Volume 179 Issue 3

The 2002 MJA/Wyeth Award went to "Sharing the true stories: improving communication between Aboriginal patients and healthcare workers", which was published in the 20 May 2002 issue of The Medical Journal of Australia. At the recent AMA National Conference, Dr Alan Cass accepted the Award's commemorative plaque from Dr Kerryn Phelps, AMA President, and a cheque for $10 000 from Ms Erica Mann, Managing Director of Wyeth Australia. Dr Cass and his coauthors, Anne Lowell, Michael Christie, Paul L Snelling, Melinda Flack, Betty Marrnganyin and Isaac Brown, are from the Cooperative Research Centre for Aboriginal and Tropical Health, Darwin. The award was for their research into factors limiting the effectiveness of health communication between Aboriginal patients and healthcare workers. Despite the ever increasing influence of science and technology in medicine, what has remained unchanged from antiquity is the patient–doctor consultation. At its centre is effective communication, which is influenced by language, context, and culture, and no more so than in the interaction between Indigenous people and their healthcare workers. As noted by Ms Mann: "Australian Indigenous culture encompasses a vast tapestry of experiences, language and mythology that both enriches our lives and presents considerable hurdles in communication about healthcare from a traditional non-Indigenous medical perspective". Cass and his fellow researchers set out to determine barriers that may impede this culturally laden communication, using qualitative research, which included videotaped interactions. Their research showed that, in Aboriginal healthcare, full understanding in the clinical context was rarely achieved. Barriers included lack of control by Aboriginal patients over the timing, content, and circumstances of the predominantly biomedical interactions; cultural and linguistic divides; limited use of interpreters; and lack of training opportunities in cross-cultural communications. Commenting on the research, Ms Mann said: "There is a great and continuing need for research like this, if improvements in Aboriginal health are to be sustained and [Aboriginal Australians] are to approach the quality of life enjoyed by non-Indigenous Australians". Left to right: Dr Anne Lowell, Ms Betty Marrnganyin, Dr Martin Van Der Weyden, Dr Alan Cass, Ms Erica Mann, Dr Kerryn Phelps

Australia is lagging behind other developed countries in efforts to control chlamydial infection Australian politicians are concerned about the falling fertility rate and are debating measures, such as cash incentives and paid maternity leave, to reverse the “baby bust”.1 If enacted, these measures are expected to cost several hundred million dollars per year — perhaps several thousand dollars per extra baby. Yet, Australia is at high risk of — if not already undergoing — a silent epidemic of preventable infertility and foetal loss through ectopic pregnancy caused by Chlamydia trachomatis infection. This condition can be detected by a $24 test and effectively treated with a single dose of antibiotics. Some commonly held assumptions about chlamydial infection in men need to be addressed. Chlamydial notifications have increased fourfold over the past decade (Box). However, as most infections are asymptomatic, the 26 000 cases reported in 2002 probably represent only a fraction of the true incidence and prevalence.2-4 This trend may be partly due to a reporting artefact or greater numbers or sensitivity of tests.5 Yet, if these factors were the complete explanation, the graph of notifications should have plateaued long ago. The passage of time and enhanced surveillance data6,7 indicate that most of the increase is real. The proposed National Sexual Health Strategy was shelved before the last federal election, and state-initiated Chlamydia programs designed to enhance case-finding through selective testing by general practitioners (and, therefore, Medicare) were discouraged. Australia is overdue to follow the lead of other developed nations by getting serious about controlling chlamydial infection.8 Because infected women are usually asymptomatic, and because they incur the bulk of the serious morbidity, Chlamydia programs have traditionally focused on screening women.9 Selective testing criteria for women include combinations of age under 25 years, reported change of sexual partner, non-use of condoms, unintended pregnancy, and an inflammatory Pap smear result. However, this testing is only secondary prevention — some women identified in this way will already have silent damage to their fallopian tubes and their fertility. True primary prevention mandates that women never acquire chlamydial infection. As there is no vaccine, this means avoiding infection either by behavioural means (use of condoms, non-penetrative sexual practices or sexual abstinence) or by having male partners who are not infected. In this light, some commonly held assumptions about chlamydial infection in men need to be addressed. The first is that men are less likely to be infected than women. Recent population-based surveys in Scandinavia, the United Kingdom and the United States have consistently shown similar chlamydial prevalences among heterosexual men and women.3,4,10 Higher notification rates for women (Box) probably reflect more testing of women than men.7,11,12 Longer duration of infection in women could also be part of the explanation, although how long untreated chlamydial infection can persist in either sex remains uncertain.13 Another apocryphal belief is that the bulk of men with chlamydial infection present for treatment, driven by genital symptoms.9 However, studies in the community have revealed that most men with urethral chlamydial infection, like women, are symptom-free3,4,10 — perhaps as many as three-quarters10 — and that asymptomatic men are less likely than asymptomatic women to present for testing.10 Although there are few data on the duration of chlamydial infection in men,13 it may be months or years. A better understanding of the duration of infection would enhance our ability to model potential interventions. Sweden has a long and much-acclaimed history of screening women for chlamydial infection. This has reduced the prevalence of chlamydial infection and the incidences of both pelvic inflammatory disease and ectopic pregnancy. However, these successes have begun to reverse recently, with the suggestion that Sweden’s failure to test men is a significant reason.8 Since the advent of urine tests for chlamydia, screening men has become feasible and potentially cost effective (using US parameters).12 Without this screening, the success possible with interventions aimed exclusively at women may be limited.8 To determine whether screening of men is justified, more population-based research is required on chlamydial infection in Australian men. The prevalence of infection in different subpopulations would help determine where future screening initiatives are most needed and provide a baseline for evaluating control measures. Factors associated with infection should be identified and assessed as criteria for selective screening. Studies on the natural history of infection and the cost-effectiveness of interventions would also be of global interest. While definitive screening guidelines cannot be promulgated without such data, clinicians could be remiss if a urine test for C. trachomatis was not part of the routine assessment of a young man who reports unprotected sex with a new sexual partner (female or male), regardless of symptoms. More generally, we should be asking what other factors are contributing to the re-emergence of chlamydial and other sexually transmissible infections in Australia. We also need to debate whether single-sex health models can sometimes ultimately harm women. Most women live in an environment that is also populated by men. Chlamydia trachomatis notifications in Australia Source: National Centre in HIV Epidemiology and Clinical Research (http://www.med.unsw.edu.au/nchecr/)

