LETTERS Salt intake and health in the Australian population 526 Jennifer B Keogh, Peter M Clifton “I want the one for older women” — extending the human papillomavirus vaccine population base 526 Lilon G Bandler 527 Helen S Marshall, David Isaacs 528 Jeffrey HJ Tan, Michael A Quinn All in a day’s work: an observational study to quantify how and with whom doctors on hospital wards spend their time 528 Mark Mackay, Pamela J Castle An observational study of emergency department intern activities 529 Belinda Doherty, Mark A Brown A day in the life of a doctor-in-training 529 Lisa Caputo, Fiona R Lake, Margaret Potter, Ian Rogers Evidence-based advocacy: the public roles of health care professionals 530 Bill Williams Respiratory rate: the neglected vital sign 531 Allen C Cheng, James F Black, Kirsty L Buising 531 Olivier Steichen, Gilles Grateau, Eric Bouvard 532 Simon C Gandevia, David K McKenzie Management of Mycobacterium ulcerans infection in a pregnant woman in Benin using rifampicin and clarithromycin 532 Ange D Dossou, Ghislain E Sopoh, Christian R Johnson, Yves T Barogui, Dissou Affolabi, Sévérin Y Anagonou, Théophile Zohoun, Françoise Portaels, Kingsley Asiedu Kaposi’s varicelliform eruption in a healthy adult 534 Hajime Kimata Serotonin toxicity precipitated by concomitant use of citalopram and methylene blue 534 Ali Khavandi, John Whitaker, Hanney Gonna Cancer care: what role for the general practitioner? 535 Jon D Emery Venous thromboembolism associated with train travel 535 Jeet Ram Kashyap, Sanjay D’Cruz, Sandeep Chauhan, Suman Kochhar
Transcript
MJA • Volume 189 Number 9 • 3 November 2008 473
LETTERS
Salt intake and health in the Australian population526 Jennifer B Keogh, Peter M Clifton
“I want the one for older women” — extending the human papillomavirus vaccine population base
526 Lilon G Bandler527 Helen S Marshall, David Isaacs528 Jeffrey HJ Tan, Michael A Quinn
All in a day’s work: an observational study to quantify how and with whom doctors on hospital wards spend their time
528 Mark Mackay, Pamela J Castle
An observational study of emergency department intern activities529 Belinda Doherty, Mark A Brown
A day in the life of a doctor-in-training529 Lisa Caputo, Fiona R Lake, Margaret Potter, Ian Rogers
Evidence-based advocacy: the public roles of health care professionals530 Bill Williams
Respiratory rate: the neglected vital sign531 Allen C Cheng, James F Black, Kirsty L Buising531 Olivier Steichen, Gilles Grateau, Eric Bouvard532 Simon C Gandevia, David K McKenzie
Management of Mycobacterium ulcerans infection in a pregnant woman in Benin using rifampicin and clarithromycin
532 Ange D Dossou, Ghislain E Sopoh, Christian R Johnson, Yves T Barogui, Dissou Affolabi, Sévérin Y Anagonou, Théophile Zohoun, Françoise Portaels, Kingsley Asiedu
Kaposi’s varicelliform eruption in a healthy adult534 Hajime Kimata
Serotonin toxicity precipitated by concomitant use of citalopram and methylene blue
534 Ali Khavandi, John Whitaker, Hanney Gonna
Cancer care: what role for the general practitioner?535 Jon D Emery
494 Men surviving cancer reviewed by Dawn Hooper, Mark Tweeddale
SNAPSHOT
Ooh — bet that hurt524 Robert J Douglas
OBITUARIES
Sarah Mitchell523 Karen Simmer, Katherine Gardiner
Clifford Warmbrunn523 Trevor A Banks
474 IN THIS ISSUE
525 IN OTHER JOURNALS
From the Editor’s Desk”ON THE ONE HAND … BUT ON THE OTHER HAND …”
Amid the recent celebrations for the 60th anniversary of the United Kingdom’s National Health Service (NHS), a report appeared that outlined future directions for Britain’s cherished free health care system. Entitled High quality care for all, it had been assembled by Lord Ara Darzi, a practising surgeon and professor of surgery, a peer in the House of Lords, and Parliamentary Under Secretary of State for Health. It detailed reforms designed to ensure high-quality care for patients and programs to promote the health of the public at large.
The report also proposed an NHS Constitution that proclaimed the purpose, principles and values of the NHS, along with the rights and responsibilities of patients, the public and NHS staff. Lord Darzi’s report is a classic of measured reform and epitomises both leadership and vision.
This seminal report was preceded by the release of an equally impressive report on reform to promote quality medical practice, entitled Good doctors, safer patients, by England’s Chief Medical Officer, Sir Liam Donaldson.
This activity begs the question of why our own politicians and health bureaucrats fail to spawn similar reports. Instead, we have an undue reliance on the recommendations of expert working parties and committees. Such bureaucratic reliance recalls President Truman’s famous wish for “one-handed” experts, as the advice he received from experts was perpetually prefaced by double-speak: “On the one hand … but on the other hand …” This desire prompted President George W Bush to add, in desperation: “If [these experts] had three hands they’d say, ‘on the one hand, on the other hand, and then on the third hand’.”*
But there is a more fundamental question. Where are the one-handed, clear-headed and creative advocates such as Lord Darzi and Sir Liam in creating Australian health policy?
Martin B Van Der Weyden
*Bush GW. President Bush discusses economy, trade[presidential speech]. 2 May 2008. http://www.white-house.gov/news/releases/2008/05/20080502-8.html(accessed Oct 2008).
Salt intake and health in the Australian populationJennifer B Keogh and Peter M Clifton
TO THE EDITOR: There is an establishedlink between salt intake and blood pressure.The public health impact of a 1–3 mmHgreduction in blood pressure by lowering saltintake could be substantial. An Americanstudy found that a projected reduction indiastolic blood pressure of 2 mmHg wouldresult in a 17% decrease in the prevalence ofhypertension, a 6% reduction in the risk ofcoronary artery disease events, and a 15%reduction in risk of stroke and transientischaemic attacks.1 In Finland, a one-thirddecrease in average salt intake achieved over30 years was accompanied by a fall of morethan 10 mmHg in the population averages ofsystolic and diastolic blood pressure.2 How-ever, in the absence of active measures toreduce salt in the food supply, public healthmessages to reduce salt intake have largelybeen unsuccessful.
The National Health and MedicalResearch Council (NHMRC) has recentlyrevised its recommendations and now statesthat an adequate sodium intake for adults is460–920 mg/day (20–40 mmol/day), with asuggested dietary target for chronic diseaseprevention of 1600 mg/day (70 mmol/day).3
The most recent Australian sodium intakedata are from the 1995 Hobart Salt Study, inwhich the then national target of 6g/day wasachieved by only 6% of men and 36% ofwomen, with an average salt intake of 7–10g/day.4 Volunteers in weight-loss studies at theCommonwealth Scientific and IndustrialResearch Organisation (CSIRO) Human Nutri-tion unit over the past 5 years continue to havea high salt intake of 8–11g/day (urinarysodium/24h: men [n=85], 181±95mmol;women [n=189], 136±61mmol; referencerange, 40–100mmol).5 Recent data fromanother Australian study report similar urinary
sodium concentrations.6 The average saltintake of Australian adults appears to be 7–12g/day, which is little changed from 10 yearsago.
Achieving a low salt intake in the presentfood supply is difficult, as more than 80% ofintake is from salt added to food duringprocessing. As well as the more obviousfoods in which salt is a preservative, staplefoods such as bread also contain salt. Thevariety of foods has increased considerably,and many of the numerous processed foodsnow available contain very high salt levels.Processed and convenience foods frequentlyhave salt added that the consumer cannotavoid. It is clear that large changes to thefood supply are needed to reduce saltintake. We believe that salt reduction in thefood supply should be the first line of attackto reduce the risk of cardiovascular diseasein the population.
Jennifer B Keogh, Research Scientist and Senior DietitianPeter M Clifton, Theme Leader Obesity and HealthCSIRO Preventative Health Flagship, Adelaide, [email protected]
1 Cook NR, Cohen J, Hebert PR, et al. Implications ofsmall reductions in diastolic blood pressure forprimary prevention. Arch Intern Med 1995; 155: 701-709.
3 National Health and Medical Research Council.Nutrient reference values for Australia and NewZealand [website]. http://www.nrv.gov.au (accessedSep 2008).
4 Beard TC, Woodward DR, Ball PJ, et al. The HobartSalt Study 1995: few meet national sodium intaketarget. Med J Aust 1997; 166: 404-407.
5 Brinkworth GD, Wycherley TP, Noakes M, CliftonPM. Reductions in blood pressure following energyrestriction for weight loss do not rebound after re-establishment of energy balance in overweight andobese subjects. Clin Exp Hypertens 2008; 30: 385-396.
