Volume 180 Issue 5

GPs need a means to easily and accurately identify prescription shoppers The Health Insurance Commission (HIC) defines “doctor shoppers” as people who have 30 or more Medicare consultations a year or see more than 15 different general practitioners to obtain more Pharmaceutical Benefits Scheme (PBS) prescriptions than appear to be clinically necessary. In 1995–96, there were 13 240 Australians who met this definition, and in 1999–2000 this figure had fallen to 8780.1 The current system places the legal standing of prescription shoppers above that of the doctors who are trying to deal with them. Recently, the HIC introduced a new definition of “prescription shopper” as a person who has, in a 3-month period, been supplied prescription drugs by six or more different prescribers, or has been prescribed a total of 25 target pharmaceutical benefits or 50 or more pharmaceutical benefits in total. These broadened criteria have resulted in a new figure of 22 000 prescription shoppers.2,3 The agenda of doctor shoppers is to obtain benzodiazepines and opioid analgesic drugs, either for their own use or to swap or sell. The upper quartile of doctor shoppers work hard at their task, and will have seen up to two different GPs a day for every working day of the year.1 Doctor shoppers confront GPs with a confusion of our usual roles and trouble us in many ways. They are not like our usual patients and only want drugs, not help.4 Their dissembling destroys trust and, when unsuccessful in obtaining prescriptions, they can become aggressive and unsettle regular patients and reception staff. They are also quick to spread the word about any new doctor who has been a “soft touch”. Although many doctors have ethical and humanitarian concerns for the wellbeing of these patients, most do not want to get involved. Even reputable and dedicated doctors who espouse a philosophy of harm minimisation can face disciplinary proceedings if they are accused of prescribing excessive amounts of drugs of addiction.5 Strangely, prescription shopping is not illegal, and doctor shoppers are not subject to the same legal constraints as those who prescribe for them. For an experienced GP, making a diagnosis of “doctor shopper” can be easier than diagnosing the trickier presentations of cholecystitis. But for less-experienced doctors, used to giving patients the benefit of the doubt, it can be a problem, and requires educational input. Doctor shoppers are of either sex, and most are between 20 and 40 years old. They often present with fairly transparent stories involving severe pain of some description, stress, insomnia, or a request for benzodiazepines to help them withdraw from opiates or alcohol.4 They often claim to have recently arrived from interstate and present a letter, which may be forged on a stolen letterhead, attesting to their diagnosis and need for opiates and tranquillisers. They are usually much more medically sophisticated than the average patient and are quite explicit about the medication they want.4 They will tell the GP that tramadol is useless for their pain, which only responds to various derivatives of morphine. Similarly, temazepam tablets do not help them to sleep, but capsules do. Subsequent attempts at getting further prescriptions involve a variety of unlikely stories about the loss of previous prescriptions through various forms of theft, washing machine mishaps, and prescription-devouring dogs. In this issue of the Journal, Martyres et al (page 211) analyse the doctor-shopping behaviour of 202 people aged 15–24 years, who died between 1994 and 1999 after using heroin.6 Martyres et al found that the frequency of doctor shopping over a 4-year period increased threefold in the year before death. They see this rapid escalation of doctor shopping as both a cry for help and as an opportunity for GP intervention — even if this is only advice on the options available for help and treatment.6 They are also of the view that the government sees doctor shopping (which costs the PBS more than $30 million a year) as more of an economic than a medical problem. Indeed, the focus of the HIC’s Prescription Shopping Project has a large economic component aimed not only at doctor shoppers, but also at people who hoard drugs or send PBS drugs to relatives in other countries.7 Besides its economic cost, doctor shopping is a public health and ethical problem for the medical profession. Most GPs do not write prescriptions for doctor shoppers — half these prescriptions are written by 7.5% of Australian GPs, most of whom practise in one of 10 residential postcode areas.1 These GPs appear to have an irresponsible, laissez-faire approach to prescribing. The Prescription Shopping Project will provide feedback and educational intervention to excessive prescribers, with the aim of changing their prescribing practices.7 The Prescription Shopping Project also gives the HIC “special authority to contact the patient or to give drug information to their doctor without the patient’s consent”.7 However, if a young heroin user can see up to 613 GPs in a year,1 how will the HIC know which of the 613 GPs is that patient’s doctor? The Prescription Shopping Project legislation empowers the HIC to assist a “prescriber to make decisions about prescribing to the prescription shopper, if that prescription shopper is visiting that prescriber or is a patient of that prescriber”,3 but the immediate need of the busy GP is quick access to information. And the easiest and fastest technology to assist the busy GP is access to a dedicated prescription shoppers’ telephone line. Until August 2002, a doctor could quickly confirm, to a high level of probability, who was a known doctor shopper by using a dedicated telephone line, “The Doctor Shopping Line”. This was the diagnostic equivalent of the ultrasound in confirming the diagnosis of cholecystitis and the number and type of gallstones involved. Indeed, the HIC won a Government Technology Productivity Award for developing the software for generating the required doctor-shopping information within 30 seconds.8 Budgetary constraints, fears about privacy provisions, and a re-examination of the secrecy provisions of the National Health Act 1953 (Cwlth) led to a cancellation of this dedicated telephone line. Its replacement requires patients to sign a voluntary release-of-information form and it takes 7–10 days for the GP to receive the prescription-shopping history. The current system places the legal standing of prescription shoppers above that of the doctors who are trying to deal with them,9 and may have placed these individuals’ fragile lives at greater risk than is necessary.6 If Martyres et al are correct in seeing an escalation in prescription shopping as a cry for help, GPs must have the information on which to act. The success of the federal government’s Prescription Shopping Project also depends on GPs accessing quick and accurate prescription-shopping information. The necessary legislation and technology to reactivate the previously effective dedicated doctor-shopping line is already in place. 3,8 There is no logic in further governmental delay in its reintroduction. Doctors want it and need it, and will not in the least mind if the new politically correct term is “Prescription Shoppers’ Line”.

