Volume 178 Issue 6

Building a patient's trust is just as important as following the letter of the law The cases and discussion in the article by Braunack-Mayer and Mulligan in this issue of the Journal (page 277)1 provide informative examples of legal and ethical dimensions of confidentiality and privacy in doctor–patient relationships. It is important to clarify the foundations and scope of both legal and ethical duties. In law, information provided to a medical practitioner by a patient becomes subject to a statutory duty to protect the patient's privacy and a common-law duty of confidence owed by the medical practitioner to the patient. *A failure to fulfil this duty is not an offence, although it can be the foundation of a complaint to the Office of the Privacy Commissioner. Privacy Act 1988 (Cwlth), section 36. †There is specific legislation in the Australian Capital Territory (Health Records [Privacy and Access] Act 1997), New South Wales (Privacy and Personal Information Protection Act 1998) and Victoria (Health Records Act 2001), and other States are actively considering such legislation, including New South Wales in relation to health information. Statutory duty. The statutory duty* varies according to whether federal or state legislation applies.† The federal Privacy Act 1988 applies to health information used by a private organisation and permits use or disclosure of such information without the patient's consent in a specified list of circumstances.2 Those that relate to the examples given by Braunack-Mayer and Mulligan are (a) disclosure for purposes directly related to the purpose of collection in ways that the patient would reasonably expect;3 and (b) disclosure that is reasonably believed to be necessary to prevent or lessen a serious and imminent threat to a person's life, health or safety.4 The scope of the statutory duty is not yet clear, as guidelines5 and public interest determinations6 issued by the Federal Privacy Commissioner indicate. Common-law duty. The common-law duty arises from a contract between patient and doctor or the presumption that the relationship is one of a class to which the law attaches that obligation. The duty is said to encourage patients to disclose full information so that medical practitioners can provide effective healthcare, a basis for a public interest in such duties of confidence.7 Correctly understood, it is not a duty to keep all information secret, but a duty to use the information only for the purposes for which it was provided and not for any other purpose.8 Medical ethics. In ethics, the duty of confidence in medical practice has strong historical origins in formal statements of medical ethics. Different translations of the Hippocratic oath recognise that the duty applies only to some and not to all information. These statements include "what should not be published abroad",9 "things shameful to be spoken about",10 and "things that should never be blurted out".11 Thus, its scope can be described by reference to the purpose of the disclosure.12 The justifications for this duty include a respect for patient autonomy and an expression of the professional virtue of fidelity.13 In Cases 1 and 2 presented by Braunack-Mayer and Mulligan, Ms X's and Mr Y's information was clearly provided for the purpose of providing diagnosis, advice and/or treatment to them. Their doctors' uses of that information to clarify a diagnosis, confirm decisions about treatment or seek additional advice could fairly be described as uses for that same purpose. As such, those uses would not be breaches of the common-law duty of confidentiality. However, the particular use described in Cases 1 and 2 may not conform to the Privacy Act, as it seems clear that neither Ms X nor Mr Y reasonably expected that use of their information. (There is no suggestion that the disclosure was reasonably necessary to prevent or lessen a serious and imminent threat to their life, health or safety.) The legal and ethical implications of access to Ms Z's test results in Case 3 are less clear, because of the involvement of two medical practitioners and the lack of explanation as to how the second doctor had access to the test results. Clarification of these details is important. However, if there was an explanation of access, it is clear that the information was used for the purpose of diagnosis and treatment, the purpose for which it was provided. Ms Z's being unaware of that use remains relevant for the Privacy Act. Thus, the common-law duty of confidence may not have been breached by any of the doctors in the three cases. The statutory duty to protect privacy may have been breached, depending on clarification of some uncertainties of interpretation. However, what remains important is that the patients all plainly felt that their information had been used in ways that surprised or troubled them. It could be said that the patients thought that an ethical duty had been breached. It seems there were two main causes for their concern, both of which have ethical importance. First, they did not know about (and did not feel that they had consented to) the way their information was used, and, second, that use diminished their trust in their doctors. Consent that is based upon an adequate and clear disclosure of how information will be used is the best response to the first cause of concern. Being given that information and, in turn, giving consent also respects a patient's autonomy. Routine advice as to whom a patient's information will be disclosed in the course of using it for diagnosis and treatment will probably also meet the requirements of the Privacy Act.3 Further, patients can, by their consent, agree to wider uses or disclosures of their information. As to the second cause of concern, acting in order to generate and maintain a patient's trust is the best response. In doing so, a doctor expresses the virtue of fidelity. This lies at the foundation of the doctor–patient relationship: it extends beyond merely keeping promises (eg, to maintain confidentiality) and speaks to character and the establishment, and not the assumption, of a relationship of trust.14 The authors are correct to identify the ethical importance of attending carefully to patients' awareness of and understanding about how their information is used. Exceeding minimal legal duties by doing more than merely making patients aware of how their information will be used is important to building trust and to providing effective healthcare.

Colin JH Thomson BA LLB LLM

The IF is a poor measure of the worth of journals, journal articles and authors Tell me the number; what is the ranking? All of us seem to love ratings. Whether it is the standings in the Rugby World Cup, the box office success of Harry Potter or the melting rate of Arctic ice, we all want numbers. So, why would it be any different for medical journal articles or even medical journals themselves? Who attaches importance to medical journal ratings? The owners/publishers of the journals, readers, advertisers, librarians and journalists may all be interested in journal ratings to varying degrees. Likewise, authors have a need to discern just how a publication is valued before deciding where to send the products of their labours. How can we evaluate the quality of an article or a journal? Properties of a medical journal that can be assessed include total circulation; readership numbers and surveys; quality of the editorial board, staff and peer reviewers; number of manuscripts received, percentage accepted, and turnaround; Science Citation Index (SCI) raw numbers, Immediacy Factor and Impact Factor (IF); number of paid subscribers; advertising revenue; listing on Medline; international distribution; cost to the reader; and page or peer-review charges to the author.1 But what do authors most value? Frank and colleagues have surveyed the Stanford University School of Medicine faculty regarding the factors that influenced their decisions about where to send manuscripts. The top attribute selected was "prestige".2 Impact factors are also used to adjudicate on academic performance. Some universities, especially in certain European countries, have decided that the IF of journals in which a faculty member publishes will enter into personnel decisions such as appointment, promotion and rate of pay.3 One would like to think that intelligent deans, chairs of departments and administrators, who work daily with faculty members, would have a better way to ascertain quality of performance than an arbitrary number. Seglen, of Norway, was an early critic of the IF, drawing attention to its narrow worth, and calling for its application to be reined in3 — but apparently to no avail. My belief is that the IF has one specific meaning: it is a clear measure of the extent to which a given journal functions as a connector of researchers in a specific field. This is one (but only one) critical function of medical journals. When I began as the editor of JAMA in 1982, JAMA's IF was in the range 3–4. Some considered this an embarrassment, so we set out to raise the IF as part of our efforts to improve the quality of the journal. We succeeded, to the extent that by the time I left the journal in 1999 its IF was in the range 10–11. Strange as it may seem, during the mid-1990s I deliberately tried to slow the growth of JAMA's IF. I was afraid that we were changing the character of the journal away from its fundamental purpose — to be useful to all doctors in their practices — and too far towards a research journal, used by researchers to communicate with each other. In this issue of the Journal, Walter and colleagues4 (page 280) criticise the IF, clarifying what it is and what it isn't. They describe an alternative way they have devised to judge the quality of articles (and presumably journals, if article scores are aggregated and averaged), using a five-person voting method guided by six criteria. It would have been interesting to see a side-by-side comparison between the article rankings of the selection panel and the SCI IF scores for each article. Walter and colleagues' form of post-publication peer review is now into its second year. The authors invite others to try it, and I hope there will be some who take up the challenge. In 1982, when I and my colleagues were developing plans to celebrate the JAMA Centennial, we tried an approach to evaluating medical articles somewhat like that of Walter et al. We wished to identify and republish the best 50 articles from the first 100 years of JAMA as "landmark articles". A list of prospective articles for inclusion was compiled from three sources: nominations by JAMA editorial board members and staff, entries in the 1976 edition of A medical bibliography (Garrison and Morton), and the most-cited JAMA articles from the Institute for Scientific Information. A total of 150 articles were nominated. The editorial board and staff then ranked the articles by a Delphi process and the top 50 were named "landmark articles".5 The article publication dates ranged from 1884 to 1968, with representatives from each decade. A subsequent analysis of the landmark articles by Eugene Garfield, founder of the Institute for Scientific Information (and father of the noted [or notorious] IF), demonstrated that of the 100 JAMA articles most cited by SCI up to 1983 only 13 were among the top 50 landmark articles, garnering from 174 to 506 citations by 1987.6 Thus, 37 landmark articles were not included in the top 100 JAMA articles ranked by total citations alone. Notably, such hugely important articles as those of Salk7 and Sabin et al8 had only received 39 and 90 citations, respectively, by 1987. So, number of citations and the derived IF are connected, but only to a limited degree. I would hesitate to suggest that the post-publication peer review process described by Walter et al could supplant the IF as the way that academic institutions, or even governments, decide on the merit of a publication or an author. But I can say with conviction that man (and academia) should not live by numbers alone.

