Letters

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

To the Editor: Humans may serve as intermediate hosts in hydatid disease, a parasitic infection caused by the tapeworm Echinococcus granulosus. They are infected through contact with infected dogs or by ingestion of tapeworm eggs in contaminated food, water, or soil.1 The larvae form cysts in body organs. Although the liver is the most common site, lung cysts are seen in up to 30% of cases of hydatid disease. Lung cysts are generally asymptomatic, but symptoms occur if the cysts rupture.2 Here, we describe an adolescent girl with a lung cyst that ruptured across the thoracic cage into the subcutaneous fascia, presenting as a breast swelling. A 14-year-old girl had had left-sided pleuritic chest pain, a high-grade fever, and marked swelling of the left breast for 10 days, which did not respond to antibiotics (oral amoxycillin and parenteral amikacin). Clinical examination revealed a slender, febrile and tachy-pnoeic patient with a tender swelling of the left mammary region. The swelling had a tense cystic feel, and transmitted impulses were felt when she coughed. A diffuse pleural rub was heard anteriorly, with reduced air entry. Investigations revealed a neutrophilic leukocytosis of 12.7 × 109/L. Chest x-ray showed diffuse opacification of the left hemithorax, and a computed tomography scan revealed a cystic, low-attenuation lesion in the left hemithorax extending into the submammary region (Figure A). On anterolateral thoracotomy, an infected ruptured cyst was seen in the left upper lobe of the lung, with degenerated membranes and pus extending across the chest wall into the submammary space. The cyst was removed, capitonnage of the residual cavity was performed, and pus and laminated membranes were removed from the submammary space. Small communications seen between the pus cavity and the bronchi were closed. After the operation, parenteral anti-biotics (vancomycin and amikacin) were administered for 10 days and albendazole for 4 weeks. Casoni’s skin test was positive and antihydatid antibodies were detected in serum. Surgically obtained pus revealed non-viable scolices of E. granulosus (many degenerated), and the histopathology of the surgical specimen was consistent with hydatid membrane (Figure B). Pulmonary hydatid cysts can rupture; however, rupture into the pleural cavity is rare.1-3 Although spontaneous rupture of a cyst into the pleural cavity, or rupture after trauma, has been reported,4,5 a rupture across the pleural cavity into the submammary fascial tissues has, to our knowledge, not been reported previously. A. Computed tomography scan showing a cystic lesion in the left hemithorax, extending into the submammary region (arrow). B. Degenerated hydatid cyst membrane (original magnification × 200).

Parvaiz A Koul · Abdul Wahid · Ghulam N Lone · Tariq A Bhat

To the Editor: St John’s wort (SJW) (Hypericum perforatum) is a natural medicine commonly used for treating depression. We recently encountered a case of an overdose of SJW leading to serious manifestations in the patient. A 16-year-old girl presented to the emergency department with seizures and confusion. She was intubated and admitted to the intensive care unit. The only relevant history was of febrile convulsions at the age of 4 years. There had been no head trauma. Results of a computed tomography brain scan and cerebrospinal fluid examination were unremarkable. Electrolyte levels were normal, and standard drug toxicological screens were negative. An electroencephalogram (EEG) confirmed diffuse spike wave activity consistent with generalised epileptic activity. On further questioning, it was found that she had taken large quantities of SJW — up to fifteen 300 μg tablets a day in the 2 weeks leading up to admission and an additional 50 tablets just before presentation — for a recent “depressive episode”. Depression had not been formally diagnosed, and the tablets had been obtained “over the counter” from a local pharmacy. A provisional diagnosis of seizures due to an overdose of SJW was made. High performance liquid chromatography was not performed to quantify hypericum extract in serum and urine, as these tests are not available in our hospital. A repeat EEG at discharge on Day 6 was normal, and there were no further seizures in the following 6 months. Psychiatric assessment during the patient’s hospital stay revealed a likely suicide attempt following recent social stresses. There is some evidence for the efficacy of SJW in treating depression.1 In the United States and Australia it is available without prescription, but in Germany, where it is prescribed more frequently than fluoxetine for depression, it is available by prescription only. The reported incidence of adverse drug reactions to SJW is 0–5.7%.2 Although these are usually minor and transient, more serious adverse reactions (such as serotonin syndrome) have been reported.3 SJW was implicated as a likely, but unproven, cause of seizure-related events in a recent review,4 but our case appears to be the most severe reported so far. Adverse reactions are thought to be more common if SJW is taken in conjunction with selective serotonin reuptake inhibitors, but have also been described when SJW is taken alone.5

