From the Editor’s Desk LETTERS INCREASED MEDICAL Systemic allergy to topical hexamidine 177 Raymond J Mullins SCHOOL PLACES: A CRISIS IN THE MAKING? Microbial keratitis associated with overnight wear of silicone hydrogel contact lenses This year, some 2400 young Australians 177 John A Landers, John L Crompton entered our medical schools, and in the TB or not TB: treat to see coming years their numbers will increase 178 Paul L A van Daele, Marleen Bakker, further. The Prime Minister recently P Martin van Hagen, G Seerp Baarsma, Robert W A M Kuijpers announced yet another new medical school and continues to top up medical school Mycobacterium ulcerans infection: a rediscovered focus in the Capricorn places. Coast region of central Queensland 179 Glenn Francis, Michael Whitby, Marion Woods With these developments one thing is obvious — policy announcement is easy, but Clinical outcomes associated with changes in a chronic disease policy implementation is not. Already, there treatment program in an Australian Aboriginal community is talk that the existing health system might 180 Ross S Bailie 181 Wendy E Hoy find it difficult to meet the educational needs of increased numbers of students. Already, Mutual obligation and Indigenous health: thinking through medical students are voicing concern about incentives and obligations the effect of increased student numbers on 181 John N Burry the quality of their education in the clinical More doctors, but not enough: Australian medical workforce years, especially the high student-to-teacher supply 2001–2012 ratios and projected bottlenecks in future 182 Peter C Arnold vocational training. And this pressure- 182 Catherine M Joyce, John J McNeil, Johannes U Stoelwinder cooker environment can only worsen. Do women in rural and remote areas need different guidelines for In short, we are heading to a crisis in medical management of low-grade abnormalities found on cervical screening? education. 182 Stewart Bryant There is talk in academic circles of 183 Gerard V Wain, Ian G Hammond, Penelope I Blomfield, Marion A Saville, “new ways” — sharing teaching hospitals Margaret Davy, on behalf of the Guidelines Review Group among medical schools, simulation centres, The success and unrealised potential of the National Cancer increased involvement of private hospitals, Control Initiative specialist and general practices, and 183 J Mark Elwood, Robert C Burton, Michael A Quinn community health services in teaching. But the realisation of these new ways CORRECTION requires time, as does the development of skilled clinical teachers. 144 Sackings at the Canadian Medical Association Journal and Undoubtedly, the issue is complex. editorial independence Crucial to effective medical education is (Med J Aust 2006; 184: 543-545) the capacity of an already stretched public hospital system to sustain both service OBITUARY delivery and quality clinical training. 168 John Howard Tyrer by Lawrie Powell It’s time for the federal and state governments to take stock and ensure BOOK REVIEWS that medical education and training are not jeopardised by overburdened, 174 Ethical choices: case studies for medical practice. 2nd ed under-resourced and suboptimal clinical reviewed by Wendy L Lipworth environments. Funding for capacity building is necessary, but undoubtedly will fall victim 175 The vulva and vagina manual to the federal–state political game of who reviewed by Gregory K Davis pays. No matter that both are responsible for the health rights of all Australians. SNAPSHOT The last thing we want is a future generation of medical students disillusioned Paraspinal tuberculosis through questionable quality of clinical 175 Simon Goldenberg, Nicholas Price exposure and experience.
130 IN THIS ISSUE
Martin B Van Der Weyden 176 IN OTHER JOURNALS
MJA • Volume 185 Number 3 • 7 August 2006 129 LETTERS
tions Advisory Committee (ADRAC) in the Systemic allergy to Microbial keratitis in a 24-year-old past 6 years (Dr K Mackay, Acting Director, topical hexamidine woman ADRAC, Adverse Drug Reactions Unit, Raymond J Mullins Therapeutic Goods Administration, per- sonal communication). There have been TO THE EDITOR: Food, medication or more reports of systemic allergic reactions insect stings are the major causes of systemic (including anaphylaxis) triggered by chlor- allergic reactions.1 That topical agents can hexidine or cetrimide,4 with one description mimic such reactions is not commonly of anaphylaxis to hexamidine after patch appreciated. I report here a systemic allergic testing, but none with clinical use.3 Under- reaction to a topical medication (initially lying dermatitis is a risk factor for sensitisa- attributed to food). tion to topical agents.5 A 7-year-old boy experienced generalised This case emphasises the importance of urticaria and facial swelling within an hour documenting exposure to potential aller- of eating a peanut-containing slice. His father recalled applying a topical antiseptic genic triggers in the setting of a short-lived episode of urticaria (where the search for an (Medi Creme [Pharmacare]) to a graze over avoidable trigger is more likely to be pro- lens wearers when they use silicone hydro- the boy’s right elbow at about the same time. ductive) or anaphylaxis. Exposure to sting- gel contact lenses overnight. There were no respiratory or cardiovascular ing insects is usually obvious, whereas A 36-year-old woman presented 11 days symptoms, and the urticaria settled within 2 exposure to particular foods or medications after sleeping with her silicone hydrogel hours of taking oral promethazine. Six months later, the same cream applied is often poorly recalled. That topical aller- contact lenses in overnight. She had increas- gens can also trigger systemic reactions to a graze over the boy’s right chest resulted ing right ocular pain and photophobia over should be considered. in a localised 15 cm urticarial welt. Intercur- the preceding 9 days, which had not rent problems included atopic dermatitis resolved with chloramphenicol drops. On Raymond J Mullins, PhD, FRACP, FRCPA, examination, visual acuity was 6/18 right but no known food or drug hypersensitivity. Clinical Immunologist The Medical Journal of Australia and 6/6 left. Corneal cultures grew Acan- The ISSN:active ingredients0025-729X of7 MediAugust Creme 2006 are John James Medical Centre, Canberra, ACT. hexamidine isethionate, chlorhexidine ace- [email protected] thamoeba, which responded to polyhexa- 185 3 177-183 tate, cetrimide and lignocaine