Volume 180 Issue 7

Adequate staffing and devices to impIement active strategies are the key Pressure ulcers significantly reduce the quality of life of patients and increase the costs of patient care, as well as length of hospital stay. The most notable feature of pressure ulcers is that most are preventable. Prevalence studies in Australian acute-care hospitals have found their prevalence to range from 4.5% to 27%.1 . . . The most notable feature of pressure ulcers is that most are preventable. Guidelines for preventing and treating pressure ulcers have been developed in many countries, beginning with the Netherlands2 and the United States.3 Guidelines specifically tailored to Australian healthcare were released in 2001 by the Australian Wound Management Association.4 A major limitation of all these guidelines is the level of evidence on which they are based. Using the evidence-grading system of the National Health and Medical Research Council,5 only one recommendation in the Australian guidelines achieved level 1 (evidence obtained from a systematic review of all relevant randomised controlled trials) — the recommendation that pressure-reducing or pressure-relieving mattresses or beds be used in place of standard hospital mattresses in high-risk patients. As is common with many guidelines for preventing pressure ulcers, much recommended practice is based only on consensus statements from experts in the field. In this issue of the Journal, Jolley and colleagues (page 324) report a randomised controlled trial of a newly developed pressure-reducing surface, the Australian Medical Sheepskin, compared with standard care in the prevention of pressure ulcers.6 The trial was in 441 hospital patients considered at low to moderate risk of developing pressure ulcers. Patients using the sheepskin developed new pressure ulcers at a rate half that of patients receiving standard care. Clearly, in this group of patients, the Australian Medical Sheepskin is better than standard care. However, it must be appreciated that standard care in this study was itself suboptimal. It consisted of “any other pressure-relieving device or prevention strategy deemed appropriate by ward nursing staff, comprising standard hospital mattress and sheet, with or without other low-technology constant pressure-relieving devices and repositioning as determined by nursing staff”. Standard care resulted in 16.6% of patients developing a pressure ulcer. The answer to reducing the prevalence of pressure ulcers lies not in implementing any one strategy, but in providing an institution-wide prevention program. Common to guidelines for preventing pressure ulcers is identification of patients at risk. It is imperative that some form of structured method to identify those at risk is applied to all hospital inpatients. Assessments need to be repeated regularly throughout a patient’s hospital stay and when there is a significant change in health status. A number of risk-assessment tools can be used, the most common being the Norton Risk Assessment Score,7 the Braden Scale8 and the Waterlow Risk Assessment card.9 The major risk factors for developing pressure ulcers are immobility, sensory loss, impaired cognitive state, urinary and faecal incontinence, age over 65 years, male sex, European background, chronic illness, poor nutritional status, impaired oxygen delivery to tissues, raised skin temperature, skin dryness and the presence of pressure, shear or friction forces. After establishing a patient’s risk of developing a pressure ulcer, the next step is to implement preventive strategies to reduce that risk. This requires the support of hospital administrations in providing both the necessary trained staff and pressure-reducing or pressure-relieving devices. It is also imperative that staffing levels are adequate to ensure that nurses have sufficient time to provide the “hands-on” care necessary for these high-risk patients. For patients at low to moderate risk of developing pressure ulcers, the ideal preventive strategy may include any one of a wide range of pressure-reducing or pressure-relieving surfaces, including the Australian Medical Sheepskin, combined with a repositioning strategy. The Australian Medical Sheepskin has yet to be compared with other surfaces and devices in this group of patients. A major challenge in many areas of medical practice is to successfully implement guidelines for clinical practice. A recent review of effective strategies for implementing pressure-ulcer guidelines concluded that active strategies were more successful in reducing ulcer prevalence.10 The most effective strategies used targeted educational sessions and, in particular, multiple approaches. Such a strategy was recently shown to reduce pressure-ulcer prevalence in a multicentre Australian study.11 This indicates that developing guidelines alone is not sufficient to influence outcomes, but that they need to be linked to educational strategies to ensure their successful implementation and subsequent influence on clinical outcomes.

Michael C Stacey DS, FRACS

Smokers who undergo surgery have higher risks and are a greater burden on healthcare resources. Is it acceptable to give them lower priority on surgical waiting lists? A wide range of elective surgical procedures should not be offered to smokers who do not try or do not succeed in quitting. There is no denying that this approach is controversial and overtly discriminatory, but it is also evidence-based. New concerns are not based on well-recognised cardiac and respiratory risks, but on increased risks of wound infection and the adverse complications that ensue. The extent of this evidence is such that it is no longer possible for surgeons and others in the healthcare system to ignore it. What, then, is the evidence? Wound infection rates are higher in smokers than in non-smokers who have had joint replacement surgery,1 breast reconstruction,2 “facelifts”, and a variety of other plastic surgery procedures.3 For example, with breast reconstruction, abdominal-wall site necrosis is seen in 7.9% of current smokers compared with 1% of non-smokers, and mastectomy-flap necrosis in 7.7% of smokers compared with 1.5% of non-smokers.2 Furthermore, after abdominoplasty, secondary surgery for dehiscence was necessary in 24% of smokers and 8.2% of non-smokers.4 In a randomised study examining smoking cessation intervention before joint replacement surgery, wound infection rates were reduced from 27% in continuing smokers to zero in those who quit smoking.1 Reduction rather than cessation in smoking is inadequate.1 Infection rates in parasacral incisions made to remove punch biopsy scars were reduced from 12% to 2% in those who abstained from smoking for 4 weeks, while, in the same study, wound ruptures occurred in 12% of smokers but in no non-smokers.5 The optimum period of smoking cessation is uncertain but it is probably at least 6 weeks. Periods of smoking cessation of less than 3 weeks before colorectal surgery are not associated with a benefit.6 The mechanism for the increased wound infection rate is not clear. Tobacco combustion produces more than 3000 products. Nicotine, the best known of these, is a potent vasoconstrictor and impairs revascularisation of bone.3 Reassuringly, nicotine replacement treatment, used to assist smoking cessation, does not increase infection rates in experimental incisions5 or after joint replacement surgery.1 Of the many other combustion products, carbon monoxide decreases tissue oxygenation and a range of other compounds impair the microcirculation. In surgical wounds, there is relative hypoxia in smokers to an extent that is known to impair wound healing in animals.7 Wound infections are never trivial, but in certain clinical situations they can have particular, deleterious sequelae. Immediate breast reconstruction may be desirable for some patients after mastectomy. An infected prosthesis, or necrosis of a flap or tissue donor site, can delay important adjuvant chemotherapy or radiotherapy. Wound infection after joint replacement surgery is associated with increased risk of infection in the prosthesis,8 delays in hospital discharge, increased time to effective rehabilitation and massively increased cost of hospital care. The extent to which doctors seek, and the wider community provides, permission for discrimination is an issue for serious community debate. An essential part of a surgeon’s role is to be selective in choosing who to operate on, and when, in line with current evidence. Policies and practices that flow from this may be regarded by the healthcare community as discriminating, but by smokers and the wider community as discriminatory. Continuing smokers must accept that some risks are simply unacceptable given the intent of the surgery. To put the smoking-related risk in context in orthopaedic surgery, the adverse effect of failing to quit smoking is similar to that of omitting antibiotic prophylaxis.9 The risk of adverse outcomes from wound infections alone is clear enough evidence to suggest that aesthetic plastic surgery should not be offered to current smokers, and that surgery should be delayed for 6 weeks after cessation. Doing otherwise would be simply foolish. Joint replacement surgery presents a different decision-making framework. Patients are likely to have had time to consider and address cessation of smoking. In relation to an individual, pain and limitation of mobility may be deemed sufficient to justify a procedure, despite an increased risk associated with continuing to smoke. However, public health systems are faced with overwhelming demand and must generate the greatest benefit from limited resources. If smokers, as a group, have a reversible factor that causes a longer hospital stay, incurs greater costs and leads to poorer outcomes, might it be reasonable to allocate them a lower priority? Given that the end of a joint replacement waiting list is likely never to be reached, allocating smokers a lower priority could be tantamount to an indefinite deferral of surgery for a smoker unable to quit. A recent Victorian study found that less than 10% of smokers having day-stay surgery recalled being advised by their surgeon or general practitioner to quit smoking.10 Clearly the medical community needs to do better. The message to the wider community is this: continued smoking in the face of elective surgery increases the risk to the individual and stretches the already stretched healthcare resources and expenditure unnecessarily. The community has to decide whether this waste is justified. Critically, if discriminatory policies are implemented, they must be matched by a commitment to fully and effectively support smokers in quitting, which is an altogether different challenge. This applies particularly to smokers who are already socioeconomically disadvantaged and those with mental illness. Failure to help these individuals risks exacerbating existing health and economic inequalities.

