familiar with any procedures. Thirty-six per cent knew someone who had had cosmetic surgery and 11% knew at least one person in their family who had had cosmetic surgery. Only four respondents (1%) had themselves had cosmetic surgery. Many respondents were fearful of undergoing surgical procedures (53% “agreed” or “strongly agreed”). Over a third disapproved of people surgically altering their appearance for reasons of self-esteem (36%) or to feel better about themselves (35%), and 38% thought cosmetic surgery was a waste of money. Most respondents (63%) indicated they would be embarrassed to let others know if they had had such surgery, although 52% believed that appearance was an important facet of a person. The majority (70%) would not consider cosmetic surgery in later years, even if their partner wished them to (79%). These findings are in stark contrast to a United States study of female college students, which found that about 5% of participants had undergone cosmetic surgery, 67% knew someone who had received a cosmetic surgical intervention, and around 33% had a family member who had undergone cosmetic surgery.3 Overall, their attitudes to cosmetic procedures were much more favourable, which might reflect a greater acceptance, availability and prevalence of cosmetic surgery in the US. Our findings have relevance for the future Australian medical workforce, and suggest that broader issues relating to body image should be covered in the medical curriculum. Proportion of students familiar with cosmetic enhancement procedures Procedure Proportion of students Lipoplasty 83% Botox injections 82% Facelifts 78% Breast augmentation 78% Rhinoplasty 73% Breast reduction 71% Abdominoplasty 69% Cellulite treatment 48% Chemical peels 47% Blepharoplasty 41%

David J Castle · Riteesh Bookun

To the Editor: We are concerned about aspects of the study of selection predictors of medical school performance in Australian medical schools by Groves et al,1 and how they may be interpreted. A “voluntary” response rate of 13.6% is very small and unlikely to be representative, and selection or response bias is likely. Although noted by the authors, this fundamental flaw may be overlooked in interpreting the results. This aside, of what value is the outcome measure of clinical reasoning skills among students, some of whom are only in second year, and whom we would not expect to have developed substantial expertise in clinical reasoning at this early stage? More significantly, we consider that the research question itself may be flawed, as we are not at all convinced that selection scores are intended to predict relative performance in programs. Groves et al, of course, show that, in fact, they do not. Selection serves two purposes, one obvious and the other questionable. The first is to reduce the large pool of well qualified students to the available number of places. The second is the Holy Grail of selection: attempting to select those best suited to success in medicine. The key problem is that nobody can fully define, let alone measure, such success, other than in the negative terms of professional misconduct after graduation.2 Moreover, medicine offers a wide range of careers requiring different attributes, making a broad range of entry characteristics beneficial to the profession and the community at large, and putting in question the pursuit of a profile of critical criteria. Further research is needed, involving large, representative samples to confirm or discount putative outcome measures, but most medical students succeed in medical school and do not create problems as doctors, indicating that we are currently getting more of this right than wrong. If the predictive value of entry attributes for (often questionable) outcomes is modest at best, and if we teach and assess communication skills, clinical reasoning and professionalism during the programs, does it not make sense to focus our energies and resources more effectively there, and relinquish our continuing anxiety over selection? We should remember what motivated the flurry of activity towards more complex selection processes in the first place: concern over communication by doctors, failure in aspects of professionalism, and to a much lesser extent, clinical competence.

Malcolm H Parker · David Wilkinson · Ray G Peterson · Ieva Z Ozolins · Haida Luke · Jenny Zhang · Gerard J A Byrne

In reply: The limitations of our study have been acknowledged, and we agree with Parker and colleagues that further research is needed. However, their proposition that selection scores may not be intended to predict relative performance in programs seems at odds with their recommendation to select principally on the basis of academic performance. If selection scores do not provide predictability, why bother establishing any criteria at all? Why not simply use a lottery system, as they have been claimed to be equally effective?1 Although our study did not set out to evaluate the relative merits of cognitive versus non-cognitive criteria for selecting medical students, surely the first question to be decided is whether non-cognitive characteristics, including interpersonal skills, attitudes and behaviour, are important in medical practice and should be considered in selecting future doctors. If so, then the next question is how best to select students with these characteristics or, at least, the capacity to develop them during their medical training. The selection processes of most medical schools indicate that the answer to the first question is “yes”. In answering the second question, not only the validity of the chosen method, but its feasibility in terms of cost and effectiveness need to be considered.

