Letters to the Editor
of tendonitis and tendon rupture.1 Approximately 0.1% to 0.4% of patients taking fluoroquinolones are affected,2 with the Achilles tendon the most common site, implicated in 96% of fluoroquinolone-associated tendon disease.3 The pathophysiology of fluoroquinolone-associated tendon injury is poorly understood. Studies that have examined histological biopsies of several tendon specimens have shown necrotic changes with neovascularisation, multiple fissures, interstitial oedema and cystic changes.2,3 This histological picture is similar to that seen in tendon overuse injuries in athletes. A systematic review of fluoroquinolones and tendon injury found that the risk of tendonitis and rupture is particularly pronounced among patients greater than 60 years of age, patients who are non-obese and patients who use oral
References
glucocorticoids.4 Aside from fluoroquinolone antibiotics, there are several other known precipitant risk factors for spontaneous tendon rupture without a significant mechanical force. These include glucocorticoid steroid use, haemodialysis or renal dysfunction, renal transplantation, rheumatic disease, gout, diabetes mellitus and hyperparathyroidism.5,6 Received 15 March 2015; accepted 31 March 2015. doi:10.1111/imj.12934
R. Glick,1 D. S. Epstein1 and D. T. Aponso2 1
Medical Services and 2Orthopaedic Surgery, Alfred Health, Melbourne, Victoria, Australia
3 Movin T, Gad A, Guntner P, Foldhazy Z,
5 Donck JB, Segaert MF, Vanrenterghem YF.
Rolf C. Pathology of the Achilles tendon in
Fluoroquinolones and Achilles tendinopathy
Zhang Y. Impact of age, sex, obesity,
association with ciprofloxacin treatment.
in renal transplant recipients. Transplantation
and steroid use on quinolone-associated ten-
Foot Ankle Int 1997; 18: 297–9.
don disorders. Am J Med 2012; 125: 1223–8.
4 Stephenson AL, Wu W, Cortes D,
1 Wise BL, Peloquin C, Choi H, Lane NE,
1994; 58: 736–7. 6 Khaliq Y, Zhanel GG.
Rochon PA. Tendon injury and
Fluoroquinolone-associated tendinopathy: a
Arnaud M, Bonnet C, Bertin P et al.
fluoroquinolone use: a systematic review.
critical review of the literature. Clin Infect Dis
Fluoroquinolone induced tendinopathy: re-
Drug Saf 2013; 36: 709–21.
2003; 36: 1404–10.
2 Zabraniecki L, Negrier I, Vergne P,
port of 6 cases. J Rheumatol 1996; 23: 516–20.
General correspondence Genuine open-mindedness In the July 2015 issue of Internal Medicine Journal, PanekHudson and Ritchie write, ‘To realise fully the potential of the NP (nurse practitioner) within specialist healthcare streams will require open-mindedness,…’.1 Their final sentence, in which they call for the application of ‘regulatory and institutional tools’ suggests that they believe the truth to be manifest and resolved and that they are not calling for the open mindedness of Hare: ‘Open-mindedness is an intellectual virtue and educational ideal that involves being receptive in a critical manner to new ideas and to ideas that conflict with one’s own beliefs; without a critical component there would be no contrast with credulity, and open-mindedness would be no virtue at all’.2 Rather, they are simply calling for the acceptance of their views without the need for further critical evaluation. Their proposition that ‘… the NP role… is not a replacement of traditional doctor led healthcare…’ is negated by one of the major reviews they use to bolster © 2015 Royal Australasian College of Physicians
their claim, which is titled ‘Substitution of doctors by nurses in primary care’.3 Panek-Hudson and Ritchie allude to a gradual extension of the NP role when they say ‘the NP role was implemented primarily to address shortfalls in …rural and remote areas, …’ but refer to ‘long consultations and a focus on preventative practice’ and the ‘rapid development of NP roles in specialist medical disciplines’. It is not clear where the NP role begins and ends, and it is certainly not clear that there will be no substitution for traditional doctor roles. This is not task substitution being advocated, it is role substitution. There is already considerable anecdotal evidence of the difficulty of accessing training positions for specialist training, and Health Workforce Australia predicts a shortfall of position of 404 in 2016 and 1265 in 2025 with a possible oversupply of doctors of between 13 032 in 2016 and 18 690 by 2025. Conversely, there is a predicted undersupply of nurses of up to 109 490.4 There are no manpower issues driving NP utilisation. Australia currently has one of the best and most efficient healthcare systems in the world,5 yet Panek-Hudson and Ritchie are advocating the complete usurpation of our 1315
Letters to the Editor
current GP-led model and replacing it with ‘an entry point (which) will be determined by a stratification of the needs of individual patients and (which) directs them to the most appropriate provider…’. This begs the question – who will direct them? This proposal does indeed merit an ‘open minded’ approach, but in the true Socratic form invoking critical thinking – and before there are any further regulatory changes.
