Letters

To the Editor: Cryopreservation has been an integral tool in the development of modern assisted reproductive technologies, beginning with sperm cryopreservation in 1953 and extending to embryo cryopreservation in 1983, with the evolution of in-vitro fertilisation (IVF) and embryo transfer as a major tool in the treatment of infertility.1 Until recent times, however, there has been a lack of reliable cryopreservation methods for human oocytes. The world’s first recorded pregnancy arising from frozen oocytes occurred in Australia in 1984,2 and although occasional live births following oocyte cryopreservation were subsequently announced,3 it was another 11 years before more reliable protocols were developed4 — hundreds of live births have since been reported.5 The most common protocol follows that of embryo cryopreservation, using slow freezing with propanediol as the cryoprotectant, although rapid vitrification methods are also being developed. Reliable oocyte cryopreservation protocols are important for patients for whom embryo cryopreservation is unacceptable under some national laws or religions, and in whom there may be sperm collection problems or unexplained azoospermia during IVF procedures. We report four live births, one ongoing pregnancy, and an ectopic pregnancy following oocyte cryopreservation. Three of these cases involved religious opposition to embryo freezing. In each case, only two oocytes were fertilised fresh and the remainder frozen. No pregnancies resulted from the fresh embryo transfers, and the frozen oocytes were subsequently thawed, fertilised, and transferred, to produce the pregnancies. Two cases involved idiopathic azoospermia on the day of IVF, while in another, no sperm could be obtained from testicular aspiration on the day. Oocytes from these men’s partners were frozen until the sperm supply problems were resolved. As these cases demonstrate, oocyte cryopreservation can serve as a valuable adjunct to assisted reproduction programs, by providing a solution to the occasional logistical problems caused by unavailable spermatozoa. It also provides another option for patients with ethical or religious objections to the cryopreservation of embryos, and for fertility preservation in women with cancer facing chemotherapy or for women who may wish to insure against age-related fertility decline. The six pregnancies described here arose from embryo transfers in 13 women who had oocytes cryopreserved. The results, combined with others achieved worldwide, suggest that oocyte cryopreservation may at last be coming of age.

Keith L Harrison · Michelle T Lane · Jeremy C Osborn · Christine A Kirby · Regan Jeffrey · John H Esler · David Molloy

To the Editor: We write in response to recently published consensus recommendations for the off-label use of pharmaceuticals, which provide a common-sense, evidence-based approach to a commonly encountered clinical problem.1 The recommendations indicate that, other than for exceptional or research indications, off-label use of a medicine is generally not recommended unless there is high-quality evidence supporting such use. However, for some older pharmaceuticals, there is little incentive to perform additional trials to generate good evidence to support off-label use. An example is rifampicin, which is commonly used in combination with fusidic acid to treat methicillin-resistant Staphylococcus aureus (MRSA) infection, but is not licensed or subsidised by the Pharmaceutical Benefits Scheme (PBS) for this indication. Rifampicin has a well defined toxicity profile, with a long history of use in treating tuberculosis and preventing meningococcal disease. Rifampicin-based combinations for staphylococcal infection are recommended by Australian and international guidelines,2,3 and supported by small clinical trials.4 For rifampicin, a generic drug, there is no financial incentive for the manufacturers to apply for an additional indication for treating MRSA infection. Since 1998, an orphan drugs policy has encouraged sponsors of patented pharmaceuticals to apply for indications that may only involve small numbers of patients and has waived Therapeutic Goods Administration (TGA) fees for such marketing applications. A “rule of rescue” has also operated, lowering the regulatory bar for serious diseases that are otherwise untreatable. Despite these initiatives, no application to add the treatment of MRSA infection as an indication for rifampicin (in combination with another active agent) has been received by the TGA.5 A solution would be for the National Health and Medical Research Council (NHMRC) to commission clinical trials where further evidence is required. This proposal could see an expanded role for the National Institute of Clinical Studies (NICS), which will soon be incorporated into the NHMRC. The NICS/NHMRC could also make applications to the TGA for the approval of pharmaceuticals for particular indications, particularly for orphan diseases and generic drugs. Reviews of evidence could be generated from within the NHMRC or from external bodies such as professional Colleges and societies, or groups of experts such as those appointed by the Board of Therapeutic Guidelines Limited. Clinical trials could be performed in conjunction with overseas research agencies and draw from within the existing budget of the NHMRC. This initiative would improve prescribing through the generation of appropriate evidence and may also redefine the utility of some established off-label indications. It could reduce out-of-pocket expenses for patients by facilitating PBS listing. As this initiative would focus on relatively low-cost generic drugs and/or uncommon orphan indications, it would be unlikely to have a significant impact on the cost of the PBS. It would also help focus the clinical research agenda on clinical practice and encourage the use of appropriate generic pharmaceuticals.

