Volume 180 Issue 12

Now we know these services are widely used, we need to know how best to support them The Australian government has recently released the report of the independent National Review of Tele Counselling and Web Counselling Services.1 Initiated by the Office of the Prime Minister in 2001, the review aimed to “take stock of the expanding and dynamic sector” and to describe the use, management, financing and role of web and telecounselling services. The report was commissioned in response to the recognition that the rapid expansion of these services created ethical, legal, funding, service delivery and education issues. The main findings of the review are summarised in the Box. In Australia, telecounselling (communication by telephone between a counsellor and a caller) is a large, diverse industry provided by 131 not-for-profit organisations and an unknown number of commercial organisations or individuals. The largest provider, Lifeline, consists of a federation of 42 centres, employs 5000 volunteers and provides 24-hour service 7 days a week. Web counselling (synchronous and asynchronous communication online or through email between a counsellor and a user) is a smaller, newer industry, with 17 not-for-profit agencies providing services mostly directed at youth. Two key points emerged from the review. First, many Australians use telecounselling services, although the benefits of the services have not been evaluated. Two of the largest service providers answer a combined total of about 850 000 telephone calls annually. (Precise estimates of numbers of users cannot be provided because individuals do not identify themselves, and may visit many times to the same or other agencies.) Despite this extensive use, the review confirmed that no randomised controlled trials (RCTs) have been conducted of the efficacy of web or telecounselling either in Australia or internationally.2 However, telecounselling as an adjunct to professional care has demonstrated effectiveness in RCTs3,4 and has been associated with changes in suicidality and mental health in uncontrolled evaluations.5 A second finding was that mainstream healthcare professionals, including general practitioners, refer patients to web and telecounselling services, although these services are not a formal part of the healthcare system. More than 20% of web and telecounselling agencies estimated that at least half their caseload was referred by healthcare providers, and reported that many calls relating to mental health were answered in the evenings or at weekends. Moreover, although crisis intervention is a component of the caseload, telecounselling agencies report that they are increasingly responding to a core group of individuals with ongoing mental health needs and loneliness. For Lifeline, less than 25% of callers were first-time callers, and across all of the agencies that were surveyed nearly 40% of callers had rung 20 times or more. Different counsellors in different locations talk to these individuals and are not privy to their concurrent medical service use. These key findings suggest three directions for action. First, better integration of telecounselling within mainstream mental health services may be desirable. A core group of users will be better served by being linked to healthcare and other services (for example, accommodation) and by information being shared about concurrent service use. Although telecounselling and mainstream services may have different locations, one solution is to link Lifeline web or telecounselling directly to telepsychiatry services. Telepsychiatry provides consultations with formal healthcare services (either face-to-face using technology, or through email). Although telepsychiatry may be costly and difficult to implement in practice, the advantages are the potential for geographical reach, accessibility, responsiveness, Medicare cover for users, the provider’s attention to evidence-based care and the provider’s duty of care. Software that records user contacts with major community agencies and the healthcare system would be a great step forward, although issues of anonymity, consent, privacy and, importantly, user preference and acceptance need consideration. Access for rural users to affordable telephone and internet services also requires attention. A second direction to consider involves implementing strategies for improving mental healthcare delivery within a web or telecounselling framework. There is a range of educational initiatives that allow high quality, evidence-based interventions to be delivered by non-specialists.6,7 This direction may involve integrating web or telecounselling with internet therapy and psychoeducation. A third clear direction is the need to evaluate the effectiveness of web and telecounselling. Fee-based web counselling with specialists and non-specialists is readily available to users, and these services are likely to accelerate, driven by a body of consumers who use internet resources. There is now the opportunity to test the usefulness and effectiveness of web counselling before this proliferates further. The emerging managed-care models delivered by an engaged and organised workforce of experienced telecounsellors is an exciting research opportunity not to be missed. Before the web and telecounselling review, no one knew the extent, quality or standards of delivery of these services, or even who used them. Now we know that these services are used frequently, both by the community and by healthcare agencies, and that they play a major role in managing vulnerable individuals with mental health problems. If telecounselling services are found to be effective, there is an urgent need to adequately support the sector and improve continuity of care between the systems. To date, telecounselling has been seen as non-core — a poor cousin to mental health services. However, given the development of communication technology, consumer empowerment, and the infrastructure, workforce, and capacity in the web and telecounselling sector, we foresee a central role for these services in delivering flexible, evidence-based, cost-effective help to the community. The National Review of Tele Counselling and Web Counselling Services Method Survey of 131 agencies in July 2002. Analysis of caller data from Lifeline, Kids Help Line and Care Ring, using statistics collected since 1999. Surveys of 80 interviews with web and telecounsellors and allied service providers. 20 focus groups of industry stakeholders. Telephone surveys of 125 users of web and telecounselling. Results Few national services exist, although there is a proliferation of state and regional services. Between 62% and 90% of calls are not answered because of under-resourcing and poor routeing of calls among centres. Nearly 80% of services relate to a specialist issue, such as sexual assault, domestic violence or cancer. Most calls concern mental health. Major telecounselling providers perceive themselves to be increasingly supporting highly vulnerable people rather than offering crisis intervention. Many callers ring repeatedly. More than 20% of services estimated that more than half their caseload was referred by main sector healthcare providers. Most telecounsellors are formally trained, with almost two-thirds being paid professional rates. Research team Urbis Keys Young. Advisors to Urbis Keys Young: Professor Trevor Waring and Dr Nick Kowalenko. Reference group Mr Dermot Casey, Mr Conrad Gershevitch, Professor Matt Sanders, Dr Margaret Tobin, Dr Bronwen Harvey, Mr Gordon Gregory, Professor Helen Christensen, Mr Des Graham, Ms Dawn Smith, Mr Trevor Carlyon, Ms Barbara Hocking, Mr Jack Heath.

Helen Christensen PhD · Barbara M Hocking BSc (Hons), DipEd, Dip H Eed, GAICD · Dawn Smith MBA

Only when spirometry is performed in a uniform way can we expect its widespread use in primary care Spirometry appears to be an undervalued investigation in general practice, despite its capacity to inform clinicians about diagnosis, severity assessment, and optimal treatment for airways disease. The omission of spirometry from a thorough assessment of patients with breathlessness seems just as inappropriate as failing to measure the blood sugar level in a patient with thirst, polyuria and blurred vision. There are substantial individual and community risks in not performing a simple diagnostic test such as spirometry. In Australia, underdiagnosis of chronic obstructive pulmonary disease (COPD) and asthma is a documented consequence of this.1,2 Yet, anecdotal reports from general practitioners suggest that it is difficult to incorporate spirometry into the consultation, and there have been variable outcomes after systematic efforts to teach optimal performance of the test.3,4 There are many reasons for this, including the complexity of properly performing the test, the cost of equipment, the time taken to perform bronchodilator reversibility testing, and controversy regarding interpretation of results. Although Australian guidelines for the diagnosis and management of asthma and COPD5,6 clearly define the central role of spirometry in making a diagnosis and assessing severity, the practical implementation of the test remains a challenge. Bronchodilator reversibility testing should inform the clinician about the presence and severity of airway obstruction and its reversibility in response to a standard dose of bronchodilator. Once this information is reported, the clinician can determine — in combination with the other information available — whether asthma or COPD is likely. There is considerable overlap in the bronchodilator responsiveness of these two diseases, so that spirometry may not be diagnostic. However, the consistent performance and interpretation of any test is essential to maximise its value, allow comparison of results and to ensure its sensitivity and specificity are maintained. In this issue of the Journal (page 610), Borg et al report the results of a survey of 60 lung-function laboratories in Australia and New Zealand, and highlight marked differences between laboratories in performance and interpretation of bronchodilator reversibility testing.7 These variations, in a setting where rigorous quality assurance and standardisation would be expected, indicate that substantial work is needed to bring uniformity to spirometry and establish commonly agreed criteria for assessing reversibility of airway obstruction. Do such criteria exist? There are international guidelines for the performance and interpretation of lung-function tests,8,9 and respiratory laboratories would generally aim to achieve these standards, although they may be more difficult to attain in primary care. Recommendations for assessing reversibility are given in a Thoracic Society of Australia and New Zealand (TSANZ) position paper.10 These are similar to the American Thoracic Society (ATS) standards, which indicate that a 12% increase in forced expiratory volume in 1 second (FEV1) over baseline and a minimum 200 mL improvement in FEV1 or forced vital capacity (FVC) constitute a positive response to bronchodilator. However, the TSANZ guidelines lack detail, particularly with regard to the type, dose and timing of bronchodilator administration, the factors that varied most between laboratories. By contrast, the ATS guidelines indicate that bronchodilator reversibility should be assessed by use of a short-acting β2-agonist, equivalent to 200 μg salbutamol or 500 μg terbutaline by a metered-dose inhaler. Although laboratories may choose to enhance the sensitivity of the test and optimise delivery of β-agonist by using spacers, it does not appear appropriate to administer high doses of combination bronchodilators by nebuliser for conventional reversibility testing.11 It is also outside current ATS guidelines for standardisation of reversibility testing. Is this variability between respiratory function laboratories of concern, and what are the implications? Firstly, comparisons between results from different laboratories should not be made with the assumption that the test has been performed under identical conditions. Secondly, it is essential for clinicians referring patients to respiratory laboratories to know the local features of spirometry testing to be able to interpret the results appropriately. Thirdly, it would be most desirable, and many would argue essential, for Australian laboratories to agree to a set of standards and apply them universally for spirometry and reversibility testing. Fourthly, implementing spirometry testing in primary care and educating and up-skilling GPs is unlikely to succeed without an agreed position on acceptable standards for performance and interpretation. Among respiratory scientists and thoracic physicians, there is a range of views on the feasibility of implementing more widespread use of spirometry in primary care. Although it is a highly desirable goal, expressly supported by the peak bodies in asthma and COPD care, there are major challenges. Many argue that accurate performance and interpretation of bronchodilator reversibility testing is difficult and that GPs should be offered a range of options, which should include greater access to laboratories and pathology services for spirometry. There is a plethora of articles which provide background information to assist in implementing quality control procedures to standardise equipment and test performance, and provide reference values and guidelines for interpretation of results. Despite these specifics, the ATS guidelines frankly acknowledge “There is no clear consensus on what constitutes reversibility in subjects with airflow obstruction”. Nevertheless, agreement should be reached regarding the way in which a standard test is performed, even if reaching agreement on its interpretation is difficult. The article by Borg et al highlights the urgent need for agreed standards in Australia for spirometry. The TSANZ and the Australian and New Zealand Society of Respiratory Scientists are in the best position to take up this urgent task. Transferring this expertise into community practice, either in specialist or in primary care, remains a challenge that must be met if we are to maximise the possibilities for diagnosing and managing airways disease.12 One of the perceived hurdles to this process is the Medicare Benefits Schedule descriptor for office spirometry (Item 11506), which specifies that the test should be done before and after administration of bronchodilator to attract payment. The TSANZ and the Royal Australian College of General Practitioners have prepared a submission to have this descriptor changed to allow payment for testing before or after administration of bronchodilator. The availability of a wide range of affordable, electronic spirometers with built-in software for determining reference values, along with a “Buyers guide to spirometry”, currently being written, will add to the educational resources needed to help GPs in their use of spirometry for assessing patients with breathlessness. Standardised guidelines should greatly assist the implementation of spirometry in primary care and result in more appropriate treatment and better outcomes for patients.