George D Lundberg MD

Previous recommendations for preventing allergic disease need to be critically re-examined A marked increase in allergic disease has occurred over the past century. For example, between 1992 and 1997, the prevalence of asthma increased by 26% and skin-prick sensitivity to house dust mite (HDM) increased by 63% in Australian children.1 In determining the causes of this increase it is important to distinguish between primary and secondary causes of allergic disease. Primary causes are those considered to induce allergic disease in a non-sensitised person, while secondary causes are those that trigger symptoms in people who are already sensitised. Primary prevention strategies are aimed at reducing sensitisation. In the early 1980s it was considered that a clean environment, avoidance of pets, the provision of synthetic "allergy free" bedding (rather than feather bedding) and prolonged breastfeeding were all important in primary prevention. But recent epidemiological studies have challenged these beliefs. There is evidence that a clean environment in early life may actually promote rather than inhibit the development of allergy. The "hygiene hypothesis" is based on epidemiological studies comparing the prevalence of allergic disease in "clean" and "dirty" environments. For example, children growing up in East Germany before the fall of the Berlin Wall had a lower prevalence of allergic disease than children in West Germany, despite having more exposure to pollution and infection.1 These results have been confirmed in similar comparative studies. Other relevant studies supporting the "hygiene hypothesis" have demonstrated fewer allergies in children from large families, in younger siblings, in children exposed earlier to day-care centres, and in children growing up on farms in Europe. Prevention programs for allergic disease have recommended avoidance of pets, particularly cats. However, recent studies showing either less asthma or less sensitisation among children exposed to cats in infancy have challenged this view.2,3 Exposure to cats in infancy does not appear to increase the risk of developing asthma. With regard to sensitisation, the evidence is conflicting, with some studies suggesting decreased sensitisation following cat exposure in infancy and others indicating the reverse. Cat exposure is associated with increased environmental levels of bacterial endotoxin. There is a hypothesis that endotoxin derived from pets may play a role in the prevention of allergy, as endotoxin can induce immune deviation away from "allergic" TH2 responses. The common belief that feather bedding promotes and synthetic bedding prevents allergic disease is now in doubt. This belief arose because of purported allergy to feathers or accumulation of HDM allergen in feather products. In fact, feather pillows contain up to eightfold lower levels of HDM allergen and accumulate this allergen more slowly than synthetic pillows. Children using a feather quilt are less likely to be sensitised to HDM.4 Prospective studies show that use of feather bedding in early childhood is associated with reduced asthma5 and use of synthetic bedding with increased asthma6 in later childhood. Studies of bedding are potentially complicated by selection bias: children with asthma may preferentially use synthetic rather than feather bedding, because of the widely held belief that synthetic bedding is less harmful. It is widely believed that breastfeeding should be recommended for primary prevention of allergic disease. Exclusive breastfeeding beyond four months of age reduces the development of atopic disease in early life,7 but the long-term benefits are now in question. One study has suggested that breastfeeding increases both asthma and allergen sensitisation in adult life;8 however, the fact that the breastfeeding was not necessarily exclusive may be a possible confounder. Another study demonstrated a protective effect of breastfeeding in early life but increased asthma in older children.10 A parental history of allergy is the most important risk factor for childhood allergy. What, then, are we to recommend to parents? Firstly, it is not possible to guarantee that any steps taken will prevent allergic disease. It seems reasonable to recommend exclusive breastfeeding for at least four months to increase the chance of reducing allergic disease in early childhood. It is not clear that the benefits extend to later life. Currently, it is not possible to provide firm recommendations on allergen reduction measures. Local environmental factors are important for HDM replication, and the benefits or otherwise of measures to reduce HDM exposure in infancy need to be demonstrated in the local environment. An Australian study of the effect of HDM reduction measures in infancy is in progress and the results are awaited with interest. Feather pillows or Doonas do not need to be avoided and may in fact be more beneficial than synthetic bedding. Once a child is sensitised, there may be a role for effective HDM encasing on any type of bedding, although again not all studies agree on this issue. Avoidance of household pets is not likely to prevent the development of allergic disease and cannot be recommended as a prophylactic measure. Nevertheless, it is advisable for clinically sensitive patients. It is clear that we need to critically re-examine the previous recommendations given to parents.

Andrew S Kemp FRACP PhD

Objective: To determine the chance of at least one live birth from one round of in-vitro fertilisation (IVF) treatment and the effect of the woman's age on that likelihood.Design: Retrospective analysis of outcomes from IVF treatment that did not involve donated gametes, but which included embryos cryopreserved in the retrieval cycle.Setting and patients: All IVF patients (median age, 36 years; range, 22–48 years) who attended a private IVF clinic in Sydney for an egg retrieval between 1 January 1998 and 31 December 1998, and had embryo placements (fresh and cryostored) performed up to 30 June 2001.Main outcome measure: Independently audited live births surviving the neonatal period.Results: 565 women had 648 egg retrievals during the period. The age of peak utilisation of IVF was 39 years. For women aged 34 years or less, the chance of a live birth from one round of egg retrieval and IVF treatment was 52.4% (95% CI, 47%–59%). For women aged 35–44 years, there was a linear decline in the live birth rate, and no babies were born from retrievals at age 45 years and over. There was an age-dependent rise in the frequency of miscarriages, from 10.5% (95% CI, 5%–18%) for women under 35 years, to 16.1% (95% CI, 9%–25%) for those 35–39 years, and 42.9% [95% CI, 24%–63%] for those over 40 years (P < 0.001). A third of the first births resulted from embryo transfers performed after a period of cryostorage.Conclusion: As fertility with IVF falls from the age of 34 years, and the age of peak IVF utilisation is 39 years, many Australian women are seeking IVF at an age when the likelihood of a live birth is reduced.

Robert P S Jansen MD, FRACP, FRANZCOG, CREI

Objective: To evaluate the benefits of coordinating community services through the Post-Acute Care (PAC) program in older patients after discharge from hospital.Design: Prospective multicentre, randomised controlled trial with six months of follow-up with blinded outcome measurement.Setting: Four university-affiliated metropolitan general hospitals in Victoria.Participants: All patients aged 65 years and over who were discharged between August 1998 and October 1999 and required community services after discharge.Interventions: Participants were randomly allocated to receive services of a Post-Acute Care (PAC) coordinator (intervention) versus usual discharge planning (control).Main outcome measures: Comparison of quality of life and carer stress at one-month post-discharge, mortality, hospital readmissions, use of community services and community and hospital costs over the six months post-discharge.Results: 654 patients were randomised, and 598 were included in the analysis (311 in the PAC group and 287 in the control group). There was no difference in mortality between the groups (both 6%), but significantly greater overall quality-of-life scores at one-month follow-up in the PAC group. There was no difference in unplanned readmissions, but PAC patients used significantly fewer hospital bed-days in the six months after discharge (mean, 3.0 days; 95% CI, 2.1–3.9) than control patients (5.2 days; 95% CI, 3.8–6.7). Total costs (including hospitalisation, community services and the intervention) were lower in the PAC than the control group (mean difference, $1545; 95% CI, $11–$3078).Conclusions: The PAC program is beneficial in the transition from hospital to the community in older patients.

