Volume 176 Issue 2

The ability to remain continent is fundamental to our functioning as socially capable individuals. Loss of faecal continence leads to physical, psychological and social disability. Contrary to common belief, the condition is not confined to the disabled elderly. Rather, it affects people of all ages. The greatest contribution to improving the care of people with faecal incontinence would come from improved recognition by doctors. If those who experience faecal incontinence are able to overcome embarrassment, they will seek help from a doctor, usually their general practitioner. To be told that there is nothing to be done (still a common response) is disheartening — and incorrect. In this issue of the Journal (page 54), Kalantar and colleagues have published important data about the prevalence of faecal incontinence in the Australian community.1 They used a postal questionnaire to determine the prevalence of faecal incontinence over the previous 12 months. Incontinence for solid stool occurred in 2% of respondents, and of liquid stool in 9%. These figures are similar to, or somewhat higher than, data published from the USA and Europe over the last 10 years. All recent studies demonstrate that faecal incontinence is common. Current figures are much higher than estimates from the 1980s and earlier, which appear to have markedly underestimated the true prevalence, probably because of the methods of case ascertainment used and the unwillingness of sufferers to disclose the presence of such a stigmatised symptom. In the study by Kalantar et al, men and women were affected in approximately equal proportion. A perineal tear or surgical trauma were identified as associated factors, as were feelings of impaired rectal emptying, loose bowel actions, and a sense of bowel urgency. Only one in eight of those with incontinence had sought medical care. This was despite impaired quality of life and perception of poorer health. In a specialist centre, the commonest cause of faecal incontinence is structural anal sphincter damage associated with childbirth.2 The most important risk factor is instrumental delivery; other risk factors are a large baby, occipito-posterior position, and a long second stage of labour. Anal endosonography, a painless, quick and non-invasive test, has demonstrated that such damage occurs in up to a third of first vaginal deliveries.3 A third of those with damage will have new bowel symptoms after their delivery. The vast majority of these women have not had a recognised third-degree tear. It is therefore perhaps not surprising that 31% of female obstetricians, when asked about their preferred mode of delivery for their first uncomplicated pregnancy, said they would opt for a caesarean section.4 The main reason given was to prevent perineal trauma. The second-commonest cause of incontinence in a specialist referral unit is postsurgical sphincter damage.2 Some patients have anal sphincter damage as an unavoidable consequence of a necessary treatment (eg, in the care of anal fistula). Others sustain irreversible sphincter damage as a consequence of procedures which are now outdated, such as manual dilatation performed for chronic anal fissure, constipation and non-specific anal symptoms. When there is no structural damage present, the commonest cause of faecal incontinence appears to be a degenerative disorder affecting the delicate smooth muscle which keeps the anal canal closed, the internal anal sphincter.2 In patients with congenital anorectal abnormalities, it has only recently been appreciated that, despite corrective surgery in infancy or childhood, impaired continence can persist into adult life.5 Encopresis, often related to behavioural issues, can also severely affect a child's development. In the elderly, many factors can contribute to impaired continence, including co-morbidity, medications, and social circumstances. Faecal impaction is an important factor in some. Patients with a range of primary disorders, such as neurological disease, inflammatory bowel disease, and connective tissue disorders, can experience severe faecal incontinence. For many this hidden symptom causes them the greatest uncertainty and substantially impairs their quality of life. Is it worth making a diagnosis? Can anything useful be done? Emphatically, yes. Many individuals can be helped substantially, often by a combination of careful history taking, examination for sphincter damage or impaction, and correction of predisposing factors. A broad range of therapies have been applied to this condition. Selection of an appropriate therapy, after correcting simple contributory factors, should be based on the aetiology and severity of a patient's incontinence. The least invasive and safest treatments should be used first. Many patients with excessively strong bowel contractions, or sphincter weakness, can have their well-being transformed by a small dose of an antidiarrhoeal medication such as loperamide. This drug is extremely effective and safe in adults. If patients become constipated, the dose can be reduced. Behavioural techniques, such as "biofeedback" (teaching patients to improve sphincter function using physiological feedback, such as anal electromyography or pressure measurement) and sphincter exercises, help about two-thirds of patients, including some with structural sphincter damage.6 Such behavioural techniques are not simply "exercises"; rather, they involve a complex package of care that includes dietary advice, proper use of constipating drugs, teaching patients to resist urgency, decreasing their sense of panic, sphincter training and counselling. Topical pharmacological therapies have radically altered the management of anal fissure, thereby preventing the need for surgical sphincterotomy (one of the causes of incontinence). The first such topical therapy was glyceryl trinitrate (GTN), which lowers anal tone, thereby allowing fissures to heal. Topical GTN is associated with headache in two-thirds of patients, limiting compliance.7 The use of calcium-channel blockers such as diltiazem offers the same therapeutic benefit but without the side effects.8 Injectable botulinum toxin also lowers anal pressure and allows healing. Topical preparations which raise sphincter tone and prevent leakage, such as phenylephrine, are also under development.9 Only a very small proportion of patients require surgical treatment. Sphincter repair for major obstetric structural damage produces a good short term outcome, but the longer-term results are less satisfactory.10 New surgical techniques include: The artificial bowel sphincter (a circular cuff implanted around the anal canal and inflated to maintain sphincter closure).11 Sacral nerve stimulation by means of a fine electrode implanted through a sacral foramen.12 This is connected to a battery to provide continuous low level stimulation, resulting in altered rectal and sphincter motor function. Dynamic graciloplasty. The gracilis muscle is mobilised from the inner thigh and wrapped around the anal canal. Battery stimulation produces muscle contraction, which increases anal pressure.13 This procedure has limited application owing to its complexity and associated morbidity. When all else has failed, a tiny proportion of patients will be well served by a colostomy. Data such as those published in the Journal today should serve to remind doctors that faecal incontinence is a common and treatable condition. A range of treatments is required if patients with different types and severities of incontinence are to be successfully managed. Such a range of expertise is not readily available in many centres. These data should therefore also remind healthcare planners that this is a health issue which requires action in the community, in addition to multiskilled centres of expertise for the minority of patients who need more intense treatment.

Michael A Kamm

We are well aware of the excess mortality of Australian Aboriginals and Torres Strait Islanders, their higher hospital admission rates and their longer duration of hospital stay.1,2 However, despite this, relative to their need, Aboriginals and Torres Strait Islanders underutilise specialist healthcare, both as inpatients3 and outside hospitals.4 This situation is exacerbated by demonstrable underfunding of primary care services for Indigenous Australians.4 In this issue of the Journal, Cunningham (page 58)5 reports an analysis of Australian hospital separation data which documents significantly fewer diagnostic and therapeutic procedures performed on patients identified as Indigenous. Cunningham took into account variables possibly affecting use of procedures, including diagnosis, age, sex and place of residence, and acknowledged the problem of incomplete identification of hospital patients as Indigenous. The adjusted data still show fewer recorded procedures in Indigenous compared with non-Indigenous inpatients. These differences are significant within certain disease and diagnostic groups, and of a magnitude which cannot be ignored. Cunningham's study is also consistent with a large body of research from other countries showing disparities according to ethnic group and gender in the use of procedures.6,7 Are the reasons for these disparities in use of procedures related to disease characteristics (including severity), the patient (including preferences and comorbidities), the clinician or the institutional setting? Are they appropriate? And what exactly do these findings indicate? Ideally, decisions regarding medical care are based on evidence, or at least consensus opinion as reflected in a range of standard practices or options. Patient goals and values are then factored in, together with provider and institutional preferences and consideration of available resources. The end-result should be an individualised decision for each patient. Cunningham's findings suggest that, somewhere along this chain within hospitals, different decisions about use of procedures are being made that correlate with, but may not be caused by, ethnic origin. It seems implausible that such significant and Australia-wide differences could implicate large numbers of individual clinicians and result from purely personal biases based on race. The disparities are more likely a result of subtler systemic practices, not ill-intentioned but still discriminatory, and almost invisible within an individual patient–provider encounter. The challenge for clinicians is to further dissect the available information and identify the true cause from the many possible contributory factors. For example, it is likely that in some disease conditions where aetiology is well identified in a population and where the disease is endemic that fewer investigations (and therefore procedures) are needed. Renal biopsy may be performed less frequently to investigate renal disease in Indigenous patients, in whom identified antecedent chronic diseases are endemic. Iron-deficiency anaemia may be treated with anthelmintic drugs rather than first confirming the cause. Alternatively, there may be situations in which a population is genuinely underserviced relative to need (eg, some forms of elective or semi-elective surgery). Possible patient factors should also be identified and dealt with. These include stage of presentation, comorbidities, consent and anticipated postprocedural compliance. All may be reasons why a procedure is not performed, but all these factors can be ultimately overcome, in particular with greater recognition of the importance of primary care. The Royal Australasian College of Physicians has emphasised that adequate primary care is a prerequisite for effective specialist care.8 The uptake of services is more than "patient related" and cannot be separated from the provision of services; societal and institutional factors also structure the doctor–patient encounter within which decisions are made.9 Compliance is likely to improve when a patient's understanding and ownership of his or her disease is matched by a commitment (in the broadest sense) to providing high quality communication and a range of treatment options. The national underdevelopment of key services — Aboriginal Health Workers, Liaison Officers, and particularly interpreter services — shows a lack of appreciation by health institutions of the importance of involvement of Indigenous patients in decision making. Finally, could clinician factors be a major issue in this disparity in the use of procedures? Do we try hard enough and devote sufficient resources to the early diagnosis of serious conditions, to ensuring stabilisation of comorbidities, to obtaining meaningful consent, and to ensuring good postprocedural care and compliance? Do we have preconceived and incorrect perceptions of cultural appropriateness? Are the expectations we factor into our decision making, often derived from our knowledge of group outcomes, appropriate for this individual patient? It is certainly interesting that for trauma and infectious diseases, in which the decision-making process may be less subjective, Cunningham found no difference overall in the likelihood of having a procedure. However, even within these groups, large differences could be seen at an individual "principal diagnosis" level. To improve and structure our medical decision making, we need to continue to develop standardised protocols based on best evidence. Subsequent careful recording of consent processes, together with documentation of the decisions reached and the reasons behind them, will shed further light on the issues raised by Cunningham's data. Cunningham's article shows why clinicians need to contribute to the interpretation of population health information. As presented, these data do not identify the specific clinical procedures possibly denied to Aboriginal and Torres Strait Islander inpatients, and, although the findings have flagged the disparity in procedures, more information is needed for clinicians to take these concerns to the next level of analysis. Specifically, these findings should prompt us to review the decision-making processes determining use of diagnostic and therapeutic procedures in Aboriginal and Torres Strait Islander inpatients. Specialist colleges, societies, hospital units and individual clinicians now have a responsibility to review their own data and establish whether the trend in differential use of procedures applies to their area and, if so, what is driving this difference. The next chapter in this story needs to tease out the connections between healthcare need, use of procedures and health outcomes. If healthcare services are to foster equity rather than further institutionalise inequity, inappropriate reasons for different use of procedures need to be identified and the problems rectified.

