Medical practices

A 39-year-old woman with AIDS (CD4 count, 30 cells/mL) had a 4-day history of nausea, vomiting and profuse watery diarrhoea. The patient was afebrile and had a distended abdomen with diffuse guarding without rebound tenderness. Abdominal x-rays (Box 1) and computed tomography scans (Box 2) were performed. The white blood cell count was within normal limits and stool cultures were negative. Colonoscopy revealed yellow plaques throughout the colon. The patient improved clinically after taking oral metronidazole. Bowel wall "thumbprinting" (the appearance of "thumbprint"-shaped projections) is a radiological sign of thickening of the colonic wall. It occurs secondary to submucosal haemorrhage and oedema from capillary leakage.1 It can result from any process that leads to oedema of the bowel wall, including pseudomembranous colitis (as shown here), ischaemic colitis, non-infective inflammatory bowel disease, other infective bowel diseases, submucosal/intramural haemorrhage and other conditions.2 The mucosal damage and inflammation seen in pseudomembranous colitis are caused by Clostridium difficile toxin.3

Moishe Liberman MD · Chris Labos · Jeff Wiseman MD

Objectives: To determine the utility of capsule endoscopy in patients referred for investigation of suspected disease of the small intestine.Design and setting: Single centre, prospective, cohort study from 4 July 2001 to 8 September 2002.Patients: Sixty consecutive patients who underwent capsule endoscopy for investigation of suspected disease of the small intestine.Main outcome measures: Abnormal findings at capsule endoscopy.Results: ...

André K H Chong FRACP · Andrew C F Taylor MD, FRACP · Ashley M Miller PhD, FRACP · Paul V Desmond FRACP

Academic pathology needs to be reinvigorated For well over a century, pathology has played a pivotal role in our understanding of disease. Its principles underpin many of our teachings in medicine and surgery, for, as Rudolf Virchow — the eminent 19th century pathologist and founder of modern pathology — so aptly observed, "Through the application of its doctrines ... it helps to deepen biological knowledge, and to light up still further that region of the unknown which still envelops the intimate structure of living matter".1 In short, an understanding of pathology is an essential prerequisite to an understanding of medicine. Against this background, it is of serious concern to the Royal College of Pathologists of Australasia that the role of pathology has been downgraded and marginalised with the ascendancy of problem-based learning in Australian medical schools.2,3 It is true that medical curricula over the previous half century placed too much emphasis on the basic sciences at the expense of the social and communicative aspects of medicine. However, as so often happens when changes are made, the pendulum has now swung too far the other way, to the detriment of pathology and anatomy. As Sir John Lilleyman, past President of the Royal College of Pathologists (UK), recently observed, "Current students are taught everything about grieving, but little about the causes of death".4 By its very nature, problem-based learning involves a multidisciplinary approach to clinical problems.2 Sometimes the facilitator for problem-based learning sessions is not a medical graduate. Furthermore, pathologists in academia are now in such short supply that those remaining have limited time to participate in these sessions. (In one Australian university with a faculty of medicine, there is only one half-time academic in pathology, and another university no longer has an independent department of pathology.) The end result is reduced exposure of medical students to pathologists and loss of invaluable mentoring. Consequently, more and more teaching is falling on already overburdened hospital pathologists and registrars-in-training. Furthermore, pathologists in private practice are reducing their teaching commitments because of heavy workloads. Anecdotal evidence suggests that the recruitment of medical graduates into a specialist discipline depends on a number of factors. These include the exposure to that discipline in the medical course and in postgraduate years 1 and 2, and the presence of role models in particular fields. Over the past half century, Australian pathology has been fortunate in having people of stature in academic positions. A recent Australian Medical Association study5 showed that lifestyle issues are becoming an increasingly important subject in career selection. With the currently decreasing staffing levels in academic departments of pathology and lack of formal rotations into pathology in the immediate postgraduate years, there is every likelihood that future recruitment of Australian graduates into pathology will be difficult. We are currently awaiting the report into the pathology workforce of the Australian Medical Workforce Advisory Committee. It will provide recommendations on the number of training positions needed in each State to satisfy future workforce requirements. What can be done to reverse the decline in pathology, particularly in academia? Firstly, the profile of pathology needs to be raised in the pre-university, medical, and general communities. To this end, the College introduced "Pathology Week" in 2002. It involved laboratory tours for secondary-school students, meetings with medical students in some universities, and a dinner bringing together pathologists and leaders in the business community. This year, "Pathology Week" will be held on 10–16 March. Part of the purpose of the Week is to raise the profile of pathology in the wider community: very few Australians know what a pathologist does, despite millions of pathology tests being performed each year. The College has also produced educational material for members of the public and for students contemplating a career in pathology. The Federal Government, through its Quality Use of Pathology Committee, is seriously considering providing financial support to create teaching modules for use in problem-based learning courses. The aim is to ensure that medical graduates of the future have some knowledge of the proper ordering of pathology tests in clinical practice. The Federal Government has also supported the production of a new edition of the Manual of use and interpretation of pathology tests6 for use by students and the profession. Both these initiatives, while most welcome, are unlikely to have medical graduates clamouring to choose a career in pathology. The Academic Advisory Committee of the College has prepared a core curriculum for use in medical schools, although advice from various Deans suggests that a surplus of curriculum content already exists. At the end of the day, the "committee sitters" usually win out in such exercises. Until such time as academic salaries in all branches of medicine become more realistic and aligned with other sectors in medicine, the future of academic pathology looks bleak. As New Zealand and the United Kingdom are experiencing similar shortages,4 there is little likelihood that academics can be recruited from those countries. In exchanges of correspondence with various Deans of medical schools, one has suggested that the College should do more to assist in the recruitment of pathologists to our universities. Perhaps it is time for governments and the private sector to put their support behind academic pathology to help resurrect the field of pathology and ensure it receives due recognition in the curricula of our medical schools.

David Weedon AO, MD FRCPA

Before I visited the Department of Forensic Medicine in Glebe, my concept of an autopsy lacked insight. I now realise that autopsies have many roles and affect us at as many different emotional levels. My first impression was that a very strong "impersonal" aura prevailed in the autopsy suite. Two rows of cold, steel tables laden with bodies were surrounded by uniformly dressed pathologists and technicians — opening bodies, removing organs, examining organs, replacing organs, restoring bodies. As I observed this routine, I became aware of the social chatter, similar to the conversation that takes place in operating theatres. Here, the chatter seemed to trivialise the situation. The emotional spectrum then shifted dramatically when I focused, not on the body, but on the person that the body represented. Each person has a history and it was at this level that the concept of death became very personal. I found myself studying their facial expressions and becoming immersed in the circumstances surrounding their death. For people who had died by suicide, I tried to comprehend the terrible anguish and hopelessness they must have felt before taking their own lives. For those who died in accidents, I realised that they would not have expected to die that day. The face of a motorcyclist killed in an accident did not show pain, although the reports indicated that death was not instantaneous. Did he have any last thoughts or reflections as he lay dying on the side of the road? Then I wondered how the families would deal with the devastating news of these deaths. I witnessed a young man who had survived surgery and then died of a massive pulmonary embolism at home. I reflected on the pain that his family, girlfriend and friends must have been feeling. The fact that he was well loved was obvious from all the graffiti on his plaster cast and the tattoo of his girlfriend's name on his abdomen. These incidents impressed on me how precious and unpredictable life is and how I so readily take it for granted. I found that what disturbed me most was not, as I had anticipated, that a person was "dead", but rather the emotions involved in death. I found that I could not detach myself from the profound feelings of sadness that the deceased person's family would be feeling. A powerful compounding factor was the short time frame between death and autopsy. In most autopsies, the person had died in the past 24 hours. I would go home each night knowing that someone alive right now would die, and I would see them in the morgue in the morning. At the end of each day I was exhausted. I had moved through a kaleidoscope of emotions, from sadness to helplessness, from anger to frustration. I became aware of the extent to which I was personalising each case and of the toll this was taking on me. I needed to detach. It was at this point that I began to understand the "impersonal aura" that I had initially felt was inappropriate. The social chatter and humour provided protection from a narrow focus and draining emotions. On a daily basis, one could not survive this high emotional intensity without such a coping mechanism. Even knowing this, I still found it difficult to stay detached, especially during an autopsy. The body is opened by a series of incisions in the head, neck and trunk, then the internal organs are removed for dissection and examination. I felt this intermediate presentation of the body (with empty chest, abdominal and cranial cavities) to be a violation of that person. I imagined the distressing reaction of the family if they could see what was happening to their loved one. I asked the questions "Was it not enough that they had already lost their loved one? Was an autopsy really necessary? How do we justify this added pain?". These questions played on my mind all through the week. I learnt that family consent is not needed for a coronial autopsy in New South Wales, although a family does have a legal right to object to the examination. The pressure of having to make such a decision at a time of great emotional distress and vulnerability doesn't seem fair. This decision could also conflict with the family's religious or other beliefs. On the other hand, an autopsy is clearly a valuable procedure. Determining whether a person died of natural causes, or as a result of unnatural interference by others, is necessary both for the emotional recovery of family members and the maintenance of justice in our society. Autopsies also provide information about diseases that may directly affect relatives, and, cumulatively, aid in the prevention of future deaths. I learnt a lot during my week at the morgue — particularly about my "personal and professional development". I had never experienced death on a personal level, and my reactions to death were not what I expected. I had experienced a similar inability to detach during hospital rounds. I realise now that it is a trait that I must confront, particularly if I want to remain sane in the medical field. I need to find a balance between becoming what I perceive as too impersonal and becoming too involved.

