Letters

To the Editor: We congratulate Johnson et al on their article, which illustrates a successful hand hygiene program associated with a fall in transmission of multidrug-resistant organisms.1 Their publication is significant for three reasons: It is only the second article2 to demonstrate the anticipated relationship between increased hand hygiene and a fall in multidrug-resistant organism transmission; It again indicates that 100% compliance in hand hygiene is not necessary to significantly improve outcomes;2,3 and It suggests that environmental contamination with MRSA has little relationship to patient colonisation. However, the specific aspects of their program that led to success are not obvious, and may not relate to a sustained response to either education or the provision of alcohol/chlorhexidine hand hygiene solution. Alternative explanations include: The education program and/or overt observation induced a Hawthorne effect on hand hygiene practice; The screening and treatment program induced the same effect on hand hygiene behaviour; or The treatment of MRSA carriers reduced the size of the MRSA reservoir and thus the probability of transmission and subsequent colonisation. Although we agree that the approach of Johnson et al is laudable, without teasing out those causal factors that induce the improvement in hand hygiene in health care workers, it remains expensive to implement and maintain. Moreover, there is no evidence that improved hand hygiene would continue if the alcoholic gel alone remained, without all other aspects of the program. This was recognised in the successful Geneva program on which the protocol used by Johnson et al was modelled. In that study, the authors remained so uncertain as to what elements of the program were causal that they stated: Whether improved hand-hygiene practice will outlast the intervention remains uncertain; we decided to refrain from testing this issue by maintaining a permanent component of the intervention.2 Evidence currently available4 and soon to be amplified5 suggests that hand hygiene practice in health care workers is simply an extrapolation of their community behaviour. Unfortunately, community hand washing behaviour is not microbiologically founded, being developed on the basis of emotion not science. Both the Austin and Geneva protocols supported the introduction of alcoholic hand gel with strong promotion of specific behavioural elements to induce change in hand hygiene practice. Our findings suggest that alcoholic gel is not pivotal to the improvement of hand hygiene, in that behavioural modelling suggests its effect is relatively small and very dependent on concomitant behavioural change.4,5 The World Health Organization World Alliance for Patient Safety has recently advocated the introduction of alcoholic gel into all hospitals.6 While not denying that this is a step toward improvement, we strongly caution against unrealistic expectations of this single intervention. The hand hygiene practices of health care workers are learned behaviours of childhood, continued as professionals, and reinforced in everyone’s daily lives.4,5 Entrenched, longstanding behaviour patterns will not be changed in a sustained fashion by the introduction of a new hand hygiene product.

R Michael Whitby · Mary-Louise McLaws

In reply: Woollard is critical of the lack of randomised controlled data to support the use of alcohol/chlorhexidine hand rub solution (ACHRS). Although a placebo-controlled study would be ideal, it is doubtful whether one could be performed. Apart from the complexity of design and cost, there would be the requirement to ask patients to consent to being treated in a hospital where there was a substantial risk of nosocomial sepsis, but where half the health care workers would not have clean hands when attending them. Woollard argues that our failure to reduce colonisation or contamination with MRSA shows that our project failed. However, he offers no alternative explanation for the reduction in MRSA bacteraemia, clinical MRSA isolates and resistant gram-negative bacteria that we reported. Our project was a multimodal quality intervention, and we cannot know which component of the project resulted in the benefit, or whether the improvement should be attributed to other confounders, as suggested by Whitby and McLaws. However, we have presented all our data so that readers can draw their own conclusions. It seems unlikely to us that the intervention on which we concentrated our major effort, the progressive introduction and promotion of ACHRS, would be the one component that failed to contribute to the improvement. Woollard also mentions the potential toxicity of asking health care workers to scrub with a chemical agent, and proposes the use of gloves instead. Our ACHRS is a quick to apply, self-drying solution. It is rubbed on the hands, but scrubbing is not required. We actively monitored rates of cutaneous reactions and found it to be extremely well tolerated.1 Gloves must be changed between patients or when moving from a dirty to a clean site.2 We know that busy health care workers often do not have time to do this, and that hands can become contaminated despite the use of gloves.3 We agree with Whitby and McLaws that simply providing ACHRS, without an active campaign to support its use, is pointless. The provision and promotion of ACHRS is a tool to assist health care workers improve hand hygiene, and is just one component in a web of interventions needed to control nosocomial sepsis. Whether it is cost-effective depends on the largely unknown costs to Australian hospitals of preventable infections. At our institution, we believe that it is worth the money, and continue to require all clinical staff and students to know where to find and when to use ACHRS before they start work.

Paul D R Johnson · M Lindsay Grayson

To the Editor: Last year was the 60th anniversary of the liberation of the Nazi concentration camps. We would like to draw your attention to an anatomy textbook, Atlas of topographical and applied human anatomy, authored by a Nazi physician, Eduard Pernkopf, and the alarming evidence which has emerged about the source of subjects used for the illustrations of this book. The context of raising this issue is that this text is listed as available for loan in a general collection on the catalogue of several university libraries around Australia, including the University of Sydney, the University of New South Wales, the University of Adelaide, the University of South Australia, La Trobe University, the University of Western Australia, the Queensland University of Technology and the University of Tasmania, often with multiple copies, which suggests that it may be held as teaching material. Evidence overwhelmingly suggests that the Pernkopf anatomical atlas contains pictures of victims of the Nazi regime. An investigation into this issue by the University of Vienna in the mid 1990s revealed that at least 1377 bodies of murdered victims, including children, were accepted by the Institute of Anatomy.1 The bodies of the victims were used, without the victims’ or their families’ consent, for research and teaching, including by Pernkopf for his atlas.1,2 Pernkopf, an enthusiastic Nazi, took over as Dean of the Vienna Medical School after the annexation of Austria by Nazi Germany, and led the expulsion of the then majority Jewish faculty, including several Nobel laureates.3 He is known to have willingly accepted specimens from murdered children and adults. Original editions, even as recently as 15 years ago, contained swastikas painted at the bottom of the pictures. These have been airbrushed out in more recent editions.4,5 Internationally, there have been a number of different approaches to managing this item within library collections. Some have asked their libraries to remove this book from their general collections. For example, a US physician, upon finding the book in his centre’s library, convinced them to expunge it from their collection. He also resigned from editorial responsibilities to the publisher of the atlas, and cancelled his subscriptions to their journals.1 Another approach has been placing a summary of the report from the University of Vienna’s investigation inside the front cover of the book, so that library patrons are given the context for the drawings and can make an informed choice.1 While acknowledging the need to preserve freedom of access to information, the unethical use of executed victims for this atlas leads us to believe that it has no place as a general anatomy text in an academic setting. The atlas may have a role as a reminder of the atrocities committed in the name of medical science during the Nazi era, and could remain available for researchers examining abuse of human rights, medical ethics and history. We have contacted our library (the University of Sydney library) about this atlas and asked them to take appropriate action. They have elected to move copies held in high usage collections to special collections. We urge others whose institutions hold this text to do the same.

