Volume 179 Issue 9

Pets probably do confer health benefits, but we don’t know precisely how In the current issue of the Journal (page 466), Parslow and Jorm1 reopen the debate about whether pets benefit human health. They give the results of a high quality Australian sample survey indicating that pet owners do not have lower blood pressure than non-owners, and, in this respect at least, are not at lower risk of heart disease. Their results run counter to an earlier Australian study,2 based on a large volunteer sample, in which pet owners were found to have lower blood pressure and cholesterol levels. . . . the benefits of pets appear linked to the human desire to be close to nature . . . Where are we up to in this debate — are we back to square one? The case I will present here is that we can be fairly confident that pets do confer health benefits, but we do not know exactly how. Several types of research by very different kinds of scientists — medical scientists and social scientists — have been conducted on this topic. These scientists have different understandings of causation (ie, of what it means to claim that pets cause their owners to have better health), and, because of this, it is difficult to have a meeting of minds. However, it can be argued that social science research forms a natural prelude to medical research, and that the social science evidence in favour of health benefits of pet ownership makes it worthwhile to mount a substantial medical research effort to discover how the benefits occur. Social science surveys in Australia,3 Britain,4 Germany5 and the United States6 during the 1990s have come pretty close (in social science terms) to establishing that pets produce health benefits. The first surveys were cross-sectional (ie, they provided snapshot evidence at one point in time). With some exceptions, they showed that pet ownership is associated with better self-reported physical and psychological health, and also fewer doctor visits. Controlling for the main demographic variables associated with health problems, including sex, age, marital status, education and income, did not change the results. Of course, social scientists recognised that causation might run the other way round, or even both ways. It was possible that people who were healthy and happy in the first place tended to acquire pets, rather than that having a pet caused better health. So, as a next step, efforts were made to design valid longitudinal studies (ie, studies following people over a period of time) to see whether owning a pet made a difference. The strongest positive evidence has come from the German Socio-Economic Panel Survey,5 which asked a sample of about 10 000 respondents about pet ownership in 1996 and again in 2001. Controlling for health status in 1996 (as well as for the usual demographic variables), it was found that people who continuously owned a pet reported the fewest doctor visits (in the 3 months before interview), and those who had acquired a pet during the 5-year period reported the next fewest number of visits. Both these groups went to the doctor about 10% less often than people who did not have a pet at either time, or who had ceased to have a pet. The German sample is very large and most of the questions are about income and work, so the respondents could not possibly have suspected that the researchers were looking for a link between pets and health. Similar results were found in a smaller Australian longitudinal study, although here the evidence was based on recall, not on repeated interviews.5 Because the German and Australian results came from national representative samples, it was possible to make preliminary estimates of savings in national health expenditure arising from lower use of medical services by pet owners. A second type of study is based on examining the effects of interventions (either natural or intentional), and thus takes the causal reasoning further. An American study of heart attack victims showed that those with pets at home were twice as likely to survive for a year.7 A British longitudinal study involved giving a pet to people who had not recently owned one and following their lives for 10 months.4 The new pet owners showed improvements in physical and mental health, and dog owners took more exercise. A control group who did not own pets showed no change. The study could perhaps be criticised on the grounds that the new pet owners might have known or suspected why they were given pets. The same cannot be said of an American longitudinal study of Medicare enrollees that measured the impact of adverse life events (eg, bereavement or marital separation) on mental health.6 Pet owners coped significantly better. But medical researchers want better evidence of causation than this. They want to know precisely which medical conditions, if any, are improved by pet ownership, and, ideally, they want to understand things at the molecular level. It has to be said that research along these lines has made only limited progress. The American heart attack study7 is relevant here, and, although criticised, has since been replicated.8 On the other hand, studies of blood pressure,1,2 and of the potentially anxiety-reducing effects of pets,9,10 have yielded contradictory results. Arguably then, the state of debate is that pets probably do confer health benefits, but we don’t know precisely how. Continuing medical research is needed to move things forward. At a fundamental level, the benefits of pets appear linked to the human desire to be close to nature and other living creatures. The famous zoologist Edward O Wilson has called the belief that humans need and benefit from closeness and companionship with other species “the biophilia hypothesis”.11 About 50% of adults and 70% of adolescents who own pets report that they confide in them.12 It is most unlikely that all this communication and companionship is wasted.

Bruce Headey PhD

The concept of “first-responder” defibrillation is not being embraced The article in this issue of the Journal by Finn and Jacobs (page 470)1 challenges our professions to find better ways of dealing with sudden unexpected cardiac arrest in the nation’s hospitals — that is, in those places which should be best able to deal with it. Nurses, with a nursing perspective, wrote the article. It underscores the important role played by nurses, and the problem that needs to be addressed by nurses through their influence within our hospitals. Australia played a major role in initiating coronary care wards for managing ventricular fibrillation (VF) in the early stage of myocardial infarction, through the work of Desmond Julian at Sydney Hospital2 and Graeme Sloman at Royal Melbourne Hospital3 during 1961 and 1962. While now taken for granted, one is apt to forget how controversial this development initially was, and how poor the initial results were until nurses were permitted to use defibrillators and so shorten the time from cardiac arrest to termination of VF. At the time, physicians claimed the high ground — defibrillators were too dangerous to be entrusted to nurses — ignoring the fact that the first article on successful use of external defibrillators was written in 1960 by two engineers and one surgeon.4 Fortunately, reason and logic triumphed, and defibrillation became the most important priority for coronary care unit and intensive care unit nurses, with a doctor being summoned concurrently, and usually arriving in time to document return of consciousness and plan ongoing management. Such pioneering work was followed by the development of automatic internal and external defibrillators (AIDs and AEDs, respectively). These are able to sense and interpret VF, and will operate and deliver a shock only if VF is present. They are small and ubiquitous. The US Vice-President, Dick Cheney, has an implanted AID. Indeed, the man who is “a heartbeat behind” the world’s most powerful man is himself “a heartbeat behind” (obviously a number of heartbeats behind) the scrutiny of an automatic implanted defibrillator. Implantation is one mode of use for defibrillators in people at high personal risk of VF. Another mode is public access defibrillation, where AEDs are placed in public places, like fire extinguishers, for use by minimally trained or untrained people, who apply chest pads to an unconscious person and respond to voice prompts delivered by the device. Providing such devices in Chicago’s airport complexes (Box) has resulted in long-term, neurologically intact survival of 56% of sudden cardiac arrest victims, compared with no cases of neurologically intact survival before the devices were made available.5 One of us (C S D) is responsible for a national program,6 in which nearly 700 defibrillators have been installed in airports, train stations, and other busy public places across England. Early results suggest that 29 people have survived to hospital discharge after sudden cardiac arrest. The downside has been minimal, with no injury from use, and virtually no theft, misuse or vandalism. Other highly favourable experiences involving police and the community have recently been reported.7,8 What relevance does the community experience have for Australian hospitals? Finn and Jacobs have identified a number of anomalies. Certainly, AEDs are now available in many Australian hospitals, so that training for nurses in their use is easier, less formidable, and less costly. But most Australian hospitals (57%) still do not have these devices. In hospitals with any kind of defibrillator, 16% in Australia do not permit nurses to defibrillate; in those with AEDs, this figure is 9%. This practice persists despite the knowledge that survival decreases by 10% for each minute that passes after onset of VF until defibrillation is achieved — automatically by an implanted defibrillator, or with manual intervention after placement of pads by doctor, nurse — by anyone. It matters not who places the pads and pushes the button, but hospital procedures are often based on the view that it does. The outcome, demonstrated by hospital, national and published data, is that cardiac arrest is more successfully treated in Chicago or Heathrow airport, on an American Airlines or Qantas jet, or in a Boston post office, than in the vestibules, corridors or general wards of Australia’s premier hospitals. An example of the existing problem is shown in the Box, which contrasts the well signed, alarmed, and easily accessible defibrillator at O’Hare Airport with the unsigned, unalarmed, padlocked defibrillator in the corridor of a major Australian hospital. Providing a defibrillator in such a way is a contemptuous gesture to modern knowledge, and to pronouncements of the Australian Resuscitation Council, as described by Finn and Jacobs. This “AED in a cage” symbolises the problems exposed by Finn and Jacobs,1 and illustrates the 1960s view — that defibrillation is the preserve of the enlightened few with access to the key. We are not overly concerned with the issue raised by Finn and Jacobs in relation to CPR training for medical staff. Their survey was sent to directors of nursing and the replies reflect the nursing perspective, which may not include full knowledge of medical staff activities. Medical practitioners usually prefer to train themselves in resuscitation, and there are surely few who cannot initiate CPR or use a defibrillator, so the number of hospitals identified as offering CPR training to doctors may not be important. We are delighted to see how many hospitals train lay staff in resuscitation. Hopefully, the future will see more communication between doctors, nurses and lay staff at hospitals where issues of “turf”, keys, and locked cages can be resolved, and where the chain of survival can be initiated expeditiously wherever and whenever the need arises. Forty years ago, the Australian hospital system was slow to pick up on the inspirational but logical initiative of Julian, Gaston Bauer (who recruited Julian to Sydney Hospital and encouraged subsequent developments) and Sloman. It remains slow in throwing off the shackles of officialdom. Finn and Jacobs are to be complimented on their fine work. Two approaches to providing automatic external defibrillators (AEDs) One of the many AEDs deployed along a concourse of Chicago’s O’Hare Airport. The device is clearly signposted (not seen in picture), alarmed, and connected by automatic phone to the emergency medical centre. AED in a corridor of a major Australian hospital. There is no signposting, the case is locked and no advice is given on the location of the key.

