Volume 169 Issue 11

Editorial Biodiversity loss: a human health issue What do Wollemi pines and a sea squirt with "kidney stones" have in common? MJA 1998; 169: 568-569 The environmental issue most often linked to human health has been the damaging effects of toxic substances and pollutants. Lately, however, the health effects of climate change and loss of biodiversity1 have attracted increasing attention. The Australian State of the Environment report2 has identified biodiversity loss as the most significant environmental problem of the next millennium. Biodiversity loss is generally attributed to degradation of ecosystems, with accompanying loss of species. It is implicated in the rise of infectious diseases3 and in the loss of potential new medicines and medical models. Moreover, the scale and rate of current biodiversity loss is such that the continued viability of our own species is threatened by the disruption of vital ecological processes. The general public has a limited understanding of the concept of biodiversity. Even the more informed regard it as a simple tally of all the plant and animal species. However, biodiversity is a systems concept that refers to the variation of life at different levels of organisation (Figure). It refers to the function of the species known as the "environmental engineers", which provide us with clean air and water, and fertile soils, as well as much of our food, shelter, medicines and industrial products. The value of biodiversity to human health has been highlighted in a recent forum.5 The most obvious benefit is the large proportion of the pharmaceutical armamentarium that is derived from the natural world. Over 50% of commercially available drugs are based on bioactive compounds extracted (or patterned) from non-human species.6 Of the top 100 prescribed drugs in the United States, 55% are natural or semisynthetic, and these percentages are even greater for drugs used for respiratory, dermatological, gastrointestinal, gynaecological and infectious diseases.6 A recent example is taxol, first identified in yew trees (Taxus) of North America. It is one of the most promising drugs for the treatment of ovarian and breast cancer.7 Importantly, taxol has now been isolated from fungi associated symbiotically with the Wollemi pine, a living fossil discovered recently near Sydney. Furthermore, it is not generally acknowledged how widespread the use of traditional medicines is in developing countries. It has been estimated that 80% of the world's population rely on plant-based medicines for their primary health care.8 The value of this ethnobiological knowledge is also recognised by pharmaceutical company researchers, who use this information source routinely in the acquisition phase of drug discovery. Of the 265000 species of flowering plants, it is estimated that less than half of 1% have been screened for their beneficial pharmaceutical properties.9 It has been argued that the loss of species will also result in loss of medical models which can increase our understanding of human physiology and disease.10 Numerous examples exist in species closely related to humans. However, examination of invertebrates is also yielding important models, such as a species of sea squirt (Molgula manhattensis) that develops stones in kidney-like organs. Study of this species has increased our understanding of how both uric acid and oxalate kidney stones form in humans.10 The consequences of such losses pale in comparison with the dire effects of the emergence and re-emergence of infectious diseases. In many cases these events are attributed to the erosion of biodiversity and human ecology. Any disturbance of ecosystems can result in loss of species diversity, a population explosion of competitive species, and host switching of pathogens from primary hosts to humans. For example, the emergence of hantavirus pulmonary syndrome in the south-western United States can be traced to an explosion in the population of deer mice,11 the natural host of the virus, and the subsequent exposure of humans to the excreta of the mice. A similar population explosion of mice in agricultural areas in South Australia occurred in 1993, and, although no infectious diseases were associated with this outbreak, it serves as a warning. The capacity of pathogenic microorganisms to switch hosts is well known. This, coupled with their high reproductive rate and mutation rate, increases their potential to cause serious illness and death in humans. For example, HIV has most likely switched hosts, possibly originating from a mutant simian immunodeficiency virus strain. The outbreak of infection caused by a morbillivirus in horses and humans in Brisbane in 1994,12 resulting in fatalities in both species, is an Australian case that indicates that such switches can occur in any country. Unfortunately, biodiversity loss occurs incrementally and is not apparent to most people. The extent of this loss is measured in terms of species extinction and destruction of habitats. Some scientists estimate that we are losing 100 species per day and that more than a quarter of all species may vanish within 50 years. This rate of loss would be at least 1000 times greater than modelled natural extinction rates. Some studies indicate that as many as 60000 plants could be extinct by the middle of next century.13 The disappearance of vertebrates continues unabated, with Australia having the worst mammal extinction record in the world.2 But the most severe losses are occurring among the invertebrates, most of which are undescribed and yet play critical roles in ecological processes. The habitats of these species are being destroyed at an alarming rate. In the 20 countries with the greatest identified biodiversity, it is predicted that about a quarter of the remaining natural habitats will be cleared by the middle of the next century.14 Australia has an appalling record in this regard, and in the past decade has been identified as one of the worst land-clearing countries in the world.15 Aside from land clearance, the major threats to biodiversity are the impact of alien species, the indiscriminate harvesting of species, and the effects of pollution, urbanisation, and climate change. Fundamentally, living in an ecologically sustainable way is essential, and there is an urgent need for humans to accept that natural resources are limited and, once exploited, are unlikely to be repaired. There is a pressing need for an assessment of human population and consumption.16 Causation in science is empirically difficult to establish. None the less, the argument is persuasive that human population size, urbanisation and malnutrition in sections of the population enhance the emergence of diseases. Human health and well-being can be seen as indicators of the health of global biodiversity. The signs of a difficult future are gathering. The conservation ethic advocated by biological scientists needs to be embraced by all sectors of the community. There is a unique opportunity for the healthcare sector to promote the principles of biodiversity, conservation and sustainable development.17 The obvious links between human health and biodiversity have not been exploited. It would be timely for major medical associations and members of the medical profession to be engaged in public debate on this issue and to support the need for an education program in schools, among doctors and for the general public. Gerry Cassis Centre for Biodiversity and Conservation Research Australian Museum, Sydney, NSW GerrycATamsg.austmus.gov.au Perrings C, Maler K-G, Folke C, et al. Introduction: framing the problem of biodiversity loss. In: Perrings C, et al, editors. Biodiversity loss: economic and ecological issues. Cambridge: Cambridge University Press, 1995: 1-17. Commonwealth of Australia. Australia, State of the Environment. An independent report presented to the Commonwealth Minister for the Environment by the State of the Environment Advisory Council. Melbourne: CSIRO Publishing, 1996. Garret L. The coming plague. Newly emerging diseases in a world out of balance. London: Virago Press, 1994. Commonwealth of Australia. The National Strategy for the conservation of Australia's biological diversity. Canberra: Commonwealth Department of the Environment, Sport and Territories, 1996. Grifo F, Rosenthal J. Biodiversity and human wealth. Washington, DC: Island Press, 1997. Grifo F, Newman D, Fairfield AS, et al. The origins of prescription drugs. In: Grifo F, Rosenthal J, editors. Biodiversity and human health. Washington, DC: Island Press, 1997: 131-163. Nicolaou KC, Guy RK, Potier P, et al. Taxoids: new weapons against cancer. Sci Am 1996; 274(6): 94-98. Farnsworth NR, Akerele O, Bingel AS, et al. Medicinal plants in therapy. Bull World Health Organ 1985; 63: 965-981. Cox PA. Biodiversity and human health conference. Session III: Biodiversity and traditional health systems. Washington, DC: Smithsonian Institution, 1995. Chivian E. Global environmental degradation and biodiversity loss: implications for human health. In: Grifo F, Rosenthal J, editors. Biodiversity and human health. Washington DC: Island Press, 1997: 7-38. Dobson A, Campbell MS, Bell J. Fatal synergisms: interactions between infectious diseases, human population growth, and loss of biodiversity. In: Grifo F, Rosenthal J, editors. Biodiversity and human health. Washington, DC: Island Press, 1997: 87-110. Murray K, Selleck P, Hooper P, et al. A morbillivirus that caused fatal disease in horses and humans. Science 1995; 268: 94-97. Farnsworth NR. Screening plants for new medicines. Wilson EO, Peters FM, editors. Biodiversity. Washington DC: National Academy Press, 1988: 83-97. United Nations Environment Programme. Global environment outlook. Oxford: Oxford University Press, 1997. Glanznig A. Native vegetation. Australia still in top ten land clearing country club. Life Lines: Bulletin of the Community Biodiversity Network, 1998; 4(2): 14. Cohen JE. How many people can the Earth support? New York: WW Norton and Company, 1995. Shearman D, Sauer-Thompson G. Green or gone. Health, ecology, plagues, greed and our future. Kent Town, South Australia: Wakefield Press, 1997. Reprints: Dr Gerry Cassis, Centre for Biodiversity and Conservation Research, Australian Museum, 6 College Street, Sydney, NSW. Photograph courtesy Land Information Services Division, Department of Primary Industries, Water and Environment, Hobart, Tasmania. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Gerry Cassis

Editorial Cancer immunotherapy: new leads on an elusive goal Emerging data increase optimism for mobilising immune cells against cancer MJA 1998; 169: 570-571 The prospect of mobilising the body's immune defences against cancer cells has been an elusive goal in cancer therapy for many decades. The optimism held for this idea has fluctuated over the years, but there are now concrete data emerging from a number of fronts that give good reason to be optimistic about cancer immunotherapy in the medium term. The new data on prospects for cancer immunotherapy were brought together at a recent meeting in Canberra.* Australia has outstanding researchers in this field, and this meeting was an opportunity to assess the current hopes and limitations from multiple perspectives. One chief limitation to cancer immunotherapy has been the difficulty in finding good, cancer-cell-specific target antigens. Immunological tolerance to self antigens on healthy tissues has mistakenly been thought of as an absolute process, barring the prospect of ever getting immune cells to react against cancer cells unless antigens unique to the cancer could be found. Two new developments dispel this perceived limitation. Firstly, many of the cellular processes responsible for immunological self-tolerance are at last being illuminated, through new technologies to genetically engineer transgenic mice.1-4 Definitive work on the process of tolerance to tissue-specific antigens was presented by B Scott (University of Western Australia, Perth), W Heath (Walter and Eliza Hall Institute, Melbourne), F Alderuccio (Monash University Medical School, Melbourne), D Hanahan (University of California, San Francisco) and myself. The data show that tolerance to tissue-restricted antigens, such as proteins made only by specific epithelial, neuronal or endocrine cells, is acquired by regulatory processes that still allow circulation of T cells and B cells with tissue-reactive antigen receptors. If these regulatory processes can be defined and temporarily relaxed by specific drug antagonists, this potential reservoir of immune cells might, in principle, be called into action to destroy cancer micrometastases. One potential target for such antagonists is suggested by inherited mutations in a novel gene, Autoimmune Regulator (AIRE); mutations of AIRE cause a failure of tolerance to multiple endocrine tissues in patients with autoimmune polyendocrinopathy- candidiasis syndrome (N Shimizu, Keio University). Conversely, a potential immune agonist is the cytokine granulocyte-macrophage colony-stimulating factor (GM-CSF), which is a potent inducer of immunity and appears essential for destructive autoimmunity in experimental diabetes mellitus (T Kay, Walter and Eliza Hall Institute, Melbourne). Notionally, such an immunotherapeutic course would follow after a primary tumour is surgically resected or debulked by radiotherapy or chemotherapy. The second development that opens the field of cancer antigen targets is coming from a clinical serum analysis technique called SEREX, which shows that tumours induce "autoimmune responses" much more frequently than has been appreciated.5,6 Autoantibodies against neuromuscular receptors have long been known to cause paraneoplastic syndromes of myasthenia gravis and Lambert-Eaton syndrome in patients with specific types of tumours such as thymoma or small cell lung carcinoma. Results obtained using SEREX show that patients who have any of a broad range of tumours are often making autoantibodies against various tissue-restricted antigens carried by the tumour cells (J Cebon, Ludwig Intitute, Melbourne; B Robinson, University of Western Australia, Perth). These results make it likely that immune defences can be mobilised against many tumours, but how effective will this be and how can they be improved? J Cebon summarised data suggesting that some patients with high antibody responses to tumours survive somewhat longer, but it is still uncertain that immune surveillance is a factor even in these cases, and it is clear that, ultimately, the tumour exceeds or escapes any immune surveillance.5 Genetically engineered mouse models of pancreatic cancer or skin cancer display spontaneous immune responses to cancer antigens,7,8 but augmenting these immune responses only delays tumour progression,9 and the extent to which the spontaneous immune responses restrict tumour growth appears quite limited (D Hanahan and D Daniel, University of California, San Francisco; C Parish, John Curtin School of Medical Research, Canberra). A review of individual case studies provides provocative examples of patients where squamous cell carcinomas or melanomas have spontaneously regressed, accompanied by vigorous immune cell responses to the tumour (G Halliday, University of Sydney).10 The potential for immune control of cancer cells is best illustrated by cancers of viral origin and by organ-specific autoimmune diseases. Only a small proportion of people infected with Epstein-Barr virus or human papillomavirus 16 develop lymphoma or cervical cancer, and there is clear evidence that this is due partly to effective immune responses against the viral antigens carried by the tumour cells (R Khanna, Queensland Institute of Medical Research, Brisbane; I Frazer, Princess Alexandra Hospital, Brisbane).8,11 The devastating destruction of pancreatic islet beta cells in type 1 diabetes mellitus, where no virus is known to be involved, is testimony that immune defences can be unleashed against common tissue antigens as well. Why do most tumours not remit despite ongoing immune responses? Several factors were clearly indicated at the meeting. Firstly, K Lafferty (John Curtin School of Medical Research, Canberra) reviewed recent studies in diabetes showing that vigorous immune responses can be "benign" (non-destructive) or "malignant" (destructive).12 Islet tissues can be heavily inflamed by a benign autoimmune response without any damage to beta cell mass because of poorly understood regulatory processes for self-tolerance.1,3,4 Genetic predisposition only allows a switch to malignant inflammation in certain individuals. As discussed above, the solution to this problem lies in charting the molecular pathways regulating tolerance and developing specific ways to interfere with them transiently. Secondly, tumour cells are genetically unstable and constantly evolving. In viral tumours, cancer cells escape immune surveillance by losing antigens or by losing the machinery needed to present antigens to T cells.11 Tumour instability is a serious problem for any single therapeutic approach, as it is for radiotherapy or chemotherapy, and successful application of immunotherapy will probably also depend on the tumour type and tailored combination with other measures. Thirdly, D Hanahan, B Robinson, G Halliday, and C Parish each drew attention to fragmentary evidence that secreted products from tumours -- such as activins -- and tumour influences on local vasculature and extracellular matrix may create suppressive or non-permissive environments for immune responses.13 It is conceivable that some of these products, such as transforming growth factor b, are key elements of normal mechanisms to prevent organ-specific autoimmunity. This is the least understood of all the obstacles facing immunotherapy. Counteracting such tumour products should not be an insurmountable barrier, but it may take considerable time and effort to define the molecular pathways involved and develop small-molecule antagonists against the best targets. Christopher C Goodnow Professor, Australian Cancer Research Foundation Genetics Laboratory Medical Genome Centre, John Curtin School of Medical Research The Australian National University, ACT Scott B, Liblau R, Degermann S, et al. A role for non-MHC genetic polymorphism in susceptibility to spontaneous autoimmunity. Immunity 1994; 1: 73-83. Heath WR, Kurts C, Miller JF, Carbone FR. Cross-tolerance: a pathway for inducing tolerance to peripheral tissue antigens. J Exp Med 1998; 187: 1549-1553. Forster I, Hirose R, Arbeit JM, et al. Limited capacity for tolerization of CD4+ T cells specific for a pancreatic beta cell neo-antigen. Immunity 1995; 2: 573-585. Akkaraju S, Ho WY, Leong D, et al. A range of CD4 T cell tolerance: partial inactivation to organ-specific antigen allows nondestructive thyroiditis or insulitis. Immunity 1997; 7: 255-271. Old LJ, Chen YT. New paths in human cancer serology. J Exp Med 1998; 187: 1163-1167. Robinson C, Robinson BW, Lake RA. Sera from patients with malignant mesothelioma can contain autoantibodies. Lung Cancer 1998; 20: 175-184. Skowronski J, Jolicoeur C, Alpert S, Hanahan D. Determinants of the B-cell response against a transgenic autoantigen. Proc Natl Acad Sci U S A 1990; 87: 7487-7491. Frazer IH. Immunology of papillomavirus infection. Curr Opin Immunol 1996; 8: 484-491. Ye X, McCarrick J, Jewett L, Knowles BB. Timely immunization subverts the development of peripheral nonresponsiveness and suppresses tumor development in simian virus 40 tumor antigen-transgenic mice. Proc Natl Acad Sci U S A 1994; 91: 3916-3920. Halliday GM, Patel A, Hunt MJ, et al. Spontaneous regression of human melanoma/nonmelanoma skin cancer: association with infiltrating CD4+ T cells. World J Surg 1995; 19: 352-358. Khanna R, Burrows SR, Moss DJ. Immune regulation in Epstein-Barr virus-associated diseases. Microbiol Rev 1995; 59: 387-405. Gazda LS, Charlton B, Lafferty KJ. Diabetes results from a late change in the autoimmune response of NOD mice. J Autoimmun 1997; 10: 261-270. Jarnicki AG, Fitzpatrick DR, Robinson BW, Bielefeldt-Ohmann H. Altered CD3 chain and cytokine gene expression in tumor infiltrating T lymphocytes during the development of mesothelioma. Cancer Lett 1996; 103: 1-9. * Autoimmunity workshop: the interface between autoimmunity and cancer immunity, sponsored by the John Curtin School of Medical Research, Australian National University. 11-13 September 1998. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Christopher C Goodnow

Editorial Email: editors, doctors and patients We had better learn to live with it, and to use it wisely MJA 1998; 169: 571-572 Recently, my personal computer at the Journal office was linked to the Internet, and thus, belatedly, electronic mail (email) became part of my life. Great were my expectations -- no more lonely and frustrating journeys through voicemail systems with their network of black holes, no more interminable periods of being suspended, "on hold", on the telephone or being bounced along the speaknet from receptionist to personal assistant to doctors.1 Even better, the telephone messages left on my desk, only to be lost amidst piles of wanted and unwanted paper, were to be a thing of the past! Email was to be my salvation -- my escape from the tyranny of the telephone. Despite my initial euphoria, the jury is still out! In the United States the use of email has increased dramatically from 100 000 users in the late 1970s to about 50 million in 1997, and it is predicted that there will be over 100 million users by 2000.2 In Australia, over 1.5 million people have access to email, and the number of subscribers is increasing at a phenomenal rate. These subscribers include about 500 000 home users, but educational institutions are the main users.3 This unprecedented expansion and the uptake of electronic communication have revolutionised effective and efficient communication, but there is also a downside. The release of my personal email address into cyberspace has meant that e-"junk"-mail and e-"chain"-mail can now be added to the irritating influx of irrelevant letters, facsimiles and brochures I already receive. It has also made me feel a loss of privacy. My office is now nakedly exposed to the world and I live in fear of 24-hour-a-day bombardment with irrelevant and inappropriate email. Thus, I have had to confront my first email crisis -- how will I manage this unwanted avalanche? The answer came from an illuminating speaker at a recent local communication conference who, when asked how he managed the large volume of email he received, explained that he does not read emails from people he does not know, as, if a message is important enough, the sender will usually phone him (Dr Karl Sveiby, Visiting Research Fellow, Queensland University of Technology, personal communication). What an elegant solution! In essence a hybrid between a telephone conversation and a conventional letter,2 email has its own language and defined protocols. Telephone conversations are valued for their spontaneity, flexibility and the important nuances of voice inflexions; letters have a long-standing tradition of etiquette, format, punctuation, capitalisation and observance of the rules of syntax. Email offers more permanence than telephone conversations, but its expression is often more spontaneous than that of letters. Thus, emails may be dispatched without editing, punctuation or capitalisation (the ee cummings email), or with no identification or contact details beyond those of the email address (the orphan email). The language of email is developing its own peculiar acronyms and abbreviations and, as its use proliferates, this "espeak" may eventually threaten the current vernacular. An email esperanto may yet evolve! However, despite my personal reservations, there is no doubt that email can and will revolutionise communications between physicians and their patients.4 Not only will email augment patient-doctor communication, it also has the potential to facilitate communications between the consumer, the medical practitioner and other healthcare providers. An overriding concern in the use of email in healthcare involves issues of security and confidentiality of medical information, protocols governing doctor-patient communication and potential medicolegal issues. The American Medical Information Association has recently published guidelines for email communication and for administrative and medicolegal aspects of the use of email.2 The communication guidelines include not using email for urgent matters, informing patients about who actually processes messages, establishing the types of transactions permitted over email, and instructing patients to put the type of transaction in the subject line of the message for filtering. The administrative and medicolegal guidelines include instructing patients on when and how to escalate to phone calls and hospital visits; not forwarding patient-identifiable information to a third party without the patient's express permission; double-checking all "To" fields prior to sending messages; using email encryption whenever practicable, but waiving this at the patient's request; and backing up email onto long term storage media at least weekly. Similar issues are touched upon by Carter in this issue of the Journal,5 but, to date, there are no comparable published Australian guidelines for the use of email in healthcare. With the progressive invasion of our lives by the Internet, surely the time has come for explicit local guidelines. Martin B Van Der Weyden Editor, Medical Journal of Australia Van Der Weyden MB. Hospital doctors and telephones. Med J Aust 1990; 103: 568-569. Kane B, Sands DZ, for the AMIA Internet Working Group Task Force on Guidelines for the Use of Clinic-Patient Electronic Mail. Guidelines for the use of electronic mail with patients. JAMIA 1998; 5: 104-111. Summers A. E-mail: first past the post. The Sydney Morning Herald 1997 Nov 13: 17. Mandl KD, Kohane IS, Brandt AM. Electronic patient-physician communication: problems and promise. Ann Intern Med 1998; 129: 495-496. Carter M. Should patients have access to their medical records? Med J Aust 1998; 169: 596-597. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Alternative Medicine Promoting evidence-based alternative medicine All therapies, orthodox or alternative, require high quality clinical trials MJA 1998; 169: 573-574 Alternative medicine is an integral part of the healthcare of many Australians. Approximately half of our population use at least one non-medically prescribed alternative medicine each year, and about 20% of Australians visit an alternative medicine practitioner.1 The estimated annual expenditure is over $900 million.1 There are probably many reasons for this widespread use of alternative medicine; one that has been suggested is a growing dissatisfaction with orthodox medicine.2 That alternative medicine is of increasing relevance to orthodox medicine is illustrated by the finding that almost two-thirds of United States medical schools have courses on alternative or complementary medicine.3Despite the demand for alternative medicine, there is a paucity of rigorous evidence about its effectiveness; there are few studies, and those that exist are often inconclusive. For instance, a meta-analysis of placebo-controlled trials of homoeopathy found "insufficient evidence that homoeopathy is clearly efficacious for any single condition", but, interestingly, that homoeopathy may be better than placebo for seasonal allergies and postoperative ileus.4 On balance, it must also be acknowledged that there are many gaps in the evidence about the effectiveness of orthodox medicine; however, orthodox medical practitioners are increasingly committed to evidence-based practice.5 A major challenge for evidence-based orthodox medicine is the availability of high quality clinical studies to form its evidence. For alternative medicine, there is a similar, if not greater, challenge that is demonstrated in this issue of the Journal. Liu and Douglas reviewed published reports (in English and Chinese) on the use of Chinese herbal medicines for acute respiratory infections (ARI);6Bowler et al studied the efficacy of Buteyko breathing techniques (BBT) in the management of asthma.7 Both articles highlight the difficulties in designing and implementing clinical research for interventions outside of the double-blind randomised controlled trial (RCT) of conventional drug therapy. In the systematic review of Chinese herbal medicines for ARI by Liu and Douglas, we learn of 27 studies that evaluated these products using RCT or controlled clinical trial methods.6 Although it is clear that scientists are trying to establish the efficacy of alternative therapies using widely accepted methods, the quality of the studies was insufficiently rigorous to allow conclusions to be drawn about the efficacy of herbal medicines. Specific problems with the reports included inadequate information about randomisation, and doubts about the quality of outcome data and statistical analysis. Liu and Douglas did identify one preparation, Shuang Huang Lian, as a promising remedy worthy of further study. The reviewers identify approaches that may lead to more rigorous evaluation of this form of alternative medicine. The evaluation of BBT by Bowler et al was designed to overcome many of the limitations in clinical methodology that occurred in the trials of Chinese herbal medicines.6 Buteyko breathing techniques are based on the premise that the pathophysiology in asthma is due to hypocapnia as a result of hyperventilation.7 Participants are taught a series of exercises that purport to correct hyperventilation and hypocapnia. As well as comparing BBT with placebo breathing and relaxation exercises for managing asthma, Bowler et al addressed the question of mechanism of action by testing directly whether BBT corrected hyperventilation and hypocapnia. They found no benefit of BBT compared with placebo breathing and relaxation techniques on objective measures of asthma, such as forced expiratory volume in one second, peak expiratory flow, and exacerbations, despite the study having adequate power to detect an important difference. However, there were important changes in other outcomes, including a significant reduction in the self-reported use of short-acting bronchodilators and trends for reduction in the self-reported use of inhaled steroids and for improved quality of life. The dilemma of having inconsistent results is made more complex by the potential of bias associated with the unanticipated failure of matching for telephone contacts when some of the BBT subjects were contacted frequently to ensure compliance with BBT. This co-intervention could bias the results, especially for self-reported outcomes, by creating an expectation of greater benefit from BBT. An additional observation of the study was that BBT did not correct hypocapnia, although it was associated with a reduction in minute ventilation. Consequently, it remains unclear whether hypocapnia and hyperventilation are important contributors to the pathophysiology of asthma, or merely a consequence of asthma itself. Overall, the study showed no improvement in the clinical severity of asthma in the BBT group, but there was a significant reduction in the use of beta2-agonists. These data indicate that some patients can cope with less medication and suffer no loss of control of their asthma. If this is the case generally, then many patients are taking unnecessary medication, leading to increases in adverse effects and expenses for these drugs. Medical practitioners should review regularly the asthma therapy of their patients and consider dosage reductions (back-titration).8 Both the above studies reinforce the need to improve the quality and quantity of evidence that is used to guide healthcare practice. This applies equally to both alternative and orthodox therapies. The increasing recognition of this need has prompted greater emphasis on clinical epidemiology in undergraduate and postgraduate education. The Cochrane Collaboration is an example of an organised approach to the production and dissemination of high quality evidence. It has an Airways Group, which produces systematic reviews of therapy in respiratory disease and includes alternative therapies in its scope.9 As demonstrated by the studies of Liu and Douglas and Bowler et al, particular problems in trials of alternative therapy include adequate blinding and the use of an appropriate placebo. Nonetheless, these are crucial elements to obtaining valid results. They require ingenious solutions, as demonstrated recently by the report of a "placebo" acupuncture needle.10 Essential in the evaluation of any healthcare intervention is the detection of adverse effects. Compared to the substantial regulation and surveillance of orthodox medicine, the relative lack of regulation for alternative medicine may suggest that it is without adverse effects. That this is not the case was most recently illustrated by reports in the New England Journal of Medicine on the direct, indirect and potential harm from alternative medicines, summarised in an accompanying editorial.11 The risks included delay in the use of scientifically validated therapy, and contamination of traditional or herbal medicines with oestrogenically active chemicals, digitalis, heavy metals and a neurologically active solvent. The need for attention to the safety of alternative medicines has been recognised in Australia.12 In summary, alternative therapies should be approached in the same way as some parts of orthodox medicine are evaluated now and how most, if not all, will be assessed in the future. That is, if shown to be effective and safe, they should be part of the range of interventions available to patients. Ineffective or unsafe therapies should be abandoned, and unproven interventions should be evaluated in high quality clinical trials. As proposed in the New England Journal of Medicine editorial,11 it may be time to stop using the terms "orthodox" and "alternative" and to classify health interventions into whether or not they have been shown to do more good than harm in scientifically valid studies -- an evidence-based approach to healthcare. Michael J Hensley Professor of Medicine, University of Newcastle, Newcastle, NSW and Director of Respiratory Medicine, John Hunter Hospital, Newcastle, NSW Peter G Gibson Staff Specialist in Respiratory Medicine, and Director, Airways Research Centre John Hunter Hospital, Newcastle, NSW and Conjoint Senior Lecturer, University of Newcastle, Newcastle, NSW MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of alternative medicine in Australia. Lancet 1996; 347: 569-573. Porter R. Medicine and the people. In: The greatest benefit to mankind. A medical history of humanity from antiquity to the present. London: HarperCollins, 1997; 668-709. Wetzel MS, Eisenberg DM, Kaptchuk TJ. Courses involving complementary and alternative medicine at US medical schools. JAMA 1998; 280: 784-787. Linde K, Clausius N, Ramirez G, et al. Are the clinical effects of homoeopathy placebo effects? A meta-analysis of placebo-controlled trials. Lancet 1997; 350: 834-843. Sackett D, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine. Melbourne: Churchill Livingstone, 1997. Liu C, Douglas RM. Chinese herbal medicines in the treatment of acute respiratory infections: a review of randomised and controlled clinical trials. Med J Aust 1998; 169: 579-582. Bowler SD, Green A, Mitchell CA. Buteyko breathing techniques in asthma: a blinded randomised controlled trial. Med J Aust 1998; 169: 575-578. Asthma Management Handbook. Melbourne: National Asthma Campaign, 1996. Cates C, DuCharne F, Gibson PG, et al, editors. Airways module of the Cochrane database of systematic reviews. The Cochrane Library [database on disk and CDROM]. Oxford: Update Software, 1998. Streitberger K, Kleinhenz J. Introducing a placebo needle into acupuncture research. Lancet 1998; 352: 364-365. Angell M, Kassirer JP. Alternative medicine -- the risks of untested and unregulated remedies. N Engl J Med 1998; 339: 839-841. Drew AK, Myers SP. Safety issues in herbal medicine: implications for the health professions. Med J Aust 1997; 166: 538-541. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Michael J Hensley · Peter G Gibson

Alternative Medicine Buteyko breathing techniques in asthma: a blinded randomised controlled trial Simon D Bowler, Amanda Green and Charles A Mitchell MJA 1998; 169: 575-578 For editorial comment see Hensley & Gibson Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on Respiratory medicine Abstract Objective: To evaluate the effect of Buteyko breathing techniques (BBT) in the management of asthma. Design: Prospective, blinded, randomised study comparing the effect of BBT with control classes in 39 subjects with asthma. The study was conducted from January 1995 to April 1995. Participants and setting: Subjects recruited from the community, aged 12 to 70 years, with asthma and substantial medication use. Main outcome measures: Medication use; morning peak expiratory flow (PEF); forced expiratory volume in one second (FEV1); end-tidal (ET) CO2; resting minute volume (MV); and quality of life (QOL) score, measured at three months. Results: No change in daily PEF or FEV1 was noted in either group. At three months, the BBT group had a median reduction in daily beta2-agonist dose of 904 µg (range, 29 µg to 3129 µg), whereas the control group had a median reduction of 57 µg (range, - 2343 µg to 1143 µg) (P = 0.002). Daily inhaled steroid dose fell 49% (range, - 100% to 150%) for the BBT group and 0 (range, - 82% to +100%) for the control group (P = 0.06). A trend towards greater improvement in QOL score was noted for BBT subjects (P = 0.09). Initial MV was high and similar in both groups; by three months, MV was lower in the BBT group than in the control group (P = 0.004). ET CO2 was low in both groups and did not change with treatment. Conclusion: Those practising BBT reduced hyperventilation and their use of beta2-agonists. A trend toward reduced inhaled steroid use and better quality of life was observed in these patients without objective changes in measures of airway calibre. Introduction Proponents of Buteyko breathing techniques (BBT) suggest that hyperventilation resulting in alveolar and airway hypocapnia is a major contributor to the pathophysiology of asthma.1 Advocates claim that exercises designed to reduce minute volume lead to improvements in asthma control and allow reduction of medication.1 To our knowledge, no formal study of the techniques has been reported in accessible publications. Aside from considerations of hyperventilation, a variety of breathing and relaxation techniques have been advocated for the complementary control of asthma. These include yoga,2,3 diaphragmatic breathing4 and progressive muscle relaxation.5 Although varying claims of efficacy have been made, no technique has been adopted by mainstream medical practice. We undertook a blinded, prospective, controlled, randomised study in people with asthma, in which we compared BBT with a placebo breathing technique, and measured lung function, medication use and quality of life. Methods Participants Subjects aged 12 to 70 years were recruited following a publicity campaign about breathing techniques in asthma by the Asthma Foundation of Queensland. People telephoning the Foundation enquiring about BBT were referred to the investigators. Individuals were accepted if they reported a history of asthma (variable difficulty in breathing, wheeze or chest tightness with response to beta2-agonist) and were taking substantial doses of asthma medication. To match the BBT and control groups for symptomatic asthma severity, trial participants were stratified by whether they were taking more or less than 5000 µg of salbutamol or equivalent a day, and were randomly allocated to treatment groups on the basis of a sealed envelope prepared by a clerical staff member not involved in the study. Trial participants, investigators and attending staff were blinded to which group randomisation had occurred; the term Buteyko was not used at any time by either control or BBT instructors. Subjects were excluded if there had been a change in inhaled steroid dose or use of oral steroids within the four-week run-in period, if there were other significant unstable medical conditions, or if they had undertaken BBT previously. Subjects were randomised if they were using at least 1400 µg of short acting beta2-agonist or equivalent doses of nebulised or long acting beta2-agonist in the last week of the run-in period. Nebulised beta2-agonist was considered one-fifth as effective as a dose delivered by metered dose inhaler.6 Standard doses of terbutaline and salbutamol were considered equipotent. Two doses of salmeterol (25 µg) via metered dose inhaler twice a day (100 µg/day) was considered equivalent to 200 µg of a short acting beta2-agonist every four hours (1200 µg/day).7 Intervention Trial participants underwent training simultaneously in two separate groups. Teaching occurred over seven days; each session lasted 60-90 minutes. BBT was taught by a representative of Buteyko Australia. Buteyko training consisted of the teaching of a series of exercises in which subjects reduced the depth and frequency of respiration. Breath holding exercises measured the impact of this training and gauged progress. Participants were encouraged to practise these exercises several times a day. The BBT instructor made follow-up phone calls to participants as she considered necessary, and people experiencing difficulty with the technique were given extra breathing classes, in accordance with standard Buteyko practices. In the control group, subjects were given general asthma education and relaxation techniques, and were taught abdominal breathing exercises which did not involve hypoventilation. The control group instructor made one follow-up phone call to each participant. In both groups subjects were directed to use beta2-agonists only when symptomatic. Subsequently, we telephoned the participants from both groups fortnightly and reiterated the beta2-agonist advice. Subjects were advised to reduce long acting bronchodilator dose only when short acting therapy was used once a day or less. At clinic review, six weeks after tuition, subjects using one dose a day or less of short acting beta2-agonists were directed to reduce their inhaled steroid dose. Further review and, where possible, inhaled steroid reduction was undertaken every two weeks by telephone. The study design is summarised in Figure 1, below. Outcome measures Patients kept diary cards at home for scoring symptoms (0 = no symptoms, 3 = maximal symptoms) and recording daily peak expiratory flow (PEF) and medication use. At clinic visits at the end of the run-in period and three months later, flow volume loops were recorded before and after administration of bronchodilator, and patients completed a self-administered quality of life questionnaire.8,9 The questionnaire measured the effect of asthma on quality of life across four domains: breathing, mood, social interaction and concerns for the future. At each clinic visit, indices of resting ventilation were measured. Subjects were told these techniques were to "assess breathing patterns" and were asked to "breathe normally". End-tidal (ET) CO2 (as a surrogate for arterial CO2) was recorded using continuously sampled nasal expired air, aspirated by nasal cannula and analysed using infra-red absorption (POET, Sensormedics, Wawkesha, USA). Minute volume (MV) was recorded with a 5 L water-sealed spirometer with a CO2 absorber using a mouthpiece and noseclip (Gould 2400, Sensormedics, Yoba Linda, USA). Twenty non-smoking healthy subjects age and sex matched with subjects with no history of upper or lower respiratory tract disease or other illness were recruited from hospital staff to provide comparative data for ET CO2 and MV. Statistical analysis Data were analysed using Statview.10 Paired data were compared using paired t test for normally distributed data, and Wilcoxon signed-rank test for non-parametric data. For unpaired data, unpaired t tests and Mann-Whitney U tests were used for parametric and non-parametric data, respectively. For non-parametric data Spearman's rank was used to investigate correlation. Data are expressed as median (range), or mean ± standard deviation. Ethical approval The Mater Adult Hospitals Ethics Committee approved the protocol, and informed consent was obtained from all subjects. Results Participants One hundred and seventy patients were screened for the study. Most proved either not to have asthma or to have unstable asthma as described above. Thirty-nine patients were randomised, 20 to the control group and 19 to the BBT group. No significant differences existed between the groups (Box). One person from each group was lost to follow-up after the intervention. Twenty normal subjects (10 women) were recruited; their median age was 43 years (range, 25-68). Follow-up calls BBT subjects each received a mean of seven (range, 0-20) follow-up telephone calls from the instructor, and extra classes were scheduled for seven BBT subjects who had difficulty with the technique. Indices of airway function There was no difference between the groups in measures of airway function. Morning pre-bronchodilator PEF was similar at both run-in (BBT, 385 ± 90 L/min; control, 375 ± 117 L/min; P = 0.3) and at three months (BBT, 374 ± 115 L/min; control, 383 ± 103 L/min; P = 0.6). Pre-bronchodilator percentage predicted FEV1 was also no different at run-in (BBT, 75% ± 17%; control, 73% ± 19%; P = 0.4) and at three months (BBT, 72% ± 22%; control, 72% ± 15%; P = 0.4). Indices of resting ventilation End-tidal CO2: No significant difference in mean ET CO2 existed between BBT and control groups either at run-in (BBT, 33 ± 5 mmHg; control, 32 ± 4 mmHg) or at three months (BBT, 35 ± 3 mmHg; control, 33 ± 3 mmHg). The normal subjects had significantly higher mean ET CO2 levels (41 ± 4 mmHg) than both the BBT and the control groups (Figure 2a). Minute volume: The normal subjects recorded a mean MV of 11.9 ± 0.8 L/min. Despite a trend (Figure 2b), there was no significant difference between these subjects and the BBT and control groups either at run-in (BBT, 14.0 ± 6.5 L/min; control, 14.2 ± 4.9 L/min) or at three months (BBT, 9.6 ± 3.1 L/min; control, 13.3 ± 4.0 L/min). At three months the mean MV for the BBT group was significantly less than for the control group (P = 0.004). The relative reduction in beta2-agonist use in the BBT group was related to the proportionate reduction in minute volume (r = 0.51; P = 0.04) Medication use Three months after intervention, there was a significant difference in beta2-agonist use between the BBT group and the control group (P = 0.005). The BBT group had a median reduction in daily adjusted beta2-agonist dose of 904 µg (range, 29 µg to 3129 µg) and the control group had a median reduction of 57 µg (range, - 2343 µg to 1143 µg) (P = 0.002) (Figure 3a). Despite a trend in inhaled steroid use (Figure 3b), there was no significant difference between the groups in absolute daily doses or change in dose at any time. The median reduction in daily dose at the third month, compared with run-in, was 49% (range, - 100% to + 83%) for BBT subjects and 0 (range, - 82% to + 100%) for control subjects (P = 0.06). Serious adverse events During the study, three subjects from each group were admitted to hospital for exacerbations of asthma. Apart from these, six BBT and seven control subjects received short courses of prednisone at some stage during the eight months after intervention. Quality of life No significant difference existed between the mean quality of life score of the two groups at any stage (Figure 4). At three months, there was a trend towards greater improvement in the BBT group: median improvement of 1.2 units (range, 5.2 to - 1.6) in the BBT group compared with 0.4 units (range, 3.4 to - 2.9) in the control group (P = 0.09). These changes were spread fairly evenly across all four domains. Discussion In this largely self-selected cohort of asthma sufferers with high medication use, those randomised to BBT lowered their minute volume, reduced beta2-agonist use, and demonstrated a trend towards lower inhaled steroid doses and greater improvement in quality of life than did those randomised to a control breathing program. No change in lung function was noted. To minimise the effect of environmental influences and to maintain blinding, BBT and control group classes ran simultaneously. This posed logistic problems not often encountered in asthma intervention studies, where subjects are usually enrolled sequentially over a substantial period of time, giving an opportunity to adjust treatment. The need to complete randomisation for all subjects before the interventions precluded comprehensive pre-study medication optimisation. Conventional teaching argues that hyperventilation and hypocapnia are the result rather than the cause of airway narrowing in asthma. Thus, increases in ventilation are seen in normal subjects with methacholine-induced bronchoconstriction.11 On the other hand, hyperventilation may cause bronchoconstriction.12,13 Gardner suggests that asthma and hyperventilation may interact through a process in which symptoms due to asthma and the consequent induced hyperventilation result in anxiety and further increases in minute volume.14 We could not show any change in ET CO2 in either BBT or control subjects; for both groups, ET CO2 remained significantly below that of normal individuals. MV was high (accepting a mean predicted resting MV of 5 L/min) in both BBT and control groups, and to a lesser (although statistically similar) extent in the normal subjects. Perhaps this may be explained in part by the use of a water-sealed spirometer, mouthpiece and noseclip, which have been shown to elevate tidal volume and respiratory rate.15 MV declined in the BBT group. Because MV and ET CO2 were measured at different times and on different devices, no direct correlation of MV and ET CO2 is possible. What alternative explanations are there for the observed improvements with BBT? Both groups were contacted fortnightly by the research team. In addition, some of the BBT subjects who were experiencing difficulties with the technique were contacted frequently by the Buteyko therapist. We did not anticipate this contact, which leaves the study open to the criticism that the BBT group were influenced in ways the control group were not. The study clearly would have been stronger with matched, controlled phone contact between both BBT and control practitioners and subjects. BBT might also have altered subjects' perceptions of asthma severity without affecting the underlying disease. This could account for the reduction in medication use and trends toward improvements in quality of life, and is consistent with the absence of any change in objective measures of airway calibre. On the other hand, the reduction in medication use in the BBT group did not lead to a decline in lung function, and rates of oral steroid use and hospital admission were similar in each group. Reduction in beta2-agonist use itself might have led to an improvement in asthma control. There are suggestions that excess beta2-agonist use may adversely affect asthma control.16 To our knowledge, no study has suggested the converse, that reduction in beta2-agonist use may improve asthma control. In conclusion, we found that those practising BBT reduced hyperventilation and their use of beta2-agonists. A trend toward reduced inhaled steroid use and better quality of life was observed in these patients without changes in objective measures of airway calibre. Acknowledgements A grant from the Australian Association of Asthma Foundations and assistance from Buteyko Australia supported the study. Ms Tess Graham of Buteyko Australia conducted the Buteyko breathing classes and reviewed the manuscript. Ms Jeanette Martin undertook the control group classes. The technical assistance of Mr Andrew Coates; the administrative help of Mr John Laing; and the assistance of the staff of the Asthma Foundation of Queensland are gratefully acknowledged. References Stalmatski A. Freedom from asthma: Buteyko's revolutionary treatment. Hale Clinic Health Library. London: KyleCathie Ltd, 1997; 175. Singh V, Wisniewski A, Britton J, Tattersfield A. Effects of yoga breathing exercises (pranayama) on airway reactivity in subjects with asthma. Lancet 1990; 335: 1381-1383. Jain SC, Talukdar B. Evaluation of yoga therapy programme for patients of bronchial asthma. Singapore Med J 1993; 34: 306-308. Girodo M, Ekstrand KA, Metivier GJ. Deep diaphragmatic breathing: rehabilitation exercises for the asthmatic patient. Arch Phys Med Rehabil 1992; 73: 717-720. Renfroe KL. Effects of progressive relaxation on dyspnea and state anxiety in patients with chronic obstructive pulmonary disease. Heart Lung 1988; 17: 408-413. Gibson PG, Wlodarczyk JH, Borgas T. Drug delivery in asthma: a comparison of spacers with a jet nebuliser. Aust N Z J Med 1995; 25: 324-329. Smyth ET, Pavord ID, Wong CS, et al. Interaction and dose equivalence of salbutamol and salmeterol in patients with asthma. BMJ 1993; 306: 543-545. Marks GB, Dunn SM, Woolcock AJ. A scale for the measurement of quality of life in adults with asthma. J Clin Epidemiol 1992; 45: 461-472. Marks GB, Dunn SM, Woolcock AJ. An evaluation of an asthma quality of life questionnaire as a measure of change in adults with asthma. J Clin Epidemiol 1993; 46: 1103-1111. Statview [computer program]. Version 4.1. Cary, North Carolina: SAS Institute, 1995. Chadha TS, Schneider AW, Birch S, et al. Breathing pattern during induced bronchoconstriction. J Appl Physiol 1984; 56: 1053-1059. Gayrard P, Orehek J, Grimaud C, Charpin J. Bronchoconstrictor effects of a deep inspiration in patients with asthma. Am Rev Respir Dis 1975; 111: 433-439. Van den Elshout FJ, van Herwaarden CL, Folgering HTM. Effects of hypercapnia and hypocapnia on respiratory resistance in normal and asthmatic subjects. Thorax 1991; 46: 28-32. Gardner WN. The pathophysiology of hyperventilation disorders. Chest 1996; 109: 516-534. Gilbert R, Auchincloss JH Jr, Brodsky J, Boden W. Changes in tidal volume, frequency, and ventilation induced by their measurement. J Appl Physiol 1972; 33: 252-254. Taylor DR, Sears MR, Herbison GP, et al. Regular inhaled beta agonists in asthma: effects on exacerbations and lung function. Thorax 1993; 48: 134-138. (Received 11 Aug 1997, accepted 18 Aug 1998) Authors' details Mater Adult Hospital, South Brisbane, QLD. Simon D Bowler, FRACP, Thoracic Physician. Brompton Hospital, South Kensington, London, UK. Amanda Green, GradDipPhys, Physiotherapist. Department of Medicine, University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD. Charles A Mitchell, FRACP, Associate Professor. Reprints: Dr S D Bowler, Director, Respiratory Medicine, Mater Adult Hospital, South Brisbane, QLD 4101. Email: sbowlerATmater.org.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Simon D Bowler · Amanda Green · Charles A Mitchell