C Raina MacIntyre · Catherine L King · David Isaacs

To the Editor: Music is often played in operating theatres, for a variety of reasons. It has been shown to decrease the anaesthetic requirements of patients1 and the autonomic reactivity of surgeons,2 and not to interfere with laparoscopic task performance under non-clinical conditions.3 However, I have witnessed several events that have “pushed back the boundaries” of this common practice. In one case, a surgeon requested that a videocassette player and monitor be moved into the operating suite before a major operation. Thinking that this might be for educational purposes before use of a new technique, the nursing staff obliged. After the operation was under way, the surgeon directed that a commercial videocassette of an opera be taken from his briefcase and played during the operation. The anaesthetic team were concerned about this, and the video player was turned off when the operation became more difficult. In another case, a surgeon undertook an operation while listening through ear-bud headphones to low-level music from his digital music player. Before the operation began, the anaesthetist questioned the surgeon about the wisdom of this practice and asked several times if it might interfere with communication or concentration. The operation proceeded without incident with the surgeon listening to his music. These examples may represent extremes of practice, but they do remind us that we should remain vigilant and not allow developments in entertainment technology to interfere with patient care. Further studies are required to determine the effect of these practices on technical performance and decision-making of surgeons and also communication between staff in the operating suite.

Richard H Riley

Comment: Ask most surgeons about their operating theatres, and they will describe them as havens from the stresses and pressures of a busy clinical practice. The theatre protects them from the interruptions of telephone calls, the demands of patients and their relatives, and the politics of medicine. It is a microcosm where a surgeon may rule autocratically. Within reason, most theatre personnel would gladly accommodate any means that might diminish the stress or enhance the smooth running of an operation. Techniques such as dimming the lights, decreasing human traffic, eating lollies and playing music are common practices in operating theatres. As a surgeon, I find background music essential during surgery. It masks the chatter of the scout nurse, the telephone conversation of the anaesthetist, and the beeping of the diathermy machine and the electrocardiograph monitor. Without the pleasant background sound of ABBA or the love songs of Elvis, my stress levels would be compounded by every other audible distraction. The question of whether surgeons should be able to use whatever means necessary to achieve the best outcome, even if the anaesthetic and nursing staff perceive it as inappropriate, could only be answered with a prospective study using patients’ clinical outcomes as the end-point. With so many variables, a study of this nature would be impossible. Personally, I have no objection to the scenario in Riley’s second case if the surgeon can maintain adequate communication with the scrub nurse. However, I cannot accept that a person would not be distracted by watching a video while operating. Even if the surgeon was simply listening to the music, the video playing on the monitor would be a distraction to other theatre personnel. I agree with Riley that we must continually re-evaluate technology in the workplace. Patient care is paramount, and, unless audiovisual technology is helping us achieve this end, we would be wise to return to simpler times.

Charles Teo

Ivan Cher Retired Ophthalmologist, 54 Aroona Road, Caulfield North, VIC 3161. ursivanATbigpond.net.au To the Editor: McCallum and Smith’s1 quest for pathology in children’s literature took me back 50 years, to a memorable weekend in New Zealand. News had reached Wellington on the previous day that Hilary and Tenzing had climbed Everest — a coronation gift to Princess Elizabeth, who was to be crowned on the following Tuesday. On the morning of Sunday, 31 June 1953, I was on paediatric call at Wellington Public Hospital. I had been told of the admission of a boy of 11 months, who was neither short of breath nor otherwise ill, despite being very blue. As I approached the ward I could hear him crying at the top of his clarion lungs. He was, as it were, “blowing his horn”, upset at being abandoned by his parents, who would have to wait four more hours for visiting time. (Such was the cruel practice in those days.) He was standing in his cot bellowing energetically. Apart from his dramatic discolouration, he looked well. I expected a cardiac tetralogy, but he had turned blue only the previous day and there was no evidence of a heart or lung problem. I was bewildered with no idea of a diagnosis. I called my boss, John Harding, and met him in the corridor. Even before entering the ward, the paediatrician sniffed and said, “There’s a child here with diabetes.” Of course he was right, and sure enough, it was my little boy blue. I learned a lot that day: A child with diabetes mellitus can be acutely keto-acidotic; Our patient’s distressed cries probably disguised hyperventilation; In some people, acidosis can lead to methaemoglobinaemia; and I am unable to detect acetone from diabetics, although I can recognise its smell from a bottle. My little boy blue was too young for agricultural responsibilities and was not somnolent, so couldn’t have been the prototype for the rhyme.

Ivan Cher

Elizabeth May Pepper,* Dominique A Cadilhac,† Dora C Pearce,‡ James Burrow,§ Tarun S Weeramanthri¶ * Neurology Registrar, John Hunter Hospital, Newcastle, NSW. † Manager, Public Health Division; ‡ Biostatistician; National Stroke Research Institute, Melbourne, VIC. § Neurologist; ¶ Physician, Royal Darwin Hospital, NT. hornblowerATinternode.on.net To the Editor: Although the age-standardised stroke mortality rates among Australia’s Indigenous people is more than twice that of the non-Indigenous population,1 the medical literature contains only one audit of Indigenous stroke patients in Perth metropolitan hospitals.2 No review of hospital care has been reported. Royal Darwin Hospital (RDH) is the referral centre for Australia’s “Top End”, where 8.7% of Indigenous Australians reside; 40% of RDH inpatients are Indigenous. In 2002, while planning for the RDH stroke service, we audited stroke admissions from the previous year. Among 121 eligible patients admitted between 1 July 2001 and 31 June 2002 with International classification of diseases, 10th revision, Australian modification (ICD-10-AM) codes 160–164 (haemorrhages [subarachnoid, intracerebral, other non-traumatic intracranial] and cerebral infarction), records for 116 (96%) were available, but six patients were excluded because of incorrect coding. Box 1 outlines patient characteristics, while Box 2 examines risk factors and medication use for ischaemic stroke (because haemorrhages were few). Despite the observed differences between subgroups, there were no significant differences in mortality (4/36 for Indigenous v 7/42 for non-Indigenous; P = 0.204) or stroke severity at admission or discharge. Box 3 highlights differences in risk factors between Indigenous males and females. Retrospective data, particularly from a sample identified by medical record coding, should be interpreted with caution. In addition, the potential for random error due to small numbers, and the referral bias inherent in tertiary hospital admissions, mean our results may not truly represent the “Top End” Indigenous population. However, our data corroborate findings that Indigenous Australians suffer premature cerebrovascular disease, and have higher rates of vascular risk factors than other Australians,1 with some risk factor differences between males and females. Further, recent evidence suggests differences in standards of stroke care in regional (Queensland) hospitals.3 We found disparity in hospital care of Indigenous patients, and this requires further detailed investigation. A prospective, community-based study is urgently needed. 1 Baseline characteristics for 110 patients admitted to Royal Darwin Hospital with subarachnoid, intracerebral, and other non-traumatic intracranial haemorrhages and cerebral infarction in 2001–02 Baseline characteristics Indigenous Other P Number of patients 45 65 Female sex 22 (49%) 19 (29%) 0.018 Mean age (years) 54 61 0.005 Rural dwelling 41 (91%) 22 (34%) < 0.001 Ischaemic stroke 36 (80%) 42 (65%) 0.081 2 Risk factors and medication use for the 78 patients who had ischaemic stroke Risk factors and medications Indigenous Other P All patients 36 42 Smoking 23 (64%) 11 (26%) 0.001 Diabetes mellitus 16 (44%) 10 (24%) 0.030 Rheumatic heart disease 8 (22%) 1 (2%) < 0.001 Males 19 (53%) 30 (71%) 0.089 Smoking 14 (74%) 12 (40%) 0.017 Diabetes mellitus 10 (53%) 7 (23%) 0.030 Females 17 (47%) 12 (29%) 0.089 Smoking 9 (53%) 0 0.002 Rheumatic heart disease 6 (35%) 0 0.026 Antiplatelet therapy Before admission 11 (31%) 19 (45%) 0.078 Admission 20 (56%) 38 (91%) < 0.001 Discharge 18/32 (56%) 29/35 (83%) 0.013 Anticoagulant therapy Before admission 4 (11%) 1 (2%) < 0.001 Discharge 4/32 (13%) 6/35 (17%) 0.235 3 Risk factor differences between Indigenous males and females who had ischaemic stroke Males Females P Number of patients 19 17 Hypertension 16 (84%) 6 (35%) 0.003 Non cerebral vascular disease 6 (32%) 1 (6%) < 0.001 Excessive alcohol intake 7 (37%) 1 (6%) < 0.001