Marcus Y Chen MRCP, DTM · Basil Donovan MD, FACSHP

Given the controversy over this strategy, Australia should be involved in its evaluation Lung cancer is the leading cause of cancer death in Australia and has a dismal prognosis, with 7800 new cases and 6800 deaths each year, and a 5-year post-diagnosis survival of only 12%. New cases increasingly occur in ex-smokers.1 Helical computed tomography (CT) is a fast and sensitive screening technique that can detect early-stage lung tumours, potentially increasing the proportion of patients who can be offered curative treatment. Newer scanners can perform studies with lower radiation exposure. However, use of this technique is controversial; the studies suggest that it has benefits that are uncontrolled, with no concurrent or randomised comparison group. Proponents of helical CT screening argue that its high sensitivity and the early results of studies showing that it detects small, early stage and operable cancers demonstrate its clear benefits.2,3 In the Early Lung Cancer Action Project in the United States, 1000 asymptomatic smokers or former smokers aged over 60 were screened with low-dose helical CT and conventional chest x-rays; 23% had non-calcified pulmonary nodules detected by CT, while only 7% had abnormalities detected by chest x-ray. Of those with nodules on CT, 12% were eventually diagnosed with malignancy, of which 85% were stage I tumours.4,5 In contrast, only 20% of lung cancers in patients presenting in Victoria in 1995 were localised.6 Other similar uncontrolled studies in the United States, Japan, Germany and Finland showed that from 5%7 to over 50%8 of people screened have an abnormality detected. While many can be investigated with non-invasive tests and reassessment, the substantial rate of false-positive scans requiring potentially hazardous interventions is a real concern. Others argue that studies with no control group are open to severe biases and give misleading results.9,10 Non-randomised comparisons between screen-detected and conventionally diagnosed patients that assess outcomes such as tumour size and survival are open to selection, lead time, prevalence–duration and overdiagnosis bias, all of which tend to make the outcomes in the screened group appear more favourable.11 The experience with previous trials of screening for lung cancer, using chest x-ray and sputum cytology, shows these problems. A randomised trial in Czechoslovakia demonstrated that, in the screening group, 53% of tumours were at an early stage, 25% were operable, and 5-year survival was 23%, compared with figures of 21%, 16% and zero 5-year survival in the unscreened group.12 However, the death rate from lung cancer over the subsequent 15 years was actually higher in the screened group; this discrepancy arises from the biases noted above. A trial at the Mayo clinic in the United States showed similar results.13 A Cochrane meta-analysis of trials of lung cancer screening shows no difference in all-cause mortality (relative risk, 1.01; 95% CI, 0.94–1.08), and a higher mortality from lung cancer in the screened groups (relative risk, 1.11; 95% CI, 1.00–1.23).14 Randomised trials of helical CT screening have begun. The US National Lung Screening Trial started in 2002 and plans to recruit 50 000 high-risk subjects aged 55–74 over 2 years; in the first 6 months, 16 000 subjects have been recruited. The intervention group will be offered helical CT, and the comparison group will be offered conventional chest x-ray, each at baseline and annually for 2 years. Follow-up will continue to 2009.15,16 The trial will have power to detect a 20% reduction in mortality, and costs are estimated at US$200 million. Other smaller randomised trials are in progress. A trial with 40 000 participants has been planned in the United Kingdom, but funding has not been approved. Many non-randomised trials, most linked to the Early Lung Cancer Action Project, are in progress. In 2002, the National Cancer Control Initiative in Australia set up a working group and a wider advisory group to review the state of knowledge of helical CT screening and make recommendations about its future in Australia. Their report recommends that a coordinated analysis of Australian clinical experience with helical CT screening be undertaken, along with a study to determine the prevalence of benign nodules in Australia, which may differ from that in other countries.17 Cost–benefit studies are recommended, largely to assess what degree of mortality benefit would have to be shown by the randomised controlled trials to fulfil acceptable economic criteria for screening. The report concludes that an Australian-based randomised trial would be impractical and too expensive, but recommends that one or more Australian centres should be involved in the international randomised trials. Such involvement would need funding of around $1 million for 3–5 years; but would let us fully contribute to the essential evaluation of a challenging new approach to our leading cause of cancer deaths.

Mark Elwood MD, DSc · Donald A Campbell MD, FRACP · Margaret P De Campo FRACR, MPH

With release of the ALRC/AHEC inquiry report, we are now in a position to develop sound policies The report Essentially yours: the protection of human genetic information in Australia,1 launched in May this year, represents the first comprehensive exploration in this country of the ethical, legal and social implications of the emerging revolution in genetic science and technology. The report is the outcome of a major, two-year, public inquiry conducted by the Australian Law Reform Commission and the Australian Health Ethics Committee of the National Health and Medical Research Council (NHMRC). Although the central themes of the inquiry were ethical standards, privacy protection and protection against unlawful discrimination, the final report examines the impact of the “new genetics” across a very wide range of social and professional contexts — accounting for the “super-sized” 1200-page document, presented in two volumes and containing 144 recommendations for reform. The inquiry covered obvious issues such as the ethical oversight of genetic research and the increasing use of DNA collection and testing by law enforcement authorities. Other questions considered by the inquiry included: the regulation of genetic testing in the workplace; the collection and use of genetic information by the insurance industry; genetic testing by immigration authorities; DNA parentage testing; the use of genetic testing as an element in the construction of kinship and identity; and the use of genetic testing to identify potential sporting champions. This may sound like the stuff of science fiction, but the report documents contemporary cases and controversies in all these areas. In the course of its extensive community consultation effort, the inquiry found significant optimism in Australia about the promised benefits of genetic science for improved diagnostics and therapies. However, there is also an underlying anxiety about the rapid pace of change and the capacity of our institutions to regulate science effectively in the public interest. Thus, the centrepiece of the recommendations is the establishment of a standing Human Genetics Commission of Australia (HGCA). The role of the HGCA would be to provide independent, high-level, technical and strategic advice to Australian governments, industry and the community generally about current and emerging issues in human genetics, and to provide a consultative mechanism for the development of policy statements and national guidelines in this area. One of the threshold questions for the inquiry was whether to accept arguments in favour of “genetic exceptionalism”. This is the idea that genetic information is so fundamentally different from, and more powerful than, all other forms of personal health information that it requires different or higher levels of legal protection. In contrast, genetic “inclusivists” argue that genetic information is neither distinctive nor unique in its ability to predict an individual’s health, but indicates only a rough range of probabilities. The inquiry concluded that an exceptionalist approach would be unhelpful to the extent that it would divorce genetic information from the principles, processes and institutions that have been developed over time to provide ethical oversight of research and ensure best practice in clinical medicine. However, the inquiry accepted that genetic information has some special features and issues that necessitate a thorough inspection of existing principles, practices and safeguards, and of the legal, ethical and regulatory landscape, to ensure these are all adequate to the task. The inquiry concluded that “big law” — an omnibus genetic regulation act — is inappropriate at this time. Nevertheless, the report makes a large number of recommendations for careful fine-tuning of existing legislation in the areas of privacy, discrimination, industrial law, and occupational health and safety, to meet the challenges of the new genetics. For example, it recommends that the federal Disability Discrimination Act 1992 be amended “to clearly prohibit unlawful discrimination based on a person’s real or perceived genetic status”, and that the federal Privacy Act 1988 be amended to cover genetic samples as well as data. The report also strongly emphasises that we need not only adequate protection against the unlawful use of genetic information, but also measures to ensure that, where genetic information may be used lawfully, it will be used fairly and intelligently. As a consequence, the inquiry’s recommendations go beyond simply changing laws — they involve a broad mix of strategies and approaches, including the promulgation of ethical codes, codes of practice and official standards (eg, by the NMHRC and the Federal Privacy Commissioner); industry codes and best practice standards; community and professional education; and better coordination of governmental and intergovernmental programs. Medical practitioners are well aware of how difficult it is to keep abreast of all the implications of the genetic information explosion. The report calls for all the parties involved in medical education (initial and continuing) to work collaboratively to greatly enhance genetics education for all doctors. The report also makes plain the increasingly important role that genetic counselling will play in everyday clinical practice. For some genetic tests, counselling will be adequately provided by medical practitioners; nevertheless, the report recommends that Australian healthcare authorities give urgent priority to assessing and responding to the need for increased, adequately resourced, genetic counselling services. The inquiry recognised the powerful “familial dimension” of genetic information — that is, the extent to which an individual’s genetic information can also reveal information about, and therefore have implications for, that person’s relatives, including those in preceding and succeeding generations. This leads to a recommendation that, despite the traditional importance of confidentiality to the doctor–patient relationship, there may be exceptional circumstances in which doctors (and familial cancer registries) should be permitted to disclose confidential information to genetic relatives without the patient’s consent, if such a disclosure is necessary to lessen or prevent a serious threat to an individual’s life, health or safety. In this sensitive area, the inquiry asks that guidelines be developed to assist healthcare professionals in this task. Some other recommendations of particular interest to the scientific and medical communities are summarised in the Box. The inquiry’s findings and recommendations have been presented to the two relevant federal Ministers — the Attorney-General and the Minister for Health and Ageing — and the government is expected to respond and outline its plans for implementation soon. However, the pervasive influence of genetic science means that recommendations for change have been addressed to more than 30 bodies across the public and private sectors — many of these organisations do not need to wait for the federal government before they can take action. We have an excellent opportunity in Australia now to develop policy based on sound principle, rather than managing emerging problems on the run. The area of genetic testing and information is so personal and so sensitive that it is critical we get this right — and do so now — to avoid the crisis of confidence and the public backlash that would inevitably follow from the revelation of poor or unethical practices. Some specific recommendations of the Australian Law Reform Commission/Australian Health Ethics Committee inquiry National ethical and privacy guidelines should be developed specifically to cover the use of genetic information held in tissue banks, research databases and genetic registers (including “inchoate” databases, such as Guthrie card collections). The support and guidance given to human research ethics committees when reviewing proposals dealing with genetic issues should be significantly strengthened. Laboratories that conduct genetic tests for medical, diagnostic or treatment purposes (rather than for research purposes) should be accredited by the National Association of Testing Authorities, and accreditation requirements should be strengthened to deal more broadly with ethical standards in genetic testing, such as proof of consent. The Therapeutic Goods Administration should be empowered to more effectively regulate medical devices used in genetic testing, as well as DNA test kits provided directly to the public, whether such kits are marketed for health purposes or for identification (such as for parentage testing). Nationally consistent standards should be developed in relation to population genetic screening programs, covering such matters as informed consent, testing standards, quality assurance, cost–benefit considerations, and reporting and data collection. Employers should not be permitted to collect or use genetic information in relation to job applicants and employees, except in rare and compelling circumstances. Such circumstances might be when this is necessary to protect the health and safety of workers or third parties, and the action complies with stringent standards developed for this purpose by the HGCA and occupational health and safety authorities.