Christine Jenkins MB BS, MD, FRACP · Iven Young MB BS, PhD, FRACP

Health policy decisions are based on more than evidence Benjamin Franklin’s 18th-century slice of wisdom that “In this world nothing can be said to be certain except death and taxes” still rings true today. But, in these modern times, adding “and rising health costs” would not be inappropriate. The inexorable increase in public spending on healthcare is a political issue for much of the developed world, and Australia is no exception. Our healthcare expenditure rose from 7.5% of GDP in 1989 to 8.5% in 1999, and it shows no sign of abating.1 Indeed, the federal treasurer recently observed that “When we look across the next forty years we find that the largest area of pressure in relation to Government spending is going to be in the health area.”2 So what are we to do? Commenting on a North American view of the United Kingdom’s National Health Service,3 the President of the Royal College of Physicians recently wrote: To contain the costs of growing needs and expectations for health and care services, there is an increasing emphasis on the clinical and cost effectiveness of health care, with evaluation of procedures and technologies, targeting of resources to services and interventions of proven effectiveness . . .4 This endorsement of evaluation of evidence, effectiveness and efficacy is the stuff of which evidence-based medicine (EBM) is made, and must be a godsend for governments, health ministers and their public servants. For, as noted by a UK social scientist, “EBM offers the vision . . . of solving all health care funding problems by eliminating unnecessary and unproven health care.”5 In short, stringent evidence is required if the public purse is to pay for new drugs, medical technology or other interventions. Policing bodies exist to effect this policy. For decisions regarding government funding support in Australia, the Federal Minister for Health seeks the advice of the Pharmaceutical Benefits Advisory Committee (PBAC) for new drugs and the Medical Services Advisory Committee (MSAC) for emerging medical technologies or procedures. How do these committees arrive at their advice? What are their modi operandi and tensions? Answers to these questions have not been readily forthcoming, as these bodies work behind closed doors, the details of their deliberations are confidential, and participants are bound by a code of silence. In this issue of the Journal (page 627), the door of a bureaucratic conclave is opened slightly as Ware and his colleagues examine the government’s deliberations regarding public funding of positron emission tomography (PET) services.6 Much of their information was obtained through freedom of information requests and, despite its inherent limitations, their account was of sufficient interest to the Journal for us to pursue the long road to publication. Each story has two sides and we also sought the views of the Australian Government Department of Health and Ageing (page 633).7 The “exposé” by Ware and colleagues raises issues about the political pressures that come to bear on potential “big ticket” medical technology roll-outs, the processes involved in technology assessment and the values attending this exercise. As certain as death and taxes is that new technology spawned by research and commercial concerns will increase pressure on the already runaway cost of healthcare. PET is one such technology. It is the latest in a stream of imaging modalities, following computed tomography and magnetic resonance imaging. PET capitalises on the differential metabolism of glucose by malignant cells and is of significant clinical utility in cancer diagnosis and staging, and for following the effects of treatment. But it is expensive, and not readily seen as cost-effective if judged exclusively through standard outcomes such as survival or mortality. PET fell victim to the health bureaucracy doctrine that new technology should not be comprehensively funded by the public purse in the absence of high levels of evidence of both clinical and cost effectiveness. Supposedly because of this, and much to the disappointment of Ware and colleagues, the current Commonwealth government funding arrangements for PET limit the number and location of publicly funded PET services8 and the clinical indications for its use.9 Ware’s qualms about MSAC’s deliberations raise questions about the hype of EBM in health policy. Nobody would disagree with the then Health Minister’s ideal that with the establishment of MSAC “the gap between research knowledge and clinical practice will narrow and patients will benefit earlier from the most advanced procedures drawing on the best scientific medical evidence”10 — in short, EBM. But it appears that the rhetoric surrounding EBM has led to a misunderstanding of policymaking. Indeed, the certainty value of EBM in this setting is more fanciful than real, as other considerations are involved.5,11 These include: competing goals other than clinical effectiveness (social, financial and political); beliefs that some of the research is irrelevant to circumstances in which assessments are taking place; lack of consensus in understanding, interpretation and applicability of the research; other types of competing evidence (personal experience, local information, eminent opinions and evidence provided by advocacy groups); a social or political environment that is not conducive to policy change; and scientific information being poorly presented to the policymakers. Ware et al’s critique of MSAC’s deliberations is not unique. Similar concerns have been raised about Britain’s National Institute of Clinical Excellence in its regulatory role for the introduction of new technology, interventions and pharmaceuticals in the NHS.12 Finally, the experience of Ware et al in extracting information through freedom of information provisions raises the issue of transparency and accountability of health-policy formulation. Most Australians would accept that even healthcare resources are finite. Most would expect our governments to make the tough decisions about how public funds are spent, however unpalatable the decisions may be to sections of the community. But the public is not impressed by the secret milieu in which this occurs. It leads to mistrust and suspicion. Professional disquiet can also arise when expert opinions proferred in committees are not reflected in the final outcome. Onora O’Neill, in the 2002 BBC Reith Lectures, counselled that, to confront society’s burgeoning culture of suspicion, “We need genuine rights, genuine accountability, genuine efforts to reduce deception and genuine communication”.13 More transparency in decision-making that affects the public is not unreasonable. Meanwhile, for the foreseeable future, rising healthcare costs will remain one of life’s certainties. Evidence-based medicine alone will not contain this.

Martin B Van Der Weyden MD, FRACP, FRCPA · Ruth M Armstrong BMed

Objectives: To determine the variation in the methods used to assess and interpret the reversibility of airflow limitation in lung-function laboratories throughout Australia and New Zealand.Design: A postal survey performed in 2000, requesting details of methods used to assess and interpret bronchodilator reversibility.Setting and participants: 60 lung-function laboratories identified from the Australian and New Zealand Society of Respiratory Science mailing list.Main outcome measures: Bronchodilator agent, dose, mode of administration, time to repeat spirometry and definition of a significant response.Results: 37 laboratories responded (response rate, 64%). Thirty-three laboratories used salbutamol as their routine bronchodilator agent. Twenty-four laboratories used a metered-dose inhaler (MDI) with (21) or without (3) a spacer device as the preferred mode of bronchodilator administration. There was wide variation in the bronchodilator dose administered (median, 400 μg; range, 200–800 μg salbutamol for MDIs) and the time to repeat spirometry following bronchodilator administration (median, 10 min; range, 4–20 min). Ten laboratories used criteria consistent with either the National Asthma Council or Thoracic Society of Australia and New Zealand COPDX guidelines to define a significant bronchodilator response, and two used American Thoracic Society criteria. The remaining 25 respondents listed a variety of other criteria.Conclusion: The methods used to assess and interpret acute bronchodilator reversibility in lung-function laboratories in Australia and New Zealand vary considerably. This may have a significant effect on the diagnosis and management of patients. Laboratories should report the method used to assess bronchodilator response.

Brigitte M Borg BApplSc · David W Reid MB BS, FRACP · E Haydn Walters DM, FRACP · David P Johns PhD, FANZSRS

Objective: To determine the incidence of congenital heart defects (CHD) in Aboriginal and non-Aboriginal infants in Central Australia and to compare this with the incidence elsewhere in Australia.Design and setting: Data on cases were obtained from patient records of the Alice Springs Hospital, Central Australia, the sole referral centre for paediatric and initial cardiac diagnostic services for the region.Participants: Patients with CHD proven by echocardiography reported between 1 January 1993 and 30 June 2000.Main outcome measures: Incidence of CHD using all live births in Central Australia as the denominator.Results: 108 patients with CHD were detected among 6156 live births (incidence, 17.5 per 1000; 95% CI, 14.9–21.7 per 1000); 57 of 2991 were Aboriginal (19.0 per 1000; 95% CI, 14.4–24.6 per 1000) and 51 of 3165 were non-Aboriginal (16.1 per 1000; 95% CI, 12.0–21.1 per 1000). The difference between the two groups was not statistically significant (relative risk, 1.18; 95% CI, 0.81–1.72). CHD incidence in Central Australia was significantly higher than that reported for other parts of Australia (4.3 per 1000 live births in New South Wales and the Australian Capital Territory, 1981–1984; 7.65 and 12 per 1000 total births in Western Australia, 1980–1989, and South Australia, 1993–2000, respectively).Conclusions: The high rates of CHD in Central Australia may partly reflect the high utilisation of echocardiography for assessing minor lesions. However, the incidence of both major and minor types of CHD was significantly higher than previously reported from other regions of Australia. The role of socioenvironmental factors in this high incidence should be explored.