Michael F O’Rourke AM, MD, FRACP · C Siân Davies MBE, RN

We understand the molecular basis, and a cure may soon be possible The French neurologist Duchenne de Boulogne (1806–1875) originally described paralysie hypertrophique de l’enfance in 1861, outlining the key clinical features, including lordosis and calf hypertrophy.1,2 Although the English physician Edward Meryon had recognised similar cases 10 years earlier, Duchenne’s name became associated with this condition through a series of illustrated articles in which he described key features, including male predominance, progressive course, waddling gait, pseudohypertrophy of calf muscles, loss of ambulation by adolescence, and early death. Duchenne devised a muscle biopsy needle and established that hyperplasia of fibrous connective tissue and destruction of the muscle cytoarchitecture (arrangement of cells) are key abnormalities. By the 1880s, the English neurologist Sir William Gowers was able to identify 81 case reports confirming the clinical features established by Duchenne. Clinicians established the clinical heterogeneity of the muscular dystrophies, and various disorders were identified, including facioscapulohumeral muscular dystrophy, limb-girdle muscular dystrophy and myotonic dystrophy. Importantly, Becker muscular dystrophy (BMD) was identified as a much less severe condition with some similarity to Duchenne muscular dystrophy (DMD). Success in delineating the basis of the dystrophies awaited the molecular era. Kunkel and coworkers identified a patient with a cytologically recognisable deletion on the X chromosome (Xp21) and realised that, if they allowed this to hybridise (pair) with normal DNA, they could find the gene.3 By ingenious use of their novel techniques, they created probes containing part of the Duchenne gene and found that one detected submicroscopic deletions in some affected boys.3 This led to the identification of the gene and eventual delineation of its sequence. Boys with DMD were found to have mutations that produced non-functional dystrophin protein.4 BMD patients were identified as having mutations that produced dystrophin protein with some function.4 The structure of the functional protein was predicted from the genetic sequence,5 and immunocytochemical investigation revealed a close relationship to the sarcolemma.6 Dystrophin’s function as a key cytoskeletal protein was subsequently defined in elegant studies in many laboratories, but especially by Kevin Campbell and colleagues.7 Dystrophin links the actin filament of the contractile apparatus to a complex series of linking proteins in the cell membrane, and hence to the extracellular matrix (Box). It was found that the C-terminus of dystrophin, which binds it to the sarcolemma, is crucial, as is the actin-binding zone, but the helical zone can be shortened with some preservation of function, explaining the differences between BMD and DMD. Subsequently, defects in the dystrophin-associated glycoprotein complex were found to underlie many other types of muscular dystrophy, including the limb-girdle syndromes and the congenital muscular dystrophies. Indeed, it was through pursuit of the cause of DMD that an understanding of much of what we now know about the muscle cytoskeleton has been achieved.7,8 Much new knowledge, but what has been achieved of practical importance for the patients and their families? Diagnosis has improved a great deal. Established DMD is not difficult to diagnose, but molecular causation can now be defined in most cases, allowing accurate confirmation of female carrier status and, with in-vitro fertilisation techniques, selection of a healthy embryo for implantation.9 Advances in clinical management include the use of steroid therapy to improve muscle strength,10 orthopaedic techniques, especially Luque rods, to prevent kyphoscoliosis,11 and regular respiratory monitoring, including sleep studies, to maximise use of non-invasive ventilatory techniques to improve quality of life. Later, depending on patients’ wishes, tracheostomy-dependent ventilation can be used to prolong duration of life. What of new potential treatments? The aim is to develop curative treatments, and it is somewhat disappointing that, more than 20 years after Kunkel’s pioneering discoveries, this is yet to be achieved. Studies with cell therapy (myoblast transfer therapy) have not fulfilled initial promise, although they are still proceeding in several laboratories.12 Major effort in gene therapy has led to an understanding of the key parts of the dystrophin gene that must be incorporated to achieve reasonable function.8 New techniques of gene repair are under evaluation in several laboratories, including our own.8 Skeletal muscle has an enormous capacity for regeneration, and there is every chance that effective strategies to achieve functional muscle remodelling will be achieved, especially if applied before irreversible fibrosis has occurred. Indeed, skeletal muscle, by virtue of its relatively simple structure, enormous capacity for regeneration, and easy and safe accessibility, is an ideal tissue for many of the new therapies in the cell and gene area. Correction of causative mutations through gene repair in autologous mesenchymal stem cells derived from bone marrow, manipulation to a committed myogenic lineage, and systemic delivery, once a concept in the realm of science fiction, may be practical in the years ahead. However, even with the promise so close, there need to be further advances in several areas to achieve this. For example, we need better understanding of the factors that drive pluripotent stem cells into myogenic lineages, and of other factors, mainly immunological, that have limited stem cell survival in vivo. Gene vectors capable of encompassing the whole dystrophin gene are likely to be tested in human studies, and promising new techniques of gene repair are likely to reach clinical trials. It is important that various potential treatments be pursued in parallel, as it is not currently possible to determine which of the approaches available will enjoy most success. Equally important to the search for a cure is the maintenance of quality of life for people who currently have muscular dystrophy. This necessitates adequate funding for clinical care in key paramedical areas, including access to state of the art wheelchair and ventilatory equipment. The role of the Muscular Dystrophy Association in providing support for carers and families is especially important. The next decade is full of promise for robust advances in the management of the dystrophies, and there is real hope that by 2011, the 150th anniversary of Duchenne’s landmark description, a cure for DMD will have been found. Dystrophin: the key protein in Duchenne muscular dystrophy Dystrophin links actin filaments to a complex of transmembrane proteins and hence to the extracellular matrix. Mutations that affect the C-terminus or actin-binding region cause Duchenne muscular dystrophy. Mutations that shorten the a helix cause Becker muscular dystrophy. Other muscular dystrophies are caused by defects in the dystrophin-associated glycoprotein complex.

Edward Byrne DSc, MD, FRCP, FRACP · Andrew J Kornberg MB BS, FRACP · Robert Kapsa PhD

Objective: To test the claim that pet ownership reduces cardiovascular risk.Design: Community survey.Participants: 2528 adults aged 40–44 years and 2551 aged 60–64 years who lived in the Australian Capital Territory and Queanbeyan, New South Wales, and were drawn randomly from the Australian electoral roll in 2000 and 2001.Main outcome measures: Sociodemographic measures, including pet ownership, and measures of physical health (including body mass index [BMI], alcohol and cigarette consumption, and levels of physical activity). Two readings of diastolic and systolic blood pressure were also taken.Results: While pet owners and non-pet owners had similar levels of systolic blood pressure, those with pets had significantly higher diastolic blood pressure. Pet owners also had higher BMI and were more likely to smoke. While those with pets undertook more mild physical activity, they continued to have significantly higher diastolic blood pressure after controlling for hypertensive risk factors.Conclusions: In this study, we found no evidence that pet ownership per se is associated with cardiovascular health benefits. Rather, pet owners had higher diastolic blood pressure than those without pets. It is likely that this increased health risk is linked to other hypertensive risk factors that are only indirectly associated with pet ownership.

Ruth A Parslow MPH, PhD · Anthony F Jorm PhD, DSc

Objective:To describe the policy and practice relating to cardiopulmonary resuscitation (CPR) and defibrillation in cardiac arrest in Australian hospitals.Design:Cross-sectional postal survey conducted in December 2001, using a semi-structured, four-page questionnaire.Participants:Australian hospitals with more than 10 beds.Main outcome measures:Type of defibrillator; provision of CPR/defibrillation training for healthcare professionals; hospital policy as to who can use the defibrillator.Results:Of the 878 hospitals surveyed, 665 (76%) responded. All but one hospital indicated that CPR training was provided for nursing staff, with 12-monthly or more frequent updates; only 55% of hospitals (366) indicated that CPR training was provided for doctors. 21 of the 665 responding hospitals (3.2%) indicated that they did not have a defibrillator. 43% of hospitals had one or more defibrillators with shock advisory capacity (ie, automated external defibrillators [AEDs]). Of the 644 hospitals with defibrillators, 16% (101) indicated that registered nurses were not permitted to defibrillate; this included 9% of hospitals with AEDs.Conclusions:The importance of CPR in cardiac arrest has been accepted by Australian hospitals, but the overwhelming evidence that “time to defibrillation” is the single most important determinant of cardiac arrest outcome seems less accepted. All Australian hospitals should review their resuscitation policies and practices to reflect this fact, with defibrillation by nurses, who are usually first on the scene, providing the best opportunity to minimise time to defibrillation.

