Medical practices

Re: “Use of thoracic computed tomography by general practitioners”, by Graham Simpson and Garry S Hartrick, in the 2 July issue of the Journal (Med J Aust 2007; 187: 43-46). A university affiliation of one of the authors was omitted. Graham Simpson’s affiliations are Director, Thoracic Medicine and Regional TB Control Unit, Cairns Base Hospital, Cairns, QLD, and Clinical Associate Professor, Department of Medicine, James Cook University, Cairns, QLD. The html and pdf versions of this article have been corrected.

Graham Simpson · Garry S Hartrick

To the Editor: I note with interest the results of the study by Morris and colleagues comparing survival outcomes for patients with colorectal cancer treated in public and private hospitals.1 Stage of disease is a major determinant of survival in colorectal cancer, yet, as stated in their article, stage of disease was derived solely from pathology reports. I believe that this method would have very limited accuracy in diagnosing stage IV disease. Determining stage IV disease requires additional investigations such as computed tomography, which may either not have been performed before surgery, or the results of which may not have been noted on the pathology request form. Underdiagnosis of stage IV disease appears likely, as the incidence of stage IV disease of about 10% noted in this study is substantially less than the 20%–25% incidence observed in other epidemiological studies.2 Moreover, the limitations associated with the use of pathology reports to determine stage IV disease have been observed by other investigators.3 Although this study evaluates an interesting question in relation to the management of colorectal cancer, the significant possibility of an imbalance of important prognostic factors (such as tumour stage) between public and private patients creates major doubt about its conclusions.

Niall C Tebbutt

To the Editor: We suggest that marked differences in comorbidities could be one explanation for the superior outcomes for patients with colorectal cancer treated in private hospitals as reported in the study by Morris et al.1 We also have concerns about the quality of the data used in their study. We used a comprehensive prospective database to examine a cohort of Victorian patients treated at the Royal Melbourne Hospital (n = 260) and the adjacent Melbourne Private Hospital (n = 118) between 2003 and 2006. Specifically, we included data on important patient variables that were not considered in the Western Australian series (Box). These data showed a clear bias towards improved postoperative and long-term survival outcomes for patients in the private system, independent of cancer treatment. Significantly, diabetes, which affected a much larger proportion of public than private hospital patients, is also associated with inferior cancer-specific outcomes.2 Together, these results could explain the differences reported by Morris et al. In support of this, the 5-year cancer-specific survival rates they report for stage I cancer in the two hospital groups is similar (89% public versus 92% private), but the overall survival rates are markedly different (74% public versus 85% private) — consistent, we contend, with an excess of non-cancer deaths in public patients. Morris et al also report an imbalance in the receipt of adjuvant chemotherapy between public and private patients, possibly a marker of inequality of care. We analysed prospectively collected data for our patients with stage III colon cancer, where adjuvant chemotherapy has a proven impact on survival. As shown in the Box, a similar percentage were offered, accepted and completed adjuvant chemotherapy, suggesting, in Victoria at least, similar access to care and support for public and private patients. The pathology-based staging used by Morris et al may also be inaccurate, as recording of stage IV disease relies on the surgeon noting this on the pathology request form and patients having been fully evaluated before surgery (we contend that preoperative computed tomography scanning would not have been routine). This may explain the relatively low percentage of patients recorded as having stage IV disease (12% public; 9% private) compared with 17% in our combined series in which prospective clinicopathological staging was used. Finally, inaccurate data are suggested by the reported 5-year overall survival figures for patients with stage IV cancer (17% in private care).1 That this is superior to figures reported in recent clinical trials is an unexpected finding, particularly as clinical trials enrol only a select subset of patients and provide access to novel combination chemotherapy, and presentation with metastatic disease is an adverse prognostic factor. Comparison of public and private hospital patients with colorectal cancer Public hospital Private hospital P Number of patients 277 122 Smoker 141 (51%) 16 (13%) < 0.001 Diabetes 57 (21%) 8 (7%) 0.002 Emergency presentation 22 (8%) 2 (2%) 0.02 ASA score* 1 28 (10%) 36 (30%) 2 131 (47%) 32 (26%) 3 89 (32%) 22 (18%) 4 15 (5%) 0 Unknown 14 (5%) 32 (26%) Stage III colon cancer 64 38 Chemotherapy advised 50 (78%) 30 (79%) 0.22 Patient followed advice 44 (88%) 29 (97%) 0.12 Chemotherapy completed 28 (64%) 21 (72%) Chemotherapy not completed 16 (36%) 8 (28%) Toxicity 7 (44%) 3 (38%) Patient request 4 (25%) 0 Ongoing computed tomography 3 (19%) 4 (50%) Other 2 (12%) 1 (12%) * American Society of Anesthesiologists physical status score.

Suzanne Kosmider · Ian T Jones · Ian P Hayes · Peter Gibbs

In reply: The first issue is whether we accurately identified patients with stage IV disease, as the incidence in our study was only 11% and the anticipated incidence is normally 20%–25%. We agree that simply reviewing pathology reports would tend to underdiagnose stage IV disease. However, all patients were crosschecked to the linked database to see if they had had a computed tomography scan or ultrasound image showing metastatic disease. In addition, we only reviewed patients whose primary cancer was resected. This excluded about a third of all the patients with stage IV disease. In my (C P) own surgical prospective colorectal cancer database of 781 patients, (1996 to 2007), 24% of the 185 referred with colorectal cancer had stage IV disease (private hospital patients, 21% v public hospital patients, 25%). Resection of the primary cancer was only undertaken in 126 of the 185 patients with stage IV disease (68%). Therefore, only 16% of all patients with colorectal cancer who had resections had stage IV disease (126/781). Tebbutt argues that there could be a possibility of some imbalance between public and private patients based on this observation. We argue that the difficulty in diagnosing stage IV disease applies equally to public and private patients. Similarly, my own database does not show a significant difference in the incidence of stage IV disease between public and private hospital patients. Kosmider et al report that, at their own institution, completion rates for chemotherapy for stage III colon cancers are the same for public and private patients, “. . . suggesting, in Victoria at least, similar access to care and support for public and private patients”. These results are hardly comparable with our study. Their observations are limited to a select subgroup and only relevant to a small section of the Victorian population, where there is a collocated public and private hospital. In contrast, our study included the entire population of Western Australia, and all public and private hospital patients. Interestingly, we noted wide variations in the rates at which chemotherapy was used, not only between public and private hospitals, but also between individual hospitals. We also noted that there are few collocated public and private hospitals within WA. The fact remains that, at a population level, public hospital patients in WA were less likely to receive chemotherapy. Finally, Kosmider et al raise the issue that comorbidities can influence overall and cancer-specific survival (especially in relation to diabetes). We recognise this as a weakness of our study, and highlighted it in the discussion. Nonetheless, we did include a number of measures of social disadvantage in the analysis. Such measures can act as surrogate markers of common comorbidities. For example, there is a fairly clear association between type 2 diabetes and disadvantage.1 We therefore do not believe that comorbidities can account for all of the observations seen in our study. Our conclusion therefore remains — that patients with colon and rectal cancer treated in private hospitals in WA had superior outcomes. In reality, given the inequities between the two systems, is this really so surprising?