Srinivas Bolisetty FRACP · Ameet Daftary MD · Dan Ewald FAFPHM · Brodie Knight FRACP · Gavin Wheaton FRACP

Objective: To analyse cancer survival in New South Wales by geographic remoteness.Design, setting and participants: A survival analysis of all patients with cancers diagnosed in NSW between 1 January 1992 and 31 December 1996. Survival was determined to 31 December 1999.Main outcome measures: The relative excess risk (RER) of death over 5 years was estimated for each geographic remoteness category relative to the highly accessible category for 20 cancer types adjusted for age, sex, years since diagnosis and, subsequently, stage of cancer at diagnosis.Results: There were statistically significant differences in the RER of death across remoteness categories (P < 0.001) for cancers of the cervix and prostate and for all cancers. The RERs for the most remote categories (compared with the highly accessible category) before and after adjustment for stage were cervix, 3.22 (95% CI, 1.54–6.75) and 2.25 (95% CI, 1.06–4.77); prostate, 3.38 (95% CI, 2.21–5.16) and 2.53 (95% CI, 1.60–4.01); all cancers, 1.35 (95% CI, 1.20–1.51) and 1.25 (95% CI, 1.11–1.41). In addition, there were significant variations in RER of death by remoteness for head and neck, lung and colon cancers and cutaneous melanoma.Conclusion: Cancer survival varies by remoteness of residence in NSW for all cancers together and some cancers individually. Access to screening or early diagnosis probably contributes to this variation, but persistence after adjustment for stage suggests that treatment variation is also important.

Katharine E Jong MPH · David P Smith MPH · Xue Q Yu MPH · Dianne L O’Connell PhD · David Goldstein MB BS, MRCP, FRACP · Bruce K Armstrong PhD

Objective: To examine trends in hospital admission for hip fracture in New South Wales between July 1990 and June 2000.Design: Analysis of routinely collected hospital separation data.Setting: Public and private acute-care hospitals in NSW.Participants: Admissions of patients aged 50 years and over with a primary diagnosis of fracture of the neck of femur (International classification of diseases, 9th revision [ICD-9] code 820 or ICD-10 codes S72.0–S72.2).Main outcome measures: Number and rates of hospital admission for fracture of the neck of femur per 1000 population; inpatient mortality rates per 1000 admissions.Results: Between July 1990 and June 2000, the number of admissions to NSW acute-care hospitals for hip fracture increased by 41.9% in men (from 1059 to 1503 per year) and by 31.2% in women (from 3160 to 4145 per year). However, age-specific and age-adjusted rates remained practically unchanged. The average length of stay for admissions for hip fracture decreased significantly from 19.2 days (95% CI, 18.5–19.8 days) in 1990–1991 to 14.2 days (95% CI, 13.8–14.6 days) in 1999–2000. No significant change was observed in the overall inpatient death rates per 1000 admissions.Conclusions: The findings support recent reports that the increase in hip fracture rates during most of the past century may have ended. However, the number of admissions for hip fracture is still rising. Preventive measures to reduce the burden of this condition on the healthcare system and community need to be pursued and strengthened.

Soufiane Boufous BH(Hons), MPH(Hons) · Caroline F Finch BSc(Hons), MSc, PhD · Stephen R Lord BSc, MA, PhD

The Commonwealth Government constituted the Medicare Services Advisory Committee (MSAC) to implement its commitment to entrench the principles of evidence-based medicine in Australian clinical practice. With its recent review of positron emission tomography (PETReview), the Commonwealth intervened in an established MSAC process, and sanctioned the stated objective to restrict expenditure on the technology. In our opinion: The evaluation of evidence by PETReview was fundamentally compromised by a failure to meet the terms of reference, poor science, poor process and unique decision-making benchmarks. By accepting the recommendations of PETReview, the Commonwealth is propagating information which is not of the highest quality. The use of inferior-quality information for decision-making by doctors, patients and policy-makers is likely to harm rather than enhance healthcare outcomes.

Robert E Ware MB BS, FCP · Hilton W Francis MB BS, FRACP, FFPMANZCA · Kenneth E Read LLB(Hons)

Ware, Francis and Read (page 627) express some concerns about the processes used in the Australian government’s decisions about funding for positron emission tomography (PET). We appreciate the Journal’s invitation to comment. I will briefly describe the workings of the Medical Services Advisory Committee (MSAC), the particular processes that have been undertaken in respect of PET, and the recommendations and funding decisions that flowed from those processes. MSAC advises the Minister for Health and Ageing on the strength of evidence pertaining to new and emerging medical technologies and procedures. In doing so, the committee considers safety, effectiveness and cost-effectiveness, and under what circumstances public funding should be supported. MSAC consists of eminent surgeons, physicians, health economists and experts in epidemiology and medical research, as well as representatives of consumers and of the Australian Health Ministers’ Advisory Council. In addition, for each technology under review, MSAC appoints experts in the relevant fields to supporting committees to help interpret the evidence. Since its inception in 1998, MSAC has established a reputation as one of the foremost sources of advice to government on new healthcare technologies. The processes surrounding the consideration of PET, including MSAC’s assessment, have been as follows: In 1999, PET first came to MSAC’s attention through applications from the Peter MacCallum Cancer Institute (Melbourne) and the Wesley Hospital (Brisbane). In August 1999, the then Minister for Health and Aged Care asked the department to conduct a broader review of PET to determine its proper role in the Australian clinical setting. The review incorporated an assessment by MSAC of PET in six clinical indications, but also considered a range of other matters, including the distribution of services, and workforce and accreditation issues. The review was guided by a steering committee comprising representatives of the medical profession, state and territory governments, and consumers. It received submissions from professional associations, states, hospitals, technology suppliers and medical service providers.1 In May 2000, MSAC concluded that there was insufficient evidence to draw definitive conclusions about PET’s clinical effectiveness and cost-effectiveness for the six indications.2 However, it did recommend that interim funding be made available on condition that facilities collect data to inform longer-term decisions about the role of PET in Australian clinical practice. In August 2000, the Minister agreed to implement the recommendations of the broader review, incorporating MSAC’s findings. This included a limited expansion of funded PET facilities through a tendering process. In May and August 2001, MSAC published further assessments of PET in respect of seven additional indications.3,4 MSAC again concluded that there was insufficient evidence to warrant unrestricted Medicare funding, but that interim funding should be provided under certain conditions, including that data should be collected to aid further assessment. The PET tendering process was completed in September 2001. By April 2003, eight facilities were receiving Medicare funding to provide PET services: three in Victoria, two in New South Wales, and one each in South Australia, Western Australia and Queensland. Funded facilities are participating in a data collection and evaluation program, as recommended by the PET review. This is expected to be completed in 2006. MSAC considered PET within the context of a broader review of the technology, but it applied its normal methods and evaluation criteria. The committee recommended funding for PET both in its initial report in 20002 and in subsequent reports in 2001.3,4 The Minister accepted that advice, and a wide range of PET services now attracts a Medicare benefit. This will continue until MSAC next reviews the technology. In addition to offering Medicare benefits for PET services, the government is funding the collection of data by service providers to improve the evidence base relating to the use of PET in a wider range of indications. The government does not routinely fund such data collection, but has done so in this case in acknowledgement of the potential impacts of PET on patients and the Australian healthcare system. Finally, one of the concerns that has been raised about the PET reviews is that the government did not follow the views of individuals who were involved in the processes. But that is by no means unusual. It is common for advisers appointed to MSAC supporting committees to bring a range of views to the table. Indeed, the supporting committees and MSAC itself are constructed to enable a diversity of perspectives to contribute to constructive and rigorous debate and decision making. MSAC’s challenge is to marry the published evidence with a diverse range of opinions and come to a definitive conclusion. The examinations of PET have been no exception. Having provided significant interim funding for PET, and substantial support for further data collection to build the evidence base, the Australian government has accepted MSAC’s advice to leave the door open, and will consider further evidence of PET’s safety, effectiveness and cost-effectiveness as it emerges in 2006.

Philip Davies MSc

Systematic reviews of randomised trials of tPA in acute ischaemic stroke indicate a clear benefit of treating selected patients within 3 hours of stroke onset. Moreover, a net benefit remained after adjustment for chance baseline imbalances between subgroups in stroke severity within one of these trials (National Institute of Neurological Disorders and Stroke [NINDS]). Rates of favourable outcomes and intracranial haemorrhage comparable with those in randomised trials can be achieved in routine clinical practice; however, translation of net benefit from tPA therapy requires organised and coordinated stroke management across the continuum of care. Prerequisites for well organised and coordinated acute stroke care are: consensus among care providers on the use of tPA; stroke-care teams spanning the gaps between pre-hospital care, emergency departments and stroke units; and collegiate relations and effective communication networks between care providers.

on behalf of the Australasian Stroke Unit Network, the New South Wales Greater Metropolitan Transition Taskforce Stroke Initiative, and the Towards A Safer Culture Stroke Expert Working Group

Attempted repair of human spinal cord injury by transplantation of stem cells depends on complex biological interactions between the host and graft. Extrapolating results from experimental therapy in animals to humans with spinal cord injury requires great caution. There is great pressure on surgeons to transplant stem cells into humans with spinal cord injury. However, as the efficacy of and exact indications for this therapy are still uncertain, and morbidity (such as rejection or late tumour development) may result, only carefully designed studies based on sound experimental work which attempts to eliminate placebo effects should proceed. Premature application of stem cell transplantation in humans with spinal cord injury should be discouraged.