Wen K Lim FRACP · Sue F Lambert PhD, BEcons · Len C Gray PhD, FRACP

Aim: To determine effectiveness of treatment for hepatitis C outside clinical trials, by testing the hypothesis that apparent effectiveness and tolerability of interferon alfa-2b/ribavirin combination therapy would be less in a hospital liver clinic setting.Design: Retrospective analysis of all patients in one centre commencing interferon alfa-2b/ribavirin therapy, but not in clinical trials, between 1998 and 2000.Main outcome measures: Effectiveness as sustained virological response (SVR); tolerability as premature discontinuation of treatment.Results: The 121 patients had similar demographic and viral characteristics as those in Australian trials (age, 44 ± 10 years; males, 66%; genotype 1, 44%; genotype 3, 36%), but 38% had advanced fibrosis, including 17% with cirrhosis. Sixty (50%) were previously untreated, 38 (31%) had relapsed after initial response (response relapse) and 23 (19%) were non-responders to interferon monotherapy. Sustained viral response (SVR) was achieved in 53% of patients overall: 47% of patients with genotype 1 HCV, 71% of patients with genotype 3. For patients with genotype 1 HCV, SVR was 43% in those previously untreated, 63% in response relapsers, and 38% in non-responders. Corresponding SVRs for genotype 3 were 65%, 87% and 33%. These results are similar to those obtained in published trials. Only 7% of our patients discontinued treatment because of adverse effects, fewer than reported in most clinical trials. Dose reduction was required in 18% of patients.Conclusions: In a hospital clinic setting the effectiveness of interferon alfa-2b/ribavirin combination therapy appears equivalent to published results from clinical trials.

Dinesh Kumar* MD, DM · Craig Wallington-Beddoe* BSc, MB BS · Jacob George PhD, FRACP · Rita Lin PhD, FRACP · Dev Samarasinghe PhD, FRACP · Chris Liddle PhD, FRACP · Geoffrey C Farrell MD, FRACP

An Expert Working Group of the National Heart Foundation of Australia undertook a review of systematic reviews of the evidence relating to major psychosocial risk factors to assess whether there are independent associations between any of the factors and the development and progression of coronary heart disease (CHD), or the occurrence of acute cardiac events. The expert group concluded that (i) there is strong and consistent evidence of an independent causal association between depression, social isolation and lack of quality social support and the causes and prognosis of CHD; and (ii) there is no strong or consistent evidence for a causal association between chronic life events, work-related stressors (job control, demands and strain), Type A behaviour patterns, hostility, anxiety disorders or panic disorders and CHD. The increased risk contributed by these psychosocial factors is of similar order to the more conventional CHD risk factors such as smoking, dyslipidaemia and hypertension. The identified psychosocial risk factors should be taken into account during individual CHD risk assessment and management, and have implications for public health policy and research.

Stephen J Bunker PhD, RN · David M Colquhoun MB BS, FRACP · Murray D Esler PhD, FRACP · Ian B Hickie MD, FRANZCP · David Hunt FRACP, FACC · V Michael Jelinek FRACP, FACC · Brian F Oldenburg PhD, MPsychol · Hedley G Peach PhD, FFPHM · Denise Ruth FRACGP, FAFPHM · Christopher C Tennant MRCPsych, FRANZCP · Andrew M Tonkin MD, FRACP

Careful consideration of the ethical implications is required before patient information should be shared without the patient's knowledge. Routine and apparently uncontroversial releases of information can be perceived as problematic by patients. The ethics of such "ordinary" breaches of confidence can be explored by considering the patient's autonomy, the patient's best interests, and the public interest in preserving or breaching confidentiality. Patient autonomy can be supported and ethical problems may be avoided when patients are given as much information as possible about foreseeable information disclosures.

Annette J Braunack-Mayer BMedSci(Hons), PhD · Ea C Mulligan BMBS MHAdmin

The journal Impact Factor and citation counts are misconstrued and misused as measures of scientific quality. Articles must be read in order to judge their quality. We have introduced a system, which may be easily replicated, to identify the best articles published in a journal. Gloom or glee? Each September, journal editors and publishers anxiously await news of a particular figure from the Institute of Scientific Information (ISI) in Philadelphia, USA. The figure's value is promptly met with despair or delight. We are referring, of course, to the Impact Factor (IF) and the ritual surrounding its release that has come to dominate the editors' and publishers' calendar. Two of us, as editors ourselves, participate in this practice, albeit reluctantly and with rising apprehension that scientific publishing is being undermined by "numerology". What was introduced as an aid to librarians more than four decades ago to guide their selection of scientific journals has become, in the view of some people, an inappropriate means of scrutinising an applicant's "track record" when allocating research funds or considering academic promotions.1-4 Why inappropriate? Because the IF (defined as "the number of citations to a journal's articles published in the previous two years divided by the number of articles published by that journal during those two years"4-6) is conceptually and technically flawed, on a number of grounds: the quality of published material cannot be constrained by time — the two-year period set by the ISI for citations is arbitrary;7 the number of journals in the ISI's database is a minute proportion of those published;4 reviews are cited more frequently than original research, thus favouring journals that opt for these articles as part of a publishing strategy;1 the IF does not take into account self-citations, which amount to a third of all citations;8 errors are common in reference lists (occurring in up to a quarter of references), inevitably affecting IF accuracy;9 and the assumption of a positive link between citations and quality is ill-founded, in that we cite articles for diverse reasons, including to refer to research judged suspect or poor.10 If these flaws were not enough to instil scepticism about the IF's validity and precision, then the arbitrary assumption that the quality of a specific article correlates with the IF of the journal in which it appears is entirely ill-founded and, in itself, sufficient to warrant concern about its continuing use. As editors and researchers, we are duty-bound to analyse this assumption rigorously. What do we find? Consider two psychiatric journals published for a general readership: the Australian and New Zealand Journal of Psychiatry (ANZJP) and the Canadian Journal of Psychiatry (CJP). Applying the ISI's own "Web of Science" database,11 we can examine the purported link between IF, citations and the worth of a particular article. For instance, if we calculate the proportion of citations to all articles in each journal that is accounted for by the most-cited 50% of papers, a striking pattern emerges. In the case of the ANZJP, the most-cited 50% of papers published between 1990 and 1995 account for 94% (range, 91% [1992] to 98% [1990]) of all citations to articles in that journal. Figures for the CJP are virtually identical: 94% (range, 91% [1991] to 96% [1994]). A blunt summary of these findings is that half the articles published in both journals receive virtually no citations. We can conclude from the data (and from comparable findings from other journals, such as those in cardiology10) that to determine the academic worth of a paper from the IF of the journal in which it appears is ill-conceived and misleading. In an era of evidence-based medicine, its proponents avow that scientific progress can only be achieved by dint of diligent scrutiny of available data. Is it not incongruous, then, that the scientific community continues to cling to such an inadequate tool as the IF? What's more, the "parent" IF has spawned a range of flawed offspring, including "Scope-adjusted IF", "Discipline-specific IF", "Journal-specific influence factor", "Immediacy index" and "Cited half-life". As if that were not disconcerting enough, lo and behold, ISI recently faced a new rival, albeit short-lived (the venture collapsed in the wake of a threat from ISI to sue for violation of intellectual property rights). "PrestigeFactor.com" was launched in 2001, enticing us to ditch the IF and supplant it with another measure of journal quality, the "Prestige Factor" (PF).12 Its proponents boldly asserted that the PF provided "truer value" than the IF.12 There was, however, a fly in the ointment. Despite minor refinement (eg, the PF separated review articles from research reports and included citations to journal articles over the previous three years versus two), the underlying premise of both measures — that quality and number of citations are inextricably linked — was identical. It is also worth reporting the contemporary practice of open-access "e-journals" tracking their most popular articles through "hit rates".13,14 Again, we doubt that a popularity poll can indicate academic merit and fear that it may be misconstrued in this way. A watershedWe have reached a watershed — either we persevere with the notion that citations lie at the heart of scientific quality or we make a clean break. The latter option is attracting growing support. For instance, Richard Frackowiak, Dean of the Institute of Neurology in London, asserts that current measures are crude and reliance on them in making hiring-and-firing decisions is counterproductive.15 Zach Hall, a leading figure in US research, sees numerical methods as "excuses for not thinking".15 David Adam, a writer for Nature, highlights the absurdity of the situation in Finland, where government funding of university hospitals utilises a sliding scale corresponding to the IF of journals in which researchers publish their work.16 A notable development is a similar questioning among scientific bodies. The Deutsche Forschungsgemeinschaft, Germany's central research organisation, has promulgated innovative guidelines emphasising qualitative criteria in evaluating published material.17 As they posit, "Publications must be read and critically compared with the relevant state of the art and to the contributions of other individuals and working groups".17 Admirable but vexing. How are we to judge quality objectively? A more appropriate option?We have grappled with this challenge and devised an option for the ANZJP. Five international members of the journal's advisory board were invited in 2001 to identify that year's "top" articles. The quintet, selected on the basis of scholarship, professional integrity and knowledge of scientific psychiatry, were asked to select three publications per issue that satisfied one or more of the following criteria: adds consequentially to the field through original, innovative research findings; expands or challenges current knowledge; opens additional areas for new research activity; opens a pathway to advance knowledge; integrates discoveries obtained by different approaches and/or disciplines through creative synthesis, thus bringing new insights to bear on original research; and reflects critically on research findings to guide the direction of further research. The data were collated, and the titles of the nine articles gaining the most votes were announced in the April 2002 issue of the journal and posted on the websites of the Royal Australian and New Zealand College of Psychiatrists and Blackwell Publishing. This procedure is familiar in that it is, in essence, an extension of peer review. While by no means foolproof, we proffer this approach as a fresh way to establish the quality of the individual article. We sought feedback from the judges and learned that the task is feasible and the clarity and utility of the assessment criteria are satisfactory. The judges also found the assignment personally rewarding, even enjoyable! We are examining the method's reliability. Testing validity, of course, is more taxing given the lack of an objective yardstick. Interestingly, our experiment has been echoed by another initiative to highlight meritorious papers, namely the "Faculty of 1000" (F1000). Launched in November 2001 by the publishers of BioMed Central (a collection of wholly electronic biomedical "journals"),18,19 F1000 aims to identify the best papers in the basic biological sciences through the eyes of a "faculty" of over 1000 selected scientists who are experts in their fields. Thus, for instance, cell biology is divided into 18 categories, and the faculty members for each category select two to four papers each month from any journal, ranking them as "recommended", "must read" or "exceptional". The experts also briefly explain their choices. We applaud this initiative and see our own effort as complementary. Indeed, it is commonsensical that more than one method of identifying outstanding papers should be instituted, as there cannot be an absolute consensus. An invitationWe invite editors, publishers and authors to consider trying our experiment. We selected a new set of judges, again all distinguished figures in international psychiatry, to undertake a similar task for articles published in 2002. After this replication, we hope to be well placed to determine whether the method needs change. It would be disingenuous of us to conceal our fantasy that the annual "gloom or glee" ritual will be supplanted by published lists of "best quality articles", with their authors duly acknowledged. We may even witness the ISI collating the results, including the names of the judges and the criteria applicable for participating journals (consensually agreed criteria across all journals would be ideal). The implications are clear: successful authors will be able to cite articles that have made it to the "top" when documenting their academic track record, whatever the purpose (eg, applying for research grants). Depending on a measure devoid of any rational link to the appraisal of academic worth will be but a hazy memory.

