Volume 178 Issue 9

Differences in kava extraction methods may affect hepatotoxicity In this issue of the Journal, Gow and colleagues (page 442) report the first Australian case of fulminant hepatic failure attributed to a herbal product containing kava,1 while Moulds and Malani (page 451) note the cultural and economic importance of kava for Pacific island nations, and provide a balanced overview on kava safety and availability.2 For centuries kava has been widely consumed in Pacific island countries as a ceremonial beverage and for its mood-altering and stress-relieving properties. It is prepared as an aqueous emulsion of the crushed fresh or dried roots or lower stems of the kava shrub Piper methysticum ("intoxicating pepper").3 Pharmacological properties, such as anxiolytic activity, are attributed to a poorly characterised group of compounds termed kavalactones.3,4 In 1982, kava was introduced to some Arnhem Land Aboriginal communities from Pacific island countries, in part to reduce the harmful effects of alcohol.5 Kava use continued to rise during the 1980s and 1990s, supplied by a lucrative black market. Concerns about adverse health, social and economic effects of widespread heavy consumption resulted in the Northern Territory Kava Management Act in May 1998, which made the possession of more than 2 kg of kava illegal unless in accordance with a licence. However, an illegal trade continued, with profiteering by those distributing kava imported from several Pacific island countries. In October 2000, the Kava Management Act was amended to incorporate harm reduction objectives and a system of licensed kava supply, controlled by local Aboriginal community organisations. Over the last decade, there has been an expanding global market for herbal preparations made in Western countries and containing kava extracts.4 These products have been marketed for the treatment of anxiety, insomnia, premenstrual syndrome and stress, and sold over the counter as complementary medicines or dietary supplements.6 Since 1999, cases of severe hepatic toxicity in people using kava-containing herbal products have been reported from Europe and the United States.6,7 Subsequently, kava-based herbal products have been banned in some European countries, including the United Kingdom. In Australia, a practitioner alert and consumer advice were issued in February 2002 by the Therapeutic Goods Administration (TGA) concerning hepatotoxicity possibly related to kava-containing products. By late 2002, eight cases of liver transplantation after hepatic failure associated with use of kava-containing products had been reported from Europe, and two from the United States.6 The patient reported by Gow et al died soon after liver transplantation.1 As a result of this case, the TGA initiated a voluntary recall of all complementary medicines containing kava extracts on 15 August 2002.8 The TGA has 87 products containing kava on its Australian Register of Therapeutic Goods.8 Although details are sketchy for many of the at least 68 cases of suspected kava hepatotoxicity,4 with the herbal products sometimes containing additional ingredients, the increasing number of well documented cases1,6,7 make it likely that kava extracts are responsible for occasional severe progressive hepatotoxicity. However, the mechanism of this toxicity remains to be determined. Histological examination has shown portal inflammation with lymphocytes and eosinophils,6,7,9 and an idiosyncratic immune response to a reactive metabolite has been suggested as a possible cause.9 In two patients, phenotyping of the activity of cytochrome P450 isoform CYP2D6 showed that they were "poor metabolisers", and it was postulated that genetic differences in liver metabolism of kavalactones may be important.9 Moulds and Malani discuss the paradox that fulminant hepatic failure has not been documented with traditional kava use in Pacific countries.2 Kavalactones in herbal products are usually extracted with ethanol or acetone,6 and may differ critically from the aqueously extracted kavalactones used in Pacific countries and Aboriginal communities. Of note is an early study of the health effects of kava use in Aboriginal communities, which documented consistent abnormalities in liver function tests in heavy kava drinkers.5 A recent study in Arnhem Land has confirmed these findings, with abnormal serum levels of γ-glutamyl transferase (GGT) and alkaline phosphatase (ALP) in 61% and 50% of kava users, respectively.10 However, serum levels of alanine aminotransferase (ALT) were not raised in any kava drinkers. Furthermore, the abnormalities in liver function usually return to normal within 1–2 months of stopping kava use.10 The raised GGT and ALP levels combined with normal ALT levels in Aboriginal kava users do not suggest acute inflammation and are not consistent with the changes documented in the cases of hepatotoxicity associated with herbal products, where aminotransferase levels are especially high.1,6,7 Clinical surveillance in the Northern Territory over 20 years has not documented any cases of fulminant hepatic failure attributable to kava use. This is despite Aboriginal kava drinkers consuming kavalactones in doses estimated to be 10–50 times the recommended therapeutic doses for herbal products.3 However, the recent study confirmed adverse effects of kava, such as kava dermopathy and lymphocytopenia,10 which were documented in the 1980s.5 Although a rigorous systematic review found kava to be an effective symptomatic treatment option for anxiety,4 herbal preparations should not be used until the mechanism for hepatic toxicity is clearly ascertained. The abnormal but reversible GGT and ALP levels seen in heavy kava drinkers does not reflect the same pathological process. Whether the apparently idiosyncratic fulminant hepatic failure documented with herbal kava preparations can also occur with traditional aqueous extracts requires further surveillance. Close monitoring for this and other potential adverse effects of kava use in Aboriginal communities and Pacific countries is recommended, in addition to initiatives encouraging moderation in consumption.

Bart J Currie FRACP, DTMTH · Alan R Clough MSc

The overarching cause is energy imbalance The health and wellbeing of Australia's children and adolescents, now and in the future, is under threat. In 2002–2003, the most prevalent child health issues affecting children are preventable: obesity, dental disease, emotional and behavioural problems, bullying and learning delays. These problems often present as comorbidities. Overweight and obesity affect about 23% of Australian children and adolescents, with 6% being obese.1 These are conservative estimates, as there has been no systematic monitoring of the prevalence of overweight and obesity in Australian children and adolescents since 1995. However, over the previous decade, the prevalence of overweight children almost doubled, and the prevalence of obese children more than tripled.1,2 There is no reason to believe that the rapid rise in prevalence rates has not continued. Studies of historical datasets have also revealed that the prevalence of overweight and obesity in children and adolescents doubled over the period 1985–1997, a far greater rate of increase than in the preceding 16 years.3 Health inequalities related to overweight and obesity are evident. There is a higher incidence of overweight and obesity in children of parents of particular backgrounds,3 and maternal education is the strongest social determinant of overweight and obesity in childhood.4 Although there are limited national data, and combined New South Wales, Victorian and National Nutrition datasets1 failed to find a rural/urban difference, Victorian epidemiological data show a statistically significant, higher proportion of overweight and obese boys in metropolitan areas, but this difference was not found for girls (Ms K Hesketh, NHMRC PhD Scholar, Centre for Community Child Health, Melbourne, VIC, personal communication). The health consequences of overweight and obesity are substantial, although Australian data remain unclear in certain areas.5 At least in the United States, obesity carries more stigma in children than any physical disability, and this is evident across all socioeconomic and ethnic groups.6 Issues of social acceptance, athletic competence and physical appearance are well known to obese children and affect their sense of social and psychological wellbeing. Obese children with decreasing self-esteem are more likely to smoke and drink alcohol compared with those whose self-esteem increases or remains the same.7 Obese children and adolescents may also have a range of medical conditions including hypertension, dyslipidaemia, and even type 2 diabetes. Other problems, such as musculoskeletal discomfort, obstructive sleep apnoea, heat intolerance, asthma and shortness of breath, greatly affect their lifestyle.8 Implications for the future can be gathered from longitudinal studies. Combined cohort studies indicate that relative body weight is sustained from childhood to adulthood, and, once children or adolescents are overweight or obese, their weight is unlikely to track backwards.5 If this is not sufficient reason for concern, reflect that these studies (of the long-term consequences of child and adolescent obesity) were all performed before the worldwide obesity epidemic developed. What, then, will be the outcome, in 10 or 20 years' time, of large numbers of children and adolescents entering adulthood, already with abdominal obesity and well established risk factors for cardiovascular disease and type 2 diabetes? Focusing on children highlights their contribution to contemporary society and future populations. Addressing the determinants of health and wellbeing for children and adolescents will improve population health and wellbeing overall. The overarching cause of the obesity epidemic is energy imbalance — a relative increase in energy intake (food intake) together with a decrease in energy expenditure (decreased physical activity and increased sedentary behaviour). Identifying the most important predictive determin-ants of each of these behaviours, as well as the most effective and sustainable remedial strategies, is complex and involves parental education and employment; housing environments; play, recreation and physical activity; food and nutrition; accessible active transport; and child-friendly physical and social environments.9 Some simple trends suggest relatively amenable remedies. Children's fruit and vegetable consumption has decreased over the past 20 years. Their physically active time has also decreased, while time spent in sedentary activities such as television watching and computer games has increased. Finally, consumption of energy-dense foods (including sweet soft-drinks and snack bars with a high sugar content) has increased. Possible remedies include: parental education strategies regarding healthy food choices, activity options, obesity trends, as well as supportive behavioural change strategies; supportive policies and environments in the places children and families spend their time (child care, school, workplaces, home, local neighbourhoods); and prioritisation of free time for physical activities. Evidence from controlled trials (although these trials are heterogeneous as regards the age groups and settings studied) highlights the potential for school-based programs that promote physical activity, modify dietary intake and reduce sedentary behaviours. However, recent qualitative research indicates that differences in outcomes will only be achieved if sustainable changes involve all generations, tackle the widely held beliefs regarding eating and activity,10 involve population-wide health promotion messages, and dispel myths such as children's overweight being just "puppy fat". Further, there are environmental aspects that are well beyond an individual family's ability to modify, including: regulation of marketing of unhealthy food choices for children; provision of safe, cheap and accessible public transport; and urban planning initiatives that give priority to child-friendly and pedestrian-friendly environments. The latter options are more controversial, and vested interests may seek to cloud the community's perceptions of factors driving the overweight epidemic. We need to actively involve industry in partnerships for environmental change. Health practitioners working in the community, child and family nurses and general practitioners are crucial in any comprehensive strategies, as they provide a widely available service to families and can tailor specific strategies for individual families.11,12

