Issues
Volume 170 Issue 4
Editorials The pneumococcus in the new millennium Joseph G McCormack (MJA 1999; 170: 147-148)Hospital in the home: take the evidence and run Michael Montalto (MJA 1999; 170: 148-149)Disability and work-related injury: time for a change? Allan R Molloy, Fiona M Blyth, Michael K Nicholas (MJA 1999; 170: 150-151)The Lundberg affair Martin B Van Der Weyden (MJA 1999; 170: 151) Research Rapidly emerging antimicrobial resistances in Streptococcus pneumoniae in Australia John D Turnidge, Jan M Bell, Peter J Collignon, on behalf of the Pneumococcal Study Group (MJA 1999; 170: 152-155)Apolipoprotein E polymorphism in indigenous Australians: allelic frequencies and relationship with dyslipidaemia Joanne TE Shaw, Jill Tate, Janine B Kesting, Maureen Marczak, Janet R Berkholz, Paul K Lovelock, David Purdie, Peter Hickman, Donald P Cameron (MJA 1999; 170: 161-164) Healthcare Characteristics of patients with community-acquired pneumococcal pneumonia Alexander A Padiglione, Jessika Willis, Michael Bailey, Christopher K Fairley (MJA 1999; 170: 165-167) Diagnostic Dilemma Cat scratch disease diagnosed by polymerase chain reaction in a patient with suspected tuberculous lymphadenitis Tom Gottlieb, Bridget L Atkins, Jenny M B Robson (MJA 1999; 170: 168-170) Viewpoint Primary care psychiatry is not specialist psychiatry in general practice Ian B Hickie (MJA 1999; 170: 171-173) For Debate The 100-year conflict: salt intake and cardiovascular disease Universal recommendations for sodium intake should be avoided Priscilla Kincaid-Smith, Michael H Alderman (MJA 1999; 170: 174-175) Restriction of salt intake is needed to ameliorate the cardiovascular disease epidemicTrefor O Morgan (MJA 1999; 170: 176-178) The salt dilemma: some answers, many questions M Gary Nicholls, A Mark Richards (MJA 1999; 170: 178-179) Information Technology Information technology in medical practice: safety and privacy lessons from the United Kingdom Ross J Anderson (MJA 1999; 170: 181-184)
Editorials
Hospital in the home: take the evidence and run
Editorial Hospital in the home: take the evidence and run The time for apathy and cynicism towards home-based care is over MJA 1999; 170: 148-149 Australians are credited with making global contributions in biomedical research,1 and the same can now be said for their contribution to developing acute home-based care. Hospital in the home (HIH) units have been established for more than four years in Australia (mainly in Victoria), yet in this short time important work of international standard has shown that HIH is a safe, effective, acceptable and efficient alternative to acute hospitalisation for certain patients and conditions.2-5 Now, in this issue of the Journal, Caplan and colleagues,6 from New South Wales (a virtual HIH desert), report a randomised controlled trial (RCT) of home versus hospital care, something that has hitherto seldom been reported in the medical literature (the only other similar RCT is an Australian study in patients with cystic fibrosis7). Caplan et al found that frail elderly patients requiring intravenous therapy or low molecular weight heparin deserve active consideration for HIH care: there were fewer geriatric complications and greater patient and carer satisfaction in the HIH group. Although no differences in the rates of adverse events and death were found, the small numbers of patients involved meant that the study's power to draw these conclusions was limited. HIH care around the world has varied widely, and so too have the studies it has generated. Thus, for the Cochrane review of HIH care,8 a meta-analysis was not possible, and for good reason. In HIH studies so far there have been: Variations in intervention models; Non-uniformity of conditions, patients and therapies; and Relatively small patient numbers, allowing only for large effects to be detected. Other factors impeding meta-analysis have included: The impact of dedicated and motivated staff self-selected to care for the intervention groups; The refusal of some patients to consent to remain in hospital when HIH treatment was offered as an option; The need for units to be well established before any trial; and The reluctance of established HIH programs to reduce their throughput. Landmark RCTs of HIH care of patients with deep venous thrombosis have taken four years to complete,9 and RCTs of home-based care in the United Kingdom have really examined postdischarge coordination.10 Americans are educated by their constitution to hold some truths to be self-evident, and the appropriateness of HIH appears to be one of them. They have demonstrated this with an expenditure of 2 billion dollars per annum on HIH programs in the absence of RCT evidence.11,12 If HIH were, for example, an imaging technology, it would have crossed the threshold from the novel and experimental. But hospitals are insecure -- they have difficulty letting go even when the evidence is