Volume 180 Issue 1

A missed opportunity for improvements to medical practice Medical practitioners in New Zealand are to be regulated by a new piece of legislation — the Health Practitioners Competence Assurance (HPCA) Act. The stated purpose of the Act — “to protect the health and safety of members of the public by providing for mechanisms to ensure that health practitioners are competent and fit to practise their professions” — while laudable, is ambitious and conceptually flawed. The resulting legislation is complicated and undermines professional functioning. Its effect may be exactly the opposite of its intention . . . The initial aims of the Bill, as proposed by the Minister of Health, were widely supported. It was to be an omnibus piece of legislation designed to bring 16 health practitioner groups (including dentists, nurses, chiropractors, midwives, pharmacists, psychologists and other allied health practitioners), regulated by 11 statutes, into line with the registration, competency and discipline provisions of the NZ Medical Practitioners Act 1995. The Medical Practitioners Act was modern, effective and cognisant of societal changes (such as the need for openness by having disciplinary hearings in public). There had been wide consultation and debate associated with its development, and it had the support of major medical professional groups, both in the development phase and in practice. During a long gestation period, however, the initial concept of the HPCA Bill became lost under the onslaught of multiple competing agendas. The resulting legislation is complicated and undermines professional functioning. Its effect may be exactly the opposite of its intention — to make the provision of health services safer and of higher quality. From initial tentative support, the leading medical professional organisation in New Zealand — the New Zealand Medical Association (NZMA) — along with the union representing senior hospital doctors (the Association of Salaried Medical Specialists), and the major medical colleges of surgery and general practice, ended up opposing the legislation in favour of retaining regulation under the Medical Practitioners Act. We were unsuccessful. So how did these changes come about? And how did the New Zealand Government come to pass a law that was actively opposed by organisations representing many of the people who would be bound by it? First of all, there was no doubting that much of the legislation covering other health practitioners was outdated and in need of modernising (eg, laws regulating occupational therapists and physiotherapists dated back to 1949). The advocacy of many of these other health practitioner groups, while publicly supportive of the concerns of the medical profession, was in the end more muted because of issues with their existing outdated legislation. Secondly, Ministry of Health consultation on the Bill was primarily with the statutory bodies that would be administering the new legislation (such as the Medical Council of New Zealand). These bodies do not and cannot represent practitioners, as their statutory role is to regulate them. Professional medical organisations received little consultation. Such consultation that did occur was late and completely inadequate, and despite strong and detailed responses, concerns raised were largely dismissed. Thirdly, there is a political perception that more political and external controls on the professions are what society wants. This runs counter to repeated polls that place professions such as medicine and nursing high in the public trust, with politicians scoring poorly in this regard. It also ignores the growing body of international opinion that competence, quality and safety are better assured through models structured on professionalism rather than state control.1 Consequently, as the legislation developed, it moved substantially away from the concepts and clarity of processes of the Medical Practitioners Act on which it was supposed to be based. The NZMA believes the new Act is a missed opportunity for improvements to medical practice and offers no assurance of further benefits to patients. It will increase political influence and bureaucratic involvement in the practice of medicine, with a consequent decrease in professional self-regulation, which has been at the core of the development of safe healthcare for New Zealanders.2 As Onora O’Neill, Cambridge Professor of Philosophy, as well as teacher, bioethicist and politician, said in her 2002 Reith lectures:3 Plants don’t flourish when we pull them up too often to check how their roots are growing: political institutional and professional life too may not go well if we constantly uproot them to demonstrate that everything is transparent and trustworthy. Perhaps the culture of accountability that we are relentlessly building for ourselves actually damages trust rather than supporting it. The Act, as passed (among other things): provides for additional Ministerial powers; introduces scopes of practice for all health practitioners; introduces restricted activities; and mandates regulatory authorities to set standards of ethical conduct. Along with cumbersome bureaucratic requirements, the HPCA Act significantly increases political control over doctors. The Minister of Health now has powers to resolve disputes over scopes of practice, to designate restricted activities, and to appoint all the members of regulatory authorities (eg, the Medical Council, which currently has four members elected by the profession). The Minister may also allow new health practitioner groups to become regulated under the Act. The introduction of legislation-based scopes of practice is an unproven concept and has the potential to bring about substantial change to the practice of medicine, particularly if scopes of practice are narrow and, as the NZMA fears, become highly codified and prescriptive. Practitioners will be limited in the activities they can practise by the details of their scope of practice, irrespective of possible wider competencies, and disciplined if they step outside that scope. The Minister of Health now has powers to resolve disputes between authorities over scopes of practice, which should be entirely a matter for the professions and not subject to bureaucratic influence or political decisions. Consequent changes in other statutes, the decisions of future authorities appointed by the Minister of Health, determinations by case law, and inclusion in employment contracts, with time, are likely to make scopes of practice more restrictive and task oriented. Restricted activities, which may be undertaken only by specified practitioners or disciplines, are another new and untested legislative concept, with uncertain outcomes. As the process is defined in the Act, the declaration of restricted activities may potentially be responsive less to professional and patient safety realities than to political pragmatism. Another major concern is the mandating of statutory regulatory authorities to set standards of ethical conduct. Effectively, this could mean people appointed by the government setting ethical standards for the profession. For the safety of patients, the independence of medical ethics must be protected from political agendas. William Sullivan, a prominent North American sociologist said: Neither economic incentives nor technology nor administrative control has proved an effective surrogate for the commitment to integrity evoked in the ideal of professionalism.4 Health legislation can actively promote professionalism — or it can discourage it. The NZMA believes that the HPCA Act is a backward step for the promotion of professionalism in medicine. We are establishing a monitoring process to assess the effects of the Act on both doctors and their patients so that we will be prepared for the planned review in 2006.2

Tricia A Briscoe MB ChB, BSc, DipObst

Improving safety is important, but in many regions antivenoms are not available Although snakebite has been a subject of medical interest since antiquity, and despite it continuing to affect millions of people annually,1,2 it remains one of the neglected health problems of the tropics.1-3 Today, almost lost amidst the preoccupation with shortages of vaccines and antiretroviral medication in the developing world, there is a crisis in antivenom availability in the very same nations.3 In response, the World Health Organization recently held its first antivenom workshop in more than 20 years, to discuss the global supply and quality of antivenoms.4 However, perhaps more importantly, a growing community of physicians from the regions with the greatest snakebite burden have become more active in seeking solutions to at least some part of this ancient problem. The study by Gawarammana and colleagues in Sri Lanka (page 20) is one example of such scholarship.5 It is a welcome addition to the relatively scant clinical trial literature examining the management of snakebite. In a well conducted but underpowered study, the authors document a reduction in mild-to-moderate acute reactions to antivenom with an antihistamine bolus in conjunction with a hydrocortisone infusion. However, in the clinically important endpoints of moderate and severe reactions, there was insufficient power to confirm a trend toward fewer reactions in the hydrocortisone-containing regimens. This study is in contrast to a previous study from Brazil that failed to demonstrate any difference in early antivenom reactions with prophylactic promethazine alone.6 Most notable in this and an earlier Sri Lankan study,7 which assessed subcutaneous adrenaline as prophylaxis against acute antivenom reactions, was the extremely high rate of such reactions — in this study, almost half the patients had moderate or severe reactions sufficient to require adrenaline. This differs considerably from the rates in Australia (reported as 10% in the absence of premedication8 and 4.6% with premedication9). Snake antivenom is derived from antibodies of immunised animals; the rates of reactions appear to vary with the species of antibody origin, the extent of pepsin digestion, the presence of molecular aggregates and the total protein content of the product.4,10 It has been presumed that most acute reactions relate to the extent of complement activation from Fc receptor binding,10,11 with improvements in quality having largely resulted from enhancements in antivenom processing.4 However, the recent WHO workshop called for a re-examination of old assumptions concerning such reactions and, consequently, what constitutes “best practice” for antivenom manufacture and administration.4 Although Sutherland attributed the low reaction rate to Australian snake antivenoms to a series of refinements in the recommendations from the former Commonwealth Serum Laboratories concerning antivenom administration, including the practice of prophylactic use of adrenaline and hydrocortisone,9 current national reaction rates and associated clinical practice remain unclear.12 It is intended that recently introduced refinements to the Australian coding standards for ICD-10-AM (third edition)13 will assist in closing this gap in the national toxinology evidence base. However, because of the inherent delays in the collation of national statistics, and as current methods are far from complete,12 it would seem appropriate to mandate reporting of adverse antivenom reactions to facilitate appropriate follow-up. Such a system is in place in Brazil.14 Meanwhile, there is a dichotomy in current premedication recommendations for reducing acute reactions to snake antivenoms in Australia. In Australia’s toxinology textbook,15 Sutherland and Tibballs considered the evidence available up to 2001 and concluded that “premedication with subcutaneous adrenaline is recommended (0.25 mg for an adult, 0.005 mg/kg for a child) before antivenom therapy”. By contrast, a recent review by Currie concluded: “with the very low rate of severe reactions to antivenom seen in Australia . . . and the ability of emergency medicine physicians to adequately manage reactions that may occur, a policy of withholding premedication but always having adrenaline drawn up and ready is now recommended by many authorities and is policy in the Northern Territory”.16 In the middle is Australia’s antivenom manufacturer, CSL Limited: “Some authorities have advocated premedication with subcutaneous adrenaline and intravenous antihistamine, particularly in those patients who are known to be at risk, but such use is controversial”.17 Readers should consult the references for further details of the respective arguments and the history and evolution of the manufacturer’s recommendations.8,9 Although it is likely that well staffed major hospitals can, if it is recognised early, readily and rapidly manage antivenom reactions, such events can be severe, progressive and are not necessarily remediable.18 Therefore, it is the small rural centres, with more limited staffing and facilities, that may benefit most from the apparent efficacy of adrenaline premedication.7,9,15 If premedication is to be given, currently the best evidence is that it should be subcutaneous adrenaline.7 However, it is notable that Sutherland himself was agreeable to some “alternative but equally effective replacement for adrenaline”.9 And so we return to the search in Sri Lanka for such a replacement (or adjunct). The apparent benefit from the combination of an H1 antagonist and hydrocortisone described here suggests that a combination of H1 and H2 blockers may bring additional benefit, as has been proven for the treatment of acute allergic syndromes.19 However, the applicability of this study, in which a poor-quality antivenom resulted in extreme reaction rates, to the situation in Australia (where low reaction rates are reported) is uncertain. Interestingly, the antivenom used (the Haffine polyvalent snake antivenom) appears to be an equine Fab2 product,20 the same as that used in Australia.17 The Indian antivenom that was used in Sri Lanka, however, is a lyophilised preparation5, whereas the Australian antivenom is a liquid product. Therefore, aside from the premedication issue, there are clearly opportunities to improve the reaction rate by improved processing of this Indian product.4 Unfortunately, these debates are irrelevant for most people affected by snakebite, predominantly in the rural tropics. For example, in Papua New Guinea the high cost of Australian antivenoms puts adequate supplies beyond the reach of the health budget.2 For people in countries where the available antivenoms are of poorer quality, studies such as these, even if they only demonstrate reductions in reaction rates from 80% to 50%, are applauded; more are sorely needed. But for most countries where antivenoms are unavailable or unaffordable, there is little to do but measure smoke from the burning house while praying for rain.