Garry Walter PhD, FRANZCP · Karen Fisher MB BS · Sidney Bloch PhD, FRANZCP · Glenn Hunt MSc, PhD

The Longitudinal Study of Australian Children (LSAC) is a major research endeavour to assess emerging health and developmental concerns and their determinants in children. Previous longitudinal studies of children in Australia and New Zealand have contributed significantly, but have had limitations, which LSAC will attempt to address. A new generation of longitudinal studies is needed to enable transnational and historical comparisons. Members of the LSAC (Longitudinal Study of Australian Children) Research Consortium John Ainley, Australian Centre for Educational Research; Donna Berthelsen, Queensland University of Technology; Michael Bittman, University of New South Wales; Dorothy Broom, Australian National University; Linda Harrison, Charles Sturt University; Bryan Rogers, Australian National University; Michael Sawyer, University of Adelaide; Sven Silburn, Curtin University; Lyndall Strazdins, Australian National University; Judy Ungerer, Macquarie University; Graham Vimpani, Newcastle University; Melissa Wake, Murdoch Children's Research Institute; Stephen Zubrick, TVW Telethon Institute for Child Health Research. In March 2002, the Commonwealth Department of Family and Community Services announced the commencement of the Longitudinal Study of Australian Children (LSAC).1 This study is being implemented by a large multidisciplinary research consortium led by the Australian Institute of Family Studies. It will track the health and development of two national, population-representative cohorts of children recruited in their first and fourth years of life. The study will assess a broad range of individual, family and environmental determinants of health and wellbeing, and will focus on identifying factors that influence good and poor life-course outcomes. The study aims to provide data that will inform the development of health, family and social policy and services within Australia (Box 1). LSAC represents a significant government investment ($20.2 million over nine years) in longitudinal research on children, and it is timely to consider the extent to which it will address the shortcomings of past studies and add to our knowledge of children's health and development. Longitudinal studies are essential to understand the causes of health problems and identify possible solutions.2 Using this type of study, Australian and New Zealand researchers have contributed significantly to our knowledge of health and development3-7 (Box 2). However, there are several reasons why Australia needs a new longitudinal study of children. Past studies typically recruited cohorts during the 1970s and 1980s8 and are therefore limited. First, the health profile of Australian children has changed significantly in recent decades. Emerging health concerns include increasing rates of atopic and chronic diseases and mental health problems, and unacceptably high levels of suicide, preventable injuries and harmful health behaviours during childhood and adolescence.9 Second, the environments in which children are being raised have altered profoundly in the last 30 years.9,10 There have been changes to children's immediate environments (family, childcare, schools and neighbourhoods) and the broader sociopolitical climate (including widening social disparities).10 Past study findings may not be relevant to modern childhood environments. In addition, past cohorts were typically drawn from confined geographical locations,8 and data on health and social services and policies may not be more widely applicable. Third, there have been considerable advances over the last 30 years in theory, measurement tools and analytic techniques.11 Current epidemiological models highlight the central role of individual genetic and pathobiological factors in the expression of poor health and the need to examine multiple levels of influence (Box 3).12 Past studies have been unable to explore these factors adequately, often lacking sufficient sample sizes or the appropriate measures to disentangle multilevel influences. LSAC addresses a number of these limitations. Specifically, it will: measure a wide range of outcomes and determinants; recruit cohorts nationally from rural–regional and urban settings; and have a sufficient sample size to explore multiple determinants and the occurrence of relatively rare events.1 However, it is unrealistic to expect this study to address all research needs. For example, LSAC will not capture sufficient children from minority groups to enable exploration of life-course pathways that may be unique to these populations. In addition, cost and methodological constraints are likely to result in the exclusion or under-representation of children from remote areas, and some forms of data collection will be too time-intensive or costly to use (eg, certain observational, biological or environmental measures). Also, LSAC will not involve the systematic provision of interventions. Given the growing evidence of the benefits to health that arise from prevention and early intervention,13 a strong case can be made for a coordinated program of longitudinal intervention trials to assess the impact of interventions delivered around key life-course transition times.14 Thus, studies of specific populations, studies addressing research questions that require costly data collection, and studies that involve the assessment of interventions could all add value. These could be designed in parallel with LSAC, or as studies nested within LSAC for creating efficiencies in research costs. Australia is unique in geographical distribution of the population, family structures, ethnic diversity, social structures, policies and service provision. International research may have limited applicability in the Australian context. Nonetheless, it is important to consider Australian longitudinal research in an international context. Other Western nations are establishing new longitudinal studies,8 with European countries notable for coordinating studies that enable cross-country comparisons.15 LSAC may provide a foundation upon which other studies could be built to facilitate transnational comparisons and comparisons of changes to health pathways over time. Use of common design and measurement tools will facilitate these objectives. Longitudinal studies are expensive and demanding, not to be embarked upon lightly.2 Coordinated research efforts that strategically build upon the substantial national investment in LSAC may further enrich the evidence base for policy development and service provision to facilitate our nation's future health and wellbeing. 1: Questions to be addressed by the Longitudinal Study of Australian Children1 How well are Australian children doing on key developmental outcomes? What are the pathway markers, early indicators, or constellation of behaviours that are related to different child outcomes? How are child outcomes interlinked with children's wider circumstances and environment? In what ways do features of children's environment (such as families, communities and institutions) affect their outcomes? What helps maintain an effective pathway, or change one that is not promising? How is a child's potential maximised to achieve positive outcomes for children, their families and society? What role can government play in achieving these outcomes? 2: Achievements of past Australian and New Zealand longitudinal studies of children's health and development Study (starting date) Achievements Australian Temperament Study (1983)3 Clarified the contribution of temperament, family and environmental factors to later life adjustment. Christchurch Health and Development Study (1977)4 Contributed to child health, family and mental health policy, safety regulations for swimming pools and bicycle riding, and the development of early intervention programs for high risk mothers of infants. Dunedin Multidisciplinary Health and Development Study (1972)5 Findings across a range of physical and psychosocial health areas contributed to the development of health interventions for substance use, safe driving and cycling practices. Port Pirie Cohort Study (1979)6 Assessed the effects of environmental lead exposure and provided the impetus for changes in regulations relating to lead in petrol. Tasmanian Infant Health Study (1988)7 Assessed possible causes of sudden infant death syndrome, resulting in changed recommendations for infant sleeping positions, with documented reductions in infant deaths. 3: Ecological model of health across the life-course (modified from Lynch12)