there. So, let us assume that this issue of the Journal is a defining moment for HIH in Australia, and NSW in particular. Let us assume that hospital administrators will conclude that the time is now right for a concerted move to HIH care, and that to deny appropriate patients this intervention is no longer sustainable and may even be unethical. Let us even fantasise that private insurers will look favourably at the benefits of HIH care now that they will receive an injection of 1.5 billion dollars of public funds (Private Health Insurance Incentives Bill 1998 (Cwlth)). How could these interested groups move on with the development of HIH? They might be forgiven for concluding that models for HIH are somewhat ill-defined. In fairness, HIH units have been influenced by the manner in which they were funded, and the background of the staff who volunteered to take on the task. The studies have concentrated on comparisons with inhospital care rather than between HIH models. A more analytical approach is now required, but some principles have emerged. Firstly, let us get the definition clear. The substitution of acute hospital stay is at the heart of HIH.13 Thus, HIH is the delivery of care and services which, without HIH, can only be provided by admission to hospital. At present, the healthcare interventions suited to HIH are intravenous therapy of all types (including antibiotics, antifungals and antivirals, some chemotherapeutic agents, corticosteroids, inotropes, and blood products), and acute anticoagulation. Acute rehabilitation, insulin initiation and some complex wound care are also included in some HIH programs. Although new applications will be found, it is important that HIH should adhere to the demonstrable substitution of hospital inpatient care and not establish intermediate care programs or duplicate current community services. HIH is probably best established through a stand-alone unit within the hospital, with its own budget and staff. It has its own technologies, such as computerised pumps and peripherally inserted central catheters, and is skilled in the use of pharmaceuticals at home. It has its own body of research. It is expert at assessing people for acute home-based care, with involvement in the actual delivery of that care continually updating its expertise. It accepts patients from all other hospital units, services and disciplines. It is therefore generalist in its approach -- a dangerous attribute in a modern hospital environment -- yet is rapidly accumulating its own core of specialist knowledge. It is able to embrace specialist requirements through direct staffing of nurses with appropriate experience, or through the education of current staff. It is developing specific standards that will allow improvement in quality and benchmarking. Australian Council on Healthcare Standards (ACHS) clinical indicators for HIH care are expected this year.14 HIH units should offer nurse-administered and medically supervised and attended care. The ability to establish venous access and detect, treat or transfer patients with complications of illness or therapy is required. Twenty-four-hour nursing and medical telephone support, with the ability to visit after hours, is mandatory. There should be clear lines of clinical responsibility and continuity within HIH, and between it and the hospital, with a clear link to the hospital (in Victoria patients retain their inpatient status while in HIH). Community-based healthcare service providers may then be able to deliver HIH services. When patients understand and consent to the service level offered, their acceptance is high, as is their subsequent satisfaction.5 Patients who have had nosocomial infections or have chronic or relapsing illnesses best understand the advantages of HIH. There is also a level of community altruism, whereby people understand that, as long as they are cared for appropriately, traditional hospital space should go to those who need it more. To keep this faith, Australian HIHs should reject the notion of these programs being built entirely around self-administration of therapy. Even with all of these inputs, HIH will still offer care equivalent to traditional hospital care at a lower cost.11,15 Future studies of hospital and HIH patients examining costs and quality-of-life measures will acknowledge the additional advantages of HIH care. To date, Australian costing studies of HIH have suffered from the problems described earlier for the conduct of trials, together with inconsistent cost-accounting across different hospitals.16 But, even if HIH offered no cost advantage in direct care, in the context of waiting lists and emergency department backlogs HIH offers capital expansion of the hospital's work at a fraction of the usual cost. Until recently, hospitals have only seen their future as involving exponential growth. The view that the hospital is an Aladdin's cave, where the rich rewards of