Alternative Medicine Chinese herbal medicines in the treatment of acute respiratory infections: a review of randomised and controlled clinical trials Chaoying Liu and Robert M Douglas MJA 1998; 169: 579-582 For editorial comment see Hensley & Gibson Abstract - Introduction - Methods - Results - Discussion - References - Authors' details Make a comment - - - More articles on Complementary medicine Abstract Objective: To review clinical trials of Chinese herbal medicines (CHMs) in the management of acute respiratory infections (ARIs). Data sources: MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library and three Chinese medical journals available in Australia. Study selection: Studies in which a control group was used in comparing CHMs with a placebo or "Western medicine" (usually antibiotics) for treating ARIs were included. Data synthesis: 27 of 46 studies identified in the search of the databases and the Chinese journals fulfilled the inclusion criteria. Twenty-six of these were published in Chinese, and one in English. Twenty were randomised controlled trials and seven were "controlled clinical trials". Although most of the studies reported that CHMs are better than antibiotics for the treatment of ARIs, the quality of the studies was generally poor when evaluated for patient allocation, treatment description, outcome measurement and data analysis. Conclusions: Because the trial methodology of these studies was often inadequate or insufficiently documented, it is difficult to recommend the use of CHMs in ARIs. However, Shuang Huang Lian does appear to be useful for treating lower respiratory tract infections. More rigorous evaluation of CHMs is needed, as they are becoming popular treatments in many countries, including Australia. Introduction Acute respiratory infection (ARI) is the most common illness in childhood and is the leading cause of death in children younger than five years.1,2 In Western medicine, although ARIs are most commonly caused by viral infection, antibiotic agents are widely used in their treatment, despite evidence that the clinical benefits of antibiotics may be slight.3-5 In China, many physicians believe that traditional agents are effective in alleviating symptoms of ARIs, shortening the course of disease, helping recovery from severe illness, and minimising potential long term consequences of lung infections (Box 1).6-8 Chinese herbal medicines (CHMs) are not only routinely used for most respiratory ailments in hospitals in China, but are also commonly used by many Chinese people in the community. The effort to integrate Western and traditional approaches has resulted in a number of publications comparing the benefits of CHMs with Western medicine. Our aim was examine the available evidence in order to explore the generalisability of the traditional Chinese approach to clinical management and determine whether CHMs might be advocated in Australia, where CHMs are now widely marketed.9 Methods Data extraction MEDLINE (1966 to May 1997), the Cumulative Index to Nursing and Allied Health Literature (1982 to May 1997) and the Cochrane Library (1995 to May 1997) were searched for all studies in which CHMs were used to treat ARIs. We also performed a search of three Chinese publications available in Australia: Chung Kuo Chung Hsi I Chieh Ho Tsa Chih (the Chinese Journal of Integrated Traditional and Western Medicine) (1982 to 1996), Chinese Traditional Patent Medicine (1991 to 1996) and Chung Huo I Hsueh Tsa Chih (Taipei) (the Chinese Medical Journal of Taipei) (1986 to 1996). The search keywords were CHMs and acute respiratory infections (or bronchiolitis, pneumonia or viral infections); random allocation; treatment group/control group; CHMs group/Western medicine group. Inclusion criteria Studies were included in our review if they had used a control group to compare CHMs with a placebo or Western medicine. We assessed the quality of these studies from four perspectives: patient allocation, treatment description, outcome assessment, and data analysis. Results Of the 46 studies identified from the search, 27 fulfilled our inclusion criteria.10-36 Ten studies involved upper respiratory tract infections (URTI) (Box 2), and 17 involved lower respiratory tract infections (LRTI) (Box 3). Twenty-six studies were published in Chinese, and one in English.29 Only the article written in English was found in the databases. Treatment Most studies used a herbal tea or patent medicine, although six used parenteral preparations and one study36 used a topical herbal preparation. Treatment duration was three to seven days for URTIs, and more than seven days for LRTIs. The control treatment was antibiotics in 18 studies, antiviral agents in five, symptomatic and supportive therapy in three, and a placebo in one. Clinical outcomes Various methods of reporting outcome were described; a common approach was to report an "effect rate" from less effective to significantly effective. CHMs were reported to have a significantly higher effect rate in 15 of 22 studies (Box 4). Generally, CHMs were reported to produce greater improvement in clinical symptoms and physical signs and a shorter hospital stay. Five out of seven studies testing Maxingshigangton20-24,28,32 and all studies using Shuang Huang Lian29,31,34 reported better treatment effects on bronchiolitis and pneumonia. Assessment of study quality We rated only two studies as of high methodological quality. Both examined the efficacy of intravenous Shuang Huang Lian for LRTIs.29,34 Patient allocation: Twenty studies reported a randomisation strategy, but only three21,30,35 described the allocation method. Three studies29,30,36 reported using single- or double-blind methods in the study. Treatment description: Most studies provided information about the main herbs included in the formulation, dose, course and treatment approach. Information on safety or side-effects of the herbal medicines tested was provided in only four studies.11,17,23,29 In eight studies11,12,14,16,18,21,23,31 the treatment applied to the control group was not described or was manifestly not identical to that of the experimental group in manner of administration. Outcome assessment: Twenty-two studies used a rate to assess the outcome. Eight of these14,15,19,22,23,28,30,36 did not provide adequate information on what constituted the degree of effect or on the defined time point for outcome measures. Satisfactory outcome measures were identified in only eight studies.11,12,22,26,27,29,32,34 Data analysis: Thirteen studies reported baseline data about the participants; only one29 tabled the baseline comparison. Six studies11,17,20,21,29,34 presented statistical results such as mean and standard deviation. Two studies18,28 drew a conclusion regarding efficacy without any reference to statistical analysis. Discussion Although CHMs are the subject of many Chinese research publications, definitive conclusions about their efficacy are difficult to draw. There are perceived ethical constraints about conducting rigorous randomised controlled trials in China, and placebo and double-blind methods are not generally accepted in clinical research, especially for time-honoured and widely used treatments. The inadequate methods of most studies make it difficult to transfer the Chinese confidence in CHMs to other settings. In the articles we reviewed, there was insufficient information on randomisation and baseline comparisons, outcome measures were either complicated or of doubtful validity, and terms were poorly defined or explained. Data analysis and presentation were generally too limited to enable us to assess the adequacy of the statistical analysis. Most of the studies failed to deal with potential confounding factors, and for several reports the timing of outcome measures was inappropriate. Nevertheless, in Chinese practice these traditional approaches are seen as appropriate treatment for ARIs. They are often used as life-saving remedies in preference to antibiotics. From this review, we have been impressed by the "clinical effects" of Maxingshigantong and intravenous Shuang Huang Lian for treating bronchiolitis and pneumonia. On the evidence provided, Shuang Huang Lian appears to be a promising remedy worthy of further study. Interestingly, no studies evaluated the herbs and formulas most widely used in the community for treating the common cold and other common URT infections in China. Perhaps the most widely used herbal medicines, such as Banlangen Chong Ji (tea) and Ganmaoqingre Chong Ji, are so firmly trusted by both clinicians and the community that evaluation is not considered necessary. The one trial published in English was carried out collaboratively between the University of Newcastle, Australia, and the Harbin Medical University, China, and used rigorous procedures to conclude that bronchiolitis was better treated with Shuang Huang Lian than with antibiotics.29 More studies of this calibre are needed. In our view, the scientific evidence that CHMs are more effective than antibiotics in ARIs is inadequate. Our analysis indicates the need for more rigorous evaluation of CHMs, including descriptions of their derivation, preparation, standardisation, potency, safety, and efficacy, if they are to meet modern Western criteria for their use. We suggest that, acknowledging the difficulty in conducting randomised controlled trials in China, the following approaches may be needed: further studies should examine herbs and formulas that are widely used and accepted by Chinese practice as well as those that show promise in treating ARIs; further international collaborations should be encouraged; protocols for studies in which CHMs are tested in clinical settings outside China should be developed; and training for Chinese doctors in clinical trial methodology should be supported through the International Clinical Epidemiology Network, with a view to more rigorously testing the clinical value of CHMs. References BOSTID Researchers. 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[Comparison of Chinese medicine with Western medicine for treatment of paediatric bronchitis.] Chung Kuo Chung Hsi I Chieh Ho Tsa Chih 1989; 9: 30. Chinese.* Pang JC. [Clinical investigation on 50 cases of severe paediatric pneumonia treated with Danshi (Salviae miltiorrhirae) injection.] Chung Kuo Chung Hsi I Chieh Ho Tsa Chih 1990; 11: 566. Chinese.* Zhu CY. [A report of 56 cases of paediatric pneumonia with heart failure treated by combined Chinese and Western medicine.] Chung Kuo Chung Hsi I Chieh Ho Tsa Chih 1991; 11: 56. Chinese.* Hu RS, Li YQ, Yuan W, Zhang SL, et al. [Clinical and experimental study of Xiao Er Ke Chaun Ling oral liquid in treating infantile bronchopneumonia.] Chung Kuo Chung Hsi I Chieh Ho Tsa Chih 1992; 12: 719-737. Chinese. Kong XT, Fang HT, Jiang GQ, et al. Treatment of acute bronchiolitis with Chinese herbs. Arch Dis Child 1993; 68: 468-471. Wu KH, Hu TC, Liu XF. [Clinical investigation on 119 cases of paediatric pneumonia treated with Jieduling (defebrile and detoxication) injection.] Chung Kuo Chung Hsi I Chieh Ho Tsa Chih 1994; 14: 116-117. Chinese.* Li MZ, Lu S, Tong QM, et al. [Investigation on therapeutic effect of Shuang Huang Lian injection for treatment of paediatric pneumonia.] Chung Kuo Chung Hsi I Chieh Ho Tsa Chih 1994; 14: 232-233. Chinese.* Li YX, Zhang YH. [Investigation on therapeutic effect of Chinese medicine in treating paediatric pneumonia.] Chung Kuo Chung Hsi I Chieh Ho Tsa Chih 1994; 14: 573. Chinese.* Hong JX, Xie T, Gao YW, et al. [Clinical and experimental study on oral liquor night-cough tranquiller in treating infantile cough.] Chung Kuo Chung Hsi I Chieh Ho Tsa Chih 1995; 15: 25-27. Chinese. Yu JE, Zheng Y, Tang WY, et al. [Analysis of curative effect of Shuang Huang Lian powder for injection for paediatric pneumonia in 110 cases.] Chinese Traditional Patent Medicine 1996; 15: 24-25. Chinese. Shi YM, Zhang YQ, Fang SQ. [Clinical and experimental studies of Zhenkeling Oral Liquor on treatment of infantile cough.] Chung Kuo Chung Hsi I Chieh Ho Tsa Chih 1996; 16: 390-393. Chinese. Weng CX, Li G, Zheng SL. [Application of modified therapeutic system in treatment of upper respiratory viral infection in childhood with Chinese medicine.] Chung Kuo Chung Hsi I Chieh Ho Tsa Chih 1996; 16: 693. Chinese.* * Title translated by C L. (Received 24 Feb, accepted 23 Jul, 1998) Authors' details National Centre for Epidemiology and Population Health, The Australian National University, Canberra, ACT. Chaoying Liu, MB BS, PhD, Visiting Fellow; Robert M Douglas, MB BS, MD, Director. Reprints will not be available from the authors. Correspondence: Dr C Liu, National Public Health and Planning Branch, Public Health Division, MDP 16, Commonwealth Department of Health and Aged Care, Woden, ACT 2601. Email: chaoying.liuAThealth.gov.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> We appreciate

Chaoying Liu · Robert M Douglas

Alternative Medicine Hypericum perforatum (St John's wort) in depression: pest or blessing? Joseph M Rey and Garry Walter St John's wort (SJW) was introduced into Australia during the 1880s for medicinal purposes, but was subsequently declared a noxious weed. There is now a resurgence of interest in the therapeutic properties of this herb. In particular, use of SJW as an antidepressant has increased in recent months owing to reports of its effectiveness and safety. Nevertheless, the controlled trials available have limitations. Increasing use of SJW in the community poses a variety of questions. For example, should medical practitioners become more knowledgeable about the effects and interactions of alternative remedies? What are the ethical and medical implications of "antidepressant" prescribing by non-medical persons? Who is to fund further research and treatment studies? How can quality of SJW preparations be guaranteed? (MJA 1998; 169: 583-586) Introduction - Botany - Active constituents - Antidepressant? - Mechanism of action - "First, do no harm" - Other health claims - Preparations - Precautions - Implications - Acknowledgements - References - Authors' details - - More articles on Complementary medicine "What is a weed? A plant whose virtues have not been discovered" - Ralph Waldo Emerson, Fortune of the Republic. Introduction Although a considerable proportion of the Australian population uses herbal medicines regularly,1,2 most medical professionals distrust herbal remedies and know little about them.3 This scepticism may be related to the perception that many of the claims of herbalists are unproven or fanciful. One of the current health crazes in Europe and the United States concerns Hypericum perforatum, more commonly known as St John's wort (SJW). Used to treat a range of ailments for more than 2000 years, and said to have been prescribed by Hippocrates himself,4 it is the apparent value of SJW as an antidepressant that has captured most recent attention, and been the subject of a recent meta-analysis.5In the past year alone, 10 books extolling the antidepressant effects of SJW were published. The titles are eloquent enough, among them St John's wort: nature's blues buster6 and The natural Prozac program: how to use St John's wort, the antidepressant herb.7 There have also been many review articles published in botanical and herbal medicine journals.8 An article in Time9 in 1997 elevated the herb to superstar status in the United States, and sales of SJW in that country skyrocketed. In Germany, SJW is used more extensively than conventional antidepressants for treating depression.10 In Australia, SJW has been attracting increasing media attention. Undoubtedly, consumption of this herb will become more prevalent. Are assertions about the antidepressant effects of SJW justified? The fact that the National Institute of Mental Health (NIMH) in the United States recently funded a US$4 million trial gives some credence to the claims. The NIMH study is testing whether SJW is more effective than a placebo or a selective serotonin reuptake inhibitor in the treatment of depression. If SJW does reduce depressive feelings, should we recommend its use? Are the extracts from SJW safe for human consumption? In this article, we seek to answer these questions and to inform clinicians about this herbal treatment, particularly in relation to depression. Botany The genus Hypericum contains more than 300 species. Hypericum perforatum is the species most often used in herbal remedies. It is an upright bush, growing to a metre tall, with oblong, perforated leaves and bright yellow flowers (see Figures). The leaves are dotted with translucent glands. There are many explanations for the appellation "St John's wort" (wort means "plant" in Old English); one is that the plant was named after St John the Baptist because the flowers were said to bloom on the anniversary of his execution. SJW is native to Europe, Asia and Africa, but not Australia. It has been introduced to parts of Queensland, New South Wales, Victoria, South Australia and Tasmania. The original introduction has been traced to the Ovens Valley in Victoria during a gold boom in the 1880s, when a German woman imported seed of the plant and established it for medicinal purposes.11 It soon overran her garden and spread to the nearby racecourse, from where it attracted the local name of "racecourse weed". As the goldminers moved out seeking new fields, the plant went with them, mainly in chaff for their horses. SJW has been declared a noxious weed in most areas; however, in some quarters the attitude towards the herb has changed and it is beginning to be seen as a cash crop. Earlier this year, the St John's Wort Landholders' Association was launched in Bathurst, NSW, to encourage harvesting of the weed.12 Australia expects to provide up to 20 per cent of the 7000 tonnes of SJW used worldwide each year.12 Active constituents Many constituents with potential biological activity have been extracted from the flowers and leaves, the parts of the plant used for medicinal purposes.4,8 These include naphthodianthrones, flavonoids, phloroglucinols and xanthones. Hypericin, one of the naphthodianthrones, has traditionally been considered the main active ingredient, but it is not known whether it is the antidepressant compound. The amount of hypericin varies widely in different parts of the plant, under different growth conditions, and at different times of the year.4,8 Is St John's wort antidepressant? Most of the research on SJW has been performed in Germany and published in Continental journals. There have been numerous open trials of SJW in depression and 24 double-blind studies: eight randomised, double-blind studies comparing SJW to other active medications (desipramine,13 imipramine,14,15 amitryptiline,16,17 diazepam18,19 and maprotiline20) and 16 randomised, double-blind studies comparing SJW to placebo. In two studies13,21 SJW was used in combination with valerian. There have been no head-to-head trials with newer antidepressants. As noted, an NIMH study is currently comparing SJW with a selective serotonin reuptake inhibitor and a placebo. A meta-analysis assessing 23 of the double-blind trials was published recently,5 and will not be replicated in this article. In summary, most patients in the reports had mild to moderately severe depression. (In mild depression the patient is distressed by depressive symptoms but will probably be able to perform most activities; symptoms are more numerous and intense when depression is of moderate severity, and the patient is likely to have significant difficulty in continuing with ordinary activities.)22 Three trials included patients with severe depression. Most trials lasted four to eight weeks. Across all reports, 50%-80% of patients improved with SJW, a rate similar to that achieved with conventional antidepressants. Patients with mild to moderate depression fared best. Vorbach et al found SJW superior to imipramine (75 mg/day) in severe depression,15 but the dose of imipramine was inadequate. SJW was found to be as effective as phototherapy in patients with seasonal affective disorder.23 A field of St John's wort. Declared a noxious weed in most areas of Australia, St John's wort is now being seen as a cash crop. Inset: Details of the flower. Photos courtesy of NSW Agriculture. Linde et al concluded that these studies had significant limitations.5 Most of the trials were small and used heterogeneous patient groups. Classification of depression was not uniform and none of the studies lasted longer than 12 weeks. Dosages of antidepressant in the comparison trials were subtherapeutic or in the low therapeutic range. Mechanism of action Although the exact mechanism of action remains obscure, substances contained in SJW extracts have been found to interact with a number of neurotransmitter systems implicated in depression and in psychiatric illness generally. SJW inhibits uptake of serotonin, noradrenaline and dopamine. Crude extract of SJW has a potent affinity for g-aminobutyric acid (GABA) receptors and inhibits monoamine oxidase.24 Recently, it has been postulated that the antidepressant effect of SJW may be due to its effect on interleukin-6.25 It is also of interest that the plant has high concentrations of melatonin,26 increases nocturnal production of melatonin,4 and increases deep sleep.27 Melatonin is thought to play a role in the aetiology of seasonal affective disorder and sleep.28 "First, do no harm" The popular belief that "natural products are safe" has not always been vindicated, as the tragic experience with royal jelly revealed.29 However, SJW has not been associated with serious adverse events in humans and appears well tolerated. The rates of adverse events with placebo (4.8%) and SJW (4.1%) in placebo-controlled trials are comparable.5 Fewer than 2% of patients in studies have stopped taking SJW.30 In an open trial of 3250 patients taking hypericum, side effects were reported by 2.4% of subjects.30 The most commonly noted adverse events were gastrointestinal symptoms (0.6%), allergic reactions (0.5%), fatigue (0.4%) and restlessness (0.3%). Other adverse reactions reported were emotional vulnerability, pruritus, weight gain and dizziness.4 Severe phototoxicity has been reported in cattle and sheep grazing on the plant8 (the veterinary term is "hypericism"), but not in humans taking therapeutic (antidepressant) doses. However, photosensitivity does appear to be a common problem for AIDS patients treated with high doses of hypericum in studies of the antiviral properties of SJW.4During the past 25 years there have been three reports, all in the past few months, to the Australian Adverse Drug Reactions Advisory Committee (ADRAC) relating to SJW (Dr Patrick Purcell, Acting Head, ADRAC, personal communication). These comprised hyperaesthesia in a 38-year-old woman; a combination of dyspnoea, flushing, headache, hyperventilation, mydriasis, nausea, pain, palpitations, rhinitis and tremor in a 47-year-old woman; and a fall in cyclosporin levels to 25% of previous levels in a woman in her mid-twenties (enzyme induction?). The low rate of reports to ADRAC may be due to under-reporting, insufficient identifying information about many of the herbs reported, uncommon use (until recently), or a low actual rate of adverse effects.31 Other health claims SJW is being promoted as a treatment for a range of other ailments besides depression, including anxiety and "stress", sleep problems, nocturnal enuresis, bacterial and viral infections, respiratory conditions, peptic ulceration, inflammatory arthritis, cancer, and skin wounds.4 It is also said to increase libido, an application dating from the Middle Ages: Take the ash of starlizard, civet oil and St John's wort oil. Smeared on the toe of the left foot and on the loins, the ointment will serve to reinvigorate.32 Tradition further had it that the herb would be most effective for stimulating sexual desire when picked at night while the picker was naked!32 Preparations, dosage and administration SJW is available as tablets, capsules, drops and teas and is produced by many manufacturers. An oil form is available for external use but has no place in treating depression. The optimum adult dose of SJW for treating depression, based on available studies, appears to be 300 mg of plant extract orally three times daily. However, doses used varied considerably among studies, and there are no systematic studies on the minimum therapeutic dose. Furthermore, the amount of active substances might vary depending on factors such as the extraction process, season, and plant part used. As with prescription antidepressants, there is a lag in onset of action. If side effects are intolerable, or if at six weeks SJW is deemed to be ineffective, the patient can be weaned off SJW and another antidepressant considered. Unfortunately, there are no data about "washout periods" following discontinuation of SJW. A conservative approach is to wait two weeks after ceasing SJW before commencing another agent. Precautions Because SJW may potentiate monoamine oxidase inhibitors (MAOIs), its combination with these compounds is best avoided. At this stage, combining SJW with other antidepressants is strongly discouraged for the same reasons. To our knowledge, there are no reports of dietary interactions with SJW, similar to those found with MAOIs, and no empirical studies dealing with this issue. Uterotonic activity has been reported in animal experiments,33 and for this reason SJW is not recommended in pregnancy. SJW has not been evaluated in children and adolescents. Because of the potential risk of phototoxicity, it has been suggested that patients should be advised not to sunbathe (naturally or artificially) while taking SJW and not to concurrently use photosensitising drugs such as chlorpromazine or tetracyclines. Implications for practice, research and policy Over the past few years the physical treatment of depression has been bolstered by the emergence of a number of new classes of antidepressant (such as selective serotonin reuptake inhibitors, reversible inhibitors of monoamine oxidase type A, serotonin and noradrenaline reuptake inhibitors, and 5-HT2 antagonists). A variety of augmenting agents are available and electroconvulsive therapy retains a place for more severe cases. Cognitive-behaviour therapy is also effective. Nevertheless, not all patients benefit from "standard" treatments and some people experience troublesome side effects. Further, antidepressant drugs are yet to meet with uniform community acceptance. A recent national survey found that, for depression, conventional antidepressants were perceived as helpful by 29% of respondents and harmful by 42%.34 In contrast, the treatment category that included vitamins, minerals, tonics and herbal medicines was considered helpful by 57% of respondents and harmful by 3%. Clearly, there is scope for alternative antidepressants if they can be shown to be safe and effective. SJW is the best known of several herbs being touted as antidepressant.24 However, available evidence for SJW is insufficient at this stage. Indeed, one of the aims of treating depression, the prevention of suicide, could be compromised by using a treatment that is yet to be fully investigated. If SJW is to consolidate a place in the medical armamentarium, several issues relating to clinical practice, research and policy will need to be addressed: Acknowledgement by medical practitioners of the existence of an alternative treatment system. The presence of another therapeutic system cannot be ignored.3,34,35 We need to routinely ask our patients about their use of SJW and other herbal preparations. This is particularly important as concurrent use of SJW and other antidepressant drugs may be harmful. Quality control of SJW preparations. The Register of Therapeutic Goods currently categorises SJW and most herbal preparations as "listed drugs", which are subject to fewer checks than "registered drugs". Apart from having to satisfy less-rigorous efficacy and safety criteria compared with registered drugs, listed drugs lack standardised preparation and are more prone to contamination, substitution, adulteration, incorrect packaging, wrong dosage, and inappropriate labelling and advertising.31 For example, in the case of SJW there is presently no way of knowing that the correct species of Hypericum is used, that the plant is harvested at the right time of year, that appropriate plant parts are chosen, dried and stored properly, and that the extraction process is uniform. All of these are known to affect biological activity. Funding of further research. Several breakthroughs in therapeutics have resulted from the study of natural substances,24 and SJW also promises to be rewarding in this area. However, further research into SJW will need to be funded from outside the pharmaceutical industry, by the National Health and Medical Research Council or other institutions. Herbal treatments cannot be patented, so the financial incentives for research that drive the pharmaceutical market are limited. Determination of the antidepressant component. SJW has many biologically active components. Determination of which of these are antidepressant may, in turn, contribute to the development of more refined preparations of SJW and further antidepressants, as well as increase our knowledge about the aetiology of depression. New treatment studies. To date, duration of trials has ranged from two to 12 weeks. Longer-term studies should be done to assess long term effects and the effectiveness of SJW in preventing relapse. Patient populations need to be described better and therapeutic doses of comparison antidepressants need to be used. Evaluation of SJW in certain subgroups. SJW has mainly been studied in adults with mild to moderate depression. There is a need to evaluate the herb in severely depressed patients. There is also a growing realisation that major depression is not uncommon in young people. Adult data cannot necessarily be generalised to the young, as the experience with tricyclic antidepressants has shown.36 Trials with children and adolescents are therefore necessary. The current situation in which treatment of depression with SJW is initiated by non-medical persons is fraught with danger. Suicide risk has been mentioned already. Non-medical prescription and supervision may preclude patients from receiving antidepressant treatments of demonstrated effectiveness. This has ethical implications, particularly in the case of children.37 Also, medical conditions that mimic depression, some of them common (eg, hypothyroidism), may remain unidentified and untreated. On the other hand, access to an over-the-counter antidepressant might be useful for patients with subclinical depression who are unlikely to be treated otherwise.38 For these reasons, a wider debate about who should prescribe SJW may be necessary. We find ourselves in the midst of an era in which new, better-tolerated therapeutic agents are being regularly introduced. Paradoxically, patients are turning to herbal remedies. Time will tell whether, in Australia, SJW is allowed to blossom in medicine as a bona fide antidepressant, or whether it should be weeded out. Acknowledgements Con Spiliopoulos, Glenda Schaffer, Susie Freeman, Rachel Rees, Patrick Purcell and Helen Cameron are thanked for their assistance. References MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of alternative medicine in Australia. Lancet 1996; 347: 569-573. Kristoffersen SS, Atkin PA, Shenfield GM. Uptake of alternative medicine [letter]. Lancet 1996; 347: 972. Thompson A. As patients embrace herbal remedies, dearth of scientific evidence frustrates clinicians. Am J Health Syst Pharm 1997; 54: 2656, 2658, 2664. Chavez ML, Chavez ML. Saint John's wort. Hosp Pharm 1997; 32: 1621-1632. Linde K, Ramirez G, Mulrow CD, et al. St. John's wort for depression: an overview and meta-analysis of randomised clinical trials. BMJ 1996; 313: 253-258. Cass H. St John's wort: nature's blues buster. New York: Avery Publishing Group, 1998. Zuess J. The natural Prozac program: how to use St John's wort, the antide pressant herb. New York: Three Rivers Press, 1997. Wohlmuth H. St John's wort -- phytotherapy for depression. Botanical Pathways 1997; 2: 3-5. Nash M. Nature's Prozac? Time 1997; Sep 22: 80-81. De Smet PAG, Nolen WA. St John's wort as an antidepressant. BMJ 1996; 313: 241-242. Parsons WT. Noxious weeds of Victoria. Melbourne, Inkata Press, 1973. Crossweller A. Farmers to cash in by weeding out wort. Daily Telegraph (Sydney). 1998; July 6: 5. Steger W. Depressive verstimmungen. Z Allgemeinmed 1985; 61: 914-918. Werth W. Psychotonin M versus imipramin in der chirurgie. Der Kassenarzt 1989; 15: 64-68. Vorbach EU, Hubner WD, Arnoldt KH. Effectiveness and tolerance of the hypericum extract L1 160 in comparison with imipramine: randomised double blind study with 135 outpatients. J Geriatr Psychiatry Neurol 1994; 7 Suppl 1: S19-S23. Kniebel R, Burchard JM. Zur therapie depressive verstimmungen in der praxis. Z Allgemeinmed 1988; 64: 689-696. Bergmann R, Nubner J, Demling J. Behandlungen leichter bis mittelschwerer depressionen. Therapiewoche Neurologie/Psychiatrie 1993; 7: 235-240. Warnecke G. Beeinflussung klimakterischer depressionen. Z Allgemeinmed 1986; 62: 1111-1113. Panijel J. Die behandlung mittelschwerer angstustande. Therapiewoche 1985; 41: 4659-4668. Harrer G, Hubner WD, Podzuweit H. Effectiveness and tolerance of the hypericum extract L1 160 compared with maprotiline: a multi-centre double-blind study. J Geriatr Psychiatry Neurol 1994; 7 Suppl 1: S24-S28. Ditzler K, Gessner B, Schatton WFH, Willems M. Clinical trial on Neuropas versus placebo in patients with mild to moderate depressive symptoms: a placebo- controlled, randomised double-blind study. Complement Ther Med 1994; 2: 5-13. World Health Organization. The ICD-10 classification of mental and behavioral disorders. Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization, 1992; 121-122. Martinez B. Hypericum in the treatment of seasonal affective disorder. J Geriatr Psychiatry Neurol 1994; 7 Suppl 1: S29-S33. Cott J. Natural product formulations available in Europe for psychotropic indications. Psychopharmacol Bull 1995; 31: 745-751. Thiele B, Brink I, Ploch M. Modulation of cytokine expression by Hypericum extract. J Geriatr Psychiatry Neurol 1994; 7 Suppl 1: S60-S62. Murch SJ, Simmons CB, Saxena PK. Melatonin in feverfew and other medicinal plants. Lancet 1997; 350: 1598-1599. Schulz H, Jobert M. Effects of hypericum extract on the sleep EEG in older volunteers. J Geriatr Psychiatry Neurol 1994; 7 Suppl 1: S39-S43. Wirz-Justice A. Biological rhythms in mood disorders. In: Bloom FE, Kupfer DJ, editors. Psychopharmacology: the fourth generation of progress. New York: Raven Press, 1995; 999-1018. Bullock RJ, Rohan A, Straatmans JA. Fatal royal-jelly induced asthma [letter]. Med J Aust 1994; 160: 44. Woelk H. Benefits and risks of the hypericum extract L1 160: drug monitoring study with 3250 patients. J Geriatr Psychiatry Neurol 1994; 7 Suppl 1: S34-S38. Drew AK, Myers SP. Safety issues in herbal medicine: implications for the health professions. Med J Aust 1997; 166: 538-541. Fletcher K. Themes for herbal gardens. Ringwood, Victoria: Viking, 1996; 16. Shiplochliev T. Extracts from a group of medical plants enhancing the uterine tonus. Vet Med Nauki 1981; 18: 94-98. Jorm AF, Korten AE, Jacomb PA, et al. Mental health literacy: a survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Med J Aust 1997; 166: 182-186. Shenfield GM, Atkin PA, Kristoffersen SS. Alternative medicine: an expanding health industry. Med J Aust 1997; 166: 516-517. Hazell P, O'Connell D, Heathcote D, et al. Efficacy of tricyclic drugs in treating child and adolescent depression: a meta-analysis. BMJ 1995; 310: 897-890. Komesaroff PA. Use of complementary medicines: scientific and ethical issues. Med J Aust 1998; 169: 180-181. Cott JM, Fugh-Berman A. Is St John's wort (Hypericum perforatum) an effective antidepressant? J Nerv Ment Dis 1998; 186: 500-501. Authors' details Rivendell Unit, Concord West, NSW. Joseph M Rey, PhD, FRANZCP, Director, and Clinical Professor, Department of Psychological Medicine, University of Sydney; Garry Walter, FRANZCP, Inpatient Director, and Clinical Lecturer, Department of Psychological Medicine, University of Sydney. Reprints will not be available from the authors. Correspondence: Dr J M Rey, Rivendell Unit, Hospital Road, Concord West, NSW 2138. E-mail: jreyATmail.usyd.edu.au ©MJA 1998 Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Joseph M Rey · Garry Walter

Soundwaves Otoacoustic emissions and recreational hearing loss Noise-induced hearing loss may now be detectable before it becomes clinically obvious MJA 1998; 169: 587-588 The risk of noise-induced hearing loss from amplified music was predicted by Carter et al in 1982, who noted that, in a study of 994 subjects aged 16 to 20 years, ". . . the accumulated exposure of some of them to noise is such that, if their recreational patterns remain the same, they are at risk of some noise-induced hearing loss by their mid 20s. Further empirical studies are necessary to determine whether these hearing losses will eventuate".1 In this issue of the Journal (page 588), LePage and Murray use the relatively new technique of otoacoustic emission (OAE) analysis to investigate noise-induced hearing loss resulting from the use of personal stereo headsets.2 Their results suggest that personal stereo use results in a decline in cochlear function analogous to rapid ageing of the cochlea, and comparable to hearing loss from industrial noise trauma. They also emphasise that, as OAE analysis can detect decline in cochlear function long before there is any clinically detectable hearing loss, this technique can potentially provide early warning of noise-induced hearing loss. Otoacoustic emissions were first described by Kemp3 in 1978. They are sounds thought to be generated by the cochlear outer hair cells in response to an external sound stimulus. Normal hearing threshold is achieved by a cochlear mechanism, thought to reside in the healthy outer hair cell, which magnifies the stimulus internally. When this mechanism loses the peak of its performance, OAEs diminish and hearing threshold is raised. As OAEs can be recorded in the outer ear, they may provide an objective, non-invasive and quantitative measure of hair-cell function.4,5 High test-retest reliability has been demonstrated for individuals, although there is variability between subjects.6 Four types of OAEs have been described.7,8 Spontaneous OAEs occur in 68% of infants younger than 18 months, but the incidence falls to 35% in adults under 50, and to 20% of adults over 50 years.9 Transient-evoked OAEs (TEOAEs), a response to acoustic clicks delivered to the outer ear, are currently thought to be the most clinically useful OAEs, as they are detectable in 98% of people with normal hearing, regardless of age or sex, and the two ears of any individual produce similar TEOAEs. Stimulus-frequency OAEs occur in 88%-100% of people with normal hearing, and resemble TEOAEs in behaviour. They represent fixed-place emissions corresponding to specific frequency sites along the organ of Corti, but their usefulness as a clinical test is limited by technical factors. Distortion-product OAEs (DPOAEs) also occur in 100% of people with normal hearing, and, while small in amplitude, can be used to intentionally test a specific frequency region of the cochlea. DPOAEs are technically difficult to measure, but will become an essential tool in the investigation of tonotopic outer hair cell function. Probst et al have provided an extensive review of the technical details, experimental and clinical findings of otoacoustic emission analysis.10 Measurement of OAEs has become a useful audiologic and otoneurologic diagnostic test for neonatal screening,4,9 otosclerosis,11 sensorineural hearing loss,4,5,12 Meniere's disease,5 acoustic neuroma,5 tinnitus,13 ototoxicity,7 and noise-induced hearing loss.5,12,14 A limiting factor in this kind of ear testing is that eustachian tube dysfunction will reduce otoacoustic emission energy.4 Thus, tympanometry is essential if no otoacoustic emission can be measured. The reduction in outer hair cell activity in patients with noise-induced hearing loss, measured by DPOAEs, is directly related to frequencies of the audiometric loss.5 In one study, emissions were abnormal in 93.2% of ears with noise-induced hearing loss and in teenagers exposed to noise, and were found to be useful in the prediction of noise susceptibility.12 In another, ears with a noise-induced impairment showed a significant reduction in the incidence of both spontaneous emissions and spectral peaks in evoked emissions that was not evident in ears with similar patterns of hearing loss caused by other factors.14 Are the listening habits of the younger generation potentially dangerous to hearing? Ising et al studied 681 students aged 10 to 19 years.15 Although 50% of students listened to music for less than one hour per day, 10% listened for four or more hours. Among those aged 12 to 16 years, 10% chose to set the listening level at 110 dB(A). It was estimated that 7% were exposed to noise levels likely to damage the cochlea. They recommend that the sound levels for portable music players be limited to 90 dB(A).15 Hearing loss has been documented in people who attended rock music concerts,16 in employees of urban music clubs,17 and one report indicates that exercise combined with exposure to music presents a greater risk to hearing than the music alone.18 These authors conclude that "the results have implications related to contemporary lifestyle issues such as aerobics and the utilisation of personal music systems during physical exertion". The risk of recreational noise-induced hearing loss is real, and our patients must be advised of this risk. LePage and Murray have demonstrated that early warning is now available in the form of the transient-evoked otoacoustic emission test. John T Redhead Director, Jean Littlejohn Deafness Investigation and Research Unit Royal Victorian Eye and Ear Hospital, East Melbourne, VIC Carter NL, Waugh RL, Keen K, et al. Amplified music and young people's hearing. Review and report of Australian findings. Med J Aust 1982; 2: 125-128. LePage EL, Murray NM. Latent cochlear damage in personal stereo users: a study based on click-evoked otoacoustic emissions. Med J Aust 1998; 169: 588-592. Kemp DT. Stimulated acoustic emissions from within the human auditory system. J Acoust Soc Am 1978; 64: 1386-1391. Kemp DT, Ryan S, Bray P. A guide to the effective use of otoacoustic emissions. Ear Hearing 1990; 11: 93-105. Ohlms LA, Lonsbury-Martin BL, Martin GK. Acoustic-distortion products: separation of sensory from neural dysfunction in sensorineural hearing loss in human beings and rabbits. Otolaryngol Head Neck Surg 1991; 104: 159-174. Ohlms LA, Lonsbury-Martin BL, Martin GK. The clinical application of acoustic distortion products. Otolaryngol Head Neck Surg 1990; 103: 52-59. Martin GK, Lonsbury-Martin BL, Probst R, Coats AC. Spontaneous otoacoustic emissions in a nonhuman primate. I. Basic features and relations to other emissions, Hearing Res 1988; 33: 49-68. Martin GK, Probst R, Donsbury-Martin BL. Otoacoustic emissions in human cars: normative findings. Ear Hearing 1990; 11: 106-120. Bonfils P, Avan P, Francois M, et al. Clinical significance of otoacoustic emissions: a perspective. Ear Hearing 1990; 11: 155-158. Probst R, Lonsbury-Martin BL, Martin GK. A review of otoacoustic emissions. J Acoust Soc Am 1991; 89: 2027-2067. Rossi G, Solero P. Evoked otoacoustic emissions (EOAE) and bone conduction stimulation. A preliminary report. Acta Oto-Laryngologica 1988; 105: 591-594. Tanaka Y, Suzuki M, Inoue T. Evoked otoacoustic emissions in sensorineural hearing impairment: its clinical implications. Ear Hearing 1990; 11: 134-143. Norton SJ, Schmidt AR, Stover LJ. Tinnitus and otoacoustic emissions: is there a link? Ear Hearing 1990; 11: 159-166. Probst R, Lonsbury-Martin BL, Martin GK, Coats AC. Otoacoustic emissions in ears with hearing loss. Am J Otolaryngol 1987; 8: 73-81. Ising H, Hanel J, Pilgramm M, et al. Risk of hearing loss caused by listening to music with head phones. HNO 1994; 42: 764-768. Yassi A, Pollock N, Tran N, Cheang M. Risks to hearing from a rock concert. Can Fam Physician 1993; 39: 1045-1050. Gunderson E, Molinc J, Catalano P. Risks of developing noise-induced hearing loss in employees of urban music clubs. Am J Industr Med 1997; 31: 75-79. Vittitow M, Windmill IM, Yates JW, Cunningham DR. Effect of simultaneous exercise and noise exposure (music) on hearing. J Am Acad Audiol 1994; 5: 343-348. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

John T Redhead

Soundwaves Latent cochlear damage in personal stereo users: a study based on click-evoked otoacoustic emissions Eric L LePage and Narelle M Murray MJA 1998; 169: 588-592 For editorial comment see Redhead Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - Abstract Objective: To assess the effects of use of personal stereo systems (PS) on hearing by means of the objective measure of transient-evoked otoacoustic emissions. Participants and setting: People aged between 10 and 59 years who had otoacoustic emissions recorded by the National Acoustic Laboratories between 1989 and 1997 were eligible for inclusion. Recordings from participants with hereditary disorders or any form of aural disease (eg, otitis media, otosclerosis, fluctuant hearing loss, Meniere's syndrome, or exposure to ototoxic substances) were excluded. Methods: Transient-evoked otoacoustic emission (TEOAE) records were obtained with a standard 260 repetitions of an 80 dB train of clicks used for recording outer hair cell activity. The measure of otoacoustic emission strength was the Otodynamics ILO88 variable Waverepro%. For each participant, all the key factors relating to their hearing history were assessed from patient referral information or from demographic information obtained in writing at the time of recording either in the form of a detailed questionnaire or verbal assessment. Otoacoustic emission data were analysed according to age, industrial noise exposure and personal stereo use. Results: Usable otoacoustic emission records were obtained from 1724 people (1066 males and 658 females). Otoacoustic emission strength declined with age, and was significantly lower in males than females, lower in people exposed to industrial noise than those not exposed, and significantly lower in users of personal stereo systems than non-users. People with both kinds of noise exposure had values which were significantly lower again, indicating an additive effect. Conclusions: As only 39 people with PS exposure admitted any hearing problems, decline in otoacoustic emission strength forewarns premature hearing loss in personal stereo users. Introduction The use of pure tone audiometry to assess the potentially harmful effects of amplified music on young people's hearing has failed to show any marked effect.1-3 However, good grounds for concern remain as (i) the sound-pressure levels generated by live and recorded rock music are associated with premature hearing loss in industrial workers,4,5 (ii) inexpensive stereo components have the capacity to generate high sound levels,6 and (iii) the preferred listening levels of those listening to rock music through earphones in "Walkman"-style headsets is high -- an average of 95dB(A) for females and 97dB(A) for males, with an overall range of 75-110dB(A)7-16 ("A" signifies the standard "A-weighting" correction to indicate approximately equal loudness across the audible frequency range). One research group felt that "further research may reveal more sensitive measures of cochlear damage than pure tone audiometry".2 One such measure may be otoacoustic emissions, the principle of which is described in Box 1. In this study, we examined the effects of personal stereo use on transient-evoked otoacoustic emissions (see Box 1) to investigate the possibility that this technique may indeed be a more sensitive method of early detection of ear damage resulting from sound amplification. To shed light on the significance of our findings, we compared people exposed to personal stereo use with those exposed to industrial noise -- a recognised high risk form of exposure. Methods The protocol we used for obtaining transient-evoked otoacoustic emission records is described in Box 1. The data for this study were obtained from the records of some 2500 people tested as part of the National Acoustic Laboratories research program between 1989 and 1997. Information about participants' hearing histories was obtained from details supplied by referring clinics or otologists (12%), standardised questionnaires filled out (60%) or verbal evaluation (18%) at the time of recording, or from Australian Hearing's NALCAM (National Acoustic Laboratories Computer Aided Management) database (10%). Subjects were asked about hereditary hearing loss, exposure to industrial and leisure noise, prescription drug use (particularly antibiotics, diuretics and cytotoxic drugs), head injury and any hearing-related symptoms they were currently experiencing. Sound-exposure histories were obtained by asking subjects to estimate their average number of hours per week and their years of exposure to any noisy activity, such as industrial noise, sporting activity, firearm use, the music industry, personal stereo use and other exposure to amplified music. Participants' data were included in the analysis only if an acceptable pair of recordings were obtained for both left and right ears in the same recording session. Participants' records were excluded if the recording stability values (see Box 1) were less than 80%, if participants failed otoscopic inspection, or if they had a clear inherited factor or any form of aural disease (eg, otitis media, otosclerosis, fluctuant hearing loss, Menieres syndrome, or exposure to ototoxic substances). No form of noise or music exposure was considered grounds for exclusion. For the 4.3% of participants who provided repeat records over the nine years of recording, we included only the pair of records with the highest emission strength. Participants were aged 10 years to less than 60 years on the day of recording. On the basis of the sound exposure histories recorded in the database, participants who reported personal stereo (PS) use were divided into three categories: PS = 0 (negligible, < 1 hour per week), PS = 1 (moderate, 1 hour to < 6 hours per week), and PS = 2 (heavy, >6 hours per week). Similarly, subjects were classified into two industrial noise (IND) categories according to whether they had ever worked in noisy industry: IND = 0 ("no"), and IND = 1 ("yes"). These classifications did not exclude other noise exposure factors. Statistical analysis We applied analysis of variance with multiple linear regression in which the independent variables were sex, age (grouped by decade: 10-19, 20-29, 30-39, 40-49 and 50-59 years), PS use category, and industrial noise category. The dependent variable was the mean of values for both ears of otoacoustic emission strength (TEOAE Waverepro%; see Box 1). The multiple linear regression was performed using Statistica software.22 Results Records from 1724 people (1066 males and 658 females) were included in the analysis. Box 2 shows the relationship between age and otoacoustic emission strength for all subjects who reported being negligible, moderate or heavy users of PS systems (regardless of other noise exposure) and the corresponding sample sizes for these three groups. Considering each age range in turn, for the teenage range (10-19 years) there was no significant difference between any of the three PS use groups. For people aged 20-29 years and 30-39 years the PS = 0 (negligible exposure) group was significantly different from both the PS = 1 and the PS = 2 groups (P < 0.01). For people in both the 40-49-years and 50-59-years ranges the PS = 0 group was significantly different from the PS = 1 group and also from the PS = 1 and PS = 2 groups combined (P < 0.01). For all the adult age ranges, PS users had significantly lower values of the Waverepro% than non-users, with the lowest values in heavy users. Box 3 compares, firstly, females and males with no industrial noise exposure and negligible PS use (the top two curves with open symbols) and shows that, for the three oldest age groups, the values of emission strength for males were significantly lower than those for females (P < 0.01). Secondly, the bottom three curves with filled symbols show the effect of PS use, industrial noise exposure and both forms of exposure for males only (we did not include females in this comparison as very few women [33] had had industrial noise exposure compared with men [286]). Thus, the four lowest curves in Box 3 compare four mutually exclusive noise exposure groups for males only. The corresponding sample sizes for males in these exposure categories are also shown in Box 3. Considering each age range in turn, there was no significant difference between four noise exposure groups at 10-19 years of age. However, for participants aged 20-29 years, all noise exposure groups were significantly different from each other (P < 0.01), with the exception of groups IND = 1 (industrial noise exposure only) and PS = 0, IND = 0 (negligible PS use and no industrial noise exposure). In the 30-39-years group the only significant difference was between the PS = 0, IND = 0 group and the group with both PS and industrial noise exposure (P < 0.01). For both the 40-49-years and the 50-59-years groups, the PS = 0, IND = 0 group was significantly different from the group with PS use only, and also the group with both PS and industrial noise exposure (P < 0.01). The mean values for the industrial noise exposure only group were the same as for the PS exposure only group but the sample size was small. Box 4 shows the results of the multiple linear regression. For each of the selection conditions tested, the slopes (the "Effect" column) representing the rates of decline of Waverepro% are highly significant. This Table indicates that Waverepro% for males was about 5% lower than for females. Waverepro% for moderate PS users was about 11% lower than for non-users, while for heavy PS users this value was 1.6% lower still; Waverepro% for respondents indicating industrial noise exposure was also 8% lower than for non-exposed people. The age dependence was a decline in Waverepro% of 0.49% per year, or 4.9% per decade. Discussion Our findings suggest that there is a strong trend for the strength of otoacoustic emissions to decline with protracted use of PS headsets, and that the size of this decline is proportional to the amount of exposure. Although the separation of PS users into moderate and heavy categories was based on self-report, the multiple regression showed an effect between the moderate and heavy users. However, the design of our study did not exclude the effects of other forms of noise to which people who tend to use PS systems may also be exposed. If PS exposure is associated with other lifestyle factors, our analysis would not have differentiated between them. Other factors, such as leisure and other non-occupational noise exposure (eg, power tools, car racing, concerts) and forms of injury to which males are more exposed (eg, head injury, barotrauma), may have accounted for the significant differences between the sexes in people with neither industrial nor PS exposure. We believe all such factors contribute to the high level of variance of the otoacoustic emission levels.23Further, for males exposed to both PS use and industrial noise, the otoacoustic emission strength was significantly lower (P < 0.001) in all age ranges other than the 10-19-years and 40-49-years range. Remarkably, for the 30-39-years range there was no significant difference between the group exposed to industrial noise and the PS user group, both of which were significantly different from the non-exposed groups (P < 0.001). Yet the young adult PS users (20-29 years) had otoacoustic emission strengths significantly lower than non-users (P < 0.001), suggesting that the decline occurs in the late-teenage and early-adult period -- a decade earlier than the expected industrial effect. The multiple regression analysis showed that, in our sample, the apparent rate of decline in otoacoustic emission strength among young adults was greater for PS users who were also exposed to industrial noise. However, it is worth noting that this group included a subgroup of 26 deep coal miners whose mean values were a whole standard deviation lower than males with no industrial noise exposure. Based on existing guidelines for occupational noise level limits in all Australian States and Territories of an eight-hour equivalent continuous A-weighted sound pressure level of 85 dB, it is surprising that PS use for less than six hours weekly at typical sound levels of 95 dB results in such a high level of damage accumulation. This leads to speculation that there may be other factors involved with sound delivered through earphones compared with free-field sound, such as more efficient delivery of high-frequency sound coupled with the high dynamic range of modern PS units. The popularity in recent years of units offering "additional bass boost" is consistent with the notion that users may be endeavouring to enhance the sense of sound envelopment which occurs at higher levels. Our findings strongly support the previous assertions by Waugh and Murray24 of increased risk of ear damage from PS use, particularly if personal stereos are used in other environments in which users tend to raise the listening level to mask out background noise (such as on public transport or while engaging in aerobic exercise), which may lead to generalised inner-ear problems.25 A 1996 study by Meyer-Bisch appears to be the only one to have succeeded in showing a significant difference between actual hearing levels of PS users and those of a control group.26 Our findings illustrate why most previous studies of PS exposure have failed to observe any effect -- the preclinical phase of hearing loss23 is extended, and PS units have not been around for long enough for critical levels of damage to be apparent in most users. Indeed, as only 39 PS users in our sample reported any hearing difficulties, the primary significance of our study is that transient-evoked (or click-evoked) otoacoustic emission measurement offers early warning for hearing loss. Our findings on the effects of PS use and industrial noise exposure, both separately and together, illustrate an additive effect long held to be a basic property of noise-induced hearing loss.23 In our study this effect may be partly the result of a small association between PS use and industrial exposure -- PS use was higher in the group who had industrial exposure. The technique of measuring evoked otoacoustic emissions has direct application beyond the screening of neonates to programs for hearing loss prevention. It sheds light on the nature of presbycusis, or the normal hearing loss during ageing. Thus, by comparing the rates of decline shown in Box 4 with the relationship between Waverepro% and audiometric hearing level illustrated in Box 1, it is possible to linearly estimate the remaining period of normal hearing. Beginning with Waverepro% values above 80%, as in normal neonates, and assuming a linear model, a decline in Waverepro% of up to 5% per decade should result in no hearing problems for life, while a decline of 7% per decade results in normal presbycusis (about seven decades of normal hearing). However, a decline of 20% per decade would give only 2.5 decades of normal hearing. The fact that many young people in our sample appear to have been subjected to such accelerated hearing loss suggests that it is not unreasonable to predict a rise in the number of young adults with premature hearing impairment.27 In summary, our findings highlight three important points related to hearing health: otoacoustic emissions may offer new precision in determining an individual's risk of hearing loss; the use of PS headsets, even in typical moderate use, is associated with rapid ageing of the cochlea comparable with industrial noise trauma; as personal stereos are here to stay, the essential message for preventing premature hearing loss in users is that listening times and volumes should be moderate, and that users should be aware of the potentiating effect of noisy background conditions which both add directly to the noise dose and encourage them raise the PS volume. Acknowledgements We thank audiologists from Australian Hearing's centres, A Butler of the NSW Department of Health and R Deller for assistance with data collection. We also thank Professor John Kaldor and Matthew Law for assistance with the statistical analysis. References Carter NL, Waugh RL, Keen K, et al. Amplified music and young people's hearing. Med J Aust 1982; 2: 125-128. Carter NL, Murray NM, Khan A, Waugh RL. A longitudinal study of recreational noise and young people's hearing. Aust J Audiol 1984; 6: 45-53. Carter NL, Murray NM, Bulteau VG. Amplified music, recreational noise and hearing in people aged 16-21 and 28-33 years. Aust J Audiol 1985; 7: 79-83. Rintelmann WF, Bienvenue GR. Rock music and noise induced hearing loss: a review of research. J Audio Eng Soc 1977; 25: 134-145. Cabot RC, Genter CR, Lucke T. Sound levels and spectra of rock music. J Audio Eng Soc 1979; 27: 267. Wood WSI, Lipscomb DM. Maximum available sound-pressure levels from stereo components. J Acoust Soc Am 1972; 52: 484-487. Kuras JE, Findlay, RC. Listening patterns of self-identified rock music listeners to rock music presented via earphones. J Aud Res 1974; 14: 51-56. Clark WW. Noise exposure from leisure activities: a review. J Acoust Soc Am 1991; 90: 175-181. Kirkwood DH. Washington starts waking up to hazards of recreational noise. Hearing J 1992; 45: 13-4, 16, 18, 20-23. Bienvenue GR. Personal stereo systems: can they be used safely? New York: The New York State Speech/Language Hearing Association, 1984. Catalano PJ, Levin SM. Noise-induced hearing loss and portable radios with headphones. Int J Ped Otorhinolaryngol 1985; 9: 59-67. Clark WW. Amplified music from stereo headsets and its effect on hearing. Hear Instrum 1990; 41: 29-30. Fearn RW, Hanson DR. Hearing level of young subjects exposed to amplified music. J Sound Vibr 1989; 3: 509-512. Rice CG, Breslin M, Roper RG. Sound levels from personal cassette players. Br J Audiol 1987; 21: 273-278. Royster JD, Royster LH. Amplified music and its effect on hearing. Hear Instrum 1990; 41: 28-29. Turunen-Rise I, Flottorp G, Tvete O. A study of the possibility of acquiring noise-induced hearing loss by the use of personal cassette players (Walkman). Scand Audiol Suppl 1991; 34: 133-144. Kemp DT. Stimulated acoustic emissions from within the human auditory system. J Acoust Soc Am 1978; 64: 1386-1391. LePage EL, Murray NM, Tran K, Harrap MJ. The ear as an acoustical generator: otoacoustic emissions and their diagnostic potential. Acoustics Aust 1993; 21: 86-90. Murray NM, LePage EL. Age dependence of otoacoustic emissions and apparent rates of ageing of the inner ear in an Australian population. Aust J Audiol 1993; 15: 59-70. LePage EL, Murray NM. Click-evoked otoacoustic emissions: comparing emission strengths with pure tone audiometric thresholds. Aust J Audiol 1993; 15: 9-22. Davis AC. The prevalence of hearing impairment an reported hearing disability among adults in Great Britain. Int J Epidemiology 1989; 18: 911-917. Statistica for Windows [computer program]. Version 5.1.2. Tulsa, Okla.: Stat Soft Inc., 1997. LePage EL. Occupational Noise-Induced Hearing Loss: Its Origin, Characterisation and Prevention. Acoust Aust 1998; 26: 57-61. Waugh D, Murray NM. The auditory hazards of using muff-like personal radio headsets in high ambient noise levels. Aust J Audiol 1989; 11: 107-114. Weintraub MI. Vestibulopathy induced by high impact aerobics. A new syndrome discussion of 30 cases. J Sports Med Phys Fitness 1994; 34: 56-63. Meyer-Bisch C. Epidemiological evaluation of hearing damage related to strongly amplified music (personal cassette players, discotheques, rock concerts): a high-definition audiometric survey on 1364 subjects. Audiology 1996; 35: 121-142. LePage EL. A model forecasting the prevalence in hearing loss in the Australian population over the next 20 years based on trends in decline in otoacoustic emission strength. Proceedings of the Better Hearing Australia Conference, Adelaide, 7-11 August, 1994. Adelaide: Better Hearing Australia, 1994. (Received 7 Jul 1997, accepted 1 Oct 1998) Authors' details Hearing Loss Prevention Research, National Acoustic Laboratories, Sydney, NSW. Eric L LePage, PhD, Senior Research Scientist; Narelle M Murray, MA(Aud), Senior Audiologist. Reprints will not be available from the authors. Correspondence: Dr E L LePage, Hearing Loss Prevention Research, National Acoustic Laboratories, 126 Greville Street, Chatswood, NSW 2067. Email: Eric. LePageATnal.gov.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Eric L LePage · Narelle M Murray

