Volume 177 Issue 6

The logic is simple, but the implementation difficult and the costs potentially astronomical. Simple, because the cause is usually ventricular fibrillation (VF), which, if corrected within one minute, leads to survival in well over 90% of patients.1 Implementation is difficult because of the 10% fall in survival for every minute that passes from onset of VF until a defibrillator can be used.1 Astronomical cost is anticipated if all people at high risk of VF were to be offered an implantable defibrillator,2 or if the conventional ambulance service were geared up to provide a response time of less than five minutes in metropolitan areas. Novel approaches are required, as the average Australian ambulance response to cardiac arrest is 8–10 minutes even in metropolitan areas, and the survival to discharge for VF is generally less than 10%. A new initiative is presented on page 305 of the Journal — Smith et al report the experience in Melbourne, where fire fighters have been trained to defibrillate, fire trucks are equipped with defibrillators, and a three-tier response (ambulance, intensive care ambulance, and fire vehicle) is made to 000 calls for suspected cardiac arrest.3 The Victorian Government and the Victorian Department of Health are to be complimented on trying a new approach, as are the emergency service officers who participated. But the results are disappointing, despite overall mean response time of 6.0 minutes and time to defibrillation of 8.8 minutes. Of 2942 events, 1331 patients were in cardiac arrest and considered for resuscitation, but just 155 were in VF. From these, there were 26 known survivors, of whom 10 received initial care from fire fighters and 16 from ambulance paramedics. Of the 10 initially treated by fire fighters, possibly half would not have survived with the later arrival of an ambulance. The low prevalence of VF (12% of all [155 of 1331]; 36% of presumed cardiac arrests [155 of 430]) contrasts with the 100% prevalence at the Melbourne Cricket Ground,4 suggesting that there was substantial delay in calling 000. In the Melbourne experience for three-tier response, costs were not estimated, but must include the wage margin negotiated with fire fighters, the cost of training and equipping vehicles, and any overtime worked. A rough estimate for a possible five lives saved among almost 3000 calls reported by Smith et al is more than $1 million. The question arises, is there a better way? In the United States, emergency medical services are usually provided by town or city fire departments. However, except in model cities like Seattle, response times are similar to or longer than those in Australia, and survival rates correspondingly bad. In Rochester, Minnesota (home of the Mayo Clinic), defibrillators are carried in police vehicles. As in Melbourne, these vehicles respond to an emergency (911) call and have reduced response time to five minutes, with overall survival boosted to more than 40%.5 This system has been tried in other US cities and rural areas, but without the same commitment or success. Regrettably, in most instances, the overall survival rate remains less than 10%, and could be worse in an environment where security is more intense and access more difficult. Is there another way to tackle this problem? Clearly, we can identify high-risk individuals and insert a pacemaker/defibrillator (as in US Vice President Dick Cheney), but at high cost, and with benefit to a small fraction1,2 of the more than 10 000 people who suffer cardiac arrest outside hospital each year in Australia. Most cardiac arrests are unexpected and occur in people with little or no apparent risk.1 A different way was first suggested by Frank Pantridge, who initiated the "coronary ambulance" concept. In 1968, he developed a small portable defibrillator, which he suggested be located like a fire extinguisher in buildings and public places.6 His idea fell flat, since the device could be used as a weapon, but has regained credibility with development of semi-automatic defibrillators that can only be activated if a person is in VF.7 These defibrillators were introduced into all ambulances in New South Wales in 1990, then into the Qantas aircraft fleet in 1991,8 then much more widely. The high survival rates for VF at the Melbourne Cricket Ground (71%),4 Chicago (O'Hare) Airport (75%)9 and Las Vegas casinos (53%)10 are attributable to very early use by first responders (St John volunteers, airport staff, passers-by, or security officers), who can initiate defibrillation well within the time it takes for conventional emergency services to arrive. What then is the current status of "public access defibrillation" — the fire extinguisher approach? The program has the blessing of the American Heart Association and the International Liaison Council on Resuscitation, which have been promoting it with increasing enthusiasm since 1990. In Australia, it has been promoted by St John Ambulance (the most experienced voluntary body), the Heart Foundation, and the Australian Resuscitation Council. In the US,7 state legislation has been introduced to permit early implementation, and federal legislation has been passed to provide defibrillators for isolated areas, and to require installation of defibrillators for "public access", with key staff trained, into all major federal buildings and into all passenger aircraft with one or more cabin attendants by mid-2004. In the United Kingdom,11 more than 800 defibrillators have been deployed in public places and another 3000 placements planned — and key staff trained — under a government initiative. Australia, regrettably, has fallen behind. The NSW Ambulance Service provided key advice in development of the original Laerdal semi-automatic defibrillator, while Qantas was the pioneer in the sky and set the benchmark for aircraft and airports in 1991. The National Health and Medical Research Council (NHMRC) has, to date, not seen cardiac arrest as a health priority, despite more than 10 000 lives lost yearly and a potentially high salvage rate. Currently, St John Ambulance Australia has a proposal before the federal government for a program with strong community links and has a belated chance to match or better what is happening in the US, the UK and elsewhere. The Melbourne experience reported in this issue may be disappointing, but it is an important step by the Victorian government, emergency services and medical personnel, who have already achieved recognition for other initiatives in pre-hospital care. We have new tools and we need to implement them to address the most common cause of sudden unexpected death in our community.

Michael F O'Rourke MD, DSc

In this issue of the Journal, Loke and colleagues (page 291) present data from an analysis of 174 advertisements for pharmaceuticals appearing in six Australian medical publications.1 The findings are striking enough to be restated. Fewer than 8% of the advertisements contained quantitative data about the outcomes of therapy, and most of these framed the information in relative rather than absolute terms. Only 28% of the therapeutic claims in the advertisements conveyed clinical outcomes in any specific, substantive and unambiguous way. In the United States, pharmaceutical advertising is subject to the Federal Food, Drug, and Cosmetic Act,2 and Loke et al suggest that, in Australia, advertisements for drugs may be less informative than in the US. The pharmaceutical industry has long maintained that drug advertisements are an important vehicle for conveying important information about new drugs to prescribers. Is this how industry believes it should communicate with highly trained healthcare professionals? Should we really be surprised by the results of Loke et al, and, more importantly, should we be concerned? We know that the pharmaceutical industry spends enormous sums on promoting its products (about twice the amount spent on research and development),3 but most data on the effect of advertising on prescribing are unpublished, and have been gathered by advertising companies. The Association of Medical Publishers (AMP), a US-based organisation whose membership includes the publishers of nearly 200 biomedical journals, boasts "advertising in medical publications alone... can generate sales for both new and more-established products" [original emphasis].4 AMP reports a number of studies that have shown a significant increase in market share and retail sales as a result of medical journal advertising, which is reported to provide a return on investment (ROI) of about US$5.00 for every dollar spent, greater than detailing (ROI US$1.72) and direct-to-consumer advertising (ROI US$0.19).5 Most advertisements are for new and expensive drugs, so increased use due to promotion will contribute to the financial pressures on the Pharmaceutical Benefits Scheme (PBS). Does journal advertising also lead to inappropriate practices? Although there is a substantial body of research on the effects of pharmaceutical industry promotion generally, relatively little involves printed advertisements in medical journals. In a landmark study, Avorn and colleagues studied physicians' beliefs about the efficacy of two classes of drugs (propoxyphene analgesics and central/peripheral vasodilators) that were being heavily promoted as effective, despite evidence that they lacked any efficacy and offered no advantages over existing treatments.6 The authors found that, even though doctors reported paying little attention to drug advertisements, most doctors believed that these agents were effective. Do the results reported by Loke and colleagues have other implications? What is their relevance for the development of government policy? The Australian Competition and Consumer Commission (ACCC) is currently examining an application for reauthorisation of the Code of Conduct of the Australian Pharmaceutical Manufacturers' Association (now Medicines Australia). As part of the examination of the relationships between pharmaceutical industry participants, the ACCC is investigating claims in the media about some practices and whether they are in the best interests of the community (Lin Enright, Director, Public Relations, ACCC, personal communication). The ACCC should heed the results reported here. It is only two years since the review of direct-to-consumer advertising of pharmaceutical products in Australia.7 Although the review recommended against direct-to-consumer advertising, the subject is under continuing review, and some within the pharmaceutical industry are still pressing for change, maintaining that such a facility would enable them to provide important educational information about drugs to the public. Similar moves to relax laws relating to direct-to-consumer advertising are also occurring in Europe and Canada.8 The information reported by Loke et al on journal advertisements suggests that direct-to-consumer advertising is likely to be uninformative and promotional rather than educational in nature. Where should we look for guidance on appropriate standards for advertising pharmaceutical products? Medicines Australia polices a voluntary code of conduct that aims to set "standards of conduct for the activities of companies when engaged in the marketing of prescription products".9 This document places more emphasis on what not to do when promoting medicines, rather than offering guidance on how to provide balanced advice to clinicians about the efficacy and safety of medicines. Perhaps we should pay more attention to the advertising standards maintained in other industries. Generally, advertisements for technologically sophisticated products include prominent displays of their specifications, performance and selling price. Is it too much to ask that advertisements for modern drugs provide similar information? In an era of evidence-based medicine this should include data on the absolute effects of therapy, such as the response rates with and without treatment, and the number needed to treat, in order to avoid the ambiguities of relative measures such as the relative risk reduction. It would be best if this information related to comparisons with established therapies, not just placebo. Clinicians should also be told the dispensed price of the drug under the Pharmaceutical Benefits Scheme.

