Health services administration

To the Editor:We present a case that illustrates the need for careful medical evaluation of pigmented lesions, and the potential risks associated with laser treatment by non-medical providers. A 56-year-old nurse presented to the Victorian Melanoma Service for management of a biopsy-proven lentigo maligna on her right cheek. The patient described an 18-month history of a growing pigmented lesion that had initially been treated by a non-medical cosmetic clinic using laser. There had been no formal clinical or dermoscopic assessment of the pigmented lesion before the laser treatment. Although initially there was complete clearance of the pigment, the lesion recurred over the following 12 months (Box), prompting the patient to seek medical advice. Relevant melanoma risk factors included a family history of melanoma and significant prior sun exposure. Pigmented lesions should only be treated by medical experts given that the diagnostic possibilities range from benign to malignant pathologies, including melanoma.1 There is an increasing tendency in the aesthetic industry to treat pigmented lesions with modalities such as laser, as if they were merely a cosmetic problem. The potentially fatal consequences of laser treatment of pigmented lesions performed by untrained providers has been described in the literature.1,2 However, causation of melanoma by laser, with resultant malignant proliferation or transformation, has not been proven.2 Nevertheless, performing laser treatments on undifferentiated pigmented lesions can delay diagnosis and lead to more devastating outcomes, including metastasis.2,3 To maintain patient safety, pigmented lesions should be assessed medically before any cosmetic treatment.2,4 There is a vast array of unregulated, non-medical cosmetic practices that may use destructive treatments, such as laser, for pigmented lesions. It is therefore essential to increase the awareness of the general public in the face of this potential danger. Box – Recurring lesion after laser therapy

Harini Rajgopal Bala · Yan Pan · Rosemary L Nixon

To the Editor:I read with interest the Medical Education article by Elder and Nair1 and I was surprised that it suggested that the assessment of the jugular vein pulsation should be done “in whatever position the patient is in”. I am often shocked by the fact that medical students are taught to look for the jugular venous pulsation with the patient positioned at 45 degrees. In a person who is asymptomatic and lying flat, without any obvious distress and who has no fluid retention clinically, the pressures in the right atrium will be in the range of 2–8 mmHg and it would be impossible to see the top of the jugular venous pulsation if the patient was elevated. In most patients, the jugular venous pulsation should be assessed by examining the patient in the supine position. Elevation should only be undertaken if there is obvious fluid retention or dyspnoea when lying flat. If there is any question after examining the patient in the supine position, then the patient may be elevated to ensure that the correct peak of the jugular venous pulsation is seen. However, if students are taught to examine the jugular venous pulsation only when the patient is sitting up, then it will seldom be seen in a person who has normal right atrial pressure. I believe this concern should be brought to the attention of all clinical educators so that they clearly explain when the jugular venous pulsation should be examined in the supine position and when it is necessary to elevate the patient to the 45 degrees position.

Stanley Peter Woodhouse

In reply

Andrew Elder · Balakrishnan (Kichu) R Nair

To the Editor:Zhao and colleagues1 quantified the burden of indigenous health inequality in Australia’s Northern Territory. Any physician who has worked in the NT would agree, although the quantum calculated may shock readers. However, Zhao and colleagues appear to have left out an epidemiological principle in presenting their analysis: stratify appropriately, or risk unbeknown confounding. The authors have not taken into consideration the differences between the regions where Indigenous Australians live. The detrimental causes affecting Indigenous populations in the NT are more intense there than among Indigenous people on Australia’s eastern coast, for example, and increase as one moves away from Darwin to remote areas, across the whole spectrum of causes of inequality. Gray and colleagues,2 cited in the article, list many of the causes of Indigenous health inequality, including “lower levels of education, training and skill levels, … living in areas with fewer labour market opportunities, higher levels of … interactions with the criminal justice system, … and lower levels of job retention”. Employment, or lack of it, integrates and acts as a proxy measure of effect for many of these causes. If Zhao and colleagues had considered this variability of effect, they might have realised that the statement that “between 1994 and 2008, Indigenous employment in Australia increased by 55–70%” is misleading. If Australia is to close the gap between its Indigenous and non-Indigenous people, the government needs to recognise this spectrum of effect across the continent.

Richard X Davey

In reply

Yuejen Zhao

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Paul Zev Zimmet · Judi Moylan · Stephen Colagiuri

Access and funding are the greatest challenges

Davinder Singh-Grewal

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Uma Jatkar · Mitchell D Anjou · Hugh R Taylor