Elizabeth May Pepper · Dominique A Cadilhac · Dora C Pearce · James Burrow · Tarun S Weeramanthri

Annabelle D Donaldson,* Raymond C Chan,† Iain B Gosbell‡ * Infectious Diseases Registrar, Department of Microbiology and Infectious Diseases, Liverpool Health Service, Sydney, NSW; † Infectious Diseases Physician, ‡ Director, Department of Microbiology and Infectious Diseases, South Western Area Pathology Service, Locked Bag 7090, Liverpool BC 1871, and Conjoint Associate Professor, School of Medical Sciences, University of New South Wales, Sydney, NSW. i.gosbellATunsw.edu.au To the Editor: Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is usually susceptible to a wider range of antibiotics than nosocomial or multiresistant MRSA, but evidence is lacking to guide antibiotic choices. Rifampicin plus fusidic acid is commonly used in multiresistant MRSA infection, and familiarity makes this combination attractive for CA-MRSA. We report two cases of CA-MRSA infection in which rifampicin resistance developed during treatment. Non-compliance may have been a significant factor, but high bacterial load and persistent foci of infection were also likely contributors. We caution against using regimens containing rifampicin in such cases. Patient 1: A previously well 16-year-old girl presented with a 4-day history of left knee pain. She had fever and a moderate joint effusion. Plain x-rays were unremarkable, and blood cultures showed no growth. An aspirate of the knee joint had a white blood cell count of 1100 × 106 cells/L, but showed no growth on culture. Non-multiresistant MRSA (sensitive to all non-β-lactams) was subsequently grown from a synovial biopsy specimen. She was treated with 7 weeks of intravenous vancomycin, followed by 6 months of oral rifampicin (450 mg daily) plus fusidic acid (500 mg twice daily). Her compliance was uncertain, and she did not return for follow-up appointments. The patient presented again 12 months later with increasing pain in the left knee and thigh. X-ray and magnetic resonance imaging revealed extensive osteomyelitis of the distal femur. Culture of purulent material removed at sequestrectomy grew MRSA with the same sensitivity profile as previously, but now resistant to rifampicin. She was treated with clindamycin, but required further sequestrectomy. She continues to take clindamycin long term. Patient 2: A 74-year-old man developed severe cellulitis and an abscess of his left hand after a golfing injury. He had bacteraemia with non-multiresistant MRSA (sensitive to all non-β-lactams). He also had significant pain in his left prosthetic hip. After 7 weeks of intravenous vancomycin and oral moxifloxacin, levels of inflammatory markers remained high. He was treated with oral rifampicin (600 mg daily) plus fusidic acid (500 mg twice daily) for several weeks until lost to follow-up. Four months later, the patient still had pain in the hip, and rifampicin plus fusidic acid treatment was begun again. After 3 months with no improvement, he underwent surgical exploration, and the loose femoral prosthesis was replaced. Culture of debrided material showed MRSA with the same sensitivity pattern as previously, but now resistant to rifampicin. He was treated with intravenous vancomycin for 6 weeks, followed by trimethoprim–sulfamethoxazole, which was later changed to clindamycin because of intolerance. He remains taking indefinite clindamycin suppression therapy. Traditional oral therapy for MRSA infection is rifampicin plus fusidic acid, but alternative oral agents for non-multiresistant CA-MRSA include clindamycin,1 tetracyclines2 and trimethoprim–sulfamethoxazole.3 There is wider experience with clindamycin, which penetrates well into skin and soft tissues, has good oral bioavailability, and has been used successfully.1 However, a concern is erythromycin-inducible clindamycin resistance, which may lead to clindamycin failure, particularly in severe infections.4 Its prevalence varies. Studies in vitro have shown that rifampicin resistance develops as readily in CA-MRSA as in nosocomial MRSA,5 through a single-step mutation. Resistance did not develop in vitro to clindamycin,5 suggesting it may be a more reliable alternative in situations where compliance is uncertain, the bacterial load is high, or the source (eg, an infected prosthesis) cannot be removed. Further in-vitro and in-vivo investigations are urgently required to determine the optimal drug therapy for CA-MRSA infections.

Annabelle D Donaldson · Raymond C Chan · Iain B Gosbell

Tania Shelby-James,* Amy P Abernethy,† David C Currow‡ * Research Fellow, Southern Adelaide Palliative Services, Repatriation General Hospital, 700 Goodwood Road, Daw Park, SA 5041; † Assistant Professor of Medicine, Duke University Medical Center, Durham, North Carolina, USA; ‡ Professor, Department of Palliative and Supportive Services, Flinders University, Adelaide, SA. tania.shelby-jamesATrgh.sa.gov.au To the Editor: Aoun and Kristjanson’s article highlighted some of the difficulties facing researchers in palliative care1 and questioned the role of randomised controlled trials (RCTs). These difficulties do not exempt palliative care from seeking to improve care through thoughtful research but, rather, highlight areas that need to be specifically designed to cope with these difficulties. In our recently completed large RCT of palliative care in southern Adelaide, for which we recruited 461 patients,2 we were able to overcome many of the obstacles cited by these authors. As they rightly stated, many trials in palliative care are pragmatic. This should not be seen as a bad thing, as pragmatic studies are designed to test clinically relevant interventions3 within diverse populations across different settings and to report on a broad range of health outcomes. Such studies are more in keeping with the realities of palliative care. We would argue that traditional RCTs that examine a specific intervention within a specific patient type are less applicable to a palliative care population. In such a population, unlike many other areas of health, the diagnosis and prognosis do not dictate care needs. Among the methodological issues, recruitment and retention are perhaps the biggest hurdles to be overcome. We found that developing systematic, evidence-based protocols, which were pilot tested before initiating the trial, significantly enhanced recruitment.4 To minimise burden, we ensured that all data collection was kept to a minimum and, where possible, data were recorded by study staff or collected from other sources as part of routine clinical encounters. Sample size calculations need to allow for attrition caused by increasing severity of disease. This will, however, inflate the numbers required for a study. Use of multiple sites for recruitment is a strategy that we have used successfully to reach sample size goals. The article states that “RCTs are seldom acceptable to patients and their families”.1 This has not been our experience. Patients are willing to participate in research and find it a meaningful way to give back to the community.5 The challenge is to ensure that this willingness to participate in research is not exploited by palliative care researchers. The other ethical concern raised by Aoun and Kristjanson is the use of a control arm in which patients “deliberately have support services withheld”. We would agree that, if that were to happen, it would be a serious ethical breach. For RCTs in palliative care, the control arm should consist of the standard care provided — the rationale for doing a trial is that there is equipoise regarding the benefit of the intervention. We feel that RCTs are feasible and appropriate for palliative care research.