David A Newby BPharm, PhD · David A Henry MRCP, FRCP

In 1990, while the Royal Commission into Aboriginal Deaths in Custody was in progress, a group of Aboriginal women requested a meeting with the Federal Minister for Aboriginal Affairs so they could talk with him about issues of deep concern. They were granted 10 minutes. Two minutes into the meeting, as they told the Minister of the escalating incidence of violence within our communities, the Minister interrupted: "I know the problem. You tell me some solutions."1 Most Indigenous Australians regard research and researchers with cynicism and suspicion. We have good reason. We have been researched to death and beyond. Research does have an important role in helping find solutions. It can uncover what is happening and why. If designed and implemented appropriately, it can navigate a way forward and show what is, or is not, working. An accurate description, analysis and understanding of "problems" determines the actions of activists, workers in the field, policy-makers and service providers. Research therefore has a vital role to help inform both Indigenous peoples in their pursuit of appropriate services and non-Indigenous policy makers as we work together. In this issue of the Journal, Williams et al (page 300), reporting on assault-related admissions to hospital in Central Australia, conclude: ". . . assault-related admissions to hospital in the proportions we describe suggest a significant public health problem that requires attention."2 Their article is important, if only to strengthen the voices of Aboriginal women, who have been saying for some time that violence, in its many forms, is escalating at an alarming rate within our communities.3 But more is needed. Williams et al present their results from a reductionist research focus on morbidity and mortality. These parameters represent only the end-result of a vicious cycle of violence — a cycle that has had profound and lasting impacts on Indigenous families and communities across generations.4 No reference is made to the context, which embraces where, why and how such violence is occurring. A reference is made to "many resources . . . developed to assist healthcare workers, communities and individuals with alcohol and violence", but these are not discussed. Research into the health status of Indigenous peoples must begin to focus beyond statistical data. For research to have value and to be of benefit, we must try to find out if the strategies referred to are working or not, and why. Some researchers have observed that "there is abundant evidence that psychosocial factors have a profound impact on health", but that "little research to date has targeted the possible biopsychosocial pathways by which social, environmental and contextual conditions of living affect health".5 Indeed, the Australian Institute of Health and Welfare, while recognising the multiplicity of factors that might account for poor health status, relies predominantly on biomedical indicators of health.9 This fails to embrace the less easily measured aspects of community living and wellbeing, now deemed to be of prime importance by Indigenous peoples and public health researchers alike.7 The 1986 Ottawa Charter of Health Promotion outlines the fundamental conditions and resources for health: peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity, which requires, among other things, equity in housing, education, income, and social power.8 Its principles resonate strongly with punyu. The word punyu, from the language of the Ngaringman of the Northern Territory, explains that concepts and functions of health or wellbeing must be considered from an interdisciplinary and multidisciplinary approach. Punyu encompasses person and country, and is associated with being strong, happy, knowledgeable, socially responsible (to "take a care"), beautiful, clean, and safe — both in the sense of being within the law/lore and in the sense of being cared for.9 Being well would therefore be an "achieved quality, developed through relationships of mutual care".10 We do not have peace in Indigenous communities, and all the other prerequisites listed here for health and wellbeing are also left wanting. The Ottawa Charter and the subsequent Sundsvall Statement bring into sharp focus the connectedness between human beings, their physical and social environments and their health and wellbeing. They emphasise that "Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love. Health is created by caring for oneself and others, by being able to make decisions and have control over one's life circumstances and by ensuring that the society one lives in creates conditions that allow the attainment of health by all its members."11 This view echoes the same beliefs that underpin the quest for equality in health, which ensures all people have a right to be part of the process that impacts on their wellbeing at both personal and professional levels within the health service, education and research industries. As we reflect on this major public health problem, we must also consider our potential for doing things differently. There is an appealing reciprocity about the Indigenous punyu and the Western new public health movement, with its strong ecological framework. There exists an opportunity for strong partnerships between Indigenous and non-Indigenous healthcare professional educators and practitioners in shaping or reshaping the future education of healthcare professionals and meaningful health research, even research that focuses on violence. The Minister was right. We do need to focus on solutions. Some Indigenous Australians have argued for process evaluation research, looking at the application and outcomes of interventions and services within our communities. The search for solutions will have to involve greater discussion between Indigenous and non-Indigenous researchers in consideration of the more ecologically grounded interpretation of health promoted by Indigenous peoples, the Ottawa Charter and the Sundsvall Statement. We must develop ways of thinking about and engaging with problems, such as assault-related injuries, as we work together to find better tools for changing the wellbeing of Indigenous communities.

V Judy Atkinson BA, PhD · Jenny Graham DipOT, MSc(Ed), AFCHSE · Gloria Pettit BA, MA · Liz Lewis BA

Over the past 20 years, inhaled corticosteroids have become established as cornerstone therapy in the treatment of obstructive pulmonary disorders, ranging from asthma and chronic obstructive pulmonary disease to cystic fibrosis. The appropriate use of inhaled corticosteroids has transformed the management of asthma in children, improving the quality of life of children and their families, improving exercise tolerance, and reducing hospitalisation and mortality rates. Asthma mortality rates in Australia have fallen by more than 50% over the past 12 years, in parallel with our increased use of inhaled corticosteroids and the development of clinical guidelines.1 We have gained confidence in the safety of inhaled steroids at recommended doses, supported by national guidelines and extensive reviews.2 Local side effects, including oropharyngeal candidiasis and laryngeal dysfunction, can usually be controlled with the use of spacer devices. Further, at recommended doses, initial concerns about growth failure and impaired bone mineralisation have not been realised.2 In recent years, with the advent of more potent steroids and more efficient delivery systems, the relative doses commonly used have increased. There have been several reports of serious adverse events resulting from doses of inhaled corticosteroids in excess of those recommended. These include growth failure,3 and suppression of the hypothalamic–pituitary–adrenal axis4-6 — resulting in acute hypoglycaemia, altered consciousness and coma, convulsions7,8 and death.9 While the majority of these effects have been reported at higher doses, some have occurred at a dose within the recommended range, suggesting that individual susceptibility may also be important. These effects are more commonly associated with one potent inhaled corticosteroid, but this is probably a result of over-representation of that drug in the higher dosage range. Comparative studies would suggest that this is a class effect of inhaled corticosteroids.4 Are we overusing inhaled corticosteroids? New evidence-based National Asthma Council guidelines define the need for inhaled corticosteroids in asthma. They recommend an upper limit of 500 μg per day of fluticasone propionate (or equivalent) in children, and 1000 μg per day in adults with severe asthma. In support, a recent meta-analysis, examining the dose response to inhaled corticosteroids in adolescents and young adults, reported that 90% of the maximum benefit was achieved at a daily dose equivalent to 250 μg fluticasone propionate.10 Minimal further improvement resulted from increases up to 600 μg/day. The introduction of long-acting β-agonists at low doses of inhaled corticosteroids can achieve improved asthma control, avoiding the need for higher doses of inhaled corticosteroids. When asthma is not controlled by a dose of inhaled corticosteroids equivalent to 500 μg/day fluticasone propionate and long-acting β-agonists, consideration should be given to issues of adherence to the treatment regimen, inhaler technique or an alternative diagnosis. In the UK survey of adrenal crisis due to inhaled corticosteroids,9 three of the 28 children did not have asthma and, in five, asthma did not account for all the respiratory symptoms. Inhaled steroids have been shown to be ineffective in children with recurrent cough and those with episodic viral-associated wheeze. Clinicians should be alert to the clinical features of hypoadrenalism, particularly when precipitated at a time of metabolic stress, perhaps indicating adrenal crisis. Children taking excessive doses of inhaled corticosteroids (> 500 μg/day fluticasone propionate) should have their hypothalamic–pituitary–adrenal axis assessed, and their parents should be informed of the risks and the potential need for systemic corticosteroid cover during intercurrent illness and surgery. The National Asthma Council recommends the introduction of inhaled corticosteroids (alone or in combination) to gain control of symptoms. On clinical review, there should be a reduction (ie, back-titration) to an appropriate dose to optimise symptom control and reduce the likelihood of adverse effects. By comparison with their United States and European counterparts, Australian prescribers have used higher doses of inhaled corticosteroids, but there is now a clear incentive to reverse this trend. The availability of effective anti-inflammatory therapy, useful and well-publicised guidelines, as well as incentive payments to general practitioners for the treatment of moderate to severe asthma under the 3+ Visit Plan (http://www.health.gov.au/pq/asthma/3plusgp.htm), should pave the way for greater improvements in the management of asthma. The goal of asthma management is to achieve optimal control of asthma symptoms with the lowest effective medication dose, allowing children to enjoy a normal quality of life neither burdened by, nor at risk of, serious adverse events. Inhaled corticosteroids remain the cornerstone of asthma management. Responsible use of inhaled corticosteroids will reinforce confidence in the consumer, whereas irresponsible use will promote steroid phobia — a significant barrier to adherence.

John W Wilson PhD, FRACP · Colin F Robertson MD, FRACP

Objective: To determine the quality of claims in advertisements published in Australian medical publications, describe how benefits and harms are presented, and examine the level of underpinning evidence.Design and setting: Audit of a consecutive three-month sample of advertisements appearing in six popular Australian medical publications.Main outcome measures: Proportion of advertisements with quantitative information; proportion of claims conveying clinical outcomes; where retrievable, level of underpinning evidence.Results: Of 1504 claims, 855 could be substantiated quantitatively. Of these, 45% were supported by compelling evidence (randomised controlled trials or better). Of 13 claims explicitly reporting quantitative outcomes, none provided the absolute risk reduction or the number needed to treat.Conclusions: Our audit invites greater diligence by pharmaceutical companies in substantiating their claims and greater vigilance among clinicians when reading them.

Tim W Loke MB BS(Hons) · Fong Chee Koh MB BS(Hons) · Jeanette E Ward PhD, FAFPHM

Objectives: To explore the burden of asthma on the lives of people presenting to hospital emergency departments for asthma treatment.Design: A qualitative study. Consenting individuals with asthma who presented to emergency departments were interviewed in-depth, and interviews were taped, transcribed and thematically analysed. Questionnaire data on medication use, respiratory health and asthma knowledge were also collected. Asthma severity was determined from the medical records.Setting: A tertiary teaching hospital and a suburban hospital during March and April 2000, and a rural hospital during July and August 2000.Participants: Sixty-two participants (19 male and 43 female), aged 18–70 years.Results: The burden of asthma was broad, affecting social life, personal relationships, employment and finances. The cost of asthma medication was an issue for nearly two-thirds of participants. Individuals performed their own "cost–benefit analysis" for medication use, weighing up expense, perceived side effects and potential benefits. As a consequence, several participants chose to alter their medication dose, or not to take prescribed medications. For some participants, asthma directly contributed to diminished employment opportunities.Conclusions: To achieve a therapeutic partnership, doctors need to be aware of the substantial social, personal and financial burden of asthma for their patients. They should also recognise that patients' perceptions of treatment cost may compromise treatment adherence.

