Medical practices

The golden rule is to treat your fellow medicos as you would wish to be treated When I was a medical student in the 1950s, we learned about medical etiquette, which our teachers then confused with medical ethics. There were rules governing the relationships between doctors, especially about “pinching” each other’s patients. And consultants were supposed to meet the patient and his or her general practitioner and give an opinion, not take over the patient. Being asked to treat a colleague, or a member of their family, was regarded as the ultimate professional accolade, and charging a fee was not an option. The same principles applied to nurses, medical students and clergy. Since then, the organisation of medical practice has become more complex. There are many more doctors and specialties. Doctors involved in the care of a patient may not know each other, or even understand each other’s main task or daily work. Some do not even trust each other. For example, recommendations in radiology and pathology reports for further, more expensive tests are in most cases sound medicine, but, in areas of medicolegal phobia or fierce competition, some GPs are sceptical of the underlying reasons. They forget that two minds are usually better for patient safety than one, and see themselves as the patient’s personal doctor who knows what is good for that patient. Radiologists and pathologists are regarded as part of a service industry. They should provide what they are asked for, neither more nor less. The combination of personal distance resulting from relative anonymity together with authoritarian personality traits is the probable underlying psychopathology behind the crass examples cited by Nuttall in this issue of the Journal1 . Anonymity is also a major reason for the vast difference in courtesy between hospital discharge letters written by registrars and those from consultants in private practice. My pet hate is the registrar who replies to my detailed letter for admission, addressing me as “The LMO” (local medical officer). Medicare also changed the courtesies doctors displayed to each other. One reason for using it was that it was “free”, and the other was the convenience for the doctor-patient in not feeling obliged to say “thank you” with an expensive present. Doctors also became more militant about being paid their due worth. Even medical students were charged full fees, and this has spelt the death knell for the Hippocratic rules governing lifelong obligations between teachers and learners. Medical students also absorb many of their future attitudes and behaviours from their teachers. Medical craft groups tend to judge other doctors according to their own standards. This results in “bad-mouthing” of other doctors, which is one of the more unedifying features of modern medicine.2 Even specialist writers of problem-based learning modules subconsciously tend to begin their scenarios with a patient “stuffed up” by a GP and rescued at the 11th hour by the clever consultant at the “Royal Excellent Hospital”.3 The golden rule of medical relationships is to treat your fellow medicos as you would want to be treated. This would be more likely if doctors of all persuasions were to meet more often and learn something of each other’s views and daily tasks. Members of the medical profession are a team fighting a battle against mental and physical disease and disorder. Courtesy comes from the habit of giving credit and thanking others for their contribution to the wellbeing of a patient. I was particularly moved by a letter to a journal from an orthopaedic surgeon who remarked that, after having performed 1200 hip arthroplasties, he had received his first letter of feedback from a GP, informing him that the operation had revolutionised the life of a patient.4 My fantasy would be to dine out once a year with each of the doctors and their support staff who have contributed to the management of my patients. The Federal Treasurer could contribute to the quality of patient care and the reduction of medicolegal cases by making such events tax deductible.

Max Kamien MD, FRACP, FRACGP, FACRRM

Professional discourtesy to radiologists does not enhance patient care In this issue of the Journal, Nuttall describes some interactions between radiologists and their colleagues which suggest professional discourtesy.1 We do not know the individual circumstances of these, but we do know that collaboration, communication and courtesy are critical aspects of professionalism that will help to promote the quality use of diagnostic imaging. The patient and all other professionals involved are direct beneficiaries of such good conduct. It is of concern to the Royal Australian and New Zealand College of Radiologists (RANZCR) and to many radiologists that they have become distanced, not only from patients, but also from their medical colleagues. Workforce shortages, pressure on film reporting, and remote reporting arising from technological advances may all contribute. The distance and limited direct interaction may help explain some of the examples of discourtesy described by Nuttall. This is an issue not only in Australia and New Zealand, but internationally.2 Professionalism is not a new word to readers of the Journal — it has been canvassed in editorials and other articles and is strongly embedded in the day-to-day lives of medical practitioners. It is nonetheless something that we must continue to reflect upon and not take for granted. It is a trait that we must explicitly support and promote among medical students, trainees and colleagues. The roles defined for specialists in the CanMEDS (Canadian Medical Directions for Specialists) framework3 — the basis for a current curriculum development project at RANZCR — include those of communicator and collaborator. The specialty of radiology is fuelled by communication and collaboration. The decision to request an imaging study acknowledges that there is a clinical question requiring additional information before it can be answered fully. Imaging is now so embedded in modern medicine, that its impact on patient care is often overlooked and even taken for granted. Interventional radiology has revolutionised some previously complex open surgical procedures, all aimed at improving patient care and wellbeing. However, at present, the expertise of radiologists is not being utilised effectively in the Australian health care system. This is because the referral process requires a specific test to be requested, instead of enabling the radiologist to recommend the most appropriate diagnostic test in the clinical situation. Furthermore, the almost complete reliance on written reports by many clinicians diminishes the radiologist’s ability to interpret complex imaging studies in consultation with the relevant clinician. “Professional values and responsibilities” is a strand of the Learning, Education and Professionalism (LEAP) program, a framework for continuing professional development which is being piloted across Australian specialist medical colleges, including the RANZCR. The program was developed with reference to the literature on medical professionalism,4 and breaks down professionalism into three components — relationships and accountability, advocacy and equity, and education. Underpinning these concepts is the Quality Use of Diagnostic Imaging Program, which is being undertaken by the RANZCR with funding from the Australian Government Department of Health and Ageing. A central tenet of this program is to “recognise the role of consumers, diagnostic imaging providers and referring practitioners in attaining quality use of diagnostic imaging and involve them through collaboration, consultation and partnership and multidisciplinary activities.”5 Each individual, whether as patient, referrer or radiologist, has much to gain and nothing to lose from a commitment to quality diagnostic imaging embedded within clinical investigation, treatment and management, and with communication that is polite, professional and informative. It is encouraging to observe in Nuttall’s article the personal and professional value that can be derived from presentations at scientific meetings. Scientific and medical expertise is a vital part of our professional role. So also is the capacity to advocate for good and appropriate care for patients. This requires overt communication and collaboration, and Nuttall has highlighted examples where the contrary has occurred.