hydro- methylene biguanide and brolene drops ©The Medical Journal of Australia 1 Golden DB. Patterns of anaphylaxis: acute and late hourly. Her final best corrected visual acuity chloride.2006 Withwww.mja.com.au the assistance of the phase features of allergic reactions. Novartis Found manufacturer,Letters skin prick tests using a 10% Symp 2004; 257: 101-110; discussion 110-115, 157- was 6/9 right, 5 weeks later. weight/volume suspension of Medi Creme 160, 276-285. A 24-year-old woman presented with 2 2 Perrine D, Chenu JP, Georges P, et al. Amoebicidal days of left ocular pain, conjunctival injec- or a 10% suspension of hexamidine efficiencies of various diamidines against two isethionate in normal saline produced 5 mm strains of Acanthamoeba polyphaga. Antimicrob tion, and epiphora following continuous itchy weals at 15 minutes in the patient (but Agents Chemother 1995; 39: 339-342. silicone hydrogel contact lens use over the 3 Revuz J, Poli F, Wechsler J, Dubertret L. [Contact preceding week. On examination, visual not controls). By contrast, skin prick tests to dermatitis from hexamidine] [French]. Ann Derma- the other active ingredients, inert vehicles tol Venereol 1984; 111: 805-810. acuity was 6/6 right and 6/18 left. A central and relevant foods (including peanut, 4 Krautheim AB, Jermann TH, Bircher AJ. Chlorhexi- corneal ulcer with stromal infiltrate and almond, brazil nut, cashew, hazelnut, pecan, dine anaphylaxis: case report and review of the significant anterior chamber activity was literature. Contact Dermatitis 2004; 50: 113-116. present in her left eye (Box). Corneal cul- walnut, sunflower seed and sesame seed) 5 Guillet G, Guillet MH, Dagregorio G. Allergic con- were negative. Avoidance of hexamidine was tact dermatitis from natural rubber latex in atopic tures grew Pseudomonas aeruginosa, which advised. The child has eaten peanut prod- dermatitis and the risk of later Type I allergy. Con- responded to topical gentamicin 1% drops ❏ ucts before and since without any adverse tact Dermatitis 2005; 53: 46-51. hourly. Her final best corrected visual acuity reaction. was 6/5 left, 3 weeks after diagnosis. Hexamidine is an aromatic diamidine An 8-year-old girl was seen 2 months after antiseptic (other members of the group Microbial keratitis associated commencing continuous wear of her sili- include pentamidine and dibrompropami- cone hydrogel contact lenses for uniocular dine). These drugs have broad antibacterial with overnight wear of silicone myopia. She had worn the same lenses for 4 and antifungal properties and are also used hydrogel contact lenses weeks continuously when she presented topically to treat corneal infections and John A Landers and John L Crompton with a 2-day history of right ocular irrita- some skin infections.2 In Australia, hexami- tion, photophobia, and conjunctival injec- dine is an ingredient of one topical local TO THE EDITOR: Extended-wear silicone tion. On examination, visual acuity was 6/36 anaesthetic/antiseptic cream (Medi Creme) hydrogel contact lenses allow the conven- right and 6/6 left. She was commenced and one nappy rash cream, as well as some ience of 24-hour correction of refractive empirically on cephalothin 5% and gen- tinea treatment creams, medicated sham- error and freedom from cleaning solutions tamicin 1% drops hourly. Corneal cultures poos, sunscreens and cosmetic facial wipes and storage containers. However, they are did not grow any causative organism, and in other countries. Adverse reactions (such associated with an increase in the risk of her clinical condition improved significantly as contact allergic dermatitis and microbial keratitis when worn overnight over the following 7 days. Her final best photodermatitis3) are rare — only four compared with daily wear.1-5 corrected visual acuity was 6/9 right. reports of localised dermatitis have been The following cases from a single ophthal- Although microbial keratitis may only reported to Australia’s Adverse Drug Reac- mology practice illustrate the risk to contact affect a small proportion of individuals1,2,5
MJA • Volume 185 Number 3 • 7 August 2006 177 LETTERS and our patients did not experience signifi- TB or not TB: treat to see later had a positive culture result for tuber- cant reduction in vision following treatment, culosis on lymph node biopsy. This patient Paul L A van Daele, Marleen Bakker, microbial keratitis is potentially blinding had complete remission of uveitis after P Martin van Hagen, G Seerp Baarsma and should not be trivialised. tuberculostatic treatment, but was excluded and Robert W A M Kuijpers Silicone hydrogel contact lenses have a from this study as the aim was to assess lower risk of associated microbial keratitis TO THE EDITOR: Uveitis is an intraocular whether antituberculosis treatment is war- than other lens types, but they do not inflammation which potentially leads to per- ranted based solely on a positive tuberculin remove it completely. In view of this, contact manent loss of vision.1,2 Tuberculosis is con- skin test. lenses should not be worn overnight or for sidered to be an infrequent infectious cause We treated the patients with a complete an extended period. Furthermore, a painful of uveitis in the developed world. However, tuberculostatic regimen (2 months of isoni- red eye in a contact lens wearer should be its recurrence as a major public health prob- azid, rifampicin, ethambutol and pyrazina- considered microbial keratitis until proven lem raises the possibility that the incidence mide, followed by 4 months of isoniazid, otherwise, and needs a prompt ophthalmol- of tuberculosis-related uveitis in the devel- rifampicin and ethambutol). All had been ogist referral. oped world may rise.3,4 Uveitis in tuberculo- previously treated for more than 3 years sis is presumed to result from either direct with immunosuppressive drugs (mainly cor- John A Landers, Ophthalmology Registrar ticosteroids), either local or systemic, or John L Crompton, Ophthalmologist invasion or a hypersensitivity reaction. both, without adequate response. Royal Adelaide Hospital, Adelaide, SA. At the ophthalmology departments of the [email protected] Erasmus Medical Center and the Eye Hos- Main outcome measures were visual acu- pital in Rotterdam, The Netherlands, all ity and degree of intraocular inflammation 1 Stapleton F, Edwards K, Keay L, et al. The incidence patients presenting with refractory uveitis seen on ophthalmological examination of contact lens related microbial keratitis in Aus- before and on completion of antituberculo- tralia [abstract]. Invest Ophthalmol Vis Sci 2005; 46: undergo investigation for a systemic cause, B228. Abstract No. 5025. including tuberculin skin testing. When sis therapy. 