Judith C Finn PhD, RN · Ian G Jacobs PhD, RN

In 1988, I attended a workshop of healthcare service managers sponsored by the King’s Fund of London. Participants included such managers and the odd academic from the United Kingdom, the United States, Canada, Australia and New Zealand. We were discussing resource allocation, and frustration mounted during the first 2 days. Ideologically, participants had divided into two teams — the US and the Rest. On the third day, the leader of the US team said, “The difference between us is that you guys believe in equity and we don’t. In the US, people are less interested in making sure everyone gets care than that those who can get it get great care. They accept not getting care now if they can see the opportunity to improve their position and succeed, so that, when they get the money, they will be able to buy great care the minute they want it. It is all about opportunity. People in the US want opportunity, not equity. That’s what they think is fair.” It was important that the US delegate said what he did. It cleared the air. It reminded us that not all societies, and not all people within a society, share a common view of what is fair. In the US, fairness means that you will be encouraged to seek personal success without having to worry much about anyone else. In the UK, Canada, New Zealand and Australia, there is a general interest in the well-being of others. I doubt that Robert Putnam could have written his book Bowling alone1 about Australia. Putnam’s book mourns the loss of social capital, a resource that grows from community trust and participation. Putnam especially laments its replacement with a fierce individualism. The meaning of equityEquity conveys a sense of fairness, but sharpens fairness by adding equality and fellow-feeling. Equity it is not the same as equality, which simply implies similarity of status, capacity, or opportunity. Indigenous Australians, whose life expectancy is shorter than that of non-Indigenous Australians, represent the pre-eminent example of an inequality that is also an inequity. Equity is an ethical value. US health and human rights academics Braverman and Gruskin defined equity as it applies to health: “. . . An ethical concept grounded in the principle of distributive justice . . . Equity in health reflects a concern to reduce unequal opportunities to be healthy [which are] associated with membership in less privileged social groups, such as poor people; disenfranchised racial, ethnic or religious groups; women and rural residents. . . . Pursuing equity in health means eliminating health disparities that are associated with underlying social disadvantage or marginalisation. Equity . . . focuses [our] attention on socially disadvantaged, marginalised or disenfranchised groups within and [among] countries, but not limited to the poor.”2 This definition emphasises that individuals’ need for healthcare services is based on both their medical condition and their social situation. Of course, the problem of inequity in health is not due only to the healthcare system. According to Matthews, the poor health of Indigenous Australians is linked inextricably to social, cultural and educational as well as more classically medical causes.3 She reminds us that, when addressing the health needs of the less socially privileged, we must do much more than just provide equitable access to healthcare. Australia’s health economists have also written and spoken frequently about equity in healthcare, but none has done so more consistently, clearly and passionately than Gavin Mooney. He accepts that there are many definitions of equity, but the one that he endorses is “equal access to equal care for equal need”.4 That is fine for people on the same income and living in the same suburb. Nevertheless, as do Braverman and Gruskin, Mooney extends this definition by recognising the additional needs of underprivileged people. These people may need more access to more care for the same health problem than those with more money, better social support and better opportunities. Ring and Brown5 and Deeble6 observe that current healthcare service funding for Indigenous Australians does not match their severe and special needs. The extent of the positive discrimination we make in favour of such people will reflect how caring our society is. In New South Wales, the resource allocation formula that guides the distribution of funding among geographical regions includes a loading that recognises the greater needs of Indigenous people by multiplying the allocation for Indigenous populations by 2.5.7 This is a good start, but we need to do more. When equity is at work, sick individuals who seek help have their needs met. There is no compulsion or competition. No one is told, “Your need is too great; we can’t afford to treat you — unless you can pay for it yourself.” Patients in need of a heart transplant or expensive long-term therapy for HIV have the same degree of access — equitable access — to medication and care as patients with hypertension or mild asthma. Nor are sick people told, “Because you are old or poor or receive a pension, the government will pay for your healthcare, but will pay the doctor only half or three-quarters of what he or she would receive from treating a younger, rich person.” So the care provided under this definition is impartial. Who you are or how much money you have does not determine your care. Equitable care does not depend on your fame, fortune, or your ability to pay. The principle of universality, on which Medicare has been built, takes seriously the reality that sickness and accidents happen chaotically to any of us, and that a humane and caring society wishes all its citizens to have the same access to the same standard of care, according to need, and unrelated to their financial status. This principle should apply to all public expenditure on healthcare in this country. At present, many Australians do not have equitable access to good quality healthcare. The reasons for this are as follows: Some general practitioners have closed their books, healthcare services are scarce in poorer areas, and, in rural towns, “up-front” payments for consultations are increasing while bulk-billing is in decline.8 Indeed, there were recent reports of some patients having received more speedy attention because they were willing to pay a surcharge (Professor J Richardson, Director, Health Economics Unit, Monash University, personal communication). All these things tear us away from equitable primary healthcare. Public hospital infrastructure is growing old and needs replacement. Access to high technology is patchy. Richardson (see personal communication, above) has shown that investigation and treatment of heart disease is three times more common among privately insured patients. Access to timely surgery is uneven, with private patients getting it quickly and public patients often waiting for a long time. Access to dentistry and ancillary healthcare services is inequitable — better access to high-quality services is offered to those who are privately insured and/or wealthy.9 Public funding for healthcare and equityI want to examine two aspects of the relationship between public funding for healthcare and equity. The first follows from the observation that rich countries apply more public funding to healthcare (as a percentage of GDP) than do underdeveloped countries.10 Investment in healthcare is a sign of a country’s economic strength, and a reflection of its democratic values. Government investment in healthcare is both ethically desirable and economically rational. This has some clear implications. To honour equity, as a nation, we must set aside enough resources to buy appropriate, quality services and safe treatments, and make these accessible to our citizens based on their need. If the level of remuneration to doctors and other health professionals is lower than is economically or socially appropriate, or if the funds do not allow procurement of the most appropriate treatments, problems follow. Deeble estimated that the consumer-price-index-adjusted Medicare rebate for a standard general practitioner consultation (Item 23) has declined by $6 since 1984.6 The recent fall in bulk-billing by general practitioners has led to reform proposals from the Commonwealth Government and the Opposition. While these proposals are different, both would cost an extra $300 million per annum, and neither would apply the funds equitably. General practice is by no means the most expensive item in the healthcare system. As well as supporting general practice, we must ensure that our public hospitals are adequately funded. It is disappointing that the federal budget surplus has been used to fund a tiny personal tax cut when $2.4 billion, or thereabouts, would greatly help in raising our public hospital infrastructure to acceptable standards. Canadian social commentator John Ralston Saul has suggested that governments which are committed to corporatism, rationalism and cost cutting as means to achieve greater efficiency can make beliefs such as “publicly-funded healthcare services cannot cope” come true. The failure of publicly funded healthcare services is an inevitable consequence of insufficient investment or disinvestment. Indeed, the Romanow Commission, set up to review Canadian Medicare, recommended an increase in its funding.11 I am convinced that, as a nation, we need to spend more public money on healthcare services, and that much of the strain on Australian healthcare in recent years is the result of underfunding. Furthermore, there is room to improve the effective, safe and efficient use of the allocated money, thus assuring its support for equitable access. The second aspect of the relationship between public funding of healthcare and equity that I want to discuss is the observation that high levels of government funding for healthcare do not guarantee equity. A strong investment by government in healthcare may be necessary, but is not sufficient, to achieve equity. Big private-sector contributions bias the government contribution in favour of the rich. This is the case in India12 and the US, and is increasingly the case in Australia. About 14% of GDP goes on healthcare funding in the US, compared with about 9% in Australia. The difference is the result of healthcare spending in the private sector, not the public sector. The public sector accounts for 44% of US healthcare spending,13 and the proportions of GDP spent on public-sector healthcare are similar in the US and Australia. However, US public-sector healthcare expenditure is distributed preferentially to middle-class Americans because of the huge additional expenditure from private sources which drags government funding in its train. In Australia, the private health insurance rebate actually increased overall government spending on healthcare.14 However, the rebate tends to distribute government expenditure preferentially to those with private health insurance — that is, the wealthier members of the community. Moving forwardTo place equity on the agenda in the public funding of healthcare for Australia, we need two things: Greater clarity as to what Medicare and other public money for healthcare actually fund (clearly, where the nature or means of funding is inadequate or inefficient, we should develop new funding mechanisms); and A way to determine funding priorities that has equity as its centrepiece. On the first of these, we should consider a few funding additions and redistributions. First, we should extend the principles of the Pharmaceutical Benefits Scheme and the Commonwealth Medical (previously Medicare) Benefits Schedule to cover other essential services in our healthcare system. We currently support dental and allied health professional services with public money, but preferentially for those with private insurance. We pay for a third of private health insurance premiums from public funds. From the 1998 Australian Bureau of Statistics Health Insurance Survey and AXA/National Mutual data for NSW, Spencer estimated that each year we give some $300 million of public funds for dental care of those with private insurance.9 I believe that we should subsidise basic dental services for all Australians, as dental health is not a luxury. Private health insurance rebates for physiotherapy, podiatry and other support services also channel public-sector funds to those who are privately insured. This runs counter to the principle of Medicare. If we consider dental and ancillary services justifiable areas of public expenditure for those with private health insurance, then we should assess what public funds provide to all other citizens in respect of these services. We should focus on equity in what we do and do not fund. Second, the disparity in the payments that general practitioners receive from bulk-billed versus non-bulk-billed patients needs to be redressed. The Commonwealth Government is about to increase this disparity through its “Fairer Medicare” proposals.15 This is unacceptable. I understand the complexity of the issues, and the need to increase remuneration for general practitioners, but the present proposal widens the gap between those who are bulk-billed and those who are not. We must be able to come up with something better. Third, the Australian Health Care Agreements should take account of chronic disease management. For example, we could make more use of casemix methods in funding chronic disease management, although the AR-DRGs (Australian refined diagnosis-related groups) would have to be expanded to encompass continuing care and reflect the growing burden of chronic disease. The care of the chronically ill is an aspect of Medicare arrangements that requires substantial revision, including a full exploration of capitation rather than fee-for-service funding. Funding of healthcare provided by all professionals, not just doctors, is critically important for people with multiple chronic health problems. Models of care for chronic illness urge team approaches with good leadership and management. Extended and coordinated care is difficult to achieve if we only pay doctors at bulk-billing rates, or, indeed, if we continue to rely on a fee-for-service basis. Fourth, we need a coordinated plan to improve public hospital infrastructure in Australia. We need substantial additional capital funds, as well as ongoing funding. In the meantime, public hospital waiting lists, which disproportionately apply to those without private health insurance, constitute a real problem of equity. How do we move forward? Our healthcare services change incrementally, and from time to time we need to review and consolidate them. Yet it is easy to overlook the importance to us of equity in such reviews. This requires that we establish a process of determining what we should pay for through Medicare. For this reason, I propose the formation of a National Council for Equity in Healthcare, accountable to the Australian Parliament, with a mission to make the healthcare system more equitable. Its terms of reference would concentrate on the extent to which the resources available for healthcare are used equitably. As part of its charter, the Council for Equity in Health Care should support community debate leading to the development of a national healthcare charter containing principles for a more equitable healthcare system. The debate would provide an opportunity for citizens, patients and carers to state their expectations clearly, and might produce some surprising results. When Gavin Mooney recently asked a citizens’ jury in Perth to set priorities, it voted for equity and public health. When asked to set priorities within equity, Aboriginal health came first in the jury’s agenda, ahead of rural and remote health and aged care.16,17 The proposed Council for Equity in Health Care could also review the contribution of the taxation system to healthcare. This is especially timely now that the GST is in place. The Australian economy is in good shape and it could sustain an increase in public spending on healthcare and health. Although some say that there would be strong resistance among voters, a small progressive increase in the Medicare levy, to be used for the provision of more equitable healthcare, may well be acceptable. Opinion polls conducted by the major political parties have found that such an increase would be acceptable to most people in the way I have described.18 There are barriers to the achievement of equity that are not financial, and these deserve the careful attention of the proposed Council for Equity in Health Care. In remote Aboriginal communities, the absence of basic services compromises the universality of Medicare, and equity suffers.19 People who live a long way from a city do not have equal access to equal care for equal need, and may never fully do so. A previous federal Health Minister, Dr Michael Wooldridge, was correct when he said that Medicare was not the instrument to address the special needs of rural Australia. The Australian Institute of Health and Welfare has documented that Australians in large cities are bulk-billed for general practice services much more frequently than those living in remote areas.8 One description of Medicare is that it is a metropolitan system.20 On the positive side, the Commonwealth Government has been energetic in seeking to improve healthcare services in rural areas. It has funded programs for medical student education and registrar training, and provided enhanced funding for services. These efforts are laudable, as are the levels of dedication of many healthcare professionals who have worked hard under less than ideal circumstances. The government is also working to open up access to Medicare and the Pharmaceutical Benefits Scheme for many rural and remote Indigenous Australian communities, and this is commendable. There are also cultural and language barriers to equity in healthcare that can limit access to quality care. If there are not enough interpreters available in public hospitals, those who do not speak English fluently are disadvantaged. The cultural norms of the medical profession may easily prevent doctors from treating working-class patients in appropriate ways. Apart from underfunding, lack of cultural security is a major block to improving Aboriginal health.20 The proposed National Council for Equity in Health Care should include these issues in its remit. With increasing affluence, we can choose to invest more as a nation in the healthcare of our citizens. We can do much more to improve the degree of equity in healthcare in Australia. This is the course of a humane, caring nation with a belief in the value of civil society. We can apply business principles with benefit to many parts of healthcare. There is also a strong case for investing more in innovation and the evaluation of healthcare, and more in improving its quality and safety. At its core, though, healthcare is about sharing and caring — sharing the load of illness and caring about ensuring access to the privilege of hope that humane medical care offers. We need political leadership, both lay and medical, that will seek to strengthen, not weaken, worthwhile achievements, and build on what this country has achieved over recent decades in providing equitable healthcare for all Australians.