Michele A Groves · Jill Gordon · Greg Ryan

To the Editor: Could I use a tiny fragment of a recent article as springboard to a plea for a change in terminology? Wilcken et al refer to two observations on the use of tamoxifen changing clinical practice, “and thousands of lives were potentially saved”.1 Are we fooling ourselves? Surely it is more accurate to say, in the situation of breast cancer in lives already well advanced, that thousands of deaths were postponed? “Humankind cannot bear very much reality.”2 Could we leave “lives saved” to the populist sensationalist media, and only use it in medicine for interventions in trauma, and possibly infection, in young people whose life expectancy is otherwise so good that their life has been truly “saved”? “. . . speech impelled us to purify the dialogue of the tribe and urge the mind to aftersight and foresight . . .”3

Warwick H Ruse

In reply: We agree that attention to terminology is important, and that claims about potential medical advances are often exaggerated. On the other hand, on the rare occasions when things go really well, we should not hide our light under a bushel. In the overview cited in our article, the risk of death 15 years after diagnosis was about 35% for the controls and about 25% for those who were given tamoxifen for 5 years1 — a reduction in the death rate of about a third. Another example is the finding from the earliest chemotherapy trials that significantly more women in the treatment arms were alive nearly 30 years later,2 showing that postoperative systemic therapy can have very long-lasting effects on the chances of being alive or dead. Over the years, this adds up to a lot of women not dead from breast cancer. However, whether these are really “lives saved” may be more a philosophical than a medical question. It is true that, despite decades of research and billions of dollars spent, the mortality rate remains at 1.0 per person, and death still consumes much of our thoughts.3 Rather than “lives were potentially saved”, perhaps a compromise could have been the less poetic “breast cancer deaths were avoided”.

Nicholas R Wilcken · Val J Gebski · Anthony C Keech · Rhana Pike

To the Editor: Awareness about atypical and malignant modes of presentation of a clinical condition can avoid catastrophic outcomes, assist in correct diagnosis in the appropriate clinical setting and, as typified by the following case, offer complete cure. A 39-year-old woman presented with a 5-year history of intermittent, recurrent brief syncopal episodes. During an episode at presentation, telemetry showed torsade de pointes with ventricular fibrillation (Box), and external defibrillation was required to restore sinus rhythm. Amiodarone infusion was initiated at a local hospital before the patient was referred to our institution for further investigation and management. On presentation, her heart rate was 50 beats/min and her blood pressure was 170/95 mmHg. No other abnormalities were detected on examination. A resting electrocardiogram (ECG) showed prominent U waves, with a long QT interval (QTc of 540 ms). As the patient had mild hypokalaemia (serum potassium level, 3.1 mmol/L), mild hypocalcaemia (serum calcium level, 2.10 mmol/L) and a prolonged QT interval, the amiodarone infusion was discontinued, and supplementation with potassium and calcium was initiated. In view of the hypertension and hypokalaemia, primary aldosteronism was suspected. Serum cortisol, 24-hour urinary cortisol and 24-hour urinary catecholamine levels were normal. The plasma aldosterone/renin ratio was markedly elevated (1920/1.2 = 1595; normal, < 99). Failure of aldosterone suppression after acute saline loading was also noted. Computed tomography of the abdomen showed a right adrenal ovoid mass (1.9 × 1.2 cm). Adrenal vein sampling confirmed right lateralisation (right to left ratio, 40 : 1; aldosterone level in the right vein was 224 000 pmol/L while that in the left vein was 5570 pmol/L). Despite initial potassium supplementation, the hypokalaemia persisted and only improved after initiating diuretic therapy with amiloride. Two weeks later, laparoscopic right adrenalectomy was performed, and adrenocortical adenoma was confirmed histologically. After surgery, plasma aldosterone and renin levels normalised to 106 pmol/L and 8.9 mU/L, respectively. Nine months later, the patient was normotensive (without treatment) and had a normal ECG with no further recurrence of arrhythmias. This was a case of primary aldosteronism presenting as aborted sudden cardiac death and malignant syncope secondary to hypokalaemia-induced torsade de pointes. Most patients with primary aldosteronism are either asymptomatic or have symptoms related to hypertension or hypokalaemia (eg, polyuria, cramps, paraesthesia or muscle weakness); the diagnosis is often missed because of the non-specific clinical features. Primary aldosteronism presenting with cardiovascular collapse caused by hypokalaemic torsade de pointes and recurrent ventricular fibrillation is extremely rare, as is presentation as sudden cardiac death secondary to ventricular fibrillation.1 A prolonged QT interval has been reported in cases of primary aldosteronism,2 with values normalising after adrenalectomy.3 Torsade de pointes noted on telemetry in a 39-year-old woman