Allen C Cheng · Priscilla M Robinson · Ken Harvey

To the Editor: The human costs of the war in Iraq are mounting. The war has already claimed the lives of about 3000 Coalition service men and women1 and well over half a million Iraqi men, women and children.2 Reports by the United Nations Assistance Mission for Iraq indicate that hundreds of thousands of civilians have been displaced, and that military operations in the country are limiting civilian access to health and education services, food, electricity and water supplies.3 Furthermore, the reports describe a generalised breakdown of law and order in the country, continued growth of militias and organised gangs, and abhorrent human rights violations such as torture in the form of electrical and chemical burns, injury inflicted to eyes and genitals, and wounds from power drills and nails.3 Currently, the Iraqi health system is unable to cope with the health care needs of its population. Iraqi health infrastructure has not escaped the damage or destruction of war. Hospitals lack basic medical supplies such as intravenous fluids, antibiotics, oxygen, disinfectants and bed sheets.4 The precarious security situation in the country has also contributed to a severe shortage of medical personnel. About 25% of Iraq’s physicians have left since the beginning of the war, while those remaining are the targets of violence, intimidation and kidnappings.4 Such an exodus of health personnel has required many of the remaining medical staff to undertake procedures for which they are not qualified.4 Recognising the need for action in Iraq, a workshop was arranged by the International Committee of the Faculty of Public Health, Royal Colleges of Physicians of the United Kingdom, in 2003. The workshop, which included representation from the World Health Organization and the Iraqi Ministry of Health, called for health organisations to be active advocates for improving the health of Iraqis and to provide technical support and assistance to their Iraqi health colleagues.5 Training and professional development opportunities for health staff and the provision of up-to-date health information were identified as specific areas of need in the Iraqi health sector to which health organisations could make a meaningful contribution. In Australia, there has been a small move in this direction, with the federal government providing in-principle support for an initiative to train three Iraqi physicians in emergency surgery. Australian health associations, agencies and professionals need to do more to respond to the humanitarian crisis in Iraq. Carefully coordinated training programs, particularly in the areas of medicine and public health, and the provision of medical aid, resources and information by Australian health organisations, would enhance the capacity of the Iraqi health system to alleviate the effects of war on its citizens. Furthermore, health organisations and professionals need to advocate on behalf of Iraqis, raise awareness of the inadequacies of Coalition government aid, and demand a more effective humanitarian relief effort for victims of the 2003 invasion.

Luke Wolfenden · John Wiggers

To the Editor: I was surprised by Wong’s letter on the role of history-taking and examination in the diagnostic process.1 I would suggest that Wong, as a surgical registrar, receives the majority of his abdominal pain referrals from the medical staff of the emergency department. Although he advocates the liberal use of abdominal computed tomography (CT) scanning, I believe he ignores the fact that another medical practitioner has already taken a history and performed an examination that has suggested a surgical cause of pain for which a surgical opinion is then requested. Wong would thus remain unaware of other cases in which patients present with abdominal pain but the case is ruled non-surgical on the basis of history, examination and limited investigation not involving abdominal CT scanning. History, examination and even appropriately targeted investigations remain imperfect diagnostic tools, but I agree with Schattner2 that history-taking and examination are very important adjuncts in the diagnostic process.

Andrew P Wright

To the Editor: Like Schattner, I am appalled by the attitude to diagnosis displayed by Wong regarding the use of computed tomography (CT) scanning in preference to initial history-taking and physical examination in abdominal pain.1 Unfortunately, this approach is becoming increasingly more prevalent among junior staff (and even among some senior staff). Wong poses the question, “[W]hy do some clinicians continue to routinely promulgate the sacred and arcane ritual of taking a history and doing an examination, which, as diagnostic tools, are clearly second-rate?” There are several reasons why I continue to promulgate the classical paradigm. Firstly, I would remind him of Bayes’ theorem: post-test probability equals pre-test probability multiplied by the likelihood ratio of the test. Put simply, this means that, for a test that is not 100% accurate (ie, effectively, all imaging tests), you cannot interpret the meaning of the result without having some idea of the pre-test probability of a diagnosis. And how can you satisfactorily arrive at a pre-test probability without having clinically assessed the patient? In addition, the radiologist is able to interpret the images more accurately when there are clinical details provided.2 Secondly, is Wong seriously suggesting that all patients with abdominal pain, including young adults and children, undergo CT scanning without any kind of clinical filtering or assessment? This is wrong and potentially negligent. The radiation dose received by the patient from an abdominal CT scan is a serious consideration. Assuming a total effective body dose of 10 mSv, there is an excess risk of a radiation-induced fatal cancer of about 1 in 2000.3 Apart from the risk to the individual, the number of iatrogenic cancers potentially induced in the community by indiscriminate use of CT would be a major concern.4 Thirdly, the implication of Wong’s letter is that clinical assessment and imaging are somehow in competition with each other, whereas nothing could be further from the truth. Of course, modern imaging has contributed to making diagnosis far more accurate than in the time of Hippocrates, but a complementary approach is far more rewarding for patients and doctors. Lastly, in patients with abdominal pain, there are many occasions when no imaging is required and others when ultrasonography is more appropriate than CT, because it avoids ionising radiation in young patients and is more accurate for diagnosing gynaecological causes of pain.5

Richard M Mendelson

To the Editor: It is clear Dr Wong1 has a practice rather different from mine. He is not used to the truly undifferentiated patients that present in their thousands to emergency departments and general practices every day. There, the art of history and examination is truly alive. No one questions the value of complex imaging. It has its place after a detailed history has been taken and focused examination and relevant investigations have been carried out, leading to a risk assessment and management plan. One does not order computed tomography (CT) scans willy-nilly. For example, the Canadian CT Head Rule2 for patients with minor head injury sets out which patients should have a head CT scan, based on a simple set of historical and examination findings. Moreover, CT scans are wasted on conditions for which CT imaging is inappropriate — it is rare that I order a CT scan for a child with abdominal pain. When I ask surgical registrars for their opinion, I am actually asking for their consultant’s opinion. Nothing guides like an experienced hand, whether it be feeling a belly or writing a CT request form. On many occasions, I have concluded that all the imaging performed on a patient with abdominal pain did not contribute to the diagnosis and the patient simply needed a laparotomy. At my insistence, the consultant is called, appropriate treatment commences, and the patient boards the experience express on the track to recovery. As Shem quips, in his satirical book on medical training and hospital life — nothing heals like cold steel.3 CT is not the be-all and end-all of medicine. Hopefully, by the end of his training, Wong will have developed the hand of experience and be able to continue the art of medicine through the ages. In the words of William Osler: The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish.4