Max Kamien MD, FRACGP, RACP

Behavioural sciences can make a substantive contribution There is continuing evidence of the failure to translate clinical research findings into existing practice: it is thought that 30%–40% of patients do not receive treatments of proven effectiveness and, more disturbingly, 20%–25% of patients receive care that is not needed or is potentially harmful. 1,2 However, the mere existence of evidence is not sufficient to ensure the adoption of best practice into routine clinical care.3 It is not surprising, then, that there is a growing interest in making knowledge transfer from research into clinical practice more effective.4 Many approaches to changing clinical practice revolve around idiosyncratic beliefs and tradition rather than scientific evidence.5 Evidence is needed on which interventions are the most cost-effective for changing clinical practice and healthcare delivery. A recent systematic review of 235 evaluations of guideline dissemination and implementation strategies concluded that “the majority of interventions observed modest to moderate improvements in care”.4 However, the quality of reporting of important aspects of the studies reviewed (such as details of the study interventions and contextual factors) was poor, and often the rationale for the choice of intervention was obscure. Further, only 30% of studies provided any economic data. The results of this review should therefore be interpreted cautiously, as the methodological quality of many of the contributing studies, and of research in this area more generally, is poor.4 There is growing interest in developing strategies to encourage the adoption of best evidence into practice, including efforts to change behaviour. The effectiveness of these efforts is likely to depend on a complex interaction between the nature of the clinical activity to be changed and the costs and benefits of adopting the change for the healthcare professionals, patients and organisations involved. At a recent National Institute of Clinical Studies meeting, involving multidisciplinary experts in the field of promoting the uptake of research evidence,6 these issues were discussed. Delegates agreed that behavioural scientists, working within multidisciplinary teams of researchers, are important players in the process of understanding how change in healthcare providers’ behaviour may be achieved. Behavioural science refers to a broad range of disciplines, including psychology, sociology, management science and education. This disciplinary group may contribute in several ways to the scientific study of changing healthcare providers’ behaviour. Use of behavioural change theories. Behavioural scientists have developed a number of theoretical frameworks to explain how behavioural change is achieved. These include persuasive communication, diffusion of innovation,7 social influences, adult learning theory8 and social cognition.9 Such models can provide useful overviews of issues to be considered when attempting to change healthcare providers’ behaviour. The development of theoretical models for predicting when targeted individuals are likely to respond to different types of intervention would be of considerable benefit. The development of accurate and acceptable measures. Without adequate measurement of relevant clinical behaviour it is difficult to provide accurate feedback to health professionals and to evaluate the effectiveness of any interventions. Behavioural science has addressed issues about how human behaviour can be effectively, accurately and acceptably measured. Techniques include the use of direct observation, examination of the accuracy of self-report by healthcare providers and patients, as well as more controversial strategies such as the use of “simulated” patients. The discipline has also been involved in developing a wide range of other potentially relevant outcome measures, such as satisfaction scales, patients’ perceived needs, quality of life and other indices that may be used to measure the quality of healthcare delivery. Examination of the prevalence of certain behaviours, and the incentives and barriers to the adoption of best-evidence practice. Behavioural science has a long history of exploring variables that may explain why individuals and groups may or may not engage in specific behaviours. There has also been a substantive examination of variables correlated with the performance of behaviours of interest. Strategies to determine the potential prevalence of different behaviours include the use of qualitative group methods such as focus groups, self-completed questionnaires, open-structured interviews with key informants, and a wider representation of the target group. Behavioural science has also examined methodological strengths and weaknesses of the various approaches designed to determine barriers and incentives. Development, implementation and evaluation of interventions designed to change human behaviour. Strategies effective in changing human behaviour have been derived from educational research, health promotion, and other fields in behavioural science. Change strategies that have been evaluated include modifying individuals’ knowledge, attitudes and skills; the social environment surrounding the individual; and the organisational or sociopolitical structure in which individuals operate. The last includes changes in the financial costs and benefits, organisation structures, and more effective ways of communicating information. While the majority of this research has not focused specifically on healthcare providers, many of the principles are likely to be generalisable to healthcare providers. In essence, the behavioural sciences can make a substantive contribution to our understanding and implementation of behavioural change in healthcare providers. This is critical to the process of translating evidence into clinical practice. To achieve the potential that the behavioural sciences can offer to this process, we need to actively involve behavioural scientists in efforts to change provider behaviour and evaluate such interventions. As in other areas of healthcare research, the involvement of multidisciplinary teams working on a common problem is more likely to achieve positive results.

Robert W Sanson-Fisher PhD · Jeremy M Grimshaw PhD, MB ChB, FRCGP · Martin P Eccles MD, FMedSci, FRCGP

Specialist palliative care services and services involved in the pre-palliative phase of a patient’s disease must accept GPs as an integral part of the care team The number of Australians requiring palliative care is set to rise as the population ages. Although specialist palliative care services now cover most regions of Australia, rationing will be inevitable. Addressing the gaps and shortfalls to enable successful care of dying people will always require general practitioners to shoulder most of this clinical load. Unfortunately, specialist palliative care services report that some GPs are disinclined to continue to care for patients who need palliative care. They also report variability in the palliative care skills GPs possess, and struggle to work out how to support the GP colleagues whose care they perceive to be suboptimal. In 2002, the Commonwealth Department of Health and Ageing commissioned research to identify the barriers and propose solutions to this perceived problem. The outcome of this exercise provides a series of options for managing the engagement of GPs in palliative care.1 Most of the barriers to GP participation in palliative care are complex structural factors that will take some time to address (Box 1). GPs are increasingly opting for part-time work and there is a rising proportion of female GPs. In view of family responsibilities and safety issues, female GPs may have to consider their willingness to undertake home visits and after-hours work.2 For some GPs, regardless of gender, performing the time-consuming services involved in palliative care is becoming socially, financially and professionally non-viable.1 Practice costs, and the pressures arising from them, continue to increase. Several interim measures may improve GP participation in palliative care. Financial incentives (in the form of palliative-care-specific item numbers, or a substantial Special Incentives Program payment that recognises the intense work required in palliative care) may help. Items within the Enhanced Primary Care Program that encourage multidisciplinary care need to be simplified if they are to be used more often.3 For some GPs, exposure to only a small number of palliative care patients each year,4,5 combined with rapid advances in the evidence base for palliative care, undermines their confidence in managing patients appropriately. Given these disincentives, GPs may well ask, “Why should I be involved when there is a specialist palliative care unit in the district?”. Education providers, specialist palliative care services, governments and GPs themselves can all play a part in reinforcing the central role of GPs in palliative care. Defining a minimum set of palliative care skills to be taught to all doctors at undergraduate and intern level would ensure that all GPs have the knowledge and confidence to manage most common problems in palliative care. Medical schools should accept the challenge of embedding the national undergraduate palliative care curriculum6 into their programs. Currently, neither the national intern training curriculum7 nor the Royal Australian College of General Practitioners vocational training curriculum8 includes palliative care as a distinct entity. Many parts of both curricula could be covered by structured teaching of palliative care. Educational strategies aimed at established GPs should take into account the variable level of their skills and interest in palliative care. Such strategies include: reinforcing the core skill set, especially during vocational training; opportunistic case-based education, based on adult learning principles; accessible and available local teaching; financial support to attend educational sessions (including locum fee support); and funded longer-term placements for GPs interested in making palliative care a major part of their practice. Both specialist palliative care services and services involved in the pre-palliative phase of a patient’s disease (when the focus is on curative measures) must accept GPs as an integral part of the care team and work towards integrating GP input into patient care planning, patient review and management. Maintaining clear lines of communication between hospitals and GPs is important, but, unfortunately, not always done well.1 When patients are discharged from curative care, GPs need to be informed and their responsibilities delineated. Direct transfer of patients to palliative care units without keeping GPs informed and without giving them a defined role sends a message that they are not valued in this setting. Case conferences at the point of transfer can be useful. Furthermore, offering GPs responsibility during care planning and seeking their involvement in routine surveillance of patients during the pre-palliative phase (with clear protocols in place)9 might facilitate their involvement when patients enter the palliative phase of the illness. Specialist palliative care services should not take on the role of finding an alternative GP or acting as primary care provider for patients whose GP will not or can not accept this responsibility — rather, this role should be referred back to the GP.10 GPs, in turn, should accept this responsibility and embrace or initiate shared-care models (Box 2). Such models have been established successfully here and overseas.11-13 Divisions of General Practice could play a key role (not yet well exploited) in encouraging formal shared-care arrangements — only 9% of Divisions were involved in palliative care shared-care projects in 2002.14 A significant proportion of Australians are from minority ethnic backgrounds, including Indigenous Australians. Many GPs who care for people from minority cultural groups require cross-cultural training relating to issues of death and dying. Many GPs who care for people of their own cultural group, while understanding the barriers to care that different cultural beliefs may pose, nevertheless have difficulty reducing the impact of these beliefs. Some GPs and communities require assistance in participating in and benefiting from mainstream models of palliative care. Palliative care should be a rewarding part of general practice,15 and indeed the skills of good palliative care closely mirror those of good general practice care. It is essential that this core task is not diminished by, or lost in, the current rapid evolution of consumer needs, financial uncertainties, structural changes and increasing training imperatives. 1: Barriers to greater general practitioner participation in palliative care Structural barriers GP undersupply and uneven distribution Time constraints for adequate service provision Changing demographics (eg, increased proportion of female and part-time GPs) Safety fears around home visits Cost inefficiencies of providing quality palliative care Rising practice costs and related pressures Knowledge barriers Sporadic patient load Rapidly expanding knowledge base of palliative care Competing educational priorities Practical barriers to undertaking training (eg, time, cost, availability of locum support) Lack of structured basic training undergraduate curricula national intern training curricula culturally specific palliative care Service barriers Suboptimal planning of palliative care provision after attempted curative measures Lack of active GP involvement in care during curative phase or in transition from curative to palliative care “Specialisation” of palliative care Unclear role definition for GPs in specialist palliative care service environment or among multiple service providers with palliative care brief 2: Roles of general practitioners and specialist palliative care services in palliative care General practitioners Provision of contextual knowledge of patient, family dynamics, history of illness to team’s care plan Routine medical surveillance Early intervention to prevent or control symptoms Medical care of carers Specialist teams Provision of specialist advice on symptoms and treatment to team’s care plan Nursing and allied health services Pastoral care Access to inpatient admission Either GPs or specialist teams (by negotiation) Care coordination After-hours emergency care Bereavement surveillance of carers