medical and nursing skill and biotechnology are gathered and bestowed on those who surrender themselves, might be usefully reassessed.17 But the real danger is that any such reassessment will merely result in briefer glimpses of the skills and technology where they are genuinely required. This appears to be the current direction of public hospital reform. Hospitals have been accustomed to taking responsibility for only those within their walls. While understandable, this limits the effective use of the technologies and skills held tight within those walls. HIH urges hospitals to adapt their infrastructure to take responsibility for the delivery of appropriate, high quality acute care in and for their community. State and federal health authorities could assist with genuine, targeted medium to long term incentives. Caplan et al offer the best evidence yet that the time for apathy and cynicism towards HIH should be over. We are at the end of a century of unparalleled advances in medical science and hospital care. Any pause in the speed of advance, or any rationing of access due to the burgeoning costs of acute-care delivery, can allow Western healthcare systems to take stock.18 In their review, the return to home-based care, so prevalent before the early 20th century, should be seen as maximising the quality use of technology to fulfil the wishes of the patients and their families, reasserting their pre-eminent position within the acute-care system into the 21st century. Michael Montalto Director, Frankston Hospital in the Home Executive Member, Australian Home and Outpatient Intravenous Therapy Association, Frankston Hospital, Frankston, VIC Bourke PF, Butler L. Mapping Australia's basic research in the medical and health sciences. Med J Aust 1997; 167: 610-613. Grayson L, Silvers J, Turnidge J. Home intravenous antibiotic therapy: a safe and effective alternative to inpatient care. Med J Aust 1995; 162: 249-252. Lowenthal R, Piaszczyk A, Arthur G, O'Malley S. Home chemotherapy for cancer patients: cost analysis and safety. Med J Aust 1996; 165: 184-187. Montalto M. How safe is hospital in the home? Med J Aust 1998; 168: 277-280. Montalto M. Patient and carer satisfaction with hospital in the home care. Int J Qual Healthcare 1996; 8: 243-251. Caplan G, Ward J, Brennan N, et al. Hospital in the home: a randomised controlled trial. Med J Aust 1999; 170: 156-160. Wolter JM, Bowler S, Nolan P, McCormack J. Home intravenous therapy in cystic fibrosis: a prospective randomized trial examining clinical, quality of life and costs. Eur Respir J 1997; 10: 896-900. Sheppard S, Illife S. Effectiveness of hospital at home compared with inhospital care. Cochrane Review in: The Cochrane Library, Issue 3, 1998. Oxford: Update Software, 1998. Koopman M, Prandoni P, Piovalli F, et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low molecular weight heparin administered at home. N Engl J Med 1996; 334: 682-687. Richards S, Coast J, Gunnell D, et al. Randomised controlled trial comparing effectiveness and acceptability of an early discharge hospital at home scheme with acute hospital care. BMJ 1998; 316: 1796-1801. Balinsky W. Home care -- current problems and future solutions. San Francisco: Jossey-Bass Publishing, 1994. Tice A, Marsh P, Craven P. Response to a call for a randomised controlled trial. Am J Med 1993; 94: 115. Grayson L. Hospital in the home -- is it worth the hassle? Med J Aust 1998; 168: 262. Clinical indicators for hospital in the home -- Final Report to the Victorian Department of Human Services. Melbourne: ACHS Care Evaluation Program. October 1998. Montalto M, Watts J. Considering the cost of hospital in the home care. Report to the Victorian Department of Human Services. Melbourne: Centre for Health Program Evaluation, 1998. KPMG Consulting Services. KPMG hospital in the home evaluation. Melbourne: Victorian Government Department of Human Services, 1997. Stoeckle J. The citadel cannot hold: technologies go outside the hospital, patients and doctors too. Milbank Q 1995; 73: 3-17. Komesaroff P, Clunie G, Duckett S. What is the future of the hospital system? Med J Aust 1997; 166: 17-22. 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 Montalto
Viewpoint
Primary care psychiatry is not specialist psychiatry in general practice