Dale A Fisher FRACP, DTM · Tarun S Weeramanthri PhD, FRACP, FAFPHM

In a recent issue of the Journal, Blake and colleagues described a cluster of three cases of measles from western Sydney.1 The index patient acquired measles overseas, while the other two patients acquired the infection during a hospital visit and probably in the waiting room of a general practice, respectively. Measles is highly contagious and can spread with relative ease in healthcare settings, especially if there is a failure to diagnose the infection, to isolate the infectious patient or to notify the case so that other infection control measures can be implemented. Other recent Australian outbreaks of measles have also been associated with virus importation from overseas and subsequent nosocomial transmission.2-4 Measles was imported in nine separate incidents investigated in Western Australia between March 1999 and October 2000, and subsequently transmitted among hospital patients, visitors and healthcare workers on two separate occasions. Victoria has experienced two outbreaks in the past three years,3,4 and a third is evolving (Dr Sean Tobin, Medical Officer, Communicable Diseases Section, Department of Human Services, Victoria, personal communication). In two of the three outbreaks, the index patient had returned from overseas during the incubation period, and genotyping provided strong evidence that the viruses were imported. All three outbreaks involved predominantly young adults. Healthcare staff aged in their 20s or early 30s accounted for six of the 75 cases in the 1999 Victorian outbreak (a doctor, three nurses, a social worker and a medical student3), and for two of the 51 cases in the first of the 2001 Victorian outbreaks (a medical student [the index case] and a nurse who remained unvaccinated despite being identified as susceptible in the previous outbreak5). In the latter outbreak, an unvaccinated 11-year-old child also became infected after attending an emergency department at the same time as an infectious patient. In the current outbreak, one case was in a 36-year-old hospital orderly, and another in a 30-year-old pharmacy assistant, both almost certainly infected while at work (Dr Sean Tobin, personal communication). The hospital orderly, born in 1965, might have been expected to be immune to measles, having grown up when measles virus was circulating in the community and measles epidemics occurred every two years.6 However, people born between about 1968 (when measles vaccine was first licensed in Australia) and 1981 (when a measles–mumps combination vaccine was introduced to the Australian childhood schedule) grew up when exposure to wild measles virus was decreasing. Because of initial poor vaccine coverage, there was inadequate compensation for the subsequent decline in natural immunity in the population, leaving a proportion of this age group, now aged 20–33 years, at risk of measles infection.7 These cases of measles transmission in healthcare settings in Victoria, Western Australia and New South Wales illustrate failure to implement the published guidelines for measles control.8 These involve four key components: isolate the patient, confirm the diagnosis, identify other cases and identify and protect all susceptible persons. However, the failures may be caused by a general lack of awareness of the guidelines rather than an unwillingness to follow their recommendations. In particular, the guidelines are not useful if measles has not been diagnosed. Measles is now relatively uncommon and more likely to affect young adults than children.2 A high index of suspicion is needed, and measles should always be considered in the differential diagnosis of fever and rash in an unwell adult, especially if the person was born between 1968 and 1981. Had the four key components of outbreak control been implemented in some or all of the reported measles outbreaks, some or all of the infections in these outbreaks may have been prevented. As recommended in the guidelines for measles control,8 vaccination of some or all of the young adults involved in these outbreaks may also have prevented further cases. Australia has recently spent more than $30 million on a highly successful mass-vaccination campaign that has effectively protected school-aged children against measles.9 It seems extraordinary that measles transmission can still occur in hospitals or general practice surgeries. Case reports are very unlikely to reveal the extent of the problem. It might be said that transmission of measles — or any other vaccine-preventable disease — in a healthcare setting is a sentinel sign of system failure. Offering susceptible healthcare workers measles–mumps–rubella vaccine has been made a quality standard for all healthcare workers in the United States,10 and a similar approach may be warranted in Australia. Healthcare providers in hospitals and the wider community should record which staff members are susceptible to vaccine-preventable diseases that may be occupationally transmitted, and should provide facilities for vaccination of all those who wish to protect themselves and their patients. As recommended in the Australian guidelines for measles control, young adults intending to travel to measles-endemic countries should be advised to check and update their measles vaccination status. At a time when measles transmission has probably been interrupted in several Australian States,2,11 it is important to suspect the diagnosis of measles in young adults with rash and fever, especially those with a history of international travel, and to take pro-active infection control measures to prevent measles transmission in healthcare settings.

Heath A Kelly · Michaela A Riddell · Ross M Andrews

Percutaneous liver biopsy, a technique first accredited to Paul Ehrlich over 100 years ago, is still considered an essential component in the management of most liver diseases. However, the revolution in imaging techniques and development of serological investigations means that, at least for certain conditions, biopsy may no longer be necessary. The usual technique for obtaining liver tissue for histological evaluation of diffuse parenchymal liver diseases is percutaneous needle biopsy, which is performed either blind or guided by ultrasound or computed tomography. The attendant mortality ranges from 0.01% to 0.1%,1,2 the major cause of death being intraperitoneal haemorrhage. Controversy still exists over whether guided biopsies can reduce the complication rate and whether an increased diagnostic yield renders them more cost-effective.3,4 To maximise diagnostic yield, it is usual practice to perform liver biopsy with a 14 G or 16 G needle. Increased complications are observed when clinicians perform liver biopsy less frequently5 and when more than three passes are made.6 It is only relatively recently that guidelines have been established for performing liver biopsies on a day-case basis7,8 and these recommend subsequent observation of patients for 6–8 hours, although the majority of complications are apparent within the first three hours. In this issue of the Journal, Pokorny and Waterland (page 67)9 have examined the safety and possible cost benefits of performing liver biopsy in an out-of-hospital radiology clinic. Of 251 patients who underwent liver biopsy with an 18 G needle, 91.2% were discharged at 60 minutes and none were kept for longer than 2 hours 45 minutes. Moderate to severe pain was reported in 3.6% of patients, but no serious complications were observed. While a histological diagnosis was possible for all patients, it is not usual practice to use an 18 G needle for assessment of diffuse parenchymal liver disease, and there are no data regarding the adequacy of the biopsy (as regards number of portal tracts and number of sections). Could the low morbidity of the study simply reflect the use of a small biopsy needle rather than a positive benefit of radiological control? While a cost benefit was suggested when compared with in-hospital, day-case liver biopsies, the method of cost comparison relied upon two discrepant funding models — the Australian Medicare Benefits Schedule (for out-of-hospital biopsy) and DRG-based funding (for in-hospital biopsy). Ideally, actual resource costs should have been derived for each biopsy setting in order to determine an economic advantage. Does this mean that we should be performing all our routine liver biopsies out of hospital? Although the mortality rate after liver biopsy in Pokorny and Waterland's study was low, the study does not have the power to demonstrate a clearly comparable safety profile between out-of-hospital and in-hospital liver biopsy. However, it is unlikely that a formal study with sufficient power will ever be conducted to prove this point, and perhaps ongoing audit of in-hospital and out-of-hospital biopsy and documentation of similar outcomes is all that is required to prove the safety of shorter recovery times and out-of-hospital biopsy. Nonetheless, if a major complication such as haemorrhage did occur, it would require urgent intervention that would be easier to provide in a hospital environment. The American Gastroenterological Association recommends that biopsies be performed in a unit with blood-banking facilities and an approved laboratory.7 Apart from the logistics of where liver biopsy is carried out, there is a major issue of why biopsy should be performed. There are differing opinions on the indications for liver biopsy. Current practice has recently been reviewed2 and the British Society of Gastroenterology has published guidelines for the use of liver biopsy in the United Kingdom.8 A key factor in the decision-making process should be whether knowledge of liver histology is likely to affect patient management. Histological assessment can help either to reach a diagnosis or to grade severity of disease in patients with a known hepatic disorder. Therefore, deciding whom to biopsy can be approached in one of two ways. In patients with a known or suspected disorder, biopsy enables staging of inflammation and fibrosis, providing the clinician and patient with a well-informed and accurate prognosis. This can guide or determine eligibility for treatment regimens and, in patients with cirrhosis, determine whether they should be enrolled in screening programs for hepatocellular carcinoma. The other major role of liver biopsy is in investigating patients with abnormal liver function tests (LFTs) for whom serology and imaging have been unhelpful in reaching a diagnosis. Chronic hepatitis C is probably the most rapidly growing indication for liver biopsy in Australia. Current S100 Pharmaceutical Benefits Scheme regulations require liver biopsy before consideration of treatment of chronic hepatitis C, except in patients for whom liver biopsy is contraindicated. Should liver biopsy be performed routinely in all patients before antiviral treatment, and how does it really benefit the patient? There is growing debate on this issue within Australia10 and overseas,11 indicating that we need to re-evaluate the role of liver biopsy in hepatitis C. The commonest cause of persistently abnormal LFTs (in the absence of markers for infectious, metabolic, autoimmune or hereditary liver disease) is non-alcoholic fatty liver disease. In a study by Daniel et al of 81 marker-negative patients with abnormal LFTs who had liver biopsies, eight patients had normal liver histology, while the remaining 73 patients all had some degree of steatosis.12 Non-alcoholic steatohepatitis was found in 26 of these patients and two had cirrhosis. Although there is a risk of cirrhosis in patients with non-alcoholic steatohepatitis, this is minimal in the absence of diabetes and obesity and in patients under 45 years.13 The result of a biopsy in patients at low risk of cirrhosis is unlikely to influence management and has not been shown to improve the benefit–risk ratio. A final issue relates to who should perform liver biopsy. Clearly, appropriately trained clinicians should do so.5 If out-of-hospital biopsy becomes routine, there will be less opportunity to provide supervised training for registrars in this procedure. Current Gastroenterological Society of Australia guidelines for advanced training recommend that around 50 successful, supervised biopsies be performed to ensure adequate training. So, who should be trained to perform liver biopsy and how do we accredit such individuals? Liver biopsy provides invaluable information and a histological diagnosis remains the gold standard in many liver disorders. However, the benefits for diagnosis and management need to be clearly defined before subjecting patients to an invasive procedure, albeit one with low risk. While the study by Pokorny and Waterland9 tempts us to move to an out-of-hospital, short-stay approach to liver biopsy, the issues of safety and diagnostic adequacy of relatively small core biopsies need to be well proven before this approach can be more widely adopted.