Geoffrey K Mitchell FRACGP, FAChPM · Elizabeth J Reymond PhD, FRACGP, FAChPM · Barry P M McGrath MB BS, MPH, PhD

Have you got a paper burning a hole in your desk, waiting to be sent to your favourite journal? Or an idea for an article, needing just a little more inspiration to push it into print? Now could be your big chance! MJA theme issues 2004 17 May — Indigenous Health Closed to research manuscripts 5 July — MJA’s 90th Anniversary Closing date 19 April 19 July — General Practice Closing date 15 March 16 August — Doctors’ Health and Lifestyle Closing date 10 May 18 October — Adolescent Health Closing date 5 July Contact details: email editorialATampco.com.au phone (02) 9562 6666 This year, the MJA will be publishing five special theme issues, and we are inviting submissions in all categories of articles (Research, Viewpoints, For Debate, Clinical Updates, Snapshots, and even Editorials, although these last should be discussed with an editor first to check suitability). Last year’s big hits were Women’s Health (16 June 2003) and Chronic Illness (1 September 2003). This year’s special issues are shown in the Box and the closing dates for submissions. Please remember that a lot of work is involved in preparing a manuscript for publication, including editorial assessment, peer review, revision, editing and finally page layout — it doesn’t happen overnight, so the sooner you can submit your material, the better. July will be a very special month for us because it is our 90th birthday — we hope our readers will be able to help us celebrate in style. In the decade since our last anniversary issue, there have been major changes to the Journal and to how readers prefer to receive and use their medical information. We would like to know what you think of the Journal, how medical journals and the MJA have changed over your years of reading, and what kind of journal you would like the MJA to be on our 100th anniversary. We would also be very interested to know which MJA articles have made a difference to the way you practise medicine or have affected the way you treated a particular patient. Finally, we would be interested in your views on changes in medicine in the last decade. In all issues and all categories, we’re looking for originality, innovation, topicality and positivity, with a focus on “health” rather than disease. Do consult our Advice to authors for submission requirements and details of article categories (www.mja.com.au/public/information/instruc.html). We look forward to receiving your submissions.

Bronwyn Gaut

Objective: To identify prescription drug-seeking behaviour patterns among young people who subsequently died of heroin-related overdose.Design: Linkage of Medicare and Pharmaceutical Benefits Scheme and Coroner’s Court records from Victoria.Subjects: Two hundred and two 15–24-year-olds who died of heroin-related overdose between 6 January 1994 and 6 October 1999.Main outcome measures: Patterns of use of medical services and prescription drugs listed on the Pharmaceutical Benefits Scheme in the years before death, and use of all drugs just before death.Results: Polydrug use was reported in 90% of toxicology reports, and prescription drugs were present in 80% of subjects. Subjects accessed medical services six times more frequently than the general population aged 14–24 years, and more than half of all prescribed drugs were those prone to misuse, such as benzodiazepines and opioid analgesics. A pattern of increasing drug-seeking behaviour in the years before death was identified, with doctor-visitation rates, number of different doctors seen and rates of prescriptions peaking in the year before death.Conclusions: An apparent increase in “doctor shopping” in the years before heroin-related death may reflect the increasing misuse of prescription drugs, but also an increasing need for help. Identification of a pattern of escalating doctor shopping could be an opportunity for intervention, and potentially, reduction in mortality.

Raymond F Martyres MB BS, MMed, FRACGP · Danielle Clode BA(Hons), DPhil(Oxon) · Jane M Burns BA(Hons), PhD

Objective: To determine changes in morbidity and management of disease in children in Australian general practice.Design and setting: A comparative study of general practice consultations in children under 15 years, using data from cross-sectional general practice surveys (1990–91 and 2000–01), and a descriptive comparison with a similar study from 1971.Main outcome measures: Relative rates of management (rate/100 general practice encounters) of the most common children’s problems and treatments.Results: Problems with significantly higher management rates in 2000–01 compared with 1990–91 included vaccination (11.1 v 7.6 per 100 encounters in 1990–91) and contact/allergic dermatitis (3.1 v 2.5). Those managed significantly less often in 2000–01 v 1990–91 included acute otitis media (7.7 v 9.4), asthma (5.4 v 8.8), tonsillitis (4.4 v 6.0), acute bronchitis (3.8 v 5.3) and gastroenteritis (1.7 v 2.7). Asthma management rates rose from 2.4% of all problems managed in 1971 to 7.2% in 1990–91, then fell in 2000–01 to 4.6%. More frequent rates of counselling and advice in 2000–01 (28.4% of encounters v 22.9% in 1990–91) were associated with a decrease in rates of prescribing and supply of medication (56.6% of encounters v 64.3% in 1990–91). Antibiotic prescribing declined significantly (from 33.8 per 100 encounters in 1990–91 to 25.2 in 2000–01), as did prescribing of respiratory medications (from 15.5 to 9.9 per 100 encounters), while prescribing of vaccines and systemic corticosteroids doubled (from 9.6 to 18.8 per 100 encounters, and from 0.6 to 1.2, respectively). (All comparisons between 1990–91 and 2000–01 are significant at P < 0.01.)Conclusions: These findings point to the emergence of a generation of Australian children who are generally well vaccinated and are less likely to present to GPs with “traditional” childhood illnesses.

Janice Charles BA, MSc(Med) · Ying Pan MCH · Helena Britt BA, PhD

Objective: To assess the effectiveness of the Australian border entry screening program to detect arriving travellers with symptoms of severe acute respiratory syndrome (SARS).Design and setting: Descriptive study of outcomes of screening at Australian airports and seaports between 5 April 2003 and 16 June 2003. To determine the number of international travellers who were symptomatic on arrival in Australia but missed by screening, data were obtained on the number of arrivals screened and the number with symptoms (from the Australian Quarantine and Inspection Service [AQIS]), as well as the number of people investigated for SARS (from the Australian SARS Case Register).Results: There were 1.84 million arrivals into Australia during the study period, and 794 were referred for screening to AQIS staff. Of these, the findings in four travellers were consistent with the World Health Organization case definition for SARS, and they were referred by the Chief Quarantine Officers to designated hospitals for further investigation. None of these people was confirmed to have SARS. One person reported as a probable SARS case acknowledged being symptomatic on arrival, but had been missed by border screening.Conclusions: The low identification rate was attributed to the low prevalence of SARS, the use of exit screening by affected countries, and the subjective measures used in the screening process. With current knowledge about SARS, border screening should focus on educating incoming travellers, especially groups at high risk of transmitting the disease (the elderly and those with underlying chronic illnesses). Objective screening measures should be used during SARS outbreaks to prevent importation of the disease.