Tina Kastowsky BSc (Biomed)

An elderly patient with diabetes presented with oesophageal obstruction after taking a regular dose of metformin. A lateral neck radiograph confirmed the presence of an obstruction in the upper oesophagus. The patient underwent rigid oesophagoscopy, at which time the tablet, complete with packaging, was removed (see Box). The patient went on to make a full recovery.

Peter A Monksfield MRCS · Olivia JH Whiteside MRCS · Stuart CA Winter MRCS · Nicholas B Steventon FRCS · Graham J Cox BDS FRCS

Pattern recognition in diagnostic imaging. Peter Corr. Geneva: World Health Organization, 2001 (x + 205 pp). Here is another useful WHO publication. It stays close to the topic of pattern recognition through most of its 205 pages, but it does enter the field of radiography to emphasise issues of quality and safety — a relevant reminder, since many in its target audience would be involved closely in taking x-rays. In this era of CT and MRI, plain x-rays are often overlooked in favour of high technology solutions, but in rural areas they remain the mainstays of diagnosis. Many readers will enjoy having access to a book that addresses this topic, without having to pay for a tome which also describes how to interpret digitised images. For the generalist doctor who has to interpret his or her own x-rays, it provides a useful primer. The book is organised into sections on the chest, musculoskeletal and gastrointestinal/urinary systems. Each chapter is well set out, with learning points providing a succinct summary at the end. This systematic approach provides a good collation of standard approaches to the assessment of such areas as the cervical spine. The patterns alluded to in the title are patterns of disease rather than radiographic patterns. The disease-based approach provides a practical compromise for the clinician. There is an emphasis on tuberculous disease which reflects the South African origins of many of the authors, and this means that the book has practical applications in many developing countries where the disease is rife. The lack of an index is a deficiency, although the systematic approach of the book allows the reader to find the relevant area reasonably easily. The photographs and line drawings are generally of a high standard but some, especially in the musculoskeletal section, lack sufficient annotation. The inclusion of renal ultrasound seems out of place. The book would be a useful text for those entering rural or remote practice, or practice in the developing world. This is especially true for those in training or early in their career as it provides a useful framework of patterns of disease, which will augment their knowledge base and help them organise their experience. Alan B ChaterRadiological Advisory Council of Queensland

Alan B Chater

To the Editor: White emphasised problems that can arise if medical decisions are overly reliant on the results of laboratory tests.1 He relates the case of a patient who, because of a peculiarity of her immunology, consistently produced a false-positive test result. In probabilistic language, the issue is are there risks of both random errors and patient-specific errors? It is important to distinguish between them. Suppose a test has a false-positive rate of 10%. If this is truly random error, the probability of two false-positive results in the same person is 1%, and the probability of three false-positive results is tiny. But if it is due to there being 10% of healthy people for whom the test is invalid and who consistently give a positive result, the probability of two false-positive results in the same person is 10%, and the probability of three false-positive results is 10%! Major textbooks of medicine have excellent chapters on decision-making. These warn about limitations of sensitivity and specificity (eg, that data from the general population may not apply to people who have tested positive in screening). But, other than this, little is said about reasons for errors in testing, and the consequences for how sensitivity and specificity should be used. In most cases, the impression given is that errors occur completely randomly. However, it appears that White's example, in which repeated testing led to repeated errors, is not unique. Lee2 writes as follows: "Suppose a low-risk patient has an abnormal lung ventilation–perfusion scan. Obtaining that same test result over and over will not truly raise that patient's probability of coronary disease further and further." Perhaps Goldman3 had something similar in mind when writing, "It may be quite difficult to distinguish random laboratory errors from test results that might be falsely positive or negative because of coexistence of a process that can affect the test". Lists of possible reasons4,5 for errors include both short-acting (eg, distracting external noise, and biochemical effects of foods recently eaten) and long-term (eg, physical handicaps, and demographic factors) influences. I wonder if information about tests should routinely include separate random and patient-specific components of sensitivity and specificity. For example, it might be stated that a false-positive rate of 15% arises from 10% random errors and 5% patient-specific factors, or that a false-negative rate of 10% arises from 3% random errors and 7% patient-specific factors. This is the conclusion I have been led to by White's article.

T Paul Hutchinson

In reply: Many factors potentially contribute to error in generating a diagnostic test result, and include random pre-analytical errors arising from patient preparation and specimen collection, random errors associated with the act of measurement, and systematic errors caused by, for example, drug interference. Tested individuals may also harbour an interfering substance, such as a drug or immunoglobulin. The theoretical and practical description of these components of test error is generally well understood and documented by laboratories, and the basics of test error and diagnostic sensitivity and specificity are taught in medical schools. However, I think trying to apply probability data to a test result for a specific patient is of limited value to the treating doctor. The commoditisation and automation of much of pathology testing contributes to a perception that tests are 100% reliable, and there is also a perhaps related decline in communication between requester and provider. Most tests have limitations, many inconsequential, some important and patient-specific. Although Hutchinson draws a valid conclusion, I hope readers also concluded that communication with diagnostic laboratories remains important for safe patient care, and that test results still need to be interpreted in the context of other clinical information about a patient, and not accepted without question.

Graham H White

To the Editor: While agreeing that sensible utilisation of pathology tests in emergency departments (EDs) is important, we are concerned that the article by Stuart et al1 might be misinterpreted to justify wholesale reductions in important diagnostic microbiological tests, particularly blood cultures. Stuart and colleagues imply they could safely reduce the number of blood cultures by 80%.1 Other local data have suggested a minority of blood cultures in the ED influence patient management.2 Confirmation of aetiology will be denied for patients by "rationalisation" of blood cultures in EDs. Although most pathogens are susceptible to broad-spectrum anti-microbial agents, widespread empiric prescribing of such agents in an era of increasing antimicrobial resistance is unwise. A recent Australian study evaluating blood cultures found that a third of patients with positive blood culture results were not clinically suspected to be bacteraemic.3 Furthermore, the Journal recently reported the emergence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA),4 and increasing resistance in Streptococcus pneumoniae.5 Missing MRSA or multidrug-resistant pneumococcal bacteraemia will result in adverse patient outcomes. What about missed cases of meningococcal disease, or typhoid fever, with their associated public health costs? Paradoxically, amid emerging antimicrobial resistance, we may become less aware of the problem. Furthermore, what about the infection control costs required to control the resultant outbreaks of multidrug-resistant organisms? Empiric broad-spectrum antibiotic prescribing, driven by failure to undertake important microbiological investigations, is bad medicine: It teaches everyone to guess the microbiological diagnosis, and, if you do not test, who can prove you wrong? Perhaps only when the patient presents to the tertiary referral hospital with therapeutic failure and evolving multisystem organ failure. It logically extrapolates to all patients getting vancomycin plus meropenem to ensure covering MRSA and resistant gram-negative bacilli. It inevitably drives resistance, which is increasing rapidly. It has never been subject to rigorous scientific scrutiny with cost-effectiveness studies. Moreover, the study by Stuart et al1 provides no data on readmission rates, lengths of stay, adverse events and rates of missed or incorrect diagnoses; the ED setting studied has limited generalisability; and United States guidelines, which may be inappropriate in the Australian healthcare context, were used to develop the diagnostic testing protocol. Might not reducing the ordering of some microbiological tests cause "spiralling therapeutic empiricism"? Might not the overall healthcare budget growth accelerate because of increased prescribing of expensive broad-spectrum antimicrobials?

Iain B Gosbell · Peter J Collignon · John D Turnidge · Christopher H Heath · Joan L Faoagali

To the Editor: The practice of radiology and pathology has changed dramatically in the past two decades. Increased use of multidisciplinary assessments and interventional techniques has meant greater exposure of patients to radiologists and pathologists. When patients undergo investigations, they are invariably anxious, usually expect the worst, and want the result as soon as possible. Therefore, there is pressure to provide an immediate answer to the problem at hand. In most instances, it would be possible to offer a diagnosis. However, many radiologists and pathologists are reluctant to discuss investigations with patients in detail.1 During interventional procedures, radiologists and pathologists see patients only briefly; they often don't know all the facts about them, and are not ultimately responsible for their clinical management.1 As the patient is only temporarily in the care of the radiologist or the pathologist, it is not appropriate to discuss complex issues or offer opinions and advice. Such advice may put the patient's doctor in an awkward position, forcing the referring practitioner to follow a course of action which may not be in the best interests of the patient. At a patient's insistence, radiologists and pathologists can sometimes indicate to someone who has a clearly benign condition that the problem under investigation is unlikely to be serious.2-4 This may be the case with screening mammography, as, in most cases, the results are either normal or indicate a non-malignant condition. However, in diagnostic radiology and pathology, such an opinion is usually based on a preliminary impression, which may change when all the facts are considered. The cost of providing on-the-spot written reports to the patient has to be factored into the equation. It has been estimated that the additional cost of immediate reporting of results of screening mammography is about US$28.22. When additional equipment and space were not required, the cost would increase by US$4.38. Although most patients in the study preferred immediate reporting, they were unwilling to pay the additional fees.5 With respect to pathology, a formal fine-needle aspiration result can be delivered within an hour, but, for the reasons outlined above, this would not be advisable. Further, the pathologist's contract is with the referring doctor and the report is written in scientific language, which may not be easily understood by the patient, leading to unnecessary anxiety. Giving bad news to a patient is not an easy task even for trained professionals. It is even harder for radiologists and pathologists who are not generally equipped to provide counselling and support, and who may not be indemnified by their insurers to carry out such tasks. Further, neither radiology departments nor pathology laboratories are suitable settings for giving bad news,1 as very few support avenues are usually available to patients there. Predicting the impact that bad news will have on a patient is extremely difficult, and radiologists and pathologists should, for compassionate and for medicolegal reasons, refrain from providing immediate answers to patients.