Stephen R Leeder PhD, FRACP

The potential for discrimination when applying for insurance can be of concern for individuals with a family history of cancer or of a genetic disorder and who are considering genetic counselling or genetic testing. The actual incidence of “genetic discrimination”, however, is not known, despite considerable media coverage of this issue. The clinical details required by insurers have received less attention. We obtained primary application and personal statement forms used by 21 different underwriters of voluntary life insurance and found substantial differences in the information requested about family history and genetic testing. All insurance applications, however, contained a duty of disclosure that would require revealing the result, if known by the applicant, of a genetic test in a family member. Therefore, decisions made by family members can affect insurance applications, and people considering genetic testing may also need to consider the implications of the results for other family members. Health practitioners should balance the potential benefits of appropriate genetic testing against potential restriction to life and income-protection insurance when advising people about genetic testing.

Elly L Lynch BSc, GradDipGenet Counselling · Rebecca J Doherty BSc, GradDipGenet Counselling · Clara L Gaff BSc(Hons), PhD, FHGSA (Genetic Counselling) · Finlay A Macrae MD, FRACP, FRCP · Geoffrey J Lindeman BSc(Med), MB BS, PhD, FRACP

Confident localisation of ectopic parathyroid adenomas, particularly those outside the neck, can be difficult. Even preoperative radiological imaging may not be helpful, as there are few characteristic findings. We report a case in which hyperfunctioning ectopic parathyroid tissue in the mediastinum was detected with technetium-99m-sestamibi single-photon emission computed tomography and accurately localised non-invasively with image-fused computed tomography. This technique directly modified management. Ectopic parathyroid adenomas are uncommon, but can complicate the surgical treatment of primary hyperparathyroidism. In particular, those outside the neck, and thus not found on neck exploration, produce a substantial diagnostic challenge. Clinical recordA 60-year-old woman was found incidentally by a life insurance blood screening test to be hypercalcaemic. She did not complain of specific symptoms referable to hypercalcaemia, but bone mineral density assessment 2 months previously had shown osteopenia. Her past medical history was unremarkable. She was taking no medications and gave no family history of parathyroid disease. Clinical examination showed no abnormality. The results of investigations (Box 1) showed raised plasma corrected calcium, intact parathyroid hormone and ionised calcium levels, but levels of creatinine and serum phosphate were normal. Alkaline phosphatase and osteocalcin levels were mildly elevated. Urinary N-telopeptide level was within the reference range, and the fasting urine calcium : creatinine ratio was slightly elevated. A dual-phase, dual-tracer technetium (Tc)-99m-pertechnetate/Tc-99m-sestamibi nuclear medicine study revealed a solitary focus of abnormal tracer uptake in the anterior mediastinum on both initial and delayed sestamibi images and on subtracted images (Box 2, Figure A). Retained activity in the left subclavian vein was noted incidentally. No abnormality was seen within the thyroid bed. It was suspected that the activity indicated ectopic parathyroid tissue, although it may have represented retained activity within a large vessel. Single-photon-emission computed tomography (SPECT) imaging confirmed the finding in the right mediastinum (Box 2, Figure B). Thoracic computed tomography (CT) showed a 9 mm soft-tissue mass, lying anterior to the aorta at the level of the carina (Box 2, Figure C). Its appearance was non-specific, but incidental lymphoid tissue was considered most likely. Utilising a software co-registration package (Philips/ADAC Laboratories, Milpitas, Calif, USA), the sestamibi SPECT images were fused onto the CT images. The resulting views showed abnormal mediastinal sestamibi activity localised to the soft-tissue mass, suggesting the presence of ectopic parathyroid tissue (Box 3). Thoracoscopic excision of the mediastinal mass was performed. No discrete abnormality matching the usual macroscopic appearance of a parathyroid adenoma was seen. A small fat pad, lying anterior to the ascending aorta, below the brachiocephalic vein and superior to the pericardium, was found and excised. Digital palpation of this tissue revealed an area of focal hardening. Histology of the operative specimen confirmed the presence of parathyroid tissue, weighing 100 mg, within the fat pad. Differentiation between adenoma and parathyroid hyperplasia was not possible. Incidental thymic and lymphoid tissue was also seen in the pathology specimen. After the operation, plasma corrected calcium and intact parathyroid hormone levels normalised almost immediately and the patient recovered uneventfully. DiscussionWe have described successful preoperative localisation of an ectopic adenoma using image-fusion software, which directed the successful excision of the tissue. In this patient, either a conventional bilateral neck exploration, or a single image study without image co-registration before minimally invasive surgery, would have been less likely to result in successful or certain management. The conventional approach for parathyroid disease is bilateral neck exploration under general anaesthesia to expose and identify all parathyroid tissue, without preoperative imaging.1 Obviously enlarged parathyroid glands are resected. If intact parathyroid hormone levels do not fall intraoperatively, a partial parathyroidectomy, including thymectomy, may be considered. In our patient, however, it was felt that even thymectomy may not have been curative, as the position of the ectopic parathyroid adenoma made it inaccessible by a conventional approach. The minimally invasive approach used in selected patients involves directed and limited neck exploration under local anaesthesia, and is usually preceded by preoperative localisation of the parathyroid adenoma with sestamibi scintigraphy. An intraoperative γ probe can also be used to help identify or confirm the adenoma (minimally invasive radioguided surgery).2,3 The role of preoperative parathyroid localisation using imaging techniques in patients who have not had previous neck exploration is currently debated.2-5 While local cost-effectiveness data are still pending, additional advantages of preoperative imaging are being found,4,5 including the detection of unsuspected ectopic parathyroid adenomas, which may otherwise be missed on routine surgical neck exploration. Some advantages of this approach include avoidance of general anaesthesia, improved cosmetic result, and a shorter operating and recovery time. Multiple diagnostic modalities exist for imaging the parathyroid glands. These include radionuclide scintigraphy, ultrasonography, CT and magnetic resonance imaging (MRI). Dual-phase, dual-tracer Tc-99m-pertechnetate/Tc-99m-sestamibi SPECT scintigraphy has increased the sensitivity of detection of parathyroid adenomas (up to 90%).6-9 The increased tracer uptake by hyperfunctioning parathyroid tissue is explained by the abundance of mitochondria within these abnormal cells, for which sestamibi demonstrates high avidity.10 Occasionally, as in our patient, the sestamibi scan may indicate ectopic parathyroid tissue. Developmentally, the parathyroid glands are derived from the pharyngeal pouches. The two inferior glands arise from the third brachial cleft, descending with the thymus during embryogenesis, which would account for the presence of ectopic tissue within the mediastinum.11 In ectopic disease, imaging experience is limited. Ishibashi et al,12 in a blinded, comparative study, suggested superior sensitivity of scintigraphy compared with CT or magnetic resonance imaging (MRI) in detecting such adenomas, with the sensitivity and specificity of sestamibi imaging calculated to be 70% (14/20) and 88%, respectively. The sensitivity and specificity of CT were 40% (8/20) and 88%, and of MRI, 60% (12/20) and 88%.12 Our finding on initial sestamibi scanning could have represented retained activity within a large vessel, and, as false-positive results may occur with all imaging, many investigators have advocated the need for concordance on at least two diagnostic modalities before surgical excision.4,13 On further investigation, the mediastinal abnormality seen on CT was so small that its clinical significance could not be confidently assessed. Traditionally, such a problem is unlikely to be resolved non-invasively. In our patient, the use of new image-fusion software allowed the accurate integration of both functional and anatomical data on the one image set. This image fusion clearly confirmed abnormal sestamibi activity arising from the mediastinal mass seen on CT, implying the presence of ectopic parathyroid tissue. A similar case of ectopic adenoma detection using this technique has been described previously.14 However, in that report, the CT findings of a 2.0 × 1.0 cm mediastinal mass were clearly abnormal and strongly suggestive of an adenoma.14 Our case is the first to highlight the incremental diagnostic value of image fusion, as the CT, and indeed intraoperative, findings in isolation were inconclusive. After confirming the presence of ectopic parathyroid tissue, a thoracoscopic approach to surgery was undertaken rather than a conventional approach. Advances in both nuclear scintigraphy and, more recently, image fusion have expanded our ability to accurately and confidently localise ectopic adenomas non-invasively. In our patient, the preoperative imaging techniques used significantly altered surgical management. 1: Clinical laboratory measurements Investigation Value (reference range) Plasma corrected calcium 2.9 mmol/L (2.15–2.55 mmol/L) Intact parathyroid hormone 27.8 pmol/L (0.8–8.0 pmol/L) Ionised calcium 1.46 mmol/L (1.14–1.29 mmol/L) Creatinine 75 mol/L (45–90 mol/L) Serum phosphate 0.8 mmol/L (0.8–1.5 mmol/L) Alkaline phosphatase 109 U/L (< 105 U/L) Osteocalcin 53.5 μg/L (< 46 μg/L for postmenopausal women) Urinary N-telopeptide (N-terminal telopeptide of collagen) 57 nmol BCE/mmol creatinine (5–65 nmol BCE/mmol creatinine) Fasting urine calcium : creatinine ratio 0.65 (0.10–0.58) BCE = bone collagen equivalence. 2: Preoperative imaging in a patient with raised levels of plasma corrected calcium, intact parathyroid hormone and ionised calcium A: Tc-99m-pertechnetate-sestamibi subtraction imaging, confirming an ectopic focus of tracer activity in the chest to the right of midline (red arrow). Retained activity in the left subclavian vein is incidentally noted on the 30-minute sestamibi scan and on the subtraction image (blue arrow). B: Transaxial, coronal and sagittal single-photon-emission computed tomography (SPECT) slices, indicating focus of increased sestamibi activity (red arrow) in the right anterior mediastinum. C: Oval lesion (9 mm) in anterior mediastinum to the right of midline, thought initially to be non-pathological lymphoid tissue (red arrow). 3: Localisation of an ectopic parathyroid adenoma Fusion of single-photon-emission computed tomography (SPECT) and computed tomography data, showing the site of ectopic parathyroid tissue (red arrow).

Patrick Ng MB BS · Nat P Lenzo BMedSc(Hons), MB BS, MMed, FRACP · Michael C McCarthy MB BS, FRACP · Ivan Thompson MB BS, FRACS · Peter J Leedman MB BS, FRACP, PhD

Objective: To update evidence-based guidelines for the treatment of proximal femoral fractures published in the Journal in 1999.Data sources: Systematic literature search of MEDLINE, CINAHL and EMBASE from January 1996 to September 2001 and the Cochrane Database of Systematic Reviews (most recent issue searched — Issue 2, 2002).Study selection: Randomised controlled trials and meta-analyses of all aspects of acute-care hospital treatment and rehabilitation of proximal femoral fractures among subjects aged 50 years and over with proximal femoral fractures not associated with metastatic disease or multiple trauma.Data extraction: All studies were read independently by two reviewers. Reviewers recorded individual study results, and an assessment of study quality and treatment conclusions according to Cochrane Collaboration protocols. If necessary, a third review was performed to reach consensus.Results: 93 new studies were identified and 82 met our inclusion criteria. Recommendations for thromboprophylaxis, anaesthesia, surgical fixation of fractures and nutritional status have been altered to incorporate new evidence. Recommendations have been added regarding postoperative blood transfusion, the management of subtrochanteric fractures, and the type of surgical swabs which should be used.Conclusions: Although there have been few significant changes to the previous recommendations, updating the guidelines has required substantial effort. The common clinical problem of hip fracture should be treated according to the most up-to-date evidence to achieve the best possible outcomes and optimal utilisation of limited resources. Guideline updates also require resourcing.