Allen C Cheng MB BS, FRACP, GradDipClinEpid · Ken D Winkel BMedSci, PhD, FACTM

Almost 200 health leaders from Australia, New Zealand, the United Kingdom, Canada and Singapore attended the Health Leaders Network’s conference “Designing the health workforce for the 21st century”, held in Melbourne, 2–3 April 2003. The conference allowed participants to think afresh about healthcare and its current and future demands, and to explore what type of health workforce, especially clinical, is required to meet the demands of the 21st century. Two key themes ran through the conference — recruiting and retaining the workforce, and the need for changed and new roles to meet changing work requirements. 21st century healthcareThe conference theme used the picture of 21st century healthcare painted by Liam J Donaldson (Chief Medical Officer for England):1 The agenda for healthcare in developed countries in the 21st century will be dominated by a vision of quality which seeks to address the deep seated problems of the past . . . The need for health services to give priority to developing health professionals equipped to practise in a new way and thrive in new organisational environments requires a rapid response to reshape curricula and training programmes . . . Health care in the 21st century will require a new kind of health professional: someone who is equipped to transcend the traditional doctor–patient relationships to reach a new level of partnership with patients; someone who can lead, manage and work effectively in a team and organisational environment; someone who can practise safe high quality care but also constantly see and create the opportunities for improvement. The conference explored the development of a sustainable health workforce and the range of new skills that health professionals will require into the future, including: the requirements for the sustainable development of the 21st century health workforce; how various changes are affecting the clinical workforce; the implications of new emerging models of service provision and modes of practice for the clinical workforce; and what challenges these emerging models present for the development of the current health workforce and the training and development of new healthcare workers. International workforce benchmarkingSeveral overseas speakers addressed the conference, providing an opportunity to learn how workforce issues are being handled elsewhere, using comparison as a stimulus for critical reflection and analysis of their own situations. The Canadian speakers, Dr Linda O’Brien-Pallas (Professor, Faculty of Nursing, University of Toronto) and Gail Tomblin-Murphy (Associate Professor, School of Nursing, Dalhousie University, Nova Scotia) indicated that Canada has identified human resource planning for the healthcare sector as the dominant health policy issue for the next 5 years. High-level commitmentThe keynote speaker, Mr David Fillingham (Chief Executive Officer, National Health Service [NHS] Modernisation Agency), identified some healthcare challenges.2 These are not unique to the United Kingdom, and include: the ageing population; the burden of chronic disease; the emergence of information and communications technology supporting new forms of care delivery; the shift in emphasis from services centred on the healthcare professional to patient-centred services; technological advances in healthcare that are prompting changes in the demand for services (eg, increased interest in health and access to health-related information through online services are driving consumers’ expectations of quality and choice, and creating more discerning and demanding patients); and issues in relation to education, training, regulation, accreditation, and pay and reward. Clearly demonstrating the commitment to workforce development and reform in the UK, he discussed the ambitious 10-year program that is underway to transform the NHS.2 This includes establishing the NHS Modernisation Agency, which has been set up to promote improvement within the UK health system, and the funding of a major “Changing Workforce Programme” in 2000. The Programme . . . has been based initially on 13 national pilot sites, which have developed well over 100 new job roles. Each site has focussed on a theme where new ways of working could improve patient care, the aim being to test out job and role changes in a practical healthcare setting and to identify and overcome the blocks to the development of new job roles . . . Some examples of the types of new roles being developed include those of chronic disease practitioners in disciplines such as cardiac care and respiratory medicine. These posts operate on the interface between primary and secondary care, and help avoid unnecessary hospitalisation and facilitate earlier discharge. Challenging work roles and valuesThis conference challenged participants to move away from traditional ways of doing things and to “open their minds and hearts” to different agendas. Training and education were key discussion points by several speakers. Di Lawson (Chief Executive Officer, Community Services and Health Training Australia) spoke about “Changing work roles in the health services industry” and the effect this would have on the workforce of the future. She discussed the vocational education and training (VET) sector, which provides education and training for work, and ways to develop and recognise the competencies and skills of learners. Work is under way in the VET sector to develop better training programs for a variety of health technicians and support workers. She highlighted that it is easy to forget that the work of high-performance healthcare professionals depends on the knowledge and skills of many others in the organisation. Although the health technicians workforce (numbering about 10 000) is a small proportion of the overall vocational workforce in health (about 150 000), it makes a vital contribution to service delivery. Ms Lawson highlighted the constraints on modern healthcare (such as population factors, government policy, quality and safety of services, funding, workplace culture, productivity and staff retention), and challenged participants to consider the three noticeable trends that are emerging in the workforce (across the board, not just in health): People are moving very strongly towards work–life balance models. People are motivated by a complex structure of rewards that are heavily supported by non-financial benefits. People will move quickly if their expectations are not met. These contributions were reinforced by Dr Michael Walsh (Chief Executive Officer, Bayside Health, Victoria), who also stressed that health is facing significant workforce challenges in the near future (Box). The broadcaster Julie McCrossin, who has had a longstanding interest in consumer issues in health, highlighted that benefits will occur if healthcare professionals join with consumers in addressing the many and varied challenges in healthcare. Lessons learnt from other industry sectorsThe conference also explored workforce issues in the banking industry. The paper presented by Greg Barnier (Head of People and Performance Service and Operations Centre, Westpac Banking Corporation), “Effective recruitment and retention strategies in the face of a changing demographic picture”, highlighted the workforce planning implications of Australia’s ageing population, “a global issue which impacts our future business sustainability”. Developing a sustainable workforce for bankingA review of Westpac’s workforce demonstrated a mismatch between its workforce and customer base. Eighty per cent of the future workforce growth will be in age groups 45 and over. Barnier pointed out that the current workforce age profile in banking does not match current Australian labour force projections3 (more than 36% of Westpac staff are aged between 26 and 35 years, whereas the current Australian labour force has only 23% in that age group and the number is declining). Nor do the projections match Westpac’s customer base (39% of its customers are aged 45 years or more, whereas 20% of employees match that age profile). Furthermore, Westpac research shows that older customers prefer to deal with more experienced staff, especially when discussing certain banking issues, such as superannuation and investment strategies. The bank is now actively recruiting older workers. All the evidence internationally and in Australia4 suggests that many of the myths about older workers are wrong. Mature aged workers have a stronger work ethic; higher productivity or work quality; lower absenteeism due to sickness; better corporate knowledge; and an ability to learn new skills. Westpac is also focusing on making itself more competitive in recruitment. All indications suggest that it is increasingly becoming a sellers market for skilled labour, whether in banking or health. Westpac research shows that we already have a multigenerational workforce: Matures/veterans (aged 55–70); Baby Boomers (aged 38–54); Generation X (aged 23–37); and Generation Y (born after 1980). Each generation has different drivers that will attract and retain them in the workforce. The different approach that the four generations in your workforce have to their jobs, careers, families and personal lives means as the labour market shifts we need to adapt our approach to managing people. Barnier questioned whether the healthcare sector faced similar issues with their workforce planning, recruitment and retention. The consensus was that it did. In coming years, the source of new recruits will change significantly for both industry sectors (banking and healthcare), effectively putting them in direct competition in the “war” for talent. Recruitment and retentionIn addition to the banking industry, the conference turned to the airline industry as a model for lessons in safety and quality. Both Dr Darryl Mackender (Gastroenterologist, Erromed, Brisbane — Human Factors in Health Training) and Professor Cliff Hughes (Cardiothoracic Surgeon, Royal North Shore Hospital, and Council Member, Safe Staffing Taskforce, Australian Council for Safety and Quality in Healthcare) highlighted the importance of communication skills and teamwork. They drew from the experiences of the aviation industry and its shake-up in the 1960s after some tragic accident statistics prompted the industry to look at staffing, work practices, rostering and how technology might be able to assist in reducing fatalities, and the reporting and investigation of “near misses”. In 1960, there were 45 major accidents per million departures, but by 1993 this figure had been reduced to two major accidents per million departures.5 Eighty per cent of airline accidents were shown to be due to avoidable human factors. Both presenters urged that health systems take note of these lessons and consider how successful approaches in other industries can be used in health. Of special relevance to health is the information about safe working hours and the effect of fatigue on performance. Health–tertiary education interfaceRecognising the crucial role tertiary education plays in preparing graduates for the healthcare sector, a couple of speakers analysed the benefits of good working relationships between the health system and tertiary education so that graduates are prepared for work in the health system, and the transition to work is smooth. Professor Peter Smith (Dean, Faculty of Medical and Health Sciences, Auckland University) and Dr Judith Clare (Professor of Nursing, Flinders University) both highlighted new approaches to health workforce training. Smith focused on quality and safety issues around systems failures and the benefits of interprofessional learning (“Occasions where 2 or more professions learn from and about each other to improve collaboration and the quality of care”)6 and Clare discussed clinical education in nursing and partnerships for improving patient care, recruitment and retention of registered nurses. Citing the level of dissatisfaction with the models of clinical placement implemented by schools of nursing (long before the transfer of nursing education to the tertiary sector), Clare discussed work at Flinders University in 1997, with the establishment of four dedicated education units (DEUs). There are now 32 DEUs in a range of healthcare agencies, managing 1100 students each year. In these units, optimal clinical learning is driven by practice-based assumptions and activities. ConclusionThe conference identified the issues of current and projected health workforce shortages in Australia and New Zealand. The take-home message was that we are only just touching the tip of the iceberg — and that further exploring and exchanging of ideas on new ways of working and new approaches to healthcare delivery will be crucial as we try to do more with less. Participants were challenged to: Think beyond numbers when considering recruitment and retention issues, and to explore how developing a better understanding of the specific needs of the different age cohorts and new roles and categories of healthcare workers can assist with maintaining a sustainable health workforce; Explore ways of working more effectively with consumers as partners; and Ensure that the health workforce is appropriately skilled for the 21st century, particularly recognising the importance of communication skills and teamwork as specific and identifiable capabilities, in addition to the traditional clinical skills. The conference presentations from the 2003 event are available on the Health Leaders Network website (www.hln.com.au). Workforce challenges that will affect the healthcare sector in the near future Demographic or social Ageing workforce Decline of “careers for life” Recruitment (more choices of career, which compete with health) Professional requirements More pre- and post-practice training More specialisation Safe practice, safe working hours Individual preferences Lifestyle matters and flexibility Retention (mobility in an era of shortage) Pressure, scrutiny and burn-out Nature of work Specialisation and integration Safe practice and audit More time training, retraining and auditing practice, less time practising Place of work Increasingly towards community and home Who you work with Multidisciplinary teams Working across traditional structures New roles, new professionals Machines and the caring professions Information technology “Labour-saving” technology