Jeffrey V Rosenfeld MS, FRACS · Grant R Gillett PhD, FRACS

Clinical recordsOutbreak 1In January 2002, an outbreak of influenza A occurred at a Melbourne aged-care facility (ACF) housing 42 residents (median age, 86 years; range, 64–98 years). There were 29 staff working at the facility (median age, 46 years; range, 29–64 years) (Box 1). The index case (Visitor A) was an 86-year-old woman who regularly visited her husband (Resident A) at the ACF. Visitor A developed respiratory symptoms on 26 Dec 2001 (Day 0), was hospitalised with fever and respiratory symptoms on Day 2, and died of pneumonia on Day 17. Visitor A had a history of emphysema and had received the influenza vaccine in March 2001. On Day 5, Resident A developed respiratory symptoms, and between Days 8 and 13, 15 more residents developed respiratory illness, of whom nine were hospitalised. The hospitalisation of four residents on a single day (Day 13) with suspected pneumonia led to the emergency department manager notifying the Victorian Department of Human Services (DHS) of the outbreak. On Day 14, DHS staff visited the ACF and collected nose and throat swabs from symptomatic individuals whose onset of respiratory symptoms had occurred less than 5 days earlier (ideally, specimens should be collected within 72 hours of onset). Where possible, acute and convalescent sera were collected. The Victorian Infectious Diseases Reference Laboratory tested combined nose and throat swabs for influenza virus RNA using a respiratory multiplex polymerase chain reaction (PCR) assay, designed to detect RNA from respiratory syncytial virus; parainfluenza virus types 1, 2, and 3; influenza A virus (subtypes H3N2, H1N1); influenza B virus; and picornaviruses (rhinoviruses, enteroviruses). The reference laboratory also tested acute and convalescent sera for antibodies to influenza A virus, influenza B virus, Mycoplasma pneumoniae, Legionella spp., and Chlamydia pneumoniae antibodies. On Day 14, the DHS recommended that the ACF implement infection control measures (Box 2). The DHS also gave notification of the outbreak to attending general practitioners and infection control staff at hospitals where patients had previously been admitted. Thirty-eight of 42 residents, but only two of 29 staff, had received the 2001 influenza vaccine in either February or March 2001. As an outbreak control measure, 22 of 23 unvaccinated staff who were unaffected by illness were vaccinated (the four unvaccinated residents had already developed respiratory symptoms). On Day 15, 24 hours after collection, PCR test results showed that the samples were positive for influenza A (H3N2). The DHS then recommended antiviral therapy for all residents and all unvaccinated staff: amantadine for prophylaxis and zanamivir for therapy or prophylaxis. Oseltamivir was not recommended at the time, as it was not licensed for prophylaxis. Because of the perceived difficulties in administration and possible gastrointestinal and neurological side effects in elderly and chronically ill people, the facility elected not to use amantadine, and decided on zanamivir for treatment and prophylaxis. However, as the ACF was unable to obtain sufficient stock of zanamivir for these purposes, two residents and four staff members received zanamivir for treatment and 21 unaffected residents received prophylactic oseltamivir (despite its use being outside the licensed indications for the drug at the time). None of the residents who were given prophylactic oseltamivir developed influenza. The latest date of onset of respiratory illness occurred on Day 18 (13 January 2002). The World Health Organization (WHO) Collaborating Centre for Reference and Research on Influenza (Melbourne) identified the outbreak strain as influenza A/H3N2/Moscow-like and concluded that the H3N2-like strain in the 2001 vaccine protected against infection with this virus. Outbreak 2In March 2002, an outbreak of influenza A occurred at a Melbourne ACF housing 32 elderly residents (median age, 84 years; range, 55–91 years). There were 31 staff working at the facility (median age, 42 years; range, 20–55 years) (Box 1). The first two cases in the outbreak were residents who developed respiratory symptoms on 3 March 2002 (Day 0). Their infection could not be linked with a source case. Between Day 1 and Day 3, 22 more people associated with the ACF developed respiratory symptoms. The DHS was notified of the outbreak on Day 5 by an attending GP. On Day 5, the DHS recommended infection control measures (as with outbreak 1), and nose and throat swabs and acute and convalescent sera were collected. Infection with influenza A (H3N2) was confirmed on Day 8, but, by that stage, most affected individuals had recovered and antiviral therapy was not recommended. Although 30 out of 32 residents had received the 2001 influenza vaccine, only three of the 31 staff members had been vaccinated in 2001. Because the outbreak occurred in March, all staff and residents received the influenza vaccine as part of the 2002 influenza vaccination program. The WHO laboratory determined that the outbreak strain was influenza A/H3N2/Moscow-like and concluded that the H3N2-like strain in the 2001 vaccine protected against infection with this virus. However, the infecting viruses in outbreaks 1 and 2 were genetically different, suggesting they were not directly linked. Preventing and controlling influenza outbreaks in ACFsVaccinationIn Australia, influenza vaccination is recommended and funded annually for people aged 65 years and over and recommended, but not publicly funded, for healthcare workers in ACFs.1 Elderly residents may have an impaired response to the vaccine because of age or comorbidities.2,3 Outbreaks have been reported in ACFs, despite high vaccination coverage rates (> 85%) in residents using a vaccine that matches the circulating strain.4,5 This was the case in the outbreaks described here, in which at least 90% of residents had received the influenza vaccine. In view of this, the priority for preventing influenza outbreaks in ACFs should be to prevent individuals introducing the virus into the facility. The key way to do this is to ensure that ACF healthcare workers (including attending GPs) are vaccinated. Educating visitors about vaccination and instructing them to stay away from the ACF when unwell is less likely to be successful. In both outbreaks, there was low staff vaccination coverage, and in outbreak 2, staff appeared to contribute to ongoing transmission. Diagnosis and infection controlThe current non-systematic method of notification of influenza outbreaks in Melbourne ACFs is inadequate. Facilities should be encouraged to establish a sentinel surveillance system to recognise, notify and diagnose early cases of respiratory illness to allow timely outbreak control measures to be implemented.2,6 The response to influenza outbreaks in ACFs should be a collaborative effort between the ACF, the attending GPs and the DHS. The DHS is currently developing guidelines to manage outbreaks of respiratory virus infection in ACFs and will be piloting a system of ACF respiratory diseases surveillance for the 2004 respiratory virus season. Antiviral therapyAntiviral agents available in Australia include amantadine, zanamivir and oseltamivir. Amantadine has been shown to be 70%–90% effective in preventing illness caused by naturally occurring strains of influenza A virus7 and has been successful in controlling 60%–80% of influenza A outbreaks.8 In Australia, amantadine is approved for prophylaxis of influenza A virus but not treatment. Amantadine has several disadvantages, including lack of activity against influenza B, the potential for the occurrence of adverse side effects (despite individualised dosing based on renal function), and the rapid emergence of resistance to the drug.9 Spread of amantadine-resistant viral strains has been associated with simultaneous prophylaxis and treatment in the same facility.8 Zanamivir and oseltamivir are a newer class of antiviral agents (neuraminidase inhibitors) that are effective against both influenza A and B and have less serious side effects. Initial reports indicate that the frequency of emerging resistance to these agents is low during clinical use.9 In Australia, both agents have been recently licensed for prophylaxis. Neuraminidase inhibitors are 74% effective (95% CI, 50%–87%) in preventing illness caused by naturally occurring strains of influenza viruses in healthy adults.10 From the few available published reports of the use of these antiviral agents for chemoprophylaxis in outbreaks, both appear to be effective in stopping outbreaks in ACFs.9,11 When ACF staff and attending GPs are making decisions about antiviral treatment and prophylaxis in outbreak situations, they should take into account the influenza strain, the health status of the residents, the dosage schedules required, the potential side effects of the drug and the cost (antiviral drugs are not covered by the Pharmaceutical Benefits Scheme). The following recommendations for the use of antiviral agents to control influenza outbreaks will be detailed in guidelines being developed by the DHS: To be effective, treatment with zanamivir or oseltamivir must be started within 48 hours of symptom onset and continued for 5 days; Antiviral prophylaxis should be offered to all residents (whether vaccinated or unvaccinated) and to all unvaccinated staff members and should continue for 10 days or until the outbreak is declared over; If the outbreak is caused by a strain of influenza not covered by the vaccine, prophylaxis should be considered for all staff members, regardless of their vaccination status; To limit the potential transmission of drug-resistant virus during outbreaks, measures should be taken to reduce contact as much as possible between people taking antiviral drugs for treatment and those taking them for prophylaxis; and ACF staff should make arrangements with attending GPs to ensure residents can be prescribed antiviral treatment and prophylaxis rapidly and efficiently. Lessons from practice Even when vaccination coverage is high among residents, influenza outbreaks (with a strain covered by the vaccine) can still occur in aged-care facilities (ACFs), including during the summer months. Because of the poor health status of many residents, influenza outbreaks in ACFs can cause significant morbidity and mortality. When influenza vaccine coverage among residents is high, coverage in ACF healthcare workers is a priority for preventing outbreaks. If an influenza outbreak is suspected, this should be confirmed using nasopharyngeal aspirates or nose and throat swabs tested by a polymerase chain reaction assay. Serological testing may also be useful when symptoms have been established for longer than 72 hours. When influenza outbreaks occur in ACFs, antiviral therapy should be considered as an outbreak control measure. 1: Timeline for influenza A outbreaks in two aged-care facilities (confirmed and probable cases) Outbreak 1 Day Number of people with onset of respiratory symptoms and major events (action taken/findings) 0 1 visitor 5 1 resident 8 1 resident 10 1 resident 11 4 residents 12 5 residents 13 4 residents DHS notified of outbreak 14 1 resident, 4 ACF staff members Laboratory specimens collected. ACF advised to implement infection control measures 15 1 resident, 1 ACF staff member Specimens confirmed positive for influenza A (H3N2) by PCR assay. Antiviral therapy recommended 16 1 DHS staff member 17 2 residents Antiviral therapy implemented 18 1 ACF staff member Summary.* Residents (n = 42): 20 Inf (19 C, 1 P); 10 H; ACF staff (n = 29): 6 Inf (4 C, 2 P); Visitors: 1 Inf (1 C); 1 H; 1 D; DHS staff: 1 Inf (1 C). Outbreak 2 Day Number of people with onset of respiratory symptoms and major events (action taken/findings) 0 2 residents 1 5 residents 1 ACF staff member 2 2 residents 5 ACF staff members 2 visitors 3 3 residents 4 ACF staff members 4 2 residents 1 visitor 5 1 ACF staff member DHS notified of outbreak. Laboratory specimens collected. ACF advised to implement infection control measures 6 1 ACF staff member 8 1 ACF staff member Specimens confirmed positive for influenza A (H3N2) by PCR assay 9 2 residents Summary.* Residents (n = 32): 16 Inf (15 C, 1 P); 8 H; 1 D; ACF staff (n = 31): 13 Inf (3 C, 10 P); 3 H; Visitors: 3 Inf (3 P). ACF = aged-care facility. DHS = Victorian Department of Human Services. PCR = polymerase chain reaction. * Inf = developed influenza A (C = confirmed; P = probable); H = hospitalised; D = died. 2: Infection control measures for influenza A outbreaks in aged-care facilities (ACFs)* Restrict visitors from entering the ACF. Isolate sick residents in their rooms until 5 days after the onset of illness or until symptoms have completely resolved. Exclude sick staff from work for 5 days from the onset of symptoms of a respiratory illness or until symptoms have resolved. Restrict all admissions of new residents during the outbreak; Cancel daily activities programs. Instruct staff to increase hand washing, wear masks while providing care to symptomatic residents and enhance environmental cleaning. * Recommended by the Victorian Department of Human Services to control the outbreaks described here.