Aditya Kapoor · Timothy A Wells · Daniel Wong · John P O’Shea

To the Editor: Childhood overweight and obesity have become a major public health concern in Australia. Between July 2003 and December 2004, we conducted the Australian National Iodine Nutrition Study (NINS) among schoolchildren.1 While visiting primary schools across Australia, we observed that many children were overweight or obese. The NINS data allowed us to estimate the prevalence of overweight and obesity among 8–10-year-old Australian schoolchildren, and to determine whether the prevalence was associated with socioeconomic background. The study population comprised a one-stage random-cluster sample from all Year 4 school classes in 92 government and non-government schools.1 Children were aged 8–10 years (mean, 9.3 years). Height and weight were measured by standard techniques and were used to calculate body mass index. Overweight and obesity were identified using international standard definitions.2 Socioeconomic status was defined by the Index of Relative Socio-Economic Advantage/Disadvantage of the Census of Population and Housing’s Socio-Economic Indexes for Areas (postal areas).3 This index is a continuum of advantage to disadvantage. A higher score indicates that an area has a relatively higher proportion of people with higher incomes or a skilled workforce. The prevalence of overweight and obesity in 8–10-year-old schoolchildren was 18.5% and 6.5%, respectively. There was no significant sex difference in prevalence and no significant evidence of an association between socioeconomic status and overweight or obesity (Box). The prevalence of overweight and obesity combined and of obesity alone was similar to previously reported prevalence,4,5 although the age range of the participants was more limited than in other studies. We minimised measurement error bias by using the same equipment throughout, in the same setting. Furthermore, most measurements were taken by the same person. We could not demonstrate an association between socioeconomic status and the prevalence of overweight and obesity combined, or of obesity alone. This suggests that childhood overweight and obesity is common to all Australian communities, irrespective of socioeconomic background. Preventing overweight and obesity in children may reduce the risk of adult overweight and obesity and related diseases. Regular monitoring and surveillance of the situation is needed. Australia is one of the first countries in the world to develop a national strategy for overweight and obesity.6 However, the strategy needs to be communicated to the wider community and turned into action to combat this public health problem. Proportion (number) of boys and girls categorised as overweight or obese by index of advantage/disadvantage* SEIFA percentile Not overweight or obese Overweight Obese n Overall Boys Girls Overall Boys Girls Overall Boys Girls Lowest 10 130 79% (102) 77% (56) 82% (46) 12% (16) 12% (9) 13% (7) 9% (11) 11% (8) 5% (3) 10–25 286 72% (207) 72% (103) 73% (103) 22% (64) 22% (31) 23% (33) 5% (15) 6% (9) 4% (6) 25–50 210 74% (156) 72% (72) 76% (84) 17% (35) 18% (18) 16% (17) 9% (19) 10% (10) 8% (9) 50–75 505 75% (379) 72% (183) 79% (195) 19% (98) 21% (53) 18% (45) 6% (28) 8% (20) 3% (8) 75–90 427 75% (319) 78% (179) 71% (140) 18% (78) 17% (39) 20% (39) 7% (30) 6% (13) 9% (17) Highest 10 225 77% (174) 79% (84) 76% (89) 17% (39) 16% (17) 19% (22) 5% (12) 6% (6) 5% (6) Total 1782 75.0% (1337) 74.4% (677) 75.6% (657) 18.5% (330) 18.4% (167) 18.8% (163) 6.5% (115) 7.3% (66) 5.6% (49) * Overall χ2 = 11.42, P = 0.33; Boys χ2 = 8.73, P = 0.56; Girls χ2 = 12.36, P = 0.26. SEIFA = Socio-Economic Indexes for Areas (a higher score corresponds to higher socioeconomic status).