References
Received 28 August 2015; accepted 11 September 2015. doi:10.1111/imj.12926
P. Hanrahan University of Western Australia, Perth, Western Australia, Australia
3 Laurant M, Reeves D, Hermens R,
5 Most efficient health care 2014: countries.
Braspenning J, Grol R, Sibbald B. Substitu-
[Cited 2015 Nov 6]. Available from URL:
of advanced practice nursing. Intern Med J
tion of doctors by nurses in primary care.
http://www.bloomberg.com/visual-data/best-
2015; 45: 691–2.
Cochrane Collab 2014; CD001271.
and-worst//most-efficient-health-care-2014-
1 Panek-Hudson Y, Ritchie D. The rise and rise
2 Hare W. Socratic open-mindedness. Padeusis 2019; 18: 5–16.
4 Health Workforce Australia 2012: Health
countries
workforce 2025 – doctors, nurses and midwives – volume 1.
Author reply We are delighted that Hanrahan1 took the time to write in response to our paper.2 The public airing of opinion regarding the role and the practice environment of advanced practice nursing is exactly what we were hoping for. We strongly advocate ongoing critical evaluation of all healthcare disciplines including that of the nurse practitioner (NP). However, all such evaluations, should arise from an appropriate evidence base, such as those referenced in our paper, rather than from an ingrained position of ‘business-as-usual’ or medical work force protectionism. Our position is to encourage open mindedness and invite rigorous evaluation of how all roles contribute to meeting the specific needs of patients and their communities. Whilst in some settings, NP positions have been established as modified medical roles to deal with the shortfall in the availability of doctors, the actual value of the NP (as demonstrated in our model of care) is directly linked to augmenting care to meet the needs of patients
References 1 Hanrahan P. Genuine open-mindedness. Intern Med J 2015; 45: 1315–6.
Received 4 October 2015; accepted 5 October 2015. doi:10.1111/imj.12920
Y. Panek-Hudson1 and D. Ritchie2 1
Peter MacCallum Cancer Centre and Royal Melbourne Hospital, 2
Nursing and Haematology and BMT Service, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
2 Panek-Hudson Y, Ritchie D. The rise and rise of advanced practice nursing. Intern Med J 2015; 45: 691–2.
The silent canine – a clarification I write to thank Chew-Harris et al. for their salutary letter1 regarding creatinine in acute kidney injury, and to provide a clarification thereof. 1316
through improving multidisciplinary collaboration, co-consultation and timely access to health care. The ongoing work of the Medicare Benefits Scheme Review Taskforce, chaired by Professor Bruce Robinson, is a timely reminder that patterns of practice do require revision and realignment in order to evolve to meet the appropriate healthcare needs of the community within the resources available. Ongoing evaluation, examination of resource allocation, policy reviews and a strategic system-wide approach are needed to ensure the highly skilled and expert resource of the NP role is able to evolve to its full potential.