Elizabeth B Waters MPH, DPhil · Louise A Baur PhD, FRACP

The evidence for behavioural therapy Autism is a developmental disorder characterised by impairment of communication and social interaction, and stereotyped, restricted patterns of behaviour. The young child with autism fails to develop normal language and imaginative play. Autism (or autistic disorder) affects one in 1000 children and is the core disorder of a wider spectrum of pervasive developmental disorders. Australian paediatricians identify it as one of the more difficult areas of practice1 — there is still no cohesive explanation for the child's developmental arrest, and a plethora of therapies exist. Diagnosis needs to be made by a multidisciplinary team. Parents then face a long list of possible interventions, and will usually be directed first to speech pathologists. Sensorimotor integration therapy (which stimulates or desensitises visual, auditory and tactile senses), and dietary interventions (eg, casein and gluten exclusion) are widely practised in Australia, but data for their efficacy are inadequate.2,3 A controlled trial of auditory integration (where the patient listens to music that has been computer modified to remove frequencies to which he or she is hypersensitive) showed no effect, yet it continues to be offered as a therapy.2 While ineffective therapies may be harmless, they waste parents' money and the child's valuable therapy time. Furthermore, the delay in implementing effective treatment may compromise the child's outcome. Augmented communication, using visual modes such as pictures, symbols and signs, promotes communication and language in children with severe communication deficits and poor verbal imitation skills.4 However, the early intervention that has been subjected to the most rigorous assessment is behavioural intervention. There is now definite evidence that behavioural intervention improves cognitive, communication, adaptive and social skills in young children with autism. In 1987, Lovaas showed apparent recovery, persisting into adolescence, in nine of 19 young children who received an intensive home-based intervention based on applied behavioural analysis, a scientific method of reinforcing adaptive and reducing maladaptive behaviours.5,6 Subsequent studies also showed that behavioural intervention caused significant, albeit somewhat lesser, gains.7-11 This has modified the orthodox view that autism is always a severe, lifelong disability. Criticisms of the adequacy of the design and power of these studies are being addressed by the multisite Lovaas replication Early Autism Project. The first US site has released data (Wisconsin Early Autism Project).12 Again, after three to four years of intensive applied behavioural analysis intervention, about half the preschool children with autism acquired near-normal functioning in language, performance IQ and adaptability. Ninety-two per cent of intervention children acquired some language. Control children who received special education showed no gains in IQ or adaptability.12 Why is intensive applied behavioural analysis intervention more effective than special education for children with autism? This can not be simply explained by the intensity of these programs (30–40 hours per week). Children in a school-based Scandinavian study who received behavioural intervention gained an average of 25 language IQ points in the first year of the intervention, with improvements in performance IQ, communication and adaptability. On all scores, they surpassed control children who received special education according to best practice for autism, and the same intensity, duration and supervision of therapy.13 The superior outcome from behavioural intervention is thought to result from the targeting of specific deficits in autism that prevent learning: imitation, attention, motivation, compliance, and initiation of interaction. Skills are taught in small steps, mastered, and then generalised. Intensive, individualised one-to-one therapy is usually provided by students, behavioural therapists, or parents, under the supervision of behavioural experts. More natural settings of play and learning, augmented communication support, and other powerful visual learning tools, such as video modelling, may be used. Parents play a major coordinating role, and are trained to generalise the skills learnt by the child and to provide incidental teaching. Only positive reinforcement is used to teach the children. Several preschool programs in the United States and the United Kingdom report comparable success to home-based behavioural programs. These programs have low child-to-staff ratios, collect detailed behavioural data, generally integrate the children with typically developing peers, and train parents intensively in behavioural methods.14 However, most young children with autism in Australia do not receive intensive behavioural intervention programs — partly because such programs are not recommended by many health professionals and partly because of their prohibitive cost for families. Only Western Australia has achieved partial government funding for preschool behavioural programs, as justified by a review by the Disability Services Commission of Western Australia.15 This State is also the first to have a prospective autism register, placing it in a unique position to provide Australian outcome data. We are unaware of comprehensive Australian outcome data (from specialised preschools and schools for autism) with which to compare outcomes of applied behavioural analysis programs. For those of us who are parents of children with autism, this seems to be a pressing need. In the United States, parents have effectively advocated for evidence-based interventions using expert statements.2 If intensive behavioural programs in young children with autism allow about half of the children to no longer require special education and other costly interventions, government funding of such programs would provide economic returns in the long term. The returns to the children who respond and their families would, of course, be priceless.