James L Mallows

To the Editor: Apropos the letter by Wong entitled “Clinical paradigms revisited” in the Christmas issue,1 declaring fossilisation of the very pillars on which medicine stands, we would like to express a contrary opinion. To be adept physicians, clinicians must hone their skills at taking a lucid and informative history and conducting a thorough physical examination. It would be a crying shame if young doctors, having slaved for 5 or more years to obtain a medical degree, had to rely solely on expensive investigations when they have the God-given tools of the five senses. To confirm a clinical diagnosis and assess the extent of disease, doctors should order specific and appropriate investigations, rather than ordering tests that may be irrelevant and financially bleeding the patient. The issues of cost, radiation hazard, availability of trained personnel, and need for expensive equipment have been trivialised. In a country like India, where the majority of the population cannot afford even minimal hospital fees, to even contemplate using a computed tomography scan as a first-line diagnostic tool for something as basic as abdominal pain is absurd. Moreover, the use of advanced technology does not guarantee a correct diagnosis. A recent case of aortic dissection was misdiagnosed as acute coronary syndrome on the basis of electrocardiography.2 If due emphasis had been given to pulse and blood pressures in both limbs, this mistake could have been avoided. In another case, involving recurrent loss of consciousness, investigations were non-contributory, but a history of substance misuse at home pointed to the correct diagnosis.3 In another study, clinical judgement regarding the severity of pneumonia was found to be a more reliable predictor than a standardised scoring system based on clinical signs and laboratory findings.4 Doctors ought to be able to make a clinical judgement in the first instance, rather than resorting blindly to expensive investigatory tools. We do not deny the usefulness of modern technological devices for confirming or ruling out clinical possibilities, but they must be used judiciously. Such investigations cannot take precedence over physicians’ reliance on their clinical skills, lest we become helpless without technology.

Sandeep Chauhan · Ruth D’Cruz · Sanjay D’Cruz · Ram Singh · Atul Sachdev

To the Editor: Schattner1,2 and Wong3 raise issues that examine what has been the core of medical practice since antiquity. Grasping antiquity for its own sake is problematic, at best, and possibly heralds the extinction of long held practices, at worst. As technology improves, we are witnesses to improved imaging modalities that provide higher diagnostic yields, with improved sensitivity and specificity, at increasingly reduced costs. Refusal to even acknowledge the possibility that the history and examination may be terminal is not prudent. Instead, we need to examine carefully our mantra(s) with respect for the temporal nature of medicine. History and examination evolved in their current form because previous generations could not see inside the body, or examine physiological and pathological processes in real time. Our predecessors amassed a series of verbal cues and physical rules that generally conformed to the presentation of a particular disease. The future of medicine heralds dramatic departure from the world view that preceded computed tomography and magnetic resonance imaging. Wong raises an important issue with regard to diagnosing emergency abdominal conditions in busy hospital practice. He does not discount a role for the history or physical examination. He does, however, challenge their pre-eminence in “conditions that require emergency surgical treatment”. Is it really in the best interests of patients and the health care system for the emergency department intern/resident, then the registrar/consultant, then the surgical fellow, to all take the history and perform a physical examination? In essence, doesn’t Wong’s “scan first approach” reflect a prudent reliance on, and respect for, the information already gathered? Schattner4 states that “all imaging studies combined (computed tomography, magnetic resonance imaging, ultrasound, and echocardiography) were decisive in only 10.5% of cases” whereas “the patient’s history and the evolution of the condition proved to be the decisive diagnostic method in 23% of cases”. Doesn’t this show that Wong’s approach provides a heuristic that increases the diagnostic yield, reduces delays and guesswork, and streamlines the processing of patients presenting with acute abdominal pain — or is it acceptable to miss the significant percentage of diagnoses that are decided by imaging alone?!

Stuart Kostalas

To the Editor: In his message From the Editor’s Desk,1 Van Der Weyden laments what he perceives to be “the absence of many voices in protest” against the current Council of Australian Governments’ (COAG) proposals2 for national systems of registration and accreditation of the Australian health workforce. The absence of an “overwhelming public response” to the proposals can surely be attributed to the general public’s lack of awareness of the proposals. It cannot be said, however, that the medical profession has been idle. By the time this letter is published, the situation in regard to the proposals is likely to be much clearer. To date, all elements of the medical profession have been very active in seeking to achieve the best possible outcomes from the COAG proposals for our patients and for the profession. These efforts were impeded initially by the lack of specificity available from the COAG Health Working Group. Clear evidence of the effectiveness of the efforts of the Australian Medical Council, the Australian Medical Association, and the Committee of Presidents of Medical Colleges (CPMC) and its individual member Colleges was the abandonment of the second consultation paper after the profession’s analysis and evaluation of the proposals presented. As I write, government officials are meeting to develop a new model which recognises the profession’s criticisms and views. The profession’s message clearly has reached the federal Minister for Health, who asserted recently that it appeared that “the best way forward is to have separate national registration boards for medicine and for each of the other health professions”.3 This is a significant departure from the original COAG proposal. The CPMC and its member Colleges are well aware of the undesirable developments in other countries where governments are attempting to take control of regulation of the medical profession, as mentioned by Van Der Weyden.1 At their meeting on 15 February, the College presidents endorsed a two-page statement of key issues in regard to the COAG proposals. This statement has been sent to the premiers, chief ministers and health ministers in each state and territory, as well as to the relevant federal government agencies. At the same time, it is appropriate for the Colleges to cooperate responsibly with government initiatives, provided those initiatives do not diminish in any way the safety and quality of health services provided in Australia or threaten the sovereignty of the Colleges in the determination and maintenance of standards for their respective disciplines.