Lizbeth M Kenny FRANZCR · Fiona Pacey

Death is a fearful thing. William Shakespeare (Measure for measure) It is well recognised that hospital autopsy rates have been declining for a number of years.1 It now seems to be almost an “accepted” fact that hospital autopsies are a procedure of the past, having been bypassed by newer and more effective technologies for evaluating illness and disease states. This is, of course, completely incorrect. Every study into autopsy practice has demonstrated the usefulness and necessity of a careful dissection after death to determine not only the true cause of death, but also the response of the patient to various treatment modalities. The autopsy is, and will always be, the ultimate audit of clinical practice.2 Following appropriately conducted autopsies, it has been consistently demonstrated that suggested clinical causes of death may be inaccurate and require correcting; unsuspected but significant conditions are often discovered; and unexpected effects of therapy and procedures may be revealed. The autopsy provides an excellent basis for teaching students the fundamentals of anatomy and the manifestations of disease. It also provides important information on the effects of newer drugs on normal as well as on diseased tissues.3-5 Given these well established facts, the obvious question is, “Why are autopsy rates in such decline?”. A short questionnaire to determine the status of the autopsy in your pathology department 1. When was the last time your head of department... a. Performed an autopsy? b. Observed an autopsy? c. Touched a dead body? d. Saw a dead body? e. Read about a dead body? (Scoring: 1–6 days ago, 5 points; 7–30 days ago, 4 points; 4–52 weeks ago, 2 points; 1–10 years ago, 0 points; > 1 decade ago, automatic fail) 2. Who teaches registrars autopsy techniques? a. Pathologists 5 points b. Other registrars 1 point c. Mortuary technicians 2 points d. What teaching? – 5 points 3. Do CPCs occur regularly? a. Yes 5 points b. No 0 points c. Don’t understand the question – 5 points 4. What is the average time for provisional and final autopsy reports to reach clinicians? a. 1–6 days 5 points b. 7–30 days 3 points c. 1–6 months 1 point d. 6 months to 1 year 0 points e. > 1 year – 5 points f. After retirement automatic fail 5. When was the last time an attending clinician was seen in the autopsy room? a. 1–6 days ago 5 points b. 7–30 days ago 3 points c. 1–6 months ago 1 point d. 6 months to 1 year ago 0 points e. > 1 year ago – 5 points f. Not recognised as such automatic fail and escorted out by security 6. When was the last time senior pathologists waxed lyrical about an interesting autopsy case? a. 1–6 days ago 5 points b. 7–30 days ago 3 points c. 1–6 months ago 1 point d. 6 months to 1 year ago 0 points e. > 1 year ago – 5 points f. Never automatic fail Interpretation of results. Frankly, if your score is anything less than 35 points, I would not be blaming clinicians for the fall in autopsy rates, but would be looking much closer to home. CPC = clinicopathological conference. Pathologists often complain that the responsibility for the alarming fall in autopsy rates rests squarely on their clinical colleagues. Clinicians’ palpable lack of interest and their obvious reluctance to ask relatives to give consent for autopsy are seen in a very unfavourable and disapproving light in the corridors of pathology departments the world over. However, it must be recognised that the lighting in many pathology departments is suboptimal, often due to their temporary or basement locations, and that such perceptions may not always be absolutely correct. For autopsies to be meaningful, there needs to be a clear understanding of the patients’ specific clinical issues. This means that contact and discussion between the treating clinicians and the supervising/autopsy pathologist needs to occur before, often during, and certainly immediately after autopsy examination. Accur-ate dissection with photographic and written documentation of abnormalities is essential, and reports need to be issued promptly, with presentation of findings immediately after the autopsy or at least at regular weekly autopsy rounds. Provisional and final reports, with clinicopathological correlations and clear gross and microscopic descriptions, are the responsibility of the pathologist. Failure to disseminate them in a timely fashion causes both the clinician and the pathologist to lose interest in the case. Once a month, a clinicopathological conference needs to be held for general hospital medical, nursing and ancillary staff and students to review interesting cases and to answer clinical questions.6 Does any of this occur? I would suggest that it often does not, and that this lack of support of autopsy practice from within the heartland of pathology may be one of the real reasons for clinicians’ lack of interest and the fall in autopsy rates. It has been observed that hospital-based pathologists, excluding those involved in paediatric/perinatal or forensic practice, do not even seem to like autopsies. Autopsies are considered to be technically messy and physically demanding and to detract from the more “scientific” and sterile world of histological and molecular pathology. In fact, they are sometimes seen as some sort of atavistic medical throwback, to be undertaken only by second-rate academics and those who are unemployable in the real world of 21st century anatomical patho-logy! Proof of the lowly status of the autopsy can be seen in the delegation of responsibility within hospital departments. All too often, the most junior registrar with the least training in anatomical pathology is designated to perform autopsies. The autopsy may even be undertaken in the absence of a consultant. Often it is a mortuary technician — one with many years of experience but no formal training, except in the “university of life and the school of hard knocks” — who teaches the unhappy registrar autopsy techniques. Registrars complain about how difficult it is to get consultants to review cases once dissections have been completed; and yet the literature maintains, and surveys have found, that “the necropsy is an invaluable investigation which is currently under-used”7 and that “most pathologists consider autopsies to be valuable and important for quality assurance in health care”.2 However, perhaps we should judge pathologists by what they do, rather than what they are quoted as saying? Could this be a scurrilous and unfair suggestion? Possibly. However, one way to assess the validity of these assertions would be to examine pathology department records to find out when the last time was that senior pathologists performed an autopsy examination by themselves. I would suggest that years might well run into decades. Perhaps the most impartial and unemotive way to assess this would be to use a scoring system to objectively determine a pathology department’s commitment to autopsy practice . . . And fortunately, one just happens to be available (see Box).