Cameron Platell · Melinda Morris · Barry Iacopetta

To the Editor: Obesity in adults presents significant issues for health care providers, including practical problems in transporting and accommodating large individuals, and in performing standard tests and investigations.1 However, this issue has been little addressed in the mortuary setting, although a recent media report detailed the need for larger crematorium furnaces to accommodate oversized coffins, as well as larger graves for burials.2 We reviewed the body mass index (BMI) of individuals who had undergone coronial autopsies in South Australia in the first 3 months of 2007. Weight and height of all bodies were measured using standardised equipment and were used to calculate BMI by the usual formula.3 A total of 255 individuals aged over 17 years were included in the study (male to female ratio, 2 : 1; age range, 17–97 years). A third of individuals were classified as obese (BMI ≥ 30 kg/m2), and 6% as morbidly obese (BMI ≥ 40 kg/m2). The highest BMIs were: 132.3 kg/m2 (175 kg, 115 cm); 109.0 kg/m2 (315 kg, 170 cm); 82.8 kg/m2 (220 kg, 163 cm); and 79.5 kg/m2 (201 kg, 159 cm). In comparison, over a similar time period at the same institution in 1986, 17% of individuals were obese, and 3% were morbidly obese, with the four highest BMIs being: 55.2 kg/m2 (137 kg, 157.5 cm); 48.3 kg/m2 (148 kg, 175 cm); 44.7 kg/m2 (137 kg, 175 cm); and 41.9 kg/m2 (104 kg, 157.5 cm). This study demonstrates that forensic facilities are now dealing with individuals of considerable body mass. Despite government and industry guidelines for manual handling practices,4 these bodies are difficult to lift, move and store, and present major logistical problems for pathologists and technicians attempting to perform standard examinations. Mechanical lifting hoists, x-ray tables and trolleys are often not designed to cope with such weights. Putrefaction is hastened in morbidly obese individuals, and associated skin slippage and purging makes the bodies even more difficult to handle. Given that autopsies are often required in such individuals to determine the cause of death, consideration must be given to the significant occupational health and safety issues they create for staff in facilities with substandard equipment (ie, designed for normal-sized bodies). The construction of specially designed mortuaries will be required if this trend continues, with larger storage and dissection rooms, and more robust equipment engineered to cope with increasing numbers of individuals with BMIs sometimes considerably greater than 30 kg/m2. Failure to provide these may compromise the postmortem evaluation of markedly obese individuals, in addition to potentially jeopardising the health of mortuary staff.