Mu Li · Karen Byth · Creswell J Eastman

To the Editor: Obesity in adults presents significant issues for health care providers, including practical problems in transporting and accommodating large individuals, and in performing standard tests and investigations.1 However, this issue has been little addressed in the mortuary setting, although a recent media report detailed the need for larger crematorium furnaces to accommodate oversized coffins, as well as larger graves for burials.2 We reviewed the body mass index (BMI) of individuals who had undergone coronial autopsies in South Australia in the first 3 months of 2007. Weight and height of all bodies were measured using standardised equipment and were used to calculate BMI by the usual formula.3 A total of 255 individuals aged over 17 years were included in the study (male to female ratio, 2 : 1; age range, 17–97 years). A third of individuals were classified as obese (BMI ≥ 30 kg/m2), and 6% as morbidly obese (BMI ≥ 40 kg/m2). The highest BMIs were: 132.3 kg/m2 (175 kg, 115 cm); 109.0 kg/m2 (315 kg, 170 cm); 82.8 kg/m2 (220 kg, 163 cm); and 79.5 kg/m2 (201 kg, 159 cm). In comparison, over a similar time period at the same institution in 1986, 17% of individuals were obese, and 3% were morbidly obese, with the four highest BMIs being: 55.2 kg/m2 (137 kg, 157.5 cm); 48.3 kg/m2 (148 kg, 175 cm); 44.7 kg/m2 (137 kg, 175 cm); and 41.9 kg/m2 (104 kg, 157.5 cm). This study demonstrates that forensic facilities are now dealing with individuals of considerable body mass. Despite government and industry guidelines for manual handling practices,4 these bodies are difficult to lift, move and store, and present major logistical problems for pathologists and technicians attempting to perform standard examinations. Mechanical lifting hoists, x-ray tables and trolleys are often not designed to cope with such weights. Putrefaction is hastened in morbidly obese individuals, and associated skin slippage and purging makes the bodies even more difficult to handle. Given that autopsies are often required in such individuals to determine the cause of death, consideration must be given to the significant occupational health and safety issues they create for staff in facilities with substandard equipment (ie, designed for normal-sized bodies). The construction of specially designed mortuaries will be required if this trend continues, with larger storage and dissection rooms, and more robust equipment engineered to cope with increasing numbers of individuals with BMIs sometimes considerably greater than 30 kg/m2. Failure to provide these may compromise the postmortem evaluation of markedly obese individuals, in addition to potentially jeopardising the health of mortuary staff.

Roger W Byard · Maria Bellis

To the Editor: The increase in medical graduates expected over the next decade presents a huge challenge to the many stakeholders involved in providing their prevocational and vocational medical training.1 Increased numbers will add significantly to the teaching and supervision workload for registrars and consultants, while specialist training and access to advanced training positions may be compromised. However, this predicament may also provide opportunities for innovation in the way internships are delivered. Although facing these same challenges, regional and rural hospitals could use this situation to enhance their workforce by creating opportunities for interns and junior doctors to acquire valuable experience in non-metropolitan settings. We surveyed a representative sample (n = 147; 52% of total cohort) of Year 3 Bachelor of Medicine and Bachelor of Surgery students at the University of Queensland about their perceptions and expectations of their impending internship and the importance of its location (ie, urban/metropolitan versus regional/rural teaching hospitals) to their future training and career plans. Most students (n = 127; 86%) reported a high degree of contemplation about their internship choice. Issues relating to career progression and support ranked highest in their expectations. Most perceived internships in urban/metropolitan hospitals as more beneficial to their future career prospects compared with regional/rural hospitals, but, interestingly, felt that they would have more patient responsibility and greater contact with and supervision by senior staff in a regional setting (Box). Regional and rural hospitals should try to harness these positive perceptions and act to address any real or perceived shortcomings in order to enhance their future workforce.2 They could look to establish partnerships with rural clinical schools3 to enhance recruitment of interns as early as Year 3. To maximise competitiveness with their urban counterparts, regional and rural hospitals need to offer innovative training and career progression pathways to junior doctors, to combat the perception that internships in urban hospitals are more beneficial to future career prospects. Partnerships between hospitals, medical schools and vocational colleges, with input from postgraduate medical councils, should provide vertical integration4 in the important period between student and doctor. Work is underway to more closely evaluate and compare the intern experience across regional/rural and urban/metropolitan hospitals, and track student experiences and career choices longitudinally. This information may benefit teaching hospitals and help identify the optimal combination of resources necessary to provide quality teaching and a clear career pathway for the expected influx of new interns. Year 3 medical students’ perceptions of internship in a regional/rural hospital versus an urban/metropolitan hospital Perception Strongly disagree Disagree Not sure Agree Strongly agree My acceptance onto a training program will be influenced by the reputation of the hospital in which I do my internship 4% (5) 18% (24) 28% (38) 43% (59) 8% (11) I would have less responsibility for my patients in a regional/rural hospital 21% (29) 67% (92) 12% (17) 0 0 There would be more contact with senior staff in an urban/metropolitan hospital than in a regional/rural hospital 11% (15) 48% (66) 29% (39) 11% (15) 2% (2) I would have more clinical supervision in an urban/metropolitan hospital than in a regional/rural hospital 11% (15) 47% (64) 25% (34) 15% (20) 2% (3) I would feel more part of a team in an urban/metropolitan hospital than in a regional/rural hospital 11% (15) 60% (83) 27% (38) 2% (3) 0 Numbers are percentage of respondents (number of respondents). Denominators vary due to missing responses.