Consumers & Healthcare Patient, client or customer? "There is nothing in a name, provided there is care" (hospital outpatient) Balakrishnan R Nair MJA 1998; 169: 593 Introduction - Survey - Acknowledgements - References - Authors' details - - More articles on Social issues Patient: One who is under medical treatment;1 or person who undergoes, suffers or endures a problem with respect to which health professionals can provide preventative, curative, comforting, caring and diagnostic interventions2 (derived from the Latin pati, "to suffer"3). Client: One who is under the protection or patronage of another or one who employs the services of a legal adviser.1 Customer: One who customarily purchases anywhere.1 The term "patient" has been used for centuries. However, over the past decade many allied health professionals have advocated replacing it with the terms "client"4 or "customer". Perhaps this is to demedicalise the issues of care or to avoid notions of dependence.5 In this era of political correctness which term should we use, and why? Acting on the advice "If in doubt, ask",6 we surveyed people attending outpatient departments of a university teaching hospital. Our method and results are shown in the Box. We found that people in a healthcare setting prefer to be called "patients", rather than "clients" or "customers". One might argue that, as the survey was done in a hospital, these represent the views of the "sick". However, about 40% of the subjects were accompanying patients to the clinics, and were presumably "healthy". Previous studies of visitors to a hospital open-day found similarly that 87% preferred to be called "patients".7 Nevertheless, our study results may not be generalisable to inpatients or to people who are chronically disabled or disabled and well. The patient-doctor relationship has evolved over the centuries and now consists of a partnership built on mutual trust, openness and respect. Despite this change, I believe there is no need to throw out the word "patient" -- it is better to accept the shift in its meaning.8 By calling people patients, I believe we are not making them sicker or denying their rights, as has been argued.9 "The unfortunate trend to stereotype honourable patients as obsequious clients and conscientious doctors as scheming entrepreneurs" should be resisted.10 Until we have stronger or better reasons to change the term "patient", it should be continued. Likewise, I prefer to be called "doctor" rather than "provider", "teacher", "clinician" or "adviser", even though my role might vary from patient to patient. Survey on preferred form of address Setting: John Hunter Hospital, Newcastle, NSW, on three consecutive weekdays in September-October, 1997. Questionnaire: This began "Dear Sir/Madam" and stated "there are recent discussions about the term we use in hospitals, for people we are dealing with". Subjects were asked their preference from "a client, patient or any other title" and for their comments. To avoid selection bias for the first option, questionnaires with "patient" first and "client" first were alternated. Subjects: 308 patients and their companions attending outpatient departments between 9 am and 3.30 pm were approached. All but one completed the questionnaire. Respondents were attending the following departments: radiology (51), accident and emergency (56), pathology (21), medical (45), surgical (40), obstetrics and gynaecology, including the antenatal clinic (54), paediatrics (25) and allied health (15). About 40% were companions. Almost two-thirds of respondents (199) were female. Age distributions for females were: under 20 years, 9%; 21-40 years, 45%; 41-60 years, 27%; and over 60 years, 20%. Corresponding figures for males were 6%, 35%, 29%, and 33%. Results: "Patient" was nominated as the preferred term by 85% of women and 83% of men (Figure, below). "Client", "first name" and "other" were each nominated by about 5%, while "customer" was nominated by only one person. The percentage preferring "patient" varied little between age groups, from 83% among those aged 21-40 years to 90% among the those aged over 60 years. Comments by respondents included: "'Client' implies business, 'patient' affirms the service nature of hospitals"; "It is not a business"; "'Client' sounds too commercialised"; "Because your hospital is not a solicitor's office"; "Any heading said politely"; "Politeness is more important than political correctness"; "Personal recognition is preferred"; "I feel 'patient' is sufficient to cover all"; "Always been called it. No need to change"; and "There is nothing in a name, provided there is care". Acknowledgement Thanks to Jeanne Ford and Lorraine Mayo for doing the survey, and to Dr Lynnette Lim for statistical advice. Thanks are also due to our patients, customers, clients and others for participating. References Onions CT, editor. Shorter Oxford English Dictionary on Historical Principles. 3rd edition. Oxford: Oxford University Press, 1968. Englehardt HT, editor. Foundations of bioethics. Oxford: Oxford University Press, 1996. Keks NA. Are patients clients or people? [letter]. Med J Aust 1991; 154: 432. Herzberg SR. Client or patient: which term is more appropriate for use in occupational therapy. Am J Occup Ther 1990; 44: 561-564. Raphael B, Emmerson B. Are patients clients or people? Med J Aust 1991; 154: 183-184. Wing PC. Patient or client? If in doubt ask. Can Med Assoc J 1997; 157: 287-289. Elliot J, White H. Patients are patients [letter]. N Z Med J 1990; 103: 593. Doumani SJ. Should people visiting a doctor be called "patients"? Aust Med 1997; 9: 10-11. Carter M. Healthcare partnership should be reflected. Aust Med 1997; 9: 10-11. George CRP. Patients and clients [letter]. Med J Aust 1988; 149: 568. Authors' details Department of Geriatric Medicine, John Hunter Hospital, Newcastle, NSW. Balakrishnan R Nair, FRACP, Associate Professor. Reprints will not be available from the author. Correspondence: Associate Professor B R Nair, Department of Geriatric Medicine, John Hunter Hospital, Locked Bag No 1, Hunter Region Mail Centre, NSW 2310. Email: mdbnATcc.newcastle.edu.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Balakrishnan R Nair

Consumers & Healthcare The Internet and the changing roles of doctors, patients and families It's time to embrace the concept of the informed patient and use their websurfing skills Patrick J Pemberton and Jack Goldblatt MJA 1998; 169: 594-595 Introduction - A rare disorder - The patient surfer - Managing information - References - Authors' details - - More articles on Public and environmental health Introduction As the Internet spreads its electronic web across the world, doctors are more and more often encountering patients who have done their own research into the disease they have, or think they have. This is often seen as a nuisance by doctors, who are accustomed to a position of unquestioned superiority in knowledge. We recently had an enlightening experience with the parents of a child with congenital disease which showed us that the Internet can provide the basis for a new, fruitful partnership between doctor and patient. A rare disorder The story began when an 18-week antenatal ultrasound scan had shown the fetus of a non-consanguineous young couple to have an isolated right axillary cystic hygroma. The parents had appropriate guidance from fetal medicine specialists and an antenatal referral to a paediatric surgeon to discuss surgical management. They were a well informed and intelligent couple with access to the Internet, through which they sought much current medical information. As the pregnancy progressed, the ultrasound appearance became atypical and a diagnosis of pediatric (KTW) syndrome was suggested. The couple then focused their Internet searches on this diagnosis. However, after the baby was born it became apparent that the clinical features were most consistent with a diagnosis of Proteus syndrome. The parents found difficulty with this change of diagnosis, which negated the worth of their Internet searches and eroded their confidence in the attendant specialists. During the neonatal intensive care period, which involved major surgery, we discussed the parents' involvement with the Internet with them. Their initial information on cystic hygroma and KTW syndrome had become irrelevant, but some of their Internet information on Proteus syndrome was of value, including that from an international Proteus support group. Local experience with unusual neonatal complications of such a rare disorder was limited and we were ourselves searching the Internet for advice. It was decided that it would be best to share information. To save time, it was agreed that the parents could email the doctors directly with data from the Internet. They were made aware of the specialist's time constraints and agreed to be, and indeed were, selective. Some of the information was useful in planning management of their baby's troublesome deep ulcerating haemangiomas. The parents were also able to provide serial documentation of these lesions by emailing scans of appropriate photographs, which they took at home. This reduced the need for clinic visits. The parents were grateful for the acceptance and value given to their involvement in information gathering. They proved to be useful research assistants. In the process, we gained a better understanding of their emotional state when we realised that their perception of the disorder was coloured by some of the case studies of severely affected children that they had encountered on the Internet. 1. Dealing with the internet-literate patients and their families Do Try to react in positive manner to information from the Internet Warn about the variability in the quality and reliability of material from the Internet Warn about your time constraints regarding information overload Develop a stragety for dealing with Internet information from patients (eg, get patient to email a summary before visiting) Accept patient and family contributions as part of the management team Accept that they may have valid information that you have not come across Don't Be dismissive or paternalistic Be derogatory of comments made by others on the Internet Refuse to accept Internet material Try to one-up your patients and their families regarding the information Break normal rules of patient confidentiality via the Internet The patient surfer Access to the enormous amount of information on the Internet is having a major effect on the practice of medicine. Health care professionals can access valuable databases such as PubMed1 or OMIM,2 and rapidly communicate with colleagues via email or request opinions through specialised bulletin boards.3 The whole concept of telemedicine is also beginning to influence practice by the rapid transfer of diagnostic images, electrocardiograms and even remote psychiatric counselling.4 However, what presents doctors with a unique challenge is dealing with the ready availability of these electronic resources to non-professionals. In the past, it was relatively difficult for patients to have access to current medical information from public libraries, and the information "volunteered" by doctors was often sanitised for the patient's perceived benefit. Many patients now have the ability to access detailed and accurate medical information on the Internet, which may be more up to date or more comprehensive than their attending doctor's knowledge. This exposure of an apparent gap in the doctor's knowledge may alarm both parties and, in view of the potential disruption to doctor-patient relationships, a new approach of trust and teamwork is required. Patients or their families often have more time to spend surfing the Internet looking for information that is potentially relevant to their health, and as they are often interested in only one clinical condition their search is very focused. Their doctors, while not having the time to devote to an extensive search for current details on every disorder they encounter, have the skill and knowledge to analyse the data and assess their relevance to the particular patient. These factors provide an opportunity for exploiting this readily accessible information in a revised doctor-patient partnership. In the new age of computer-assisted medical care, information is superabundant and rapidly changing. Rather than being intimidated by information overload, doctors may do well to acknowledge the problem and cooperate with patients in changing the concept of whose responsibility it is to own the information. In some situations patients and their families can perform the tasks of librarian and research assistant, particularly in dealing with rare disorders or unusual management options. Managing information Doctors can pre-empt potential problems with this approach by warning patients of the variable quality and integrity of the information accessible on the Internet,5 and offer them appointments to discuss material that might cause concern or encourage the individual to consider potentially harmful self-management. A major problem for both doctor and patient is being able to distinguish good information from bad. Many patients may access medical information that is totally irrelevant to their own clinical situation. Some of these problems have been addressed in general practice,5,6 with some good electronic guides.6 But in relation to rare or unusual clinical conditions, patients may have to search further and often come upon individual reports, frequently written as testimonials. There are also many websites that offer quackery, often for exploitative commercial reasons.7 Some simple quality checks to suggest to patients are shown in Box 2. 2. Simple quality checks for medical information on the Internet Who is the author? Credentials can sometimes be checked through MEDLINE What institution/affiliation supports the athor? Does the website properly identify the publisher? Is the information current Is the information balanced (ie, are both sides of a case represented, does the author discuss possible biases in the evidence, are the author's and publisher's interests in the subject declared?) Does the information include traceable references to support the evidence? Is the information designed to sell you something? Does the website identify its sources of revenue? Medical colleagues may feel threatened by patients who gather information on the Internet and they may attempt to discourage the process. This attitude has the potential to undermine the doctorpatient relationship and drive patients and their families to seek alternative help or self-manage their medical problems. Many people who surf the net use it to retrieve information pertaining to personal health care,6 and the reality is that individuals will aggressively seek more information to help them understand and cope with medical conditions diagnosed in them or their families, particularly when they have a rare syndromic condition. By accepting this new trend to patient education via the Internet, a pattern of cooperation and teamwork can be developed with mutual benefit. References Pub Med. http://www.ncbi.nlm.nih.gov/PubMed/ Online Medical Inheritance in Man. http://www.ncbi.nlm.nih.gov/omim/ Fikar CR. The Internet and the pediatrician: should there be a connection? Clin Pediatr 1996; 35: 229-235. Johnson C. Psychiatrist says counselling via e-mail may be another use for the Internet. Can Med Assoc J 1996; 155: 1606-1607. Wyatt JC. Commentary: Measuring quality and impact of the world wide web. BMJ 1997; 314: 1879-1881. Health on the Net Foundation. Internet usage for health purposes. Survey May/June 1998 -- results. http://www.hon.ch/cgi-bin/quest/quest_Jun98 Quackwatch. http://www.quackwatch.com/ Authors' details Department of Neonatal Paediatrics, Princess Margaret Hospital for Children, Perth, WA. Patrick J Pemberton, FRCP(Edin), Head. Genetic Services of Western Australia, King Edward Memorial Hospital for Women, Perth, WA. Jack Goldblatt, FRACP, Director. Reprints will not be available from the authors. Correspondence: Patrick J Pemberton, Department of Neonatal Paediatrics, Princess Margaret Hospital, Box D184, Perth WA 6001. Email: patrick.pembertonAThealth.wa.gov.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Patrick J Pemberton · Jack Goldblatt

Consumers & Healthcare Should patients have access to their medical records? Paradoxically, access to one's own medical records is the best safeguard to privacy Meredith Carter MJA 1998; 169: 596-597 Introduction - An outdated model? - Impact of information technology - Benefits of subject access - The dilemma of disclosure - Should access to records always be given? - Conclusions - References - Authors' details - - More articles on Law Introduction With the advent of the electronic era, I believe a major deficiency of common law is its failure to provide the person who is the subject of a medical record with a right of access to that record. While legislation gives Australians an enforceable right of access to public sector health records, this is not generally the case for records created by private practitioners or agencies, as highlighted by the 1996 High Court decision in Breen v Williams.1 In this test case, a consumer was denied access to records held by her plastic surgeon, sought for the purpose of legal action against the manufacturer of silicone breast implants. The difference in right to access between the public and private sectors is surprising given the extensive interrelationships between public and private healthcare in this country, and the worldwide efforts to ensure that people have access to files -- including medical records -- kept about them. Australia is now lagging behind most of the developed world in this regard (see Box). Why is addressing this issue so important? Patient access to medical records Australia Only the Australian Capital Territory has legislated to provide individuals with a generic right of access to private sector clinical records.2 New South Wales gives some access under 1996 regulations governing private hospitals, day-procedure centres and nursing homes.3-5 Other developed countries6 The European Union Data Directive (applicable October 1998) requires all 12 member countries to enact legislation enabling subject access to medical records, if not already enacted. The United Kingdom, a member of the European Union, passed the Access to Health Records Act in 1990. The New Zealand Health Information Privacy Code, which came into force in 1993, creates an enforceable right of access. Canadian courts have recognised a common law right of access. Most states in the United States have enacted legislation to ensure subject access to health records, whether created in the public or private sector. An outdated model? Traditionally, consumer interests in health records have been protected through the doctor-patient duty of confidentiality, whereby third-party access to records relied on the doctor's discretion and ability to control flow of the information in the patient's best interests. Now, concerns are increasing that the duty of confidentiality is inadequate for protecting consumer interests. Doctors today interact with a host of other health practitioners, diagnostic services and hospitals, all of whom contribute to the record. An army of support staff also has access. Even the solo private practitioner is no longer an island, but both employs administrative staff and shares relevant patient information with other treating clinicians. Further, many of those who have access to records (eg, receptionists, clerks, administrators and laboratory technicians) have no ethical or other duty to protect consumer confidentiality unless this is built into their contracts. The wider dissemination of data made possible by developments in information technology adds to concerns. Impact of information technology Integration and use of a consumer's personal health information is facilitated by information technology applications such as smart cards, electronic networks between healthcare providers, computerised databases and unique consumer identification systems. Many of these applications involve linking personal information between different health practitioners and providers, and across the public and private sectors. For example, a typical data linkage project might share relevant information between the consumer's general practitioner, pharmacist, hospital, diagnostic and specialist services and perhaps a home nursing service. This enhanced electronic capacity to collate, share, match and manipulate information generates risks as well as benefits. Policies and procedures are needed to ensure that no more than the relevant information is actually disclosed to other treating practitioners, particularly when information is likely to be especially sensitive (eg, psychiatric history and reproductive and sexual matters). Indeed, the Broadband Expert Services Review, commissioned by the Federal Government to consider potential uses of information technology, concluded that current attitudes to consumer access to personal health records were a significant barrier to acceptance of information technology in the healthcare sector.7 This is because of the large array of secondary uses of clinical records over which consumers have little control and which often involve identifiable information. For example, health departments are keen to access health records to determine exactly where health funds are spent and how to target them more effectively. Clinicians want access for peer review and quality assurance, while researchers and public health practitioners can also cite legitimate reasons for access. Outside the healthcare sector, personal health records can influence many aspects of life, such as obtaining employment, life insurance or consumer credit. All too often, consumers are forced to gamble that consenting to disclosure of clinical records to third parties will not damage their interests. Unauthorised access to personal health information by third parties can be very damaging; the Australian Law Reform Commission noted, for example, that commercial clinics doing paternity tests would have a "goldmine" of information about their clients which could cause considerable harm if misused.8 This damage may be even greater if the records were incorrect or misleading. Thus, the clinical record of the future, whether or not correct, will probably be increasingly used to inform highly detailed dossiers about consumers which could affect them significantly. I believe consumer access is crucial in minimising any negative effects. Benefits of subject access As health records become more comprehensive and more widely shared, it becomes correspondingly more important that consumers are comfortable with what goes in the record in the first place, that it is accurate, that they are aware of what information is being distributed and whom it goes to. As absolute security of information in an electronic environment is a myth, the best security consists in ensuring the individual record is accurate. Indeed, without a right of access, some suggest data protection laws are of little use.9 Personal access and a right of challenge and correction are a basic way to promote accuracy.10 Subject access is intrinsic to the concept of individual participation underpinning the Information Privacy Principles in the Privacy Act 1988 (Cwlth). According to Justice Michael Kirby of the High Court, participation is the most notable and important privacy protection safeguard.11 As he has also noted: If you can have access to information about yourself, check it, remove it in some cases and correct it when it is wrong, you have a most powerful weapon to protect your privacy . . . It is privacy used as a sword . . . To protect and assert [one's] own personal interests from the inquisitiveness of government and others alike.8 Organisations such as the Health Issues Centre and the Consumer Health Forum hope that increased access to health records will lead people to participate more in their healthcare decisions. Consumers will have a clearer idea about their condition and treatment and the roles of the various people involved in their care. The evidence available indicates that increased access does have this effect and is likely to have a positive rather than negative impact on doctor-patient relationships.6,12-15 The dilemma of disclosure Access to records is also inextricably linked with effective notice of third party use and informed consent to disclosure. Effective notification and truly informed consent require that individuals know and understand the contents of the record.16Clinicians often hold "confidential" information provided by people other than the subject of the record. Providing a report rather than subject access to the record itself is not a solution to this problem. Information provided by third parties has obvious dangers -- it may be inaccurate and seriously prejudice the consumer's treatment. Most privacy guidelines require confirmation of the accuracy of information on the record before it is acted on,17 and this is particularly important for secondhand information. As subject access becomes more common, health practitioners will need to be circumspect about information from third parties and more open with consumers about what they have been told. Should access to records always be given? The starting point should be a presumption in favour of disclosure to the individual concerned, but this is not to argue that access to records should always be given, especially when it is likely to cause serious harm, either to the consumer or to a third party. However, withholding the record should be considered unusual and subject to review to ensure the practitioner's concerns are substantiated (eg, by an alternative clinician nominated by the consumer). As Bloch and colleagues have noted, studies focusing on patients' reactions to their records have shown therapeutic benefits, even when they did not like what they learned.12 While some patients may need support when accessing clinical files, these findings apply generally, even in psychiatric cases.12 It also seems likely that, as consumer access becomes the norm, a more participatory approach to creation of the record will result. So, access is not just about privacy, but also about facilitating communication, informed consent to treatment and quality of healthcare. Conclusions Traditional approaches to protecting personal health information focus on the doctor's discretion and security of the record. Today, in an electronic environment with a team approach to health care, this approach is inadequate and undermines the trust fundamental to the doctor-patient relationship. Consumer access to their records will help reinforce that trust. We must move from a focus on security to a focus on participation. References Breen v Williams (1996) 186 CLR 71. Health Records (Privacy and Access) Act 1997 (ACT). Private Hospitals Regulation 1996 (NSW). Day Procedures Centres Regulation 1996 (NSW). Nursing Homes Regulation 1996 (NSW). Cornwall A. Consumer access to health records. Health Law Bull 1996; 5: 81-90. Anthony D, Mandeville T, Hearn G, Holman L. Demand for Broadband services in the health sector. Brisbane: Communication Centre, Queensland Institute of Technology, 1994: 46-47. Australian Law Reform Commission. Freedom of information discussion paper 59. 1995: para 11.21, footnote 58. Gellman R. Approaches to privacy protection in the United States: genetic privacy. Proceedings of the 14th International Data Protection and Privacy Commissioners Conference. 1992: 69, 74. Crowe B. Telemedicine in Australia. Australian Institute of Health and Welfare Discussion Paper. Canberra: AIHW, 1993: 9. Kirby M. Reform the law: essays on the renewal of the Australian legal system. Canberra; AGPS, 1983: 201-202. Bloch S, Riddell C, Sleep T. Can patients safely read their psychiatric records? Med J Aust 1994; 161: 665. Bergen L. Patient access to medical records: a review of the literature. Aust Med Rec J 1988; 18: 102. Parrott J, Strathdee G, Brown P, et al. Patient access to psychiatric records: the patient's view. J R Soc Med 1988; 8: 520. Westbrook J. Patient access to medical information, Part 1: a review of the issues. Aust Med Rec J 1988; 18: 11. O'Connor K. Confidentiality, privacy and security concerns in the modern health care environment. Aust Computer J 1994; 26: 70. Privacy Act 1988 (Cwlth). Information Privacy Principle 2. Authors' details Health Issues Centre, Melbourne, VIC. Meredith Carter, LLB, BA, Director. Reprints will not be available from the author. Correspondence: Ms Meredith Carter, Health Issues Centre, Level 11, 300 Flinders Street, Melbourne, VIC 3000. E-mail: hicjmcATvicnet.net.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Meredith Carter

Consumers & Healthcare Children with severe disabilities: options for residential care Is living under the same roof necessary for a nurturing family relationship? Kevin J Bain MJA 1998; 169: 598-600 Introduction - References - Authors' details - - More articles on Paediatrics Introduction In the past 10 years, professional and government opinion has changed about where children with severe disabilities and high support needs should live. Previously, families were encouraged to place these children in an institution and to "forget" them. Then, in the late 1980s, the process of closing large institutions began in most Australian States, and "permanency planning" (Box 1) gained professional favour, although not always practical government support. The objective now is for children with severe disabilities to live with a family -- preferably their birth family but, failing that, an adoptive or foster family. But is this enthusiasm for virtually all children with disabilities to live with a family unrealistic or doctrinaire? Are other options worthwhile? What are the important considerations for public policy? 1: Permanency planning Permanency planning (which also informs policy in the child protection field1) is based on the view that a long-term day-to-day relationship between the growing child and at least one continuous caregiver is necessary in any model of care. It arose from the concern that children in foster care drift, with a loss of contact with natural parents and negative emotional and social consequences for the child as placements break down and foster agency staff move on.2 The philosophy is also not comfortable with rostered staff models ("group homes"). Specific aims of permanency planning are:3 To identify and provide the financial and other supports needed by the birth family to enable the child to stay at home, at least until legal adulthood; For children who have previously been relinquished or placed in institutions, to pursue permanent reunification with the natural family as the most desirable option; and If parents request an out-of-home placement, to pursue adoption or long-term placement with a foster family, preferably on an "open" basis so that the birth parents continue with an informal parenting role. What impact can a child with a severe disability have on a family? A child with a severe disability invariably leads to great personal and financial stress in the home.4-6 While some children have a need for intensive medical and therapeutic support or continuous care, others have long-term behavioural patterns that include regular violence to themselves or others, chewing or breaking furniture and house fittings, screeching or being noisy at all hours, ingesting inedibles, smearing faeces, or absconding. Despite therapeutic or behavioural interventions there may be very slow development, or regression.7 While "in-home support" will cater for the needs and preferences of many parents, the sometimes severe restrictions on the family's life choices will not be acceptable to all, particularly if the burden of care is offloaded onto other family members. Can society regard a solution as satisfactory when chronic stress is hidden in the private domain? For example, a Queensland agency which implemented faithfully the total movement of children with high medical and physical support needs back into birth family settings after a period of institutionalisation reported that the outcome was often "harsh".8 While families were reported happy to have their children home, the care required was stressful, demanding, labour-intensive, constant, costly, tiring and mostly unacknowledged. Other reported impacts on the family included:8 Very little social life; Reduced time and energy for other family members; Expectations on other children to share physical and emotional caring; Restrictions on types of family activities (eg, camping); Very little time off and few holidays; Reduced career opportunities; Working part rather than full time or not being able to work at all; Coping alone when carers were sick or on leave; Extra demands of school holidays; Physical and emotional tiredness; and Feelings of low self esteem and worth. Instead of an exclusive focus on what is believed best for the child, there needs to be an acknowledgement of the wider impact on the family. An analysis of the impact of deinstitutionalisation on families in the United States pointed out that the disabled child's right "to live in the least restrictive environment" is only a half-statement of the issue: The right to live in the least restrictive environment should apply to family members as well as to handicapped individuals. Thus [the] concept of least restriction should be considered in light of the needs of each family member. Placing many severely handicapped children and youth in the least restrictive environment of their families results in their family being required to live in a highly restrictive manner.9 Additionally, the 1993 Australian Bureau of Statistics survey of carers found that, while many resident carers of people with severe or profound handicaps have been brought closer to the person being cared for, a quarter feel that this role has put a greater strain on the relationship.1 The presumption that family care is superior care may not be true: there is clear potential for destructive and perhaps abusive relationships. More financial and other support for the family, while helpful, is not always a complete solution. A NSW survey of 171 families of children under seven years with disabilities and high support needs found that 25% had either sought alternative residential care for their child or considered it might become necessary, particularly if the mother, as main carer, was unable to continue, or the child became larger and harder to manage.10 The degree to which these circumstances can be avoided by more and better services may be limited. For the 6% who had already sought care, family survival -- physically, socially and emotionally -- was at stake. However, the push from Australian governments to keep the child at home is strong, and out-of-home placement is usually difficult to access. Because urgent cases move to the top of the queue, anecdotal reports are that a cat-and-mouse game ensues as parents are required to demonstrate their trauma. The game-playing to access accommodation services may also involve giving up the child to the State as a ward, manufacturing a situation of homelessness, or following the child protection route (ie, abuse or threatened abuse of the child). Should foster care be the only alternative to living at home? In the past, foster care arrangements were generally admitted to be difficult to establish and maintain for children with autism, severe disabilities and certain types of challenging behaviour.11 Is the current enthusiasm for foster care evidence-based or cost-based? Evidence cited to support foster care as the universal solution12-16 generally comprises case reports of its success in sustaining arrangements rather than achieving measured improvements for the child. In fact, one of the few longitudinal studies (a three-year study of 148 children in the United States) suggested that the developmental opportunities claimed for specialised foster care were unlikely to be realised for children at the lower levels of intellectual functioning.17 Furthermore, low levels of attachment behaviour, often associated with severe intellectual disability or the autistic spectrum diagnosis, are likely to jeopardise foster care.17 Yet, these children are generally the target group for foster care programs in Australia. Lower cost to government is also cited as a major advantage of substitute family care over rostered staff arrangements. However, children with high support needs may be expensive to support irrespective of setting. In the Victorian alternative care program (Family Options), the level of annual caregiver payments starts at $4160 and rises to between $10 886 and $22 144 for children with very high needs, with additional discretionary payments of up to $10 000 per annum, and possibly extra money for home modifications.18 This compares to a benchmark of $47 000 in annual operating costs to support a high-needs person in a small group home (Ms Diana Heggie, General Manager, Operations and Residential Services Development, Spastic Society of Victoria, personal communication). These financial disbursement policies also lead to tensions. Birth families often report that financial support available to foster carers to look after severely disabled children is not available to their parents to do the same. Providers report that clients who may be able to avoid a crisis if supported modestly at an earlier stage end up as genuine emergencies. In practice, foster care may be distorted to resemble a rostered staff situation to maintain the placement, with a large number of volunteer carers and parenting shared between different families at different sites. The operational needs of care for some children are going to involve many rostered carers however the model is labelled. The view of many parents, advocacy groups, academics, foster agencies and child welfare practitioners is that the pendulum has swung too far in reducing access to other options, such as group homes (see Box 2). 2: Where do children with severe disabilities live now? In 1993, an estimated 63500 Australian children in the 5-14 years age group had a severe or profound handicap (meaning they always or sometimes need personal assistance or supervision with activities of daily living - self-care, mobility or verbal communication).1 There are no official figures for Australia on how many of these children are cared for at home. Figures for New South Wales suggest that it is the overwhelming majority, and that families who seek alternative care usually do so when the child reaches adolescence.10Similarly, the number of formal requests to State disability services departments for out-of-home placements is not generally available. However, the main agency in South Australia experienced a 300% increase in these requests in the five years to 1994, with 28 children listed as needing alternative accommodation urgently.19 When it is acknowledged that remaining at home is not viable, government departments in most Australian States pursue "specialised" foster care as the preferred option. (NSW is a notable exception, with group homes and large institutions more common.) Tasmania focuses on in-home support. In South Australia and Queensland, planners claim the emphasis on foster care and in-home support is highly successful. However, in Western Australia and Victoria, children either unsuited or unable to be matched to foster carers remain for years in respite houses or residential units attached to hospitals. Should we retain non-family options? The disfavour towards non-family models of residential care comes from the days when children with disabilities lived in large institutions, and their families were encouraged to forget them. Institutions are well on the way out in Australia, and planners adopt a strong "gatekeeping" role to minimise any divergence from the two approved models -- birth or substitute family. A 1993 US study found that families who placed their child in a residential facility were much more likely to continue a high level of contact with their child than did previous generations, including visits to the residential facility, visits by the child to the family home, phone calls, and involvement in the child's individualised habilitation plan.20The authors hypothesised that, because families are no longer likely to place their children at birth, they develop attachment, which buffers against non-involvement during subsequent placement. Tangible benefits for other family members occurred after placement in a residential facility, including better relationships with other children, more normal social life and more employment and educational opportunities.20,21 While today's parents want community living for their children with disabilities, those seeking out-of-home placement may see a group home with rostered staff as an attractive option. It has the potential to provide long-term security, trained staff, and greater authority to birth parents to influence decisions about the child's welfare than does foster care. Rostered staff carers can resist "burnout", and often develop a familiarity and attachment to the child, even when it is not strongly returned. A situation in which the child lives in a rostered staff home but has regular visits to and from the birth family, which is also heavily involved in the child's educational and medical issues, behavioural plans, and personal development, is desired by some parents and already exists in Australia, albeit in a policy "twilight zone". This approach can allow important objectives of permanency planning to be achieved, if high levels of family involvement are encouraged. Permanency planning in Australia needs to drop slogans appropriate to a different time and accommodate subtlety, an openness to evolution and changing values and preferences. Incorporating "best practice" into policy With the current redevelopment of accommodation services in most Australian States, a participatory and transparent evaluation process is needed. Planners and providers should continuously share the results of the implementation process with the families they serve, other professionals and service providers. Although the policy of integrating people with disabilities into the community is widely supported, there is still little knowledge of how it can be achieved when disabilities are severe. Independent evaluations of successful foster care and rostered staff programs are needed, with results made available to all. These should examine the priorities not just of planners (minimal placement breakdowns, placement avoidance, and service cost reduction), but also of families (family satisfaction, strengthening of birth family links, and quality of care). It is doubtful whether this will happen without changed reporting arrangements, because of political sensitivities and organisational rivalries derived from the contracting-out process. A recent House of Representatives Committee heard many negative stories about contracting-out of welfare services, including reduced sharing of professional knowledge, lack of contract management expertise, blurred lines of accountability, contract clauses which prohibit public comment, and unwieldy and inconsistent performance standards.22 It recommended that the responsibility for setting standards and measuring performance of the welfare sector be assumed by the Australian Institute of Health and Welfare (AIHW, a statutory authority established in 1987 as an independent health and welfare statistics and information agency). The committee also recommended service-specific advisory committees to facilitate the effective flow of information from States to the AIHW. The technical expertise and independence which the AIHW brings to the evaluation process can only help in establishing a firmer knowledge base for policy development in this important and under-researched area. References Australian Institute of Health and Welfare. Australia's welfare 1997. Canberra: AGPS, 1997: 206, 329, 307. Taylor SJ, Lakin KC, Hill BK. Permanency planning for children and youth: out of home placement decisions. Except Child 1989; 55: 541-549. Center for Human Policy (Syracuse University). Introducing a statement in support of families and their children. <http://soeweb.syr.edu/thechp/fsbintro.htm> Sighted 3 Nov 1998. Casey S. Barriers to women returning to the paid workforce when they have a child with a disability. Melbourne: Association For Children With A Disability, 1998. Birenbaum A, Cohen HJ. On the importance of helping families: policy implications from a national study. Ment Retard 1993; 31: 67-74. Schofield HL, Murphy B, Nankervis J, et al. Family carers: women and men, adult offspring, partners, and parents. J Fam Stud 1997; 3: 149-168. Moore TG. Promoting the healthy functioning of young children with developmental disabilities, and their families. Fam Matters 1996; 44: 20-25. Fleming R. Post-institutionalisation -- policy and services. Proceedings of the Australian Cerebral Palsy Association National Conference, Brisbane, 1998: 97-99. Turnbull AP, Brotherson MJ, Summers JA. The impact of deinstitutionalisation on families: a family systems approach. Paper presented at the Working Conference on Deinstitutionalization and the Education of Handicapped Children. Minneapolis, 1982. Llewellyn G, Dunn P, Fante M, et al. Families with young children with disabilities and high support needs. Sydney: University Of Sydney Family Support and Services Project, 1996: 3. Department of Human Services (Victoria). Family options policies and procedures manual interim guidelines. Melbourne: DHS, 1997. Macaskill C. It's a bonus. Adoption fostering (Barnado's United Kingdom) 1988; 12: 24-28. Elliot B, Young M. Melanie's program evaluation final report. Sydney: Centacare Catholic Community Services, 1993. Provencale G. Characteristics of a successful community living program and support service. Melbourne: Yungaburra Foundation, 1988. Shoultz B, O'Connor S, Hulgin K, Newman P. Permanency planning in Michigan: from philosophy to reality. Syracuse, NY: Center on Human Policy, Syracuse University, 1994. Center on Human Policy, Syracuse University. Families for all children. <http://soeweb.syr.edu/thechp/bullfams.htm#tab> Sighted 3 Nov 1998. Borthwick-Duffy S, Widaman K, Little TD, Eyman RK. Foster family care for persons with mental retardation. Washington DC: American Association for Mental Retardation 1992. Monograph 17. Napthine D. Letter to the Association for Children with a Disability from the Minister for Youth and Community Services, Victoria, 5 September 1997. Kelly F, Clark J, McEntee P, Dench S. Factors contributing to the relinquishment of children with intellectual disability. Social policy reports and proceedings no. 123. Sydney: Social Policy Research Centre, University of New South Wales, 1995: 77-87. Blacher J, Baker BL. Family involvement in residential treatment of children with retardation: is there evidence of detachment? J Child Psychol Psychiatry 1994; 35: 505-520. Blacher J. Placement and its consequences for families of children who have mental retardation. In: Blacher J , editor. When there's no place like home: options for children living apart from their natural families. Baltimore: Paul H Brookes, 1994: 213-243. House of Representatives Standing Committee on Family and Community Affairs. What price competition? A report on the competitive tendering of welfare service delivery. Canberra: AGPS, 1998. Authors' details Melbourne, Vic. Kevin J Bain, Travelling Fellow, Rosemary F Dybwad International Fellowship Trust, former Board member of Victorian intellectual disability advocacy bodies, and parent of an 11-year-old boy living in a respite house. Reprints: Mr K J Bain, 9 Caroline Street, East Hawthorn, VIC 3123. Email: kevinbainATyahoo.com.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Kevin J Bain