Michael N Chilov MB BS, BOptom · Ian D Cameron MB BS, PhD, FAFRM(RACP) · Lyn M March MB BS, PhD, FRACP

Clinical recordA 71-year-old white woman presented with increased shortness of breath over a 6-day period, followed by acute onset of severe back and interscapular pain. Her past medical history consisted of hypertension, type 2 diabetes, and a distant history of alveolar-cell carcinoma of the lung, with right lower lobectomy in 1974. Physical examination revealed an obese lady weighing 95 kg, with a blood pressure of 80/40 mmHg, pulse 110/min, and a respiratory rate of 36/min. The patient was afebrile, diaphoretic and restless. Her venous pressure was elevated. Chest examination showed reduced breath sounds at both lung bases. Heart sounds were dual with no murmurs. Electrocardiography showed sinus tachycardia, 110/min with an S wave in lead I, a Q wave in limb lead III, and T-wave inversion in limb lead III. Arterial blood analysis (inspired oxygen content of 21%) showed pH, 7.156; Pao2, 61 mmHg; Paco2, 52 mmHg; Sao2, 83%. The patient’s chest x-ray showed a widened mediastinum on a mobile supine film, and previous right lower lobectomy. The provisional diagnosis was aortic dissection. The patient was intubated and ventilated in the emergency room, then taken to the intensive care unit, where she was resuscitated with intravenous fluids (both crystalloid and colloid) and an infusion of adrenaline. Transoesophageal echocardiography showed a small left ventricle with hyperdynamic systolic function. The right ventricle was dilated, with poor systolic function. There was grade 2/4 tricuspid regurgitation, with an estimated right ventricular systolic pressure of 60 mmHg. There was grade 3/4 mitral regurgitation secondary to systolic anterior motion of the anterior mitral leaflet, and dynamic left ventricular outflow tract obstruction with a maximum gradient of 90 mmHg. Significant thrombus was seen in the proximal right and left pulmonary arteries (Box 1A). There was no evidence of aortic dissection and no pericardial effusion. Other laboratory results included elevated D dimer level of 2.93 mg/L (normal, < 0.28 mg/L), with normal serum creatine kinase and cardiac troponin I levels. The patient was given 7000 U of unfractionated heparin and thrombolysis with 40 mg of intravenous tenecteplase administered twice, but she remained profoundly hypotensive (BP, 78/47 mmHg). Surgical embolectomy was considered, but was declined due to the recently administered thrombolysis. A decision was made to take the patient to the cardiac catheterisation laboratory for an attempt at mechanical intervention. While the laboratory was being prepared, a pulmonary artery flotation catheter was passed from the right internal jugular vein into the main pulmonary artery. This resulted in significant clearance of the “saddle” embolism from the main pulmonary artery, as determined by transoesophageal echocardiography. The time from administration of thrombolysis to commencement of the interventional procedure was 55 minutes. The activated clotting time, measured when femoral access was obtained, was 352 seconds. The main pulmonary artery was accessed via the right femoral vein with a multipurpose catheter. As a rheolytic thrombectomy catheter and other commercial devices were not available, an Amplatz 0.035" wire was used to remove the multipurpose catheter and insert a 7 Fr long sheath and a pigtail catheter. With the pigtail catheter, the embolism was mechanically cleared from the main pulmonary artery. A pulmonary angiogram then showed extensive embolism in the left main pulmonary artery, extending into several lower lobe segmental arteries (Box 1B). The pigtail catheter was used to macerate this embolism. Once some blood flow had been restored, a snare was then made using an 0.025" wire, but attempts to snare the clot were not successful — the clot was pushed further into the segmental arteries. Nevertheless, fragmentation of the embolism and clearance of the main pulmonary artery and left pulmonary artery was achieved. A multipurpose catheter was then passed to the right pulmonary artery and the stiff wire was used to remove the multipurpose catheter and insert the 7 Fr long sheath and a pigtail catheter. Pulmonary angiography of the right lung showed the right main pulmonary artery to be clear of thrombus, which had lodged in the right segmental branches. At the completion of the intervention, the systemic blood pressure had stabilised (90/54 mmHg) and the pulmonary pressures were only moderately elevated (44/24 mmHg). Angiography showed that blood flow through the lungs had improved. Anticoagulation was continued with intravenous unfractionated heparin. The activated partial thromboplastin time 4 hours after the intervention was > 250 seconds. The following day the patient was extubated and discharged to the ward. Her dyspnoea and mobility gradually improved, and she was started on warfarin. Four days after the procedure, transthoracic echocardiography showed the right ventricle to be at the upper limit of normal in size, with normal systolic function. The right ventricular systolic pressure was estimated at 62 mmHg. Acute major pulmonary embolism is associated with right ventricular dysfunction and shock.1 This condition is frequently lethal, despite thrombolysis.1,2 Adjunctive catheter fragmentation may prevent death.1-3 However, commercial systems for fragmentation of thromboembolic material are not widely available, and reported experience with these techniques is limited. In cases of major pulmonary embolism, patients are at serious risk of death due to right ventricular failure within the first hour of onset.4 Survival depends on rapid recanalisation of the pulmonary arterial occlusion and reduction of the right ventricular afterload. According to the results from a multicentre registry, overall in-hospital mortality rate ranges from 25% for patients presenting with cardiogenic shock to 65% for patients undergoing cardiopulmonary resuscitation.2 Thrombolytic therapy is a useful adjunct to heparin in patients who have pulmonary embolism and who are haemodynamically unstable.5 Rapid improvement of right ventricular function and pulmonary perfusion, accomplished with thrombolytic therapy followed by heparin, may lead to a lower rate of death and recurrent pulmonary embolism.1,5 However, in severe cases, even high-dose thrombolytic therapy may not prevent death.2 Transvenous catheter embolectomy or open surgical embolectomy should be considered in patients for whom thrombolysis is contra-indicated or deemed unsuccessful.3,6 Greenfield et al introduced the first percutaneous catheter thrombectomy device, an aspiration catheter, in 1969.7 There are currently several catheter thrombectomy techniques: aspiration thrombectomy, fragmentation thrombectomy, and rheolytic thrombectomy.3,6-8 However, the commercial devices used in these procedures are not widely available, and there is limited experience reported with any of these techniques. This type of procedure is typically confined to major interventional laboratories with experienced operators. There are several reports of successful fragmentation of pulmonary emboli with improvised equipment in patients with shock.9 Our case is of particular interest, as thrombolysis had failed to improve the patient’s immediate clinical state. The use of a pulmonary flotation catheter to dislodge the embolism from the main pulmonary artery proved to be a useful temporising measure. This type of catheter is easily passed without the need for fluoroscopic control. In this situation, transoesophageal echocardiography proved pivotal in diagnosing the embolism rapidly, and in monitoring the response to therapeutic manoeuvres.10 Movement of the embolism from the main pulmonary artery was visualised in real time, which may be better achieved with transoesophageal rather than transthoracic imaging. Further mechanical fragmentation could then be achieved in the catheterisation laboratory. The technique consists of fragmentation of central emboli and dislocation of the fragments to the periphery, resulting in a relative gain of non-obstructed, cross-sectional artery area. Moreover, the increased total surface area of the fragments may ac-celerate the efficacy of concurrent thrombolysis. In summary, for patients with major pulmonary embolism for whom thrombolysis is contraindicated or unsuccessful, the passage of a pulmonary flotation catheter and improvised catheter fragmentation of thrombus may be considered if there is suitable access to an interventional laboratory and an experienced interventionist. Lessons from practice Transoesophageal echocardiography, although more invasive and technically more demanding than transthoracic echocardiography, can be very useful for diagnosing pulmonary embolism. It also provides valuable information about prognosis and response to therapy. Mechanical fragmentation and dispersion of embolism can be a successful adjunctive strategy for treating massive pulmonary embolism when response to thrombolysis is suboptimal. Mechanical fragmentation and dispersion of embolism can be achieved with improvised equipment that is available in most interventional catheterisation laboratories. Images of the embolism A: Pulmonary “saddle” embolism situated in the proximal main pulmonary artery, as shown by transoesophageal echocardiography. B: Pulmonary angiography, showing the fragmented embolism that was dispersed to the segmental pulmonary arteries.

Warong Lapanun MD, FRCPT · Darren L Walters MB BS, FRACP · John McCarthy MB BS, FJFICM · Darryl J Burstow MB BS, FRACP

Diabetes complications are common and almost triple the annual cost of managing diabetes. Microvascular complications are the major risk in type 1 diabetes, while macrovascular complications are the major cause of morbidity and mortality in type 2 diabetes. Control of hyperglycaemia (target HbA1c level ≤ 7%) and hypertension (target blood pressure ≤ 130/80 mmHg) prevents microvascular complications in both types of diabetes; a multifactorial approach, comprising behaviour modification and pharmacological therapy for all risk factors, reduces the development of micro- and macrovascular complications in type 2 diabetes. The benefit of treating dyslipidaemia is at least as great in the diabetic population as in the non-diabetic population. Angiotensin-converting enzyme inhibitors and low-dose aspirin are indicated in people with diabetes and other cardiovascular risk factors. Regular annual screening for diabetes complications allows treatable disease to be identified.