Roger W Byard MD, FRCPath

A 62-year-old woman presented to the emergency department with a persistent cough and severe abdominal pain. Computed tomography showed the rare condition of a spontaneous rectus sheath haematoma on the right side (Figure A). The patient commented that her husband had been suffering the same symptoms for days, and that he was taking warfarin therapy. Six hours later, he presented to the same hospital with a matching rectus sheath haematoma on the left side (Figure B), and required blood transfusion. This completed a “marriage of inconvenience”, but did bring them closer to marital bliss — they shared a room in hospital, although in separate beds! Spontaneous rectus sheath haematoma is very rare. Coughing can rub the inferior epigastric artery or its perforating branches against the free posterior edge of the rectus sheath. Clinical suspicion should be raised in the elderly patient taking anticoagulant therapy. To our knowledge, this is the first reported case of simultaneous presentation of rectus sheath haematoma in family members. Computed tomography scans of matching rectus sheath haematomas in a married couple.

David James FRACGP, GradDipSurgAnat · D Ong Hii FRACS · Nathan Lawrentschuk MB BS

A middle-aged man with type 2 diabetes was brought to hospital with a history of loss of consciousness for an unknown period of time. He had refractory hypotension and hypoglycaemia. A magnetic resonance imaging scan showed an infarct in the splenium of the corpus callosum (Figure). The splenial infarct resembled a “boomerang”, which is characteristic.1 Strokes involving the splenium of the corpus callosum are associated with hypoperfusion,2 and can be seen in association with metabolic changes such as hypoglycaemia, hyponatraemia, hypernatraemia, and renal failure.1 Magnetic resonance image: axial FLAIR [fluid-attenuated inversion recovery] sequence, showing boomerang-shaped signal hyperintensity in the splenium of the corpus callosum.

Jeyaraj Durai Pandian MD, DM · Robert D Henderson MB BS, FRACP

A 25-year-old woman with clinical depression was referred with vague epigastric pain and early satiety after meals for 6 months. Abdominal examination revealed an indentable J-shaped mass in the epigastrium. A barium meal examination was subsequently carried out. The image shows a whorled, stippled mass occupying the stomach, forming a ‘J’ shape. The most likely diagnosis was a trichobezoar. Bezoars are of different kinds and commonly include hair (trichobezoar), vegetable fibres (phytobezoar) or medications (pharmacobezoar). About 90% of bezoars are encountered in women, and about 10% of these patients have a psychiatric disorder. The patient underwent exploratory laparotomy with gastrotomy and removal of a large hairball, which had an extension into the duodenum.

Guneesh Dadayal MB BS · Dipesh D Duttaroy MB BS, MS · Sashidhar Yeluri MB BS, MS

The explosion in psychiatric neuroimaging research has led to the establishment of stressful and dark neuroimaging laboratories in which young researchers sweat in front of computer monitors performing laborious and tedious imaging analysis. These conditions have contributed to the development of a new psychiatric syndrome, described below. Diagnostic criteria“Lesionnaire’s syndrome” predominantly affects younger researchers examining magnetic resonance imaging (MRI) scans of the brain. These researchers: (a) Work in large institutions; (b) Have a fixed belief that volume change in a brain structure causes schizophrenia; (c) Feverishly spend hours tracing brain structures to prove this belief; (d) Alter their beliefs if their attempts are unsuccessful and begin work on a different brain structure or new method; (e) Attribute negative findings to “methodological limitations”; (f) Begin to see non-brain images in brain scans on which they are working. The diagnosis may only be made if the patient satisfies criterion (f) and any three of criteria (a)–(e). The diagnosis cannot be made if the MRI scan has revealed an organic disorder. Case reportA 38-year-old psychiatrist had spent hundreds of hours tracing hippocampal volumes on MRI scans. He would lock himself in a darkened room, staring at a computer monitor, often listening to ’80s music in an attempt to relieve the mind-numbing tedium of the repetitive tracing behaviour. After tracing scans for 4–5 years, he revealed to his colleagues that he had discovered religious images — in particular, a vision of the Crucifixion (Box). He was successfully treated with complete tracing abstinence, but has had episodic relapses of his delusional visions, during which he has been heard to cry out “Maybe if I trace a few more it will reach statistical significance”. In order to ensure that the syndrome was related to the tracing behaviour rather than the music, a further trial was undertaken. Fortunately, re-exposure to ’80s music outside the imaging laboratory did not lead to a relapse in his symptoms.