Roger W Byard · Maria Bellis

Unnecessary examinations expose patients to risk without benefit and are a threat to the effective allocation of resources Things aren’t as they used to be. Imaging investigations are replacing the old paradigm of history-taking, physical examination and provisional clinical diagnosis.1 We may blame intellectual laziness, but short consultation times in general practice, fear of litigation, and the expectations of patients all contribute to the burgeoning use of medical imaging. Unfortunately, a lack of understanding of the role of imaging in specific clinical situations leads to unnecessary imaging or imaging that is inappropriate in terms of timing or the choice of modality. The article by Simpson and Hartrick2 regarding requests for thoracic computed tomography (CT) scans by general practitioners has, by the authors’ own admission, certain shortcomings: for example, it was a retrospective study and the appropriateness of CT requests was judged on subjective criteria; the value of a negative test for exclusion of disease was understated (→ Use of thoracic computed tomography by general practitioners). Nevertheless, the article is a useful starting point for considering the problem of inappropriate imaging investigations in a wider context. Most radiologists are aware that diagnostic imaging is often inappropriately used. Perhaps up to a third of radiological examinations are totally or partially unnecessary.3 In 2002, Hammett and Harris4 suggested that it was time to reduce inappropriate test ordering, but there is little evidence of any change in practice since that time. Unnecessary examinations expose patients to risk without benefit and are a threat to the effective allocation of resources. There are many circumstances in which there is no indication for imaging at all. Simpson and Hartrick allude to this in their article with regard to chest CT scans, but overuse of imaging of the lumbar spine in acute back pain is another example. The wrong choice of test may lead to delay in diagnosis, hazards of the test itself and the risk of false-positive results. Reducing the inappropriate use of CT is especially important, as it is the predominant cause of the marked increase in population exposure to ionising radiation in recent years. Although there is a lack of consensus on the exact degree of risk posed by medical exposure to ionising radiation, the principles of radiation protection dictate that exposure be kept to the lowest level reasonably achievable. To reduce inappropriate use of diagnostic imaging, action is needed both by referring doctors and by providers of radiological services. Simpson and Hartrick have highlighted a specific situation relating to referral by GPs, but there are undoubtedly similar problems in hospital environments and in specialist practices. How can GPs improve their capacity to use imaging properly and effectively? Prohibiting referrals for CT by GPs would result in unacceptable stress on specialist services, long waiting times and, probably, increased costs. Restriction of CT requests to specific clinical indications would also most likely be impractical and open to interpretation. Picano3 has suggested a “radiological driving licence” for requesting doctors (with penalty points for inappropriate requests and licence withdrawal for repeated infringements) — a nice idea, but potentially difficult to administer. Education of referrers is surely the most practical solution. Imaging technology is becoming increasingly complex and expensive. Keeping abreast of the choices of modalities may be bewildering. GPs need to call on the consultative role of radiologists more frequently and effectively to ensure that the correct test and correct test protocol are used, to be made aware of the accuracy and limitations of the test, and (armed with an estimate of the pre-test probability of a disease) to better assess the significance of the result. Imaging guidelines based on evidence and expert consensus need to be disseminated, “marketed” and made easily accessible. Targeting the reduction of unnecessary tests in highly specific areas of general practice can be successful,5 but it is uncertain whether this approach is applicable over the wide range of imaging services and clinical scenarios. Simply mailing out information is inadequate6 and doesn’t guarantee accessibility or enable easy updating. The Royal Australian and New Zealand College of Radiologists (RANZCR), for example, has circulated its excellent booklet Imaging guidelines to GPs in the past, but the last edition appeared in 2001 (available on request at http://www.ranzcr.edu.au/contact/index.cfm). There is a need for guidelines in electronic format (such as the online publication Diagnostic Imaging Pathways, developed by the Western Australian Department of Health, http://www.imagingpathways.health.wa.gov.au), enabling continuous modification as new evidence appears,7 and these should preferably be integrated into other computerised systems already used by GPs. Hammett and Harris4 foresee the implementation of computerised order-entry systems providing guidance on test appropriateness, information on each test, and feedback on ordering patterns. Such guidelines would enable referrers to answer specific questions in relation to clinical scenarios and individual patients: Is imaging indicated? Will it change the diagnosis? Will it change the patient’s management? Will it do more harm than good? Am I asking for the appropriate imaging and in the correct order? Is there a non-ionising alternative to an x-ray-based examination?8 It behoves all clinicians to be aware of the approximate radiation dose and the attendant risk associated with the test they are requesting. Such knowledge is generally lacking.9 Radiologists, too, must take more responsibility for effective and appropriate use of imaging. The RANZCR, in its Quality Use of Diagnostic Imaging program,10 is facilitating this, but individual radiologists need to take action as well. GPs need education seminars on this topic. Radiologists have a duty to ensure that radiation exposure to individuals and communities is the lowest necessary. They have a consulting role that they have been guilty of ignoring and that referrers are guilty of underutilising. Radiologists need to act as gatekeepers, vet each request and provide feedback to the referrer if the request is inappropriate. This requires the referrer to provide adequate clinical details to ensure that the appropriate imaging protocol is used (eg, high-resolution chest CT for diagnosis and monitoring of diffuse interstitial lung disease with minimum radiation exposure versus higher dose helical chest CT for malignancy or pleural disease). When CT is required, radiologists (and radiographers) need to be reminded that modern CT scanners can employ techniques to reduce patient exposure. Low-dose and ultra-low-dose techniques (including CT,11 renal colic and CT colonography protocols) are often an option, but these require the active involvement and judgement of the radiologist. A marriage of knowledgeable and informative request writing, vigilant vetting of requests, and application of correct protocols will bring the enormous benefits of radiological imaging to the population in a safer manner.

Richard M Mendelson MRCP, FRCR, FRANZCR · Conor P J Murray MB BS, DCH, FRANZCR

Objective: To audit requests for computed tomography (CT) examination of the chest emanating from general practitioners and assess the appropriateness and usefulness of these requests.Methods: We reviewed 50 consecutive requests for CT examination received by two private radiology practices in Cairns between August 2004 and March 2005. Clinical details were abstracted from request forms and clarified by telephone if necessary. A subjective assessment of the appropriateness of the investigation was made by the authors. The study was performed in a large regional centre.Main outcome measures: Indications for requesting a CT scan; appropriateness of CT scan for indication specified.Results: Fifteen patients had had recent normal chest x-rays, all of whom proved to have normal CTs; eight had not had a recent chest x-ray performed. The CT scan was considered appropriate in 16 cases (32%), but 10 of these patients required referral to specialists anyway. Thirty-four CT scans (68%) were felt to be inappropriate and, of these, 10 were subsequently referred to specialists. In only six cases did the CT scan resolve the GP’s clinical problem. In six cases the wrong type of CT scan was performed (five were conventional CT scans instead of high-resolution scans; one was a high-resolution instead of low-resolution scan).Conclusions: Many CT examinations of the chest requested by GPs could be avoided or replaced by simpler, cheaper tests with lower radiation exposure. Assuming a fatal cancer risk of 1 in 3000, the radiation exposure involved in unnecessary chest CT scans could be responsible for about 40 fatal cancers a year in Australia.

Graham Simpson MD, FRACP, FRCP · Garry S Hartrick MB BS

To the Editor: The recent article by Miller and colleagues regarding adverse drug events (ADEs) in general practice highlights the high frequency and considerable morbidity associated with ADEs in the general community.1 The authors identified recognised side effects, drug sensitivity, and allergy as responsible for most ADEs. The contribution of the patient’s genotype to drug response, via altered metabolism or responsiveness to pharmaceuticals, is increasingly recognised as potentially responsible for a significant proportion of ADEs. The science of determination of the genetic contribution to an individual’s response to drug action is referred to as pharmacogenomics,2 and represents a potentially beneficial diagnostic tool to aid in the prevention of ADEs. Treatment with warfarin, one of the most frequently prescribed drugs in Australia, has been estimated to account for up to15.1% of all severe ADEs, manifest as minor and major bleeding.3 We have recently determined the presence, frequency and laboratory sequelae of genetic variants (single nucleotide polymorphisms) in two genes responsible for the metabolism (cytochrome P450 2C9 [CYP2C9]) and potency (vitamin K epoxide reductase complex, subunit 1 [VKORC1]) of warfarin4 in an Australian population. In our study of 120 patients in an anticoagulation clinic, the frequencies of allelic variants of the CYP2C9 and VKORC1 genes responsible for altered warfarin activity were 31%5 and 59% (unpublished data), respectively, in keeping with previously published studies.4 Detection of these variants was associated with increased induction international normalised ratio (INR) readings compared with controls, and reduced overall warfarin requirements.6 These findings support previous studies,7 and suggest that genotype determination may be of benefit in identification of patients with increased sensitivity to empiric induction phase warfarin dosing schedules. This may allow for a reduction of induction doses of warfarin, decreasing the risk of excessive INR and bleeding sequelae, commonly observed with induction of warfarin treatment. Furthermore these benefits may aid in reduced time to stabilisation. Additional cost–benefit analysis8,9 will enable determination of the economic viability of genotype determination as an adjunct to management of warfarin dosing. The high population frequency of genetic variants associated with warfarin response emphasises the significant contribution genetic factors can play in patient reaction to drugs and highlights their involvement as potential causes of ADEs.