Rebecca J Guy MAppSc, MAppEpid · Richard Di Natale MB BS · Sean Tobin MB BS, MPH, FAFPHM · Priscilla M Robinson PhD, MPH, MHlthSc · Graham Tallis MB BS, FAFPHM · Heath A Kelly MB BS, MPH, FAFPHM · Stephen B Lambert MB BS, MAppEpid, FAFPHM · Alan W Hampson BSc, MSc

Setting You are in the emergency department and have just treated a patient with ventricular tachycardia. You have 5 minutes you can spend with some new interns and decide to discuss the management of VT. Teaching can be thought of as a planned learning activity.1 Clinicians think teaching “on the run” in the clinical setting can’t be planned. But given that we know we will be teaching, we know we are going to be busy, and we know the topics that recur, we can plan. With experience from seeing many patients, we build up “teaching scripts” on common topics (such as ventricular tachycardia) related to diagnosis, management, social circumstances and so forth.2 We can draw on these, in the context of assessing the patient, to guide us in covering the essential points. This can be in a 5-minute grabbed moment, a 30-minute interactive tutorial or a 1-hour lecture, as appropriate. Peyton and colleagues3 have described a method for planning any teaching event based on a triad of concepts: Set: what you need to think about beforehand; Dialogue: what happens during the event; and Closure: how you finish off. Some aspects of Set can be decided during the planning stage, but others occur as you are starting your session. The essentials of Set include being clear about the desired learning outcomes, which should be specific and achievable in the time available. They should be relevant and important for the learner and pitched at the right level. Remember the principles of adult learning discussed in our “Tips 2” article.4 Consider the environment and whether the seating, the room and the teaching “props” are adequate. Ensure that there is privacy, that the patient is suitable, and that the learners are not tired or distracted by other work. Think about the roles of the patient and learner. Tell learners what teaching method will be used and what is expected of them.5 Dialogue is the crucial part of the learning experience and involves interaction between the learner and the teacher. Given that the attention span of an adult is 10–15 minutes, varying your delivery in longer sessions (eg, by including a learner activity or case study in the middle of a tutorial) can significantly increase factual recall in learners.6 The essentials of Dialogue include delivering the content in a stimulating way to make it engaging. Use eye contact, address people by their names, and ask questions to keep them involved. Questioning also allows you to check understanding. In the Closure, provide a summary with the take-home message and links to topics for self-directed or future learning (as not everything can be covered in the time available), and make sure you finish on time. Remember that sometimes, when you or the learners are too busy, it isn’t worth trying to teach. Delay teaching for a time when you and they are all able to concentrate, but don’t delay it forever. Stop and think! How could you apply Set, Dialogue, and Closure next time you teach? Reflective teachingImprovements in your teaching can only occur if you reflect on how each encounter went.6,7 You can do this in simple ways. Ask yourself, How did that go? What went well? If you did it again tomorrow, what would you change to make it better? Think through how well you did with Set, Dialogue and Closure. Too often we rush on to our next busy task and never do this, then find ourselves doing the same thing year after year. Ask the learners for feedback: Verbal. Ask them what they thought went well and what could be improved; Written. Ask them to write down any points that were not clear, then collect and read the comments to find out what they are still confused about. Also ask learners to fill in an evaluation form. Review the learners’ progress. Next time, do they remember the lessons learnt, and did they perform well in assessments? Ask a colleague to observe your teaching and provide feedback in a structured way. Take-home message When you next teach “on the run”: Consider the concepts of Set, Dialogue and Closure in planning teaching sessions. During a session, vary your methods to keep learners engaged. After a session, make time to reflect on or ask “What went well?” and “What could be improved?”.

Fiona R Lake MD, FRACP · Gerard Ryan MB BS, FRACP

Integrated clinics have already been established in response to community demand. The growing evidence base for complementary and alternative medicine (CAM) and its widespread community use compels doctors to understand complementary therapies and to refer patients to CAM practitioners where appropriate. Most general practitioners have patients with chronic illness who could benefit from the services of CAM practitioners, and virtually all CAM practitioners have patients who require access to mainstream diagnosis and therapy. Collaboration requires shared respect and trust, and education. Dangers of not integrating care include delaying or depriving patients of safe and effective management, and the potential for harmful interactions. Integration is currently being supported by government initiatives such as the new MedicarePlus package, as well as by initiatives from organisations such as the Australian Medical Association, the Royal Australian College of General Practitioners and the Australasian Integrative Medicine Association.

Marc M Cohen MB BS(Hons), PhD, BMedSc(Hons)

A complementary and alternative medicine (CAM) system divorced from scientific medicine means that patients can only benefit from the best of both systems by dividing their care. Science must be used to stimulate convergence of complementary and traditional healthcare. First class research to examine the more interesting claims of the alternative health industry is essential to broaden the range of therapeutic options available, while minimising fraudulent, ill-informed and sometimes dangerous practices. Mutual respect and interest between orthodox and alternative practitioners is appropriate, but there can be no compromise involving unscientific approaches to care. Health departments must play a greater role in stopping fraudulent claims being publicised, and in warning consumers about such claims.

John M Dwyer AO, FRACP, PhD

To the Editor: We report a case in which routine use of transesophageal echocardiography (TOE) during cardiac surgery almost certainly prevented a patient’s death. This is important, as the Australian Government Department of Health and Ageing has recently decided that TOE during routine coronary artery cardiac surgery should not attract a Medicare benefit as there is no Level 1 or 2 evidence of its efficacy.1 A 65-year-old man with critical aortic valve stenosis and severe left ventricular dysfunction, requiring an intra-aortic balloon pump, was scheduled for mechanical aortic valve replacement. He had been in atrial fibrillation intermittently, but was in sinus rhythm for the 24 hours before surgery and his heparin had been at therapeutic levels since balloon pump insertion 36 hours before. Like most cardiac anaesthetists in Australia, we routinely perform TOE during cardiac surgery. Following induction of anaesthesia, TOE examination confirmed severe aortic stenosis and poor left ventricular function, but the left atrial appendage was not specifically examined and a routine preoperative transthoracic echocardiogram had shown no other abnormalities. With the patient on cardiopulmonary bypass, the diseased valve was replaced. Before weaning the patient from bypass, a TOE examination showed a large free 2.5 × 2 cm mass in the left atrium resembling thrombus (Box [a]). The surgeon then reported having invaginated the left atrial appendage while de-airing. While the patient was still on bypass, a large organised clot was removed from the left atrium (Box [b]) — this had presumably developed sometime during the preoperative period. Subsequent separation of the patient from bypass was uneventful, and he made a good recovery. The thrombus would not have been suspected or found without the TOE, and almost certainly would have migrated from the left atrium into the left ventricle following the return of cardiac output, and would likely have precipitated a sudden cardiac arrest with acute valvular obstruction. Despite the lack of Level 1 or 2 evidence, most cardiac anaesthetists and surgeons consider TOE an invaluable diagnostic and monitoring tool, particularly for assessment of left ventricular function and filling. While TOE has not rendered the Swan–Ganz catheter obsolete, it provides similar information with fewer complications. This case is a dramatic illustration of the usefulness of TOE during cardiac surgery, but less dramatic examples occur much more frequently. The Department of Health and Ageing decision not to support TOE (except in valve repair or replacement) seems shortsighted. While we support the Department’s evidence-based approach, it would be interesting to know how many procedures listed in the Medicare Benefits Schedule would withstand the same scrutiny. Randomised trials are difficult to perform, but, at the very least, TOE has excellent peer consensus, strong anecdotal evidence and large series reviews2,3 supporting its routine use in cardiac surgery. Atrial thrombus in left atrium detected by transoesophageal echocardiography during cardiac surgery (a) Echocardiogram showing the mass. (b) The clot that was removed.