Gina Samaan BPsych(Hons) · Jenean Spencer PhD, MAppEpid · Leslee Roberts MB BS, PhD, MAppEpid · Mahomed Patel MB BCh, FRACP, FAFPHM

Objective: To determine the clinical significance of definite bites by mouse spiders (Actinopodidae: Missulena spp.) from published case reports/series and museum records.Data sources: A computerised literature search of MEDLINE and EMBASE was undertaken. All cases reported to major Australian museums and reports from venom researchers working with mouse spiders were also reviewed. Textbooks on clinical toxinology were searched and further reports of cases were located.Study selection: All cases of definite spider bites where the spider was collected and identified by an expert as a mouse spider were included.Data extraction: All reports were evaluated and the following data extracted: patient demographics (age, sex, geographical location, season), bite site, local and systemic effects, and hospital attendance. Clinical effects were classified into three groups: severe neurotoxic envenoming, local neurotoxic effects or mild systemic effects, and minor local effects.Data synthesis: Forty definite bites were identified from around Australia, with only one case of severe envenoming (a 19-month-old child). Local neurotoxic effects occurred in six cases and minor systemic effects in five. There was no evidence of envenoming in most bite victims, and the rate of severe envenoming was 2.5% (95% CI, 0–13%). There were no recorded deaths.Conclusions: In most cases, bites by mouse spiders cause only minor or moderate effects. Severe envenoming is rare and far less common than for funnel-web spider bites. Mouse spider bites do not appear to be a major medical problem.

Geoffrey K Isbister MB BS, BSc, FACEM

Objective: To assess if there are any differences in statin prescribing across Australia by socioeconomic status or sex and to relate prescribing rates to coronary heart disease (CHD) mortality rates.Design: Cross-sectional study using data on statin prescribing by age, sex and patient postcode for the period May to December 2002.Setting and participants: The Australian population, stratified by sex and quintile of Index of Relative Socio-Economic Disadvantage (IRSD).Main outcome measures: Age-standardised rates of statin scripts per 1000 population per month for each sex and IRSD quintile.Results: 9.1 million prescriptions for statins were supplied between May and December 2002, for a total cost of $570 million. The age-standardised rates for statin prescribing in women varied from 56.9 (95% CI, 56.6–57.2) scripts per 1000 population per month in the most disadvantaged socioeconomic quintile through 53.4 (95% CI, 53.0–53.7), 50.3 (95% CI, 50.0–50.6), 48.4 (95% CI, 48.1–48.7) to 46.3 (95% CI, 46.0–46.6) in the least disadvantaged quintile. For men the figures were 52.6 (95% CI, 52.3–52.9), 50.9 (95% CI, 50.6–51.2), 48.8 (95% CI, 48.6–49.1), 47.7 (95% CI, 47.4–47.9), and 51.9 (95% CI, 51.6–52.2). There was a significant linear association between statin prescribing and CHD mortality by quintile of socioeconomic disadvantage in women (weighted least squares slope, 0.380; 95% CI, 0.366 to 0.395; P < 0.0001), but not in men (slope, − 0.002; 95% CI, − 0.010 to 0.006; P = 0.65).Conclusions: Our results suggest that in men there is either overprescribing of statins in the highest socioeconomic quintile or underprescribing in the lowest. Furthermore, contrary to expectation, women — relative to men — are prescribed statins at higher rates at lower levels of risk (using CHD deaths as a proxy measure of risk).

Nigel P Stocks MD · Heather McElroy DipStats · Philip Ryan MB BS · James Allan MB BS

Osteoarthritis is a common, chronic condition which requires an individualised management plan involving multiple kinds of treatment. Exercise programs and the Arthritis Self-Management Program reduce pain and disability associated with osteoarthritis. Paracetamol is the most appropriate first-line analgesic. Non-steroidal anti-inflammatory drugs may be used as second-line analgesia on an as-needed basis (including continuous use), but must be used with caution. Cyclo-oxygenase-2-specific inhibitors are used if there are risk factors for upper-gastrointestinal complications, but only after considering cardiovascular risk. Glucosamine sulfate is a safe and effective over-the-counter treatment. Intra-articular therapies are used when others have failed.

Rebecca Grainger MB ChB (Distinction) · Flavia M Cicuttini FRACP, PhD

The current practice of non-consensual medical treatment of hunger-striking asylum seekers in detention needs closer inquiry. An Australian Government regulation empowers the Department of Immigration and Multicultural and Indigenous Affairs (DIMIA) to authorise non-consensual medical treatment for a person in immigration detention if they are at risk of physical harm, but there are doubts about whether the regulation would withstand legal challenge. Authorisation by DIMIA does not compel medical practitioners to enforce treatment if such action is contrary to their “ethical, moral or religious convictions”. The World Medical Association has established guidelines for doctors involved in managing people on hunger strikes. The Declaration of Tokyo (1975) and the Declaration of Malta (1991) both prohibit the use of non-consensual force-feeding of hunger strikers who are mentally competent. If called upon to treat hunger strikers, medical practitioners should be aware of their ethical and legal responsibilities, and that they should act independently of government or institutional interests.

Mary A Kenny BJuris, LLB(Hons), LLM · Derrick M Silove FRANZCP, MD · Zachary Steel BA (Hons), MPsychol (Clinical)

Thyroid nodules are common clinically (prevalence, about 5%) and even more common on ultrasound examination (about 25%). About 5% of thyroid nodules are malignant. Most thyroid cancers are well-differentiated papillary or follicular tumours with an excellent prognosis (10-year survival, 80%–95%). The incidence of papillary thyroid cancer appears to be increasing on the east coast of Australia. Fine-needle aspiration biopsy of the thyroid is the most cost-effective diagnostic tool. Recommended initial management of all follicular carcinomas and of papillary carcinomas > 1.0 cm is total thyroidectomy followed by radioiodine ablation. Most patients should be managed postoperatively with doses of thyroid hormone sufficient to suppress plasma levels of thyroid-stimulating hormone. Recurrences can occur many years after initial therapy, and follow-up should be lifelong.

Emily J Mackenzie MB BS · Robin H Mortimer FRACP, FACP

Sanjaya N Senanayake,* Mark J Ferson,† Susan J Botham,‡ Roslyn T Belinfante§ * Infectious Diseases Physician, † Director and Medical Officer of Health, ‡ Infectious Diseases Team Coordinator, § Environmental Health Officer, South Eastern Sydney Public Health Unit, Locked Bag 88, Randwick, NSW 2031. djayaATbigpond.com To the Editor: Keeping fish as pets, as with other animals, carries the risk of zoonotic infections. A 2000 review of bacterial zoonoses that can be acquired topically from fish commented on infection with Aeromonas hydrophila, Edwardsiella tarda, Erysipelothrix rhusiopathiae, Mycobacterium marinum, Streptococcus iniae, Vibrio vulnificus and Vibrio damsela.1 Our public health unit was recently notified of a case of Salmonella infection acquired from a fish tank. In October 2003, a 14-month-old boy was admitted to hospital with a 2-day history of fever, vomiting and diarrhoea. Culture of three stool specimens revealed a Salmonella isolate. This was identified by serotyping (at the Institute of Medical and Veterinary Science, Adelaide, South Australia) and phage typing (at the Microbiological Diagnostic Unit, Melbourne, Victoria) as Salmonella enterica serotype Paratyphi B var Java phage type Dundee. The child had no recent history of overseas travel or overseas visitors. Other family members were well, and their stool specimens were negative for Salmonella spp. However, the family kept a tropical fish tank, and the child’s parents reported that he would place his hands in the water to help feed the fish. Culture of water from the tank revealed a Salmonella isolate identical to that in the stool specimens. We believe that the boy became infected after touching the water while feeding the fish. The fish tank contained red-eyed tetras, bala sharks, silver dollars and angel fish, which had been purchased from three local aquariums several years previously. None appeared sick at the time of the child’s illness. It is important for clinicians to recognise that Salmonella infections are not always foodborne in origin. Salmonellosis is a well-known zoonosis that can be found in a variety of pets, including cats, dogs, birds, rodents and even reptiles.2 In fact, an estimated 90% of all reptiles shed Salmonella spp. in their faeces.3 Salmonella spp. have been isolated from tropical fish aquariums previously; unusual Salmonella serotypes were found in eight of 100 tropical aquariums sampled in Wales.4 Fish can excrete Salmonella without appearing unwell.5 Our patient was a 14-month-old child. In a Canadian outbreak of S. enterica serotype Paratyphi B linked to aquariums, five of seven cases were also in children aged under 10 years.5 This may reflect a combination of immature immunity and behaviour — young children may not wash their hands properly (or at all) before eating or touching their mouths. This case highlights the importance of good handwashing at all times after contact with an aquarium, regardless of the appearance of the fish. It may also be worthwhile recommending close supervision of children under 5 years of age around aquariums.

