Letters

To the Editor: I would like to put forward a consumer’s perspective in response to the recent article by O’Leary and colleagues.1 I am puzzled that they concluded that the National Health and Medical Research Council (NHMRC) guideline is in step with policies of the United Kingdom and Canada. My research of Canadian policy suggests that it is in direct contrast to current NHMRC guidelines. Health Canada states very clearly, “Whether you are trying to get pregnant or are pregnant already, stop drinking alcohol”,2 and “No amount or type of alcohol during pregnancy is considered safe”.3,4 The potential harm to the birth mother that results from an abstinence-based message was also raised by O’Leary and colleagues. Elizabeth Russell, the birth mother of two sons affected by prenatal exposure to alcohol, offers an alternative viewpoint: By not discussing alcohol and pregnancy through misplaced compassion, we are hurting one person for the sake of another. Very few mothers would want that but that is exactly what is happening — children are being sacrificed to ensure that the anxiety level of a mother is kept within acceptable limits — neither mother nor child will benefit from this methodology.5 Many pregnant women give up eating shellfish and processed meats and drinking coffee but still continue to consume alcohol, thinking it is safe because they have not been told otherwise. I would like to pose the following questions. What is the potential harm of not having an abstinence message? Might this prevent women who are alcohol-dependent from seeking help to alter their drinking behaviour when pregnant because they are not aware of the risks? Should further research to “elucidate the true association between low to moderate alcohol consumption and fetal harm” really be a priority? What are the benefits to the unborn child of trying to ascertain a safe level of consumption of a teratogen and neurotoxin that is known to disrupt fetal development, particularly the fetal brain, throughout the three trimesters of pregnancy?6 While I acknowledge the importance of scientifically sound research on the risks of prenatal exposure to alcohol, I am concerned that this argument is diverting attention and dollars away from the urgent need for diagnosis and management of fetal alcohol spectrum disorder (FASD) in Australia. The reality is that children, adolescents and adults with FASD are seldom recognised, seldom treated effectively, and seldom connected to service dollars. Addressing this situation needs to be the priority.

Sue Miers

In reply: Morley and colleagues and Miers raise a number of interesting discussion points. As we reported in our policy review, the Canadian, United Kingdom and Australian guidelines have similar intent but differ in emphasis.1 Health Canada’s policy position is that, although abstinence is the prudent choice, fetal risk is relative to the amount of alcohol consumed and is minimal with low levels of maternal alcohol intake. Australian policy addresses the same issues, with less emphasis on abstinence and more on avoiding intoxication and ensuring low-level alcohol consumption. Since our review was published, UK guidelines have been reframed to emphasise abstinence, but their message has not changed — they now place more weight on avoiding alcohol during pregnancy.2 We strongly agree with Morley and colleagues that screening for alcohol should be routine in all pregnant women, and that standardised items should be included in a core dataset.3 If this were implemented, Australia would be in a unique position to make a valuable contribution to alcohol and pregnancy research. Miers comments that research into the impact of low to moderate alcohol exposure during pregnancy should not be a priority, because it may direct “attention and dollars away from the urgent need for diagnosis and management of fetal alcohol spectrum disorder”. Although we agree that specialised clinical services are important — and lacking — in Australia, it is short-sighted to suggest that there is no need for further research to establish the true risks from low to moderate alcohol consumption. Rates of alcohol consumption in Australia are high: about 80% of women report alcohol consumption in the 3 months before pregnancy, 14% report binge drinking, while 47% report that pregnancy was unplanned.4 Many fetuses may thus be exposed to alcohol before women are aware they are pregnant. Unfortunately, many women are unable to stop drinking and may expose their babies to high alcohol levels. Health professionals need to have a true estimate of risk to the fetus and know what additional factors (eg, genetics and nutrition) may alter risk, and women deserve to be well informed. The need for research is well articulated by Morley et al. Research evidence in humans does not clearly indicate a risk to the fetus from low levels of alcohol consumption, and this has led to inconsistent policy.5,6 As we point out, the potential for harm from an abstinence message should be considered when Australian alcohol guidelines are reframed. Whatever the policy, it needs to be widely disseminated, in a “digestible” format, to health professionals and the community. Research being conducted at the Telethon Institute for Child Health Research is evaluating educational materials for health professionals about alcohol and pregnancy.