Dianne P Goeman MA, PostgradDipSoc · Francis C K Thien MD, FRACP · Michael J Abramson PhD, FRACP · Jo A Douglass MD, FRACP · Rosalie A Aroni PhD · Susan M Sawyer MD, FRACP · Kay Stewart PhD, BPharm(Hons)

Objective: To determine the number of assault-related admissions to hospital in the Central Australia region of the Northern Territory over a six-year period.Design and setting: Retrospective analysis of all patients admitted to Alice Springs Hospital (ASH) and Tennant Creek Hospital (TCH) from July 1995 to June 2001, where the primary cause of injury was "assault".Main outcome measures: Frequency of assault-related admission to hospital; demographic characteristics of the victims.Results: In the six years, there were 2449 assault-related admissions to ASH and 545 to TCH. Adults aged 25–34 years were most frequently hospitalised for assault, in a proportion greater than their proportion in the NT population. Females represented 59.7% of people admitted to ASH and 54.7% to TCH, greater than their proportion in the NT population. Aboriginals comprised 95.2% of ASH and 89.0% of TCH admissions, and were admitted in a significantly greater proportion than their proportion in the NT population (P < 0.001). The age-adjusted hospital admission rate resulting from assault has increased (P = 0.002) at an average rate of 1.6 (SE, 0.2) per 10 000 people per year. The proportion of assault-related admissions associated with alcohol has also increased significantly (P < 0.001).Conclusion: The frequency of assault-related admissions to hospital, especially among the Aboriginal population, suggests that this major public health issue is escalating.

Ged F Williams RN, FRCNA · Wendy P Chaboyer RN, PhD · Philip J Schluter MSc(Distinction), PhD

The Emergency Medical Response (EMR) program is a Victorian Government initiative in which fire fighters trained in cardiopulmonary resuscitation and equipped with automatic external defibrillators are dispatched to suspected cardiac arrests simultaneously with ambulance paramedics across metropolitan Melbourne. During the first 12 months (February 2000 to February 2001) of the expanded EMR program, 2942 events involved simultaneous dispatch of ambulance paramedics and fire fighters. In 430 events, patients had suffered a cardiac arrest of presumed cardiac cause, and resuscitation was attempted by the emergency medical services. Fire fighters provided the initial defibrillation to 41 (26.5%) patients presenting in ventricular fibrillation. Survival to hospital discharge for bystander-witnessed ventricular fibrillation cardiac arrests was 21.8%. The mean emergency services (fire and ambulance) response time to cardiac arrest patients was 6.03 (SD, 1.65) minutes. The mean time to defibrillation for ventricular fibrillation patients was 8.75 (SD, 2.07) minutes.

on behalf of the Emergency Medical Response Steering Committee

Every five years over the past 15 years, the Commonwealth, States and Territories have negotiated healthcare agreements, and new agreements are about to be signed for the next five-year period (2003–2008). The Australian Health Care Agreements (AHCAs), which are negotiated bilaterally with each State, provide Commonwealth monies to the States in exchange for ensuring the States continue to provide free hospital care. Previous agreementsIf the negotiations of previous agreements are any guide, the States will stick together in arguing the overall size of the Commonwealth's contribution to the States, until the Commonwealth courts one State (usually a smaller one or one going into election mode) and offers a very good deal to break from the pack. That State accepts, and the "domino principle" then cuts in. If the content of previous agreements is any guide, the next agreement will be devoid of national health policy, contain perverse performance measures, be largely incomprehensible to all but its authors, and preserve the existing capacity and incentives to shift costs from State to Commonwealth funding sources and vice versa. Will this one be any different?Based on the April 2002 Joint Statement by the Commonwealth and State Health Ministers, it will be substantially different. In this statement the Ministers: 1 acknowledged that previous negotiations had focused more on health funding than on health outcomes; acknowledged the long history of "buck-passing" between States and the Commonwealth; agreed to a cooperative approach to the 2003–2008 agreement, focused on best care and health gain; and identified priority areas for commissioned work to inform the 2003–2008 agreement. The Joint Statement indicated that the 2003–2008 agreement would encapsulate national objectives for providing improved healthcare to all Australians.1 If these aims are only partially realised, they will substantially change the relationship between healthcare and healthcare financing in Australia. What are the problems with current AHCA arrangements?The focus of the existing agreements is narrowly limited to one aspect of healthcare. AHCAs provide money to the States on the basis that the States preserve the core feature of Medicare — the maintenance of universally accessible public hospital care free of charge. The call for the agreements to be used to articulate a national health policy for Australia highlights the fact that there is currently no such policy which is used actively by governments to guide the Australian health system. In the negotiations for the 1993 agreement, an ultimately unsuccessful attempt was made to use the agreements to commit States and the Commonwealth to developing and implementing a national health policy. To use the AHCAs to articulate national health policy objectives would constitute a major change. It is appropriate that such health policy objectives are incorporated in AHCAs, as the monies provided through the agreements are not specifically earmarked for hospital care. As there is no alternative broad health agreement between the Commonwealth and States, the AHCAs are currently, somewhat undeservedly, viewed as the major vehicle for Federal–State health debate. If, as Health Ministers have agreed, the "2003–2008 Agreement . . . [is to] encapsulate national objectives for the provision of improved care for all Australians",1 the AHCAs will need to extend beyond public hospital issues to incorporate primary care. There will need to be discussion in the agreements on primary care, chronic care, mental health, Indigenous health, aged care, rural health, public health, and, presumably, agreed quantifiable measures to assess achievement of these national objectives, while maintaining flexibility of resource allocation. The existing agreements have only one performance indicator for which funding is contingent — a commitment by States to provide public hospital inpatient services at an agreed level. For example, the current New South Wales agreement states: "New South Wales commits to provide services to public patients at an indicative public patient weighted separation rate [ie, public inpatient discharges from hospitals] of 261.21/1000 applicable weighted population."2 The Commonwealth can review its financial commitment to New South Wales if the level of inpatient separations falls below this figure. Other performance measures are reported under the agreement, although these do not affect funding provided to the States. At present, States are unlikely to significantly reduce hospital care unless other primary or community care programs can be substituted, presumably with Commonwealth approval, for hospital care. The commendable exploration by some States for ways to reduce hospital readmissions of people with chronic and complex conditions through improving community-based care depends on Commonwealth support, directly or indirectly, for care beyond the hospital. It would be good for this to be recognised in the new AHCAs. The agreements do not include the total value of Commonwealth contributions to the States for healthcare provision, much less the total value of health expenditure that is incurred by States, regardless of the source of funding. Other health monies which are expended in the State health sector are provided to States through their share of the goods and services tax (GST) revenue, and there remain a number of specific health programs and payments which are funded outside the AHCAs. These include payments for highly specialised drugs, Commonwealth subsidies to privately insured patients in public hospitals, payments for eligible veterans and their dependants, and payments for residents in State-owned residential-care facilities. Solving the cost-shifting problemCan the renegotiated agreement limit "the buck-passing between the States and the Commonwealth"?1 Clearer lines of financial management of care and appropriate incentives are needed if this problem is to be solved. Assuming the 2003–2008 agreement maintains the existing arrangements of the Commonwealth and States in co-financing the provision of healthcare, it is difficult to see how cost-shifting will be fully removed. Aged care provides a good example. The Commonwealth Government has responsibility for residential aged care. In the absence of what is generally taken to be an adequate residential capacity for infirm elderly people, some are inappropriately accommodated in public hospitals. In many cases, the care they receive in hospitals is inappropriate — better care could be more efficiently provided in purpose-built residential-care settings. Solving this problem will require a combined approach from the Commonwealth and the States, and a willingness by both to shake off an unhappy history. Several initiatives have led to a reduction of cost-shifting. The different funding streams for pharmaceuticals — whereby the States subsidise pharmaceuticals provided in hospitals, but generally under capped budget allocations, while the Commonwealth subsidises those provided through community pharmacies on an open-ended basis — has sometimes resulted in hospitals not providing adequate pharmaceuticals for patients at hospital discharge. So, the cost is shifted to the Commonwealth and also to the patients. Arrangements are now in place in some States for the Commonwealth to accept funding responsibility for pharmaceutical products dispensed in both hospitals and the community. How has the Ministers' April 2002 statement been carried forward?The strategy adopted by Ministers of tackling important health policy issues by involving the clinical workforce was initiated at the meeting of the Australian Health Ministers Council in April 2002 by the New South Wales Health Minister, Craig Knowles, and is based on a similar process introduced in New South Wales. Nine national reference groups have been formed to address the following policy issues: the continuum between preventive, primary, chronic and acute models of care; the interface between aged and acute care; collaboration on workforce, training and education; hospital funding and private health insurance; improving Indigenous health; improving mental health; improving rural health; quality and safety; and information technology, research and "e-health". Each reference group has about 12 members and is co-chaired by a clinician and senior bureaucrat. Each of the nine groups has clinicians as members, an endeavour designed to forge greater interaction between bureaucrats and clinicians. The terms of reference for the groups are ambitious given the short timeframe for reporting. The documentation guiding the reference groups3 states: "The reference groups will develop and implement a workplan, the outcomes of which will enable the next agreements to identify: national objectives for the provision of best care and health outcomes regardless of jurisdictional boundaries; opportunities to improve health service delivery; and linkages to other relevant health strategies. The reference groups will provide guidance to health ministers: on opportunities to improve the performance of service provision in relation to each group's designated segment of the health system; on how best to minimise the barriers which impede improved performance." The documentation then sets the scene for dampening overly high expectations from the process by stating: "The reference groups will consider: the primary focus of the AHCAs being an agreement between the Commonwealth and the States/Territories on funding for the provision of free public hospital services, and secondarily of services at the interface of hospitals and the greater community; the capacity of the AHCAs to generate significant health system reform in and of themselves; mechanisms outside the AHCAs through which to take forward the identified policy objectives; existing work by other bodies in the above areas, including subcommittees of the AHMC and AHMAC; and the requirement on all governments to be fiscally responsible".3 The Australian Health Ministers meeting in Darwin in July 2002 received progress reports from each of the nine national reference groups. There was then discussion by Ministers only, behind closed doors, as to whether they would allow the final reports to be collated and summarised by Commonwealth Health Department officials, or whether the Ministers themselves would meet again in September to personally receive the final reports from each group. They opted for the latter. Informal feedback to me from group members about the usefulness of the process to date is variable. Some report lively debate, while other groups are reportedly traipsing unproductively over old worn pathways. There is consensus that the time constraints for completing the documents will seriously limit the quality of the product. Most participants in the reference groups I spoke to supported the process, but many saw little prospect of the groups making any meaningful contribution to the 2003 AHCAs. One co-chairperson indicated that it would be more realistic to see the process as input to the 2008–2013 agreement! National health policy discussions involving key groups and individuals are both useful and overdue. That these discussions involve both clinicians and bureaucrats is valuable as well. These and other clinicians, and presumably the Australian Medical Association, will expect that this process is not merely window dressing. Whether the outcome of this process can achieve Health Ministers' objectives "that the 2003–2008 agreement would encapsulate national [health] objectives"1 is yet too early to judge. There is considerable danger, particularly to the Commonwealth, if, by the time the financial aspects of the new agreements are being negotiated (probably later this calendar year or early in 2003), there is little linkage between the "products" of the nine reference groups and the content of the agreements. The role of the Commonwealth and State Treasuries between now and 1 July 2003 will be critical. State Treasuries may be reluctant to accept increases in the numbers of performance measures with the agreements. The Commonwealth may cite such factors as the positive impact of the GST on State coffers and the increase in the proportion of the population holding private health insurance as reasons for not substantially increasing Commonwealth contributions to the States. Health Ministers have started down a pathway of significant involvement of Australia's clinical workforce in policy discussions, with a clear public focus on fundamentally reshaping the next AHCAs. The purpose is admirable. From it may come a new expression of national health policy on which funding decisions can be based. This would be good for everyone's health.