Sanjaya N Senanayake · Mark J Ferson · Susan J Botham · Roslyn T Belinfante

Lyndon E Llewellyn,* Cedric E Robillot,† Andrew P Negri‡ * Principal Research Scientist, Bioactive Molecule Discovery; † Senior Research Specialist, Bioinnovation; ‡ Senior Research Scientist, Bioinnovation, Australian Institute of Marine Science, PMB 3, Townsville, QLD 4810. L. LlewellynATaims.gov.au To the Editor: Seafood is not only consumed as food, but also as dietary supplements and complementary medicines. Examples are capsules of freeze-dried oysters and mussels, or freeze-dried extract of shellfish meat, sold as reputed antihypertensives, cardioprotectants, and anti-inflammatories, among other medical claims. However, oysters and mussels can become dangerously toxic after they ingest poisonous microscopic algae. If these molluscs are sold as food in Australia, they are subject to the Food Standards Code,1 under which their sale is prohibited if biotoxin levels per kilogram of wet shellfish meat exceed 800 g of paralytic shellfish poisons, 200 mouse units of neurotoxic shellfish poisons, 200 g of diarrhoetic shellfish poisons, or 20 mg of amnesic shellfish poisons. Shellfish capsules can be simply manufactured by milling dried meat and encapsulating the powder, a process unlikely to degrade shellfish biotoxins, which are stable to heat, pressure and freeze-drying. 2,3 Such capsules may then become subject to regulation by the Australian Therapeutic Goods Administration (TGA), which distinguishes therapeutics from food, on the basis of whether there is a “tradition of use as a food in the form presented”, especially if there is an associated health claim. Such complementary medicines can be either “registered” or “listed”. Registered medicines require extensive safety, quality and efficacy data. Listed medicines are considered to pose a lower risk than registered medicines, and regulations allow product sponsors to “self-assess” products. Listing is a route commonly taken for complementary medicines. A pertinent example is the TGA listing of therapeutic goods containing dried green-lipped mussel (Perna canaliculus).4 Where manufacturers of shellfish capsules have undertaken the responsibility of ensuring product safety, they invariably adopt existing biotoxin testing protocols developed for food safety. However, as the allowable biotoxin level is based on wet weight, and the dry weight of bivalve shellfish is only 10%–15% of the wet weight,5 safety limits for shellfish meat as food are incorrect by an order of magnitude, and potentially more for capsules containing extracts of shellfish meat. While important for acute exposure to these toxins, this may be even more relevant in chronic exposure. Okadaic acid, the cause of diarrhoetic shellfish poisoning, is a tumour promoter,6 and epidemiological studies suggest that rates of cancer have increased in regions with regular dietary exposure to low levels of this toxin.7 Capsules are available that contain 500 mg of dried shellfish meat, which may equate to 5 g of wet shellfish meat.5 Unlike a shellfish meal, which may be considered equivalent to a single acute exposure, recommended doses for shellfish capsules can be as many as five capsules a day for many weeks, if not months, therefore magnifying the risk of chronic exposure. It is known that different classes of biotoxins can co-occur in shellfish, adding to the potential hazard outlined here.8 Further complications arise because some shellfish capsules include other natural extracts (such as ginseng) or pharmaceutical formulations that might affect toxin uptake. While this situation needs to be subjected to risk assessment, testing products in accordance with an inappropriate standard can make them seem safe when they might not be. This is especially so for products which are usually self-prescribed, and where patients can exceed recommended doses in the belief that more is better. For products such as shellfish capsules that straddle the food/therapeutic divide, it is better for manufacturers to test the final consumer product and not the raw supply.

Lyndon E Llewellyn · Cedric E Robillot · Andrew P Negri

Shanthi Kannan,* Christine H Rowland,† Gregory I Hockings,† Peta M Tauchmann,‡ Edwin A Blackwell§ * Endocrine Advanced Trainee, † Endocrinologist, ‡ Nurse Educator, § Haematologist, Greenslopes Private Hospital, Brisbane, QLD. Correspondence: Dr Christine Rowland, Greenslopes Private Hospital, Newdegate Street, Greenslopes, Brisbane, QLD 4120. c.rowlandATmailbox.uq.edu.au To the Editor: Intravenous immunoglobulin preparations containing maltose (eg, Intragam P [CSL Limited]) can interfere with the readings of blood glucose monitors that use test strips with glucose dehydrogenase, such as Advantage (Roche).1 Glucose dehydrogenase is an enzyme of the Pyrroloquinolinequinone class which reacts with the disaccharide isomer maltose present in Intragam P at concentrations of 10 g/100 mL,2 resulting in falsely elevated blood glucose level results. Blood glucose monitors, such as Precision (Medisense products), Medisense (Medisense products)3 or Accutrend (Roche), that use the glucose oxidase system, do not react with maltose and can be safely used for patients receiving Intragam P. We have had two patients in whom capillary blood glucose levels were over-estimated. One was a 64-year-old woman with type 2 diabetes who was being treated with haemodialysis, and who received Intragam P for immune-mediated thrombocytopenic purpura. Before being admitted, her diabetes was reasonably controlled by 10 units of protophane twice daily. She received prednisone (100 mg/day) from Day 1 to Day 13 and Intragam P intravenously each day from Day 2 to Day 6 and from Day 14 to Day 18. While the patient was receiving Intragam P, the Advantage monitor gave persistently higher readings than both the Precision monitor and plasma glucose level measurements. The following paired readings were obtained: Advantage capillary glucose reading of 9.3 mmol/L while the plasma glucose level was 2.3 mmol/L; and Advantage capillary glucose reading of 24.4 mmol/L while the plasma glucose level was 10.4 mmol/L. During the second course of Intragam P we noted that readings with the Precision monitor were equivalent to the measured plasma glucose level. This patient developed hypoglycaemia because her insulin doses were increased on the basis of falsely elevated capillary glucose readings as measured on Advantage blood glucose strips. A Precision monitor was used for this patient until after the haemodialysis treatment which followed the final dose of Intragam P. After this time Advantage blood glucose readings approached those obtained with the Precision monitor. A second patient — a 35-year-old woman who was not known to have diabetes, but was having her glucose levels monitored while undergoing total parenteral nutrition — was given Intragam P for idiopathic thrombocytopenic purpura. While receiving Intragam P, capillary glucose levels by the Advantage monitor were elevated by 13–20 mmol/L compared with concurrent (and normal) plasma glucose level measurements. It has previously been reported that icodextrin, used in some peritoneal dialysis fluids, can have similar effects, as it is hydrolysed to oligosaccharides, including maltose, maltotriose and maltotetraose.4,5 The reaction with maltose has important clinical implications. Although it is stated in the product information for Advantage test strips that glucose readings may be affected by maltose levels over 16 mg/dL (0.89 mmol/L), clinicians may not be aware that Intragam P is in a maltose solution. For patients receiving Intragam P, the Advantage monitor is not suitable, and the Precision, Medisense or Accutrend blood glucose monitors, which use glucose oxidase which does not react with maltose, should be used instead. We have reported our experience to the Australian Red Cross Blood Service as an adverse event.