Michael J Cousins

To the Editor: Your statement that the present “grab for control [of Australian medicine] by governments” is unprecedented is not correct.1 Between 1946 and 1949, the federal government came close to nationalising the medical profession.2 The lines were drawn earlier. In 1941, the Federal Council of the British Medical Association (BMA) in Australia (now the Australian Medical Association) made recommendations about the provision of medical services. Two years later, in response to a report by the National Health and Medical Research Council, Outline of a possible scheme for a salaried medical service, the BMA laid down a more detailed policy, with retention of the existing (largely private) general practitioner and specialist services. The government responded by proposing a scheme under which patients would pay nothing directly for medical care, with costs to be met from general revenue.3 Asking the doctors to cooperate, the government indicated that it would if necessary seek other means to achieve its object.4 The referendum of 1946, one of the few to be passed, gave the federal government power to provide a range of social services, including pharmaceutical and hospital benefits and medical and dental services. There were, however, a few words of critical importance in the question put to the people — “but not so as to authorise any form of civil conscription”. It was the Leader of the Opposition, Mr (later Sir) Robert Menzies (acting on a request from Sir Henry Newland, President of the BMA Federal Council and a surgeon of great distinction), who moved the amendment, which the government accepted. The referendum enabled the government in 1948 to pass the National Health Service Act 1948–49 (Cwlth). Resistance by the BMA to what it regarded as objectionable features led to an attempt to coerce the profession by enforcing the Pharmaceutical Benefits Act 1947 (Cwlth), which required compulsory use of a Formulary issued to all doctors. (In the event, only 2% of doctors ever used it.) The BMA took the issue to the High Court of Australia, which decided in August 1949 that a section of the Act amounted to civil conscription and was invalid. Later in the year, the heavy defeat of the government, the result of its attempt to nationalise the banks, sealed the doctors’ victory.5 Over the next few years, the coalition led by Menzies introduced a health service based on the principle of voluntary insurance for hospital and medical benefits, which is still in force. There are clear lessons to be learned from this history.

Derek H Meyers

To the Editor: Safe sports participation has become a key national issue, especially in view of the potential for concerns about safety to inhibit sports participation,1 in a nation where obesity rates are rising2 and more exercise is recommended. Australians participate in many sports, but the safety of the football codes is especially criticised by the media and the community because of the intense focus on injuries to players at the elite level. This is particularly the case for Australian Football (AF) and its elite game, the Australian Football League (AFL). National reports released in 2006 have identified AF as the sport most associated with injury admissions to hospital3 and with private health insurance claims.4 These have sparked media commentary about the safety of AF. Response to these injury reports prompted an unprecedented media release5 from the country’s peak sports medicine body, Sports Medicine Australia, detailing issues with the report figures, urging caution in their interpretation and supporting the efforts of the football codes in improving participant safety. The modified version of the game (Auskick), which is played by children, has been shown to be safer,6 but there is a progression to adult rules by the under-15 age group, and the umbrella of safety provided by modified rules is eventually gone, raising the question of how safe the non-modified version is. Recently released AFL figures suggest that injury rates at the elite level are at a historical low,7 but the report provided insufficient information to assess whether this represents a significant decline since 1997, and the data are already one season behind. Equivalent information for the more than 450 000 adult, non-elite participants is not available. Published literature related to injury prevention highlights a dearth of knowledge relating to the causes of injuries in non-elite participants and a very small evidence base for ways to prevent injuries in AF. With AF played almost exclusively in Australia, the onus to provide evidence for improving the safety of participation clearly falls on the stakeholders of the sport here. Gains in reducing both the public health impact of football injuries and the fear of injury associated with participation will only come from substantial investment in large-scale trials at the non-elite level, and a multidisciplinary approach to safety and injury issues across all levels of play. This will require active and committed collaboration of key stakeholders such as clinicians, allied health practitioners, researchers, clubs, sports administrators, coaches and the participants themselves.

Belinda J Gabbe · Caroline F Finch · Peter A Cameron

To the Editor: The recent viewpoint by Kamien1 and letter by Gunasekera2 rightly highlight the benefits of folate fortification and the unlikely occurrence of masking pernicious anaemia. Food Standards Australia New Zealand recently submitted a proposal supporting the mandatory fortification of bread-making flour to increase folate intakes in women of child-bearing age, with the aim of reducing the risk of children being born with neural tube defects.3 This proposal has had extensive public comment and will be considered by the Australia and New Zealand Food Regulation Ministerial Council. Several public groups and individuals continue to raise concerns that higher dietary folate levels could increase B12 deficiency. Our data, collected from a population-based sample of 2596 older people in the Blue Mountains region, from 1997 to 2000, do not suggest that this is a likely outcome. We recently reported the prevalence of low serum vitamin B12 levels in the Blue Mountains Eye Study cohort of people aged 50 years and older. We found that 22.9% had low serum B12 levels (< 185 pmol/L).4 New data from this study show that higher intakes of folate (from diet and supplements) did not increase the likelihood of low serum B12 levels; in fact, people whose diets included folate in the highest quintile of intake had significantly higher serum B12 levels than those consuming lower dietary folate (Box), after accounting for age and sex (P < 0.001). After also adjusting for vitamin B12 from diet and supplements, there was no significant difference in mean serum B12 levels for the various quintiles of folate intake. We also investigated older people who reported consuming high amounts of folate (> 500 μg dietary folate equivalents [DFE] [n = 645] and > 1000 μg DFE [n = 123]) and found higher mean serum B12 levels in these groups than in people who consumed < 500 μg DFE, after adjusting for age and sex (P for trend < 0.001). After further adjustment for vitamin B12 intake, there were no significant differences in mean serum B12 levels for these high dietary folate intakes (Box). We also examined the frequency of macrocytic anaemia in our cohort (n = 6; 0.2%); two of these had low serum B12 levels (0.3% of subjects with low serum B12 levels). In the United States, where mandatory folate fortification began a decade ago, a study of the presence of anaemia in people with B12 deficiency found no significant change in the proportion with anaemia before and after the introduction of mandatory fortification.5 Although many older Australians have low serum levels of vitamin B12, our data show that higher intakes of folate do not increase the likelihood of low serum B12 levels. Given the relatively high prevalence of low serum B12 levels among older people, it would seem reasonable for this to be monitored more frequently in this age group. We suggest that this is not a valid concern that should prevent moves to proceed with mandatory folate fortification of key foods in Australia. Mean serum vitamin B12 levels in a population of older Australians, for various folate intakes (from diet and supplements) (n = 2596) Folate intake Mean serum B12 (95% CI) adjusted for age and sex Mean serum B12 (95% CI) adjusted for age, sex and B12 intake (diet and supplements) Folate (μg DFE) Quintile 1–4 (< 571.8) (n = 2077) 273 (263–289) 278 (267–289) Quintile 5 (> 571.8) (n = 519) 316 (295–337) 297 (275–319) P < 0.001 0.132 Folate cut-points < 500 μg DFE (n = 1828) 273 (261–284) 278 (267–290) 500–1000 μg DFE (n = 645) 294 (276–314) 289 (270–308) > 1000 μg DFE (n = 123) 346 (303–389) 300 (253–348) P for trend < 0.001 0.239 DFE = dietary folate equivalents.