Matthew J Peters · Lucy C Morgan · Laurence Gluch

Practical contributions towards solving the medical workforce problems of rural Australia A viable practice is one that meets the particular medical needs of the community by providing appropriate services in a way that takes account of the financial and personal costs to both the practitioner and the community at large.1 Since 1978, there has been a plethora of inquiries, conferences and symposia on how best to recruit more rural doctors.2-6 These endeavours have resulted in a series of loosely articulated initiatives such as affirmative medical school entry for rural high school students, scholarships, decentralised medical education and other support mechanisms. It is envisaged that these initiatives will eventually ease the rural workforce shortage and diminish our reliance on overseas-trained locum doctors, many of whom are from underdeveloped countries with doctor shortages of their own. However, there is not much sense in recruiting and training rural doctors if the conditions under which they are expected to practise are not viable. In this context, two recent reports — Viable models of rural and remote practice and Easy entry, gracious exit — break new ground in defining the conditions necessary to build and ensure a viable rural medical practice.1,7 The reports are based on two separate studies. The larger study, the basis of the viable models report, was initiated and managed by the Rural Doctors Association of Australia, funded by the Australian Government Department of Health and Ageing and carried out under the guidance of the Bendigo branch of the Monash University School of Rural Health. The investigators used a rigorous, triangulated methodology, which included a national survey of all 4403 rural and remote general practitioners in Australia, focus groups and detailed site visits to a representative sample of 53 practices across Australia. There was a 34% response rate (1498 GPs), representing 53% of all practices. And what did the study find? Demographics: The major finding was the large proportion of ageing and overworked rural GPs, a matter of obvious concern to governments charged with providing healthcare for all people in Australia. Doctors over 50 years of age comprised 40% of the current workforce, and 61% of all rural doctors worked in areas with a shortage of GPs. A quarter of all doctors in the study were trained overseas, predominantly in the United Kingdom, Africa and Asia. Doctors in towns of 10 000–20 000 people need between two and three extra GPs, while those in towns of less than 10 000 people require an extra four to five GPs. Female doctors are now making an increasing contribution to the rural and remote workforce: they comprised 27% of the 1498 doctors responding to this study.8 Contrary to popular belief, they work the same number of hours as their male counterparts. This demographic picture has a fluid element, as a third of all rural and remote GPs intend to leave their current practice in the next 5 years. The proportion intending to leave ranged from 31% in the bigger towns to 66% in the more isolated communities. Capabilities: The ability to cope in depth with procedural presentations and emergencies, both in the consulting room and in the hospital, defines the rural and remote doctor. Over 50% of doctors working in population centres of between 5000 and 25 000 were involved in accident and emergency work outside of their surgery, 22% were doing obstetrics, 12% major surgery and 15% provided general anaesthesia. Work conditions: Rural and remote practitioners worked an average of 48 hours per week in patient-related activities and 8 hours in non-patient-related activities, mostly patient and practice administration. The weekly workload consisted of an average of 160 consultations per week, with a mean of 14 minutes per consultation. In addition, the practitioners were on-call one day and one weekend in three. Their vacation time averaged 24 days per year. Economics: A detailed economic and staffing analysis was performed for 91 of the participating practices. The average full-time rural doctor earned $266 000 per annum from all sources, including hospital work. Of this, 33% was consumed by staff costs and 19% by practice costs. The net taxable income was $127 680, which equates to $47.50 per hour net for a 56-hour week. Half of the GPs surveyed were practice principals and their yearly average profit was $201 000. From this, they paid for motor vehicles, medical indemnity, and continuing medical education. However, a quarter of all practice principals were financially unviable, with a net profit of less than $120 000 per year. Nearly all practices had a manager, and 72% had at least one practice nurse. In response to increasingly complex regulations and red tape, most managers had resorted to a reactive rather than a strategic approach to management. Dimensions of viability: Viable models of rural and remote practice identified a hierarchy of three core interrelated dimensions of viability that are amenable to systematic intervention. These are: A level of remuneration that reflects rural GPs’ skills, workload and commitment; A sufficient number of medical colleagues to limit after-hours workload to one night and one weekend in four, as well as adequately skilled locum support to enable annual recreation and study leave; and The physical facilities and administrative support to do their job. The habit of state governments of closing country hospital obstetric and anaesthetic facilities has been shown to be a major factor in procedural country doctors leaving their practice.9,10 Previously identified family, social and environmental factors were significant, but were found to be dependent on the above three dimensions and therefore less important in a doctor’s likelihood of remaining in rural practice.2-4 Benchmarks: These data have been used to derive benchmarks for models of viable practice. The authors of the report stress that these benchmarks are not a wish list, nor an ambit claim, and explain clearly how they have reached their conclusions. For example, income benchmarks of $110 per hour are derived from the median incomes of private GPs, government salaried GPs, rates for locum GPs, and the hourly rate paid to GPs engaged in divisional activities. Other benchmarks cover education, workforce numbers according to emergency and after-hours requirements, and various forms of leave. They also include purpose-built practice premises, a required number of support staff, and business systems which enhance practice management and include broadband internet access. The final chapter of the report illustrates the use of the viability framework in three different geographical locations. Easy entry, gracious exit complements the viable models report. It is a case study of an innovative model piloted in the towns of Brewarrina, Collarenebri, Lightning Ridge and Walgett in the far west of New South Wales.7 The unique feature of this model is a third-party provider as the owner and manager of the practice. This relieves doctors of the hassles of being a small-business owner, worried about a low return on infrastructure investment, and allows them to concentrate on practising medicine. In addition, this project is supported by the New South Wales Rural Doctors Network, which provides for safe working hours, regular holidays and promotes a guilt-free “walk-in, walk-out” approach by concentrating on continuity of the practice rather than continuity of the doctor. This model has proven to be an important factor in recruiting and retaining doctors. Both these reports make major conceptual and practical contributions towards solving the medical workforce problems of rural and remote Australia. They provide clear guidelines for health planners, consumers and medical stakeholder groups on what is required to give their particular geographical area the best chance of obtaining a viable and ongoing medical service.