Dennis Velakoulis MB BS, FRANZCP · Christos Pantelis MD, MRCPsych, FRANZCP · Mark Walterfang MB BS, FRANZCP

Megan A Bohensky,* Joseph E Ibrahim,† David L Ranson‡ * Research Officer, † Consultant and Head of Research, Clinical Liaison Service, ‡ Deputy Director, Victorian Institute of Forensic Medicine, Monash University, State Coroner's Office Victoria, 57–83 Kavanagh Street, Southbank, VIC 3006. meganbATvifm.org To the Editor: Van Der Weyden highlights the need for a health system with a focus on patient safety that is open, transparent and connected to local communities and clinicians who are able to make decisions about health care delivery.1 The editorial refers to the Bundaberg and other Australian hospital “scandals” that went undetected by medical boards, the clinical governance structures within each hospital, and sentinel event reporting processes. However, no consideration is given to the role of the Coroner’s Office, where a formal structure is already in place for reviewing particular deaths associated with health system failures. The role of the Coroner’s Office in these incidents is worth reflecting on, as the Coroner is external to the health system, has the capacity to review reported hospital deaths, and can address the concerns of doctors and nurses as well as the family members of the deceased. The case involving Dr Patel begs the question of whether this system of judicial investigation was utilised. If not, how could the system improve to encourage the disclosure of internal problems in our hospitals? One option to improve the system has been developed by the Clinical Liaison Service. This service was initiated by the State Coroner’s Office in Victoria to involve clinicians in a regular review of deaths in hospital as a means of identifying potential instances of hospital system failures.2 Through a system-based approach, issues of communication failure, unclear work protocols and a lack of supervision for junior doctors have been highlighted. These issues are fed back into the health care community through coronial findings and the service’s quarterly publication Coronial communiqué.3 Improving the clinical input into judicial investigation may, by encouraging clinicians’ trust in the system, remove barriers to identifying system issues relevant to health care. Currently, Victoria is the only state or territory in Australia where clinical input is a routine part of the Coroner’s review process. Although the Coroners’ jurisdiction only extends to instances resulting in death, their findings are often far-reaching and garner public attention and support.4 Another initiative to improve this system is the development of the National Coroners Information System (http://www.vifp.monash.edu.au/ncis/). This database provides a national repository of information about reported deaths, and has the potential to be used as a health and injury surveillance system to inform policy for death prevention. As noted by Morton, system analysis requires a process that is just and transparent.5 The coronial process inherently comprises both of these features through its legislative structure. It is conceivable that a team of clinical reviewers within the Queensland Coroner’s Office could have identified issues at Bundaberg earlier on. Our health system unquestionably requires a better strategy for preventing the patient deaths that occur every day. The Clinical Liaison Service and the National Coroners Information System are helping the legal and health care community to work towards identifying and preventing incidents that compromise patient safety.

Megan A Bohensky · Joseph E Ibrahim · David L Ranson

Imaging should only be undertaken if it is likely to influence patient management. The dose of ionising radiation to the patient should be considered. Requesting the appropriate imaging method requires an understanding of the pathological process. Plain x-ray should still generally be the first imaging technique; exceptions include some forms of superficial tendinopathy, in which ultrasound may be more appropriate, and situations where radiation exposure is contraindicated, such as in a pregnant patient. The cost of the examination to the patient and the community should also be considered (eg, ultrasound v magnetic resonance imaging).

John W Orchard PhD, FACSP, FACSM · John W Read MB BS, FRANZCR, DDU · Ian (Jock) F Anderson MB BS, FRANZCR, FRACSP(Hon)

Born at Bombala, NSW, on 22 December 1912, Geoff was the son of a general practitioner. After early schooling in Kempsey, he attended The Armidale School and Sydney Grammar School. He graduated in medicine from the University of Sydney in 1936, and was appointed to Sydney Hospital as a Resident Medical Officer. He married Claire Probert in secret, the hospital appointment being then unavailable to a married man. In 1939, Geoff went to work in the Radiology Department, which was “a bit of a shambles”. His knowledge and interest grew as he learned from the visiting Honorary Radiologists, and his technical skills were honed, of necessity, after half of them enlisted in the armed forces in 1939. In 1942, Geoff left for New Guinea and the 9th Australian General Hospital, treating the wounded in tents during the Kokoda Trail retreat. On discharge in 1946, Geoff joined a private radiology practice in Macquarie Street, Sydney. He was accepted by the Australian and New Zealand Association of Radiologists and became a Foundation Member of the College on its formation in 1949. He worked as an Honorary Radiologist at Sydney Hospital, Crown Street Women’s Hospital and Royal North Shore Hospital. A shy and gentle man, Geoff was a mentor to other radiologists in the practice, John Cashman, Peter Geddes and Bruce Roberts. He was even-tempered, innovative, honest to a fault, widely read and a thoughtful and well regarded radiologist. He served on two NSW government committees, the Radiological Advisory Committee and the State X-ray Committee. In 1991, Geoff retired due to macular degeneration, but his mental acuity and memory remained sharp until his last illness. Geoff was fascinated by astronomy and built a 9-inch reflecting telescope, hand grinding and polishing the mirror himself. He played the flute and built two harpsichords from scratch. He also had an abiding love of the sea and all things nautical, sailing with his friend, Robert Scot Skirving, on “Phalarope” many times. His wife Claire died in August 2004, after 68 years of marriage. On 17 January 2005, Geoff succumbed to a stroke. They are survived by their four children, Michael, Phoebe, Anne and Lucy, and Geoff’s sister, Pamela Marsh.