Adrian Griffiths MB BS, MRCP · Charlie H Viiala MB BS · John K Olynyk MD, FRACP

Objective: To determine the prevalence of faecal incontinence in the community and evaluate identifiable risk factors.Design and setting: Cross-sectional survey using a validated questionnaire. A short version of the questionnaire was sent to 220 subjects and a long version to 770 subjects, randomly selected from western Sydney, Australia.Main outcome measures: Self-reported faecal incontinence, defined as involuntary loss of anal sphincteric control leading to unwanted release of liquid or solid faeces (not flatus) at an inappropriate time or in an inappropriate place, within the past 12 months. The long questionnaire also sought information on bowel habit and potential risk factors for faecal incontinence.Results: The response rate was 66%. The prevalence of solid or liquid faecal incontinence was 2% and 9%, respectively. The mean age of subjects with faecal incontinence was 53 years; 55% were women. After adjusting for age and sex, there was a significant association between faecal incontinence and perianal injury (P = 0.03), perianal surgery (P < 0.001), feelings of incomplete defecation (P < 0.0001), loose or watery motions (P < 0.0001) and urgency (P < 0.0001). Seven of 48 subjects with faecal incontinence reported being asked by their physician about faecal incontinence and nine of 33 reported seeking medical advice for their incontinence. Subjects with faecal incontinence perceived their health to be significantly poorer than did other subjects (P = 0.02).Conclusion: There is a high burden of faecal incontinence in the community, and the prevalence in men may be greater than is usually appreciated. Despite significant associated morbidity, most cases of faecal incontinence were unrecognised by doctors.

Jamshid S Kalantar MB BS, FRACP · Stuart Howell BA(Hons) · Nicholas J Talley MD, PhD

Objectives: To determine whether hospital patients identified as Indigenous are less likely than other inpatients to have a principal procedure recorded, and the extent to which any disparity in procedure use can be explained by differences in patient, episode and hospital characteristics. Design: Retrospective analysis of routinely collected administrative data from the National Hospital Morbidity Database (NHMD). Setting: Australian public and private hospitals. Patients: All patients included in the NHMD whose episode type was recorded as acute and whose separation occurred between 1 July 1997 and 30 June 1998. Patients admitted for routine dialysis treatment were excluded. Main outcome measure: Whether a principal procedure was recorded. Results: In public hospitals, patients identified as Indigenous were significantly less likely than other patients to have a principal procedure recorded, even after adjusting for patient, episode and hospital characteristics (adjusted odds ratio [OR], 0.67; 95% CI, 0.66–0.68). This disparity was apparent for most diseases and conditions. In private hospitals, no significant difference was observed (adjusted OR, 0.94; 95% CI, 0.83–1.06). Conclusions: The disparity in procedure use after adjustment for relevant factors indicates that in Australian public hospitals there may be systematic differences in the treatment of patients identified as Indigenous.

Joan Cunningham ScD (Epidemiol)

Objectives: To describe the management of early-pregnancy bleeding and miscarriage reported by general practitioners in Victoria.Design, setting, and participants: Self-administered, mailed survey of a stratified random sample of GPs in Victoria. Responses weighted by strata to reflect GP population.Main outcome measures: Reported management in referral; investigation (especially ultrasound); expectant versus interventional management; and prevention of rhesus iso-immunisationResults: 382 of 621 eligible GPs responded (response rate, 62%). GPs' reported referral was more likely if the patient had painful bleeding (55%) or if the pregnancy was not viable (77%). Ultrasound strongly influenced the assessment of bleeding. Two-thirds of doctors (262/369; 66%) would routinely order ultrasound for painless bleeding, and 328/369 (84%) for painful bleeding. Expectant management was recommended by 15/353 (4%) for incomplete miscarriage with light bleeding and by 6/351 (2%) when bleeding was heavy. Some GPs are uncertain of the indications for anti-D prophylaxis, including instrumentation of the uterus, for which 261/337 (77%) said they would routinely offer anti-D. There was less agreement about anti-D after threatened miscarriage, for which 213/353 (57%) said they offered the injection.Conclusions: GPs need a working knowledge of the management of early-pregnancy bleeding, and can probably encourage more rational management. There are significant areas where GPs are uncertain, often reflecting uncertainty elsewhere, and some areas where a minority of GPs are not aware of essential requirements.

Bruce McLaren DRANZCOG, FRACGP, MPH · Julia M Shelley MPH, PhD

Objective: To evaluate the safety, the quality and adequacy of specimens obtained and the cost benefits associated with performing liver biopsy out of hospital, on a short-stay basis, using radiological guidance.Design and setting: A prospective study undertaken over a three-year period, from March 1998 to March 2001, in a private radiology practice.Patients and procedures: 251 patients (159 men) with stable liver disease participated. Coagulation studies were performed within a two-week period before biopsy, which was carried out under the guidance of ultrasound (143 patients) or computed tomography (108 patients). A disposable, spring-loaded gun with an 18-gauge biopsy needle was used in each case. A repeat ultrasound or CT scan was performed after the procedure to monitor for complications such as haemorrhage.Main outcome measures: Complications of liver biopsy; adequacy of specimens for histological examination; cost of out-of-hospital procedures compared with liver biopsies performed in the hospital setting.Results: Two hundred and twenty nine patients (91.2%) were discharged 60 minutes after the biopsy. The only post-biopsy complication was pain, either at the biopsy site or in the right shoulder. Pain was severe in three patients and, for one of these patients, a subcapsular hepatic haematoma was found on ultrasound eight days after the biopsy. Sufficient material for histopathological examination was obtained from all patients. The cost of out-of-hospital biopsies was substantially less than the cost of hospital-based, day-stay procedures.Conclusions: Short-stay, out-of-hospital, radiologically guided liver biopsy is safe for patients who have stable chronic liver disease and acceptable coagulation profiles.

Christopher S Pokorny MB BS, FRACP · Mark Waterland MB BS, FRANZCR

We document the first case of the sickle-cell gene — Hb-S gene importation leading to Hb-S/β-thalassaemia double heterozygosity — in the apparently previously Hb-S gene-free setting of Papua New Guinea.

Evelyn K Lavu FRCPA · John D Vince MD, FRCP(UK) · Gilchrist Oswyn MMed(Child Health)

Injectable heroin maintenance has been advocated as a form of treatment for opioid dependence that would attract, and retain in treatment, addicts who have either not sought treatment or who have failed at other forms of treatment, including methadone maintenance. Advocates of heroin maintenance argue that it would increase the proportion of addicts in treatment and reduce heroin use, drug-related crime, and deaths due to overdose.1 A 1991 proposal by a Select Committee on HIV, Illegal Drugs and Prostitution of the ACT Legislative Assembly led to a feasibility study for a heroin trial in the ACT.1 In 1997, the Ministerial Council on Drug Strategy voted in favour of a heroin trial, but the trial did not proceed, as the Federal Government would not amend legislation to allow heroin to be imported for the trial or allocate funds to monitor the use of heroin in accordance with international treaties.2 Dramatic rises in deaths caused by opioid overdose in the late 1990s prompted more calls for a heroin trial.3 The Federal Government refused to countenance a trial, creating a policy deadlock that prevented the evaluation of what proponents2 claimed was a potentially valuable policy option. If we can avoid the fixation on a trial of heroin per se, there is a way out of this policy deadlock. The alternative option we are proposing is to trial hydromorphone (Dilaudid), an injectable opioid that has similar effects to heroin.4,5 Even if the Federal Government's attitude towards a heroin trial were to change, we believe that trialling hydromorphone would be a better option than trialling heroin, for a number of reasons: The subjective effects of hydromorphone are very similar to heroin in experienced heroin users and both have short durations of action.5 Hydromorphone is a registered drug (Schedule 8) in Australia, so it can be prescribed for medical purposes and used in clinical trials. There would be no need to change federal legislation to allow a trial of injectable hydromorphone. Nor would there be any need for oversight of heroin importation and distribution by the International Narcotics Control Board. The use of hydromorphone can be distinguished from the use of heroin by urinalysis,6 thus allowing detection of any covert use of street heroin by trial participants. (A major criticism of the Swiss heroin trials was that this could not be done.)4 Hydromorphone lacks the political symbolism of heroin.5 This would allow a clinical trial to be conducted in the absence of the media sensationalism that would probably attend a trial of heroin maintenance. A protocol for a clinical trial of hydromorphone could be assessed by peer review and funded by the National Health and Medical Research Council. (On the other hand, a trial of hydromorphone might have the disadvantage of discouraging participation of dependent heroin users who only want heroin. Assessing the attractiveness of hydromorphone to the patient population would therefore be an important part of a feasibility study for a clinical trial.) A trial of hydromorphone may reduce the need to inflate the public health benefits of heroin maintenance in order to enlist community support for a heroin trial. Allowing the prescribing of injectable opioids, whether heroin or hydromorphone, would be unlikely to substantially reduce the heroin black market or heroin-related crime. The cost of providing this form of treatment, and the restrictions that the community would probably impose on eligibility for it, mean that too few heroin-dependent people would receive this form of treatment to have a substantial effect on heroin use and its consequences in the population.7 Injectable opioid maintenance would most likely be a treatment option reserved for dependent heroin users who have failed at existing forms of treatment (the model that was trialled in Switzerland).8 Any trial of hydromorphone maintenance for opioid dependence should include an economic evaluation of the comparative costs and benefits of competing forms of maintenance treatment. These could include alternative forms of injectable opioid maintenance using longer-acting agonists such as methadone and partial agonists such as buprenorphine. Oral methadone maintenance should be the comparison condition, as in a recent trial of heroin maintenance.9 For these reasons, we believe a controlled clinical trial of injectable hydromorphone maintenance would break the impasse over a heroin trial and enable the Australian community to decide what role injectable opioid maintenance has to play in the public health response to dependent opioid use.