Jennifer J Couper MD, FRACP · Amanda J Sampson FRACOG, DDU, COGUS

Reforms to the management of schizophrenia in Australia have stalled A decade ago, the management of schizophrenia languished in medicine's backwaters. Treatment still occurred in asylums, using drug therapies serendipitously discovered decades earlier. Even these had proved ultimately disappointing and were used in excessive doses, with inevitable serious adverse effects, a great deal of suffering and only modest benefit. Psychosocial treatments were similarly obsolete or simplistic, with a weak evidence base. Therapeutic nihilism was pervasive and stigma profound. The public knew little about schizophrenia and gave little thought to it unless they happened to be directly touched by the disorder in their own lives. The Burdekin Report graphically captured this bleak scenario.1 The situation 10 years on is much more promising. Spurred on by the reintroduction of clozapine, a new wave of drug discovery has produced a second generation of antipsychotic drugs. Because of their better tolerability, and boosted by potent marketing campaigns, these "atypical" drugs have now become the first-line treatment in Australia and have engendered greater optimism in managing schizophrenia. Psychosocial treatments have undergone a similar renaissance,2 with the advent of evidence-based family interventions, cognitive behaviour therapy for persistent psychotic symptoms, and vocational rehabilitation models. The first National Mental Health Strategy catalysed an overdue reform process and created a real sense of progress. Early intervention strategies, not seriously attempted previously in schizophrenia, were effectively developed in Australia, evaluated and exported.3 The prospects for people with schizophrenia never seemed better. However, the potential for greatly improved outcomes has not been realised in Australia. The daily reality for most people with schizophrenia is that quality of treatment and quality of life are relatively poor.4 Many live in poverty in substandard housing, having little to occupy their time and trying their best to cope, often with the aid of harmful amounts of legal and illegal substances. The plight of family members is also serious and all too often leads to frustration and despair. Despite the early intervention reform, which is being taken up enthusiastically overseas,3 long delays in obtaining treatment for first episodes of schizophrenia are still common. Treatment is typically withheld until it can no longer be denied.5 In 2002, the Mental Health Council of Australia was contracted by the Federal Government to conduct a comprehensive review of the mental health system. The review concluded that, despite a decade of reform, Australia still does not have effective or accessible mental healthcare. Serious under-resourcing was identified as the fundamental cause. By the end of the 1990s, the devolved and mainstreamed mental healthcare system had developed a raft of problems. The reform process had stalled behind the complacent facade of a "mission accomplished". A recent review of Victoria's mental health services by the State's Auditor General found evidence of unmet need, poor access to and continuity of care, and low levels of satisfaction with services — problems attributed primarily to under-resourcing.6 Similar problems are likely to exist in other States. Furthermore, a substantial proportion of people with schizophrenia, whose management requires a team approach with specialist review, are being managed in minimalistic fashion by general practitioners with insufficient support from a beleaguered and reactive specialist system. As a result, despite significant advances in treatment efficacy, there is a vast gap between efficacy and effectiveness, which could be bridged if it were possible to implement optimal evidence-based treatment. The Royal Australian and New Zealand College of Psychiatrists is poised to release new clinical practice guidelines for the treatment of schizophrenia.7 The guidelines emphasise the need for an optimistic therapeutic approach to treating schizophrenia, and stress that the social environment of people with schizophrenia needs to be improved (eg, through housing support, vocational rehabilitation and family support). The guidelines also endorse atypical antipsychotics as the first-line treatment for schizophrenia because they are better tolerated in the short term by the vast majority of patients.11 Some have claimed that these outcomes could be achieved if the "typical" (first-generation) agents were used in lower doses,12 but there is increasing evidence that this is not the case, and in practical terms such low-dose use of typicals is unlikely to be achievable. Used over longer periods, the atypical agents are showing a significant advantage in relapse prevention13 and lower rates of tardive dyskinesia than the typical agents. However, this has to be balanced against the increased risk of adverse effects, such as weight gain and impaired glucose tolerance. Clozapine is clearly superior to other drugs for managing "treatment resistant" patients and reducing suicide risk.14 Despite practical difficulties relating to its use (notably the need for routine blood monitoring), clozapine should be more widely used in Australia. Psychosocial treatments2 are now solidly evidence-based, but are still only sparsely available in Australia.15 This reflects a major failure of public policy and practice. The failure to continue the reform process means that what is currently on offer is little more than acute-phase containment of risk in a reactive and rationed manner, with, at best, rapid disposal to minimal outpatient care. It has been claimed that much current funding for mental health services is not put to good use and that replacing some existing practice with evidence-based interventions is all that is required.13 This is clearly desirable but a manifestly inadequate response, which also ignores the costs that would be involved in achieving such global change in clinical practice. Despite the much-emphasised high direct cost of treating schizophrenia,14 treating it adequately, let alone optimally, will cost substantially more, and will require a much more professional and proactive approach, with widespread community support. For disorders that are treatable but not yet curable, achieving better outcomes is quite feasible but comes at a threshold price (my estimate of that threshold would be at least $24 000, but further research is needed). Current direct costs are about $18 000 per patient per year,14 a figure that has been labelled high, yet which is clearly below this threshold. Indirect costs (eg, costs of social security, costs involved in reduced working capacity of family members and the patient, and prison costs) are very substantial and could ultimately be diverted to proactive direct treatment. In fact, treatment in psychiatry is not intrinsically expensive in contrast to other complex medical disorders, yet Australia provides less funding per patient with schizophrenia than many other developed countries. Sartorius claims that "there is enough money around to help those with mental illness, but it is not available because of the attitude of most decision makers and a large part of the general public towards mental illness and all that surrounds it".15 People with schizophrenia are most affected by the lack of funding. Members of the public do not discover this until a friend or relative develops the disorder, by which time it is too late. Australians need to consider the following question: "Are you willing to pay to make optimal treatment freely available? — you or your family may need it.".

Patrick D McGorry MD FRANZCP

Objective: To measure the prevalence of obesity in Australian adults and to examine the associations of obesity with socioeconomic and lifestyle factors.Design: AusDiab, a cross-sectional study conducted between May 1999 and December 2000, involved participants from 42 randomly selected districts throughout Australia.Participants: Of 20 347 eligible people aged > 25 years who completed a household interview, 11 247 attended the physical examination at local survey sites (response rate, 55%).Main outcome measures: Overweight and obesity defined by body mass index (BMI; kg/m2) and waist circumference (cm); sociodemographic factors (including smoking, physical activity and television viewing time).Results: The prevalence of overweight and obesity (BMI > 25.0 kg/m2; waist circumference > 80.0 cm [women] or > 94.0 cm [men]) in both sexes was almost 60%, defined by either BMI or waist circumference. The prevalence of obesity was 2.5 times higher than in 1980. Using waist circumference, the prevalence of obesity was higher in women than men (34.1% v 26.8%; P < 0.01). Lower educational status, higher television viewing time and lower physical activity time were each strongly associated with obesity, with television viewing time showing a stronger relationship than physical activity time.Conclusions: The prevalence of obesity in Australia has more than doubled in the past 20 years. Strong positive associations between obesity and each of television viewing time and lower physical activity time confirm the influence of sedentary lifestyles on obesity, and underline the potential benefits of reducing sedentary behaviour, as well as increasing physical activity, to curb the obesity epidemic.

Adrian J Cameron MPH · Paul Z Zimmet MD, FRACP, FAFPHM · David W Dunstan PhD · Marita Dalton GradDipEpidemiol · Jonathan E Shaw MD, MRCP · Timothy A Welborn MB BS, PhD · Neville Owen PhD · Jo Salmon PhD · Damien Jolley MSc

Objective: To determine whether warming or rubbing adult diphtheria tetanus (ADT) vaccine immediately before administration affects its temperature and reduces the incidence of pain.Design: Double-blind, randomised controlled trial and in-vitro temperature study.Setting: Emergency department (ED) of a regional hospital between April and December 2001.Patients: Convenience sample of 150 patients aged 16 years or over who presented to the ED requiring ADT booster vaccination.Intervention: Patients were randomised to receive vaccine that was "cold" (no deliberate warming), "rubbed" between the palms for 1 minute, or "warmed" in a 37°C incubator; vaccine was administered as recommended in Australian guidelines.Main outcome measures: Incidence of pain and pain score on McGill Present Pain Intensity Questionnaire at 5 minutes, 24 hours and 48 hours after injection; and temperature of vaccine after preparation for simulated administration.Results: The "cold" vaccine had significantly lower temperature (mean, 19.1°C; 95% CI, 17.5–20.7°C) than the "warmed" vaccine (mean, 28.9°C; 95% CI, 28.4–29.4oC) and "rubbed" vaccine (mean, 26.9°C; 95% CI, 24.5–29.3°C). There was no significant difference in incidence of pain between the groups who received vaccine prepared in different ways at any follow-up (5 min: P = 0.62; 24 h: P = 0.58; 48 h: P = 0.61) or overall (P = 0.99). Among those who completed follow-up, incidence of pain at any time was 77/138 (56%); there was no difference in their time-averaged pain scores (P = 0.63) or peak pain scores (P = 0.60).Conclusions: Warming or rubbing ADT vaccine does not reduce the incidence of pain after administration. Regardless of how ADT vaccine is prepared, its temperature approaches ambient by the time it is injected.