2 Morgan PB, Efron N, Hill EA, et al. Incidence of ocular findings are consistent with intraocu- The predominant clinical finding was keratitis of varying severity among contact lens lar tuberculosis, and the tuberculin skin test blurred vision. Five patients exhibited wearers. Br J Ophthalmol 2005; 89: 430-436. decreased intraocular inflammation and an 3 Holden BA, Sankaridurg PR, Sweeney DF, et al. is positive, while no other cause of uveitis is Microbial keratitis in prospective studies of suggested by symptoms, signs or ancillary increase in visual acuity after antituberculo- extended wear with disposable hydrogel contact testing, then a diagnosis of presumed sis treatment, allowing tapering of the corti- lenses. Cornea 2005; 24: 156-161. intraocular tuberculosis is made. Using costeroid treatment. One patient had no 4 Lam DS, Houang E, Fan DS, et al; Hong Kong these criteria, eight cases of presumed response. Improvement as part of the natu- Microbial Keratitis Study Group. Incidence and risk factors for microbial keratitis in Hong Kong: com- intraocular tuberculosis were identified ral history was regarded unlikely. parison with Europe and North America. Eye 2002; among 89 people referred with refractory As our department is a tertiary referral 16: 608-618. uveitis between January 2002 and January centre for patients with uveitis, our patient 5 Schein OD, McNally JJ, Katz J, et al. The incidence 2004. Characteristics of the eight patients population is not a representative sample of of microbial keratitis among wearers of a 30-day silicone hydrogel extended-wear contact lens. are shown in the Box. One patient (F) all patients with uveitis in The Netherlands. Ophthalmology 2005; 112: 2172-2179. ❏ withdrew from clinical care, and another (A) Nevertheless, our findings suggest that
Details of eight patients with presumed intraocular tuberculosis
Visual acuity Affected Uveitis Antituberculosis Patient Sex Ageeye Uveitis Place of birth Before* After*treatment treatment Response AM25LeftAnteriorCongoNR† NR† NR† NR† NR† B F 40 Both Posterior Cape Verde 1.8/6 (R), 4.8/6 Local HRZE, Partial response, 1.2/6 (L) (both) steroids HRE local steroids continued C F 69 Left Posterior Netherlands‡ 4.8/6 4.8/6 Local HRZE, Complete response, steroids HRE local steroids stopped D M 49 Right Posterior Surinam 0.6/6 0.8/6 Vitrectomy, HRZE, No response local steroids HRE E F 36 Both Anterior Morocco 2.4/6 (R), 4.8/6 (R), Local HRZE, Complete response, 3/6 (L) 6/6 (L) steroids HRE local steroids stopped F F 62 Both Posterior Morocco 0.6/6 (R), Local — Lost to follow up 0.6/6 (L) steroids before treatment G M 54 Right Posterior Surinam 2.4/6 5.5/6 Local and HRZE, Partial response, systemic steroids HRE systemic steroids stopped H F 19 Both Intermediate Netherlands‡ 4.3/6 (R), 6/6 (R), Local steroids HRZE, Complete response, 1.2/6 (L) 6/6 (L) HRE local steroids stopped
* Before and after antituberculosis therapy. † NR = no result as patient excluded from the study. ‡ Patient C’s parents were born in The Netherlands, but Patient H’s parents were from Morocco. M = male. F = female. H = isoniazid. R = rifampicin. Z = pyrazinamide. E = ethambutol. ◆
178 MJA • Volume 185 Number 3 • 7 August 2006 LETTERS intraocular tuberculosis should be consid- Mycobacterium ulcerans lived in north Queensland and left behind at ered in the differential diagnois of uveitis, infection: a rediscovered focus her home numerous potted plants originally even in developed countries. in the Capricorn Coast region from that area. However, investigation of We believe that, given our results, antitu- soil from potted plants, gardens and roses at berculosis therapy is justified in patients with of central Queensland the home using polymerase chain reaction uveitis even when a positive tuberculin skin Glenn Francis, Michael Whitby and (PCR) failed to detect any evidence of M. test is the only argument for tuberculosis as Marion Woods ulcerans. the cause of the eye disease. An additional Patient 2 lived near a coffee plantation argument for antituberculosis treatment is TO THE EDITOR: Mycobacterium ulcerans originally planted with seeds transported that many patients with uveitis refractory to is an environmental pathogen with a global from north Queensland. Sampling of plants immunosuppressive therapy can be ade- geographic distribution and focal disease and soil in the area by PCR revealed no quately treated with tumour necrosis factor-α clusters. The World Health Organization atypical mycobacteria. (TNF-α) blocking drugs.5 However, as severe considers M. ulcerans infection to be of M. ulcerans is an environmental organism tuberculosis infection has been described increasing global importance, particularly in associated with bodies of water, but its spe- after use of these agents, antituberculosis West Africa. cific ecological niche is unknown.4 The therapy is warranted in any patient with a In Australia, the clinical and pathological organism is difficult to culture from the envi- positive tuberculin skin test who is a candi- features were fully described in 1948, when ronment but has been identified by PCR in date for TNF-α blocking therapy. the disease was named Bairnsdale ulcer.1 water, biofilms, aquatic insects, snails and Since then, the number of cases has increased, fish. The mode of transmission to humans Paul L A van Daele, Internist1 1 and new focal areas continue to emerge remains unknown. It has shown a marked Marleen Bakker, Pulmonologist 2 P Martin van Hagen, Internist1 around southern coastal Victoria. In Queens- propensity for causing intense focal out- G Seerp Baarsma, Ophthalmologist2 land, the disease is most frequently reported breaks in Victoria (Phillip Island and Point Robert W A M Kuijpers, Ophthalmologist1 in the Mossman area (north of Cairns in north Lonsdale) and Queensland (Daintree region). 