6 Margerison C, Nowson CA. Dietary intake and 24-hour excretion of sodium and potassium. Asia Pac JClin Nutr 2006; 15 Suppl 3: S37. ❏
"I want the one for older women" — extending the human papillomavirus vaccine population baseLilon G Bandler
TO THE EDITOR: It’s all very difficult isn’tit? Teasing out the issues around impartial-ity, weighing evidence and competing inter-ests? Wain wrote a recent editorial for theJournal, and included a list of his “compet-ing interests”:• Chair of the CSL Gardasil AdvisoryBoard;• speaker fees, travel assistance and con-sultancy fees from CSL Biotherapies andfrom Merck and its affiliates in relation toGardasil; and• shares in CSL Limited.1
He helpfully advises that Gardasil (Merck)“is available at no cost to Australian girls andwomen between the ages of 12 and 26 aspart of the National Immunisation Program.The bivalent vaccine, Cervarix (GlaxoSmith-Kline), has to date not been included in theprogram, having initially been rejected bythe Pharmaceutical Benefits Advisory Com-mittee (PBAC) on the basis of uncertaincost-effectiveness, but subsequently recom-mended for inclusion.”1
This is disingenuous at best. Initially, thePBAC also “rejected the application for[Gardasil] . . . based on unacceptable anduncertain cost-effectiveness at the pricerequested.”2 At the request of the thenHealth Minister, the PBAC reviewed its deci-sion after the company made some smallchanges to its submission, including achange in pricing.
At about the time Wain’s editorial waspublished, a hard copy of the previousMedical Journal of Australia article on humanpapillomavirus (HPV) arrived on my desk,3
courtesy of GlaxoSmithKline. That article onHPV vaccination listed the “competinginterests” at the end. Clearly, all the authorshave received some sort of funding throughGlaxoSmithKline, CSL and/or Merck.
I am not impressed by authors whoreceive funding from pharmaceutical com-panies that market the drugs they are dis-cussing. It seems to me that the problem lieswith interests not competing, or at least notcompeting with the author’s intent. Perhapsa little healthy competition would bring outsome more thoughtful, articulate articles,unaffected by any commercial pressures.
“A plague o’ both your houses.” Let’sconsider where we could best spend our
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money without the help of the competinginterests of various pharmaceutical market-ing mechanisms. “HPV vaccination will notprevent all cases of cervical cancer, thereforevaccinated women should continue to havetwo yearly Pap smears.”4 Given that HPVvaccination (in this country) will not changethe rate of cervical screening required in thenear future, perhaps the money would bebetter spent on ensuring that all Australianwomen are screened in a timely manner.That is, ensuring that poor women, Indigen-ous women, rural women, and immigrantwomen are part of “Cervical screening inAustralia . . . one of the great public healthsuccess stories, as witnessed by a continuingdramatic fall in the incidence of carcinomaof the cervix and mortality from this diseasesince the introduction of the National Cerv-ical Screening Program (NCSP).”5
1 Wain GV. “I want the one for older women” —extending the human papillomavirus vaccinepopulation base [editorial]. Med J Aust 2008;188: 501-502.
2 Australian Government Department of Healthand Ageing. Quadrivalent human papillomavi-rus (types 6, 11, 16, 18) recombinant vaccine,injection, 0.5 mL, Gardasil November 2006.Pub l i c summary document . h t tp : / /www.health.gov.au/internet/main/publish-ing.nsf/Content/pbac-psd-gardasil-nov06(accessed May 2008).
3 Skinner SR, Garland SM, Stanley MA, et al.Human papillomavirus vaccination for the pre-vention of cervical neoplasia: is it appropriateto vaccinate women older than 26? Med J Aust2008; 188: 238-242.
4 Australian Government Department of Healthand Ageing. Policy for screening women vacci-nated against HPV. Approved by the AustralianPopulation Health Development PrincipalCommittee — February 2007. http://www.can-cerscreening.gov.au/internet/screening/pub-lishing.nsf/Content/hpv-vaccinated-policy(accessed May 2008).
5 Farnsworth A, Mitchell HS. Prevention of cervi-cal cancer. Med J Aust 2003; 178: 653-654. ❏
Helen S Marshall and David Isaacs
TO THE EDITOR: We would like toexpress our disappointment with the Jour-nal’s decision to publish an editorial onhuman papillomavirus (HPV) vaccines thatdemonstrated significant bias.1 It seems thatsimply documenting an author’s conflicts ofinterest exonerates the author and relievesthe Journal of the responsibility of consider-ing whether or not the article is biased.
In his article, Wain states that the bivalentvaccine, Cervarix (GlaxoSmithKline), has notbeen included in the National ImmunisationProgram, having initially been rejected by thePharmaceutical Benefits Advisory Committee(PBAC) on the grounds of uncertain cost-effectiveness. He omits to mention thatGardasil (Merck), was initially also rejected,and only funded after political intervention,an emergency meeting of the PBAC and fur-ther price negotiations with CSL.2
Wain claims that Cervarix is being pro-moted to older women despite the absence ofefficacy data and the uncertain populationbenefits in this age group. Surely a balancedargument would include the fact that Gardasilis licensed for boys aged from 9–15 yearsbased on immunogenicity data only, and thatefficacy has not been established in this popu-lation. Why does the author consider this tobe acceptable, but that licensing the vaccinefor older women where the indication is toprevent cervical cancer is unacceptable? Manyvaccines are licensed on the basis of immuno-genicity data provided these have been shownto predict efficacy. While the efficacy of HPVvaccines in older women is being established,there are good data to show that an immuneresponse to HPV vaccine is predictive of effi-cacy.3 Women aged over 26 years produce arobust immune response to HPV vaccines,similar to levels achieved in women aged 15–25 years, for whom efficacy has already beendemonstrated. The Therapeutic GoodsAdministration has licensed Cervarix forwomen aged 26–45 years, before efficacy data
became available, based on the assumptionthat efficacy will be demonstrated in seronega-tive older women.
Women of all ages have shown interest inbenefiting from a vaccine to protect againstcervical cancer.4 Women of any age have theright to be informed, and to have the opport-unity to discuss with their treating physicianthe relative benefits and risks of receiving theHPV vaccine for prevention of cervical cancer.
Many vaccines are initially available onlyif purchased by individuals and, althoughthis may result in inequity, ultimately, this isa decision of priority (individual financialand public health funding priorities) andnot a reason to withhold licensing a vaccinewith proven benefit.
Competing interests: Helen Marshall is a memberof a CSL Gardasil Advisory Board; has been aprincipal investigator for clinical vaccine studiessponsored by both CSL and GlaxoSmithKline; andhas received travel assistance to present scientificdata at international meetings.
Helen S Marshall, Director, Paediatric Trials Unit1
David Isaacs, Paediatric Infectious Diseases Physician2
1 Department of Paediatrics, Women’s and Children’s Hospital, Adelaide, SA.
2 The Children’s Hospital at Westmead, Sydney, NSW.
1 Wain GV. “I want the one for older women” —extending the human papillomavirus vaccinepopulation base [editorial]. Med J Aust 2008;188: 501-502.
2 Australian Government Department of Healthand Ageing. Archived fact sheets. AustralianGovernment funding of Gardasil. http://www.health. gov.au/internet/main/publish-ing.nsf/Content/gardasil_hpv.htm (accessedAug 2008).
3 FUTURE II Study Group. Quadrivalent vaccineagainst human papillomavirus to prevent high-grade cervical lesions. N Engl J Med 2007; 356:1915-1927.
4 Marshall H, Ryan P, Roberton D, Baghurst P. Across-sectional survey to assess community atti-tudes to introduction of human papillomavirusvaccine. Aust N Z J Public Health 2007; 31: 235-242. ❏
MJA • Volume 189 Number 9 • 3 November 2008 527
LETTERS
Jeffrey HJ Tan and Michael A Quinn
TO THE EDITOR: Wain’s criticism of theAustralian Therapeutic Goods Administra-tion (TGA) approval of the bivalent vaccine,Cervarix (GlaxoSmithKline), suggesting itdid not adhere to World Health Organiza-tion guidelines,1 should not detract from thepotential benefits of human papillomavirus(HPV) vaccination in women over 26 yearsof age.
An immunogenicity study showed allwomen up to the age of 55 years serocon-verted to both HPV types and, while meanantibody concentrations at Month 7 werelower than in the younger age group, theywere still three to four times higher thanthose observed in 15–25-year-old women inthe long-term follow-up study (up to 4.5years after vaccination), where continuedefficacy was demonstrated.2 HPV infection ismost prevalent in younger age groups, withone study showing a prevalence of 44.8% inwomen aged 20–24 years.3 As indicated byWain, the vaccine has diminished efficacy inpopulations with high rates of previousexposure. Thus, 20–24-year-olds wouldbenefit least, and if we extrapolate his argu-ment, should not be included in any catch-up vaccination program. The United King-dom has, in fact, recommended a catch-upcampaign for girls aged up to 18 years only.The prevalence of HPV infection decreasesafter 26 years of age, and these “older”women should benefit from vaccination assupported by preliminary efficacy data ofthe quadrivalent vaccine Gardasil (Merck) inan older population.4 This vaccine may alsobe protective for women who have beenpreviously exposed to the same subtypes ofHPV as the vaccines, as shown by 100%efficacy against cervical intraepithelial neo-plasia (CIN) grade 2/3 or adenocarcinoma insitu (AIS) among people who are seroposi-tive but HPV-DNA-negative to the relevantHPV type.5
The Pharmaceutical Benefits AdvisoryCommittee initially did not recommendfunding for Gardasil on the basis of cost-effectiveness until after an extraordinarymeeting to consider a revised submission,following an “unusual” request from theHealth Minister.6,7 CSL agreed to reduce theprice, undertook to make a substantial con-tribution to any booster program if itbecame necessary in the next 20 years, andalso to the costs of setting up a nationalregister to link vaccination data to latercervical screening records.