Michael A Reid BEcon

In their Joint Statement of 5 April this year, the Federal and State Health Ministers acknowledged a widely recognised but rarely voiced truth — that past negotiations under the Australian Health Care Agreements (AHCAs) had focused more on health funding than health outcomes. The Ministers' candor took many completely by surprise. They laid a framework for work toward the 2003–2008 agreements, which emphasised a focus on provision of best care and health outcomes rather than jurisdictional boundaries, with jurisdictions working cooperatively to advance community health and well-being. To this end, they decided the agreements should contain a statement of principles, objectives and proposed outcomes. They also decided that work should be initially organised around a continuum across preventive, primary, chronic and acute care; improvement of the interface between aged and acute care; cross-jurisdictional collaboration on workforce, training and education; the interaction between hospital funding and private health insurance; improvements in Indigenous, mental, and rural health; quality and safety; information technology; research; and "e-health". This work is to precede and inform negotiations about funding within the AHCA. In that same week in April the Commonwealth Chief Medical Officer, Richard Smallwood, told a health conference in London that Australia's public hospitals are in "varying degrees of dilapidation", and that morale among doctors and nurses was fragile. He was quoted as saying: "The results of our care and patient experiences of the health care system are too often less than ideal, . . . Our public healthcare systems never seem to have enough resources . . . Access to care, while universal, is too often delayed. The medical workforce is undermanned, maldistributed, or both, and the shortage of nurses verges on the calamitous. In both professions, morale is fragile."1 Primary diagnosisThe indications noted by our Chief Medical Officer are uncontroversial, and could easily be extended. Do they reflect separate causes, capable of treatment seriatim, or are they symptoms of a deeper malaise? The work proposed in the Ministers' Statement has been allocated to nine separate working groups, implying at least some separability. An underlying ailment seems more likely — this is not the first time Health Ministers have committed themselves to "outcomes", yet the problems besetting the system have not diminished, or even changed much. There has to be more to this than meets the eye. Across countries in the Organisation for Economic Cooperation and Development (OECD) — that is, the rich world: many doctors are disgruntled, overworked and professionally unsatisfied; nurses are restless and in short supply; richer countries poach healthcare workers from wherever they can get them; popular demands for more health spending are universal; payers are widely unpopular, whether national governments or United States Health Maintenance Organisations (HMOs); many patients feel vulnerable and uncared for; and the politics of healthcare is ugly — governments retreat into obfuscation and the difficult issues are systematically avoided. The explanation can only lie in common and fundamental characteristics of system architecture. Structural questions are not explicitly on the Health Ministers' agenda. They need to be. Opinions as to cause will differ, but here are mine. RoboDoc and Nurse MechatronA burgeoning international literature on "unhappy" doctors and nurses offers all manner of causal explanations, and proposals for remediation. This literature usually presupposes that the causes lie in the specifics of healthcare.2-4 However, this seems unlikely. Commoditisation, which results from payment of a standard unit price for an implicitly standardised product or service, is a more probable cause. Commoditisation of the product of any industry leads to commoditisation of its labor force, and that always causes "unhappiness", and worse. When, as in healthcare, that labor force is bright, individualistic, highly educated, conscientious and oriented toward professional autonomy, reducing the fruits of their efforts to item numbers and "one price fits all" is clearly counter-indicated. Australian general practice represents commoditisation par excellence. The squirrel-wheel reimbursement system and narrow tasking imposed on GPs foster personal and professional isolation and disillusionment. GP work content has narrowed steadily over the years. Opinions differ as to whether the number of GPs is too many, as the Australian Medical Workforce Advisory Committee thought,5 or too few, as Access Economics thinks.6 Regardless of the findings of such studies, the elaborate system used to control doctor numbers in Australia means there are unquestionably too few GPs at prevailing "prices". The absence of unemployment among GPs, and the difficulties across the nation in filling the less desirable posts, puts the matter beyond doubt. Numbers are an important issue in other ways, but, regardless of numbers, general practice under Medicare is purpose-built to create discontent. A narrow majority of doctors and the substantial majority of nurses work in hospitals rather than in general practice and other forms of primary care.7,8 Public hospitals are kept alive on a lean diet of funding by governments, and are under intense pressure to maximise patient throughput. Governments are obsessively interested in hospital-throughput statistics, and in minimising indicators of excess demand, such as waiting lists and the frequency of ambulance bypass. These make headlines — quality of care and patient satisfaction does not. Facing an institutionalised payer, hospital managers respond by institutionalising working arrangements, and directing their efforts to the performance targets by which they are measured. Input controls and statistical output targets provide little defense against horrors such as those that emerged at the King Edward Memorial Hospital in Perth.9 However, these were no more than a minor departure from mainstream public hospital practice in professional deployment and quality management practice across Australia. Institutionalised and depersonalised working arrangements are the absolute enemies of professional satisfaction, high morale, and respectful, high quality care. It is not surprising that many doctors and nurses are unhappy. The surprising thing is that Australian healthcare, operating under such compromised arrangements, manages to be as good as it is. Good people can beat bad systems, at least for a time, but at enormous cost to themselves. Many are burned in the process. Institutionalised production systems destroy leadership talent and break the hearts of professionals of skill and integrity. Vital, customer-responsive organisations breed professional talent, active, committed leadership and display the high professional morale that, for most good people, is its own reward. Third-party payersA remote third-party payer is in itself a guarantee of alienation and quality problems. Australia did away with agricultural marketing boards in the 1980s, with good reason, and to impressive effect. The Western world largely abandoned nationalised industries in the 1980s and 1990s. The Union of Soviet Socialist Republics (USSR) never managed to produce decent consumer goods. Healthcare is the ultimate individualised product — no centrally planned and controlled production system ever succeeded at mass-customisation. Third-party payer systems are bad for the payer as well as the consumer. Western governments, other than that of the United States, meet 72% to 97% of all health expenditures, and this accounts for 12% to 18% of all public outlays.10 A blowout in health spending means a blowout in the Budget. Regardless of the feelings of Health Ministers, the overall interest of governments in healthcare centres on expenditure control, not health outcomes. The Health Minister's duty to the government is to protect the Budget and hose down the political consequences of doing so, not to open up difficult questions. Whenever the compact between the customer and the producer is nullified, there are dire consequences. Large, bureaucratised, third-party payers are a universal feature of modern healthcare the world over, and the consequential symptoms of malaise are also ubiquitous. None of this goes against the aims of universality and equality of access to healthcare, which all civilised nations embrace. However, the payer must stand behind the patient, and not between the patient and the provider. The starting point on the way back must lie in the realm of system design, not clinical reform — the professions will see to the clinical side if structures are right. System-based problems demand system-oriented remediesRemedies for the immediate roadblocks on the path to outcome-oriented healthcare lie not in the clinical realm, but in general properties of constrained optimisation. Instead of producing services in response to demand, the system is controlled by layer upon layer of regulatory constraints, operating both on aggregate-level inputs (dollars and doctor numbers) and product-level outputs (item numbers, descriptions and reimbursements) as follows: Budget caps constrain public hospital spending and most of the smaller healthcare and aged-care programs. Non-transparent restrictions on the supply of doctors, through limits on medical school intakes and doctor immigration, are used to control Medicare outlays. Pharmaceutical Benefits Scheme outlays are constrained by more complicated, though more rational and direct, measures. Capital investment is even more tightly rationed than "recurrent" inputs to force every possible dollar into statistically measured outputs rather than into investments in system improvement. New structures are not properly maintained — hence Smallwood's hospitals in "varying states of dilapidation". Governments may find the dollars for showy new equipment, often "opened" with elaborate political ritual, but the recurrent funding required for its operation and maintenance is another story. Investment in information and communications technology (ICT), being largely invisible, is even more restricted, with serious consequences for efficiency, quality and safety of care. The average age of the capital stock in Australian healthcare is 16 years, compared with 10–12 years in most of the private sector.11 According to Gartner Corporation, a major international ICT consultancy, spending on ICT is equivalent to about 3% of turnover in the centrally planned and controlled European and Australian healthcare systems.12 In the market-exposed United States health sector, ICT spending is equivalent to between 5% and 6% of turnover.12 The first objective en route to an outcome-enabled health system must be to relieve the constraints that bind inputs and distort the health services' "production" system. Ubiquitous input controls also distort the pattern of outputs, as, in the presence of input rationing, outputs reflect the supply of constrained inputs rather than the demand for health services. This is why the interminable academic debate about supplier-induced demand is just that — academic. If reform is to be possible, the system must be given some additional degrees of freedom. Eventually output must come to reflect demand rather than supply to make an outcome-oriented health system possible. Other measures will, of course, be needed, such as universal personal health records and other supports for quality and safety enhancement, before reform is complete, but the initial steps must centre on capacity building. The recent Wanless Review of the United Kingdom health system came to somewhat similar conclusions regarding input constraints.13 Wanless (Group Chief Executive of NatWest for seven years until he retired in 1999) carried out the Health Trends Review at the request of the Chancellor of the Exchequer in 2001–2002 as a key contribution to the Blair government's planning for a major increase in spending on the United Kingdom National Health Service. His report found that improving the use of information and communication technology in the Health Service is a key issue in improving quality and productivity. Wanless also concluded that there is scope for major changes in skill mix and the way professionals work in the healthcare service, although he was diplomatically silent as to how the existing distortions may have come about, and what might be done about ongoing causes. He stopped well short of questioning the structural features of the UK's monolithic National Health System. A modest proposalIf Ministers wish to entrench quality, safety and patient choice as the primary drivers of care, they must take measures to move the locus of control away from the input end of the production chain and toward the output end — that is, toward the consumer. This does not imply dismantling equitable and universal health insurance. It simply means that government must move towards a health financing system that insures the patient. It will take time, and must be done openly and carefully, if the effort is to endure. There is a growing consensus that Australia, like the UK, should be spending more on healthcare. However, if we were simply to increase spending the effect would be immediate inflation of healthcare costs. First we must feed out some slack in doctor numbers, settle the major nursing issues, and relieve the pinch points that stem from a history of capital rationing — a 5–10-year recovery program. While this may sound backward looking, there is no prospect that we can accurately see the system of the future while the system we already have does not match the demands of the present.14 Five to 10 years is also long enough to build a base for a universal longitudinal patient record, and to do so in the only way that can succeed — from the bottom up. The foundation of a national system must be electronic patient record systems in routine and ubiquitous daily use by providers. At present, only general practice makes widespread use of electronic records and orders. Practice grants brought about the revolution in GP computing. Tied grants must be offered to hospitals so that they can overcome their ICT investment backlog. Many of the elements of the wider program of reform require that hospitals begin the transition to enterprise-level electronic clinical support systems and electronic patient records as soon as possible. There will be no outcome-driven healthcare system until the system recognises the whole patient — a person with a past, a present, and a future. Ambitions for major gains in safety and quality of healthcare will come to very little until every patient encounter with any healthcare provider is supported by the patient's personal health record. Whether we stay with the present third-party payment system or move gradually to patient-based funding, as I believe we should, the injection of funds must not run ahead of real capacity or the whole project will end up in disrepute. Governments are right to dread healthcare cost inflation. ConclusionWe should look to Health Ministers neither for radicalism nor for a financial bonanza. Barriers to continuity of care and patient-based outcomes must be carefully dismantled. None of the conceptual, practical or financial requirements for fundamental reform is beyond us. The path will be long; there are 50 years of history invested in the existing Australian system and its counterparts elsewhere. The system has allowed people in all walks of life to achieve standards of health and longevity unimaginable 50 years ago. The next broad advance will take the form of healthcare which is precisely matched to the wishes of the individual. A mass-oriented public health system has taken us a long way, but it cannot do what is now required.