Matthew J Maiden BSc, BM BS, DRANZCOG · Gregory N Benton RN, CCRN · Russell A Bourne MB BS(Hons), FANZCA

Objective: To identify any association between asthma and depression and quality of life.Design and setting: A face-to-face Health Omnibus Survey of a random and representative sample of the South Australian population in August 1998.Participants: 3010 randomly selected participants aged 15 years and over.Main outcome measures: Prevalence of doctor-diagnosed asthma, and scores for depression (measured by PRIME-MD instrument) and quality of life (measured by SF-36) in affected participants.Results: The prevalence of asthma was 9.9%. The prevalence of major depression was significantly higher for those who experienced dyspnoea, wakening at night with asthma, and morning symptoms of asthma. Quality-of-life scores were also lower for the same groups.Conclusions: Depression is a serious but potentially remediable comorbidity with asthma that may affect appropriate diagnosis and outcome.

Robert D Goldney MD, FRANZCP · Richard Ruffin MD, FRACP · David H Wilson MPH, PhD · Laura J Fisher BA(Hons)

We describe a case of acute liver failure and death associated with the use of a preparation containing the "natural" anxiolytic kava (Piper methysticum) and passionflower (Passiflora incarnata). The patient died after a report by the Therapeutic Goods Administration (TGA) warning of the potential for hepatotoxicity associated with the use of kava-containing products. The general public and alternative medicine practitioners need to be aware of the potential for non-prescription drugs to cause serious hepatic reactions. Preparations containing kava (Piper methysticum) have become freely available in Australia and have gained widespread use as over-the-counter anxiolytics or sedatives. We report the first Australian case of fulminant hepatic failure associated with a kava-containing preparation. Clinical historyIn July 2002, a 56-year-old woman was referred to the Austin and Repatriation Medical Centre, Melbourne, for investigation of jaundice. She had been previously well apart from a history of benign monoclonal gammopathy (IgG, 24 g/L; normal, 6.9–15.4 g/L), which had been diagnosed 12 months previously. The patient had presented to her local doctor with a two-week history of fatigue, nausea and increasing jaundice. She had no risk factors for viral hepatitis, no history of liver disease and drank minimal amounts of alcohol. Over the preceding three months she had been taking a herbal supplement for anxiety, prescribed and provided by a naturopath (Kava 1800 Plus, Eagle Pharmaceuticals, Castle Hill, NSW; one tablet thrice daily, labelled as containing kavalactones 60 mg, Passiflora incarnata 50 mg and Scutellaria laterifloria 100 mg). She had also been taking some vitamin and mineral supplements but no other medications. Examination on presentation to hospital revealed the patient to be deeply jaundiced without stigmata of chronic liver disease. Relevant abnormal pathology test results are presented in Box 1. Extensive investigations to screen for recognised causes of acute liver failure failed to reveal any cause. Assays for acute hepatitis A, B, and C viruses, Epstein–Barr virus and cytomegalovirus were all negative. Serum copper and ceruloplasmin levels were normal and Kayser–Fleischer rings were not present. Antinuclear antibodies were detected at a titre of 1:160, but anti-smooth-muscle antibodies were not detected. No paracetamol was detected in the blood. An abdominal doppler ultrasound revealed a small liver with normal flow in the hepatic arteries, hepatic veins and portal veins. The paraprotein level had remained stable over the previous 12 months. A repeat bone marrow biopsy did not suggest the presence of multiple myeloma. A trans-jugular liver biopsy performed on the fifth day of admission showed non-specific severe acute hepatitis with pan-acinar necrosis and collapse of hepatic lobules. Over the subsequent week, the patient's condition deteriorated and she was urgently listed for transplantation. On Day 17 of admission the patient underwent liver transplantation. Unfortunately, the procedure was complicated by massive bleeding that did not correct following implantation of the donor liver, and the patient died of progressive blood loss, hypotension and circulatory failure. Histological examination of the explanted liver confirmed the presence of massive hepatic necrosis (Box 2). Subsequent analysis of the supplement she had taken revealed it contained kava and Passiflora incarnata as labelled, and a third, as yet unidentified, compound. Although the label listed Scutellaria laterifloria as an ingredient, none was identified in the compound. DiscussionThis case report describes the first case of fulminant hepatic failure in Australia in a patient after taking a product containing kava and Passiflora incarnata. We used the Naranjo Adverse Drug Reaction Probability Scale1 and found it was "probable" that the kava-containing preparation caused this patient's illness. Worldwide, at least 68 cases of suspected hepatotoxicity associated with the use of kava-containing products have been reported, including six resulting in liver transplantation and three deaths. Passiflora incarnata has also been described in association with the development of hepatotoxicity, but in only one case report, involving a patient who took several herbal medicines, including Passiflora incarnata.2 In February 2002 (despite the absence of any Australian reports of kava-associated hepatotoxicity), the Therapeutic Goods Administration (TGA) issued an alert regarding the potential hepatotoxicity of kava-containing products.3 This alert was widely distributed to doctors, pharmacists and alternative medicine practitioners. The patient we described began taking a kava-containing preparation after the TGA alert was issued, and apparently was unaware of the alert. Medication reactions resulting in abnormalities of liver function tests are relatively common, yet rarely result in severe liver injury. It is important to take a careful history of any drug or herbal remedy use in all patients with unexplained hepatitis, as the continuation of the agent after the onset of injury may have catastrophic consequences. Spontaneous recovery is unlikely in patients who develop encephalopathy or severe coagulopathy, and in such cases liver transplantation may offer the only realistic chance of survival.4 This report emphasises the need for the general public and alternative medicine practitioners to be aware of the potential for non-prescription drugs to cause serious hepatic reactions. The lack of regulation within the alternative medicine community and general availability of non-prescribed medications may have contributed to the death of this woman. A statutory obligation for dispensers of non-prescribed medications to provide information to the consumer at the point of sale regarding any future drug alerts may help to limit further morbidity and mortality. 1: Patient laboratory data on presentation to hospital and 17 days later (day of transplantation) Serum albumin (g/L) (normal, 35–50 g/L) Serum bilirubin (μmol/L) (normal, < 18 μmol/L) Serum alkaline phosphatase (U/L) (normal, 40–129 U/L) Serum alanine aminotransferase (U/L) (normal, < 55 U/L) International normalised ratio (normal, 1–1.2) Presentation 34 209 190 4539 2.3 Day 17 23 607 357 438 6.6 2: Histological section of the explanted liver The image shows an "empty" necrotic lobule which is devoid of hepatocytes (arrow). This is surrounded by proliferating bile ductules derived from portal tracts. Much of the liver had this appearance. (Haematoxylin and eosin stain; original magnification × 100. Image prepared by Mr Simon Rosalie.)

Paul J Gow FRACP, MD · Nathan J Connelly MB BS · Peter Crowley MB BS · Peter W Angus FRACP, MD · Richard L Hill MB BS

Persistent pain is a complex mix of physical and psychological symptoms and is ideally managed by a biopsychosocial approach. Often the relative contributions of family and personal relationships, finances, work, past pain experiences and personality outweigh those of the nociceptive or neuropathic processes from which most pain originates. Recent advances in our understanding of the pathophysiology of pain may lead to improved drug treatments; however, non-drug treatments — education, lifestyle modification, exercise and reassurance — should be used routinely to improve patients' quality of life. Patients with persistent pain that is difficult to control or has complex psychosocial influences, or who have a history of medication misuse, should be referred to a multidisciplinary pain centre. Selected patients may be offered invasive options such as nerve blocks or spinal-cord stimulation. The best outcomes are achieved in patients treated in group-based pain-management programs using cognitive-behavioural therapy to improve physical function, change unhelpful thinking and improve patients' understanding of their situation.