on behalf of the LSAC Research Consortium

Objective: To compare the cancer knowledge and skills of interns in 2001 who graduated from graduate medical program (GMP) courses with those from non-GMP courses, and to compare the cancer knowledge and skills of interns in 2001 with those who completed a similar survey in 1990.Design: Questionnaire survey of recently graduated interns in a random sample of Australian and New Zealand hospitals. The questionnaire was designed to allow direct comparison with the 1990 survey, and was guided by the Australian Cancer Society's Ideal Oncology Curriculum for Medical Schools.Results: 443 interns completed the survey (response rate, 62%; 42 were excluded, leaving 401 surveys for analysis: 118 from GMP courses and 283 from non-GMP courses). Interns from GMP courses felt more competent than those from non-GMP courses at discussing death (P = 0.02), breaking bad news (P = 0.04) and advising on smoking cessation (P = 0.02), but less competent at preparing a patient for a hazardous procedure (P = 0.02). More GMP interns would refer a breast cancer patient to a multidisciplinary clinic (83% versus 70%; P = 0.03). Knowledge about cancer risks and prognosis was significantly less in GMP interns, but GMP interns rated their clinical skills, such as taking a Pap smear, higher than non-GMP interns. The GMP and non-GMP groups did not differ in their exposure to cancer patients, but compared with 1990 interns recent graduates had less exposure to patients with cancer.Conclusions: GMP curricula appear to have successfully introduced new course material and new methods of teaching, but have not always succeeded in producing doctors with better knowledge about cancer. Recent graduates have less exposure to cancer patients than those who trained 10 years ago.

Michael B Barton MB BS, FRANZCR · Sharon E Miles BAppSc(HIM) · Martin H Tattersall MD, FRACP · Phyllis N Butow PhD, MClinPsych · Sally Crossing BEc · Konrad Jamrozik DPhil, FAFPHM · Bin Jalaludin PhD, FAFPHM · Christopher H Atkinson MB ChB, FRANZCR

Traumatic brain injury (TBI) commonly affects younger people and causes life-long impairments in physical, cognitive, behavioural and social function. The cognitive, behavioural and personality deficits are usually more disabling than the residual physical deficits. Recovery from TBI can continue for at least 5 years after injury. Rehabilitation is effective using an interdisciplinary approach, and close liaison with the patient, family and carers. The focus is on issues such as retraining in activities of daily living, pain management, cognitive and behavioural therapies, and pharmacological management. The social burden of TBI is significant, and therefore family education and counselling, and support of patient and carers, is important. General practitioners play an important role in providing ongoing support in the community, monitoring for medical complications, behavioural and personality issues, social reintegration, carer coping skills and return-to-work issues.

Fary Khan MB BS, FAFRM(RACP) · Ian J Baguley MB BS, FAFRM(RACP) · Ian D Cameron PhD, FAFRM(RACP)

To the Editor: It was estimated in 1989 that cervical screening in Australia was preventing only 46% of squamous malignancies, against a theoretical capacity of 90%.1 This suboptimal achievement after almost 25 years of cervical screening led to a major reorganisation of the program. The 1989 analysis has been repeated, using the most recent year (1998) for which incidence rates have been published (Box). The more recent figures suggest that cervical screening in Australia is now preventing 70% of squamous carcinoma of the cervix. This remarkable improvement can probably be attributed to the improved participation by women in regular screening, improved standards within laboratories, and better follow-up of cytological abnormalities. While there is still scope for improvement, there is clear evidence of a substantially better gain from cervical screening. Continued efforts to increase the participation rate among women aged 60–69 years is appropriate given that the prevented proportion appears to be lower in this age range. Percentage of squamous carcinoma of the cervix prevented, by age group, Australia 1998 Age group Number of women (estimated number with a cervix*) in Australia2 Expected rate (per 100 000 women) of squamous carcinoma without screening† Expected number of squamous carcinomas‡ Estimated number of squamous carcinomas observed in 1998§ Percentage prevented 20–24 665 691 (665 025) 5 33.3 9.6 71.1% 25–29 733 145 (732 412) 15 109.9 34.8 68.3% 30–34 706 925 (687 838) 25 172.0 62.9 63.4% 35–39 748 913 (728 692) 45 327.9 74.7 77.2% 40–44 702 629 (608 477) 45 273.8 76.2 72.2% 45–49 649 539 (562 501) 45 253.1 81.4 67.8% 50–54 570 287 (410 607) 45 184.8 48.1 74.0% 55–59 431 183 (310 452) 45 139.7 40.7 70.9% 60–64 370 123 (251 314) 45 113.1 40.7 64.0% 65–69 348 707 (236 772) 45 106.6 44.4 58.3% Total 5 927 142 (5 194 090) 1714 514 70.0% * Calculated by multiplying the number of women in Australia by the estimated age-specific hysterectomy fractions.3 † Methodology as for the study by the International Agency for Research on Cancer,4 using incidence in Norway at a time when the rates would have been little affected by screening. ‡ Calculated by multiplying the estimated number of women in Australia with a cervix by the expected rate of squamous carcinoma of the cervix in the absence of screening.4 § Calculated by multiplying the number of cases of cervical cancer observed in 1998 by 0.74, which was the proportion of all cervical cancers that were squamous.5

Heather S Mitchell

To the Editor: The recent article by Scott and colleagues1 described a retrospective analysis by postal questionnaire of the attitudes of family members to participation (about a year earlier) in a face-to-face interview about their child's diagnosis of Ewing's sarcoma. This was accompanied by an editorial exposing the complexities of research participation, including the potential risks of interviews as well as the role of altruism.2 Although results derived from the questionnaire have only recently been published (November 2002), the questionnaire was distributed in November 1997, before introduction of the National statement on the ethical conduct of research involving humans.3 Some ethical uncertainties and questions of historical interest arise. First, what was the nature of the original consent obtained for the initial interviews? Presumably it involved written informed consent in which the risks of participation were clearly mentioned, including the possibility of distress associated with the interview. Did it mention a procedure for aborting or complaining about the interview? Second, did the patients (aged up to about 35 years) and their families give permission to be contacted again by the same research group? Third, for the follow-up on research participation, was consent implied simply by return of the questionnaire? Finally, how would the conduct of the initial interviews and the follow-up questionnaire differ in the light of recent developments in the ethics of research involving humans? Importantly, the respondents (84% of those surveyed) indicated that participation in the original study had not "upset them".1 While the attitude of non-responders is unknown, this would seem to confirm that the original process had been sensitive and appropriate. This is supported by the finding that families whose child had died after the initial interview were more likely to respond to the questionnaire. As a long-time member of a university human research ethics committee, I have often been required to evaluate research protocols that involve potentially threatening or distressing interviews. This has occurred more frequently since introduction of the National statement, as much qualitative research previously conducted under different jurisdictions (such as quality control or clinical audit) has been submitted for formal ethical review. The risk of harm to participants in qualitative research cannot be trivialised. Its impact can be minimised by wording the consent form to warn of possible adverse psychological reactions to interviews and questionnaires, using trained interviewers and providing counselling support if needed.