Max Kamien MD, FRACP, FRACGP, FACRRM

During Australian Football League (AFL) grand final week in 2003, a three-day Football Australasia conference was held in Melbourne on 23–25 September, immediately after the annual conference of the Australasian College of Sports Physicians. The Football Australasia conference was attended by over 300 delegates, including doctors (sports physicians, general practitioners, orthopaedic surgeons and rheumatologists), other experts (such as physiotherapists, podiatrists and conditioning coaches), and representatives from Australian football, rugby union, rugby league and soccer. One of the achievements of the conference was the sharing of information across the football codes. Each topic (which focused on a body area, such as “shoulder injuries”, or a general issue, such as “career ending injuries”) established a list of controversial practical and research issues to be examined in over 100 presentations or posters and assorted panel discussions. Knee injuriesThe recent developments in autologous chondrocyte implantation for knee chondral defects1 were outlined by Ian Henderson (orthopaedic surgeon, Melbourne), who concluded that most professional footballers would find the 12 to 18 months currently required for satisfactory rehabilitation too lengthy. Merv Cross (orthopaedic surgeon, Sydney) spoke on the dilemma of meniscal tear repair for the professional footballer who must weigh up the short-term gains from early return to football after resection against the long-term benefits of retaining the meniscus, but taking a longer time to return to match play. Although current research supported the use of glucosamine after the development of joint degeneration,2 its role in prophylaxis against joint degeneration remains uncertain. Despite this, anecdotal evidence suggests that many professional footballers use glucosamine for this purpose (Geoff McColl, rheumatologist, Melbourne, personal communication). The prevention of anterior cruciate ligament (ACL) injury in footballers brought together experts in biomechanics, agronomy and epidemiology. Previous studies have implicated ground conditions as a potential cause of ACL injuries,3-5 and recent research conducted by Ian Chivers and David Aldous (turfgrass experts, Institute of Land and Food Resources, University of Melbourne) suggests that grass type and thatch depth, rather than ground hardness, is more closely linked with the incidence of ACL injury in AFL players. Julie Steele (biomechanist, Biomechanics Research Laboratory, University of Wollongong) reported on using supervised repetitive jump landing training to increase knee flexion angle and therefore reduce the risk of ACL injury from knee hyperextension.6 David Lloyd (biomechanist, School of Human Movement and Exercise Science, University of Western Australia) presented an update of ongoing research on balance training with single-leg stance on a wobble board (compared with traditional weight training), and indicated that balance training subsequently reduced stress on the ACL during side-stepping techniques.7 Vigorous debate raged over the choice of patellar versus hamstring tendon for surgical reconstruction of the ACL. The consensus was that previous injury to these structures and surgeon’s preference were the main determinants. Julian Feller (orthopaedic surgeon, Melbourne) outlined the results of a recent randomised controlled trial which supported the notion that patellar tendon grafts lead to higher morbidity, but greater stability, than hamstring grafts,8 a finding consistent with other studies.9,10 Shoulder injuriesFor a first-time glenohumeral subluxation or dislocation episode, Martin Raftery (Medical Coordinator, Australian Wallabies) broached the controversial subject of whether to manage this condition surgically or conservatively, favouring a trial of conservative management until the end of the season provides an opportunity to consider surgery.11 Brett Robinson (General Manager, Australian Rugby Union High Performance Unit, Sydney) disclosed that repetitive microtraumas to the glenohumeral joint in rugby lineouts, scrums, rucks and mauls (both in games and training) led to progressive instability, subluxation, possible internal impingement and, finally, rotator cuff tears. According to Daniel Biggs (orthopaedic surgeon, Sydney), the results of arthroscopic stabilisation of the shoulder were potentially similar to open shoulder stabilisation,12 except if there was significant bony abnormality, when an open procedure is preferred. ConcussionMichael Makdissi (Medical Officer to the AFL–Australian Institute of Sport U18 team) presented evidence that most AFL players who have concussion return to competition without missing a game, with no detrimental effects in performance, no increased risk of injury and no persistent defects in neuropsychological functioning. Testing after concussion increasingly involves a computer program that tests cognitive performance,13 which, in conjunction with clinical assessment, can be used as a guide to determining the safety of returning to sport. Hamstring and groin injuriesJohn Orchard (Team Physician, Sydney Roosters) identified the mechanisms of hamstring injury in football as overstriding when sprinting, bending to pick up the ball while running, or attempting to break out of a tackle.14 The risk of recurrence is high, and persists for 3 months after return to play, because players often return with subtle strength deficits, biomechanical compensations, or both.15 Geoff Verrall (sports physician, Adelaide) presented research identifying the role of magnetic resonance imaging (MRI) in predicting safe return to play (without recurrence) from hamstring strains by measuring the size of the lesion,16 whereas Uwe Proske (physiologist, Melbourne) explained that hamstring length could be moderated with eccentric exercise as a preventive measure against strains.17 Sallie Cowan (physiotherapist, School of Physiotherapy, University of Melbourne) reported research that identified delayed onset of transversus abdominis contraction in individuals with chronic groin pain. She hypothesised that this change in coordination of abdominal activity may leave the pubic symphysis unprotected from reactive forces, resulting in osteitis pubis. Geoff Verrall described a correlation between increased MRI signal intensity in the parasymphyseal bones and pain and tenderness in this area among athletes. Ankle sprainsThere was debate over the role of preventive ankle taping (strapping to reduce the risk of inversion sprain) in footballers. It was concluded that players who benefit most from taping are those with a past history of ankle sprains. Gordon Waddington (physiotherapist, School of Physiotherapy, University of Sydney) discussed football boots and injury prevention, including improving joint position discrimination by enhancing sensory stimulation to the plantar sole through insole design,18 and elite soccer players choosing to play in smaller-size boots to enhance proprioceptive feedback, ensuring better control of foot and ankle position, which perhaps enhances function and reduces injury. Andrew Jowett (Team Physician, Collingwood Football Club) suggested the characteristics of studs used on football boots may have an impact on the risk of ankle sprain in a similar way to their role in some knee injuries.3-5 Related issuesThat retired AFL players have a fourfold increase in risk of hip replacement and a twofold increase in risk of knee replacement compared with the normal population was confirmed by a survey reported by Matthew Hopkinson (physiotherapist, Melbourne).19 John Orchard reported that a 10-year survey of AFL doctors indicated that injury was a factor in 29% of players who are delisted from their clubs, with the proportion highly correlated with increasing player age. Hugh Hazard (Chief Medical Officer, National Rugby League [NRL]) spoke on the research that will contribute a basis for the NRL’s heat policy through predicting the meteorological factors (such as ambient temperature and humidity) that contribute to players’ heat stress (as measured by weight loss and core temperature increase). The conference clearly showed that football has become a fruitful area of research into prevention and management of sports injury and athletes’ performance. The AFL established a Research Board in 1999 to fund research into many aspects of football, and sports medicine has been a beneficiary of this support. The Australian Rugby Union is following suit, and it is hoped that the profile of broad research initiatives at the conference will prompt the NRL and the new Australian Soccer authorities to take similar initiatives. The attitude taken by the professional football bodies is praiseworthy, especially as research efforts are directed not only at the elite level, but also at more amateur levels.

Hugh G Seward MB BS, FACSP · John W Orchard MB BS, PhD, FACSP · Andrew D Jowett MB BS, FACSP

Objective: To estimate the effectiveness of a new high-performance Australian medical sheepskin (meeting Australian Standard 4480.1-1998) in preventing pressure ulcers in a general hospital population at low to moderate risk of these ulcers.Design: Open-label randomised controlled clinical trial.Setting: A large metropolitan teaching hospital in Melbourne, Victoria, in 2000.Participants: 441 patients aged over 18 years admitted between 12 June and 30 November 2000, with expected length of stay over 2 days and assessed as at low to moderate risk of developing pressure ulcers.Intervention: Patients were randomly allocated to receive a sheepskin mattress overlay for the duration of their hospital stay (218 patients) or usual treatment, as determined by ward staff (referent group, 223 patients).Main outcome measures: Incidence rate and cumulative incidence of pressure ulcers, assessed daily throughout hospital stay.Results: 58 patients developed pressure ulcers (sheepskin group, 21; referent group, 37). Cumulative incidence risk was 9.6% in the sheepskin group (95% CI, 6.1%–14.3%) versus 16.6% in the referent group (95% CI, 12.0%–22.1%). Patients in the sheepskin group developed new pressure ulcers at a rate less than half that of referent patients (rate ratio, 0.42; 95% CI, 0.26–0.67).Conclusions: The Australian Medical Sheepskin is effective in reducing the incidence of pressure ulcers in general hospital inpatients at low to moderate risk of these ulcers.

Damien J Jolley MSc(Epi), MSc · Robyn Wright RN, GradDipAppSci(SM) · Sunita McGowan RN, MAppSci · Mark B Hickey BAppSci(Hons) · Kenneth C Montgomery BSc, PhD · Don A Campbell MD, MMedSci(ClinEpi) · Rodney D Sinclair FACD

Objective: To assess obstetricians’ current antenatal screening practices for blood-borne viruses (hepatitis B, hepatitis C and HIV) and how they manage pregnant women infected with a blood-borne virus.Design and participants: National cross-sectional survey conducted between September 2002 and January 2003. All obstetricians (n = 767) registered with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) were mailed a questionnaire assessing their antenatal screening practices and knowledge of management of women potentially infected with a blood-borne virus.Outcome measures: Concordance of clinical practice with RANZCOG recommendations and current evidence-based guidelines.Results: 523 obstetricians (68% response rate) completed the questionnaire. Fifty-one per cent of respondents said they would always offer HIV screening and 60% would always offer HCV screening. For HIV-infected women, 36% of obstetricians would always recommend elective caesarean section and 33% would always avoid rupture of membranes. Despite a lack of evidence, 34% of obstetricians advise patients that the risk of HBV transmission is increased with breastfeeding, and 47% give the same advice about HCV transmission.Conclusion: There is some discordance between the RANZCOG antenatal screening recommendations for HCV and HIV and current practice. Knowledge about the management of HIV-infected women could be improved, and more obstetricians need to be aware that current evidence suggests there is no increased risk of transmission of HBV or HCV with breastfeeding.

Michelle L Giles MB BS · Suzanne M Garland MB BS, FRCPA, FRANZCOG · Joseph J Sasadeusz MB BS, FRACP, PhD · Sonia R Grover MB BS, FRANZCOG · Margaret E Hellard MB BS, FRACP, PhD

Kidsnet was established in 1997 at the Children’s Hospital at Westmead as a paediatric telephone triage service. The demand for Kidsnet increased from 18 327 in 1997/98 to 22 844 in 2001/02, with an average of 1669 callers per month. Most callers were able to proceed to seeking care at a more appropriate time and were satisfied with the service provided. The service is highly valued and the advice given perceived to be accurate. Kidsnet has shown that it can play a key role in providing safe advice to families.

Ralph M Hanson FRACP, FACEM, MPH · Bronwyn J Exley RN, GradDip(Paed) · Paul Ngo BSc · Maureen P Fitzpatrick BPhty(Hons), MCogSc · Elizabeth L Petering RN, BN, GradDip(Paed) · Sara J Matthews CNS · Diana Lechner RN · Celeste J Daniels RN, GradDip

Research into adolescent health issues is hampered by absolute requirements for parental consent. Society’s recognition of adolescents’ autonomy and decision-making capacity has been embodied in the legal recognition of the mature minor’s right to make decisions on matters affecting his or her life. Psychological research indicates that young people from 14 years have decision-making capacity. US and UK research ethics guidelines acknowledge the mature-minor principle, but Australian guidelines are out of step with international practice. An absolute requirement for parental consent in Australian research ethics guidelines is potentially unethical if it denies mature adolescents’ autonomy and is a barrier to participation, study validity and improved health outcomes through research findings. There are grounds for considering a mature-minor clause in the National Health and Medical Research Council research ethics guidelines, particularly in the context of youth participation in minimal-risk research.