Tania Shelby-James · Amy P Abernethy · David C Currow

Jennifer Tieman,* David C Currow† * Project Manager, † Head, Department of Palliative and Supportive Services, Flinders University, c/- Repatriation General Hospital, 700 Goodwood Road, Daw Park, SA 5041. Jennifer. TiemanATflinders.edu.au To the Editor: Aoun and Kristjanson’s viewpoint on palliative care research reminds us of the possible limitations of an evidence schema that is built on efficacy of intervention studies.1 For emerging fields and for care areas that cross disciplines, the possible sources of useful knowledge to guide practice — particularly in advance of the establishment of a significant evidence base — need to be recognised and valued. To further complicate the gathering of evidence for such fields are the difficulties of accessing useful knowledge. Preliminary research on search strategies suggests that even good quality searches may recover fewer than half the articles relevant to palliative care in the general biomedical literature.2 More disturbing is the possibility that much of the research and thought in this field is not published, and therefore cannot be easily and actively searched. In a systematic review of publication rates associated with conference presentation, the usual publication rate was seen to be around 45%.3 A recent investigation into publication rates associated with conference presentation in palliative care in Australia suggests a “conversion” rate of less than 20%.4 Publication represents an important step in the spectrum of knowledge dissemination. Such a low rate of publication of conference abstracts therefore represents a significant loss of information, opinion and evidence for the discipline of palliative care. Evidence issues for complex and emerging areas are complicated not only by the restrictions of an evidence hierarchy that is intervention based, but also by the difficulties in searching and retrieving existing knowledge and evidence in such fields.

Jennifer Tieman · David C Currow

C Scott Masters,* Michael J Yelland† * Vice-President, Australian Association of Musculoskeletal Medicine, Caloundra Sports Medicine Centre, 39 Minchinton Street, Caloundra, QLD 4551. † Associate Professor of Primary Health Care, Griffith University, QLD. scotty1ATozemail.com.au To the Editor: Paoloni and Orchard provided a concise summary of the evidence for injections for soft-tissue injuries,1 but omitted some important references on the mechanism of action of corticosteroids and on prolotherapy. An important action of corticosteroids is blocking of transmission in nociceptive C-fibres.2 Given the lack of evidence of inflammation in chronically painful tendinopathies,3 this is a more probable mechanism of action than the suppression of inflammation. Paoloni and Orchard correctly report that steroids have only a temporary effect in suppressing soft tissue pain. However, in low back pain, if their use is preceded by manual therapy and exercises they have the potential to give more prolonged relief of pain and disability.4 A recent Swedish randomised controlled trial (RCT) of polidocanol prolotherapy injections for chronic Achilles tendinopathy showed reduced pain and normalisation of ultrasound abnormalities.5 Similarly, a New Zealand case series of glucose prolotherapy injections showed very positive results for the same condition.6 An Australian RCT into prolotherapy for chronic low back pain (average duration, 14 years) showed sustained reductions in pain and disability with glucose prolotherapy injections, although similar results were obtained with saline injections.7 A pilot study of glucose prolotherapy in 24 elite male kicking-sport athletes with chronic groin pain (mean duration, 15.5 months) who had failed physical therapy reported a pain-free state and return to sports in 82% at an average follow-up of 17.2 months.8 This evidence would suggest there is a role for this glucose prolotherapy in managing soft-tissue pain, especially as musculoskeletal pain is one of the major presentations to primary practice in Australia. Training primary care physicians in prolotherapy injection techniques should be a priority in medical education.

C Scott Masters · Michael J Yelland

Justin A Paoloni,* John W Orchard† * Conjoint Senior Lecturer, Orthopaedic Research Institute, St George Hospital Campus, University of New South Wales, Sydney, NSW. † Sports Physician, Sports Medicine at Sydney University, Sydney, NSW. pao_26AThotmail.com In reply: We thank Masters and Yelland for their interest in this topic and their notification of additional references, some of which were published after our article was written. We stated in our article that “the mechanism of any effect of corticosteroid injections in reducing symptoms in purely degenerative tendinopathies is unknown”, and that only where bursitis or tenosynovitis is present would the implication of an anti-inflammatory effect be appropriate.1 While blocking nociceptive C-fibres in normal tendon is demonstrated in the study quoted by Masters and Yelland,2 we still believe that corticosteroids should be used with caution for any tendinopathy where tendon weakening would be potentially harmful. We agree that corticosteroids have a much greater potential role in low back pain, which is a broad entity involving both soft-tissue and joint disorder. At the time of writing our article there was a pilot study on polidocanol in painful tendons displaying neovascularisation;3 we thank the authors for advising that a randomised controlled trial has since been published.4 While undoubtedly an exciting new therapy, proponents of polidocanol do not consider its mechanism to be simply a “prolotherapy” effect; they also consider sclerosing the neovessels to be critical, and therefore, that hypertonic glucose (the most commonly recommended prolotherapy agent) may not work as well. We still maintain that prolotherapy currently lacks evidence of efficacy for the treatment of soft-tissue injury in general, although it is relatively cheap and generally free of side effects. Both chronic low back pain, and chronic groin pain, are multifactorial conditions involving joint/bone abnormality which we considered slightly beyond the scope of an article on soft-tissue injuries. We await further publications on the efficacy of prolotherapy with interest.

Justin A Paoloni · John W Orchard

Henry Ekert Haematologist, Children's Cancer Centre and Department of Haematology, Royal Children's Hospital, PO Box 2096, Brighton North, Melbourne, VIC 3186; and Haematology Advisor, Australian Government Department of Health and Ageing. ekerthenryAToptushome.com.au To the Editor: The editorial on mandatory fortification of flour with folic acid by Maberly and Stanley is subtitled: “The scientific benefit is clear, but translating this into practice requires advocacy”.1 The only benefit that is scientifically clear is the reduction in the incidence of neural tube defects. All the other “benefits” listed by the authors are observational and have occurred in a setting where myriad environmental changes have occurred concurrent with folic acid fortification. To imply that the reduction in the rate of heart attacks and stroke is the result of folic acid fortification is, at best, anecdotal, because it is not supported by any randomised controlled studies, and is an extrapolation from the relationship between reduced homocysteine levels and the incidence of stroke and heart disease. The authors also did not mention the increased incidence of multiple pregnancies that has been observed with folate supplementation (relative risk, 1.02; 95% CI, 0.97–1.07).2 While this represents only a slight increase in the risks associated with the birth process, it should not be ignored when considering perceived risks. It is also possible that in a planned pregnancy where the mother is prescribed folic acid before conception, the additional folate intake from fortified flour may further increase the risk of multiple pregnancy. It seems to me that the editorial was in fact an item of advocacy rather than a dispassionate scientific assessment of the arguments for and against mandatory folic acid fortification. At the very least, if mandatory folic acid fortification is implemented, prospective mothers will have to be made aware of the increased risk of multiple pregnancy and the as yet unknown risk of combining the fortified diet with medically prescribed folic acid.