1 Erasmus Medical Center, Rotterdam, Queensland), where it is known as Daintree The recognition that M. ulcerans occurs in 3 The Netherlands. ulcer. However, the organism is probably coastal central Queensland is important, as 2 The Eye Hospital, Rotterdam, more widely distributed. early diagnosis of M. ulcerans infection mini- The Netherlands. We describe four patients recently diag- mises the extent of tissue debridement nec- [email protected] nosed with proven M. ulcerans infection in essary and improves outcomes. The patients the Capricorn coast region of central we describe had complicated disease requir- 1 Durrani OM, Meads CA, Murray PI. Uveitis: a poten- tially blinding disease. Ophthalmologica 2004; 218: Queensland (Box). The suspected epicentre ing multiple debridements and, in one case, 223-236. of infection is around Yeppoon, approxi- amputation. Awareness of the possibility of 2 Rothova A, Buitenhuis HJ, Meenken C, et al. Uveitis mately 1000 km south of Mossman. M. ulcerans infection is critical, as diagnosis and systemic disease. Br J Ophthalmol 1992; 76: 137-141. None of the patients had significant con- by PCR is straightforward once the infection 3 Morimura Y, Okada AA, Kawahara S, et al. Tubercu- tact with recognised endemic areas in north is considered in the differential diagnosis. lin skin testing in uveitis patients and treatment of Queensland or Victoria. Patient 1 had vis- In 1942, Cilento described possible M. presumed intraocular tuberculosis in Japan. Oph- ited Townsville in July 2000, but had mini- ulcerans infections from around Rockhamp- thalmology 2002; 109: 851-857. 5 4 Sheu SJ, Shyu JS, Chen LM, et al. Ocular manifesta- mal contact with the natural environment. ton. Four other culture-confirmed cases tions of tuberculosis. Ophthalmology 2001; 108: She undertook extensive gardening at her were reported between 1957 and 1962 from 1580-1585. home in North Rockhampton, using sugar the Glass House Mountains (Sunshine 5 Lindstedt EW, Baarsma GS, Kuijpers RW, van Hagen 3 6-8 PM. Anti-TNF-alpha therapy for sight threatening cane bagasse mulch from north Queensland. Coast) and Maryborough (Fraser Coast) uveitis. Br J Ophthalmol 2005; 89: 533-536. ❏ The previous occupants of her house had regions in Queensland. Our four cases
Four patients with Mycobacterium ulcerans infection in central Queensland
Clinical Age/sex Location Presentation Site features Diagnosis Treatment 47 F North Sep 2000 Fifth Nodule Histology, Debridement, Rockhampton finger PCR antimycobacterial (left hand) antibiotics, amputation 33 F Yeppoon Jun 2003 Left knee Ulcer Histology, Debridement culture 64 M Bungundarra Aug 2004 Right Ulcer Histology, Multiple elbow PCR debridements 18 M Keppel Sands Nov 2004 Right Ulcer Histology, Multiple knee culture debridements, antimycobacterial antibiotics
PCR = polymerase chain reaction. F= female. M = male. ◆
MJA • Volume 185 Number 3 • 7 August 2006 179 LETTERS occurred within a small geographic area Clinical outcomes associated control does not support the conclusion centred on Yeppoon and the suburbs of with changes in a chronic regarding impact of the “handover” on the Rockhampton. If the cases previously disease treatment program program. The data presented in the 2005 described by Cilento were truly related to M. article show a decline in control commenc- ulcerans, then there appears to have been a in an Australian Aboriginal ing in the third year. An earlier analysis of five-decade gap in identification of M. ulcer- community the same data showed the decline in blood ans infection in the Capricorn Coast region Ross S Bailie pressure control began as early as the second of central Queensland. Possible explana- year after entry into the program.4 Neither tions for this include low organism numbers TO THE EDITOR: analysis shows any clear change in the resulting in sporadic infection, focal concen- • “… what a difference can be made and declining trend in blood pressure control trations of the organism with environmental how bureaucracies can stuff things up”. around the time of “handover” of the pro- changes, such as development, land clearing • “… systematic testing and treatment of gram. and cultivation modifying human contact, people with high blood pressure and kidney While the discussion of the findings of the or failure to diagnose the condition. Patients disease dramatically improved blood pres- 2005 article is circumspect, at the time of who acquired the infection in central sure and resulted in a 50% reduction of interview, Hoy conspicuously did not deny Queensland may also have been diagnosed deaths”. the statement of The health report host that outside the area. • “… excellent results were achieved by the primary cause of the apparent loss of the The increase in cases in Victoria raises the good management and they were lost when early impact of the program was the possibility of a potentially similar dramatic intensity of management was relaxed”. bureaucracy “stuffing up”. The article makes increase in cases in central Queensland. The above quotes are from an episode of some important points about the operation Consideration should be given to making M. The health report broadcast late last year on of chronic disease programs, but makes no ulcerans infection a reportable disease to Radio National.1 The episode, which mention of the commonly experienced diffi- 5,6 enable monitoring. described a deterioration in the health of an culties of sustaining health programs, or Indigenous community after a chronic dis- the research requirements for understanding Glenn D Francis, Director, Department of sustainability.7 Pathology1 ease treatment program was handed over to Michael Whitby, Director, Infection a community health board, caused me to These issues raise serious questions about Management Services1 take a closer look at the articles in the the validity of the conclusions and the sim- 2 Marion Woods, Infectious Diseases Physician Journal by Hoy and colleagues on which the plistic claims arising from the articles. 1 Princess Alexandra Hospital, Brisbane, QLD. claims were based.2,3 I found several issues 2 Royal Brisbane Hospital, Brisbane, QLD. Ross S Bailie, MD, FAFPHM, Professor of Public [email protected] of concern. Health The small numbers of deaths each year Menzies School of Health Research, Charles 1 Macullum P, Tolhurst JC, Buckle G, Sissions HA. A in the study community and the analysis Darwin University, Tiwi, NT. new mycobacterial infection in man. J Pathol Bac- teriol 1948; 60: 93-122. and presentation of the death data mean [email protected] 2 Johnson PD, Veitch MG, Leslie DE, et al. The that the conclusions about trends in mor- 1 Aboriginal health [transcript of radio program]. The emergence of Mycobacterium ulcerans infection tality over time are tenuous. This is high- health report. ABC Radio National broadcast, 08:30; near Melbourne. Med J Aust 1996; 164: 76-78. 