Ibrahim M Zardawi

It is time to focus on reducing inappropriate test ordering The complexity of modern medicine has promoted an excessive reliance on the results of empirical tests rather than clinical acumen. In Australia, this is reflected in the fact that the rise in the costs of diagnostic testing in pathology and radiology is second only to the rise in cost of pharmaceutical prescriptions, the fastest-growing sector in our healthcare budget. Many reasons have been cited for this increase in clinicians' reliance on pathology and radiology testing. Among community-based practitioners, ordering patterns are most likely to be influenced by medicolegal concerns, time constraints, screening needs, or ingrained practice habits. Among hospital-based clinicians, test-ordering practice may be determined by level of clinical experience, fear of censure for lack of testing, medicolegal concerns, and the desire to provide a "one-stop" service to evaluate all possible physiological parameters.1 In addition, the pressures of shorter consultation times in community practice and diminishing hospital beds have led to the increased use of investigations to fast-track patient throughput. In acute hospital settings, it has been estimated that as many as a third of all tests ordered are inappropriate in terms of their ability to contribute to the diagnosis and treatment of individual patients.2 This overtesting is not without consequences. If a healthy individual is subjected to 10 unnecessary tests, there is a 40% chance of at least one false-positive result.3 As well as exposing the patient to potential harm from unnecessary tests and treatment, this may expose the clinician to an increased, rather than a decreased, medicolegal risk, as patients are exposed to greater risks of complications while they proceed along an unnecessary testing spiral. In a community that is struggling to cope with the financial demands of modern healthcare, the wastage of resources on unnecessary pathology and imaging testing has an adverse effect on the provision of services that are legitimately required. Furthermore, in most settings, it is the relatively cheap, common tests that account for the bulk of testing expenditure. In our own institution, about 80% of the costs of biochemistry and haematology testing are accounted for by full blood counts and testing of electrolytes, urea, creatinine, liver function and cardiac markers. Although more complex investigations, such as gene testing, may individually be more expensive, the sheer volume of common tests drives the overall costs of investigations, and suggests that attempts to reduce inappropriate testing should focus on these tests. In this issue of the Journal, Stuart and colleagues (page 131) report on a comprehensive program of education, audit, feedback and structural change to reduce the number of investigations performed in a public hospital emergency department.4 Although their program focused on reducing inappropriate testing and improving result follow-up in an emergency department, the lessons learned about how to produce sustainable change in clinician practice are equally applicable to the rest of the acute hospital environment, and to the community sector. There has been a plethora of reports on the implementation of educational or other programs aimed at curbing the costs of inappropriate testing. Most describe utilisation of tools such as education programs,5,6 incentives for clinicians,7,8 information about costs of testing, audit of ordering profiles, feedback on ordering patterns, guidelines, decision-support systems, and process changes.9,10 The study by Stuart et al demonstrates the key features required for sustainable improvement in test-ordering behaviour. A multifaceted approach that results in alteration to the core processes of test ordering is more likely to promote lasting improvements than strategies aimed just at increasing awareness or knowledge among individuals. In public hospitals, where the junior medical staff who are responsible for most test-ordering rotate through departments at three-monthly intervals, it is essential that whatever changes are made to improve test-ordering are capable of affecting a mobile workforce. It is unlikely that educational programs alone could cope with the demands of this rostering pattern, unless concomitant process changes are implemented hospital-wide to ensure applicability in all clinical settings. As conceded by Stuart et al, the effects on patient outcomes of attempts to reduce overtesting were not addressed. No data are provided on readmission rates, length of stay, adverse events and rates of missed or incorrect diagnoses. It is possible that attempts to reduce numbers of tests performed could result in harm to patients through underinvestigation of symptoms. Therefore, future studies in this area should include measures of patient outcomes to ensure that an overall improvement in patient care accompanies the reduction in costs of investigation. Computerised systems are widely available in general practice for prescribing, and, in some places, for test ordering, but have yet to be widely implemented in the acute care sector. At present, these systems have focused on facilitating the ordering process rather than ensuring its appropriateness. The future is likely to see implementation of computerised order-entry systems that provide real-time feedback on ordering patterns, guidance on test appropriateness, improved result checking, and information on the costs of tests ordered. Such systems already exist, and are currently being tested in several Australian hospitals. It is hoped that overcoming existing deficiencies in information systems will enable clinicians to order tests and check results more efficiently and more appropriately than they currently do. An academic analysis of current test-ordering practices might suggest that further research is needed into why doctors order tests the way they do, whether there really is such a high rate of unnecessary testing, and what value current ordering patterns add to our highly complex healthcare system. A pragmatic view, however, would suggest that there is enough published evidence that overtesting is a characteristic of healthcare systems in the developed world, and enough information in existing research to guide what should be done to reduce waste and harm resulting from inappropriate testing. It is time that the focus of work in this area shifted to development of practical, sustainable means of improving the appropriateness of testing. Future research may be best directed to understanding the place of sophisticated decision-analysis models, the role of point-of-care guidance and feedback systems, and effective clinical change-management strategies. In the meantime, hospitals around Australia have already embarked upon attempts to change current practice. In Melbourne, the National Institute of Clinical Studies is sponsoring a 12-month project, involving hospitals from four States and Territories, aimed at developing transferable and sustainable changes in test-ordering practices. Similarly, hospitals involved in the Health Roundtable in Sydney have been involved in exchanging information on effective strategies to improve test ordering. The Royal Australasian College of Pathologists is developing undergraduate education programs aimed at improving ordering practices. The lessons learned from these groups should inform national strategies to deal with the problem of inappropriate testing. As in the study by Stuart et al, it is likely that a coordinated, multifaceted, sustained approach to this problem will be required to achieve lasting success.

Rohan J H Hammett MB BS, FRACP · Roger D Harris MB BS, FACEM

Diagnostic laboratories are increasingly seen as no more than "factories" that generate fast, reliable test results. The dangers of complacency about the use of tests are highlighted by recent cases of unnecessary surgery and chemotherapy based solely on false-positive test results. There are many causes of misleading laboratory data that can potentially lead to clinical mismanagement. Re-emphasis of the value of patient-relevant communication between the requesting doctor and the laboratory, and better undergraduate and postgraduate education about the appropriate use of tests, will help reduce the risks of test results leading to harm.

Graham H White PhD, MAACB

Cases in surgical radiology. David C Howlett and Michael P Saunders. Oxford: Blackwell Science, 2001 (ix + 220 pp). ISBN 0 632 05822 6. The presentation of radiological images is an excellent method for teaching all aspects of medicine to students and advanced trainees. It provides an introduction to the condition under examination and acts as a springboard for further discussion. Cases in surgical radiology is a published version of this commonly utilised teaching technique. It is set out as a series of tutorials constructed by nine consultant radiologists from Eastbourne, Guy’s and St Thomas’s hospitals in the United Kingdom and Vancouver General Hospital in Canada. Each “tute” consists of 12 diverse surgical cases, including radiographs, computed tomography (CT), ultrasound, contrast studies, occasional magnetic resonance imaging (MRI) and nuclear medicine scans, and is set out as a brief clinical history and accompanying radiological study. The reader is asked a series of questions based on these studies. Image interpretation is provided on the following page, together with further imaging and a clinical perspective such as differential diagnosis. Follow-up reading on the subject is facilitated by the inclusion of a literature or textbook reference. The book works and is fun. The format is simple and concise, and this pocket size, soft-cover book is easy to whip out and read when a spare moment arises. It is not a comprehensive text for the on-call surgical or radiology registrar, although it does have a reasonable index allowing for review of a specific pathological condition. My only complaints are that the contributors have delved a little too deeply into their teaching files, producing one or two cases that are quite esoteric, and that photographic reproduction, especially for the abdominal radiographs, is not always optimal. I have no hesitation in recommending this book for a medical library catering to students or surgical trainees. Given that it is reasonably cheap, it would also be a good buy for individuals. In summary the concept is excellent, the format well executed and the cases instructive. It is a useful resource for the teaching of surgery through the interpretation of radiological studies. Christopher J O’DonnellRadiologist, Brighton East, VIC