Henry Ekert

Fiona J Stanley,* Glen F Maberly† * Director, Telethon Institute for Child Health Research, PO Box 855, West Perth, WA 6872. † Professor of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA. fionaATichr.uwa.edu.au In reply: Ekert suggests that in our article advocating for mandatory fortification with folate to reduce neural tube defects,1 we omitted to mention the “increased risk of multiple pregnancies”. He then misquotes the Lumley meta-analysis “(relative risk, 1.02; 95% CI, 0.97–1.07)” — the real relative risk was 1.40 (95% CI, 0.93–2.11). This Cochrane systematic review shows that folate supplementation does not carry a statistically significant risk for multiple births, but confirms the dramatic reduction in neural tube defects.2 Another study, which did suggest an increased risk, did not control for the known increased risk of multiple births following infertility treatments, which could explain the increase observed.3 Ekert suggests that we inform women about this unsubstantiated risk and “the as yet unknown risk” which mandatory fortification might add to “medically prescribed folic acid”. Folic acid is found in leafy green vegetables and in many fruits, nuts and other components of a healthy diet. Tablets are available over the counter. What advice would he give to women about these “risks”? Our evidence is that we are not reaching many women in our society by education and voluntary fortification, and that countries that have fortified their flour have achieved much better reductions in these major defects than we have in Australia. Hence our advocacy. We acknowledge that the evidence for stroke and heart disease reduction is not as solid as that for neural tube defects. However, there is an increasing literature on the protective effects of folate on cardiovascular risk and possible mechanisms.4-8 Hence, with consideration of the proven benefits and the unsubstantiated risks, we will continue to advocate for the mandatory fortification of flour with folate.

Fiona J Stanley · Glen F Maberly

Paul D Fitzgerald General Practitioner, Suite 303, 83 Mount Street, North Sydney, NSW 2060. docfitzATihug.com.au To the Editor: It is heartening to see a positive professional response to clinical quality systems in the wake of Bundaberg. However, these are secondary responses, and overlook the primary, preventive solution. Clinical monitoring systems presuppose that some damage is done before a problem becomes apparent. Hospitals already have mechanisms to examine clinical competence, and their appointments credentialing and privileging procedures. The Queensland Health Systems Review Final Report (the Forster report)1 comments repeatedly on the apparent failure of these procedures in the Patel case at Bundaberg Hospital: It appears that the process of checking credentials did not involve the College of Surgeons and no written clinical privileges appeared to have been granted on appointment. (p 169) The report draws specific attention to special purpose registration for areas of need, pointing out the inherent conflict of interest: As an employer under pressure to fill medical vacancies, Queensland Health faces a conflict of interesting making . . . determinations of area of need to allow special purpose registration of overseas trained doctors. (p 175) It adds that these doctors are not subject to the same requirements as locally trained doctors, and recommends: No overseas trained doctor should commence employment in a senior position intended to be filled by a specialist before . . . [assessment via the established Australian Medical Council / Specialist College pathway]. (p 174) Furthermore, deemed specialists should participate in the usual clinical performance management processes applicable to all doctors. (p 175) And, finally: . . . local clinical leaders and managers have a conflict between credentialing someone about whom they are uncertain and having no one to deliver the service. It appears that these issues may have been relevant at Bundaberg. (p 176) More recently, the Queensland Public Hospitals Commission of Inquiry report (the Davies report)2 confirms a practice of appointing overseas trained doctors as senior medical officers in specialist roles in hospitals in designated areas of need. Such appointments in Bundaberg, Hervey Bay, Townsville and Charters Towers not only bypassed procedures for recognition as a “deemed specialist”, but were also not considered by hospital credentialing and privileging committees. The Davies report states that, in some hospitals, these committees did not exist. It may be premature for the proponents of clinical quality systems to dance on the ashes of Bundaberg. These recent reports outline a chain of existing systems problems including the Medical Board, the Department of Health, successive Health Ministers and Cabinets, and appointments, credentialing, privileging and complaints procedures in a sample of Queensland public hospitals. According to the Davies report (section 6.173), around half of the doctors in Queensland public hospitals were appointed under area-of-need arrangements by 2002. How are other states balancing the politically sensitive area of need registration with long-standing appointments, credentialing and privileging procedures?

Paul D Fitzgerald

David van Gend Queensland Secretary, World Federation of Doctors who Respect Human Life, Mackenzie House Medical Centre, 116 Russell Street, Toowoomba, QLD 4350. vangendATmachousemedical.com.au To the Editor: As politicians prepare to debate the Therapeutic Goods Amendment (Repeal of Ministerial responsibility for approval of RU486) Bill 2005,1 one question is central: why should mifepristone require special approval from the Minister of Health and Ageing, when all other drugs are simply assessed by the Therapeutic Goods Administration (TGA)? The answer is that abortifacients such as mifepristone are unique in that they are the only drugs designed to end a human life, and therefore their use demands a unique level of ethical assessment and accountability, beyond the scope of the TGA. The TGA has the vital but limited role “to ensure the quality, safety and efficacy of medicines”. These criteria are adequate for assessing most medications, but inadequate for a drug designed to extinguish life. The TGA in its approval process does not consider ethical criteria.2 However, without broader ethical considerations, such as what medical conditions might justify the use of mifepristone, or the moral status of the life to be extinguished, no meaningful assessment of an abortifacient can be made. Abortion “on demand” (ie, without medical justification) is readily available in Australia, even where, as Judge Fred McGuire stated in a Queensland case: “There is no legal justification for abortion on demand”.3 Evidence for the predominantly non-medical justification for abortion was documented in a 1995 survey of women seeking termination of pregnancy in New South Wales.4 The most frequently listed contributing factor, given by 60% of the 2249 respondents, was “financial concerns”. Younger women were more likely to cite youth, career, single parenthood and changes to lifestyle, while women aged over 30 were more likely to cite completed family and problems in their relationship with their partner. Because abortion law is under state jurisdiction, the federal government has no stated position on abortion “on demand”. Now that it is being asked to authorise a drug for abortion, the government has the opportunity and responsibility to defend basic standards of law and ethics by limiting mifepristone use to medically essential terminations of pregnancy, excluding abortion for non-medical reasons. The government should establish, in consultation with medical authorities, valid medical indications for mifepristone, including certain cancers, hormonal diseases, and medically essential termination of pregnancy, and approve the drug for those uses. The criteria could be specified using the existing authority prescription mechanism. This would exclude abortions for which there is no medical indication; for this category, the compelling task for government and the profession is to address the underlying social stresses for which abortion is seen as a solution, reconstructing social supports for women distressed by unplanned pregnancy. Certainly, setting ethical parameters for the use of mifepristone will not affect the availability “on demand” of surgical abortion, which operates without effective ethical or legal restraint. Yet, even largely symbolic acts can be important. If it is right ethically and medically to set limits on the use of abortifacients such as mifepristone, these limits should be set. The medical profession should use the debate on mifepristone to reaffirm ethical limits on abortion, upholding our duty of care to both mother and unborn baby. Disappointingly, in the debate so far, leaders of organised medicine have limited discussion of mifepristone to sterile technical matters of safety and efficacy, as if ethical concerns have no bearing on public policy or medical practice.5 Much expert advice would be needed concerning authentic medical grounds for the use of mifepristone, and even then the authority prescription system could still be abused. But at least the attempt will have been made to establish valid medical indications for this gravest of medical acts, and the profession will be seen to distance itself from abortion “on demand”.