Shanthi Kannan · Christine H Rowland · Gregory I Hockings · Peta M Tauchmann · Edwin A Blackwell

Anna Peeters,* Jason Ting,† Mark R Nelson,‡ John J McNeil§ * Research Fellow, Department of Epidemiology and Preventive Medicine, Monash University, and Department of Public Health, Erasmus Medical Centre, PO Box 1738, Rotterdam, 3000DR, The Netherlands; † Intern, Geelong Hospital, Geelong, VIC; ‡ NHMRC Research Fellow; § Head, Department of Epidemiology and Preventive Medicine, Monash University, Prahran, VIC. a.peetersATerasmusmc.nl To the Editor: Coronary heart disease (CHD) risk prediction for primary prevention now focuses on multifactorial risk,1-3 and various risk calculation tools exist.1-3 The need for such tools depends on the degree to which risk status can be estimated by healthcare professionals. We performed a study to assess general practitioners’ intuitive calculation of multifactorial CHD risk for patients likely to be considered for lipid-lowering therapy. In 1999 we posted a survey to a random sample of 400 GPs in Victoria, and received back 155 completed surveys (39% response rate). The respondent population was demographically similar to the Australian GPs and trainees who billed Medicare in 1998–99. GPs were asked to estimate 5-year absolute risk of CHD for four vignettes (two primary prevention and two secondary prevention), each based on the average characteristics of a published lipid-lowering clinical trial cohort4-7 (vignette descriptions are available from the authors). For the primary prevention vignettes, GPs were also requested to estimate the risk relative to other Australians of the same age and sex. Estimated risks were compared with reported risks to derive risk ratios. GPs accurately estimated the relative CHD risk for the two vignettes of patients with no prior CHD, with mean risk ratios of 0.84 (95% CI, 0.77–0.91) and 1.23 (95% CI, 0.97–1.49). However, they overestimated absolute risk, with risk ratios ranging between 2.79 (95% CI, 2.61–2.96) and 6.43 (95% CI, 5.59–7.27). The proportion of GPs estimating within 10% of the actual risk was 9% for a 62-year-old man with prior CHD and average cholesterol level, 13% for a 60-year-old woman with prior CHD and high cholesterol level, 17% for a 55-year-old man with no prior CHD and high cholesterol level, and 43% for a 58-year-old man with no prior CHD and average cholesterol level. Although the two primary prevention vignettes had 5-year absolute CHD risks below 10%, most GPs’ estimates (93% and 71%, respectively) were greater than 10%. In conclusion, GPs in Victoria have a good understanding of a patient’s relative risk of CHD, but they consistently overestimate absolute risk. The problem with absolute risk estimation may not be the sophisticated multifactorial calculations required, but rather a general overestimation of risk within the population, at least for middle age. The GPs’ estimates of absolute risk for the four vignettes were correctly ranked, suggesting that they recognised the degree to which a risk was lower or higher, but were unfamiliar with the scale. This overestimation led most GPs to categorise patients such as those from the AFCAPS/TexCAPS trial, with only a 3.3% 5-year risk of CHD,6 as having a risk of greater than 10%. GPs would therefore incorrectly consider these patients appropriate for lipid-lowering therapy according to national and international guidelines. 1-3 Education may improve understanding and accuracy of risk communication for CHD in middle-aged patients, but tools for accurate assessment of coronary risk are needed in routine clinical practice.

Anna Peeters · Jason Ting · Mark R Nelson · John J McNeil

Keri Lockwood,* Ian D Cameron,† Susan E Kurrle‡ * Coordinator, Hip Protector Studies Unit; ‡ Director, Rehabilitation and Aged Care Service, Hornsby Ku-ring-gai Hospital, Hornsby, NSW; † Head, Rehabilitation Studies Unit, University of Sydney, PO Box 6, Ryde, NSW 1680. iancATmail.usyd.edu.au To the Editor: Hip protectors may be an effective means of preventing hip fracture in residents of aged-care facilities, if there is adequate compliance with their use.1 Research studies conducted in the Northern Sydney and Illawarra health regions2,3 have found that, if a hip protector is worn at the time of a fall, the chance of hip fracture is reduced by about 80%. We wished to determine the extent to which hip protector use had become a routine part of healthcare in residential aged-care facilities generally, and whether there was a greater uptake of their use in areas where the research had been conducted. A brief questionnaire about hip protector use was sent to all residential aged-care facilities in the Northern and South Eastern Sydney health regions, and the region covered by the New South Wales Southern Area Health Service. The response rate was 60% in each region, and responses are summarised in the Box. Only 30 residential aged-care facilities participated in the previous study, and the results indicate that use is now much more widespread. Another contrast is that, in the research study, hip protectors were provided free of charge, whereas most current users pay for hip protectors. Overall, the survey indicates that 61% of aged-care facilities across three regions of NSW are either using hip protectors or have used them in the past. Hip protector use was similar in Northern Sydney and Southern NSW; however, comparing Northern Sydney (where previous research had been conducted) with the other two regions combined showed a greater prevalence related to conducting previous research. Issues such as cost, laundering of the hip protectors, and comfort are seen as major barriers to their use, but many aged-care facilities continue to use them for selected residents at high risk of hip fracture. It is our impression that the more residents within a facility who wear hip protectors, the better the adherence to hip protector use and the management of these issues. It is also evident that hip protector research encourages use of hip protectors. We are unsure of the mechanism involved, but believe that knowledge and enthusiasm for use of hip protectors is spread by word of mouth between health professionals, staff working in nursing homes and hostels and, in some cases, through relatives of the residents of residential aged-care facilities. Hip protector use in residential aged-care facilities in three health service regions of New South Wales Region (no. of residential aged-care facilities) Any hip protector use* Northern Sydney (99) 74% South Eastern Sydney (104) 43% Southern NSW (35) 75% * χ2 = 7.5, df = 1, P = 0.006 for comparison of frequency of use in Northern Sydney with use in the other two area health services combined.

Keri Lockwood · Ian D Cameron · Susan E Kurrle

Timothy J McCulloch Anaesthetist, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050. tmccullATusyd.edu.au To the Editor: Chilov and colleagues have presented an updated set of guidelines for management of hip fracture, which included the statement “regional anaesthesia is recommended for most patients”.1 The evidence for this recommendation was graded as Level I (National Health and Medical Research Council) and was supported by a single reference, namely a systematic review from the Cochrane Database by Parker et al.2 Parker et al performed a meta-analysis of the published trials examining the effect of regional versus general anaesthesia on a variety of outcomes after surgery for hip fracture. A possible difference in 1-month mortality was found in favour of regional anaesthesia, but this difference was borderline using one statistical model (relative risk, 0.7; 95% CI, 0.5–1.0) and non-significant using another model. There was no significant difference in mortality at 3 months or 1 year, and no significant difference in a variety of other outcomes. Appropriately, the authors concluded that “both regional and general anaesthesia produce comparable results and therefore anaesthetists should choose which technique is most appropriate for each individual patient”.2 One of the many difficulties in interpreting meta-analyses of regional anaesthesia is that most of the published trials were performed some decades ago. For example, one study that contributed a large proportion of the data within the Cochrane meta-analysis was conducted between 1980 and 1982, and patients were explicitly excluded if they were receiving low-dose anticoagulation therapy.3 The relevance of such trials to patients receiving general anaesthesia today is highly questionable, given the improvements in general anaesthetic drugs and techniques and the importance now placed on routine thromboprophylaxis. There is a wide range of opinion within the specialty of anaesthesia regarding the place of major regional blockade, with little outcome-based evidence to support any particular advantage of these techniques. Although medical practitioners can benefit greatly from the efforts of reviewers to develop guidelines based on the best available evidence, care must be taken to ensure that recommendations do not go beyond what is supported by available data. Particular care needs to be taken when recommendations are made for areas of practice outside the reviewers’ expertise. The authors of these guidelines might consider withdrawing their recommendation regarding choice of anaesthesia.