David Weisbrot BA, JD · Kerry J Breen MD, FRACP

Objectives: To provide detailed projections for the prevalence of disability and associated common health conditions for older Australians for the period 2006–2031.Design: Secondary analyses of datasets (national 1998 Survey of Disability, Ageing and Carers; and projections of Australia’s population from 2006–2031) collected by the Australian Bureau of Statistics.Outcome measures: (i) The projected number of people with differing levels of disability (core activity restrictions in self-care, mobility or communication) up to 2031; (ii) The projected number of people with the main health conditions associated with disability in 2006 and 2031.Results: Projections indicate a 70% increase in the number of older people with profound disability over the next 30 years. The main conditions associated with profound or severe core activity restriction in older Australians are musculoskeletal, nervous system, circulatory and respiratory conditions and stroke.Conclusions: In the future, there will be many more older Australians requiring assistance because of disability. This will present a challenge to families, friends, volunteers and paid service providers. The Australian planning ratio for residential aged-care services and community aged care services should be changed to take account of the shift to an older population with greater need of support.

Lynne C Giles MPH, AStat · Maria Crotty PhD, FAFRM (RACP) · Ian D Cameron PhD, FAFRM (RACP)

Objective: To measure the prevalence of untreated hypertension in Australian adults, and examine the associations with clinical and lifestyle factors.Design: AusDiab, a cross-sectional survey conducted between May 1999 and December 2000, involved participants from 42 randomly selected census districts throughout Australia.Participants: Of 20 347 eligible people aged ≥ 25 years who completed a household interview, 11 247 attended a physical examination (response rate, 55%).Main outcome measures: The prevalence of hypertension (blood pressure ≥ 140/90 mmHg or self-reported use of antihypertensive drugs) and its treatment; associations of clinical and lifestyle factors with the treatment of hypertension; and adequacy of treatment for primary and secondary prevention of cardiovascular disease.Results: The prevalence of hypertension was 28.6 per 100 (95% CI, 25.0–32.3), and the prevalence of untreated hypertension was 15.2 per 100 (95% CI, 13.2–17.2). Of those with untreated hypertension, 80.8% (95% CI, 74.7%–85.0%) had had a blood pressure check within the preceding 12 months. At least one modifiable lifestyle factor was present in 71.7% (95% CI, 68.5%–74.8%) of participants with untreated hypertension. Although lower risk clinical characteristics of younger age and lack of hyperlipidaemia were independently associated with untreated hypertension, 53.5% warranted treatment based on current cardiovascular disease prevention guidelines and multivariable absolute risk assessment.Conclusions: Considerable scope remains for reducing the burden of cardiovascular disease through lifestyle modification and rational treatment of hypertension.

Esther M Briganti MB BS, MClinEpi · John J McNeil MB BS, PhD · Jonathan E Shaw MD · Paul Z Zimmet MB BS, PhD · Steven J Chadban MB BS, PhD · Robert C Atkins MB BS, DSc · Timothy A Welborn MB BS, PhD

Objective: To determine the rate of handheld mobile telephone use among motor vehicle drivers.Design and setting: Observational study of motor vehicle drivers at three times (10:00–11:00; 14:00–15:00; 17:00–18:00) on three consecutive Fridays in October 2002 at 12 highway sites in metropolitan Melbourne.Main outcome measures: Rates of mobile phone use overall and by sex and age group, highway site (major metropolitan road, central business district, freeway exit ramp) and time of day (morning, afternoon, evening).Results: 315 of 17 023 drivers were observed using mobile phones (18.5 users/1000 drivers; 95% CI, 16.5–20.6). Men had a slightly higher rate of use (19.0; 95% CI, 16.5–21.6) than women (17.5; 95% CI, 14.1–20.9), but the difference was not significant. Older drivers (50 years or more) had a significantly lower rate (4.8; 95% CI, 2.5–7.0) than middle-aged (21.9; 95% CI, 18.8–25.1) or young drivers (23.2; 95% CI, 18.9–27.5). Central business district drivers had a slightly, but not significantly, higher rate (20.5; 95% CI, 16.8–24.3) compared with those on major metropolitan roads (16.7; 95% CI, 13.3–20.2) or freeway exit ramps (18.2; 95% CI, 14.8–21.6). The rate of mobile phone use was significantly higher in the evening (23.5; 95% CI, 19.8–27.3) compared with the morning (16.0; 95% CI, 12.6–19.4) and afternoon (15.2; 95% CI, 11.9–18.4).Conclusion: Mobile phone use is common among Melbourne metropolitan drivers despite restrictive legislation. This issue needs to be further addressed by Victoria Police and public health and education agencies. Similar research is indicated to determine the extent of mobile phone use in other states.