Chris J Cokis · John Faris

Sebastiaan J M van Hal,* Jeffrey J Post† * Advanced Trainee, † Infectious Diseases Physician, Prince of Wales Hospital, Barker Street, Randwick, NSW 2031. j.postATunsw.edu.au To the Editor: Community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) infection is an increasingly recognised cause of skin and soft tissue infection, as well as more serious manifestations, including necrotising pneumonia, endocarditis, osteomyelitis and severe sepsis.1,2 We report another serious manifestation of CAMRSA infection. A 24-year-old Australian-born white, HIV-negative, male prison inmate was transferred to hospital. He had previously injected drugs, but not for more than 2 years. He reported a 10-day history of cervical neck pain, left-sided pleuritic chest pain and a 2-cm occipital carbuncle, which developed after a laceration on the scalp from a close haircut with barber’s shears. Examination revealed a temperature of 37.9°C, sinus tachycardia, profound neck stiffness and signs of left basal consolidation with a left pleural effusion. There were no focal neurological signs or other signs of meningism. Investigations revealed a neutrophil leukocytosis of 22.7 × 109/L (reference range, 1.7–7.0 × 109/L) with mild elevation of hepatic transaminases and hypoalbuminaemia. CAMRSA was isolated from blood cultures and a swab of the occipital carbuncle. The organism was susceptible to erythromycin, vancomycin, rifampicin and fusidic acid. A chest radiograph showed extensive left-sided consolidation consistent with pneumonia. A magnetic resonance imaging scan of the entire spine revealed asymmetric thickening and enhancement of the epidural tissue from C2 to C5, with no discrete abscess, osteomyelitis or discitis. The patient made a full recovery after 4 weeks of intravenous therapy with vancomycin (1 g every 12 hours) and clindamycin (600 mg every 6 hours). This is the first reported case of epidural tissue infection (epiduritis) caused by CAMRSA, and adds to the spectrum of potential clinical manifestations. In addition, this is the first reported case of CAMRSA infection occurring in an Australian prison inmate. There have been several reported outbreaks of CAMRSA in US correctional facilities.3,4 Although no similar outbreaks have been described in Australia, clinicians should be aware that correctional facilities may contribute to the spread of CAMRSA. The most common manifestations of CAMRSA infection in the prison setting in the United States are skin and soft tissue infections, with invasive infection occurring in 1.7% of patients.4 Clinicians providing care to inmates should be aware that strategies have been identified to reduce the incidence of CAMRSA infection.5 Clinicians need to be aware of the increasing incidence of CAMRSA infection, the diverse and potentially severe manifestations, and the treatment and preventive strategies available.

Sebastiaan J M van Hal · Jeffrey J Post

Sandy Reid Head, School of Rural Health, University of New South Wales, PO Box 5695, Wagga Wagga, NSW 2560. s.reidATunsw.edu.au To the Editor: The editorial by Wearne and Wakerman on the subject of rural training and its relationship to rural practice is timely.1 There is widespread belief that the rural problem lies in small country centres, and it is generally not realised that most of the regional centres, in New South Wales at least, are seriously short of both general practitioners and specialists. The statistics are highly unreliable, as many people, such as me, are listed as GPs even though we do not practise. It seems likely that improved selection processes and the undergraduate rural training initiatives will increase student interest in rural practice. Many students express intent to practice in a rural or regional centre, but are later deflected from this by the necessity for training after graduation. Several large centres are not primary allocation centres, so a student who trained there may never get back. (The Australian Medical Students’ Association study puts the figure for rural internships as 9% of the total.)2 All too often, regional centres are understaffed, and junior staff lack adequate supervision and educational possibilities. Their negative experience is highly visible to students. The allocation of registrars and senior resident medical officers, who supervise or make time for consultants to supervise, rests between the major hospitals and the various colleges. Regional hospitals are often low on their priority list when shortages occur. Yet there are regional hospitals that rate very highly in the quality of the training experience they provide. Regional hospitals that do not enjoy this reputation need to take active steps to improve their training and supervision or their plight will worsen. Training packages also need to be developed for those who express an interest in rural practice so they can plan their future. This must be a collaborative process between the different seconding agencies: without such a process, much of the impetus of the undergraduate initiatives will be lost.

Sandy Reid

Barney J McCusker Orthopaedic Surgeon, Wavell House, PO Box 1998, Mount Gambier, SA 5290. To the Editor: I recently had the opportunity to analyse the home postcodes of medical students at the University of Adelaide over five recent consecutive years. Although this analysis is rather simplistic, its findings are quite startling (see Box). Between 50 and 60 students per year were from the Adelaide metropolitan area. My colleagues in the Department of Human Services tell me that we struggle every year to fill the junior posts at our metropolitan public hospitals. A considerable number of students (25–41) were from outside South Australia. It is only natural that these students would want to go home after completing their degree, and I believe that considerable effort is made every year to encourage these students to stay and staff junior positions in our hospitals. There has been much discussion about students from outside Australia and I will not add to the debate on this complex issue. The most alarming feature is the small number of students from rural South Australia. This ranged from zero to three or four. Moreover, I have included in this category students whose home address was in the Adelaide Hills, which is between 5 and 20 km from the Adelaide metropolitan area. We spend a lot of time encouraging students who grew up and were educated in cities to come to rural settings, using various schemes of bonding and financial inducement, with limited success. After 18 years’ practice in a rural area, I am firmly of the belief that we should be starting much earlier. If a person is born and reared in the country, and has their secondary schooling in the country, it is much easier to transplant that person back to the country after tertiary eduction. If these figures of students’ home residence are representative, we will always be fighting an uphill battle to attract doctors to rural areas. This is not the fault of our universities, as they are constrained by federal regulations. I believe the solution lies in Canberra. In our parliaments, we have proportional representation. As far as medical students are concerned, I think South Australia has disproportionate representation. Medical students attending the University of Adelaide, by area of residence (determined by home postcode) (years not specified) Total number of students 145 139 131 110 107 Students from metropolitan Adelaide 56 50 60 50 53 Students from outside South Australia 32 41 36 28 25 Students from outside Australia 53 45 35 28 26 Students from rural South Australia 4 3 0 4 3

Barney J McCusker

S Bruce Dowton,* Danielle Brown† * Chair, † Executive Officer, Committee of Deans of Australian Medical Schools, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052. b.dowtonATunsw.edu.au Comment: Data collected by the Committee of Deans of Australian Medical Schools (CDAMS) would appear to broadly support the pattern of medical student origins reported by McCusker from the University of Adelaide. CDAMS has been collecting medical student statistics annually for the past few years. Box 1 sets out the basic enrolment figures for Australian and international students across all years in 2003. In 2003, CDAMS also commenced collecting data on interstate mobility (ie, students attending medical school in another state) among first-year medical students at the 12 medical schools. As a general principle, some level of interstate mobility brings positive benefits by fostering diversity in the medical student body and broadening educational and social opportunities for individual students. However, as McCusker rightly points out, this can create problems when interstate medical graduates choose to return to their home states (or move to other states) when they enter their intern training years. In this regard, South Australia faces particular problems, as it has the highest proportion of students entering medicine from interstate. Box 2 shows that just under half of all commencing medical students at Adelaide and Flinders medical schools in 2003 were from other states. This may well have an impact when these students come to choose their intern training locations. Box 3 sets out state averages for first-year students with a rural background. The figure for South Australia as a state suggests that it is reasonably comparable with other states. However, there is a sizeable gap between the rural student cohorts at Flinders and Adelaide medical schools: in 2003, 26% compared with 12%, respectively, were from a rural background. All medical schools in Australia have committed their energies to a range of collaborative programs, together with the Australian Department of Health and Ageing, aimed at ensuring a sustainable medical workforce that is equitably distributed across the nation. 1: Australian and international medical students at Australian medical schools, 2003 No. of students Percentage of total (n = 8684) Australian students, all years 7111 82% International students, all years 1573 18% 2: Interstate mobility (number of students attending medical school in another state — first-year Australian students, 2003) State No. of students Total (%) SA 85 174 (49%) Tas 25 64 (39%) Vic 82 344 (24%) Qld 62 346 (18%) NSW 63 446 (14%) WA 14 140 (10%) National total 331 1514 (22%) 3: Rural background (first-year Australian students, 2003) State No. of students Total (%) SA 31 174 (18%) Tas 14 64 (22%) Vic 80 344 (23%) Qld 93 346 (27%) NSW 71 446 (16%) WA 20 140 (14%) National total 309 1514 (20.5%)