Timothy J McCulloch

Michael N Chilov,* Ian D Cameron,† Lynette M March‡ * Intern, Concord Hospital [corresponding author], 50 Mi Mi Street, Oatley, NSW 2223; † Chair, Rehabilitation Medicine, University of Sydney; and Director, Aged Care and Rehabilitation Services, Northern Sydney Area Health Services, Rehabilitation Studies Unit, Ryde, NSW; ‡ Senior Staff Specialist in Rheumatology and Clinical Epidemiology, Department of Rheumatology, Royal North Shore Hospital, St Leonards, NSW. mchilovATgmp.usyd.edu.au In reply: We thank McCulloch for his comments regarding the use of regional anaesthesia in the surgical management of hip fracture. He makes the point that surgical and anaesthetic techniques have improved and implies that the advantage seen for regional anaesthesia in published studies may no longer be present. Given that controversy still exists, we would recommend that further randomised controlled trials be conducted. However, for the following reasons, we stand by our recommendation that the available evidence supports the use of regional anaesthesia for most patients with this condition. Our current recommendation is unchanged from the earlier version of the guideline (published in the Journal in 1999),1 and is also consistent with at least one other published guideline.2 A number of the concerns raised by McCulloch were addressed in the response to a letter by another correspondent after the publication of the original guidelines.3 While we acknowledge that the review by Parker et al4 only found the reduction in mortality at 1 month to be of borderline significance, when our review team reassessed the original articles using the Cochrane Collaboration protocol we reached a summary odds ratio for mortality of 0.68 (95% CI, 0.49–0.96). With time and further studies we expect that this estimate of effect will become more precise as the power of the meta-analysis is increased. This view is supported by a systematic review of all randomised studies comparing regional anaesthesia with general anaesthesia across surgical specialties. The study of Rodgers et al found a statistically significant reduction in mortality (odds ratio, 0.70; 95% CI, 0.54–0.90) when regional anaesthesia was compared with general anaesthesia.5 This overall point estimate is very similar to that of Parker et al in their meta-analysis of patients with hip fracture. Although lack of power meant that statistical significance did not exist within individual surgical specialties, there was, in fact, little difference in the effect across surgical groups, with no significant heterogeneity between studies. Serious complications of regional anaesthesia (eg, spinal haematoma) are extremely rare, as shown in the recent PEP study in Australia and New Zealand that reported no cases in 4603 patients undergoing regional blockade.6 This should be compared with the number needed to treat with regional anaesthesia to prevent one death of 38, according to the data of Parker et al.4 There is no doubt that our recommendation needs to be considered in the context of individual patient characteristics and, while the recommendation may not apply to all patients with hip fracture, we feel that the available evidence supports the use of regional anaesthesia.

Michael N Chilov · Ian D Cameron · Lynette M March

Alan Rodger Medical Director, and Professor of Radiology Oncology, Beatson Oncology Centre, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, UK. alan.rodgerATnorthglasgow.scot.nhs.uk To the Editor: I strongly support the editorial comments and recommendations of McNeil et al1 on public funding of clinical trials. Having worked in the Australian healthcare system for 11 years, and having returned to a changed National Health Service in Scotland a few months ago, I can vouch for the benefits that accrue from adequate funding for clinical trials. While McNeil and colleagues focus on large-scale trials, their comments apply equally to smaller trials. Certainly, in oncology, several trials organisations in Australia have struggled for years to continue conducting trials in spite of inadequate government funding. The ANZ Breast Cancer Trials Group and the Trans Tasman Radiation Oncology Group are but two organisations with which I am familiar. In addition to precarious funding, I believe the consequences in the past 2 years of upheaval in the insurance industry have placed all such groups on an uncertain and untenable footing. Clinical trials must be ethical, scientific and well managed. Clinicians entering patients into trials need support from essential data managers and clinical nurse specialists. Governments encourage and, in fact, demand evidence-based medicine. The only effective way to produce the evidence is to conduct clinical trials. That costs money. In Victoria, cancer trial management was supported by about $800 000 per annum in grants from the Cancer Council Victoria. Those funds provided start-up assistance to institutions new to clinical trials and supported the others that could not rely on pharmaceutical company largesse. However, only part of that money was state government funded and then only for rural and regional centres or for breast cancer. The diagnosis-related-group-based casemix funding of Victorian hospitals included a notional element for research. That sop was lost in budget deficits. In Scotland, where health matters are totally devolved to the Scottish Parliament, the latter’s Scottish Executive Health Department has very recently enhanced funding for cancer care. This includes £500 000 (A$1.25 million) annually to support clinical research in cancer. Each of the three cancer networks has a guaranteed share of that sum to resource clinical trials in all the associated health boards and cancer units. This is in addition to the excellent clinical trials units in the main cancer centres, often funded by the charity Cancer Research UK and industry. There is also a national system of considering and approving clinical research in cancer. Such approval places obligations on health boards to support such trials. Lastly, accreditation of cancer centres can depend on clinical trial participation. The evidence that this (still imperfect) system has an effect is seen in trial entry at our oncology centre, where 11% of patients are already entered into trials. The new funding should see that increase. Government needs to put its money where its mouth is: evidence needs resourcing. The alternative is to rely on charity or on industry (whose eye is more often on marketing than science).

Alan Rodger

Paul Walker Paediatric Otolaryngologist, John Hunter Children’s Hospital, PO Box 293, New Lambton, NSW 2305; and Conjoint Associate Professor, Disciplines of Surgery and Paediatrics, University of Newcastle. walkerpATtpgi.com.au To the Editor: The study by Paradise et al on tympanostomy tubes for persistent otitis media,1 which was expertly reviewed by Morris and Leach in the Journal recently,2 has since been updated.3 The findings of both studies from Pittsburgh should only be applied with caution in Australia. Indications for inserting ventilating tubes (VTs) can be divided into three: bilateral hearing loss of more than 25–30 dB continuously for 3 months after failed non-operative management; structural damage to the tympanic membrane (TM) which may lead to irreversible hearing loss or cholesteatoma; and a miscellany which includes under-lying sensorineural hearing loss or learning difficulties or similar conditions with deterioration associated with bilateral middle ear effusion (MEE), and recurrent middle ear infections with use of VTs as an alternative to antibiotic prophylaxis, among others. The conclusion of the more recent article by Paradise et al3 — that there was no difference in expressive or receptive speech or cognition between children in whom VTs were inserted early or late — is valuable, but may not readily be extended to Australian practice. Although 6350 children were enrolled, only 397 were actually randomly allocated into the early or late treatment groups. Thus, the numbers are not large. Of more concern is that only 18% of those analysed had bilateral continuous MEE (40 in the early and 32 in the late treatment group), with the remaining 82% having unilateral (continuous or discontinuous) or bilateral discontinuous MEE. Only the 18% with bilateral continuous MEE would ordinarily be candidates for VTs in Australia, as Paradise et al underline the fact that intermittent and/or unilateral MEE is not associated with speech and language difficulties in the absence of other handicaps to learning. An abnormal hearing test result was identified by the study as a 15 dB loss. This could well fall in the normal range for the Australian Hearing Service for children wearing headphones, and a minimum threshold of 25-30 dB should typically be required for considering VTs in Australia. As Morris and Leach2 pointed out for the earlier study,1 the later study also excludes children “not otherwise healthy”,3 and the results cannot be generalised to such children, or to those with moderate rather than mild hearing loss. Pointing to studies such as that of Paradise et al can be very helpful in reassuring parents who want VTs for their child with unilateral or intermittent hearing loss that not having VTs does not place the child’s speech and language development at risk.