Viewpoint Primary care psychiatry is not specialist psychiatry in general practice Current psychiatric diagnostic systems are not useful for general practice Ian B Hickie MJA 1999; 170: 171-173 Introduction - Barriers to psychiatric treatment in primary care - Classification systems in specialist psychiatry - Primary care psychiatry - Psychological disorders present with somatic symptoms - Psychological assessment in primary care - Acknowledgements - References - Authors' details - - More articles on Psychiatry Introduction At least 30% of patients who present to primary care have psychiatric disorders, while another third have sufficient psychological symptoms to justify detailed psychological assessment.1 While patients who present to primary care represent a minority of those with psychological disorders in the Australian community,2 less than half receive a psychiatric diagnosis when seen by their general practitioner.3 Specific pharmacological treatment is provided to less than half of patients in whom a diagnosis is made.3The public health and personal costs of this situation are large,4 and persist despite the increasing willingness of general practitioners to treat psychological disorders,5 the increased availability of safe and effective pharmacological agents, and the fact that patients prefer to be assessed by their general practitioner rather than mental health specialists.6 Current public health initiatives are designed to increase the likelihood that persons at risk (especially men and younger people) will present for treatment and that general practitioners will receive increased support and training to provide such treatments.5 Barriers to psychiatric treatment in primary care A range of patient, doctor and service factors contribute to the ongoing problems of under-recognition and undertreatment of psychological disorders in primary care. Patient-related factors include the presentation of somatic rather than psychological symptoms,7,8 the co-occurrence of medical and psychological problems, and the stigma associated with psychological diagnoses and treatments.6 Doctor-related factors include inadequate interview and diagnostic skills,9,10 insufficient undergraduate and postgraduate training,5 insufficient time devoted to adequate diagnostic assessment,5 and a lack of acquisition of new knowledge relevant to provision of treatments. Service-related factors5 include insufficient remuneration for psychological interventions, insufficient support from specialist public and private mental health services, and inadequate access to non-medical mental health professionals. An important but little-discussed factor is the current lack of a useful psychiatric diagnostic system for use in primary care. General practitioners typically report that, although they recognise behavioural disturbance, the common symptom patterns and deviant behaviours presented do not fit readily within the patterns described by specialist psychiatry. Currently, psychiatric education highlights the problems of under-recognition and undertreatment, but does not concede that much of the morbidity detected is not classical "major depression" or one of the discrete anxiety disorders.11 Moreover, much of the treatment data that forms the "evidence-base" for current recommendations has not been obtained in patients from primary care settings.12 Inevitably, therefore, practice guidelines for primary care represent extrapolations from treatment trials conducted within the specialist sector with patients without concurrent medical morbidity.12 Classification systems in specialist psychiatry During the past two decades, specialist psychiatry has focused on the development of complex criteria-based diagnostic systems (eg, DSM-IV, ICD-10).11,13 While such systems have improved diagnostic reliability for psychiatric research, they have often been inappropriately transferred directly to clinical settings. In practice, the systems frequently result in multiple diagnoses for individual patients (now termed "psychiatric comorbidity"), as the borders between the different diagnostic categories are indistinct. For example, many patients with "major depression" will also meet criteria for other anxiety disorders, such as generalised anxiety disorder and panic disorder.14As the current systems were designed for patients who present primarily with psychiatric disorders, their application in general medical and primary care settings is problematic. Patients frequently do not meet criteria for any specific psychiatric diagnosis, or fall into one of the "waste-basket" categories such as 300.81 Undifferentiated Somatoform Disorder or 311 Depressive Disorder, Not Otherwise Specified. Much of the psychological morbidity encountered in general practice falls into the "not otherwise specified" categories, and the diagnostic systems have tended to reinforce the notion that such disorders are not worthy of further systematic study. This is despite their clear contribution to ongoing healthcare costs and disability.1 Primary care psychiatry In contrast with specialist psychiatry, the emerging discipline of "primary care psychiatry" deals with those issues which are pertinent to psychological assessment and intervention in the primary care sector.15 This focus is justified by the fact that most patients in this sector present an admixture of affective and somatoform symptoms,7,16 and are managed without referral to the specialist sector.2 When referring, there is a strong preference towards those patients with overt psychological syndromes (eg, major depression, panic disorder) and away from those patients with somatoform disorders (eg, chronic fatigue, chronic pain), as the latter are poorly recognised by the current classification systems.8,17 This is despite the considerable disability associated with such disorders and the likelihood that such patients will seek a variety of treatments, including non-specific pharmacological and alternative medicine interventions.8,17Additionally, general practitioners frequently assess psychological disorders which occur in the context of obvious life stressors (eg, marital separation, job loss, or financial hardship). The diagnostic systems typically describe such disorders as "adjustment disorders" and imply that such maladaptive behavioural responses are usually shortlived and associated with minor degrees of disability. DSM-IV specifically describes adjustment disorders as a "residual category". This approach substantially underestimates the impact of such presentations on primary care practitioners and the degree of risk and disability which may result. Psychological disorders present with somatic symptoms Few patients simply report the syndromes described in DSM-IV or ICD-10. Typically, patients report prolonged fatigue, sleep disturbance and musculoskeletal aches and pains in association with mood, anxiety and/or neurocognitive symptoms.7,16,18 Consequently, primary care psychiatry emphasises diagnostic categories that are more useful to general practitioners. The most important of these are "mixed anxiety and depression" and "neurasthenia" (ie, nervous exhaustion or chronic fatigue). Together, these disorders are largely discounted by specialist psychiatry, even though they describe common presentations. The psychiatrist's "bible", DSM-IV, deals particularly poorly with both these disorders. Mixed anxiety and depression is presented simply as a possible form of depressive disorder that may warrant further investigation. Neurasthenia/chronic fatigue is not recognised, although the symptom pattern is described obliquely within 300.81 Undifferentiated Somatoform Disorder. The most recent and comprehensive community study of psychiatric disorders in North America (published from 1994 onwards) chose not to record the prevalence or health impacts of somatoform disorders.19 In contrast, studies supported by the World Health Organization continue to demonstrate the frequency of neurasthenia and its relevance for primary care practitioners.1 Fortunately, the recent National Health and Wellbeing Survey,2 conducted in the second half of 1997, obtained data on these conditions in Australia. Pilot data from that study support this emphasis in terms of prevalence and associated disability.20 Longitudinal studies suggest that these disorders are often chronic and likely to remain prevalent in the primary care setting.21 Although such disorders are distinctly lacking from many educational initiatives in primary care, emerging literature can be used to guide primary care physicians.8,22 The relevant notions include not only descriptions of key symptom sets (eg, chronic fatigue, irritable bowel, chronic pain, fibromyalgia and chronic headache), but also more coherent approaches to identification of problem behaviours (eg, rejection of medical reassurance, inappropriate investigation). This results frequently in combined medical and psychological approaches to treatment (eg, non-steroidal anti-inflammatory drugs and behavioural treatment for fibromyalgia; antidepressant drug and sleep-wake cycle behavioural management of chronic fatigue). Psychological assessment in primary care Current educational initiatives in primary care often emphasise the importance of simplistic diagnostic checklists for disorders such as "major depression" or "panic disorder". A more rational educational and treatment approach is based on the following framework: The common somatic and psychological presentations of distress and the psychosocial environment within which such presentations occur must be recognised. Within the logistic constraints of general practice this process may be assisted either by relevant screening instruments7 and/or by improving interviewing techniques.9 Behavioural constructs (eg, depressed mood, panic attacks, psychomotor retardation, chronic fatigue, chronic pain, sleep disturbance, and suicidal ideation) that require specific treatments independent of the final diagnosis need to be recognised. The degree of immediate risk to self and others should be determined. An assessment of those comorbid medical factors (eg, co-prescription of antihypertensives) that will influence treatment choice needs to occur. Within this framework there is the potential to bring a much larger group of currently untreated patients, particularly those with somatoform or adjustment disorders, into the diagnostic and treatment process. For individual management to succeed, the practitioner needs