Colleen M O’Leary · Louise M Heuzenroeder · Elizabeth J Elliott · Carol I Bower

To the Editor: Kawasaki disease (KD) is an acute vasculitis of unknown aetiology occurring mostly in infants and young children. KD is characterised by fever of more than 4 days’ duration; conjunctivitis; rash; cervical lymphadenopathy; erythema of the lips, oral mucosa, palms and soles; and oedema of the hands and feet.1 Coronary artery aneurysms develop in 15%–25% of untreated children,2 with attendant risk of ischaemic heart disease, myocardial infarction and sudden death.3,4 Treatment with intravenous immunoglobulin (IVIG) within the first 10 days reduces the incidence of aneurysm to less than 5%.4 A KD diagnosis is clinical, based on the recognition of a characteristic set of signs and symptoms.4 The 10%–45% of children who meet only some of the classical criteria are said to have “atypical” or “incomplete” KD. These children have a higher risk of coronary artery aneurysm than children with typical KD.4 Abdominal symptoms, including acute appendicitis and appendicular vasculitis, can occur before the development of classical features of KD.4,5 A 50% coronary artery aneurysm rate has been reported in children with KD and acute abdomen. It is still unclear whether this reflects a delay in diagnosis and treatment or is a marker of a more severe vasculitis involving the intestinal tract. A 3-year-old boy presented with a 2-week history of remittent, high-spiking fever (37.5–39.0° C; 2–3 spikes/day), right lower quadrant abdominal pain, and McBurney’s sign with rebound tenderness. Abdominal ultrasonography suggested a diagnosis of acute appendicitis with peritonitis. The postoperative diagnosis was appendicular vasculitis with peritoneal inflammation and serous secretion. Fever persisted despite treatment with intravenous cephalosporin. Several days later, the boy developed conjunctivitis, cracked lips, a raised erythrocyte sedimentation rate and C-reactive protein level, and thrombocytosis (715 × 109 platelets/L). KD was suspected, and an echocardiogram revealed two sacciform coronary artery aneurysms (diameters, 3.1 mm and 2.9 mm) in the proximal part of the common trunk. The child was given IVIG (2 g/kg) and oral acetylsalicylic acid (100 mg/kg per day in four divided doses). As the fever failed to resolve, the patient was given a second dose of IVIG,4 this time leading to a dramatic clinical improvement. Five days later, he developed oedema of the hands and periungual peeling of the fingers. His aspirin dose was reduced to 5 mg/kg/day. Follow-up echocardiograms at 3 months and 6 months demonstrated persistent coronary artery dilatation. Persistent fever with conjunctivitis and cracked lips should alert clinicians to the possibility of KD. At our patient’s age, acute appendicitis is rare, and other causes of abdominal pain must be excluded. In this case, the unusual postoperative course, with persistent fever even after antibiotic treatment, was another clue to establishing the correct diagnosis.

Maria Cristina Maggio · Andrea Liotta · Salvino M Vitaliti · Giovanni Corsello

To the Editor: Gerber’s article1 about the case Royal Women’s Hospital v Medical Practitioners Board of Victoria raises important issues but contains significant errors. The Medical Practice Act 1994 (Vic) states that the main purposes of the Act are “to protect the public by providing for . . . investigations into the professional conduct . . . of registered medical practitioners” — Section 1(a). Section 22(1) makes it clear that any person may notify the Board if they believe a person may have engaged in unprofessional conduct. Section 25(1) states that the Board must investigate notifications unless they meet certain criteria, which the Board did not believe were met in this case. Gerber is not correct in stating that the Board made no attempt to question the medical practitioners involved. In the absence of the patient’s consent, all but one of the doctors refused to provide any information in response to the complaint. Gerber’s statement that the subcommittee of the Board that conducted the preliminary investigation concluded that the complaint was “frivolous and vexatious” is wrong. The subcommittee recommended that the matter be closed. Later, the full Board chose not to accept this recommendation, as the investigation had been hampered by lack of information, including access to the original hospital records. While formal hearing panels have the power to subpoena documents or persons, this power does not extend to the Board’s preliminary investigations. The Board does have the power to apply to a magistrate for the issue of a search warrant. Gerber refers to the powers of the Board under Section 48 and Section 49 of the Act. These powers only come into play if the Board has determined that it will conduct a formal hearing. He is also incorrect when he states that the Board can compel medical practitioners to appear before the Board. This power is not available during preliminary investigations. The considerable delay in the matter being finalised was due to the legal appeals mounted by the Royal Women’s Hospital against the decision of the Magistrate to allow the Board access to the hospital records. Another issue raised by Gerber requires clarification: the Board does not currently have the power to conciliate disputes or conduct mediations. The Board did not ultimately dismiss the matter as frivolous and vexatious. When the subcommittee, having been provided with the records, reported to the Board that it did not find evidence of unprofessional conduct, the Board closed the investigation. I trust that this information will correct the public record on this important matter.