Keith A Byron · Anthony E Dear

Diagnostic imaging is a key component of patient management and must be provided in a clinical context Task transfer has been suggested as a solution to medical manpower shortages in this issue of the Journal1 and elsewhere.2-4 The Royal Australian and New Zealand College of Radiologists (RANZCR) has recently explored this issue pertaining to diagnostic imaging (DI)5 in response to the Quality Use of Diagnostic Imaging (QUDI) Program’s discussion paper on role evolution. Radiologist workloads are heavy and increasing.6 In addition to the general growth of medical services, traditional history taking and clinical examination are increasingly supplemented by and dependent on multiple and more complex DI to provide a definitive diagnosis. Expansion of DI is placing workforce pressures on all members of the DI team. Radiographers are also in short supply. Radiology services have always been provided by a multidisciplinary team, including radiologists and radiographers. The optimal DI outcome is dependent on team members working in a cooperative manner, mutually recognising and maximising individual areas of expertise. Rapid changes in DI technology necessitate constant review of work practices to provide the most efficient service. Optimal patient outcome must form the cornerstone of any changed practice. Role evolution, including task substitution and delegation, is one potential means of better utilising the skills of the whole DI team. It must be considered in the context of responsibilities and core competencies to perform tasks. Clear definition of all DI tasks and essential task competencies is thus essential. The radiologist carries a duty of care and legal responsibility to the patient and referring doctor for the overall conduct and result of the radiology service. The radiologist’s expertise is built on a background of medical training and experience followed by specialist training in medical imaging. The comprehensive radiology service is an integral component of patient management. It includes appropriate use, performance and interpretation of DI and imaging-guided intervention, drawing on the specialist skills and knowledge of the radiologist. The radiology report, which requires technical observations and medical interpretation in the clinical context, documents the medical specialist service. Such a report can only be provided by a radiologist. Focusing on image reporting by non-medical personnel assumes that preclinical, clinical and specialist training and experience can be fast-tracked or avoided without negative impact on the nature and quality of the DI service. In addition, radiology has become a more body-system-based rather than modality-based service — reflecting patient presentation and radiology’s increasingly clinical role. Plain x-rays are just one component of the often complex and integrated imaging required to optimise patient management. There is also a misconception that plain x-ray interpretation is simple and thus readily delegated, and that the radiologist’s role is limited to provision of images and reports. This ignores the clinical context of the DI service. The RANZCR is constantly considering entire service delivery measures to mitigate the impact of DI team workforce shortages. Providing additional training places may eventually ease the burden on DI teams, but there will be a considerable lag period. There is little doubt that a substantial proportion of current imaging has no impact on patient outcomes and is thus unnecessary. Increased early involvement of the radiologist in clinical management, particularly to advise appropriate imaging, would minimise unnecessary studies. This would relieve workforce pressures across the entire DI team, whereas reporting by radiographers would exacerbate current radiographer shortages and potentially diminish the clinical value of the DI service. Quality and efficiency of service to patients is paramount, and system changes should not be driven primarily by the desire to create potential new career paths, although the RANZCR recognises that work satisfaction of all DI team members should always be considered. Introducing new technologies such as picture archiving and communication systems (PACS) will largely eliminate the need for film production by radiographers and handling by radiologists, thus contributing significantly to workforce efficiency. In summary, the RANZCR recognises that coping with increasing demands on DI services requires innovative approaches. The cooperative team approach remains crucial to service delivery. Scope for review of tasks within the team may exist, but any changes must occur with current key competencies maintained. The radiologist’s responsibility for the totality of the DI service is a function of core skills and experience and is non-delegable. Radiologists are uniquely placed to advise the need for and choice of imaging. They supervise and interpret radiological and interventional procedures and communicate results to referring clinicians. Any system redesign must build on these pivotal roles of the radiologist. The RANZCR is firmly of the view that the radiology report, which communicates the medical interpretation of the patient’s imaging in a clinical context, cannot be currently delegated to those who are not trained initially as medical practitioners and then as medical imaging specialists.

Lizbeth M Kenny MB BS, DRACR, FRACR · Matthew W Andrews MB BS(Hons), MMed, FRANZCR

The demand for diagnostic imaging services has grown faster than the supply of radiologists in Australia. Given the predicted ageing of the population and contraction of the health care workforce, the current workforce model is not sustainable. Extending the role of radiographers in a specific range of radiological reporting tasks may help meet demand, relieving some pressure on radiologists. Experience overseas suggests that radiographer reporting can reduce patient waiting times, release radiologists for other duties and improve the retention of radiographers. Evidence shows that, with appropriate education and training, the accuracy of radiographers in interpreting plain x-rays is comparable to that of radiologists. Australian universities are well placed to offer radiographers postgraduate education in image interpretation.

Tony N Smith PhD · Marilyn Baird PhD

Variation between laboratories and reference sources in the units used for reporting pathology results raises the possibility of medical error. Data submitted to the RCPA Quality Assurance Programs demonstrate wide variation in the units used for reporting therapeutic drug concentrations. This potential source of medical error needs to be addressed by all parties involved in communicating drug concentrations and providing support information.