C Roger Goucke FANZCA, FFPMANZCA, FAChPM

The Better Medication Management System (BMMS) is an Australian project to provide electronic access to patient medication records. It aims to improve access to patient medication information and to reduce adverse drug events and hospital admissions. Evidence supporting the achievability of the BMMS aims is limited. Voluntary participation of patients in the BMMS may limit its ability to achieve its aims and capitalise on its potential benefits.

Jeremy P Wrobel LLB, BCom, MB BS(Hons), Hospital Medical Officer, Barwon Health

Following reports of liver toxicity, including liver failure, associated with extracts from the Pacific islands plant kava (Piper methysticum), these have been banned from sale as a herbal anxiolytic in many Western countries, to the detriment of Pacific island economies. Pacific Islanders have used kava extensively for centuries, without recognised liver toxicity. However, the population is small, and there has been no systematic evaluation of possible liver damage. For both economic and public health reasons, it is important to determine if kava is inherently hepatotoxic, and what the mechanisms of toxicity are. Such research could lead to safer kava extracts for sale in Western countries, or identification of a subpopulation who should not consume kava.

Robert F W Moulds PhD, FRACP · Joji Malani MB ChB

Rationing, the equitable allocation of medical resources, is both an economic and moral challenge — economic, because the various components of healthcare must be budgeted; moral, because the prioritisation of these resources is a value-laden decision. The moral debate about rationing pits individual choice against communal interests. The advocacy of equitable distribution of healthcare resources originates in arguments for distributive justice and a revised version of individual autonomy. If autonomy is defined strictly in terms of atomistic individuality, then the social obligations and duties of persons are subordinated to their individual rights. Alternatively, when people are defined by their relationships, "relational autonomy" balances responsibilities against the claims of individual rights to maximise distributive justice. The concept of relational autonomy provides medicine with a philosophical basis for communal rationing of healthcare resources.

Alfred I Tauber MD

The "new genetics" will provide new genetic tests that can be used for diagnosis, prognosis, treatment selection, carrier and predictive testing in affected families, and potentially for susceptibility testing for later-onset multifactorial disease and population screening. Doctors will increasingly need to consider the family implications of a genetic diagnosis — to identify family members at risk of the disorder or of having affected children and to consider how these individuals might be advised of their situation. Clinical geneticists can be a valuable resource for doctors who need advice about whether genetic testing is available, which tests to pursue, how to access testing services, and how to interpret and act on test results. Clinical geneticists also provide genetic counselling, a process which gives people understandable information about the genetic disorder in the family, and makes the information useful for decision-making given the person's unique circumstances and beliefs. The Internet will increasingly be a key source of information about genetic disorders for patients, their families and healthcare professionals.

Eric A Haan MB BS, FRACP

To the Editor: An 8-month-old girl, born in Perth, Western Australia, who received only breast milk feeds for her first six months of life, was referred urgently to Princess Margaret Hospital for Children (the tertiary paediatric hospital in Western Australia) for investigations of seizures. Her parents described the seizures as episodic, involving all limbs, lasting less than five minutes and occurring over the 10 days before presentation. At presentation, the infant had carpopedal spasm. She was afebrile, and a septic screen gave negative results. Venous blood gas analysis showed a low ionised serum calcium level of 0.71 mmol/L (reference range [RR], 1.13–1.32 mmol/L). An x-ray film of her wrists showed signs of rickets, with cupping and fraying of the distal metaphyses of both radius and ulna. Other blood tests revealed elevated parathyroid hormone levels of 8.6 pmol/L (RR, 0.80–8.00 pmol/L), an elevated alkaline phosphatase level of 523 U/L (RR, 100–350 U/L), and an extremely low level of serum 25-hydroxyvitamin D3 (25OHD3) of 5 nmol/L (RR, 30–150 nmol/L). The infant responded to treatment with an infusion of 0.5 mg/kg of calcium gluconate and a 4-month oral course of 0.2 μg calcitriol daily. After treatment commenced, she did not have any further seizures. Radiogaphy performed 4 months later showed increasing calcium deposition at the distal metaphyses of the radius and ulna. Seizures are described as a presenting feature of hypocalcaemia in vitamin D deficiency rickets.1,2 Ultraviolet radiation and/or dietary vitamin D are required to prevent rickets in children. Perth, Western Australia, located at latitude 32° South has an average daily sunshine duration of at least five hours per day. However, even with this amount of sunshine, vitamin D deficiency can still occur in people who, for various reasons, receive little or no sun exposure, especially if their skin is darkly pigmented, and who have an inadequate dietary intake of vitamin D. The girl's mother, who wore a veil and clothing which protected her body from exposure for religious reasons, had a serum 25OHD3 level of 7 nmol/L. Breast milk is a poor source of dietary vitamin D, especially when the lactating woman is vitamin D deficient.3 In Australia, vitamin D deficiency rickets in infants of parents who have migrated from Mediterranean, African, Middle Eastern and southern Asian regions has been reported since the 1960s.4,5 Education of healthcare providers and their patients about the requirement for sunlight exposure or dietary supplementation to prevent vitamin D deficiency rickets needs to continue.

Graeme H Johnson · Francis Willis

Comment: Nutritional rickets is highly prevalent in countries such as Mongolia, Tibet and China1 where winter sunlight is reduced and there is no universal vitamin D supplementation. Paradoxically, rickets is also prevalent in developing countries in the tropics and subtropics where sunlight is unlikely to be a limiting factor. Low calcium intakes (including vegetarian diets), prolonged breast feeding, and covering of the skin may all contribute.2,3 Published reports and clinical experience in Sydney suggest an increase in prevalence of rickets, especially in infants and mothers in immigrant populations2,4-7 Other Western countries have reported similar findings. The vitamin D deficiency described by Johnson and Willis in an infant in Perth highlights a high-risk group — infants of mothers who are veiled. Treatment of associated nutritional deficiencies, especially iron deficiency,4,5 and giving a minimum of 300 000 IU of vitamin D over 6–8 weeks, should resolve the rickets. Data on the epidemiology of vitamin D deficiency in these high-risk groups in Australia and other Western societies are lacking and should be the subject of future research. The major source of vitamin D and its circulating form, 25-hydroxyvitamin D3 (25OHD3), in children and adults is the skin. It is estimated that exposure to sunlight for 15 minutes three times per week normalises 25OHD3 levels.8 Dark skin, increasing age, sun protection agents, and the angle of the sun in winter will attenuate this increase in 25OHD3.8 Neonates acquire their vitamin D3 stores from their mothers via the placenta, with only a small amount transferred in breast milk.9 By screening high-risk pregnant women, specifically veiled women and those with dark skin,10,11 prevention of most cases of infant rickets is possible. Levels of 25OHD3 should be measured and, if low, the mother should receive 4000 IU of vitamin D daily until 25OHD3 levels are normal. There is currently no recommendation for routine supplementation of vitamin D in infants, and most cereals and foods are not fortified with vitamin D. However, infant formulas are supplemented with 200 IU of vitamin D per litre. It is estimated that sufficient vitamin D levels to prevent rickets could be achieved if 400 IU of vitamin D were provided daily as part of a multivitamin supplement to high-risk infants.