David van Gend

Philip L P Morris Psychiatrist, 16 Riverbank Court, Ashmore, QLD 4214. pmorrisATiprimus.com.au To the Editor: In their letter on “GP Psych Opinion”, Wong and Tiller highlighted the poor uptake by general practitioners of a psychiatric consultation service based in a private psychiatric hospital in Melbourne.1 They compared the results of their service to the similar poor uptake by GPs of the public hospital-based psychiatric consultation service in Brisbane.2 One explanation for this disappointing result may be that most psychiatric illness is chronic, and continuity of care and advice from a consistently available psychiatric colleague is of great importance to GPs — over and above having the patient assessed. This does not seem to have been a strong characteristic of the Melbourne service, given that the assessing psychiatrist was a psychiatric trainee registrar, who is usually either rotating between clinical placements as part of training, or waiting to move on to a more senior position. GPs’ referral practices to specialists are based on a multitude of influences, of which availability is only one. Personal contact, quality of service and continuity of assistance are highly relevant. Perhaps if the Melbourne and Brisbane consultation services can push on and attend to these issues, then utilisation by GPs will increase over time — as this is what happens in more conventional private practice referrals.

Philip L P Morris

Dorothy L Robinson Senior Statistician, Armidale Air Quality Group, Building W46, University of New England, Armidale, NSW 2351. drobinsoATmendel.une.edu.au To the Editor: There should be no contradiction in recommending that people enjoy recreational exercise when air pollution is low but nonetheless walk/cycle for transport.1 I cycle home after 5 pm, when pollution increases to health-hazardous levels (Box), but it is astounding to see people out jogging in such unhealthy air. Cycling for transport is undoubtedly better than driving. Despite dangers from pollution and busy roads, commuter-cyclists have 40% lower mortality than drivers.2 Nonetheless, cycling in diesel fumes at concentrations typically present on busy roads causes significant damage to blood vessels,3 and should be avoided if there is a choice. This concept is no harder to understand than the concept that moderate intake of mono- and polyunsaturated fats is beneficial but excessive saturated fat intake is bad. Regrettably, this distinction was once considered so complicated that people were told simply to reduce all fat consumption. Until people understand the hazards of air pollution, controls will remain inadequate. In Sydney, Melbourne, Brisbane and Perth, air pollution causes an estimated 1611 premature deaths every year, with more than 3000 estimated for Australia as a whole. The most serious health problems relate to fine particles (PM2.5), emitted predominantly by diesel-powered vehicles and woodheaters.4 Winter measurements in Liverpool, Sydney, follow a similar temporal distribution to those in Armidale, in regional New South Wales (Box), suggesting that both regional and metropolitan residents should jog at lunchtime in winter, rather than after work. A recent review estimated that health costs of PM2.5 emissions in urban Australia range from $100 to $300 per kilogram of particles. A typical woodheater (emitting 20 kg of these particles every winter) therefore generates $2000–$6000 in health costs — considerably more than switching to non-polluting heating.4 Older (pre-1990) diesel cars and utilities emit about 0.75 g PM2.5 particles per kilometre (13.8 kg per 20 000 km), generating estimated annual health costs of $1380–$4140. This exceeds the cost of converting to liquid petroleum gas or retrofitting a particle trap/oxidation catalyst. When PM2.5 pollution was reduced in Dublin by banning non-smokeless coal in 1990, there were 2154 fewer deaths in the first 6 years of the ban than the previous 6 years (15.5% fewer respiratory and 10.3% fewer cardiovascular deaths/year).1 Euro II emission limits for new diesel-powered vehicles became mandatory in 1996/97 in Europe (and in 2002/03 in Australia). Simple, cost-effective measures for reducing the major sources of urban PM2.5 pollution — including converting or retrofitting diesel-powered vehicles that exceed Euro II limits, phasing out woodheaters and strongly discouraging stubble-burning in areas where it increases smoke pollution in rural towns1 — would significantly reduce pollution-related illness. It would also allow cyclists, pedestrians and joggers to exercise whenever desired, with fewer worries about air quality. Hourly concentrations of fine particle pollution (PM2.5 measured by nephelometer scattering coefficient) in Armidale (regional NSW) and Liverpool (Sydney) on the first occasion (11 June 1997) that Sydney residents were asked to reduce pollution by not using woodheaters. (Data sources: Sydney, NSW EPA; East Armidale, Armidale Air Quality Group, with assistance from CSIRO Department of Atmospheric Resources.)

Dorothy L Robinson

Katina Kardamanidis,* Bruce Armstrong† * Research Fellow, Injury Prevention and Trauma Care, The George Institute for International Health, PO Box M201, Camperdown, NSW 2050; † Head, School of Public Health, University of Sydney, NSW. kkardATdoh.health.nsw.gov.au To the Editor: Not all asylum seekers in Australia are confined to detention centres. Those who arrive with a valid visa live in the community. If they apply for refugee status within 45 days of arrival, they are entitled to work and to Medicare while their refugee claims are processed;1 if they apply too late, they are denied these benefits. In New South Wales in 2003 about 1500 men, women and children were in this situation, which may last from 3 months to 3 years. Asylum seekers who appeal a refusal of their application, or are released from mandatory detention with an application outstanding, are in the same situation.2 Some are eligible for the federally funded Red Cross Asylum Seeker Assistance Scheme, but, for most, access to health care is jeopardised because they are unable to pay full fees for medical services.3,4 We asked health professionals working with asylum seekers about the costs of asylum seekers’ difficulties in accessing health care. Their responses, with illustrative quotes, are divided into “tangible costs” and “intangible costs” (Box). Some individuals and institutions sympathetic to the plight of asylum seekers give their professional time or donate money to pay for health care, but are not able to address the full range of health care needs. Obtaining access to secondary care, particularly admission to hospital, is very difficult. There is no uniform approach to charges, either between hospitals or within any one hospital on different occasions. The approach seems to depend on the decision-maker present. Such difficulties in accessing care may lead to uncomplicated health problems developing into chronic and more serious ones. The attempt to save costs is likely to lead to higher costs in the future. The effect on asylum seekers is increased physical, psychological and social disadvantage and diminished opportunities for a healthy life. Health professionals are faced with the dilemma of turning these people away, or aiding them without financial compensation. In either case, they cannot provide the necessary standard of care. Although many Australians are conscious of the hardship of these people, the society as a whole seems unaware of it or of the impact that its unfairness may have on the social fabric of their communities. If all Medicare-ineligible asylum seekers in NSW were to have the same access to health services as other Australians, we estimate that the total annual cost would be about $3.4 million.5 This is about 0.015% of the total annual recurrent health expenditure in NSW in 2000–01.6 This economic cost, some if not most of which will be spent regardless, does not justify the disadvantage created by the Australian Government’s immigration rules. We suggest that state governments consider giving this small group of asylum seekers free access to public hospital services. Costs of asylum seekers’ difficulties accessing health care and who bears the costs: responses of health professionals working with asylum seekers Theme Illustrative quote Tangible costs Insufficient voluntary aid to address all health needs “We have one patient . . . with a urinary infection, and it was decided that . . . he needed a TURP [transurethral resection of the prostate], and then they realised he didn’t have any funds and they discharged him . . .” Inconsistent attitudes of hospitals “There’s quite a difference between different hospitals. For example, the X hospital at Y is very tough. . . . much tougher than the hospital here, on refugees. . . . They are different Area Health Services . . . it may not even be the Area Health Service directors, but the hospital manager’s idea that these people should pay.” More costs in the long term “I have a lot of patients with diabetes and high blood pressure . . . Now if their diabetes or their blood pressure or their cholesterol is not managed properly, then they get heart disease or strokes. So, I have a patient who has had a stroke . . . high blood pressure and so on . . . if he had [had] better access to health care, would he have had the stroke? . . . So [now], the government has had to pay . . . it doesn’t make any sense really.” Intangible costs To the asylum seeker (recounted by a health professional) “If you say to someone, I really think you need to have this test, but, if I refer you, you have to pay a lot of money, so I’m not going to refer you, how does that make you feel? It makes you feel worried and powerless.” To health professionals “. . . if someone came in complaining about it [diarrhoea, losing weight], you would do a whole lot of checks, and with that particular lady . . . we were able to negotiate to get a couple of tests done free, and the family and she paid a certain amount of money to get some others [done] . . . if the person had Medicare, you’d take it that step further and do extra just to be 101% sure. So, there is that real ethical dilemma . . .” To the Australian society “. . . if people actually knew on a face-to-face level . . . what it meant to deny a newborn baby the right to health care, [or] . . . turn away someone who is extremely depressed . . . [Would they] actually be able to say ‘No, they don’t [have a right to health care]’.”