Jennifer A Alexander MB BS, MHP, MComm · Sue M Thomson · John A Ramsay

Objective: To establish the prevalence and predictors of skin screening by general practitioners in regional Queensland.Design: Questionnaire administered to participants by professional interviewers via telephone.Participants and setting: Participants were 3100 adults aged ≥ 30 years (66.9% overall response rate), selected from residents of 18 regional Queensland communities with populations of between 2000 and 10 000 (as recorded in the 1996 Australian census). Within the last 10 communities surveyed, an additional telephone survey of 727 participants evaluated mole density. The survey was conducted between January and October 1998.Main outcome measure: Prevalence of whole-body skin examinations by GPs.Results: 11% of participants reported a whole-body skin examination by a GP during the previous 12 months, and 20% during the previous 3 years. Men and women reported a similar prevalence of whole-body skin examinations. Factors associated with a significantly increased likelihood of having had a whole-body skin examination within the previous 3 years included a positive attitude towards skin screening, a personal history of non-melanoma skin cancer, a tendency to burn, and having more than four moles on the right upper arm.Conclusions: A substantial proportion of Queenslanders undergo skin screening. Those at highest risk for skin cancer are more likely to be screened.

Monika Janda PhD · Philippa H Youl MPH · Joanne F Aitken PhD · Mark Elwood MD · Ian T Ring FAFPHM · David W Firman MMath · John B Lowe DrPH

Objective: To identify doctor and patient characteristics associated with excision of benign versus malignant pigmented skin lesions.Design, setting and participants: Retrospective audit of data on 4741 pigmented skin lesions excised from November 1998 to February 2000 by 468 general practitioners (39% response rate) from 223 practices in Perth, WA. (The data used were from the baseline period of a randomised controlled trial of a diagnostic aid for pigmented skin lesions.)Main outcome measure: The number needed to treat (NNT), defined as the number of pigmented lesions needed to be excised to identify one melanoma, in relation to demographic characteristics of GPs and patients.Results: Relatively more benign lesions were excised per melanoma (NNT = 83) in the youngest patients (aged 10–19 years) compared with the oldest (aged ≥ 70) (NNT = 11) (P [trend] < 0.001), in females (NNT = 37) compared with males (NNT = 23) (P = 0.02), and in the most socioeconomically disadvantaged (NNT = 60) compared with the least disadvantaged group (NNT = 20) (P [trend] < 0.001). The most recently graduated GPs excised more benign lesions for each melanoma (NNT = 59) than the least recently graduated (NNT = 22) (P [trend] = 0.01).Conclusions: GPs could raise their threshold for excising pigmented lesions in patients who are young, female, or from areas of low socioeconomic status, or if the GPs themselves are recent graduates.

Dallas R English PhD · Chris Del Mar MD · Robert C Burton MD, PhD

Objective: To investigate the efficacy of continuous infusion of hydrocortisone with or without chlorpheniramine bolus against early adverse reactions to polyspecific antivenom.Design and setting: Prospective, double-blind, randomised, placebo-controlled trial at General Hospital, Anuradhapura, Sri Lanka.Subjects: 52 patients with snake envenoming were randomised to receive infusion of hydrocortisone (Group A), hydrocortisone with chlorpheniramine bolus (Group B) or placebo (Group C) during the administration of antivenom.Intervention: Hydrocortisone 1000 mg in 300 mL of normal saline infusion was started 5 min before and continued for 30 min after antivenom. Chlorpheniramine 10 mg intravenous bolus dose was given 5 min after commencement of antivenom.Main outcome measures: Occurrence and severity of adverse reactions to antivenom.Results: Adverse reactions were observed in 80% (12/15) of Group A, 52% (11/21) of Group B, and 81% (13/16) of Group C. Reactions were mild or moderate except in two patients. A significant reduction in the number of adverse reactions was seen in Group B compared with the placebo group (difference, 29 percentage points; 95% CI, 0.2 to 58 percentage points). There was no significant difference between Group A and the placebo group.Conclusion: Prophylaxis with a parallel hydrocortisone infusion alone is ineffective in reducing the occurrence of acute adverse reaction to antivenom serum, but combining it with chlorpheniramine seems efficacious.

Indika Bandara Gawarammana MB BS · S Abeysingha M Kularatne MB BS, MD, FRCP(UK) · Ranjith P V Kumarasiri MB BS, MSc, MD · Nimal Senanayake PhD, DSc, FRCP · Wasantha P Dissanayake MB BS, DCH, MD · H Ariyasena MB BS, MD, MRCP

Objective: To describe an outbreak of Plasmodium vivax malaria in Far North Queensland in 2002.Design: Epidemiological and entomological investigations; molecular analyses of the infecting parasites.Main outcome measures: Case characteristics, adult and larval mosquito counts at the outbreak location, haplotyping of parasites in blood samples from different cases determined through sequencing of AMA1 and MSP1 genes.Results: A man with imported P. vivax malaria stayed at a camping ground 95 km north of Cairns in late September 2002. This led to an outbreak of P. vivax malaria in 10 adults who stayed at the camping ground in October. Large numbers of Anopheles farauti sensu lato larvae were present in stagnant pools in a creek at the camping ground, and many adult mosquitoes were collected nearby. Not only had most of the infected patients been exposed to mosquitoes at night, they were also less likely than other campers to have used insect repellents appropriately (odds ratio, 0.01; P < 0.001). Two different haplotypes of P. vivax, only one of which was detected in the imported case, were involved in the outbreak.Conclusions: Although local transmission of malaria is rare in Far North Queensland, the risk is probably higher in the dry season (September to December). Campers need to be aware of the increased risk of mosquito-borne diseases. Sexual recombination of multiple gametocytes in mosquitoes infected by the imported case may have resulted in the two haplotypes of P. vivax involved in the outbreak.

Jeffrey N Hanna MPH, FAFPHM · Scott A Ritchie PhD · Dianne L Brookes MPHTH · Brian L Montgomery MSc · Damon P Eisen MD, FRACP · Robert D Cooper PhD