Simon C Gandevia

To the Editor: The article by Mant et al1 and the letters following its publication focus attention on a long-standing problem that, despite concerted efforts by governments, healthcare providers and other stakeholders to address it, remains a major obstacle to effective and appropriate continuity of pharmacotherapy following discharge from hospital. There is little doubt that many of the difficulties arise as a result of poor communication between hospitals and general practitioners. This is further exacerbated by a lack of standard protocols for the preparation and dissemination of discharge summaries. Nowhere is this more evident than in the case of residents of aged-care facilities returning from hospital with radically changed medication regimens. To establish appropriate communication channels, Mant et al mention hospital GP liaison officers.1 New canvasses the potential problems and suggests sensible solutions, including the involvement of community pharmacists.2 However, every hospital has a readymade resource that requires only a set of formal protocols and procedures to make it function — clinical pharmacists. Clinical pharmacists view every patient's chart at least once every day. The chart not only provides information for dispensing, but also gives pharmacists an opportunity to monitor Quality Use of Medicines and communicate with hospital doctors regarding existing or potential problems. By the time the "prescription" is processed and the medication dispensed, quality issues have been addressed and a detailed record created. From the dispensing record, a "medication profile" could be generated. This can provide the patient with consumer information regarding each drug, its dose, frequency of administration and mode of action, and can act as an accurate and up-to-date discharge summary. In addition, a clear, legible copy can be faxed, mailed or electronically transmitted to the patient's GP, pharmacist, specialist, allied healthcare professional, rehabilitation hospital or aged-care facility. Our organisation provides medication management services to a large number of aged-care facilities as well as to public and private hospitals, and correctional facilities. Quality Use of Medicines monitoring constitutes a vital part of our clinical pharmacists' duties. It provides an effective, accurate and timely method of communicating detailed discharge summaries (which have undergone thorough Quality Use of Medicines screening) to GPs and other interested parties. By including hospital clinical pharmacists in the Quality Use of Medicines monitoring and evaluation process, meaningful information can be obtained, appropriate judgements made, effective communication conducted and optimum pharmacotherapy outcomes achieved.

Joseph J Gelb

In reply: Gelb points out that clinical pharmacists can, and in some cases do, provide useful communication to general practitioners following hospitalisation, as well as for their patients in aged care facilities. Regrettably, clinical pharmacists are in short supply, even in teaching hospitals; thus, in practice, their expertise often cannot be fully utilised.1 Attention to this shortage is clearly warranted to safeguard patient care. We agree that clinical pharmacists (hospital and community based) should be included in the Quality Use of Medicines monitoring and evaluation process. In addition, we urge all healthcare providers to take responsibility for careful and timely communication to ensure continuity of patient care.

Karen I Kaye · Andrea Mant · Linda Kehoe · Wendy C Rotem

To the Editor: We would like to comment on a recent article by Chan et al on clinical practice guidelines for depression in young people.1 We disagree with their proposal to amend National Health and Medical Research Council (NHMRC) guidelines2 to include a statement that "SSRIs [selective serotonin reuptake inhibitors], particularly fluoxetine and paroxetine, should also be considered as a first-line treatment" for major depression in young people. We believe that there is insufficient evidence to assign a grade of "E1"2 to this statement. Chan et al1 quote three randomised controlled trials (RCTs) and one systematic review in support of their argument, but as yet the results of only two of the three RCTs have been published.3,4 Unfortunately, Chan et al do not include a critical appraisal of the significant methodological and analytical problems with each of the studies. Nor is any comment made about risk–benefit ratios, or the fact that even if the results were sound the clinical relevance of such small differences between active drug and placebo is questionable.5 The following brief commentary on the two studies highlights the dangers of carrying out sophisticated procedures such as meta-analysis without sufficient attention to the quality of the trials included in the analysis. The very high dropout rates (46% of 48 for placebo; 29% of 48 for fluoxetine) in the study by Emslie et al3 raise questions about the reliability of the results. Other interpretations of the findings are plausible. For example, in their study, significant advantage to fluoxetine over placebo on the Clinical Global Impressions improvement rating (a primary outcome measure) was lost when only patients completing the trial were counted (P = 0.2). More worrying is that Chan and colleagues do not seem to have noticed the dangerously distorted reporting in the study by Keller et al.4 On neither of the two designated primary outcome measures (change from baseline in Hamilton Rating Scale for Depression [HAM-D], and response, set as "fall in HAM-D to ≤ 8 or by ≥ 50%") did paroxetine differ significantly from placebo. But Keller and colleagues never report this negative finding. Instead, the criteria for response are covertly altered (to "fall in HAM-D to ≤ 8", which does achieve significance). The authors then erroneously claim significance on this (altered) primary outcome measure, ignoring the lack of significant change. Thus, a study that showed no significant improvement on either of two primary outcome measures is reported as demonstrating unqualified efficacy. Similar problems can be found in a more recent article by Emslie and colleagues6 (published after the review by Chan et al1), in which the authors openly acknowledge that the difference between fluoxetine and placebo on their prospectively defined primary outcome measure did not reach statistical significance, yet claim to have demonstrated the drug's efficacy. Another worry is that Chan and colleagues, in their list of proposed changes to NHMRC recommendations,1 suggest that the availability of SSRIs obviates the need for more expert and thoughtful assessment and management of depression. We are uncomfortable that the prescribing and management of psychotropic medication is portrayed as requiring relatively few skills and resources, to be carried out by those general practitioners who lack training in mental health and/or access to expert mental health services. We urge the NHMRC to maintain a conservative approach to the use of psychotropic drugs in children with depression unless more convincing evidence is forthcoming.

Jon N Jureidini · Anne L Tonkin

In reply: We thank Jureidini and Tonkin for their comments. In relation to their criticism of the study by Emslie et al,1 intention-to-treat analysis is the accepted standard. In relation to the study by Keller et al,2 their criticism about the criteria for response has already been answered elsewhere. (Criteria were defined in the report as a final Hamilton Rating Scale for Depression [HAM-D] score that was ≤ 8 or a reduction from baseline of ≥ 50%. Dual criteria were selected because the scores at entry could range from a minimum of 12 [set by protocol] to a maximum of 53 [highest scores for the 17-item HAM-D]. Limiting response to either a 50% reduction or a specified cut-off point would impede patients at the lower end of the ranges from meeting the criterion.3) The concern about the absence of differences in change scores on the HAM-D cannot be resolved, as mean change in scores and standard errors of the means were not reported. However, 63.3% (57/90) of subjects taking paroxetine (P = 0.02 versus placebo) achieved a HAM-D total score of ≤ 8 at endpoint. With respect to the size of difference in response rate to active treatment versus placebo, the results of trials involving selective serotonin reuptake inhibitors (SSRIs) in children and adolescents are similar to those reported in adults (ie, SSRIs achieve a response in about 20% more participants than placebo,4 which is similar to the 26% difference between cognitive behavioural therapy and various control conditions5). Consistent with these results, the US Food and Drug Administration has recently approved fluoxetine to treat children and adolescents aged seven to 17 years for major depression. We believe that there are sufficient new treatment data (including a study,6 published since the submission of our article, showing fluoxetine's superiority over placebo in symptom improvement and in remission rates) to warrant revision of the 1997 guidelines. Depression affects one in 20 Australian teenagers, few of whom will access specialist mental health services.7 Contrary to the view of Jureidini and Tonkin, we believe general practitioners must provide treatment for young people suffering depression. A strength of the National Health and Medical Research Council guidelines is that they offer comprehensive advice to promote thoughtful assessment and management of depression in young people.

Raphael TW Chan · Joseph M Rey · Philip L Hazell

To the Editor: I do not believe that Dinnen's comments1 should be so easily dismissed as suggested by the academics proposing that general practitioners should do questionnaires,2,3 at least in New South Wales. I write this as barely a month has passed since a most damning report was released by a NSW Parliamentary Inquiry into Mental Health Delivery. A prime example of arrogance and loss of contact with the reality of clinical services by academia and administration is that, during the demise of mental health services in NSW, the services have been forced to complete a new 30-page admission process for every admission. Just what was needed by registrars spending hours trying to find beds for seriously mentally ill patients! The gulf between academia and administration on the one hand and real clinical services on the other is now huge in NSW, at least in mental health services. No one outside real clinical services has any credibility or right to demand doctors, let alone hard-pressed GPs, engage in dubious and very likely useless research projects without very special funding to support the project. I found the K10 questionnaire extraordinarily simplistic compared with a Mental State Examination (MSE). Surely, if there is concern, doctors should be encouraged to revise how the MSE is carried out, and not encouraged to adopt "cookbook" medicine.