Katina Kardamanidis · Bruce Armstrong

To the Editor: British authors Wilson and Parker in their editorial on hospital in the home1 acknowledge the outdated Cochrane review of 20012 in relation to costs of hospital in the home. More recent research in New South Wales provides compelling evidence of cost saving in excess of 50% when community costs are compared with inpatient costs for certain diagnosis related groups.3,4 Patient selection for these services is based on safety, functional ability, carer support, and consent. The treatment regimens are based on evidence and governed by strict quality assurance. These elements form the foundations of successful acute and post-acute care programs. Amendments to the National Health Act 1953 (Cwlth) in 2001 endorsed the provision of acute care in places other than hospital beds.5 The Macarthur Health Service in south-western Sydney received Commonwealth acute outreach accreditation in 2004 and currently supplies at least 13% of total bed-days in the specialties of medicine, surgery and paediatrics. An added benefit is a system that allows people to choose a private outreach service instead of a hospital bed and have expenses covered by their health fund, which pays a bed-day rate for this care in the community. Patient quality of care, choice and satisfaction have been the drivers for hospital in the home. Demonstrated savings for ambulatory sensitive diagnoses and the opportunity for revenue from private patients should be appealing to hospital administrators in an environment of chronic bed shortages. Editor’s note: The Cochrane review was updated after Wilson and Parker submitted their editorial: Shepperd S, Iliffe S. Hospital at home versus in-patient hospital care. Cochrane Database Syst Rev 2005; (3): CD000356. Available at: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000356/frame.html (accessed Dec 2005).

Stephen F Wilson · Nicholas Collins

Allen C Cheng,* Andrew J Hughes,* Julian B Stella,† Eugene Athan* * Infectious Diseases Physician, Hospital in the Home Programme, Department of Infectious Diseases, † Emergency Department Physician, Geelong Hospital, Geelong, VIC 3220. allencATmenzies.edu.au To the Editor: We note with interest the studies published in the Journal by Richards et al and Ong et al.1,2 The authors conclude that treating pneumonia and pulmonary emboli in an ambulatory setting is safe for selected patients. However, this represents a large change in the conditions traditionally treated on this basis, from conditions that are associated with a very low mortality (such as cellulitis) to a subgroup of patients with potentially serious infections that are identified as being of low risk. We feel that safety is of prime importance in hospital-in-the-home programs because of limited or delayed access to acute medical care, and that both studies were underpowered to define this endpoint. Both studies incorrectly quote previous work that suggests that the groups they have identified have mortality rates of up to 5% (for pulmonary emboli) and up to 9.2% (for mild to moderate pneumonia). Published data suggest that the mortality of mild pneumonia (with CURB-65 scores ≤ 2) is in the range 1.7%–3%,3,4 and that mortality from treated sub-massive pulmonary emboli is in the range 1.0%–1.3% within the first week.5 These rates, although seemingly small, are still much higher than that associated with the treatment of soft tissue infections on ambulatory care programs. Recurrent pulmonary embolus, in particular, may be sudden and unexpected. Although admission to hospital may not necessarily prevent these deaths, the additional trauma of a death at home, particularly soon after transfer to ambulatory care, may carry a higher significance in the minds of patients, their families and the public than a death in hospital. We acknowledge that benefits for patients in ambulatory treatment programs need to be balanced against potential adverse outcomes. However, if these conditions are to be treated where access to medical attention may be delayed, it is imperative that informed consent be obtained from patients (including an awareness of the possibility of death), a mechanism be available for patients to summon urgent attention at any time, and patients and health care providers be aware that readmission to the hospital may be necessary in the event of clinical deterioration.

Allen C Cheng · Andrew J Hughes · Julian B Stella · Eugene Athan

Dee A Mangin (née Richards),* Les J Toop,† Michael J Epton,‡ Graham R B McGeoch,§ G Ian Town,¶ Simon M H Wynn-Thomas,** Robin D Dawson,†† Michael C Hlavac,‡‡ Anja M Werno,§§ Paul D Abernethy¶¶ * Senior Lecturer, † Head, †† Research Fellow, Department of Public Health and General Practice, ‡ Senior Lecturer, ¶ Dean, ‡‡ Research Fellow, Department of Medicine, Christchurch School of Medicine and Health Services, Otago University, PO Box 4345, Christchurch, New Zealand; § Director, Community Care, ** Medical Director, Extended Care @ Home, ¶¶ Manager, Health Services, Pegasus Health Independent Practitioners Association, Christchurch, NZ; §§ Community Patholgist, Canterbury Health Laboratories, Christchurch, NZ. derelie.manginATchmeds.ac.nz In reply: Thank you for the opportunity to reply to the letter from Cheng et al. The mortality figures we cited are correct.1 The cited article by Lim et al supports our statement that “Patients with a CURB-65 score of 0–2 have a low mortality (0.7%–9.2%)” (Table 4 shows mortality for CURB-65 score 0 is 0.7% and for score 2 is 9.2%).2 The 3% figure in the abstract is a summary measure obscuring the difference across the CURB 0–2 range — important information for anyone considering community management of community-acquired pneumonia where, we agree, safety is paramount. The rate of 1.7% cited by Cheng et al is for a modified CURB-65 score, which adds a further point, and thus is for the equivalent of CURB-65 scores of < 1.3 Cheng et al correctly observe our study was not powered to detect mortality differences. As explained in our discussion, mortality was not a primary outcome measure. With low mortality, large numbers are required to detect a statistically significant difference — the base rate of 3% in the validation study would require 10 602 patients in a randomised controlled trial to detect a 33% relative (1% absolute) increase in mortality. The study did provide for informed consent (including the possibility of readmission) and the ability to summon urgent attention. Careful patient selection, routine twice-daily nurse and daily doctor visits, along with a highly trained nurse available by telephone 24 hours a day who can dispatch a doctor or nurse immediately, provides a structure that should match hospital care. Careful patient monitoring will detect failure to respond as expected. It is important to treat in hospital those who will benefit, but not feasible to admit all with potential mortality risk (nor is there evidence of benefit). Hospitalisation also has risks. With this tool for predicting accurately who will suffer worse outcomes, it could be argued there has to be good evidence that better outcomes will result from continuing inpatient treatment of mild to moderate community-acquired pneumonia. These wider issues are worthy of debate. There is an assumption by some professionals and consumers that hospital-sanctioned death is more acceptable, that everything possible has been done, and that community-based death implies unsatisfactory management. As a counterpoint to this, there is a clear patient preference for treatment in the home where possible. Avian influenza may, of course, drastically redefine our expectations about locus of care and of death.