Rescue Medical response to disasters Doctoring at its best MJA 1998; 169: 601 Disasters are predictable, not in time or place, but in their inevitability. In the South Pacific region there is an ever-present threat of cyclones, floods, fires, earthquakes and volcanic activity. Australian health teams, both defence force and civilian, have played major roles in the Brisbane floods (1974), Cyclone Tracey (Darwin, 1975), the Ash Wednesday bushfires (1983), the Newcastle earthquake (1989), and the Katherine floods (1997), to name but a few. Emergency offshore deployments involving military medical services have brought rescue and relief to victims of the Mt Lamington disaster in Papua New Guinea (1951), to Rwanda in the aftermath of the civil war (1994-1995), to the drought and famine devastation in Irian Jaya (1998), and in recent months to the Aitape tsunami disaster in Papua New Guinea. RAAF health, rescue and reconstruction teams are deployed regularly to the Solomon Islands and other South Pacific nations after cyclone disasters. By their nature, disasters disrupt the normal functioning of society, and extra and specialised training and skills are needed to equip doctors, nurses and other health professionals to operate in a devastated environment. Adrenalin surges are high, and the response team members must constantly face personal and collective risks. Relations at the interface between the defence force and civilians may become strained, and there are always political issues of cost, job demarcation and international liaison, and sometimes (as in Rwanda) armed conflict, which impinge on doctors involved in disaster response. After prior training and rehearsal of training systems, being a doctor in a disaster response team can be an experience of the greatest professional fulfilment. There is no better example of this than the health response to the 1998 Aitape tsunami disaster. What lessons have re-emerged from that deployment? A disaster implies numbers of sick and injured that overwhelm the resources available for rescue and treatment. However, irrespective of the scale of a disaster, it is individuals who are dead, trapped or injured, and from each individual's point of view treatment is needed irrespective of whether or not there are a hundred or a thousand others in a similar plight. But the collectivity of individual victims of necessity changes the approach of the medical teams involved in disaster response. The skills (and heartbreak) of triage, the need for speed (the greatest good for the greatest number), and the importance of prevention of secondary trauma and disease are core themes in the repertoire of health teams responding to disaster. The articles in this issue of the Journal by Taylor et al and Holian and Keith illustrate well the importance of these themes. One of the greatest resources for individuals and societies afflicted by disaster is the preservation of family units. By Day 8 following the Aitape tsunami disaster, all surviving orphan children were being cared for by relatives of their extended families; and surviving parents who had lost all their children had, in some cases, adopted the children who had been recently orphaned. Before the arrival of medical teams, the application of simple first aid skills may often save lives and prevent serious complications of injury and disease. In the Aitape tsunami disaster many victims with fractures, impalements and lacerations had not had simple self-applied or buddy-applied first aid, with the inevitable consequences of unstabilised fractures, cellulitis, and gangrene and septicaemia of the wounds. Currently, 1 in 30 Australians are trained in first aid; this becomes a priceless resource when disasters strike. All military personnel are trained in the skills of first aid, but many civilian workers in non-government organisations are deployed without these basic skills. In the Rwandan emergency less than 20% of the civilian field workers possessed a current first aid certificate. The most effective way in which Australian doctors can help in future disasters is by joining one of the three Services (as reservists) or one of the non-government organisations (such as the Red Cross or St John Ambulance, Australia). As part of a trained, properly equipped team they can then offer the necessary personal skills for emergency deployment. In the 1998 Aitape tsunami disaster, health reservists from the Royal Australian Navy, the Australian Army, and the Royal Australian Air Force served as essential members of the regular military teams. To these teams were added the Monash Medical Centre Surgical Team and health professionals of the defence forces of New Zealand and the United States. Such is doctoring at its best. Major General John Pearn, AM, RDF The Surgeon General, Australian Defence Force c/- The Royal Children's Hospital, Brisbane, QLD Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Rescue Operation Shaddock -- the Australian Defence Force response to the tsunami disaster in Papua New Guinea Operation Shaddock was the name given to the deployment of a major field medical unit of 58 Australian Defence Force medical and other personnel to Vanimo, in northwestern Papua New Guinea. Hundreds of victims of the tsunami disaster were treated and more than 200 surgical procedures performed in a 10-day mission. Paul R P Taylor, David L Emonson and James E Schlimmer MJA 1998; 169: 602-606 Introduction - A command perspective - A clinical perspective - Conclusions - Authors' details - - More articles on Emergency medicine Introduction When the extent of the devastation caused by the Aitape tsunami (Box 1) was realised, over 12 hours after the wave hit, a request from the Government of Papua New Guinea (PNG) for air transport support and a field hospital was sent to the Australian Government aid agency AusAid. The request was passed to Emergency Management Australia(the link organisation between military and civilian agencies), which in turn asked the Australian Defence Force (ADF) to respond. By 1900 on Saturday 18 July, the requirements were more clearly defined as: Surgical teams; Nursing teams (for low and medium dependence patients); Primary healthcare teams; An aeromedical evacuation capability; and Preventive medicine (public health) support. Personnel from the 1st Parachute Surgical Team, the 1st Field Hospital and an Aeromedical Evacuation (AME) team from No. 3 RAAF Hospital (all Sydney units, based at Holsworthy and Richmond) worked through the night of 18 September to prepare essential equipment. Early on the evening of Sunday 19 July two RAAF C-130 transport aircraft carrying the health facility left Richmond RAAF base and landed at dawn the next day at Vanimo, a town some 70 km to the west of the disaster area. By nightfall the initial team of 25 ADF health personnel (six doctors, six nurses, two operating theatre technicians, 10 medical assistants and a preventive medicine officer), supported by logistics, movements and communications staff, had erected a field health facility around an abandoned PNG military barracks about 1 km from Vanimo hospital. The threat of further seismological events was very real and an evacuation plan was put in place in the event of a subsequent tsunami. The team worked around the clock for the next four days, stopping only briefly to grab a snack from field ration packs. Around the periphery of the area devastated by the 33 km wide tsunami, houses like the one above were badly damaged; in the central area nothing was left standing. The ADF team at Vanimo was later reinforced by an orthopaedic surgical team (three surgeons, one physiotherapist, one operating theatre nurse and a cast technician) from Monash Medical Centre in Melbourne (see Holian & Keith), an additional ADF orthopaedic surgical team (surgeon and anaesthetist from Sydney), a health team from the New Zealand Defence Force (NZDF) and one from the US military (one surgeon, two preventive medicine officers). An ADF health team consisting of a medical officer, a nursing officer, a health logistician and two health administration officers, who were in Port Moresby to assist in the review of the PNG Defence Force Health Services, were also made available to support the mission. In total, 251 patients were treated at the ADF health facility during Operation Shaddock and 209 surgical procedures were completed. Hundreds more patients were seen and treated by the teams in the disaster area and the care centres. Only two deaths occurred in the facility, both non-surgical cases involving aspiration pneumonitis from near-drowning. While the surgeons operated, primary health care and public health teams worked with engineers and aircrew to prevent the outbreak of disease. ADF personnel were involved in ensuring that drinking water was potable, waste (including sewage) was disposed of, and the dead were buried. RAAF aircrew worked to transport food, water, and counterdisaster equipment, and to evacuate the victims of the disaster. In all, nearly 200 ADF personnel contributed to Operation Shaddock. A command perspective The immediate challenge to the Parachute Surgical Team and other units was how to plan for a disaster in which, potentially, the scale of destruction and the numbers of injured were enormous, but for which exact details were unknown. We also had to tailor our units, designed to treat war wounds of fit young men, to care for the young and the old with all types of injuries and concurrent medical illnesses. 1: The Aitape tsunami disaster, Papua New Guinea, July 1998 A series of three tsunamis struck the north Papua New Guinea coast, west of the village of Aitape, at about 1930 (local time) on Friday 17 July 1998. The local population had virtually no warning of the approaching waves, variously reported as 7, 10 and 15 m in height, which travelled across the surface of the Pacific Ocean at speeds in excess of 100 km/h and struck the coast across a 33-km front. News of the disaster and the plight of the people first became known when a Catholic Church mission began its daily radio broadcast to its outstations the following morning. By mid morning of Saturday 18 July, reports received in Port Moresby revealed the magnitude of the disaster. As a result of the tsunamis at least 16 villages were destroyed, causing more than 2200 deaths, displacing about 9000 people and devastating an area of 40 km2. More than 700 people were hospitalised in the various medical facilities in the area. All that Saturday night (18 July) we worked to deploy in 14 hours an organisation which notionally requires seven days' notice. Personnel were recalled to duty and worked around the clock to pack equipment and procure items from stores. The next morning was spent reconciling orders and deliveries, further packing, and in briefings and administration. By mid-morning on Sunday 19 July the trucks and buses arrived to take us to RAAF Richmond. Even before we left we were weary. The first flight left at last light, arriving in Port Moresby at 0300 Monday morning (20 July). After quickly refuelling and changing crew, we took off for Vanimo, arriving just as dawn broke. It was now 52 hours after the first tsunami had struck. We arrived amid preparations for the third day of the evacuation of people from the disaster area. Every available light aircraft and helicopter was being prepared for non-stop operations in the daylight hours in an attempt to complete the evacuation. Brother James Coucher, the missionary who had been coordinating the relief effort so far, was at the airport, exhausted but obviously relieved and happy to see us. In a desperate bid to maximise the evacuation airlift back to Vanimo, casualties had been brought in piled on top of one another, with injured limbs lying at odd angles. Placing the injured in splints and on stretchers would have greatly reduced the numbers able to be evacuated. Pilots described having to perform triage themselves in making decisions about who to leave behind. Teams consisting of a doctor, an interpreter and a medical assistant were immediately sent into the disaster area in order to collect information on the situation. The evacuees and those still awaiting evacuation appeared bewildered. The scale of the disaster was simply incomprehensible to them. Entire communities had been washed away in a moment. Everyone had lost at least one relative; many had lost all. Many survivors were wandering around the lagoon desperately trying to find a relative, dead or alive. The evacuation was in its last stages. The issues now needing attention were those of displaced people, disposal of the dead, and the definitive treatment of patients already evacuated. Our first action, while setting up the facility, was to visit each of the care centres and the hospital in Vanimo. Vanimo Hospital did not have surgical staff, so several patients required immediate surgery. Nine major surgical procedures were undertaken at Vanimo before the field hospital was set up. Other patients requiring surgery were found in the care centres. The response by the local population in Vanimo was overwhelming. Within minutes of our arrival, a fleet of vehicles was at our disposal, and pledges given for all the assistance we could ask for. Local church communities guaranteed that all of the patients would be fed and looked after, and that orphans would have someone by their bed. Our field hospital consisted of a triage/resuscitation area, an operating theatre with equipment to run two operating tables, a self-contained ward facility with 20 beds, supported by x-ray, pathology (we could perform most routine tests and cross-match blood), and a preventive medicine laboratory. Initially, we ran two operating tables and a third for minor wound debridement. Our staff comprised a consultant surgeon, an orthopaedic registrar, a consultant anaesthetist and three general duties medical officers. 2: Surgical load and new patients admitted to the ADF facility, Days 1-9. Just as we were completing the first phase of setting up the field hospital, the evacuation aircraft began to return, and on the first day alone 124 patients were delivered to our facility. Thirty-nine surgical procedures were performed that day (Box 2, above), and by day's end we had 76 patients in a 20-bed facility. Extra wards were "commissioned" in the surrounding barracks using our soldiers' camp beds. Low- dependence patients were transferred to care centres in local schools and community centres. One of the eight-bed field wards of the ADF facility. The pace was similarly hectic on the second and third days; however, by the end of the fourth day, as most of the primary surgery has been completed, the pace began to slow. Then a phone call from Aitape reported that a patient had developed gas gangrene. A light aircraft and a pilot were found within an hour of last light and dispatched to retrieve this patient as well as some with less serious conditions. The aircraft returned with 13 patients, all requiring surgery that night! During the second week tactical aeromedical evacuation of patients was undertaken to spread the surgical workload between the hospitals at Vanimo, Wewak and Aitape. This also enabled us, working with the Monash Orthopaedic Surgical Team, to move nearly 40 patients (and relatives) to Wewak Hospital, where the operating and recovery facilities were more suited to patients needing orthopaedic surgery. After the fifth day the majority of surgery undertaken involved delayed primary closure of wounds, with or without skin grafting. The wider problems were now largely those of coordination and appropriate management of the care centres for displaced people and the attendant public health implications. Significant effort was needed to channel the international donations of staff and supplies to areas of need. Coordination of resources is the key to any disaster relief situation. In time, the organisation and response became increasingly efficient. The care centres were well set up inland, and various teams, both military and civilian, were providing basic medical care, well organised shelter and food. By 10 days after arrival, the workload was declining (Box 2). Each patient's wounds had been debrided, and many wounds were now closed or grafts had been performed. Although surgical procedures were performed right up to the last day of the deployment, we concentrated our efforts in the last few days on discharging patients from the ADF facility and arranging their ongoing care within local health facilities. When our remaining postoperative patients had been transferred we stopped operating, with only three out of 209 surgical patients still requiring wound closure. A clinical perspective As we arrived in Vanimo 52 hours after the tsunami, we had missed the first two peaks in deaths from trauma (Box 3), but had arrived in time to prevent the third peak, which occurs several days or weeks after injury. Indeed, the ADF contingent treated no patients with intracranial, intrathoracic, abdominal or spinal injuries as these patients had already succumbed before our deployment. Furthermore, few infants and elderly people had survived. 3: Trimordial distribution of deaths from traumatic injuryFirst peak -- seconds to minutes Injury incompatible with life (eg, aortic dissection). Second peak -- minutes to hours Focus injuries of early management of severe trauma (eg, haemorrhage, haemopneumothorax). Third peak -- days to weeks Complications, sepsis, multiorgan failure. Every patient treated on the first day had some degree of aspiration pneumonitis from near-drowning. Two patients were admitted in respiratory failure and treated with antibiotics, nebulisers and oxygen, but had little chance of survival. Many also had underlying respiratory disease; tuberculosis is endemic in the local communities. Anaemia was also common, usually owing to malaria or intestinal parasite infestation. All these problems complicated the patients' anaesthetic and surgical management. There were many large flap scalp lacerations caused by floating debris, and many fractures and dislocations, both open and closed. At least a quarter of all patients were children, many with simple soft-tissue injuries and lacerations. Another patient is moved to the recovery area after operation. Many patients required immediate surgery, but those triaged into the delayed-treatment group were rapidly deteriorating. All wounds were grossly septic and contaminated with foreign material such as sand, coral and vegetation and, as such, were at least limb if not life threatening. Many victims had been impaled upon the mangroves behind the Sissano lagoon by the force of the waves. The complete destruction of village aid posts and their workers resulted in virtually no medical attention being available to casualties initially. Dehydration compounded blood loss and worsening cardiovascular shock. Patients with large bone fractures were often transported unsplinted, and some developed presumed fat embolism syndrome, further worsening their preoperative condition. Surgery All patients brought to the ADF facility were initially rapidly triaged, with assessment and resuscitation proceeding simultaneously. All casualties were treated according to Australian Defence Force casualty treatment regimens -- a system of simple, reliable, reproducible treatment protocols based on accepted practice. Surgical procedures were based on principles espoused by the Red Cross (Box 4), which has by far the most extensive current experience of dealing with large numbers of casualties in situations with limited resources. 4: Red Cross surgical principlesWound assessmentWound excision and "decompression"Antibiotics (intravenous chloramphenicol)Undisturbed dressing techniquesOdour, temperature and pulse as indicators of inadequacy of initial wound surgeryDelayed primary closure with or without skin grafting at 4-5 days All wounds were extensively debrided and devitalised tissue removed. An aggressive approach was often required, and 14 amputations were performed. Fractures were aligned and immobilised with plaster slabs and improvised splints. Open fractures were debrided and thoroughly lavaged with sterile saline and immobilised with combinations of plaster and skeletal traction. Femoral fractures were managed initially with skeletal traction using Steinman pins and the patients were then flown to Wewak for definitive treatment by the Monash orthopaedic surgical team. Surgery was performed in two stages -- initial wound surgery, and then delayed primary closure. All surgical wounds were left open, using ample absorbent gauze dressings. Chloramphenicol and metronidazole, used in local practice and hence readily available, were used for antibiotic cover. Delayed primary closure was carried out four to five days later, as were the first split skin grafts. All split skin grafts were successful, at least until the time of our departure! Six wounds required further debridement. The parameters of odour, temperature and pulse rate were effective in identifying patients in whom initial debridement had been inadequate. Anaesthesia With such great demands on our meagre resources, there was a need to adopt a "standardised" approach to anaesthesia while still tailoring techniques to individual patients. As a result, recovery staff and medical assistants with little or no experience knew what to expect and how to manage patients postoperatively. Airway management, monitoring, induction and maintenance of anaesthesia often had to be performed before complete volume expansion had been achieved. Despite good interpreters, a complete medical history was frequently lacking and we thus had to be ever- vigilant for occult injuries and problems. We would often be overseeing three or sometimes four or five patients under general anaesthesia, with assistance from the ADF general medical officers. Anaesthesia was kept simple and safe and, where possible, the selection of anaesthetic agents was individualised. No premedications were used. For induction, ketamine was preferred, although thiopentone and propofol (Diprivan; ICI) were also used. Ketamine, which does not induce hypotension on induction and stimulates ventilation, was most suitable in these circumstances. In some cases, rapid-sequence induction and intubation using suxamethonium was used. Laryngeal mask airways were extensively used, as spontaneous breathing was the order of the day. This was safe, made monitoring simpler, used resources (one ventilator) more effectively and allowed a greater margin of error -- we were all exhausted. We used oxygen concentrators for oxygen supply. These are solid little machines producing 3-4 L/min of 90%-95% oxygen. We did not take nitrous oxide, which was considered dangerous cargo by the RAAF. Maintenance of anaesthesia was achieved with either ketamine, halothane or isoflurane. Narcotics were given intraoperatively; fentanyl, preferred because of its short half-life and high potency, was given intravenously. A standard combination of crystalloid and colloid (Hartmann's solution and Haemaccel) was used for intravenous volume replacement. Transfusions (a maximum of two units per patient, as supply was limited) were given when indicated; blood was obtained initially from Sydney and later from Port Moresby. Non-invasive methods of intraoperative monitoring were used. At times monitoring equipment was in short supply. Blood pressure, electrocardiograms, pulse oximetry and capnography provided basic information and proved reliable. Very little local or regional anaesthesia was used. Brachial plexus blocks were successful; however, spinal or epidural blocks were generally contraindicated because of coexisting sepsis. Postoperative requirements for opiates were minimal. The patients were uncomplaining; in some instances they had to be forced to accept pain relief. The atmosphere on the wards was sombre. The enormity of the disaster was simply too great to comprehend in those first few days. All of our patients looked shell-shocked, simply lying still, and taking little food. Conclusions In all, 124 primary surgical procedures and 85 secondary procedures were performed at the ADF health facility in Vanimo in the space of 10 days. In addition, about 25 other patients were operated on by ADF personnel at both Vanimo and Wewak hospitals. The success of our mission, in both humanitarian and international terms, lay in the ADF team approach -- fast, efficient and effective management of the casualties, and utilisation of all available personnel and resources for the best possible patient care. Medical officers, nursing officers and medical assistants, both regulars and reservists, all worked tirelessly to achieve this common goal. When we completed our mission each of the hospitals and care centres in the area had the staff, experience, stores and pharmaceuticals needed to continue its work. Displaced persons camps were well established, with shelter, clean water, food, health support and appropriate preventive health measures in place. Vaccination programs were planned, and resources and staffing needs identified. We were satisfied that we were leaving with all of the infrastructure in place to cope with the needs of the people, now and for the foreseeable future. Many of the soldiers deployed knew well the stories of how, during the second world war, the PNG people, who became known as the "fuzzy wuzzy angels", had helped wounded Australian soldiers back to aid posts. We considered our mission as simply "returning an old favour". A very moving farewell "sing sing" was testimony to the difference that our efforts had made and of the special relationship that exists between Australia and Papua New Guinea. Authors' details Holsworthy MILPO, Sydney, NSW. Paul R P Taylor, MB ChB, FRCS(Edin), Major, Officer Commanding, 1st Parachute Surgical Team, Coral Lines. James E Schlimmer, MB BCh, MMed(Anaes), Major; Medical Officer and Anaesthetist, 1st Field Hospital, Manunda Lines. Defence Health Service Branch, Canberra, ACT. David L Emonson, MB BS, Group Captain, Director of Health Planning and Intelligence. Reprints will not be available from the authors. Correspondence: Group Captain D L Emonson, Director of Health Planning and Intelligence, Defence Health Service Branch, Campbell Park Offices, Canberra, ACT 2600. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

David L Emonson · James E Schlimmer

Rescue Orthopaedic surgery after the Aitape tsunami "No gat mama, no gat papa, no gat pikinini -- olgera i lus pinis long solwara" Got no mother, got no father, got no children -- all lost forever in the salt water Annette C Holian and Prue P Keith MJA 1998; 169: 606-609 Introduction - Vanimo Hospital - Surgery at Vanimo - Coordination with the ADF - Medevac - Wewak - Farewell, for now - Authors' details - - More articles on Orthopaedic surgery Introduction There is a sense of fascination, horror and helplessness as the news of a vast natural disaster breaks. With the Aitape tsumani these feelings were heightened immensely -- we had been to this area of Papua New Guinea as members of surgical teams that had recently visited Aitape, Vanimo and Wewak. On these occasions congenital foot deformities and other orthopaedic problems were our targets -- a far cry from disaster medicine! As the magnitude of the disaster became apparent, there was a flurry of telephone calls between team members. The only thing we could not do was to do nothing. We knew the local hospitals' resources would be quickly overwhelmed, and that, at best, only limited orthopaedic care could be offered. The rapid announcement that an Australian Defence Force (ADF) medical team was to be dispatched was heartening news. We needed to ensure that orthopaedic expertise arrived too. We contacted the ADF on Sunday 19 July to offer the services of our surgical team (Box 1). They readily agreed and our core team of orthopaedic surgeon, registrar and theatre nurse left as part of the ADF's deployed Joint Task Force, but took almost three days to get to Vanimo (via Sydney, Brisbane, Townsville and Port Moresby). Some days later the remainder of the team made the same journey in 12 hours. Vanimo Hospital We went to Vanimo, where the ADF had established its base, as we were familiar with the medical resources at the Vanimo Hospital, and were sure the local Catholic mission and our good friend Brother James Coucher of the Passionist order would provide accommodation. Arriving in the early afternoon of Wednesday 22 July we met with the ADF surgical team and were most impressed! There were over 250 patients in the ADF base. Surgery was constantly being performed and a sense of intense urgency prevailed. At Vanimo Hospital the situation was quite different. Patients with every imaginable limb injury had been arriving for five days. The two local doctors were coping with over 200 patients and there was an acute shortage of space, beds, linen and nursing staff. Dr Les Roberts-Thompson had spent the first few days in the disaster area giving first aid and sending the injured to the hospital, where Dr John Novette and the health extension officers (who have three years' medical training and assist in the emergency department) provided what further medical care they could. Only the most severely injured patients had beds in the wards; others slept on the verandahs or on the grass outside under a tarpaulin (Figure 1). Some single beds accommodated two patients. Sheets, not normally provided by the hospital, were in short supply, with people sleeping directly on the vinyl-covered mattresses. There were very few pillows, and bags of belongings, which on previous visits we had used to elevate limbs, were notably absent. At times only one nurse was responsible for up to 50 patients. Beds were crammed in so closely that there was barely room to step between them (Figure 2). Each patient had at least one other person sleeping nearby to help care for them. The Vanimo Hospital's main operating theatre was so small that a trolley could not fit into the room unless the operating table was moved. It opened directly off a covered walkway and had no holding bay or recovery area. A kitchen sink in one corner doubled as a scrub sink and clean-up area. The orthopaedic equipment available was laid out for use: an amputation saw and a T-handled chuck. Fortunately, we had brought with us a general orthopaedic surgical instrument tray. Lois van Heuzen, our theatre nurse, ran between the theatre and the labour ward (where Elizabeth Lewis, one of the surgeons, was attending to wounds), and managed to ensure that our equipment was washed, dried and resterilised ready for each patient. Frequently, this involved only soaking in spirit. It was a challenging environment for orthopaedic surgery. Surgery at Vanimo The immediate aims in wound and fracture management were simple: to diagnose the injuries, debride soft-tissue wounds, establish effective traction and immobilise the fractures. This would provide the best preparation for definitive surgery in the second week, when internal fixation equipment was expected to arrive. Many hours were spent examining patients and establishing treatment plan priorities. There were numerous patients with dirty lacerations, penetrating joint injuries, and closed and open fractures who had spent days in salt water or mangrove swamps until help arrived. In addition to their orthopaedic problems, almost all had soft-tissue injuries and most had aspirated salt water. Not surprisingly, some had concurrent malaria. Record keeping and accurate patient identification were difficult. Before our arrival patients were identified by bed numbers. There were no identification bands and the medical records and radiographs were stored on patients' beds. Unfortunately, some beds had two numbers and other beds had two patients! We identified our patients creatively using key tags, baggage labels and, later, arm bands. Given the limited orthopaedic tools available, Thursday 23 July was designated as Steinman pin day; we inserted some eight pins and aspirated six knee effusions. The pins were extremely sharp and double-ended. The chuck would not lock reliably on the pins, even with encouragement from the local plumber's pliers. After we had both received penetrating injuries to the palm, we resorted to an unorthodox technique. Holding the sterile pin in one sterile hand, the other, unsterile hand put the plumber's unsterilisable hammer to good use, driving the pin home. We then covered the sharp pin ends with any available tubing, including the rubber tubing from spearfishing slings. Hard work by a team of Port Moresby theatre nurses, cleaning and hanging curtains to create a recovery area, allowed us to move to the larger outpatients operating theatre, and over the next few days we concentrated on drainage of pus, debridement and stump revision. Surgical priority was based largely on the intensity of odour. Necrotising fasciitis was rampant (Figure 3). Extensive debridement of fascial sheaths was often required, and wounds were packed open and reviewed regularly to ensure that we kept ahead of infection. It became obvious that several people with swollen limbs and grazes actually had wringer injuries, with degloving, fat necrosis and devitalised muscle. We were still finding foreign bodies in soft tissue a week after our arrival, but as far we are aware no further infections necessitating amputation occurred. Chris Blackburn, the team's physiotherapist, and John Kinealy, the cast technician, spent every day in the wards. They set up traction on patients as we returned them with their pins or new skin traction. This was difficult, as there were very few traction beds, no proper weights, no knee slings and the adults were too long for the beds. Brother Martin, also of the Passionist order, was engaged to construct some wooden frames to elevate limbs. These were lined with rice bags held in place by thumbtacks. The rice bags were also used to construct pelvic traction for a girl with diastasis of the pelvis. Fruit juice bottles filled with sand were used as weights (Figure 4). As beds with overhead beams were scarce, beds were positioned under the partly demolished partitions when required and traction suspended from the roof. Chest physiotherapy was vital for most of the patients. Chris spent hours making "bubble-pep" equipment from mineral water bottles, oxygen tubing and dish-washing liquid, then encouraging the children to blow, breathe, blow. As the days wore on, the condition of the patients on the grass became of increasing concern. Several were able to walk, but with significant limps and a swollen knee. When examined their expression of pain was so minimal that our initial clinical diagnosis was of a complete rupture of the medial ligament of the knee. A radiograph performed before casting revealed the true diagnosis -- a depressed lateral tibial plateau fracture. Patients with these fractures and with medial ligament injuries to the knee were immobilised in plaster cylinders topped with fibreglass to counteract the negative effect of humidity on the plaster. Coordination with the ADF There was considerable cooperation between the civilian orthopaedic team and the ADF medical team. ADF personnel supplied drinking water, Steinman pins, surgical consumables, and occasionally food. They visited us at the hospital several times each day to offer assistance. Their presence was an invaluable physical and mental support when we were stressed by the heat and humidity, and overwhelmed by the enormity of the task and the limited facilities. Medically, we performed complementary functions, each taking responsibility for patients on our own site, but readily transferring patients between sites to facilitate their care. Vanimo Hospital took patients who needed immediate specialist orthopaedic care or were stable enough to rest in bed with the available level of nursing care. To expedite their surgery, we temporarily transferred to the ADF some patients who needed dressing changes and possible further wound debridement. The ADF also helped to conduct a large scale transfer of patients from Vanimo to Wewak. Medevac from Vanimo to Wewak During the first week it became apparent that the facilities at Vanimo were unsuitable for many aspects of orthopaedic surgery and we contemplated moving patients to Wewak, some 40 minutes' flying time to the east. Wewak Hospital is the surgical centre for the Sandaun and East Sepik Provinces of PNG. It offered many attractions for the management of our patients, none more so than its remarkable resident general surgeon, Sister Martin Joseph, a British vascular surgeon trained at St Bartholomew's Hospital, London, and belonging to the Passionist order. Sister Joseph informed us that their operating theatres were open and staff ready for surgery. We knew from previous visits that the theatres, equipment, sterilising capabilities and nursing staff cover were all superior to those at Vanimo. As the surgeon responsible for the region, Sister Joseph would also be the most capable hands in which to leave the more complex cases for ongoing medical care. Careful thought was given as to which patients to take. The need for further surgery, including internal fixation, as well as the need for continuing close observation, physiotherapy, and proximity to family and friends were all taken into consideration. Patients were transferred to Wewak on two C-130 Hercules aircraft flights: the first occurred on Sunday 26 July and the second, larger group followed on Tuesday 28 July. These were both impeccably organised events and constituted, we were informed later, the largest transfers of injured patients performed by the ADF since the Vietnam War. Preparation for transfer included femoral nerve blocks, application of Donway splints, tying off traction, and splitting some encircling casts. Patients were ferried to the airfield by open truck, assembled and loaded on to the aircraft. Personal luggage, walking wounded, families, stretcher patients and finally our mission-made frames and other supplies were all neatly stacked in the aircraft. Stretchers were suspended three deep on taut seatbelt webbing that hung vertically from the aircraft's roof. We could only begin to imagine the anxiety that the children on board must have been experiencing. Wewak A fleet of tray-back light utility vehicles met us at Wewak Airport and transferred us to the Wewak Hospital. Patients were assigned to wards according to a plan arranged by Sister Joseph using a previously faxed list. Traction was re-established where required and split casts repaired. We reviewed our surgical capabilities. Our orthopaedic tools now included a Mathys rechargeable drill/wire driver/oscillating saw, boxes of Howmedica GK intramedullary nails (size 12-16) without reamers, a K-rod set with an almost complete set of T-handled reamers up to size 12, an assortment of external fixation equipment, as well as various loose screws and recycled plates without the appropriate drills, taps or depth gauge; nothing matched and no "set" was complete. Desperate attempts over the next few days to get better equipment from various sources were largely unsuccessful. Equipment was stalled in Customs, held up by transport companies, arrived incomplete or just disappeared. We planned a surgery list each day by trying to match up the fixation devices available with patient requirements. Tibial external fixateurs were constructed mostly from old Hoffman blocks, but as one type of connector was missing constructs were not always optimal. One frame was put on an open fracture of the ulna for which there were two blocks but only three pins. The fourth pin was created by putting some split intravenous tubing around a long cortical screw. The bar was a Steinman pin that fitted the block beautifully. One child had a fractured neck of femur, which we decided needed to be internally fixed to reduce the risk of non-union. In the absence of any conventional implant or image intensifier, we did an open reduction and secured the fracture with a tibial plateau T-plate with two cancellous screws along the femoral neck. The postoperative radiograph looked promising. In the third week we managed to obtain some basic and small-fragment instruments that allowed us to spend a satisfying, albeit difficult, day fixing the adult forearm fractures. On Thursday 6 August, nearly three weeks after injury, the remaining adults with complex, segmental and comminuted femoral fractures were treated. Open reduction was not easy but was ultimately achieved. Only two patients with fractures that we had expected to treat with internal fixation remained. One, an adult with a forearm fracture, had nearly succumbed to pneumonia and was not fit enough for anaesthesia, and the other had refused surgery. Farewell, for now Late at night on 6 August we completed our last ward round. The children's orthopaedic ward had become a centre of intense activity. Fifteen children in split Hamilton-Russell traction, four children with amputations and just about everybody else were watching the television/video that a mining company had donated. Everyone seemed comfortable and happy. Over 15 days we had performed 134 surgical procedures and treated a further 50 injuries conservatively (Box 2). We left knowing that we had made a difference. However, the orthopaedic disaster is not over yet. There will be people with non-union, delayed union, malunion, infections, physeal arrest and other unforeseen complications. Further operations will be necessary. Ideally, these should occur close to the patient's home and family and with the optimal equipment available to the surgical team. We will be back. Authors' details Monash Medical Centre, Melbourne, VIC. Annette C Holian, MB BS, FRACS, Paediatric Orthopaedic Surgeon. Prue P Keith, MB BS, Senior Orthopaedic Registrar. Reprints: Miss A C Holian, Monash Medical Centre, Locked Bag 29, Clayton, VIC 3168. Email: pruekATozemail.com.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Annette C Holian · Prue P Keith

Rescue Transport of the critically ill Is there a doctor in the helicopter? MJA 1998; 169: 610-611 In this issue of the Journal, Bartolacci, Munford and coworkers1 present an Australian perspective on major controversies in aeromedical transport. The controversies revolve around two central questions: the benefit of helicopter as opposed to ground transport, and the benefit (or otherwise) of a doctor as part of the transport team. While articles on these aspects of patient transport have been published since the early 1970s, good research is lacking. This largely reflects the difficulty of conducting controlled trials in an extremely complex field with many uncontrolled variables. The article by Bartolacci et al illustrates some of these problems: comparison groups were not randomised and data being compared (eg, admission versus scene data) were not directly comparable. This emphasises the need for a more scientific approach to this form of research. Even the often-quoted landmark studies by Baxt and Moody,2,3 which concluded that medical staffing of a helicopter rescue service significantly improved outcome, had similar drawbacks. They used scene data to calculate trauma scores for the cohort of patients treated by doctors (as part of a helicopter team) and compared outcomes with scores calculated from admission data for the group of patients treated by paramedics. Another study came to the opposite conclusion. Nicholl and colleagues4 found that the London HEMS (Helicopter Emergency Medical Service) made little impact on survival, except perhaps in the most severely injured patients. They used complex statistical manoeuvres in an attempt to artificially separate the effect of the helicopter team's intervention from that of the helicopter transfer and of the major trauma service receiving the patient. Even when the methodological flaws of these studies are overlooked, the conclusions reached are often specific to the system studied, and therefore have little external validity. For example, like Bartolacci et al, Dalton and colleagues concluded that a doctor was of benefit on a HEMS, as he or she could perform procedures that paramedics were not trained to do, such as orotracheal intubation.5 This may apply to the London HEMS, but other systems train non-physician flight staff to perform orotracheal intubation with or without muscle relaxants.6,7 A further concern is that most of the published work to date, like that of Bartolacci et al, focuses on trauma patients, and particularly on scene response. While trauma is important and rapid access of patients to definitive care has been demonstrated to be of benefit, it accounts for only about a third of patient transfers to hospitals (by all modes) for provision of specialised care. Several studies of all forms of interhospital transfer of critically ill non-trauma patients support the view that in such cases not only is it beneficial to have a doctor as part of the transport team, but that the doctor must be highly experienced in the management of critically ill patients -- junior doctors provide no benefit.7-9 While it will not be possible to make valid, universally applicable conclusions until detailed databases are established to act as a basis for integrated transport research, the work conducted to date suggests that the presence of an appropriately trained physician on a helicopter may make a significant impact on the outcome of patients in some circumstances: stable patients with cardiac problems, for example, may not require medical treatment during transport, whereas patients with complex critical illnesses may require an experienced clinician. Despite the limitations and difficulty interpreting studies to date, some aspects of a critical care transport system seem from first principles to be beyond debate. The medical transport system must utilise an integrated approach: it must be clear where patients with given conditions should go, and clinicians and hospitals must identify their role and areas of special expertise within the system. Lines of referral and communication must be clear and established as part of the inherent structure of the system. The process of initiating the transfer should be as simple as possible. A single, 24-hour telephone number which permits rapid communication between the referring doctor, the accepting unit and the transport team permits smooth access to the system. A clinician experienced in critical care should coordinate the process, prioritise transport, facilitate referral and determine which form of transport is most appropriate. Dedicated helicopters must be readily available, with all the equipment necessary for monitoring and safe transport of patients where appropriate. Minimum standards for such transport are detailed in the joint policy document of the Australasian College for Emergency Medicine (ACEM) and the Australian and New Zealand College of Anaesthetists (ANZCA),10 the essential principles being that transport should aim to improve patient care, and that "management during transport should equal or better management at the point of referral". In the debate about the benefit of helicopters as opposed to ground transport, helicopter transport is more expensive, but has the advantage of being able to collect patients from the roadside or referring hospital and deliver them more rapidly to the receiving institution. However, patients less than 30 minutes by road from hospital generally do not benefit from helicopter transport. Similarly, beyond 300 km, or when helicopter flight time exceeds one hour, the question becomes whether the greater air speed of fixed-wing aircraft can overcome the delays inherent in transferring patients between hospitals and airports. The actual point at which the balance favours fixed-wing aircraft probably depends on the conditions, patient needs and the type of aircraft used.11 It is clear that methodologically sound systems research is scarce in the field of critically ill patient transport, but that medical staffing is required for optimal management of some critically ill patients. Peter A Cameron Associate Professor, University of Melbourne; and Director of Emergency Medicine, Royal Melbourne Hospital, Melbourne, VIC Salomon Zalstein Staff Specialist, Department of Emergency Medicine Royal Melbourne Hospital, Melbourne, VIC Bartolacci RA, Munford BJ, Lee A, McDougall PA. Air medical scene response to blunt trauma: effect on early survival. Med J Aust 1998; 169: 612-616. Baxt WG, Moody P. The impact of rotorcraft aeromedical emergency care service on trauma mortality. JAMA 1983; 249: 3047-3051. Baxt WG, Moody P. The impact of a physician as part of the aeromedical prehospital team in patients with blunt trauma. JAMA 1987; 257: 3246-3250. Nicholl JP, Brazier JE, Snooks HA. Effects of London Helicopter Emergency Medical Service on survival after trauma. BMJ 1995; 311: 217-222. Dalton AM, Botha A, Coats T, et al. Helicopter doctors? Injury 1992; 23(4): 249-250. Emergency intubation. Ambulance Service Victoria. Clinical Practice Guidelines. 9th edition. Melbourne: Victorian Department of Human Services, 1997: 137-140. Murphy-Macabobby M, Marshall WJ, Schneider C, Dries D. Neuromuscular blockade in aeromedical airway management. Ann Emerg Med1992; 21: 664-668. Waddell G, Scott PD, Lees NW, Ledingham IM. Effects of ambulance transport in critically ill patients. BMJ 1975; 1; 386-389. Bion JF, Wilson IH, Taylor PA. Transporting critically ill patients by ambulance: audit by sickness scoring. BMJ 1988; 296: 170. Gentleman D, Jennett B. Hazards of inter-hospital transfer of comatose head-injured patients. Lancet 1981; 17: 853-854. Australasian College for Emergency Medicine and Australian and New Zealand College of Anaesthetists. Policy on minimum standards for transport of the critically ill. Emerg Med 1993; 5: 245-324. Schneider C, Gomez M, Lee R. Evaluation of ground ambulance, rotor-wing, and fixed-wing aircraft services. Crit Care Clin 1992; 8: 533-564. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Peter A Cameron · Salomon Zalstein

Rescue Air medical scene response to blunt trauma: effect on early survival Robert A Bartolacci, Blair J Munford, Anna Lee and Patricia A McDougall MJA 1998; 169: 612-616 For editorial comment see Cameron & Zalstein Abstract - Introduction - Methods - Results - Discussion - Conclusions - Acknowledgements - References - Authors' details - - More articles on Emergency medicine Abstract Objective: To assess the impact of on-scene treatment by an experienced critical care physician on prehospital resuscitation, the initial hospital phase and early survival of patients with major blunt trauma. Design, setting and participants: (i) Historical cohort of patients with trauma treated on scene by a helicopter emergency medical service (HEMS), 1986-1994, comparing medical and paramedical treatment and outcomes. (ii) Comparison of a subgroup of 77 patients (injury severity score [ISS] ≥15) treated by the air medical team (AMT) with (a) an ISS-matched group of 308 patients treated by ground paramedics (GPMs) and (b) the Major Trauma Outcome Study cohort. Main outcome measures: Procedural requirements assessed by the Therapeutic Intervention Scoring System (TISS), comparing resuscitation by medical and ambulance personnel; and observed versus expected mortality. Results: (i) Of 445 patients treated on scene, 270 (61%) had sustained trauma, and 215 of these received early management by the AMT. Problems with ventilation or with volume resuscitation were encountered by general duties ambulance personnel (40%) and paramedics (60%) before arrival of the AMT. (ii) Matched patients treated by GPMs required significantly more emergency department interventions on arrival at hospital (P < 0.01), and were possibly more likely to die in the first 48 hours (relative risk of death, 1.43; 95% confidence interval, 0.74-2.78) than patients treated by the AMT. Comparing the AMT-treated patients with the Major Trauma Outcome Study cohort, 9 deaths occurred of the 18 that were predicted -- a 50% reduction in predicted deaths (Z = 3.38; P < 0.001) -- and there were 11 unexpected survivors and one unexpected death. The adjusted "W" statistic was 12.18 (ie, there were 12 more survivors per 100 patients than the Major Trauma Outcome Study prediction, after adjustment for casemix. Conclusions: As part of the air medical team for response to major blunt trauma, a physician can provide significantly improved prehospital stabilisation, especially in airway and ventilatory control. Our results suggest improvement in mortality in AMT-treated patients, probably due to the enhanced procedural capabilities of physicians, despite longer prehospital times. Introduction Helicopter emergency medical services (HEMS) in Australia perform a variety of missions, including search and rescue, scene (or "primary") response to trauma or medical emergencies, and interhospital transport. Critical care physicians are included in the interhospital critical care transport teams, in accordance with specialist medical college policy,1 but staffing for scene responses varies. Some Australian HEMS use only ambulance officers (usually with paramedic certification),2 while others have scene response teams which include an emergency or critical care physician. The value of a physician for scene response is controversial.3-9CareFlight is a medically staffed helicopter service operating from Westmead Hospital, near the demographic centre of Sydney. The air medical team (AMT) comprises a specialist or registrar in anaesthesia, emergency medicine or intensive care, as well as a paramedic and/or aircrewman medical assistant. Since its inception in July 1986, the service has been available for both scene response and interhospital transport. Dispatch for scene response is at the discretion of the New South Wales Ambulance Service and is based on injury severity, entrapment, remote location, or difficult access (including the need for rescue hoist extrication). To assess the value of an experienced critical care physician as a member of scene response teams, we studied a retrospective cohort of patients treated on scene by CareFlight. Our aims were: To analyse the requirement, if any, for resuscitation of major trauma patients on scene and during transport by medically staffed HEMS; To use the Therapeutic Intervention Scoring System (TISS) (Box 1) to compare the hospital interventions required by patients with major blunt trauma after on-scene treatment by either an AMT or by ground ambulance paramedics (GPMs); and To use the Trauma Score - Injury Severity Score (TRISS) to compare early mortality of patients with major blunt trauma treated by an AMT with a matched group of patients treated by GPMs only, as well as with the cohort of the Major Trauma Outcome Study (Box 1). TRISS has been used to evaluate an Australian paramedic-staffed helicopter ambulance,2 but no previous Australasian study has done this for a medically staffed HEMS. Methods Our historical cohort of patients treated on scene by CareFlight was from the period July 1986 - June 1994. A number of groups were analysed (Box 2). CareFlight data Data were collected from CareFlight's clinical database and the Westmead Trauma Registry by one of us (R A B). Mission details from CareFlight's database included dates, patient demographics, nature of the accident, response, turnaround and transport times, injuries, staff on scene, assessment at scene, treatment before the arrival of the AMT, and treatment on scene/in transit by them. This information was supplied by the attending doctor at the completion of the mission. The treatment given by the AMT was in accordance with the principles of early management of severe trauma (EMST).21 On-scene procedures TISS scoring was done by one of us (R A B), and three groups of patients were compared for their resuscitation requirements when (1) AMT first on scene; (2) general duties ambulance officers already on scene; and (3) GPM ambulance officers already on scene. TISS scoring was done for the period from first intervention until arrival at hospital. Patients with major blunt trauma All patients who were transported to Westmead Hospital by the AMT who had major blunt trauma (injury severity score [ISS] ≥15) were identified from the Westmead Trauma Registry. Each of these 77 AMT-treated patients were matched with four randomly chosen patients with equivalent ISS (± 5) treated and transported by GPMs in the same year. Patients who had been treated by GPMs only and who were pronounced dead on arrival at hospital were excluded from this analysis. Other data collected included observations and procedures on arrival in the Emergency Department. TISS scoring was done for procedures performed in the Emergency Department. The predicted mortality of these 77 AMT patients was determined using TRISS and the coefficients derived from the Major Trauma Outcome Study16 (using the 1990 Abbreviated Injury Scale).15,20The revised trauma score (RTS)19 and the ISS14 were calculated from information on injuries sustained recorded in the case notes or the autopsy reports. To calculate the RTS, the Glasgow Coma Scale (GCS) and respiratory rate were obtained from CareFlight's records. The predicted mortality could not be calculated for the ISS-matched GPM group as these data are not recorded by the ambulance service. The comparison between predicted and observed mortality of AMT patients was made at 48 hours after hospital admission. Survival intervals as short as 6-12 hours have been used previously9,22 to measure efficacy of prehospital care, while 48 hours was recommended by Baxt and Moody, who found that all deaths related to prehospital factors occurred within this time.6 Statistical analysis On-scene procedures Kruskall-Wallis ANOVA was used to compare the resuscitation requirements of the three groups with different staff first on scene, as evaluated by TISS. Major blunt trauma patients We compared patient demographics, hospital interventions and outcomes of patients treated by the AMT with these data for patients treated by GPMs using appropriate Student's t tests, Mann-Whitney U tests and chi-squared analysis. Early death was defined as death due to initial injuries or complications of those injuries within 48 hours of hospital admission. The relative risk (RR) of early death and 95% confidence intervals (CI) were estimated to compare outcomes of patients treated by the AMT and GPMs, respectively. Comparisons between predicted and observed mortality of AMT patients were made using the "Z", "W" and "M" statistics.16 Flora's "Z" statistic estimates the deviation of mortality in the study group compared with the Major Trauma Outcome Study benchmark.16 The "W" statistic provides a clinical perspective on a statistically significant "Z" score,19 and calculates the number of survivors more (or less) than the Major Trauma Outcome Study norm per 100 patients analysed.23 The "M" statistic evaluates the match of injury severity between the study group and the entire Major Trauma Outcome Study cohort.16 An adjusted "W" statistic was also estimated using the method of Younge et al,23 which was developed to adjust for the more severely injured patients treated by HEMS. Results Over the study period, the AMT attended 445 patients in scene responses, of whom 270 had trauma (Box 2). This excluded minor injuries where the HEMS was required only for remote access or hoist extrication. Most patients were male (70%). Vehicle-related trauma occurred in 138 patients (51%); 19 patients (7%) were entrapped. The trauma cases included 61 (23%) with spinal injury only, 19 (7%) with head injury only, 81 (30%) with head plus other injuries, and 109 (40%) with other injuries. Only three cases (1%) had penetrating trauma. The median response time for the ATM from initial call to arrival at the patient was 26 minutes (range, 6-624, including several cases requiring prolonged secondary access). The median turnaround time (time from arrival at patient to departure from scene) was 33 minutes (range, 1-400, including entrapments and difficult access). Median transport time (time from scene departure to arrival at tertiary facility) was 18 minutes (range, 3-205). Comparison of on-scene treatment Of 270 patients with trauma, 215 required AMT assistance. The AMT was first on the scene for 31 of these patients (14%); general duties and paramedic ambulance officers were on the scene before the AMT's arrival for 50 (23%) and 125 (58%) patients, respectively. In the remaining nine patients (4%), other health professionals were on the scene. Of the 61 spinal injury patients, 26 (43%) did not require AMT assistance. Conversely, of the 209 remaining patients with head and/or other injuries, only 29 (14%) did not require AMT assistance. No patients died during transport, but 12 died at the scene. Eleven of these were already in traumatic cardiac arrest when the AMT arrived and one was an entrapped motor vehicle accident victim who exsanguinated during release. The on-scene procedures performed by general duties ambulance officers and paramedics, the supplementary patient management by the AMT, and problems identified with treatment given by ambulance officers and paramedics are shown in Box 3. Of the 35 paramedic-treated patients with a low score on the Glasgow Coma Scale (< 9), only 15 (43%) were correctly intubated at the time of the arrival of the AMT. Even in the 16 patients with a score on the Glasgow Coma Scale of 3 or 4, six (37%) were not intubated before AMT arrival. Of the 18 patients with endotracheal tubes placed by paramedics, there were problems in five (28%) cases, including three oesophageal intubations. Intubations by the AMT were all oral, with the aid of muscle relaxants, with no failed or oesophageal intubations. No patient with a low score on the Glasgow Coma Scale (< 9) was transported unintubated. There was a significant difference in median TISS scores between the three patient groups -- AMT first on scene, and general duties ambulance or paramedics first on scene (P = 0.04). There was a significantly higher number of interventions in the paramedic group (median TISS score, 12) than in the AMT (median TISS score, 7) (P = 0.01). Patients with major blunt trauma Hospital interventions and outcome There were no significant differences in patient characteristics between the AMT-treated (n = 77) and matched GPM-treated (n = 308) groups transported to Westmead Hospital (Box 4). Patients in the GPM group required significantly more interventions in the Emergency Department (median TISS score, 3) than those in the AMT group (median TISS score, 2; P < 0.01). In comparing the various resuscitation procedures (Box 4), the AMT group required fewer intravenous line placements and endotracheal intubations and less mechanical ventilation than the GPM-treated group. Patients in the GPM group were 1.43 (95% CI, 0.74-2.78) times more likely to die in the first 48 hours compared with those in the AMT group. Comparison with the Major Trauma Outcome Study The outcomes for the patients in the AMT-treated group using TRISS (1990 coefficients20) are shown in Box 5. The predicted number of deaths for the group analysis was 18. Nine patients actually died within 48 hours, a 50% reduction in expected mortality. The difference in the observed and expected number of survivors was significant (Z = 3.38; P < 0.001). The W statistic was 11.88. The M statistic was 0.52, which is less than the 0.88 acceptable level16 for comparing populations (ie, there was a higher proportion of patients with a low probability of survival in the AMT group compared with the Major Trauma Outcome Study cohort) (Box 6). This required calculation of an adjusted "W" statistic (using the method of Younge et al to compensate for casemix difference), which was 12.18 (95% CI, 5.29-19.07). This suggests that there are 12 more survivors per 100 patients with major blunt trauma than would be predicted by comparing with the Major Trauma Outcome Study, after adjusting for casemix differences but not for late deaths (> 48 hours). Discussion Our study shows the advantages of a medically staffed HEMS, compared with paramedics alone, for prehospital stabilisation of major trauma patients. Of note was the number of patients with low scores on the Glasgow Coma Scale (< 9) who were not able to be intubated by paramedics, reflecting the difference between airway control in patients with cardiac arrest (unmodified oral intubation is usually possible) and those with trauma (likely to require techniques incorporating sedatives and muscle relaxants outside paramedic protocols). Medically treated patients required significantly fewer interventions in their initial hospital phase compared with patients treated by GPMs. Because of hospital proximity, some patients in the paramedic group may have been rapidly transported, thus generating additional interventions and TISS points. However, some interventions (eg, airway control) should be performed as soon as possible regardless of hospital proximity. In AMT-treated patients with severe blunt trauma, there were significantly more early survivors than predicted by TRISS. There were also more survivors compared with the ISS-matched group of GPM-treated and GPM-transported patients, although the 95% confidence interval does not exclude a similar risk of death or even a better chance of survival in the GPM-treated group. The percentage improvement in both comparisons is very similar, suggesting a real improvement over the GPM-treated group. As this occurred despite longer prehospital times, it is presumably due to the enhanced prehospital stabilisation by the AMT. Baxt and Moody were the first to use TRISS to assess the impact of HEMS scene response in trauma. They found a 52% reduction in predicted mortality from blunt trauma in an AMT-treated group versus a non-significant increase in a standard GPM-treated group, despite greater distances and prehospital time in the former.17 Two other studies have found that physicians contributed judgement or procedural skill, or both, in 22%5 to 25%24 of missions. A subsequent US multicentre study showed a 21% reduction in mortality, using the Major Trauma Outcome Study cohort as a benchmark.25 Only four out of seven of these services included a physician in the medical crew. However, this study cannot be directly compared with ours as the non-physician crew were more highly trained and often worked under direct radio control of a critical care or emergency physician, while the physicians were more junior than their Australian equivalents. In Australia, procedures performed by paramedics are limited and on-line medical control is not used. Our study found major differences in resuscitation compared with an earlier Australian HEMS study by Cameron et al with a paramedic crew,2 in which 42% of patients with a low score on the Glasgow Coma Scale (< 9) were transported unintubated (compared with none in our study). This non-intubation rate was almost identical to that before AMT arrival in our study, reflecting the shortcomings of current paramedic protocols as discussed above. Limitations to our study include its small sample size, which may reflect underutilisation of the service, and the fact that it is retrospective. Selection bias cannot be ruled out, and this may have affected the results either way: the AMT may not have been called out for some older patients or those with a poor prognosis; and, conversely, anecdotal evidence suggests that the AMT may be called out by paramedics when a patient's death is imminent. However, we found no difference in demographics between AMT- and GPM-treated patients. The main limitation was that data collection by the NSW Ambulance Service does not include all the variables necessary to calculate the RTS. Hence, TRISS could not be calculated for the matched GPM group, only the ISS. TRISS itself has limitations: the physiological component (RTS) varies with time and therapy. Thus, consistent timing of data collection is logistically impossible in any trauma population, whether this is done prehospital or at admission. Nevertheless, there is a need for better data collection and more outcome studies of all Australian trauma patients. Ideally, TRISS data should be available for all trauma patients to aid in evaluation of trauma care, with calculation of local norms for survival. Only then will it be possible to accurately assess the value of HEMS with and without advanced medical capability. The significance of our study needs to be viewed in the light of the regionalised system of trauma centres, the benefit of which lies in the centralisation of experience and resources available to patients on reaching the trauma centre. The disadvantage is that some patients will now find themselves further from this destination. The need for pretransport stabilisation must be balanced against the need for rapid transport to definitive care. Rotary wing transport can shorten transport times, but may not decrease total prehospital time when used as a secondary response (ie, when called in by emergency services already at the scene). Helicopters, although two to three times faster than road ambulance, must travel twice as far (out and back), plus launch time and time on scene. Consequently, the value of HEMS is limited if the staff are unable to provide a higher level of clinical care on scene and in transit. A study of paramedic-staffed urban HEMS showed no improvement in prehospital time or survival when called in by ground paramedics already on scene.22 This is consistent with the findings of the Australian study by Cameron et al.2 While care must be taken not to unnecessarily prolong scene times, our study showed almost identical scene times to those for Australian paramedics.2 A study of rural HEMS also found that scene times are not prolonged by performance of advanced procedures by physicians.26 Conclusions Our study suggests that an appropriate critical care doctor should be considered, if not routinely incorporated, as part of any air medical scene responses to major blunt trauma. Air medical transport is currently relevant only to those trauma patients who have significant injuries and, because of distance, entrapment, or difficult access, cannot be rapidly transported to an appropriate hospital by conventional ambulance. In these circumstances, prolongation of prehospital time is frequently inevitable despite HEMS. Consequently, more advanced prehospital measures from a critical care medical team may be required aboard the HEMS. The use of HEMS allows an AMT to respond rapidly over a wide area. Acknowledgements We thank Dr P D Middleton, FRACS, formerly Trauma Fellow at Westmead Hospital for his contribution to the pilot study. We also thank Valerie Kuther and Larry Bain from Tri-Analytics Inc for providing unpublished data from the Major Trauma Outcome Study. References Australian and New Zealand College of Anaesthetists/Australasian College of Emergency Medicine. Minimum standards for the transport of the critically ill. Melbourne: Australian and New Zealand College of Anaesthetists/Australasian College of Emergency Medicine, 1992. (Policy Document P23.) Cameron PA, Flett K, Kaan E, et al. Helicopter retrieval of primary trauma patients by a paramedic helicopter service. Aust N Z J Surg 1993; 63: 790-797. Munford BJ, Manning R. Paramedic helicopter retrieval of trauma patients [letter]. Aust N Z J Surg 1994; 64: 640-642. Cameron P. Paramedic helicopter retrieval of trauma patients [letter]. Aust N Z J Surg 1994; 64: 640-642. Rhee KJ, Strozeski M, Burney RE, et al. Is the flight physician needed for helicopter emergency medical services? Ann Emerg Med 1986; 15: 174-177. Baxt WG, Moody P. The impact of a physician as part of the aeromedical prehospital team in patients with blunt trauma. JAMA 1987; 257: 3246-3250. Hamman BL, CuŽ JI, Miller FB, et al. Helicopter transport of trauma victims: does a physician make a difference? J Trauma 1991; 31: 490-494. Burney RE, Passini L, Hubert D, Maio R. Comparison of aeromedical crew performance by patient severity and outcome. Ann Emerg Med 1992; 21: 375-378. Schmidt U, Frame SB, Nerlich ML, et al. On-scene helicopter transport of patients with multiple injuries; comparison of a German and an American system. J Trauma 1992; 33: 548-555. Cullen DJ, Civetta JM, Briggs BA, Ferrara LC. TISS (Therapeutic Intervention Scoring System): a method for quantitative analysis of patient care. Crit Care Med 1974; 2: 57-60. Keene AR, Cullen DJ. Therapeutic intervention scoring system: update 1983. Crit Care Med 1983; 11: 1-3. Rhee KJ, Burney RE, Mackenzie JR, et al. Therapeutic Intervention Scoring as a measure of performance in a helicopter emergency medical services program. Ann Emerg Med 1986; 15: 40-43. Burney RE, Rhee KJ, Cornell RG, et al. Evaluation of hospital-based aeromedical transport programs using therapeutic intervention scoring. Aviat Space Environ Med 1988; 59: 563-566. Baker SP, O'Neil B, Haddon W, Long WB. The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974; 14: 187-196. Champion HR, Copes WS, Sacco WJ, et al. The Major Trauma Outcome Study: establishing national norms for trauma care. J Trauma 1990; 30: 1356-1365. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. J Trauma 1987; 27: 370-378. Baxt WG, Moody P. The impact of a rotorcraft aeromedical care service on trauma mortality. JAMA 1983; 249: 3047-3051. Champion HR, Sacco WJ, Carnazzo AJ, et al. Trauma score. Crit Care Med 1981; 9: 672-676. Champion HR, Sacco WJ, Copes WS, et al. A revision of the Trauma Score. J Trauma 1989; 29: 623-629. Champion HR, Sacco WJ, Copes WS. Injury severity scoring again. J Trauma 1995; 38: 94-95. Royal Australasian College of Surgeons, Road Trauma Committee. Early management of severe trauma course manual. Melbourne: RACS, 1989. Schiller WR, Knox R, Zinnecker H, et al. Effect of helicopter transport of trauma victims on survival in an urban trauma centre. J Trauma 1988; 28: 1127-1134. Younge PA, Coats TJ, Gurney D, Kirk CJC. Interpretation of the W s statistic: application to an integrated trauma system. J Trauma 1997; 43: 511-515. Snow N, Hull C, Severns J. Physician presence on a helicopter emergency medical service: necessary or desirable? Aviat Space Environ Med 1986; 57: 1176-1178. Baxt WG, Moody P, Cleveland HC, et al. Hospital based rotorcraft aeromedical emergency care services and trauma mortality: a multicenter study. Ann Emerg Med 1985; 14: 859-864. Anderson TE, Rose WD, Leicht MJ. Physician staffed helicopter scene response from a rural trauma center. Ann Emerg Med 1987; 16: 58-61. (Received 23 Sep 1997, accepted 28 Jul 1998) Authors' detailsNRMA CareFlight, Westmead Hospital, Westmead, NSW. Robert A Bartolacci, MB BS, Provisional Fellow in Anaesthesia. Blair J Munford, MB ChB, FANZCA, Specialist Anaesthetist. Anna Lee, MPH, Honorary Epidemiologist. Department of Surgery, Westmead Hospital, Westmead, NSW. Patricia A McDougall, RN, CNC, Trauma Nurse Coordinator. Reprints: Dr B J Munford, NRMA CareFlight/NSW Medical Retrieval Service, PO Box 159, Westmead, NSW 2145. Email: bmunfordATozemail.com.au Make a comment Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Robert A Bartolacci · Blair J Munford · Anna Lee · Patricia A McDougall