It is obvious that the efficacy of HPVvaccines will inevitably be lower after com-
mencement of sexual activity, but we believethat it is the medical practitioner’s respons-ibility to offer women aged over 26 years thecurrent, albeit incomplete, information onvaccine efficacy, and allow women to makethe choice.Jeffrey HJ Tan, GynaecologistMichael A Quinn, DirectorOncology and Dysplasia Unit, Royal Women’s Hospital, Melbourne, [email protected]
1 Wain GV. “I want the one for older women” —extending the human papillomavirus vaccinepopulation base [editorial]. Med J Aust 2008;188: 501-502.
2 Schwarz TF. Human papillomavirus-16/18 can-didate vaccine adjuvanted with ASO4 and itsimpact on the incidence of cervical cancer.Expert Rev Obstet Gynecol 2007; 2: 293-303.
3 Dunne EF, Unger ER, Sternberg M, et al. Preva-lence of HPV infection among females in theUnited States. JAMA 2007; 297: 813-819.
4 Luna J. The safety, efficacy and immunogenicityof quadrivalent HPV (types 6/11/16/18) L1 virus-like-particle (VLP) vaccine in women aged 24 to45. Proceedings of the 24th International Papil-lomavirus Conference and Clinical Workshop;2007 Nov 3-9; Beijing, China.
5 Markowitz LE, Dunne EF, Saraiya M, et al.Quadrivalent human papillomavirus vaccine.Recommendations of the Advisory Committeeon Immunization Practices (ACIP). MMWRRecomm Rep 2007; 56 (RR02): 1-24. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5602a1.htm (accessed Aug 2008).
6 The Hon Tony Abbott MHR, Minister for Healthand Ageing. PBAC advice on GARDASIL[media release]. 8 Nov 2006. http://www.health.gov.au/internet/ministers/publish-ing.nsf/Content/487014123B6EBBA1CA257234008126EC/$File/abb155.pdf (accessed Aug2008).
7 The Hon Tony Abbott MHR, Minister for Healthand Ageing. Government funds Gardasil[media release]. 29 Nov 2006. http://www.health.gov.au/internet/ministers/publish-ing.nsf/Content/487014123B6EBBA1CA257234008126EC/$File/abb155.pdf (accessed Aug2008). ❏
All in a day’s work: an observational study to quantify how and with whom doctors on hospital wards spend their timeMark Mackay and Pamela J Castle
TO THE EDITOR: Recent articles in theJournal describing endeavours to measureand classify the tasks of doctors are indica-tive of the re-emergence of work analysisand time and motion studies.1,2
While commending the authors on theirendeavours, it is concerning that the articlesstate almost contradictory findings. West-brook and colleagues reported that profes-sional communication, social activities andmeal breaks represented the greatest propor-tion of observed time.1 Zhu and colleaguesreported that direct patient-related tasksaccounted for 86% of intern time.2
Acknowledging the different contexts of theindividual studies, the collective picture isone of confusion and may lead to misrepre-sentation of the work of doctors.
We have also analysed the work of doc-tors using observational techniques.3 Webuilt on work done in the United States4
that is underpinned by functional job analy-sis (FJA)5 to produce a list of tasks (tasktaxonomy) that describe the work in theacute-care setting, and coordination of rolesbetween hospitals and the community.3,6
The task is the fundamental unit of work,and FJA describes each task in terms ofbehaviours and interdependencies betweenpeople, data and things for the achievementof the task. The method seeks to achievequality information through adopting pre-cise language descriptions and benchmarksfor levels of tasks required for jobs.5 Data arerecorded by means of a simple electronictool.6
Our method captures contextual infor-mation about the service (eg, location ofwork) and rigid details about the observedtasks. We have presented our findings atthe 5th Health Services and Policy ResearchConference of the Health Services ResearchAssociation of Australia and New Zealand,6
and the Change Champions Skill Mix andWorkforce Development conference, bothin 2007. We found that doctors in the unitsstudied spent about 11% of time on educa-tion and training, between 50% and 60%on direct clinical activities (depending oncontext and role), and less than 10% oftime on non-clinical administration. Wesuggest that if observations are recordedaccording to the purpose of the output,what may appear to be “socialising” may, in
528 MJA • Volume 189 Number 9 • 3 November 2008
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fact, be waiting for something or someone.It is far more important to measure whatthe impediment to getting on with the jobis, rather than inferring that socialising isthe main activity.
There is a need for a consistent taskclassification system that can be used acrossunits and across professions to describe thework that is being performed. A commonunit of measure would provide a strongfoundation for collaboration and learning inwork redesign projects across the nation.Without such a system, planning for thefuture and evaluation of new roles willcontinue to be hindered. To this end, we arehappy to share the task taxonomy that wehave developed, and welcome contact viaemail.
Competing interests: Pam Castle and MarkMackay were formerly employed by the SouthAustralian Department of Health. They conductedthe research mentioned in this letter during theiremployment with the Department.
Mark Mackay, Senior Program Manager, Research and Scheme Reform,1 and Visiting Research Fellow2
Pamela J Castle, Senior Human Resources Consultant3
1 TRACsa: Trauma and Injury Recovery, Adelaide, SA.
2 University of Adelaide, Adelaide, SA.3 ACH Group, Adelaide, [email protected]
1 Westbrook JI, Ampt A, Kearney L, Rob MI. All in aday’s work: an observational study to quantify howand with whom doctors on hospital wards spendtheir time. Med J Aust 2008; 188: 506-509.
2 Zhu JN, Weiland TJ, Taylor DM, Dent AW. Anobservational study of emergency departmentintern activities. Med J Aust 2008; 188: 514-519.
3 Mackay M, Castle P. Building better work. Measur-ing what gets done: a task analysis approach for thehealth sector. Adelaide: South Australian Depart-ment of Health, 2007. http://www.publica-tions.health.sa.gov.au/cgi/viewcontent.cgi?article=1001&context=wplan (accessed Aug 2008).
4 Fine SA, Harvey RJ, Cronshaw SF. FJA strategies foraddressing O*NET limitations in a post-DOT envi-ronment. In: Fleishman, EA (Chair). Things, data andpeople: fifty years of a seminal theory. Proceedingsof the 19th annual conference of the Society forIndustrial and Organizational Psychology; Chicago,2004. http://www.siop.org/Conferences/04Con/Program/saturday_am.aspx (accessed Aug 2008).
5 Moore FI. Functional job analysis — guidelines fortask analysis and job design. Geneva: World HealthOrganization, 1999.
6 Mackay M, Castle P. The development of a work-force tracking tool — gaining insight to influencethe future workforce [abstract]. Proceedings of the5th Health Services and Policy Research Confer-ence; 2007 Dec 2-5; Auckland, New Zealand. Syd-ney: Health Services Research Association ofAustralia and New Zealand, 2007: 55. (Abstract No.37.) http://www.hsraanz.org (accessed Jun 2008). ❏
An observational study of emergency department intern activitiesBelinda Doherty and Mark A Brown
TO THE EDITOR: The study of internactivities in Melbourne emergency depart-ments (EDs) highlighted gaps in the EDtraining of interns.1 In particular, it wasshown that interns undertake a low numberof procedural tasks. Most did not performurinary catheterisation, nasogastric tubeinsertion or reductions of fractures and dis-locations, just some of the skills highlightedas important in the Australian CurriculumFramework for Junior Doctors (ACFJD).2
Time pressure on supervisors was cited as areason for this.
New South Wales will experience a doub-ling in the number of medical graduates inthe next few years. Increased capacity inemergency terms will be needed. Thereported capacity (available supervision,clinical workload and funding) in NSW EDsindicates that a shortage of terms coulddevelop from 2011.
The NSW Institute of Medical Educationand Training (IMET) recently explored theeducational validity of retaining the emer-gency term as a mandatory requirement forgeneral registration3 in view of the reportedlimited capacity.
IMET-accredited emergency term descrip-tions were reviewed and mapped against the“Common presenting problems and condi-tions” listed in the ACFJD. The study foundthat an ED term would likely provide expo-sure to most of the common conditions,many of which were unlikely to be encoun-tered in other medical or surgical hospitalrotations. The acute phase of key condi-tions, that all medical practitioners areexpected to be able to recognise and treatappropriately, were often unique to the EDterm. Further, most of the “Skills andprocedures” for junior doctors were likely tobe learned in the ED, and around 50% werenot commonly experienced elsewhere.Many of the broader competencies of thecurriculum such as “Doctor and society” arealso covered in an ED term.