Victoria Flood · Paul Mitchell

To the Editor: The adverse health effects of environmental tobacco smoke (ETS) are well documented. Workplaces are increasingly smoke-free, and restrictions on smoking in restaurants, pubs and clubs are increasing. Paediatricians counsel parents to make their children’s home smoke-free and to smoke outside if they can not quit. In Australia, attention is turning to ETS exposure in cars, in the belief that the confined space may result in increased exposure, even if the windows are wound down. However, few, if any, objective data on the health effects of ETS exposure in cars have been published. We report here the risks of current wheeze at the age of 14 years in children exposed to ETS in their parents’ car. Questionnaire data were available from parents of 1427 children taking part in the 14-year assessment of a longitudinal birth cohort in Perth. Characteristics of the cohort have been described elsewhere.1 Information about current wheeze (defined as the occurrence of wheeze in the previous 12 months) and asthma risk factors, including ETS exposure in the house and car, was obtained. Standard spirometry, methacholine challenge and skin prick tests to local aeroallergens were performed in 1400, 1334 and 1308 children, respectively. Current wheeze was reported in 191 children (14.0%) at the age of 14 years, compared with 537 (38.2%) when they were seen at 6 years of age. Persistent wheeze, at both 6 and 14 years of age, was reported in 145 children (10.2%). ETS exposure in the parents’ car was common. The 14.6% of children who were exposed at 14 years had increased risk of both current wheeze (odds ratio [OR], 1.55; 95% CI, 1.02–2.35; P = 0.038) and persistent wheeze (OR, 2.14; 95% CI, 1.34–3.42; P = 0.001). These risks were higher than those for ETS in the home: for the 8.9% of children exposed in the home, the OR for current wheeze was 1.33 (95% CI, 0.80–2.22; P = 0.27) and the OR for persistent wheeze was 1.98 (95% CI, 1.12–3.50; P = 0.016). Those with current wheeze and ETS exposure in the car had increased methacholine responsiveness: PC20 (provocative concentration required to produce a 20% fall in forced expiratory volume in 1 second) was 5.9 mg/mL in children with ETS exposure compared with 15.2 mg/mL in those not exposed (P = 0.004). These effects were independent of sex and atopic status. These data provide evidence that the community needs to be educated about the adverse health consequences of ETS exposure in cars and suggest that health care professionals should include such education in counselling sessions for families of children with asthma. Teenagers can escape ETS exposure in the home, either by removing themselves or by their parents smoking outside. However, children of this age and younger have no choice but to travel with their parents in the car, especially given the phenomenon of “mum’s taxi” transporting children to school and extracurricular activities. Smoke-free cars are important for all children.

Peter D Sly · Marie Deverell · Merci M Kusel · Patrick G Holt

To the Editor: Refugees are a particularly marginalised group, often originating from countries where immunisation coverage is low.1 As vaccine-preventable diseases such as hepatitis B and measles are endemic in both their countries of origin and the countries in which they spend time in displaced persons camps, the potential burden of disease for refugees is greater than for Australians.2 It is important to determine whether our health systems provide refugees with access to optimal health care, including vaccines. From May 2004, refugee families arriving in Newcastle, New South Wales, have attended the Newcastle Refugee Clinic, where, with the assistance of interpreters, health screening is provided and catch-up vaccination regimens are commenced according to the Australian Standard Vaccination Schedule.3 Vaccines administered are documented in an appropriate personal health record. All age-appropriate vaccines are registered with the Australian Childhood Immunisation Register (ACIR). Families are provided with a copy of the catch-up schedule and, through interpreters, are advised to complete their vaccination schedule through a general practitioner. In NSW, general practices can obtain free vaccines for refugees through public health units. In March and April 2006, there was an outbreak of measles in NSW. A review of ACIR records of refugee children seen over the previous 12 months (May 2005 to April 2006) at our clinic showed that, of the 35 children aged under 7 years, all were overdue for subsequent vaccinations, and only two children had received any additional vaccines after their Refugee Clinic visit. By contrast, vaccination coverage for all children in the Greater Newcastle area is high, and exceeds 90% for scheduled vaccines. Older members of refugee families also required additional vaccines, highlighting concerns that refugee families are not attending general practices for this basic preventive health care measure. While the reasons for this are unclear and need further research, it is likely that multiple factors, including lack of knowledge of the health system, lack of transport, no local government or community vaccination services, and lack of bulk billing by general practices, all play a role. Further, a number of local general practices have closed their books and do not accept new patients. Consequently, catch-up vaccination sessions were conducted at the Refugee Clinic, and transport was provided. Home visits were conducted for families unable to attend these clinics. Seventy-seven people were vaccinated and 209 vaccine doses administered. A thorough assessment of refugees for important medical and psychological conditions is merited soon after they arrive in Australia.4 It is also essential that early access to general practice is secured for continuity of care and completion of vaccination. It is the responsibility of all — the Department of Immigration and Citizenship, contracted resettlement organisations, proposers, public health services and general practitioners — to ensure that vaccinations are accessible to newly arrived refugees. We believe they deserve the same protection against vaccine-preventable diseases as other Australians.