S Bruce Dowton · Danielle Brown

To the Editor: We read with interest the article by Mitchell et al and the editorial by Cole on comparatively adverse outcomes in adolescents and young adults with cancer.1,2 The improvements in cancer survival, most remarkably demonstrated in children, have failed to similarly benefit older adolescents and young adults, a population with a higher and increasing incidence of cancer.3 Most authors advocate increasing research, networking resources and information, enhancing support for clinical trials and facilitating participation in them. Recently announced funding for a comprehensive cancer-care program for adolescents and young adults at the Peter MacCallum Cancer Institute in Melbourne is a welcome step towards these goals. The specific emotional and psychosocial needs of this age group are also poorly addressed within traditional models of care.4 Patients in this group express strong preference for peer support, opportunities to be cohorted with each other and access to specific support services.4 The short and long term sequelae of cancer, as well as of its treatment, in adolescents and young adults create particular challenges for both healthcare professionals and the broader community. In December 2003, an entire issue of the European Journal of Cancer was dedicated to adolescent oncology — this science, clinical care and the needs of the patient population.5 An important development in the United Kingdom has been the establishment of eight “teenage cancer units” with a comprehensive approach to all aspects of care.6 Preliminary research in Australia and New Zealand by one of our group (J E) highlights gaps in service and support perceived by consumers, concerns yet to be addressed by appropriate policy and funding.7 The paediatric model of care has provided not only excellent survival but also an exemplary family-centred and comprehensive support system. The recent emphasis on the transition process for adolescents with a variety of chronic illnesses has highlighted systemic differences between the paediatric and adult models. Some paediatric oncologists, especially in the United States, have proposed raising the upper age limit for eligibility to childhood cancer units as a solution. A more realistic approach, particularly in Australia, requires establishing specialist facilities operated in partnership between (preferably collocated) adult and paediatric units, with subspecialisation of the multidisciplinary workforce, an age-appropriate environment and peer support from groups like the Australian Organisation for Young People Living with Cancer (CanTeen). This approach is capable of addressing all of the above issues, from better science through to psychosocial expertise appropriately targeted for age. The ideal number and distribution of such centres/partnerships should be guided by the paediatric track record for balancing centralisation and quality with access and family focus.

Les White · Jane Ewing · Anne M Senner · Madeleine King · Belinda Goodenough

To the Editor: It has been claimed that patients are missing out on the most effective current treatments if they are not given an opportunity to enrol in clinical trials. Such statements are misleading and have the potential both to create concern in those without access to trials and to reduce the likelihood of true informed consent for involvement in trials. Trials are, by definition, just that — trials. Treatment in the “innovative” arm(s) may result in worse outcomes. The finding that those involved in trials have a better outcome (eg, 5-year survival) may have numerous explanations. It is unlikely that the innovation is an adequate explanation for the finding — confounding factors such as selection bias, adherence to best current practice, and intensity of monitoring are more likely explanatory factors. Furthermore, it is important to focus on other outcomes of therapeutic endeavour, such as quality of life, and the impact of the illness on other family members. Patients who live some distance away from tertiary referral centres or trial centres may have a greater adverse effect from involvement in a trial than other patients who live close to such centres. Well designed trials are a crucial part of advancing medical therapeutics. However, the recent editorial by Cole1 and the article by Mitchell and colleagues2 in the Journal have been picked up by the news media as demonstrating that only through involvement in clinical trials can patients get best-quality care. It is not surprising that this is the way that the message has been received. The truth is importantly different. It is only through the conduct of clinical trials that best practice can be defined. However, patients anywhere in the country should be able to access current best-practice treatment even if they do not want to be involved in a clinical trial. Encouragement to participate in clinical trials should be based on arguments about the “greater good” and not about issues of quality of care. To use the latter as the basis for argument must be seen as coercion and as unethical.

Alex N Thomson

In reply: Thomson is correct in stating that patients involved in clinical trials have better 5-year survival rates when compared with patients not recruited into clinical trials. There may, as Thomson points out, be numerous possible explanations for this finding. Nonetheless, this improvement in survival is well documented and has been recognised for some time.1 Although it is becoming increasingly important to focus on other therapeutic outcomes, such as quality of life, it is incorrect to assume that involvement in clinical cancer trials equates to impairment of quality of life and an increase in adverse effects. In fact, the primary end-point of numerous clinical cancer trials is improved quality of life.2 We agree with Thomson when he states that patients anywhere in the country should be able to access current best-practice treatment. We agree that best-practice treatment can only be defined through the conduct of clinical trials. Hence, well designed clinical trials are necessary, and indeed crucial, to the advancement of cancer therapy. In the context of adolescents and young adults with cancer, the lower than expected improvement in survival may be explained, in part, by a low rate of participation in clinical trials.3 There is no doubt that participation in late-phase clinical trials provides a “benchmark” and ensures the provision of quality medical care. Rural and regional settings should not, a priori, be a barrier to trial participation. Adequate infrastructure and support should be available for such centres to participate. Greater cooperation between all adult and paediatric clinicians involved in the care of adolescents and young adults with cancer is essential to ensure that the inequity in survival is corrected.

Anne E Mitchell · Deborah L Scarcella · Gemma L Rigutto · David M Ashley · Vicky J Thursfield · Graham G Giles · Maree Sexton

John Orchard,* Caroline Finch† * Sports Physician, Sports Medicine Unit; † Director, NSW Injury Risk Management Research Centre, University of New South Wales, 111 Anzac Parade, Kensington, NSW 2033. johnorchardATmsn.com.au To the Editor: We agree with very few of the conclusions in the recent article by Mitton et al.1 It is fascinating that the authors single out elite athlete funding as being the only notable area of discretionary government spending that prevents more from being spent on healthcare. We suspect that the authors share the widely-held view within the healthcare professions that sport is an indulgence rather than a contributor to the good health of this nation. Sports medicine is the only recognised branch of medicine in Australia that is considered an “area” of medicine (all other recognised branches being considered “specialties”), a view held by both the Health Insurance Commission and the Australian Medical Association. Therefore, an Australian athlete who suffers a sports injury and is referred to a sports physician receives lower Medicare rebates for the visit than all other patients referred elsewhere in the system, and is unable to claim any Medicare rebate if he or she requires a magnetic resonance imaging scan for an injury, again the only such example in the Australian healthcare system.2 Injuries which occur as a result of traffic accidents, workplace accidents, falls, assaults and suicide attempts are all monitored by various government departments, with priority funding specifically directed towards their prevention. The federal government in Australia directs no funding towards sports injury monitoring or prevention3 and does not devote sufficient resources towards making the population more active.4 The article by Mitton et al ignores the concept of efficiency (in terms of prolonging life) within healthcare spending. Health promotion and prevention of illness and injury are far more efficient ways of prolonging life than treating existing disease (compare smoking cessation programs with coronary care units). Lack of sport and exercise is an increasingly prevalent risk factor for major diseases.4 The use of elite athletes as role models may or may not contribute to a more active population — we suspect the former. We also believe that the disrespect shown within the Australian healthcare system towards sports injuries (compared with other injuries and illnesses) is a major disincentive for Australians to become more active. This is a disincentive for which we will pay a high penalty in terms of decreased life expectancy and increased healthcare costs in the future.

John Orchard · Caroline Finch

Craig R Mitton,* H Dele Davies,† Cam Donaldson‡ * Assistant Professor, Department of Health Care and Epidemiology, University of British Columbia, 4480 Oak Street, E414 A, Vancouver, BC V6H3V4, Canada; † Professor, Pediatrics and Human Development, Michigan State University, USA; ‡ Professor, School of Population and Health Sciences and Business School, University of Newcastle, UK. cmittonATcw.bc.ca In reply: We thank Orchard and Finch for their letter about our article comparing spending on the Sydney Olympics to expenditure on healthcare for Australia, Canada and Britain.1 The reason we “singled out elite athlete funding” was simply to choose a high profile expenditure as an illustration that government does indeed make decisions about priorities with the limited societal resources available. While we would strongly agree, and in fact state, that “spending more on athletics may improve the health of the population”,1 the necessary public debate about how societal resources should be best spent is lacking. In our view, such a debate should be informed by the costs and wide-ranging benefits of government expenditure and be based on clearly articulated public values. Contrary to the claim that we “ignore the concept of efficiency”, it is precisely here, when costs and benefits of alternative claims on limited resources are explicitly compared (both within healthcare and across government sectors), that the notion of efficiency is addressed.2 Upstream investment in promotional activities may well be an appropriate way to spend health and non-health dollars — let’s just make these choices, and the underlying values, explicit.

Craig R Mitton · H Dele Davies · Cam Donaldson

Donald M Clark Obstetrician, PO Box 503, Mount Lawley, WA 6929. To the Editor: Giles et al1 have “poisoned the well” for future research by attacking the obstetricians who took the trouble to help them with their study on management of hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV. Many of the discrepancies noted between current practice and the recommendations/guidelines are easy to explain: Failure to screen. Many obstetricians were told that it is discriminatory to screen for HIV and HCV without extensive pretest counselling. The advice is obsolete, but old habits die slowly. Failure to recommend caesarean section for women with HIV. Many obstetricians have never seen a case of HIV and would most certainly phone for advice if the situation arose. Failure to promote breastfeeding. Many obstetricians leave advice on breastfeeding to the midwives and paediatricians. However, the article does concede that mother-to-baby transmission is a theoretical risk, so patients are entitled to be informed. Failure to adhere to guidelines. Many obstetricians regard guidelines issued by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) as just that — guidelines, not gospel.