Graham R D Jones MB BS, DPhil

A 55-year-old woman was admitted to hospital with a 1-year history of recurrent haemoptysis. A chest radiograph showed a well defined, rounded left hilar mass with surrounding air-space shadowing (Box, A). Contrast-enhanced computed tomography revealed a thrombosed aneurysm of the left main pulmonary artery that extended into its branches, with surrounding lung consolidation (Box, B). Echocardiography excluded any valvular lesions or shunt. Tests for tuberculosis and HIV were negative, and antinuclear antibody levels were not raised. The aneurysm was thought to be idiopathic. It was surgically resected, and the postoperative course was uneventful. A: Chest radiograph showing a left hilar mass. B: Contrast-enhanced computed tomography of the thorax showing an aneurysm of the left pulmonary artery extending distally into its branches with evidence of curvilinear thrombus (1), patent vessels (left pulmonary artery [2], right pulmonary artery [3], ascending aorta [4], superior vena cava [5] and descending aorta [6]), and consolidation of lung parenchyma adjoining the thrombus, with pleural thickening (7).

Zubair Ahmad MD, FCCP · Imrana Masood MB BS · Saurabh K Singh MB BS

Radiograph showing diffuse dense pleural thickening encasing the left hemithorax, multiple metastatic nodules in the left lung, and a solitary deposit in the right mid zone. A 21-year-old man with a high-grade osteoblastic sarcoma of the tibia had a tumour resection and adjuvant chemotherapy. Eight months later, he became dyspnoeic and a radiograph showed a large left-sided pleural effusion and a nodule in the right mid zone. Calcified pleural metastases were confirmed on biopsy, and talc pleurodesis was performed. High-dose methotrexate was commenced, but 2 months later a chest radiograph showed marked calcification of the pleura and pulmonary metastases on the left side (Figure). The right pulmonary nodule had increased in size and the patient’s serum alkaline phosphatase level had risen to 4459 U/L (reference range, 30–130 U/L). A trial of ifosfamide transiently reduced the alkaline phosphatase level. The patient died 4 months later.

Georgina Long PhD, MB BS · Martin H Tattersall MD, MSc

Radiographs of a woman presenting with abdominal pain revealed a large foreign body within the pelvis. A diagnosis of perforation of the colon was made, and at laparotomy an 8.5 cm long glass fragment was removed from the bowel. A laceration to the lower back, sustained in a fall onto a glass coffee table, had been explored and sutured 20 months earlier. Imaging findings showed the subsequent course of the overlooked glass fragment within the pelvis. Clinical record A Abdominal radiograph A: A large triangular foreign body is visible in the pelvis. Note the deformity of the right transverse processes of L4 and L5 (arrows). B Surgical photograph B: The sigmoid colon is opened to show a large triangular glass fragment in the lumen of the bowel. C Computed tomography scan C: A loop of terminal ileum is in continuity with the anterior surface of the right psoas muscle (arrow), directly in line with the bony tract created by the glass fragment. A 60-year-old woman presented to the emergency department complaining of abdominal pain, nausea and bloating, that had developed over the previous 3 days. On examination, there was generalised guarding and tenderness. A chest radiograph showed a pneumoperitoneum, and an abdominal radiograph showed a large, triangular, radiopaque foreign body within the pelvis (Figure, A). A diagnosis of bowel perforation by a foreign body was made, although the patient denied any history of foreign body insertion or ingestion. Further questioning revealed that 20 months earlier she had fallen onto a glass coffee table, sustaining a large laceration to the lower back, just above the natal cleft. She had presented to the emergency department of a large metropolitan hospital where the wound was explored and sutured, but no radiographs were taken. At laparotomy, the patient had faeculent peritonitis, with a small perforation of the antimesenteric wall of the sigmoid colon. An 8.5 cm long triangular fragment of glass was found within the mid sigmoid colon (Figure, B). A Hartmann’s procedure was performed. DiscussionInitially, this was a baffling case. The source of the glass foreign body was obviously the earlier coffee table accident — but how did the glass fragment get into the bowel and why did it take 20 months to present clinically with intestinal perforation? The radiographs and subsequent computed tomography (CT) scans provided the answers. The abdominal radiograph was reviewed the day after clinical presentation and surgery. It was noticed that there was partial bony fusion of the right transverse processes of the fourth and fifth lumbar vertebral bodies. A CT scan confirmed that new bone formation at this level had produced a solid block of bone with a central defect in the shape of a rectangle. It is thought that the glass fragment snapped off deep to the skin and fractured the right transverse processes of L4 and L5, with the subsequent fracture healing process giving rise to a perfect bony cast of the fragment. It is well documented that a fracture initiates a sequence of inflammation, repair and remodelling, and that the remodelling process continues for years.1 Another CT scan showed the bony tract caused by the glass fragment projecting anteriorly into the right psoas muscle. Directly anterior to this, the terminal ileum could be seen lying on the anterior surface of the right psoas muscle (Figure, C). It is thought that the sharp end of the glass fragment gradually worked its way out the front of the psoas muscle and into the terminal ileum. The radiographs and CT scans provide a vivid account of the course of the glass fragment after it penetrated the skin. All but the most superficial and easily explored penetrating injuries caused by glass should be assessed radiographically at the time of injury.2

Sally A Johnston MB BS · David A Lisle MB BS, FRANZCR · Roderick C Borrowdale MB BS, FRACS

To the Editor: We read with interest the letter by Breeze et al on management of abnormalities detected on cervical screening.1 Their study identifies a universal and fundamental feature of the Pap smear — namely, that it is an imperfect predictor of underlying abnormalities in the cervical epithelium. For smears reported as a low-grade squamous intraepithelial lesion (LSIL) (atypical squamous cells of uncertain significance) or possible LSIL, Breeze and colleagues have shown that underestimation of the extent of the underlying abnormality is greater in infrequently screened women than in frequently screened women. They claim that following the latest National Health and Medical Research Council (NHMRC) guidelines for cervical screening2 will put women in rural and remote areas with cytologically detected low-grade lesions at risk of developing high-grade lesions that go undetected through lack of timely follow-up. I contend that following the new NHMRC guidelines presents a significant risk to all women with LSIL or possible LSIL reported on smears, regardless of ethnicity, locality or social class. The risk is merely greater for women living in rural and remote areas. In addition to delays in diagnosis of high-grade lesions, data from cervical cytology registries indicate that there will be delays in diagnosis for the 30–50 women each year whose smears show changes only of LSIL or possible LSIL but who are shown on biopsy to have cervical cancer.3 The problem of women defaulting on clinic appointments or being lost to follow-up is a phenomenon commonly encountered in cervical screening programs in general, but in Far North Queensland the risks of inadequate follow-up are magnified. For these and other reasons, the Royal College of Pathologists of Australasia, other learned societies and individuals have consistently and strenuously opposed the latest NHMRC guidelines during the period of their development and during the consultation period of many months. Rather than advocate a separate set of guidelines for women in rural and remote areas, it would be better to have a universally accepted safe set of guidelines that conforms to international best practice and applies to all Australian women. Using the guidelines that were in use until 20054 and that have served us so well in the past is one option. Another option, which is backed by first class scientific evidence,5 is to use human papillomavirus DNA testing for triage of women with smears reported as possible LSIL.