Diann S Eley · David K Morrissey

To the Editor: We report that the internship location choices of the second cohort of medical students to graduate from James Cook University (JCU) are very similar to those of the first cohort.1 Of the 75 students who graduated in the second cohort in 2006, 65 (87%) are working in Queensland; 42 (56%) in North Queensland (roughly the area north of Mackay). Fifty-three (71%) are in non-metropolitan hospitals, including three of the 10 graduates who moved or returned interstate. These proportions reflect the cohort’s geographic origins. As in the first cohort, a small number of students (13; 17%) of North Queensland origin moved away and a similar number (14; 19%) from elsewhere stayed in North Queensland. Further, a majority of the first cohort have remained where they undertook internship: 24 of 29 (83%) have remained in North Queensland and one commenced remote practice, consistent with the group’s stated intentions to work in regional locations.2 Hence, JCU’s first two graduating cohorts had a combined effect of strong recruitment to non-metropolitan hospitals, particularly in Queensland, some of which have experienced difficulty in recruiting junior staff. These results have two implications. First, they contribute to the debate on selection into medicine.3 JCU gives weight to rural schooling, with about two-thirds of each cohort having a rural background, and a similar proportion coming from North Queensland.4 Second, there are workforce policy implications. The growth in medical school numbers over the past 3 years has not evenly reflected workforce needs or availability of postgraduate training places. As some urban areas become oversupplied with junior doctors, it will be important not to neglect areas of maldistribution that are drivers of growth. Regional training pathways for specialist and generalist careers need urgent definition; graduates in Queensland are expected to increase from 300 in 2007 to 727 in 2014, so vocational training places will need to more than double.5 An impact on the Australian medical workforce shortage will only be felt when a number of cohorts have graduated from JCU and other regional schools, and bottlenecks to subsequent training are removed. It will take another decade to obtain a clear picture of postgraduate career outcomes for this group, but the investment in regional medical education in North Queensland appears at this stage to be having the desired effect. If this effect is sustained and replicated in other new regional medical schools, Australia may soon have an adequate supply of medical graduates who both understand and choose to live and work in regional Australia.

Tarun Sen Gupta · Richard B Hays · Richard B Murray

To the Editor: The Transition Care Program (TCP) is a joint federal and state government program that provides short-term (8–12 weeks) support and therapy to improve functioning for older people who are hospitalised (either in public or private hospitals) and would otherwise require admission to a residential aged care facility.1 Participants are provided with a care package that assists with activities of daily living, and provides limited allied health, nursing and medical input, with the aim of improving functional status, if possible. The TCP is currently being implemented across Australia. We selected and audited three transition care services that commenced operation early in the program (2005 and early 2006), with the aim of describing the outcomes of these services, and determining whether the older people participating in the various services were similar. Approval was obtained from the relevant ethics committees. Three services were purposefully sampled: two services in Adelaide (Service A providing packages in a community setting, and Service B providing packages in a high-level care, residential aged care setting); and one service in Sydney (Service C providing packages in a community setting). The residential package allocates temporary residential placements for patients with defined rehabilitation goals, and thus also frees up acute care hospital beds. These services supplied de-identified audit data about the first 30 participants, who were in the program between June and December 2006. A summary of the data is given in the Box. The participants in the residential program tended to be older, more likely to be male, and less likely to have “fracture or fall” as their primary diagnosis. These older people also had more severe disability that generally does not improve, and were significantly less likely to return to community living. The two community-based programs were generally similar. The data suggest that there is considerable variation between the TCP services, with the residential service providing packages to older people with severe disability who generally remain in a residential aged care program, although some may improve from high- to low-level aged care services. By contrast, the outcome of the community-based services is generally maintenance in the community and is associated with an improvement in functioning. This profile is similar to that of a community-based rehabilitation service for older people. It is not clear from the TCP guidelines whether this level of variation in program implementation was anticipated.1 This limited audit suggests that the Australian TCP is not homogeneous and is substituting for other forms of treatment and care. Thus, there is provision of high-level residential care as a substitute for waiting for residential aged care in a hospital bed, and community rehabilitation as a substitute for rehabilitation services provided by state health departments. This situation is potentially beneficial to older people who previously did not have access to these services, but it also could mean that state governments may not establish rehabilitation services for older people, or may even cease providing these services. Comparison of background, status and outcomes for participants in three Transition Care Program (TCP) services Service A (community) (n = 30) Service B (residential) (n = 30) Service C (community) (n = 29) Statistical significance* Mean age (SD) in years 80.9 (7.9) 84.5 (5.1) 80.4 (8.0) ns Female 60% 47% 59% ns Living alone 40% 47% 62% ns Primary diagnosis — trauma (fractures and falls) 43% 20% 41% ns Barthel Index On admission to the TCP — mean (SD) 66.9 (13.8) 55.2 (26.8) 69.2 (19.1) F = 3.85; P = 0.025 On discharge from the TCP — mean (SD) 72.8 (17.6) 56.4 (34.2) 82.8 (22.0) F = 7.69; P = 0.001 Mean change (SD) 5.9 (21.3) 1.5 (19.0) 11.6 (13.3) ns Discharge status — in the community† 60% 20% 76% χ2 = 35.6; P = 0.000 * Based on a comparison between the three groups (χ2 test for categorical data, and analysis of variance [F test] for continuous data). † Patients were in the Program for 12 weeks unless they left early because of admission to hospital or permanent admission to a residential care facility. ns = not significant.