Wayne D Hall PhD · Jo Kimber BSc (Hons) · Richard P Mattick PhD

A 2000 survey of Australian medical schools showed that use of anatomical dissection and autopsies for teaching has declined. Opinions vary between schools as to the effect on teaching of anatomy and pathology. However, exposure to the dissected human body may have benefits beyond this teaching, including inculcating the trait of “detached concern”, teaching about medical fallibility and uncertainty, and raising issues of death and dying.

Lisa M Parker MB BS, BMedSci

For some time, I have taught communication and relational skills to medical students and physicians-in-training in an internal medicine residency program in the United States. What became apparent to me early on was that the humanistic, relationship-centred attitudes and behaviours being fostered in the classroom were not always finding their way into the clinic or onto the hospital floors. Sadly enough, this observation is supported by studies on patient–physician communication.1,2 In discussing this phenomenon with my students and colleagues, a common response emerged. They believe the relational behaviours taught in the classroom are not wholly credible in the “real world” of medical practice. Empathic attitudes and behaviours make little sense in terms of survival in residency training or success in practice. It seems as if these compassionate behaviours are being extinguished by a lack of incentive or reward in the system. Valued and rewarded instead are academic acumen, technical knowledge and skill, business savvy, and financial success. To better understand this situation, I began to study the “real world” of medicine more intently. Based on this examination, it is my impression that the fundamental problem in the current healthcare system is a lack of meaning. For the purpose of this article, “meaning” will be defined as the underlying beliefs, guiding principles, and defining philosophies that make up the professional ethic of medicine. What follows are my observations and thoughts, as well as a brief outline of my recommendations. Over the past century, there has been an insidious decline in attention to the philosophy of medicine. We have become less interested in or aware of the age-old values and ethical traditions of our healing profession. This claim is supported by the many studies demonstrating that medical training and professional socialisation, rather than developing and fostering humanistic attitudes and behaviours, actually erode them.3,4 As a result, the core meanings of medicine have been subsumed by the current, dominating societal paradigms of business,5 consumerism,6 the information age,7 technology,8 and the legal system. Clearly, these paradigms are integral and necessary to world culture and modern healthcare, but problems arise when they control the healthcare system, directing the way we care for patients and relate to clinicians. Patient-care surveys reveal a steady decline in public satisfaction with medical care. Research studies repeatedly demonstrate a lack of communication, empathy, and trust in the doctor–patient relationship.9 Although a significant percentage of patients are satisfied with their individual physicians, they and their families are largely displeased with the overall healthcare experience.10 Escalating discontent and distrust are evidenced weekly in newspaper articles and best-selling books.11,12 This widespread public discontent with mainstream medical care is further evidenced by the large and growing movement to seek alternative avenues of medical treatment by turning, literally, to “alternative” practitioners.13 Dangling on the other end of the stethoscope, physicians and other clinicians increasingly find themselves frustrated and demoralised by a work environment devoid of respect and compassion for its employees.14 Morale within the healthcare work environment is at an all-time low.15 Physicians, emotionally exhausted and burned-out, are claiming disabilities and leaving the practice of medicine in unprecedented numbers.16 Loss of autonomy in medical decision-making, burdensome and time-consuming administrative hurdles, fear of malpractice litigation, and financial disincentives threaten physicians' livelihood and their sense of responsibility and professionalism.17 Clinicians, entering the profession with an expectation of providing humanistic medical care, quickly become disappointed and disillusioned.18 The present healthcare system, embedded in the principles of the marketplace, has become a caustic and dehumanising environment for patient and physician alike. Physicians are reduced to interchangeable “providers” and patients to generic “consumers". Clinicians, now treated like factory-line workers, are forced to process patients as if they were items on a conveyor belt. And so we find ourselves entangled in the paradox of modern healthcare19 — despite astounding scientific achievements and dazzling technological sophistication over the past few decades, societal satisfaction with the healthcare system is declining.20 The question we return to is why. One of the greatest tragedies of the 20th century is that in developing the means we have forgotten the “meaning".21 Our society has forgotten that the practice of medicine is primarily a humanistic endeavour, not a scientific one.22 We have forgotten that medicine is a healing profession, not a technological one, and that the contribution of a doctor adds up to more than the sum of his or her knowledge and skill. We have forgotten that the patient, as a person, is far more important than the illness; that the illness is far more than the presence of a disease; and that when the cure of disease is not possible, as is so often the case, the humanistic care of patient and family fosters hope and healing. Our society has become myopic in its focus on technical treatment to the exclusion of how we might treat each other as sublime human beings. The fundamental flaw in applying technological and mercantile approaches to healthcare is that they do not acknowledge or allow for a relational response to the inherent suffering in being a patient or a family member of a patient. Peering through the prisms of consumerism, informatics, science, and technology blinds us to the deeply personal relationships necessary for the transcendence of suffering and its transformation into a healing experience. Strategic plans, business ledgers, and diagnostic codes do not account for the unique and graceful relationships required in patient care. Yet, one of our primary responsibilities in medical practice involves this complex and time-consuming process of helping people cope with suffering.23 Suffering which extends from the physical, to the emotional, relational and spiritual domains. The personal care that a doctor, nurse, social worker and every other healthcare professional offers to his or her patients on these multiple levels cannot be scripted, packaged, or coded. These intimate, sometimes gut-wrenching relationships are often “white knuckle journeys” in which patient, family and doctor hang on, literally, for dear life. It has been eloquently described by one patient as a journey in which the doctor “[enters] my condition . . . [mingles] his daemon with mine; . . . [and] we . . .wrestle with my fate together".24 Compassion and a sense of service to humanity are not commodities or provider services. Medical care, notwithstanding the current industry nomenclature, is an offering, not a provision. Mindful, dignified and collaborative healthcare requires time — the time to listen, to touch, and to create meaningful relationships together. Research strongly suggests that, more than any other aspect of medical care, it is the empathic bond and trusting relationship between patient and physician that bring about measurable improvements in health outcomes.25 It is this humanistic and relational approach that the mechanistic paradigms of business, science, and technology cannot fathom. These intangible qualities are difficult to document in quarterly earnings reports or customer satisfaction surveys, or even in blinded, randomised, placebo-controlled trials. The question remains — how to advocate for and re-create the practice of a humanistic healthcare philosophy in the modern era of medicine. First, I believe it would be useful to begin on the individual level by re-evaluating our personal philosophies toward medicine and healing.26 A few examples of questions I have found myself asking are: How do I define “health” and “healing"? How do my behaviours and relationships reflect and represent those values? What values would I want my patients and colleagues to recognise in my behaviours? What might I do to increase the likelihood of those values being expressed? To aid in this exploration, seminars in medical history and philosophy should become a staple in medical schools, residency training programs, and postgraduate continuing medical education conferences. Even more importantly than formal educational programs, physicians should use each clinical and teaching encounter as an opportunity to develop and foster a meaningful philosophy of medicine for themselves, their patients, and their students. Second, we need to be supported in caring for our families and ourselves. If we are physically, emotionally and spiritually exhausted, it is unlikely that we will be able to provide the type of medical care and healing that our patients want and need.27 We must advocate for a healthcare system that not only allows, but also encourages and even requires, the healing of its healers.28 Third, we need to create an ongoing public dialogue around the relational and ethical aspects of healthcare.29 This dialogue must include non-professional partners and extend outside of hospitals and healthcare centres into communities across the country. Given the pluralism of ethnicity and language in our society, it is essential that this dialogue be made available and accessible to people from a wide variety of cultural backgrounds and socioeconomic standings. Also of importance is the inclusion of patients' family members and non-professional caregivers as integral partners in this dialogue. Fourth, what is required is a renewed focus on institutional or systemic ethics. The practical application of medical ethics has been, in large part, devoted to individual case analysis.30 What is sorely needed is an examination of the principles and behaviours of the larger system. We must examine the messages and beliefs underlying the verbiage, policies, and actions of healthcare organisations. And we must challenge them if we believe they are inconsistent with a healthful vision and mission.31,32 Examples of questions that demonstrate this initiative are: What healing values and principles does my healthcare organisation demonstrate in its daily functioning? How does my organisation support the development of its staff and encourage collaborative relationships? What healthful visions would I want to see implemented and integrated into the infrastructure? What might I do within this organisation to move it closer to that vision? Fifth, we must take advantage of every opportunity to act and be perceived as agents of positive change within the system, rather than as protectors of the status quo. Needless to say, attaining and maintaining clinical and technical competence within any field of medicine requires a tremendous amount of time and effort. However, given the inter-relatedness and interdependence of medical practice, it is no longer sufficient for physicians to limit themselves to being individually competent practitioners in examination rooms, operating rooms or on hospital wards. What is required is not only clinical competence but also “systemic competence". Finally, we must re-create the system so that it recognises, rewards, reinforces and reimburses humanistic standards of medical care.33 Accreditation and regulatory bodies should evaluate for the presence of these ethical and empathic attitudes and behaviours in individuals and within healthcare organisations. We must legislate these ideals so they become mandated and integral to the way our society provides healthcare, preserving the unique healing relationships between patients and clinicians. We must operationalise these ideals so they become active, functional components of our organisations — a dominant, leading presence within the system rather than a marginalised addendum. Ultimately, it is our larger societal context that will determine how medical care is practised. It is the public who will choose which philosophies govern the healthcare system. The 20th century brought miraculous advances to medicine, but it also bled our healing profession of some of its vital meaning. Perhaps one of our chief professional responsibilities in the 21st century will be to repair the torn relational fabric of our healthcare system. Perhaps, as suggested here, our critical role as physicians at this particular moment in history is to reclaim the moral compass of our profession and to map out the lost meanings of medicine. It is my hope and belief that physicians will seize this opportunity and rise to meet the challenge of assisting our society to develop a more healing healthcare system — a system that combines the caring with the curing, the healing with the fixing, and the sacred with the science.