Stewart Bryant

In reply: In June 2005, the National Health and Medical Research Council (NHMRC) endorsed new guidelines for managing asymptomatic women with screen-detected abnormalities because they were safe for Australian women and were based on the best available Australian and international evidence.1 The NHMRC accepted that new information about the natural history of human papillomavirus (HPV) infection of the cervix and cervical neoplasia demanded a reassessment of our traditional approach to this disease. HPV infection of the cervix and associated, potentially neoplastic precursor lesions are very common, but not all of these have malignant potential. Optimal prevention of cervical cancer will depend on timely diagnosis and treatment of lesions that are most likely to progress. Overdiagnosis and treatment of all incident lesions is unnecessary and potentially results in avoidable morbidity. The approach recommended in the latest guidelines moves away from probabilistic prediction and intensive investigation based on a single cytological specimen to an evidence-based program of intermittent cytological surveillance of this chronic viral infection. Intervention is timed to coincide with evidence of persistent and potentially dangerous infection. Contrary to Bryant’s claim about Australian registry data, there is no evidence that the new guidelines will mean any increase in the diagnosis of cancer, a view that is supported by independent epidemiological expert review (M Clements, Research Fellow, National Centre for Epidemiology and Population Health, Australian National University, personal communication). The experience of Breeze and colleagues in Far North Queensland suggests that the greatest risk factor for any woman to develop cervical cancer is infrequent screening.2 Furthermore, in the unlikely event that the latest guidelines do result in increased cancer incidence, such an increase will immediately be detected by the monitoring program that is integral to the new approach. Bryant advocates increased pathology testing using HPV DNA tests. We are not aware of any population data demonstrating that such an approach would result in improved cancer prevention, nor that such an approach would be cost-effective. Consequently, the Guidelines Review Group did not recommend the use of HPV DNA testing as part of triage of women with abnormal smears. The approach recommended in the guidelines is also consistent with contemporary international experience3 — namely, that the clinical significance of a single incident measurement of HPV status is not established. We believe that the latest NHMRC guidelines1 are safe and acceptable for all Australian women and that all women deserve appropriate investigation and treatment of cervical abnormalities in a manner that will protect them from both cervical cancer and unnecessary, potentially harmful interventions. Finally, to address the concerns of Breeze and colleagues, the guidelines specifically advise that clinical management be tailored to the patient’s individual circumstances.

Gerard V Wain · Ian G Hammond · Penelope I Blomfield · Marion A Saville · Margaret Davy

Objective: To review our experience with percutaneous radiofrequency ablation (RFA) for osteoid osteoma.Participants, design and setting: Retrospective review of 24 patients with osteoid osteoma treated with percutaneous RFA at St Vincent’s Hospital, Melbourne, from August 2000 to February 2005.Main outcome measures: Initial response to treatment, return of symptoms, time to recurrence, complications and histopathological correlation.Results: In 23 of 24 patients, there was immediate relief of symptoms. One-third of patients had a return of symptoms. The 24 patients underwent a total of 32 RFA procedures. Of the eight patients who had a recurrence, five had an initial lesion ≥ 10 mm in maximum diameter. Twenty-three of the 24 patients were pain-free at the end of the study period. Patients were followed up for a median of 26 months. There were no long-term complications.Conclusions: Percutaneous RFA is a safe and efficacious treatment for osteoid osteoma with a low morbidity rate. Despite recurrence after treatment, re-treatment is simple and effective.

Richard A Kjar MB BS · Gerard J Powell MB BS, FRACS · Stephen M Schilcht MB BS, FRANZCR · Peter J Smith MB BS, FRANZCR · John Slavin MB BS, FRACPA · Peter F M Choong MD, FRACS

To the Editor: I note with interest the findings of Diamond et al.1 However, I would like to make some comments about the validity of the results presented. The authors state that an intention-to-treat analysis was used. However, this was unusual as the intention was to treat everybody, with the control group being made up of patients who were offered the intervention but refused it because of the lack of published data on the safety of the procedure. There was a marked decrease in the pain scores at 24 hours in the intervention group. The methods state that all patients were offered similar analgesia titrated to individual need. However, there was no mention of how many of the intervention group (if any), compared with the control group, received parenteral analgesia. The intervention group may have tended to receive more parenteral analgesia than the control group, but this was not mentioned. Indeed, Predey et al2 specifically mention this possibility in their review. Diamond et al state that lower pain scores persisted in the vertebroplasty-treated group at 6 weeks. However, from the results given in Box 3, it seems that there was no clinically significant difference between the intervention and control groups at 6 weeks. I would have liked the report to have included pain scores at 1 week. The decision to use means ± 1 SD instead of 95% CIs in the results is interesting. One SD will only include 66% of a normal population whereas a 95% CI would refer to the mean ± 2 SDs. More importantly, the size of the SD introduces the possibility of an enormous spread in the pain scores for both groups, which was not commented on in the Results or the Discussion. Finally, it was unclear whether the patients were treated in the private or public hospital system. Regardless of my comments above, I applaud any attempt to treat back pain in elderly people (especially that caused by osteoporotic crush fractures) in a time-expedient fashion. I look forward to the day when this therapy is first-line treatment for this disease and not something to consider 2 weeks down the track. The cost savings in reduced length of stay and the decreased morbidity associated with this treatment, as well as the reduced geriatric workload with the more rapid improvement in function, must outweigh the initial up-front costs.