The ED provides a unique context forlearning, bridging community and hospitalsituations. The approach to acutely illpatients, with as yet undifferentiated prob-lems, for whom JMOs learn to initiate treat-ment and appropriate investigationsconcurrently, cannot be reliably replicatedelsewhere.
Emergency departments bear the brunt ofthe growing demand for acute care from anageing population with multiple comorbidi-ties, and also of the growing demand forexcellent and accountable postgraduatemedical training. In NSW, about 30% ofdirectors of prevocational training are EDphysicians, reflecting their commitment toeducation. They typically supervise numer-ous trainees at a time. The educator role ofED physicians and other senior doctors inEDs is essential. Resources should bedirected to supporting this role and enhanc-ing the capacity of EDs to train medicalgraduates.Belinda Doherty, Senior Medical OfficerMark A Brown, DirectorNSW Institute of Medical Education and Training, Sydney, [email protected]
1 Zhu JN, Weiland TJ, Taylor DM, Dent AW. Anobservational study of emergency departmentintern activities. Med J Aust 2008; 188: 514-519.
2 Confederation of Postgraduate Medical EducationCouncils. Australian Curriculum Framework for Jun-ior Doctors project. http://www.cpmec.org.au/cur-riculum/welcome.cfm (accessed Oct 2008).
3 NSW Institute of Medical Education and Training.Discussion paper. Emergency terms — a mandatoryrequirement for general registration in NSW? http://www.imet.health.nsw.gov.au/www/472/1001127/dis-playarticle/publications-resources--1001214.html(accessed Oct 2008). ❏
A day in the life of a doctor-in-trainingLisa Caputo, Fiona R Lake, Margaret Potter and Ian Rogers
TO THE EDITOR: Learning in the clinicalsetting remains central to the developmentof well trained health care professionals. Theissue is whether that learning should occurthrough formal or informal learning oppor-tunities. Westbrook and colleagues define“supervision or education” in a way thatfocuses mainly on formal experiences,1 pos-sibly because trained observers could accur-ately classify such experiences. As noted byBrown and Arnold, much learning in thehospital setting is largely informal innature.2 Although learning is likely to beoccurring during the many discussions thatjunior doctors have with consultants orduring the procedures they perform in anemergency department,3 it can be difficult todescribe, and may not be recognised aslearning by the individuals involved.4
There is a divide between the perceptionsof teachers and trainees about how muchlearning is occurring, whether teaching has
occurred and feedback has been given. Con-sultants believe they are providing a greatdeal, but junior doctors do not recognise it.Although junior doctors perceive they haveadequate informal contact with registrars,and some (but not enough) with consult-ants, what they want is more teaching in“formal” sessions.5 Additionally, supervisorsthink they give detailed feedback, but juniordoctors view it as less than adequate.6
The answer might lie in upskilling bothjunior doctors and teachers to make teach-ing and learning more effective, in part bymaking it more explicit to all involved.
At Sir Charles Gairdner Hospital in Perth,an innovation has been to create new posi-tions known as “medical education regis-trars” who, as supernumerary staff at asenior registrar level, have time to advise onpatient management, supervise and teachskills.7 Much of this is provided at thepatient’s bedside. The very nature of theirjob title makes it explicit that they are thereto help learning during daily activities.
The staff development program, “Teach-ing on the Run”, developed by the Educa-tion Centre at the Faculty of Medicine andDentistry, University of Western Australia,8
aims to make teachers more effective. Morerecently, we have piloted another program,“Learning on the Run”, for junior doctorsand students, to provide them with the skillsto recognise opportunities and drive theirown learning agendas.
We agree with Brown and Arnold thatlearning and service are not mutually exclu-sive.2 By providing both junior doctors andsenior medical staff with the necessary skills,many tasks within a day in the life of a newdoctor could become a valuable learningexperience. Whether this will ultimatelytranslate into improved teaching and learn-ing outcomes is a question we are continu-ing to explore.Lisa Caputo, Lecturer, Clinical Education1
Fiona R Lake, Head of School of Medicine and Pharmacology, and Associate Professor of Medicine (Respiratory)1
Margaret Potter, Consultant2
Ian Rogers, Associate Professor of Emergency Medicine,1 and Director of Postgraduate Medical Education3
1 University of Western Australia, Perth, WA.2 Smart Moves Consultancy, Perth, WA.3 Sir Charles Gairdner Hospital, Perth, [email protected]
1 Westbrook J, Ampt A, Kearney L, Rob MI. All in aday’s work: an observational study to quantify howand with whom doctors on hospital wards spendtheir time. Med J Aust 2008; 188: 506-509.
2 Brown MA, Arnold S. A day in the life of a doctor-in-training [editorial]. Med J Aust 2008; 188: 500-501.
3 Zhu JN, Weiland TJ, Taylor DM, Dent AW. Anobservational study of emergency departmentintern activities. Med J Aust 2008; 188: 514-519.
4 Eraut M. Informal learning in the workplace. StudContin Educ 2004; 26: 247-273.
5 Dent A, Crotty B, Cuddihy HL, et al. Learningopportunities for Australian prevocational hospitaldoctors: exposure, perceived quality and desiredmethods of teaching. Med J Aust 2006; 184: 436-440.
6 Carless D. Differing perceptions in the feedbackprocess. Stud Higher Educ 2006; 31: 219-233.
7 O’Gorman R, Rogers IR, Celenza A. Medical educa-tion registrars: a step in the right direction. In:Proceedings of the 12th National PrevocationalMedical Education Forum; 2007 Oct 28-31; Sydney.Sydney: NSW Institute of Medical Education andTraining, 2007: 28.
8 Lake FR, Ryan G. Teaching on the run: teaching tipsfor clinicians. Sydney: MJA Books, 2006. ❏
Evidence-based advocacy: the public roles of health care professionalsBill Williams
TO THE EDITOR: In his exploration of thehealth advocacy potential of modern clini-cians, Gruen1 observes that the public firstneeds to be convinced that “the professionhas its own house in order”. Unfortunately,one room in that house accommodates oneof the serious health threats identified by theauthor: terrorism. Currently, over 95% ofthe world’s radiopharmaceuticals are gener-ated from highly enriched (bomb-grade)uranium (HEU), an unnecessary nuclearweapons proliferation hazard.2 Prompt con-version of the global medical isotope supplychain to low enriched uranium (LEU, con-taining less than 20% uranium 235, so notviable for weapons production) is techn-ically feasible.3 Clinicians are thus uniquelyplaced to advocate conversion to the use ofLEU, while pressuring their imaging andisotope providers to end reliance on HEU,thereby blocking one of the most vulnerablepathways to producing a “terrorist bomb”.
But, as Gruen suggests, we can do evenmore through “collective advocacy” toaddress the much larger nuclear threat: thatis, the 26 000-plus nuclear weapons remain-ing in the arsenals of Russia, the UnitedStates, the United Kingdom, France, India,Pakistan, Israel, China and North Korea.While a sophisticated terrorist group armedwith home-manufactured nuclear weaponscould devastate a few cities, the existingnuclear-armed states have the capacity todestroy between tens and thousands ofurban centres and their populations within afew short hours.
Worse still, recent research indicates that100 Hiroshima-sized (ie, “small”) nuclearweapons exploded on major cities would becapable of precipitating a “nuclear winter”that could persist for 10 years.4 The disper-sal of carbonaceous material into the strato-sphere from major urban firestorms coulddramatically reduce terrestrial sunlight,lower surface temperatures by severaldegrees, shorten the growing season, reducerainfall and trigger global famine. One bil-lion deaths from starvation is a realisticassessment of the consequences.5 Such acatastrophic scenario is within the firepowercapacity of all currently nuclear-armednations except North Korea.
A new generation of medical students andyoung physicians has launched several initi-atives over the past few years to challengethis threat, including the Nuclear WeaponsInheritance Project and Target X (http://www.ippnw-students.org). Most recently,International Physicians for the Preventionof Nuclear War launched the InternationalCampaign to Abolish Nuclear Weapons(http://www.icanw.org), whose goal is toestablish a nuclear weapons convention toeliminate all nuclear weapons once and forall.
By ending our reliance on bomb-gradeHEU in medical imaging, we can certainlybegin to put our own house in order. Butlet’s also follow Virchow’s lead: let’s “engagewith the broader social concerns that causeillness and harm”,1 get active for ourpatients’ — and our own — wellbeing, andhelp prevent a global nuclear pandemic.Bill Williams, Vice PresidentMedical Association for Prevention of War (Australia), Melbourne, [email protected]
1 Gruen RL. Evidence-based advocacy: the publicroles of health care professionals [editorial]. Med JAust 2008; 189: 684-685.
3 Kahn LH, von Hippel F. How the radiologic andmedical communities can improve nuclear security.J Am Coll Radiol 2007; 4: 248-251.
4 Robock A, Oman L, Stenchikov GL, et al. Climaticconsequences of regional nuclear conflicts. AtmosChem Phys 2007; 7: 2003-2012. http://www.atmos-chem-phys.org/7/2003/2007/acp-7-2003-2007.pdf(accessed Aug 2008).