Christopher J O’Donnell

To the Editor: Chronic hepatitis C virus (HCV) infection affects almost 200 000 Australians.1 It is monitored clinically by serial liver function tests (LFTs) and HCV RNA detection by polymerase chain reaction (PCR). HCV RNA is a marker of chronic infection and levels reflect response to antiviral therapy. However, testing for the presence of HCV RNA is expensive and, under the current Medicare Benefits Schedule, is not available to people with HCV antibodies and abnormal LFTs unless they are undergoing antiviral therapy. Using an in-house PCR assay, it has been shown that abnormal LFTs largely predict the presence of HCV RNA.2 We aimed to confirm this finding using a more reproducible PCR assay (Roche Amplicor HCV test) and to further investigate the relationship between LFTs and HCV RNA. We studied 323 HCV antibody-positive patients seen at the Fairfield Infectious Diseases Hospital, Melbourne, between May 1995 and September 1996. The Victorian Infectious Diseases Reference Laboratory performed all PCR assays and LFTs on these patients. Approval for the use of de-identified data was obtained from the Ethics Committee of the Royal Melbourne Hospital Research Foundation. Normal serum alanine aminotransferase (ALT) levels from at least two tests over a period of at least six months were considered to demonstrate normal liver function. In order to determine improved predictors of the presence of HCV RNA, the proportion of patients who were HCV RNA-positive and had an initially normal ALT level and the proportion with a normal ALT level persisting over six months were examined for each 10-IU/mL subdivision within the normal ALT range (0–50 IU/mL). Of the 323 patients, 88% were aged between 20 and 49 years and 68% were men. At initial testing, 251 (78%) were HCV RNA-positive by PCR, 206 (64%) had an abnormal ALT result and 183 (57%) had both a positive PCR result and an abnormal ALT level. An abnormal ALT level predicted the detection of HCV RNA in 89% (183/206) of patients and in 82% (14/17) if an abnormal ALT result was found within six months of an initial normal result. Of the 117 patients with a normal initial ALT level, only 49 (42%) had a negative PCR result. However, an initial ALT level of ≤ 20 IU/mL was more likely to be associated with a negative PCR result than an initial normal ALT level > 20 IU/mL (78% v 23%, respectively; P < 0.001). The probability of a negative PCR result was highest if the initial ALT level was ≤ 20 IU/mL and remained normal for at least six months (see Box). We concluded that, while an abnormal ALT level in a patient with HCV antibody generally predicted the presence of HCV RNA, the absence of HCV RNA was best predicted by an initially low ALT level that remained within the normal range for at least six months. Proportion of patients with normal initial serum ALT level and persistently normal ALT level who were positive for HCV RNA by PCR, divided into 10-IU/mL subdivisions of the normal ALT range Initial ALT range (IU/mL) Number (%) PCR positive, all patients Number (%) PCR positive, patients with persistently normal ALT over six months ≤ 10 2/11 (18%) 2/3 (67%) 11–20 7/29 (24%) 0/11 (0) 21–30 18/30 (60%) 11/12 (92%) 31–40 23/27 (85%) 8/8 (100%) 41–50 18/20 (90%) 2/2 (100%) ALT = Alanine aminotransferase. HCV = Hepatitis C virus. PCR = Polymerase chain reaction.

Heath A Kelly · William J Maskill · William Sievert · D Scott Bowden

To the Editor: In late 1998, a clinical audit in the Thoracic Division of the Prince Charles Hospital found the autopsy rate was 7% of all patients who died in the Division (excluding Palliative Care) for the 12 months to September 1998. Following discussions and acknowledgement of the importance of hospital autopsy as a clinical audit tool, the Division's policy to consider an autopsy in all patients who died was reinforced. Registrars were educated in seeking approval and in counselling relatives. As a result of these interventions and ongoing audit, a decision in relation to autopsy is now recorded in more than 90% of charts following a patient's death, compared with 40% initially. The autopsy rate progressively increased, and, from March 2000 to January 2001, it was 35%, five times the baseline rate, and the refusal rate was 11% (Box). The rate of limited autopsies (generally only excluding the brain) increased from 20% to 50%. However, from early 2001, coinciding with the ongoing negative Australian press coverage related to aspects of autopsies, there has been a marked decrease in relatives' agreement to allow autopsy and extent of autopsy. The refusal rate for autopsy increased to 30% for the four months to May 2001, and was 25% to September 2001. The autopsy rate fell dramatically to 27% and 13% for the same periods. Nine of the 10 autopsies were limited, usually to a single organ or body cavity. Data from death certificates are vital for education, research and public health purposes.1,2 Autopsies remain the only way to audit the accuracy of death certificates. A review found that the rate of clinical diagnostic inaccuracy for major findings at autopsy is about a third, and this rate has not changed since 1912.3 This unavoidable baseline of diagnostic error4 does not necessarily indicate incompetence or malpractice. It is essential that the public understand that medicine is not an exact science, that we do misdiagnose conditions, and that identification of these "errors" is of value to relatives, to future patients and to society. Legislative changes are being proposed in Australia that will make obtaining consent for autopsies more complex and potentially distressing for relatives. Education of medical staff and the general public must accompany these changes if they are not to be the final "nail in the coffin" of the hospital autopsy and remove an important facet of continuing improvement of medical practice. Autopsy rates in the Thoracic Division of the Prince Charles Hospital

Helen E Ward · Belinda E Clarke · Paul V Zimmerman · Michael I Cleary

An Australian study, published in 1998, described histological features of breast cancers occurring in young women with germline mutations in two specific genes.1 In 2000, a multicentre US group conducting molecular analysis of a series of diffuse large B-cell lymphomas reported that, within this group of morphologically indistinguishable tumours, two distinct types of lymphoma could be identified by gene-expression profiles, and that these two types had significantly different prognoses.2 Figure: A tissue array containing 109 samples of a specific cancer type, courtesy of Associate Professor Deon Venter, University of Melbourne. These two studies have important implications for the future of diagnostic medicine and anatomical pathology, although the message is different in each case. In the first study,1 Armes and colleagues identified morphological features associated with specific genetic alterations in a group of cancers, combining morphological interpretation and pattern recognition with knowledge of mutations at specific points of the chromosomes in the cancer cells. By examining thin tissue sections stained with vegetable dyes, a pathologist can not only name these cancers, grade them and provide staging information, but can now also suggest likely molecular and genetic events occurring in the tumour cells and assess the likelihood that cancer risk was inherited from the patient's parents and will be passed on to her children. In the second study,2 Alizadeh and colleagues used molecular techniques to identify biological differences between tumours that histopathologists were unable to distinguish microscopically. These techniques allowed a deeper understanding of the biology of the cancer than was possible by morphological examination alone, with significant prognostic implications for patients. So, what will be the impact of molecular biology on diagnostic tissue pathology? Skill in identifying the gross and microscopic features of diseases will remain important in the next few decades. The management of cancer demands more than simply a diagnosis, and much of the information provided by traditional histopathology (eg, margins of surgical excision and data for staging) will still be required. Moreover, much routine diagnostic histopathology and cytopathology involves diagnosis of non-neoplastic conditions — in the foreseeable future, this is likely to be performed most efficiently by individuals trained to recognise these conditions by microscopy. Nevertheless, there is no argument about whether molecular techniques will become important in diagnostic medicine — they already have. Array technology already allows profiles of gene expression to be developed for any specific tumour (see Figure),3 with the prospect in the next few years of therapy directed at specific molecular targets in an individual's tumour. Expertise in morphological interpretation will remain necessary for the utilisation of such techniques (eg, in both the studies described,1,2 morphological recognition of the cancers was vital before molecular analysis could be undertaken). Some histo- and cytopathologists are likely to incorporate molecular techniques into their repertoire, while others will focus on their expertise in morphology and leave molecular technology to non-pathologists, being content to provide diagnoses and tissue for other studies. The findings of Armes and colleagues were the result of merging the skills of morphological diagnosis and molecular biology within a small group; the analysis by Alizadeh and colleagues involved two distinct steps — morphological diagnosis then molecular analysis — that could have been carried out by different people at different times and places. Molecular biology will continue to alter our concepts of disease, and pathologists will have to adapt to providing new information required by clinicians for prognosis and therapy. In large centres, both public and private, pathologists will be expected to contribute tissue and information for clinical trials, which may require a willingness to be flexible in styles and protocols for handling and reporting specimens. At the same time, pathologists will retain their custodial responsibilities for tissue, and will be required to decide on the appropriate allocation of tissue for immediate diagnostic purposes, for clinical trials, and for other research projects. Many of the most obvious changes to histopathology and cytopathology relate to molecular biology, but debates and decisions in tissue pathology will not only be about advances in biotechnology. Although the attention of government and the media has moved on from the autopsy, the future of hospital autopsies is by no means clear, and pathologists will need to clarify their own commitment to the autopsy, possibly in the face of diminishing support from clinicians and hospital administrators. Medical teaching in Australia is undergoing a revolution, and the allocation of time and resources to pathology teaching has suffered considerably in many of the new integrated curricula. The consequences of this remain to be seen. The spectacular advances in molecular technology are costly, requiring sophisticated laboratories and highly trained people. One of the many challenges in healthcare in the future will be to minimise inequities in access to diagnostic information necessary for appropriate management, not just between richer and poorer nations but within each nation, including Australia.