After holidaying in Vanuatu, a 24-year-old man presented with pleuritic chest pain and chest wall tenderness thought to be musculoskeletal in origin. He developed fatal acute renal failure, jaundice, respiratory failure, myocarditis and rhabdomyolysis. Subsequent serological results showed a rise in serum titre of antibodies to Leptospira grippotyphosa, from 1 : 50 to 1 : 800, consistent with acute infection. Leptospirosis is a spirochaetal zoonosis uncommon in Australia. There were 245 reported cases in Australia in 2000 and 230 in 2001, most in Queensland.1 However, many cases would be mild and self-limiting, remaining undiagnosed and unreported.2 We describe a young man who developed multi-organ failure after presenting with pleuritic chest pain and chest wall tenderness. To our knowledge, this presentation of leptospirosis has not been reported previously. Clinical recordA 24-year-old man presented to an emergency department with a 1-day history of left-sided pleuritic chest pain. He worked as a metal machinist and was previously well. Two weeks before his presentation, he had returned from a 10-day trip to Vanuatu, where he had injured the sole of his foot on coral. After injuring his foot, he had swum in freshwater rivers. The physical examination revealed slight left-sided chest wall tenderness alone. The wound in his foot showed no sign of local inflammation. His full blood count, renal and liver function tests, coagulation profile, arterial blood gases and chest x-ray were all normal. He was admitted to hospital for observation and pain management. The initial diagnosis was musculoskeletal chest pain of unknown origin. Over the next 2 days, his condition deteriorated. He developed a non-specific erythematous rash, vomiting, diarrhoea and a mild headache. He was afebrile, had tachycardia (heart rate, 120/min), was hypotensive (blood pressure, 80/64 mmHg), hypoxic (Po2, 71.9 mmHg; Fio2, 0.6), jaundiced (bilirubin, 102 μmol/L [reference range (RR), 0–18 μmol/L]), and had abnormal renal function (creatinine, 356 μmol/L [RR, 70–110 μmol/L]). The white cell count was 13.4 × 109/L (RR, 4–11 × 109/L). A chest x-ray showed left lower lobe consolidation. A diagnosis of severe pneumococcal pneumonia was made. The differential diagnoses included atypical pneumonia and leptospirosis. He received intravenous fluids and penicillin (1.2 g twice daily), ciprofloxacin (200 mg daily) and metronidazole (500 mg twice daily), but became oliguric and required inotropic support. He was then transferred to a tertiary hospital for renal support. On admission to that hospital, he was alert with no evidence of meningism or conjunctivitis. He was febrile (39.2°C) and tachypnoeic with left-sided bronchial breathing on auscultation. His electrocardiogram (ECG) showed sinus tachycardia with inferolateral T wave inversion. After an initial period of continuous positive airway pressure ventilation by mask, he was intubated and ventilated for respiratory exhaustion. Continuous veno-venous haemodiafiltration was commenced for oliguric renal failure (urea, 22.9 mmol/L [RR, 3–8 mmol/L]; creatinine, 498 μmol/L) in association with increasing acidosis (pH 7.37; base excess, − 6.1 mmol/L). Antibiotics were changed to benzylpenicillin (1.2 g four times a day), erythromycin (1 g four times a day), ceftazidime (1 g three times a day, to cover possible melioidosis) and metronidazole (500 mg twice daily). All cultures remained negative, and no serology results were available. The chest x-ray showed cardiomegaly, extensive consolidation in the left upper and lower lobes, and some right-sided patchy opacification ( Box). Over the next 2 days, he required increasing inotropic support with infusions of adrenaline (2.22 μg/kg per minute), noradrenaline (2.22 μg/kg per minute) and vasopressin (3 U/h) to maintain adequate blood pressure. A transthoracic echocardiogram showed a mildly dilated left ventricle with a left ventricular ejection fraction of 35%–45% (RR, > 50%), and a mildly dilated right ventricle with moderate depressed contractility. He was in atrial fibrillation with intermittent runs of ventricular tachycardia and one episode of ventricular fibrillation that required cardioversion. Because of the possibility of an immunological diagnosis (eg, vasculitis or Wegener’s syndrome), he was treated with pulses of 1 g intravenous methylprednisolone and then started on maintenance dexamethasone (4 mg four times a day). A short synacthen test excluded adrenal insufficiency. He developed rhabdomyolysis and hyperkalaemia (7.1 mmol/L [RR, 3.5–5 mmol/L]), with flaccid upper limbs and rigid lower limbs. His creatinine phosphokinase (11 557 U/L [RR, 0–250 U/L]) and white cell count (59.4 × 109/L) continued to rise. On Day 8, he suffered an asystolic arrest from which he could not be resuscitated. Subsequent serological results showed a 16-fold rise in the titre of antibodies to Leptospira grippotyphosa by microscopic agglutination, from 1 : 50 on admission to 1 : 800 on the day of his death. All microbiological cultures remained negative, including four sets of blood cultures. Thick and thin blood films examined at the time for malaria parasites were negative. Serological testing for dengue fever and rickettsia was negative, as was that for seven other serovars of leptospiras, influenza viruses A and B, Mycoplasma, adenovirus, Chlamydia psittaci, Toxoplasma, Legionella, cytomegalovirus, Epstein–Barr virus and HIV. At autopsy, the right and left lungs were extensively mottled and haemorrhagic in appearance, with bilateral lobar- and bronchopneumonia. There was no evidence of pulmonary embolism. Sections of myocardium showed a diffuse, full-thickness interstitial neutrophilic infiltrate, indicating acute myocarditis. Both kidneys showed widespread acute tubular necrosis and multiple well-demarcated areas of infarction. No attempt was made to isolate leptospiras at autopsy. DiscussionLeptospirosis has not previously been described to present with pleuritic chest pain and chest wall tenderness. We report this patient so that leptospirosis can be considered as a cause of such a presentation and to emphasise that the disease can occur in travellers who visit endemic areas. We assume that the cause of our patient’s chest pain was probably early myalgia from his chest wall musculature, and the start of pulmonary manifestations of leptospirosis. About 90% of recognised cases of leptospirosis are mild and self-limiting, involving a spirochaetaemic phase followed by an immune phase. The former occurs after an incubation period of 1 day to 4 weeks, and causes fever, headache, myalgia, abdominal pain, nausea, vomiting and conjunctival suffusion. In the past, jaundice has been the indicator of severe disease (Weil’s syndrome), characterised by hepatic and renal impairment, haemorrhage and vascular collapse. However, recent studies show that jaundice is no longer an accurate marker of disease severity.2 Leptospira species are endemic in feral and domestic mammals, reptiles and amphibians. Rats and other rodents are the most important sources for human infection. This usually occurs through contact with urine-contaminated soil or water, contact with infected animal tissue, or through rat bites.3 Traditionally, farmers, sewer workers, miners, fishermen and meat workers have been at greatest risk of infection. However, outdoor leisure activities such as triathlons, swimming and rafting in fresh water provide opportunity for infection, particularly in endemic areas.4 A review of notifications in Australia between January 1998 and June 1999 shows that more than 60% of patients complained of one or more of headache, fever, chills, sweats and myalgia, 56% had nausea and vomiting, 15% had renal involvement, 15% had respiratory symptoms, and 4% had pulmonary haemorrhages.3 No deaths were reported in this period. The highest occupational group was banana farmers (19%), followed by meat workers (17%) and dairy farmers (11%). Whitewater rafting guides and tourists each accounted for 1%.3 Pathogenic leptospiras rapidly invade the bloodstream after penetrating skin or mucous membranes, and multiply in small blood vessel endothelium, resulting in damage and vasculitis in major organs. The mortality rate ranges from 4% to 10%, and adverse indicators are dyspnoea, oliguria, raised white cell count, abnormalities on ECG, and alveolar infiltrates on chest x-ray.5 Acute renal tubular necrosis, rhabdomyolysis, pulmonary haemorrhage, myocarditis with cardiac arrhythmias, meningitis, and uveitis are common manifestations of severe disease. Death is from multi-organ failure.6 There is no sensitive, specific, low cost, rapid and widely available diagnostic test for leptospirosis.2 Because of the non-specific nature of symptoms and lack of a rapid test, leptospirosis is difficult to diagnose. Although early antibiotic therapy may shorten the duration of renal failure and hospital stay,7 no decrease in the mortality rate has been demonstrated.5 Indeed, a recent Cochrane review of antibiotics for leptospirosis suggests that the evidence for their use is not convincing.8 Chemoprophylaxis is effective for people with potential risk of exposure. Oral doxycycline is highly efficacious, but is not recommended for long-term use. Chest x-ray of a patient with leptospirosis The x-ray shows cardiomegaly and extensive consolidation in the left upper and lower lobes, and some right-sided patchy opacification.

Fenton M O’Leary MB BS, MRCS · Jaspal S Hunjan MB BS, MBA, DDU · Ross Bradbury MB BS, FRACP, FRCPA · Govindasamy Thanakrishnan MRCP, FRACP, FJFICM

Travel insurers and medical evacuation companies have a responsibility to provide an efficient high-quality service to their clients. These companies often deliver a standard far short of best practice and far short of their promotional brochures. Their services are overdue for governmental review and a lifting of standards. Travellers must be given realistic advice about the risks of foreign travel and that healthcare resources at their destination may be very limited. Travellers must check with their insurer that the policy they buy truly meets their needs. Some people should not travel overseas.

Robert F Grace FANZCA, FRACP · Darren Penny DipHlthSc

The sun protection factor (SPF) of sunscreens is determined by a testing protocol that specifies a sunscreen application rate of 2 mg/cm2 on the skin. Most people, for cosmetic and economic reasons, only apply enough sunscreen to achieve an SPF of about a third or even a quarter of the level stated on the product. To increase public awareness of the problem, manufacturers could be required to state both a “tested SPF” and an “expected SPF” (a third of the tested SPF) on product labelling. The “SunSmart” message could be modified to make the public more aware of the actual protection level they are achieving with sunscreen. Other aspects of the SunSmart message (eg, sun avoidance, wearing protective clothing) should also be reinforced.

Stephen R D Taylor MB ChB

A previously well 30-year-old man presented with severe progressive back pain, joint pain and fever. Magnetic resonance imaging confirmed an epidural abscess. A sexual history revealed both risk factors for and previous symptoms of a sexually acquired infection. Neisseria gonorrhoeae was isolated from a rectal swab and from a wrist aspirate, consistent with disseminated gonococcal infection. The epidural abscess resolved clinically and radiologically after treatment for N. gonorrhoeae with ceftriaxone. Localised back pain and fever are important symptoms, which may indicate an epidural abscess or vertebral osteomyelitis. In assessing such a patient, a sexual history is often omitted, but it can provide useful information, as illustrated here. Clinical recordPresentation (Day 0): A 30-year-old man presented to hospital with an 8-day history of progressive severe thoracic back pain and a 5-day history of left knee pain. The back pain had occurred suddenly after lifting weights, and radiated to the right chest wall. Chiropractic manipulation and paracetamol had been unsuccessful in relieving the pain. His family history in relation to rheumatological or inflammatory disorders was unremarkable, and he had never used intravenous drugs. He had no symptoms of fever, conjunctivitis, urethritis, rash, early morning joint stiffness or neurological dysfunction. On initial examination he looked well but had a slightly raised temperature (37.8°C). There was tenderness over the fifth to the seventh thoracic vertebrae, and his left tibiofibular joint was erythematous and warm. Examination of the skin and of musculoskeletal, neurological and genitourinary systems showed no abnormalities. Initial investigations revealed a neutrophil leukocytosis of 9.5 × 109/L (reference range [RR], 1.7–7.0 × 109/L) and raised inflammatory markers: C-reactive protein, 73 mg/L (RR, < 3 mg/L); and erythrocyte sedimentation rate, 47 mm/h (RR, 0–10 mm/h). Test results for haemoglobin concentration, platelet count, serum electrolytes, renal and liver function, rheumatoid factor and antinuclear antibody were within normal limits. Blood cultures were negative. The patient was admitted to hospital after a magnetic resonance imaging scan of the thoracic spine revealed an epidural mass at T6/T7 level (Figure A, B). Day 1: A computed-tomography-guided biopsy of the epidural collection was undertaken. This revealed an acute inflammatory exudate with neutrophils. Cytological examination did not detect malignant cells, and no organisms were seen on Gram stain. The patient’s left wrist became painful, red and swollen, and an infectious diseases consultation was arranged. A sexual history revealed that the patient had experienced mild anal pruritis associated with a white anal discharge 3 months before presentation. This occurred after he had had sexual intercourse with multiple male partners, and it resolved without treatment. Microscopic examination of the fluid aspirated from the wrist joint revealed numerous pus cells and gram-negative diplococci on Gram stain (Figure C). Urethral, rectal and throat swabs were taken. A provisional diagnosis was made of disseminated gonococcal infection with an epidural abscess. Therapy was initiated with ceftriaxone 2 g intravenously twice a day. A single dose of 1 g azithromycin orally was also given to treat possible associated Chlamydia trachomatis infection. Serological tests for sexually transmitted diseases, including syphilis, HIV and hepatitis B virus infection, were negative. The patient’s regular sexual partner was treated with ceftriaxone 250 mg intramuscularly and azithromycin 1 g orally. Further contact tracing was not possible as the identity of other sexual partners was unknown. Day 3: Culture of the wrist aspirate and rectal swabs isolated Neisseria gonorrhoeae that was fully sensitive to ciprofloxacin and ceftriaxone, but resistant to tetracycline and penicillin. The urethral swab, throat swab and the epidural aspirate were sterile. Most of the patient’s symptoms resolved 48 hours after starting ceftriaxone. Course: The patient was discharged from hospital after 7 days and instructed to take oral ciprofloxacin 500 mg twice a day for 4 weeks. At review 1 month later: The patient’s symptoms had completely resolved and a repeat magnetic resonance imaging scan revealed total resolution of the epidural collection. The patient elected to go to his local doctor for follow-up serological testing. DiscussionEpidural abscesses are rare and in most cases are caused by Staphylococcus aureus.1 To our knowledge, this is the first reported case of disseminated gonococcal infection presenting as an epidural abscess. With an increasing incidence of N. gonorrhoeae infection in our community, clinicians need to be aware of the manifestations of disseminated gonococcal infection, and to consider it in the differential diagnosis of inflammatory syndromes in sexually active patients. Disseminated gonococcal infection is an uncommon manifestation of N. gonorrhoeae infection. It most commonly follows asymptomatic mucosal infections and is more common in women (female : male ratio, 3 : 1).2 The reported incidence of disseminated infection ranges from 0.5% to 3% of mucosal infections,3 and its incidence in Australia is increasing (predominantly in men who have sex with men).4 Patients typically present with either a triad of tenosynovitis, dermatitis and polyarthralgia without purulent arthritis, or purulent arthritis without skin lesions.2 These two syndromes are not exclusive and some overlap can occur. The most commonly involved joints are the knee, the elbow, and the joints distal to these. Other reported complications are rare and include osteomyelitis,5 meningitis,6 and overwhelming sepsis.7 The bones typically involved in gonococcal osteomyelitis are those adjacent to the sites of gonococcal arthritis, as the organism spreads through the synovium into the adjacent bone. In our patient, N. gonorrhoeae was isolated from the wrist and rectum, confirming disseminated gonococcal infection, which was temporally associated with an epidural abscess. Although N. gonorrhoeae was not isolated from the site of the abscess, complete symptomatic and radiological resolution followed antimicrobial therapy directed against N. gonorrhoeae. For the investigation of symptoms of localised back pain and fever, magnetic resonance imaging is the investigation of choice.8 Appropriate microbiological sampling is essential to determine the aetiological agent and guide antimicrobial therapy. Our case illustrates the importance of obtaining a sexual history, both for the differential diagnosis and for selecting investigations to perform. The recommended empirical treatment for N. gonorrhoeae infection in Australia is ceftriaxone, as more than 5% of isolates are resistant to penicillin, ciprofloxacin and tetracycline.9 Screening for other sexually transmitted infections, and contact tracing and treatment of sexual partners are important to control epidemics. A: T1-weighted sagittal magnetic resonance imaging scan through the cervical and thoracic spine shows an epidural abscess lying posteriorly to the T6 vertebral body (arrow). B: T1-weighted axial magnetic resonance imaging scan at T6 level shows a poorly defined extradural space-occupying lesion, extending through the right neural exit foramen (arrow) with a small paravertebral component. There was an associated effusion within the facet joint (not shown) and no evidence of bony erosion, destruction or oedema. C: Gram stain of wrist aspirate, revealing numerous polymorphs and gram-negative intra- and extracellular diplococci.