Brian M Boettcher

To the Editor: As a general practitioner I was gratified to see Dinnen's letter1 in which he questioned the "urgent need" for GPs to use more questionnaires for depression management. Reading the professorial reply,2 I despair. As more and more specific health promotions are introduced (eg, Asthma 3-Step Plans, Diabetic Care protocols, Health Assessments, Care Plans) we have to consider not just our patient's problems, but which forms to fill out or numbers to put down to fulfil Health Insurance Commission requirements or be correctly remunerated. By the time a depressed patient is sitting in my room, he or she wants to be correctly diagnosed and treated, not to be given a form to fill out. In my opinion, to hand a form to a depressed patient who has tearfully told me his or her problems is an insult. We do not (yet) expect patients to fill out a checklist for heart failure. As to the suggestion that the form be filled out in the waiting room, how is this to be done? Should the patient be sent out again with form in hand? Privacy concerns do not allow reception staff to hand out such forms, and the waiting room is not the best place to fill them out if they are needed. In reality, the GP is likely to give the patient a form and then go have a coffee or make a telephone call. No psychiatrist will ever receive a referral from me based on a K10 score. I may, however, mention that my patient still has suicidal impulses, cries a lot, has trouble sleeping and cannot concentrate at work. That should be easy enough for anyone to understand.

Heidi Andersen-Dalheim

To the Editor: I read with great interest about your search in dictionaries for the word "pathography".1 Pathography2 originates from reflections on genius and its possible association with insanity, a question that has occupied experts in many fields since Socrates, Plato and Aristotle. The first psychiatric scientific treatise concerning this question was contributed by Moreau de Tours in 1859.3 Inspired by him, Cesare Lombroso, in 1863, coined the famous expression genio et follia, and contributed many, albeit somewhat uncritical, pathographies. The term pathography was first used about 1899 by the German psychiatrist Paul Julius Möbius, who contributed with several seminal pathographies, including Rousseau, Goethe, Schopenhauer and Nietzsche. Among other famous pathographers should be mentioned Freud, W Lange, Jaspers, Birnbaum and Kretschmer. Pathography can be defined4 as . . . historical biography from a medical, psychological and psychiatric viewpoint. It analyses a single individual's biological heredity, development, personality, life history, and mental and physical pathology, within the socio-cultural context of his/her time, in order to evaluate the impact of these factors upon his/her decision-making, performance and achievements. No preconceived format can be assumed as the method depends on the nature of the various available materials and on the specific inquiry. A prerequisite for plausible pathographical results is a thorough knowledge and understanding of psychopathology, and of the borderland between normal and abnormal mental life, combined with a capacity for [sober] historical judgement. . . . The pathographical method is applicable to any personality, sick or sound, provided that sufficient biographical sources are available. The pathographical result is a facet but often an indispensable one. Subjects of pathography have traditionally been famous people in all areas of human achievement. Pathography is also indispensable in assisting historians, political scientists and other groups in their quest for a better understanding of events where leaders or other "very important persons" have played a significant role, and where personality or illness, physical or mental, has been decisive, at times with far-reaching consequences for nations.5,6 History is replete with such examples.

Johan A Schioldann

To the Editor: In the abstract of his article on asthma prevention with dietary manipulation,1 Mellis states that "we know" that the major modifiable dietary environmental risk factors for childhood asthma are not having been breastfed and low intake of omega-3 fatty acids. In his discussion of the evidence, Mellis suggests that breastfeeding may be protective and, importantly, acknowledges the controversy. He further states (in the abstract) that observational studies have shown a reduction in childhood asthma in children who eat fish regularly (that is, have a high intake of omega-3 fatty acids), similar to those who were exclusively breastfed for three months. However, he provides no references for these observational studies, and nor does he discuss any specific evidence in support of including omega-3 fatty acids for reducing childhood asthma. While there are some suggestions of such an association, the evidence is extremely limited compared with the extensive literature on the potential for the protective effect of breastfeeding. Further, there are substantial methodological issues associated with the few studies that do exist, not the least of which is the measurement of the relevant dietary parameters. Australian studies have suggested a protective influence of at least two fish meals per week on bronchial hyperresponsiveness in 7–11-year olds2 and of eating oily fish3 on the prevalence of childhood asthma. However, neither of these studies had the capacity to measure omega-3 fatty acid nor fish intake in a valid way. These limitations were acknowledged by the authors of the studies, and have been noted by others;4 they need to be included in any discussion of a putative protective effect. It should also be noted that the biological plausibility of such an association has been challenged.4 There are many valid reasons for promoting the consumption of omega-3 fatty acids, but shouldn't we wait for the outcome of the randomised clinical trial currently under way before accepting the statement that "we know" that a low intake of these fatty acids increases the risk of childhood asthma?

Jill L Sherriff

In reply: Sherriff is correct in pointing out that the studies showing protection from bronchial asthma (and bronchial hyperresponsiveness) are based on consumption of fish meals rather than a direct measure of omega-3 fatty acid intake. This protection has been observed consistently in cross-sectional studies of New South Wales primary school children. Thus, the level of evidence is at best Level III, albeit using a proxy for omega-3 fatty acid intake. Results of a randomised-controlled trial of omega-3 fatty acid supplementation currently under way in western Sydney are now in the public arena at 18-month follow-up.1,2 At this early stage, it is uncertain who has genuine asthma rather than other wheezing syndromes. Nevertheless, the group who received omega-3 fatty acid supplementation have differences in rates of wheeze compared with those not supplemented.1,2 For example, the rate of "ever" having had wheeze was 52.6% in the controls versus 42.8% in the supplemented group (absolute risk reduction, 9.8%; number need to treat, about 10). In the table of recommendations in my article,3 I carefully pointed out that supplementing infants with omega-3 fatty acid is something to "consider" rather than strongly recommending it. It should also be noted the level of evidence is low (Level III). Stronger recommendations will depend on the long-term results of randomised trials, such as the western Sydney trial.1,2 In summary, at this stage the only strong dietary recommendations which can be made are: not to use strict elimination diets during pregnancy (Level I evidence); and to consider using lactobacillus probiotic supplements. The evidence for lactobacillus is Level II (from a single randomised controlled trial), although the protection shown is for atopy rather than asthma. Clearly, the children in the lactobacillus study will need further follow-up, and the trial will need to be repeated in other populations. All of this highlights the need for better-quality studies in the area of primary prevention of asthma, based on dietary factors during pregnancy or early infancy.

Craig M Mellis

To the Editor: The publication of the main results of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), and the accompanying editorial, triumph the role of thiazide diuretics as first-line management for hypertension.1,2 It brought to mind the lines from the nursery rhyme Old Mother Hubbard — "And when she went there, the cupboard was bare." Simple frequency analysis of diuretic antihypertensive medications listed in the Australian Medicines Handbook (1998 and 2003) revealed that the total number of thiazide diuretics available as monotherapy in 1998 was six (bendrofluazide chlorothiazide, chlorthalidone, hydrochlorothiazide, methyclothiazide and indapamide), and in 2003 three (bendrofluazide, chlorthalidone and indapamide).3,4

Mark R Nelson

Whether it was his unusual culinary flair or the way he discovered his profession, there was nothing conventional about Vernon Richard Keep. Born in Harrow, UK, on 22 July 1927, Vernon had set his sights on being a naval engineer. Joining the Royal Navy in 1944, he spent four years as Chief Stoker aboard the Duke of York and various Australian warships, until pulmonary tuberculosis cut short his naval ambitions. Twelve months of being laid up in various sanatoria kindled Vernon's interest in bacteriology and sowed the seeds of his medical career. On release, he was advised that he would need a medical degree if he wanted to be a bacteriologist. Upon matriculating, Vernon enrolled in Middlesex Hospital Medical School, London, in 1949. Recurring TB meant a protracted study period, and he graduated in 1957. After various training posts in medicine, surgery, casualty and urology, he settled on the emerging field of anaesthesia. Training included thoracic surgical anaesthesia at the Brook Hospital, London, and plastic and faciomaxillary surgical anaesthesia at the Queen Victoria Hospital, East Grinstead. His pioneering work included opening one of the world's first intensive care units at Middlesex Hospital. Disenchanted with the British National Health Service, Vernon migrated with his young family to Perth, Western Australia, in 1962. On arrival, he briefly held the position of Staff Anaesthetist at Royal Perth Hospital before being appointed the first Director of Anaesthesia at Fremantle Hospital. It was during his tenure at Fremantle that he formulated the Civil Disaster Plan for the busy port city. Improvements in anaesthetics led him to experiment with the concept of rapid-recovery day surgery, and he opened the first custom-designed clinic, Kaleeya House, in 1968. Interest was so great that, in 1974, the first purpose-built outpatient hospital in Australia, Kaleeya Hospital, was opened in East Fremantle. As Chairman of the Board, he oversaw the finer details, such as the selection of lime-green paint and psychedelic bed linen. In 1980, Vernon and his wife Lyn retired to their farm, "Lanark Park", in Wokalup, for some "peace and quiet". But retirement proved short-lived, and he took up various medical positions around the Harvey area until ill health forced him into hospital in October 2002. From his ward on the ninth floor of Fremantle Hospital, Vernon was reassured to see his old surgery, Kaleeya House, and the Medical Library at Fremantle Hospital, which he had founded nearly 40 years previously. He died on 4 January 2003 from pneumonia complicated by TB damage and emphysema. He is survived by three sons and three grandchildren.