James L Mallows

In reply: We thank Mallows for his constructive comments, and would like to reply as follows. 1. Intention-to-treat analysis is normally associated with randomised controlled trials (RCTs). Our study was not an RCT, as patients who refused vertebroplasty formed the comparison group.1 We used intention-to-treat analysis to indicate that all patients who were assessed as eligible for our study at the outset were enrolled and were all included in the results presented, irrespective of subsequent events (ie, whether they were completely compliant, had died or were lost to follow-up). We thought it was important to make clear that the study was prospective, that all patients entered into the study were represented in the outcomes, and that patients had not been selected on the basis of later events or results. 2. A description of the analgesic requirements of a subgroup of the patients in our study has been published.2 More than 90% of the vertebroplasty-treated cohort were either able to cease or reduce their analgesia dose by at least 50% within 24 hours after the procedure. Before the procedure, an intravenous injection of pethidine (50–100 mg) was the only parenteral analgesia given routinely and would not have affected the pain scores at 24 hours. 3. Pain scores at 6 weeks were statistically lower in the vertebroplasty-treated group compared with the control group. The clinical significance was not apparent, as measured by the changes in the Barthel indices. This indicator is only a crude assessment of patients’ wellbeing, and a more detailed questionnaire of activities of daily living may have shown a difference. Pain scores recorded at 24, 48, 72 and 96 hours after the procedure would have been more sensitive, so that the additional pain, without vertebroplasty, could have been calculated from the area under the pain curve; the more data points, the more accurate the curve. 4. We elected to report the results as means ± 1 SD instead of 95% CIs. We used SDs to be consistent with our previous publications and other reports in this field. We agree that we could have used 95% CIs. 5. Patients were referred to Sydney Imaging Group from the inpatients and outpatients departments of St George public and private hospitals. All patients were treated without any out-of-pocket patient expenses. Private hospital inpatients were billed according to standard Medicare fees and outpatients were bulk-billed, which was revenue neutral for the radiology practice.

Terrence H Diamond · Carl Bryant · Lois Browne · William A Clark

To the Editor: Reading the excellent Christmas edition of the Journal, I was struck by the symmetry of the computed tomography scans of rectus sheath haematomas in a husband and wife, reported by James and colleagues1 (Box). I was wondering if the couple had not been involved in a minor car accident or incident of heavy braking several days earlier, where the lap–sash or buckle of a seatbelt might explain the mirror injuries?

Mark R Nelson

In reply: The rare and spontaneous nature of rectus sheath haematoma leaves its origins open to such interesting questions. Neither of our patients was able to recall a history of motor vehicle trauma, but minor braking trauma certainly remains a possibility, as does respiratory infection leading to protracted cough. Computed tomography scans of matching rectus sheath haematomas in a 62-year-old woman (A) and her husband (B).

David James

Charles Marshall died peacefully in his sleep at his home in Seattle on 12 November 2005, at the age of 93. He was born on 13 July 1912 in Cowell, South Australia, but his early years were spent with his parents in Scotland and England. In 1929, he returned to Australia and settled in Sydney, where he worked in a pharmacy for 2 years. This led to an interest in medicine, which he studied at the University of Sydney from 1934 to 1940. During World War II, from 1940 to 1946, he served with the Royal Australian Army Medical Corps in various locations in the Middle East and Australia. After 2 years at the Kanematsu Memorial Institute of Pathology, Charlie began his career as a pathologist at Sydney Hospital. Between 1950 and 1952, he did a postgraduate course in pathology at London University. He then returned to Sydney Hospital, where he spent several years working in bacteriology and anatomical pathology, and also worked as a Teaching Fellow at the University of Sydney from 1953 to 1955. Charlie was Associate Professor of Pathology at Dalhousie University in Halifax, Canada, from 1955 to 1957, then took up a position as Pathologist (the first ever appointed) at Group Health Cooperative of Puget Sound in Seattle, Washington, where he worked for the next 20 years. He also served as Assistant Professor of Pathology at the University of Washington during that time. He was a Fellow of the Royal College of Pathologists of Australasia and the College of American Pathologists, and a founding member and Fellow of the Royal College of Pathologists of England. Charlie’s published work included an essay on infectious hepatitis for which he was awarded a British Medical Association prize.1 Friends and colleagues will remember Charlie as an avid painter and musician, a kind and compassionate person, as well as a great friend to many whose lives he touched. He was a true gentleman at all times, with a wonderfully dry sense of humour. We will miss him greatly. Charlie was married to his wife Thelma from 1941 until her death in 1978. He is survived by his daughter Carol, granddaughter Diana and three great-grandsons, all of Orange County, California.

Carol MacDonald

Raymond David Rothfield (commonly called “David”) was born in London on 22 June 1920. The family emigrated to Australia in 1924 and David grew up in Sydney. He attended Sydney Grammar School and went on to study medicine at the University of Sydney. After graduating in 1943, David did his residency at Royal Prince Alfred Hospital (RPAH), then worked for a short time with Keith Inglis, who aroused his interest in pathology. In 1944, he enlisted in the Australian Defence Force, serving as a Medical Officer in Morotai and then with the occupation forces in Japan. From 1945 to 1950, while a Postdoctoral Fellow at RPAH, he joined the Citizen Military Forces. He joined the pathology department at St Vincent’s Hospital (SVH), Sydney, in 1950 and obtained a Diploma of Clinical Pathology in the same year. In 1957, David became one of the early members of the College of Pathologists of Australia (later to become the Royal College of Pathologists of Australasia [RCPA]). He was appointed Director of Biochemistry at SVH in 1964, a position he held till his retirement in 1986. In 1968, he became a Fellow of the Australian Association of Clinical Biochemists. David had a passion for excellence and quality in the laboratory. In the early 1980s, he persuaded (I could say “hassled”) the Executive Committee of the RCPA to join with the National Association of Testing Laboratories (NATA) to establish a laboratory accreditation scheme. The resultant NATA/RCPA scheme stands as a lasting tribute to his dedication to quality laboratory practice. On his retirement, he became NATA’s staff pathologist, a position he held part time until his death in 2005. He was also an enthusiastic teacher whose contribution to training young pathologists was valued highly. As acknowledgement of his contribution to pathology, David was awarded both an Order of Australia Medal and an RCPA Meritorious Service Award. Alongside his career, David maintained an involvement with the military. In 1970, he served as a pathologist in Vietnam. In 1982, he was promoted to the rank of Colonel and in 1984 was appointed Consultant Pathologist and supervisor of the multidisciplinary laboratory for the Australian Defence Force at Holsworthy. David also had an abiding interest in boxing, became a qualified instructor and helped many socially disadvantaged youngsters. David was deeply religious, and liturgical music was yet another of his varied interests. He was a kind, gentle and considerate person with an impish sense of humour that made him a delightful companion. David died of metastatic prostate cancer on 21 September 2005. He is survived by his wife Diana, brother Neville and sons Andrew and James.