David McD Taylor MD, FACEM · Dianne M Bennett RN, BA · Michael Carter · Devinder Garewal

Objective: To describe the results of a program for detecting high cardiovascular risk in an urban Aboriginal community.Design: Cardiovascular risk assessment program conducted between January 1998 and October 1999. Participants completed a questionnaire and underwent a physical assessment and biochemical tests.Participants: 738 self-selected members of the Perth Aboriginal community (332 men, 406 women; age range, 18–79 years).Results: The participants represented approximately a fifth of the Perth Aboriginal population aged 25–64 years (those aged 18–24 years comprised < 5% of Aboriginals aged 15–24 years in Perth). Eighty-four per cent fell within National Heart Foundation “high risk” or “highest risk” categories for cardiovascular disease; 15% of men and 6% of women had an absolute risk of a cardiovascular event of over 15% within 10 years. A high proportion of participants reported diabetes, hypertension, smoking, overweight and obesity. A fasting plasma glucose level indicative of diabetes or impaired fasting glucose was found in 8.6% (95% CI, 6.2%–11%) of people not previously known to have diabetes. Obesity and smoking were twice as prevalent in study participants as in the general population. Less than a third of subjects with hypertension and diabetes had attained recommended target levels for blood pressure reduction or glycaemic control, and only a third of those at high risk and one in six of those at highest risk had attained recommended lipid-level targets.Conclusions: A cardiovascular risk assessment program with strong community support in an urban Aboriginal population can identify a significant number of people with high cardiovascular risk who are candidates for intensive risk-factor reduction strategies.

Peter L Thompson MD, FRACP · Pamela J Bradshaw RN, MSc · Margherita Veroni MSc · Edward T Wilkes BA

Secondary prevention Aspirin provides benefit in nearly all groups of patients with clinical manifestations of coronary heart disease. This includes patients with evolving acute myocardial infarction or after recovery from myocardial infarction, with unstable or stable angina, and those who undergo coronary artery bypass grafting or coronary angioplasty. Aspirin provides benefit in patients with peripheral arterial disease. This includes patients with acute or previous history of ischaemic stroke or transient ischaemic attack, those with lower limb arterial insufficiency, and those who undergo grafting or angioplasty of peripheral arterial vessels. Primary prevention People without symptoms but at increased risk of a coronary heart disease event (> 1% annual risk) may reduce this risk by taking low-dose aspirin. However, the decision to take aspirin requires detailed consideration of individual cardiovascular risk and the potential benefit versus harm of treatment, particularly bleeding. Aspirin should only be used to prevent a cardiovascular event in association with an overall program of lifestyle measures including healthy eating, cessation of smoking, control of blood pressure and regular physical activity. Aspirin for prevention Prevention benefits of aspirin in heart disease can be achieved with doses as low as 75–150 mg daily. Unwanted effects of aspirin include stomach upsets, activation of peptic ulcers, an increased tendency to bruising, allergic reactions and increased risk of major gastrointestinal and other bleeding, including intracranial haemorrhage. In general, the risk of bleeding increases with increasing dose of aspirin and when it is used in combination with non-steroidal anti-inflammatory drugs or oral anticoagulants.

for the Medical Issues Committee of the National Heart Foundation of Australia

The increasing rate of hepatitis C virus (HCV) infection in the community means that there is increased risk of occupational exposure for healthcare workers. In metropolitan hospitals in Victoria, we found that 80–150 healthcare workers have occupational exposures from HCV-infected patients annually. As there is a 1.8%–3% risk of transmission of HCV from a needlestick injury, two to five healthcare workers are likely to acquire HCV each year in Victoria. These needlestick injuries pose a personal, legal and professional risk to healthcare workers and their patients. Recent information shows that early antiviral treatment of acute HCV infection has high cure rates. Current local and international protocols for management of healthcare workers exposed to HCV do not address these issues. We propose a management protocol after needlestick injury that is stratified according to the likelihood of HCV acquisition and potential risk of staff-to-patient transmission, and that is consistent with the current legal and clinical context of HCV infection in Australia.

Patrick GP Charles MB BS · M Lindsay Grayson MD, FRACP, FAFPHM · Peter W Angus MD, FRACP · Joseph J Sasadeusz PhD, FRACP

The sexual health needs of teenagers differ from those of adults. Young sexually active teenagers are at high risk of Chlamydia trachomatis genital infection and its complications. Teenage pregnancy continues to be a problem in Australia. Current preventive strategies and clinical services in this domain of adolescent health in Australia are deficient. Australia can learn from the innovative and effective strategies developed in various countries for preventing high-risk sexual behaviours in teenagers.

S Rachel Skinner MB BS, PhD, FRACP · Martha Hickey MRCOG, FRANZCOG, MD

Clinical record At 03:00 on a Friday in 2002, a clinical staff member in the intensive care unit sustained a needlestick injury involving a suture needle through a glove. An unrelated cardiac arrest occurred soon after, causing a delay in reporting of the injury. At 07:00 (4 hours after the injury), the staff member (recipient) reported the injury, using the paging arrangement and occupational exposure protocol at the time (ie, a message was left for the staff health nurse, as no designated person was on-call for occupational exposures overnight). At 10:00 (7 hours), the recipient received a response to the report from the staff health nurse who initiated action in accordance with the protocol in place at the time. The source patient had a recently recorded negative HIV antibody result by enzyme-linked immunosorbent assay (ELISA). At 10:30 (7.5 hours), a further blood sample was collected from the source patient, along with a baseline blood sample from the recipient. These were processed at 12:30 (9.5 hours). At 13:00 (10 hours), the source patient’s ELISA test gave a positive result for HIV antibody. However, because of the previous negative result, this was assumed to be a false positive. On Sunday, a repeat (western blot) HIV test was performed for confirmation and was again positive for HIV antibody. On Monday at 10:00 (79 hours), the infectious diseases unit was notified of the positive HIV antibody result. At 15:00 (84 hours), the recipient was counselled by an infectious diseases physician and commenced post-exposure prophylaxis. The laboratory subsequently tested stored serum samples from the source patient; all four samples were positive for HIV antibody. Investigation of the previous negative result revealed that the test specimen was not from the source patient, but from another patient with the same surname in the same ward. This report documents a multifactorial failure of the system of reporting and responding to occupational exposures, which led to a substantial delay in instituting prophylaxis for HIV exposure. About half the percutaneous sharps injuries sustained by healthcare workers in the United States go unreported.1 At our 621-bed institution, 66 needlestick injuries were reported in 2001–2002, translating to a rate of 10.6 per 100 beds per year. As data from the US Exposure Prevention Information Network suggest that hospital healthcare workers incur about 30 needlestick injuries per 100 beds per year,2 our rate of 10.6 probably reflects significant underreporting. Increased staff confidence in the quality and confidentiality of follow-up for occupational exposures may help increase reporting.3 The average risk of HIV transmission for healthcare workers after percutaneous exposure to HIV-infected blood is about 0.3%.4 However, post-exposure prophylaxis with zidovudine has been shown in a retrospective case–control study of healthcare personnel to reduce transmission by about 81%.4 The Department of Human Services (Victoria) recommended in 1997 that post-exposure prophylaxis be initiated promptly, preferably within 1–2 hours of exposure (based on 1996 recommendations from the US Centers for Disease Control and Prevention).5 The US Department of Health and Human Services recommends that employers protect healthcare workers from needlestick injuries by providing a safe working environment with effective programs and safer needle devices, notwithstanding additional costs. This includes a combination of prevention strategies for reducing needlestick injuries, and involving workers in the effort.6 Improving response to occupational exposuresAt Southern Health, the occupational exposure protocol was under review before this incident occurred. Root-cause analysis of the incident led to the following changes to occupational exposure and pathology protocols: A uniform system of notification that was under development was implemented across all sites in the Southern Health service of Melbourne. Changes included: A dedicated pager number, operating 24 hours a day 7 days a week, was provided at each site for reporting of occupational exposures and was advertised by posters displayed prominently in clinical areas. Previously, there were different contact numbers for different times of the day, and cover was not around the clock. Occupational exposure coordinators were appointed (one per shift at each site) and attended inservice education about occupational exposure, provided by the infection control unit. Staff were informed of the new pager number and notification process through a memorandum sent to all nursing and clinical support staff and an internal flyer sent to all senior medical staff from the Chair of the Infection Control Advisory Committee for Southern Health; the latter highlighted the urgency in reporting exposures. The new notification process is described in the orientation material for new staff. The pathology department implemented a streamlined testing protocol for all specimens related to occupational exposures; these are processed urgently, and all results are reported to the occupational exposure coordinator. The pathology department also reviewed protocols for blood collection and reception; use of informal “norms” rather than strict adherence to protocol was deemed unacceptable, and inservice education and review were conducted in all areas. All high-risk exposures are discussed by the occupational exposure coordinator with the on-call infectious diseases physician to develop an action plan. Future quality assurance activities will include surveys of staff awareness of the notification process and training status of occupational exposure coordinators. Outcome of measures to improve responseTen weeks after this adverse event, 58 health service staff had been trained as occupational exposure coordinators. The senior infection control practitioner conducted nine education sessions for these coordinators, providing course notes and contact details for troubleshooting or general enquiries. An infectious diseases physician discussed issues of informed consent for testing for bloodborne viruses at each session. Initially, reports of occupational exposures increased threefold, from 1 every 48 hours before implementation of the new protocol to 3 per 48 hours after implementation. Within 4 weeks of implementation, reporting returned to the previous level. The posters displayed in clinical areas appeared to prompt reporting; some exposures occurred before implementation of the new protocol but were reported only after the posters were displayed. The time from occupational exposure to reporting of HIV results for source patients decreased from a range of 7.5–192 hours to 1.1–23 hours (including any delay in reporting by healthcare workers, as well as laboratory processing time). This report demonstrates the importance of effective mechanisms for reporting exposures, accurate specimen labelling, urgent processing of pathology tests and accurate reporting of results with appropriate follow-up, in achieving timely and appropriate action after an occupational exposure. Recognition of the system failure in this incident led to a system change at our institution designed to minimise future incidents and improve quality of care. The education and reporting systems have been revised to be efficient and robust and to achieve long-term effectiveness in reducing morbidity from occupational exposure. Lessons from practice The system for staff to report an occupational exposure needs to be simple and available 24 hours per day, 7 days per week. Testing after an occupational exposure needs to be prioritised and processed urgently to ensure results are available as soon as possible. High-risk exposures need to be discussed with the on-call infectious diseases physician to develop an action plan. All serum should be collected with strict adherence to blood collection and labelling protocols. Serum from the source patient should be collected and tested at the time of the incident to confirm HIV status, even if a recent negative result is known.