Kylee J Parsons · Maggi Osbourn · David N Durrheim · Murray T Webber

To the Editor: Post-publication audits of the quality of medical research studies are vitally important. I support the conjecture of Nath et al1 that the small number of retractions for mistakes and misconduct (about 20 per year for articles published between 1982 and 2002) represents the tip of the iceberg. I recently wrote a systematic review of studies (published between 1972 and 2005) of growth in children taking stimulant medication for attention deficit hyperactivity disorder (ADHD), and I was astounded by the poor quality of much of the research.2,3 Of the 22 studies reviewed, I felt that 11 were flawed, either because their conclusions were not fully supported by the data, or because of poor methodology, or both. Some had quite subtle mistakes or misinterpretations, such as failure to consider that a child’s height velocity might vary with duration of treatment (two studies). Others were more obvious; for example, a study with a design that introduced systematic errors. Two studies had negative findings associated with inappropriate controls; however, in both of these studies the suitability of the control data was fully discussed. Two studies appeared underpowered, but a full assessment of this could not be made because some of the essential information was either insufficiently detailed or completely lacking. There were three studies lacking any rigorous comparison with control data on which to base their conclusions. I did not detect any trend for studies with unsupported conclusions or flawed methodology to be published in journals with higher impact factors (median impact factor in both groups, 3.9), suggesting that, while these journals might report a higher rate of retractions (as found by Nath et al1), it may not necessarily reflect a higher rate of mistakes or misconduct among their authors. Likewise, the number of authors and level of funding — pharmaceutical industry or otherwise — appeared to be similar between studies whose conclusions were judged as valid or invalid. Nearly all of the more rigorously designed studies showed statistically significant slowing of growth in height during the first 1–3 years of treatment with stimulant medication.2 By contrast, the flawed studies as a group supported the notion that stimulant medication does not have any statistically or clinically significant effect on growth in height, the individual studies varying in the extent to which this was emphasised. None of the studies has been retracted, and it is likely that poor quality research has had a substantial influence on clinical opinion in this area. I do not think that my sample is representative of the quality of medical literature as a whole. I have to admit that my decision to write the review was based on my perception of the poor calibre of many of the studies of growth in children with ADHD. However, I have no reason to believe that the level of poor quality research in my area of interest is unique. While retractions are important, the medical readership also has a responsibility to evaluate the scientific validity of published studies and, when necessary, correspond with the journals.

Alison Poulton

To the Editor: Aspects of the article by Dunbar and his colleagues on the impact of hospital inquiries are disturbing.1 The abstract states, “In the aftermath of the inquiries, common themes included loss of trust in management and among clinical colleagues, and loss of trust from patients and the community”. Rather, the loss of trust in these instances arose from fundamental problems with the culture in the organisations involved. It was this that led to the inquiries. In the case of King Edward Memorial Hospital (KEMH), the Douglas Inquiry was set up to investigate obstetric and gynaecological services at the hospital between 1990 and 2000, and sought “to identify and assess the deficiencies in the provision of those services, over that period”.2 But when the final report of the Douglas Inquiry was originally published in 2001,2 there was a chapter missing, which was only released under Freedom of Information legislation in December last year. I have seen a copy of this “missing chapter”, courtesy of The West Australian newspaper, which gained its release. It revealed various problems with clinical practices at KEMH, many of which were described as “very unsafe” and which had been going on throughout the 1990s. Nearly 100 cases were covered in this missing chapter, but these were only a small selection of the total adverse outcome events, including several deaths, that occurred over the decade. And the reason for not releasing this chapter? It was kept secret for 5 years because of intense lobbying of the state government by members of the medical profession — to quote The West Australian, “The current State Government [caved] in to the medical lobby and kept secret the most crucial chapter”.3 Just before it was released, the President of the Australian Medical Association (WA) was still arguing against its release and was quoted as saying, “I can imagine that it would be very painful to these families who were involved and I very much doubt there is anything in it that would serve the public interest by releasing it now”.4 What about accountability? Transparency? Trust? Dunbar et al state that, “At ... KEMH, there were longstanding problems that had not caused harm”.1 This is an extraordinary comment given that an inquiry was thought necessary, and the clinical problems revealed by this inquiry stretched back over 10 years — during which time no action was taken — until a newly appointed chief executive officer at KEMH, Michael Moodie, blew the whistle. What concerns me most about Dunbar and colleagues’ article is that in the wake of these inquiries, the authors, who “include the Directors of Medical Services who went into the hospitals following these events” (ie, the inquiries), now seek to argue that such matters are best left to be dealt with internally by “health service providers”.1 We need transparency in such matters. The health service “belongs” to the Australian people — or at least it ought to. It is not the doctors’ health service. These inquiries and the details outlined by Dunbar and colleagues show that, in addressing these sorts of problems, we cannot have trust in most internal reporting systems in hospitals. We cannot trust some of our doctors. When will they ever learn?

Gavin H Mooney

In reply: Mooney makes assertions in his letter and elsewhere1 that cannot go unchallenged. He is wrong in stating that the “missing chapter” from the Douglas Inquiry report2 “was kept secret for 5 years because of intense lobbying of the state government by members of the medical profession”. To quote the then Minister for Health, “... sections of the [inquiry’s] report were withheld on advice from the Crown Solicitor, mainly for the protection of patients”.3 Detailed reasons for information provided to the inquiry being kept private were published in 2001.4 I stand by my statement that “I very much doubt there is anything in [the missing chapter] that would serve the public interest by releasing it now”. The report on the Douglas Inquiry made 237 recommendations. The reality is that Dr Bill Beresford, who stepped in as Acting Chief Executive Officer (CEO) of King Edward Memorial Hospital (KEMH), did an outstanding job in implementing the report’s recommendations and making a good but under-resourced hospital much better. Mooney is also wrong to describe Michael Moodie as a whistleblower. He was the CEO of the hospital and accountable for the services it provided. The only person he would be blowing a whistle to was himself, if he failed to act. True, the problems stretched back over 10 years; many of the issues were highlighted in a report released in 1990.5 Among these were the findings that “King Edward is understaffed by 5.2 FTE [full-time equivalent] generalist obstetricians and gynaecologists” and “... the after hours cover is inadequate and potentially unsafe” (Vol. II, p152). I believe it was the failure to act by successive state governments and health ministers, who had the ultimate responsibility for provision of health services, that led to the problems at KEMH. For at least a decade now, the need to collocate Western Australia’s tertiary obstetric services with adult tertiary services has been advocated, so the increasing proportion of mothers with significant comorbidities, including diabetes, heart disease and substance misuse, can have optimum access to services, including adult intensive care. While this principle appears to have been accepted,6 there has been no indication as yet of its implementation. Mooney and the community can trust doctors; the lessons from the Douglas Inquiry have been learnt, and its recommendations implemented.