Matthew J Keep

Measurement of clinical performance. Practical approaches in acute myocardial infarction. Robert West, Robin Norris (editors). London: Royal College of Physicians, 2001 (viii + 128 pp). ISBN 1 86016 152 9. Evaluating the quality of clinical care is now the accepted, indeed mandatory, duty of all who practise medicine. Medical colleges have introduced programs for maintaining professional standards, and many of these feature clinical audit as a necessary activity. For the busy clinician, however, finding both the time and the means to perform accurate and consistent audits poses major challenges. This work, from the Royal College of Physicians (RCP), offers pragmatic strategies at both a national and a local level for conducting meaningful clinical audit. While focusing on the care of patients with myocardial infarction, the messages contained in this book can apply to any area of medicine. The first half deals with clinical governance (UK style): use of performance indicators and league tables; the choice between process or outcome measures; and an overview of national benchmarking projects in the UK dealing with coronary heart disease, asthma and stroke. The second half covers the practicalities of auditing the care of patients with myocardial infarction, as exemplified by the Myocardial Infarction National Audit Project. This ambitious project aims to recruit all hospitals in England and Wales, and uses a nationally funded, RCP-sponsored data collection, analysis and reporting system which is standardised, computer-based and centrally coordinated. Such a system relieves local clinicians of the need to develop their own audit system from the ground up. The authors of each chapter speak authoritatively from personal experience about the good and bad in conducting clinical audit, and offer advice on what to avoid. Finding a "how to" book in performance measurement that is short (128 pages), easy to read, inexpensive and rich in practical applications is a rare delight for this jaded healthcare researcher. My only regret — I would have liked a little more on how to use the results of audit to full effect in improving quality of care at the local level. Ian A ScottDirector of Internal Medicine Princess Alexandra Hospital, Brisbane, QLD

Ian A Scott

Systematic reviews in health care: a practical guide. Paul P Glasziou, Les M Irwig, Christopher J Bain, Graham A Colditz. Melbourne: Cambridge University Press, 2001 (viii + 137 pp). ISBN 0 521 79962 7. Why should you choose this book in what is a relatively crowded market? The authors are Australian experts and well qualified to write it. It is an introductory text, presumably for Master of Public Health students or mid-career clinicians attempting to come to grips with one of the foundation stones of evidence-based medicine. The flyleaf states “this is a book for those with an interest in synthesising healthcare research and for those studying for a degree in public health”. The book provides an excellent overview of the general methods of systematic reviews and is a useful primer on the topic, particularly the chapter on diagnosis and the discussion concerning heterogeneity. The second part addresses question-specific methods. It has some exercises at the end of each chapter, but would benefit from the inclusion of worked examples. Inevitably with a text of this size, the question arises: What was left out that should have been included? I think a more substantial treatment of the relationship between study results reported as proportions, odds ratios, relative risks and the number needed to treat (NNT) is warranted, with appropriate references (a passing reference is provided in the question section at the end of the chapter on interventions). The chapters on interventions, frequency and rate could benefit from the incorporation of “look-up” answers to the questions. The chapter on diagnosis should discuss the diagnostic odds ratio as a summary measure of the accuracy of a test. The answer to the question “Should I buy this book?” is “Yes”, if you want to get started and wish to move beyond the User’s guide series in JAMA. I would also advise downloading the Cochrane review handbook. Donald CampbellClinical Epidemiologist Royal Melbourne Hospital, VIC NB: The reference (page 115 to the website for the Easy MA software) is incorrect (it should be www.spc.univ~lyon1.fr/mcu/easyma/).

Donald Campbell

Under pressure The Second Australian National Blood Pressure study has reported that initiating antihypertensive treatment with an ACE inhibitor in older patients, especially men, may lead to better health outcomes than initial treatment with diuretic agents, despite achieving similar reductions in blood pressure.1 The study involved 6083 subjects aged 65–84 years of age being cared for at 1594 family practices. After a median 4.1 years of follow up, male subjects, in particular, were less likely to have died or experienced a cardiovascular event if they had been randomised to start treatment with an ACE inhibitor rather than a diuretic. A linked editorial2 addressed the clinical conundrum raised by studies that report contradictory results such as this one and the major ALLHAT trial. Such trials only describe population averages to assist in the development of guidelines. They cannot replace the doctor’s need to independently assess the best agent for each individual patient, based on his or her unique combination of problems and clinical responses. 1. N Engl J Med 2003; 348: 583-592 2. N Engl J Med 2003; 348: 639-641 Exploring aspirin resistance UK research has lent support to the hypothesis that ibuprofen may interfere with the cardioprotective effects of aspirin in patients with established cardiovascular disease. MacDonald and Wei studied 7107 patients who had been discharged on low-dose aspirin after a first admission for cardiovascular disease. All had survived for at least one month and were followed up for a median of 3.3 years. Compared with the 6285 patients who used aspirin alone, the 187 patients taking aspirin plus ibuprofen had an increased risk of both all-cause and cardiovascular mortality (adjusted hazard ratios of 1.93 and 1.73, respectively). The researchers found no such increased risk in users of aspirin plus other NSAIDs. Lancet 2003; 361: 573-574 Predicting death by lung clot A cardiac troponin T level may be a useful predictor of the severity of pulmonary embolism and the likelihood of death, according to results from a small cohort study published by Austrian authors. They reported that troponin levels were assayed within 12 hours of admission in 106 patients with pulmonary embolism confirmed by computed tomography or scintigraphy. The troponin levels increased with increasing severity of pulmonary embolism; the median level in patients with ECG signs of right ventricular strain was 0.03 ng/mL, compared with < 0.01 ng/mL in patients without ventricular strain. Further, troponin levels were higher in the five patients who died than in survivors (0.18 ng/mL v 0.01 ng/mL). A cut-off value for troponin of 0.09 ng/mL was considered a suitable predictor for death in hospital. The authors say these results need to be confirmed in larger, prospective studies. BMJ 2003; 326: 312-313 When the abused abuse The risk of victims of childhood sexual abuse becoming abusers themselves is lower than previously thought, according to a UK study of 224 male former victims. The victims had a mean age of 11 years when initially referred to a specialist sexual abuse clinic between 1980 and 1992, and had reached a median age of 22.3 years when the study was conducted. Only 26 (12%) had subsequently been reported to have committed sexual offences. Childhood risk factors found to be associated with later offending included material neglect, lack of supervision and abuse by a female person. Further, victim-abusers were more likely to have been exposed to intrafamilial violence. Findings did not support the belief that those who had been more severely abused or who had learning difficulties are more likely to become abusers. Lancet 2003; 361: 471-476 Hush little baby Not only can we identify which babies are more likely to fail to sleep through the night — a simple behavioural program can help to prevent this problem, say London researchers. In a community sample of newborn infants, they found that the infants at-risk were those who at one week of age had more than 11 feeds in 24 hours (about 25% of the sample). These infants were 2.7 times more likely than others to fail to sleep through the night at 12 weeks of age. A three-step behavioural program — maximising the difference between day- and night-time environments, settling a sleepy baby without feeding or cuddling, and delaying feeding when baby wakes at night — increased the likelihood that at-risk babies would sleep through the night at 12 weeks of age. The results were similar in breast- and bottle-fed infants. Arch Dis Child 2003; 88: 108-111

Med J Aust 2003; 178 (6 Suppl).