John P Paterson BComm, PhD, AO

Human neural stem cells (HNSCs) can be isolated from both the developing and adult central nervous system (CNS). HNSCs can be successfully grown in culture, are self-renewable, and can generate mature neuronal and glial progeny. Embryonic HNSCs can be induced to differentiate into specific neuronal phenotypes. HNSCs successfully integrate into the host environment after transplantation into the developing or adult CNS. HNSCs transplanted into animal models of Parkinson's disease and spinal cord injury have induced functional recovery. The risks associated with stem cell transplantation trials are difficult to assess, but have not become overtly apparent throughout preclinical investigations. Major hurdles remain to be overcome before human clinical trials can be embarked upon.

Kerry A Galvin BSc(Hons), PhD · D Gareth Jones MBBS, DSc

"Humanistic medicine" is a term compounded, for therapeutic purposes, with the good intent of reminding clinicians of their need to be compassionate and empathic. Although the expression is arresting, and demands thought, it does not go far enough. "Values-based medicine" is a stronger term, reminding clinicians of the sustaining values that underpin the whole health endeavour. These values include an acceptance of the value of individual human life in quantity and quality, and of the importance to both individuals and communities of human security and flourishing. Values-based medicine can incorporate all the other paradigms of medicine, including scientific and evidence-based medicine, within it, because it can include anything that contributes to human security and flourishing. If we are to seek a new paradigm for a reconstructed view of healthcare, the term "values-based medicine" might have more power and relevance than "humanistic medicine".

J Miles Little MD, MS

Clinical record A 55-year-old woman with type 2 diabetes of 8 years' duration experienced, over 2–3 days, the onset of pain, tenderness and swelling of the medial aspect of her right thigh. She had recently commenced insulin therapy and was displaying good glycaemic control (HbA1c level of 6.4%). She had diabetic complications of autonomic and peripheral neuropathy, but no retinopathy. Other medical problems included chronic renal impairment, hypertension, polyarticular gout and hydralazine-induced lupus. A renal biopsy had not been performed, but her renal insufficiency was believed to be a result of diabetic nephropathy and hypertension. She was taking twice-daily mixed insulin (16 units in the morning and 10 units at night), felodipine (10 mg/day), paroxetine (10 mg/day), allopurinol (75 mg/day) and prednisolone (7.5 mg/day). Her serum creatinine level had peaked at 0.31 mmol/L, but stabilised at 0.21 mmol/L after cessation of an angiotensin-converting enzyme inhibitor. A 24-hour urine collection showed a creatinine clearance rate of 0.12 mL/s (normal range [NR], 1.5–2.5 mL/s) and a protein excretion rate of 4.6 g/day. Renal duplex ultrasound showed that her kidney size was well preserved, but there was a suggestion of renal artery stenosis on the right side. There was no history of recent injury or injection to her thigh. She had not experienced any rigors and was afebrile. The area of the localised, tender swelling on the medial aspect of her right thigh was not erythematous and no local lymphadenopathy was noted. Apart from the thigh swelling, there was generalised wasting and weakness of the lower limbs, loss of ankle reflexes, and loss of sensation in a stocking distribution, consistent with a diagnosis of peripheral neuropathy. Examination of her left foot revealed two small gangrenous areas. Foot pulses were present and the gangrenous areas were thought to be caused by inappropriate footwear. Figure 1: Computed tomography image of the thigh, showing marked oedema and thickening of the adductor muscle group (A), extensive subcutaneous oedema (B), and sparing of the hamstring muscle (C). Investigations showed an elevated white cell count of 16 x 109/L (NR, 4.0–11.0 x 109/L), a platelet count of 432 x 109/L (NR, 150–400 x 109/L), an erythrocyte sedimentation rate of 110 mm/h (NR, 7–18 mm/h) and a C-reactive protein level of 119.3 mg/L (NR, 1.6–8.7 mg/L). Creatine kinase (174 U/L; NR, < 215 U/L) and lactate (0.6 mmol/L; NR, 0.5–2.0 mmol/L) levels were normal. Separate to the swelling on the medial aspect of the thigh, a presumed thrombus was palpable in the lateral accessory long saphenous vein. A subsequent ultrasound detected this thrombus extending from the mid thigh to the lateral aspect of the knee, but no deep venous thrombosis was found. She was treated with cephalexin and aspirin. Over the next two weeks, the thigh swelling evolved into a tender, palpable mass measuring 6 x 20 cm. A computed tomography (CT) scan revealed marked swelling of the entire adductor muscle group, but no discrete mass (Figure 1). In the absence of a clear diagnosis, an exploratory operation of her right thigh was performed. This showed no haemorrhage or abscess, but evidence of extensive oedema and necrosis of the adductor muscles. Samples taken for microbiological analysis were sterile. Histological examination of a biopsy specimen showed necrotic muscle, an inflammatory cell infiltrate, fibrosis and evidence of muscle fibre regeneration. The occasional small blood vessel containing fibrin thrombus was also seen, but no features of vasculitis were identified (Figures 2 and 3). A diagnosis of diabetic muscle infarction was made. Photomicrographs (original magnification x 250) of a biopsy specimen of the adductor group of muscles. Figure 2: Longitudinal section, showing necrotic muscle fibres (A) and granulomatous tissue (B). Figure 3: Cross-section showing necrotic muscle (A), an inflammatory cell infiltrate (B) and a blood vessel containing a thrombus (C). No evidence of vasculitis was seen. The diagnosis of diabetic muscle infarction was made retrospectively on clinical grounds and after reviewing the subsequent investigations. The differential diagnoses — muscle strain, rupture, haematoma, myositis, infection, deep venous thrombosis, thrombophlebitis, femoral artery aneurysm, fracture or a connective tissue tumour — were excluded by the clinical presentation, together with the ultrasound, computed tomography (CT) scan and biopsy findings. The CT scan did not reveal a discrete mass, but extensive oedema of one muscle group and sparing of an adjacent muscle group. Histologically, there was evidence of skeletal muscle fibre necrosis, with a variable amount of muscle regeneration and fibrosis. These are the typical features of diabetic muscle infarction.1 Reports of spontaneous muscle infarction appear to be virtually confined to patients with diabetes. Spontaneous muscle infarction is a rare diabetic complication. There have been fewer than 100 patients reported since 1965.1-12 However, it is becoming more frequently recognised; almost half of the cases have been reported since 1999.3-12 It has a predilection for the quadriceps (62%), hip adductors (13%), hamstrings (8%) and hip flexor (2%) muscles. Rarely, the calf and anterior tibial muscles are involved. The pathogenesis of diabetic muscle infarction is still unclear, but a diffuse microangiopathic process, possibly associated with hypoxia–reperfusion injury, has been implicated as a cause.1,10,12 Magnetic resonance imaging (MRI) is the preferred diagnostic test, revealing swollen and oedematous muscles (ie, increased signal intensity of T2-weighted images).4,7 Abnormal MRI findings have been reported in all patients with diabetic muscle infarction. Although, in retrospect, our patient's CT findings were consistent with muscle infarction, a CT scan is considered a less sensitive test, as only 83% of patients with muscle infarction have abnormal CT findings.1 An MRI scan was not performed in our patient, as diabetic muscle infarction was not initially considered in the differential diagnosis. Consensus opinion suggests that muscle biopsy is not necessary in a patient presenting with the typical clinical features of diabetic muscle infarction — without fever, erythema, or elevated white cell count — if the MRI findings are appropriate.1 Management consists of the avoidance of weightbearing, and simple analgesia. After resolution of the acute phase, physical therapy and rehabilitation are useful. As with our patient, total recovery over 4–6 weeks can be expected. In about 50% of patients recurrences occur, but not necessarily in the same muscle group.