Medical Research Perspectives Medical research in New South Wales 1993-1996 assessed by Medline publication capture Emmanuel J Favaloro MJA 1998; 169: 617-622 Abstract - Introduction - Methods - Results - Discussion - Conclusions - Acknowledgements - References - Author's details - - More articles on Informatics and computers Abstract Objectives: To assess medical research publication output in New South Wales (NSW). Design: Analysis of publication information from the Medline indexing database, 1993-1996 inclusive. Setting: Teaching hospitals and affiliated universities and medical research institutes within NSW, the major sites for NSW medical science publications. Major outcome measures: Cumulative number and location of Medline-identified publications; journal citation indices (impact factor and immediacy index). Results: 8860 published articles were captured for the analysis period. Universities and hospitals accounted for most of the publications (n = 7755). A mean of 73.1% (range, 36%-100%) of all articles were published in overseas journals, and the rest in Australian journals. This average trend applied to most universities and teaching hospitals, whereas research institutes published almost exclusively in overseas journals. Average publication impact factor values for most universities and teaching hospitals were around the average value for all NSW publications (2.203). The range for teaching hospital publications was 1.000-2.823, but for the overseas-publishing medical research institutes it tended to be higher (2.480-5.423). Immediacy index data yielded similar findings. Conclusions: The universities and teaching hospitals account for most of the medical publications arising from NSW, and also those appearing in Australian journals. Thus, these sites provide the bulk of Australian medical practice end-user information. In contrast, the medical institutes concentrate on publishing in overseas journals with higher and quicker citation rates (higher impact factor and immediacy index). Introduction The Medline database can be used to capture research publications arising from within one institution or the search can be expanded to include, for example, all Medline-held publications from one State. Further, to help analyse publication activity, publication data derived from Medline searches can be merged with markers of publication citation, such as "impact factor" and "immediacy index". This latter information comes from the Institute for Scientific Information (ISI; Philadelphia, USA), which catalogues most of the major research journals in Science Citation Index (SCI) publications,1 and publishes "impact factor" and "immediacy index" data. Data on impact factors are often also used as surrogate markers of publication "quality", although there is much debate about the validity of this approach.2-5Recently, Bourke and Butler analysed individual article citation rates as a measure of basic medical and health sciences research in Australia and concentrated largely on universities and high profile research institutes.6 Although these authors have produced several other reports analysing Australian research activities,7 none has looked specifically at teaching hospitals, "affiliated" research institutes (defined as the "research arm" of the hospital) and associated universities within New South Wales (NSW). This article reports the results of such a sampling analysis. Methods A complete description of the methods used is beyond the scope of this report. In brief, the Medline publication indexing database (Silverplatter version) was used to capture "quantitative" research publication information. This database indexes most major journals in medical and related fields (veterinary, pathology and cell science), and each publication indexed includes the primary author's address. A hospital-affiliated medical research institute was defined as such if more than a third of its publications included the teaching hospital as part of the Medline address field. That is, the medical research institute itself, and its researchers, clearly recognised the affiliation within the context of the publication. Adoption of this strict criterion resulted in exclusion of some research institutes, or their not being identified as hospital-affiliated sites, despite being "popularly perceived" as affiliated with a particular teaching hospital. The teaching hospitals, their affiliated universities and medical research institutes included in this report are listed in Box 1. Data capture: The approach which was found to best capture publication data was to use (i) general ("primary") locality markers (ie, the terms "New South Wales", "NSW", "Sydney"), and (ii) separate specific ("secondary") locality markers (ie, names of "suburbs" in which the medical research organisations were located). This led to more complete capture of relevant publications than use of specific organisational names because of inconsistencies in the organisational names in the publications (eg, University of Sydney v. Sydney University, etc). Captured data were then merged with journal citation data. Years of analysis: Medline capture and analyses were conducted for the years 1993 to 1996 (inclusive), as these were the most recent four consecutive years for which SCI-published impact factor and immediacy index information was available. Subsequent analysis: Applicable publications were downloaded to a personal computer, and a composite database was constructed specifically for analysis of derived information. Author's address: Author's address, and thus research institution location, was defined essentially as indicated by the downloaded author's address and Medline publication information, always attempting to be as objective as possible. If a publication noted Sydney University as the author's address, then Sydney University was the designated publication address. Where multiple authors' addresses were noted then the address was "shared" (Box 2). Analysis of research output and outcome measures: Research output can be assessed in various ways according to its underlying purpose. Thus, several objective analyses were undertaken to answer separate questions, including: Gross research (publication) output of medical or related subjects -- this is assessed by the total number of publications captured; Journal publication patterns -- assessed by analysis of journal citation data using impact factor and immediacy index (Box 3) (only available for certain publications); and Relevance to Australian medical practice -- assessed by analysis of the number and proportion of papers published in Australian versus overseas journals. Results Publication output The composite NSW-derived Medline-captured database (1993-1996 inclusive) showed that "medical, veterinary, pathology and cell science" researchers (having given one of various localities within NSW as their address) published 8860 articles in this period. A total of 7755 of the NSW-based publications captured by Medline arose from the universities and hospitals. Figure 1 shows data for teaching hospitals and research institutes with more than 35 publications, and Figure 2 shows data for universities affiliated with these research sites. Figure 1: Medline-captured publications arising from NSW teaching hospitals and medical research institutes (1993-1996 total; only those sites with more than 35 publications over this period are shown). Data shown as a composite bar graph for those hospitals with an affiliated research institute (as defined in Methods). POWH=Prince of Wales Hospital. Figure 2 (inset): Medline-captured publications arising from NSW universities affiliated with the research sites in Figure 1 (1993-1996 total). Overseas v. Australian publication More than 70% (73.1%; range, 36%-100%) of the research publications from NSW researchers appeared in overseas journals and the remainder in Australian journals, with a similar division evident across different hospital and university sites (Figure 3). In contrast, the medical research institutes tended to publish almost exclusively in overseas journals. Figure 3: Medline-captured publications arising from NSW research. Percentage of journal articles in Australian journals v. overseas journals; data shown are 1993-1996 average. Data shown separately for the hospitals, universities and research institutes in Figures 1 and 2. POWH=Prince of Wales Hospital. Journal citation data Excluding publications not listed in the SCI1 publication statistics, the NSW-based average impact factor (all NSW Medline-captured journal publications) was 2.203 (1993-1996 averaged). Averaged impact factor and averaged immediacy index data for each research organisation are shown in Figure 4. For comparison, data for hospital, university and medical research institute sites are shown separately. Figure 4: Average impact factor and immediacy index (1993-1996 average) for Medline-captured publications arising from NSW research. Data shown separately for the hospitals, universities and research institutes in Figures 1 and 2. (Average impact factor = cumulative impact factor of all journal publications for each research site divided by total number of journal articles captured for that site. Average immediacy index = cumulative immediacy index of all journal publications divided by total number of journal articles captured for that site.) POWH=Prince of Wales Hospital. Average impact factor values for most hospital sites (around 2) are similar to those generated from each of the affiliated universities. Indeed, the "all hospital average" impact factor was similar to the "all university average" impact factor. In general, the research institutes' tendency to publish in overseas-based journals increased their impact factor averages (Figure 4). The pattern of immediacy index data closely followed the pattern observed for impact factor (Figure 4). Discussion General findings This report confirms the importance of the NSW teaching hospital system in ongoing medical research and teaching activity. Together with their affiliated universities, these sites provided the great bulk of medical publications arising from NSW. While the research institutes tended to target "international" journals directed at specialised scientific research, teaching hospitals and their affiliated universities targeted Australian journals as well. This means that the "non-research institute" sites play the predominant role in providing local educational support to Australian health practitioners via journals published and widely read within Australia. Although publishing in Australian journals often carries less international "prestige" or "visibility" than publishing in overseas journals, Australian publications play an important role in education of medical, scientific, nursing and allied health practitioners. Furthermore, Australian publications have particular relevance to Australian medical practice, with reporting of specific local data or locally relevant issues (eg, local epidemiological or local infectious disease data). Advantages and disadvantages of the method Data were collected by a well recognised and accepted method of capturing publication information. The Medline database has previously been used with success in bibliometric studies to show publication trends,8-10 and has been consistently shown to provide the strongest health discipline indexing coverage when compared with other databases.11-15 Based largely on internal comparative research estimates, the method used would be expected to capture in excess of 60% of the published research output from NSW medical researchers, and is thus only an approximation of the level and scope of all such activity. Missing would be: Valid research publications not indexed by any indexing service (eg, reference book chapters, articles in popular science or society journals); and References in non-Medline indexing services. Moreover, the Medline indexing service may exclude certain journals preferentially favoured by some research organisations. However, an advantage of the method is that it does not capture: Non-standard publications (which would complicate any analysis); Low grade ("self-promotional") publications which may be included in subjective analyses (eg, publications in annual research reports, "in press" publications, conference presentations); and It minimises the likelihood of "tally duplication" because of research collaborations. Some exclusions or errors in location assignment will have occurred despite extensive cross-checking to certify a publication's origin. I relied almost entirely on authors to provide their own affiliation information. However, this was not always provided, or the address details were not always consistent. Finally, Medline catalogues only the primary author's address, so that publications of research collaborations for which the base research site (ie, principal author(s) address) is (i) outside the Medline capture search limit, or (ii) does not contain collaborating ("secondary") authors' addresses will be excluded from the tallies from these institutions. Importantly, while research output will necessarily be underestimated by this process, it would be expected that (apart from the limitations noted above) no individual hospital or other research organisation would be differentially disadvantaged in a direct-comparison process. The process employed within this report can easily be validated by any institution should there be any concern regarding objectivity or validity. Journal citation analysis The research institutes tended to target journals with higher and quicker citation rates (ie, average impact factor and immediacy index, respectively, was highest in their chosen journals), partly because these institutions published almost exclusively in overseas journals. These tend to have higher citation rates, and thus higher impact factor and immediacy index values (as shown by a breakdown of average impact factor values for SCI-listed journals with publications from NSW in 1993-1996 found by Medline capture) (Box 4). Impact factor listings derive from the United States and most strongly favour US journals.3 Recalculating average research site impact factor data for overseas publications only (ie, excluding Australian publications) tends to increase the relative average impact factor value for most hospital sites by between 0.5 and 1.0, and thus brings their average values very close to those of the research institutes. The medical research institutes concentrate more specifically on publishing specialist research work targeted at other research scientists, which cultivates further research activities and citing of publications by research peers, maintaining these journals' high impact factors. The core hospital sites publish this sort of research as well as publishing "generalist education" or "local content" papers aimed at non-research ("end-user") health specialists. Both forms of publication are valid and valuable, although only the former has high "international visibility". That immediacy index data largely follow the pattern of the impact factor data suggests that use of both citation markers may not be required in subsequent analyses, and that journals with high citation rates (impact factor values) also have quicker citation (immediacy index) values (confirmed by review of the Medline database and SCI publications1 -- data not shown). Citation values as markers of research quality Publication citation data are popularly used as a surrogate marker of publication "quality" on the premise that the higher the citation rate, the greater the scientific quality of the articles in that journal. The validity of this approach can be questioned and has given rise to much recent debate.2-5,16-18 The main problems relate to: Accessibility of journals and journal listing bias, with only journals in the SCI database included in the analysis and listings strongly favouring English language journals published in the United States; Inferences that a journal's impact factor or citation pattern reflects each article's citation pattern (which is not the case; also article citation rates determine journal impact factor, not the other way around), and that citation reflects scientific quality (not necessarily -- an article may be cited often to exemplify a scientific flaw); Citation bias, as there is no correction for the influence of self-citation in impact factor calculations (authors and journals may both favour self-citation); and Specialty bias, as impact factors differ according to the research field. There are many other potential traps.2-5 However, the impact factor process is relatively easy, and it offers an achievable comparison process, so its popular use as a quality marker persists. In practice, the impact factor may better reflect "international visibility" than "scientific quality". Furthermore, use of averaged data (eg, average impact factor and average immediacy index) perhaps shows "average visibility". A fairer comparative process might be to correlate total (or cumulative) impact factor as a marker of "total visibility", as shown in Figure 5. Figure 5: Total, (ie, cumulative) impact factor (1993-1996 period) for Medline-captured publications arising from NSW research. Data shown as a composite bar graph for those hospitalswith an affiliated research institute (as defined in Methods). Cumulative impact factor derived by addition of individual impact factor values from all journal publications for each research site. POWH=Prince of Wales Hospital. In a recent comparable analysis, Bourke and Butler6 assessed Australia's basic research in the medical and health sciences, using individual article citation rates to assess the "visibility" of research in different general research sectors (ie, universities, hospitals, medical research institutes, other institutions) by calculating the average number of citations received per publication (cpp). They also listed specific institutions with high cpp values. Use of this more specific marker of article citation, rather than journal citation, overcomes some of the limitations noted above of the use of impact factor as a surrogate marker of publication quality. However, use of cpp is still based on the premise that a high citation rate reflects high scientific quality. With this tool, Bourke and Butler6 concluded that "the bulk of Australia's basic research in the medical and health sciences comes from the universities and hospitals, but Australia's medical research institutes, the members of AAMRI [Australian Association of Medical Research Institutes], have the highest international profiles". In this our data agree. Thus, while these institutes produce publications which appear in the most highly "visible" journals, the universities and hospitals produce the vast bulk of the research output, and contribute most to local medical issues. However, if, as an exercise, Australian journal publications are excluded from the calculations, the remaining overseas-published medical research from the universities and hospitals also appears in these highly "visible" journals. Finally, it is likely that some significant under-representation of specific teaching hospital sites would have occurred in Bourke and Butler's6 study, as "where a research group based in a hospital with a university connection lists the university in the address, we consistently assign the publication to the university". In this report, publications are assigned to both the university and the hospital, and comparisons then made differentially. Based on the Medline database, an average of 14% (but, on a case-by-case basis, up to 43%) of hospital publications include a university address. Conclusions This survey confirms the important contribution to medical research and teaching made by NSW teaching hospitals. Thus, both publication output and perceived scientific quality and visibility can be considered as high compared with peer NSW research institutes. In addition, it is the non-research-institute-based hospital sites that most significantly contribute to research published in Australia. It is hoped that the process of identifying quality research from Australian research institutions, as outlined in this report, will help promote research activity and its future development at these sites, and help to set benchmark standards for this research and teaching activity. Acknowledgements The concept derives from four previous internal research review reports to the Westmead Scientific Advisory Committee (SAC). Most of the data analysis was performed "after-hours", and I am grateful to Ms Beryl Dawson for her patience and understanding. Professor Tony Cunningham and Professor Cres Eastman are thanked for their support and encouragement. Sincere appreciation also to my colleague Dr Brian Nankivell, who set me upon this path of discovery, and to Ms Claire Wolczak, who sought out and found copies of the required SCI reports. Conflict of Interest: I am employed within one of the institutions in this report, but have attempted at all times to be objective. References Science Citation Index. Journal citation reports. A bibliometric analysis of science journals in the ISI database. Philadelphia: Institute for Scientific Information, 1993, 1994, 1995, 1996. Garfield E. How can impact factors be improved? BMJ 1996; 313: 411-413. Seglen PO. Why the impact factor of journals should not be used for evaluating research. BMJ 1997; 314: 498-502. Smith R. Unscientific practice flourishes in science. Impact factors of journals should not be used in research assessment. BMJ 1998; 316: 1036. Williams G. Misleading, unscientific, and unjust: the United Kingdom's research assessment exercise. BMJ 1998; 316: 1079-1082. Bourke PF, Butler L. The research enterprise: mapping Australia's basic research in the medical and health sciences. Med J Aust 1997; 167: 610-613. Research School of Social Sciences, Australian National University, Internet webpage (URL site: <http://rsss.anu.edu.au/>). Accessed August, 1998. Sittig DF. Identifying a core set of medical informatics serials: an analysis using the MEDLINE database. Bull Med Libr Assoc 1996; 84: 200-204. Takahashi K, Hoshuyama T, Ikegami K, et al. A bibliometric study of the trend in articles related to epidemiology published in occupational health journals. Occup Environ Med 1996; 53: 433-438. Dunn K, Chisnell C, Sittig DF. A quantitative method for measuring clinical user journal needs: a pilot study using CD Plus MEDLINE usage statistics. Medinfo 1995; 8: 1428-1432. Schloman BF. Mapping the literature of allied health: project overview. Bull Med Libr Assoc 1997; 85: 271-277. Schloman BF. Mapping the literature of health education. Bull Med Libr Assoc 1997; 85: 278-283. Wakiji EM. Mapping the literature of physical therapy. Bull Med Libr Assoc 1997; 85: 284-288. Burnham JF. Mapping the literature of radiologic technology. Bull Med Libr Assoc 1997; 85: 289-292. Burnham JF. Mapping the literature of respiratory therapy. Bull Med Libr Assoc 1997; 85: 293-296. Hecht F, Hecht BK, Sandberg AA. The journal "impact factor": a misnamed, misleading, misused measure. Cancer Genet Cytogenet 1998; 104: 77-81. Gallagher EJ, Barnaby DP. Evidence of methodological bias in the derivation of the Science Citation Index impact factor. Ann Emerg Med 1998; 31: 107-109. Opthof T. Sense and nonsense about the impact factor. Cardiovasc Res 1997; 33: 1-7. (Received 3 Feb, accepted 20 Oct 1998) Author's details Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, Western Sydney Area Health Service, Westmead, NSW. Emmanuel J Favaloro, BSc(Hons), PhD, Senior Hospital Scientist, Haematology. Reprints: Dr E J Favaloro, Senior Hospital Scientist, Haematology, ICPMR, Westmead Hospital, Westmead, NSW 2145. Email: emmanuelATicpmr.wsahs.nsw.gov.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Emmanuel J Favaloro

Medical Research Perspectives Is there gender bias in research fellowships awarded by the NHMRC? Jeanette E Ward and Neil Donnelly, on behalf of the Research Fellowships Committee, NHMRC MJA 1998; 169: 623-624 Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on Administration and health services Abstract Objective: To assess whether there is gender bias in the allocation of research fellowships granted by the Research Fellowships Committee of the National Health and Medical Research Council. Data sources: Anonymous data from applications for a research fellowship from 1994 to 1997. Results: More men than women apply for research fellowships (sex ratio, 2.5:1), but there is no difference in the proportion of male or female applicants who succeed in their application. Among new applicants, men tend to apply for a higher level of fellowship than women. Conclusions: Lack of data about the numbers of eligible men and women means that we cannot draw conclusions about self-selection biases among potential applicants. However, the selection procedures of the Committee appear to be unbiased. The gender of applicants does not influence the outcome of their application. Introduction Australian researchers seeking to advance their careers in health and medical science can apply for appointment as a National Health and Medical Research Council [NHMRC] Research Fellow. Applications for fellowships from researchers outside the research institutes that receive block-funding from the NHMRC are considered by the Research Fellowships Committee.1 Four levels of fellowship are awarded: Research Fellow, Senior Research Fellow, Principal Research Fellow, and Senior Principal Research Fellow. Applications by researchers for appointment, reappointment or promotion are highly competitive. Criteria used to evaluate applications include the applicant's independence and track record in research, originality of the research, national and international recognition, publications and broader contribution to the applicant's area of research. These criteria are not weighted: rather, the overall merit of each case is assessed from diverse sources of evidence such as curriculum vitae, reports from referees nominated by the applicant, reports from external assessors nominated by the Research Fellowships Committee, consideration of the regional grants interviewing committee score (which indicates the scientific quality of the project or program to which the fellowship application is tied) and interview. A Swedish study showed that reviewers' scores of postdoctoral fellowship applications to the Swedish Medical Research Council were strongly influenced by the gender of the applicant.2 This prompted the Research Committee of the NHMRC to ask the Research Fellowships Committee to conduct its own review. Methods Anonymous data on all applicants for research fellowships were manually extracted from the records for the period 1994-1997. We counted the number of applications from men and women seeking and receiving appointment, reappointment or promotion to research fellowships at each level, calculated sex ratios, and tested for evidence of gender bias by means of 2 tests. Analyses were not conducted for reappointments as we could not be confident that these would not include repeated applications from individuals who had failed in an initial application or an application for promotion within the same period. Results During the study period, 301 applications for appointment, promotion or reappointment were received from men, of which 102 (34%) were successful. One hundred and twenty applications were received from women, of which 43 (36%) were successful. This difference was not significant (2 = 0.14, df = 1, P = 0.7). Applications for initial appointment to the research fellowship scheme We noted that 202 applications for initial appointment to the research fellowship scheme were received from men, yet only 83 were received from women (an unequal ratio, specifically 2.4 : 1). However, the total denominator of eligible applicants by gender could not be determined. Over the study period, 81 applications for initial appointment at Research Fellow level were received from men compared with 45 from women (ratio 1.8 : 1). Similarly, 121 applications for initial appointment to a Senior Research Fellowship or higher were received from men compared with only 38 from women (ratio 3.2 : 1); 30 applications for initial appointment as Principal Research Fellow or Senior Principal Research Fellow were received from men and only four from women (ratio 7.5 : 1); a total of five applications for initial appointment as Senior Principal Research Fellow were received from men compared with only one from a woman (ratio 5 : 1). We combined applications for appointment as Research Fellow or Senior Research Fellow and compared these by sex with those for Principal Research Fellow or Senior Principal Research Fellow. Of the 202 applications received from men, 30 (15%) were for Principal Research Fellowships or Senior Principal Research Fellowships. For women, only 4 (5%) of 83 applications were for initial appointment as Principal Research Fellow or Senior Principal Research Fellow. Having applied for an initial appointment, men were significantly more likely than women to apply for a senior appointment (2 = 5.6, df = 1, P = 0.02). For the study period, 26 applications (13%) from men for initial appointment (irrespective of level) were successful and 176 (87%) were not. In contrast, 14 (17%) applications from women for initial appointment (irrespective of level) were successful compared with 69 (83%) unsuccessful. The difference between men and women is not significant (2 = 0.8, df = 1, P = 0.4). Applications for promotion from Fellows already appointed At different career stages, but typically when they have reached the top of the scale and submitted an application for research grant renewal, Fellows are eligible to apply for promotion. Over the study period, 71 applications for promotion were received from men: 14 (20%) for promotion to Senior Research Fellow and 57 (80%) for promotion to Principal Research Fellow or Senior Principal Research Fellow. Over the same period, 24 applications for promotion were received from women: 9 (38%) for promotion to Senior Research Fellow and 15 (63%) for Principal Research Fellow or Senior Principal Research Fellow (2 = 3.1, df = 1, P = 0.08). For the study period, 34 (48%) applications from men for promotion (irrespective of level) were successful and 37 (52%) were not, out of the total of 71. In contrast, 14 (58%) applications from women for promotion (irrespective of level) were successful compared with 10 (42%) unsuccessful, out of the total of 24. Again, there was no significant gender effect (2 = 0.8, df = 1, P = 0.4). Discussion We are concerned that more applications for initial appointment are received from men than women (a ratio of 2.5:1). As we do not know the size of the pool of eligible men and women, we cannot state whether eligible women are less likely to apply than men, but in 1997 there were more women than men enrolled in PhD degrees in health faculties of Australian universities.3 Were women scientists concerned that the NHMRC research fellowships scheme is biased against women, they might be less likely to apply for initial appointment because they perceived themselves to have a less-than-equal chance of a fair evaluation. Our data shed no light on this question, but analysis of data relating to NHMRC PhD scholarships, postdoctoral awards such as C J Martin Fellowships and R D Wright Scholarships would generate further testable hypotheses about gender bias outside the Research Fellowships Committee. Our study also shows that, among new applicants, men are more likely than women to apply for fellowships at the higher levels. The data might also suggest that male research fellows are more likely to seek promotion to the higher levels than female research fellows. However, these analyses were not adjusted for age or years of postdoctoral experience, so our data on potential gender bias in promotion are very limited. To obtain better data, it would be necessary to select a cohort of research fellows appointed in one year and track their progress, testing statistically whether gender is associated with further applications for promotion or reappointment. The Research Fellowships Committee itself has five male and four female members.1 In keeping with increasing community and professional interest in the accountability of the NHMRC,1,4-6 we place our findings in the public domain to generate discussion. We conclude that the influence of gender bias, if present at all in the research fellowships scheme, is indirect and acts before the process of evaluation of a specific application. Women may be less likely to apply and, once appointed, perhaps more cautious in their applications for promotion. However, having applied and specified a particular level, the gender of applicants does not influence the outcome of their application. We acknowledge the limitations of the available data. Access to applications to calculate publication outputs and acquisition of competitive grants as indicators of research proficiency (as in the Scandinavian study)2 would have required the written consent of the applicants. Further debate and resources to support such a study are recommended, as is research to examine any differential success rates in project or program grant applications to the NHMRC by male and female investigators. Acknowledgements This commentary was written on behalf of the NHMRC's Research Fellowships Committee, of which the first author is a member. We thank Professor John Finlay-Jones (chair); Professor Daine Alcorn; Professor Peter Brooks, Professor Murray Esler; Professor Simon Gandevia; Dr Emanuela Handman; Professor Ieva Kotlarski and Associate Professor David Roder for their interest and constructive advice regarding analysis and writing. Professor Warwick Anderson also provided encouraging support. Kerry Warren, formerly Committee Secretary, NHMRC Career Fellowships, manually extracted data from the NHMRC database. References National Health and Medical Research Council. 1997 Annual Report. Canberra: NHMRC, 1998. (Commonwealth of Australia Catalogue No. 9804863.) Wenneras C, Wold A. Nepotism and sexism in peer review. Nature 1997; 387: 341-343. Department of Employment, Education, Training and Youth Affairs. Selected Higher Education Student Statistics, 1997. <http//www.deetya.gov.au/divisions/hed/ highered/statpubs.htm>. Accessed 18 September 1998. Anderson W. Funding Australia's health and medical research. Med J Aust 1997; 167: 608-609. Ward J, Slaytor E. Enhancing NHMRC investment in public health research. Aust N Z J Public Health 1998; 22: 189-190. Larkins R, Anderson P. Australian medical research: more resources and the right balance. Med J Aust 1998; 168: 535-536. Authors' details Central Sydney Area Health Service Needs Assessment and Health Outcomes Unit, Sydney, NSW. Jeanette E Ward, PhD, FAFPHM, Director. Neil Donnelly, MPH, Statistician. Reprints will not be available from the authors. Correspondence: Associate Professor J E Ward, CSAHS Needs Assessment & Health Outcomes Unit, Locked Bag 8, Newtown, NSW 2042. Email: jwardATnah.rpa.cs.nsw.gov.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Medical Research Perspectives The Menzies School of Health Research offers a new paradigm of cooperative research John D Mathews The Menzies School has addressed problems in Aboriginal and tropical health through research that requires cooperation between disciplines as well as improved communication and trust between researchers, Aboriginal people and the wider community. MJA 1998; 169: 625-629 Introduction - The politics of Aboriginal health - Success in interdisciplinary and crosscultural collaboration - Some research highlights of medical importance - The Menzies School's work in central Australia - Research highlights in tropical and international health - Resources and links - Cooperation is the secret of success - Looking ahead - Acknowledgements - References - Author's details - - More articles on Aboriginal health Introduction The Menzies School of Health Research, in the Northern Territory, has been a surprisingly successful research investment. The dividends since 1985 include increased understanding of Aboriginal and tropical health problems, the transfer of knowledge and skills into training and improved health services, and some 70 research publications each year. The Menzies School is a brave and cooperative venture of the Northern Territory Government, the Menzies Foundation (commemorating the name of our longest-serving prime minister), and the University of Sydney. I was appointed as Foundation Director and we moved to Darwin in January 1985, in quixotic mood, and not knowing what to expect. My wife had found a Thomas Keneally quote: . . . the north is littered with the detritus of great hopes, and Darwin is still an outpost . . . but with a sense of destiny that would have done Athens credit.1 We were naive enough to ignore the implicit warning, and to dream of Athens in the north. To Darwin I brought a research background in medicine and epidemiology; experience from New Guinea, the Walter and Eliza Hall Institute and Oxford; and 10 years as an NHMRC Fellow at the University of Melbourne. My first dream for the Menzies School was to establish a centre of research excellence. The second dream was to somehow make a difference in Aboriginal health. The potential nightmare was to work out how to realise each dream without jeopardising the other. The politics of Aboriginal health Countries with the least education and income tend to have the poorest health, and within any one country persons with the least education and income tend to have the worst health. Box 1 shows the causal linkages between education, income and health in any society, and Box 2 shows how the social dislocation suffered by Aboriginal Australians since colonisation has specifically contributed to their poor health.2 The poor health of Aboriginal Australians is primarily due to social and environmental disadvantage. It is not due to any absolute lack of knowledge about the causes of their ill-health (Box 3), but to the fact that Aboriginal people have had limited access to health resources and knowledge because of their own poverty and educational disadvantage. There has also been limited understanding of Aboriginal health issues by those responsible for funding decisions, compounded by inadequate knowledge and training of health advisers and providers. Unfortunately, the poor state of Aboriginal health has also been perpetuated by disagreements about what should be done and how, who should do it, and who should pay for it. This lack of consensus, amounting to a modern Babel (Box 4), is only now beginning to be resolved. The Menzies School has contributed to the debate on Aboriginal health by helping to fill gaps in understanding, communication and implementation. It has attracted expert staff to the Northern Territory, driven research to identify areas of unmet health need, tested innovative health interventions, and been an evaluator, critic and advocate for Aboriginal health policy. Success in interdisciplinary and crosscultural collaboration The success of the Menzies School has been driven by the quality of our staff, the challenges faced, and by the added value that comes from collaboration and communication between diverse disciplines. Above all, success would have been impossible without the expertise and commitment of Aboriginal staff and colleagues. Major contributions have been made by Lorna Fejo, Jessica Bujevich, the late Sally Ross, Louisa Collins, Daisy Yarmirr, Josie Crawshaw, Annie Bonson, Geoffrey Angeles, Mai Katona and many others. Their achievements have been to communicate the health priorities and values of Aboriginal people to non-Aboriginal researchers, to facilitate research projects in a culturally appropriate manner, and to work with other Aboriginal people to show how knowledge and research findings can be fed back to communities and applied to achieve practical health benefits. Recently, the Tiwi Health Board has played a key role in codifying the many sensitive issues that arise in crosscultural research and providing a framework for future research in a Legal Agreement signed with the School (Box 5). Some research highlights of medical importance (See also Box 6) Understanding streptococcal infection and rheumatic fever At any one time, up to 60% of Aboriginal children in bush schools have skin sores infected with group A streptococci, and there are occasional epidemics of acute poststreptococcal glomerulonephritis. Bart Currie, Jonathan Carapetis and colleagues have shown that the same communities suffer from the highest rates of rheumatic fever in the world. To overcome the limited awareness of rheumatic fever and the low rates of compliance with penicillin prophylaxis, Geoffrey Angeles, Norma Benger and other members of our Aboriginal Unit have developed The Rheumatic Fever Story, a successful education program (booklets, songs and videos) for patients, relatives, health workers and the wider community. K S Sriprakash, a talented molecular geneticist, has led molecular studies of group A streptococci, detecting as many as 13 immunologically distinct types present at the same time in a single bush community of a few hundred children, with a total of about 100 different types circulating through Aboriginal communities in northern Australia, many that have never been identified elsewhere. Candidate nephritogenic strains have recently been identified. This work is linked to studies of the epidemiology and population biology of group A streptococci in Aboriginal communities, to studies of treatment efficacy, and to studies directed towards vaccine development with Michael Good and the Cooperative Research Centre for Vaccine Technology in Brisbane. Understanding endemicity of respiratory bacteria For Aboriginal children, persistent otitis media is a major cause of illness, hearing loss and educational disadvantage. Amanda Leach, Judith Boswell, Terry Nienhuys and others have shown that otitis media develops in all Aboriginal infants within a few weeks of birth immediately after nasopharyngeal colonisation with Streptococcus pneumoniae and Haemophilus influenzae. Although each infection seems to be eventually cleared by the host response, there are some 30 different serotypes of pneumococcus and at least 50 types of haemophilus which can queue up to infect every child in every community. The persistence of nasal infection and respiratory disease is associated with the persistent colonisation by such multiple bacterial strains into adult life. Cross-infection is driven by overcrowding, poor hygiene and the large numbers of bacterial strains circulating. Detailed modelling suggests that each strain is maintained indefinitely, even in relatively small populations, because there are always a few carriers of each strain left to infect susceptible newborn infants. Furthermore, with the carriage of multiple serotypes or strains at the same time by the same host individual, some of the strains are "hidden" from the immune system, giving them an extra survival advantage. Likewise, antibiotic-resistant strains "hide" behind sensitive strains, only to be revealed by antibiotic treatment. Understanding scabies in dogs and people Skin infections associated with scabies infestation are frequent in Aboriginal communities, particularly among children. Because dog scabies was thought to be a source of infection for people, scabies control programs have sometimes treated dogs rather than people. Now, using molecular genotyping, Shelley Walton and colleagues have shown that populations of scabies mites from dogs in Australia and America do not overlap with scabies from people in those same areas. This strongly suggests that scabies from dogs are not driving human scabies in remote communities and that control programs for human scabies must focus on people. Jonathan Carapetis and Daisy Yarmirr, in cooperation with Aboriginal and health service colleagues, have shown that community-based treatment with pyrethrin can reduce both scabies and streptococcal impetigo. Understanding renal disease and cardiovascular disease Mortality from renal failure for Aboriginal Australians is very high and rising. Up to 50% of Aboriginal adults have proteinuria and in some communities 2% are receiving renal dialysis to stay alive. Paul van Buynder and colleagues identified obesity, hypertension and non-insulin-dependent diabetes mellitus (NIDDM) as risk factors for proteinuria in Aboriginal communities. Modelling studies with Alison Goodfellow and others suggest that proteinuria develops from very early in life in those with evidence of past infection with group A streptococci. Wendy Hoy and colleagues have shown that low birth weight is predictive of NIDDM, proteinuria, and presumably renal disease, and have suggested that the risk factors for renal disease can also help to explain the high rates of cardiovascular disease in Aboriginal adults. Causes of disease acting from early in life The role of low birth weight as a predictor of poor health in later life has attracted much recent attention, and is of particular importance for Aboriginal Australians. Wendy Hoy and others have shown that the combination of low birth weight with adult obesity appears to confer the highest risk of NIDDM, proteinuria and other disorders. Sue Sayers has shown that high rates of Aboriginal low birth weight are due to intrauterine growth retardation, possibly resulting from maternal malnutrition, infection and substance abuse. Thus, low birth weight may be best regarded as a marker of those adverse influences in pregnancy that are the actual mediators of adverse health effects in later life. This hypothesis would explain how poor health can pass from generation to generation, and may provide another reason why health has been slow to improve for many Aboriginal Australians. Early treatment of renal disease The epidemic of Aboriginal renal disease should eventually be controllable through public health measures such as improved nutrition and infection control, particularly in pregnancy. In the meantime, there is a strong rationale to provide "best-practice" clinical treatment, not previously available for Aboriginal people. Accordingly, Wendy Hoy, as an adjunct to the NHMRC-funded research program, has introduced treatment with ACE inhibitors for Tiwi people with early renal disease. Compliance is good, and treatment markedly reduces the rate of deterioration of kidney function, which will in turn prolong life and reduce the escalating social and financial costs of dialysis services. The Menzies School's work in central Australia We have a small research unit in Alice Springs to complement our major operation in Darwin. Major contributions include those of Tim Rowse (historical, social and nutritional studies), David Scrimgeour, Robyn McDermott, Ilan Warchivker and John Wakerman (evaluation studies), and Komla Tsey (health and education). Research highlights in tropical and international health David Kemp, FAA, joined the School as Deputy Director in 1992, with support from the Wellcome Trust and from the Howard Hughes Institute to continue his fundamental work with falciparum malaria, and to commence new molecular studies of haemophilus, donovanosis, and scabies. This year saw the culmination of his 10-year search, begun at the Walter and Eliza Hall Institute, to find the cytoadherence gene in Plasmodium falciparum that is believed to explain the stickiness of red blood cells in cerebral malaria. The new gene, designated CLAG, was identified and sequenced, and a CLAG knock-out was shown to have lost the stickiness phenotype. The team has subsequently identified additional genes, similar to CLAG, elsewhere in the malaria genome, opening up exciting new possibilities for treatment or prevention of cerebral malaria. Other malaria projects in Indonesia are funded by a grant from the Northern Territory Government to mark the 50th anniversary of Indonesian independence and a US National Institutes of Health grant to Nick Anstey, and are being carried out in cooperation with Emiliana Tjitra and Indonesian colleagues. Resources and links (See also Box 7) The achievements of the Menzies School have depended on the generous financial support of the Northern Territory Government and the Menzies Foundation, competitive grants from the National Health and Medical Research Council and other agencies in Australia and overseas, and private and corporate donations. In 1998, the annual budget was $6 million to support about 100 employees and postgraduate research students. The School has also enjoyed the goodwill and cooperation of Territory Health Services and other arms of government, Aboriginal communities, medical services and organisations, the National Heart Foundation and other non-government organisations, the University of Sydney, the Northern Territory University, and Flinders University Clinical School at the Royal Darwin Hospital. The Menzies School became the lead agency in a successful bid to establish the Cooperative Research Centre for Aboriginal and Tropical Health in 1997. Through its Board, chaired by Dr Lowitja O'Donoghue, and with a majority of Aboriginal members, the Cooperative Research Centre has an agenda to discover and disseminate knowledge about Aboriginal health problems, to provide more research and training positions for Aboriginal people and to facilitate Aboriginal control of the planning and implementation of health research and health services. From 1994, the School has taught postgraduate coursework in public health to help develop skills in the local health workforce. Now, in partnership with the Northern Territory University, the School is promoting a broader vision of public health education through a Faculty of Public Health. This Faculty will continue postgraduate teaching and promote access to accredited courses at multiple levels and to short courses to meet the needs of teachers and educators, administrators, Aboriginal people and others in need of public health knowledge and expertise. Cooperation is the secret of success The Menzies School has become a leader in tropical and Aboriginal health research, not only through the talent and commitment of individuals, but also because of its capacity to encourage cooperation between disciplines, and to build and sustain cooperative partnerships with Aboriginal stakeholders, health services and governments in northern and central Australia. This cooperative research paradigm, linking the laboratory with the clinic and the community, has delivered important understandings and contributed to more effective strategies for training of health staff, and to improved health promotion, prevention and treatment strategies. Despite its short-term opportunity costs, cooperation in health research pays off in the longer term by helping to translate modern scientific knowledge into direct community benefit, just as natural selection has discovered that cooperative processes provide pay-offs in the longer term in most otherwise competitive biological and social systems. Indeed, interactions that balance competition with cooperation turn up in all evolving systems to achieve a balance between short term returns (efficiency) and longer term strategic outcomes. Looking ahead The multidisciplinary focus of the Menzies School of Health Research has more than justified the vision of its founders by delivering value for money to its stakeholders and the wider community. However, as the School faces the new millennium, it needs to serve the community with a broad public health perspective while maintaining the deep biomedical expertise that underpins strategic research to be an academic critic of health policy, while working in partnership with health services to promote necessary improvements to persuade funding agencies to recognise the value of, and to pay the full opportunity costs of, cooperation and collaboration between different disciplines and organisations to maintain its cohesion, corporate identity, shared values and vision for the future. Talent and enthusiasm are always welcome! Acknowledgements This summary is based on the work of many colleagues to whom I am deeply indebted. Special thanks to Coralie Mathews, Bart Currie, Dave Kemp and Lindy Warrell for reviewing the manuscript, and Debra Davis for its preparation. References Keneally T. Outback. Sydney: Coronel Books, 1983. Mathews JD. Historical, social and biological understanding is needed to improve Aboriginal health. Recent Adv Microbiol 1997; 5: 257-334. Author's details Menzies School of Health Research, Darwin, NT. John D Mathews, AM, MD, Professor and Director. Reprints will not be available from the author. Correspondence: Professor J D Mathews, Menzies School of Health Research, PO Box 41096, Casuarina, NT 0811 Email: johnATmenzies.su.edu.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> 1: Social determinants of good health Back to text 2: Historical impacts of colonisation upon Aboriginal health Back to text 3: Lessons about Aboriginal health and research Aboriginal health is limited more by the failure to apply knowledge that already exists than by the lack of knowledge itself. Aboriginal people have always understood this, and they have been naturally suspicious of research projects that seem to serve the interests of researchers more than those of Aboriginal people. The most relevant research questions are: How to ensure that existing knowledge is taken up and acted upon by public sector decision-makers and managers and health professionals. How to ensure that Aboriginal people have access to the knowledge and resources that they need to use to improve their own health. How to plan specific research projects to make a difference by finding better ways of working across cultural boundaries. improving access to knowledge, resources, education and health services for Aboriginal people providing social or biomedical insights about better ways to promote health or prevent or treat disease for Aboriginal people. Back to text 4: The modern Babel The biblical Tower of Babel (Genesis, xi) is the traditional metaphor for the schisms in language, beliefs and culture in the modern world. It reminds us that without a common language and shared concepts, we are unable to understand each other. In the Northern Territory in 1985 many different voices were speaking about Aboriginal health. Those on the political right tended to blame the victims, and saw the emergence of Aboriginal control as a threat. There were differences between levels of government. Some officials lacked appropriate expertise and were unused to problem solving, let alone to academia. Some health professionals were escaping from academia, or had a postmodern scepticism about science and medicine. Some romantics said that traditional Aboriginal people should be taught as little as possible about Western culture. Urban Aboriginal people voiced their hurt from discrimination or family experiences as stolen children. At the same time, Aboriginal health workers had strong cultural skills, but only limited health training. Traditional Aboriginal people, with insufficient support to deal effectively with the outside world, saw a progressive erosion of their culture and values. In such a Babel there could be little consensus about how to improve Aboriginal health. Without consensus, our political masters had a continuing excuse to ignore many issues. As a result, the poor state of Aboriginal health has continued to burn into the conscience of Australia. It is likely to be long remembered as the worst-ever failure of our nation. Back to text 5: Creative partnership - Tiwi Health Board and the Menzies School of Health Research Ms Alberta Puruntatameri and Dr Val Asche signing the Legal Agreement between the Tiwi Health Board and the Menzies School of Health Research, 22 October 1998. Back to text 6: Some important research areas at the Menzies School Cultural understandings of Aboriginal illness and death (Tarun Weeramanthri, Ada Parry, Norma Benger, Clifford Plummer, Vicky Nangala-Tippett and others) Education and health Otitis media and hearing disability contribute to poor educational outcomes (Anne Lowell, Terry Nienhuys, Judith Boswell, Joan Koops, Al and Lesley Yonowitz) Poor education contributes to poor health (Komla Tsey)Social and environmental determinants of health Community comparisons (Estrella Munoz, John Mathews and others) Environmental health study (Katherine Henderson, Ross Bailie) Melioidosis and contaminated water supplies (Mark Mayo, Bart Currie and Nick Anstey)Studies of substance abuse and appropriate interventions Evaluations of community interventions for alcohol (Peter d'Abbs, David Scrimgeour) Health effects and interventions for petrol sniffing (David Scrimgeour, Chris Burns and Bart Currie) Health effects of kava drinking and policy implications (John Mathews, Malcolm Riley, Estrella Munoz, Peter d'Abbs, Chris Burns, and Alan Clough)Interventions to improve Aboriginal health Community Nutrition Program at Minjilang (Mandy Lee, Annie Bonson, Daisy Yarmirr and others) Strong Women, Strong Baby, Strong Culture Program Evaluation (Lorna Fejo, Dorothy Mackerass and others) Diagnosis and treatment of donovanosis and sexually transmitted diseases (Frank Bowden, Jenny Carter, David Kemp and colleagues) Improved diagnosis and treatment of otitis media (Amanda Leach, Al Yonowitz, Peter Morris, Harold Koops and colleagues) Treatment of trachoma with azithromycin (Andrew Laming, Annie Bonson and colleagues) Smoking prevention (Rowena Ivers, Ross Bailie and the National Heart Foundation)Health service research and evaluation Best practice procedures (Bart Currie, David Scrimgeour, Peter Morris) Evaluation and planning of service models (David Scrimgeour, Chris Burns, John Wakerman and others) Health economic aspects (Robyn McDermott, Ilan Warchivker, John Wakerman) Coordinated care trials evaluation (Peter d'Abbs, Ross Bailie). See http://www.menzies.su.edu.au for a much more detailed account of the work of the Menzies School over the last five years. See also reference 2. Back to text 7: The Menzies building The Menzies School of Health Research was able to secure generous joint funding from the Northern Territory and Commonwealth governments for its new building in Darwin, opened in November 1996. Back to text