Dharshi C Karalapillai · Rinaldo Bellomo

To the Editor: Sanderson et al provide an interesting viewpoint about how the community, including medical practitioners, have embraced complementary and alternative medicine (CAM).1 However, if we were reviewing this article for publication, we would ask the authors to: make a valid distinction between those complementary and alternative therapies promoted as curative versus those considered palliative; define how they decided which therapies belong to one or other side of the arbitrary CAM boundary; review and justify the boundaries for the “therapeutic footprint” in a more evidence-based and rigorous way; locate specific therapies inside the footprint; locate where chemotherapy lies within the footprint, in light of the recent review showing, for the vast majority of adult malignancies, its marginal survival benefits considering its high costs, both monetary and healthwise;2 emphasise that there are relatively few recorded adverse events for CAM compared with conventional cancer care (Therapeutic Goods Administration Medicine Summary reports 2003, 2004, 2005 — Dr K Mackay, Acting Director, Adverse Drug Reactions Unit, TGA, personal communication); and vigorously question the marketing of conventional medicines, such as trastuzumab (Herceptin, Roche), to vulnerable patients and an uncritical public when the evidence suggests huge expense and little, if any, survival benefit.3 Perhaps a distinction also needs to be made between CAM therapies, many of which provide proven symptomatic relief, and those lifestyle interventions, such as exercise,4 dietary change,5 and social support, which provide symptomatic relief and may also confer a survival benefit. It does not serve the profession well when many cancer patients and their carers have to go outside the medical system to access information, advice and therapies which they should have easy access to within the system. In fact, we might even question how helpful these arbitrary boundaries are when all that patients and doctors want is to use what works and what is safe.

Craig S Hassed · Vicki Kotsirilos · Marie Pirotta · Avni Sali

In reply: We would like to thank Hassed and colleagues for their comments on the “therapeutic footprint” and their questions about locating specific therapies within the model. While it was outside the scope of our article to critically analyse different treatments using the model (as benefits and risks will vary from patient to patient), we would like to direct Hassed et al to a more detailed consideration of the risks and benefits of chemotherapy.1 We do not see our model as a tool to categorise or economically appraise specific treatments, but rather as one to help conceptualise the key issues to be considered when proposing treatment — the evidence for benefits and risks, contextualised according to treatment goals. The model provides a basis for comparison, taking us beyond arbitrary and unhelpful arguments about the distinctions between complementary and alternative therapies and their boundaries. We hope that the model will encourage evaluation of evidence for all therapies and support critical evaluation not only of drugs, but also lifestyle interventions that may benefit patients. The primary or essential purpose of the model is to encourage the posing of questions like those articulated by Hassed and colleagues to any therapist — whether they identify as medical, complementary or alternative.