Paul Walker

De-stressing doctors. A self-management guide. Valerie Sutherland, Cary L Cooper. Edinburgh: Butterworth Heinemann, 2003 (xii + 193 pp). ISBN 0 7506 8783 5. The prevalence and consequences of stress associated with medical practice have been a subject of research and reflection for at least three decades. Despite enormous advances in medical care over that period, there is no evidence of a decline in the experience of stress or its sequelae among our medical colleagues. This book is intended, as the name implies, as a self-help guide for practitioners. The authors are well credentialled and well versed in the literature relating to the topic, and the book is set out in a useful and readable format. The first sections deal with an explanation of the traditional stress construct, with remaining sections dealing with prevention and management strategies. These are presented as primary prevention (strategies for stress minimisation in the work environment), secondary prevention (coping strategies for situations in which stress can not be altogether eliminated), and tertiary prevention (stress management strategies for situations where stress is established and adversely affecting the practitioner’s life). The evidence for adverse psychoneuroimmunologic effects of chronic or recurrent stress is reviewed, and the book achieves a balance between behavioural, psychological and physical reasons for individual doctors to manage stress in their lives more effectively. The academic underpinnings are presented in a clear and integrated style, and the practical strategies, while not new or revolutionary for readers, are a good summary of commonsense principles that medical practitioners routinely prescribe for their patients, but often neglect in their own lives. Although the British authors do not deal particularly with some current local stressors, including the indemnity insurance crisis and medicolegal concerns, the principles espoused are generic and the book is relevant to an Australian audience. Simon M WillcockLecturer, Department of Academic Medicine Hornsby Hospital, NSW

Simon M Willcock

Sports injuries and emergencies. A quick-response manual. Aaron Rubin. New York: McGraw-Hill, 2003 (xvii + 470 pp). ISBN 0 07 139610 1. Aaron Rubin has assembled a team of 46 doctors, athletic trainers and paramedical personnel from across the United States to produce a book which is intended for use as a handbook for the doctor sitting on the sidelines at American sporting contests. It should be recognised that in the US training to practise sports medicine is one of the many elective professional development programs a doctor can undertake. These "fellowships" generally take about 1 year and are added to an intern/residency program. This book is pitched at the resident undertaking some first-hand training in sports medicine and, no doubt, caring for athletes at College level undertaking various sporting activities. The book covers all the usual topics in orthopaedic and musculoskeletal injuries, cardiovascular and respiratory emergencies, as well as medical conditions such as asthma, exercise-induced bronchospasm, and the treatment of cardiac arrest. There are chapters on subjects such as the psychology of injury, and a number of appendices which describe the team physician’s bag, the athletic trainer’s kit, emergency medical supplies etc. The book does focus on specific sports- related injury and gives very useful guidelines for management for each of these diagnoses. It would certainly serve as a useful tool for the doctor sitting on the sidelines at a competition. The book is well illustrated, and each chapter contains a few useful current references. The authors were not all well known to me. However, some of the names were familiar as experts in their respective areas within the domain of sports medicine. As a clinician interested in sports medicine, I found it an easy read, notwithstanding its very American focus. The book does fill a gap in the market in that it is directed at a more sophisticated "first-aid for sport" niche. I did not find anything in the book with which I would strongly disagree, and the book is topical. I note the retail price inscribed on my reviewer’s copy was $119.95 (presumably Australian dollars) and I would say this is expensive for a handbook. It would be valuable, though, among its target readership. Peter A FrickerChair of Sports Medicine University of Canberra, ACT Order this book

Peter A Fricker

Meet the metapneumovirus In young infants with a lower respiratory tract illness, infection with the RNA virus human metapneumovirus accounts for a substantial proportion of cases that would previously have been relegated to the "undiagnosed" category, say US experts.1 They believe human metapneumovirus infection is probably less common than respiratory syncytial virus infection but more common than parainfluenza virus infection. The experts were commenting on a US study conducted in a primary care clinic over a period of about 25 years (1976–2001), in which more than 2000 normal children were followed from birth at full-term to up to 5 years of age.2 By using newly available molecular studies as well as culture, the study was able to prove that 49 of 248 snap-frozen nasal-wash specimens taken from children with lower respiratory tract infection and previously found to be negative for viruses were actually positive for human metapneumovirus. About three-quarters of the cases occurred in the first year of life (mean age, 11.6 months; range, 1.5 to 50 months). Infection occurred most frequently in late winter, with a spectrum of disease somewhat similar to respiratory syncytial virus infection; bronchiolitis or croup were frequent diagnoses. The study also found human metapneumovirus in samples from children with upper respiratory tract infection but in only one asymptomatic child. 1. N Engl J Med 2004; 350: 431-433 2. N Engl J Med 2004; 350: 443-450 Buckle up, everybody People who insist on not wearing a seatbelt when in a car could be putting the lives of others at risk in the event of a crash. US researchers have conducted a matched cohort study using data from the US national Fatality Analysis Reporting System for tens of thousands of passenger car crashes that occurred in the period 1988–2000. They found that restrained occupants were at increased risk of death within 30 days of an accident if they had had an unrestrained person sitting behind, in front of or beside them — these people had remained fixed in the path of someone else who was catapulted forward, backward or sideways. The risk of death was lowest when all occupants were restrained. JAMA 2004; 291: 343-349 Net benefit Interventions delivered via the Internet can probably reduce symptoms of depression in a subset of patients living in the community, say Australian researchers. Christensen and colleagues' randomised controlled trial in 525 individuals found that 6-week programs based on either BluePages, a psycho-education website offering information about depression (www.bluepages.anu.edu.au), or MoodGYM, an interactive website offering cognitive behavioural therapy (moodgym.anu.edu.au), were more effective in reducing symptoms of depression than a controlled intervention using phone calls. Study participants had to have Internet access, and turned out to be highly educated. BMJ 2004; 328: 265-268 Short odds Contrary to popular belief, people of short stature are no more likely to experience problems in their development than are individuals of average height, say UK researchers. They were reporting findings from the Wessex Growth Study, which has followed over 100 participants from the ages of 7–9 years to 18–20 years. The study found that adult personality functioning (eg, in domains such as education, employment, friendships and coping) was not affected by either height at study recruitment or height attained by adulthood. Similarly, aspects of daily living, such as drug-taking behaviour and experience of violence (which were nevertheless of concern), did not seem to be related to height. Arch Dis Child 2004; 89:17-21 Putting x-rays under the cancer scanner Radiological investigations, including computed tomography and angiography, may account for more than 400 cases of cancer each year in Australia, suggest UK researchers.1 They calculated estimates of the risk of cancer from diagnostic radiation exposure for each of 15 developed countries, including Australia (which "scored" the fourth highest estimate), by using information from various sources, including what is known about the effects of radiation on Japanese atomic bomb survivors. The researchers acknowledged that their estimates may overestimate the risk of cancer, being based on a fair few assumptions, for example that radiation-induced risks persist indefinitely. An accompanying commentary points out that, although there is no threshold of radiation dose below which the absence of any cancer risk has been proven, equally there are no reliable data proving that radiation doses as used in diagnostic x-rays do, in fact, induce cancer.2 1. Lancet 2004; 363: 345-351 2. Lancet 2004; 363: 340-341 — Dr Ann Gregory, MJA

Ann Gregory

Med J Aust 2004; 180 (5 Suppl).