John D Cashman DDR, DRACR, FRANZCR · H Michael Marsh FANZCA, FFICANZCA, FACA · Bruce A Roberts FRACP, FRACR

To the Editor: The clinical update on venous thromboembolism by Lee and colleagues advises that “Ventilation perfusion (V/Q) isotope scanning reliably establishes the diagnosis of PE [pulmonary embolism] if the V/Q features suggest a high probability of PE . . .”.1 Although this is probably true for patients with intermediate or high pretest probability, a discordant result (low pretest probability and high probability V/Q) should be regarded with suspicion. From the original PIOPED data, high probability V/Q was predictive of angiographically confirmed PE in 80% of patients,2 which drops to 56% by Bayesian analysis if the pretest probability is low. False positive results may be due to previous PE or unrelated parenchymal lung disease. There is significant potential morbidity associated with a false positive result for PE, both from the acute anticoagulation and for future presentations with PE-type symptoms, where PE will be accorded a higher probability because of the previous documented diagnosis. As Lee and colleagues also state, D-dimer testing must be combined with an estimate of pretest probability to be useful. They advocate excluding PE on the basis of low pretest probability and negative D-dimer result. However, a negative D-dimer result (rapid enzyme-linked immunosorbent assay [ELISA] type) may be used to exclude PE in intermediate as well as low probability patients.3 This is dependent on the type of assay available as well as the local PE prevalence, and local guidelines should therefore be developed.

Matthew J Bragg

To the Editor: I read with interest the article by Lee et al regarding the investigation and treatment of pulmonary embolism (PE).1 The investigation of patients presenting with PE as a diagnostic possibility is of great interest to emergency physicians, and such presentations are a daily occurrence in emergency departments around the country. Unfortunately, only a small amount of text is devoted to describing the relative merits of ventilation perfusion (V/Q) scanning and computed tomography pulmonary angiography (CTPA), and no guidance is provided as to which is the test of choice when both are available. The British Thoracic Society has recommended CTPA as the lung imaging modality of first choice for patients presenting with non-massive PE.2 There is a large and increasing body of evidence that CTPA provides superior specificity to V/Q scanning in the detection of PE. CTPA also provides the opportunity of establishing diagnoses other than PE and, in addition, a negative multi-slice CTPA is of sufficient sensitivity to enable the withholding of anticoagulation.3 It is also my experience that CTPA is easier to obtain out of hours, compared with V/Q scanning. The authors state that V/Q scanning “reliably establishes the diagnosis of PE if the V/Q scan features suggest a high probability of PE . . .”.1 Unfortunately, this statement is incorrect. It is essential that V/Q scan results be interpreted in the light of the patient’s clinical probability for PE. In the PIOPED study, only 56% of patients with high probability V/Q scan reports had pulmonary embolism if the pretest probability was low.4 No mention is made of the special situation of pregnant women presenting with pleuritic pain, or which lung imaging test is considered “safest” for both mother and baby. Although the risks of PE are generally agreed to be increased in pregnancy, it is my experience that pregnant women are extremely reluctant to undergo any form of diagnostic investigation that exposes the fetus to radiation. The Wells criteria have been validated for the assessment of PE in emergency department patients only, and provide a means for clinicians with little experience to make an accurate assessment of an individual patient’s clinical probability of PE.5 Once initiated, clinical assessment of the patient with possible PE is straightforward. The key question facing emergency physicians is this: is there a group of patients that have such low probability for PE that no investigation at all is required?