7 Nov 2005. Available at: http://www.abc.net.au/rn/ 3Radford AJ. Mycobacterium ulcerans in Australia. lighted by the discrepancies between the talks/8.30/helthrpt/stories/s1496205.htm (accessed Aust N Z J Med 1975; 5: 162-169. two articles in the terminology used to May 2006). 4 Roberts B, Hirst R. Immunomagnetic separation classify deaths, in the numbers of deaths 2 Hoy WE, Kondalsamy-Chennakesavan SN, Nicol JL. and PCR for detection of Mycobacterium ulcerans. reported, and in the trends over time. Clinical outcomes associated with changes in a J Clin Microbiol 1997; 35: 2709-2711. chronic disease treatment program in an Australian 5 Cilento R. Leprosy (elephantiasis graecorum). In: Discrepancies in terminology or numbers Aboriginal community. Med J Aust 2005; 183: 305- Tropical diseases in Australasia. Brisbane: WR Smith of reported deaths are not explained. The 309. and Paterson, 1944: 306. 6 Annual report of the health and medical services of declining trend in the number of “natural” 3 Hoy WE, Baker PR, Kelly AM, Wang Z. Reducing the State of Queensland for the year 1957-58. deaths described in the 2000 article is not premature death and renal failure in Australian Brisbane: SG Reid, Government Printer, 1958: 95. apparent in the “non-renal” deaths in the Aboriginals. A community-based cardiovascular 7 Annual report of the health and medical services of and renal protective program. Med J Aust 2000; the State of Queensland for the year 1958-59. 2005 article. The rate of “non-renal” death 172: 473-478. Brisbane: SG Reid, Government Printer, 1959: 95-97. for the period 1996–97 to 1998–99 4 Robinson G, Bailie R, Wang Z, et al. A follow-up 8Lane D. Mycobacterium ulcerans infection in reported in the 2005 article appears to be study of outcomes of the Tiwi Renal Treatment ❏ Queensland. Med J Aust 1964; 1: 124-125. increasing rather than declining, as Program. Darwin: NTUniprint, Northern Territory University, 2003. described in the 2000 article (rates for 5 Shediac-Rizkallah MC, Bone LR. Planning for the earlier years are not presented in either sustainability of community-based health programs: article). It is clear that, with these small conceptual frameworks and future directions for numbers, the reclassification or misclassifi- research, practice and policy. Health Educ Res 1998; 13: 87-108. cation of a single death can affect the trends 6 Bossert TJ. Can they get along without us? Sustain- in “renal death” or end-stage renal disease ability of donor-supported health projects in Cen- over time, and that the use of “rolling tral America and Africa. Soc Sci Med 1990; 30: 1015- averages” hides the year-to-year variability 1023. that would be expected in these data. 7 Jackson N, Waters E, Anderson L, et al. Criteria for the systematic review of health promotion and The trend over time in the key intermedi- public health interventions. Health Promot Int 2005; ate outcome indicator of blood pressure 20: 367-374. ❏
180 MJA • Volume 185 Number 3 • 7 August 2006 LETTERS
Wendy E Hoy ment increased, and the timing of their 3- 3 Baker PRA, Hoy WE, Thomas RE. A cost and effects year blood pressure measurements moved analysis of a kidney and cardiovascular disease treatment program in an Australian Aboriginal pop- IN REPLY: I appreciate the feedback on the from a mix of 1998–1999 to 1999–2002, ulation. Adv Chronic Kidney Dis 2005; 12: 22-31. 2000 and 2005 articles describing the when, as program dynamics suggest, 4 Hoy WE, Wang Z, Baker PR, Kelly AM. Secondary dynamics and outcomes of the “Tiwi treat- intensity of management was relaxed, and prevention of renal and cardiovascular disease: 1,2 results of a renal and cardiovascular treatment pro- ment program”. mean values deteriorated, as we reported gram in an Australian aboriginal community. J Am Thorough and timely identification and in 2005. Soc Nephrol 2003; 14: S178-S185. enumeration of deaths is a problem, espe- The blood pressure measurements in the 5 Robinson G, Bailie R, Wang Z, et al. A follow-up cially for people not enrolled in the treat- 5 study of outcomes of the Tiwi Renal Treatment report by Bailie’s group were compiled from Program. Darwin: NTUniprint, Northern Territory ment program. Without a register of such a review of paper-based medical records, the University, 2003. ❏ people, systematic checking of their fate was clinic’s newly implemented Coordinated not possible. The additional “non-renal” Care Trial Information System, and the Ter- deaths in the community-at-large presented ritory’s Information System (Systematic in our 2005 article, compared with previous Health Information Logically Organised), as Mutual obligation and articles, seem to have been captured largely well our from our treatment program data- Indigenous health: thinking by the broad net spread by the Tiwi Health base. Those blood pressures were allocated through incentives and Board when it assumed responsibility for its time definitions in a different way, and the obligations primary care services, in an attempt to iden- summary data were derived from adjusted tify all its potential clients. This process predictions from cross-sectional time series John N Burry identified several hundred more people than modelling, rather than from factual record- TO THE EDITOR: expected and captured additional deaths, ings at the stated intervals.5 As I have said elsewhere, several dating back years. The precise defini- I did not solicit the interview for The “The last thing the majority wants is that the tion of a community member is also a health report, nor determine its directions tyranny of the majority be applied to it. It is problem, especially for people living perma- nor the resulting headlines. However, the much easier to apply the tyranny of the nently or intermittently elsewhere (eg, in under-resourcing of primary care relative to majority to a minority. In a properly func- Darwin or other communities). needs in remote Aboriginal settings, and tioning democratic society minorities are not The broadened definition of “renal the lack of stability in the organisations in subjected to, but are protected against, the deaths” in the 2005 article,2 which accom- which it is delivered, are very detrimental. I tyranny of the majority. Is the tyranny of the modates people who died with renal failure regret that, once the Tiwi Health Board was majority being applied through the medium but did not begin dialysis, more fully repre- constituted, it was not mentored and sup- of the Howard government onto the Aborig- inal communities of Australia