Geoffrey J Dobb

In reply: We are grateful to Mooney for drawing our attention to the “missing chapter” of the Douglas Inquiry report, which came to light after we had submitted our article for publication. Open and fully public inquiries are necessary for all parties involved.1 To the best of our knowledge, the Douglas Inquiry is the most thorough review ever undertaken of clinical standards in an Australian hospital.2 It is difficult to know how other hospitals would have compared over the same period.3 Our article concentrated on how these hospitals recovered, as organisations, to improve patient safety. We called for “open, honest, and timely investigation undertaken within the organisation”, which avoids prolonging the recovery that, paradoxically, can make hospitals less safe.4 In the United Kingdom, the General Medical Council enforces a national system that puts patient safety first and makes covering up for a poorly performing colleague an offence.5,6 It also requires Directors of Medical Services to act in patients’ best interests. Concerns about a colleague’s performance are handled locally, because experience has demonstrated that this works best for patients and doctors. We would like to see the proposed national registration body for health professionals in Australia make reporting such concerns obligatory.

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

To the Editor: In their report of Hendra virus infection acquired by a veterinarian from an infected horse, Hanna et al1 mention that the likely reservoir for this virus is fruit bats (Pteropus spp.), and suggest that transmission of the virus to horses may be via contamination of pasture by birth products from fruit bats. During 5 years of fieldwork in north-eastern Australia for my PhD thesis on Toxocara pteropodis, an intestinal roundworm of flying foxes,2 which included hundreds of hours observing fruit bats in their natural habitats, not once did I come across a case of natural birth or abortion in fruit bats away from their communal roosts (“camps”), which were always within pockets of dense forest, such as mangrove, eucalyptus or melaleuca swamps. Furthermore, the three coastal fruit bat species exhibited a short, well defined birthing season, generally over 3 weeks from late October through to November. The birthing season of the wide-ranging, inland little red flying fox, P. scapulatus, is 6 months out of phase with this; it produces its young in May3 in remote inland camps. During birth, which is a short process lasting usually less than an hour, the mother bat remains alone, quite separate from and ignored by her neighbours. All my observations of flying fox births were during daylight hours, and in the camps. While it is possible that an individual female might give birth away from her camp while out feeding at night, this would seem to be such an isolated event as to exclude it from being a reliable, and therefore major, transmission route for the virus. Moreover, the first recorded cases of equine and human infection occurred in the month of September,1 further diminishing the likelihood of birth products being the mode of transmission from bats. On the other hand, while feeding in mango trees or on other exotic or native fruits and blossoms growing in horse paddocks, these bats do defecate and urinate frequently; this, to my mind, may be a more likely infection route. Resting in camps, individual bats urinate indiscriminately, contaminating any neighbours roosting below. While out collecting flying foxes for my research, I found it impossible to avoid aerial contamination by their excrement — although I do not recall ever experiencing symptoms suggestive of Hendra virus infection.

Paul Prociv

To the Editor: The enormous influence of the news media on health issues is widely acknowledged,1 and health and medicine rank among the most frequent topics covered.2,3 This influence extends from the setting of personal health agendas to shaping public health policy. Health and medical agencies have an obvious interest in how their areas of concern are depicted, and health interest groups can use the news media as a means of influencing government policy and legislation. Much of the existing research into the portrayal of health topics in the news has been based on newspapers and other print media, yet television is the most popular mass communication medium for Australians.4 A study underway at the School of Public Health, University of Sydney, is investigating how television frames health stories, and how this influences personal, institutional and political priorities. Since May 2005, all news, current affairs and “infotainment” programs concerned with health or medicine on five free-to-air Sydney television channels have been digitally recorded. Recordings are then indexed by category (date, program, broad topic, specific issue, and sources quoted) and stored in a large digital archive that will be used by researchers to undertake critical studies of media content, audience response and deconstruction, and studies of the journalistic framing process. Early returns of the project include a study of media narratives in coverage of Kylie Minogue’s recent breast cancer diagnosis, and an assessment of the impact of this reporting on bookings for breast cancer screenings by mammography in four states.5 Other studies include media depiction of obesity and notions of personal responsibility and a recently commenced analysis of news discourse on prostate cancer screening. Currently, the nearly 9000 news items collected address a broad range of topics including cancer, cardiovascular disease, environmental health, mental health, nutrition, obesity and medical technology. We are keen to collaborate with agencies and researchers who wish to draw on this unique resource for research purposes.

Simon Chapman · Ross MacKenzie

To the Editor: I read with great interest Ellard’s article “The adventures of an alienist” in the Journal’s recent Christmas issue.1 Few have equalled or surpassed Ellard’s contribution to Australian psychiatry. However, as the only member of the College Committee still living, I must take issue with his statement, “In the 1960s, David Maddison created the College virtually single-handedly”. He was, of course, referring to the Australian and New Zealand College of Psychiatrists (the “Royal” prefix not granted until 1978). In May 1962, Dr J D Russell, President of the Australian Association of Psychiatrists, moved at the Council meeting that “Council resolve to take the necessary action forthwith to convert the Association into a College”. The Council appointed a College Committee, consisting of Dr Russell, as Chairman, with Professor David Maddison, Dr Ian Simpson and myself to plan the “necessary action”. At the Council’s annual general meeting in September 1962, members approved the formation of a College and its memorandum and articles of association, and, after legal approval, the College was officially incorporated on 28 October 1963. David Maddison was able to attend only some of the many meetings of the College Committee, but he did make a major contribution to our deliberations. Nevertheless, it could hardly be said that he “created the College virtually single-handedly”.