Duncan P MacGregor MBBS, PhD, FRCPA

Forensic pathology is the application of the principles and practice of pathology to the needs of the courts, or, more broadly, the law. The administration of justice. Arguably the single biggest global advance in the administration of justice in the past 60 years has been the advent of international criminal tribunals. This has meant that gross abuses of human rights and related offences, committed in times of war or insurrection, can no longer be perpetrated with impunity. The tribunals need evidence, some of which has been provided by Australian forensic practitioners in places such as Bosnia, Kosovo and East Timor (although, in the last case, no such tribunal exists). The aim of forensic pathology in these circumstances (often involving multiple deaths) is to identify the deceased, to establish the cause of death and to help reconstruct the circumstances surrounding the death. The likely development of a standing International Criminal Court, possibly within the next two years, will increase the potential for contributions by Australia's forensic community in this important area. Domestically, DNA typing has provided the courts with valuable evidence in helping to convict those guilty of rape, assault and murder. The exclusion of suspected offenders is a less well appreciated but vital application of this methodology — in several cases overseas it has been used to identify wrong convictions. DNA typing has also led to important advances in identifying decomposed or skeletal remains and grossly traumatised remains in mass disasters. Healthcare delivery. Forensic pathology is also influencing healthcare delivery, with forensic and other medical specialists beginning to interact more closely. Tissues from complex cases of sudden and unexpected death are being submitted for cytogenetic and molecular biology studies, resulting in far more accurate diagnoses of rare conditions.1 There have been moves to institute national and international protocols to standardise the investigation of infant and childhood injuries and deaths. The use of such "gold standards" has been shown to improve diagnostic accuracy,2 identifying deaths incorrectly attributed to sudden infant death syndrome (SIDS). Future epidemiological studies, such as those that resulted in dramatic falls in the rates of SIDS during the nineties, will only be useful if diagnostic precision is maintained. Intervention and prevention. A recent innovation has been the setting up of the National Coroners' Information System at Monash University to store information about deaths reported to Australian coroners. The information will be available to coroners, forensic pathologists, researchers and others with an interest in preventable injury and death. "Tissue issues." The retention and use of organs and tissues removed at autopsy has been a matter of substantial publicity over the past 12–18 months. Formal inquiries were carried out in New South Wales and South Australia. The Australian Health Ethics Committee has provided advice on the handling of stored tissue, and the Australian Health Ministers' Advisory Council is currently developing national guidelines for the future conduct of autopsies. Repositioning the autopsy. The autopsy needs to be repositioned, not simply subjected to greater regulation. The information provided to pathologists before coronial autopsies (which constitute 80%–90% of autopsies in Australia) is generally poor. This is a global phenomenon, as it is unreasonable to expect police officers to provide what, in many cases, is a medical history. Much of this information resides with families. The complexity of the processes surrounding autopsy, and the necessity or desirability of retaining organs and tissues, is such that a proper understanding of them will only reside in pathology departments. Many, if not most, autopsies yield information of intense interest, or of healthcare relevance, to the families of the deceased. Increasingly, pathology services are recognising a duty to take more responsibility for informing families when autopsy has unexpectedly revealed a condition with a hereditary component (eg, prolonged QT interval, hypertrophic obstructive cardiomyopathy3 or haemochromatosis). For these reasons, pathology services need to consider the establishment of a relationship, like the normal therapeutic relationship between doctor and patient, with the family of the deceased. Such a relationship would clarify and facilitate the processes and necessary communications surrounding autopsy. But this will not be achieved within current resources.

Stephen Cordner FRCPA, FRCPath · Roger W Byard MD, FRCPC, FRCPath

Through improvements in radiopharmaceuticals and instrumentation, nuclear medicine continues to develop and refine in-vivo approaches for diagnosis (including staging and prognosis) and treatment of disease. Diagnosis. Positron-emission tomography (PET) using the glucose analogue 18F-fluorodeoxyglucose exploits the higher rate of glycolysis in malignant tumours relative to most normal tissues. PET is cost-effective, and is more sensitive than anatomical imaging for diagnosis, staging or restaging of patients with cancers of the lung, breast, colon, head and neck, oesophagus, lymphoma and melanoma.1 Nevertheless, optimal targeting of therapy requires careful correlation of the metabolic data derived from PET with the anatomical detail provided by CT or MRI, ideally by "fusing" the datasets from these modalities. The illustration shows a "fused" PET-CT image. In Australia, the Commonwealth Government will expand its present funding of two PET facilities to six in 2002, which will improve patient access to this technology. Myocardial perfusion imaging (MPI) using thallium-201 chloride or technetium-99m-labelled agents (sestamibi, tetrofosmin) has been validated for diagnosis of coronary artery disease (CAD) and detecting viable myocardium after myocardial infarction. More recently, its prognostic value for known or suspected CAD has been established: MPI provides incremental predictive value for overall cardiac mortality and major cardiac events over clinical evaluation, exercise testing or coronary angiography. A normal scan indicates a probability of less than 1% for death or non-fatal infarction within 12 months; this benign prognosis applies equally to patients at high risk of CAD who are to undergo non-coronary surgery. Assessment of regional and global left ventricular function is now possible, so MPI can be used to assess regional myocardial perfusion at rest and exercise, and simultaneously quantify left ventricular performance. A novel application of MPI is evaluation of patients presenting with chest pain and indeterminate ECG results. A normal MPI examination rules out myocardial infarction or significant ischaemia, and permits safe discharge of the patient for later outpatient evaluation.2 The most important prognostic indicator for breast carcinoma is axillary lymph node involvement at the time of surgery. This is conventionally ascertained by axillary clearance, which is associated with significant morbidity. Assuming that lymphatic dissemination from breast cancers is predictable, the sentinel lymph node (SLN) represents the first draining lymph node encountered by tumour cells. If the SLN can be shown to be free of metastatic disease, no further axillary exploration should be necessary. Lymphoscintigraphy following the peritumoral injection of Tc-99m-labelled microcolloid — coupled with the intraoperative use of a radiosensitive probe and (non-radioactive) isosulfan blue dye — can accurately identify the SLN in patients with apparently localised breast cancer.3 Tc-99m sestamibi imaging, particularly when coupled with high-resolution ultrasound, can accurately localise parathyroid adenomas in over 90% of patients. Confident preoperative localisation allows minimally invasive parathyroid surgery, which can be combined with the intraoperative use of a radiosensitive probe and rapid parathyroid hormone assays to shorten operating time, hospital stay, and convalescence. Intervention. Several β-emitting radiopharmaceuticals selectively localise in skeletal metastases and reduce pain, presumably by irradiating the metastatic lesions. Strontium-89 (for metastatic prostate carcinoma) and samarium-153 lexidronam (for prostate or breast cancer) reduce pain in up to 80% of patients and have excellent safety profiles. Preliminary evidence in patients with advanced androgen-independent prostate carcinoma suggests that 89Sr added to doxorubicin chemotherapy improves overall survival.4 Monoclonal antibodies directed against the CD-20 antigen expressed on B lymphocytes have been conjugated with β-emitting radionuclides to treat non-Hodgkin's lymphoma. Two such antibodies (iodine-131-labelled tositumomab and yttrium-90-labelled ibritumomab) have entered phase III trials. In 52 patients with relapsed B-cell lymphoma treated with 131I-tositumomab, chemotherapy and stem-cell transplantation, progression-free survival was 68% at two years.5 Many neuroendocrine tumours express cell-surface somatostatin receptors and can be detected with γ-emitting somatostatin analogues. A new class of somatostatin analogues labelled with 90Y allows targeting of somatostatin-receptor-positive tumours with high radiation doses. In patients with refractory progressive disease, response rates of up to 80% have been reported with minimal toxicity. As our understanding of disease increases, nuclear medicine will find new targets and roles, such as individual drug dosimetry, prediction of likely response to therapy, and early documentation of responses to therapy.

Frederick A Khafagi FRACP · S Patrick Butler MD, FRACP

Major advances in radiology in recent years can be attributed to the change from analogue to digital imaging and to advances in electronics and computing.1 Digital imaging. Modalities such as ultrasound, computed tomography, magnetic resonance imaging and nuclear medicine are digital, but have been displayed in analogue format (ie, film) for easy manipulation with conventional radiographs. However, digital radiography units, digital screening units and scanning of conventional films (computed radiography) are now accepted technologies, with resolution similar to that of film/screen techniques. Digitisation itself is a critical advance, as it allows manipulation of the images. Digital images can be transferred within a hospital's network as part of a picture-archiving and communication system (PACS), or examined from remote locations via telecommunication networks (teleradiology), which obviates the need to physically transport films to a reporting location and better enables distance radiology services for outlying communities. Radiology still uses techniques similar to those discovered by Roentgen in 1895. Film is exposed, developed, coded and placed in packets, reported, and then stored for review. With PACS, a clinician (or many clinicians simultaneously) can review the images as soon as they have been processed, and consultation between physicians can take place without physical meetings. The PACS connects to the Radiology Information System (RIS) and the Hospital Information System (HIS), avoiding multiple entering of patient data and allowing planning for patient bookings. Future PAC systems will be able to track patient progress via the RIS and HIS and pre-emptively fetch images from the electronic archive to the appropriate clinical workstations for outpatient lists or operative lists. Cross-sectional imaging. Advances in electronics and computing, combined with helical CT technology and the development of fast-gradient coils in MRI, has made possible rapid high-resolution scanning. The consequent reduction in motion and respiratory artefacts leads to: The ability to optimise the timing of intravenous contrast medium enhancement, which enables relatively non-invasive CT and MR angiography and multiphasic post-contrast scan acquisition, such as in liver imaging; The capability for volume-acquisition of data, leading to multiplanar reformatting from data acquired in a single plane, and three-dimensional reformatting for surgical planning or for endoluminal navigation (eg, "virtual endoscopy"); and Functional imaging, such as perfusion CT and MR imaging of the brain and MR spectroscopy. Current multidetector-array CT scanners have four rows of detectors. Scanners with larger arrays will be released soon, enabling finer, morphologically detailed three-dimensional and even four-dimensional imaging (virtually real-time functional imaging). MRI has diversified from its original musculoskeletal and neurological applications.3,4 Many of the potential benefits of MRI are limited only by availability of scanners and funding. For example, MR cholangiopancreatography could replace many diagnostic endoscopic cholangiopancreatograms. MR spectroscopy has tremendous potential for assessing tumour spread and recurrence, and an MRI-equipped operating theatre enabling perioperative guidance of surgical resection of tumour tissue is already a reality. It is also possible to guide and monitor percutaneous tumour ablation with MRI. New tissue-specific MR contrast agents, such as those taken up by lymph nodes, are likely to become available. This could lead to targeted therapy, with the therapeutic agent attached to a tissue-specific contrast agent. The next five years are likely to see expansion of the accepted applications for MRI. Interventional radiology. Many recent advances relate to the increasing sophistication of hardware such as catheters, stents and embolisation materials. Percutaneous access to small vessels is now possible, expanding the range of therapeutic options (eg, stenting of intracranial arteries, treatment of intracranial aneurysms and thrombolytic therapy). Other innovations likely to affect therapeutic practices include imaging-guided radiofrequency tumour ablation, percutaneous aortic aneurysm stenting, percutaneous vertebroplasty, and uterine fibroid embolisation. These emerging technologies need critical appraisal to avoid the risks attending uncontrolled introduction. Such "horizon scanning" by government agencies working with medical experts has been instituted in Australia and elsewhere. With such a choice of expensive imaging modalities, evidence-based guidelines are needed more than ever for cost-effective imaging. The education of clinicians is a priority of the Royal Australian and New Zealand College of Radiologists and is addressed by the latest edition of Imaging Guidelines.5

