Michael Lowe

'These sorts of people don't do very well': race and allocation of health care resources.

Recent literature has highlighted issues of racial discrimination in medicine. In order to explore the sometimes subtle influence of racial determinants in decisions about resource allocation, we present the case of a 53-year-old Australian Aboriginal woman with end-stage renal failure. The epidemiology of renal failure in the Australian Aboriginal population and amongst other indigenous peoples is discussed. We show that the use of utilitarian outcome criteria for resource allocation may embody subtle racial discrimination where consideration is not given to issues of justice, race, culture and gender. It is only where the processes by which resources are allocated are transparent, clearly defined and based upon consultation with individual patients that issues and justice are likely to be adequately addressed.

Do patients have an obligation to participate in student teaching

Context  Patients may participate in teaching in many ways, in different settings and with different degrees of expert supervision. The majority of patients are generally very willing to participate in teaching. At times, however, patients may decline to see students because they are too sick, wish to maintain their privacy, prefer to have more expert care, or simply wish to have no involvement with students. This raises the question as to whether patients have any obligation to participate in education.

Dementia prevalence and incidence among the Indigenous and non-Indigenous populations of the Northern Territory.

Objective: To estimate the prevalence and incidence of dementia in Northern Territory Indigenous and non‐Indigenous populations.

Ethical problems of evaluating a new treatment for melioidosis.

When mortality from melioidosis fell sharply after multiple changes in management at an Australianhospital, doctors wanted to identify whether a new drug was responsible. But designing a trial that was ethically acceptable proved impossible Effective treatment of patients requires that is based on the best available evidence, ideally a randomised controlled trial. However, when observational evidence suggests that a treatment has a large benefit, the potential risks to participants make a randomised trial hard to justify. We had to abandon a trial to evaluate the use of granulocyte-colony stimulating factor (G-CSF) in patients with melioidosis in septic shock because we were unable to balance the risks to patients against the scientific uncertainty. This article describes the problems experienced and considers other methods of obtaining good evidence. Melioidosis, the infection caused by Burkholderia pseudomallei , is endemic in South East Asia1 and is the commonest cause of death from bacteraemic pneumonia in the Northern Territory of Australia.2Patients with severe infection present with septic shock, a condition associated with a high mortality. The Royal Darwin Hospital has treated 341 patients with culture confirmed melioidosis over 13 years, with an overall 18% mortality. Forty two of these patients presented with severe sepsis. In 1998, the hospital decided to start treating patients with melioidosis and septic shock withgranulocyte-colony stimulating factor (G-CSF). The decision was based on the evidence available atthat time (box). G-CSF was introduced at the same time as the hospital appointed a specialist in intensive care medicine. Previously, anaesthetists had supervised the unit, and the appointment resulted in appreciable changes to management protocols, including the more aggressive use of haemodynamic monitoring, empiric antibiotic protocols, the adoption of a closed intensive care model, andearly enteric feeding. Mortality from severe melioidosis fell from 95% (20 of 21 patients) to 10% (2 …

Celecoxib allergies and cross-reactivity

A 65-year-old woman was transferred from a regional hospital with hypotension, pulmonary oedema and generalized urticarial rash after commencement of celecoxib. Her medical history included hypertension and polymyalgia rheumatica. Ten years previously, she had developed a generalized urticarial rash after taking a sulfonamide antibiotic. In 1993 she had a similar reaction to penicillin. Four days before admission to our hospital, she had taken 200 mg of celecoxib for backache and 1 hour later had developed a localized pruritic rash. The rash improved slightly and she took a second dose 3 days later. Within an hour, she developed a diffuse pruritic maculopapular rash involving face, trunk and limbs, swelling of the lips and tongue and a fever, forwhich she presented to the regional hospital. She was treated with hydrocortisone and promethazine and discharged, but soon afterwards she lost consciousness, became hypotensive and was returned to the Emergency Department. She was treated with i.v. fluids, hydrocortisone, prednisolone and adrenaline. She was then transferred to our hospital. On arrival, she was febrile and tachycardic, but normotensive and saturating well on 4-L supplemental O2. She was talking in sentences, and there was a generalized urticarial rash. Auscultation of the chest showed widespread wheeze with bibasal crackles and she had marked pedal oedema. She was given i.v. frusemide and was gradually weaned off oxygen. Investigations showed increased creatinine (195 lmol/L), thrombocytopenia (platelets of 112, reaching a nadir of 31 10/L) and abnormal liver function tests. Subsequently, neutropenia was also noted (reaching a nadir of 0.4 10/L 5 days after her second dose of celecoxib). Her rash settled slowly over 5 days and her liver function tests and renal function and haematology slowly returned to normal. This case illustrates the effect of a severe allergic reaction to a non-antimicrobial sulfonamidemedication in someone with a sulfonamide allergy. Celecoxib, a non-antimicrobial sulfonamide, triggered this reaction, and other sulfacontaining medications, such as frusemide, may have exacerbated the symptoms. The Product Information for Celebrex (Pfizer, New York, NY, USA) states that a sulfonamide allergy is a contraindication to use, but there is little pharmacological evidence of allergies to celecoxib (and other non-antimicrobial sulfonamides) cross-reacting with antimicrobial sulfonamides. Instead, most analyses have shown that the incidence of celecoxib reactions in people who are allergic to sulfonamides is comparable to the incidence of reactions that they get from taking placebos or other medications. Yet, patients with a history of allergy to a sulfonamide antibiotic may have a greater risk of having an allergic reaction to sulfonamidenon-antibiotic drugs, as illustrated by our patient. This risk may not to be related to crosssensitivity, but may instead be due to a predisposition to multiple allergic reactions, including to non-sulfonamides such as penicillins. The patient of our study had multiple drug allergies (including allergy to penicillin). In conclusion, the chance of cross-reactivity between sulfonamide antimicrobials and non-sulfonamide

Evidence-based medicine and clinical practice.

Evidence-based medicine (EBM) has been defined as the integration of the best research evidence with clinical expertise and patient values. 1 Great progress has been made recently in finding ways to obtain this evidence, which often takes the form of detailed statistical information about different outcomes. What is less clear is how we should integrate this evidence with clinical expertise and patient values. In this issue of the Journal, Williams et al. suggest one approach in their paper entitled ‘Using an evidence-based approach to a paediatric problem’ (pp. 139–144). 2 They demonstrate how it is possible to gather evidence about prognosis in children with pneumococcal meningitis, assess whether the evidence is valid and consider the best ways to communicate it to the child and family. Although we are not opposed to this approach, or to EBM in general, we do believe that applying evidence to prognostic decisions is more complex than the example given and that clinical judgement might be a better guide than epidemiological data alone in dealing with prognosis in clinical practice.