John D Mathews

Medical Research Perspectives The TVW Telethon Institute for Child Health Research The birth and growth of a research institute Fiona Stanley Diverse research workers, variously funded by public and private sources, were drawn together to create an Institute and an opportunity to work together on the complex problems in child health. MJA 1998; 169: 630-633 Introduction - Research origins - Rationale for a multidisciplinary institute for child health research - Growth - Successes - Threats - References - Author's details - - More articles on Aboriginal health Introduction In 1967 two men shared a game of golf and a vision for research to improve child health. Sir James Cruthers, then Managing Director of Channel 7 (TVW, Perth), suggested to Jim Clarkson, then the Chief Executive Officer of the Princess Margaret Hospital for Children (PMH) in Perth, the concept of a "Telethon" to raise money from the community for research at PMH. The Telethon became an annual event and in the first year raised funds for the PMH Children's Medical Research Foundation, which funded two small hospital research groups: a clinical immunology research unit founded by Dr Keven Turner, an immunologist from Adelaide, and a clinical nutrition research group established by Dr Michael Gracey, a paediatric gastroenterologist from Melbourne with a special interest in Aboriginal children and their health. From these beginnings, the TVW Telethon has gone on to fund a range of medical research in Western Australia, ultimately providing the essential infrastructural finance for the Institute for Child Health Research, established in 1990 and now a vigorous multidisciplinary research centre employing nearly 200 people. The Institute's name acknowledges not only this beginning but the continuing support from the TVW Telethon. Sir James Cruthers has only recently stepped down from the Institute's Board of Directors. Research origins The first two research groups funded by the Telethon were based at PMH. In the 1970s, the immunology group was beavering away, almost in isolation, in the neglected area of mucosal immunology, looking particularly at the developing respiratory tree and what role the immune system might play in allergy and asthma. This area of immunology and cell biology has now become of global importance in attempts to explain the epidemic of asthma and allergy sweeping the Western world. The work of Patrick Holt was particularly important at the time and has continued to be pre-eminent in the study of the development of allergic sensitisation and asthma.1,2Meanwhile, I had been fortunate enough to be awarded a National Health and Medical Research Council (NHMRC) overseas training fellowship in epidemiology at London University and at the National Institutes of Health, USA. When I returned to Perth in 1977, I used the $4000 setting-up grant in the last year of my fellowship to establish the Western Australian Cerebral Palsy Register (the only other registers at that time were in Sweden and Denmark) and the first congenital malformations register in Australia (funded by the Commonwealth Government in the wake of the Agent Orange scare). Then, as Senior Medical Officer in Child Health for the Health Department of Western Australia, I and my colleagues developed statewide links with midwives and child health nurses which laid the foundations for the Maternal and Child Health Research Data Base. This population-based, record-linked database has become the best in Australia (and probably the world) and now underpins much of the epidemiological work of the Institute.3 They were great days, as there was so little going on in maternal and child health epidemiology in Australia and we felt like pioneers! In 1980 these databases moved with me into a new NHMRC Unit of Epidemiology and Preventive Medicine at the Queen Elizabeth II Medical Centre, and spawned a range of epidemiological studies describing maternal and child health in WA and testing a range of hypotheses, focusing on birth defects, cerebral palsy and low birth weight. Telethon grants in the 1980s funded the Cerebral Palsy Register for nearly 10 years and a case-control study of dietary folate and neural tube defects as well.4,5 We commenced our work in indigenous maternal and child health and employed Aboriginal health workers in research before others had considered it important. The resulting partnerships with Aboriginal communities have grown even stronger since the Institute was established. Towards the middle of the 1980s I sensed that only by collaborating with basic scientists were epidemiologists ever going to get at biological mechanisms, properly elucidate causal pathways and be able to develop effective preventive strategies. Telethon funds appeared less secure at this time as they were being given away to other causes. I discussed these problems with Professor Lou Landau, who in 1984 had just accepted the Chair in Paediatrics in Perth, and we began to think of setting up an institute of child health research at the Children's Hospital, taking those with NHMRC funding with us, trying to get some additional funds for infrastructure and solving complex diseases! We both thought it a wonderful idea and invited Sir Gus Nossal across from Melbourne to address the hospital on "The birth of a research institute" -- this inspiring lecture was given in 1985 and aroused interest among local people in the concept. By this time Dr Wayne Thomas (from the Walter and Eliza Hall Institute in Melbourne), Dr Geoff Stewart (from the United Kingdom) and Dr Ursula Kees (from Switzerland) had all joined the Clinical Immunology Research Unit at Princess Margaret Hospital, and most of them now had "secure" NHMRC funding. Ursula Kees' group worked closely with the oncologists in the hospital, particularly Dr Michael Willoughby, the head of the oncology unit, who was determined that the Children's Cancer and Leukaemia Foundation would provide some secure funding for her laboratory in the new Institute. He could see this was crucial to the success of better identification of childhood cancers, investigating aetiology and discovering new therapies. Were we mad? We planned to set up a world-class institute in an isolated city in the biggest but most deserted State in Australia, in the middle of the crisis over business and political corruption known as "WA Inc" and as a recession was in full swing. We invited a group of Australia's leading researchers to Perth in 1986 and asked them to interview all of the researchers in child health and make an assessment. Despite the difficulties, the committee felt we had the right ingredients and encouraged us to go ahead. With the support of the Princess Margaret Hospital Board, and particularly of Professor Lou Landau, the proposal was developed further. In 1989, encouraged by Sir Gus Nossal, I applied for and was appointed Director of the new Institute. In 1990 we moved into our building -- the old School of Nursing at PMH, which was renovated with donations from the WA Lotteries Commission and the Incorporated Body of PMH. The support from other groups like the Variety Club of WA and the community has been the most crucial aspect of our success in this whole venture. Rationale for a multidisciplinary institute for child health research The problems in child health are now complex -- epitomised by diseases such as asthma, birth defects and other developmental problems, cancers and psychosocial problems. These stem from a complicated series of interactions between genes and environment, with variable causal pathways demanding complex solutions for their management or prevention. Our thinking was that if we brought together scientists from different disciplines under one roof we might be able to unravel the causes more successfully than working away separately in our little research areas. The aims of the Institute were to describe the burden of diseases in children and families in WA, to seek causal pathways using all types of scientific methods, and then to apply any knowledge to prevent disease in the community or to improve treatment at the bedside. We started as 90 scientists in four separate groups in 1989, with little infrastructure support, although our research grants from the NHMRC and other local foundations were adequate. Cell Biology, Molecular Biology and Cancer and Leukaemia moved in under the direction of Patrick Holt, Wayne Thomas and Ursula Kees, respectively, from the old PMH Children's Medical Research Foundation. My group from the NHMRC Unit moved to form the Division of Epidemiology and Biostatistics. Research in all these groups has blossomed at the Institute. Ursula Kees' group is making a seminal contribution on the role of homeobox gene malfunction in childhood leukaemia and has, in close collaboration with the PMH Oncology Unit and the international Children's Cancer Group, made significant contributions to the use of genetic markers to determine the prognosis and treatment for children.6,7Wayne Thomas's group is best known for its detailed work on the structure and immunology of house dust mite allergens, and a molecular approach to developing new types of immunotherapy8,9and the development of a candidate vaccine for all types of Haemophilus influenzae based on a conserved outer membrane protein.10 Patrick Holt's group has continued to describe the immunological mechanisms which operate during the development of tolerance to inhaled antigens,11,12 which are of extreme interest to both fundamental immunologists and allergists alike. Growth 1992 was the year of recruitment! We conducted an international search for a top biostatistician, which paid off with the recruitment of Dr Paul Burton, who became the Institute's senior biostatistician, and his wife, Dr Jenny Kurinczuk, an outstanding perinatal epidemiologist with a special interest in reproductive issues. Dr Burton conducted theoretical biostatistical research in a range of analytical problems (such as the analysis of complex interacting data sets and new methods of randomised trials), supported much of the biostatistical needs of the Institute and of our collaborators and spearheaded our new endeavours in genetic epidemiology. Within two years he became head of our new Division of Biostatistics and Genetic Epidemiology. Also in 1992 we sought an outstanding clinical researcher to establish a new Division of Clinical Sciences, with the brief of not only doing research in the Institute bridging the basic and clinical sciences, but also being a role model and stimulus for clinical research on the PMH campus. Dr Peter Sly was lured from Melbourne by offering him "fame and poverty" (he still has the letter) and he has continued to be a great success, collaborating with many groups in the Institute, the hospital and with fetal physiologists and respiratory researchers locally and internationally. In that year as well we were extremely fortunate in convincing the Health Department of Western Australia to second to us two outstanding clinical psychologists, Dr Steve Zubrick and Sven Silburn, whose research has underpinned the State Policy on Youth Suicide and other strategies in child and adolescent mental health. Dr Zubrick became head of the new Division of Psychosocial Research, with Silburn his very able deputy. The arrival of Australia's first MacFarlane Burnet Fellow, Professor Colin Sanderson, whose work on interleukin-5 was recognised internationally, created our last new division (Molecular Immunology) in 1994. This was an important bit of the jigsaw in our multidisciplinary attack on the complex disease of asthma. Dr Dierdre Coomb also arrived and established a laboratory specialising in the extracellular matrix, adhesion molecules and the mechanisms of inflammation, metastasis and haematopoiesis. As I look back now, some of our recruitment was part of a grand plan and some, as you would understand if you were in such an isolated and remote community, was opportunistic. Whatever the reason, the resulting mix has worked, as shown by our growth (from less than 50 to nearly 130 research staff in eight years), the way that many groups are collaborating in the Institute and the output to meet our goals. Successes A major reason for our success in fundraising from the local business community was that our research was focused on health problems that were well known as major burdens to the community -- asthma, adolescent suicide, birth defects, cerebral palsy, cancers and Aboriginal health. Another major factor was that we have had significant success in translating results into action (see Box); examples include the research on folate and spina bifida, reducing suicidal behaviours, improving outcome following bone marrow transplants in children with leukaemia, influencing the uptake of Haemophilus influenzae type b vaccination (which virtually eradicated the disease) and establishing a successful maternal and child health program for Aboriginal families in Kalgoorlie. Most of these are national and international issues and our Institute is increasingly being seen as a source of information for government and a model of success in multidisciplinary research and in translating research into policy. So, eight years on, have we been successful? How do you measure success in a multidisciplinary Institute? At the end of the first year of operation (June 1991) the Institute had $1.4 million in peer-reviewed grants, with a total operating revenue of $3 million (which included ongoing refurbishment costs). By the close of 1997 the Institute had gained $5.9 million in grants (including $2.5 million in NHMRC funding) and a total operating revenue of $8.3 million. You cannot force groups of different disciplines such as immunology and epidemiology and biostatistics to work together; all you can do is recruit thoughtful and good scientists and put them next to each other and hope that they talk! I remember two episodes vividly -- Patrick Holt saying "we have a great hypothesis we have developed in the lab and we need you epidemiologists to test it out for us"; this spawned our multidisciplinary asthma cohort study with Patrick Holt, Paul Burton, Peter Sly, Anne Read and myself testing the hypothesis that early and repeated infections may influence the immune response away from allergy and reduce the risk of asthma. The other episode was Colin Sanderson (head of Molecular Immunology) commenting that one of the best people in the Institute was Steve Zubrick, the head of Psychosocial Research -- given the usual contempt in which psychologists are held by "serious" scientists, this was great praise indeed! Bridges being developed between groups enhance the chances of collaboration. Threats With all this success and delight that we have survived our birth, with the new joint Commonwealth and State government $22.5 million building program heading for an early 2000 completion date, with such community support and government acceptance of our role, why am I concerned for our future? Our vulnerability now relates mainly to research funding and the support for our next generation -- our current students and postdoctoral staff. We are finding that research funding is much better in other countries and in other States and that we cannot offer our senior and rising bright young minds incentives to stay with us or even to stay in full time research. Some are off to overseas positions or into the private sector or into academic jobs with all the toil of teaching but at least some security. Our most recent sadness was that Paul Burton and Jenny Kurinczuk have been head-hunted back to the UK to tenured, well paid (at least double the NHMRC salaries they are currently receiving) academic positions at the University of Leicester. We will miss them greatly, but we can take some pride in having provided an environment for these two outstanding young people to develop their research careers to this level. Our policy of establishing an Institute by asking successful scientists to join us and bring their own salaries (usually NHMRC funded) was our only way of getting things going, but is not the way we can continue. It ensured that we only had peer-reviewed science in the Institute and meant that we could spend our precious and scarce resources on infrastructure and not research salaries. This ensured our survival, but it is not good policy in the longer term. The NHMRC roulette is not conducive to recruiting the brightest and the best. The Board needed little convincing to realise that such vulnerability is unacceptable and we are now looking at ways of securing our best people. Independent institutes are disadvantaged compared with universities because they do not receive direct infrastructure support from the Department of Employment, Education and Youth Affairs. Our Institute cannot match this year's increases in academic salaries as the NHMRC decided not to fund such an increase for research for its grant holders. Yet young scientists cannot be expected to work for low wages when salaries in other similar countries are much higher. We continue to lobby at Federal and State level, and wonder why, with our successes in improving child health, excellent research and scholarship, we are so undervalued in this country. Private funding alone is not the answer. I salute the likes of the visionary Sir James Cruthers and all the past, current and future corporate and private sponsors of research in Australia: what you could now do for us is to become advocates to convince governments to join with you in investing in our brightest and our best. Any less and our capacity to do research and benefit from it will be limited. References Holt PG, Yabuhara A, Prescott S, et al. Allergen recognition in the origin of asthma. Ciba Found Symp 1997; 206: 35-49. Holt PG, Macaubas C. Development of long-term tolerance versus sensitisation to environmental allergens during the perinatal period. Curr Opin Immunol 1997; 9: 782-787. Stanley FJ, Croft ML, Gibbins J, Read AW. A population database for maternal and child health research in Western Australia using record linkage. Paed Perinat Epidem 1994; 8: 433-447. Stanley FJ, Watson L. Methodology of a cerebral palsy register. The Western Australian experience. Neuroepidemiology 1985; 4: 146-160. Bower C, Stanley FJ. Dietary folate as a risk factor for neural-tube defects: evidence from a case-control study in Western Australia. Med J Aust 1989; 150: 613-619. Kees UR, Burton PR, Lu C, Baker DL. Homozygous deletion of the p16/MTS1 gene in pediatric acute lymphoblastic leukemia is associated with unfavorable clinical outcome. Blood 1997; 89: 4161-4166. Salvati PD, Ranford PR, Ford J, Kees UR. HOX11 expression in pediatric acute lymphoblastic leukemia is associated with T-cell phenotype. Oncogene 1995; 11: 1333-1338. Thomas WR, Smith W. House dust mite allergens. Allergy 1998; 53: 821-832. Thomas WR, Smith W, Hales BJ. House dust mite allergen characterisation: implications for T-cell responses and immunotherapy. Intern Arch Allergy Immunol 1998; 115: 9-14. Thomas WR, Flack FS, Callow MG, Chua KY. A high-molecular-weight outer membrane protein that is a potential target for protective immunity to type b and untypeable Haemophilus influenzae. J Infect Dis 1992; 165 Suppl 1: S75-S76. Stumbles PA, Thomas JA, Pimm CL, et al. Resting respiratory tract dendritic cells preferentially stimulate Th2 responses and require obligatory cytokine signals for induction of Th1 immunity. J Exp Med 1998. In press. McMenamin C, Pimm C, McKersey M, Holt PG. Regulation of IgE responses to inhaled antigen in mice by antigen-specific gamma delta T cells. Science 1994; 265(5180): 1869-1871. Author's details TVW Telethon Institute for Child Health Research, Perth, WA. Fiona Stanley, AC, MD, FAFPHM, FRACP, Director, and Variety Club Professor of Paediatrics, The University of Western Australia. Reprints: Professor Fiona Stanley, TVW Telethon Institute for Child Health Research, PO Box 855, West Perth, WA 6872. Email: infoATichr.uwa.edu.au URL: http://www.ichr.uwa.edu.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> Milestones for the TVW Telethon Institute for Child Health Research Year Corporate history Research highlights 1985–1990 Planning for an Institute: including international review Cloning of house dust mite allergens (Wayne Thomas et al, from 1988) 1989 Professor Fiona Stanley appointed Director 5 year NHMRC project awarded to Epidemiology division 1990 Institute opened with a Board of Directors and Scientific Advisory Committee and the following research divisions: Cell Biology (Patrick Holt), Molecular Biology (Wayne Thomas), Epidemiology (Fiona Stanley), Leukaemia and Cancer (Ursula Kees) Cloning of outer membrane protein of all types H influenzae (vaccine candidate) (Wayne Thomas et al) 1991 Affiliation with The University of Western Australia Commonwealth grant to complete laboratories Psychosocial Research (Stephen Zubrick) Clinical Sciences (Peter Sly) Folate confirmed to prevent neural tube defects (Carol Bower and Fiona Stanley) 1992 Affiliation with Princess Margaret Hospital for Children Senior Biostatistician appointed (Paul Burton) Launch of Hib vaccination program World first folate and NTD prevention project launched 1993 New Board and other committees: Intellectual Property, Finance, Fundraising Molecular Immunology (Colin Sanderson) Cell Adhesion Laboratory (Dierdre Coombe) WA Child Health Survey commenced 1994 Biostatistics and Computing (Paul Burton) becomes a division Epidemiology Division now headed by Carol Bower Immune deviation by g/d T cells (Christine McMenamin and Patrick Holt) 1995 Administration and Corporate Services established (Robert Ginbey) State Government pledge for new building "Give every Child a Chance" fundraising campaign ($10 800 000 pledged) International review Child Health Survey Vol 1 (Stephen Zubrick and Sven Silburn) HOX 11 deregulation in T cell leukaemias (Patricia Salvati and Ursula Kees) 1996 Consolidation of infrastructure (UWA, HDWA) New approach to Commonwealth Government for building grant First NHMRC Program for Public Health (Maternal and Child Health) Child Health Survey Vol 2 (Stephen Zubrick and Sven Silburn) Only one case of Hib meningitis reported (after vaccination program) Aboriginal maternal and child health research project in Goldfields becomes a government-funded health service 1997 Joint announcement of Capital Works Grant totalling $22 500 000 from State and Commonwealth Governments Child Health Survey Vol 3 (Stephen Zubrick and Sven Silburn) First reduction in rate of NTD (from average of 2 to 1.2 per 1000) 1998 Commence new building program in September Persistence of fetal Th2 immune responses in atopic versus non-atopic individuals (Susan Prescott and Patrick Holt) 2000 New building complete Second international review

Fiona Stanley

Medical Research Perspectives Working with the Wellcome Trust Bridget M Ogilvie In June 1998, Dr Bridget Ogilvie retired as Director of the Wellcome Trust, the world's largest medical charity. The MJA invited Dr Ogilvie to tell us about her career (see "Speaking personally") and the work of the Trust. MJA 1998; 169: 634-639 Introduction - Supporting scientists in their careers - Funding innovative science - The Genome Centre - Diversifying interests - History of medicine and the public understanding of science - Considering outcomes - Relations with government - Author's details - - - More articles on Administration and health services - Introduction The Wellcome Trust was created in 1936 by the will of Sir Henry Wellcome. Under the terms of the will, the entire share capital of his pharmaceutical company, the Wellcome Foundation Ltd, was vested in Trustees (now known as Governors) who are responsible for distributing the income according to the wishes laid down in the will. The guiding principle is that the Wellcome Trust should support "scientific research which may conduce to the improvement of the physical conditions of mankind". The income grew slowly but surely and the pharmaceutical company remained a private company owned by the Trustees of Sir Henry Wellcome until 1986. By then, the company was doing particularly well, largely because of its invention of the antiherpes drug aciclovir. The Trustees decided the time had come to diversify their asset base and 25% of the equity was sold on the London stock market. The company, now known as Wellcome plc, continued to flourish, a further tranche of shares was sold in 1992, and in 1995 Glaxo bought the remaining shares in a cash + shares deal which resulted in the Wellcome Trust owning 4%-5% of the shares of Glaxo Wellcome plc. By these sales of shares, the Wellcome Trust has become the largest endowed medical research charity in the world. In 1998, the Trust's asset base of about £10 billion enables it to spend about £350 million on medical research and allied subjects. The Trust's investment base comprises more than 2000 investments in more than 30 countries. About £7 billion is managed externally by investment managers in London, Geneva, Hong Kong, New York and Baltimore. A further £3.5 billion is managed internally, mainly the continuing investment in Glaxo Wellcome plc, real estate investments in the UK and investments in private (unlisted) shares throughout the world. The Trust seeks income to support its spending programs, but also capital growth over the long term (ie, it is a "total return" investor). The only specific ethical restriction is the exclusion of investment in companies with major involvements in the tobacco industry. Investment decisions are taken entirely separately from the grant-making process. Supporting scientists in their careers The Wellcome Trust has functioned as a grant giving body for about 50 years -- before that it was engaged in sorting out the complications of Sir Henry Wellcome's will. The Trust always funds scientists by grants to support a defined research program. While the Trust devises the various schemes through which it provides support, grants are decided on the basis of competition guided by peer review. For the past 35 years and more, it has put great emphasis on career support schemes. Its flagship career support scheme, the Wellcome Senior Clinical Fellowships, was set up in the early 1960s to provide five-year fellowships for medical graduates to devote themselves to research free from the demands of clinical service. As the Trust has grown in financial strength, it has put continual effort into devising schemes to support medical, basic science and veterinary graduates at all stages of their research careers. Recently it set up a number of four-year PhD training schemes for basic scientists in response to a request that PhD students should receive a broad grounding in research approaches before choosing their research project. All Wellcome Trust PhD students are expected to take part in communication courses during their studentship and the Trust also tries to monitor the quality of their supervision. The Trust helps people in all sorts of ways: for example, starting with the scientists who went to tropical countries to do research with Trust support, the Trust now provides individuals who win fellowships to work abroad with a guaranteed year back in the UK. Funding innovative science Once the Trust's income was stabilised by the initial sale of part of its shareholding in Wellcome plc, it began to fund research on a larger scale and through longer-term grants. Five-year program grants have been awarded since 1986, and in the decade since then many longer-term awards have been given and major centres have been established with Trust support. When funds for research become harder to obtain, there is a tendency to wish to spread the money as widely as possible by cutting the amount and the duration of grants. One admires this characteristic fair-minded habit of the academic community, but innovative science is more likely to be produced by individuals who are given time and the financial flexibility to try new approaches, many of which may fail. At the same time that funds for research have become harder to obtain, the cost of biological science has soared and the technological requirements at the cutting edge of research are continually changing. For these reasons, it is regrettably not sensible to give grants of more than about five years' duration. However, even when the Wellcome Trust was a relatively small organisation, it tried to ensure that an increasing percentage of the grants awarded were for more than three years and that all grants were fully funded (ie, were not reduced in an arbitrary way to spread funds around). While the Trust's funds grew throughout my nearly 20 years on its staff, the most profound change followed the second sale of its shares in Wellcome plc in 1992, during my first year as Director. Overnight our budget went up from £90 million per annum to £200 million. This huge increase opened up the potential to completely change the way the Trust operated. Should the Trust establish its own fully funded research laboratories outside the University system? Should it open up its funds for competition by scientists outside the UK and Ireland? Should it work more closely with other national or even international funding bodies? It was an extraordinary and exhilarating time. In practice, the Trust has remained a grant-giving organisation, primarily funding via grants to the staff of UK universities. While it has set up major centres in the universities, these are not solely Trust funded. Apart from its wide portfolio of career awards and project program grants, to which the Trust has devoted more than half its income, over the past decade the Trust has invested more than £200 million in new and refurbished buildings and equipment in the universities of the UK. It is widely recognised in Government as well as academic circles that without this investment by the Trust UK biomedical science would no longer be internationally competitive. The Genome Centre The major Trust initiative of the past five years has been the establishment of the Wellcome Trust Genome Centre at Hinxton near Cambridge, the Trust's only investment outside the university system. This development began as a joint enterprise with the UK Medical Research Council, building on its long-term investment in its distinguished Laboratory for Molecular Biology. A group at the Laboratory led by Dr John Sulston had developed expertise in genome sequencing through their project to establish the free-living nematode Caenorhabditis elegans as a model system for developmental biology and genetics of complex organisms. In 1992, it was felt that the time had come to apply their technology to the mammoth task of sequencing the human genome. This enterprise was established as a freestanding institute which has become known as the Sanger Centre, after the Nobel laureate Fred Sanger, whose technique is used in genome sequencing. The Sanger Centre now occupies a building built for its purposes at Hinxton village near Cambridge, where it has been joined by the Medical Research Council's Human Genome Mapping Project Resource Centre and the European Molecular Biology Laboratory's outstation (the European Bioinformatics Institute). These laboratories, together with a conference centre, make up the Wellcome Trust Genome Campus. The Trust has already invested over £180 million in this complex and its research projects, which now include a major program of pathogen sequencing. One of the first fruits of this investment was the sequence of Mycobacterium tuberculosis, completed and released electronically in December 1997 and published in Nature in an annotated form in June 1998. Earlier this year, the Wellcome Trust's Governors committed the Trust to a further investment of more than £100 000 000 to speed up the sequencing of the human genome, which should be complete in about the year 2001, and additional funds have been made available to sequence the genomes of various pathogens which cause tropical diseases (eg, malaria, leishmaniasis and trypanosomiasis). Diversifying interests The Trust tries to strengthen research in areas of medical importance. It takes many years to develop strength in neglected areas. The Trust has had special research training programs in mental health, clinical epidemiology, tropical and veterinary medicine throughout my time there. More recently, biodiversity, mathematical biology, bioinformatics, cardiovascular medicine and clinical microbiology have been added to this list. While the Trust has always had an international program (mainly in exchange fellowships and travel grants), this portfolio was extended when it agreed to award two five-year Senior Fellowships in Australia in 1984. This scheme, run in partnership with the Royal Australasian College of Physicians, was extended to New Zealand, South Africa and this year to India. The international portfolio has been enlarged in other ways, perhaps most significantly by the Trust's population initiative: a grant scheme to fund research into human demography and the global problems caused by population growth and change. This is the only Trust-funded scheme that is open to scientists with appropriate expertise from anywhere except the United States. The Trust does not fund in the United States, as it has endowed a sister organisation, the Burroughs Wellcome Fund, to operate there under the auspices of Sir Henry Wellcome's will. The Governors of the Trust believe the Trust should operate primarily in the UK, but have decided that up to 15% of its funds should be used to support a variety of international programs, mainly in Europe and the tropics. History of medicine and the public understanding of science Apart from its activities funding scientific research, the Trust spends about 4% of its funds supporting its Library of the History of Medicine (which was part of Sir Henry Wellcome's legacy) and academic activities associated with it. Over the past 10 years, a substantial program of activities to promote public understanding of science and studies in the social and ethical consequences of scientific advance has been established. These include £16.5 million towards a new wing at the Science Museum, which houses some of the original Wellcome collections, grant giving activities, competitions for books on science, the production of plays, and meetings and workshops. Considering outcomes All funding bodies are keen to develop their policies in a thoughtful, knowledgeable way and to ensure that outcomes of their grant giving activities are known and applied to the public good. As The Wellcome Trust now has over 3000 active grants at any one time, it is not an easy matter to determine outcomes, especially when the main outcome, publication, mostly occurs some years after a grant ends and new knowledge may take years before it bears fruit in the form of better medical care. In 1989 these considerations led the Trust to establish its Policy Research in Science and Medicine Group (PRISM), with a remit to devise ways to help policy development and assess outcomes. Relations with government As the Trust grew to the same size in funding power as the national body, the Medical Research Council, it became necessary to work more closely with the UK government. This has mainly been through officer to officer discussion with the staff of the relevant government bodies. Apart from the initial joint grant to establish the Sanger Centre and some small joint enterprises in public understanding of science, the Trust has not made grants jointly with the research councils. However, earlier this year, the Trust agreed to contribute to a fund together with the government to support the early stages of development of university research which has indications of industrial value; and in July this year, the Trust agreed to become a full partner with the government in establishing a £600 million fund to which each will contribute £300 million. This money will be used to upgrade UK university buildings and equipment infrastructure for research. These decisions herald a much closer working relationship between the Trust and the UK government in the future. Wellcome on the Web: www.wellcome.ac.uk Author's details 1 Park Square West, London NW1 4LJ, United Kingdom. Bridget Ogilvie, DBE, DSc. Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Bridget M Ogilvie

Bites and Stings A year's experience of Irukandji envenomation in far north Queensland Mark Little and Richard F Mulcahy MJA 1998; 169: 638-641 Envenomation by the Irukandji jellyfish (Carukia barnesi) can result in an array of systemic symptoms known as Irukandji syndrome. In 1996, 62 people presented to Cairns emergency departments with Irukandji envenomation: 57 developed systemic symptoms, and 38 required parenteral narcotics. All patients were discharged home within 24.5 hours, except for two who required high-dependence care for pulmonary oedema. Patients were more likely to be stung on hotter days, with lower-than-average rainfall in the past seven days, and with winds from the north, but less-than-average wind speed. We offer a protocol for treating patients with Irukandji envenomation. Introduction - Methods - Results - Discussion - Conclusion - Acknowledgements - References - Authors' details - - More articles on Insects, bites and stings Introduction Very little is known about the Irukandji jellyfish (Carukia barnesi), which is responsible for a substantial number of envenomations in far north Queensland, and other parts of northern Australia, each year. It was first named by Flecker in 1952, after an Aboriginal tribe that lived in the Cairns region.1 However, it was Barnes who, in 1964, was finally able to identify the jellyfish and demonstrate that it produced the Irukandji syndrome.2 The jellyfish is small (its bell is up to 2.5 cm across), but the tentacles may be up to one metre long.3 It is rarely seen before envenomation.4 The stinging apparatus, located along the tentacles, is called the nematocyst, and contains what has been likened to a coiled "harpoon".5,6 On stimulation, the nematocyst bursts open discharging the harpoon. Envenomation by the Irukandji jellyfish can lead to an array of systemic symptoms known as the Irukandji syndrome. Symptoms include severe backache, muscle pains, chest and abdominal pain, nausea and vomiting, headache, sweating, and (rarely) pulmonary oedema.7-9 No antivenom exists. Other than the observations of Flecker and Barnes, many of the published medical reports are anecdotal, discussing small numbers of cases.4,7-11 In view of the large number of envenomations seen in Cairns and the fact that this jellyfish was first identified in Cairns, we reviewed all cases of Irukandji envenomations presenting to hospital emergency departments in Cairns in 1996. We have previously reported 30 of these cases (patients who presented to Cairns Base Hospital in December 1996).5 Our aim was to reproduce the observations of Flecker and Barnes, identify where and when people would be more likely to be envenomed, and to develop a protocol for their management. Methods The Cairns Base Hospital Emergency Department and the Calvary Emergency Centre (a private hospital) were the only emergency departments in Cairns in 1996. Both maintain a database of all patients presenting, and these databases were searched to identify all patients with possible marine envenomation. We reviewed the charts and included in the study patients who had at least two symptoms or signs of Irukandji envenomation.1,2The Bureau of Meteorology in Cairns supplied daily weather information for 1996. Clinical and weather data were collated. All data were analysed using SPSS.12 Results In 1996, 62 patients with Irukandji envenomation were seen by the two emergency departments. The patients ranged in age from 18 months to 56 years; 23 (37%) were younger than 14 years. Twenty-nine (47%) were male. Box 1 shows the monthly distribution of the cases. No patients with Irukandji envenomation presented to either emergency department between 18 May and 11 October. Forty-seven (76%) patients were stung at coastal locations, seven (11%) were stung on the Reef, and five (8%) on the islands just off Cairns (Box 2). Of the 34 patients seen in December 1996, 30 (88%) were stung at coastal locations, compared with 17 of 26 (65%) for the period from January to May. Thirty-nine patients (63%) were stung while swimming inside stinger net enclosures on the beaches. Signs and symptoms Fifty-seven of the 62 (92%) patients had systemic signs and/or symptoms of envenomation, and 38 (61%) required parenteral narcotics. Two patients developed pulmonary oedema. The most common signs and symptoms are listed in Box 3. Treatment Vinegar: For nine patients, the use of vinegar was not recorded. Of the remaining 53 patients, 43 (81%) had vinegar applied. We saw no adverse effect from the use of vinegar, with no worsening of symptoms. Opiate analgesia: Thirty-eight (61%) patients received opiates: 30 pethidine, two morphine, and six both morphine and pethidine. Twenty-four adults received pethidine; 16 required 100 mg or more, with one patient receiving 750 mg of pethidine over 10 hours. One adult received a dose of 60 mg morphine in 12 hours. Fourteen (61%) children required opiates: seven received 2 mg/kg or more of pethidine, with two receiving more than 5 mg/kg of pethidine, both over 14 hours. Promethazine: Promethazine was administered to 16 patients, primarily as an antiemetic. There was a significant reduction in the amount of pethidine used when promethazine was administered to adults (univariate analysis of variance, F = 4.811; df = 1, 58; P = 0.032). On average, 40 mg of pethidine was administered to patients who received promethazine, compared with 140 mg to patients who did not receive promethazine. Retrievals Six (9.7%) patients required aeromedical transfer to Cairns Base Hospital, five by Cairmed (the helicopter emergency retrieval service staffed by the Emergency Department), and one by the Royal Flying Doctor Service. Outcome Of the 62 patients treated, 28 were discharged home within six hours of envenomation with minimal or no symptoms. One child, who initially received more than 5 mg/kg of pethidine, re-presented with pain, hypertension and sweating five hours after being discharged. Thirty-five (56%) patients were admitted to hospital (Box 4). Weather Fifty-seven (92%) patients were stung on days hotter than the average for the month when the sting occurred. Forty-three (69%) patients were stung on days with more hours of sunshine than average. Fifty-four (87%) patients were stung on days when 5 mm or less of rain fell during the day, and 47 (76%) were stung when less than the average amount of rain had fallen in the past seven days. Forty-seven (76%) patients were stung on days when the wind was between the north-north-west (NNW) and north-north-east (NNE). During 1996, the prevailing wind was between the NNE and NNW for 99 of 366 days (27% of the time). Using backwise multiple regression analysis, weather conditions that were significantly associated with Irukandji stinging were temperature hotter than average, less-than-average rainfall in the past seven days, and wind speed less than average (F = 7.919; df = 36, 214; P < 0.001). Discussion In 1996 we saw 62 cases of Irukandji envenomation, with two patients developing pulmonary oedema. To our knowledge, this is the largest number of Irukandji envenomations reported from a single location in one year. During this period we treated only two patients for minor box jellyfish (Chironex fleckeri) envenomations. We have been able to confirm many of Barnes's observations.2 There appears to be a brief period in the year when there are a large number of envenomations, usually associated with northerly winds.2 Forty-seven (76%) of our patients were stung on days when the wind was between the NNW and NNE. In our study, 35 (56%) patients were stung between 30 November and 19 December 1996. Like Barnes, we found the most frequent location to be stung was Palm Cove (17/62; 27%), about 25 km north of Cairns. The reason the Irukandji has this swarm period, which was also described by Flecker1 and Barnes,2 is not clear. We believe that the Irukandji may originate from the coastal region. There is a higher proportion of people stung on the Reef between January and May (9/26; 33%) compared with October to December (3/37; 8%). We believe the "swarm" occurs because the Irukandji are either breeding or pursuing food, before moving to open water later in the season. In Cairns, the risk from jellyfish stings in the "wet" season (November-May) is well known, and stinger-resistant swimming enclosures are placed at all main beaches. The holes in the nets are 25 mm x 25 mm. Previous reports5,8,10 have noted people being stung within these enclosures. In our study, 39 (63%) patients were stung within the stinger-netted areas. Clearly, the nets do not offer protection against the Irukandji, which has a bell size up to 25 mm. Most people we spoke to while they or their children were being treated believed that the netted area protected against all jellyfish. All beaches in the Cairns region have the same warning message, which we believe to be inadequate. The second paragraph of the warning message states: The stinger net enclosure is designed to afford a reasonable measure of protection from marine stingers. We believe better warnings need to be placed on all beaches where a stinger net enclosure exists, especially when the conditions are favourable for the "swarm" of Irukandji. As six people were envenomed at the water's edge, the warning needs to include this risk. Two (3%) patients developed pulmonary oedema, suggesting that the frequency of pulmonary oedema may be more common than previously realised. Pulmonary oedema is a documented complication of Irukandji envenomation,5,8-10,13 usually occurring 10-12 hours after envenomation. In both our patients with pulmonary oedema, echocardiography showed reduced left ventricular function, as demonstrated in previous studies.9,13 The toxin may have a direct myocardial depressant action. Others have hypothesised that capillary leak is secondary to catecholamine release.10 Concerns have been raised about the effectiveness of vinegar,14 and whether or not all the nematocysts are inactivated. We found that vinegar caused no adverse reaction in any patient. Vinegar has been shown to inactivate the nematocysts of other jellyfish (eg, the box jellyfish), and the nematocysts of the Irukandji have been shown to be inactivated in vitro by vinegar.8 Accordingly, we continue to advocate its use. The use of compression bandages is currently recommended by some,13 and appears on posters produced by Queensland Surf Rescue at beaches in the Cairns region. Only one patient in our trial had a bandage applied. Like Holmes,3 we have concerns regarding the use of bandages. Firstly, if there are nematocysts remaining on the skin, direct pressure may cause more of them to fire and worsen the envenomation. Secondly, the toxin may reach the systemic circulation by the lymphatics, as there is usually a 30-60-minute delay between the sting and systemic symptoms developing.15 Application of a pressure bandage may delay the venom reaching the systemic circulation. However, its removal may result in the patient receiving a sudden bolus of toxin. Pethidine has been recommended in preference to morphine.2 However, we are concerned at the dose of pethidine some of our patients required. Pethidine has direct myocardial and respiratory depressant effects and has a toxic metabolite (norpethidine). As the Irukandji toxin may exhibit a direct myocardial depressant effect, a large dose of pethidine may worsen the cardiovascular function of the patient. We feel that, if there is ongoing pain, fentanyl would be more appropriate. Fentanyl has almost pure narcotic receptor action with no cardiac depression and has no toxic metabolite. We found promethazine was of benefit in treating pain. Promethazine, an antihistamine, also blocks a variety of receptors, including muscarinic, a-adrenergic and serotonin receptors. It has local anaesthetic properties and is an effective antiemetic. Whether it works in treating Irukandji syndrome by blocking one of the above-mentioned receptors or whether it acts to potentiate the effect of the opiate is unclear. Reassuringly, 27 patients were discharged after an average stay of 2.1 hours in the emergency department, and did not return with further symptoms. Only one child re-presented. This patient had received a total of 5 mg/kg of pethidine in the six hours after envenomation, and clearly should have been admitted then. All other patients who received more than 2 mg/kg pethidine were admitted. They were discharged when they were asymptomatic or had had minimal symptoms for six hours. Other than the two patients admitted to the high-dependence areas, all were discharged within 24.5 hours. We have designed a management protocol for Irukandji envenomation (Box 5). If patients have no systemic symptoms during the first two hours after presentation they may be discharged home. If there is any opiate requirement, they need to be admitted until they have remained symptom free, with no analgesia requirement, for six hours. We suspect that pulmonary oedema is under-recognised. Therefore, any patient who has more than 2 mg/kg of pethidine (suggesting significant envenomation) requires investigations such as chest x-ray and electrocardiogram. If available, echocardiography, which is more accurate in diagnosing ventricular dysfunction, should be performed. Fentanyl should be used for further analgesia. Conclusion Very little is known about the Irukandji, its life cycle or its toxins. We have demonstrated that it causes significant morbidity, with potentially life-threatening symptoms. In view of the varied nature of our patients' presentations, and that 27 (44%) patients were discharged home within 2.1 hours, we suspect, like Barnes,15 that there may be more than one type of jellyfish responsible for the Irukandji syndrome. Irukandji presents a significant workload to the hospital emergency departments in presentations, retrievals and admissions. We have developed a protocol for managing patients; however, we would like an antivenom to be developed. Acknowledgements We are grateful for the assistance of the Bureau of Meteorology Office in Cairns. We are also grateful for the helpful advice and assistance with the statistical analysis of the data by Dr Jamie Seymour of James Cook University (Cairns campus). References Flecker H. Irukandji sting to North Queensland bathers without production of weals but severe general symptoms. Med J Aust 1952; 2: 89-91. Barnes JH. Cause and effect in Irukandji stingings. Med J Aust 1964; 1: 897-904. Holmes JL. Marine stingers of far north Queensland. Aust J Derm 1996; 37 Suppl 1: S23-S26. Hadok JC. "Irukandji" syndrome: a risk for divers in tropical waters. Med J Aust 1997; 167: 649-650. Mulcahy R, Little M. Thirty cases of Irukandji envenomation from far north Queensland. Emerg Med 1997; 9: 297-299. Gurry D. Marine stings. Aust Fam Physician 1992; 21: 26-34. Fenner PJ, Rodgers D, Williamson J. Box jellyfish antivenom and "Irukandji" stings. Med J Aust 1986; 144: 665-666. Fenner PJ, Williamson J, Callanan VI, Audley I. Further understandings of, and a new treatment for "Irukandji" (Carukia barnesi) stings. Med J Aust 1986; 145: 569-574. Fenner PJ, Burnett JW, Colquhon DM, et al. The "Irukandji Syndrome" and acute pulmonary oedema. Med J Aust 1988; 149: 150-156. Martin JC, Audley I. Cardiac failure following Irukandji envenomation. Med J Aust 1990; 153: 164-166. Fenner PJ, Heazlewood RJ. Papilloedema and coma in a child: undescribed symptoms of the "Irukandji" syndrome. Med J Aust 1997; 167: 650. SPSS for Windows [computer program]. Version 6.0. Chicago, Ill: SPSS Inc, 1992. Williamson JA, Fenner PJ, Burnett JW, Rifkin JF, editors. Venomous and poisonous marine animals. Sydney: University of New South Wales Press, 1996: 246-255. Hawdon GM, Winkel KD. Venomous marine creatures. Aust Fam Phys 1997; 12: 1369-1374. Kinsey B, editor. More Barnes on Box jellyfish. Townsville: James Cook University of North Queensland, 1988; 33-107. Authors' details Department of Emergency Medicine, Cairns Base Hospital, QLD. Mark Little, DTM&H(London), FACEM, Senior Medical Officer; Richard F Mulcahy, MB, BCh, BAO, Registrar. Reprints will not be available from the authors. Correspondence: Dr M Little, Senior Medical Officer, Department of Emergency Medicine, Cairns Base Hospital, PO Box 902, Cairns, QLD 4870. Email: mulcahysATinternetnorth.com.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Mark Little · Richard F Mulcahy

Bites and Stings Redback spider antivenom used to treat envenomation by a juvenile Steatoda spider MJA 1998; 169: 642 To the Editor: Redback spider (Latrodectus hasselti) envenomation is well documented, but little is known about the equally common and closely related genus Steatoda.1,2 Here, we report a latrodectism-like syndrome caused by the bite of a juvenile brown house spider (Stetoda sp.) which was treated with redback spider antivenom (CSL Ltd, Melbourne, Vic.). A previously healthy two-and-a-half-year-old child was bitten on sthe chin while playing outside with his mother in March 1998. The spider was later identified as a juvenile Steatoda, although the species was not determined (Catriona McPhee, Collection Manager, Entomology, Museum of Victoria, personal communication). The child complained of bite-site pain and local erythema was noted, but he seemed otherwise well. However, the next morning (22 hours after the bite) he was floppy, lethargic, excessively sweaty, irritable and shivering intermittently. He refused to eat or drink and vomited three times. Twenty-six hours after the bite he was taken to the local hospital emergency department, where he was noted to have a heart rate of between 120 and 140 beats per minute, a systolic blood pressure of 120 mmHg and to be very floppy. He was drowsy but rousable and seemed to be salivating excessively. Laboratory findings were unremarkable. The spider (see Figure) had the globular abdomen of a female redback spider but lacked the familiar red stripe. In view of the latrodectism-like symptoms, the Australian Venom Research Unit medical advisory service recommended that the child be treated as for redback spider bite. Thus, after giving promethazine (7.5 mg intramuscularly) as a premedicant, the child was given one ampoule of redback spider antivenom (500 units, intramuscularly) 28 hours after the bite and a further ampoule two hours later. He was then transferred to the Royal Children's Hospital where, on admission, his hypertension and tachycardia had resolved, but he remained lethargic, floppy, irritable and drowsy, although he could converse with the examiner. The rest of the neurological findings were normal. A faint reticular erythematous rash was visible below the chin spreading towards the back of the neck. This area also seemed tender on palpation, without lymphadenopathy. Full examination revealed no other cause for his condition, which improved, allowing discharge home 48 hours after the bite. In-vitro studies on Steatoda venoms have reported stimulation of excessive neurotransmitter release reminiscent of the Latrodectus spider venom component a-latrotoxin.3,4 Consistent with this, local pain, sweating and malaise have been attributed to bites from female Steatoda species.1,2 This case shows the potential toxicity of Steatoda venom in children and suggests that redback spider antivenom may have a place in the management of envenomation by these species. Further research is clearly warranted. Mike South Director, Department of General Paediatrics Royal Children's Hospital, Parkville, VIC Peter Wirth Senior Registrar, Emergency Department Frankston Hospital, Frankston, VIC Ken D Winkel Deputy Director, Australian Venom Research Unit, Department of Pharmacology University of Melbourne, Melbourne, VIC The Australian Venom Research Unit medical advisory service can be contacted by telephone (03 9344 7753) or e-mail <avruATpharmacology.unimelb.edu.au> Rutherford AM, Sutherland SK. Large blister formation after a bite from the common cupboard spider, genus Steatoda. Med J Aust 1989; 151: 42. Warrell DA, Shaheen J, Hillyard PD, Jones D. Neurotoxic envenoming by an immigrant spider (Steatoda nobilis) in southern England. Toxicon 1992; 29: 1263-1265. Cavalieri M, D'Urso D, Lassa A, et al. Characterization and some properties of the venom gland extract of a theriid spider (Steatoda paykulliana) frequently mistaken for black widow spider (Latrodectus tridecimguttatus). Toxicon 1987; 25: 965-974. Korszniak NV, Story DF. Effects of the venom of a theriid spider, Steatoda capensis Hann, on automatic transmission in the rat isolated atria and caudal artery. Toxicon 1994; 32: 85-96. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Mike South · Peter Wirth · Ken D Winkel