in this matter sents the impact of renal disease. Con- ported through its difficulties. More 1 versely, recording only those who began recently, the fledgling community-control- of ‘shared responsibility agreements’?” I note with interest recent articles by dialysis allows estimates of the impact on led Gulf Health Service in the Borroloola 2 3 health services and potential savings from region of the Northern Territory met a Collard and colleagues and by Kowal, better management.3 Both approaches have similar fate. Chronic disease remains debating “shared responsibility agreements”. The expressions “shared responsibility their place. Rolling averages, which indeed underserviced in both these regions, where 3 have limits, were used in view of the overall the people are among the sickest in Aus- agreement” and “mutual obligation” are small and erratically spaced number of ter- tralia. variations of the expression “social con- minal events in any year. tract”. The concept of “social contract” The figures we reported in our 2005 Wendy E Hoy, Professor underlies the concept of democracy origi- article did not show a deterioration in Centre for Chronic Disease, Royal Brisbane nating in the writings of Thomas Hobbes, Hospital, Brisbane, QLD. John Locke and Jean-Jacques Rousseau. blood pressure at Year 2, either in the [email protected] treatment group as a whole, or in the Present-day political scientists discuss smaller cohort followed for a full 6 years.2 1 Hoy WE, Baker PR, Kelly AM, Wang Z. Reducing social-contract theory in their writings about An earlier analysis, which largely premature death and renal failure in Australian democracy, and may mention “mutual obli- Aboriginals. A community-based cardiovascular embraced the active years of the program, gation” or “shared responsibility”. While it is and renal protective program. Med J Aust 2000; commonplace for aspects of the social con- also showed that blood pressure at Year 3 172: 473-478. was not significantly different from that at 2 Hoy WE, Kondalsamy-Chennakesavan SN, Nicol JL. tract to apply to subgroups in the pop- Year 2 (systolic blood pressure, P = 0.68) Clinical outcomes associated with changes in a ulation, it is discriminatory to make chronic disease treatment program in an Australian arrangements that apply only to a particular (Box). With time, the number of people Aboriginal community. Med J Aust 2005; 183: 305- who had moved through 3 years of treat- 309. racial or ethnic group. Even though the agreements are declared to be voluntary, it is likely that Aboriginal Blood pressure measurements (mm Hg) over 3 years of follow-up after communities are under pressure to do as enrolment in 123 people who had observations at every interval4 they are told to achieve social contracts with the Australian Government. If Indigenous Baseline 6 months 1 year 2 years 3 years people must comply with certain conditions Mean systolic BP (SD) 136.2 (21.6) 125.4 (21.6) 123.6 (20.3) 120.6 (21.6) 121.7 (21.5) before they can achieve social contracts, how might similar conditions be applied to Mean diastolic BP (SD) 81.9 (13.2) 75.5 (13.7) 76.3 (12.9) 74.5 (13.7) 74.0 (11.0) the rest of the Australian population? The “ticking time bombs” of Australian public
MJA • Volume 185 Number 3 • 7 August 2006 181 LETTERS health are smoking and obesity. If non- apply any controls on demand, they have Do women in rural and remote Indigenous Australians refuse to stop smok- obstinately rationed supply, repeatedly cit- areas need different guidelines ing and refuse to eat less and take more ing dubious statistics and invalid interna- for management of low-grade exercise, should access to public hospitals tional comparisons to justify a diminution in and pharmaceutical benefits be denied the supply of GPs. abnormalities found on cervical them? Should they be denied petrol to force screening? Peter C Arnold, Retired GP them to walk and to use public transport? Sydney, NSW. Stewart Bryant Obviously not. These services are not sub- [email protected] ject to social-contract agreements as this- TO THE EDITOR: We read with interest would be a clear violation of Australian law. 1 Joyce CM, McNeil JJ, Stoelwinder JU. More doc- the letter by Breeze et al on management of tors, but not enough: Australian medical workforce Australian members of parliament in par- supply 2001–2012. Med J Aust 2006; 184: 441-446. abnormalities detected on cervical screen- 1 ticular, and Australians in general, for the 2 Arnold PC. The ageing GP. Quadrant 1977; XXI: 8- ing. Their study identifies a universal and sake of themselves, their families and of 9. ❏ fundamental feature of the Pap smear — Australian health care costs, would benefit namely, that it is an imperfect predictor of from negotiating “shared responsibility underlying abnormalities in the cervical epi- Catherine M Joyce, John J McNeil and agreements” with themselves to stop smok- thelium. Johannes U Stoelwinder ing and to lose weight. In current circum- For smears reported as a low-grade squa- stances, “shared responsibility agreements” IN REPLY: Our reference to a boom in mous intraepithelial lesion (LSIL) (atypical with Aboriginal communities represent medical workforce supply during the 1970s squamous cells of uncertain significance) or inequality of sharing the responsibility for was based on the marked increase in medi- possible LSIL, Breeze and colleagues have health. cal workforce entries in that decade. The shown that underestimation of the extent of John N Burry, Retired Dermatologist number of Australian medical graduates the underlying abnormality is greater in 1,2 PO Box 2251, Normanville, SA. rose from 851 in 1970 to 1278 in 1980. infrequently screened women than in fre- [email protected] In contrast — and as a result of a shift to a quently screened women. They claim that policy of constraint — graduate numbers following the latest National Health and 1 Burry JN. Inequality of sharing the responsibility for health. The Independent Weekly 2005; April: 24-30. remained quite static during the 1980s and Medical Research Council (NHMRC) guide- 2 2 Collard KS, D’Antoine HA, Eggington DG, et al. 1990s, at around 1200–1300 per year lines for cervical screening will put women “Mutual” obligation in Indigenous health: can (Commonwealth Department of Education, in rural and remote areas with cytologically shared responsibility agreements be truly mutual? detected low-grade lesions at risk of devel- Med J Aust 2005; 182: 502-504. Science and Training