Katherine L Bate FRACP · George Jerums MD, FRACP

Christopher M Pearce Senior Lecturer in Rural General Practice, Department of General Practice, University of Melbourne, 200 Berkeley Street, Carlton, VIC 3053; Director, Australian Division of General Practice; and PhD student. chris_pearceATmac.com To the Editor: The recent issue on general practice (7 July 2003) contained many statements that were inaccurate and unfair to a profession that has existed before most specialties and will exist beyond their passing. It is unfortunate that the issue represents an opportunity missed. Notwithstanding the funding issues, general practice is not “in crisis”, as many of your authors would attest.1 It is vibrant and leading the way in healthcare reform in this country, and much of its loss of appeal to new doctors has to do with the attitudes of many of the authors, who talk it down rather than up. The quoted comment from Donald Berwick — “we are carrying the nineteenth-century clinical office into the twenty-first-century world”2 — is surely the most inaccurate statement. Modern general practices bear no relationship to even their mid-20th-century counterparts, whereas the average specialist office still looks the same and functions in a similar way. General practice is over 80% computerised,3 unlike the practices of our specialist colleagues. General practice has been responding to the challenges of a community-centred approach, while specialists still respond to a disease-centred model. Indeed, many members of the profession correctly talk about research as a means of raising the profile of general practice — in this regard, the specialties have been hiding behind the power and influence of research institutes. Until funding bodies such as the National Health and Medical Research Council give general practice research priority over such esoteric areas as “Major porcine antigens for the generation and modulation of immune responses to neovascularised pig tissue xenografts” ($480,000)4 in allocating research grants, things will not change. Further, many of your articles still reflect a degree of discomfort with general practice as a distinct discipline — reflected in the confusion over “general practice” versus “primary care”. These are two separate areas, and, while general practice is well defined, primary care is not. Several authors5,6 in the recent general practice issue speak of Divisions of General Practice and of the opportunities for collaborative research therein. Unfortunately, academia has failed to engage with Divisions. Although the Board of the Royal Australian College of General Practitioners has several professors, the Board of the Australian Divisions of General Practice sports a couple of part-time senior lecturers. Divisions report that academics often have a paternalistic attitude towards general practice, without understanding the true potential of partnerships with GPs. General practice remains the most important, popular, and utilised part of the healthcare system, both in Australia and overseas. It is embracing change and responding to demands, often in innovative ways. We should be celebrating its achievements, rather than talking about imagined “crises”. Martin B Van Der Weyden Editor, Medical Journal of Australia, Locked Bag 3030, Strawberry Hills, NSW 2012. editorialATampco.com.au In reply: I would be heartened to believe that all is well in Australian general practice, that it is indeed “vibrant and leading the way in healthcare reform in this country”. But the reality appears to be otherwise. Surveys attest that doctors are unhappy, and Australian general practitioners have not escaped the mood of discontent and disillusionment.1,2 That more than 80% of our general practices are computerised is laudable. But is this technology being used in a patient-centred way? Are visits coordinated so that waiting times are minimal and queues a thing of the past? Do practices use their computers in a way that efficiently integrates office processes, patient care, patient records, prescribing, pathology, referrals and health outcomes over time? In short, is this technology being used as a vibrant tool for practice efficiency and quality patient care? It appears that there is still some way to go, as a recent survey of GPs revealed that less than 50% use their computers for prescribing and less than 30% for managing appointments and clinical records.3 Whether specialists hide behind the façades of research institutes is uncertain. But what is certain is that research output in the field of general practice in Australia lags far behind that of medicine, surgery or public health.4 Furthermore, the National Health and Medical Research Council awards research grants on merit, not on a subjective assessment of what each sector “deserves”. I am disturbed to learn that all is not well between some Divisions of General Practice and general-practice academia. A recent review of the Divisions’ role5 makes no mention of this divide, but submissions to the review did outline the need for stronger relationships between Divisions and academia. It takes two to tango and the solution lies with both parties. Finally, I am encouraged that, despite the alleged “crisis” theme of the Journal’s recent issue on general practice, there are those who believe that “general practice remains the most important, popular and utilised part of the healthcare system”. However, on the issue of whether there is a “crisis”, participants in the recent Australian Health Care Summit would beg to differ: the general opinion was that not only is general practice “in crisis”, but so too is the whole healthcare system.6

Christopher M Pearce

Joachim P Sturmberg,* Carmel M Martin† * Associate Professor of General Practice, Monash University, Melbourne, VIC; † Associate Professor of General Practice, Ottawa University, Ottawa, Canada. Correspondence: Associate Professor Joachim P Sturmberg, PO Box 3010, Wamberal, NSW 2260. jp.sturmbergATbigpond.com To the Editor: As much as we agree with the general sentiments of Del Mar and colleagues’ views about the malaise of general practice,1 we feel they simply listed some of the well known symptoms without elaborating on the underlying pathology or analysing the failure to provide appropriate treatment. Their conceptualisation of general practice focused on clinical performance within a disease-centred model of medical care, which includes the issues of published and cited papers, critical appraisal and evidence-based medicine. Their analysis did not address systems issues, including the funding of general practice/practitioners, organisational change (such as amalgamation and corporatisation), and the establishment of Divisions of General Practice that have largely failed the community as well as the discipline. We would argue that redressing the problems in general practice requires a fresh start in thinking. We need a much broader conceptualisation of general practice and its role within the healthcare system. Firstly, the specialty of general practice is patient-focused generalism — that is, a focus on patients’ bio-psychosocial healthcare needs and understanding of their illness experience. Secondly, we need to recognise the important place of general practice in healthcare delivery and population health. After all, an average 217 patients per 1000 seek medical care each month, of which only nine will be hospitalised and one will require tertiary care.2 A broader conceptualisation of general practice must embrace the discipline’s patient-centred approach to patient care and an explicit understanding of systems approaches within the context of the populations served by the discipline. This can only be achieved if we embrace different research models and understand modes of healthcare system organisation, both of which are based on dynamic, non-linear models. Such an approach implies that we continually revise our models of clinical practice around patient and community needs. In fact, the greatest strength and the greatest opportunity of our discipline is our grassroots involvement — our ability, based on our individual experience, to advocate on behalf of our patients for a system based on their care needs and our ability to deliver such care. We don’t underestimate the challenges inherent in reorienting our discipline away from the mechanistic disease model of the 20th century towards a dynamic, patient-focused model relevant to the 21st century. Christopher B Del Mar,* George K Freeman,† Chris van Weel‡ * Director, and Professor of General Practice, Centre for General Practice, University of Queensland Medical School, Herston, QLD 4006; † Professor of General Practice, Centre for Primary Care and Social Medicine, Imperial College, London, UK; ‡ Professor of General Practice, University Medical Centre, Nijmegen, the Netherlands. c.delmarATcgp.uq.edu.au In reply: We agree wholeheartedly with Sturmberg and Martin that it is often hard to separate cause from effect. Are the symptoms actually the cause? The old villains — amalgamation and corporatisation — are only two of the main culprits. After all, they have had influence on specialist practice too. The point we tried to make is simply that the intellectual deficiencies in the discipline of general practice, which attracted a public flaying1 after an international conference on general practice research this year in Canada,2 are too often ignored. Addressing them in the context of biomedical research, rather than embracing a different paradigm, may be one solution. The approach advocated by Sturmberg and Martin (ie, emphasising healthcare system organisation and using novel research methods) is fine — we need innovation in healthcare systems and new ways of improving them. Nor do we trivialise patient-focused healthcare, in which huge advances have been made based on general practice research. Patient-focused healthcare was one of the themes of the recent research conference.2 But, if general practice enquiry remains limited to health services research, and if specialists do research on disease without involving general practitioners (however old-fashioned and “mechanistic” that might appear), we will always have difficulty clawing our way out from an intellectually inferior position. A recent example to illustrate the importance of clinical research in general practice is the latest hormone replacement therapy (HRT) uproar. For many years, the benefits of HRT have been simply projected on and promoted in the general population. Now that breast cancer risks have become clearer,3,4 it is obvious that earlier research could have prevented this negative fall-out.5 As Sturmberg and Martin so rightly point out, many illnesses are principally managed in primary care. Should we not become experts (through research and teaching) in their management too?

Joachim P Sturmberg · Carmel M Martin

Umberto Boffa General Practitioner (vocationally registered), 31–35 Burgundy Street, Heidelberg, VIC 3084. Umberto. BoffaAThba.com.au To the Editor: It is fitting for the Journal to recognise the crisis facing Australian general practice (7 July 2003). Every thinking person in the profession knows general practice needs to alter course if it is to survive. They are not lulled by the widely touted sophistry of practice accreditation, vocational registration, “cookbook” talk of disease management and other distractions. However, nothing in the contributions gave me hope for the future of general practice and the community it serves. To paraphrase, Australian general practice is really a specialty, requires postgraduate training as long as that of rocket scientists and needs to be even more dependent on government involvement. It had also better look more like a specialty by doing some research. General practice training may suit the training industry and government, but does not look like producing better doctors. The product looks like a medically qualified hybrid between a social worker and a case manager, something that may titillate government but does not appear to impress the rest of the profession. General practice training relegates to the past the absolute necessity of acquiring the sharpest clinical skills as a diagnostician, and fosters instead the mantra of “better communication skills” and, worse, a disdain for core knowledge. The political nature of this training does not appear to fool potential entrants, who are shunning general practice, nor does its professional façade fool some of our more astute medical leaders.1 But the plight of general practice is posing a hidden danger to the whole profession. The move away from core knowledge in general practice has inspired a “dumbing down” of the profession that is now influencing undergraduate medical education. Under the guise of “problem-oriented learning”, core knowledge is being seriously neglected, such that physiotherapists and nurses will soon be better trained than medical graduates. I believe grassroots general practitioners (not their myriad representatives) need to rebel against government involvement in their professional training (ie, the Royal Australian College of General Practitioners) and reaffirm their “medicalness”. We can not be professionals and have governments determine our future, as suggested by Kidd of the RACGP.2 Australian general practice should look now to the august independence and academic robustness of the Royal Australasian College of Physicians to give us a new flag — not one of specialty, as we are not specialists, but one of independent professional standards and allegiance. Michael R Kidd Professor, and Head, Discipline of General Practice, University of Sydney, 37A Booth Street, Balmain, NSW 2041; and President, Royal Australian College of General Practitioners. michaelATgp.med.usyd.edu.au In reply: Boffa appears to have overlooked the key messages in my editorial, which clearly outlined the risks inherent in government involvement in vocational training for general practice. These risks include a lack of long-term funding commitments, reliance on professional support for success, and the current challenge posed by the poor image of general practice and training requirements among potential registrars. My editorial also clearly stated the need to distinguish medicopolitical objectives from the requirement for high standards of education and training. Boffa’s presumably tongue-in-cheek suggestion about general practitioners joining the Royal Australasian College of Physicians overlooks the success of the Royal Australian College of General Practitioners (RACGP) in setting and maintaining standards for high quality clinical practice, education and training, and research in Australian general practice for nearly 50 years. The RACGP is independent of government. Our core activities are funded by our members. The RACGP remains the largest medical college in Australasia, with over 10 000 GPs as financial members and over 18 000 GPs as members of our Continuing Professional Development program.

Umberto Boffa

Keith S Jones Bayview, NSW. rgjones1ATbigpond.com To the Editor: The Journal’s recent, extremely interesting issue on general practice (7 July 2003) has prompted me to look back at a symposium held at Sydney Hospital on 1 April 1966 (April Fools Day!). The subject was “The future of medicine”. The three speakers were Sir Charles McDonald, Chancellor of the University of Sydney; Mr Harry Jago, NSW Minister for Health; and myself, on behalf of the Australian Medical Association (NSW). My contribution on that day concluded as follows:1 From the facts, figures and trends which I have given you, I would forecast as follows (and again, this must be subject to no radical changes in the international, political or economic framework of the country). There will be a relative decrease in the numbers of doctors available to the community, and the greatest fall will be in the group most needed, the general practitioners. On the other hand, I expect a greater demand by the population for medical services. The average age of the patients will slowly increase, and geriatric problems will make up the bulk of day-to-day medical problems. It is likely that universities will have different types of medical training for those who plan to undertake general practice and those who intend to specialise. The State and other third parties will provide the main channel by which medical practitioners are remunerated, and I hope (but by no means feel certain) that most will be remunerated on a fee-for-service basis. Small country towns will have even less resident medical attention than they command at present, but better transportation and communications will enable them to be serviced from the large towns with base hospitals. In the hospitals, increasing use will be made of full-time and part-time paid specialists, and in addition new hospitals will arise in the form of geriatric hospitals and hospitals staffed by general practitioners. Finally, the social, financial and professional status of the medical practitioner will ultimately depend on professional unity and wise leadership. Loss of status will inevitably occur with breakdown of either of these conditions. Perhaps I should have been a fortune teller!