Zeev E Neuwirth MD

When a dying patient lacks decision-making capacity, the general practitioner needs to collaborate with family members in making decisions about forgoing life-sustaining treatment. The key to working out the best course of action is for the doctor to have a very clear idea of which treatment options he or she considers acceptable or unacceptable. The choice of treatment depends on a thorough evaluation of all the clinical information and careful reflection, bearing in mind that medicine has its own proper limits. Life-sustaining treatment may legitimately be forgone if it is (a) therapeutically futile, (b) overly burdensome to the patient, (c) not reasonably available without disproportionate hardship to the patient's carers or others, or (d) refused by the patient.

Paul A Glare FRACP, MAApplEth(Healthcare) · Bernadette Tobin MA, PhD

To the Editor: The article by Sultan and O'Sullivan on detention of asylum seekers in Australia in the 3/17 December issue of the Journal1 contains several errors of fact and distortions that I believe you have an obligation to address. While I am not addressing medical issues, this nevertheless goes to the issue of credibility. The article made several claims that are factually wrong and would not have withstood even cursory examination had you sought verification. I will not attempt to deal with all distortions and factual errors, but your readers should be made aware of at least some elements. Detention is not arbitrary. It is humane and is not designed to be punitive. Staff are provided with cultural-awareness training and are expected to interact with detainees in an appropriate manner. Further, the level and range of medical services available to detainees exceed those available in many regional areas of Australia. It is true some people have been detained for some years. However, Sultan and O'Sullivan neglected to mention that these cases are ones where people have been found to have no lawful right to remain in Australia, but have been pursuing all legal avenues or have been refusing to cooperate with departure arrangements. Another distortion and half-truth relates to a hunger strike where "power and water supplies were cut to the cell block . . . affecting uninvolved women and children". Firstly, there are no cells at Villawood and the alleged cell block was actually a recreation room. The water supplies were cut when earth-moving equipment outside the centre accidentally cut the mains supply to the area, affecting surrounding homes and the centre. Water containers were provided for the detainees until the water supplies were restored. What Sultan and O'Sullivan do not tell you about the power supply was that it was cut when detainees ripped wires out of electrical equipment and threatened to use them to electrocute staff. This action obviously also posed a risk to the children who were moving in and out of the room. A small number of protesting detainees were denied access to the visitors' area because of the disruption their actions would cause to the majority of detainees who were not involved in the protest. Head counts have taken place at 2 am, but what you were not told was that these followed escapes and are not routine. The claim that there has been a dearth of educational and resource material is a factual error. It is disappointing that a publication of your standing did not make even cursory enquiries on simple factual issues.

Aamer Sultan MB ChB · Kevin O'Sullivan BSc, PhL, DipClinPsychol · Debra Graves MB BS, MHA, FRACMA

In reply: The Minister for Immigration and Multicultural and Indigenous Affairs, Mr Philip Ruddock, claims that our article contains several errors of fact and distortions. He does not comment on the substantive concerns of the article, but implies that the errors undermine the credibility of our finding — that prolonged detention of asylum seekers appears to cause serious psychological harm. In response, we will address the alleged errors of fact and then the credibility of the observations made in our article. The Minister states that we failed to identify the factors leading to long periods of detention for some asylum seekers. It is clearly stated in the article that "lengthier detention is particularly common for detainees who appeal against adverse decisions about their refugee status". The Minister's response adds nothing of substance to this and fails to identify the other major factor accounting for prolonged detention, namely the difficulties in removing individuals who are stateless or from countries such as Iraq and Afghanistan. The Minister states that nightly head counts at Villawood occur only after escapes. Unfortunately, the Minister has not been accurately briefed on this matter. Nightly head counts have been a regular practice at Villawood. One of us (A S) has documented proof from the minutes of both the Community Reference Committee and the Centre Manager's detainee meetings held at Villawood, which record the concerns of the detainees and the refusal of management to discontinue the practice. Moreover, this practice was openly acknowledged by the operators of Villawood to the Parliamentary Joint Standing Committee which visited the centre in February 2001.1 It is pleasing to note that, after the publication of our article, nightly head counts have been discontinued in the Stage Two section of Villawood. There are conflicting accounts between detainees and management regarding the events surrounding the hunger strike referred to by the Minister. One of us (A S) sent a complaint about this incident to the Commonwealth Ombudsman. In his reply, the Ombudsman quoted a letter from the Department of Immigration and Multicultural Affairs dated 27 October 2000, which states: "I can confirm that power to the recreation room was cut-off for a short period of time to ensure the safety of the detainees participating in the protest action who had been threatening self harm". There is no mention of attempts by detainees to electrocute staff, as suggested by the Minister, and one of us (A S) has spoken to some of the detainees involved in the protest, who have categorically denied this. Many detainees remain highly sceptical of the official explanation offered regarding the lack of water to the block where the hunger strikers were being held. The very existence of the mass hunger strike and the conflicting accounts of the incident all attest to the emotionally charged environment that has at times existed at Villawood, which was the major point of discussing this incident in our article. We made it quite clear that there have been recent improvements in recreational resources at Villawood. However, as stated in our article, there had been a long history of neglect of this issue. This was confirmed by the statement of the Human Rights and Equal Opportunity Commission in 1998 that "the recreation facilities at Villawood are inadequate for the number of detainees being held there".2 Moreover, despite recent improvements, our statement that detainees face long periods of unstructured time remains true. Although we did not discuss the issue of whether mandatory detention was arbitrary, it is worth noting in response to the Minister's claim that the Human Rights and Equal Opportunity Commission concluded that "In some instances, individuals . . . have been held for more than five years. This is arbitrary detention and cannot be justified on any grounds".2 The failure of the Minister to consider the substantive issues we raised, namely the negative psychological effects that long-term detention appears to be having on asylum seekers, was disappointing. As we stated, we attempted to report our observations in what we consider to be an objective and truthful manner. Nothing in the Minister's response suggests that we have failed to do this. Even if the findings in our report were to be entirely dismissed, Steel and Silove (in the same issue of the Journal)1 document compelling evidence of the serious psychological symptoms observed among long-term detainees. In conclusion, we can only offer a continued exhortation for the Minister to attend to the collective weight of evidence indicating a mental health crisis within Australian detention centres.

Philip Ruddock MP · Derrick M Silove · Zachary Steel · George Halasz MRCPsych, FRANZCP · Michael Block · Leon Petchkovsky · Howard Cooper · Martin B Van Der Weyden · Ruth M Armstrong · Helen M Randall

In reply: Several aspects of Mr Ruddock's letter concern us. The tendency to evade the substance of the message and instead to attack the messenger, in this case the MJA, is unwarranted. Fortunately, the Journal's reputation rests secure with its more usual, considered readership, but the accusation that the MJA has acted in a cursory manner is particularly jarring — the media response by the Minister to the publication of the relevant articles occurred within hours, hardly sufficient time to subject them to a considered analysis. The haste of the response is also evident in the substance of the letter, with its focus on largely irrelevant technical aspects rather than on the key issue — the legitimate concerns raised about the impact of detention on the mental health of inmates. Are we to assume from the Minister's silence on this core matter that he acknowledges that the majority of long-term detainees are suffering from severe depression and other disabling emotional disturbances, as described in the article by Sultan and O'Sullivan and supported by other data we cite? The rates of depression reported by Sultan and O'Sullivan represent a roughly eightfold greater prevalence than is found in the general Australian population — if correct, this reflects an epidemic of mental illness among long-term detainees. Until proven otherwise, there is every reason to assume that the mental disorders identified are a direct outgrowth of the conditions of detention. One of the key findings of research in this area is that asylum seekers in detention report similar patterns of abuse and trauma as their refugee counterparts authorised to resettle in Australia. It is paradoxical and contradictory that we provide authorised refugees some of the best rehabilitative services in the world through our national network of services for survivors of torture and trauma, while at the same time creating conditions in detention centres that exacerbate the effects of past trauma in their compatriots. The claim that detention is humane is extraordinary. From a medical perspective, the obvious test of such a claim is in the health outcomes. Instead of the steady improvement in psychosocial status witnessed in authorised refugee populations after resettlement, there appears to be a progressive deterioration in the mental health of similarly traumatised persons in detention. A policy that in its implementation directly undermines the capacity of displaced persons to recover from the effects of past stresses cannot, by any stretch of the imagination, be humane. If detention is not punishment, then what is it? We are told repeatedly that detention is a deterrent aimed at discouraging the arrival of asylum seekers. How then does detention act as a deterrent if not by punishing the few to deter the many? Interestingly, punishment, according to many criminologists, is not a good deterrent. This makes the situation even worse — punishing those whose only "crime" is to seek asylum from persecution for a presumed greater benefit that remains unattainable. The practical failure of the "punishment as deterrence" approach is evident in the recent, desperate policy shift to the costly and unsustainable "Pacific solution". What next? In short, detention is not humane — prolonged detention, in particular, exacts severe costs by undermining the mental health of detainees. The stark reality is that political policy is creating a preventable public health tragedy. If doubts remain about this conclusion, then we should turn to science as the final arbiter. It is now pressing that an independent group of researchers undertake a comprehensive survey of detention centres in Australia and the Pacific to establish once and for all the impact of current policies on the mental health of the detainees.

Philip Ruddock

To the Editor: We wish to acknowledge Dr Aamer Sultan's courage in carrying out his research as a "participant–observer" into the impact of long-term detention on psychological health of asylum seekers1 at the Villawood Detention Centre, Sydney. In response to the article, Dr Louise Newman, Fellow of the Royal Australian and New Zealand College of Psychiatrists, called for an urgent assessment of the mental and physical health of asylum seekers in detention. As well, The Australian2 reported that Dr Newman advised members of the College not to accept appointments in detention centres because of serious concerns about how they were run by Australasian Correctional Management. Dr Sultan inspires the medical profession, at considerable risk to himself, in order to fulfil the obligation of the first aphorism of Hippocrates: "The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate."