Eva Raik AM, MB BS, FRCPA, FRACP

A 90-year-old woman was admitted with acute vomiting for the previous 24 hours and acute, diffuse, intense abdominal pain. Her medical history included atrial fibrillation and hysterectomy. Clinical examination revealed a generally distended, tender, tympanic and silent abdomen. Blood pressure was 98/54 mmHg; her pulse was irregular at 67 beats per minute. A plain x-ray of the abdomen revealed bowel distension without air–fluid levels. A computed tomography scan of the abdomen showed the presence of gas in the portal venous system (Box 1) and the intestinal wall (Box 2). At laparotomy, 142 cm of necrotic ileum was removed. The postoperative course was uneventful, and the patient was discharged 1 month later. The precise mechanism for formation of gas in the portal venous system is uncertain.1 The primary factors that favour this development are intestinal wall alterations, bowel distension and intra-abdominal sepsis.1 In many cases, two or three of these circumstances may coexist. In 15% of cases, the cause of air in the portal venous system remains unknown.1 Several conditions, such as perforated ulcer, interventional procedures, trauma, and infectious or inflammatory abdominal diseases, but most commonly intestinal ischaemia (as in our patient), can cause alterations of the gastric and bowel wall, permitting the passage of intraluminal gas into the portal venous system.1-3 Gas from the intestinal lumen passes through the intestinal wall and travels via the small mesenteric veins and the superior or inferior mesenteric vein to the portal venous system. Further, the presence of gas simultaneously in the portal venous system and intestinal wall seems to be specific to intestinal ischemia.4 Because hypotension was moderate and usual in our patient, we believe that the intestinal ischaemia was secondary to embolic disease related to atrial fibrillation. This case also demonstrates that portal venous system gas formation does not necessarily imply a worse prognosis and that surgery may be beneficial in the presence of this sign.1,5 Abdominal computed tomography scan with contrast showing air in the portal venous system (1) and intestinal wall (2).

Ali Mofredj MD · Harry Toledano MD · Richard Boutboul MD

A radiologist presents examples of discourtesy between doctors and suggests a return to good manners and professionalism In 2004, I presented a poster of my musings on my professional experiences as a radiologist at the hands of medical colleagues. While I felt very strongly about its contents, I thought it would provide a little amusement among the scientific works at the meeting of the Royal Australian and New Zealand College of Radiologists. To my amazement, it struck a chord with many delegates — obviously, I was not alone in seething about discourtesy, which seemed rife, between professional colleagues. Most doctors (and their medical indemnity organisations) agree that patient rudeness and aggression are an increasing problem, and there is discussion on strategies to deal with these. Insufficiently debated is what I believe to be an increasing trend to discourtesy between referring clinicians and radiologists and between radiological colleagues. There are international and Australian codes of ethics regarding behaviour between colleagues.1-3 However, my literature search for references to practical day-to-day courtesy between colleagues revealed mainly concerns as to whether it was polite to bill fellow practitioners for services rendered!4 It would be easy to dismiss interprofessional rudeness as a facet of the decline in good manners in the general community. However, I consider that loss of courtesy between colleagues reduces directly the quality of patient care, and also the enjoyment of one’s working life. The complexities of modern medicine mean that no one doctor can be a “jack of all trades”. However, a lack of respect for the unique skills of another branch of medicine, and an unwillingness to admit some ignorance of these skills and to request advice, result in behaviour such as the following: An x-ray packet was returned to the radiologist with the terse instructions “RE-REPORT” pinned to the packet. In a telephone conversation to the radiologist who had reported a normal result on breast ultrasound examination, a general practitioner said “I ordered you to do an FNA [fine needle aspiration] and I expected it to be done. In future, when I order an FNA, it will be done.” After requesting a large number of examinations without consulting the radiologist, a country GP wrote: “Do not return patient to . . . until all tests ordered have been performed.” I sometimes feel that doctors have a desire to appear powerful in the eyes of patients. This may have resulted in the handwritten note from a GP, presented to me one morning (Box 1). Fear of litigation is always with us, and it is tempting to try to share the blame, but there is no excuse for the following outburst: A surgeon opened a telephone conversation to the radiologist with the words “I have told this patient to sue you to hell”. Colleagues are always going to make mistakes, and one day it is going to be you! One-upmanship is never helpful (Box 2). Short, friendly, personal letters or phone calls (even in this age of impersonal emails and text messages) are still the better way to point out a colleague’s error. Certainly, a fax received at the reception desk, and available for all to read, causes severe angst in the recipient (Box 3). And last, but not least, bullying in the playground or the workplace causes untold distress. Remember, you were a junior hospital doctor once! As a first step towards achieving a more pleasant work environment, the medical colleges should encourage debate on maintaining good manners and professionalism between their fellows. After that, it’s over to you and me! 1 Note from a general practitioner to a radiologist This note was presented by a patient when she arrived for an ultrasound examination 2 days before her scheduled appointment. 2 Report from a radiologist to a general practitioner This report was sent by a radiologist who investigated the patient and reviewed films taken at another radiological practice 2 years previously. 3 Fax from an endoscopist to a radiologist After the suggested endoscopy, the endoscopist faxed back the radiologist’s report with this handwritten comment.

Jane L Nuttall FRCR, FRANZCR