Ian D Cameron · Owen Davies

To the Editor: In an ironic clinician–academic dichotomy, in the same month that the Royal Australian and New Zealand College of Psychiatrists published a survey showing that 79% of Australian psychiatrists combine antidepressants and 75% of psychiatrists believe that general practitioners should be given information on this topic,1 Keks et al chose a non-psychiatric journal to “mandate that combinations be used as a last resort, and only in specialist settings”.2 Specialists have voted with their prescription pads. That a large majority of Australian psychiatrists feel ethically and clinically obliged to use combination antidepressants speaks volumes about the poor results from the suggestions outlined by Keks et al. The multiple clinical reports and reviews of the benefits of combination antidepressants,3 the suffering and death from depression, and the very low rate of complications reported to the Adverse Drug Reactions Advisory Committee from combination antidepressants do not allow the luxury of awaiting combination therapy research which may never happen. Many combinations of antihypertensives or anti-asthma medications similarly lack such rigorous proof, but are widely used. Isolated case reports of medication complications must be seen as such. Access to psychiatrists for combination antidepressant therapy is a well intentioned but currently impractical suggestion. Most psychiatrists have massive waiting lists, and research confirms treatment resistance and progressive cell death in the hippocampus of depressed patients while awaiting effective treatment. Australian GPs are just as capable of using combination antidepressant therapy as their international colleagues, if given the same simple information and training. Canadian GPs read in their journals advice about using combination antidepressants. Anecdotally, many Australian GPs combine antidepressants, but express the wish that the issue could be discussed openly, without them feeling intimidated. Even textbooks of psychiatry, drafted some years ago, teach about combination antidepressants. In the United States, the National Institute of Mental Health STAR*D study of 4000 patients approved combination antidepressants such as venlafaxine with mirtazapine years ago, with no safety concerns.4 Keks et al refer to treatments that today are unacceptable to many, ranging from electroconvulsive therapy to tricyclic antidepressants, despite GPs and psychiatry trainees having been warned for years by academics that tricyclics are outdated, “dirty” and dangerous. Informed consent requires that patients be informed of all therapies that are relevant to their care and survival, and 88% of psychiatrists believe patients should be informed of combination antidepressants.1 Recent results from the STAR*D study demonstrate the superiority of modern combination antidepressants, with no statistically based evidence that they should not be used.5