The authors reference Sir Arthur Conan Doyle’s consulting detective, Sherlock Holmes, in their concluding paragraph. While the lesson certainly stands, the reference is sufficiently erroneous to require correction. © 2015 Royal Australasian College of Physicians
of tendonitis and tendon rupture.1 Approximately 0.1% to 0.4% of patients taking fluoroquinolones are affected,2 with the Achilles tendon the most common site, implicated in 96% of fluoroquinolone-associated tendon disease.3 The pathophysiology of fluoroquinolone-associated tendon injury is poorly understood. Studies that have examined histological biopsies of several tendon specimens have shown necrotic changes with neovascularisation, multiple fissures, interstitial oedema and cystic changes.2,3 This histological picture is similar to that seen in tendon overuse injuries in athletes. A systematic review of fluoroquinolones and tendon injury found that the risk of tendonitis and rupture is particularly pronounced among patients greater than 60 years of age, patients who are non-obese and patients who use oral
References
glucocorticoids.4 Aside from fluoroquinolone antibiotics, there are several other known precipitant risk factors for spontaneous tendon rupture without a significant mechanical force. These include glucocorticoid steroid use, haemodialysis or renal dysfunction, renal transplantation, rheumatic disease, gout, diabetes mellitus and hyperparathyroidism.5,6 Received 15 March 2015; accepted 31 March 2015. doi:10.1111/imj.12934
R. Glick,1 D. S. Epstein1 and D. T. Aponso2 1
Medical Services and 2Orthopaedic Surgery, Alfred Health, Melbourne, Victoria, Australia
3 Movin T, Gad A, Guntner P, Foldhazy Z,
5 Donck JB, Segaert MF, Vanrenterghem YF.
Rolf C. Pathology of the Achilles tendon in
Fluoroquinolones and Achilles tendinopathy
Zhang Y. Impact of age, sex, obesity,
association with ciprofloxacin treatment.
in renal transplant recipients. Transplantation
and steroid use on quinolone-associated ten-
Foot Ankle Int 1997; 18: 297–9.
don disorders. Am J Med 2012; 125: 1223–8.
4 Stephenson AL, Wu W, Cortes D,
1 Wise BL, Peloquin C, Choi H, Lane NE,
1994; 58: 736–7. 6 Khaliq Y, Zhanel GG.
Rochon PA. Tendon injury and
Fluoroquinolone-associated tendinopathy: a
Arnaud M, Bonnet C, Bertin P et al.
fluoroquinolone use: a systematic review.
critical review of the literature. Clin Infect Dis
Fluoroquinolone induced tendinopathy: re-
Drug Saf 2013; 36: 709–21.
2003; 36: 1404–10.
2 Zabraniecki L, Negrier I, Vergne P,
port of 6 cases. J Rheumatol 1996; 23: 516–20.
General correspondence Genuine open-mindedness In the July 2015 issue of Internal Medicine Journal, PanekHudson and Ritchie write, ‘To realise fully the potential of the NP (nurse practitioner) within specialist healthcare streams will require open-mindedness,…’.1 Their final sentence, in which they call for the application of ‘regulatory and institutional tools’ suggests that they believe the truth to be manifest and resolved and that they are not calling for the open mindedness of Hare: ‘Open-mindedness is an intellectual virtue and educational ideal that involves being receptive in a critical manner to new ideas and to ideas that conflict with one’s own beliefs; without a critical component there would be no contrast with credulity, and open-mindedness would be no virtue at all’.2 Rather, they are simply calling for the acceptance of their views without the need for further critical evaluation. Their proposition that ‘… the NP role… is not a replacement of traditional doctor led healthcare…’ is negated by one of the major reviews they use to bolster © 2015 Royal Australasian College of Physicians
their claim, which is titled ‘Substitution of doctors by nurses in primary care’.3 Panek-Hudson and Ritchie allude to a gradual extension of the NP role when they say ‘the NP role was implemented primarily to address shortfalls in …rural and remote areas, …’ but refer to ‘long consultations and a focus on preventative practice’ and the ‘rapid development of NP roles in specialist medical disciplines’. It is not clear where the NP role begins and ends, and it is certainly not clear that there will be no substitution for traditional doctor roles. This is not task substitution being advocated, it is role substitution. There is already considerable anecdotal evidence of the difficulty of accessing training positions for specialist training, and Health Workforce Australia predicts a shortfall of position of 404 in 2016 and 1265 in 2025 with a possible oversupply of doctors of between 13 032 in 2016 and 18 690 by 2025. Conversely, there is a predicted undersupply of nurses of up to 109 490.4 There are no manpower issues driving NP utilisation. Australia currently has one of the best and most efficient healthcare systems in the world,5 yet Panek-Hudson and Ritchie are advocating the complete usurpation of our 1315
Letters to the Editor
current GP-led model and replacing it with ‘an entry point (which) will be determined by a stratification of the needs of individual patients and (which) directs them to the most appropriate provider…’. This begs the question – who will direct them? This proposal does indeed merit an ‘open minded’ approach, but in the true Socratic form invoking critical thinking – and before there are any further regulatory changes.