Paul M Bailey

John W Eikelboom,* Graeme J Hankey,† Wai Khoon Ho,‡ Cindy H Lee§ * Haematologist, Thrombosis Service, McMaster University, HHS General Divison, 237 Barton Street East, Hamilton, ON L8L2X2, Canada; † Neurologist, ‡ Fellow in Haematology, § Senior Registrar in Haematology, Royal Perth Hospital, Perth, WA. eikelbj@mcmaster.ca In reply: Pulmonary embolism (PE) remains a complex diagnosis despite the availability of validated prediction models and D-dimer testing to direct the need for diagnostic imaging. We agree with Bailey that the ability to exclude the diagnosis of PE on clinical grounds in patients with a low pretest probability is highly desirable. Unfortunately, clinical features lack sensitivity and specificity for the diagnosis of PE, and clinical prediction models, laboratory investigations, and diagnostic imaging are likely to remain an integral part of the clinical work-up. As suggested by Bragg, it may be possible to simplify the diagnostic approach by using a highly sensitive D-dimer assay, and simplified pretest probability models have been proposed. However, this may come at a cost of reduced specificity,1 which leads to unnecessary diagnostic imaging studies and thus limits the clinical utility of these approaches. Further improvements in the diagnostic approach to PE are clearly needed. There are emerging data demonstrating the accuracy of computed tomography pulmonary angiography (CTPA) for the diagnosis of PE. However, CTPA has limitations (a large contrast load, high radiation dose, and lack of sensitivity of first generation scanners for small thrombi2), some of which are evident in the recently published validation study referred to by Bailey:3 25% of screened patients with suspected PE were not eligible for this study because of renal impairment, a contraindication to CT, or other reasons. The diagnostic algorithm that we provided in our review suggests that either ventilation perfusion (V/Q) scanning or CTPA can be used for patients with suspected PE who require diagnostic imaging,2 with the choice determined by patient factors and availability. The diagnosis of PE during pregnancy is challenging because of concerns about radiation exposure and uncertainty about whether CTPA or V/Q delivers more radiation to the fetus.4 Furthermore, clinical decision rules have not been validated in pregnancy. However, recommendations from experts and professional bodies suggest that V/Q scanning can be used in combination with compression ultrasound to establish or exclude the diagnosis of PE during pregnancy in most cases with minimal fetal radiation exposure.5,6 The comments by Bailey and Bragg concerning the interpretation of high probability V/Q scan results highlight the pitfalls of performing diagnostic imaging without considering the patient’s pretest probability of PE. Although a high probability V/Q scan is diagnostic in patients with a moderate or high pretest probability of PE (prevalence of disease ≥ 90%), the prevalence of disease is only about 50% in those with a low pretest probability.7,8 Therefore, V/Q scanning should not be performed in patients with a low pretest probability unless the D-dimer test is positive. In this situation the algorithm for moderate or high pretest probability should be followed,2 and a high probability scan reliably establishes the diagnosis.

John W Eikelboom · Graeme J Hankey · Wai Khoon Ho · Cindy H Lee

Richard F O’Reilly,* Ian A Burgess,† Bernard Zicat‡ * Physician, † Radiologist, ‡ Orthopaedic Surgeon, Mater Misericordiae Hospital, Rocklands Road, North Sydney, NSW 2060. roreillyATbigpond.net.au To the Editor: In a recent editorial, Gallus estimates the cost of doing ultrasonography in all patients after unilateral hip or knee replacement, with further testing in the 9% or 26% of patients, respectively, found to have deep vein thrombosis (DVT), to be about $200 000 per 1000 patients.1 We agree. He then states, “Many would argue that extended prophylaxis is likely to be the simplest, cheapest and perhaps safest solution”. However, prophylaxis is also expensive. Subcutaneous enoxaparin 40 mg administered daily for 30 days costs $170, or $170 000 per 1000 patients.2 In our study, we found DVTs in 1086 of 5999 patients (18.1%) before discharge,3 so that extended prophylaxis would involve 81.9% of patients receiving prophylactic doses of anticoagulants, with the risk of unwanted bleeding, despite the absence of DVT on ultrasound at Day 7 postoperatively. In addition, if an ultrasound scan was not done before discharge, the 18.1% of patients with a DVT would receive only prophylactic (not therapeutic) doses of anticoagulant for their DVT. We plan a further study to check the prevalence of post-discharge DVT by repeating ultrasonography at 90 days postoperatively in patients without DVT on ultrasound at Day 7. We suspect the prevalence is lower than suggested in the literature, as the data on late presentation of DVTs have been obtained by retrospective study of the number of patients re-admitted to hospital with DVT. Finally, on the question of whether performing ultrasonography on all patients has clinical benefit, we concur with Gallus when he writes that “Logic suggests it should . . .”.

Richard F O’Reilly · Ian A Burgess · Bernard Zicat

In reply: O’Reilly and colleagues belatedly address the need to consider bleeding risk and costs when choosing between management routines designed to prevent venous thrombosis and pulmonary embolism. Their otherwise valuable article1 failed to record bleeding rates when patients (almost 17%) with subclinical calf-vein thrombosis were exposed to therapeutic (not prophylactic) anticoagulant dosages. Nor did they evaluate the dollar and manpower costs of their complex management routines. Present evidence-based international guidelines from the Seventh ACCP (American College of Chest Physicians) Conference on Antithrombotic and Thrombolytic Therapy recommend effective prophylaxis for at least 10 days in all patients having hip or knee replacement, extending to 28–35 days after hip replacement.2 The ACCP guidelines also recommend against routine use of ultrasound screening because it is “neither clinically effective nor cost effective”.2 This is a Grade 1A recommendation from the ACCP (“Grade 1” implies certainty “that the benefits do, or do not, outweigh the risks, burdens, and costs”; “Grade A” refers to recommendations based on “randomized clinical trials with consistent results [that] provide evidence with a low likelihood of bias”).3 To reverse this recommendation would require randomised comparisons between routine prophylaxis alone or routine prophylaxis supplemented by screening ultrasonography — powered to permit meaningful measures, in both groups, of thromboembolism rates, bleeding rates and costs. Routinely screening for subclinical thrombosis after major joint surgery should not be done outside suitably designed clinical trials until such evidence is available. The role of logic in medicine is to generate hypotheses, which must then be tested by clinical trial. Unfortunately, evidence derived from uncontrolled cohort studies remains limited to Grade C (based on “observational studies or [on] generalization from one group of patients included in randomized trials to a different, but somewhat similar, group of patients”).3