Sebastiaan J van Hal MB ChB(Hons) · Jeffrey J Post MB BS(Hons), FRACP

Re: Lowering blood pressure in 2003, a Clinical Update article by Chalmers JP and Arnolda LF in the 15 September 2003 issue of the Journal (Med J Aust 2003; 179: 306-312). On page 308, second column, under the heading ANBP2, an error in the editorial process led to an incorrect statement: “ANBP2 was an open-labelled randomised study with blinded endpoints, a design in which study doctors knew whether the patient was on active treatment or placebo . . . ” ANBP2 is clearly a comparative study, not a placebo controlled study, as is made plain in the other sections of the article. The html and pdf versions of the article published online were corrected on 14 November 2003.

John P Chalmers MD, FRACP · Leonard F Arnolda PhD, FRACP

Suzanne P McEvoy,* Mark R Stevenson† * Research Fellow, Injury Research Centre, School of Population Health, University of Western Australia, 35 Stirling Highway, Crawley, WA 6009; † Director, Injury Prevention and Trauma Care Division, Institute for International Health, University of Sydney, Sydney, NSW. scordovaATsph.uwa.edu.au To the Editor: Taylor et al found that: “Mobile phone use is common among Melbourne metropolitan drivers despite restrictive legislation” and suggest that this constitutes “a preventable exposure to injury risk”.1 This raises two questions: Does mobile phone use while driving affect road safety? If so, do hands-free devices reduce the risk? In their introduction, Taylor et al cited six publications to provide evidence that the use of a handheld mobile phone while driving increases the risk of a road crash. The studies by Lamble et al2 and McKnight and McKnight3 involved a hands-free device and examined driver impairment, not crash risk. The three papers by Violanti4-6 had significant limitations, including no phone billing information to demonstrate that drivers were using their phones at the time of the crash,4-6 reliance on police accident reports that may have involved more thorough investigations into fatal crashes than non-fatal ones,5 and small sample size with only 14 mobile phone users in one study.6 These limitations reduce the validity of the research. The best of the epidemiological studies was a case-crossover study of 699 drivers in collisions involving property damage only.7 However, the oft-quoted four-fold increase in risk comes from the analysis of mobile phone use in a 10-minute hazard interval before the collision. This does not provide conclusive evidence that these drivers were on the phone at the time of their crash and indicates a statistical association only. Although shorter hazard intervals were also examined, one needs to be wary of the potential for misclassifying post-crash calls as pre-crash calls because the time of collision may be imprecise, mobile phone use is common following a crash and a call to the emergency services may not be the first call made after the event. If we conclude that the data are valid despite these limitations, then the fact that hands-free models did not reduce the risk must be noted. Returning to our questions, although there is good evidence demonstrating driver impairment in laboratory-based studies, the epidemiological research has limitations that need to be dealt with to determine the real-world effect of mobile phone use while driving. We are currently undertaking two large epidemiological studies in Perth, involving about 2000 drivers over an 18-month period. The limitations have been addressed in the design of our studies. Furthermore, the evidence to date suggests that hands-free devices do not confer a safety advantage and this issue should not be ignored in driver education.

Suzanne P McEvoy · Mark R Stevenson

Ric Bouvier Community Safety Consultant, 200 Cotham Road, Kew, VIC 3101. ricbouvier7AToptusnet.com.au To the Editor: In “In this issue” of the Journal of 4 August 2003,1 you write regarding “Dialling drivers” that “the jury is still out on the health effects of mobile phones”. Well, the jury is back with a guilty verdict. In June 2003, Injury Prevention2 quoted an evaluation by the Harvard Center for Risk Analysis that “the use of cell phones by drivers may result in about 2600 deaths, 330 000 moderate to critical injuries, 240 000 minor injuries and 1.5 million instances of property damage in America per year”.3 Taylor et al suggest, “Further interventions aimed at decreasing mobile phone use among drivers should be considered.”4 Occupational safety professionals consider that a worker not complying with the safe practices for using a tool should be offered remedial education. If education fails, they stop the worker using that tool. Wise parents also consider taking away a child’s toy until the child can learn to use it safely. And so with mobile phones used while driving. Driver safety education is not very effective. Police have powers to impound items related to other offences, and so should have powers to impound mobile phones used when driving. The driver could then claim it, say, four weeks later, from the police station on payment of a fee-for-service to the police that covers, at least, the relative value of the expenses of the police. The driver would also incur demerit points. Repeated offences would mean they forfeit the phone or their licence.

Ric Bouvier

Graham J Chalker,* Kenneth H Joyner,† Kelly S Parkinson† * Chief Executive Officer; † Technical Advisor, Health and Safety Committee, Australian Mobile Telecommunications Association, PO Box 4309, Manuka, ACT 2603. kellyATkppr.com.au To the Editor: The claim made in the recent article that mobile phone use while driving is more dangerous than drink driving is misleading.1 The 1997 study by Redelmeier is often misinterpreted and cited for the proposition that driving while using a mobile is the same as driving drunk. However, Redelmeier wrote to the New England Journal of Medicine to correct this inaccuracy, saying, “. . . alcohol circulates in the blood for hours, whereas a telephone call lasts only minutes. The cumulative risks associated with intoxication are greater than those associated with cellular telephones”.2 This is supported by a recent Australian study, which compared the blood alcohol levels of drivers involved in real car crashes, rather than driving simulators, and found the risk of an accident was increased by 25 times at a blood alcohol concentration of 0.08.3 Mobile phones have not been shown to present this level of risk in any research. In 2002 in the United States, alcohol was a factor in about 41% of all fatal traffic crashes and in 6% of all crashes.4 In comparison, data collected by about 20 state highway authorities show that mobile phones were a factor in an estimated one half of one percent of all accidents in the US last year. Furthermore, mobile phone subscribers provide the extra eyes and voice for police in reporting aggressive, reckless or drunk drivers, accidents and other road hazards. Almost a third of all genuine calls to 000 are made from mobile phones.5 A recent US survey found that at any given time only 3% of drivers are actively using their mobile phones,6 although it is legal to use a handheld phone in almost all states. Therefore, Taylor’s overall result that less than 2% of Melbourne drivers use a handheld mobile phone, while illegal in Australia and undesirable, is not unexpected. However, the unrelated and misleading comparison made with drink driving is not supported by the facts. No one is questioning that mobile phone use imposes physical, visual, and cognitive demands on the driver. Although technology can help to address physical and visual factors, education is required to address cognitive factors. The Australian Mobile Telecommunications Association has developed 10 safety tips for mobile phones and driving (see www.amta.org.au) and, by adhering to these simple common-sense practices, drivers can make full, productive and safe use of mobile phones.

Graham J Chalker · Kenneth H Joyner · Kelly S Parkinson

David McD Taylor Director of Emergency Medicine Research, Royal Melbourne Hospital, Grattan Street, Parkville, VIC 3050. David. TaylorATmh.org.au In reply: McEvoy and Stevenson raise some important issues. The first relates to the confusion between driver impairment and crash risk. Intuitively, this association seems valid, as any level of driver impairment could be expected to affect driving skill. However, they are correct to suggest that the two should not be used interchangeably without supporting evidence. Secondly, I agree that the quality of evidence directly linking mobile phone use with crash risk is poor.1-4 This largely relates to the difficulty in confirming mobile phone use at the exact time of the crash. Reported direct observation is uncommon, billing records are inexact, and self-report may be subject to prevarication bias. The use of hands-free devices was not examined in our study, mainly because of difficulties in detecting their use. There is anecdotal evidence of a trend towards the use of these devices while driving. However, while their use might avoid the need to physically hold the phone, they may not significantly diminish driver impairment resulting from distraction. Many questions remain, and I encourage McEvoy and Stevenson in their endeavour to more clearly evaluate the real-world risk of mobile phone use, both handheld and hands-free, by drivers. Chalker et al draw attention to the comparison of crash risk for mobile phone use while driving and drink driving. I acknowledge that interpretation of published studies is confusing. Redelmeier’s statement that alcohol circulates for hours and that a telephone call may last for only minutes relates to individuals. From the highway perspective, when one driver completes a call, another is likely to be starting one and effectively assuming the increased collision risk. This concept is consistent with our findings. Almost 2% of drivers were using mobile phones when they passed our observation points, and were therefore at risk at that time. The exact extent of this risk awaits clarification. Chalker et al provide US alcohol and mobile phone related crash statistics. Unfortunately, the latter were not referenced and their value is therefore questionable. Finally, Chalker et al are to be commended for publishing safety tips for mobile phone use while driving. However, their claim that common-sense practices can make mobile phone use safe is extraordinary and disregards emerging evidence. Indeed, this statement appears to contradict their first safety tip, which states “a hands free device can reduce the physical effort to make and receive calls; however, it alone doesn’t make using a mobile phone while driving safer”.5 At best, therefore, common-sense practices will not make mobile phone use while driving safe, only possibly safer.