Joanna M Flynn

In reply: Flynn points to some minor technical differences in my historical recount of the handling, by the Medical Practitioners Board of Victoria, of the complaint against the medical specialists involved in a late-term abortion.1 None requires a reply, save for Flynn’s assertion that “the Board does not currently have the power to conciliate disputes or conduct mediations”. The Board does not require statutory power to approach a hospital in a conciliatory manner so as to explore whether an impasse, involving confidentiality, can be resolved without recourse to litigation. Was the Board’s only remedy to raid the hospital, trawling for evidence to decide whether there were grounds for the possible suspension or cancellation of registration of the doctors involved in the complaint? We both agree that the relevant legislation mandated the Board, on the material before it, to investigate the charge of serious professional misconduct. Where we disagree is that, having overruled its own subcommittee’s recommendation that the matter be closed, the Board failed (I maintain) in its statutory duty to promptly institute a formal hearing. Had the various specialists been subpoenaed, this would have cleared them of professional misconduct, thereby preventing the considerable and unnecessary stress to these witnesses over a period of 5 years.

Paul Gerber

To the Editor: Breen’s timely call for a reality check on medical professionalism noted major global changes that affect contemporary doctor–patient relationships: new technology, changing market forces, evidence-based treatment protocols, and resource-driven health services and policies.1 The call by our colleagues in the United States and United Kingdom to restore “trust that the public used to have in the profession” was urgent. Breen’s thesis posits that lost trust is due to an “altered balance” of ethical issues faced by doctors because of a generational shift from the ethical principle of “beneficence” to “autonomy” to “justice” and “distributive justice”. This view contrasts with Green and Bloch’s analysis of the mental health care system’s ethical concerns arising from an adherence to “efficiency-driven” policies that started in many countries during the 1980s.2 They suggest the system itself is flawed. Green and Bloch suggested that the legacy of efficiency-driven policies created two current moral compromises for our profession: first, a threat to the “ethic of agency”; second, the constraints those policies imposed on ethical principles precisely because they were not based on justice, instead being created to meet wider socioeconomic and political considerations. Their views point to the heart of the matter, beyond Breen’s suggested remedy to be found in “stronger leadership”, which may be necessary, but is not sufficient without an urgent update on personal medical ethics. At the individual doctor’s experience, Green and Bloch locate conflict arising from competing interest when doctors’ “principle of fidelity is juxtaposing their financial interests alongside patients’ needs”. In the US, a study found 28% of physicians receive direct payment for consulting, lectures or enrolling patients in trials, and 94% report “some type of relationship with the pharmaceutical industry”.3 To avoid the conundrum posed by the ethics of conflict of interests we face when confronted by these physician–industry relationships, or by efficiency-driven policies, risks perpetuating the very loss of trust that we need to restore. Breen’s analysis, an important step in the needed debate on medical professionalism, should account for not merely shifts in the ethical balance, but also the incremental erosion of trust. As it stands, he expressed our very Australian attitude “she’ll be right”. Our overseas colleagues, as well as locals, have suggested that “she won’t be right, mate” when it comes to managerialism eroding the ethical foundations of medicine.4

George Halasz

In reply: My recent article was submitted under the category of “For Debate”, so it is pleasing that Halasz has joined the debate. I am disappointed that he interprets my view as “she’ll be right”. My point is that revising or repackaging existing ethical codes will not, on its own, fix any of the perceived problems of “managerialism eroding the ethical foundations of medicine”. Working constructively, consistent with existing ethical codes, within our health care system, as is also suggested by Green and Bloch,1 is more likely to achieve better outcomes for our community. As I stated and as Green and Bloch imply, this will not always be a simple matter. I am in fierce agreement with Halasz over steps to reduce erosion of trust,2 but that was not the focus of my article.