custom datasets RFI 3 Kowal E. Mutual obligation and Indigenous health: 03-312, RFI 04-360, 2004). oping high-grade lesions that go undetected thinking through incentives and obligations. Med J Although the policy shift in the 1980s was through lack of timely follow-up. I contend Aust 2006; 184: 292–293. ❏ based on a perception of surplus, judge- that following the new NHMRC guidelines ments about workforce adequacy were con- presents a significant risk to all women with tentious at that time and remain so. We did LSIL or possible LSIL reported on smears, not intend to imply necessarily that there regardless of ethnicity, locality or social More doctors, but not enough: was a surplus in the medical workforce (or class. The risk is merely greater for women Australian medical workforce the general practice workforce specifically) living in rural and remote areas. supply 2001–2012 during the 1970s. Rather, our historical In addition to delays in diagnosis of high- Peter C Arnold reference was intended to show the parallels grade lesions, data from cervical cytology with the large influx that will result from registries indicate that there will be delays in TO THE EDITOR: Where is the evidence current expansion in medical school intakes, diagnosis for the 30–50 women each year for the claim by Joyce, McNeil and and to highlight the cyclic nature of both whose smears show changes only of LSIL or Stoelwinder1 that there was a boom in med- medical workforce policy and perceptions of possible LSIL but who are shown on biopsy 3 ical workforce supply in the 1970s? adequacy. We agree with Arnold’s implica- to have cervical cancer. They are perpetuating the accepted tion that policies which attempt simply to The problem of women defaulting on macroeconomic myth of there having been a adjust gross supply (up or down) are insuffi- clinic appointments or being lost to follow- surplus at that time. The microeconomic, cient to ensure an adequate medical work- up is a phenomenon commonly encoun- marketplace truth was that there was a force. tered in cervical screening programs in gen- shortage of general practitioners throughout Catherine M Joyce, Senior Lecturer eral, but in Far North Queensland the risks the 1970s.2 This was so severe that, after John J McNeil, Professor and Head of inadequate follow-up are magnified. battling for some years after 1974 to find a Johannes U Stoelwinder, Professor For these and other reasons, the Royal partner for my suburban Sydney practice, I Department of Epidemiology and Preventive College of Pathologists of Australasia, other resorted to advertising overseas, finally Medicine, Monash University, Melbourne, VIC. learned societies and individuals have con- importing an overseas-trained graduate. [email protected] sistently and strenuously opposed the latest It is time for this myth to be laid to rest. 1 Karmel P (Chairman). Report of the Committee on NHMRC guidelines during the period of Medical Schools to the Australian Universities Com- There has been a marketplace shortage of mission. Expansion of medical education. (Parlia- their development and during the consulta- GPs since the early 1970s. mentary Paper No. 110.) Canberra: AGPS, 1973. tion period of many months. The truth is that federal governments 2 Doherty RL (Chairman). Committee of Inquiry into Rather than advocate a separate set of Medical Education and the Medical Workforce. have baulked at the expansion of payments Australian medical education and workforce into guidelines for women in rural and remote through Medibank/Medicare. Rather than the 21st century. Canberra: AGPS, 1988. ❏ areas, it would be better to have a univer-
182 MJA • Volume 185 Number 3 • 7 August 2006 LETTERS
sally accepted safe set of guidelines that and potentially results in avoidable morbid- 1 Gynaecological Oncology, Westmead conforms to international best practice and ity. The approach recommended in the latest Hospital, Sydney, NSW. applies to all Australian women. Using the guidelines moves away from probabilistic 2 Gynaecological Oncology, King Edward guidelines that were in use until 20054 and prediction and intensive investigation based Memorial Hospital, Perth, WA. that have served us so well in the past is one on a single cytological specimen to an evi- 3 Gynaecological Oncology, Royal Hobart Hospital, Hobart, TAS. option. Another option, which is backed by dence-based program of intermittent cyto- 4 Victorian Cytology Service, Melbourne, VIC. first class scientific evidence,5 is to use logical surveillance of this chronic viral 5 Gynaecological Oncology, Royal Adelaide human papillomavirus DNA testing for infection. Intervention is timed to coincide Hospital, Adelaide, SA. triage of women with smears reported as with evidence of persistent and potentially [email protected] possible LSIL. dangerous infection. Contrary to Bryant’s claim about Austral- 1 National Health and Medical Research Council. Stewart Bryant, President Screening to prevent cervical cancer: guidelines for ian registry data, there is no evidence that the management of asymptomatic women with Royal College of Pathologists of Australasia, the new guidelines will mean any increase in screen detected abnormalities. Canberra: Com- Sydney, NSW. the diagnosis of cancer, a view that is sup- monwealth of Australia, 2005. http:// [email protected] www.nhmrc.gov.au/publications/_files/wh39.pdf ported by independent epidemiological (accessed Jul 2006). 1 Breeze C, de Costa CM, Jagusch M. Do women in expert review (M Clements, Research Fel- 2 Breeze C, de Costa CM, Jagusch M. Do women in rural and remote areas need different guidelines for low, National Centre for Epidemiology and rural and remote areas need different guidelines for management of low-grade abnormalities found on Population Health, Australian National Uni- management of low-grade abnormalities found on cervical screening? Med J Aust 2006; 184: 307-308. cervical screening? Med J Aust 2006; 184: 307-308. 