David McD Taylor

Donna B Mak,* Graeme H Johnson,† Lewis J Marshall,‡ Jacqueline K Mein§ * Public Health Physician, Department of Health Western Australia, 189 Royal Street, East Perth, WA 6000; † Medical Officer, Derby Aboriginal Health Service, Derby, WA; ‡ Head, Sexual Health Service, Fremantle Hospital, Fremantle, WA; § Public Health Medical Officer, Kimberley Population Health Unit, Broome, WA. makhoATbigpond.com To the Editor: We were pleased to read Chen and Donovan’s editorial which highlighted sex-based inequalities in control of genital chlamydial infection and argued for more screening of men for this infection.1 In the Kimberley region of Western Australia, where rates of genital chlamydial infection are among the highest in Australia, control strategies encompass both sexes.2 Although chlamydial infection was not notifiable in WA until 1993, it has been part of the sexually transmitted infections (STI) control program of the Kimberley Public Health Unit (now the Kimberley Population Health Unit) since the 1980s. Since 1989, regional STI management guidelines have recommended that testing for chlamydial infection (and gonorrhoea, syphilis, hepatitis B and HIV infection) be offered to all patients presenting with STI symptoms or as a sexual contact of an STI patient, and as part of antenatal, prison and well-person’s screenings.3,4 In 1996, empirical treatment for chlamydial infection with single-dose azithromycin (funded by the Kimberley Public Health Unit) was added to the standard treatment regimen, and antibody testing and culture were replaced by nucleic acid testing, which is more transport-robust and sensitive. This led to the introduction in 1997 of active health-service-initiated contact tracing for chlamydial infection (ie, sexual contacts reported by patients with chlamydial infection are actively sought by health staff and offered an STI consultation and empirical treatment). Between 11 June 2001 and 29 June 2002, WA Health Department staff (who contribute over 70% of the region’s STI notifications) notified 94 cases of chlamydial infection in female patients and 56 in male patients.5 Coinfection was common, with 61 patients (41%) also having gonorrhoea and four (3%) also having syphilis. Of the female patients, 30% were tested for chlamydia because they had self-presented with STI symptoms, 32% as part of antenatal or well-person’s screening, 36% because they had been reported as a sexual contact of a patient with STI, and 2% for unknown reasons. The corresponding proportions in male patients were 45%, 7%, 45% and 4%, respectively (Pearson χ2 = 12.6, df = 3; P = 0.006). Prevalence of chlamydial infection in the Kimberley antenatal population (69% of whom are screened for chlamydia) is 3% (95% CI, 2%–6%).6 Prevalence in 93 Kimberley men screened consecutively on admission to prison during 18 weeks in 1998–1999 was also 3% (95% CI, 1%–9%). During this same period, prevalence among 59 Kimberley men and 68 women presenting consecutively as STI contacts was 19% (95% CI, 11%–31%) and 22% (95% CI, 14%–33%), respectively (Mak DB, unpublished data). These data demonstrate that contact tracing contributes significantly to chlamydial case-finding, and support the addition of azithromycin to the Kimberley’s empirical STI treatment regimen. Empirical treatment and contact tracing for gonorrhoea over more than 15 years have been associated with decreases in the rate of gonorrhoea and the male : female ratio of cases in the Kimberley (Box). Seven to 8 years after introducing empirical treatment and contact tracing for chlamydial infection, rates have increased in both sexes, as has the proportion of male notifications (Box). Further progress in control of chlamydial infection requires continued provision of STI screening, treatment and contact-tracing services that are acceptable and accessible to both men and women. Notifications of chlamydial infection and gonorrhoea in the Kimberley region, 1993–2002

Donna B Mak · Graeme H Johnson · Lewis J Marshall · Jacqueline K Mein

Neil R Parker Public Health Physician, Darling Downs Public Health Unit, Public Health Services, Queensland Health, PO Box 1775, Toowoomba, QLD 4350. neil_parkerAThealth.qld.gov.au To the Editor: In May 2000 and December 2001, I vaccinated two women for Q fever (Q-Vax, CSL). Both had negative blood tests (IgG < 1:10 by immunofluoresence) and skin tests. Both had local reactions similar to those described by Mills et al.1 In both women, the skin test became positive after vaccination. The first woman had visited a farm on weekends, but had had no direct exposure to cattle, sheep or goats. Swelling at the vaccination site occurred within 72 hours, forming a lump 70 mm x 30 mm in size and causing significant discomfort. The skin test became positive at the same time. A surgeon excised the lesion 5 months after vaccination, and scarring resulted. The histological appearance was similar to that described by Mills et al,1 including a granulomatous panniculitis. The tissue was weakly positive for Coxiella burnetii by a polymerase chain reaction test (Professor B P Marmion, Institute of Medical and Veterinary Science, Adelaide). The skin test was still positive 7 months after vaccination. The second vaccine recipient lived on a cattle property and was involved with calving. She reported that her skin test became positive 5 weeks after vaccination (an observation confirmed by me a week later). The test was still positive at my final review 4 months after vaccination. Although the swelling at the vaccination site reached 50 mm × 20 mm, it caused little local pain or inconvenience. The lesion resolved spontaneously without scarring. The first of these cases had a much shorter onset period than that described by Mills et al.1 Their article did not document the fate of the skin tests, but based on the two cases I report here, and other cases notified to me by general practitioners, I suspect that prolonged positivity may be the rule rather than the exception.

Neil R Parker

Sandy J Berenger,* John K Ferguson† * Area Infection Control Consultant (and Clinical Nurse Consultant, Hunter Area Pathology Service, University of Newcastle), † Director, Department of Microbiology and Infectious Diseases, John Hunter Hospital, Locked Bag 1, Newcastle, NSW 2310. sberengerAThunter.health.nsw.gov.au To the Editor: Collignon and colleagues decry the reuse of “single-use” medical devices.1 Unfortunately, the focus on reuse of items labelled as single-use detracts attention from some of the more serious issues with cleaning of reusable instruments. All hospitals have cleaning failures that occur because some instruments are virtually impossible to clean. Examples include hollow instruments such as bone reamers, biopsy needles and tissue forceps. The actual sterilisation process (as described under Australian Standard [AS] 41872) is not at issue here. Rather, it is the poor design of instruments, and the lack of any standardised assessment process to determine whether an item is capable of being cleaned against that standard. One study found that most “sterilised” artery forceps had residual tissue, visible by light microscopy, representing an unknown, but real, infection risk.3 Most Australian hospitals do not examine surgical instruments under the microscope for grooves or cracks, and instrument sets remain in circulation for many years. In contrast, the most common “single use” critical items that are reused in many Australian hospitals are electrophysiological stimulation (EPS) and aberrant cardiac pathway ablation catheters; there have been no reports of significant mechanical or patient safety issues from reuse of a wide range of cardiac catheters, including EPS and ablation catheters.4 The sterilisation process itself has been validated for these items.5 At John Hunter Hospital, the process of reuse is controlled by a quality system that is far more stringent than the existing AS 4187 Standard. Devices are used for a set number of times before discard, and each catheter use is tracked to the specific patient and procedure. After cleaning, each catheter is examined under x 10 magnification to detect defects. The catheters are tested electrically at the point of use and patient consent is obtained before the procedure. The John Hunter Hospital program has operated for 6 years with an estimated cumulative cost saving of $6 million (compared with no reuse). Patient outcomes are monitored, and no adverse events have been detected. Clinicians express a high degree of satisfaction with the program. The same standard of equipment design, assessment and cleaning should be applied to all instruments that contact sterile tissue. Whether or not a company chooses to label its product “single-use” should not determine whether the item should or should not be reused. More often than not, such labelling serves to benefit financial return rather than patient safety. Hughes entreats us to cease reuse practices until there is incontrovertible proof of the safety of reuse.6 This statement should also apply to routine surgical items. In this era of zero risk tolerance, perhaps the consent process should make patients aware that reusable instruments processed under AS 4187 cannot be guaranteed to be free from human tissue contamination.

Sandy J Berenger · John K Ferguson

Clifford F Hughes Head, Department of Cardiothoracic Surgery, Royal Prince Alfred Medical Centre, Suite 304, 100 Carillon Avenue, Newtown, NSW 2042 (and former Chairman, Therapeutic Device Evaluation Committee). clifford.hughesATemail.cs.nsw.gov.au In reply: Berenger and Ferguson correctly raise the issue of sterilisation procedures for devices used in surgery. They have also described specific measures taken at their hospital for a specific device and, more importantly, have developed a system to ensure the highest quality of sterilisation process in a medical device. Of course, the use of any surgical device should be subject to the strictest sterilisation procedures. Most reuseable surgical instruments do have documented sterilisation protocols which include verification of the process used. All surgical instruments, whether designed for reuse or not, whether used for the first time or the tenth time, should be subject to the scrutiny, surveillance and meticulous records demonstrated by the John Hunter Hospital system. This hospital is to be congratulated on its attention to detail. Were similar stringent protocols in place across all disciplines and in all hospitals, the debate would cease to rage. More importantly, many devices could be safely and efficiently reused. Others may be considered too difficult to resterilise. Nevertheless, asepsis would, once again, be positioned where it belongs, as one of the key principles of surgery.