Les J Toop · Michael J Epton · Graham R B McGeoch · G Ian Town · Simon M H Wynn-Thomas · Robin D Dawson · Michael C Hlavac · Anja M Werno · Paul D Abernethy

Bin Soo Ong,* Margaret A Karr,† Daniel K Y Chan,‡ Anthony Frankel,§ Qing Shen¶ * Director, Department of Ambulatory Care, † Research Manager, ‡ Director, ¶ Research Assistant, Department of Aged Care and Rehabilitation, § Respiratory Physician, Bankstown-Lidcombe Hospital, Locked Mail Bag 1600, Bankstown, NSW 2200. bin.ongATswahs.nsw.gov.au In reply: We acknowledge the concerns of Cheng and colleagues regarding the safety of patients with pulmonary embolism (PE) treated in an ambulatory care setting. Caution is important as this is a relatively new area of treatment in ambulatory care compared with the management of deep venous thrombosis. The main objective of our study was to describe our experience in the management of PE in ambulatory care; it was not a randomised controlled study to conclusively define safety as such. As stated in our paper, there have been reports of the management of PE in the ambulatory care setting.1,2 We now know that more than 90% of patients with sub-massive PE will have a good response to treatment. The challenge is to accurately define this group. The mortality rate we quoted of less than 5% was derived from a review article on prognosis of patients with PE.3 This article quoted three studies on sub-massive PE, one of which was referenced by Cheng and colleagues in their letter.4 We note also that the specific study that was referenced4 included patients with cyanosis and shock; these patients would have been excluded by our selection criteria. We do not advocate management of all patients with sub-massive PE in the ambulatory care setting. It is also important to be conservative initially in the selection of these patients. There have been various studies examining prognostic indicators for PE, which we have referenced in our paper. There is evidence now that, for patients with specific prognostic indicators, the risk of death and adverse outcomes is significant and such patients should always be admitted. The practice of managing patients with sub-massive PE should only occur in ambulatory care units which are appropriately resourced, have strict admission criteria and well defined protocols and specialist medical input, consistent with the recommendation of the British Thoracic Society.5 In the meantime, further studies are required before this becomes standard practice in ambulatory care or hospital-in-the-home units.

Bin Soo Ong · Margaret A Karr · Daniel K Y Chan · Anthony Frankel · Qing Shen

Stephen F Wilson,* Peter McGeorge† * Program Director, Population Health, Sacred Heart Rehabilitation Centre, † Director of Mental Health Service, St Vincent's Hospital, Darlinghurst, NSW 2010. stwilsonATstvincents.com.au To the Editor: Corbett’s recent proposal to create a “Ministry for the Public’s Health” has merit. However, this Ministry may not achieve its intended purpose in relation to disadvantaged people, chronic and complex health care, or the mental health problems confronting acute services in today’s urban communities. The current situation may be the result of long neglect of population health. However, a new Ministry runs the risk of becoming yet another compartment within an existing non-integrated health care system. The efficiencies of an integrated service for acute health care of older people are well known.2 This integration requires a reinvestment in community care and changes in roles and relationships of health workers. There is currently a gap between services maintained by state funding for acute care in and around hospitals, and services which are federally funded for the community sector via general practice, preventive and maintenance services. The gap created between these two workforces results in suboptimal “management” of chronic and complex disease and mental health, and care of disadvantaged groups. The lack of a strong focus on management drives patients to rely on the acute health care system, particularly emergency departments. This situation is aggravated by the poor coordination with general practice, non-government organisations and community services. The current challenge is to develop a health environment which simultaneously addresses the present and future needs for prevention, management and response. Another approach is to construct a health “sandwich”, with a foundation layer of population health, a “filling” of illness management services, and a top layer of acute response and hospital services. A model guided by the mission of St Vincent’s Hospital, and implemented in 2005, has created a partnership for emergency department, community health, aged care, rehabilitation and palliative care within an administrative division called Population Health. A Psychiatric Emergency Care Centre within the emergency department has established a shared approach to acute patient care along with the mental health services. In the future, a patient entering the emergency department for an acute response to physical, mental or combined illness should also be “consuming” a health program of management and disease prevention, which is lacking in current health service provision. This healthy sandwich may prove easier to digest than the dry biscuits of policy.

Stephen F Wilson · Peter McGeorge

Frank H Beard,* Jeremy M McAnulty,† John W Tapsall,‡ Angelo M Zaia§ * Senior Medical Officer, Communicable Diseases Unit, Queensland Health, 147-163 Charlotte Street, Brisbane, QLD 4001; † Director, Communicable Diseases Branch, NSW Health, Sydney, NSW; ‡ Senior Specialist in Microbiology, SEALS, Prince of Wales Hospital, Sydney, NSW; § Molecular Biologist, University of Melbourne, VIC. Frank_BeardAThealth.qld.gov.au To the Editor: We report two cases of serogroup B meningococcal disease, caused by genotypically indistinguishable organisms, where transmission is likely to have occurred on a school bus. To our knowledge, transmission of meningococcal disease on a bus has been reported only once before.1 In June 2005, two cases of serogroup B meningococcal disease in teenagers from the same school were reported to the Northern Sydney Public Health Unit. Patient 1 had symptoms of fever, headache, vomiting, and an erythematous rash. Two days after onset of this patient’s symptoms, Patient 2 also developed fever, headache and vomiting. In both cases, diagnosis of meningococcal disease was confirmed by polymerase chain reaction (PCR) testing of cerebrospinal fluid (CSF). CSF cell counts were consistent with bacterial meningitis, but blood and CSF culture were negative, despite lack of prior antibiotic administration. The patients were in different school years. No obvious links, such as common classes, sporting teams, or mutual friends, could be found. However, they reported travelling on the same buses to and from school each day. These buses carry up to 78 students (53 seated and 25 standing) from the patients’ school and other nearby schools. The patients reported that the buses were usually crowded. Chemoprophylaxis was provided 8–9 days after symptom onset in Patient 2 to 132 students who claimed to have travelled on these buses during the exposure period. The two patients recovered fully and returned to school. No subsequent cases of meningococcal disease have occurred at the school. In the absence of meningococcal isolates, porA/porB genotyping2,3 was conducted on the meningococcal DNA contained in the CSF samples, and yielded identical sequences. While genotyping is not routinely conducted, porA/porB sequence nomenclature can be equated with serotype/subserotype (phenotypic expression of porA/porB). All 38 serogroup B isolates to date in NSW in 2005 have had serotyping/subserotyping performed, with no other cases having a serotype/subserotype equivalent to that of the two cases reported here. This supports the school bus as the most likely setting of transmission, given the lack of mutual friends and activities identified between the two cases. Asymptomatic nasopharyngeal carriage of meningococci is common, with about 10% of individuals being carriers at any one time.4 While crowding and close contact increase transmission of meningococci, factors leading to invasive disease are poorly understood.5 Antibiotic chemoprophylaxis is given to close contacts to eradicate nasopharyngeal carriage and limit disease spread.5 However, the absence of further cases among the 132 fellow travellers in this setting does not provide evidence of effectiveness of the chemoprophylaxis, given that the secondary attack rate, even in close household contacts, has been estimated at 2–4 per 1000 people.6 Current Australian guidelines recommend that, in school-based outbreaks, chemoprophylaxis be considered for a wider group than solely close contacts of a household nature.7 This report provides evidence to support chemoprophylaxis in similar circumstances, where linked cases are identified in school bus co-travellers, and no other, more specific natural grouping makes epidemiological sense.

Frank H Beard · Jeremy M McAnulty · John W Tapsall · Angelo M Zaia