Richard J MacIsaac BSc, PhD, FRACP · George Jerums MD, FRACP · Lisa Scurrah MB BS, FRACP

Antibiotic resistance is a consequence of antibiotic use — we need to use antibiotics less and to use them prudently. Plans to combat antibiotic resistance were recently proposed by the World Health Organization, a United States interagency taskforce and the Australian Joint Expert Technical Advisory Committee on Antibiotic Resistance. Prudent antibiotic use includes not using antibiotics when benefit is minimal (eg, in many respiratory tract infections), using narrow-spectrum antibiotics whenever possible and using optimal dosages and regimens. The need for antibiotic therapy can be reduced by preventing infections through vaccination, infection control measures and improved sanitation. Surveillance of antibiotic resistance is needed to target interventions for minimising antibiotic use. More research is needed into new antibiotics and regimens and into improving medical devices and protocols to prevent infection.

Series Editors:

Born on 18 March 1918 at Gundagai, in New South Wales, Eric De Salis came from a family that had a long association with the pastoral industry in the Monaro district of south-eastern NSW. His early schooling was at a family property, "Soglio", near Michelago. From 1930, he attended Canberra Grammar School, where he excelled in sport (tennis, athletics, cricket and football) and was both a prefect and dux of the school in his final year, 1936. Eric graduated in medicine from the University of Sydney in 1942. During his student years he met Dorothy Pratt, whom he married in 1943. From 1944 to 1946, he served Australia in the AIF as a medical officer with the field ambulance service in Papua New Guinea and Borneo. As one of the first Australian doctors to use penicillin in the field in Papua New Guinea, he described its effect as "miraculous" in helping desperately ill soldiers to recover in a remarkably short time. After the war, Eric worked in diagnostic laboratories at the School of Public Health at Sydney University, the Royal North Shore Hospital in Sydney, and the Commonwealth Health Laboratory in Townsville, where he became adept at the laboratory diagnosis of tropical diseases. He gained a Diploma in Public Health in 1946. In 1950, Eric was appointed Director of the Health Laboratory in Canberra. He expanded its clinical diagnostic services in haematology (his subspecialty), biochemistry and microbiology, and, in 1952, introduced a Pap-smear screening service (one of the first in Australia). He gained his Fellowship of the Royal College of Pathologists of Australasia in 1956. In 1965, the diagnostic laboratory was relocated to Canberra Hospital, where, in 1968, Eric was closely involved with Dr Bill Coupland in performing one of the first bone marrow transplants in Australia. Two years later, after recovering from a severe heart attack, Eric resigned as director of the laboratory, but continued to work as senior specialist in charge of haematology until his retirement in 1979. Eric developed motor neurone disease that progressed inexorably. This was a particularly cruel blow for a pathologist and for someone who had excelled in sport. He bore the pain and the restrictions imposed by the disease without complaint, showing a quiet fortitude and remarkable courage up to the time of his death on 14 February 2002. Eric's selflessness and modesty as a professional colleague were widely acknowledged, as were his skills in many fields of pathology and his prompt response to calls for assistance, at any hour, at Canberra Hospital. He was respected by all who knew him.

Anthony J Proust FRCP FRCPE FRACP

Several low molecular weight (LMW) heparin preparations, including dalteparin, enoxaparin and nadroparin, as well as the heparinoid danaparoid sodium, are approved for use in Australia. LMW heparins are replacing unfractionated heparin for the prevention and treatment of venous thromboembolism and the treatment of non-ST-segment-elevation acute coronary syndromes. The advantages of LMW heparins over unfractionated heparin include a longer half-life (allowing once-daily or twice-daily subcutaneous dosing), high bioavailability and predictable anticoagulant response (avoiding the need for dose adjustment or laboratory monitoring in most patients), and a low risk of heparin-induced thrombocytopenia and osteoporosis. Laboratory monitoring of LMW heparin therapy should be considered in newborns and children, patients with renal impairment, those who are pregnant, and those at the extremes of bodyweight (eg, < 40 kg or > 100 kg). LMW heparins should: ■ be avoided or used with caution in patients undergoing neuraxial anaesthesia, owing to the potential for epidural haematoma formation; ■ not be used (ie, are contraindicated) in patients with immune heparin-induced thrombocytopenia, as they may cross-react with anti-heparin antibodies. Conventional unfractionated heparin retains a role in the management of patients at high risk of bleeding, undergoing invasive procedures, and patients with renal failure owing to its shorter half-life, reversibility with protamine sulfate, and extrarenal metabolism. The heparinoid danaparoid sodium is effective for the treatment of heparin-induced thrombocytopenia.

John W Eikelboom MB BS, MSc, FRACP, FRCPA · Graeme J Hankey MB BS, MD, FRCP, FRCP(Edin), FRACP

To the Editor: Linezolid is the first of a new class of oxazolidinone antibacterials which was first registered in Australia in September 2001. It represents an important advance in the treatment of infections caused by some enterococci resistant to vancomycin and staphylococci resistant to methicillin.1 In clinical trials, the most commonly reported drug-related adverse events which led to discontinuation of linezolid therapy were headache, diarrhoea, nausea and vomiting.2 We describe a patient who developed peripheral and optic neuropathy while being treated with linezolid. A 76-year-old man was hospitalised in November 2000 for the third revision of a left total hip joint prosthesis. This was complicated by infection with methicillin-resistant Staphylococcus aureus (MRSA) isolated from hip joint washout. The organism was sensitive to vancomycin, teicoplanin, rifampicin and fusidic acid, and resistant to ciprofloxacin. Vancomycin therapy was commenced, but had to be replaced by rifampicin and fusidic acid when the patient developed fever (40°C), rigors, rash and eosinophilia. However, the patient developed severe, generalised pruritus. Therapy with rifampicin and fusidic acid was ceased and oral linezolid (600 mg twice daily) was given. Linezolid was initially well tolerated. However, about six months after starting treatment with the antibiotic, the patient presented to his general practitioner with numbness of his hands, feet and legs below the knee, intermittent sharp pain in both feet and blurred vision. He was hospitalised and linezolid therapy ceased. On admission, peripheral sensory loss in a glove-and-stocking distribution was noted. Nerve-conduction studies showed severe sensory-motor axonal neuropathy, more severe in the lower limbs than the upper limbs. Formal visual field testing showed patchy field damage, suggestive of drug-induced toxicity. The patient declined further ophthalmological review. Five months after he stopped taking linezolid, he reported subjective resolution of visual impairment, but the peripheral neuropathy persists. The patient's alcohol intake had been negligible. Ongoing medications include digoxin, irbesartan, frusemide, omeprazole, piroxicam and diazepam. We are not aware of any published articles describing peripheral or optic neuropathy associated with linezolid therapy. This information was not included in the original product information, but has been added to the revised version under the heading "Post-marketing surveillance".3 Up to June 2002 there had been only 13 reports of adverse reactions to linezolid to the Australian Adverse Drug Reactions Advisory Committee (ADRAC). Four of these, including our report, describe peripheral neuropathy and involve adult males who had received 1.2 g of linezolid daily for six to nine months. No patient's neuropathy had resolved at the time of reporting. Moreover, linezolid was the sole suspected drug in all four reports. It is important to note that the maximum duration of treatment with linezolid in clinical trials has been 28 days. Reports of neuropathy received by the manufacturer have primarily involved patients treated for longer than 28 days.3 Our report highlights the importance of postmarketing surveillance and reporting of adverse drug reactions, especially when a drug is used outside original indications or duration.

Carmela E Corallo · Amalie E Paull

To the Editor: I read with interest the article on cervical screening by Dickinson.1 Cervical screening has been the most successful public health measure introduced for the prevention of cancer, and the Pap test has been highly effective in reducing cervical cancer mortality and morbidity. In New South Wales, between 1972 and 1999, the age-standardised incidence and mortality of cervical cancer fell by 49% and 66.6%, respectively.2 The overseas experience is similar, with the best screening programs reporting a 70% reduction in mortality rates, with slight annual mortality increases since 1986.3 That women continue to die from this potentially preventable disease emphasises the limitations of the current screening method and highlights the need for new directions. The conventional Pap test is "yesterday's tool for today's world", let alone tomorrow's! The Pap test is prone to errors at all levels, but, most importantly, at specimen collection and cytological interpretation. Consequently, relatively high numbers of false negative results are associated with the test. Further, the Pap test is only partially successful in predicting the biological behaviour of the cytological abnormality. As Dickinson states, minor abnormalities that come and go are unimportant, and can cause unnecessary alarm. These minor and transient abnormalities often lead to colposcopy, biopsy, surgical treatment and subsequent cytological and clinical or colposcopic follow-up, at a considerable cost to individual women, the screening program and taxpayers.4 Recent developments in cervical cytology and molecular biology have opened up new horizons.5 Liquid-based cytology, human papillomavirus (HPV) DNA testing and new molecular markers will help us to accurately select the patients who are likely to have biologically aggressive disease with a high probability of progression.4,5 With refinements, these new technologies will not only dramatically reduce the frequency of Pap test screening, but they may postpone the age for starting screening from 18 years to perhaps 25 or even 30 years. These new technologies come at a price. Liquid-based cytology costs about $30 and HPV DNA testing is about $90, and no Medicare rebates are currently available for these tests. The additional cost of these new technologies should be considered in the context of the cost of diagnosis, treatment and subsequent cytological and clinical follow-up of biologically insignificant disease. The money saved from improved patient selection for treatment and reduced frequency and late commencement of screening would allow more resources to be allocated to enrolling women (who are currently underscreened) and to funding these new technologies.