Lena A Sanci MB BS, PhD, FRACGP · Susan M Sawyer MB BS, MD, FRACP · Penny J Weller BA/LLB, MA, PhD · Lyndal M Bond BA(Hons), MA, PhD · George C Patton MB BS, MD, FRANZCP

The South Australian Workers Compensation Tribunal has found that stress contributed to a man’s colorectal cancer. The medical evidence for this is very limited, and the case highlights the difference between scientific and legal proof. The South Australian Workers Compensation Tribunal has concluded, on the basis of the evidence presented to it, that workplace stress contributed to the development of colorectal cancer in a prison officer.1 This finding highlights the role of the adversarial legal system, in which courts and tribunals are generally limited by the material the parties choose to present.2 However, this subtlety was not reflected in the subsequent media coverage, with headlines such as “Work and stress — judge finds a deathly link” and lines such as “A judge has accepted that a prison officer’s job stress contributed to the cancer that killed him in a ruling that threatens to unleash a series of cases . . .”.3 It is therefore pertinent to review the medical history on which the decision was based and the medical literature to see whether this putative link should be challenged, despite the lack of an appeal by the South Australian Crown Solicitor’s Office.3 Medical historyThe prison officer was employed by the South Australian Department of Correctional Services for 21 years, from 1977 to 1998. A diagnosis of colorectal cancer, resulting in resection of an advanced colon cancer of the caecum (Dukes’ C stage), was made at age 59 years, and the man died in 1998 aged 60 years. The prison officer’s father had died of colorectal cancer when 75 years old, with age at onset of his cancer unknown. The Tribunal noted the influence of inheritance in the development of colorectal cancer, but several factors invite comment. First, there is no indication whether a detailed family history had been obtained, for example by a family cancer service. It is well documented that history-taking by individual practitioners misses a substantial number of relatives affected by cancer.4,5 Moreover, the decision does not indicate whether the cancer tissue was submitted for genetic testing, which could provide objective evidence of inherited risk through immunohistochemistry and microsatellite instability testing.6 Medical literature reviewThe Tribunal described the “considerable examination of relevant literature” by the various medical experts as a key dimension of the case.1 Four main studies were cited.7-10 One study compared 551 individuals with colorectal cancer with 1861 controls.7 The authors concluded that “logistic analysis yielded hypotheses for colon cancer risk in males with potentially high exposure to solvents, abrasives and fuel oil and in those in jobs with . . . high stress”.7 A study by Courtney et al, involving 569 cases and 510 controls, revealed a strong association between a history of work-related problems and colorectal cancer.8 The odds ratio was 5.5 (95% CI, 2.3–23.5). The authors, explaining the wide confidence interval, stated that “because most of the events were relatively uncommon in this population, the estimates of effect were not precise”.8 Courtney et al subsequently reported another case–control study involving 774 pairs, again examining the relationship of job stress and risk for colon cancer.9 Participants in the highest-stress group had a slightly increased risk when compared with those in the lowest-stress group (odds ratio, 1.3; 95% CI, 1.0–1.6), but there was no evidence of a trend. The authors concluded that “if job stress, as reflected by perceived job demand or control, is a determinant of colon cancer, it is probably not a strong one”.9 The applicant for compensation (the prison officer’s widow) also relied on a study by Kune et al of 715 patients with colorectal cancer and 727 controls (data from the Melbourne Colorectal Cancer Study).10 Work problems were found to be significantly more common for colorectal cancer patients. Although recall bias was not completely controlled for, it was thought that it was “probably not an important factor”.10 Other articles by Kune et al were not cited by the applicant or by the prison officer’s employer (the respondent).11,12 One of these papers used data from the Melbourne Colorectal Cancer Study to evaluate the effect of personality on risk of colorectal cancer in 637 individuals with colorectal cancer and 714 controls. Questions that tested a particular personality profile with regard to cancer risk revealed a significant association between a particular personality type and risk of colorectal cancer. With the caveat that the results should be cautiously interpreted, Kune et al concluded that the data were consistent with the hypothesis that “personality type may play a role in the clinical expression of colorectal cancer”.11 Yet further data from the same study revealed that significant protection against colorectal cancer was associated with self-reported “religiousness”.12 How these findings might have affected the Tribunal’s decision is unknown. This selective use of data is a feature of the adversarial system in which “parties are not obliged to call all the relevant evidence . . . only that which favours their case”.2 Indeed, our review here may be similarly criticised for presenting further selective references. Although a comprehensive review of the factors that contribute to the occurrence and effective management of workplace stress exists,13 an objective and complete review of the medical literature with regard to stress and colorectal cancer has yet to be published. Other literature before the Tribunal included a review of evidence concerning any relationship between the mind and cancer.14 This review noted that “there is very limited evidence that either stress or depression are risk factors for the onset of cancer”. It concluded that: On balance, the findings suggest that some psychological factors probably do exert an influence on the onset and cause of cancer, but the extent of their influence is unknown. Clearly further research and replication studies are needed to clarify the nature of this relationship.14 Legal proofSamuels, writing in the Journal in 1998, provided a detailed outline of the differences between medical truth and legal proof. Commenting that the question to be answered in our adversarial legal system is not “What is the truth of the matter?”, Samuels conceded that “medicine is a science and law is not”.2 Causation in science has multiple defined criteria (such as strength and consistency of association, temporal association, specificity, dose–response relationship, known or theoretical mechanism and coherence of evidence).15 Causation in law has a different basis, being “determined as a matter of common sense”, so that an inference of causation in a legal sense may be drawn when the level of evidence may be insufficient for causation according to the scientific criteria described above.16 A medical fact is “one which can be empirically supported”, whereas a legal fact “is one which is more probable than other countervailing facts”.2 It appears from the Tribunal’s reasons for its decision that, whereas the respondent’s medical expert tried to use a scientific standard of proof in examining the evidence for a contribution of stress in cancer, the Tribunal was only concerned with the balance of probabilities. ConclusionTo date, the association between stress at work and colorectal cancer has been the subject of a limited number of conflicting and inconclusive studies. The decision made by the Tribunal turned on the medical and other evidence actually placed before it by the parties. In finding that on the balance of probabilities the prison officer’s employment contributed to his cancer, the Tribunal found it unnecessary to distinguish between causation and acceleration. Thus, the fundamental causation issue has not been subject to legal precedent. It will be of considerable interest to consider any further cases in which the question might again arise, especially in light of the then current state of relevant scientific evidence.

Allan D Spigelman FRACS, FRCS, MD · Peter Dwyer MSc(Soc), DipLaw, FACLM(Hon)

