Search

David Isaacs has been to Nauru and seen the suffering among detainees in Australia’s off-shore immigration centre In 1992 Paul Keating’s Labor government of Australia introduced a controversial policy of mandatory detention of asylum seekers to help cope with rising numbers of Vietnamese, Chinese, and Cambodian refugees. In 2001 John Howard’s Liberal government introduced the “Pacific solution,” which involved excising some islands from the mainland so that they no longer constituted Australian soil and transferred some asylum seekers, who had arrived by boat, to detention centres on the tiny Pacific island of Nauru and later also on Manus Island in Papua New Guinea.1 Some asylum seekers have been sent to detention centres on the mainland. The average time spent in detention before applications for refugee status are processed has lengthened progressively and is now well over a year.2 People seeking asylum in Australia are not told when their applications will be processed, so detention is indefinite—a truly Kafkaesque situation. Strong evidence shows that the harsh conditions under which children and adults are held, particularly on Nauru and Manus, as well as uncertainty about their fate, are highly detrimental to mental health.3 4 The Australian Human Rights Commission’s inquiry examined the …

A roundabout tale of health funding irregularities in Dickensian times from Stephen and David Isaacs

Many forces affect the final decision The introduction of a new vaccine is highly complex, particularly a new category of vaccine with no biological precedent. The new group B meningococcus vaccine Bexsero (4CMenB),1 developed using a genomic based reverse vaccinology approach,2 is a case in point. When a vaccine is targeted against a relatively common disease, the company usually sponsors a large randomised controlled trial to show that the vaccine works. Group B meningococcal infection is sufficiently rare, however, that such a trial is not feasible. In most countries, advice on vaccines and immunisation programmes is given to governments by independent committees. This advice includes data on vaccine effectiveness, the likelihood that the vaccine will confer herd immunity (protect some unimmunised people by reducing carriage or spread of disease), safety, and cost effectiveness. In the United Kingdom, the Joint Committee on Vaccination and Immunisation (JCVI) has such a role. In the UK,3 and in Australia, Canada, the United States, and many European countries, the government is not permitted in law to fund an immunisation programme unless the immunisation advisory committee says it is cost effective. Different countries allow different assumptions in the modelling, so they do not always reach the same decision. The process usefully distances …

David Isaacs, Stephen Isaacs, and Dominic Fitzgerald put a modern twist on the nativity story

Objectives To evaluate current processes by which young children presenting with a febrile illness but suspected of having serious bacterial infection are diagnosed and treated, and to develop and test a multivariable model to distinguish serious bacterial infections from self limiting non-bacterial illnesses. Design Two year prospective cohort study. Setting The emergency department of The Children’s Hospital at Westmead, Westmead, Australia. Participants Children aged less than 5 years presenting with a febrile illness between 1 July 2004 and 30 June 2006. Intervention A standardised clinical evaluation that included mandatory entry of 40 clinical features into the hospital’s electronic record keeping system was performed by physicians. Serious bacterial infections were confirmed or excluded using standard radiological and microbiological tests and follow-up. Main outcome measures Diagnosis of one of three key types of serious bacterial infection (urinary tract infection, pneumonia, and bacteraemia), and the accuracy of both our clinical decision making model and clinician judgment in making these diagnoses. Results We had follow-up data for 93% of the 15 781 instances of febrile illnesses recorded during the study period. The combined prevalence of any of the three infections of interest (urinary tract infection, pneumonia, or bacteraemia) was 7.2% (1120/15 781, 95% confidence interval (CI) 6.7% to 7.5%), with urinary tract infection the diagnosis in 543 (3.4%) cases of febrile illness (95% CI 3.2% to 3.7%), pneumonia in 533 (3.4%) cases (95% CI 3.1% to 3.7%), and bacteraemia in 64 (0.4%) cases (95% CI 0.3% to 0.5%). Almost all (>94%) of the children with serious bacterial infections had the appropriate test (urine culture, chest radiograph, or blood culture). Antibiotics were prescribed acutely in 66% (359/543) of children with urinary tract infection, 69% (366/533) with pneumonia, and 81% (52/64) with bacteraemia. However, 20% (2686/13 557) of children without bacterial infection were also prescribed antibiotics. On the basis of the data from the clinical evaluations and the confirmed diagnosis, a diagnostic model was developed using multinomial logistic regression methods. Physicians’ diagnoses of bacterial infection had low sensitivity (10-50%) and high specificity (90-100%), whereas the clinical diagnostic model provided a broad range of values for sensitivity and specificity. Conclusions Emergency department physicians tend to underestimate the likelihood of serious bacterial infection in young children with fever, leading to undertreatment with antibiotics. A clinical diagnostic model could improve decision making by increasing sensitivity for detecting serious bacterial infection, thereby improving early treatment.