Brendan D Adler · Richard M Mendelson

Forensic medicine Not murder most foul Suspicious circumstances and inexplicable wounds do not a murder make Alan D Cala and Christopher H Lawrence MJA 2001; 175: 621-622 Break and enter and fatal assault? - Assault with a steel bar? - References - Authors' details - - More articles on Pathology These two unusual forensic cases highlight the value of the autopsy in defining cases of murder. Circumstantial evidence pointed towards foul play and murder investigations were initiated, but correlation of the autopsy findings with the scene of the "crime" showed that one was a death from natural causes, and the other was an accident. Break and enter and fatal assault? An 87-year-old, 54 kg man who lived alone was found dead at his home in Sydney after he failed to maintain regular contact with relatives. The house was locked, and a relative forced entry by smashing a side window. The man was found lying on his back in the lounge room, wearing only a singlet, a flannelette shirt and short socks. It was mid-winter, with a temperature range that day of 5º-15ºC. No working heater was found in the house. The relative called the police, who suspected foul play in view of the scene they witnessed: a deceased, partially dressed man with bruises on his head, trunk and limbs, surrounded by upturned furniture, pulled-out drawers and scattered papers, suggestive of a struggle (Figure 1). The house, however, was secure (apart from the window smashed by the relative) and a wallet containing cash was found near the body (an unusual finding in a "break and enter/robbery"). The man had clearly been dead for many hours: the body was cold to touch, and there was very firm rigor mortis with dependent lividity. He had had a myocardial infarction in 1997, but recently had been well and was not taking any regular medication. At autopsy, 10 separate injuries were found on the body: abrasions on the right cheek, right ear, and right lower chest, and bruises and abrasions on the posterior aspect of both upper arms. A very large abrasion (240 x 110 mm) was noted on the right lateral upper thigh, with other abrasions around both knees. The heart weighed 640 g. The pericardial sac was obliterated by fibrous adhesions. The left ventricular wall thickness was 13 mm (reduced to 6 mm in the affected area by an anteroseptal scar), and the right ventricular wall thickness was 2 mm. The coronary arteries were severely narrowed by calcific atherosclerosis. The aorta and branches also showed severe atherosclerosis. The severe coronary atherosclerosis and left ventricular scarring were indicative of past and possibly recent myocardial ischaemia/infarction, but there was no evidence of an acute myocardial infarction. There were bilateral apical emphysematous changes in the lungs. The stomach lining had numerous superficial jet-black erosions, 2-10 mm in diameter, in the body and antrum (Figure 2). About 20 mL of altered blood was found in the stomach in association with these erosions. Toxicological analysis was negative for alcohol or other drugs. Neuropathological examination showed age-related neurofibrillary changes in the brain and a scar in the putamen. The cause of death was determined to be the combined effects of fatal hypothermia and ischaemic heart disease. Discussion Hypothermia, in which the core body temperature falls to below 35ºC,1 is rare as a cause of death in a temperate city such as Sydney. Those most at risk are thin, elderly people who live alone in poorly heated premises. They have low fat reserves, may be nutritionally and calorically deficient and usually have other significant medical problems. Poor family and social networks may lead to isolation, which can exacerbate the situation by failure to obtain timely medical assistance. Quite often, the scene findings in cases of fatal hypothermia show evidence suggesting a struggle. The premises may be in disarray, and affected individuals may be found under newspapers or furniture. Presumably, once hypothermia has set in, they become confused and disoriented, and attempt to seek warmth in unusual places. They also suffer from "paradoxical undressing", or "hide-and-die" behaviour, thought to be due to a disturbance of the temperature-regulating function of the hypothalamus that causes a feeling of overheating (and resultant attempts to cool down such as undressing) as the body's core temperature drops. The most significant finding at autopsy was the presence of gastric erosions. Although not diagnostic for hypothermia (and not present in all cases), such multiple, superficial, variable-sized ulcers or erosions, found particularly in the body of the stomach, are often seen in cases in which hypothermia is believed to be either the sole cause of death or a contributing factor to death. They are thus highly suggestive of the diagnosis. They may also be seen in cases of "stress" from any cause, for example postoperatively, or following myocardial or cerebral infarction. Other autopsy findings that have been described in fatal hypothermia are pancreatic haemorrhage or necrosis, and cherry-pink lividity, but these are not specific.2 Assault with a steel bar? In a second case, a 37-year-old, 99 kg man with no significant past medical history was found by his wife at about 8:45 am, lying in the back yard of his residence, with a penetrating injury to his right eye. This unusual injury was immediately designated as suspicious by the police, who arranged for a forensic pathologist to attend the scene. The man's usual practice had been to water the garden each morning before leaving for work at 5:30 am. The garden hose was found still running on the ground, and the man's body was almost submerged by the water collecting around him. He was lying on his back with his legs folded underneath him, on the edge of a garden bed. Several sandstone rocks were around the body, and nearby was an 18 mm diameter octagonal steel post that was upright but loose in the ground. The autopsy was conducted later that day. The main abnormality was a complex, patterned, roughly square injury on the right cheek and eye, which was covered with blood and fragments of brain tissue. On the right cheek, close to the nose, was a curved 26 mm full-thickness laceration running obliquely and medially. Two parallel lines of abrasion/laceration, 20-45 mm in length, extended upwards and laterally away from this laceration. On the lower right eyelid was a 'V'-shaped laceration. Dissection of this complex injury showed a 70 mm long haemorrhagic wound track directed upwards, left to right, and front to back. The injury had perforated the posterior wall of the orbit, superficially bruising the lateral wall of the right orbit. The globe of the right eye remained substantially intact, despite the severe injury. There was a penetrating injury to the right inferior frontal region of the brain to a depth of 35 mm, resulting in a wound defect in the brain of 18 mm diameter (Figure 3). Within the wound were several small pieces of dark material, possibly representing corroded metal. The left orbit was fractured, and 300 mL of blood from a subdural haemorrhage was in the anterior right middle cranial fossa. Detailed neuropathological examination also showed evidence of brain swelling, resulting in midline shift of structures from right to left, transtentorial herniation on the right side, and flattening of gyri over the area of the subdural haemorrhage. Duret haemorrhages, indicative of raised intracranial pressure, were present in the pons and midbrain, with some minor haemorrhage in the right uncus. Other injuries, consisting mainly of abrasions, were present on the forearms and thighs. The time of death was estimated to be between 5:00 and 6:00 am that morning, given the degree of rigor mortis, the rectal temperature and degree of skin slippage present. The rest of the autopsy showed no notable abnormalities. Examination of the metal post under a dissecting microscope revealed small strands of tissue and one small hair, possibly from the lower eyelid of the deceased. DNA analysis confirmed that the material on the post was from the body of the deceased. The cause of death was determined to be an accidental penetrating injury of the right orbit and brain by a steel post, with no evidence that the injury was inflicted by another person. Discussion Fatal penetrating injuries to the head are uncommon,3 and mostly due to gunshot rather than stab wounds. Initially, investigating police believed the injury must have been caused by some other person. Suicide was considered highly unlikely. Although the metal post was the obvious weapon to have caused the injury, it was not immediately clear what had transpired to lead to the injury. There was even speculation about the possibility of a tangential gunshot wound. Foul play was discounted after x-rays and autopsy revealed the true nature of the injury and "weapon". The most probable scenario is that while the deceased was watering his garden, he tripped on the hose, fell onto the post, sustained the penetrating injury and died a short time later. References Harrison's textbook of internal medicine. 14th ed. New York: McGraw-Hill, 1998: 97-99. Knight B. Forensic pathology. New York: Oxford University Press, 1991: 380-384. Adams JH, Graham DI. Introduction to neuropathology. 2nd ed. Edinburgh: Churchill Livingstone, 1994: 133-155. Authors' details NSW Institute of Forensic Medicine, Glebe, NSW. Allan D Cala, FRCPA, Forensic Pathologist; Christopher H Lawrence, FRCPA, Forensic Pathologist. Reprints will not be available from the authors. Correspondence: Dr A D Cala, NSW Institute of Forensic Medicine, 42-50 Parramatta Road, Glebe, NSW 2037. CalaAATemail.cs.nsw.gov.au Make a comment Figure 1Figure 1: Upturned furniture in lounge room, suggestive of a struggle (Case 1). Back to textFigure 2 Figure 2: Multiple superficial gastric erosions, suggestive of hypothermia (Case 1). Back to textFigure 3Figure 3: Steel post injury laceration to right frontal lobe of brain (Case 2). Back to text