Alexander S Gallus

A 76-year-old woman presented for a routine skin check in late spring. On examination, she was noted to have a marked purpuric rash involving her lower legs (Figure A). The rash was accompanied by a slight burning sensation. The patient had played golf the day before. A skin biopsy revealed limited changes suggestive of leukocytoclastic vasculitis (Figure B). The rash resolved over 3 days. As the patient was concerned about herbicides causing the rash, she was subsequently patch-tested to an extensive panel of contact allergens, but all tests were negative. In our experience, an erythematous-to-purpuric rash occurring on the legs and ankles of older people is not uncommon after prolonged exercise, such as golfing or hiking, in hot weather. It usually resolves within a week. Surprisingly, there have been very few published reports of this type of rash occurring. We recently reported a case series of 17 other patients,1 and suggested that the condition — a benign variant of cutaneous vasculitis, for which a combination of exercise, heat and stasis appears to be the most significant cause — be known as “golfer’s vasculitis”. However, a colleague who practises in Florida and who is familiar with the condition refers to it as “Disneyworld leg”! A: Purpuric rash on skin of lower leg. B: Skin biopsy of lower leg showing a perivascular infiltrate of predominantly lymphocytes with occasional eosinophils, endothelial swelling and some extravasated red blood cells.

Rosemary L Nixon FACD, FAFOM · Jacinta M Opie MB BS, DRANZCOG · Robert I Kelly MB BS, FACD

Bruce Gutteridge, a distinguished Queensland pathologist, died in the company of his wife and family at his beach house in Noosa, Queensland, on 12 January 2005, from metastatic colonic cancer. Over 1000 people attended his funeral. His father Noel was one of the three founders of pathology services in Queensland. Bruce and his brother Donald were the fourth generation of medical graduates in the family. Bruce was born in Toowoomba on 10 September 1928. After graduating in medicine in 1951, he spent several years at Brisbane Hospital, first as a Resident Medical Officer then as a Pathology Registrar. In 1956, he topped the Diploma in Clinical Pathology course at the Postgraduate Medical School (PGMS) in London. He then successively held three prestigious teaching registrar posts at the PGMS — in Chemical Pathology, Haematology and Histopathology. On returning to Brisbane in 1959, he joined his father in the Gutteridge Laboratories, which had eight staff and branches in Gympie, Nambour and Southport. While Noel expanded into country areas, Bruce directed technical improvements, initially establishing departments of radioisotopes, nuclear medicine and cytology. From 1967, the name “Queensland Medical Laboratory” (QML) was adopted. After his father’s departure in 1974, Bruce was Senior Partner until his retirement in 1994, when QML had over 1500 staff. Bruce was Visiting Specialist in Histopathology and Haematology at the Royal Brisbane Hospital from 1959 to 1988. He also provided 52 years of continuous service to the Royal Australian Army Medical Corps (RAAMC) (1952–2004). He was Supervisor in Pathology at 2 Military Hospital Yeronga (later 2 Health Service Battalion, Enoggera), Brisbane (1959–2004). In 1969, he spent 4 volunteer months in Vietnam as a Lt. Colonel–Senior Pathologist and resuscitationist, 1 Australian Field Hospital, Vung Tau. He published a number of papers on his work in the United Kingdom, Vietnam and Australia. Bruce’s hobbies were golf, snow skiing, contract bridge and fishing. For 20 years (1972–1992), as President of the Ski Division, Queensland Branch of the Australian Sports Medicine Federation, he led an annual medical educational and skiing pilgrimage to Smiggin Holes. His favourite saying was, “Life is like an empty bucket — you get out of it what you put into it”. His son Andrew commented that Bruce’s bucket ran at overflow level — his energy and enthusiasm for life, exercise, family, friends and humorous tales was boundless; his generosity legendary. Attacks on his health (including 22 operations in his last 10 years) did not dim his joie de vivre. He was a giant of a man in stature, energy and outlook, and has left his mark — on Australian pathology, on the RAAMC and on society — as a dedicated doctor, patron of the arts, and proud and generous family man and friend.

Donald H Gutteridge

To the Editor: Incidents involving assaults on staff by medical equipment are uncommon, but have been reported in this Journal before. 1 We report another “attack”, involving an x-ray machine and an anaesthetist. A woman was scheduled for endoscopic retrograde cholangiopancreatography in the radiology suite. During induction of general anaesthesia, the patient’s foot moved against an x-ray table control knob (Box). This triggered slow, downward movement of an x-ray “C-arm”, which was positioned above the head of the unsuspecting anaesthetist. Tracheal intubation was rudely interrupted when the C-arm met the anaesthetist’s head and pushed it towards the patient’s face. However, the radiographer in attendance quickly reversed the movement just before the anaesthetist and patient collided. The radiology suite is often regarded as an unfriendly environment for anaesthetists.2 This incident reminds us that, in some cases, it may be frankly hostile! A patient’s foot activates a control knob on an x-ray table

Richard H Riley · Leigh J Coombs

A 49-year-old man presented with medial knee pain. Arthroscopy of the knee revealed meniscal fraying and early articular cartilage degeneration (Figure). It was thought that a twisting injury may have had a hand in the matter.