5 Helfand I. An assessment of the extent of projectedglobal famine resulting from limited, regionalnuclear war. In: Nuclear weapons: the final pan-demic. Preventing proliferation and achieving aboli-tion. Royal Society of Medicine Conference; 2007Oct 3-4; London, UK. http://www.ippnw.org/News/Reports/HelfandFaminePaper.pdf (accessed Jul2008). ❏
Respiratory rate: the neglected vital signAllen C Cheng, James F Black and Kirsty L Buising
TO THE EDITOR: We note with interestthe recent commentary by Cretikos et al onthe predictive value of a high respiratoryrate for adverse outcomes.1 We wish toprovide empirical evidence from Australianpatients with pneumonia in support of theirview that simple clinical parameters aregood predictors of adverse outcomes.
We examined data from a prospectivecohort of consecutive patients presenting tothe Royal Melbourne Hospital EmergencyDepartment with radiologically confirmed,community-acquired pneumonia between2003 and 2006.2 In an earlier study of asubset of these patients,3 we found thathypotension and tachypnoea were stronglyassociated with death and/or the need forrespiratory/inotropic support (odds ratios,8.0 and 3.5, respectively).
In the full cohort (n = 740), we examinedfactors associated with either admission tothe intensive care unit (ICU) or mortality(106 patients were in one of these twocategories). Respiratory rate was docu-mented in 712 patients (96%). A combina-tion of tachypnoea (� 24 breaths/min) and/or hypotension (systolic blood pressure� 90 mmHg) had similar predictive valuefor the risk of ICU admission and/or deathto the recommended system of risk stratifi-cation, the Pneumonia Severity Index (PSI)4
(Box). The combination of respiratory rateand systolic blood pressure performed bet-ter than either sign alone in ruling out at-risk patients if both were normal (ie, a highnegative predictive value), although almost aquarter of patients with either clinical signhad adverse outcomes.
The PSI is based on 20 individual clinicaland laboratory parameters, and evidencesuggests that it is poorly documented inpatients’ records.5 Our data relate topatients with community-acquired pneu-monia from a single centre and thus havelimited statistical power for making com-parisons. However, they suggest that thesetwo routinely measured clinical parameterscan be used to stratify patients at risk ofadverse outcomes at the time of presenta-tion. We support efforts to incorporatesimple clinical indicators into systems thatcan identify seriously unwell patients earlyin the course of illness.
Allen C Cheng, Infectious Diseases Physician1
James F Black, Associate Professor2
Kirsty L Buising, Infectious Diseases Physician3
1 Menzies School of Health Research, Darwin, NT.
2 Nossal Institute for Global Health, University of Melbourne, Melbourne, VIC.
3 Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC.
1 Cretikos MA, Bellomo R, Hillman K, et al. Respira-tory rate: the neglected vital sign. Med J Aust 2008;188: 657-659.
2 Buising KL, Thursky KA, Black JF, et al. A prospec-tive comparison of severity scores for identifyingpatients with severe community acquired pneu-monia: reconsidering what is meant by severepneumonia. Thorax 2006; 61: 419-424.
3 Buising KL, Thursky KA, Black JF, et al. Identifyingsevere community-acquired pneumonia in theemergency department: a simple clinical predictiontool. Emerg Med Australas 2007; 19: 418-426.
4 Fine MJ, Auble TE, Yealy DM, et al. A predictionrule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997; 336: 243-250.
5 Maxwell DJ, McIntosh KA, Pulver LK, Easton KL.Empiric management of community-acquiredpneumonia in Australian emergency departments.Med J Aust 2005; 183: 520-524. ❏
Olivier Steichen, Gilles Grateau and Eric Bouvard
TO THE EDITOR: Cretikos et al make astrong case for routinely recording patients’respiratory rate (RR) in acute wards.1
In a prospective study designed to evaluatethe prognostic value of RR in acutely hospi-talised patients aged over 75 years, we ana-lysed data from all admissions to a single 14-bed acute-care geriatric unit between 15 Mayand 15 November 2007. Clinical data wererecorded on admission and blood tests wereperformed the next morning. The Charlsonscore was used to assess comorbidity.2
Features of the 195 admissions during thestudy period (13 patients were admittedtwice) are reported in the Box. The mainreasons for admission were falls (15%), leftventricular failure (11%), pneumonia(11%), cancer complications (9%), pyelo-nephritis (7%) and stroke (5%). Twenty-nine patients died in hospital, including sixfrom cancer complications, five from pneu-monia, four from pyelonephritis and fourfrom left ventricular failure.
Based on univariate logistic regressionanalysis at the 0.05 significance level, thefollowing variables were predictive of death
Features of the 195 admissions to the acute-care geriatric unit between May and November 2007
Age (years) 85 (81–91)*
Women 123 (63%)†
Charlson score 6 (5–8)*
Dementia 88 (45%)†
Body temperature (° C) 37.0 (36.8–37.5)*
Systolic blood pressure (mmHg)
136 (120–152)*
Heart rate (beats/min) 80 (70–92)*
Respiratory rate(breaths/min)
20 (20–25)*
Serum sodium level(mmol/L)
140 (137–143)*
Serum creatininelevel (μmol/L)
91 (76–120)*
Serum protein level(g/L)
65 (59–70)*
Serum C-reactiveprotein level (mg/L)
36 (12–108)*
Blood haemoglobinlevel (g/L)
115 (100–125)*
White blood cellcount (� 109/L)
8.3 (6.3–11.5)*
* Median (interquartile range). † Number of admissions (%). ◆
Summary statistics for tachypnoea, hypotension and PSI class as predictors of ICU admission and/or death from community-acquired pneumonia*
Number of patients Sensitivity Specificity PPV NPV
RR � 24 breaths/min 712 82% (73%–89%)
48% (44%–52%)
22% (18%–26%)
94% (91%–96%)
RR � 27 breaths/min 712 70% (60%–78%)
67% (63%–71%)
27% (22%–32%)
93% (90%–95%)
RR � 24 breaths/min and/or systolic BP � 90 mmHg
713 93% (86%–97%)
45% (41%–49%)
23% (19%–27%)
97% (94%–99%)
PSI class IV or V† 740 90% (82%–95%)
49% (45%–53%)
22% (19%–27%)
97% (94%–98%)
BP = blood pressure. ICU = intensive care unit. NPV = negative predictive value. PPV = positive predictive value. PSI = Pneumonia Severity Index. RR = respiratory rate. * Figures in parentheses represent 95% CIs calculated using the exact binomial distribution. † Severe pneumonia. ◆
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during hospitalisation: being male (odds ratio[OR], 2.42, Wald test P = 0.03); increasedCharlson score (OR, 1.50 for each additionalpoint between 3 and 13; P < 0.001);decreased systolic blood pressure (OR, 6.71for systolic blood pressure < 100 mmHg; P =0.004); abnormal heart rate (< 60 beats/minor > 100 beats/min) (OR, 3.63; P = 0.003);increased RR (OR, 1.81 for each additional 5breaths/min between 14 and 44; P < 0.001);abnormal blood sodium level (< 137 mmol/Lor > 143 mmol/L) (OR, 2.82; P = 0.01) andraised C-reactive protein level (OR, 2.67 forC-reactive protein level > 45 mg/L; P = 0.02).
After multivariate logistic regressionanalysis with stepwise backward elimina-tion, the only remaining factors that weresignificant predictors of death during hospi-talisation were Charlson score (OR, 1.53 foreach additional point between 3 and 13;P < 0.001) and RR (OR, 1.83 for each addi-tional 5 breaths/min between 14 and44 breaths/min; P < 0.001).
RR on admission was associated with anarea under the ROC (receiver operating char-acteristic) curve of 0.73 (95% CI, 0.64–0.82)for the prediction of death during hospitalisa-tion. An RR of �20breaths/min had a sensi-tivity of 97% (95% CI, 80%–100%), aspecificity of 28% (95% CI, 21%–35%) and anegative likelihood ratio of 0.12 (95% CI,0.02–0.82) for prediction of death duringhospitalisation. Only one patient (admittedfor stroke) with an RR of <20breaths/min atadmission died in hospital. Higher RR cut-offvalues increased specificity but reduced sensi-tivity. For instance, an RR of �30breaths/minhad a specificity of 90% (95% CI, 84%–94%),but a sensitivity of 38% (95% CI, 21%–58%),leading to a positive likelihood ratio of 3.68(95% CI, 1.93–7.04) for prediction of deathduring hospitalisation.