Bites and Stings Recurrent necrotising arachnidism MJA 1998; 169: 642-643 To the Editor: A 35-year-old male carpenter presented with an area of increasing central blackness of the grafted sites of his right lower leg. Twelve months previously he had had a small ulcer which progressed to necrosis of the skin over the distal third of the right leg and dorsum of the right foot following a spider bite, and required partial thickness skin graft. The spider was not caught, but the patient confirmed its identity when he visually identified another white-tailed spider. At this second presentation, about 49 weeks after complete graft healing, he described a small area of blackness at the original bite site, increasing in size over two days, associated with general pallor of the larger graft site. On examination, there was blackening, well demarcated to the graft sites only, and surrounding areas of erythema and swelling. He had no lymphadenopathy or constitutional symptoms and denied any recent trauma or bite. His white cell count, differential count, erythrocyte sedimentation rate and C-reactive protein level were all within normal ranges. Cultures of the necrotic graft showed no pus cells or organisms. A junctional punch biopsy showed necrotic tissue with acute inflammatory cell infiltrate around many small vessels, but no features suggesting vasculitis. Unfortunately, there are no laboratory tools available to test for venom or antivenom antibodies in the involved tissue. With the help of a psychiatrist, the patient was questioned about any possible self-inflicted act, which he denied. He was treated with intravenous flucloxacillin and penicillin, followed by debridement and regrafting. Three weeks later, he presented again with lower leg pain and blackness of the new graft with surrounding erythema, increasing over 6-12 hours. The graft had almost completely healed prior to this. However, in this presentation, there was involvement of new areas medially. Again, markers of inflammation were normal, and new biopsies and cultures were negative. The wounds were extensively debrided and regrafted. To date (six weeks after regrafting), there has been no complication with this current graft. I believe the patient had recurrent necrotising arachnidism, although a literature review of all MEDLINE journals to date (search terms necrotising arachnidism, spider bites and necrosis) revealed no reports of recurrent necrotising arachnidism. Similarly, another search (search terms human, skin graft rejection/failure and necrosis delayed/late) showed no reports of delayed skin graft failure. Necrotising arachnidism describes a rare complication of spider bite, which is characterised by progressive necrosis and inflammation of the bite site, occasionally requiring extensive debridement and skin grafting. The white-tailed spider (Lampona cylindrata) has been implicated in this condition,1,2 but there is currently little evidence to confirm this, and considerable difference of opinion among experts.3 The disease has some similarity with loxoscelism, a syndrome of tissue necrosis associated with the bite of the brown recluse spider (Loxosceles reclusa) in the United States. Mycoplasma ulcerans infection may be involved with this condition, but this is rare.1 Sor Way Chan Surgical Registrar, Monash Medical Centre 35 St Georges Road, Toorak, VIC E-mail: sorwayATone.net.au Acknowledgements: Dr Ken Winkel, Deputy Director, Australian Venom Research Unit, The University of Melbourne, for providing relevant information and expert advice. Hawdon GM, Winkel KD. Spider bite: a rational approach. Aust Family Physician 1997; 26: 1380-1385. Skinner MW. Necrotising arachnidism treated with hyperbaric oxygen. Med J Aust 1995; 182: 372-373. White J, Hirst D, Hender E. 36 cases of bites by spiders, including the white-tailed spider, Lampona cylindrata. Med J Aust 1989; 150: 401-403. Comment: Chan's letter documents another case of significant local tissue injury where a spider bite may have been causal. The bite is ascribed to the white-tailed spider (Lampona cylindrata), although the spider was clearly not formally identified. The apparently successful healing of the skin graft was fortunate, as some cases of "necrotic arachnidism" prove rather resistant to successful grafting. However, once grafted, lesions affected by "necrotic arachnidism" tend to recur early, not 12 months later. It is most unlikely that venom would remain active but quiescent over such a period, and so the cause for the subsequent graft failure is unclear. An immune mechanism might be invoked, and infection is also worth considering, even in the absence of positive cultures. I have seen a number of cases of suspected necrotic arachnidism over the last 20 years in which local relapse has occurred after a prolonged period of apparent healing. The cause for such relapses has never been clearly documented. "Necrotic arachnidism" encompasses bites from any spider where tissue injury occurs, from any mechanism, including direct venom effects, as in loxoscelism, or indirectly, through infection, vasculitis and immune reactions. The best-described and best-researched cause of "necrotic arachnidism" is loxoscelism,1 caused by the bite of recluse spiders, genus Loxosceles, which causes distinct and sometimes severe local tissue injury. Experience in treating these bites in North America has shown that early debridement may extend the area of damage and that grafting is often unsuccessful, especially if undertaken in the first five weeks.1 Optimal treatment is still debated, with hyperbaric oxygen therapy currently enjoying some support.1,2 In Australia, the white-tailed spider is often mentioned in association with "necrotic arachnidism", but confirmatory reports are rare.2 Most reported bites by this spider cause no significant tissue injury,3 and research on the spider's venom has failed to show necrotising ability.4 Until there is a clear body of evidence to incriminate the white-tailed spider, it is inappropriate to suggest this spider is the likely cause of "necrotic arachnidism" in Australia, especially as Loxosceles is now found here and has caused confirmed cases of necrosis.5 It is more likely that a number of spider species occasionally cause necrosis and that the necrosis has different causes, including direct venom effect, infection introduced at the time of the bite and immune reactions mounted by the patient. Julian White Head of Toxinology, Women's and Children's Hospital King William Street, North Adelaide, SA White J. Clinical toxicology of spider bites. In: Meier J, White J, editors. Handbook of clinical toxicology of animal venoms and poisons. Boca Raton; CRC Press, 1995: 259-329. Skinner MW, Butler CB. Necrotising arachnidism treated with hyperbaric oxygen. Med J Aust 1995; 162: 372-373. White J, Hirst D, Hender E. 36 cases of bites by spiders, including the white tailed spider, Lampona cylindrata. Med J Aust, 1989; 150: 401-403. Atkinson RK, Wright LG. Studies on the necrotic actions of several Australian spiders. Comp Biochem Physiol 1991; 98: 441-444. White J, Williamson J, Rieger N, et al. Necrotic arachnidism and its management: a possible role for hyperbaric oxygen therapy [abstract]. Toxicon 1996; 34: 170. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Medical Detective Lead poisoning from drinking Kombucha tea brewed in a ceramic pot Tri Giang Phan, Jane Estell, Geoffrey Duggin, Ian Beer, Diane Smith and Mark J Ferson MJA 1998; 169: 644-646 Kombucha tea is an alternative therapy that is gaining popularity as a remedy for a diverse range of ailments. We report two cases of symptomatic lead poisoning requiring chelation therapy in a married couple who had been drinking Kombucha tea for six months, brewing the tea in a ceramic pot. We postulate that acids in the tea eluted lead from the glaze pigment used in the ceramic pot, in a manner analogous to elution of lead from crystal decanters by wine and spirits. Introduction - Clinical record - Discussion - References - Authors' details - - More articles on Toxicology Introduction Lead is a ubiquitous enzymatic poison which can be found in the air, soil and drinking water. The addition of lead salts to paint at the beginning of the 19th century, and tetraethyl lead to petroleum in the 20th century, has increased environmental levels of lead, particularly in dense urban areas.1 Less-common sources of lead include cosmetics, ceramics, leaded crystal and old newsprint. Daily ingestion of more than 5 µg of lead/kg body weight will result in a positive lead balance and rising lead levels.2 Lead preferentially binds to the sulfhydryl groups of proteins and denatures them, causing cell death and tissue inflammation. Impaired haemopoiesis results in sideroblastic anaemia. Damage to the kidney may result in tubular necrosis and renal failure, Fanconi syndrome (type 2 proximal renal tubular acidosis), saturnine gout, and hypertension. Neurotoxicity may result in peripheral neuropathy, sensorineural deafness, metabolic encephalopathy, and neurodevelopmental delay. Colicky abdominal pain and constipation are frequent presenting symptoms. We report two cases of lead poisoning in a married couple who had been drinking Kombucha tea brewed in a ceramic pot. The tea is a mildly alcoholic beverage produced by fermenting sweet black tea with the Kombucha "mushroom" in a glass, porcelain or ceramic pot. The mushroom itself is a symbiosis of yeast and bacteria bound by a thin, permeable membrane. It is gaining popularity as an alternative therapy for a diverse range of ailments such as insomnia, hair loss, impotence, obesity, chronic fatigue syndrome, asthma, multiple sclerosis, rheumatoid arthritis, cancer, and AIDS.3 Clinical record A 58-year-old woman presented to the Emergency Department at the Prince of Wales Hospital with a six-week history of increasing constipation and colicky abdominal pain. She was treated with laxatives and discharged. Review of her blood film showed a hypochromic anaemia (Hb, 108 g/L) with polychromasia and basophilic stippling of her red blood cells (Figure 1). Lead poisoning was suspected, and a urine lead level was ordered. Iron studies and a haemoglobin electrophoretogram were normal. Her 24-hour urinary lead level was 1.42 µmol/L (normal range, 0.0-0.4 µmol/L) and her blood lead level was 5.95 µmol/L (normal range, 0.0-0.48 µmol/L). Her 63-year-old husband was found to have a blood lead level of 4.49 µmol/L. He was a retired telephone operator who had had no exposure to lead during his working life. His only symptom was fatigue. They had no children and there were no family pets. Six months earlier both the patient and her husband started drinking Kombucha tea as a tonic. They brewed the tea in a ceramic pot and ingested one tall glass (about 250 mL) every morning. An elevated blood lead level has been notifiable under the Public Health Act 1991 (NSW) since 1 December 1996; accordingly, the South Eastern Sydney Public Health Unit was notified. Samples of soil, paint chips, household dust, and dust from venetian blinds were taken from the family home and analysed. No environmental source of lead was found. However, samples of the Kombucha tea contained 173 mg/kg of lead. The Australian Food Standards Code A12 -- Metals and Contaminates in Food requires a lead level of less than 0.2 mg/kg in beverages and other liquid foods. After brewing in the ceramic pot, the Kombucha mushroom contained 329 mg of lead/kg dry weight, the maximum permitted being 0.5 mg/kg. The tea was brewed in a ceramic pot with internal glazing (Figure 2), and testing found a lead level of 198 mg/L of extract solution. The Food (General) Regulation 1997 (NSW) requires food vessels to comply with the British Standard Specification of Limits of Metal Release from Ceramic Ware, Glassware, Glass Ceramic Ware and Vitreous Enamel Ware (BS 6748: 1986), which specifies a maximum lead level of 4.0 mg/L of extract solution. This standard refers to containers used for food storage, and it is likely that the ceramic pot, which had been imported from Spain 25 years earlier, was not intended for food use. Both patients were offered outpatient chelation therapy with calcium disodium edetate. They received a course of five intravenous infusions of one gram of calcium disodium edetate given at two-day intervals. At follow-up six months later, the woman's anaemia and constipation had resolved and her blood lead level had fallen to 1.42 µmol/L. Her husband remained symptom-free and his blood lead level had fallen to 1.52 µmol/L. Discussion Lead contamination of food and beverages has long been recognised. In 1991, Graziano and Blum showed that wine and spirits stored in crystal decanters could elute lead from the vessel over time to produce potentially highly toxic levels of lead.4 They correlated the rise in the lead concentration in port or brandy with the lead content of the crystal decanter and the time that the port or brandy was decanted. In fact, lead poisoning has been postulated as the cause of the epidemics of gout in the nobles of 18th- and 19th-century Britain and the aristocrats of the Roman Empire.5 The consumption of port in England in the 18th and 19th century was paralleled by the high incidence of gout, and lead levels in fortified wines bottled between 1770 and 1820 are as high as 300-1900 µg/L.5 The pandemics of gout among Roman aristocrats have also been linked to chronic lead poisoning from contaminated wines. Roman wines contained boiled-down grape syrup (sapa), which had to be simmered in either a lead pot or a lead-lined copper kettle. Attempts to prepare sapa according to ancient recipes have produced lead concentrations of 240-1000 mg/L of boiled-down must.6 Nriagu reviewed the lifestyles of the Roman emperors and usurpers, and speculated that their predilection for lead-tainted Apician entrees7 and Columellan wine blends8 contributed to widespread plumbism and the fall of the Roman Empire.9In a report similar to ours, Scarlett et al described lead poisoning in a married couple who ingested non-alcoholic carbonated beverages from a pewter drinking mug.10 Traditional pewter mugs contain 25% lead and 75% tin, and are not recommended for food and drink containers. Highly toxic lead concentrations may result from elution of lead from the pewter by the acidity of effervescent non-alcoholic beverages. Kombucha tea contains 0.5%-1.5% alcohol, and organic acids such as acetic and lactic acid, which produce a pH of 2.5.11 The literature on Kombucha recommends the tea be brewed in a glass, porcelain or ceramic pot to obtain the best results.3 However, some decorative bowls contain high levels of lead oxide in the glaze or pigments used in the ceramics. Acidic beverages stored in these containers may elute the heavy metal from the bowl and produce harmful levels of lead in the brew, in a manner analogous to the elution of lead from crystal decanters by wine and spirits, and from pewter by non-alcoholic carbonated beverages. Failure to fire the kiln to a high enough temperature during glazing can result in inadequate fixation of the glaze pigments to the ceramic bowl, which can potentiate this effect. Kombucha tea itself has been associated with toxic reactions. There have been two case reports from Iowa of unexplained severe illness associated with drinking Kombucha tea.12 Both patients had a severe metabolic acidosis with high serum levels of lactate, the cause of which could not be determined. There have also been warnings of potential hepatotoxicity following the report of a man who developed a skin rash, hepatomegaly and abnormal liver function tests after drinking the tea for one month.11 His symptoms resolved and his liver function tests normalised when he stopped taking the tea. In another four cases, one patient developed jaundice and abnormal liver function tests, the second had non-specific complaints of dry mouth, dizziness, nausea and vomiting, and neck pain, and the other two patients were thought to have developed allergic reactions.13 The history of chronic ingestion of Kombucha tea over six months and demonstration of highly toxic levels of lead in both the tea and mushroom confirm that it was the source of the lead poisoning in our patients. We postulate that their exposure to lead (estimated to be about 43 mg/day) resulted from ingestion of Kombucha tea which had been brewed in a ceramic pot that was not properly glazed and was probably never intended for food storage. This method of brewing is potentially harmful. Patients with unexplained lead poisoning should be questioned about their use of alternative therapies, and their methods of food preparation and storage. References Graef J. Lead poisoning. Part I. Clinical Toxicology Review 1992; 14(8). Graef J. Lead poisoning. Part II. Clinical Toxicology Review 1992; 14(9). Tietze HW. Kombucha the miracle fungus. 6th ed. Bermagui, NSW: Harald Tietze Publications, 1995. Graziano JH, Blum C. Lead exposure from lead crystal. Lancet 1991; 337: 141-142. Ball GV. Two epidemics of gout. Bull Hist Med 1971; 45: 401-408. Gilfillan SC. Lead poisoning and the fall of Rome. J Occup Med 1965; 7: 53-60. Apicius. The art of cooking. Flower B, Rosenbaum E, translators. London: George G Harrap, 1958. Columella. De re rustica 12: 20. Nriagu JO. Saturnine gout among Roman aristocrats. Did lead poisoning contribute to the Fall of the Empire? N Engl J Med 1983; 308: 660-663. Scarlett JD, Hodges RJ, Romain PR, et al. Lead poisoning by a mug. Med J Aust 1995; 163: 589-590. Perron AD, Patterson JA, Yanofsky NN. Kombucha "mushroom" hepatotoxicity [letter]. Ann Emerg Med 1995: 26; 660-661. Unexplained severe illness possibly associated with consumption of Kombucha tea -- Iowa 1995. MMWR Morb Mortal Wkly Rep 1995; 44: 892-893, 899-900. Srinivasan R, Smolinske S, Greenbaum D. Probable gastrointestinal toxicity of Kombucha tea. Is this beverage healthy or harmful? J Gen Intern Med 1997; 12: 643-644. Authors' details Royal Prince Alfred Hospital, Camperdown, NSW. Tri Giang Phan, MB BS, Renal Registrar; Geoffrey Duggin, MB BS, FRACP, Head, Toxicology Unit. Prince of Wales Hospital, Randwick, NSW. Jane Estell, BMed, Haematology Registrar. South Eastern Sydney Public Health Unit, Zetland, NSW. Ian Beer, Diploma of Public Health Inspection, Food Inspector; Diane Smith, Environmental Health Officer; Mark J Ferson, FRACP, FAFPHM, Director. Reprints will not be available from the authors. Correspondence: Professor G Duggin, Department of Renal Medicine, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050. Email: gdugginATrenicu.rpa.cs.nsw.gov.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Jane Estell · Geoffrey Duggin · Ian Beer · Diane Smith · Mark J Ferson

True Stories Acute appendicitis in childhood: did mother know best? A pathological analysis of 1409 cases A kernel of truth? Roger W Byard, Nicholas D Manton and Richard H Burnell MJA 1998; 169: 647-648 Introduction - Subjects and methods - Results - Discussion - References - Authors' details - - More articles on Pathology Introduction As children, all three of us were subjected to repeated injunctions by our respective mothers that under no circumstances should we swallow fruit pips or seeds. Underpinning the maternal reasoning was an unshakeable belief in the inevitable impaction of such ingested material in the appendix, resulting in inflammation, distress and eventual "surgical mutilation" (referred to by surgeons as "operative cure"). We analysed a series of acute appendicitis in children in an attempt to validate the maternal hypothesis and to dispel the memories of years of childhood terror. Subjects and methods The computerised database at the Department of Histopathology, Women's and Children's Hospital, Adelaide, South Australia, was searched for records of all cases of surgical removal of a vermiform appendix over the period 1972-1997. The cases had been coded using the SNOMED1 system and were searched for under the codes T-66000 (appendix), M-41000 (acute inflammation) and M-30400 (foreign body, NOS [not otherwise specified]). Results Among 2224 consecutive cases of surgically removed appendices there were 1409 cases in which there was sufficient evidence of acute inflammation to justify a diagnosis of acute appendicitis. In only one of these cases (1/1409; 0.07%) was a fruit seed discovered. This seed enteric entrapment disease state (SEEDS) involved a three-year-old girl who had presented in 1997 with a short history of right-sided lower-abdominal pain necessitating surgical intervention. Pathological examination of the excised appendix revealed a 10 mm round fruit seed in the distal portion of the appendix (Figure) associated with a transmural acute inflammatory infiltrate. Expert analysis of the seed revealed it to be consistent with a cherry pip (unidentified elderly white man representing Fresh Fruit and Vegetables Inc., Adelaide, SA, personal communication). While no subsequent immunohistochemical, electron microscopic or molecular biological evaluations of the foreign body were undertaken, we are in no doubt that, if they had been, the results would also have been consistent with the identification of a cherry pip. Discussion Although acute appendicitis is common, its aetiology remains "vague and indefinite".2 It was rarely recognised until the latter part of the 19th century, when an eminent text noted that it had become quite common in "highly civilized countries such as Great Britain", with lower occurrence rates in Denmark and Sweden.2 (Whether it occurred in the Antipodes at that time is not known, as for some reason rates for the colonies were not given.) A perforated appendix found in an Egyptian mummy, however, indicates that the disease has been around since ancient times.3Originally known as perityphlitis (Greek; peri, around + typhlos, blind + -itis, inflammation), the disease was described by John Hunter in a case at autopsy in 1769;4 the first use of "appendicitis" is credited to Fitz, who used the term at the inaugural meeting of the Association of American Physicians in 1886.4 The appendix is an unusual organ, and is apparently found only in humans, certain apes and the wombat.3 The similarity between humans and wombats certainly comes as no surprise to our group, as, using quite elaborate, expensive and time-consuming immunohistochemical techniques, we have previously been unable to distinguish between wombats and humans.5 However, we did note at the time that wombats tended to be hairier and smaller (R W B, unpublished observation). One of the earliest aetiological theories for acute appendicitis (to which our mothers still subscribe) is that a small foreign body, such as a seed, might lodge in the appendix, thus initiating an acute inflammatory reaction.6,7 This theory has not been universally accepted, with suggestions being made, as early as 1925, that most cases thought to be cherry stones, date seeds and grape seeds found within the appendix are not really seeds at all, but concentrically laminated faecoliths.8 Our study has clearly demonstrated, however, that impaction of fruit seeds within the appendix is a very real, although seemingly rare, possibility, with potentially dire consequences. The case of a boy who "died of his first berry" was reported as early as 1887 by Jacobi.9 Although it may be argued that the rate of SEEDS in our series was rather low, at 0.07%, the impact on the affected individual was obviously quite profound. In searching the literature we have uncovered reports of a host of other swallowed foreign bodies retrieved from appendices. One of the earliest documented cases of foreign body entrapment within the appendix involved perforation by a pin in a 12-year-old boy. The case was reported in 1736 by Claudius Amyand, sergeant-surgeon to George II, under the heading of "Some observations on wounds in the guts".10 As well as further reports of pins becoming lodged in the appendix (so-called "Halloween" appendicitis),11 there were also reports involving needles,9 balls of animal hair,12 snipe shot (birdshot)13 and bullets.14 Thus, it is clearly mandatory that pathologists insist that their registrars carefully scrutinise all faecoliths, diligently searching for such elusive treasures. Although our initial conclusion was that our mothers were entirely correct in espousing the belief that fruit seeds may be potentially lethal, a reviewer for the Journal disagreed and stated that our study demonstrated instead that our mothers were "incorrect in espousing the belief that fruit seeds or pips may cause appendicitis". As publication was at stake, we agreed to reverse our opinions while still using the same data. We would defend this apparent defection from the truth on pragmatic grounds, and also look to Cervantes for support in that "one swallow does not make a summer".14 The reader should be the final arbiter. References Cote RA, editor. Systematised nomenclature of medicine. 2nd ed. Skokie, Ill.: College of American Pathologists, 1979. Boyd W. Surgical pathology. 2nd ed. London: WB Saunders, 1925: 366. Williams RS. Appendicitis: historical milestones and current challenges. Med J Aust 1992; 157: 784-787. Bouchier IAD, Allan RN, Hodgson HJF, Keighley MRB. Textbook of gastroenterology. London: Bailliere Tindall, 1984: 733. Byard RW, Carli M, Moore A. An immunohistochemical study of the southern hairy-nosed wombat (Lasiorhinus latifrons). In: Wombats. Chipping Norton, Surrey: Beatty and Sons. In press. Taylor JM, Wells WH. Manual of the diseases of children. Philadelphia: P Blakiston's Son and Co, 1898: 234. Encyclopedia Americana. Montreal: Americana Corporation. 1955: 78. MacCallum WG. A text-book of pathology. 3rd ed. Philadelphia: WB Saunders, 1925: 237-238. Jacobi A. The intestinal diseases of infancy and childhood. Detroit: GS Davis, 1887: 234-235. Amyand C. Of an inguinal rupture, with a pin in the appendix caeci encrusted with stone: some observations on wounds in the guts. Philos Trans R Soc Lond 1736; 39: 329-336. Conforti FP, Smego DR, Kazarian KK. Halloween appendicitis: pin perforation of the appendix. Conn Med 1987; 51: 507. Miller GG, Fraser GC, Jevon G. "Pilonidal appendicitis" or "the hair of the dog": an unusual case of foreign body. J Pediatr Surg 1996; 31: 703. Osler W. The principles and practice of medicine. New York: D Appleton and Co, 1892: 406. Meyer J, Abuabara S, Barrett J, Lowe R. A bullet in the appendix. J Trauma 1982; 22: 424-425. Cervantes M. Don Quixote. Harmondsworth, Middlesex: Penguin, 1974: 100. (Received 6 Feb, accepted 27 Apr 1998) Picture at top: Opened appendix, demonstrating a typical case of seed enteric entrapment disease state (SEEDS) in a three-year-old girl. A cherry stone is firmly embedded in the distal portion of the acutely inflamed appendix. Authors' details Department of Histopathology, Women's and Children's Hospital, Adelaide, SA. Roger W Byard, MD, FRCPath, Associate Professor, Senior Consultant, Histopathologist Nicholas D Manton, MB BS, Histopathology Registrar Department of Paediatrics, University of Adelaide, SA. R H Burnell, MB BS, FRCP, Paediatrician Reprints will not be available from the authors. Correspondence: Associate Professor R W Byard, Department of Histopathology, Women's and Children's Hospital, 72 King William Road, North Adelaide, SA 5006. Email: rbyardATmad.adelaide.edu.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Roger W Byard · Nicholas D Manton · Richard H Burnell

True Stories Breaching the bastions. Susannah O'Reilly -- pioneer Australian female doctor An honours graduate in medicine from the University of Sydney in 1905, Susie O'Reilly was rejected by Sydney Hospital's male-dominated medical establishment, amid much controversy in the local press. She went on to become a popular family doctor and obstetrician, and was one of the founders of the Rachel Forster Hospital for Women. MJA 1998; 169: 648-650 Ever-cheerful, with a limerick for every situation and occasion, Susie O'Reilly was a popular family doctor and obstetrician on Sydney's North Shore for much of the first half of this century. Caring little for conventional fashions, Susie made her many calls wearing, in addition to her usual broad smile, a hygienically laundered voluminous white dress or uniform (shapeless and waistless) with a black hat perched on top of her frizzy hair. But, in addition to her sparkling personality1 and appearance, Dr Susannah Hennessy O'Reilly (1881-1960) was also remarkable historically, as one of the pioneer women in medicine in Australia. In common with many true pioneers, Susie experienced at least one major set-back in her career. She was refused a residency at Sydney Hospital in 1905, despite much in her favour -- excellent academic standing, impressive family connections, and an earlier claim made by the then Board of Directors that "there is nothing in the rules and regulations to prevent women doctors from being appointed".2Susannah O'Reilly was born on 25 January 1881 in Liverpool Street, Sydney, the eldest daughter of Dr Walter William Joseph O'Reilly. Her father, born in New York and educated at Sydney's Newington College, had obtained his medical degree at Queen's University, Belfast. His father, Walter Le Croix O'Reilly, and his grandfather Bernard O'Reilly, were also medical men, both graduates of Trinity College, Dublin. Susie O'Reilly aged 12 years Susie was admitted to Methodist Ladies' College (then known as Burwood Ladies' College) on 18 July 1894, as a weekly boarder. A remark in the Admissions Book -- "studiously inclined" -- aptly sums up one aspect of her nature. As for another, it is reported that one night after "lights out" she was caught swinging from the bracket of one of the gas lamps in the dormitory.3 She was Dux of the School in 1897 and passed the Senior in 1898, matriculating with first class honours in French. Proceeding to Sydney University, Susie passed first year medicine in 1899 and, majoring in biology, also gained a BSc (with her medical subjects counting towards it), conferred in 1903. She was one of the top four students for each of the last three years of her medical studies, graduating MB early in January 1905 with second-class honours. The newly graduated Dr O'Reilly applied for the position of Resident Medical Officer at Sydney Hospital in 1905. She learnt of her unsuccessful application when she received a letter from the Registrar of the University of Sydney stating that at a joint meeting of the representatives of Sydney Hospital and the Royal Prince Alfred Hospital, held on 3 January 1905, five gentlemen -- F G W Simpson, J W Power, S Kay, E A R Bligh and A Verge -- had been selected as Resident Medical Officers for Sydney Hospital for that year. Simpson and Power had come first and second, respectively, in their graduating years' order-of-merit list; the latter three had received passes in the examination results.4 The Registrar had then asked the Board to choose between A E Finckh and Susie O'Reilly for the sixth place. Finckh obtained eight votes to Susie's seven. Of the five doctors on the Board, two voted for Finckh, two for Susie, and the fifth, the Board President (Sir Arthur Renwick), abstained.5 The Board's decision to choose Finckh over Susie was remarkable for many reasons, not the least being Susie's superior academic record. The Board had previously informed Annie Golding, President of the Women's Progressive Association of New South Wales, on 21 July 1903,2 that "when it is necessary to make appointments to the medical staff, applications are invited through the press, with no restrictions as to sex". Further, one of the Board members who voted against Susie's appointment, Dr Joseph Foreman, Honorary Gynaecologist at Royal Prince Alfred Hospital, and Lecturer in the Diseases of Women in the Faculty of Medicine, University of Sydney, gave her an excellent reference, written on 20 January 1905, less than three weeks after the ignominious Board vote (Mike O'Reilly, biographer, Sydney, personal communication). To quote: "I have much pleasure in stating that Miss O'Reilly was one of my clerks for three months. She was very keen in acquiring knowledge, and also successful as appears in her position in the pass list. I have a very high opinion of her ability and can recommend her in every way." Moreover, and perhaps most surprisingly of all in its apparent lack of influence, was the fact that Susie's father, Walter, was a member of the consulting staff at Sydney Hospital from 1888, and had previously been an honorary physician there. So, why was a man with a pass degree chosen ahead of a woman who came fourth in her year, and who possessed an honours degree? Turning to the press of the day, we are left with the strong impression that there was little more to it than gender bias, evident in Sydney more so than elsewhere in Australia at the time, with Susie and her sorority perceived as trying to prise their way into a heavily fortified male-dominated preserve. The Establishment newspaper, the Sydney Morning Herald, promptly and simply reported the Board meeting on 4 January 1905, but the Daily Telegraph lent Susie's plight editorial support the following day: "In the view of the directors her sex was a fatal disqualification. They [the directors] did not hesitate to put the matter plainly on that ground, and lay down the principle that no female shall hold the position of resident doctor at the Sydney Hospital", and concluded "The girl who braves the vulgar prejudice which seeks to prevent women from entering a profession where humanity calls so loudly for their presence deserves the support and encouragement of all enlightened people. Yet Sydney has the distinction of having men in highly responsible positions who, on principle, feel it is their duty to increase the difficulties against which the female student of medicine has to contend."6 Letters to the Editor of the Daily Telegraph followed swiftly. Dr Mary Booth wrote that the question of hospital appointments had been a bitter one among women in Sydney for many years: they had been obliged to go to Adelaide and Brisbane for experience.7 A letter from "Patient" opined that this was as it should be.8 The writer endorsed Dr Booth's opinion that there was room for both men and women doctors, "but without injury to the efficient working of the hospitals, and therefore to the patients, there is no room for women on the resident medical staffs of the Sydney and Prince Alfred Hospitals. It is unquestionably right and proper that women should have opportunities for gaining practical experience, but surely the Children's Hospital, and the four or five women's hospitals of Sydney should be amply sufficient for this purpose. Why should they wish to acquire a knowledge of men's diseases, which they will never be called upon to treat in private practice, is incomprehensible to the ordinary mind . . . I suggest, in all sincerity, that steps be taken by these dissatisfied ladies, to establish a hospital for women, managed, officered, and run entirely by women".8 A short time later, in March 1905, a three-part series on the general subject of "Sydney's Medical Women", by "AHK", ran in the Evening News, reporting further views on the matter. AHK quoted a woman doctor who did not deny that women had equality in their training at Sydney University, but that this stopped as soon as they graduated and began competing with men in the market-place for jobs and training.9 She compared Sydney very unfavourably with London. AHK also quoted a male doctor, who advanced economic reasons for the prejudice in Sydney against women in medicine: the women had come into the field at a bad time, he claimed; 1903 was the year of the financial crashes and when the land-boom had burst. Since then, things had been "horribly bad", and "the faculty" were perhaps the greatest sufferers in times of financial hardship. It had been no academic protest against women's invasion of man's sphere, but "a veritable war to the knife . . . the outcome of the bitter struggles for existence of the last twelve years". Hostilities had been more or less veiled of late, but nothing like a truce would be called until economic prospects improved. There was little likelihood of doing so at present. While many in the profession had to live chiefly by "anaesthetic fees", one could scarcely expect them to look upon the encroaching sex with equanimity. AHK went on to say that this doctor's gloomy summary was borne out by the number of houses lately vacated by professional men. In the last week there were six empty "doctor's houses" in Hyde Park, a thing unprecedented in his informant's memory. ("Starved out," he commented.) When men were fighting for bare life themselves, added the doctor, they did not feel disposed to help any poachers on their domain.10 Many years later, in the Sydney Morning Herald's obituary for Susie, Sir Herbert Schlink eloquently understated the problem: "The men doctors did not take too kindly to women in medicine at first."11 In fact, in 1906, women began to make their way in the hospitals of Sydney, claimed at the time to be the the most conservative of Australian cities.8 While women were not appointed to Sydney Hospital until 1910, Royal Prince Alfred Hospital was "breached" in 1906 with the appointment of Dr Jessie Aspinall. Luckily for Susie, female doctors were not excluded from public hospital appointments in all Australian cities, and she undertook her internship at Royal Adelaide Hospital in 1906-1907, returning to Sydney in 1908 and eventually becoming one of the foundation members of the Rachel Forster Hospital for Women in 1922. Three of Susie's family also graduated in Medicine from Sydney University: a brother, Linnell (1879-1948), appointed to Sydney Hospital in 1906, a year after Susie's rejection; another brother, Merrick (1892-1957), appointed to Perth General Hospital in 1914; and a sister, Olive (1892-1976), to Brisbane General Hospital in 1916. Today, nearly a century later, women in professions continue to come up against similar bastions of authority and power -- in the Church and the Navy, for example. Nor is the opposition confined only to men. Kelvin Grose, BA (Hons), PhD PO Box 197, Killara, NSW 2071 Obituary. Susannah Hennessy O'Reilly. Med J Aust 1960; 2: 516-517. Golding A. Letter to the editor. The Daily Telegraph (Sydney)1905 Jan 6. O'Reilly M. The O'Reilly family. In: Halstead G. The story of St Ives. Sydney: Nungurner Press, 1982: 344. University of Sydney Calendar for 1905, p 286. Minutes of Meeting of the Board of Directors, Sydney Hospital, held on 3 January 1905. Sydney Hospital Archives, pp 414-415. The Daily Telegraph (Sydney) 1905 Jan 5. Booth M. Letter to the editor. The Daily Telegraph 1905 Jan 7. The Daily Telegraph (Sydney), 1905 Jan12. "AHK". Sydney's medical women. The Evening News (Sydney) 1905 Mar 31; p 7 (column 5). This is the third of three articles, beginning on 28 March 1905. The Evening News (Sydney) 1905 Mar 29; p 6. Obituary. Susannah Hennessy O'Reilly. Sydney Morning Herald 1960 Jun 22. Margaret Coleman. This is Pymble College. Pymble Ladies' College, Sydney, 1991; p 53, p 119. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Kelvin Grose

True Stories A case of Mediterranean date louse in aircrew More tales from Masirah MJA 1998; 169: 651-652 Those of you who remember the "Caesarean section" described in the 1996 Christmas issue of the Journal will doubtless recall that I spent nine months during the mid-1970s with the Royal Air Force on Masirah, a desert island in the Arabian Gulf. It was not a posting that was highly sought after by any career-minded officer. Most of the people there knew of someone they had offended shortly before the posting notice arrived -- I had at least a dozen names on my list. Masirah had developed a slang of its own that had been handed on from generation to generation of those lucky enough to be posted there. For example, we were subject to a syndrome known as a "wobble". This could be anything from mild irritation on discovering that it was bloody crayfish for dinner again (sometimes known as a mini-wobble or "teeter") to a major affective disorder brought on by discovering that your replacement, due in seven days, had just thrown himself under a bus to avoid the posting. I once wrote a learned paper for distribution to section commanders on "The Wobble and how to deal with it when not in possession of live ammunition". It was well received, especially by the Padre, to whom the medical officers sent their incurable cases. Another of our local slang terms was a "rubber dick". The etymology is shrouded in history, but those of you who have served the Flag will be able to make a stab at it. It had come to mean a practical joke, the more devious the better. For many of the servicemen on Masirah, only just staving off alcoholism and insanity, the creation of rubber dicks had become their raison d'etre. This was true for none more so than the Medical Officers. One of our fellow officers thought it great fun to slip into someone's room, switch off the ceiling fan and place little heaps of talcum powder on the blades. When the victim returned to his room he would curse the heat, switch on the fan and spend the next 10 days dusting. We cured this fellow by the simple expedient of inflating a meteorology balloon in his room with a compressor hose passed through the window. When he returned and found that he couldn't open the door because the balloon had infiltrated every nook and cranny of his room, he resorted to stabbing the balloon with a kitchen knife through a tiny gap in the door. This was when he discovered we had filled the balloon with 10 kg of flour. My surgical colleague, GS, had been brought up without the company of dogs, resulting in a pathological fear of the species. As we were also the de-facto veterinary surgeons for the island, we were often consulted by the Chief Doggie (CD for short, but, more formally, the Flight Sergeant Dog Handler), who quickly saw my colleague's weakness and naturally sought ways to embarrass him. He told GS that one of the dogs had a very painful ear and was scratching and rubbing it. A vet would probably have prescribed antibiotics over the phone, but GS felt obliged to visit the dog section and attempt an otoscopic examination of the left ear of a 60-kg german shepherd called Rex. The "Doggies" couldn't wait to tell all and sundry about the pale, sweating "Doc" with his face 50 mm from a slobbering mouthful of teeth. They had a great laugh at GS's expense -- but they should have taken note of the glint in his eye. Some days later a signal (apparently) arrived for the Chief Doggie from his counterpart in Gan, another isolated station in the Indian Ocean. Masirah had just lent two dogs to Gan, and the signal said that the visiting dogs had come down with "a nasty case of anal strictures" and suggested that our dogs should be checked out, as the condition was "very infectious". Naturally, the first place our CD took advice was the medical section, which was only too ready to confirm the seriousness of the situation and offer advice on diagnosis. A somewhat white-faced CD left the medical centre with several examination gloves and a tube of lubricating jelly. Of course, we followed him back to the dog section and were peeking round the corner of the building when he completed the first examination, on Sheba, who at 40 kg was the smallest dog he could find. She was not amused, and let it be known in no uncertain manner. While we were looking forward to Rex's examination we decided that, as we would be the ones to suture the CD's wounds, we should probably admit to the rubber dick before any serious damage was done. The CD was so relieved that he forgot to swear undying enmity with the medical section. GS eventually served his time, and was sent home. He was replaced by DJ, who was living proof of the old adage that "You can always tell a Guy's man, but you can't tell him much". He was, however, the master of the rubber dick. DJ earned his spurs with a few notable ploys. He convinced the OC Admin Wing that paper mites were infesting the island and that he should not handle paper without rubber gloves. This reduced the number of minutes sent from his office by at least 90%. But we eventually had to own up when we were at risk of running out of gloves for surgery. DJ operated on one of the police dogs (with my anaesthetic) and became CD's hero. He operated on a camel and became my hero when it got "a bit light" and spat in his face. He won undying fame for successfully treating one of the Pakistani staff who had "gas in my stomach, which goes up through my heart to my head where it makes a ticking noise". (Diazepam 2 mg three times daily, should you ever come across the condition.) But there's no doubt that DJ's career best was the international vulcanised rubber dick of 1976. When DJ heard that we were to refuel a Vulcan bomber which was en route for the independence celebrations of a former colony, he decided that this opportunity for relief from boredom should not be allowed to pass. When the Vulcan joined the circuit to land, Air Traffic Control confirmed that its last port of call had been Cyprus. The pilot was cleared to land but told to taxi to the "disinfestation area" and await the arrival of the medical team. When the aircraft shut down, DJ, in full surgical garb, and backed up by every vehicle on the base that had a flashing light, plugged into the aircraft's intercom and spoke to the crew. He explained that there had been an outbreak of the Mediterranean date louse in Cyprus, and as dates were the only crop grown on Masirah the crew would have to be disinfested to satisfy local quarantine regulations. The pilot readily agreed to cooperate, and it was explained that the parasite was most commonly carried on the feet and hands. The crew were instructed to dangle their feet out of the hatch on the belly of the aircraft. Five pairs of desert boots appeared through the hatch and were duly sprayed with a sticky white powder from an ancient insecticide gun. They were then told to disembark, which they did, and DJ painted their arms from the elbows down with mercurochrome. So, with pink arms and white feet, they arranged with the ground staff for the refuelling of the huge bomber and headed for the mess for a nerve tightener. All parties were enjoying a drink when one of the crew sidled up to DJ and inquired quietly if there was anything else he ought to do to ensure his good health, as "I don't want to take anything home to the missus". This seemed like a good time to let them know they had been "had", and the party became more raucous than ever. They seemed to take it all with good grace, and left the next day, with appalling hangovers, for the independence celebrations. It was only after the Vulcan had been included in all the official photographs that the crew noticed the large phosphorescent orange cut-outs of a phallus our groundcrew had attached to both sides of the aircraft's tail. They seemed to take this with good humour too and, over another mammoth session in the mess on their way home, asked DJ for an official certificate of "disinfestation" as a memento for their crew-room in the United Kingdom. DJ and I thought this was the end of the matter, but two days later we were summoned to the CO's office. He slid a signal across the desk. It was from Principal Medical Officer, Strike Command. It said: "Understand you are taking precautions against Mediterranean date louse. State precautions and authority for use." The CO proffered the view that it was the glowing orange phallus that had done it, and suggested that our postings to Masirah should now be considered open-ended. Douglas N Gow Anaesthetist, Valley Heights, NSW Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Douglas N Gow

Medical Education A sea change in Australian medical education We interviewed the Deans of our medical schools, who told us "Deans live in interesting times" Kerrie A Lawson, Ruth M Armstrong and Martin B Van Der Weyden MJA 1998; 169: 653-658 Introduction - Graduate entry - New selection criteria - Curriculum changes - Clinical exposure and information technology - Medicine and our changing society - Where should medical education be going? - Conclusion - Authors' details - - More articles on Education Introduction On the brink of the new millennium, we are beset by change -- social, technological, scientific, economic; the list continues. These changes have affected all areas of life, including medicine, and the medical schools have had to respond. The past year has also seen new Deans at eight of Australia's 10 medical schools. We spoke to these eight Deans and to their two longer-serving colleagues to find what has been happening in medical education, and their visions for the future. Graduate entry Perhaps the most dramatic change in the last few years has been the adoption of graduate-entry medical programs at Flinders University and at the Universities of Queensland and Sydney. At Flinders, where "mature" entry has always been encouraged and has led to a lower student drop-out rate, it was "part of the natural evolution of the medical course", explained Lindon Wing. Peter Brooks (Queensland) said that "delaying the decision to do a course that prepares you for a lifetime career can be justified. Such a decision is extremely hard when you are 17 or 18, with no experience of the world or life in general. The graduate students are more mature, very good at questioning and very good at working in groups -- dealing with group dynamics and setting priorities." Stephen Leeder (Sydney) lauded the greater diversity among graduate-entry students: "Our students have done a wide variety of things. A tutorial group I took this year included a trained physiotherapist, a person completing a PhD in biochemistry, one with a PhD in molecular biology, another with a nursing background and an American student who had studied liberal arts and anthropology." University of Melbourne Medical school established: 1862 Course: Entry from school, 6 years; plus (from 2000) graduate entry, 4.5 years 1998 intake: 170 Australian, 70 overseas fee-paying (mostly from South East Asia) Outstanding graduates: Frank Macfarlane Burnet (Nobel laureate), Edward "Weary" Dunlop (war services) Richard Larkins Position: Dean, Faculty of Medicine, Dentistry and Health Sciences Graduated: Melbourne medical school (1966) This time last year: James Stewart Professor of Medicine, University of Melbourne Books and discs for a desert island: Cairo Trilogy by Naguib Mahfouz; Beethoven's Eroica symphony; Smetana's Má Vlast Book with most impact in past year: Nelson Mandela: a biography by Martin Meredith The University of Melbourne will move to graduate entry for a third of its intake from the year 2000. Richard Larkins explains: "This is because of the very strong arguments in favour of both undergraduate and graduate entry. Students who've done extremely well at high school and know exactly what they want to do should not have to study things they're not really interested in for three years, and then do a four-year concentrated course in medicine with little chance for lateral extension during that time . . . but there are also lots of students who miss the opportunity to go straight into medical school through educational disadvantage, or because they they are "late developers" or decide only later to go into medicine. They also deserve a realistic opportunity of getting into medicine. Mixing the two groups of students from different backgrounds will provide mutual support and benefit." The dual program will also allow the school to compare the two types of students -- evidence-based education! The issue of graduate entry is on the agenda at two other medical schools -- Monash and New South Wales. Nick Saunders (Monash) was Dean at Flinders during the move to graduate entry. He recently circulated a discussion paper on graduate entry which will be debated at Monash at the end of this year. Bruce Dowton (New South Wales) said that his school "is just about to launch into significant reformulation of the medical course." Although this will almost assuredly involve changed selection criteria, he believes that "the question of graduate or school-leaver entry is not important at the outset. I am encouraging the faculty to begin by defining the sort of medical graduate they wish to produce before debating what sort of program will best produce that graduate". University of Sydney Medical school established: 1883 Course: Graduate entry, 4 years 1998 intake: 137 Australian, 13 overseas fee-paying (mostly from North America) Outstanding graduates: Gus Nossal (former director of the Walter and Eliza Hall Institute of Medical Research), Paul Torzillo (Aboriginal health) Stephen Leeder Position: Dean, Faculty of Medicine Graduated: Sydney medical school (1966) This time last year: Pro-Dean of Faculty of Medicine, University of Sydney Books and discs for a desert island: The god of small things by Arundhati Roy; Killer plants by Gordon Cheers and Julie Silk; Wallace and Gromit fun pack; Triple J - hottest 100 (volume 5) Books with most impact in past year: Fugitive Pieces by Ann Michael; Lovesick by Angeles Mastretta The other four medical schools have considered graduate entry, but plan no immediate changes. Derek Frewin (Adelaide), Chair of the Committee of Deans of Australian Medical Schools, explained that "Adelaide would first need evidence that the product of graduate-entry programs is at least as good or better than that of school-leaver programs." Furthermore, a disadvantage of graduate entry is that "with time added for the first degree, graduate-entry programs take at least a year longer. There is concern that this longer duration may influence the decision to pursue lengthy specialist training and particularly disadvantage women. According to Allan Carmichael (Tasmania) "one of our briefs is to provide for the medical workforce needs of the State, and graduate entry would disadvantage Tasmanians". Further, "the small size of our school would make reorientation to graduate entry more difficult". On a national scale, a consequence of graduate entry in some medical schools has been migration of students to the school-leaver programs in Western Australia and Tasmania. According to Lou Landau (Western Australia) the number of interstate students at his medical school has increased over the last five years to 10%, and includes particularly Queenslanders, who now have no school-leaver program in their home State. Robert Sanson-Fisher (Newcastle) felt no pressing need for all medical schools to adopt the same entry policy, saying that "variation is needed between medical schools. There should be choice for applicants -- the consumers -- about what or how they want to specialise. And we want different sorts of people produced or encouraged in different sorts of medical schools." University of Adelaide Medical school established: 1885 Course: Entry from school, 6 years 1998 intake: 90 Australian, 35 overseas fee-paying (mostly from Malaysia) Outstanding graduates: Howard Florey (Nobel laureate), Aubrey Lewis (first Professor of Psychiatry at London Institute of Psychiatry), Hugh Cairns (first Nuffield Professor of Surgery at Oxford) Derek Frewin Position: Dean, Faculty of Medicine, and Head, Division of Health Sciences Graduated: University of Colombo medical school (1965) This time last year: Same position (appointed Dean in 1991) Books and discs for a desert island: books by Robin Cook and Jeffrey Archer; middle-of-the-road music - Celine Dion, Cliff Richard, Harry Belafonte New selection criteria Whereas once all medical schools relied on the Tertiary Entrance Rank (TER) or equivalent, now only the University of NSW retains this as the sole criterion for entry, but even there it is under review. Changes to selection procedures were pioneered at Newcastle in the 1970s. Sanson-Fisher explained that "the TER is a necessary but not sufficient criterion for entry. If you believe both technical competence and the 'care dimension' are important, then you should select for both -- ability to acquire and regurgitate information in set formats, but also ability to work and talk with people." This philosophy led Newcastle and, more recently both Adelaide and Western Australia, to use a broad-based hurdle -- TER of 90 or above -- followed by psychosocial assessments -- the Undergraduate Medicine and Health Sciences Admission Test (UMAT; a psychological test that includes problem-solving, creative thought and ethical reasoning), followed by a structured interview. According to Frewin, "the effect in Adelaide has been to almost double the number of feeder high schools (from about 20 to 35) and to more than quadruple the number of country students (from 5% to 22% in 1998). Students are also more socially interactive and more collegial in approach." Melbourne and Tasmania are also in the process of introducing UMAT to complement the TER-equivalent for school-leaver entrants. In contrast, current selection criteria at Monash are TER (97.5 or above), appropriate prerequisite subjects (eg, chemistry) and a structured interview. However, these are under review. Similarly, the University of NSW, according to Dowton, will almost assuredly change its selection criteria during any potential restructuring of its course. University of Queensland Medical school established: 1936 Course: Graduate entry, 4 years 1998 intake: 228 Australian, 1 overseas fee-paying Outstanding graduates: Reginald Withers (Professor of Radiotherapy, UCLA, US); Ralph Doherty (Emeritus Professor of Social and Preventive Medicine and Emeritus Pro-Vice Chancellor, University of Queensland) Peter Brooks Position: Executive Dean, Faculty of Health Sciences Graduated: Monash medical school (1967) This time last year: Professor of Medicine, and Head of the Medical Professorial Unit, University of New South Wales at St Vincent's Hospital Books and discs for a desert island: The awakening by Bruce Chatwin; Bach cantatas; Handel's Water Music Book with most impact in past year: The unconscious civilisation by John Ralston Saul The change to graduate entry has also involved new selection criteria. All four graduate schools (three current and one planned -- in Melbourne) use the same criteria: academic performance in any undergraduate degree; score on the Graduate Australian Medical Schools Admission Test (GAMSAT); and a structured interview with a selection panel which may include community representatives. GAMSAT, in contrast to UMAT, is a test of knowledge, communication and intellectual skills gained through prior experience and learning which specifically assesses reasoning in humanities and social sciences and in biological and physical sciences, as well as written communication. Most Deans recognise the need for positive discrimination for rural and disadvantaged students and many schools have targeted-access schemes. Newcastle was the pioneer in targeted access for Aboriginal and Torres Strait Islander people and has produced 11 of the 26 indigenous medical graduates nationwide between 1989 and 1995. Although most other schools have put effort into providing access and support for indigenous students, many have had difficulty attracting applicants -- Newcastle seems to have "cornered the market" (Wing). Most schools also have targeted-access schemes for rural students, partly in the hope of increasing the number of rural pracitioners. In support, Larkins reported that "a 15-year survey of Melbourne graduates found that 40% of those from a rural background were practising in rural areas, compared with only 10% of those from a non-rural background." Furthermore, Landau asserted that providing opportunities to rural people is important in itself: "You won't get people living in the country if they don't believe their children have the same opportunities as urban students." Curriculum changes All the medical schools are undergoing major curriculum changes. "Curricula need to be dynamic and to adjust and adapt to the circumstances," said Frewin. All the Deans spoke of vertical and horizontal integration of curriculum content, problem-based, self-directed and computer-assisted learning, and early clinical exposure. Newcastle was first to espouse these principles when it was given a mandate by the Karmel Committee to bring a fresh approach to medical education. With the move to graduate entry, Flinders, Sydney and Queensland medical schools have also adopted curricula based on the above principles. At Sydney and Queensland, this was a major change from the traditional curriculum -- basic sciences taught in individual disciplines in the early years, followed by clinical exposure. Flinders had always had a systems-based curriculum, but has now moved to problem-based learning. The curriculum, similar at the three schools, was explained by Leeder: "We've organised students' learning not according to disciplines but according to four themes -- basic and clinical science, community and doctor, patient and doctor, and personal and professional development. We also introduce students into the clinical context from Week 1, and students work in groups on clinical problems." University of Western Australia Medical school established: 1956 Course: Entry from school, 6 years 1998 intake: 125 Australian, 11 overseas fee-paying (mostly from South East Asia) Outstanding graduates: Barry Marshall (co-discoverer, with Robin Warren, of Helicobacter pylori), Fiona Stanley (child health) Louis Landau Position: Executive Dean, Faculty of Medicine and Dentistry Graduated: Melbourne medical school (1965) This time last year: Same position (appointed 1996) Books and discs for a desert island: Complete works of Shakespeare; A dictionary of modern thought; Mozart's Marriage of Figaro; The glory of Gershwin (with Larry Adler) Book with most impact in past year: The Reader by Bernard Schlink According to Larkins, Melbourne medical school will also have a "totally new curriculum" from 1999. It will be organised similarly to the curricula of other graduate-entry schools, but "a unique feature for school-leavers is an intercalated year of advanced medical studies with a significant research component. This may be chosen from about 30 different areas, ranging from Aboriginal health, rural health, health in their own country (for international students) and medical history through to bench-based medical research." Western Australia, Adelaide and Tasmania are also breaking down the discipline barriers and adopting problem-based learning. This was seen by several Deans as a key to active learning. Frewin said: "We are moving away from 'teaching' to 'active learning', because it enhances retention and allows students to see the material in the context of its applications, leading to lifelong learning." Both Monash and NSW are actively exploring the need for curriculum change. Saunders felt that "given the changes over the last two years with provider number legislation and the increasing length of postgraduate training, Monash may be best to stay with high school entry, to reduce the course to five years, and to find an innovative and creative way of allowing graduates to do a four-year course within the same curriculum envelope". This will be debated within the faculty. Monash University Medical school established: 1959 Course: Entry from school, 6 years 1998 intake: 145 Australian, 7 overseas fee-paying (mostly from South East Asia) Outstanding graduates: Michael Wooldridge (Federal Minister for Health), John Murtagh (Professor of General Practice), Tan Sri Dato Dr Abu Bakar Suleiman (Malaysian Director General of Health) Nicholas Saunders Position: Dean, Faculty of Medicine Graduated: Sydney medical school (1970) This time last year: Dean, School of Medicine, and Head, Faculty of Health Sciences, Flinders University Books and discs for a desert island: Border trilogy by Cormac McCarthy; a book by John Grisham; Mozart's serenades; Toni Childs Book with most impact in past year: Memoirs of a geisha by Arthur Golden Landau and Carmichael want to offer students more options. According to Landau, these may be in medical subjects not well covered in traditional medical courses (eg, psychology, sociology), but may also be from outside the medical school (eg, music or a foreign language). Carmichael explained: "Our students are mainly school leavers who have studied a fairly narrow range of prerequisites, and we wish to broaden their horizons." NSW may take this even further; part of Dowton's vision for the school is to enhance the flexibility of its programs. "There are opportunities for medical graduates in more diverse areas than traditional clinical medicine -- law, advocacy, ethics, business, economics and so on. I would like to see our students able to take subjects from other schools and faculties -- Arts, Engineering, the Graduate School of Management," he said. Several of the Deans spoke of multidisciplinary education. According to Brooks, "Queensland is looking at ways of having medical students train with students in other health sciences -- pharmacy, rehabilitation sciences and dentistry." Sanson-Fisher says the Faculty of Medicine and Health Sciences at Newcastle is also moving in this direction. "There are core competencies needed by all clinical healthcare providers -- communication skills, ability to critically interpret literature, ethical issues, some basic science. Next year, we will be introducing the idea that our students learn these with other professional groups, not just in a big lecture theatre, but actually working together. That's really important, because if you don't train them together how can you expect them to work together when they graduate?" Clinical exposure and information technology Not only does clinical exposure now come earlier in most medical courses, it is moving out of the teaching hospitals into smaller hospitals, general practice and the community. According to Brooks, "The major quaternary referral teaching hospitals are inappropriate for young students. A third- or fourth-year medical student in the undergraduate course should not be interviewing someone who is waiting for a double lung or heart transplant." Many Deans talked of the need to recruit general practitioners (GPs) as teachers and highlighted the difficulty of recompensing them appropriately; teaching reduces the number of patients GPs can see and consequently their incomes. Saunders said: "The easy things are to give GPs a proper clinical title and some tangible benefits -- links with the university community, access to the library, and information technology -- but the difficulty is to get real dollars out there . . . The Australian public hospital system -- mainly the teaching hospital system -- is subsidising medical education to the tune of at least $50 million per year." University of New South Wales Medical school established: 1960 Course: Entry from school, 6 years 1998 intake: 160 Australian, 30 overseas fee-paying (mostly from South East Asia and Norway) Outstanding graduates: Robert Lusby (youngest appointee to Chair of Surgery in Australia), Bob Graham (Director, Victor Chang Cardiac Research Institute) Bruce Dowton Position: Dean, Faculty of Medicine Graduated: Sydney medical school (1980) This time last year: Associate Vice-Chancellor and Associate Dean for Medical Education, Washington University, St Louis, US Discs for a desert island: Verdi's Gianni Schicci; Mozart's Così fan tutte Books with most impact in past year: A time to keep silence by Patrick Leigh Fermor; The measure of our success by Marian Wright Edelman The move out of major teaching hospitals has been facilitated by advances in information technology, enabling both supervision and delivery of the curriculum. For example, Landau explained that "the academic GP who looks after the general practice elective programs is in regular electronic contact with the supervising GP and the student, which ensures she can get involved if the experience is not optimal." This ease of communication has also allowed for lengthy rural placements. For example, at Flinders all students go to the country for a week in Year 2, two weeks in Year 3 and six weeks in Year 4, while a cohort of students spends all of Year 3 in a rural environment in the Riverland. Students at Queensland can opt to spend Years 3 and 4 at the northern clinical school in Cairns, Townsville and Mt Isa. "All clinical problems are available on the Intranet and next year we are planning to provide any campus-based tuition to these sites through telemedicine-telehealth links," said Brooks. According to Carmichael, rural rotations are also particularly important in Tasmania, the most rural State: "A lot of educational support is provided via the Internet during these rotations. Students either provide their own laptop computer or can borrow one from the school." Medicine and our changing society Until very recently, doctors were the custodians of information that was not readily available to the general community. Now, with medical information easily accessed on the Internet and popularised in the media, our community is becoming more sophisticated about healthcare. In addition, there seems to be a growing anti-science sentiment and interest in alternative medicine. We asked the Deans how they are preparing their graduates for these changes in society and in the doctor-patient relationship. Most agreed with Larkins that "one of the challenges for our graduates will be to steer patients through the morass of information on the World Wide Web and allow them to discriminate between scientifically based and non-scientifically based information." Many Deans emphasised the need for medical students to learn how to access and critically appraise information and the value of the new curricula and methods of teaching in meeting this need. According to Wing, the paradigm shift in the doctor-patient relationship is "one of the main reasons Flinders has gone to problem-based learning. The students are not just presented with information as though it is the universe of information, they're presented with a problem and have to go and seek the information. We are trying to encourage them to learn how to access and appraise information and fit it into their everyday use, skills that will underpin their continuing education." University of Tasmania Medical school established: 1963 Course: Entry from school, 6 years 1998 intake: 50 Australian, 5 overseas fee-paying (mostly from Malaysia) Outstanding graduates: Peter Stanton (first Tasmanian graduate appointed professor in the Tasmanian medical school), Tim Flanagan (rural GP and Censor-in-Chief of the RACGP) Allan Carmichael Position: Dean, Faculty of Health Science Graduated: Monash medical school (1970) This time last year: acting in same position, and Director of Women's and Children's Services, Royal Hobart Hospital Books and discs for a desert island: The Bible; Lord of the rings by J R R Tolkien; Bach's Brandenburg concertos and Mass in B minor Book with most impact in past year: The Bible Another factor important in preparing graduates for the changes in their role is, according to Leeder, "adequate real contact with patients." Many agreed that this contact should be in general practitioners' surgeries and in the community -- patient questioning of doctors "is not the sort of behaviour you see in horizontal patients in teaching hospitals", said Saunders. "Students need role models who can say 'I don't know, but I know how to go and find out and let's do that together' . . . we have to work on staff development in this area," he added. Larkins added that "it is important for graduates to have an understanding of alternative/complementary medicine -- Melbourne students are exposed to a variety of different beliefs about health in their study of the social aspects of medicine. Graduates also need the skills to listen to the views of their patients, to communicate their own views and to help patients use all their sources of information to come to a sensible decision about their health. A doctor can no longer make a statement about what's best for the patient and expect it to go unchallenged." Landau agreed, but felt that, despite the necessary emphasis on evidence-based medicine, "the community still wants an individual to talk to and discuss the options . . . The increasing need for evidence-based criteria has removed a lot of the magic from medicine, but people still want some of that magic. We have to combine the magic with the evidence-based information, so that we can give both." University of Newcastle Medical school established: 1973 Course: Entry from school, 5 years 1998 intake: 68 Australian, 20 overseas fee-paying (mostly from Norway) Outstanding graduates: Sandra Eades (first Aboriginal graduate; now researcher at the WA Institute of Child Health), Ian Kerridge (medical ethicist) Robert Sanson-Fisher Position: Dean, Faculty of Medicine and Health Sciences Graduated: B Psych Hons (1967), PhD (1978), University of Western Australia This time last year: Director, National Institute of Cancer Control Books and discs for a desert island: Lord of the rings by J R R Tolkien; the poetry of John Donne; Luka Bloom; Verdi's Tosca Book with most impact in past year: The fatal shore by Robert Hughes Where should medical education be going? We asked the Deans for their wishlists if funding were unlimited. Educational issues figured highly in their answers. Sanson-Fisher saw "a need for more evidence-based educational knowledge. We need to know in a cleaner, clearer and more precise way what works and what doesn't, and we need mechanisms for monitoring student and staff perceptions of the faculty, educational issues and curriculum modules. We also need much more multidisciplinary education and greater flexibility in our educational system." Saunders said he "would experiment in self-directed learning and flexible delivery, turning the teaching programs into learning programs, which is expensive because you need physical facilities, multimedia development and good training for your staff." In contrast, Dowton would like "to maximise the contact between the faculty and individual students or small groups in a physical environment conducive to rich, deep learning, not superficial learning. This would involve a lot of individual tutorials and informal networking between faculty and students." General practice teaching and training was a priority for Brooks: "I'd make sure we have a very active postgraduate medical school that runs training programs in the first three years of hospital training. These could be linked into the college programs. We would work with the colleges to see how the universities could add value to their programs." Boosting research was also often mentioned. For example, Saunders would "invest in 'blue sky' strategic, applied research and encourage cross-disciplinary research. The really interesting research into delivery of medicine and the practical nature of medical care is at the intersection of disciplines; it needs to bring in economics, sociology and epidemiology. At the moment it is enormously difficult to get funds for this sort of research because it looks too foreign, too risky." Similarly, Dowton felt that "Australian universities have begun to lose the edge in medical research, and that's the part of medicine that society still needs from medical schools and research institutes. While we are no longer the archives of information -- that's out in the public domain, as it should be -- we should be the engines of producing new knowledge, not just in biological sciences but in sociopolitics, ecology, sociology of medicine and so on." Dowton also identified a need for research into "information management or informatics -- the whole area of how to harness knowledge to improve healthcare. We have amassed the so-called evidence about how to treat diseases, but we can't get it into practice because we have paid too little attention to how human beings use information and knowledge to alter behaviour. We're just starting to scratch that surface in Australia." Flinders University of South Australia Medical school established: 1974 Course: Graduate entry, 4 years 1998 intake: 58 Australian, 25 overseas fee-paying (mostly US nationals or graduates from the US college system) Outstanding graduates: Steve Wesselingh (new Professor of Microbiology at the Alfred Hospital, Victoria), Chris Baggoley ("first" graduate of Flinders medical school; President of Australasian College for Emergency Medicine), Brendan Nelson (Federal MP and former President Federal AMA) Lindon Wing Position: Dean, School of Medicine Graduated: Sydney medical school (1967) This time last year: Professor of Clinical Pharmacology, Flinders University, and Director of Clinical Pharmacology, Flinders Medical Centre Books and discs for a desert island: Complete works of Shakespeare; Chopin's and Beethoven's piano sonatas Books with most impact in past year: The god of small things by Arundhati Roy; Fugitive pieces by Anne Michaels, Captain Corelli's mandolin by Louis de Bernières Investment in information technology (IT) was another high priority to facilitate decentralisation of teaching. Larkins saw a need for "proper academic teaching and research departments at dispersed sites, properly linked by IT to the central site. With the ultraspecialisation of central teaching hospitals and the shorter bedstays in those hospitals, a huge challenge is the disjunction between where we have our clinical academic departments and where we need to teach. We need to develop significant academic departments at decentralised sites, with research concentrating on clinical and population health and with really effective IT communication." Frewin mentioned the importance of "a state-of-the-art network and intranet facility to deliver the curriculum and for use in hospitals." In Tasmania, Carmichael would also like to "upgrade our information technology network, with access to the Internet, videoconferencing facilities and links to the State Telehealth network at all our teaching sites, which are widely dispersed around the State." Almost all Deans felt staff were a priority, with several mentioning the need for more staff development, appropriate remuneration for academics (academic salaries may be considerably lower than salaries in teaching hospitals), rewards for teaching merit and "a good holiday because it's very hard at the moment" (Saunders). For Landau, staff were the highest priority: "I would get more good people and pay them better to teach. Technology is good and we can use it, but individuals are still the most important resource. I would try to provide the best teachers, clinicians and scientists to be role models for students. You need a mixture of people in your faculty -- those good at teaching, the charismatic, the good researchers and the good clinicians." The special difficulties of the smaller, newer medical schools were apparent. Wing told us that "One of the problems about being a new school at a young university is that we don't have good endowment money, so we don't have any reserve pots to dip into. I would love a development pot so that we can actually kick off our own initiatives and not chase every government grant." Carmichael would like to "better equip his staff, including the clinical teachers, in the new educational methods -- problem-based and self-directed learning -- and developing new curricula, and give them more time for research." Conclusion Twenty-five years ago, there were the traditional medical schools and then there were Newcastle and Flinders. Now the medical schools are enormously diverse, in their entrants, length and structure of curricula and the range of opportunities for clinical exposure. Programs have changed to meet the evolving needs of society and, if the Deans of today have their way, many more changes are to come. Authors' details Medical Journal of Australia, Sydney, NSW. Kerrie A Lawson, PhD, Copy Editor; Ruth M Armstrong, BMed, Editorial Registrar; Martin B Van Der Weyden, MD, FRACP, Editor. No reprints will be available from the authors. Correspondence: Dr K A Lawson, Medical Journal of Australia, Private Bag 901, North Sydney, 2059. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Kerrie A Lawson · Ruth M Armstrong