David P Horgan

To the Editor: Keks et al make a number of important points about the place of combination antidepressant strategies in the pharmacotherapy of depression.1 However, it is important for readers to note that the vigorous repudiation of combination treatments is a peculiarly Australian preoccupation. Our colleagues in Europe and North America are not nearly so troubled. Combination antidepressant treatments are widely used by specialists. A recent survey of Australian doctors working in psychiatry reported that 79% of respondents had used combination antidepressants and that 75% believed that general practitioners should be given information on their use.2 There is emerging evidence for the use of combination antidepressant strategies — from case series, open clinical trials, and randomised controlled trials (RCTs). The largest summation of the data is a meta-analysis which found that combination antidepressant treatment produced a 62% response rate when monotherapy had failed.3 Although this finding alone cannot be convincing because of the acknowledged lack of large sample RCTs, it is quite another matter to decry combination prescribing as clinically unsound based only on the history of augmentation treatments such as lithium and, to a lesser extent, thyroid hormone treatment when, anecdotally, they provide such clinically disappointing results. It is not unreasonable to assert the primacy of good clinical reasoning, including sensible prescribing of combination antidepressants, over rigid adherence to evidenced-based algorithms. This sort of thinking is allowable because the evidence base for the treatment of depression is poor. Meaningful guidelines cannot be produced while the evidence is predicated on the flawed proposition that depression is an “it” (a homogenous construct).4 GPs might well be puzzled by the zeal in academic psychiatry for monotherapy. They are advised to “optimise” monotherapy, but not told what this means. They are very familiar with models of staged polypharmacy for common chronic illnesses such as hypertension, epilepsy, diabetes, and asthma, but in psychiatric pharmacotherapy this is apparently unwise or too risky. The way such admonishments are usually framed is by reference to serious but rare adverse reactions (like the serotonin syndrome), without proper attention to the equally serious and probably more common problems with the current “simple” psychotropic drug options already used by GPs. Failure to contextualise these risks leads to a distortion of risk–benefit prescribing decisions and an unnecessary restriction of treatment choices. We must have a commonsense approach to the treatment of depression that recognises the proper context of our knowledge base. Combination antidepressant treatments may be “beyond the evidence”, but this alone is not a sufficient justification to stop using them.

Murray J Walters · Alston M Unwin · Sean B Gills

In reply: The letters by Horgan and Walters et al underline our motive for reviewing antidepressant combinations. The conclusions of the survey are at least questionable, given that the response rate was only 36%, 18% of respondents were not psychiatrists, and affirmative responders may have only used combination antidepressants once.1 In any case, should clinical popularity substitute for evidence? If so, once popular but now research-discredited treatments such as insulin coma therapy would still be used. Equating combination antidepressants to combination drugs for asthma and hypertension is misleading. How often are two β-blockers given together in maintenance treatment? Major depression causes severe suffering, but this does not justify the use of unproven treatments ahead of those supported by evidence. General practitioners should be informed about antidepressant combinations, but the information must be evidence-based. We described the process of dose optimisation, and stand by our advice that complex cases that require unproven treatment (such as combination antidepressants) be referred to a psychiatrist. Patients should also be informed about combination antidepressants, including the paucity of evidence concerning efficacy and safety, the absence of information about consequences of long-term treatment, and that some combinations are lethal and others frequently unsafe. Published data from the STAR*D study provide equivocal support for the combination of citalopram and bupropion, as we noted. Evidence of modest effectiveness (remission rate, 13.7%) for the combination of mirtazapine and venlafaxine has appeared.2 Our conclusion was that some antidepressant combinations could be used in certain clinical situations where evidence-based treatments have failed, with safeguards. Given that 17% of respondents to the survey1 observed serious complications with combination antidepressants, this is good advice.

Nicholas A Keks · Graham D Burrows · David L Copolov · Richard Newton · Nick Paoletti · Isaac Schweitzer · John W G Tiller

To the Editor: In his “Personal perspective” piece, Allen1 reminded us all of how medicine can at times truly be the noblest of professions. Writing to the next of kin after the death of a patient is occasionally a difficult task, but more usually provides an appropriate form of closure, not only to the relationship with the deceased patient, but also to relationships with the person’s partner, family members and friends whom you may have met during the treatment episode and whom you may not see again. Since I began practice as a consultant 20 years ago (a practice that involves a substantial number of patients who require surgery for cancer), I have tried to write to the next of kin or significant other of every patient who has died while under my care. The letter allows me the opportunity to say perhaps how brave the patient had been in the face of adversity or to acknowledge the support the next of kin had provided. A simple expression of condolence and an indication of how much a loved one may be missed seems to be the best way to “sign off”. Such letters are only a small gesture, but I have often been gratified by how much comfort they seem to provide to those who receive them, and in all this time I have never had a response that could even remotely be considered “negative”. In this current day, when practising clinicians appear to have a diminished role in our medical schools, may I suggest that Allen’s article — which I think is a great example of what is meant by the “art of medicine” — be distributed to our universities and colleges to be considered for inclusion in their teaching material and curricula.