John C Tuffley MB BS, FRACS

Metabolic imaging with fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET) is increasing rapidly worldwide because of superior accuracy compared with conventional non-invasive techniques used for evaluating cancer. Limited anatomical information from FDG-PET images alone dictates that complementary use with structural imaging is required to optimise benefit. Recently, combined positron emission tomography/computed tomography (PET/CT) scanners have overtaken standalone PET scanners as the most commonly purchased PET devices. We describe our experience of over 5500 scans performed since the first PET/CT scanner in Australia was commissioned at the Peter MacCallum Cancer Centre (PMCC), Melbourne, in January 2002. Clinical indications for PET/CT scans performed at PMCC largely reflect current Medicare reimbursement policy. Advantages of PET/CT include greater patient comfort and higher throughput, greater diagnostic certainty and accuracy, improved biopsy methods, and better treatment planning. We believe PET/CT will underpin more effective and efficient imaging paradigms for many common tumours, and lead to a decrease in imaging costs.

W F Eddie Lau BPharm, FRANZCR · David S Binns DipAppSci, ANMT · Robert E Ware MB BS, FCP(South Africa) · Shakher Ramdave FRACP · Alexander G Pitman BmedSci, FRANZCR · Rodney J Hicks MD, FRACP

An extravagant lifestyle in the 1970s often goes undetected by computed tomography scans — unless, of course, the spleen gives it away with its vascular perfusion.

Sam McCormack

This unfortunate patient was involved in a motor vehicle accident. Being an old car there were no airbags, and valve springs are obviously a poor substitute.

Sam McCormack

We were wondering how to describe the lesion seen on this magnetic resonance image. Vertebral “body” seemed appropriate.

Brad Milner

Objective: To examine predictors of death in young offenders who have received a custodial sentence using data routinely collected by juvenile justice services.Design: A retrospective cohort of 2849 (2625 male) 11–20-year-olds receiving their first custodial sentence between 1 January 1988 and 31 December 1999 was identified.Main outcome measures: Deaths, date and primary cause of death ascertained from study commencement to 1 March 2003 by data-matching with the National Death Index; measures comprising year of and age at admission, sex, offence profile, any drug offence, multiple admissions and ethnic and Indigenous status, obtained from departmental records.Results: The overall mortality rate was 7.2 deaths per 1000 person-years of observation. Younger admission age (hazard ratio [HR], 1.4; 95% CI, 1.0–1.9), repeat admissions (HR, 1.8; 95% CI, 1.1–2.9) and drug offences (HR, 1.5; 95% CI, 1.0–2.1) predicted early death. The role of ethnicity/Aboriginality could only be assessed in cohort entrants from 1996 to 1999. The Asian subcohort showed higher risk of death from drug-related causes (HR, 2.5; 95% CI, 1.1–5.5), more drug offences (relative risk ratio [RRR], 13; 95% CI, 8.5–20.0) and older admission age (oldest group v youngest: RRR, 9.3; 95% CI, 1.3–68.0) than non-Indigenous Australians. Although higher mortality was not identified in Indigenous Australians, this group was more likely to be admitted younger (oldest v youngest: RRR, 0.31; 95% CI, 0.15–0.63) and experience repeat admissions (RRR, 1.6; 95% CI, 1.0–2.4).Conclusions: Young offenders have a much higher death rate than other young Victorians. Early detention, multiple detentions and drug-related offences are indicators of high mortality risk. For these offenders, targeted healthcare while in custody and further mental healthcare and social support after release appear essential if we are to reduce the mortality rate in this group.

Carolyn Coffey BSc, GradDipEpi · Andrew W Lovett FRACP · Eileen Cini BSc(Hons) · George C Patton MD, FRANZCP · Rory Wolfe PhD · Paul Moran MD, MRCPsych

Jean Edwards was an eminent radiologist who was also well renowned for her knowledge of general medicine. Jean was born in Woollahra, Sydney, on 25 November 1913. She attended Frensham School, and graduated in medicine from the University of Sydney in 1938. After working as a junior Resident Medical Officer at Sydney Hospital, she married George Read, a former fellow medical student, in 1940. On completing her studies, Jean intended to become a paediatrician. However, when the war intervened, her father asked her to join his radiology practice in Macquarie Street. As there was no formal training in radiology at the time, Jean became a “radiological apprentice”, learning to take, process and report on x-ray films. Soon afterwards, she was invited to join the honorary staff at the Rachel Foster Hospital (RFH) as a radiologist. During her time at RFH, she also held honorary positions at Royal Prince Alfred Hospital (RPAH) and St Vincent’s Hospital. Jean’s sons, Andrew and David, were born in 1941 and 1944, respectively. She continued her career while raising her children. However, her family commitments led her to decline a later offer to join RPAH as Director of the Radiology Department. In 1955, Jean joined a private practice at Campsie, where she remained until 1980. She continued to work as an honorary medical officer at three public hospitals (RPAH, RFH and Canterbury Hospital). These were very happy years. The patients were diverse, including many rugby league players and a pet python! Jean had developed a love of art, history and poetry while at Frensham School. She maintained a long association with the school, acting as both a Governor and Chair of the Board for many years. Jean was fond of a passage by Walter Savage Landor ending with the words “whatever may become of the fruit, make sure of the flowers and leaves”. This summed up her philosophy on life. Jean was a keen skier and a member of the Sydney University Ski Club. She was a talented artist, pursuing her interest in art as a member of the Medical Art Group. After her retirement, she worked as a volunteer at the Genealogical Society and enjoyed afternoons in Centennial Park with her grandchildren. Jean died on 30 May 2004, at the age of 90, after a prolonged illness. Rebecca Read

Rebecca L Read