There are important distinctions to be made between the inquisitorial process of a tribunal, such as the South Australian Workers Compensation Tribunal, and the adversarial process of the courts. To quote the renowned English Law Lord, Lord Devlin: In the [adversarial process], the judge presides at the trial, directs the proceedings and rules on the law; he is not there to hold an inquiry. It is quite different from the [inquisitorial process] where witnesses are summoned by the court and examined by the judges, the role of counsel being to tender a witness, and ask supplementary questions.1 A tribunal is inquisitorial. It can ask its own questions of the witnesses called, and may have the capacity to commission its own expert advice and call its own witnesses. Often a tribunal has several people sitting on it; one is usually legally qualified, but others may be experts from the field that is the basis of the proceedings. Whereas claims for compensation for personal injuries arising out of a defendant’s negligence are brought in civil courts and determined by common law processes, in Australia the most common areas of injury — work- and transport-related accidents — are covered by “statutory” schemes. These are arrangements by which claims for compensation are assessed under specific legislation, rather than at common law. Many statutory workers’ compensation schemes were not established simply as narrowly defined insurance schemes, but were given flexibility to provide social benefits. For example, Lord Campbell’s Act,2 enacted in England in 1846, was intended to overthrow the ruling made under common law in 18083 that damages for the death of a human being could not be claimed by another person. The Act was passed to protect the widows and orphans of men killed in industrial accidents by providing, through statute, access to compensation for loss of the income of a bread winner — compensation that could not be obtained at common law. Many people would think that Mrs Simpson, the applicant in the case described by Spigelman,4 had a right to bring her claim for compensation for her husband’s death. That right does not exist at common law, but is provided by statute. In the courts, the claimant (civil) or the Crown (criminal) has the burden to prove its case, and the benefit of the doubt falls to the defendant. The major difference in the meaning of “doubt” between the criminal and civil courts is that, in a criminal court, the test is “beyond reasonable doubt”, a much tougher test than the civil court’s “on the balance of probabilities”. Simpson v South Australia (Department of Correctional Services) was heard in the South Australian Workers Compensation Tribunal, but the test was still “on the balance of probabilities”. The claimant in the Simpson case introduced medical evidence that it was a “common observation” (acknowledged not to be a proven scientific fact) that there was a link between stress and cancer. In most workers’ compensation schemes, compensation will be paid if work caused, aggravated or accelerated the injury — that is, either caused or was a “significant contributing factor” to the injury. The phrase “significant contributing factor” appears in much workers’ compensation legislation. It was defined in the Victorian County Court5 as meaning a factor whose contribution was “more than de minimis but less than a major or dominant factor”. Not a very high hurdle to jump! Paragraph 70 of Judge McCusker’s decision in the Simpson case underscores the test he applied: A careful examination of the material available in this case indicates, on the balance of probabilities [my emphasis], that the worker’s employment contributed to the cancer that caused his death. Doctors are often dismayed at the difference between the standard of proof required in civil cases (the balance of probabilities) and the medical/scientific standard. Many have the perception that judges (and tribunals) award compensation to claimants seen as needy — redistributive justice, in which money is taken from rich defendants (more specifically, their insurers) and given to the unfortunate. Therefore, many doctors would be dismayed at the Simpson judgment. Most would believe that any relationship between stress and cancer is at best tenuous, and certainly not proven to the standard required of science. They are also incensed when judges make decisions in intensely technical areas of medicine, saying that judges are no more qualified to decide purely medical issues than doctors are to decide legal issues. Most Australian states now adopt a different approach to resolving medical disputes raised in workers’ compensation claims. In South Australia, the medical issue was determined by the tribunal. In Victoria, Queensland and Western Australia, such disputes are resolved by referral to a multi-doctor medical panel or medical tribunal. Doctors are appointed to any one panel on the basis of the nature of the injury. For example, impairment arising from a back injury might be assessed by a panel consisting of an orthopaedic surgeon, a neurosurgeon, a psychiatrist and an occupational health physician. If the Simpson claim had been referred to a medical panel, the panel would probably have comprised a colorectal surgeon, a gastroenterologist, an oncologist and an immunologist, or similar, with acknowledged expertise in the area. These doctors would have used their existing knowledge, and would have viewed the expert opinions provided by the parties, critically analysed them, and checked the references cited, before forming a collective view. In contrast, the adversarial process encourages the use of medical “gladiators”, who are selected because their opinion advances the client’s cause. Multiple opinions, for and against, are put into evidence. This leaves judges (or juries) in the position of having to decide between competing schools of medical or scientific opinion. The most famous Australian example of the difficulty lay juries (and judges) experience when assessing expert evidence is the handling of the forensic evidence in Lindy Chamberlain’s trial for the murder of her baby, Azaria. The trial, held in the Supreme Court of the Northern Territory, resulted in Mrs Chamberlain being wrongly convicted of murder in 1982. Much of Judge McCusker’s judgment in the Simpson case is a critical analysis — by a lawyer (ie, the judge) — of the many medical opinions put into evidence by both the claimant and the defendant, leading to a final decision as to whose opinions he preferred. An inquisitorial medical tribunal approach encourages individual doctors to act genuinely as independent medical experts (removing any perceived taint as medical “guns for hire”, or, as it has been quaintly put, “rent-a-quacks”), and the final opinion is developed on a multidisciplinary collegiate basis. Opinions of the Victorian Medical Panels, the Western Australian Medical Assessment Panels and the Queensland Medical Assessment Tribunals are, by statute, final and binding. For example, section 68(4) of Victoria’s Accident Compensation Act 1985 states: The opinion of a Medical Panel on a medical question referred to the Medical Panel is to be adopted and applied by any court, body or person and must be accepted as final and conclusive by any court, body or person irrespective of who referred the medical question to the Medical Panel or when the medical question was referred. If South Australia had such a system, a panel of medical experts would have assessed Mr Simpson’s medical records and the expert evidence submitted both in support and rebuttal of the claim, made its own investigation of the literature, and come to an informed medical view. The panel would have had access to advice regarding the legal tests required by the appropriate statute. Whether the panel would have reached the same view as the judge cannot be said. But at least the medical basis for the claim would have been seen to have been thoroughly reviewed by truly independent medical experts — and a medical decision (subject to the law) made on a medical issue.

Paul Nisselle AM, MB BS, FRACGP

There are concerns that Australia is facing an impending shortage in the medical workforce, and there are significant changes occurring in key determinants of medical workforce supply and demand. To date, workforce planning has not taken into account the full range of dynamic variables that are involved, nor accounted for their inherent uncertainty and complex interactions. Future planning will require more careful monitoring and dynamic modelling within a full healthcare system perspective.

Catherine M Joyce BA(Hons), MPsych · John J McNeil PhD, FRACP, FAFPHM · Johannes U Stoelwinder MD, FRACMA, FAFPHM

Clinical records Patient 1 A 5-month-old girl presented with biphasic stridor (ie, stridor present during inspiration and expiration) and feeding difficulties since birth. The stridor was not related to her position or to her level of wakefulness. Asthma treatment with bronchodilators, inhaled corticosteroids (up to 500 μg/day fluticasone propionate) and courses of oral steroids were prescribed by several doctors from 6 weeks of age for her “noisy breathing”. These treatments did not alter her symptoms. No investigations were undertaken. There was no significant perinatal or other medical history. The child appeared well; she was thriving and her development was appropriate for her age. The biphasic stridor was not associated with wheeze or tachypnoea. She had mild tracheal tug and chest wall recession. Her chest was clear, and the findings from the remainder of the examination were normal. A chest x-ray (CXR) showed a right aortic arch and reduced air–tissue interface at the carina, consistent with tracheomalacia. A barium swallow showed a posterior indentation of the mid-oesophagus, suggestive of a vascular ring (extrinsic compression of the oesophagus and trachea by aberrantly sited blood vessels [Box 1]). Bronchoscopy confirmed these findings and showed significant reflux oesophagitis. A magnetic resonance angiogram confirmed the presence of a vascular ring formed by a double aortic arch, with each arch giving rise to its own common carotid and subclavian arteries. Surgical correction of the compressive vascular band on the trachea 3 days later was uneventful. The proton pump inhibitor omeprazole was prescribed for the reflux oesophagitis, but this proved insufficient. After further hospitalisations for pulmonary aspiration, a fundoplication was performed and a gastrostomy tube inserted. Twelve months later, she remains asymptomatic with normal growth. Patient 2 A 9-week-old girl presented with biphasic stridor and a 3-week history of intermittent central cyanosis associated with feeding. She was noted to have had “noisy breathing” from birth. At age 6 weeks, she had been admitted to another hospital with cough and more prominent biphasic stridor. Her respiratory difficulties were attributed to bronchiolitis caused by respiratory syncytial virus. She required supportive treatment including oxygen for 5 days in hospital. On discharge, she improved, but continued to have very noisy breathing, which was worse when she was active or feeding. She was bottle fed with infant formula and noted to have occasional episodes of transient cyanosis during feeding. On examination, she appeared well and was thriving. She had a moist cough, moderate subcostal recession and audible biphasic stridor. A CXR showed a left, normally sited aortic arch and poor delineation of the distal tracheal air column suggestive of tracheomalacia. A barium swallow (Box 2A) showed significant oesophageal compression anteriorly and posteriorly, consistent with a double aortic arch. A magnetic resonance angiogram (Box 2B) confirmed the presence of the double aortic arch, as well as extrinsic, anterior compression of the distal trachea. Bronchoscopy, performed before surgery to divide the vascular ring, showed mild tracheomalacia. The infant was discharged a week later with reduced stridor and recession. No further episodes of central cyanosis with feeding occurred during the 6-month follow-up period after surgery. Biphasic stridor from birth or early infancy suggests fixed proximal airway obstruction, which may be intra- or extrathoracic. Conversely, variable inspiratory stridor suggests a less severe, extrathoracic, dynamic obstruction. Patients with biphasic stridor (such as that caused by a vascular ring) are often initially misdiagnosed as having asthma because of noisy respirations, although stridor is never a sign of asthma, but rather of proximal airway compromise. Stridor differs from wheeze in that it has a different pitch and harsher sound than the more musical pitch of a wheeze. Stridor is heard predominantly during inspiration. Children with a vascular ring usually present in infancy with non-specific symptoms of dyspnoea, cough, inspiratory or biphasic stridor, and sometimes an expiratory “wheeze” (presumably related to downstream obstruction of the intrathoracic trachea) as well as feeding problems.3-5 A vascular ring occurs when one or more aortic arch abnormalities, with or without a patent ductus arteriosus or ligamentum, produce a ring that completely encircles the trachea and oesophagus, leading to symptoms of tracheal or oesophageal compression6 (Box 1). Differential diagnosesThe differential diagnosis of persistent biphasic stridor in an infant includes severe laryngomalacia, tracheomalacia and, less commonly, vocal cord paresis (causing a hoarse cry), subglottic haemangioma (causing rapidly progressing stridor, sometimes associated with a facial haemangioma) and vascular ring. Laryngomalacia is the most common cause of neonatal inspiratory stridor, but is an unlikely cause of biphasic stridor from birth, unless it is very severe. Stridor in laryngomalacia more commonly occurs after several weeks of age, is usually limited to inspiration and varies with posture and airflow (eg, it is louder with crying). Signs usually gradually resolve without treatment by 12 to 18 months of age.7 Tracheomalacia, a condition characterised by weakness of the tracheal walls and supporting cartilage (localised to the region of external compression by blood vessels), commonly occurs in association with lesions such as a vascular ring and persists for several years until the tracheal cartilage firms. The formation of the ring depends on the preservation or deletion of specific segments of the rudimentary aortic arch complex, or the presence of major arteries with anomalous origins or remnants (eg, ligamentum arteriosum) compressing the trachea and oesophagus. The double aortic arch is the most common form of vascular ring,4 and is characterised by persistence of both embryonic aortic arches, with separate carotid and subclavian arteries originating from each arch. The ascending aorta bifurcates anterior to the trachea to form the aortic arches, and each courses either right or left of the trachea and the oesophagus. The larger of the two arches usually crosses posterior to the oesophagus and unites with the other arch in the posterior mediastinum to form the single descending aorta. This can be seen as a posterior indentation on the mid-oesophagus on a barium swallow (Box 2A). When biphasic stridor is detected in an infant, a chest x-ray (CXR) and a barium swallow are simple initial investigations that together will usually confirm or exclude a vascular ring as the underlying cause.8-10 The CXR may show a right-sided aortic arch, a poorly visualised distal trachea, or another cause for tracheal compression or deviation (eg, a mediastinal mass). A barium swallow may show abnormal indentations on the posterior oesophageal wall. If these abnormalities are detected, referral for more detailed investigations (including bronchoscopy and magnetic resonance angiography) and treatment is appropriate.11,12 Tracheomalacia may occur in isolation, and the diagnosis often relies on the bronchoscopist’s interpretation of the airway calibre and shape at bronchoscopy. ManagementAfter surgical treatment for a vascular ring, it is essential that the child’s parents receive ongoing management advice, as tracheomalacia will persist, and there is therefore an increased risk of severe croup. The child may continue to display noisy breathing for a period of a few months to several years13 and should be followed up until school age. In school-age children, any residual inspiratory flow limitation can be quantified using inspiratory flow volume loops with spirometry. Residual tracheomalacia commonly results in difficulty clearing airway secretions (impaired mucociliary clearance) through the functionally narrowed section of trachea at the site of the previous extrinsic wall compression. This may manifest as a brassy, rattly cough that persists longer than expected after a viral infection. It would be appropriate to consider influenza and pneumococcal vaccination in these children. Lessons from practice Stridor is never a feature of asthma and can be differentiated from wheezing by its predominance during inspiration, its harsher sound and different pitch. Biphasic stridor suggests fixed intra- or extrathoracic proximal airway obstruction. Any infant with biphasic stridor should have a chest x-ray and a barium swallow to detect the presence of a rare congenital anomaly in which aortic arch or large blood vessel abnormalities produce a ring encircling and compressing the trachea and oesophagus. Management of patients with vascular ring must include postoperative advice concerning the ongoing tracheomalacia and the associated risk of croup, as well as possible continuation of noisy breathing and impaired mucociliary clearance, which may prolong a viral-induced, rattly cough. 1: A double aortic arch (as in Patient 1) The simplified anatomy of a double aortic arch, which produces a vascular ring encircling the trachea and oesophagus, causing symptoms of tracheal or oesophageal compression. 2: Investigations for biphasic stridor (Patient 2) 2A: Barium swallow, showing anterior (arrow A) and posterior (arrow B) compression of the oesophagus, together with a posterior bulge (arrow C) caused by a double aortic arch. 2B: Magnetic resonance image, showing the double aortic arch — superior vena cava (A), brachiocephalic vein (B), pulmonary arteries (C, D), prominent left aortic arch (E), and smaller right aortic arch (F).