Photo Essay Practising dermatology in the South Pacific Two dermatologists describe their working visits to Samoa and Vanuatu Anthony D White and Ross StC Barnetson MJA 1998; 169: 659-662 Introduction - Diagnoses - Teaching - Problems - Discussion - Acknowledgements - References - Authors' details - - More articles on Dermatology Introduction In 1996 and 1997, we conducted a series of dermatology clinics in Samoa and Vanuatu -- countries which lack resident dermatologists -- under the aegis of the Pacific Islands Project. This three-year project was an undertaking of the Australian Agency for International Development (AusAID) to increase tertiary health service capacities in Pacific Island countries with a shortage of trained specialists. The project was implemented by the Royal Australasian College of Surgeons and covered, in addition to dermatology, anaesthesiology, general medicine, neurology/neurosurgery, ophthalmology, orthopaedic surgery, otolaryngology, paediatric surgery, plastic and reconstructive surgery and radiology. Major aims were to educate local health workers and to use inexpensive treatments which would be available long-term in the country. We describe our experience during four separate two-week visits to Samoa and Vanuatu in 1996 and 1997, and our resulting recommendations. Diagnoses We saw 1072 patients at clinics in local hospitals in Apia and Savaii in Samoa (765 patients), and in Port Vila, Espiritu Santo and Tanna in Vanuatu (307 patients). The clinics were advertised on local radio, and there was prior liaison with hospital doctors. Patients were therefore probably those with severe skin diseases, who were able to travel to the clinics. Diagnoses are shown in the Box. The vast majority of patients had common skin conditions, often in severe or extensive forms, rather than rare, exotic diseases. Fungal infection: This was the most common condition, affecting almost 40% of patients. Tinea (ringworm) was found in a quarter of patients and was often extensive, involving up to 20% of the body surface (Figure 1). Tinea (pityriasis) versicolor, caused by the yeast Malassezia furfur, affected a further 13% of patients (Figure 2), while some patients had both types of infection (Figure 3). The main contributing factors to the prevalence and extent of fungal infections appeared to be the hot, humid climate, occlusive clothing and inadequate treatment. There is a culturally determined tendency to wear multiple layers of clothing, particularly in Samoa. Antifungal drugs, even when available, were often out of patient reach because of cost. Dermatitis: 21% of patients had contact, atopic or seborrhoeic dermatitis. A predisposing factor is the tendency, despite the high ambient humidity, for Polynesian and Melanesian skins to be dry. Among Samoans, this dryness is often aggravated by overuse of soap and water and the practice of scrubbing the skin with a ball of plant fibre. Photosensitivity dermatitis was seen in six patients, all of whom had used a soap containing trichlorocarbanilide, an antiseptic known to cause a photosensitive rash. Scabies: Each year all Samoans over the age of 12 months are treated with oral diethylcarbamazine as part of a national filariasis eradication campaign. In 1997, ivermectin was added to the regimen. This drug is also active against scabies, and during the clinic visit a month after the campaign many patients were seen with the stigmata of resolving scabies. The few patients with active scabies were infants (who are excluded from the drug program) and an adult who had refused treatment. Pigmentary disorders: These included melasma, vitiligo, postinflammatory hyperpigmentation and pityriasis alba. Striking depigmentation was also the presenting symptom in two patients with chronic discoid lupus erythematosus (Figure 4). Pigmentary disorders are a greater cosmetic problem in dark-skinned than in white-skinned people, because of the greater contrast between affected and unaffected skin. Other skin disorders: Acne was surprisingly infrequent in both countries, while psoriasis was common (Figure 5). Other notable conditions which affected small numbers of patients included epidermolytic hyperkeratosis, leprosy, and lichen amyloidosis (Figures 6-8). One skin cancer was seen, in a 60-year-old Vanuatu Melanesian man. It presented as an eroded 8 cm plaque on the shoulder; biopsy showed it to be basal cell carcinoma, a condition never previously encountered by local physicians on black skin. Teaching Every opportunity was taken to discuss diagnosis and management of skin disease with interested local health workers, using clinic patients as subjects. During one visit to Samoa, one of us (R StC B) was accompanied by an indigenous physician, providing an opportunity to discuss local dermatological problems and solutions. This was not possible during other visits because of the shortage of available medical personnel. Four lectures on skin diseases were given to hospital staff. Problems The main clinical difficulties we encountered were poor conditions for examination, lack of diagnostic facilities and inadequate pharmaceutical supplies. Skin specimens were returned to Australia for histopathological examination or fungal culture, as neither Samoa nor Vanuatu had facilities for these procedures. Discussion and recommendations The spectrum of infectious skin diseases encountered in Samoa and Vanuatu was similar to that seen in Australian clinics,3 although these diseases tended to have a more severe and extensive course. In contrast, skin cancer and precancer were virtually absent. Few diseases were exotic or "tropical". Inadequate treatment because of the lack of availability or high cost of antifungal drugs was probably a contributing factor to the severity of fungal infections. Topical antifungal creams were available in impracticably small volumes. For example, clotrimazole must be applied for four weeks, but the standard 20 g tube is sufficient to treat extensive disease for only a day. The standard oral fungistatic drug, griseofulvin, needs to be taken for four weeks, but is usually prescribed in Samoa and Vanuatu for only seven days. An alternative treatment, oral terbinafine, is fungicidal and may be adequate in a seven-day course.4 The manufacturer of terbinafine, Novartis, has been approached officially to provide this drug as a humanitarian service to these countries. Inadequate treatment probably also contributed to the prevalence and extent of dermatitis. Topical steroids were available, in both countries, but only in 15 g tubes (30 g of cream/ointment is needed for one total body application). Scabies was common. It requires community-based rather than individual treatment, as repeated re-infestation occurs from untreated individuals. In Samoa, it should now be possible to capitalise on the fortuitous scabicidal effect of ivermectin (used in the filariasis eradication campaign), which is an ideal treatment in populations with high endemic rates of infestation.5 However, this needs to be backed up by topical antiscabetic treatment for those who are ineligible for ivermectin or who become re-infested. Unfortunately, no topical antiscabetic agents were available in Samoa at the time of the 1997 campaign, and an opportunity to eradicate scabies was lost. Although leprosy is endemic in Samoa and Vanuatu, only one new case was seen. This condition is well managed by the World Health Organization, which undertakes treatment, contact tracing and follow-up. Public education about preventing skin disease could be beneficial. It should define simple hygiene but explain that excessive washing, scrubbing of the skin and use of germicidal soaps, although customary, are unnecessary and often injurious. In addition, occlusive clothing is inappropriate for a hot, humid climate and encourages skin disease, particularly fungal infection. Effort is also needed to overcome the enormous stigma attached to skin disease, which delays or prevents presentation and increases individual suffering and the prevalence of infectious disease in the community. With adequate resources, most of the conditions we saw are treatable and many are preventable. Because half a dozen diseases account for two-thirds of patients presenting, it should be possible to educate primary carers to diagnose and treat most cases. We are currently preparing an illustrated booklet describing the clinical features, prevention and treatment of the main diseases. However, the need for affordable, effective treatments remains. The dermatological contribution to the Pacific Islands Project was valuable in defining the main problems, formulating solutions, educating local health workers and providing treatment in two of Australia's less-developed neighbours. We hope that the program will continue and expand to assist other countries in the area. Acknowledgements We are very grateful to Associate Professor Steven Kossard (Skin Cancer Foundation, Sydney, NSW) and Dr Andrew Gal (Sydney, NSW) for histopathological examinations, to pharmaceutical companies for generous donation of drugs, and to the Department of Microbiology, Royal Prince Alfred Hospital, for fungal cultures. We also thank our patients for allowing publication of their photographs. References Manzano-Gayosso P, Mendez-Tovar LJ, Hernandez-Hernandez F, et al. Dermatophytoses in Mexico City. Mycoses 1994; 37: 49-52. Khosravi AR, Aghamirian MR, Mahmoudi M. Dermatophytoses in Iran. Mycoses 1994; 37: 43-48. Kilkenny MF, Marks R. The frequency and nature of skin conditions seen in a private dermatology practice in central Victoria. Aust J Dermatol 1996; 37: S50-S53. Barnetson R StC, Marley J, Bullen M, et al. Comparison of one week of oral terbinafine (250 mg/day) with four weeks of treatment with clotrimazole 1% cream in interdigital tinea pedis. Br J Dermatol 1998; 139: 675-678. Meinking TL, Taplin D, Hermida JL, et al. The treatment of scabies with ivermectin. N Engl J Med 1995; 333: 26-30. (Received 22 Jul, accepted 7 Oct, 1998) Authors' details Department of Dermatology, Royal Prince Alfred Hospital, Sydney, NSW. Anthony D White, FRACP, FACD, Consultant Dermatologist; Ross StC Barnetson, MD, FRACP, FACD, Head of Department, and Professor of Dermatology, Sydney University, Sydney, NSW. Reprints will not be available from the authors. Correspondence: Professor R StC Barnetson, Department of Dermatology, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050. Email: rossATcanc.rpa.cs.nsw.gov.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Anthony D White

History Arterial disease in antiquity The study of papyrus writings and of mummified human remains provides an insight into the diseases and the practice of medicine in ancient times. Paleopathology, developed in the latter part of the last century and now incorporating modern technology and diagnostic techniques, has shown that arterial disease was not uncommon and that the arterial lesions of 3000 years ago were no different from those we see today. Reginald Magee MJA 1998; 169: 663-666 Introduction - Ancient Egypt - Vascular disease - Conclusions - References - Authors' details - - More articles on History Introduction In today's society there is a general awareness of arterial disease and its consequences. People know about coronary occlusions and strokes, and cholesterol has become a household word. In the press there are articles, almost daily, about diets, vitamins, forms of alternative medicine, the dangers of smoking and the advantages and disadvantages of consuming alcohol. Healthfood shops abound. The stresses of modern living have been implicated in arterial disease. While once senior executives worried about developing ulcers, now the concern is about coronary vessels and blood cholesterol. While we cannot be certain that the stresses we are subject to in our time are any greater than the stresses on primitive peoples and those who belonged to ancient civilisations, we do know they are different. Thus, in a context of different stresses, different lifestyles and different diet, it may be interesting to examine the occurrence of arterial disease in the past. Human remains in many countries have been examined by scientists, but those from ancient Egypt have probably been examined in the greatest detail. This article presents an overview of these studies in relation to arterial disease. Ancient Egypt In the 19th century there was an increasing interest in the ancient history of Egypt. Studies of ancient Egyptian writings, such as the Papyrus Ebers and Papyrus Edwin Smith (well known works on medical conditions and their treatment, written between 1500 BC and 2000 BC), and drawings and statues showing malformed people (Figure 1) have taught us much about disease and the practice of medicine in that civilisation. However, more direct information about diseases was obtained by the careful examination of skeletons and preserved tissue from unwrapped mummies. The unwrapping (or "unrolling", as it was often referred to) of mummies became a fashionable occupation in the last century. A number of mummies were investigated in 1834 by Thomas Pettigrew (surgeon to the Duke of Kent, whose chief claim to fame was that he vaccinated Queen Victoria). His efforts, however, made little contribution to the knowledge of disease in ancient Egypt as his unrollings were done rather hastily and the examinations were relatively superficial. It was in the latter part of the last century and the early part of this century that interest in the study of mummified tissue was regenerated with the development of paleopathology. This science was defined by Sir Marc Armand Ruffer, Professor of Bacteriology at Cairo Medical School, as "the science of diseases which can be demonstrated in human and animal remains of ancient tissues."1,2 Other notable workers in the field included Elliot Smith (Australian anatomist and anthropologist), Wood Jones (English-born professor of anatomy in Australia and Manchester), and the Egyptologist Margaret Alice Murray. Figure 1: Egyptian statue from the Old Kingdom (2686-2181BC of a person with exophthalmos. Embalming and mummification Ancient Egyptians believed that it was necessary to maintain the corpse in as lifelike a condition as possible, as the departed spirit would eventually return to the body. Thus, embalming was considered important and embalmers held some status within society. Today, we can preserve bodies by injecting fluid into the blood vessels, deep freezing and freeze drying. As these methods were not available to the embalmers of ancient Egypt, others had to be employed. The overwhelming evidence is that natron, a naturally occurring substance consisting mainly of sodium carbonate and sodium bicarbonate, was the main agent used. Three embalming methods (varying in thoroughness and in price1,3) are described in the writings of Herodotus (5th century BC) and Diodorus Siculus (1st century BC). These methods are summarised in Box 1. The study of mummies showed that embalming did not facilitate the opportunity for anatomical examination as the organs were removed roughly through a relatively small incision. 1: Embalming methods, in order of thoroughness and price, described in the writings of Herodotus (5th century BC) and Diodorus Siculus (1st century BC)The most expensive method involved physical removal of the internal organs (the brain by an iron hook passed up through the nose and the intestines and thoracic contents through a cut in the left flank, although the heart was often left as it was considered to be the seat of the mind), which were stored in Canopic jars and later may have been wrapped and returned to the body cavity. This was followed by cleansing of the cavities with palm wine and powdered aromatics, and filling of the body with myrrh, cassia and spices to add fragrance. The incision was either left, covered with a plate or occasionally sewn up. Muscles were removed through multiple small incisions and then the body was covered in natron for 70 days, then washed, wrapped in linen bandages and smeared with gum. Finally, it was returned to the relatives, placed in a case and kept in a sepulchral chamber. The next-most-expensive method was to fill the body cavity with cedar oil injected through the rectum and to cover it with natron for 70 days. On the last day the oil (which liquefies the inner parts) would be allowed to escape, leaving only skin and bone. The body would then be returned to the family. The cheapest method was simply to wash the body with a salt solution, embalm it with natron for the usual period and return it to the family for burial. Any extra filling required for the cleared body cavities was done with rags, sawdust or mud. Vascular disease Aortic calcification in two Egyptian mummies was first described by Czernak in 1852.4 The Australian Elliot Smith described tortuous calcareous temporal arteries in the mummy of Pharaoh Rameses II (XIX Dynasty, reigning 1279-1213 BC), and extreme calcareous degeneration, with the formation of large bone-like plaques, in the aorta of Pharaoh Mernephtah (XIX Dynasty). A sample of this aorta was sent to the curator of the museum at the Royal College of Surgeons, who made sections from it which he showed at a meeting of the Royal Society of Medicine in 1909.5Ruffer2,6 developed a method for preparation of the tissue sampled from mummies and examined a number of specimens from the XVIII to the XXVII dynasties (1580 BC - AD 527). In his article on arterial lesions, he commented on the extensive mutilation during the embalming process, when all of the viscera and most of the muscles were removed, so that it was only by accident that the whole or portion of the aorta or one of the large arteries was left behind.2 Thus, it was only the peroneal artery (and occasionally the arteries of an untouched arm or leg, remaining when the embalmers had not done their work properly) that was usually available for examination.2 He produced and published drawings of the gross and microscopic appearances of the specimens, some examples of which are shown in Box 2. 2: Coloured illustrations reproduced from Ruffer2 a. Pelvic and thigh arteries completely calcified. b. Calcified patches in an aorta. c. Calcified atheromatous lesion in a subclavian artery. d. Section through an almost completely calcified peroneal artery (van Gieson stain). * Remnants of endothelium and fenestrated membrane; † Calcified patches In 1972, Rosalie David, Keeper of Egyptology at the Manchester Museum, revived interest in the subject and involved many other scientific specialists in a study which became known as the Manchester Mummy Project.7 A range of multidisciplinary techniques were used in the examination of mummies, including radiology, computed tomography and magnetic resonance imaging, histological examination, electron microscopy, carbon dating, serological tests, DNA studies, fingerprinting, dental studies and scientific facial reconstruction. The team also pioneered the use of virtually non-destructive techniques, such as endoscopy, to obtain tissue samples. A mummy tissue bank has now been established at Manchester University's School of Biological Sciences to store samples from Egyptian mummies held in collections worldwide. In 1975, Aidan Cockburn and co-workers published the findings of an autopsy on the mummy known as Pum II (Pennsylvania University Museum mummy number II).8 The wrappings, resins and tissues were all examined in great detail. The aorta was found to contain large and small atheromatous plaques, and other vessels in organs returned to the body cavity in visceral packages showed some intimal fibrous thickening consistent with arteriolar sclerosis.8 Paleopathological studies of the vascular system of human remains preserved outside Egypt include those by Chinese pathologists examining the Mawangtui mummy, which was dated about 1120 BC.9 This was a mummy of a 50-year-old woman which had been immersed in a solution containing mercury salts, and sealed hermetically so that the fluid was still present. The arteries of this mummy, in particular the coronary arteries, showed atheromatous plaques and arteriosclerotic changes. Further, Zimmerman examined naturally frozen Alaskan mummies, the oldest of which (dated about AD 400) was of a 53-year-old Inuit woman who had moderate aortic and coronary atherosclerosis.10 More recently, the discovery of the body of a man estimated to be about 5000 years old near the Austrian-Italian border -- the "Ice Man" -- has become the subject of a book which describes the condition of the hair, skin and teeth.11 Although radiological studies have been done, macroscopic or microscopic studies of the internal organs have not yet been reported. There has been no study of arterial disease in Australian Aboriginal remains. This is, firstly, because their burial rites (which varied, but included often more than one of interment, mummification, cremation, platform exposure, delayed burial and burial in hollow trees) would have left little soft tissue for examination and, secondly, because of cultural sensitivities. It would, of course, be interesting to know to what extent arterial disease affected such an isolated and distinct race whose diet was simple, but characterised by indulgence at times of seasonal abundance.12 Unfortunately, paleopathological studies of Aboriginals have been limited to the study of skeletal remains which showed evidence of osteoarthritis, osteomyelitis and metastatic malignancy.13 Investigation of vascular disease Radiological examination of the mummies examined by the various pathologists showed calcification of the aorta, femoral and carotid arteries.7,8,10 High resolution computed tomography of the head of the Ice Man,11 whose estimated age was 35-40 years, showed "slight hardening of the arteries", presumably some calcification seen in the walls of the vessels, at the base of the brain. Macroscopic examination of mummies showed evidence of calcification of the arterial wall, which varied from isolated spots to bone-like plaques to rigid calcified tubes which would break when dissected out.2,6-9 Ruffer illustrated a specimen of subclavian artery which showed almost complete obstruction at its origin by thick calcified plaque. He also described arteries which appeared to be thickened and fibrous, rather like whipcord, but not calcified.2 Microscopic examination showed appearances of arteriosclerosis, atheroma, lipid deposition and medial calcification. Degeneration of the muscle coat and replacement by fibrous tissue was present in some specimens, and spots of calcification could also be seen.2,6-8,10 The elastic tissue could be easily demonstrated with such stains as phosphotungstic acid-haematoxylin and Heidenhain's iron haematoxylin, and among the degenerative changes seen was reduplication of the internal elastic lamina. Lipid could be demonstrated in plaque with such stains as Sudan 3 and 4 and Sudan black. Atheromatous lesions in mummy arteries have sometimes shown sectorial clefts, giving the impression of dissecting aneurysm.14 Figure 2: Section of a popliteal artery from a Ptolemaic mummy which shows that good tissue definition can be obtained, and that the intima media and adjacent fat are distinguishable, although intracellular details are not. Collagen and elastic tissues are the best preserved (courtesy of J T Rowling). Documented evidence of aneurysm Degenerative changes have been found in the aorta, coronary and peripheral arteries, but aneurysm has not been reported, probably because of the efficiency of the embalmers. However, Ghalioungui15 noted a description of aneurysm in the peripheral arteries in the Papyrus Ebers: "...a swelling of vessels ... it is hemispherical and grows under thy fingers at every going [ie, it pulsates], but if separated from his body it cannot become big and not come out [ie, diminish] ... it is a swelling of a vessel ... and it arises from injury to a vessel." (Eb 872) A cirsoid aneurysm (and the magic used to treat it) was also described: "...its appearance in growing on account of serpentining of the serpentry and they have formed many knots ... it is a swelling of vessels. Thou shalt not put thy hand to such a thing ... what is spoken is its effective spell 'flow out thy vessel ... that jumps in the midst of these limbs'." (Eb 873) It would appear that the lesions seen in the ancient Egyptians were no different from those we see at the present time in vascular surgery and morbid histology. Rowling, in his presentation to the Royal Society of Medicine in 1961,16 cited the mortuary inscription of Weshptah, the Architect, Vizier and Chief Justice of Pharaoh Neferirkere (2494-2345 BC), which suggested that he died of a cerebral haemorrhage. He also said that in the Papyrus Ebers there was reference to hemiplegia, and another to an association between disease of the vessels of the thigh and foot conditions which may have been gangrene. Rowling considered that it may have been fortuitous that the ancient Egyptians made this association. However, to read into this ancient text that disease of the vessels of the thigh was associated with gangrene would seem highly conjectural. Conclusions In his writings on Egyptian mummies, Ruffer speculated on the causes of vascular disease.2 He eliminated tobacco and syphilis, as neither was known in ancient Egypt. Although the Egyptians consumed both beer and wine, and did get drunk, as shown in ancient artworks, Ruffer's contemporary experience of over 800 autopsies in Muslim abstainers indicated to him that alcohol was not the cause of arterial disease. He considered meat consumption as a factor, but, while admitting that mummies represented the wealthier classes who may have eaten more meat than others, emphasised that the diet was mainly vegetable and, judging from dental wear, rather coarse. Ruffer also dismissed the stress of everyday life, as he did not consider the life of the ancient Egyptians to be any more arduous than at the time of his writing. His conclusion was that the causes of the degenerative disease were just as obscure in ancient times as they are now.2Disease has always been a part of life. Evidence of it has been found in the remains of reptiles of the Permian period through to the time when ancient human civilisations began to record it. It is clear that atherosclerosis is an ancient process, and its pattern has always been the same regardless of race, diet and the stresses of survival. However, in these days, modern man in may some ways encourage atherosclerosis by smoking and consuming foods with a high fat content. References Sigerist HE. Primitive and archaic medicine. Oxford: Oxford University Press, 1967. Ruffer MA. On arterial lesions found in Egyptian mummies. J Pathol Bacteriol 1911; 15: 453-462. Garner R. Experimental mummification. In: David AR, editor. Manchester mummy project 1979. Manchester: Manchester University Press, 1979. Sandison AT. Degenerative vascular disease in the Egyptian mummy. Med History 1962; 6: 77-81. Shattock SG. Microscopic sections of the aorta of King Mernephtah. Lancet 1909; 1: 319. Ruffer MA. Remarks on the histology and pathological anatomy of Egyptian mummies. Cairo Scientific J 1910; 4: 3-7. David AR, editor. Manchester mummy project 1979. Manchester: Manchester University Press, 1979. Cockburn A, Barraco RA, Reyman TA, Peck WH. Autopsy of an Egyptian mummy. Science 1975; 187: 1155-1160. Cockburn A. Miscellaneous mummies. In: Cockburn A, Cockburn E, editors. Mummies, disease and ancient cultures. Cambridge: Cambridge University Press, 1980. Zimmerman MR. The paleopathology of the cardiovascular system. Texas Heart Inst J 1993; 20: 252-257. Spindler K. The man in the ice. Guernsey, Channel Islands: Guernsey Press, 1995. Mulvaney DJ. The prehistory of Australia. Melbourne: Pelican Books, 1975. Webb SG. Paleopathology of Aboriginal Australians. Melbourne: Cambridge University Press, 1955. Sandison AT. Diseases in ancient Egypt. In: Cockburn A, Cockburn E, editors. Mummies, disease and ancient cultures. Cambridge: Cambridge University Press, 1980. Ghalioungui P. Medicine in ancient Egypt. In: Harris JE, Wente EF, editors. An x-ray atlas of the royal mummies. Chicago: University of Chicago Press, 1980. Rowling JT. Pathological changes in mummies. Proc Roy Soc Med 1961; 54: 409-415. Authors' details Princess Alexandra Hospital, Brisbane, QLD. Reginald Magee, FACS, FRACS, Senior Visiting Vascular Surgeon. Reprints: Dr H R Magee, "Alexandra", 201 Wickham Terrace, Brisbane, QLD 4000. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Reginald Magee

Snapshot! Occupational hazard for Father Christmas No, this is not the dejected figure of Santa on Christmas morn, awaiting the tender ministrations of Mrs Claus after a run-in with a reindeer on ritalin. Reindeer have large, wide hooves, while the cloven-hoofed beast behind these injuries, the fallow deer, is smaller, with sharp, small hooves. Figure A shows the back of a farmer who was trampled by a fallow deer and Figure B shows the hooves of the deer. The deer assures us that the whole thing was an accident. David J Williams Professor and State Pathologist Brisbane, QLD Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

David J Williams

Snapshot! Peau d'orange or Fruit of the vine With the current trend for body-piercing, this photograph, published in the October 1991 issue of the Botobolar Bugle, could be mistaken for a close-up of a punk rocker on a cold day. In fact, it was presented at a clinical meeting with the question, "Is this a known breast disease?". To a doctor the picture may resemble peau d'orange, but to the winemakers of Mudgee, NSW, it's a bird's-eye view of Botobolar organic shiraz fermenting in a Potter fermenter. Kevin B Orr General Surgeon, Kogarah, NSW Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Kevin B Orr

Snapshot! Carpenter's backache This gentleman presented to the emergency department for the second time in two months complaining of backache. The obvious foreign body was considered by the treating resident to be an "in the pocket" artifact and was thus discarded as an irrelevant finding. When I pointed out that it was actually a 10cm nail, located in the soft tissue above the right sacroiliac joint, the case was reviewed, but neither the patient nor his records could proffer any logical explanation (the patient's theory was that it must have been in his milk). As the patient had no signs or symptoms of sepsis or a pelvic abscess, it had probably been in that position for some time. The moral of the story? Sometimes it really is the x-ray findings that nail the case! Barnabus Bako Radiology Registrar The New Children's Hospital, Westmead, NSW Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Barnabus Bako

Snapshot! "Unto us is born a son..." So sings the carol; however, the long-held alternative view that children are brought by the stork may have some credence. Umbilical artery doppler from a third-trimester obstetric ultrasound shows a definite avian form perched next to the entwined vessels of the cord. Despite an eagle-eyed search of the amniotic cavity no other birds (nor any bees) were found. The stork's beak is empty, consistent with a developing intrauterine gestation. Indeed, not long afterwards the mother delivered a baby boy. David J E Lord Radiology Registrar Royal Prince Alfred Hospital, Sydney, NSW Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Snapshot! Got to cut those nails This patient attended the emergency department after a construction site accident in which a nail gun accidentally discharged into his left index finger. Could it be that there was some misunderstanding about the meaning of the word "nail" in nail-gun? Malcolm Thomson Consultant Paediatricians, Taranaki Base Hospital New Plymouth, New Zealand Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Malcolm Thomson

Snapshot! Drama in a Belfast bistro A young girl was lunching with a friend in a Belfast bistro when two teenage Irish terrorists came in with a gun and a large box, from which a fuse protruded. While one of them held the patrons at gunpoint, the other placed the bomb in the middle of the restaurant, felt in his pockets and, in the ultimate example of an Irish joke, had to borrow a box of matches from one of the terrified patrons. He lit the fuse and decamped -- the bomb went off prematurely, injuring or killing some of the people inside. Figure 1 shows the condition in which the girl presented to the hospital emergency department. The chair leg was extracted and I subsequently repaired the scars on what was, in fact, a minimally damaged leg (Figure 2). Cholm W Williams Plastic Surgeon Hornsby, NSW Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Cholm W Williams

Book Review Art brut The Cunningham Dax Collection: selected works of psychiatric art. Eric Cunningham Dax. Melbourne, Australia: Melbourne University Press 1998 (102 pp., $24.95). ISBN: 0 522 84768 4. For about half a century, the eminent Australian-based psychiatrist Eric Cunningham Dax AO has nurtured a collection of upward of nine thousand items of psychiatric art -- paintings, statues and embroideries executed by patients in the course of their treatment. The collection, currently housed in Melbourne, is one of only a handful in the world that classify items according to the patient's diagnosis for teaching, treatment and research purposes. Thanks to the sponsorship of the Gordon Darling Foundation, part of the collection is now accessible at all times and in all places via an inexpensive softcover volume of colour photographs of about 100 selected works, with succinct expert commentary and interpretation by Dax. A man feeling he is in hell tries to save himself by grasping at the roots of a tree, which he fails to reach. The artist killed himself a short time later. The three cardinal signs of a maniacal illness are elation, overactivity and a flight of ideas. This picture is unusual because a person who is acutely disturbed in this way rarely has the time or patience to complete a work. Here there are bright colours, many related ideas and symbols, an explosive jack-in-the-box and great activity. Ann Gregory Assistant Editor, MJA Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Ann Gregory

Christmas Competition Ideas and images The remarkably high quality and immense volume of the entries received this year made the Christmas competition's result somewhat of a cliffhanger. How were we to choose a clear winner from the eclectic collection of bizarre images, quirky stories and eccentric research that graced our noticeboard for one glorious week and will enliven the journal at Christmas and for several issues to come? Despite much jostling for position at the ballot box, a fair vote was conducted and winners emerged from the 17 finalists. Merlin Thomas, Brett Lyons and Robert Walker have narrowly defeated the reigning champion with a thoughtful exposition of their original research The John Thomas sign: common distraction or useful pointer. This is the kind of ground-breaking material we have come to expect from our trans-Tasman neighbours and we are most grateful that it reached us via an overseas journal to be published in its rightful antipodean place. Christmas drinks in the form of two bottles of fine Australian champagne are on us. Speaking of the reigning champ, second prize goes to Douglas Gow's equally phallocentric tale of life as a medical officer serving in Her Majesty's Royal Air Force in the 1970s, in the Arabian Gulf: A case of Mediterranean date louse in aircrew. Dr Gow wins a prize he will treasure enthusiastically but briefly -- a bottle of Jameson's Irish whisky. Last but not least, our panel of expert judges has awarded third prize to John Rusli for his whimsical reporting of a cerebral CT scan as "Batman". We can only hope that Robin and the batmobile are not spotted on any scans performed at Royal Prince Alfred Hospital over the festive season as Dr Rusli enjoys his bottle of champagne! Many thanks to all our contributors. For those of you who held back your witty observations, perverse research and surprising pictures this year there is always Christmas '99. Keep us in mind when you feel inspired to exercise your long-suppressed creative side. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Letter Removing rectal foreign bodies: is the ventouse gender specific? MJA 1998; 169: 670-671 To the Editor: A man presented in an Australian provincial town with a foreign body in his rectum that would not pass. He stated that he thought it was a bottle top. Arrangements were made for the resident surgeon to retrieve the object by sigmoidoscopy under general anaesthesia. After an uneventful induction of anaesthesia, the surgeon proceeded to try to remove the "bottle top". However, it was soon obvious to him that he was not looking at a bottle top, but rather at the bottom of a glass bottle approximately 5 cm in diameter. Attempts to remove it with fingers, assisted by abdominal pressure, very similar to bimanual pelvic examination of the female pelvis, were unsuccessful. The surgeon was considering proceeding to laparotomy, with the aim of pushing the bottle up into the sigmoid colon and then opening the abdomen and retrieving it. However, the general practitioner anaesthetist, also trained in advanced obstetrics, suggested the possible use of the ventouse. The surgeon agreed, but, having no experience in the use of the ventouse, invited the GP to perform the procedure. The management of the anaesthesia was handed over. A small disposable plastic ventouse cup (Mityvac 0044M) was gently inserted through the already lax anus and manipulated onto the bottle. The rim was checked for trapped rectal mucosa. After three attempts to seal, suction was successfully applied. The rim was then checked again for mucosa and gentle traction applied. The bottle descended easily and delivered per rectum with no obvious trauma to the anus. The surgeon then checked for mucosal tears by sigmoidoscopy. There were none, and the patient was discharged the following day. I describe this case to illustrate two points. Firstly, that general surgeons may find a use for, and possibly adapt, the well-tried ventouse cup for delivery of foreign bodies per rectum. It would be advisable to have some obstetric training to learn how to avoid the dangers of mucosal entrapment. The advantages of the suction cup are that it will mould to the object and that it doesn't increase the diameter of the foreign body. Secondly, that the multiskilled rural GP still has a place in medicine, and can occasionally bring expertise from one area to another to benefit the patient. Richard P G Mackinnon Rural General Practitioner, Crystal Brook, SA 5523 Email: rmackinnATpirie.mtx.net.au Comment: The above tale of clinical cunning is an excellent illustration of the need for lateral thinking in certain situations. The particular clinical problem described has been with us for some time and is seen all over the world. It is relatively common, and requires a sensitive, meticulous and skilfully taken history, a professional physical examination, and diagnostic imaging (usually x-rays, occasionally ultrasound or computed tomography) before a careful plan based on knowledge and experience is formulated. However, a marked degree of modification or even innovation, depending on the particular object to be removed and the clinical circumstances, is often used. Not infrequently, careful trial and error (and luck) are factors in the outcome. A quick scan of the literature confirms the diverse and international nature of the problem and of its solutions. A German report tells of an apple wrapped in cellophane, unable to be retrieved until coagulated intermittently by argon laser. The Indian gastroenterology journal tell us of screwing out carrots, removing needles and whisky bottles.1 A series from Athens reports success with obstetric forceps in 40% of cases, while highlighting the importance of negating the proximal vacuum suction effect caused by traction on the foreign body, especially smooth, round ones like bottles (see Figure 1). This is commonly done by gently passing a well-lubricated Foley-type urinary catheter up past the object to break the air seal.2 An overview of cases from California and London reminds us that, although foreign bodies can be removed in the emergency department in about two out of three cases, some 10% still require a laparotomy and a diverting colostomy to remove the object or to treat bowel perforation. Only one case report (which claimed to be a world's first) described the use of an obstetric vacuum extractor.3 As in the case described above, this report also emphasised the practical issues of ensuring that no mucosa is trapped and the need for follow-up sigmoidoscopy to check for mucosal damage or perforation. The case described above also illustrates the element of surprise when what we are led to expect from the history is nothing like what we really have to deal with (see Figures 2 and 3). As 80% of these events occur for sexual stimulation and 10% involve sexual assault,4 it is understandable that there may be an initial reluctance to tell the truth. At all times, before and after the extraction, extra effort must be made by all staff to show a confidential, sensitive and caring attitude to a patient who is deeply embarrassed and often in great discomfort. Gordian Fulde Director, Emergency Department, St Vincent's Hospital Victoria Street, Darlinghurst, NSW 2010 Vashist MG, Arora AL, Salil. Screwing a carrot out of the rectum [letter]. Ind J Gastroenterol 1997; 16: 120. Kouraklis G, Misiakos E, Dovas N, et al. Management of foreign bodies of the rectum: report of 21 cases. J Roy Coll Surg Edin 1997; 42: 246-247. Johnson SO, Hartranft TH. Nonsurgical removal of a rectal foreign body using a vacuum extractor. Report of a case. Dis Colon Rectum 1996; 39: 935-937. Cohen JS, Sackier JM. Management of colorectal foreign bodies. J Roy Coll Surg Edin 1996; 41: 312-315. Acknowledgment: Figures 2 and 3 were kindly provided by Dr T O'Connor, Colorectal Surgeon, St Vincent's Hospital, Sydney. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Letter John Thomas sign: common distraction or useful pointer? MJA 1998; 169: 670 To the Editor: Anthropomorphic studies of the penis have largely centred on comparisons of length and girth and have not always grasped the substance of a more important companion feature, namely direction. The "John Thomas" (JT) sign refers to the position of the penis in relation to unilateral disease on routine x-ray, with a positive sign being implied when inclined to the side of the disorder (eg, a fractured hip). Although readily recognised, it has attracted little scholarly attention, being confined to darkroom banter or to impressing humourless medical students. While some degree of prudishness may have been responsible for curbing potential applications of the JT sign in the past, we believe that the position of the penis now needs to be set straight. We identified 65 consecutive male patients with a fractured right hip and 65 with a fractured left hip. The penile position was graded as positive (illustrated in the Figure), negative or equivocal (part of the glans below the symphysis). The penile bent was similarly defined in a further 65 patients in whom fracture was suspected but not identified. The JT sign was positive (ie, the penis inclined toward the fracture) in 70% of patients with hip fracture (91/130), negative in 11% (14/130) and equivocal in 19% (25/130). Consequently, the sensitivity (70%; 95% CI, 62%-78%) and specificity (67%; 95% CI, 60%-75%) for the JT sign are low. The genital disposition did not correlate with length of stay (r = 0.14). Demonstration of the JT sign before x-ray may be as useful as demonstrating leg shortening and external rotation -- synonymous but in no way diagnostic. And, if all patients with suspected hip fractures are routinely x-rayed, the prognostic significance of the pointer is minimised. Nonetheless, while the clinical utility of the JT sign may be limited, it appears to be real and reproducible. Thirty-one per cent of patients (20/65) presenting with a hip injury without fracture inclined to the injured side. If at least half of x-rays for hip fracture confirm the diagnosis, the predictive value of a positive JT sign is over 69%. Similar eponymous signs, such as Homan's, are widely flaunted. By comparison, the JT has been underexposed. Genital asymmetry is common and varies with handedness,1 although most incline leftward. That equal proportions of right (46/65) and left (45/65) hip fractures had positive signs in our study would reinforce the belief that somatic sensations can override higher cerebral control. Recent data suggest that genital inclination may be related to, among other things, different patterns of cognitive function and certain malignancies.2 The findings in our study, like those of the recent United States Starr Report,3 point to at least one more discriminating relationship. Merlin C Thomas Senior Registrar and corresponding author Brett D Lyons Associate Professor, Department of Nephrology Robert J Walker Senior Registrar, Department of Radiology Dunedin Department of Medicine, Dunedin Clinical School of Medicine University of Otago, Dunedin, New Zealand Bogaert AE. Genital asymmetry in men. Human Reprod 1997; 12: 68-72. Chang RH, Hsu FK, Chan ST, et al. Scrotal asymmetry and handedness. J Anat 1960; 94: 543-548. Starr KW. Referral to the United States House of Representatives pursuant to Title 28, United States Code, ¤595(c). Submitted by the Office of the Independent Counsel, September 9, 1998. [Monica Lewinsky v. President Clinton]. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Merlin C Thomas · Brett D Lyons · Robert J Walker

Letter Faith healing or Russian roulette? MJA 1998; 169: 671 To the Editor: In response to the letter on faith healing in the Christmas 1997 issue of the Journal,1 it is extremely important to recognise that there is another side to the picture of the deliberately fraudulent "faith healer". In July 1976, in the company of another physician and two psychologists, I visited seven healers in the Philippines and collected 22 samples of "blood". All of the samples proved to be human blood. In 1977, one of those healers came to my clinic in the United States, and in the presence of four scientific observers, and with three cameras trained on the proceedings, performed "surgery" on two patients. The healer had no prior knowledge of these patients, who were local volunteers. Blood seemed to appear on the surface of the skin of both patients, although there was no opening of the body that I could see. I collected that blood, and took whole blood samples from both patients and the healer. The report from the laboratory is summarised in the Table. In each case, the blood that seemed to be removed from the patient was indeed that patient's blood type. The laboratory reported that the probability of choosing two random blood samples to match two people selected at random is 0.14. While I do not recommend that people rush off to the Philippines for treatment, what I observed was a very closely monitored scientific observation which I cannot explain. C Norman Shealy Director, The Shealy Institute, 1328 East Evergreen Street Springfield, MO 65803-4400, USA Roffey PE, Freney LC, Ansford AJ. Faith healing and Russian roulette [letter]. Med J Aust 1997; 167: 649. Make a comment Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>