References
Received 28 August 2015; accepted 11 September 2015. doi:10.1111/imj.12926
P. Hanrahan University of Western Australia, Perth, Western Australia, Australia
3 Laurant M, Reeves D, Hermens R,
5 Most efficient health care 2014: countries.
Braspenning J, Grol R, Sibbald B. Substitu-
[Cited 2015 Nov 6]. Available from URL:
of advanced practice nursing. Intern Med J
tion of doctors by nurses in primary care.
http://www.bloomberg.com/visual-data/best-
2015; 45: 691–2.
Cochrane Collab 2014; CD001271.
and-worst//most-efficient-health-care-2014-
1 Panek-Hudson Y, Ritchie D. The rise and rise
2 Hare W. Socratic open-mindedness. Padeusis 2019; 18: 5–16.
4 Health Workforce Australia 2012: Health
countries
workforce 2025 – doctors, nurses and midwives – volume 1.
Author reply We are delighted that Hanrahan1 took the time to write in response to our paper.2 The public airing of opinion regarding the role and the practice environment of advanced practice nursing is exactly what we were hoping for. We strongly advocate ongoing critical evaluation of all healthcare disciplines including that of the nurse practitioner (NP). However, all such evaluations, should arise from an appropriate evidence base, such as those referenced in our paper, rather than from an ingrained position of ‘business-as-usual’ or medical work force protectionism. Our position is to encourage open mindedness and invite rigorous evaluation of how all roles contribute to meeting the specific needs of patients and their communities. Whilst in some settings, NP positions have been established as modified medical roles to deal with the shortfall in the availability of doctors, the actual value of the NP (as demonstrated in our model of care) is directly linked to augmenting care to meet the needs of patients
References 1 Hanrahan P. Genuine open-mindedness. Intern Med J 2015; 45: 1315–6.
Received 4 October 2015; accepted 5 October 2015. doi:10.1111/imj.12920
Y. Panek-Hudson1 and D. Ritchie2 1
Peter MacCallum Cancer Centre and Royal Melbourne Hospital, 2
Nursing and Haematology and BMT Service, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
2 Panek-Hudson Y, Ritchie D. The rise and rise of advanced practice nursing. Intern Med J 2015; 45: 691–2.
The silent canine – a clarification I write to thank Chew-Harris et al. for their salutary letter1 regarding creatinine in acute kidney injury, and to provide a clarification thereof. 1316
through improving multidisciplinary collaboration, co-consultation and timely access to health care. The ongoing work of the Medicare Benefits Scheme Review Taskforce, chaired by Professor Bruce Robinson, is a timely reminder that patterns of practice do require revision and realignment in order to evolve to meet the appropriate healthcare needs of the community within the resources available. Ongoing evaluation, examination of resource allocation, policy reviews and a strategic system-wide approach are needed to ensure the highly skilled and expert resource of the NP role is able to evolve to its full potential.
The authors reference Sir Arthur Conan Doyle’s consulting detective, Sherlock Holmes, in their concluding paragraph. While the lesson certainly stands, the reference is sufficiently erroneous to require correction. © 2015 Royal Australasian College of Physicians