Keith S Jones

Peter M Brooks Executive Dean, Faculty of Health Sciences, University of Queensland, Edith Cavell Building, Royal Brisbane Hospital, Herston, QLD 4006. p.brooksATmailbox.uq.edu.au To the Editor: Let me congratulate the Editor and his team for their provocative issue on general practice in Australia (7 July 2003). Some of the major challenges are clearly delineated — particularly that of providing care to a chronically ill and ageing population. While general practice in particular may be suffering from decreasing interest among young doctors, medicine in general is not seen by school leavers of today as the profession it was 30 years ago. Many bright school leavers are pursuing the “corporate world” in economics, law and business, but we can promote the overall satisfaction and variability of medicine in general and general practice in particular. The critical issues are outlined in the editorial.1 Taking a leaf from our “economically” driven society, we need to present to governments and the public the evidence that healthcare systems focusing on primary care are associated with higher patient satisfaction, lower overall health expenditure, better population health indicators and lower per capita rates of drug prescribing.2 Surely, governments (and, more importantly, treasuries) will listen to these arguments. We also need to adopt a “whole-of-profession” approach. I am concerned that specialists (particularly in the hospital environment) continue to portray a negative image of general practitioners, particularly to young doctors.3 We can all remember, in our “resident” days, hearing negative comments from consultants: “If only the GP had done this or that or referred the patient earlier”. Part of the problem is that there is still not enough vertical integration between undergraduate and graduate medical school education, postgraduate years 1, 2 and 3 and specialist training. A particular problem is that, after having had increasing exposure to general practice as a student, medical graduates then spend 2–3 years in a hospital environment where they have little or no contact with general practice. During this time they are influenced by hospital specialists who encourage them to pursue the “illth agenda” in hospital medicine and perpetuate negative stereo-types of general practice. Trainee doctors need exposure to positive general practice experiences in these immediate postgraduate years, including general practice terms (especially in rural general practice) along with hospital attachments. This would require significant dialogue between the federal and state health departments but would go some way towards renewing interest in general practice and continuing to provide Australians with one of the best healthcare systems in the world in terms of equity, access, cost and outcomes. Graham Chaffey General Practitioner, Hazelbrook General Practice, 9 Rosedale Avenue, Hazelbrook, NSW 2779. chaffeyblowAToptusnet.com.au To the Editor: Like Julian White, I was deeply moved to read the final chapter in the fable of the white-tail spider.1 White comments that “The lack of strong evidence to support [the association of white-tail spider bites with necrotic ulcers] seemed to be a triviality to be ignored”. However, I wish to take issue with the attitude to GPs reflected in his statement “General practitioners regularly and confidently diagnosed skin lesions as ‘white-tail spider bite’.” What is the evidence for this statement, or does White view it as too trivial to deserve scrutiny? As a GP, I rarely come across a case of spider bite in which a confident diagnosis can be made. However, I am frequently asked questions such as “Could this be a white-tail spider bite?”, and frequently witness patients latching onto one of a list of possibilities, or unwilling to be dissuaded from the diagnosis they have arrived at independently of any medical advice. Furthermore, it is only after the publication of Isbister and Gray’s evidence2 that I am able to define clearly for my patients the effects of white-tail spider bites, rather than leaving room for doubt. It is a cheap shot for a specialist in such a narrow field to malign GPs on the basis of their failure to critically appraise the evidence relating to aetiology of a rare problem for which there was said to be no treatment. It has become common to read de-rogatory statements about GPs by specialists unsupported by evidence. Interestingly, such comments are not aimed at emergency department nurses, resident medical officers, physiotherapists or other specialists. I would argue that this may be of some importance. Denigration of the value of medical training and skills may contribute to negative attitudes towards GPs in the community. This may translate into adverse behaviours such as unwillingness to seek medical advice, reluctance to have children vaccinated, inadequate use of antenatal care services, degradation of communication between medical practitioners, and demoralisation of the medical workforce. It may also make it difficult for people to accept advice about white-tail spider bites. Perhaps White could afford GPs the respect that he does the white-tail spider, rather than taking a random opportunity to malign the competence of GPs. Max Kamien Research Fellow, Department of General Practice, University of Western Australia, 328 Stirling Highway, Claremont, WA 6010. mkamienATcyllene.uwa.edu.au Comment: Chaffey and Brooks draw attention to the negative effects of specialists badmouthing general practitioners: undermining GPs’ self-image and community status, and discouraging medical students and young doctors from pursuing a career in general practice. Hays has made similar observations about problem-based learning exercises, written by specialists, wherein the mismanaged rural patient is “rescued by clinicians in the nearest large teaching hospital”.1 Medical badmouthing has been defined as “unwarranted, negative and denigratory comments made by doctors about other doctors in different branches of medicine”.2 It is most visible when uttered by specialists in teaching hospitals, but is almost equally as common from GPs criticising some real or imagined lack of common sense in the treatment received by one of their patients in a teaching hospital.2 The underlying psychological mechanism of badmouthing stems from a common human need for self-aggrandisement and defining of group membership by aggressively putting down people outside the “in-group”.3 So, while badmouthing is maladaptive behaviour for the medical profession as a whole, it does have some adaptive features for different subgroups. Specialists in private practice usually have good working relationships with GPs — indeed, their practice would suffer if they didn’t. But, in my (non-evidence-based) experience (I haven’t done a study on the topic), nearly all specialists see themselves as part of a medical elite who have achieved their status through having the ambition, energy and fortitude to complete a rigorous postgraduate training and examination process beyond that required of GPs. And we GPs are appropriately grateful for their skills, especially when one of our patients is faced with a life-threatening emergency. Also, most continuing medical education is given by specialists “teaching” GPs. Reciprocal opportunity for constructive GP feedback about patients’ hospital outcomes is rarely given or gratefully received. Specialists and their junior staff are frequently inconvenienced by overloaded outpatient clinics and by emergency patients, referred by GPs, who arrive at 6 pm instead of 9 am. And on rare occasions they see a patient with a necrotic ulcer due to a basal cell carcinoma, referred by a GP who agreed with a patient’s diagnosis of “spider bite”. What the specialist doesn’t see is the other 100 patients bitten by an uncaptured white-tail spider who are managed solely, logically and effectively by GPs. Extrapolating from one or two cases to the whole of general practice is bad epidemiology and evidence of sloppy scientific thinking. Badmouthing is an ingrained feature of human nature and a historically unattractive part of medical culture. It will continue until all doctors realise that they are on the same team, fighting the same war against the many facets of disease and disability. GPs and specialists need to understand and respect each other’s role and task. This requires mechanisms to enable already time-poor doctors to interact regularly with each other. In one survey, about 10% of students admitted that negative comments by specialists about GPs had influenced their decision to reject a career in general practice.2 This was part of the rationale for setting up a medical school counterculture through rural student clubs.4 But even more harmful than badmouthing is the perception by students and young doctors that general practice is an unattractive branch of medicine, beset with governmental red tape, a divided leadership, and, after failure of the Relative Value Study initiatives,5 a guaranteed continuation of poor remuneration for heavy responsibility taken and long hours worked.

Peter M Brooks

Michael J O’Leary Intensive Care Physician, St George Hospital, Gray Street, Kogarah, NSW 2217. m.olearyATunsw.edu.au To the Editor: Hore and colleagues argue for “integrated critical care” as a solution to the problem of providing intensive-care cover for patients in rural and non-tertiary metropolitan hospitals.1 They claim that such an approach is required uniquely in these hospitals, whereas in tertiary centres “subspecialists would be involved in each phase of the management process”. That this occurs is undisputed; however, it is far from the optimal model of care.2 Over the past 3 decades, the management of critically ill patients has evolved to require its own specialty. Other than in the traditional critical-care disciplines of anaesthesia and emergency medicine, training in critical care is not a significant component of specialty training programs. Within tertiary hospitals, therefore, the requirement that critically ill patients be cared for by specialists trained in critical-care medicine (and not a “committee” of subspecialty experts) is no less important than in the rural setting. There is consequently little difference between the skills and experience required of tertiary and rural critical-care specialists, and the continuum of critical care is the same in both settings. The recent creation of the Joint Faculty of Intensive Care Medicine by the Royal Australasian College of Physicians (RACP) and the Australian and New Zealand College of Anaesthetists (ANZCA) has enabled many of the past artificial barriers to effective critical-care training and accreditation in Australasia to be broken down. It is now possible to enter intensive-care training from varied training programs, including those of the Australasian College for Emergency Medicine, the RACP and the ANZCA. Completion of training is recognised by successfully passing a broad-based critical-care examination. The argument that training could and should include rural practice is well made. However, any comprehensive critical-care training will inevitably require some high-volume experience only available within a tertiary institution. That there are differences in emphasis in the workload of our rural colleagues should be recognised. However, our job is essentially the same. There is no need for a separate specialty, but there is a need to ensure provision of high quality critical-care services to all patients into the future.

Michael J O’Leary

Neil T Matthews Dean, Joint Faculty of Intensive Care Medicine, Australian and New Zealand College of Anaesthetists and Royal Australasian College of Physicians, 630 St Kilda Road, Melbourne, VIC 3004. jficmATanzca.edu.au To the Editor: The article by Hore et al1 raises many important issues for acute-care medicine in rural settings, including the need for specialists to be multiskilled and collaborate across disciplines, the lack of professional support for rural training programs and rural specialists, and the difficulty of overseeing multidisciplinary credentialling. These issues are not unique to acute-care medicine or to the Joint Faculty of Intensive Care Medicine (JFICM). They are problems for other faculties and colleges, rural healthcare facilities and governments. Many rural specialist services in Australia and New Zealand have the benefit of considerable expertise provided by medical practitioners who are not necessarily Fellows of the relevant specialist colleges. They should be supported by collaborative efforts of the relevant colleges, which should develop initiatives to increase the numbers of specialist medical practitioners working in rural settings. The JFICM, representing some 464 Fellows and 391 trainees, has been developing frameworks to support rural intensive care. JFICM’s goals are to develop a more flexible training program to encourage rural training; to establish a rural officer on the JFICM Board; to support a rural focus group, working through rural structures with the Committee of Presidents of Medical Colleges; and to explore liaisons with other colleges. The argument for developing a specialty of integrated critical-care medicine implies that current programs are deficient and cannot provide a holistic, integrated approach to rural acute care. Hore and colleagues argue that “there is no formal program for training specialists for multidisciplinary rural critical-care practice”. I must correct them on this point. Their proposal in fact eloquently describes the elements of the JFICM training program, which has existed since 1977. An internationally recognised and comprehensive intensive-care/critical-care training program, its status has been confirmed with its successful accreditation by the Australian Medical Council. The authors also suggest that “critical care” is in some way different from “intensive care”. This is not contemporary reality. The terms “intensive care” and “critical care” are one and the same. Healthcare workers in rural and remote locations have collaboratively developed multidisciplinary working relationships that provide comprehensive acute and non-acute healthcare. The same approach should be used by authoritative bodies to resolve important issues for rural specialists and training programs. The issues do not require establishing a separate specialty. The above comments notwithstanding, the suggestion by Hore and colleagues that specialties involved in acute care lead a collaborative process to strengthen clinical links is to be applauded. The discussions need to be inclusive of medical specialists working in intensive care medicine.