Alan D Cala · Christopher H Lawrence

q Forensic medicine Dolphin deaths: forensic investigations Forensic pathologists may have an important role to play in investigating the deaths of marine or other mammals Roger W Byard, John D Gilbert and Catherine M Kemper MJA 2001; 175: 623-624 The assessment of wounds in humans is a standard part of forensic pathology practice. Injuries are routinely examined to determine how and when they occurred, and with what degree of force. Careful examination also helps to narrow down the range of possible weapons that may have been used. Injuries are examined in both living and deceased individuals, and opinions are given as to the likelihood that the injuries were accidental, self-inflicted, or inflicted by others. The legal implications of this determination are obviously significant. The following two cases demonstrate an unusual application of forensic pathology involving two deceased dolphins. Case 1: A dead adult male Indian Ocean bottlenose dolphin (Tursiops cf aduncus) was found floating off an Adelaide beach on 11 December 2000. An autopsy revealed a single, lethal stab wound to the ventral thorax between the flippers (Boxes 1 and 2). The stab had penetrated the heart and caused a left-sided haemothorax. Examination of the wound indicated that the weapon was likely to have been a single-edged blade with a maximum width of 18 mm at a distance of 85 mm from the tip. Although three wounds were present in the right ventricle (Box 3), these could have resulted from one thrust with the weapon, with movement of the weapon, the dolphin or the heart causing the three injuries. Given the right-to-left direction of the wound, it could have been inflicted from the left side of a boat if the dolphin had been swimming beside the boat and had angled over onto its left side, thus exposing the anterior thorax. The dolphin otherwise appeared to be in good health, with no evidence of significant trauma or underlying organic illnesses. The presence of regurgitated, partly digested food in the oesophagus may have indicated recent feeding, although stress is known to delay gastric emptying in a variety of species.1,2 Case 2: On 19 May 2001, an immature male common bottlenose dolphin (Tursiops cf truncatus) was found dead on a beach in southeastern South Australia. An autopsy revealed a wound that was similar in appearance to the wound seen in Case 1. The wound was in the ventral thorax between the flippers (Box 4), overlying a cavity in muscle; however, no damage to underlying vital structures was found. Although death was not caused by trauma, we could not determine the precise cause. However, the presence of stomach contents and a small, partly digested squid in the oesophagus may have indicated recent feeding. Sealice activity around the wound suggested that death may have occurred before beaching. Discussion Traditionally, forensic pathologists rarely become involved in non-human cases. In cases of dead marine mammals in South Australia, however, collaboration between the South Australian Museum, veterinarians, National Parks and Wildlife South Australia and the Forensic Science Centre has resulted in an approach that has facilitated the assessment of the significance of wounds and injuries in a non-human population. For example, in a previously investigated case in 1999, forensic examination of an infant dolphin showed that the animal had died after being speared to death (Box 5) and enabled the approximate dimensions of the weapon to be determined.3 In 1998 three other dolphins were found to have been shot. For the dolphin in Case 1, death was attributed to a stab wound inflicted to the heart, most likely by a knife or similar single-edged sharp weapon. This conclusion resulted in the launching of a coordinated search for the perpetrators, with media appeals to the public for help. Although the injury to the dolphin in Case 2 appeared superficially similar, it was not lethal. Thus, forensic examination could determine quite quickly that the injury in Case 2 had not been responsible for death, and may even have occurred post mortem. The significance of the findings in these cases is far from academic, as the penalty in South Australia for killing a marine mammal may be a $30 000 fine and/or a jail term of up to two years.4 Given these penalties, it is likely that anyone charged with such an offence would employ an active legal defence that could easily terminate the case on technical grounds if the examination and subsequent handling of evidence did not follow established guidelines. For this reason, cases of sea-mammal deaths, including the two we describe, have been processed in a routine forensic manner. This means that the examination of each dead dolphin was undertaken in a similar fashion to a standard human autopsy in a suspicious case, including accurate documentation of times, personnel present and possible trauma. The measurement, assessment and recording of injuries was undertaken in the usual manner, with descriptions being recorded in original notes and subsequently transcribed into an official signed report. Specimens that were taken for histological examination, storage for possible future DNA matching and toxicological evaluation were also signed and sealed at documented times and submitted to the Forensic Science Centre so that a formal chain of evidence could be maintained. Biological information, including species verification, was lodged at the South Australian Museum. To date, however, no charges have been laid in the reported cases. Involvement of forensic pathologists in such cases has resulted in the early determination of whether trauma was implicated in the death, and has also facilitated an understanding of the relationship between the mechanism of death and the external injuries. In addition, investigating officers have been given some idea of the type of weapon to look for, material has been secured for possible DNA cross-matching between possible weapons and a particular animal, and wounds have been recorded accurately for possible court presentation if required. In reporting these cases we have demonstrated that a standard branch of medicine, forensic pathology, may be useful in areas other than the assessment of human medicolegal cases, and that pathologists may play an important role in investigating the deaths of marine or other mammals. References Byard RW, Gilbert JD, Brown K. Pathological features of fatal shark attacks. Am J Forensic Med Pathol 2000; 21: 225-229. Knight B. Forensic pathology. 2nd ed. London: Arnold, 1996: 89-90. Gilbert JD, Kemper CM, Hill M, Byard RW. Forensic studies of a stabbed infant bottlenose dolphin. J Forensic Med 2000; 7: 150-152. Fisheries Act 1982 (South Australia). Reprint no. 8. Authors' details Forensic Science Centre, Adelaide, SA. Roger W Byard, MD, FRCPath, Specialist Forensic Pathologist and Clinical Professor of Pathology and Paediatrics. John D Gilbert, FRCPA, Forensic Pathologist. South Australian Museum, Adelaide, SA. Catherine M Kemper, PhD, Senior Curator of Mammals. Reprints will not be available from the authors. Correspondence: Professor Roger W Byard, Forensic Science Centre, 21 Divett Place, Adelaide, SA 5000. byard.rogerATsaugov.sa.gov.au Make a comment Figure 1 Back to textFigure 2Back to textFigure 3 Back to text Figure 4 Back to textFigure 5 Back to text

Roger W Byard · John D Gilbert · Catherine M Kemper

Snapshots An unusal case of immobility Kevin Ho-Shon Radiology Registrar John Rusli Radiologist Department of Radiology, Royal Prince Alfred Hospital, Sydney, NSW MJA 2001; 175: 586

Kevin Ho-Shon · John Rusli

Snapshots Cockroach bladder! David I Chadban Radiology Registrar Department of Radiology, Concored Repatriation Hospital, Sydney, NSW MJA 2001; 175: 620

Rodney H Strahan

Snapshots Seahorse Barnabas Bako Radiology Registrar Department of Radiology, The Children's Hospital at Westmead, Sydney, NSW MJA 2001; 175: 628 The young girl was restless and crying. This study was requested by the surgical team to further evaluate the distended abdomen and unusual bowel sounds. The problem soon became clear - the child had a seahorse in her belly! Further careful questioning revealed that the family had recently visited the aquarium, and had spent a long time in the seahorse section. Another brilliant diagnosis! Make a comment