Elizabeth E Cooper BN, MPubHlth(Melb) · Stephen L Blamey FACS FRACS

One of the most exciting possibilities in human therapeutics is that stem cells (embryonic or adult) may compensate for cell loss in disease, with functional recovery. This has received considerable publicity in the lay press. Much work remains to be done to turn stem cell therapy into a practical reality for major degenerative diseases, especially those affecting the nervous system. Medical scientists and journalists should work together in ensuring that the general public has a realistic understanding of the likely time frame in which benefits from stem cell therapies will be realised.

Edward Byrne MD, DSc · David W Howells PhD

Three young men aged between 19 and 30 years presented at different times with lumps over the deltoid area at the site of Q fever vaccination (Q-Vax, CSL), which had been administered 3–8 months previously. Mandatory pre-vaccination testing had shown that all three subjects were non-immune. Clinically, the lumps (of which two were tender) were considered to be either subcutaneous abscesses or lipomata. Sarcoidosis was excluded clinically and biochemically. The lesions were excised and were macroscopically similar, being 20–47 mm in size and resembling indurated fat. Histologically, the appearances were of sarcoidal granulomatous panniculitis (Box). No aetiology for the granulomata was identified. DiscussionQ fever, a serious zoonosis caused by a rickettsial organism, Coxiella burnetii, is spread to humans by body fluids of infected animals (principally cattle, sheep or goats). A vaccine, Q-Vax, produced by Commonwealth Serum Laboratories, is composed of a killed suspension of virulent phase 1 organisms. The vaccine, limited to Australia, was shown to be effective in trials between 1981 and 1994, and a national vaccination program, aimed at high-risk groups, commenced in 2001. The cases we describe here are examples of a rare idiosyncratic reaction to the vaccine (probably the result of enhanced delayed hypersensitivity) that may be confused with subcutaneous sarcoidosis. This has not, to our knowledge, been previously reported. Histological section of one of the lesions Non-caseating epithelioid cell granulomata (arrows), surrounded by a dense lymphocytic reaction. Immunostaining disclosed that more than 80% of lymphocytes were T cells and less than 20% were B cells, mainly arranged as follicular aggregates (H & E stain; size reduced by half from x100).

Alan E Mills MB ChB FRCPA · Vince Murdolo MB BS FRCPA · Stephen P Webb MB ChB

The “new genetics” will require specialist physicians to deal with an increasing number of genetic issues. Huntington disease (HD) is a rare single gene adult-onset fatal neurodegenerative disorder. It provides a model to illustrate the role of the specialist physician in the new genetics. DNA testing options in HD include diagnostic DNA tests to confirm a provisional diagnosis, and predictive or presymptomatic DNA tests to determine whether disease will develop in an at-risk individual. The specialist physician is well positioned to interact with the genetics services by providing in-depth knowledge of the clinical implications. This will become particularly relevant as the more complex multifactorial disorders (eg, Alzheimer disease) are understood at the DNA level. For optimal use of the new genetics, a team approach is essential to ensure that all areas of expertise are covered.