Christopher T Cowell

To the Editor: It has been well established that improved compliance in hand washing significantly reduces hospital-acquired infections and cross transmission of methicillin-resistant Staphylococcus aureus.1 Although there have been no reports of infections resulting from cross-contamination via stethoscopes, studies have demonstrated that 80%–100% of these appliances are colonised by bacteria.2-5 However, most of the organisms isolated are considered non-pathogenic. The most common potentially pathogenic organism isolated from stethoscopes is S. aureus, with a prevalence of 4.2%–27.5%.2-5 Cleaning with either 70% isopropyl alcohol or benzalkonium chloride wipes can reduce the bacterial count on stethoscopes by 94%–100%.3,5 We undertook a study to assess the prevalence of S. aureus carriage on stethoscopes and hands of staff of the Canberra Hospital, and to measure the effectiveness of cleaning and hand washing in reducing colonisation. A convenience sample of healthcare workers from various areas of the hospital was obtained over a period of 6 months. The diaphragm of each participant's stethoscope was directly impressed on to mannitol salt agar, before and after being cleaned with a 70% isopropyl alcohol wipe. The dominant hand of each participant was also tested before and after washing with triclosan (1%) antimicrobial handwash and water. S. aureus was identified by standard laboratory methods. There were 134 participants: 69 doctors, 50 nurses, 10 medical and nursing students and five physiotherapists. Most doctors and physiotherapists used their own stethoscopes, whereas most nurses and students used ward stethoscopes. S. aureus was isolated from five stethoscopes before cleaning (4%), but from none after cleaning. The organism was also isolated from the hands of 11 people before hand washing (8%) and of one after hand washing (0.7%). Two people had S. aureus isolated from both sites. There was no statistically significant difference between the prevalence of S. aureus on hands and stethoscopes (P = 0.15, McNemar's test). Hand washing is the best recognised means of preventing cross-contamination in hospitals. However, the simple intervention of cleaning stethoscopes with an alcohol wipe was highly effective, and we believe that this practice should be more widely promoted.

Karina J Kennedy · Dianne E Dreimanis · Wendy D Beckingham · Francis J Bowden

To the Editor: At the Australasian Schizophrenia Conference in Sydney in October 2002, Professor Patrick McGorry of the Orygen Research Centre, University of Melbourne, presented draft guidelines on the management of schizophrenia and early psychoses.1 One of the recommendations was that atypical antipsychotic drugs should be used as the first-line pharmacological treatment in preference to typical antipsychotics and depot antipsychotics. With a shift in management of schizophrenia to community-based care, the number of patients with schizophrenia managed by general practitioners has increased over the past decade (from 36 per 10 000 encounters in 1990–91 to 45 per 10 000 in 2000–02).2 With the pending introduction of the guidelines, a baseline measure of GP prescribing rates of antipsychotics, both typical and atypical, will allow future measurement of the impact of the guidelines. We analysed the 1998–2002 data from the Bettering the Evaluation and Care of Health (BEACH) program, a continuous national cross-sectional survey of general practice.3 About 1000 GPs participate in this program every year, each providing details (on structured forms) about 100 consecutive patient encounters. Data collected include GP and patient characteristics, problems managed and treatment provided. We examined 401 300 encounters from 4013 GPs, with 431 537 medications recorded. Prescription rates were calculated and regression analyses performed using SAS software4 to adjust for the cluster effect of the study design. There were 1988 schizophrenia or psychosis problems managed in the four years of data collection (a rate of 49.5 per 10 000 encounters); 1883 medications were prescribed (94.7 per 100 contacts), of which 926 (49.2%) were typical antipsychotic drugs and 484 (25.7%) were atypical antipsychotic drugs. In 1998–99, the prescription rate of atypical antipsychotics was 15.7 per 100 contacts with patients with schizophrenia or psychosis (95% CI, 11.8–19.7). This rate increased to 31.1 per 100 contacts (95% CI, 26.3–36.0) in 2001–02. In the same period, the prescription rate for typical antipsychotics fell from 51.3 per 100 contacts (95% CI, 45.6–56.9) in 1998–99 to 40.6 per 100 contacts (95% CI, 35.4–45.8) in 2001–02. Linear regression showed that the prescription rate of atypical antipsychotics had increased by an average of 5.1 per 100 contacts per year over the four years (P < 0.0001), while the prescription rate of typical antipsychotics had decreased by an average of 3.8 per 100 per year (P < 0.005). Over the four-year period, there was no significant increase in the rate of overall prescriptions for people with schizophrenia (92.0 prescriptions per 100 contacts [95% CI, 83.4–100.7] in 1998–99 v 96.3 [95% CI, 89.4–103.3] in 2001–02). Between 1998 and 2002, the relative prescribing rate of atypical antipsychotics for schizophrenia and other psychoses in general practice nearly doubled. These results show that, even before the introduction of the guidelines, there has been a shift towards prescribing atypical antipsychotics in preference to typical antipsychotics. This change may reflect a change in specialist behaviour, as specialists have a direct effect on GP prescribing.5 The BEACH study will be able to assess the effect of the guidelines on the prescription rate of atypical antipsychotics by GPs.

Christopher M Harrison · Helena C Britt

To the Editor: Figures from the Australian Bureau of Statistics show that Australians make about 3.3 million overseas departures each year.1 Few data are published on the extent to which Australian travellers seek pre-travel health advice, what vaccinations they receive, and what risks they are exposed to during travel. A series of surveys of travellers examining these questions has been conducted under the auspices of the Travel Health Advisory Group, a coalition of Australian travel and medical organisations. Surveys were conducted in 1996, 1997, 2000, 2001 and 2002. On each occasion, a market research company telephoned people from mainland capitals using numbers randomly selected from the telephone directory. This process continued until 500 people aged 18 or over who had travelled overseas in the previous two years had been interviewed. In the 2002 survey, about 10 000 calls were made to complete the interviews. The questions on vaccinations focused on hepatitis A and B, two of the most common vaccine-preventable diseases associated with travel.2 Results from the 2002 survey are shown in the Box. A minority of people (31%) reported seeing a doctor or travel clinic for pre-travel health advice. Of those who saw a doctor or travel clinic, 31% did so two weeks or less before departure. Over the series of surveys, there has been an increase in travel to destinations with high- or intermediate-risk for hepatitis A infection, from 40% of travellers in 1996 to 58% in 2002. Despite this increase, only a minority of travellers could recall ever being vaccinated for this illness. Travellers were informed about how they might be exposed to hepatitis A and B and asked if they believed that they could have been at risk during their most recent overseas trip. Substantial numbers recalled a risk (34% and 16% for hepatitis A and B, respectively) and some of these could not recall being vaccinated (18% and 7%, respectively) (Box). These surveys have methodological limitations, including lack of information on the consent rate and potential recall bias. However, the results suggest that substantial numbers of travellers do not seek pre-travel health advice and are at risk of vaccine-preventable diseases during travel. Not only does this have implications for individual travellers, it also creates public health risks, as travellers can introduce hepatitis A and B into their home communities. These results suggest more public education is needed about the importance of pre-travel health advice and appropriate vaccination. Results of 2002 survey of Australian travellers overseas Variable No. of travellers (n = 500) Age (years) 18–29 156 (31%) 30–49 188 (38%) ≥ 50 153 (31%) Not stated 3 (0.6%) Male sex 205 (41%) Hepatitis A risk in country visited* High 226 (45%) Intermediate 62 (12%) Low 212 (42%) Sought pre-travel health advice from doctor or travel clinic Doctor 135 (27%) Travel clinic 20 (4%) No professional advice 345 (69%) Believed could have been at risk of hepatitis on most recent trip Hepatitis A 168 (34%) Hepatitis B 79 (16%) Vaccinated against hepatitis Hepatitis A 195 (39%) Hepatitis B 197 (39%) Believed at risk of hepatitis on most recent trip and not vaccinated or unsure Hepatitis A 91 (18%) Hepatitis B 36 (7%) Hepatitis A risk in country visited* among those not vaccinated for hepatitis A or unsure High 123 (25%) Intermediate 40 (8%) Low 142 (28%) * As defined by the United States Centers for Disease Control and Prevention, 2000.3 Destinations for the cohort of 500 were Asia (45%), northern Europe (28%), southern Europe (14%), North America (15%), Oceania (14%), eastern Europe (3%), Africa (3%), Middle East (2%), South America (1%) and Central America (1%), with some having more than one destination.