Clifford F Hughes

Bryan G Walpole Emergency Physician, Australian Antarctic Division, Channel Highway, Kingston, TAS 7050. bwalpoleATtassie.net.au To the Editor: Your otherwise excellent issue on chronic illness (1 September 2003) was timely and appreciated. However, the article by Zajac on the future of public hospitals1 left me pondering how frequently he patrolled the wards and the emergency department. Most public hospitals have undergone the very revolution he adumbrates. Patients now arrive with automated medication records and problem lists from their general practitioner; GP liaison doctors from the Divisions attend discharge planning committees; discharge summaries are delivered by fax on discharge; multidisciplinary clinics abound for complex and chronic illness, but invited GPs claim that time commitments and insufficient payment often preclude attendance; there are target waiting times for clinic appointments; often there is a quality assurance unit, with a complaints or grievance procedure; day surgery and day of admission surgery is now the norm (and strict guidelines help control the morbidity Zajac bemoans), with vastly improved throughput; endoscopy and emergency cardiac catheterisation or angioplasty on demand are commonplace; we now acknowledge, document and rectify system errors with alacrity, without the rancour and recrimination of years ago; and evidence has replaced the wise maxims of the physician. Admittedly, all is not rosy and funding remains a perennial problem, but within available resources the public hospital is a completely different place from 15 years ago. A major issue, and Zajac agrees, is the place of general medicine in the public hospital, being rapidly subsumed by sub(super)-specialists together with emergency physicians, as they are available round the clock, skilled and equipped to perform the assessment and early management of most medical patients, while the physicians are in rooms or at home. We welcome the presence of general physicians in the emergency department, and encourage twice-daily rounds on admitting day with shared care, but so far the rhetoric of general medicine has rarely been matched by attendance. The real challenge for public hospitals at present is to effectively manage and discharge frail elderly patients, and those with cognitive impairment, thus keeping beds free to reduce access block; otherwise general medicine may suffer the fate Zajac reserves for public hospitals and become “a thing of the past”.

Bryan G Walpole

Jeffrey D Zajac Head, Department of Medicine, Austin Hospital, Level 7, Lance Townsend Building, Studley Road, Heidelberg, VIC 3084. j.zajacATunimelb.edu.au In reply: Walpole and I agree that public hospitals have changed significantly. Where we seem to disagree is that he suggests that we have got to where we are going and all the problems have been solved. Walpole clearly works in a different world from me. Even a short visit to the wards and emergency department reveals that, despite good will, planning and many of the changes Walpole lists, things are far from perfect. System errors, major and minor, occur far more commonly than they should, elderly patients spend more time as inpatients than they should, and stresses in the system continue to impair quality and efficiency. I think we need to keep working on these issues, and not pretend that they are fixed. I note with dismay the description of general physicians occasionally visiting Walpole’s emergency department, while other specialists work diligently, 24 hours a day, to heal the sick. These comments demonstrate one of the main problems with doctors in public hospitals, namely, the territorial imperative in full flight. We should be finding ways to work together.

Jeffrey D Zajac

Ron J Lord Editor, Healthcover, 28 Hereford Street, Glebe, NSW 2037. hcoverATihug.com.au To the Editor: The Editor’s article on health reform and the Australian Health Care Summit,1 in which he expressed sentiments with which I agree, included a Box setting out the “egalitarian and socially cohesive principles underpinning Australia’s healthcare” reaffirmed by the Summit. However, the Box contained a Christmas tree and an invitation to readers to enter a poem in the MJA’s Christmas Competition 2003. Among the lines were: “’Tis Christmas, the season to be kind”. While obviously the result of a glitch in the production process, you managed — much to the envy of other editors and publishers seriously wounded by such glitches (to the extent that entire print runs have had to be pulped and then reprinted) — to fall on your feet. I could not think of a better (or more comprehensive) set of principles to underpin our healthcare system than those embodied in the message and spirit of Christmas. Perhaps God moves in mysterious ways.

Ron J Lord

Robert A Jones Specialist Gynaecologist, Adelaide Private Menopause Clinic, Memorial Medical Centre, 8/1 Kermode Street, North Adelaide, SA 5006. robjonesAT senet.com.au To the Editor: 9/15 was disaster day at the MJA.1 Not only was the Editor guilty of printing perseveration, but his “Box” seems to have been transmogrified from . . . “(the) socially cohesive principles underpinning Australia’s healthcare” to an invitation to “expose” the readers of the Christmas journal to some “witty prose”. Perhaps the “healthcare dialogue” has indeed been reduced to rhyming couplets, possibly accompanied by the health ministers fiddling while the rest of us burn?

Robert A Jones

Martin B Van Der Weyden Editor, The Medical Journal of Australia, Locked Bag 3030, Strawberry Hills, NSW 2012. editorialATampco.com.au In reply: Fate (or God) moves in both mysterious and wondrous ways. Maybe the manoeuvring and machinations of our health ministers in the consummation of the 2003–2008 Australian Health Care Agreements are worthy of: If you have a little ditty You would like to expose, Send it to the Journal We’ll publish your witty prose. All I can say is that the faux pas in the production process shows that, despite its high technology, it is still a human process. To err is human, so let’s not make a very public faux pas all consuming.

Martin B Van Der Weyden

On completion of a scientific manuscript or a grant proposal, I allow my computer to proofread the written manuscript. It takes its job seriously, silently highlighting words that it does not know or like, and attempting to help by offering alternative suggestions. On a recent occasion, surprisingly, it passed my name without any comment, and instead suggested, provokingly, that my coauthor’s name, one that is noted in his field, was fragmented, and that it needed to be revised. It continued on its one-track 2 GHz/512 RAM (random access memory) mind, attempting to write a proper manuscript. It felt that “sonicated calf thymus” should be rewritten as either “solicited or fornicated calf thymus” and repeatedly suggested that aldehyde should be replaced with baldheaded. It wanted me to change “lymphocytes were lysed by sonication” to “lymphocytes were lysed by fornication or sanitation”. It even tried to be scandalous by suggesting that trypsin be replaced with try sin, that one should rinse “with demonized (deionized) water” and “that mutterers (multimers) are formed”. It asked me to change nRNP (nuclear ribonucleoprotein) to nun in a sentence that would then have read “nun was electrophoresed” and also to change neutrophils to Europhiles in a sentence that would have become “the Europhiles were incubated with biotin”. Sometimes it suggested words that I have never heard or read. It asked me to change cDNA (complementary DNA) to coda and nDNA (nuclear DNA) to nana. I could never agree with the computer that hatpin was an improvement on hapten, that stool could be used for cytosol, or that smut could serve as a substitute for the Sm autoantigen. There are times I think it has some innate commercial slant, like when it suggests that Neutrogena be used for neutropenia or that antigenicity should be split into antigen city. However, the computer flatly refused to suggest alternatives to words like fluoroisothiocyanate, haemocyanin or isotachophoresis, yet, surprisingly, agreed on words like atherosclerosis, phospholipids, toluene, electrophoresis or ELISA without further comments or suggestions. The computer clearly had no clue that obeying its directives to write something like “try sin to digest hatpins and fornicated calf thymus in stool, followed by rinsing with demonized water to form baldheaded mutterers, Europhiles and smut autoantigen in antigen city” would not make the slightest scientific sense.

Biji T Kurien PhD

A 60-year-old woman presented with a gangrenous right index finger. She had a 44-pack-year history of smoking and no significant past medical history. On examination, brachial and radial arterial pulses were normal, minimal signs of atherosclerosis were apparent on fundoscopy, and no neurological abnormalities were present. Results of a full blood count, blood chemistry (including high-density lipoprotein and low-density lipoprotein cholesterol) and coagulation tests were normal. The erythrocyte sedimentation rate was 20 mm/h (normal range, < 20 mm/h). Potential indicators of hypercoagulability, including levels of protein C, protein S, antithrombin III, factor V, antinuclear antibody and lupus anticoagulant were normal, but the level of homocysteine was raised (16 μmol/L; normal range, 5–15 μmol/L). A transoesophageal echogram showed normal cardiac and valve function, with no obvious thrombi. However, there were diffuse atherosclerotic changes in the aortic arch, with a grade-IV protruding atheroma (7 mm) proximal to the innominate artery (Box). An arterial Doppler study of both upper extremities showed a lack of flow in the right ulnar artery. Angiography was not performed, in view of the risk of causing another embolus. The gangrenous right finger was amputated. Histopathological examination confirmed gangrene of the finger, with no evidence of vasculitis or cholesterol emboli. The protruding aortic atheroma was the likely source of emboli. Warfarin, simvastatin and folic acid were started. A month after a therapeutic warfarin level (target INR, 2.5–3.5) had been achieved, the patient presented with pain in the left third finger. The finger was oedematous, erythematous and tender, and INR was 1.7. Another episode of embolisation was suspected, although repeated arterial Doppler study showed no evidence of arterial insufficiency in the left arm. The warfarin dose was adjusted, and symptoms improved spontaneously. No embolic events were apparent in other organs during the course of treatment. The patient, who has continued to take simvastatin, folic acid and warfarin, has been symptom-free to date. Transoesophageal echogram showing a protruding atheroma proximal to the innominate artery, as marked by crosses.