Christine R Sanderson · Bogda Koczwara · David C Currow

To the Editor: In From the Editor’s Desk in the 20 November 2006 issue of the Journal, Van Der Weyden acknowledged the 100th anniversary of the first performance of George Bernard Shaw’s play The doctor’s dilemma, and the fact that both society and medical practice have since changed dramatically in the ensuing century. He then asked: “. . . what is the modern doctor’s dilemma?”1 Contemporary Australian medical practice faces challenges posed by changes in community and government expectations, free market policies, workforce shortages and infrastructure changes, so this question should not be regarded as rhetorical. Answers to it will depend to some degree on the type of medical practice under consideration and where it is situated geographically, but to get the ball rolling, I suggest that in respect of general practice anywhere in Australia, a significant set of dilemmas surround notions of responsibility. Traditionally, general practitioners have held responsibilities primarily to individual patients. With increasing emphasis being placed, appropriately, on preventive and screening activities, to what extent should GPs’ responsibilities be extended to the community as a whole, and how should any such extension be resourced? Given that the interests of individuals and communities will not always be in accord, how might the resulting conflicts of interests best be managed? And, to increase the complexity of such considerations, to what extent ought responsibility to patients extend to responsibility for patients? Another dilemma for doctors in respect of responsibility relates to identifying the boundaries between altruism and martyrdom. To what extent should health care professionals be expected to put the interests of their patients or of the community before those of themselves and their families? To extend the notion of responsibility further, and with the GP’s role as patient advocate particularly in mind, to what degree should health care professionals be active against social injustices which impinge on their patients’ health? I know that in responding to the Editor’s question I have posed another set of questions, none of which are easily answered — if they could be, they would not be dilemmas. However, acknowledging and clarifying these questions is the first step towards answering them, and also towards preventing much community misunderstanding.

David E Smith

To the Editor: I am one of the septuagenarians described by Arnold in his cri de coeur over the demise of professional courtesies.1 In my medical student days, my teachers extended the courtesy of free medical treatment to my parents. I have continued this tradition, in the certain knowledge that this will be the only situation in which medical students save their parents money. Such professional courtesies are still the norm in Western Australia. But, with the exception of medical colleagues, I have only once, in the 30 years of operation of Medibank/Medicare, had a bulk-billed patient realise that he has received a discount. I recently asked a picture framer/patient for a 40% discount and he laughed. When I explained that by bulk-billing I was effectively giving him a 40% discount, he was incredulous, but he did reciprocate. In the 1970s, Australian Medical Association spokesmen and medical educators often confused etiquette (a code of desirable behaviour between doctors) with ethics (a more important set of moral principles underlying a person’s general behaviour). This is no longer the case, and etiquette has disappeared from undergraduate and postgraduate medical curricula. I think it is time to reintroduce the topic into the education of both our future doctors and our patients.

Max Kamien

To the Editor: There would be few medical students who have not had drummed into them the tautological aphorism, “Common things occur commonly!” And few practising clinicians who have not come across or read about a serious adverse event arising from the actions of a colleague or nurse who thought, “It was only X, which is so common at this time of the year/around these parts/among these people. I didn’t think it was anything serious.” The patient might have been a child with meningitis sent home with a diagnosis of a winter upper respiratory tract infection or a very anxious young woman with an intracranial haemorrhage discharged with a diagnosis of tension headache. Guided by this aphorism, we doctors will almost always make the correct diagnosis, and nurses an accurate assessment of a patient’s complaints, and we will glow with professional satisfaction. But how does this boost to our professional confidence measure up against what should be our paramount concern — the safety of each patient in our care? When assessing junior colleagues, we must, above all else, be seeking reassurance that patients will be safe in their hands. We do not want to hear a junior doctor brushing aside a commonly occurring symptom or clinical sign as of little importance merely because it is common. But we do want to know that he or she has considered, “What is the most serious condition that this could be?”, followed by relevant enquiries into the patient’s history, appropriate clinical examination and warranted laboratory or other investigations. Knowing that the doctor has checked that there is no suggestion of a serious illness, we can be reasonably assured that the patient will be safe. An excellent candidate would make the correct diagnosis sooner and perhaps with less pain, discomfort and inconvenience for the patient, and at less cost to the health care system, than a less able colleague. But the patient will be safe with either doctor, as a dangerous, perhaps life-threatening, illness has been excluded. All that remains is for the correct diagnosis to be made and appropriate treatment administered — a burden for the patient perhaps, but not a disaster. I suggest that readers of the Journal, in their role as teachers, advise their students to abandon that inane and dangerous “commonness” tautology, and replace it with: “Exclude the worst possibility and then assist Nature in its healing processes”.