Medical humour has a long history, but is short on evidence. The ancient Greeks introduced the world to bodily fluids called the four humours. You would think that a philosophy based on blood, choler, phlegm, and melancholy was no laughing matter. What is the evidence that medical humour benefits staff or patients? We performed a systematic revue, but it was not funny. We propose a randomised controlled trial of medical humour. The Royal Flying Doctor Service funded a pilot study. Hospital staff completed a standardised questionnaire about the role of humour in their department. The department of surgery expressed an interest in side-splitting jokes. The ophthalmology …

Teale and colleagues argue for the cost effectiveness of drugs to be considered when making decisions about funding.1 Their example, palivizumab, is a classic illustration of indication creep. An extremely expensive drug that reduces admission for respiratory syncytial virus but has not been shown to …

Charles Helms and Philip Polgreen (doi:10.1136/bmj.a2142) believe mandatory immunisation is necessary to achieve good uptake, but David Isaacs and Julie Leask argue that it infringes autonomy and could backfire

The main purpose of a computer is domination. A computer ensures you do not waste your time seeing patients—or waste your time on other unimportant pursuits such as eating, drinking, sleeping, or making babies. A subsidiary purpose of a computer is to provide a mini-mental test of your capacity to remember passwords. Passwords on a computer are different for every program, and change as frequently as you change your underwear. Passwords are the name of your deceased dog, or your partner’s name spelt backwards, followed by a number that increases exponentially. If you are able to remember all your passwords, you have Asperger’s syndrome and should see a doctor immediately. Normal human beings keep their passwords safely hidden on a piece of scrap paper, never to be found again. Theoretically, computers save trees, except that everyone prints out their electronic documents to read offline, thereby avoiding terminal migraine. A desktop computer is like a dominatrix. It has everything you want and more, but is determined to demonstrate your inadequacy and your total dependence. The computer knows your patients’ laboratory results, so you need never see your patients again. An endless torrent of emails will keep you hostage for hours. Your colleagues are under the delusion that their emails have direct access to your brain, and telephone grumpily if you do not reply within seconds. The emails you do open invariably impugn the size or function of a man’s private parts or offer breast enlargement. The computer is programmed to send an email every time you attempt to leave the office, the number of attachments directly proportional to the urgency of the appointment you are missing. Modern life is about portability and practicality, as you negotiate the declining distinction between work and home life. Mobility is the order of the day—mobile phones, mobile homes, and mobile morals. The solution is a laptop computer. A laptop is like a lapdog but with a brain. It requires a licence and regular nourishment, but will then act as a CAD (conversation avoidance device). A laptop is part of the dress code for all government employees you’re likely to encounter and is an essential accessory for aeroplane travel. You will, however, need the coordination of an Olympic gymnast to work the mouse, and the patience of Job when the battery runs out halfway through your flight and loses all your work.