Elizabeth A McCusker MB BS(Hons), FRACP

Patricia A Figgis,* Allan R Glanville,† John L Harkness‡ * Thoracic Registrar (currently, Senior Registrar, General Intensive Care, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW, 2050); † Head of Thoracic Medicine, ‡ Director of Microbiology, St Vincent's Hospital, Darlinghurst, NSW. patriciafiggisAThotmail.com To the Editor: A previously well 57-year-old man presented to the emergency department with a 3-day history of severe dyspnoea. Six weeks earlier he had noticed coryzal symptoms with subsequent lethargy, reduced appetite with weight loss, and a non-productive cough. He then developed ankle swelling and increasing abdominal girth. He had a background of excessive alcohol consumption, but had abstained for 10 years. On examination, he was febrile and in respiratory distress, with a respiratory rate of 35 per minute, pulse rate of 130 bpm, and blood pressure of 130/85 mmHg. Chest auscultation revealed bilateral diffuse coarse crackles. The chest x-ray is shown in Box 1, and results of additional investigations in Box 2. Despite treatment with broad-spectrum antibiotics (intravenous ceftriaxone, dicloxacillin and erythromycin), the patient’s condition deteriorated rapidly, and he required intubation within 24 hours of presentation. Trap sputa contained abundant thin, partially acid-fast, beaded, branching filaments, suggesting Nocardia asteroides, which was later confirmed on culture using conventional biochemical testing. Several blood cultures taken on admission also grew N. asteroides. All cultures for mycobacteria were negative. The patient was treated with intravenous trimethoprim–sulfamethoxazole for a total of 5 weeks and oral minocycline for 14 weeks. He spent 6 weeks in hospital. Liver biopsy, performed because of persistently abnormal hepatic function at follow-up 8 weeks after hospital discharge, showed central fibrosis and non-caseating granulomatous hepatitis (Box 3). The patientn received no further treatment and remained well 18 months later, with almost normal hepatic function and a clear chest x-ray. Nocardia bacteraemia is rare, although the incidence appears to be increasing in the immunosuppressed. Nocardia spp. are seldom isolated in blood cultures, with one study finding that blood was the source of only 8% of all Nocardia isolates.1 Up to 30% of patients with Nocardia bacteraemia have coexistent infection with gram-negative bacteria.1,2 There has been one previous report of Nocardia pneumonia associated with positive blood cultures and liver disease. However, this patient had documented end-stage chronic liver disease at presentation, was taking prednisolone, and developed nocardiosis after prolonged hospitalisation with gram-negative sepsis.1 Granulomatous reactions are well described in Nocardia infection. Although granulomatous hepatitis is also described in sarcoidosis, it is rare and usually presents with itch and obstructive abnormalities of liver function.4 In our patient, acute N. asteroides infection was the most likely cause of both the pulmonary infiltrate and the granulomatous hepatitis. Not only were results of modified acid-fast stains consistent with Nocardia spp., but cultures from multiple trap sputa and blood specimens also grew N. asteroides, suggesting a large load of this organism. No other organisms were isolated despite prolonged incubation of cultures, and the patient recovered after specific treatment directed at Nocardia spp. Furthermore, he remained well with no further treatment at 18-month follow-up, with near-normal hepatic function and no new abnormalities. We conclude that N. asteroides infection can present as a fulminant community-acquired pneumonia with bacteraemia in the absence of immunosuppression or coexistent infection. Our case illustrates the potential hepatic sequelae of Nocardia bacteraemia. 1: Chest x-ray of a patient with Nocardia asteroides pneumonia Chest x-ray taken on admission to hospital, showing widespread non-symmetrical interstitial and airspace infiltrates. 2: Results of investigations Result Reference range At presentation Arterial blood gases* pH 7.37 7.35 –7.45 pCO2 (mmHg) 43 35 – 45 pO2 (mmHg) 60 75 –105 Bicarbonate (mmol/L) 24 24 – 31 Base excess 0 − 3 to 3 White cell count Total (x 109/L) 31.5† 4 –11 Neutrophils (x 109/L) 30.2 2 – 7.5 Lymphocytes (x 109/L) 0.7 2 – 4 Follow-up at 8 weeks Liver function tests‡ Bilirubin (μmol/L) 9 < 18 Alkaline phosphatase (U/L) 124 30 –100 γ-Glutamyl transferase (U/L) 153 < 35 Iron studies Serum ferritin (μg/L) 446 30 – 400 Serum iron (μmol/L) < 3 10 – 30 Transferrin (g/L) 1.9 2.0 – 3.5 Transferrin saturation < 6% 15%–50% Vitamin B12 (pmol/L) 376 > 126 Immunological tests HIV antibodies Negative Hepatitis B and C§ Negative Autoantibody screen¶ Negative Complement C3 (g/L) 1.07 0.82 –1.45 Complement C4 (g/L) 0.25 0.15–0.45 * Breathing 10 L/min oxygen. † Occasional myelocytes, toxic granulation. ‡ Levels of alanine and aspartate aminotransferase were in the reference range. § Including hepatitis B surface antigen and hepatitis C antibody. ¶ Including antinuclear, extractable nuclear antigen, double-stranded DNA and antineutrophil cytoplasmic antibodies. 3: Liver biopsy in a patient with Nocardia asteroides pneumonia Core biopsy of liver, showing a granuloma within the central portal triad (arrow); the portal ducts are expanded and fibrosed with a patchy lymphocytic infiltrate (original magnification x 40; haematoxylin and eosin stain).

Patricia A Figgis · Allan R Glanville · John L Harkness

Sam L S Yuen,* Bruce McGarity† * Medical Registrar, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050; † Physician, Bathurst Base Hospital, Bathurst, NSW. lsyuen_98ATyahoo.com To the Editor: A 71-year-old man was admitted to hospital in 2002 with nausea, abdominal discomfort and myalgia. He was dehydrated and had mild right upper quadrant tenderness. No muscle tenderness was noted. Five weeks previously, an infected right femoropopliteal gortex graft had been surgically removed. Methicillin-resistant Staphylococcus aureus was present on culture. Therapy with fusidic acid (250 mg three times daily) and rifampicin (600 mg daily) had been commenced, and the patient’s condition improved. Fusidic acid therapy was continued because of unsatisfactory wound healing. On presentation he had been taking fusidic acid for 4 weeks. He had been taking simvastatin (40 mg nightly) for 8 years. The patient had a history of generalised vascular disease and multiple bypass procedures. He had a background of paroxysmal atrial fibrillation, myocardial infarction, left ventricular failure, hypertension, hypercholesterolaemia and chronic airways limitation. His other medications were metoprolol, irbesartan, frusemide, warfarin, paracetamol and narcotic analgesics. Test results showed the following biochemical concentrations: aspartate transaminase, 1618 U/L (normal range, < 40 U/L); alanine transaminase 657 U/L (normal range [NR], < 35 U/L); alkaline phosphatase 133 U/L (NR, 25–100 U/L); total bilirubin, 29 μmol/L (NR, < 20 μmol/L); γ-glutamyltransferase, 37 U/L (NR, < 50 U/L); urea, 24.7 mmol/L (NR, 3.0–8.0 mmol/L); creatinine, 0.35 mmol/L (compared with previous creatinine concentration of 0.11 mmol/L [NR, 0.06–0.12 mmol/L]). Drug hepatitis, secondary to fusidic acid was suspected, and therapy with this drug was ceased. The following day, the patient’s clinical status declined, with generalised muscle pains and weakness, significantly impairing his mobility. The serum creatine kinase concentration was elevated at 66 710 U/L (normal range, 60–220 U/L), with a normal troponin I concentration. Myoglobinuria (567 200 ng/mL) was detected. Simvastatin therapy was ceased, and there was prompt clinical improvement, with recovery of renal function and a gradual fall in the concentration of serum creatine kinase. On discharge 14 days after admission, his serum creatine kinase concentration was 1153 U/L and creatinine concentration was 0.12 mmol/L. Transaminase concentration readings fell rapidly in line with the creatine kinase concentration, suggesting they were of muscular rather than hepatic origin. Three other cases of rhabdomyolysis have been reported as a result of interaction between an HMG CoA-reductase inhibitor and fusidic acid,1-3 but there have been no previous reports from Australia. Fusidic acid, like simvastatin, undergoes extensive first-pass metabolism in the liver (over 98%). Simvastatin is metabolised via the cytochrome P3A4 enzyme system. It is known that, if given concomitantly with inhibitors of this system (eg, macrolides and azole derivatives), statin concentrations can become elevated and lead to an increased likelihood of adverse effects.4 Fusidic acid is not known to be an inhibitor of this system (Peter Hobbs, Manager of Medical Affairs, CSL Limited [manufacturers of fucidin], personal communication), although our case is suggestive of such an interaction. This case demonstrates the interaction of fusidic acid with simvastatin resulting in rhabdomyolysis. The extensive use of statin therapy in patients with vascular disease makes it important for doctors to be aware of this interaction when prescribing fusidic acid.