Peter C Arnold

To the Editor: The National Health and Medical Research Council’s National statement on ethical conduct in research involving humans1 recognises that prisoners can participate in research, but categorises them as “persons in dependent or unequal relationships”. They have limited capacity to provide informed consent. Responding to the high levels of transmission of bloodborne viruses in Australian prisons,2 the Australian Red Cross Blood Service excludes prisoners from donating blood and ex-prisoners are excluded for 12 months after they have been released from prison.3 The New South Wales Human Tissue Act 1983 is silent on whether prisoners can donate organs. We report here the case of a prisoner organ donor, highlighting the administrative, legal and operational hurdles that needed to be overcome. A 53-year-old male prisoner was a suitable living kidney donor for his first cousin. He provided consent willingly and without coercion. At initial assessment, the prisoner’s classification required that he be escorted to hospital and that constant surveillance by prison officers be maintained — at a cost of $1000 per day, for at least 7 days. These costs would have been borne by the family. Furthermore, as Australian prisoners are ineligible for Medicare under the Australian Constitution, the donor, as an uninsured patient, and his family would have been required to pay for all pre-, peri- and postoperative care. The donation was deferred for 14 months while these two administrative hurdles were overcome to permit the donation to proceed: 1. The Commissioner for the Department of Corrective Services gave approval for the prisoner to be reclassified to the lowest security classification, thus removing the need for surveillance while in hospital; and 2. A rarely used provision within the NSW Crimes (Administration of Sentences) Act 1999 was applied. Section 26(1) of the Act allows the Commissioner to issue a permit allowing an inmate to be absent from a correctional centre: (a) on such conditions and for such period as may be specified in the permit, and (b) for such purpose as the Commissioner considers appropriate. This allowed the prisoner to be temporarily reinstated to receive Medicare entitlements. The nephrectomy and transplantation were successfully performed. The donor returned to prison on the seventh postoperative day. The donor organ is functioning 4 months after the operation. Prisoners have a right to participate in organ donor programs; however, their precarious position to provide informed consent needs to be protected.

Elizabeth Magee · Michael H Levy

To the Editor: An important factor in the well documented shortfall of organs and eyes for transplantation is the apparent reluctance of people to agree to donate.1 One nearly universal strategy in attempting to raise donation rates has been to encourage individuals to register their wishes about donation. Although evidence that this strategy increases donation rates is lacking, there is some evidence that more individuals make and communicate a decision with appropriate education.2 Most families consent to donation when the deceased had indicated this was their wish, and virtually none override a stated wish not to donate.3 When wishes are unknown, half of families consent and half refuse.3 Encouraging declaration of intention aims to increase the rate of consent for families who would otherwise not know the deceased individual’s wishes. For this to be successful, most individuals newly recording their wishes must indicate a desire to donate. This assumption has underpinned Australian education campaigns, including “Talk about it”, “Share your life, share your decision”, and most recently the national “Sign on to save a life” campaign.4 A simple review of New South Wales Roads and Traffic Authority organ donation data over the period of these campaigns suggests this assumption may not hold. From 1997 to 2004, a significant proportion of drivers licence holders newly indicated a preference about donation; the proportion indicating some decision rose from 59.4% to 78.6%. Over the same period, the proportion indicating yes to donation of all organs rose from 35.6% to 41.9% (a 17.7% increase); however, the proportion indicating no to any donation rose from 19.9% to 31.4% (a 57.8% increase).5 These results raise the possibility that encouraging individuals to make a decision about donation may increase the number of families who refuse donation. Individuals who had previously not made a decision about donation, when encouraged to do so, displayed an unwillingness to become organ donors at twice the rate of those who indicated willingness. Although it is imperative to recognise and respect the decision of individuals to refuse organ donation, this unwillingness may reflect either formalisation of a considered desire not to donate, or a decision made without personal discussion of fears and concerns about donation. Generalised education campaigns are limited in that they encourage action without addressing fears and concerns. Further policy should recognise a possible danger in simply exhorting the public to make a decision, and research should investigate why individuals are refusing to become organ and eye donors.