Nicholas A Zwar

To the Editor: I would like to comment on a recent article by Young and Dobson on the decline of bulk-billing and the increase in out-of-pocket expenses.1 It is true, as the authors state, that "Australia has no legislation restricting how much a general practitioner can charge for a consultation". It is a shame that they did not take equal time to point out that there is no binding requirement on governments to ensure that Medicare rebates remain within striking distance of the real cost of service provision. Policy change is required — with as much political and moral urgency as Young and Dobson advocate for patient access reform — to enable doctors to provide affordable healthcare under a fee-for-service system without being penalised for accepting a substantial number of elderly or socially disadvantaged patients. Primary healthcare policy needs to be adjusted to maintain rebate justice for low-income patients by linking patients' rebates to their doctors' real-life market costs (or even to relative value studies), not budget "bottom lines". Is the patient to be out of pocket, or the doctor? Surely, both positions are equally unfair, and equally unlikely to bring about an equitable system.

Warwick H Ruse

To the Editor: Young and Dobson1 have confirmed what has been long suspected by many rural doctors and patients — that women (and patients in general) in rural areas are paying higher out-of-pocket costs for general practice consultations than those in urban areas. I wonder whether the authors have considered analysing the data by State and Territory, as the structure of a State healthcare system often has a significant impact on healthcare costs to individuals. I am also interested to know whether total costs of healthcare (including on-costs, referrals, specialist fees, hospital and investigative care) were analysed. There is a long held view that rural doctors have a more holistic approach to patient care than their urban colleagues, who are more inclined to recommend unnecessary investigations and specialist referrals. It would be fascinating to know whether urban women would actually be more "out-of-pocket" than rural women if total contact with the healthcare system (not just general practice consultations) was taken into account.

Chris A Harrison

To the Editor: Do the data in Young and Dobson's study of general practice consultation fees1 support their conclusion that women in rural and remote areas lack access to affordable healthcare services? The declining prevalence of bulk-billing by general practitioners suggests that healthcare may be becoming increasingly unaffordable for people on lower incomes. But affordability is not only income-related — it depends also on choices regarding discretionary expenditure. Considering median levels of disposable weekly income, together with the prices of basic daily commodities such as milk or bread (not to mention a $10 pack of cigarettes!), how "unaffordable" is an occasional $5–$10 out-of-pocket fee for a GP consultation? As Young and Dobson concede, a further complicating factor in their study was that "the consenters . . . tended to have higher socioeconomic status and so may be less likely to be bulk-billed". It would have been helpful if the authors had defined affordability of GP care in relation to family income (perhaps analogous to advice that rental or mortgage repayments should not exceed a third of household disposable income) and identified just how much their frequent attenders' GP costs exceeded a specified limit of affordability. Services free at point of delivery are overused, both by patients and doctors, as evidenced by the Commonwealth's implementation of the Professional Services Review Scheme and the States' legislating to curb the costs of workers compensation and third-party motor vehicle insurance claims. There is probably an optimal price range that would facilitate affordable access without penalising the less affluent or encouraging "inappropriate practice". Closer attention to the affordability of GP services for individual households would help target resources to people who truly need the services but cannot afford them. This may be a better alternative to the authors' suggestion of simply making policy changes (taxpayer-funded?) to lower the price of GP services for all women in rural and remote Australia.

Peter C Arnold

In reply: We thank the authors of these letters for raising many of the complex issues that underlie the current geographical inequities in costs of general practice consultations. Ruse is concerned that we did not point out the inadequacy of the current Medicare rebates to practitioners. An appraisal of the adequacy of Medicare Benefits Schedule fees was beyond the scope of our study. We presented data on the out-of-pocket costs of general practice consultations, according to demographic and health-related characteristics of consumers, for consideration by all interested parties — practitioners and patients. As suggested by Harrison, we could also look at differences in bulk-billing and costs by State and Territory. However, as Medicare rebates are a Commonwealth issue, looking at national data seemed a sensible first step. We cannot examine total costs of healthcare, as the Medicare data do not include all costs related to care. Arnold argues that "affordability" should be better defined by us and questions, "how unaffordable is an occasional $5–$10 out-of-pocket fee for a GP consultation?". We have three responses. Firstly, many medical practices require an "up-front" payment. As written by one older respondent living in a rural area, "Small country town medical clinics do not give bulk-billing to aged pensioners and insist on cash payment on the day of the visit . . . many pensioners would not seek medical help when needed if at the time no cash was available". Our second response is that, regardless of how "affordability" is defined, the issue is one of equity. Is it reasonable that a major factor identified in our study as influencing access to bulk-billing is whether you consult a practitioner in an urban area or a rural area? Finally, "affordability" can only be assessed in relation to income and other expenditure and commitments. In our surveys we ask women how satisfied they are with the costs of GP care and, while the responses are subjective, they are likely to take into account these contextual issues. These data have not yet been fully analysed.

Anne F Young · Annette J Dobson

To the Editor: I note with interest the case study of experimental Ancylostoma caninum infection in a 22-year-old student.1 In his accompanying editorial, Van Der Weyden highlights the courage of these researchers, as well as some of the risks and discomforts associated with their participation,2 including in two studies in which he was a co-author. However, it is also worth highlighting some of the ethical issues associated with such experimentation. Larry Altman, who provided many of the quoted examples of self-experimentation, also reflects on Walter Reed's experiments with yellow fever vectors in Cuba. Although later credited with the use of written consent forms, on an earlier occasion Altman alleges that Reed withdrew at the last moment from inoculation experiments in which one of his colleagues died.3 Although not mentioned in the published work, the A. caninum experiment was initiated and undertaken by Landmann under the supervision of Prociv, who has himself self-experimented with both A. caninum and Necator americanus (human hookworm) in previous work (Juergen Landmann, Student; Paul Prociv, Senior Lecturer, Department of Microbiology and Parasitology, University of Queensland, personal communication). In this case, the study was wholly initiated by the student so consent was not an issue, but other such studies raise the potential problem of consent in situations of an unequal power relationship. Students under supervision constitute a "vulnerable" group in that consent may be given under a form of duress.4 Just as special protection is needed for populations for whom research is combined with care, protection is required for students who may feel obliged to participate in such research. There have been recent calls for a fuller discussion of ethical issues in published experimental studies,5 where ethical justification should be accorded the same weight as statistical considerations. The unusual study by Landmann and Prociv highlights the need for such discussion in potentially controversial research protocols.

Allen C Cheng MB BS, FRACP

To the Editor: The most recent newsletter of the New South Wales Medical Board1 opens with a plea by the president for better understanding of the Board's initiatives, inspired by the "public interest". We hope that the board recognises the gulf between legitimate public interest and unrealistic, illegitimate public expectation. The newsletter goes on to justify the Board's policy against doctors self-prescribing, with six examples (hardly significant from a register of 25 000). The first, Dr A, aged 70 (the only one whose age was given) was referred to the Board by colleagues for mental impairment, and was not self-prescribing. He was prescribed warfarin by his cardiologist, but also took aspirin. The other five were all involved with drugs of addiction, earning whatever sanctions the Board applied. The newsletter then states that these were "ordinary doctors providing ordinary services in the community" (p. 3).1 They were certainly not, and it is this patronising assessment of the behaviour of ordinary doctors that is objectionable. We are next told that "these dramatic examples represent the tip of an alarming iceberg" (p. 3).1 The Board has enough to do without plumbing the depths for imagined "icebergs", and should reconsider their policy on the alleged dangers of self-prescribing, a policy both unwarranted and unwanted. The mocking adage that "doctors who treat themselves have a fool for a physician" is not made correct by repetitive quotation. There are not many fools in our profession, and sanctions applied to them should not affect the Board's assessment of the whole profession. Although not mentioned in this newsletter, similar motives are apparent in the Board's disapproval of self-referral, where we are not credited with sufficient wit to discover for ourselves appropriate specialists for clinical referral. All medical boards are currently seized with similar agenda. The Victorian Medical Board ponders the "problem" of retired doctors, with the comment in their newsletter on doctors affected by "increasing age and commensurate reduction in cognitive ability", another gratuitous observation without supporting evidence. They could as correctly, and more kindly, have referred to the accretion of clinical wisdom commensurate with age, but respect for seniors seems to have declining value in current professional ethics.