In conclusion, besides comorbidity (Charl-son score), RR was the most useful predictorof death in acutely hospitalised patients agedover 75 years. Our results extend the evi-dence base promoting regular documentationof RR in acute-care departments.1
Olivier Steichen, Fellow1
Gilles Grateau, Professor and Head1
Eric Bouvard, Head2
1 Department of Internal Medicine, Hôpital Tenon, AP-HP, Paris, France.
2 Department of Geriatrics, Hôpital Tenon, AP-HP, Paris, France.
1 Cretikos MA, Bellomo R, Hillman K, et al. Respir-atory rate: the neglected vital sign. Med J Aust2008; 188: 657-659.
2 Charlson M, Szatrowski TP, Peterson J, Gold J.Validation of a combined comorbidity index. J ClinEpidemiol 1994; 47: 1245-1251. ❏
Simon C Gandevia and David K McKenzie
TO THE EDITOR: The concept that respir-atory rate (RR) is a key vital sign is hardlynew,1 but it is being re-emphasised.2,3 Therecent article by Cretikos et al3 highlightsthe diagnostic relevance of a raised RR forserious adverse events. The authors makesensible recommendations regarding theneed to educate hospital staff about theimportance of measuring patients’ RR.
However, they do not specify how thisrate should be measured. Indeed, mosttextbooks of general medicine, and evenrespiratory medicine, fail to provide guid-ance on this or to define an abnormal rate.A wide ly used book on c l in i ca lexamination4 suggests measuring RR whilefeeling the pulse, and quotes a normal(adult) resting range of 16–25 breaths/min,but no source for this information is pro-vided.
There are few reports of true normalresting RR measurements obtained by cov-ert observation. Respiratory physiologistshave long known that RR commonlyincreases and becomes more regular assoon as a subject becomes aware of themeasurement. This is especially so if amouthpiece is in place. Rates as low as 8breaths/min may be seen at rest, and thenormal adult range quoted by physiologistsis 11–14 breaths/min.5 Bradypnoea is usu-ally defined as a rate less than 8 breaths/min and tachypnoea as a rate greater than18–20 breaths/min.
There is no gold standard method foraccurate measurement of RR in clinicalpractice. Of course, when patients arebeing monitored, particularly with a nasalcannula, it should be easy to obtain therate. Oximetry is not a surrogate measureof RR, although it is often easier to record.Inductance bands around the chest providea simple non-invasive way to measure RR.In addition to the absolute rate, an irregu-lar and erratic rate is of concern.
In settings in which formal monitoring isnot being conducted, RR is the one “vital”sign that must be assessed when the patientis resting quietly, unaware of its measure-ment, and not conversing with staff. Dupli-cate measurements should be made over aninterval of at least 1 minute. An RR of over20 breaths/min, particularly if irregular, isnoteworthy. Tachypnoea is intimatelylinked with the sensation of breathlessness,and hence the patient’s respiratory sensa-tions should be assessed. In some patientswith a normal RR at rest, marked tachy-
pnoea may be precipitated by mild exer-tion, such as walking a few paces.Simon C Gandevia, Deputy Director1
David K McKenzie, Head2
1 Prince of Wales Medical Research Institute, Sydney, NSW.
2 Department of Respiratory and Sleep Medicine, Prince of Wales Hospital, Sydney, NSW.
1 Lenfant C. Time-dependent variations of pulmon-ary gas exchange in normal man at rest. J ApplPhysiol 1967; 22: 675-684.
2 Cullinane M, Findlay G, Hargraves C, et al. Anacute problem? London: National ConfidentialEnquiry into Patient Outcomes and Death, 2005.http://www.ncepod.org.uk/2005aap.htm (accessedAug 2008).
3 Cretikos MA, Bellomo R, Hillman K, et al. Respira-tory rate: the neglected vital sign. Med J Aust2008; 188: 657-659.
4 Talley NJ, O’Connor S. Clinical examination: asystematic guide to physical diagnosis. 5th ed.Sydney: Churchill Livingstone, 2006.
5 Comroe JH, Forster RE, Dubois AB, et al, editors.The lung: clinical physiology and pulmonary func-tion tests. 2nd ed. Chicago: Year Book MedicalPublishers, 1962. ❏
Management of Mycobacterium ulcerans infection in a pregnant woman in Benin using rifampicin and clarithromycinAnge D Dossou, Ghislain E Sopoh, Christian R Johnson, Yves T Barogui, Dissou Affolabi, Sévérin Y Anagonou, Théophile Zohoun, Françoise Portaels and Kingsley Asiedu
TO THE EDITOR: Buruli ulcer, caused bythe bacterium Mycobacterium ulcerans,leads to the destruction of skin and some-times bone. It has been reported in manytropical countries in Africa and in sometemperate regions of Australia, Japan andChina.1 In 2004, the World Health Organi-zation recommended treatment with thecombination of oral rifampicin and intra-muscular streptomycin (or amikacin) for 8weeks.2,3 In-vitro studies and new datafrom mouse models suggest that combina-tions of rifampicin with clarithromycin,rifampicin with moxifloxacin, or clarithro-mycin with moxifloxacin may be as effec-tive as rifampicin and streptomycin.4,5
In June 2007, a woman who was 6-months pregnant with her first child andhad a 7-month history of Buruli ulcer on herright upper limb (Box 1, A) was admitted tothe Buruli ulcer treatment centre in Allada,
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Benin. She was otherwise in good health,and the fetal heart beat was normal. Routinelaboratory examinations, including HIVserology tests, found no abnormalities.Swabs from the ulcer were positive foracid-fast bacilli by Ziehl–Neelsen stain, andfor IS 2404 (DNA sequence specific forMycobacterium ulcerans) by polymerasechain reaction testing, but no growth ofM. ulcerans was obtained on culture. His-topathological analysis of punch biopsy spec-imens showed typical features of Buruli ulcer.
As streptomycin is contraindicated inpregnancy, we treated the patient with acombination of oral rifampicin (600 mgdaily) and oral clarithromycin (500 mgtwice daily) for 56 days, beginning 2 weeksafter presentation. The treatment was welltolerated. We monitored the clinicalresponse through serial photographs (Box 1)and measurements of the circumference ofthe affected and unaffected limbs at definedpoints (Box 2).
The patient gave birth to a healthy boyweighing 2.25 kg in September 2007, 2weeks after completing antibiotic treat-ment. She underwent skin grafting a monthlater. The lesion healed without functionallimitation (Box 1, D), and the patient wasdischarged in December 2007. At thattime, the surface area affected by the lesionwas reduced by 55%.
To our knowledge, this is the first reportof successful treatment of Buruli ulcerusing fully oral treament with rifampicinand clarithromycin alone. We hope ourexperience will contribute to future discus-sion and studies to find an oral treatmentfor this devastating disease.
Acknowledgements: Fondation LuxembourgeoiseRaoul Follereau, Luxembourg; Projet BurulicoEuropean Union (project reference number, INCO-CT-2005-051476); and the World Health Organiza-tion, Geneva.
Ange D Dossou, Medical Officer1
Ghislain E Sopoh, Medical Officer1
Christian R Johnson, Medical Officer2
Yves T Barogui, Medical Officer3
Dissou Affolabi, Assistant Professor of Biology4
Sévérin Y Anagonou, Professor of Bacteriology–Virology4
Théophile Zohoun, Professor of Public Health5
Françoise Portaels, Professor of Microbiology6
Kingsley Asiedu, Medical Officer7
1 Centre de Dépistage et de Traitemente de l’Ulcère, Allada, Benin.
2 Programme National de Lutte contre la Lépre et l’Ulcère de Buruli, Cotonou, Benin.
3 Centre de Dépistage et de Traitemente de l’Ulcère, Lalo, Benin.
4 Laboratoire de Référence des Mycobactéries, Cotonou, Benin.
5 Faculté des Sciences de la Santé, Cotonou, Benin.
6 Mycobacteriology Unit, Institute of Tropical Medicine, Antwerp, Belgium.
7 Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland.
1 Portaels F, Johnson P, Meyers WM, editors. Buruliulcer. Diagnosis of Mycobacterium ulcerans dis-ease. A manual for health care providers. Geneva:World Health Organization, 2001: 92.
2 World Health Organization. Provisional guidanceon the role of specific antibiotics in the manage-ment of Mycobacterium ulcerans disease (Buruliulcer). Geneva: WHO/CDS/CPE/GBUI.10, 2004.http://www.who.int/buruli/information/antibiotics/en/index.html (accessed 2004).
3 Johnson PDR, Hayman JA, Quek TY, et al. Consen-sus recommendations for the diagnosis, treatmentand control of Mycobacterium ulcerans infection(Bairnsdale or Buruli ulcer) in Victoria, Australia.Med J Aust 2007; 186: 64-68.
5 Ji B, Chauffour A, Robert J, et al. Orally adminis-tered combined regimens for treatment of Myco-bacterium ulcerans infection in mice. AntimicrobAgents Chemother 2007; 51: 3737-3739. ❏
1 Serial views of Buruli ulcer in a woman treated with rifampicin and clarithromycin
A: At presentation. B: After 4 weeks' antibiotic treatment. C: On completion of antibiotic treatment (8 weeks). D: At hospital discharge after skin grafting, showing full movement of the elbow joint (23 weeks). ◆
2 Clinical response to treatment
Week after treatment start
0 4 8 23
Limb circumference (cm)
At wrist
Affected limb 21 17.5 16.5 15
Unaffected limb 14 14 14 14
% difference 50% 25% 18% 7%
At mid-arm
Affected limb 36 33 30 25
Unaffected limb 22 22 22 22
% difference 64% 50% 36% 14%
At elbow
Affected limb 34 21 21 21
Unaffected limb 23 23 23 23
% difference 48% − 9% − 9% − 9%
Lesion dimensions
Diameter (cm)* 30.3 23.8 22.5 20.3
Area
Estimate (cm2) 722 446 397 325
% reduction — 38% 45% 55%
* Median diameter. ◆
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Kaposi’s varicelliform eruption in a healthy adultHajime Kimata
TO THE EDITOR: Kaposi’s varicelliformeruption (KVE) is a disseminated cutaneousinfection caused by herpes simplex virus(HSV) in patients with predisposing factorssuch as atopic dermatitis, widespread skininjury and sun exposure.1-5 I report apatient with KVE but no apparent predis-posing factors.