Kerry J Breen

To the Editor: Clark et al have claimed to map the distribution of services for people with chronic heart failure (CHF) against the distribution of these people.1 An examination will show that they have mapped the distribution of people likely to have CHF, using age and Aboriginality as surrogate markers. The stated mapping of the services shows the services probably available to these people. A map is drawn to show us what the cartographer wants us to see.2 The authors note that high prevalence in remote regions has been shown on the maps, but they have not considered different mapping methods to provide a better representation of their results.3 This has led to an anomaly so that, when calculating numbers of people with CHF, the maps show remote areas with giant households containing between 24 and 300 people. CHF programs were located by a snowball sampling technique, which by its nature will miss isolated examples. Isolation is a feature of rural and remote practice, so this method is biased to finding metropolitan examples. In my own rural practice in Griffith, I found a local program that had been operating in 2004 and a distance program run by a health fund, neither of which had been identified by Clark et al. On the medical front, the authors asserted that access to a CHF management program is a mark of equity in health services. This is based on a metro-centric model looking at admission with CHF to a major teaching hospital, and showing that rates of readmission and death were reduced where a nurse and a pharmacist made a single visit to someone with CHF in their home after hospital discharge. The relevance of this activity to a rural person with a single community pharmacist who may make a home visit, a single point of contact with medical services in their general practitioner, and the possible availability of a community nurse to visit them regularly is unproven. Perhaps the city folk were copying the principles of the services we already had?

Elizabeth A Dodd

In reply: We thank Dodd for her commentary on our article.1 We concur with many of the highlighted issues relating to our suboptimal response to the burden and management of chronic heart failure (CHF) in rural and remote Australia. These include the lack of rigorous epidemiological data and lack of specialist services “beyond city limits”. Unfortunately, we have limited space to respond fully. However, we re-emphasise that, although our previous estimates2 complement that of the Canberra Study,3 neither can replace an Australia-wide study of CHF that samples metropolitan, regional, rural and Indigenous communities. We also stand by (within the context of the stated limitations) the accuracy of our mapping of the CHF programs and the location of general practice services in Australia for the study period. Our geo-mapping approach and data have been well validated by the National Centre for Social Applications of Geographic Information Systems (GISCA).4 For example, Jenks’ (natural breaks) classification is used for all sociodemographic thematic mapping at GISCA. Overall, we identified only four CHF programs which were located in regional areas. Other rural programs were excluded as they did not meet our prespecified definition of a CHF program. In summary, we acknowledge the need for better data to describe the burden of CHF throughout Australia. We also explicitly acknowledge the need for a less “metro-centric” approach to CHF service: perhaps by using remote monitoring techniques.5

Robyn A Clark · Andrea Driscoll · Justin Nottage · Skye McLennan · David M Coombe · Errol J Bamford · David Wilkinson · Simon Stewart