Ibrahim M Zardawi

To the Editor: Life expectancy in developed countries increased by an average of about 20 years during the 20th century. An editorial in the Journal by Rodger referred to mortality in populations having screening mammography.1 Data quoted indicated that there had been only slight changes in breast-cancer mortality in Australia up to 1996. Data for 1999 are available in the report of the Australian Bureau of Statistics Causes of death, published in December 2000.2 The standardised all-causes death rate per 100 000 for all persons in 1989 was 758.9 and in 1999 was 584.2, a reduction of 23.0%. For women, the standardised death rate attributable to breast cancer in 1989 was 27.2 and in 1999 was 22.1, a reduction of 18.75%. Recent decreases in breast cancer mortality of similar magnitude have also been observed in the United Kingdom and the United States.3 However, screening mammography could only be responsible for a small portion of these changes, because population screening has been in place for little more than a decade and the benefits of earlier detection and treatment would take more than five years to become evident. The causes of these dramatic reductions in death rates are not yet understood. Regarding the effect of population screening mammography on mortality rates, this is limited to breast-cancer-specific mortality and cannot be expected to translate into a reduction in overall mortality. In a recent overview of the situation in Sweden,4 breast-cancer-specific mortality in the screened group was 22% lower than in the non-screened group. However, the age-adjusted relative risk for total mortality was 1.00 (95% CI, 0.98–1.02). In other words, the mammographically screened population died less frequently from breast cancer, but nevertheless died at the same rate as the non-screened population (from other causes such as heart disease and other cancers). If we consider that, in the age group 40–79 years, breast cancer accounts for about 3% of total mortality, a reduction in breast cancer mortality of 25% would be 25% of 3%, or 0.75%. This change is so small that it would probably never be possible to show an effect of breast-cancer screening on overall population mortality. It is therefore realistic to regard the benefits of screening mammography as limited to early detection and treatment (possibly with improved quality of survival) and a reduction in breast-cancer-specific mortality.

In reply: I agree with Gough and welcome the more recent data showing up to an 18.75% reduction in breast cancer mortality in Australia in the 10 years from 1989. Obviously, this cannot be attributed solely to the now 10-year-old National Mammographic Screening Program, but it may result from a combination of the screening program, ad-hoc screening before the program, and the more rigorous use of adjuvant therapies based on the results of clinical trials. That breast screening is unlikely to have an impact on overall population mortality gives the lie to the conclusions of Olsen and Gøtzsche's overview,1 which are based only on overall mortality. Nevertheless, Gough and I agree that screening mammography is likely to deliver other benefits through detection of earlier-stage disease and a reduction in deaths from breast cancer.

To the Editor: I would like to compliment Coiera et al for their very interesting article about communication in an emergency department.1 Nearly a third of communication events were classified as interruptions, thus having an adverse effect on communication within the department. In trying to reduce this level of interruption, perhaps it is time to rethink the role of the on-call emergency physician in an emergency department. In most large Australian emergency departments, the emergency physician is also the admitting officer, who is responsible for coordinating the non-elective admissions of the day. This involves being readily available for external and internal phone calls, usually by mobile phone. Thus, as well as the normal clinical workload of an emergency physician, he or she needs to respond immediately to the summons of a mobile phone — a recipe for interruptions and less efficient communication. It is not optimal for the person who has clinical responsibility for the emergency department to also be the person through whom most of the communication is channelled. One possible solution is to channel calls about patients whom the referring doctor considers definitely need assessment in the emergency department to non-medical clerical staff. They could enter the details in a computerised "expected patients" database, which would be available for viewing by emergency department staff. Only calls about patients where there is some uncertainty, and advice calls, would be channelled to the emergency physician on call. This would facilitate both planning of the emergency department workload and also provide access to advice for the referring doctor. This change in process would reduce the number of phone calls received by the on-call emergency physician — and thus the number of interruptions — and improve overall communication within the emergency department.

Alan E O'Connor · Antony Nocera · Thomas Hamilton · Enrico W Coiera

To the Editor: Coiera et al1 should be congratulated for highlighting the excessive communication workloads of emergency department clinical staff, and the potential for these to be a source of errors and adverse events. However, their article fails to discuss the confounding variables, making it difficult to assess the validity of the communication strategies the authors propose to remedy the problem, or the applicability of their findings to other institutions. Emergency department overcrowding results from lack of access to hospital beds.2,3 Situations in which the number of patients exceeds the number of available beds (as depicted in the emergency department shown on the cover of the same issue of the Journal) are of particular concern, and would be expected to be a significant factor in the communication workload of clinical staff. Furthermore, many emergency departments do not have ward clerks, which means emergency department clinical staff perform the functions delegated to ward clerks in other hospital areas. The lack of direct telephone access to patients in the emergency department means that telephone calls from family members to a patient have to be directed through clinical staff. This increases the exchange of information between clinical staff, especially when the emergency department is overcrowded and patients are moved within the department to accommodate new patients. It is not clear, from the communication workload identified in Box 3,1 whether these factors were relevant in the institutions surveyed. In addition, Coiera et al do not indicate the seniority of the six doctors they studied. This is important given that the ratio of staff specialists to registrars or junior staff in emergency departments may be two to three times that of inpatient wards, increasing the number of times staff specialists communicate to junior medical staff in the emergency department. Finally, there is no mention of the adequacy of nursing staff numbers during the survey periods. If there were a lack of nurses, or if there were nurses on duty who normally do not work in the emergency department, one would expect an increase in communication between nurses. When emergency department infrastructure is so stressed, important studies, like that of Coiera et al, need to describe their findings in context, because of the likelihood of communication problems emerging as a result of health system failures.

Enrico W Coiera PhD, FACMI

To the Editor: I was interested in the report by Coiera et al1 about communication in the emergency department and the accompanying editorial by Vincent and Wears2 (from the United Kingdom and the United States, respectively, where, incidentally, the practice of emergency medicine differs significantly from that in Australia). In no other discipline is facility in communication between doctors, nurses, patients and relatives, as well as colleagues in other departments, of greater importance, given the paucity of information at presentation and the time constraints for assessment, management and appropriate referral — all within a time frame of a few minutes to several hours, depending on the severity of the presenting complaint. Vincent and Wears allude to the "fluidity and complexity of the clinical environment" and rightly suggest that studies need to be designed to embrace a "need to appreciate clinicians' decision making and cognitive load". It was therefore disappointing that, after so much effort, Coiera et al did not correlate their data with severity of clinical condition and/or outcome (eg, requiring resuscitation, assessment for possible admission, treatment solely in the emergency department, or discharge to outpatients clinic or home, to name but a few possible groupings). These may, of course, be intended for future publication. Regrettably, it is not stated how much input, if any, in the design and conduct of the study was obtained from staff in the unidentified emergency departments, and their contribution goes largely unacknowledged. As Richardson3 has pointed out, the active participation of at least one member of the emergency medicine staff (preferably senior and experienced) in such studies enhances motivation in staff busy with other priorities, and facilitates cooperation and collaboration (which can thereafter properly be recognised in co-authorship). There is also a danger that in the current litigious climate an inadvertent emphasis on "errors and poor outcomes" may prejudice the real benefits of the worthwhile objective of assessing the nature, relevance and value of improved communication between those engaged in clinical practice. Nonetheless, it is encouraging to deduce from this report that, in emergency departments, doctors and nurses regularly speak to each other, presumably with an optimal outcome for the patient in mind. For one who spent two decades as head of a busy, metropolitan emergency department, it is reassuring to find, in a discussion of informatics, advocacy2 for a return to the "white board", which, even today, remains the mainstay of patient information and tracking in many emergency departments.

Alan E O'Connor

In reply: We know little about communication systems in healthcare, and our study is still only one of a handful that quantify communication processes. Consequently, the aim of our pilot study, as well as reporting specific emergency department communication patterns, was to develop a robust general observational methodology, and measures of communication load.1 With the evidence that communication load is an issue, the next stage in the research would be to design studies to identify variables that could, in principle, affect communication load, as suggested by both Nocera and Hamilton. Indeed, there are many such variables — staff level and experience, organisational structure, clinical task, patient acuity, communication infrastructure, departmental policy, etc. The difficulty we will face is to control for many of these variables, and this will require longitudinal studies and samples from multiple sites. Hence, we are not yet able to make specific recommendations about interventions to "improve" communication in emergency departments. Indeed, there are no benchmarks against which to compare these data, so we cannot even say whether the data reflect good practice. Given these uncertainties, we agree with Nocera that it is too early to say which interventions would be appropriate to the specific circumstances of emergency departments, and we made no specific recommendations ourselves, but rather summarised commonly suggested interventions. Nocera and O'Connor also suggest other interventions which in their clinical experience may improve communication loads in emergency departments. It is likely that the variability of organisational settings will mean most such interventions will need to be customised to local conditions and needs. Hamilton is correct to highlight the tension in reporting data on organisational performance, and the risks of these data being misinterpreted or misused. Given these risks and the lack of comparative benchmarks, we explicitly chose not to comment on performance, nor to identify the organisations or participating clinicians. However, we would not have been able to carry out the study without the full cooperation of the staff at both hospitals, and, while they remain anonymous, we are deeply indebted to them for their willingness to welcome us into their workplace, volunteering to be subjects, and allowing us to observe them as they carried out their work.

Alan E O'Connor

To the Editor: The recent editorial by McCarthy and Garrow1 eloquently articulates a case for a coordinated national approach to controlling parasite infections in Aboriginal populations, based predominantly on the authors' experience with chemotherapeutic intervention in one remote community in Western Australia. While sympathetic to their motives, I am not so optimistic about the outcome of their proposal. For 20 years, Queensland maintained a centrally coordinated Aboriginal health program designed to monitor and eradicate parasitic infections. The program, which used targeted chemotherapy as its core strategy, was very successful with regard to intestinal worms, suppressing trichuriasis almost to extinction (unpublished observation) and virtually eradicating hookworm.2 However, the prevalence of gut protozoan infections (such as giardiasis and cryptosporidiosis) was hardly affected, for the obvious reason that these are relatively short-lived and spread directly person-to-person, which means that personal hygiene is much more crucial to their control. Systematic surveillance ceased after the program was dismantled (for political reasons) in 1990, and anecdotal reports since indicate that hookworm is now returning to Queensland. Again, this is not surprising given the mobility of Indigenous people, and the ability of infective larvae of Ancylostoma duodenale, the local hookworm species, to persist in a dormant state in host tissues, where they are refractory to currently available treatment.3 In support of their case, McCarthy and Garrow presented lymphatic filariasis in Australia as but one successful precedent, implying that it was eradicated "through sustained control programs conducted by dedicated public health agencies . . . using effective drugs".1 This is not supported by historical facts; the disease did disappear from endemic areas, but well before effective chemotherapy became available, and for reasons that are still debatable4 (although mosquito suppression, resulting more from general improvements in living conditions with rising community affluence than from any coordinated activity, is the most likely explanation). At the community level, parasitic infections of the gut represent not so much a primary problem as a symptom of a more fundamental societal malaise. They will disappear from Aboriginal communities only with a sustained improvement in living conditions (including nutrition, sanitation and personal hygiene), driven by the people themselves when armed with effective public health knowledge. This is a challenge that continues to dwarf the capabilities of all our governments and politicians, at all levels.