Donald M Clark

Rebuilding trust in healthcare. Jamie Harrison, Rob Innes, Tim van Zwanenberg (editors). Oxon: Radcliffe Medical Press, 2003 (ix + 198 pp). ISBN 1 85775 938 9. The essays in this book were written in the aftermath of the Bristol paediatric cardiac surgery debacle, the Alder Hay scandal (over the use of dead children’s organs) and the Shipman murders. In the foreword, Rabbi Julia Newburger, Chief Executive of the King’s Fund in London, explains that, despite this context, the overall message goes far beyond calling for more accountability measures for healthcare. Other contributors reinforce her challenge. They are calling for a cultural change — one of leadership within medicine and within management. This leadership needs to take up where government leadership finds it increasingly hard to deliver. The 15 contributors include journalists, psychologists, sociologists and ministers of religion, as well as clinicians. The difference between accountability (witness the plethora of “quality committees” mushrooming in our hospitals) and trust is the underlying theme. We are warned that increasing focus on system audit may not bolster the public’s confidence. It is the insistence on professional integrity and the restoration of earned trust that will promote cultural change and bring back confidence in the healthcare system. I highly recommend this book to all clinician and management leaders. It is a powerful, challenging and exciting collection of essays by a variety of individuals, all of whom are deeply concerned by the present breakdown of trust in our healthcare system. Kerry J GoulstonChair NSW Greater Metropolitan Transition Taskforce North Ryde, NSW

Kerry J Goulston

Allergy. Your questions answered. Helen E Smith, Anthony J Frew. Edinburgh: Churchill Livingstone, 2003 (220 pp). ISBN 0 4430 7291 4. This is a compact paperback that will be of interest to primary care physicians, nurses and patients. Despite its size, it covers a broad range of allergic disorders and related topics. The authors are suitably qualified to present a resource such as this. Helen Smith is a reader in primary care medicine at the University of Southampton, and Anthony Frew is an eminent professor of allergy and respiratory medicine in the same institution. The question-and-answer format used throughout the book ensures that it provides a succinct, authoritative opinion on all aspects of allergic disease. Its layout ensures ready access to any topic, with an excellent list of chapter and topic headings as well as an easy-to-use index. There is a list of questions, which are numbered for easy reference. Within each chapter there are highlighted points, clear diagrams and a list of frequently asked patient questions at the end of each section. The material covered in this volume is relevant and up-to-date, and the authors clearly differentiate between factual material and proven therapies, on the one hand, and unproven techniques and therapies on the other. The chapter dealing with unproven diagnostic techniques and therapies is particularly well presented. The authors present a straightforward, honest appraisal of the deficiencies of many of the so-called alternative techniques used by non-medical practitioners in the pursuit of the patient with allergic disease. As with most books written in the Northern Hemisphere, sections on seasonal allergy are of limited use to an Australian audience because of the differences in our pollen seasons. The appendix of useful organisations with website addresses is also of limited use because of the predominantly local nature of this information, although two Australian organisations do rate a mention. There are a number of other international organisations listed in this section. At first glance the suggested retail price of almost $66 appears to be expensive for such a small paperback edition. In fact, this is a beautifully presented and easily accessible textbook on allergic disease, and it will have appeal both as an interesting read and as a reference book for those who desire a working knowledge of the subject. Constance H KatelarisAssociate Professor Department of Clinical Immunology and Allergy Westmead Hospital, NSW Order this book

Constance H Katelaris

Cannabis use and dependence: public health and public policy. Wayne Hall and Rosalie Liccardo Pacula. Melbourne: Cambridge University Press, 2003 (xiv + 298 pp). ISBN 0 521 80024 2. “Wayne Hall and Rosalie Pacula have written the first honest book on cannabis addressing the whole range of issues that need to be considered for a sensible policy discussion.” No, the source of this quotation is not the publisher’s advertising department. Rather, these are the words of the author of the book’s preface, Peter Reuter, one of the most perspicacious international scholars in the area of psychoactive drugs policy. Honesty and comprehensiveness are features too often lacking in debates on illicit drugs policy. Hall and Pacula (Australian scholars with outstanding reputations in the drugs field) have taken this head on, aiming “to improve the quality of public policy debate on cannabis by ensuring that all relevant issues are addressed” (p3). The book certainly is comprehensive, striking an excellent balance between reviewing and assessing the evidence about the health, psychological and social consequences of cannabis use and, importantly, the costs and effectiveness of cannabis prohibition. This volume is beautifully designed, making its contents accessible to both the busy professional and the student. This is achieved by the use of many subheadings, chapter summaries and a final topic-by-topic summary chapter. Cannabis use and dependence is a book that I will refer to frequently. It is a wonderful resource, providing in one place a sound presentation and evaluation of the current literature about the impacts of cannabis use and of society’s responses to cannabis and its use, and suggesting pathways towards sounder, more evidence-based public policy on cannabis. It fills a significant gap for students and their instructors, as no other volume provides reliable information and assessment in such a package. People of influence in public health and government, involved in the contested field of evolving policies on cannabis, should also find this an invaluable resource. As Peter Reuter said, it is both honest and comprehensive — quite an achievement! David McDonaldConsultant in Social Research andEvaluation Canberra, ACT

David McDonald

Dealing with dementia. A guide to Alzheimer’s disease and other dementias. Brian Draper. Sydney: Allen and Unwin, 2004 (xvi + 255 pp). ISBN 1 86508 853 6. Dementia is a condition that is common and costly. It affects not only those with the disease, but also their carers and families. Public awareness of dementia has increased in recent times, but many aspects are still misunderstood. Dealing with dementia is a comprehensive, easy-to-read book that covers “all you need to know” about dementia and is primarily written for those living with the condition. The strength of the book is that Draper covers all aspects of dementia care, ranging from the purely medical to alternative therapies. He addresses often-asked questions such as those about nutrition and occupational exposures. Non-pharmacological approaches to management, such as reality and validation therapy, music therapy, and a myriad of others, are described and supported by research outcomes, if these are available. Ethical and legal issues associated with the care of a person with dementia are clearly explained. A glimpse into possible future treatments gives hope to readers. This book is primarily for Australian readers. It contains a comprehensive description of community care services and residential care processes available in this country, and this is particularly useful for stressed families trying to sort through the maze of available services. Even though specifically Australian-based, the information presented in the book is easily adapted for an international audience. A useful summary of national and international websites is included for further exploration. Draper is a respected researcher and clinician in the field of dementia, including the needs of carers, who writes with a personal and often humorous style. The book is reasonably priced and health professionals can recommend it as a useful reference for patients and carers. Dina C LoGiudiceGeriatrician, Extended Care and Rehabilitation Centre, Melbourne, VIC

Dina C LoGiudice

Russian roulette It would seem the medical workforce in Russia may be due for reform on several fronts, according to two news items in the BMJ. Four Moscow doctors have been accused of plotting to murder a seriously injured patient for his kidneys, and half of the country’s doctors may be sacked if radical draft legislation aimed at improving the quality of care is passed. A third of Russia’s 1.6 million beds would be scrapped, thousands of specialist posts cancelled and more doctors encouraged to become GPs. BMJ 2004; 328: 1092 Forearm can forewarn Findings on magnetic resonance imaging (MRI) of the dominant wrist in patients with early rheumatoid arthritis can foretell future functional outcome, say New Zealand researchers. If a poor prognosis is likely, aggressive management with a disease-modifying antirheumatic agent could begin sooner rather than later. The study involved 42 patients, and found that the total baseline MRI score, and particularly the bone oedema score, was predictive of physical function assessed six years later. Bone marrow oedema reflects both bone inflammation and the potential for erosion and structural joint damage. Ann Rheum Dis 2004; 63: 555-561 Homocysteine and bone High plasma homocysteine levels are associated with an increased risk of osteoporotic fracture in older persons; the risk is similar in magnitude to the increased risk of cardiovascular disease. The evidence comes from population-based studies in the Netherlands, and data from the Framingham study. Although we don’t know whether homocysteine is the culprit or marker for other causal factors, we do know its levels can be reduced by increasing dietary intake of folic acid, B6 and B12. 1. N Engl J Med 2004; 350: 2089-2090 2. N Engl J Med 2004; 350: 2033-2041 3. N Engl J Med 2004; 350: 2042-2049 Cutting it fine Reports of promising results after carotid surgery in more than 3000 patients with asymptomatic stenoses have been tempered with caution.1,2 The international Asymptomatic Carotid Surgery Trial (ACST) found that "immediate" carotid endarterectomy halved the five-year stroke risk from about 12% to about 6% in asymptomatic patients younger than 75 years of age with carotid stenosis on ultrasonography of 70% or more (10-year results will be reported when available). However, both the triallists and a Canadian commentator warned that unsuccessful surgery can do much harm and that, in non-trial settings, poor surgery, inadequate audits and inappropriate selection of patients could result in misuse of carotid endarterectomy. 1. Lancet 2004; 363: 1491-1502 2. Lancet 2004; 363: 1486-1487 e-patients We should welcome the first generation of e-patients — those who seek online guidance for their ailments — as our new medical colleagues, say US editorialists. e-patients can not only manage their own care, but also help provide care for others, improve the quality of health professionals' services and participate in collaborations between patients and professionals.1 The editorial is one of many thought-provoking articles in a BMJ theme issue on electronic communication and healthcare. In his column "Editor’s choice" (15 May), BMJ editor Richard Smith imagines a brave new world in which sensors placed in patients' homes and clothing will feed information to all-inclusive electronic biographies. 1. BMJ 2004; 328: 1148-1149 Statins in multiple sclerosis? Dutch commentators want physicians, scientists, drug companies and regulatory agencies to come together and conduct randomised studies that further examine a possible beneficial effect of statins in mutiple sclerosis (MS). Moreover, "all involved" should ensure that such studies are not jeopardised by the premature, widespread, "off-label" use of statins.1 Their cautious hope accompanies the first reported clinical trial of a statin in MS — a US multicentre, open-label, single-arm study in 30 patients with relapsing-remitting MS — in which daily treatment with 80 mg oral simvastatin for six months led to a reduced number and volume of gadolinium-enhanced lesions on brain MRI scans.2 Simvastatin may inhibit the inflammatory components of MS that lead to neurological disability. 1. Lancet 2004; 363: 1570 2. Lancet 2004; 363: 1607-1608 — Dr Ann Gregory, MJA

Ann Gregory