Sam L S Yuen · Bruce McGarity

Andrew G Marsden Occupational Physician, Unit 6, 125 Melville Parade, Como, WA 6152. To the Editor: Modern air travel lends itself to aerosol transmission of viral infection. Infected individuals in modern aircraft represent a significant risk for other travellers during long journeys. In September 1999, a person with an influenza-like illness joined other workers returning by aircraft to an isolated mine in north-western Australia. He was identified as unwell by a mine supervisor in the airport lounge but was allowed to board the BAe 146 aircraft (a 75-seat passenger jet aircraft). The flight lasted 3 hours 20 minutes. On landing in the evening, most workers were transported to their quarters in a 10-minute bus trip, but some, including the affected worker, travelled independently. They then went to their individual rooms. The next day, the affected worker reported sick immediately on going to his work site and did not work for 4 days. The other workers undertook 12-hour shifts operating machinery or in offices, relatively isolated from other people. However, they may have mixed socially. Over the next 3–4 days, 15 other workers presented with an acute influenza-like illness, with fever, cough, nasal congestion, anorexia and prostration. No serological tests were undertaken because of the remoteness of the mine. All other workers on the flight were contacted by telephone 6 days after the flight. Five more were identified who had significant upper respiratory tract symptoms and were taking simple analgesics, but had continued to work. The airline reported that no staff from the aircraft had reported sick over the next week or so. The seating positions of the affected workers on the aircraft, which was full, are shown in the Box. The index patient sat in seat 11G. Most of the other affected workers appeared to sit in a “plume” around him. The only affected workers who sat further away were the supervisor who assessed the index patient in the airport lounge (seat 3A) and a person who conducted a raffle during the flight and walked the length of the aircraft collecting money and ticket stubs (seat 1F). In aircraft such as the BAe 146, air is circulated and filtered, entering the passenger compartment through continuous vents just beneath the overhead lockers, circulating downwards and exiting from continuous vents under the seats. Air therefore tends to flow in two contrarotating circles, from ceiling to floor on either side of the aircraft. Infection could well have been transmitted by aerosol droplets to passengers behind the index patient, as he coughed and sneezed throughout the flight. The immunisation status of the passengers was not recorded; most were aged 20–45 years. This outbreak was relatively confined, as the passengers were in an isolated community, and those affected were managed in their rooms. However, the implications for the spread of airborne infection in passenger aircraft and into the wider community are obvious. It must be stressed to the travelling public that people with this type of illness should not fly. Airport authorities at passenger check-ins should be encouraged to identify and formally assess potentially infected individuals, and should have the authority to take precautions against spread. Aircraft seat allocations of index patient and affected passengers I = index patient. F = passenger developed influenza-like illness. M = passenger developed mild upper respiratory tract illness.

Andrew G Marsden

John M Weiner Allergist, Department of Respiratory Medicine, St Vincent’s Hospital, Fitzroy, VIC 3065. jmweinerATallergynet.com.au To the Editor: Any doubts that many Australian doctors are prescribing inhaled fluticasone for asthma at inappropriately high doses are dispelled by the three reports in the 3 March issue of the Journal.1-3 Fluticasone has a flat dose–response curve for efficacy and a steep dose–response curve for adverse effects;1 individuals with asthma are receiving high doses of inhaled fluticasone;2 and there is a potential for the effects to be lethal.3 Each of these reports restricted its advice to negative recommendations about drug treatment (DON’T overtreat, BACK-titrate), but this is the right time to also promote positive recommendations about asthma management. All individuals with persistent asthma requiring daily therapy should have either skin testing or in-vitro testing to determine the presence of specific IgE antibodies to inhalant allergens.4 This might allow the option of allergen avoidance. In some studies, dust mite reduction was found to ameliorate asthma symptoms in sensitised individuals (National Health and Medical Research Council Level II evidence), although those findings are not supported by a meta-analysis. Repeated low-dose exposure to cat allergen in cat-allergic individuals with asthma leads to increased non-specific bronchial hyperreactivity (Level II evidence).5 Allergen desensitisation in carefully selected cases with consultant supervision can lead to a significant reduction in medication requirement, and reduced specific bronchial hyperreactivity (Level I evidence).6 Treatment of concomitant rhinitis can itself lead to easier asthma control. A checklist of the “A,B,C...” of asthma triggers does not take long and often yields useful tertiary prevention strategies: Allergy (seasonality, dust, pets), Bronchial infection, Cold air/exercise, Drugs, Emotion/stress, Food and food additives, Gastro-oesophageal reflux, Hormones and pregnancy, Irritants including cigarette smoke, and the Job. Inhaled anti-inflammatory treatment using cromolyns or corticosteroids, with or without consideration of oral montelukast, remains the cornerstone of asthma control when the disease is frequent or persistent. However, the search for allergic and other triggers by healthcare workers, individuals with asthma, and their carers can instil into the entire group a culture of prevention, which naturally leads to a brake on overtreatment. Such a culture is firmly entrenched in continental Europe and the United States. In Australia, there has been outstanding research into the epidemiology and immunology of asthma, but it’s at the coalface where the individual with asthma gets advice. A diligent search for triggers, with appropriate management, should start at the first consultation, as the pen (or mouse) is poised to prescribe.

John M Weiner

Jill S Butty Quality Facilitator, Werribee Mercy Hospital, 300 Princes Highway, Werribee, VIC 3030 jbuttyATmercy.com.au To the Editor: It was refreshing to see the report by South et al, describing a simple, inexpensive intervention which resulted in a positive effect on the appropriate prescribing of antibiotics and a cost saving for the organisation.1 In the current climate, it has been much more fashionable to suggest computerised prescribing as the cure-all for medication and prescribing errors. As demonstrated by Newby et al,2 computerised prescribing has inherent problems, including an increase in repeat ordering of antibiotics. The Australian Council for Safety and Quality in Healthcare suggests computerised prescribing as one of several strategies to reduce medication critical incidents.3 However, the costs of establishing such a system in smaller hospitals and community health centres can prove prohibitive. This can lead to an attitude of “too expensive” so do nothing. Other strategies and interventions can be introduced at minimal cost to the organisation and yet prove effective in reducing both inappropriate prescribing and the number of critical incidents or errors. The provision of easily accessible standardised protocols and guidelines, the review of medication charts and their ease of use, changing the times of daily medication administration to maximise access to clinicians, and empowering patients to be more aware and responsible for their medications are just a few. In summary, other strategies need to be developed and their success or failure reported. There should also be awareness that familiarity with procedures can lead to errors and reinforcement is required for all interventions. Computerised prescribing should not be viewed as the solution to all medication adverse events, but one of several strategies that healthcare organisations can use in their battle with medication errors.