Paul Prociv · Stuart C Garrow · James S McCarthy

In reply: While specific details of control strategies for intestinal parasites vary according to parasite species, available anthelmintic agents and tools for environmental intervention, it is widely accepted that sustained, coordinated programs supported by government, community and health professionals with agreed methods and targets are the key to success.1 Prociv describes the outcome of just such a program for hookworm in Queensland, and the subsequent recrudescence of infection once the program was scrapped. The program in northern Western Australia succeeded because of commitment by government, community involvement entailing community debate and ownership of the program,2 education, and behavioural change, and improvement in public sanitation facilities as well as chemotherapy.3 We believe that a critical determinant of the outcome of our program was the inclusion of the community in designing the program. We agree with Prociv that control of filariasis and malaria was achieved in Australia by mosquito control; our statement about the role of sustained public health programs refers to the control of leprosy.4 With respect to the prospects for control of intestinal protozoa as well as helminths, a single-dose regimen with broad-spectrum activity would be ideal. While albendazole shows some useful clinical activity in giardiasis, single-dose regimens of this drug are insufficient to effect cure, as was observed in our study. While the social and environmental hurdles may appear to "dwarf the capabilities of government", we believe that there is a continuing need for Aboriginal health organisations, health professions and health departments at state and national levels to tackle parasitic infections. The logical approach is to model wider programs on successful local programs, and to avoid drifting into policy and program nihilism.

Stuart C Garrow · James S McCarthy

Statistical methods in medical research. 4th edition. P Armitage, G Berry, J N S Mathews. Oxford: Blackwell Science, 2002 (xi + 817 pp). ISBN 0 632 05257 0. The chance of reviewing the new edition of this classic text came just at the right time, as my first edition copy had finally started to disintegrate. My introduction to medical statistics, or indeed any statistics apart from a brief encounter with experimental error assessment, came with the opportunity to sit in on Peter Armitage’s lectures at the London School of Hygiene and Tropical Medicine in 1971. These lectures formed the basis of his book, and since then each edition has improved and expanded considerably on the last, keeping pace with the ever-changing field of medical statistics and adding new co-authors on the way. The book has been reorganised since the last edition, including, among other changes, new sections on permutation and Monte Carlo methods, non-linear regression and multilevel modelling, and also expanding the sections on Bayesian methods and clinical trials. This book is about methods and their application and is aimed at the practitioner, but it is also suitable for anyone with an interest in statistics. It could be read as a unified text and could form the basis of a practice-oriented course, but it is most likely to be dipped into as required. The subject index appears extensive and exhaustive. There is also an excellent author index which helps to track down the context of any of the wide-ranging set of references. The authors do not present any mathematical theory; rather, they concentrate on commonsense explanation and justification for the techniques and methods that they describe, and these are accompanied by plenty of worked examples. They also direct readers to appropriate statistical software. This book belongs on the shelf of anyone who uses or needs to understand anything about medical statistics, and will be constantly on loan from library shelves. Nicholas H de KlerkTVW Institute for Child Health Research Perth, WA

Nicholas H de Klerk

International travel and health. Geneva: World Health Organisation, 2002 (viii + 193 pp). ISBN 92 4 158027 5. The World Health Organization has a measure of credibility when it comes to producing a book called International travel and health. Although this book is updated annually, in some years the most significant difference has seemed to be the change of colour to the stripe on the cover. The 2002 edition, though, is different! The book has almost doubled in size, the cover has changed from the traditional yellow to a modern teal and, most significantly, there has been a change in the content. The claim on the cover of “abundant new material” is true. The list of acknowledgements reads like a “who’s who” of travel medicine and their input has made the book up to date and value for money. A diverse range of travel medicine topics are dealt with, from the traditional to the more unusual. Vaccinations, malaria, medical kits, altitude, deep vein thrombosis, jetlag, flight phobia, stings, worms, drownings, traffic accidents, muggings, travelling when pregnant, or with pre-existing medical conditions, and even risks from aircraft disinfection, ozone and cosmic radiation, are all dealt with. There is a particularly useful reference section summarising aspects of the infectious diseases that pose risks to travellers. The book is organised logically with an extensive table of contents, index, excellent headings, and plenty of tables. The 12 maps in the centre give an excellent overview of the extent of various diseases in 2001 (eg, Japanese encephalitis, dengue, yellow fever, malaria, hepatitis A, B and C, rabies. The popular “Country List” remains — it outlines the current vaccination requirements and malaria situation for each country. This has limited value given the static nature of the publication, but takes up only 26 pages in a publication of 180 pages, so it does not detract too much from its general usefulness. This 2002 edition is a great leap forward! Deborah J MillsMedical Director Travel Medicine and Vaccination Clinic, Brisbane, QLD

Deborah J Mills

eTG complete. Melbourne: Therapeutic Guidelines, 2002 (CD-ROM: Subscription $220). Therapeutic guidelines (10 at last count) are based on world literature, published by a group without commercial, government or pharmaceutical dependence or sponsorship and have been an essential reference for over 20 years. The various Guidelines have been distributed as pocket-sized books and, more recently, as individual electronic versions. This CD-ROM is the next step: integrating a series of Guidelines into one electronic product, with a master index. Subscribers are offered updates three to four times a year. The versions which are used are noted (eg, Analgesic version 3, Antibiotic version 11), but the search capability gives access across all guidelines. The disc is easy to load, and appears on the desktop as an icon. Search characteristics are clear, reasonably intuitive and speedy, meaning that use in a GP consultation is at least as quick as looking up one of the paper-based guides. It is also better, as searches access information from more than one guideline. A search for pregnancy and depression, for example, yields information from the Neurology, Respiratory and Psychotropic Guidelines, all of which have relevant sections. The advice includes non-pharmacological information. It is also printable, to provide a basis for discussion with patients. My room has lots of books, but I find that I get up from my desk to find them less often than I used to because of desktop resources like this one. If a tool is easy to use, I am more likely to use it, rather than rely on memory, particularly for uncommon things. But the cost is high — for our five-doctor practice the cost of eTG is $220 for the first user and $110 for each subsequent user, compared with $264 for one set of the books — which we can all share. Whether the convenience is worth the cost is a question we will wrestle with. Linda MannGeneral Practitioner Leichhardt, NSW

Linda Mann

Bright lights, big city According to a study conducted in Delhi, India, one of the most polluted cities in the world, atmospheric pollution is leaving children vulnerable to rickets. Researchers compared biochemical indicators of vitamin D status in 26 children aged 9–24 months living in a heavily polluted area of the inner city (Mori Gate) and 31 age-matched children from a less-polluted area on the outskirts (Gurgaon). Pollution levels were confirmed using a haze sensor, which detects UVB radiation to produce a haze score (lower scores indicating higher levels of atmospheric pollution). All the families were Hindu vegetarians and lived in one-room dwellings with some communal outdoor space. Haze scores confirmed that UVB was less available in Mori Gate than in Gurgaon (mean scores, 2.1 v 2.7). Mean total serum 25(OH)D concentration was significantly lower in the Mori Gate children than in the Gurgaon children (12.4 ng/mL v 27.1 ng/mL) and these children’s mean alkaline phosphatase and parathyroid hormone levels were correspondingly higher. Twelve Mori Gate children had severe 25(OH)D deficiency (levels <12 ng/mL), three having levels usually associated with rickets (<5 ng/mL). Arch Dis Child 2002; 87: 111-113 A harsh mistress A recent analysis of UK mortality statistics confirms that fishermen and seafarers have the most dangerous jobs of all. Between 1976 and 1995, seafarers were 26.2 times and fishermen 52.4 times more likely than all other occupations combined to have fatal accidents at work (rates of 51.6 and 103.1 deaths/100 000 worker-years, respectively). Drowning was the most common cause of death, followed by injuries and asphyxiation. According to the researchers this is not just a British phenomenon. Fishermen in Demark, Australia and Alaska enjoy fatal accident rates of 145, 143 and 116/100 000 worker-years, respectively. Lancet 2002; 360: 543-544 Wheezy genes Recent work on the ADAM 33 gene provides insight into the pathogenesis of asthma, and possibilities for management. Researchers scanned the entire genomes of 460 Caucasian sibling pairs and found a locus on chromosome 20 which was linked to both asthma and bronchial hyperresponsiveness. They surveyed 135 polymorphisms of 23 genes, identifying an allele of the ADAM (A Disintegrin And Metalloprotease) gene, ADAM33, as being significantly associated with asthma. The gene codes for membrane proteins and is expressed in bronchial smooth muscle and lung fibroblasts, suggesting that its role in asthma susceptibility may involve airway function rather than immunological factors. Nature 2002; 418: 426-430 The end of violence? In the United States, women who obtain Civil Protection Orders against violent partners can take heart that such orders seem to afford protection in the long run, but the early benefits are much less certain. In Seattle, Washington, between August 1998 and January 2000, 2691 women reported episodes of Intimate Partner Violence (IPV) to the police: 225 obtained temporary protection orders (TPOs) for two weeks, and 185 went on to obtain permanent protection orders (PPOs) for a year or more. In the 12 months following the index incident the overall rates of police-reported IPV were 13.5 and 12.3/100 person-years for physical and psychological abuse, respectively. Women with TPOs reported slightly higher levels of physical abuse than those without orders, but were almost five times more likely to report psychological abuse. Women with PPOs reported similar rates of psychological abuse as women without orders, but were five times less likely to report physical abuse. It is estimated that police records capture about 50% of IPV incidents. JAMA 2002; 288: 589-594 Litigation and conversation As if they didn’t have enough to worry about with the current medical indemnity crisis, surgeons are now advised that the tone of voice they use with patients might lead to litigation! Consultations of 57 US surgeons (36 of whom had had at least two malpractice claims filed against them) with 114 patients were recorded. Four 10-second sound clips were extracted from each consultation: two retained content and two were filtered using an audio technique which retains the expressive features of speech without recognisable content. The clips were rated by 12 Harvard University undergraduates. Controlling for content, a dominant tone was associated with a history of litigation (OR, 2.74), while a concerned or anxious tone was not (OR, 0.46). Surgery 2002; 132: 5-9

Med J Aust 2002; 177 (6 Suppl).