To the Editor: With the ski season in Australia drawing to a close for another year, it is a good time to reflect on the injury prevention benefits of wearing helmets when skiing or snowboarding. Skiing falls can be fatal. Two people have died from head injuries on Australian skifields in recent years: a skier died after colliding with a tree branch on an intermediate run at Mt Buller, Victoria, in 2003; and in 2006, a novice snowboarder died after falls sustained while snowboarding at Thredbo, New South Wales.1 Neither person was wearing a helmet. In Australia in 2002–03, 3.5% of skiing-related hospital admissions and 6.2% of snowboarding-related admissions were due to intracranial injuries.2 During the 2004 and 2005 ski seasons we collected data on the use of helmets in snowboarders presenting to the Mt Buller Medical Centre. Of 494 snowboarders, 17.6% had been wearing helmets, and none had sustained a head injury. Of the nine patients with head injuries, none had been wearing helmets. These figures are similar to those reported in overseas studies, which have shown that wearing a helmet can reduce the snow-sport head injury rate by up to 60%.3,4 The use of helmets for snow sports makes intuitive and biological sense, as it does for cyclists, but, unfortunately, Australia is yet to issue a snow-sport helmet performance standard, as it does for bicycle helmets. Helmet use should be strongly recommended for all snowboarders and skiers. In particular, helmets should be made compulsory for children, who are more susceptible to head injury4 and who are often present at ski resorts in large organised school groups that could readily be made to comply. At present in Australia, helmet use is not compulsory for children attending skiing or snowboarding lessons, as it is in North America. This is in spite of the fact that helmet use is compulsory in Australia for school skiing and snowboarding competition events. Some skiers and snowboarders are gradually getting the message about helmets, and a recent informal survey at Mt Buller (Buller Ski Lifts personnel, personal communication) estimated the rate of helmet use to be 20% among adults and 68% among children — but this still leaves over 30% of children vulnerable. Snow-sports helmets now come in many colours, shapes and sizes, and are increasingly acceptable to young people. A helmet is probably the cheapest individual item of clothing for a ski holiday. And it may save your life.

Graham M Slaney · Judith Finn · Angus Cook · Philip Weinstein

To the Editor: It was interesting to read of the trial conducted by Manley et al1 using yoghurt containing Lactobacillus rhamnosus to clear vancomycin-resistant enterococci. I would like to add an historical note. The use of yoghurt in restoring bowel flora was practised by Dr J H Kellogg (of Corn Flakes fame) around the end of the 19th century. Kellogg was the chief physician at the Battle Creek Sanitarium in Michigan and was an advocate of high colonic irrigation, for he believed the colon was a sewer of toxic materials that were the causal factor in many diseases. Following this procedure, the patient was given a pint of yoghurt — half to be taken orally, and the remainder given by enema.2,3 By these measures, Kellogg claimed to have cured many conditions, from cancer of the stomach to psychiatric problems.

H Reginald Magee

To the Editor: Security requirements for air travel have recently become very strict and include limitations on the carriage of medication and medical equipment. International flights to and from Australia are often lengthy, and patients needing regular medication can suffer serious complications without it. Diabetic patients are particularly vulnerable, as illustrated by this case. A 54-year-old engineer was returning to Australia after a 4-month placement in Norway. He had a history of type 2 diabetes, which had become insulin dependent 5 years previously. His diabetes was well controlled with 40 units of insulin twice daily, and he had no other major medical problems. At a Norwegian airport, his insulin, needles and syringes were detected on security screening of his cabin baggage. Security staff told him that he was not permitted to carry his insulin or equipment in the cabin without a letter from his doctor and a current valid prescription. The man’s protests were to no avail, and he boarded without his insulin. During the 25-hour journey to Sydney, he developed vomiting, polyuria, sweating and dyspnoea. Despite making cabin staff aware of the underlying problem, he was offered no assistance apart from a steady supply of airsickness bags. On arrival in Sydney, he was very ill and was taken by ambulance to St George Hospital, where he required admission to the intensive care unit. His pulse rate was 130 beats/min and respiratory rate 30 breaths/min. His urine was strongly positive for ketones and his blood glucose level was 51 mmol/L. Arterial blood gas analysis showed very severe metabolic acidosis with a pH of 6.9, Pco2 18 mmHg, and Hco3 4 mmol/L. His diabetic ketoacidosis was treated conventionally, with aggressive extracellular volume and electrolyte replacement, and insulin by infusion. His condition improved rapidly, and he was discharged home the next day. Australian doctors and their diabetic patients should be reminded that airline security requirements are now very strict in most countries, and that life-threatening ketoacidosis can readily develop over the course of a flight between Australia and the northern hemisphere. Insulin-dependent patients must continue to take their insulin during these flights and should not board without their supplies. In Australia, the Department of Transport and Regional Services stipulates that people with medical requirements may carry “prohibited items” such as hypodermic needles, but must also carry a doctor’s letter, a medical certificate, or a current National Diabetes Services Scheme card.1 Supplies should be clearly labelled, carried in a clear plastic bag and declared to security staff before being screened. The United Kingdom Department of Transport2 and the United States Transportation Security Administration3 have broadly similar requirements.

George Skowronski

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