Sami Spencer · Belinda H Yeoh MB BS · Peter P Van Asperen MD, FRACP · Dominic A Fitzgerald MB BS, PhD, FRACP

Rickets in children and osteomalacia in adults are caused by undermineralisation of bone, which increases its susceptibility to bending and fracture; treatment is with calcium, vitamin D or phosphate, depending on the specific mineral or vitamin deficiency. In Paget’s disease, osteoclasts are overactive and produce woven or “repair” bone, which is mechanically weaker than lamellar bone; treatment is with antiresorptive bisphosphonate drugs. Cancers can produce bone lysis through direct spread within the skeleton or production of endocrine parathyroid hormone-like factors; treatment is with a bisphosphonate, plus appropriate therapy for the cancer. Cancer can also produce hypercalcaemia if the capacity of the kidneys to excrete the calcium dissolved from bone is exceeded; treatment is with saline infusion to increase excretion and a bisphosphonate. Primary hyperparathyroidism is the other common cause of hypercalcaemia and is usually associated with a single parathyroid adenoma; it is best treated with parathyroidectomy. Hypocalcaemia may result from severe decrease in calcium absorbed or lack of parathyroid action; both are treated with calcium and vitamin D (ergocalciferol or calcitriol).

Richard L Prince FRACP, MD · Paul Glendenning PhD, FRACP

A recent editorial looked at the way the problems at Camden and Campbelltown hospitals were managed, and has attracted a range of opinions Be very afraid Brad Frankum,* Duane Attree,† Andrew Gatenby,‡ Sandy Eagar,§ Anthony Aouad¶ * Director of Medicine, and Conjoint Associate Professor, University of New South Wales; † Clinical Decision Support Manager; ‡ Chair, Division of Surgery; § Nurse Manager, Professional Development; ¶ Chair, Clinical Advisory Council, and Physician; Macarthur Health Service, PO Box 149, Campbelltown, NSW 2560. Brad.frankumATswsahs.nsw.gov.au To the Editor: In reply to your question as to whether the crassly phrased “Cam Affair” was “an isolated incident or destined to be repeated?”,1 doctors and administrators throughout our healthcare system should be very afraid. They may be next; this was no isolated incident. We who continue to work in Macarthur Health Service (MHS) expect a daily dose of ill-informed and inaccurate “revelations” about our hospitals in the media. Our despair increases, however, when we read similar superficial comments from your esteemed publication. For the record, before the leaking of the draft Health Care Complaints Commission (HCCC) report, some of the following systems and solutions had already been put in place at MHS (implementation date in parenthesis): Performance management of all staff — including 100% of all senior medical staff — with focus on Key Performance Indicators and implementation of the Clinician’s Toolkit (March 2003). Capital development at a cost of over $100 million (ongoing). Appointment of 45 new consultants across a variety of specialties (2000 to September 2003). Appointment of an academic full time Director of Medicine (January 2003). Establishment of new and innovative services in ambulatory care, acute medicine, emergency short stay, paediatric emergency, stroke, palliative care, cancer therapy, rehabilitation/geriatrics, radiology, community maternity and paediatrics, and mental health. A local graduate nurse program with over 85% retention rate (1998–2003). Rigorous identification of all adverse events from acute settings by having dedicated staff and weekly multidisciplinary team review of cases (2001–2003). Weekly multidisciplinary grand rounds (January 2003). An active partnership with members of the community through a Community Council, community review of complaints handling and inclusion in MHS committees (2002). A functional and well represented Allied Health Council and Discipline Seniors Committee. Well attended and widely represented (including community) Clinical Advisory Council (December 2002). Multidisciplinary team meetings and quality review in all specialty departments (July 2003). Increase from one to three Royal Australasian College of Surgeons accredited surgical registrar positions since 2000. Successful Postgraduate Medical Council accreditation (2003) and recruitment of 6 additional Junior Medical Officers. Are these the actions of an “indifferent administration”? Was there any attempt to place these adverse outcomes in the context of an extremely busy health service; one with historically the poorest staffing levels of any metropolitan hospital in New South Wales (Box) and a health service existing in a population with one of the highest growth rates in Australia?7 No one wishes to minimise the impact on the families of those who suffered adverse outcomes. However, anyone who works in a public hospital knows that adverse events occur. The established rate internationally ranges from 3.7%–45.8%.8 Applying the accepted rate in Australia (16%), Camden and Campbelltown hospitals should have had 26 667 adverse events in the years 1998–2003. The number of cases highlighted in the various investigations (71) represents an adverse event rate of 0.043%. The only appropriate way to deal with these events is through a rigorous quality framework making use of the expertise of staff at the coalface. The handling of our hospitals’ adverse events by various bodies has set this quality agenda back many years. In its report, the HCCC showed that it is a completely inappropriate body to be investigating a health service. It investigated and passed judgements on clinician performance without ever consulting individual clinicians. It convened expert panels unsuitable for the nature of the cases reviewed (eg, no Visiting Medical Officer [VMO] involvement on a panel that investigated over 30 cases of patients under the care of VMO physicians). Our State Health Minister shares this opinion.9 In 2003, MHS achieved 2 years’ accreditation with the Australian Council on Healthcare Standards.10 What, then, does this mean? In 2004, significant numbers of senior clinicians have resigned, the administration has been decimated, and there is widespread bewilderment among the hard-working, skilled and dedicated staff. The media and politicians on both sides have behaved poorly. Ironically, staff now fear to speak out publicly, because to do so may jeopardise the assistance and resources we may finally be afforded. Obviously the government and bureaucracy would prefer the general public to believe that MHS is the only “sick hospital(s)” in the healthcare system, find some individuals to blame, play catch-up with resources, and watch the problem evaporate. Furthermore, a new threat is emerging: if you undertake investigation into adverse events, you risk confidential cases being easily identified and passed on to the media and regulatory bodies. If you are a clinician and you treat enough patients, one day you will make a mistake. Be very afraid. The precedent is set — blame is back on the agenda. Occupied bed-days, emergency department presentations and staffing levels at Sydney public hospitals Hospital Bankstown St Vincent’s Macarthur Sutherland Hornsby Admissions in 2002/03 26 2252 29 6813 29 4092 19 3963 16 9644 Emergency department presentations (for November 2003)5 2 710 2 755 3 713 2 590 1 922 Salaried medical officers (FTE)6 128.61 266.7 70.83 93.26 108.87 FTE = Full-time equivalent. Staff goodwill is running out David Rosenfeld Chairman, Liverpool Health Service Medical Staff Council, Liverpool Hospital, Locked Bag 7090 Liverpool, Sydney, NSW 1871. d.rosenfeldATunsw.edu.au To the Editor: In response to your recent editorial,1 I would like to point out the following. The Sydney Metropolitan Area Health Services, comprising Northern Sydney, South Eastern Sydney, Western Sydney, Central Sydney, South Western Sydney and Wentworth, had a budget expenditure for 2001/02 of $4581 million (information from internal Department of Health documents). The combined population of these health service areas was 3 887 142, and dividing this expenditure by the population gives annual expenditure of $1178.66 per person. In 2001, South Western Sydney Area Health Service (SWSAHS) had a population of 797 510,2 making it the most populous of all these health areas. Dividing SWSAHS’s expenditure by its population gives an annual expenditure of only $920 per resident. Population projections (an increase of 14.9% from 2001 to 2006) show SWSAHS to be the fastest growing of all, which means the funding per resident will continue to deteriorate. To spend the 2001 average on SWSAHS residents would require increasing this health service’s budget by $205 million. This is the crux of the whole problem. For far too long, residents of SWSAHS have lagged far behind their metropolitan neighbours in healthcare expenditure. These figures do not even take into account the marked disparity in research funding flowing to other metropolitan areas compared with SWSAHS, nor all the private hospitals and level of privately insured patients in other health areas, which would probably more than double the health expenditures already listed. Further, SWSAHS has the highest ethnic population in the country and is the most socioeconomically disadvantaged; our expenditure on interpreter services and social workers consumes a disproportionate percentage of our funding. The state Department of Health has long recognised this disparity, and has been trying to redress the problem. However, unless significant additional funds can be generated, resources will need to be redistributed from other Area Health Services. This can be extremely difficult — long-established teaching hospitals have very well resourced support networks and links that go back many years. SWSAHS includes Liverpool Hospital, which is a tertiary referral service still funded as a district hospital. Unfortunately, the only real surprise to staff working there is that the recent problems have not happened before, and that they have not happened at more of the hospitals in SWSAHS. Medical research in SWSAHS is extremely limited. We struggle to appoint advanced trainees. We are trying to teach our undergraduates in an environment with shrinking teaching resources, and the promise of $5 million is a couple of zeros short of what is needed. It is only through the goodwill of staff, and their extraordinary commitment, that we have survived this long. Senior medical staff are now leaving in significant numbers because of “burnout” and overwork. The solution is not money alone, and it is certainly not “working smarter”. Colleges need to make rotation compulsory for advanced trainees so that they can be exposed to a wider variety of clinical cases. There need to be inducements locally to attract staff — including not charging them more for parking than any other hospital! There are no simple answers, but blaming inadequately trained and resourced staff, who are placed unwillingly in situations beyond their competence, is severely damaging to all SWSAHS staff. Diagnosis before treatment: don’t blame funding Paddy A Dewan Paediatric Urologist, PO Box 152, Parkville, VIC 3052. Paddy. DewanATwh.org.au To the Editor: In your recent editorial, you make the statement “it is hoped that something more substantial than yet another list of blameworthy individuals will emerge from the inquiry”, and then blame