A 54-year-old man presented with a 3-dayhistory of a rapidly progressing vesiculopus-tular rash on his trunk, legs, arms and hands(Box). He reported a burning skin sensationand had a temperature of 38.2° C. He had nolabial or oral erosions, and no history of skindisease, HSV infection or any systemic dis-ease. He was not taking any medication andreported no excessive sun exposure beforesymptom onset. Haematological, biochemicaland immunological parameters, includinglevels of C-reactive protein, immunoglobu-lins, complement components, lymphocyteblastogenesis and natural killer cell cytolyticactivity were normal. An HIV test was nega-tive. Skin swabs from the lesion were positivefor HSV-1 by polymerase chain reaction(PCR) testing; HSV-1 was also isolated onculture. Cultures were negative for bacterial,fungal and mycobacterial pathogens. A dia-gnosis of KVE was thus established.
Based on past experience treating KVEwith a combination of oral valaciclovir andvidarabine ointment, which accelerated res-olution of symptoms,6 I treated the patientwith oral valaciclovir (1 g three times perday) and vidarabine ointment (three timesper day). The lesions were completelyhealed after 7 days of treatment. HSV-1antibody titres on Days 1 and 7, respectively,were: IgM, 3.1 and 5.2 (reference range,< 0.8); and IgG, < 2.0 and 4.7 (referencerange, < 2.0). HSV-2 IgM and IgG antibodytitres on Days 1 and 7 were within referenceranges (< 0.8 and < 2.0, respectively).
This case is unusual as it occurred in anotherwise healthy patient. KVE is usuallyassociated with healing second-degreeburns, peribuccal dermabrasion and laserskin resurfacing,2-4 and sun exposure inpatients with recurrent HSV infection.5
The origin of the patient’s HSV-1 infectionwas not identified: there was no outbreak ofHSV infection in his city of residence; hiswife and two children were healthy and hadno systemic or skin diseases; PCR testing oftheir saliva for HSV-1 and HSV-2 DNA 3days after the patient’s presentation gave
negative results; and the patient had noapparent contact with HSV-infected patientsbefore onset of symptoms.
KVE has been successfully treated withintravenous aciclovir (three times per day) ororal aciclovir (five times per day).2,5 How-ever, intravenous aciclovir requires hospitaladmission, and compliance with the dosageregimen of oral aciclovir is troublesome. Incontrast, oral valaciclovir (three times perday) and vidarabine ointment do not requirehospital admission and are easier forpatients.1,3,6 Oral valaciclovir is also veryeffective for preventing herpes infection.7
This case highlights that KVE should beconsidered in otherwise healthy patientswith a sudden, rapidly progressing vesiculo-pustular rash.
1 Kramer SC, Thomas CJ, Tyler WB, Elston DM.Kaposi’s varicelliform eruption. A case report andreview of the literature. Cutis 2004; 73: 115-122.
2 Bartralot R, Garcia-Patos V, Rodroguez-Cano L, Cas-telles A. Kaposi’s varicelliform eruption in a patientwith healing second degree burns. Clin Exp Derm-atol 1996; 21: 127-130.
3 Bestue M, Cordero A. Kaposi’s varicelliform erup-tion in a patient with healing peribucal dermabra-sion. Dermatol Surg 2000; 26: 939-940.
4 Rodriguez-Serna M, Mercader P, Pardo J, et al.Kaposi’s varicelliform eruption in an HIV-positivepatient after laser resurfacing. J Eur Acad DermatolVenereol 2004; 18: 711-712.
5 Wolf R, Tamir A, Weinberg M, et al. Eczema herpet-icum induced by sun exposure. Int J Dermatol 1992;31: 298-299.
6 Kimata H. Rapidly increasing incidence of Kaposi’svaricelliform eruption in patients with atopic derma-titis. Indian J Dermatol Venereol Leprol 2008; 74:262-263.
7 Miller CS, Avdiushko SA, Kryscio RJ, et al. Effect ofprophylactic valacyclovir on the presence of humanherpesvirus DNA in saliva of healthy individualsafter dental treatment. J Clin Microbiol 2005; 43:2173-2180. ❏
Serotonin toxicity precipitated by concomitant use of citalopram and methylene blueAli Khavandi, John Whitaker and Hanney Gonna
TO THE EDITOR: Serotonin toxicity is anunder-recognised, potentially fatal syn-drome that is becoming more common asthe use of serotonergic drugs increases.1 Wereport a case of serotonin toxicity followingthe concomitant use of the antidepressantcitalopram and methylene blue.
A 44-year-old woman underwent electivepartial parathyroidectomy for primaryhyperparathyroidism. Three hours after sur-gery, the patient became agitated and restlesswhile staring vaguely into space, makingincomprehensible sounds (Glasgow ComaScale: 11/15; motor response, 5; verbalresponse, 2; eye opening, 4). Her bloodpressure (120/66 mmHg), pulse (100 beats/minute [sinus rhythm]), oxygen saturation(92% while breathing room air), and tem-perature (37.5° C) were not clinically signifi-cant.
Neurological examination revealed bilat-eral pupillary dilatation with sluggishresponse to light, myoclonic movements ofthe lower limbs, brisk reflexes throughoutand downgoing plantar responses. Clonuswas absent and there was no focal neurolog-ical deficit. Blood tests showed a mildinflammatory response (white cell count,12.7 � 109/L [reference range (RR), 4.0–11.0 � 109/L]; C-reactive protein, 23 mg/L[RR, < 10 mg/L]), normal serum levels ofca lc ium (2 .50 mmol /L [RR, 2 .12–2.65 mmol/L]), and mildly elevated phos-phate (1.5 mmol/L [RR, 0.8–1.4 mmol/L]).A computed tomography scan of the headshowed no abnormalities.
The patient’s medical history includedischaemic heart disease, hypertension, obes-ity and depression. Regular long-term medi-cations included aspirin (75 mg daily),simvastatin (40 mg each night), atenolol(50 mg daily), isosorbide mononitrate (20 mgdaily), bendroflumethiazide (a thiazidediuretic not available in Australia; 2.5 mgdaily), felodipine (5 mg daily) and citalopram(20 mg daily). On the day of the operation,she received propofol, remifentanil, rocuro-nium, dexamethasone, morphine analgesiaand a preoperative methylene blue infusion(560 mg in 500 mL of saline over 2 hours;used to stain the parathyroid glands). She hadpreviously undergone general anaesthesiawithout complication.
Vesiculopustular lesions in a patient with Kaposi’s varicelliform eruption
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Serotonin toxicity was diagnosed, precipi-tated by the combination of methylene blueand citalopram. She was transferred to theintensive care unit, where she was sedatedfor 12 hours with propofol and alfentanil.Citalopram was withheld, and she receivedsupportive treatment only. She was dis-charged to the ward 24 hours later and thenhome (3 days after discharge from the inten-sive care unit), with no long-term adverseeffects. Three months after discharge, shecontinued to take citalopram, and serumcalcium levels were in the normal range.
Serotonin toxicity can be caused by asingle drug or a combination of drugs withserotonergic activity. Methylene blue attenu-ates the metabolism of serotonin throughinhibition of monoamine oxidase A.2 Whenused in combination with a selective sero-tonin reuptake inhibitor, such as citalopram,toxic accumulation of serotonin may result.3
Features include mental state changes, auto-nomic hyperactivity, and neuromuscularabnormalities. In mild cases, treatment issupportive, with withdrawal of serotonergicdrugs and control of agitation. Moderate tosevere cases require control of hyperthermiaand autonomic instability, and administra-tion of 5-HT2A (5-hydroxytryptamine2A)antagonists.1
Ali Khavandi, Cardiology RegistrarJohn Whitaker, Medical TraineeHanney Gonna, Cardiology RegistrarSouthmead Hospital, Bristol, United [email protected]
1 Boyer EW, Shannon M. The serotonin syndrome.N Engl J Med 2005; 352: 1112-1120.
2 Ramsay RR, Dunford C, Gillman PK. Methylene blueand serotonin toxicity: inhibition of monoamineoxidase A (MAO A) confirms a theoretical predic-tion. Br J Pharmacol 2007; 152: 946-951.