Yasuhiro Oki MD · Farooq A Chaudhry MD, FACC

Ethics and evidence-based medicine. Fallibility and responsibility in clinical science. Kenneth W Goodman. Cambridge: Cambridge University Press, 2003 (xii + 168 pp). ISBN 0 521 79653 9. Goodman explores the links between scientific knowledge, clinical practice and ethics in this well-written and enthusiastic book. The main argument of the book is that practitioners are constantly faced with clinical decisions characterised by uncertainty — decisions with serious implications for patients. This uncertainty about the right course of action can be reduced through the use of evidence, making it morally blameworthy not to use evidence. For Goodman, an uninformed practitioner is a negligent practitioner, whose patients are “no longer seeing a physician, but visiting a museum”. A series of well-informed chapters engage with some of the major criticisms of evidence-based medicine (EBM). Issues such as flawed research, redundant publishing, publication bias, and the shortcomings of research synthesis are tackled squarely. Despite these problems, argues Goodman, the use of research is well founded both conceptually and practically, creating the imperative to improve the quality of research production and synthesis rather than abandon EBM. The only weakness in his reasoning is the lack of evidence that using EBM leads to better patient outcomes, or discussion of how this might be demonstrated. The author’s expertise in philosophy and computing are evident in the discussion of ethical issues raised by internet use in research, for data collection and for recruiting. As well as a chapter on clinical EBM and guidelines, the relationship between policy and evidence is explored through three case studies, providing concrete examples of the promises and problems of evidence-based public health. Overall, this is a thoughtful and sympathetic exploration of the moral imperative to use EBM. The detailed analyses are supplemented with practical suggestions, making the book of interest to academics and practitioners alike. This is a valuable early contribution on the ethics of EBM; no doubt further contributions will engage with some of the wider ethical issues that were beyond the scope of this text. Wendy A RogersNHMRC Research Fellow Flinders University, Adelaide, SA

Wendy A Rogers

Exotic viral diseases. A global guide. Stephen A Berger, Charles H Calisher, Jay S Keystone. Hamilton, Ontario: B C Decker, 2003 (xii + 252 pp + CDROM). ISBN 1 55009 205 7. Severe Acute Respiratory Syndrome (SARS)* didn't make it into Exotic viral diseases, but every other exotic virus that might confound a healthcare worker did. This is the first clinical summary of the wide range of viral agents that have been dramatised in the media over past decades — and many have killed their fair share of healthcare workers. Many clinicians in North America would have found it convenient to have this succinct reference on hand when dealing, for the first time, with West Nile virus. Many clinicians in Australia will find it similarly valuable when confronted with a case that could be Murray Valley encephalitis, Japanese encephalitis, dengue fever, or something entirely different. The presentation and style are user friendly, with viruses in alphabetical order and appendices covering sample collection and diagnosis. Many of the graphs supporting the text are useful, although they would make an epidemiologist cringe — they are often presented as bar charts where histograms would have been better, or as hybrids of the two. Coverage is up-to-date and comprehensive, and the authors fulfil their aim of summarising the vast body of material in this field in a handy, pocket-sized volume. Information on each virus is given under headings broadly covering agent, reservoir, and vector; clinical presentation and diagnosis; and geographic distribution and further reading. The almost total absence of treatment suggestions will be disappointing to a clinician. For example, under dengue haemorrhagic fever (DHF) the only treatment suggestion is "Typical therapy: symptomatic." This would not be helpful to a house surgeon using the book to diagnose his or her first case of DHF. I make this point because two of the three authors are professors of medicine, yet Exotic viral diseases offers far fewer clinical insights than the public health based "bible" of communicable disease, Control of communicable diseases manual (by J Chin, Washington: American Public Health Association, 2000). Exotic viral diseases costs about $70 for 252 pages, compared with Chin at $100 for 624 pages. Most healthcare workers would consider Chin better value, and a more useful book, although the technologically minded virologist might find the mini-disk included with Exotic viral diseases appealing. Philip WeinsteinProfessor, School of Population Health University of Western Australia, Crawley, WA *An addendum with a brief description of SARS, written early in the outbreak, was received after the book was reviewed.

Philip Weinstein

Children in the new millennium. Environmental impact on health Geneva: World Health Organization, 2002 (vi + 141 pp). ISBN 92 807 2065 1. On World Health Day 2003, the World Health Organization called for “concerted action to protect three of our greatest assets: children, the environment and health”1. Dr Gro Harlem Brundtland, stated: “The biggest threats to children’s health lurk in the places that should be safest — home, school and community. Every year, over 5 million children aged 0–14 die, mainly in the developing world, from diseases related to their environments”. Children in the new millennium. Environmental impact on health presents these issues with disturbing clarity. The volume can be downloaded free from www.who.int and this site also contains a link to the Healthy Environments for Children Alliance (www.who.int/heca/en/). In just 141 pages we are presented with a depressingly pervasive summary of the key environment issues of our day, and children, especially poor children, suffer a disproportionate burden of this litany: Unsafe drinking water — two thirds of the world will live in “water-stressed” conditions by 2025. Poor hygiene and sanitation — diarrhoeal diseases have killed more children in 10 years than has armed conflict in 50 years. Catastrophic degradation of lands and fisheries — nearly 1 billion of us depend on fish for protein. Indoor and outdoor air pollution. Toxic chemicals — lifelong exposure to pesticides often starts in the womb. Warming habitats that favour insect vectors of killers such as malaria and dengue. This compendium of facts will be useful to teachers of public or environmental health. For each environmental threat the authors summarise proven remedies that can be applied at household, community, national and international levels. I would have liked more detail on the nitty gritty of negotiating multilateral environmental agreements, which must represent our best hope for their implementation. Most sobering is the realisation that nearly all of these harmful legacies bestowed on our children have their origins in human society — conflict, inequality, or our excessive and wasteful consumption. Christopher J MorganCentre for International Health Macfarlane Burnet Institute for Medical Research and Public HealthMelbourne, VIC 1. www.who.int/mediacentre/statements/2003/statement6/en/ accessed Apr 2003.

Christopher J Morgan

Ethical eye: Transplants. Peter Morris (editor). Strasbourg: Council of Europe, 2003 (258 pp). ISBN 92 871 4779 5. Through its Ethical eye series, the Council of Europe has addressed a number of recent developments in science and technology, including cloning and the human genome. The series aims to outline the ethical issues relating to each topic and to make these topics accessible to as wide an audience as possible. The most recent volume, edited by the eminent transplant surgeon, Sir Peter Morris, addresses the ethics of solid organ transplantation. The organisation of this collection is anachronistic and this provides a clue to its strengths and weaknesses. It begins with a historical review of transplantation and then considers a series of ethical issues raised by transplantation, including threats to identity, xenotransplantation, brain death, rights and duties, the media, conflict between individual benefit and the “common good”, and the appropriate limits of transplantation. The remaining sections cover transplantation practices in Europe, including religious perspectives. While the division of chapters according to national boundaries may seem of little relevance to non-European readers, the format actually provides tangible local exempla of many of the topical issues in transplantation, including presumed consent, cultural determinants of organ donation and organ commerce. The section dealing with religion and transplantation is excellent in its philosophical depth and practical clarity. The book discusses organ donation and transplantation in terms of issues relevant to Christianity, Buddhism, Islam and Judaism. This is invaluable and often lacking in other texts. As with all multiauthored works there is some unevenness in the contributions. A practitioner, not a patient, wrote the chapter called “Patients’ perspective” (a problem common to many medical texts), and several chapters lack references for further reading. Perhaps the weakest of the contributions is the chapter entitled “Agnostic ethics”, which is almost completely lacking in logical and philosophical substance. This book does not provide a comprehensive coverage of the ethics of transplantation, but it does provide a fascinating overview of the ethical, cultural and sociopolitical context of transplantation using examples from contemporary European practice. It is written in an engaging and accessible style that will be of interest both to the professional and the lay reader. Ian H KerridgeAssociate Professor of Bioethics Centre for Values, Ethics and the Law in Medicine University of Sydney, NSW

Ian H Kerridge

Simply screening Editorialists say that a NZ study is the first of many more to come that will give us newer simpler ways of diagnosing illness than the classic (and time-consuming) "first, take a thorough history".1,2 The study, of 421 consecutive patients aged 16 to 90 years seen in 15 general practices, found that two screening questions are all a GP need ask to virtually rule out one common illness — major depression.1 The questions (which have a common stem) are: "During the past month have you often been bothered by 1) feeling down, depressed, or hopeless; 2) little interest or pleasure in doing things." Compared with an ideal screening tool for major depression, the questions (when the answer to both was "yes") showed a sensitivity of 97% for depression. However, further evaluation is needed in the "positive" patients as only about one in six will truly have depression. 1. BMJ 2003; 327: 1144-1146 2. BMJ 2003; 327: 1117 Door-to-door strategy In 2004, Uganda will launch a door-to-door random and anonymous blood testing survey of 30 000 people across the country to try to get a more accurate picture of the prevalence of HIV/AIDS in Uganda. Consent will be obtained before testing.1 Meanwhile, international experts have called for China to take urgent action so that country can avoid duplicating the African trajectory in HIV/AIDS.2 It is estimated China has 840 000 people who are HIV-positive. 1. BMJ 2003; 327: 1186 2. Lancet 2003; 362: 1636 Backflip Spanish researchers have challenged the conventional wisdom that the best mattress for people with low back pain is a firm one. In their randomised, double-blind, controlled trial of 313 adults with chronic non-specific low back pain, they compared study subjects' self-reported outcomes after 90 days of sleeping on either a firm or a medium-firm spring mattress. Those subjects who slept on a medium-firm mattress experienced less pain when lying in bed and less disability than those who slept on a firm mattress. All bed bases supported at least 50% of the mattress surface (ie, no slats). Lancet 2003; 362: 1599-1604 Falling on deaf ears? Orthopaedic surgeons (and any assistants close by) should don earmuffs when noisy power tools are being used in theatre, says a NZ researcher. Dr Hamish Love assessed sound levels with a noise dosimeter during three uncemented total hip replacements and two cemented total knee replacements. Although he found that the overall total dose of noise was within acceptable limits, sound levels did exceed the legislated NZ maximum of 140 dB on multiple occasions, for example, when cutting bone. Love is concerned that, despite the risk of incurring long-term noise-induced hearing loss, orthopaedic surgeons will shun hearing protection, just as they have previously shown reluctance in adopting other protective devices, such as thyroid guards. Aust N Z J Surg 2003; 73: 836-838 Relief by leech Leech therapy holds promise for symptom relief in osteoarthritis of the knee, according to German researchers.1 They studied 51 patients older than 40 years with severe joint pain due to osteoarthritis of the knee. Their randomised, controlled-but-not-blinded study compared a once-off leech treatment session with more usual therapy with twice-daily topical NSAID diclofenac gel (applied for 4 weeks). Leech therapy led to greater short-term pain relief assessed at 7 days, as well as more improved function and less stiffness right up until the end of the study at 91 days. In leech therapy, four to six medical leeches (Hirudo medicinalis) were applied to the peri-articular soft tissue of an affected knee until they detached themselves (an average of just over an hour). Mild to moderate itching at bite sites was a common minor side effect. A commentator said he wasn't ready to refer patients for the treatment on the basis of this study alone, observing that "seven days is but a brief moment in the long epic of knee osteoarthritis".2 However, he did agree that novel agents might be derived from leech saliva that could eventually be given to patients without the need for a leech bite. 1. Ann Intern Med 2003; 139: 724-730 2. Ann Intern Med 2003: 139: 781-783 Suddenly After a confirmed sudden, unexplained death in the family, US experts say it is now reasonable to offer surviving first-degree relatives a screening 12-lead ECG.1 Their advice follows UK research which found evidence of inherited cardiac disease in seven of 32 families in this same circumstance.2 1. Lancet 2003; 362: 1429-1430 2. Lancet 2003; 362: 1457-1459 — Dr Ann Gregory, MJA