No, this is not the name of a movie sequel or yet another pharmaceutical company, but an updated position statement from the Thoracic Society of Australia and New Zealand consolidating new data and refined concepts. Its recommendations, based on the available evidence thus far (page 168), clarify the role of corticosteroids in managing children with asthma.
Australia’s reputation for harbouring dangerous life-forms will receive another boost with this issue’s Lessons from Practice. Jenkin et al (page 180) present an atypical case of Mycobacterium ulcerans infection, known to be endemic in south-east Victoria and parts of far north Queensland.
The Australian paracetamol market was thrown into chaos for several months in 2000, when first one major manufacturer then another was forced to withdraw its preparations of the drug. An extortionist had threatened to contaminate their products, and indeed did so, leading to several cases of strychnine poisoning in Brisbane. The periods during which the product was withdrawn provided Balit and colleagues with a “natural” experiment to test the hypothetical question: does decreased availability of paracetamol lead to fewer self-poisonings? Their report (page 162) makes interesting reading.
A drug “experiment” of another kind took place unwittingly when a patient taking the opiate agonist buprenorphine decided to divert a few of his tablets. He was enrolled on a program offering this drug as an alternative (new to Australia) to methadone for treatment of opiate dependence. While on the program, he recommenced heroin use, but continued to turn up to the clinic for each buprenorphine dose. Read this Notable Case (page 166) to see how properties of this drug enabled him to divert these tablets and to survive a buprenorphine overdose, a scenario not previously reported.
Counterculture
The son of a non-English-speaking patient with metastatic cancer asks you not to use the word “cancer” in front of his father and to direct all decisions to him rather than his father. How do you ensure your patient’s needs are heard and his beliefs respected? Irvine et al (page 174) tackle this scenario and the challenges of practising in a multicultural society as part of our Clinical Ethics series.
The sudden death of a young person is devastating for family and friends. We are now closer to understanding such deaths when they result from cardiac causes, say Semsarian and Maron (page 148). Their editorial gives valuable information on identifying those at risk and what treatments are beneficial.
This is a decidedly gutsy issue of the MJA. Literally, with five articles relating to the gastrointestinal tract, and colloquially, with criticisms of NHMRC guidelines and questions about whether GPs should administer anaesthetic agents. The latter issue is raised by Clarke et al (page 158), who determined the incidence of adverse events when propofol was given by GPs as sedation for endoscopy. Knoblanche’s editorial (page 147) gives one anaesthetist’s point of view, in the context of previous research and professional guidelines.
In Western Australia Yusoff and colleagues (page 151) examined referrals for colonoscopic surveillance in patients with a family history of colorectal cancer, and assessed their concordance with NHMRC criteria for such surveillance.
Does strictly following these same guidelines for colorectal cancer prevention lead to fewer surveillance colonoscopies being performed? To find out, Bampton et al (page 155) enlisted the aid of a nurse coordinator, who supervised application of the guidelines in a South Australian hospital. In response to these articles on guideline adherence, Bolin and colleagues (page 145) question elements of the NHMRC guidelines and advocate patient choice rather than authoritarian prescription.
It is difficult to convey the excitement of actually witnessing the amazing power of penicillin over infections... I could not then imagine the transformation of medicine and surgery that penicillin would produce. But I did glimpse the disappearance of the chambers of horrors... those old septic wards...
First clinical use of penicillin.
Charles Fletcher, BMJ 1984; 289: 1721-1723.