Philip Ruddock

To the Editor: I am writing as a member of the Australian Medical Association, and hence a subscriber to the MJA, to express my concern over the recent publication of the participant–observer account of psychological disturbances in asylum seekers,1 and the subsequent media reporting of the issue as a consequence of the publication. I would like to say at the outset my views are personal. Like most healthcare professionals, I consider access to basic medical care, including care for those with mental illness, is a human right. However, I do not support the use of a peer-reviewed journal such as the MJA for political purposes. The right of freedom of speech is fundamental in a democratic society; however, if the AMA wishes to push a political issue then such articles should be published not in the MJA but in Australian Medicine, with appropriate recognition that the issue is medicopolitical and not scientific. My concerns relate to the responsibility I consider peer-reviewed journals such as the MJA have in ensuring that articles, which include reports of alleged research, are scientifically valid. As can be seen by the media coverage on this issue, the fact that the "research study" was published in the MJA gave the impression to the general public that it was a valid scientific study and should be taken seriously. I have a number of specific issues of concern in relation to the article. Firstly, there is the fact that the principal author and researcher, in being a detainee with serious concerns over his treatment by the democratically elected government of this country, obviously has considerable potential bias in reporting observational research of this kind. Secondly, there is no attempt to assess the baseline mental health of the detainees before coming to Australia, but an assumption that all the symptoms observed are a result of detention. Thirdly, it would appear that there was no attempt to validate the observational research using more rigorous psychological testing. Finally, the methodology of the survey is not outlined, nor is the sample size discussed from the point of view of statistical validity. Admittedly, there was an acknowledgement of the survey's limitations; however, I do not consider that this article should have been published in the MJA. It does the Editorial Committee no credit and the Journal less so.

Philip Ruddock

In reply: The Hon. Philip Ruddock, the Minister for Immigration and Multicultural and Indigenous Affairs, believes that the article by Sultan and O'Sullivan1 makes "several claims that are factually wrong and would not have withstood even cursory examination". When assessing whether contributions are suitable for publication in the Journal, the editors of the MJA submit them to peer review, which has been defined as "independent assessment of the scientific merit of research by experts having knowledge of the research area equal to that of the performers of the work".2 The article referred to by the Minister posed a dilemma. Those with "equal knowledge of the research area" — representatives of the Department of Immigration and Multicultural Affairs or the Department's provider of security services (Australasian Correctional Management) — would have a patent conflict of interest. The Journal did, however, seek advice as to the accuracy of the article from a person with knowledge of the situation at Villawood, who did not advise as to "errors of fact and distortions", as alleged by the Minister. The discrepancy between the truth according to the Minister and according to Sultan and O'Sullivan may reflect differing interpretations and perceptions of information conveyed by intermediaries. Graves implies that detained asylum seekers' mental health and access to healthcare is a medicopolitical issue and that the forum for this debate should be the Australian Medical Association. So it should be! But the MJA has complete editorial independence from the AMA, and we believe that the mental health of asylum seekers transcends medicopolitics and goes to the very core of the ideals of medicine. Finally, it was very clear from the title of the article, and its authorship, that it represented the perspectives of a detained doctor (one of Graves' concerns) and a former visiting psychologist. However, we believe that our readership is sophisticated enough to interpret the content of such articles. We also believe, contrary to Ruddock and Graves, that the standing of the Journal remains solid, as does its policy of "providing a forum for . . . commentary and informed debate on standards of clinical practice, ethics, social, legal and other issues related to health care in Australia".3 To our knowledge, the information conveyed by Sultan and O'Sullivan's article is the best available data on the mental health of detained asylum seekers in Australia. We look forward to a more rigorous and independent assessment, hopefully initiated by the Minister. The opportunity is his.

Philip Ruddock

To the Editor: The recent creation of the National Institute for Clinical Studies (NICS) is an exciting new opportunity for bridging the gap between evidence and practice.1 In carrying out this task, NICS will be directed by the members of its Board. Balanced stakeholder representation on the Board is required for NICS to produce optimal results. At present the Board consists of nine members, of whom eight are medical practitioners. The importance of doctors in the process and implementation of quality improvement initiatives is indisputable. However, other healthcare professionals also play a central role in achieving quality health outcomes for patients.2 Board membership more representative of its stakeholders would provide NICS with a broader range of perspectives, which could only be seen as beneficial. Given the current debate surrounding ethics and evidence-based healthcare, the values and expectations of healthcare consumers also need to be taken into account.3 One of the definitions of quality in healthcare is "consistently meeting or exceeding informed customers' opinion".4 It is crucial that the consumer's voice be heard in matters relating to healthcare research and in the implementation of quality initiatives. As the relevance and acceptability of quality initiatives undertaken by NICS will have an impact on health outcomes for consumers, it is important that such initiatives take into account the preferences of consumers. For this reason, we believe it is imperative that NICS include a consumer on its Board. An example of successful integration of a wide range of stakeholders onto a board is the Federal Government-funded National Health Priority Action Council, with representation from State/Territory, Indigenous and consumer groups and a balanced gender mix. We hope that NICS has strategies in place to enhance stakeholder representation on its Board, as this may be a factor in determining whether or not NICS becomes another forgettable acronym.

Louise V Hall

In reply: The Board of the National Institute of Clinical Studies (NICS) agrees strongly with Hall and Lauder that closing the gap between evidence and practice involves input from consumers. We also agree that the Board of Directors should seek to incorporate input from consumers in its strategic and operational activities. Of equal concern to the Board is ensuring the input of other stakeholder groups also currently not reflected in the composition of Board membership. For example, nursing and allied health professions comprise about 80% of the healthcare workforce and have shown strong leadership in relation to evidence-based practice. We are keen to see such groups actively involved in all aspects of the Institute's work. As a Federal Government-owned company, the selection and appointment process for Board members is the responsibility of government and our constitution does not allow the Board to change its own membership. However, the Board is seeking input from both consumers and other key stakeholder groups, both through its initial consultation processes and through establishment of Board advisory groups specifically focused on consumer issues and nursing and allied health. These groups will provide direct and valued input into the strategic and operational activities of the NICS. Our first round of consultation, with over 300 organisations, highlighted a number of areas where there are currently major gaps between evidence and practice, such as cardiac failure, various forms of cancer treatment, prevention of deep vein thrombosis in hospitalised patients, prevention of bedsores, and prescribing of psychotropic drugs for children. We are now examining ways in which the NICS might usefully help in some of these areas to identify barriers and possible solutions that can be rolled out across the healthcare system and sustained. The success of the NICS in achieving this will depend on the willingness of all stakeholders (including health professionals, consumers and managers) to work together in a constructive way.

Louise V Hall BPhty · Allison E Lauder BSc(Nut), MND · Chris A Silagy

To the Editor: I am concerned that several statements in the article on cyclooxygenase-2 (COX-2) inhibition by Cleland and colleagues1 do not accurately reflect the clinical data. The authors postulate a prothrombotic tendency of celecoxib on the basis of the CLASS study (comparing celecoxib with ibuprofen or diclofenac)2 and four case reports. The authors concede that celecoxib has no effect on the rate of myocardial infarction (MI) in the CLASS study (a conclusion also reached by the United States Food and Drug Administration [FDA] review of CLASS3), which would seem to contradict their hypothesis that celecoxib is prothrombotic. Cleland and colleagues speculate that the differences between the CLASS study and the VIGOR study (which compared rofecoxib with naproxen)4 may be explained by low-dose aspirin use in CLASS and failure to use aspirin in 4% of patients in VIGOR with "CV [cardiovacular] risk factors". This speculation is unfounded. In the CLASS study patients in all treatment groups who used aspirin had higher MI rates than non-aspirin users, and presumably this higher rate would have been observed in VIGOR if aspirin users had been enrolled. This higher rate is probably because aspirin use serves as a marker for increased CV risk. In patients in CLASS similar to the 4% with "CV risk factors" in VIGOR, MI rates were similar in the celecoxib and non-steroidal anti-inflammatory drug (NSAID) groups (data on file, Pharmacia) and numerically much lower than in the VIGOR study subgroup. On the basis of these two flawed arguments, Cleland and colleagues apparently extrapolate the high rate of MI seen with the use of rofecoxib to celecoxib and suggest that high MI rates are a "class" effect. This proposal is scientifically unsound and is not supported by other clinical data, including over 12 000 patients in the celecoxib registration program (data on file, Pharmacia). No celecoxib study has shown an increased risk of MI compared with traditional NSAIDs. The authors correctly assert there is "little clinical evidence from community use to suggest that selective COX-2 inhibition has serious unwanted effects other than those seen with standard NSAIDs", but imply there are few community data. In fact, community use of celecoxib in Australia (at least 1.5 million patients exposed) and worldwide (more than 20 million) has been extensive, and with this degree of exposure one would expect significant adverse event patterns to emerge. Reference to the Adverse Drug Reactions Advisory Committee and FDA database does not indicate a prothrombotic tendency of celecoxib. Further, we at Pharmacia do not consider that the four case studies presented by Cleland et al provide strong support for a prothrombotic tendency for celecoxib, especially as all patients described had diseases with high risk for thrombosis. On the basis of a large body of controlled trial data (including CLASS) and extensive community exposure, the evidence does not show any more thrombosis with celecoxib than with NSAIDs. Results of the CLASS and VIGOR studies clearly differ. It is clinically unjustified and scientifically unsound to suggest that rates of MI seen with rofecoxib can be ascribed to celecoxib and described as a "class effect".