The main purpose of Grand Rounds is self aggrandisement. Grand Rounds are held weekly, or weakly, depending on the presenter. To medical students who ask sceptically why they are called Grand Rounds, the answer is because Grand Rounds sounds better than Petit Rounds. Grand Rounds used to be called ye Grande Olde Rounds. They were immortalised in the nursery rhyme: Ye Grande Olde Rounds of Yore They had ten thousand slides They took them up to the carousel And they dropped them on their sides. Now when they were down they were up And when they were not it was Hell, And with Grande Rounds almost halfway through They jammed the carousel. The modern presenter thinks a carousel is a merry-go-round, and is only worried that his or her carefully prepared and saved PowerPoint presentation has disappeared into the electronic ether. The chair of Grand Rounds is in a position of great power. The chair can influence the whole tenor of the weekly meeting. The chair is traditionally the oldest, most esteemed, most senior member of staff, and the person most likely to fall asleep throughout the meeting. A clinical case or two is presented at each Grand Rounds. The presenter is the most junior member of the medical team. Tradition dictates that the junior member has never met the patient but has been told to present the case by the consultant. It is considered character building to stand up in front of several hundred senior colleagues and expose yourself to ridicule. It is considered irrelevant that the character thus built will be a nervous wreck for the remainder of his or her medical career. The presented case is then masticated, ruminated on, digested, and regurgitated by senior doctors. It is considered bad form for them to prepare for their pontifications, which tradition dictates are lengthy, liberally strewn with anecdotes, and evidence-free. The end result is a hallowed form of verbal swordplay with your colleagues, in which you score palpable hits as you exhibit your own knowledge and clinical acumen while denigrating those of your colleagues. This should be done subtly and with finesse, so that the character assassination is not immediately apparent—the thrust and parry of epee rather than the coup de sabre. At the end of the Grand Rounds, the chair wakes up and asks for a grand round of applause to wake up the rest of the audience.

Kawasaki disease is an acute, self limiting febrile illness of infants and young children. In children under 5 years of age the incidence varies from about 3-6 per 100 000 in Europe1 to 90 per 100 000 in Japan.2 It causes coronary artery lesions in about 20% of untreated patients, up to 2% of whom die.3 Diagnosis is based on the presence of a prolonged fever (of more than five days duration) plus four of the following five signs: conjunctival injection, changes in the mucous membranes, changes in the peripheries (erythema of the palms and soles and swelling of the hands and feet), rash, and lymphadenopathy. The clinical features may be supplemented by non-specific laboratory investigations—for example, thrombocytosis and an increased erythrocyte sedimentation rate—but there is no specific diagnostic test. Prompt diagnosis permits early treatment with intravenous immunoglobulin, which reduces the incidence of coronary artery lesions by up to two thirds.4 5 Lymphadenopathy is …

Health economists are ideologically opposed to frivolity. It has come to our attention that an annual, quasireligious festival has been held for some years without having been subjected to the rigours of a cost effectiveness analysis. In these sombre days of economic rationalism, such an oversight is unconscionable. The money spent on gifts and wrapping paper, tinsel and turkey is a significant opportunity cost, which might be better spent on improving the health care of the nation. We present a cost effectiveness analysis of Christmas. ![][1] Our cost effectiveness analysis was carried out from a societal perspective, using clinical and economic variable estimates, derived by inspired guesswork. We assumed that the average doctor has no knowledge or interest in accountancy and will accept anything a health economist tells him or her without question; … [1]: /embed/graphic-1.gif

R Stuart-Harris, R Penny Chapman&Hall, £79, pp 512 ISBN 0 412 602504 This review is a particularly poignant one for me— “Son of interferon meets son of influenza.” My father, Alick Isaacs, codiscoverer of interferon, spent his formative years in virology in Sheffield, where Charles Stuart-Harris, father of Robin, was his teacher and mentor. When first described in 1957, interferon was hailed as the antiviral penicillin, the “magic bullet” that would do for viral infections what antibiotics had done for bacterial infections. But hailed by …

E Graham Davies, David A C Elliman, C Anthony Hart, Angus Nicoll, Peter T Rudd Saunders, pounds sterling17.95, pp 393 ISBN 0 7020 1832 5 “The only book written by a committee that is beyond criticism is the King James Version of the Bible.” Thus Stan Plotkin in his introduction to the red book. The red book is for many of us the Bible of paediatric infectious diseases, produced as a Report of the Committee on Infectious Diseases for the American Academy of Pediatrics, and revised every two to three years. We may not agree with all the recommendations, but the scientific basis behind them is likely to …

Thirty preschool children presenting with recurrent respiratory infections and their unaffected siblings were observed prospectively for a year. The index children experienced more episodes of acute respiratory infection than their siblings. Respiratory viruses were the major cause of respiratory infections. The index children had lower respiratory tract disease, predominantly wheeze, during 34% of proved respiratory virus infections compared with 11% of such infections experienced by the control children (p less than 0.02). Atopic children had an increased tendency to wheeze that did not reach significance, but atopy was not associated with increased susceptibility to respiratory infections.