funding shortages for substandard care,1 highlighting how pervasive blame and guilt are! Nonetheless, your suggestion that we have a sick, politically motivated health-care system is accurate. Improvement will occur if we, as medical service providers, take responsibility for the deficiencies and accept that we and our system are inadequate for a whole host of reasons, including less-than-perfect science, and competition rather than collaboration between specialties and specialists, to name just a few. Even more importantly, we are constrained by an unfriendly work environment in much of the public hospital system, for which we blame the budget. Money never made anyone happy! Unfortunately, hospital administrators are usually not “in for the long haul” and often seem poorly focused on the needs of the patients, let alone the emotional needs of staff — an administrator’s career is more dependent on meeting “targets”. The workplace environment is further marred by the limited ability of some of our clinical colleagues who have been “elevated” to management positions, where they manage budgets, complex interpersonal issues and patient complaints. Strategic planning, root-cause analysis and staff satisfaction are terms without real meaning to many of these doctors, who appear to be set up to fail. Once in the clinical administrative position there seems little in the way of “staff caring” performance review. Interpersonal conflict and politics often predominate, and bullying is facilitated by these high-stress environments, exacerbated by the threats of litigation from patients, some of which occur because unhappy staff lash out at consumers. As we tend to view adverse events as something for which families will seek legal solutions rather than seeing such events as opportunities for change, we are frightened. Because we are stuck in a culture of fear and blame, we avoid these patients rather than try to share the hurt that comes from an adverse outcome. Thus, minor imperfections are dismissed as inevitable, and for more major adverse catastrophes we seek qualified privilege to feel protected. However, we are not protected by hiding; we are protected by dealing with a complaint as a challenge to improve rather than a reason to abuse the person who points out a deficiency. At the Royal Children’s Hospital, Melbourne, a senior clinician expressed concern about quality of care, for which he was progressively marginalised, put through an unjust request for resignation, and exposed to a hospital board review conducted with no clinical expertise and little understanding of bullying. The clinician’s appointment was then terminated because he went to the media, and his termination was justified by a clinical review with restrictive terms of reference. The circumstances were similar to those of the “Cam affair” in the Macarthur Health Service. The public and the medical community can only conclude that politics, and not standards, drive the health agenda, a view that was confirmed during a recent Victorian parliamentary inquiry into community advisory committees of hospital boards that did not allow major concerns of selected people to be heard by the public. This lack of transparency, and lack of partnership, at all levels, should be replaced with a more open, trusting culture with greater accountability, less blame and less hollow jargon. When will we ever learn! In support of the HCCC John H T Ellard Psychiatrist, 29A Almora Street, Balmoral Beach, NSW 2088. manstumATtpg.com.au To the Editor: Your recent editorial1 raises some very interesting questions. The Health Minister commented in his press release that the “HCCC [Health Care Complaints Commission] does not go far enough in terms of finding anyone accountable for these failures”.2 He could have set his mind at rest by consulting the relevant articles in the Encyclopaedia Britannica. In essence, in the system of government that we have, with Cabinet responsibility, he is the person with the ultimate responsibility. If his departmental and administrative heads did not keep him properly informed and advised, then surely their heads should roll rather than that of the HCCC Commissioner, whose report demonstrated that there were big problems. I believe that one of your suggestions — that of dismantling the “highly centralised HCCC” and replacing it with regional panels — is very likely to make things worse rather than better. The first question to be answered in an inquiry of this kind is whether or not there was medical error, incompetence or impropriety. This involves a careful and detailed examination of the information available about the event or events in question. There are allegations and responses, and there is often a large body of clinical notes, hospital records and laboratory results to be read most carefully and considered. Sometimes the issues are simple, and sometimes they are complex, requiring the assessor to have considerable experience, detailed specialist knowledge and to make literature searches. Not every local area will have a sufficiently wide range of expert assessors. The capacity to find competent, experienced, unbiased assessors diminishes as the geographical and administrative areas to be considered become smaller. Remember that the HCCC has to deal with all the registrable healthcare professions — not only medical practitioners, but psychologists, nurses, physiotherapists, osteopaths and the like. Consider the amount of time and effort required to set up the panels in all these activities in each local area. I will conclude by indicating what I believe to be the fatal error in your suggestion. Imagine that the preliminary inquiries strongly suggest that the problems in question arose from a lack of resources and that the government of the day is substantially responsible for what happened. I have the greatest difficulty in believing that the area’s state and federal politicians would be capable of coming to an opinion which laid the fundamental blame on the government of the day, if it happened to be that of their party. I believe that the “Cam affair” provides an indication of what would happen. I have been associated with the present system since it began as the Complaints Unit and then became the HCCC. I do not suggest that it has reached perfection, but long observation convinces me that it has played a valuable role and that many errors and improprieties in medical practice have been much diminished because of its good work. No profession has ever welcomed scrutiny from outside its ranks, and there are still those in medicine who hold that position. I am in firm disagreement. The healthcare complaints commission needs reform, and politicians must accept ultimate responsibility Martin B Van Der Weyden Editor, The Medical Journal of Australia, Locked Bag 3030, Strawberry Hills, NSW 2012. editorialATampco.com.au In reply: We at the Journal welcome criticisms as treasures from which we always learn. The recent editorial on the “Cam affair” has certainly provoked responses from a number of our readers. Let me state from the outset that I fully understand the tension so evident in the remarks of Frankum and his colleagues from the Macarthur Health Service. However, I am not sure why our choice of the phrase “Cam affair” has caused so much apparent distress. The Concise Oxford Dictionary defines an affair as: “1 a concern; a business; a matter to be attended to (that is my affair). 2 a a celebrated or notorious happening or sequence of events. b colloq. a noteworthy thing or event (was a puzzling affair). 3 = love affair. 4 (in pl.) a ordinary pursuits of life (current affairs). b business dealings. c public matters.” The unfortunate events within the Macarthur Health Service over the last year certainly constitute “an affair” which will be remembered for some time; whether its use is “crass” is in the eye of the beholder. I am heartened to read the administrative and clinical progress listed by Frankum et al. However, as late as August 2003, the Macarthur Expert Clinical Review Team recommended, among other things, the need for significant leadership in the hospitals’ clinical and administrative spheres, and the involvement of academic institutions and clinical colleges to make the hospitals more professionally attractive for postgraduate training and senior staff. Central to all this is the importance of doctors in training in Sydney’s south- west to be seen to successfully withstand the scrutiny of our clinical colleges, on par with other metropolitan hospitals. This will only come with an enhanced academic presence in all major clinical disciplines of the Macarthur Health Service. Again, I am heartened to read that this is happening, albeit slowly. Rosenfeld’s data reinforce one of my editorial’s contentions, that the Cam affair was a system failure, a “mismatch between clinical capacity and clinical demand — a mismatch exacerbated by the chronic ‘poor country cousin’ status of Sydney’s outer metropolitan hospitals compared with their ‘rich city cousins’, the established inner city hospitals”. However, transfer of resources alone will not solve the problems. Our public hospitals are 19th-century institutions at sea in the 21st century, and they need reform. This will require urgent short-term and long-term solutions to meet the obvious funding and workforce deficiencies, but also fundamental system reform. How long do doctors and other healthcare professionals have to send out SOSs that the public hospital ship is sinking before bureaucrats and their political masters respond? Dewan’s comments are apt; our healthcare culture is not good at confronting criticism. Witness the experiences in Bristol1 and Winnipeg.2 We desperately need an open, blameless and depoliticised environment which allows individuals to speak frankly about individual or systemic shortfalls and failures, and clear pathways for these to be addressed. Finally, Ellard is not certain that dismantling the highly centralised Health Care Complaints Commission is a good idea. Modern management principles eschew top-down, people-insensitive systems as appropriate quality improvement tools, and the HCCC allegedly has all these attributes. Further, the Commission provides politicians, as aptly noted by Ellard, with another means of dodging their responsibilities. It is evident that the healthcare complaints system needs reform. Thus, my suggestion for local complaints panels headed by an ombudsman, and involving local health professionals and politicians, was meant not only to promote debate, but also to engage an inclusive, bottom-up approach. I am not rigidly committed to the local entity, but whatever strategies and recommendations emerge from current parliamentary enquiries they must ensure the integrity of systems and locate these close to where the healthcare action is played out. It is also imperative that local politicians on both sides of politics are involved along with healthcare professionals, and that the current emphasis on investigation of individuals is shifted to investigation of systems. Finally, it is crucial that any reporting undertaken is directed, not to health bureaucrats or the Minister for Health, but to Parliament as a whole. Our politicians must take collective responsibility for healthcare in the communities they purport to represent. Anything else is political bastardy.