Christopher G Fenn

In reply: The response from the Medical Director of Pharmacia to our article highlights some problems for all clinicians and independent scientists seeking to evaluate the balance of risks and benefits of pharmaceuticals and to validate the marketing messages of pharmaceutical companies. On the one hand, we lack the time and statistical resources to trawl through all data related to all trials with a test drug. On the other, our efforts to evaluate data are confounded by the publication and reporting biases associated with company-sponsored studies. In this regard, it is notable that the definitive results of CLASS1 have not been published, although the Food and Drug Administration (FDA) review of the data is available through an FDA website,2 as indicated by Fenn. While this document places data in the public domain, its location is neither within the pathway of MEDLINE search engines, nor is it known to the general body of clinicians. As reported in the FDA presentation, CLASS was a very large, double-blind safety study of at least six months' treatment that failed to achieve its primary endpoint of reduced complicated upper gastrointestinal events with celecoxib relative to the comparator, non-steroidal anti-inflammatory drugs (NSAIDs). While an interim analysis at six months was published, with extrapolation of event rates to 12 months,3 failure to publish the final results has withheld important results from wider scrutiny. In essence, the FDA document shows no overall long-term safety advantage of celecoxib over standard NSAIDs.2 The FDA analysis4 of the VIGOR study5 also shows no overall safety advantage for rofecoxib compared with NSAID, with fewer complicated upper gastrointestinal events being offset by a highly statistically significant (P = 0.0016) increase in serious thrombotic cardiovascular events. Collectively, these FDA analyses invalidate the promotion of selective cyclooxygenase-2 (COX-2) inhibitors as a safe alternative to NSAIDs, notwithstanding encouraging results from short-term trials. Further, although an increase in serious cardiovascular events was not seen in the CLASS study, its design was not optimal for detecting increased cardiovascular risk, and it is unlikely that CLASS was sufficiently powered to detect the degree of increased risk seen with rofecoxib in VIGOR. As explained in our article,6 unbalanced prothrombotic eicosanoid production associated with selective COX-2 inhibition (ie, a class effect) appears the most likely explanation for the increased cardiovascular events seen in VIGOR. Finally, we wish to reassert that, for effective postmarketing surveillance, it is essential that prescribers be adequately informed about safety concerns associated with new drugs, particularly when they involve events that are common and not usually seen as unwanted drug effects.

Leslie G Cleland · Michael J James

To the Editor: Chronic hepatitis C (HCV) infection affects more than 200 000 Australians.1 As the degree of hepatic fibrosis is the best predictor of morbidity, liver biopsy has a central role in management. Biopsy is also carried out to exclude additional pathology. However, because liver biopsy carries real risks and is expensive,2,3 debate exists as to whether liver biopsy should be performed routinely.3,4 Despite controversy surrounding the need to treat patients with minor histological changes,4 our impression is that many informed patients request treatment irrespective of liver histology. In Australia, liver biopsy is a prerequisite for antiviral therapy under the Pharmaceutical Benefits Scheme Highly Specialised Drugs Program (Box).5 To assess the impact of liver biopsy on management, we performed a retrospective study of patients with chronic HCV infection who underwent liver biopsy from March 1998 to December 2000. We identified 76 patients (51 men, 25 women), with a mean age of 29 years (range, 20–52 years). The biopsy was performed to stage and grade hepatitis C in all patients, and additionally to investigate a second pathology in seven patients. No alternative diagnoses were raised. Additional diagnoses (all suspected before biopsy) were confirmed in three patients and refuted in four patients. Biopsy findings were all consistent with chronic HCV infection, with some degree of fibrosis in 69 patients. There were five patients with histologically confirmed cirrhosis (including incomplete cirrhosis in three), and this was clinically evident in two patients. When S100 criteria at the time of biopsy were applied, after exclusions on clinical grounds, only one patient would have been ineligible for interferon monotherapy based on liver histology. Under current S100 criteria, nine patients would be ineligible for combination therapy, but all nine would remain eligible for monotherapy. Of our patients who attended follow-up and were HCV RNA positive, 62 of 64 patients received or are awaiting therapy. Our results confirm the finding that liver biopsy in patients with chronic HCV infection rarely identifies alternative diagnoses.3 These data reflect the fact that most chronic liver diseases can be diagnosed before biopsy. Biopsy remains an important tool for histological diagnosis of cirrhosis. However, as unexpected findings are uncommon and some patients will be treated irrespective of liver histology, there is an emerging argument not to perform liver biopsy routinely. This argument will strengthen if valid biochemical markers of fibrosis are confirmed.6 We believe each patient should be assessed individually, and treatment could be offered without biopsy to patients who: meet all criteria for treatment under current guidelines other than known liver histology; have no alternative or additional diagnoses after thorough work-up; strongly desire treatment regardless of histology, and there is sound indication for treatment (eg, extrahepatic symptoms, concerns of vertical or occupational transmission); have a high chance of sustained viral response (eg, favourable genotype); have no clinical, biochemical or haematological suggestion of cirrhosis; and with the physician, accept the implications of treatment without biopsy. An alternative strategy could be to consider a biopsy in patients who do not have a sustained virological response, to allow prognostication. Clearly, such changes would greatly affect biopsy practices in Australia. Section 1005 criteria for use of combination therapy with interferon alfa 2b and ribavirin Patients with chronic hepatitis C who satisfy the following criteria are eligible for interferon alfa 2b and ribavirin: On liver biopsy, are staged as METAVIR stage 2 or greater, or METAVIR stage 1 with grade A2 or A3 inflammation (except patients with coagulation disorders); Have abnormal alanine aminotransferase levels in conjunction with demonstration of viral infection (HCV RNA positive);* Do not have other liver disease;* Are not pregnant, not lactating, and are using two reliable methods of contraception;* Have no history of significant psychiatric illness; Would be likely to attend regularly for treatment and follow-up; and Take no more than seven standard alcoholic drinks a week. Genotype of virus should be assessed before treatment Treatment course is 24 weeks except: With Genotype 1 and patients with cirrhosis or bridging fibrosis (regardless of genotype), where treatment course is 48 weeks; and Treatment will be continued for 48 weeks only if HCV RNA qualitative assay is negative at 24 weeks. OR Patients who have relapsed after treatment with interferon 2a/2b monotherapy supplied as a Section 100 medication. This course is limited to 24 weeks. Section 1005 criteria for use of monotherapy with interferon alfa 2b Patients with chronic hepatitis C confirmed on liver biopsy (except patients with coagulation disorders) are eligible for interferon alfa 2b monotherapy if they satisfy the criteria marked with asterisks above. (When monotherapy fails, patients become eligible for combination therapy.) Treatment is to cease if plasma HCV RNA remains detectable by HCV RNA qualitative assay after 12 weeks of treatment. The course must be continuous and excludes retreatment of non-responders or patients who relapse.

Ian F Yusoff · Lindsay Mollison · Leanne Totten · John Olynyk

To the Editor: With the recognition that supplements of folate given early in pregnancy can reduce the incidence of neural tube defects,1,2 Australian manufacturers were allowed voluntary food fortification with folate from 1995, and these foods subsequently became available from August 1996. We assessed the impact of this fortification by comparing the results of assays of serum folate, a sensitive index of folate intake, before and after the introduction of folate-fortified foods. Data were available for serum folate samples assayed by the chemiluminescence method (Chiron Healthcare Pty Ltd, Scoresby, Victoria) at our laboratory in Melbourne. Quality assurance data indicated no analytical drift, and external proficiency testing yielded satisfactory results throughout the period under study. A total of 20 506 samples from women aged 14–45 years, the target group for supplementation, and 5528 samples from men of the same age group were assayed during 1993–2000. The results for the years 1993–1996, before fortification, where sample numbers were relatively small, were pooled. The results were analysed by Bhattacharya plot, eliminating the effect of outlier values,3 mindful of the limitations of extrapolating data derived from clinical material to the community. The mean values are shown in the Box. In both groups there was a small incremental rise in mean serum folate concentrations, and a fall in the prevalence of low values, after the introduction of fortification. The mean value of 14.0 nmol/L for women in 1993–1996 increased by about 19% to 16.7 nmol/L in 2000. The percentage of low values decreased from 8.5% to 4.1% over that period. Although it is possible that the increase in serum folate concentration reflects dietary education and use of folate supplements in women of reproductive age rather than food fortification specifically, parallel changes were also observed in men. In the United States, folate fortification of all enriched cereal grain products was mandated from January 1998. This led to a dramatic increase of 250% in mean folate levels in women aged 15–44 years,4 and an increase of 50% in the median values (uncorrected for outliers) for men, women and children of all ages submitted for clinical evaluation.5 By comparison, the increase in folate levels in Australia has been very small. We conclude that to obtain a significant increase in folate intake in the community by food fortification, a policy of mandatory rather than voluntary fortification is required. Serum folate concentrations in Victorian women and men aged 15–45 years before (1993–1996) and after (1997–2000) the introduction of voluntary food folate fortification Year 1993 to 1996 1997 1998 1999 2000 Women Number 3865 2989 4168 4385 5099 Mean folate concentration (nmol/L)* 14.0 14.5 15.3 16.4 16.7 95% confidence limits 6.7–28.3 5.0–38.6 5.7–38.1 5.7–41.0 5.6–45.5 % Low values† 8.5 7.1 5.7 4.3 4.1 Men Number 1077 849 1130 1117 1355 Mean folate concentration (nmol/L)* 14.0 14.9 15.7 16.5 16.2 95% confidence limits 6.4–28.7 4.7–31.0 5.5–35.6 6.2–41.6 5.9–42.1 % Low values† 7.9 8.1 6.5 4.1 5.1 * Derived from log normal distribution of community values by Bhattacharya method. † 8.0 nmol/L.