Mitchell Lawlor · Frank A Billson

To the Editor: Opdam and Silvester concluded that the small pool of organ donors limits the potential for organ donation in Victoria.1 According to the definition of death in the Human Tissue Act 1983 (NSW): a person has died when there has occurred: (a) irreversible cessation of all function of the person’s brain, or (b) irreversible cessation of circulation of blood in the person’s body. Current cadaveric organ donation takes place predominantly after brain death, although it is also possible after cardiac death. This was previously described as “non-heart-beating organ donation”, but the name was changed to “donation after cardiac death” (DCD) to emphasise that organ donation occurs only after death. DCD can be classified by the Maastricht criteria (Box).2 Category III is relevant in select patients undergoing planned withdrawal of therapy in intensive care units (ICUs). Planned withdrawal of therapy is said to occur in about 60% of all ICU deaths.3 Permission for organ donation is required before the planned withdrawal of life support, so the donor organ retrieval teams can be available and ready to retrieve organs soon after a 5-minute “cooling off” period after circulation ceases. These 5 minutes also allow families to spend time with the deceased after death. A period of less than 60 minutes between withdrawal of therapy and cessation of circulation is recommended to minimise warm ischaemia time in the retrieved organs. Withdrawal of life support may occur in the ICU or in the operating room complex, and local hospital guidelines should address the issue of where this occurs. Between 1989 and 2004, 30 Australian organ donations involved non-heart-beating organ donors (data from the Australia New Zealand Organ Donor Registry). In 2005, eight New South Wales organ donations, accounting for 14% of all cadaveric renal transplantation, proceeded after cardiac death criteria were applied. In our unpublished retrospective audit, 7% of patients who had planned withdrawal of therapy in the ICU met the criteria for eligible organ donors after cardiac death. The organ donor pool for organ donation after brain death was 1.7% in Opdam and Silvester’s study.1 The long-term function of transplanted kidneys is not significantly different for organs retrieved after cardiac death compared with organs retrieved after brain death.4 Liver and lung transplantation are also possible from organs retrieved from non-heart-beating organ donors. Draft guidelines for DCD in NSW are soon to be released by NSW Health. Similar guidelines in other states and education of staff involved in organ donation would no doubt increase the organ donation pool and the potential for organ donation. Maastricht donation after cardiac death protocol categories2 I Dead on arrival (uncontrolled) II Failed resuscitation (uncontrolled) III Withdrawal of support (controlled) IV Arrest following brain death (uncontrolled)