2 National Health and Medical Research Council. versity, personal communication). The 3 Bentley E, Cotton SC, Cruickshank ME, et al. Refin- Screening to prevent cervical cancer: guidelines for experience of Breeze and colleagues in Far ing the management of low-grade cervical abnor- the management of asymptomatic women with North Queensland suggests that the greatest malities in the UK National Health Service and screen detected abnormalities. Canberra: Com- defining the potential for human papillomavirus monwealth of Australia, 2005. http:// risk factor for any woman to develop cervi- 2 testing: a commentary on emerging evidence. J www.nhmrc.gov.au/publications/_files/wh39.pdf cal cancer is infrequent screening. Further- Low Genit Tract Dis 2006; 10: 26-38. ❏ (accessed Jul 2006). more, in the unlikely event that the latest 3 Mitchell H. Outcome after a cervical cytology report of low-grade squamous abnormality in Australia. guidelines do result in increased cancer Cancer 2005; 105: 185-193. incidence, such an increase will immediately 4 National Health and Medical Research Council. be detected by the monitoring program that The success and unrealised Screening to prevent cervical cancer: guidelines for is integral to the new approach. management of asymptomatic women with screen potential of the National detected abnormalities. Canberra: Commonwealth Bryant advocates increased pathology Cancer Control Initiative of Australia, 1994. http://www.csp.nsw.gov.au/ testing using HPV DNA tests. We are not downloads/wh16.pdf (accessed Jul 2006). aware of any population data demonstrating J Mark Elwood, Robert C Burton and 5 Schiffman M, Solomon D. Findings to date from the Michael A Quinn ASCUS-LSIL Triage Study (ALTS). Arch Pathol Lab that such an approach would result in Med 2003; 127: 946-949. ❏ improved cancer prevention, nor that such TO THE EDITOR: The National Cancer an approach would be cost-effective. Conse- Control Initiative (NCCI) was established in quently, the Guidelines Review Group did 1997 jointly by the Department of Health Gerard V Wain, Ian G Hammond, not recommend the use of HPV DNA testing and Ageing and The Cancer Council Aus- Penelope I Blomfield, Marion A Saville as part of triage of women with abnormal tralia to “provide timely advice, identify and Margaret Davy, on behalf of the smears. The approach recommended in the appropriate initiatives, and make specific Guidelines Review Group guidelines is also consistent with contempo- recommendations to the Commonwealth rary international experience3 — namely, IN REPLY: In June 2005, the National Government and other key groups regarding that the clinical significance of a single Health and Medical Research Council the prevention, detection, treatment and incident measurement of HPV status is not palliation of cancer for all Australians”. It (NHMRC) endorsed new guidelines for established. managing asymptomatic women with has been the only independent group deal- We believe that the latest NHMRC screen-detected abnormalities because they ing with all aspects of cancer nationally, and guidelines1 are safe and acceptable for all were safe for Australian women and were incorporating government, non-govern- Australian women and that all women based on the best available Australian and ment, consumer and professional input. deserve appropriate investigation and treat- international evidence.1 The NHMRC On 31 May 2006, it ceased operation due ment of cervical abnormalities in a manner accepted that new information about the to lack of funding support, and no arrange- that will protect them from both cervical natural history of human papillomavirus ments have been made to allow continuity cancer and unnecessary, potentially harmful (HPV) infection of the cervix and cervical between its work and that of a proposed interventions. neoplasia demanded a reassessment of our new body, Cancer Australia, which at the traditional approach to this disease. Finally, to address the concerns of Breeze time of writing was still not functioning. and colleagues, the guidelines specifically HPV infection of the cervix and associ- The NCCI’s contributions include advise that clinical management be tailored ated, potentially neoplastic precursor lesions national surveys of colorectal cancer man- to the patient’s individual circumstances. are very common, but not all of these have agement and of skin cancer incidence and malignant potential. Optimal prevention of Gerard V Wain, Director1 treatment; clinical trials assessing the man- cervical cancer will depend on timely diag- Ian G Hammond, Professor2 agement of skin lesions in primary care; the nosis and treatment of lesions that are most Penelope I Blomfield, Director3 first protocols for pilot programs for bowel likely to progress. Overdiagnosis and treat- Marion A Saville, Director4 cancer screening; national programs to pro- ment of all incident lesions is unnecessary Margaret Davy, Director5 mote the implementation of National Health
MJA • Volume 185 Number 3 • 7 August 2006 183 LETTERS LETTERS The Medical Journal MJA of Australia Editor and Medical Research Council guidelines on next stages of work on topics including Martin Van Der Weyden, MD, FRACP, FRCPA psychosocial aspects of cancer and on lung psychosocial aspects of cancer, lung cancer, Deputy Editors and other cancers; programs to improve and primary care in cancer, received no Bronwyn Gaut, MBBS, DCH, DA Ruth Armstrong, BMed decision making in prostate cancer screen- response from the Department of Health Ann Gregory, MBBS, GradCertPopHealth ing; a nationally agreed core clinical dataset and Ageing. Tanya Grassi, MBBS(Hons), BSc(Vet)(Hons) Manager, Communications Development for cancers; support for cancer registries to With the closure of NCCI, the Director Craig Bingham, BA(Hons), DipEd include staging and survival information; and Deputy Director are relocating overseas, Senior Assistant Editor new methods to establish evidence-based and the highly productive staff members, Helen Randall, BSc, DipOT Assistant Editors requirements for radiotherapy services; and specifically praised in the independent Elsina Meyer, BSc support for cancer research, for strengthen- review, are moving to other roles. The pre- Kerrie Lawson, BSc(Hons), PhD, MASM ing clinical trials and for consumers’ activi- mature demise of the NCCI, before Cancer Tim Badgery-Parker, BSc(Hons), ELS Josephine Wall, BA, BAppSci, GradDipLib ties. Since 2000, the small group of NCCI Australia has started to function, is short- Proof Readers staff has produced seven national work- sighted, inefficient, and wastes the experi- Christine Binskin, BSc; Sara Thomas, BSc; shops, over 30 published reports, and over ence, resources and staff that NCCI has Rivqa Berger, BSc(Hons); Katherine McLeod, BSc(Hons) Editorial Administrator 60 peer-reviewed articles. These are availa- developed. This finishes a decade-long Kerrie Harding ble online at
27,649 circulation as at 24 April, 2006 ISSN 0025-729X
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