3 Kartha SS, Chacko CE, Bumpous JM, et al. Toxicmetabolic encephaolopathy after parathyroidec-tomy with methylene blue localization. OtolaryngolHead Neck Surg 2006; 135: 765-768. ❏
Cancer care: what role for the general practitioner?Jon D Emery
TO THE EDITOR: The 21 July 2008 “gen-eral practice” issue of the Journal raises anumber of important issues about the futureof generalist medical care, including the roleof the general practitioner in the care ofcancer patients. The editorial by Weller andHarris acknowledges the importance ofmultidisciplinary teams, including the fullgamut of primary care practitioners, inmeeting the diverse needs of people withcancer, from diagnosis to long-term “survi-vorship”.1 Jiwa et al propose a new model ofan “integrated primary care hub” — with a“cancer care coordinator” — as a possiblesolution to the challenges of providing goodteam-based care.2 However, creating anentirely new disease-centred role wouldseem to ignore much of the debate in therest of the general practice issue. Multiplemorbidity is an emerging reality in Australia,and it is a fact that many survivors of cancerwill die from other chronic conditions. Dis-ease-specific care coordinators are currentlybeing promoted as the new model for deliv-ering chronic disease management to thecommunity, but how many of these carecoordinators will be needed for patientssuch as those described by Britt et al?3 Andwho will coordinate the coordinators?
Gunn et al make a strong case for thegeneralist primary care medical practitioneras the overarching coordinator of care.4 Wemust stop seeing our patients through theeyes of our disease-centred hospital col-leagues. Instead, we must create new mech-anisms that will allow the experts ingeneralism — GPs — to move away frompredominantly “reactive, consultation-basedmedicine”4 to high-quality integrated care
planning in coordination with other mem-bers of the primary care team.Jon D Emery, Head of School and Professor of General PracticeSchool of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, [email protected]
1 Weller DP, Harris MF. Cancer care: what role for thegeneral practitioner [editorial]? Med J Aust 2008;189: 59-60.
2 Jiwa M, Saunders CM, Thompson SC, et al. Timelycancer diagnosis and management as a chroniccondition: opportunities for primary care. Med JAust 2008; 189: 78-82.
3 Britt HC, Harrison CM, Miller GC, Knox SA. Preva-lence and patterns of multimorbidity in Australia.Med J Aust 2008; 189: 72-77.
4 Gunn JM, Palmer VJ, Naccarella L, et al. The prom-ise and pitfalls of generalism in achieving the Alma-Ata vision of health for all. Med J Aust 2008; 189:110-112. ❏
Venous thromboembolism associated with train travelJeet Ram Kashyap, Sanjay D’Cruz, Sandeep Chauhan and Suman Kochhar
TO THE EDITOR: Venous thromboembo-lism (VTE) is frequently described amongair travellers but data on VTE related to traintravel are limited.1-3 We report a case of VTEin a patient after a prolonged train journey.
A 35-year-old man presented with sud-den onset of breathlessness, perspirationand syncope after a 14-hour train journey,during which he had limited mobility. Hehad no history of similar episodes, nosignificant comorbidities or previous periodsof prolonged immobility and no familyhistory of thromboembolic disorders, andhe was vegetarian. Physical examinationrevealed tachycardia, tachypnoea, bloodpressure of 90/60 mmHg, raised jugularvenous pressure and a right ventricular thirdheart sound. Blood-gas analysis showedhypoxaemia with respiratory alkalosis: PaO2,49 mmHg ( re f e rence r ange [RR] ,95 ± 5 mmHg), pH 7.49 (RR, 7.40 ± 0.02),PaCO2, 22 mmHg (RR, 40 ± 2 mmHg). Aplasma D-dimer test result was positive.
Electrocardiography revealed right axisdeviation with an S1Q3T3 pattern. Echo-cardiography revealed right ventricular dila-tation, a thrombus in the main pulmonaryartery, and pulmonary arterial hypertension(pulmonary artery systolic pressure,65 mmHg) (Box, A). Computed tomo-graphic angiography of the pulmonaryartery confirmed the presence of a largesaddle embolus at the bifurcation of the
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LETTERS
main pulmonary artery (Box, B) and awedge-shaped infarct in the middle lobe ofthe right lung. Venous Doppler imagingshowed a thrombus in the left popliteal vein.
The patient had fasting hyperhomocys-teinaemia (plasma homocysteine level,36.6 μmol/L; RR, 4.4–10.8 μmol/L] second-ary to nutritional vitamin B12 deficiency(serum vitamin B12 level, 42 pmol/L; RR,206–735 pmol/L]. Tests for antithrombinIII, protein C, protein S, factor V Leidenmutation and antiphospholipid antibodiesreturned normal results.
The patient was successfully treated withintravenous streptokinase followed by stand-ard anticoagulation therapy and vitamin B12supplementation. He was well on follow-up.
The association between thrombosis andprolonged travel was first described in1954.1 Symptoms usually develop within 1–8 weeks of travel. Any journey of more than4 hours poses a risk of VTE. Factorsinvolved are low humidity, hypoxia, immo-bilisation and cramped conditions.2,3 Indi-viduals with underlying hypercoagulationstates such as factor V Leiden mutation,prothrombin gene G20210A mutation, andprotein C and protein S deficiency haveincreased risk of VTE.4 Recently, hyper-homocysteinaemia has also been identifiedas an important risk factor for VTE.5
Acquired risk factors include obesity, oralcontraceptive use, pregnancy, recent traumaor surgery, malignancy and history of VTE.
This case highlights the associationbetween train travel and VTE, and the impor-tance of considering all types of prolongedtravel as potential risk factors for VTE.
Jeet Ram Kashyap, Assistant ProfessorSanjay D’Cruz, Associate ProfessorSandeep Chauhan, Assistant ProfessorSuman Kochhar, Professor and Head of RadiodiagnosisGovernment Medical College and Hospital, Chandigarh, [email protected]
1 Homans J. Thrombosis of the leg veins due toprolonged sitting. N Engl J Med 1954; 250: 148-149.
2 Ferrari E, Chevallier T, Chapelier A, Baudouy M.Travel as a risk factor for venous thromboembolicdisease. Chest 1999; 115: 440-444.
3 Cannegieter SC, Doggen CJ, Van Houwelingen HC,et al. Travel-related venous thrombosis: results froma large population-based case control study (MEGAStudy). PLoS Med 2006; 3: e307.
4 Okumus G, Kiyan E, Arseven O, et al. Inheritedthrombophilic risk factors in venous thromboembo-lism: factor V Leiden and prothrombin 20210 A. TurkRespir J 2004; 5 (2): 82-85.
5 Delluc A, Le Gal G, Lacut K, et al. Body mass index,mild hyperhomocysteinemia and venous thrombo-embolism risk [abstract]. J Thromb Haemost 2007; 5Suppl 2: P-T-534. ❏
ISSN 0025-729X
EditorMartin Van Der Weyden, MD, FRACP, FRCPADeputy EditorsBronwyn Gaut, MBBS, DCH, DARuth Armstrong, BMedAnn Gregory, MBBS, GradCertPopHealthTanya Grassi, MBBS(Hons), BSc(Vet)(Hons)Tatiana Janusic, BMedSc, DPH, FRACGP Senior Assistant EditorKerrie Lawson, BSc(Hons), PhD, MASMAssistant EditorsElsina Meyer, BScJosephine Wall, BA, BAppSci, GradDipLibKatherine McLeod, BSc(Hons)Rivqa Berger, BSc(Hons), MASuzanne Habjan, BSc(Hons), PhDScientific Proof ReadersChristine Binskin, BScSara Thomas, BScEditorial AdministratorKerrie HardingProduction ManagerGlenn CarterProduction CoordinatorPeter HumphriesWeb ManagerPeter Hollo, BSc(Hons), BA, LMusAWeb CoordinatorRobert ParisLibrarianJackie Treadaway, BAComm(Info)Consultant BiostatisticianVal Gebski, BA, MStatContent Review CommitteeCraig S Anderson, PhD, FRACPLeon A Bach, PhD, FRACPFlavia M Cicuttini, PhD, FRACPJennifer J Conn, FRACP, MClinEdMarie-Louise B Dick, MPH, FRACGPMark F Harris, MD, FRACGPPaul D R Johnson, PhD, FRACPTom Kotsimbos, MD, FRACPCampbell Thompson, MD, FRACPTim P Usherwood, MD, FRCGPE Haydn Walters, DM, FRACPBruce Waxman, FRACS, FRCSOwen D Williamson, FRACS, GradDipClinEpiJane Young, PhD, FAFPHMJeffrey D Zajac, PhD, FRACP Australasian Medical Publishing Co Pty LtdAdvertising Manager: Peter ButterfieldMedia Coordinators: Deahn Taylor; Julie Chappell
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27729 circulation as at28 April 2008
Echocardiogram and angiogram of a patient with venous thromboembolism after prolonged train travel
A: Echocardiogram (parasternal long axis view) showing dilatation of the right ventricle (arrow) as a result of acute pulmonary arterial hypertension.
B: Computed tomographic angiogram of pulmonary artery showing a saddle embolus (arrows) at the bifurcation of the main pulmonary artery (MPA). ◆