Jill S Butty · Saji S Damodaran

Saji S Damodaran Associate Professor, Department of Psychological Medicine, Monash University, and Clinical Director, Monash Medical Centre, 246 Clayton Road, Clayton, VIC 3168 saji.damodaranATmed.monash.edu.au To the Editor: Australia has a high rate of antibiotic use. Increasing antibiotic resistance, spiralling pharmaceutical cost, need for evidence-based practice, public awareness, and widespread variation in prescribing practice, which may lead to quality and safety issues, are reported as the drivers for improving antibiotic use and prescribing. South et al are to be commended for the introduction of a laminated card for doctors as a simple intervention to improve prescribing practices.1 Despite the passive nature of the intervention, they found significant improvement in the appropriateness of prescribing. The authors acknowledge that they are not claiming that their intervention “is the cause or only cause” for change in practice. Areas like antibiotic prescribing and physician behaviour are highly complex and require a series of systematic approaches. Doctors are only one of the multiple stakeholders involved in this process. The level of experience, training background, and awareness of the public health and clinical implications of such interventions vary widely among doctors. Improvement of South et al’s methodology from a passive mailout to gathering systematic baseline information about the medical staff involved, clarifying the purpose of the initiative and finding the proportions of uptake among junior and senior staff would have made the intervention more robust. One of the fundamentals of any change process is to instil a sense of urgency and develop a coalition to drive and lead it. Development and evaluation of quality initiatives need more than just passive information provision. It has been suggested that any such quality and safety initiative should have set priorities, and these priorities should be developed using a systematic evaluation process with explicit criteria.2 Various systemic strategies that involved systematic methodology and evaluation processes, such as antibiotic decision support systems (both computer and manual) and drug utilisation reviews, reported sustainable changes in prescribing practices.3 The intervention by South et al is a welcome initiative, but it is important to realise that simplifying a complex problem like drug prescribing may lead to setting up wrong priorities for action and trivialise the problem and solution. Such initiatives will suffer the fate of the many quality programs that we hear about in hospital corridors but which fail to make a sustainable change.

Stephen C Due Editor, AMPI, Geelong Hospital Library PO Box 281, Geelong, VIC dueATbarwonhealth.org.au Readers interested in medical history may like to know about the Australian Medical Pioneers Index (AMPI), which is the first major Australian medical history website, and the first published encyclopaedia of Australian medical biography. AMPI aims to provide basic personal and professional information on every doctor resident in Australia, or professionally connected with Australia, up to the year 1875. This includes medical officers on immigrant and convict ships, doctors who practised in Australia, and doctors who pursued other occupations here. Over 3000 pioneer doctors are listed. In addition to biographical data, the website provides interesting material on the medical profession in colonial times, including a picture gallery containing rare images of pioneer medical life (Box). There is also a section on sources of information about early doctors. The original compiler of AMPI was Dr David Richards (1937–1998) of Nottingham, England, whose card file was computerised at the Geelong Hospital Library. The website was developed in conjunction with the State Library of Victoria as a community service. Anyone with additional data about a particular doctor is encouraged to contribute to the project. Colonial medical transport. Dr S R Robinson adopted this modern mode of transport when most of his colleagues still kept horses and buggies. (Geelong Heritage Centre — reproduced with permission.)

Stephen C Due

Mai Maddisson General Practitioner, Mitcham North Clinic, 188 Mitcham Road, Mitcham, VIC 3132. mmaddisson.nmcATwdgp.com.au To the Editor: I read with interest McFarlane’s article on post-traumatic stress disorder and debriefing,1 which reminded me of a long-term patient. Over a decade ago, I discovered that this patient was a Vietnam veteran, and expressed concern that he had not told me previously. His reply came thus (although, of course, I no longer remember the exact words): “How would you know what it feels like to be, by sheer chance, the only man left alive in a group of soldiers?” I acknowledged that he was correct, that I had no idea. With that poignant remark in mind, I planned his care. He is doing OK. Can we really address an abstraction that we cannot conceptualise, or predict the resulting obstacles in a person’s journey through life? This is equally valid at the beginning of the journey or anywhere along its course. Perhaps the notion of debriefing at an appropriate time is not the problem; perhaps it is the formula we use.

Mai Maddisson

Wanted, dead or alive Organ and tissue donors should receive tax breaks for their donation, just as other people can claim donations to charities in their tax returns; and, we should have an ethical market in human organs from living donors. Everyone else involved in transplantation gains significantly - why shouldn't the donors? These are two of many controversial ideas put forward in an issue of the Journal of Medical Ethics devoted to addressing the supply of organs for transplantation from both living donors and cadavers. Other opinions up for debate are that no one should have the right to say what should be done to his or her body after death, and that the state should hold responsibility for human cadavers and determine their best disposition. J Med Ethics 2003; 29: 125-202 Vitamin advice Can vitamin supplementation prevent cancer and cardiovascular disease in patients with no known or potential nutritional deficiency? The US Preventive Services Task Force has reviewed the literature. Its clinical guidelines conclude that the available evidence is insufficient to recommend either for or against supplements of vitamins A, C or E, multivitamins with folic acid, or anti-oxidant combinations.1,2 However, the Task Force did advise against the use of β-carotene supplementation for this purpose, because of a known link to a higher incidence of lung cancer and all-cause mortality in heavy smokers. 1. Ann Intern Med 2003; 139: 51-55 2. Ann Intern Med 2003; 139: 56-70 Clinical skills protest For nearly 40 years, US medical students haven't had to perform one-on-one bedside examinations as part of their Medical Licensing Exam -- they "got off" because of concerns about inconsistencies across the multitudes of testing sites and among different examiners, says a report in Texas Medicine. Now, considering that a doctor's ability to translate knowledge into practice is critical, a new Clinical Skills Examination has been proposed and trialled in the USA. It's a one-day affair in which each medical student is asked to examine 10 to 12 "standardised" patients (actors who have been extensively trained to ensure they will present to each medical student in exactly the same way) for about 15 minutes each. The cases cover common conditions that doctors are likely to encounter in a general ambulatory clinic. The report said US medical students are opposing plans to introduce the new test because of the additional financial burden to them and a lack of evidence as to the new test's validity. Tex Med 2003; 99(2): 26-29 No need for adrenaline An Australian study has overturned the popular notion that treating bronchiolitis with nebulised adrenaline will shorten hospital stay, say North American editorialists.1 They were commenting on a randomised placebo-controlled trial of 194 infants admitted to Queensland hospitals with bronchiolitis.2 Three 4 mL doses of 1% nebulised adrenaline given at 4-hourly intervals after admission did not significantly reduce length of hospital stay or the time to being ready for discharge, and did not alter respiratory rate or respiratory effort scores. The editorialists said that perhaps doctors must recognise that no known treatment of bronchiolitis will reduce the length of hospital stay required. 1. N Engl J Med 2003; 349: 82-83 2. N Engl J Med 2003; 349: 27-35 Depressed in Africa Group-based interpersonal psychotherapy (IPT) can reduce depression and dysfunction in impoverished, AIDS-stricken areas of sub-Saharan Africa, say US researchers. They conducted a randomised, controlled trial of IPT in 248 adult men and women from 30 villages in rural Uganda who had major or subsyndromal depression, using locally validated research tools. The intervention focused on four areas: grief, interpersonal disputes, role transitions and deficits (persistent problems in initiating or sustaining relationships). The researchers found that the improvement in the villagers who received IPT was over and above that seen in villagers who did not. The successful intervention is now being offered to those in the control arm of the study. JAMA 2003; 289: 3117-3124 Women's Health Initiative Breast cancers linked to relatively short-term combined hormone therapy are more advanced and occur earlier than expected. Further, there is no easy way to identify those women at higher risk, and women receiving this therapy will have a much higher rate of mammographic abnormalities, say US experts.1 They were commenting on further analysis of the aborted Women's Health Initiative randomised controlled trial of more than 16 000 postmenopausal women, which suggested that such therapy may not only stimulate breast cancer growth but also hinder breast cancer diagnosis.2 1. JAMA 2003; 289: 3304-3306 2. JAMA 2003; 289: 3243-3253