Jack Metz · Ken A Sikaris · Ellen L Maxwell · Mark D Levin

To the Editor: In late 1998, a clinical audit in the Thoracic Division of the Prince Charles Hospital found the autopsy rate was 7% of all patients who died in the Division (excluding Palliative Care) for the 12 months to September 1998. Following discussions and acknowledgement of the importance of hospital autopsy as a clinical audit tool, the Division's policy to consider an autopsy in all patients who died was reinforced. Registrars were educated in seeking approval and in counselling relatives. As a result of these interventions and ongoing audit, a decision in relation to autopsy is now recorded in more than 90% of charts following a patient's death, compared with 40% initially. The autopsy rate progressively increased, and, from March 2000 to January 2001, it was 35%, five times the baseline rate, and the refusal rate was 11% (Box). The rate of limited autopsies (generally only excluding the brain) increased from 20% to 50%. However, from early 2001, coinciding with the ongoing negative Australian press coverage related to aspects of autopsies, there has been a marked decrease in relatives' agreement to allow autopsy and extent of autopsy. The refusal rate for autopsy increased to 30% for the four months to May 2001, and was 25% to September 2001. The autopsy rate fell dramatically to 27% and 13% for the same periods. Nine of the 10 autopsies were limited, usually to a single organ or body cavity. Data from death certificates are vital for education, research and public health purposes.1,2 Autopsies remain the only way to audit the accuracy of death certificates. A review found that the rate of clinical diagnostic inaccuracy for major findings at autopsy is about a third, and this rate has not changed since 1912.3 This unavoidable baseline of diagnostic error4 does not necessarily indicate incompetence or malpractice. It is essential that the public understand that medicine is not an exact science, that we do misdiagnose conditions, and that identification of these "errors" is of value to relatives, to future patients and to society. Legislative changes are being proposed in Australia that will make obtaining consent for autopsies more complex and potentially distressing for relatives. Education of medical staff and the general public must accompany these changes if they are not to be the final "nail in the coffin" of the hospital autopsy and remove an important facet of continuing improvement of medical practice. Autopsy rates in the Thoracic Division of the Prince Charles Hospital

Helen E Ward · Belinda E Clarke · Paul V Zimmerman · Michael I Cleary

To the Editor: The National Health and Medical Research Council has launched new Australian alcohol guidelines1 to help reduce alcohol-caused deaths in Australia, estimated to have been 3290 in 1997.2 Male drinkers are advised to drink no more than an average of 40 g alcohol per day and females no more than an average of 20 g of alcohol per day to prevent chronic health problems (eg, alcoholic liver cirrhosis). Furthermore, it is recommended that, provided there are no other situational or individual risk factors (such as driving or being pregnant), men drink no more than 60 g on any day and women no more than 40 g to prevent acute conditions associated with bouts of intoxication (eg, alcohol-related injuries). Volumes of alcohol intake reported at each NHMRC risk level by 10 030 respondents to the 1998 National Drug Strategy Household (NDSH) survey were calculated.3 The data were weighted for age and sex. Volumes of alcohol reported to have been consumed at different risk levels were summed for all subjects and expressed as percentages of the total reported consumption of the sample. It was found that 39% of total consumption was categorised as being drunk by people who exceeded low-risk limits for chronic harm (36% for men, 45% for women). It was found that 51% of total consumption occurred on days when the drinker exceeded low-risk limits for acute harm (53% for men and 47% for women). Drinking that was risky for either acute or chronic harm was found to comprise 67% of total consumption (see Table). For young men aged 18–24 years this figure was 93% of all alcohol consumed. These estimates are conservative, as the level of drinking reported in the 1998 NDSH survey is consistent with an adult per capita consumption of only 46.5% of that estimated by the Australian Bureau of Statistics for that year on the basis of import, export and production data.3 The high proportion of all alcohol consumed that places drinkers at risk of serious harm helps explain why per capita alcohol consumption correlates so closely with levels of suicide, road death, homicide, liver cirrhosis and other causes of death.4 It follows that policies which reduce the total consumption of alcohol in Australia will reduce the associated health and economic costs by reducing levels of risky drinking. Further, policies which successfully reduce high-risk drinking will also reduce total population consumption of alcohol. Percentage of alcohol consumed at risk levels for acute and/or chronic harm, as specified in the new Australian alcohol guidelines,1 by age and sex (n = 10 030, weighted data) Age (years) Females (%) Males (%) Total (%) 14–17 71.3 77.4 75.1 18–24 82.3 92.9 89.9 25–39 68.1 66.4 66.9 40–64 67.7 62.0 63.6 65 + 46.5 39.5 41.4 All ages 68.4 66.5 67.0

Tim R Stockwell · Penny Heale · Tanya N Chikritzhs · Paul Dietze · Paul Catalano

Re: "What people say about their general practitioners' treatment of anxiety and depression", by Andrews G, Carter GL, in the 16 July Supplement on the SPHERE National Depression Project (Med J Aust 2001; 175: S48–S51, not available online). On page S49, column 1, the last sentence under the heading "Assessment" should be replaced by "'Perceived health need' was based on questions derived from the work by Meadows et al.1 These questions were asked principally of people who had not sought treatment. Similar concepts were used by the UK Survey of Psychiatric Morbidity questions." The authors apologise for this omission and would like to draw readers' attention to another article by Meadows et al2 for a more complete discussion of the development of the perceived need for care questionnaire.

G Andrews · and G L Carter

Gwen Nash was born in Cairo, Egypt, in 1904, of missionary parents. After World War I the family migrated to Sydney and Gwen studied medicine at Sydney University, where she was one of only seven women in a class of 56. After graduation, she worked at Prince Alfred Hospital, Crown Street Women's Hospital and the Children's Hospital. In 1932 she enrolled at the Melbourne Bible Institute, where she met her husband, Laurence Nash. When they were married in 1933 she followed him to Hong Kong, where she became Director of Women's Medical Services. Gwen returned to Australia at the outbreak of World War II when her husband joined the Royal Australian Navy. During the war Gwen raised three children and continued working in general practice in East Melbourne and at the Freemasons and Queen Victoria hospitals. In 1944 the family moved to Hobart. Gwen worked as a government medical officer, as well as giving regular religious devotional talks for the ABC (the "token woman", she said). It was when the family moved to Melbourne, in 1952, that Gwen started training in psychiatry at Royal Park Psychiatric Hospital under the tutelage of Dr John Cade. She subsequently worked as a psychiatrist at the Alexandria and Malvern clinics and resumed her religious broadcasting. In 1965, after Laurence died suddenly, she moved to Armadale, Victoria. She worked for the Victorian Health Department, including a year as Superintendent of Ararat Psychiatric Hospital and, after this, set up in private practice as a psychiatrist. She served on the Anglican diocese as honorary psychiatrist on the Diocesan Selection Board. Gwen enjoyed retirement in Glen Iris, until a fall resulted in a broken hip. From then she slowly deteriorated and in January 2000 moved to a nursing home, where she died on 4 September 2001, aged nearly 97. Gwen's passions were the well being of her patients, her Christian faith, her family, and a wide circle of friends in Australia and overseas. She was deeply concerned that women have the opportunity to be educated, to have careers and to value their own experience, and she mentored many women professionally and privately. She leaves behind many people whose lives have been enriched by her generosity and her steadfast faith.

Felicity Brown · Barbara Overbury and · Kate Nash

Cycling to diabetes Long or highly irregular menstrual cycles are a predictor of increased risk for type 2 diabetes mellitus (DM). This result comes from the Nurses Health Study II, in which 101073 American women aged 24-43 years were recruited in 1989, and followed for eight years. At baseline they self-reported on aspects of health, including family history, smoking, body mass index (BMI) and their menstrual cycle at age 18-22 years. Obesity was found to be a major risk factor for type 2 DM, but even after adjusting for BMI the relative risk of developing type 2 DM in women whose menstrual cycles were irregular or ≥ 40 days long was 2.08. Women with this menstrual history may benefit from lifestyle approaches to reduce risk. JAMA 2001; 286: 2421-2426 Two in the tub Researchers in Australia and the United States have joined forces to highlight the dangers of leaving children to supervise their younger siblings while bathing together. The researchers searched several autopsy databases in each country and found 17 cases of children aged two years and under who drowned while in the bath with another child. Depending on the individual database, this represented between 22% and 58% of all bath drownings in this age group. The victims were younger than the surviving child in every case (mean age, 11.8 v 30.4 months), and all the children had been left unsupervised. J Paediatr Child Health 2001; 37: 542-544 Supporting evidence Although the literature is divided as to whether psychosocial treatments for cancer confer any survival benefit, it seems they may have a role in reducing distress and suffering. A recent multicentre Canadian study1 examined the addition of supportive-expressive group therapy to standard care for metastatic breast cancer. In this study 158 women were randomly assigned to receive weekly group therapy for at least a year and 77 women acted as controls. Women in the intervention group did not enjoy a survival advantage (median survival of 17.9 months, compared with 17.6 months among the controls). However, group therapy did improve mood and perception of pain, particularly in women who were initially more distressed. The Canadian study was attempting to replicate the results of a previous positive trial, published in 1989. In an accompanying editorial2 the author of this earlier trial attributed the different outcome to improvements in medical treatment and the emotional support available to patients with cancer. Citing his new study,3 he concludes that, in group therapy, confronting the possibility of dying from metastatic breast cancer is emotionally helpful and not physically harmful. We await a systematic review. 1. N Engl J Med 2001; 345: 1719-1726 2. N Engl J Med 2001; 345: 1767-1768 3. Arch Gen Psychiatry 2001; 58: 494-501 Smoking on screen If the sight of Sharon Stone looking sexily inscrutable as she drew back on a cigarette in Basic Instinct made you feel like lighting up, you're not alone. A study of 4919 adolescents in the United States has found that viewing smoking in movies is associated with trying it in real life. Researchers developed a list of box office hits released between 1988 and 1999. They counted episodes of smoking in each, then asked the youngsters to nominate films they had seen. The prevalence of ever trying smoking increased with increasing exposure to smoking in movies (4.9% in those who saw < 50 occurrences, 13.7% for 51-100 occurrences, 22.1% for 101-150 occurrences and 33.1% for > 150 occurrences). The differences remained significant after adjustment for multiple potential confounders, including age, sex, and parental, personality and social factors. BMJ 2001; 323: 1394-1397 Nose for Down's marker Researchers in the UK have discovered a possible way of increasing the accuracy of early fetal screening for trisomy 21. Extrapolating from Langdon Down's original observation that people with Down's syndrome had small noses, the researchers used ultrasound to examine the nasal bones of 701 fetuses (11-14 weeks' gestation) who were about to undergo chorionic villous sampling and karyotyping. The nasal bone was absent in 43 of 59 (73%) fetuses with trisomy 21 and three of 603 (0.5%) normal fetuses. The researchers suggest that adding a look at fetal nasal bones to first-trimester screening by maternal age and fetal nuchal translucency thickness could increase the sensitivity of the screen from 75% to 85% and decrease the false positive rate from 5% to about 1%. Lancet 2001: 358; 1665-1667