then to use very specific knowledge with regard to the patient's current personal and social circumstances and past experiences. Further developments will depend on a growing awareness of the inadequacies of the current classification systems and an increased demand for relevant aetiological and treatment research within the primary care sector. As this process gains momentum so will the capacity to identify and treat more effectively the large number of patients who present to primary care. Acknowledgements This research in general practice settings is supported by a National Health and Medical Research Council Program Grant (No. 953208). The editorial assistance of Tracey Davenport was greatly appreciated. References Ustun TB, Sartorius N, editors. Mental illness in general health care: an international study. Chichester: John Wiley and Sons, 1995. Mental health and wellbeing: profile of adults, Australia. Canberra: Australian Bureau of Statistics, 1998. (Catalogue no. 4326.0.) Harris MF, Silove D, Kehag E, et al. Anxiety and depression in general practice patients: prevalence and management. Med J Aust 1996; 164: 526-529. Murray CJL, Lopez AD, editors. The Global Burden of Disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Boston: Harvard University Press, 1996. A report of the Joint Consultative Committee. Primary care psychiatry -- the last frontier. Canberra: Royal Australian College of General Practitioners and Royal Australian and New Zealand College of Psychiatrists, 1997. 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. Hickie I, Hooker A, Hadzi-Pavlovic D, et al. Fatigue in selected primary care settings: sociodemographic and psychiatric correlates. Med J Aust 1996; 164: 585-588. Hickie IB, Scott EM, Davenport TA. Somatic distress: developing more integrated concepts. Curr Opin Psychiatry 1998; 11: 153-158. Goldberg DP, Jenkins L, Millar T, Faragher EB. The ability of trainee general practitioners to identify psychological distress among their patients. Psychol Med 1993; 23: 185-193. Tobin M, Hickie I, Urbanc A. Increasing general practitioner skills with patients with serious mental illness. Aust Health Rev 1997; 20: 55-67. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994. American Psychiatric Association. Practice guidelines for major depressive disorder in adults. Am J Psychiatry 1993; 150 Supl: 1-26. World Health Organization. The tenth revision of the International Classification of Diseases and related health problems (ICD-10). Geneva: World Health Organization, 1992. Blazer DG, Kessler RC, McGonagle KA, Swartz MS. The prevalence and distribution of major depression in a national community sample: the National Comorbidity Survey. Am J Psychiatry 1994; 151: 979-986. Sartorius N, Ustun TB, Costa e Silva JA, et al. An international study of psychological problems in primary care. Preliminary report from the World Health Organization Collaborative Project on 'Psychological Problems in General Health Care'. Arch Gen Psychiatry 1993; 50: 819-824. Goldberg D, Gater R. Implications of the World Health Organisation study of mental illness in general health care for training primary care staff. Br J Gen Pract 1996; 46: 483-485. Hickie I, Hadzi-Pavlovic D, Ricci C. Reviving the diagnosis of neurasthenia. Psychol Med 1997; 27: 989-994. Mason P, Wilkinson G. The prevalence of psychiatric morbidity: OPCS survey of psychiatric morbidity in Great Britain. Br J Psychiatry 1996; 168: 1-3. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry 1994; 51: 8-19. Hickie I, Pols R, Koschera A, Davenport T. Why are somatoform disorders so poorly recognised and treated? In: Andrews G, editor. Unmet needs for psychiatric care. Darlinghurst, Sydney: World Health Organization Collaborating Centre for Mental Health and Substance Abuse. In press 1999. Merikangas K, Angst J. Neurasthenia in a longitudinal cohort study of young adults. Psychol Med 1994; 24: 1013-1024. Wessely S, Hotopf M, Sharpe M. Chronic fatigue and its syndromes. New York: Oxford University Press, 1998. Authors' details School of Psychiatry, University of New South Wales, Sydney, NSW. Ian B Hickie, MD, FRANZCP, Professor of Community Psychiatry. Reprints: Professor I B Hickie, Academic Department of Psychiatry, 7 Chapel Street, Kogarah, NSW 2217. Email: i.hickieATunsw.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/>
Ian B Hickie
Hyperbaric or normobaric oxygen for acute carbon monoxide poisoning: a randomised controlled clinical trial
Carlos D Scheinkestel · Michael Bailey · Paul S Myles · Kerry Jones · Ian L Millar · David V Tuxen
Viewpoint
Nick Crofts · Campbell K Aitken · John M Kaldor
Sceptical medicine
Stephen R Leeder · Chris A Silagy · George L Rubin
Accidental drug toxicity associated with methadone maintenance treatment
Robert L Ali · Allan J Quigley
Mortality associated with New South Wales methadone programs in 1994: lives lost and saved
Olaf H Drummer · John R M Caplehorn