Bruce H Peterson

In reply: I have no difficulty in accepting Peterson’s comment. My view of what happened at the genesis of the College arose from the fact that, at the time, Professor Maddison and I were close friends and had many conversations about academia and its institutions. This led me to greater awareness of his contribution and less of the contribution of others. I should have been more careful in reaching my opinion.

John H T Ellard

To the Editor: Improving clinical efficiency helps sexual health services deal with the demands of increasing rates of sexually transmitted infections.1,2 Many Australian sexual health centres require all clients to return in person to obtain their HIV test results; legislation only requires those who test positive to return in person.3 Giving HIV test results by phone to low-risk clients may improve efficiency. We determined the proportion of women testing positive for HIV infection at Melbourne Sexual Health Centre (MSHC) between 1 January 1996 and 1 January 2006, and reviewed the files of those who tested positive to determine their risk factors for HIV acquisition. In this period, 16 655 women were tested for HIV and 48 (0.29%) tested positive. For 11 of these 48 women (0.07%; 95% CI, 0.027%–0.10%), this was their first positive test. Six had been born in a high-prevalence country4 and had had sexual contact in those countries (two in South Africa, one in Ethiopia, one in Zimbabwe, one in Kenya, and one in Thailand); two had a sexual partner with HIV; one had had sex with a resident of a high-prevalence country (Thailand); one had had sexual contact in Australia with a man from a high-prevalence country (South Africa); and one had had sex with a bisexual man. All these risk factors were recorded in the patient’s history at the time of initial testing. Of the 37 women who tested positive and whose initial HIV test was performed elsewhere, risk factors were documented for 34. Thirty-one women (91%) had similar risk factors to the 11 who had first tested positive at MSHC. All three women without identified risk factors at the time of testing subsequently discovered their male partners were known to have HIV. We found that fewer than one in 1000 women attending MSHC tested positive for the first time, and all who did had clear risk factors. The upper 95% CI for testing positive among those without risk factors (ie, none in 16 655) was also extremely low and in the order of 1 in 1000. In the light of these findings, it is difficult to justify providing all results in person. MSHC now provides HIV test results by telephone to women without risk factors. Women with unexpected, indeterminate or positive results are recalled. This requires sensitive management to minimise stress and anxiety.

Carol A Hopkins · Rosey A Cummings · Tim R H Read · Christopher K Fairley

To the Editor: The recent editorial by White and Whiteford raises the important issue of the need to provide more extensive and more effective mental health services for the prison population.1 However, their discussion of the reasons for the increased level of need does not consider one important problem that often results in the inappropriate imprisonment of people with mental illness. This is the frequent refusal of acute psychiatric units to accept mentally ill people referred by the courts. I recently reviewed a series of 102 referrals for medicolegal assessment from Legal Aid New South Wales between February 1999 and March 2006. The results were presented at the 2006 meeting of the Forensic Section of the Australian and New Zealand College of Psychiatrists.2 Of the 55 patients meeting the criteria for mental illness under section 32 or 33 of the Mental Health (Criminal Procedure) Act 1990 (NSW), 27 (49%) were seen in custody. For 14 of these patients, their incarceration had resulted from the failure of the local area heath service to accept patients for admission if they had drug-related exacerbations of mental illness. Hospital registrars would return patients to court with a certificate saying that they had no mental illness, even though some of them were currently under a community treatment order recommended by other professionals from the same mental health service. To some extent, this may be because of the strict application of the guidelines for compulsory hospitalisation. These are more stringent than the criteria for defining mental illness under the Mental Health (Criminal Procedure) Act, but one is left with anomalous situations such as the one described above. Important issues leading to this situation appear to be the presence of dual diagnoses (10 of the patients reviewed had a combination of psychosis and substance misuse) and violent behaviour. The rejection of violent patients reflects both occupational health and safety considerations in the context of inadequate resources and an industrial stance (usually informal) taken by the nursing staff. It is therefore important that some of the additional resources recently committed by Australian governments to the reform of forensic mental health services be directed towards the provision of acute hospital inpatient services for disturbed patients, so that the incidence of imprisonment in the acutely disturbed psychiatric population is reduced. This is more humane and may be more cost-effective than simply applying all the resources within the prison system.

Gordon R W Davies

To the Editor: My father, a retired general practitioner now 86 years old, continues to lament the fact that Latin terms have fallen out of use in medical practice. Even today, he can still recite the conjugation of Latin verbs without a mistake, and he likes to tell the story of how Latin helped a young teacher in the 1950s. Although World War II had made it acceptable for single and widowed women to work (but not for equal pay with men!), women who continued to work after getting married were considered to be “stealing jobs” from men who needed to support their families. Today, a pregnancy without a marriage certificate does not even cause a raised eyebrow, but, back then, it condemned a girl to a lifetime of discrimination and gossip. Single pregnant girls went to stay with distant relatives or went to religious homes for “wayward girls”. One day, a GP colleague of my father telephoned seeking advice. He had a young, single, very distressed teacher in his surgery and he had just confirmed her pregnancy. She had told an all too common story about being “unofficially engaged” to her university-student boyfriend and not having the money to get married. Apparently, on finding out about the suspected pregnancy, the boyfriend had decided that this was the time to end their unofficial engagement. The young teacher was still unsure whether to have the baby adopted, try to find a supportive relative, or bring up the child herself. The patient, being a full-time teacher with the Department of Education, was one of the few “lucky women” for whom society considered it acceptable to work and earn a living while married or with children. It was therefore very important that she keep her job. The medical certificate for her employer was to be a very important piece of paper. My father advised his colleague to put the following words on the patient’s medical certificate: “The patient is suffering from non-pseudocyesis and will be unfit for work for 3 months”. The colleague was delighted with this diagnosis. The teacher came to see her GP a short time later and reported that departmental leave had been approved and that her teaching colleagues had wished her well in her recovery. My father’s colleague continued to chuckle about the diagnosis and enjoyed providing the additional leave certificates until full-term delivery, when the non-pseudocyesis miraculously disappeared.

Katherine A Haley