G Douglas Tracy

In reply: Tracy's letter seems to focus on age. The Board's policy about treating family members is not about age, but about the wisdom or otherwise of this practice for medical practitioners at any stage of their career. The policy is not mandatory, but reflects what the Board considers to be prudent practice. The policy does not prohibit writing referrals or repeat prescriptions, but emphasises the importance of having an independent treating practitioner responsible for initiation of treatment and ongoing management. The New South Wales Medical Board is not alone in having such a policy, with similar views being expressed by UK's General Medical Council, the Medical Council of New Zealand, and Canadian, American and other Australian medical boards. The Australian Medical Association position statement on the "Health of medical practitioners" emphasises the importance of medical practitioners and their families having their own general practitioners. The case studies were published following a request from members of the profession for the Board to provide examples of problems arising through treating themselves or family members. Sadly, there are many more instances than the five referred to in the article. The doctors were certainly not ordinary once their attempts to treat family members went astray, but the point is that they had been ordinary doctors who got into difficulties because they crossed the professional–personal boundary.

Brian C McCaughan

Communication for health care. Catherine A Berglund, Deborah C Saltman (editors). Melbourne: Oxford University Press, 2002 ($44.95, xiv + 257 pp). ISBN 0 19 551298 7. “What do others think of you as a communicator?” This book invites readers to explore their habitual communication styles, and to consider whether they are appropriate for clinical care. Most of the 18 chapters by 18 authors call for demanding self-awareness. Readers are drawn into examining their personal realities. Participants follow the path of a series of workshops supplemented by brief but succinct informal summaries. Most chapters provide activity boxes, simple categorisation models and exercises for evaluation. Frequent examples connect concepts raised to the realities of patients and their situations. Facets of techniques, personality, habits and assumptions that can help to clarify “What’s the right thing to do?” are learned. Readers can expect to gain insights into their own performance, as well as a set of frameworks and tools they can use with their students, their colleagues, their patients and their families, and even with their own children and spouse. Chapter cross-references help to maintain coherence across a range of topics that are not limited to interpersonal conversation. Subjects include information searching using libraries and informatics, writing and reporting, and working with the media. All the material is up to date, very practical, useful and readable at all levels, from the lay person to experienced practitioner. Ken CoxEmeritus Professor of Surgery Hunters Hill, NSW

Ken Cox

110 Puzzling cases of epilepsy. Dieter Schmidt, Steven C Schachter (editors). London: Martin Dunitz, 2002 (xxiv + 451pp). ISBN 1 85317 962 0. Epilepsy has been the great teacher of neuroscience. The study of the many and varied faces of epilepsy has allowed scientists to discover regional brain function. The editors of this book have asked over 100 epilepsy experts from around the world to contribute a case study of epilepsy that provided a clinical teaching message. Their collection gathers presentations of unusual causes and surprising clinical courses, as well as unforeseen problems and unexpected solutions. Those expecting carefully crafted biographical short stories in the style of Oliver Sacks will be disappointed, but the book is fun and easy to read. Many of the cases are fascinating, and titles like “A patient who would not leave his apartment for hours every three days” impart a sense of mystery to engage and challenge the reader. The cases are brief, and the messages clearly enunciated. Despite the numerous authors, the quality is relatively even. Although there is an index, this is not a volume that can be consulted easily when seeking the answer to a specific question related to epilepsy. However, the clinical case approach championed here does provide a counterpoint to cohort studies and multi-centre trials, in which subtleties of clinical diagnosis and patient-specific situations may be lost. Those with a clinical interest in epilepsy will enjoy and benefit from this book. It is clearly intended for those with at least a basic, if not a moderately advanced, knowledge of this important subject. Samuel F BerkovicDirector, Epilepsy Research Institute West Heidelberg, VIC

Samuel F Berkovic

Flu vax plus Influenza vaccination may do more for the elderly than reduce the odds of hospitalisation for pneumonia and death from all causes. A large US cohort study of 286 000 community-dwelling patients aged 65 years or older compared the health status of the 58% who had received the vaccine with that of the unvaccinated. For the two ’flu seasons studied, the vaccinated also had a lower risk of hospitalisation for cardiac and cerebrovascular disease. The effect was seen in both healthy and high-risk patients. However, the researchers were unable to rule out whether some of the benefit was due to pneumococcal vaccination. N Engl J Med 2003; 348: 1322-1332 Good odds at ASCOT One of the first randomised trials of pharmacological lipid-lowering in patients with hypertension — The Anglo-Scandinavian Cardiac Outcomes Trial, Lipid Lowering Arm (ASCOT-LLA) — has been stopped well ahead of schedule. An early analysis revealed significantly fewer coronary events and strokes had occurred in those receiving active treatment, 10 mg atorvastatin, compared with those taking placebo. The 10 305 patients were at fairly high risk: although their baseline total cholesterol was less than 6.5 mmol/L, they had at least three cardiovascular risk factors other than their well-controlled hypertension.1 However, an accompanying commentary pointed out that the benefit, in absolute terms, was modest.2 1. Lancet 2003; 361: 1149-1158 2. Lancet 2003; 361: 1144-1145 The hole story Body piercing has been with man for centuries — for example, according to a review in The Lancet, Mayan royalty pierced their tongues and genitals as part of religious bloodletting rituals as early as 700 AD. In our time, the practice of body piercing at all sorts of sites, including the mouth and tongue, genitalia and even the armpit, is on the rise in many Western societies, including Australia, and medical practitioners are seeing related side effects and complications. Local bacterial skin infection and bleeding are more usual; tetanus, leprosy, tuberculosis and endocarditis, as well as possible interference with resuscitation in emergency situations, have also been reported. Lancet 2003; 361: 1205-1215 Pill fears A WHO-commissioned systematic review of published evidence has reported that the risk of cervical cancer increases with increasing duration of use of hormonal contraceptives. Findings were similar when adjusted for human papillomavirus infection states. The risk might decline after cessation of use, but the available data relating to this possibility are currently limited. Lancet 2003; 361: 1159-1167 Pap smears Conventional Pap smears are more reliable and less likely to give false positive and false negative results than monolayer cervical cytology for low-and high-grade lesions, according to the French Society of Clinical Cytology Study Group. In each of 2585 women, they took a conventional smear and used the remaining material to prepare a monolayer slide (n = 2585) and, when sufficient, went on to papillomavirus testing (n = 1785). A reference method was used for comparison: colposcopy, followed by biopsy if abnormalities were detected. BMJ 2003; 326: 733-737 Catching cockroaches Cockroaches may play a role in hospital-acquired infections, say Taiwanese researchers. They set traps to catch cockroaches in clinical and other areas, including drug stores and kitchens, in 90 hospitals. They also set traps in 40 households. In the total catch of 203 cockroaches from 42 of the hospitals, six non-tuberculous mycobacteria were identified in 12 of 139 American cockroaches (Periplaneta americana). No mycobacteria were isolated in the 64 German cockroaches (Blattella germanica) caught in hospitals. No mycobacteria were isolated from 226 cockroaches of either species caught in half of the households. J Hosp Infect 2003; 53: 224-228 SARS unmasked Case series covering the first 10 patients with severe acute respiratory syndrome (SARS) in Hong Kong and in Canada have been published on The New England Journal of Medicine website. All of the Canadian patients who either required intubation or died had underlying medical illnesses, such as type 2 diabetes, or were older than 55 years of age. Smoking may also be a risk factor for more severe SARS, the Canadian report said. At time of posting, the microbiological origins of SARS were unclear, although a novel coronavirus and a human metapneumovirus had been isolated from some of the cases. http://nejm.org/earlyrelease/sars.asp [accessed 4 Apr 2003]

Med J Aust 2003; 178 (9 Suppl).