Neil T Matthews

John Stokes Director of Intensive Care, Mater Private Hospital, Fulham Road, Pimlico, QLD 4812. john.stokesATmatertsv.org.au To the Editor: Hore et al1 raise some very pertinent issues relating to the delivery of integrated critical care in the rural setting and raise the possibility of a new specialty to help solve the problem. The issue of providing many services in rural, remote and regional Australia will not be solved by more subspecialisation, which is actually having the effect of centralising services in major metropolitan centres distant from important and productive portions of our population. Rather than propagate another group of subspecialists, our medical colleges, and in particular the Australian Medical Council (AMC), need to look at new ways to empower specialists and generalists who work in regional areas to continue to provide services without their expertise being undermined in the eyes of the public. We need to encourage state governments to spread services more widely rather than to centralise and remove rural services. The push for so-called “centres of excellence” that draw all patients to a few centres is for the convenience of the few and is financially attractive to governments. Artificial standards for care (produced by the medical colleges), with restrictions on practice related to the number of patients treated or the number of patients ventilated, are unrelated to the quality of care delivered to individual patients. These restrictions may soon lead to many specialties not being sustainable outside capital cities or major urban centres because of insufficient caseload to meet the guidelines. In regional areas, specialists (such as anaesthetists) who have the experience to provide additional services (eg, intensive care), but not the formal recognition, are being discouraged from doing so by the college guidelines and the current legal climate. My observation of the actions of most medical colleges is that, by their good intention to maintain standards, they are supporting the concentration of services but are discouraging the wide delivery of services. Surely, when we do studies that demonstrate that care is better delivered in special or centralised units, the aim should be to find out why, and to seek ways to deliver that expertise in less specialised and more decentralised units, rather than to immediately call for more centralisation of services. This, I believe, is the real challenge for our AMC and our Committee of Presidents of Medical Colleges.

John Stokes

Craig T Hore,* William Lancashire,† John B Roberts,‡ Robert Fassett§ * Director of Critical Care, † Director of Critical Training, ‡ Director of Emergency Medicine, Port Macquarie Base Hospital, PO Box 2466, Port Macquarie, NSW 2444; § Director of Renal Unit, Department of Medicine, Launceston General Hospital, Launceston, TAS. horeATmaynegroup.com In reply: We thank the correspondents for their interest, insights and discussion. In general, there appears to be much common ground between our views and theirs, although a few points of clarification need to be made. We do not argue that a “committee of subspecialty experts” undertakes critical care in tertiary centres, as O’Leary suggests. The subspecialists we refer to are those within the discipline of critical care, particularly intensivists, emergency physicians and anaesthetists. In tertiary settings, these specialists operate predominantly within their base critical-care “subspecialty”. In rural settings, they are also involved in the other phases of critical care on a regular basis. Hence, while the principles of critical care are similar in rural and metropolitan settings, their effective delivery differs. We do not question that the Joint Faculty of Intensive Care Medicine (JFICM) provides a comprehensive intensive-care training program. However, there are very few JFICM-accredited intensive-care units in Australia outside metropolitan centres, and few JFICM-endorsed specialists working in the public sector in rural and remote intensive-care units.1 Unfortunately, this suggests that the current JFICM program is not addressing the needs of rural and remote centres. Indeed, in their recent review, the Australian Medical Council encouraged the JFICM to give more opportunity and encouragement for trainees to gain rural experience.2 The steps being undertaken by the JFICM that Matthews outlines are encouraging. We believe the statement by Matthews that “intensive care and critical care are one and the same” is insular and at odds with the reality of critical care, especially outside tertiary metropolitan centres. It is pleasing to note that O’Leary includes emergency medicine as a “traditional critical-care discipline”. There are strong clinical and curriculum similarities between emergency medicine and intensive-care medicine that cannot be overlooked. In this respect, rural centres may be leading the way in further breaking down barriers. The formation of the JFICM has been a positive step, but it remains a liaison of only two bodies. A greater presence from emergency medicine, rural anaesthesia, rural medicine and surgery would be beneficial and a significant step towards a truly multidisciplinary specialty. We reaffirm that, to ensure high standards of critical care for rural patients, solutions need to match the existing realities of rural practice. We agree that these must be collaborative and inclusive. The integrated critical-care model has been successful in a number of rural hospitals and offers potential for wider implementation.

Craig T Hore · William Lancashire · John B Roberts · Robert Fassett

John Boyages Executive Director, New South Wales Breast Cancer Institute, PO Box 143, Westmead, NSW 2145. johnbATbci.org.au To the Editor: I read with interest the position paper on breast self-examination by Crossing and Manaszewicz.1 I would like to point out an error of fact. The New South Wales Breast Cancer Institute (NSW BCI) has been promoting breast self-examination for many years. As a practising clinician, every month I see several women who have found small breast cancers using instructions from an old New Idea shower card or similar information. The position of the NSW BCI, which is stated clearly on our website, is as follows: Women should consider an annual breast examination by their general practitioner, particularly when they attend for a Pap test or a blood pressure check. Mammography should be performed at least every 2 years, particularly for women over 50 years, and earlier for women with a family history of breast cancer. Women should practise regular breast self-examination (BSE). Information about BSE can be obtained from GPs and the BCI has produced a fact sheet (www.bci.org.au/public/guides/g8bse.htm). BSE costs nothing and, in our opinion, does more good than harm. However, BSE should be combined with regular mammography and an examination by a GP. For a woman with a family history of breast cancer, or who has been diagnosed with breast cancer, BSE can be helpful in finding disease. Mammography is only about 95% reliable. BSE complements mammography. Certain types of breast cancer are often difficult to diagnose with mammography, for example “lobular” cancer, and BSE may help in finding such cancers. No evidence has been published that would justify a change in this position.

John Boyages

Back to the bedside When his medical students queried the importance of physical examination in caring for patients already admitted to hospital, an experienced physician-educator in the USA sought directly relevant evidence-based data. Finding none, he has filled the gap admirably with, literally, his own hands. Dr Brendan Reilly conducted a daily bedside assessment of 100 consecutive patients admitted by a general medical service team at a public teaching hospital. An independent panel confirmed that, in one out of four cases, his findings led to a revised diagnosis and a major change in clinical management. Bedside is bedrock! Or, as Dr Reilly put it, "the practice of evidence-based medicine is the practice of medicine, not the practice of evidence". Lancet 2003; 362: 1100-1105 Of genes and gender Australian researchers may have found out why men are predisposed to atherosclerosis — not because they lack "helpful" oestrogen, but because they have "unhelpful" testosterone on board. Using a range of techniques, the researchers discovered that dihydrotestosterone acts on the human macrophage in a gender-specific way. In macrophages derived from male donors, androgens led to increased expression of atherosclerosis-related genes and a net increase in cholesteryl ester accumulation. Such effects were not seen in macrophages derived from female donors. J Am Coll Cardiol 2003; 42: 1306-1313 Call for sick cover UK authors suggest that providing adequate cover for junior doctors who are sick with an infectious illness is one measure that could help protect patients from undesirable exposure to iatrogenic risk. Another would be to encourage doctors to use hospitals' occupational health services. The authors conducted a survey of junior hospital doctors who worked in a large teaching hospital in 1993, and repeated the survey in 2001. Over a 6-month period, most of the doctors had one or more episodes of infectious illness (eg, an URTI or vomiting and/or diarrhoea). At the time of the later survey, more doctors were taking at least some sick leave; however, most still stayed at their posts or returned while still sick. When asked why they had done so, concern about consultant pressure and increasing colleagues' workloads were commonly cited. Occup Environ Med 2003; 60: 699-700 Mummy speak Rehydrated tissue obtained from a paravulval skin lesion in a 16th- century mummy of noblewoman Mary of Aragon has provided direct evidence that human papillomavirus (HPV) infection existed at the time of the Renaissance. Not only was infection with the highly oncogenic HPV 18 detected but also JC9813 DNA, a recently "discovered" HPV with low oncogenic potential. The mummy is one of 38 housed in the sacristy of the Basilica of Saint Domenico Maggiore in Naples, Italy. Lancet 2003; 362: 1160 Hip health The Rotterdam Study, a cohort study of 7891 individuals aged 55 years or older, has linked long-term thiazide diuretic use with reduced risk of hip fracture. During a total follow-up of 58 009 person-years, 281 hip fractures had occurred. Risk for fracture was reduced by about half in people who had been exposed to thiazides for more than one year. However, the protective effect disappeared after four months of stopping thiazide treatment. Study authors said thiazides may protect against hip fracture by reducing renal calcium clearance or by inducing metabolic alkalosis, thus inhibiting bone resorption. Ann Intern Med 2003; 139: 476-482 Ulcer all-clear According to Taiwanese researchers, maintenance treatment is not needed when managing patients with bleeding peptic ulcers associated with Helicobacter pylori — as long as H. pylori has been successfully eradicated and the ulcer has healed. In their randomised controlled trial involving 82 patients followed for 5 years, peptic ulceration did not recur in anyone, whether or not the subject had received one of three 16-week maintenance regimens (antacids, bismuth or famotidine). Arch Intern Med 2003; 163: 2020-2024 Beer bellies are unreal Czech researchers have challenged the popular notion that drinking beer leads to obesity. They compared waist-hip ratio (WHR) and body mass index (BMI) in 845 "exclusive" beer drinkers with the same values in 1144 non-drinkers. Taking other risk factors for obesity into account, beer intake was not related to WHR or BMI in men. In women, there was no link with WHR but a weak inverse association with BMI. Their paper stated that, at 155 L per person, the Czech Republic has the highest registered per capita beer consumption of any country. Eur J Clin Nutr 2003; 57: 1250-1253 — Dr Ann Gregory, MJA

Ann Gregory