Ian T Jones

To the Editor: Human normal immunoglobulin (NIG) has historically been used to provide passive immunity against hepatitis A infection for susceptible travellers to areas where the virus is endemic.1 The introduction of effective hepatitis A vaccines in recent years (which result in active, long-term immunity to the virus) should have largely replaced the use of NIG for travel prophylaxis.2 However, the Australian Red Cross Blood Service still receives requests to supply NIG for travellers, even though the intended recipients have no contraindications to vaccination. Requests for use of NIG for this purpose appear in many cases to be a consequence of the “out-of-pocket” cost to the patient of the hepatitis A vaccine, which is about $70–$100 (depending on the formulation used and the private dispensing fee charged). In contrast, NIG is provided free of charge to the recipient, but the community still incurs substantial costs related to blood collection and fractionation of plasma products. There is also the concern of unnecessary exposure of a healthy traveller to a pooled plasma product, which, despite blood donor screening, dedicated viral inactivation steps, and an excellent safety record in Australia, may theoretically transmit infectious agents. In addition, even if a small amount of NIG is used for this purpose, the plasma source would be better used for production of greater amounts of other scarce plasma-derived products (such as intravenous immunoglobulin). While NIG can effectively prevent hepatitis A infection from developing in susceptible contacts, immunity is short-lived and likely to be inferior to the results of active vaccination.1-3 Accordingly, NIG is only indicated for at-risk people who have a contraindication to vaccination, or in whom there is insufficient time to mount an endogenous antibody response (active immunity develops within 7–10 days of vaccination,3 and vaccination may also prevent hepatitis A infection even when the vaccine has been administered up to a week after exposure4). Use of NIG is also appropriate where at-risk contacts may be unable to mount a protective antibody response because they have a congenital or acquired immune deficiency. Although the extent of NIG use for travellers appears to be limited, we wish to highlight that, in the absence of contraindications to vaccination, it can no longer be advocated as best practice, and it is certainly not an appropriate cost-saving measure.

Jake Shortt · Denis Spelman · Erica M Wood

To the Editor: Rabies vaccine is recommended for pre-exposure prophylaxis in travellers over 1 year old who intend to travel to predominantly developing countries where canine rabies is endemic. The incidence of dog bites in such countries is relatively high, being more common among travellers than typhoid fever.1 Postexposure rabies treatment of pre-immunised travellers is simpler, cheaper and safer than treatment of those who have not been immunised. Rabies vaccines currently available in Australia are given intramuscularly as three doses of 1.0 mL on Days 0, 7, and 21–28, but are relatively expensive at more than $100 per dose. Some travellers will choose not to be vaccinated because of this cost. For at-risk travellers who might choose to decline vaccination because of the cost, and to facilitate use of pre-exposure vaccination in poorer countries, the World Health Organization approves the intradermal route of vaccination, where 0.1 mL of vaccine is administered, also on Days 0, 7 and 21–28.2 However, the intradermal technique is technically more difficult, may result in lower antibody levels that decline more quickly, and may be interfered with by concurrent administration of chloroquine or immunosuppressants. The Australian immunisation handbook therefore recommends that this technique be performed by vaccinators experienced in the technique, and that satisfactory antibody production is confirmed after vaccination.3 Antibody levels of at least 0.5 IU/mL are considered protective, and the commercial enzyme immunoassay, available under Medicare, has been shown to correlate well with the gold-standard virus neutralisation test.4 We have been using the intradermal method for over 10 years for travellers considered at high risk, but who decline vaccine on cost alone; we use imported human diploid cell vaccine of potency of at least 2.5 IU/mL. As several travellers can be vaccinated from the same vial, costs are $30–$40 per dose, and vials can be stored and reused within 7 days under aseptic conditions. However, travellers must be vaccinated 7–8 weeks before departure to enable antibody testing and a booster vaccination if required. Recent analysis of 1532 non-immunosuppressed travellers (aged between 9 and 77 years; 55% female) who received three intradermal doses of 0.1 mL rabies vaccine on Days 0, 7, and 21–28 in our Melbourne clinic showed that only seven (0.46%) failed to reach the protective antibody level of 0.5 IU/mL on testing 2–4 weeks after the third dose, with readings of 0.4 IU/mL (in four), 0.3 IU/mL (in two) and 0.2 IU/mL (in one). None had undetectable antibody levels. All seven were advised to receive an intramuscular booster dose of 1.0 mL. These data support the contention that the intradermal method is appropriate for use in travellers who may otherwise decline pre-exposure rabies vaccination, when the vaccine is administered by vaccinators with relevant experience.5 Recipients of intradermal rabies vaccine who have satisfactory antibody levels may be considered fully vaccinated in the postexposure situation and managed accordingly.

Anthony Gherardin · Sonny Lau