Barnabas Bako

Personal Perspective Part-time specialty training — my experience Meegan T Gun MJA 2001; 174: 410-412 For editoral comment, see Sewell; see also Whitelaw & Nash The problem - The idea - The experience - Changing attitudes - References - - More articles on Education It is almost four years since I completed my training in radiology and, now that I have the time, I feel it is important to share my experiences with others, particularly women wishing to pursue specialty training. Both the medical literature and popular press draw our attention to the statistics on women in medicine and particularly the lack of women in postgraduate training programs. In 1998, 57.8% of general practice trainees but only 33.8% of trainees in other specialties were women;1 in 1999, 44.1% of vocational trainees (GP and specialist) were women, but there were marked differences in the proportion of women training in individual specialties (ranging from 12.6% of surgery trainees to 66.7% of paediatrics trainees2) (Box 1). Between 1989 and 1999 the proportion of women commencing medical training increased from 43.6% to 52.7%, while the proportion of female vocational trainees in the same period increased only marginally, from 43% to 43.7% (including trainees in general practice).2 Thus, the increasing number of women entering the medical workforce is not reflected in the proportion of women in specialist training. The problem It is very difficult to fulfil the rigorous requirements for specialist training and maintain a "normal" life. After five or six years at medical school, the thought of undertaking another four or five years of training is daunting. The Medical Labour Force 1998 report1 revealed that about 20% of specialists-in-training worked more than 65 hours per week, and the highest proportion of doctors working more than 80 hours per week were surgeons, internal medicine specialists, specialists-in-training and vocationally registered GPs. Male medical practitioners are more likely to be in a relationship than women, and female practitioners in a relationship are more likely to work part-time (rather than full-time) than those not in a relationship.3 It has been noted that "female practitioners are more likely than male practitioners to have curtailed their careers for family reasons".3 This may involve suppressing career expectations, restricting choice in favour of career paths that provide greater flexibility and allow part-time work, prolonging the training process and/or limiting their role within the profession. Barriers to career advancement that influence the structure of the medical workforce occur most noticeably during vocational training and the child-rearing period of a woman's life.3 Women in training programs who want to have children are at a great disadvantage. When is the best time? — during an intern year, before the Part 1 examination, between Parts 1 and 2, before or after a PhD or master's degree? Or perhaps during an overseas fellowship? I was fortunate at the start of my radiology training to be assigned to a department with a very supportive director. After completing my internship I began my training immediately (this is now not allowed — at least one year of hospital work is required). After about four months I became pregnant. Members of the department, including my fellow registrars, were supportive. At that stage they were all ahead of me in the training program. I did all the work that I could comfortably and safely perform, passed my Part 1 examination, and had my baby. After seven months of maternity leave, I reluctantly returned to full-time work. This was extremely difficult for me — I wanted to continue my training, but not at the expense of spending little or no time with our daughter. The idea In the program at the same time was a female colleague who had already had one child during her training and was having similar thoughts about the difficulty of balancing job and family commitments. We decided to approach the heads of our departments and broach the idea of job sharing. The head of my department was extremely supportive of our plan. Our proposal was put to the warden of the College and accepted, and so began a long and successful partnership between myself, my colleague and the training program. The experience Our working arrangements changed from time to time depending on our hospital placements and on the need to fit in with fellow colleagues. We tried to cover each other's holidays where possible. Issues such as overtime payments, long service leave entitlements and holiday pay were not satisfactorily addressed — they remain important, outstanding items that will require resolution. The system worked very well for both of us, allowing time with our children and continuation of our training. Initially there was some opposition to our arrangement from our contemporaries in the program, who were concerned that we would not fulfil our duties and that it would add to their workload. I do not believe this occurred. My working partner completed her training almost two years before I finished and, as there was no one to continue to job-share with, I was permitted to work alone part-time. Training took over seven years (instead of the usual five), and had I not been given the opportunity to work part-time I would probably not have completed the training. Some women have described the "elongated journey" to specialist qualification in negative terms, but others have found it more "rewarding".3 Certainly, my experience was not negative; the reward for me lay in the fact that at the end of the journey I had maintained a relationship, built a family and completed my training, so the extra time taken was well worth it. During the period of our training, my colleague and I between us had five children (almost six, as I completed the last six months pregnant). I now work two and a half days per week in a public hospital, which is far more flexible than working in private practice. Although my priorities lie mainly with my family, I make a significant contribution to my work environment and my input will probably increase as my children get older. The problems for women doing specialist training are similar worldwide. For example, in the United Kingdom, Maingay and Goldberg found that the "combination of four factors — manpower, duration of specialist training, working hours and maternity provisions — means that in the UK it is particularly difficult for women doctors with families to combine successful full-time specialist training with raising a family".4 Importantly, they noted that "the health care system cannot afford to waste these doctors". The Flexible Training Scheme has been introduced in the UK in an attempt to redress the situation. Changing attitudes The need for revised working patterns and part-time training posts not only arises because of the increased female representation in medicine, but also from changing perceptions of what is expected from all doctors, whether men or women, and the desire for a reasonable lifestyle. A 1994 survey of doctors in the Netherlands (most of whom were working full-time) found that only one-third of female doctors and two-thirds of male doctors wanted to work full-time in the future.5 In 1999, in Australia, only 6.8% of trainees were undertaking part-time training2 (Box 2). Opinions on the issue of allowing part-time specialist training are divided. The Medical Training Review Panel has stated that "Change is required in the organisation and management of many of the specialist training programs so that female practitioners can have the opportunity to better participate in the training program and then, ultimately, within the medical workforce".2 Yet, general opinion among the leaders of the medical profession continues to favour full-time training. At a workshop in 19996 to assess progress in implementing the recommendations of the Brennan Report,7 there was a strong view expressed that any changes to training schemes should not increase the overall length of vocational training "in the process of making work practices and training schemes flexible for women".2 There is also a concern that "With the increasing proportion of female medical undergraduates, if the current preference for [postgraduate training in] general practice continues to predominate, it could be expected to contribute to a continued shortage of specialists and to increase the gender imbalance between general practice and specialist practice".8 It is not just women who are asking for more flexible training arrangements. The career expectations of male doctors also appear to be changing, with choices influenced by flexibility and manageable hours. My training was certainly different from that of my contemporaries. I can not judge whether it was better or worse, or neither, but it certainly allowed me to fulfil my ambitions to become a qualified radiologist and to have a family. I can only hope more women will have the opportunity to do the same. References Australian Institute of Health and Welfare. Medical Labour Force 1998. Canberra: AIHW, 2000. (National Health Labour Force Series, No. 16) (AIHW Catalogue No. HWL 15.) Medical Training Review Panel. Third Report. Canberra: MTRP and Commonwealth Department of Health and Aged Care, August 1999. Australian Medical Workforce Advisory Committee. Influences on participation in the Australian medical workforce. Sydney: AMWAC, 1998. (AMWAC Report 1998.4.) Maingay J, Goldberg I. Flexible training opportunities in the European Union. Med Educ 1998; 32: 543-548. Cohen-Schotanos J, Huisjes HJ. [Status of the job market of physicians who started their education in Groningen in 1982 and 1983.] Ned Tijdschr Geneesk 1994; 138: 1434-1437. Medical Workforce Training and Employment Workshop — April 1999. Summary of outcomes. Sydney: Australian Medical Workforce Advisory Committee, 2000. Summary available at <http://amwac.health.nsw.gov.au/corporate-services/amwac/movingforward.html>. Accessed 5 February 2001. Brennan PJ and Associates. Trainee selection in Australian medical colleges. Canberra: Medical Training Review Panel and Commonwealth Department of Health and Family Services, January 1998. (Publication No. 2291.) Australian Medical Workforce Advisory Committee. Female participation in the Australian medical workforce. Sydney: AMWAC and Australian Institute of Health and Welfare, 1996. (AMWAC Report 1996.7.) Authors' Details Department of Radiology, North Western Adelaide Health Service The Queen Elizabeth Hospital Campus, Adelaide, SA. Meegan T Gun, MBBS, FRANZCR, Radiologist. Reprints will not be available from the author. Correspondence: Dr M T Gun, Department of Radiology, The Queen Elizabeth Hospital Campus, 28 Woodville Rd, Woodville South, SA 5011. olmtosiATchariot.net.au Make a comment 1: Female vocational trainees (%), by College and State/Territory, 19992 College NSW VIC QLD SA WA TAS NT ACT Total Anaesthetists 54.5 43.0 51.6 45.6 51.1 54.5 0 30.8 49.0 Dermatologists 40.0 33.3 36.4 25.0 33.3 - - - 36.0 Emergency Medicine 47.6 39.0 34.7 38.2 24.2 35.0 * * 39.4 General Practitioners 63.2 63.1 49.1 57.3 61.8 61.0 53.2 52.3† 58.9 Medical Administrators‡ 38.7 13.0 25.0 60.0 23.1 0 0 25.0 25.7 Obstetricians and Gynaecologists 56.3 60.0 56.6 54.1 55.5 42.9 100.0 60.0 56.8 Ophthalmologists 21.1 33.3 9.1 0 16.7 0 0 - 19.8 Pathologists 44.4 54.1 34.5 47.1 61.1 60.0 0.0 28.6 42.7 Physicians - Adult Medicine 31.9 39.7 46.2 29.7 39.5 25.0 33.3 25.0 36.7 Physicians - Paediatrics 67.4 56.8 63.0 77.8 76.9 100.0 100.0 100.0 66.7 Physicians - Occupational Medicine 16.0 25.0 33.3 0 11.1 - - - 16.3 Physicians - Public Health Medicine‡ 50.0 50.0 43.7 60.0 50.0 0 66.7 50.0 50.7 Physicians - Rehabilitation Medicine 20.0 36.4 0 66.7 - - - - 26.8 Psychiatrists 46.2 41.5 47.4 46.9 49.4 50.0 40.0 44.4 45.9 Radiologists 32.9 25.7 25.0 51.7 19.0 25.0 * 20.0 30.4 Surgeons 10.5 15.0 12.1 19.0 9.1 0 0 33.0 12.6 Total 44.8 43.3 41.6 44.7 45.1 45.1 50.6 45.2 44.1 - Indicates no trainees at all (male or female). * NT is included in the SA total and ACT is included in the NSW total. † Includes southern NSW. ‡ The data provided are for 1998. Back to text 2: Number of trainees undertaking part-time training, by College, 1995 to 19992 College 1995 1996 1997 1998 1999 Anaesthetists 2 1 4 1 1 Dermatologists 0 0 0 0 0 Emergency Medicine* - - - 67 65 General Practitioners 327 234 247 183 215 Medical Administrators† - - - - - Obstetricians and Gynaecologists 2 2 5 0 2 Ophthalmologists 0 0 1 0 1 Pathologists 1 2 2 3 3 Physicians - Adult Medicine‡ 21 23 2 6 8 Physicians - Paediatrics‡ - - 12 17 15 Physicians - Occupational Medicine 0 0 0 - 2 Physicians - Public Health Medicine 3 6 5 5 Physicians - Rehabilitation Medicine 0 0 2 3 4 Psychiatrists 16 28 16 52 70 Radiologists 1 1 - - 1 Surgeons 0 0 0 0 0 Total 372 296 296 337 387 % Of total trainees - - 5.2% 6.1% 6.8% *Unknown because College database does not record this information. Figures for 1998 and 1999 are an estimate based on 10% of total trainees. † Unknown because College database does not record this information, as hospital employing the trainee makes these arrangements. ‡ Includes paediatric medicine for 1995 and 1996. Back to text

Meegan T Gun