Deepak Bhonagiri · Patricia Wills

To the Editor: In 2004, there were 580 cases of suicide in Queensland, and not 453, as reported by the Australian Bureau of Statistics (ABS) on 14 March 2006.1 These data alone reverse the declining trend for suicide mortality nationally in the most recent years. The Queensland Suicide Register, maintained by the Australian Institute for Suicide Research and Prevention (AISRAP), receives data directly from the Office of the State Coroner, and crosschecks them with other Queensland coroners, the John Tonge Centre (the Queensland Health Scientific Services mortuary), and the National Coroners Information System (NCIS). The ABS receives data from the state registries of births, deaths and marriages, and crosschecks them with the state coroners’ offices. The agreement between the two agencies has been decreasing in recent years, with AISRAP detecting 550 suicide cases in 2003 and 588 in 2002, compared with 466 and 537, respectively, detected by the ABS (Box). The ABS has acknowledged difficulties in getting reliable data for 2004 in a number of endnotes to its yearly report.1 Most of the problems were related to a very large backlog of cases still under investigation by coroners, a phenomenon that is reported as increasing in recent years. A confirmation of problems in official data comes from the NCIS, whose most recent report has evidenced, from 2000 on, declining percentages of completeness in mortality data in Queensland and elsewhere in Australia, with the most incomplete figures in 2004.2 It is important to note that cases that are under investigation and those that end with an open verdict would not enter official suicide mortality data, as these are never reconciled. Following the example of many European countries, it would be desirable to start a periodical publication (eg, every 3–5 years) to provide a more comprehensive picture of suicide mortality, including finalised investigations, reclassified (ex-accidental or ex-undetermined) causes of deaths, and deaths that occurred (especially in hospitals) with a delay from a self-injurious event. This would provide a more credible depiction of suicide mortality in the country, and permit better research.3 Meanwhile, efforts should be made to homogenise certification procedures (International classification of diseases, 10th revision terminology has yet to be extensively adopted) and streamline the bureaucratic procedures (we still suffer from a number of “lost in the system” data). In the registries of births, deaths and marriages, by law, the word “suicide” (or analogous term) does not appear. Frequently, the ABS, which collects data from the registries each month, has to reclassify the data obtained, and integrate the information received with further enquiries. Apart from being time-consuming, this routine does not provide foolproof results, and has potential for improvement. Some underreporting in suicide statistics is virtually ubiquitous,3,4 and has to be tolerated (eg, misclassification as accident, road accident, or disease-related, particularly in the elderly; cover-up because of stigma, sociocultural norms, or insurance reasons; or remoteness of location). However, federal and state governments in Australia are committed to suicide prevention plans that require credible baselines for evaluating their effects. All relevant parties need to work jointly on improving data quality. This is of crucial importance for scientists and policymakers, and for those personally affected by a suicide death. Number of suicides in Queensland according to the Australian Bureau of Statistics and the Queensland Suicide Register (QSR) QSR data were provided by the Office of the State Coroner, the National Coroners Information System and the John Tonge Centre. “Possible” suicides are not included. Data for 2005 are an estimate.

Diego De Leo

To the Editor: We read with interest the “Diagnostic Dilemma” by Peter et al.1 The case raises interesting management issues. The first is initiation of antibiotics. Despite 1 week of fever, rigors, haematuria and loin pain, we are informed that the patient was in no distress at initial assessment. In this situation there is, despite the anxieties of resident staff, no urgent need to administer antibiotics; hospitals are controlled, monitored environments in which observation, review and investigation can be undertaken, within reason, if a diagnosis is not immediately made. The second issue is antibiotic selection. The provisional diagnosis was a urinary tract infection, and ceftriaxone and gentamicin were administered. The justification for the use of two agents with a similar spectrum of antimicrobial activity is not given.2 Likewise, no justification is given for the use of a potent nephrotoxin in the presence of moderately severe acute renal failure. Flucloxacillin was added “to broaden the gram-positive antibiotic cover”. It is not apparent why staphylococcal cover was sought at this stage. All cultures (blood, urine and pleural fluid) remained negative. At Day 14, ceftriaxone and gentamicin were changed to ticarcillin/clavulanic acid and ciprofloxacin “because of persistent fever and rising [white cell count]”; this decision in the absence of positive cultures is not explained. The patient’s renal function deteriorated further and he became profoundly acidotic. In fact, the patient’s renal function had performed heroically, given administration of gentamicin for 2 weeks in the presence of acute renal failure at admission. In the intensive care unit, flucloxacillin was replaced with vancomycin; the rationale is not explained. This case illustrates important points regarding antibiotic use. Despite significant renal impairment at admission, the patient was administered a 2-week course of a nephrotoxic antibiotic, which contributed to renal collapse. This situation would have been terminal if not for supportive intensive care. The treating team appears to have managed the patient as if sepsis were a given, and yet all cultures remained negative. This illustrates a basic but crucial teaching point — fevers, chills, rigors, raised inflammatory markers and neutrophilia do not necessarily equate with sepsis. If this experience reflects routine practice elsewhere (and it is our experience that it does), is it any wonder that we have reached an era in which we now encounter organisms so resistant that they are essentially untreatable?3

Mark A Boyd · Stephen Hedger