Brad Frankum · Duane Attree · Andrew Gatenby · Sandy Eagar · Anthony Aouad

Andie S Lee,* John R Dyer† * Registrar, † Senior Infectious Diseases Physician, Department of Microbiology and Infectious Diseases, Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042. John.dyerATfmc.sa.gov.au A 79-year-old man presented with 5 days of right-leg pain, high fever, severe headache and deteriorating conscious state. He was previously fit and healthy and took no medications. The patient appeared unwell, had a temperature of 39.5°C, moderate irritability and depressed conscious state. There was marked neck stiffness and his left wrist and right knee joints appeared swollen and inflamed. There was a cardiac systolic murmur, but no stigmata of bacterial endocarditis. Aspirates of the left wrist and right knee yielded purulent fluid containing numerous gram-positive cocci. The patient was admitted to the intensive care unit and treated with high dose benzylpenicillin plus vancomycin. A cerebral computed tomography scan was normal; lumbar puncture was not performed. The affected joints were washed out within 24 hours. All cultures of blood and synovial fluid yielded a Lancefield Group C β-haemolytic streptococcus, identified further using the ID 32 Strep strip (BioMerieux, Marcy l’Etoile, France) as Streptococcus equi subspecies zooepidemicus (S. zooepidemicus) based on its ability to ferment sorbitol and not trehalose. This isolate was shown to be sensitive to penicillin (minimum inhibitory concentration, < 0.1 mg/L). Intravenous penicillin therapy was continued. Transoesophageal echocardiography showed echodensities close to the aortic valve which suggested vegetations. The patient’s condition improved steadily, and he ultimately received intravenous antibiotics for 6 weeks. Further history revealed that the patient collected fresh horse manure for his garden daily from a local paddock. He reported no direct contact with animals or ingestion of unpasteurised dairy products. S. zooepidemicus could not be cultured from a single specimen of horse manure collected from the paddock, and it was not possible to collect clinical specimens directly from any of the horses that used the paddock. Human infection with S. zooepidemicus can usually be traced to an animal source.1 Outbreaks associated with ingestion of unpasteurised milk and cheese have also been described.2,3 Likely entry routes include the respiratory or gastrointestinal tract and skin.1 Severe sequelae of S. zooepidemicus infection include endovascular infection, meningitis, septic arthritis, and epidemic post-infectious glomerulonephritis. Our patient’s clinical picture indicated multifocal sepsis, with polyarthritis, endocarditis, and probable meningitis. In a recently reported case of S. zooepidemicus meningitis, pulsed-field gel electrophoresis showed molecular identity between patient isolates and a throat swab isolate from a horse with which the patient had been in close contact.4 Our patient was most likely infected via the respiratory or cutaneous routes, or by ingestion after contact with respiratory secretions of horses deposited in the environment. Exposures in the garden can lead to a variety of severe infections.5 This is the first reported case where S. zooepidemicus infection appears to have been acquired through gardening. Severe disease with this organism can be a particular hazard in elderly gardeners with comorbid conditions.1

Andie S Lee · John R Dyer

John Coutsouvelis,* Carmela E Corallo† * Oncology Pharmacist, † Deputy Director of Pharmacy, Box Hill Hospital, Nelson Road, Box Hill, VIC 3128. John.coutsouvelisATboxhill.org.au To the Editor: Thalidomide has recently been approved for use in treating recurrence of erythema nodosum leprosum and multiple myeloma after failure of standard therapies. Common side effects of thalidomide treatment include drowsiness, sedation, rash and paraesthesiae.1 Dizziness, hypotension and bradycardia occur less commonly.1-3 Of 91 patients treated with thalidomide (80 with multiple myeloma), we have had one case of symptomatic bradycardia. We describe this patient, who was able to continue treatment on a reduced dose of thalidomide. A 71-year-old woman, with a history of breast cancer (treated with radiotherapy and tamoxifen), arthritis, crush fractures, and hip and knee replacement, was diagnosed with multiple myeloma. She was prescribed intravenous pamidronate 90 mg every month and oral therapy with melphalan, but she experienced haematological toxicity and the melphalan was stopped. After progression of the disease, 100 mg of thalidomide was commenced at night, with the aim of increasing the dose by 100 mg every fortnight until a response was achieved. Three weeks later, the patient presented to hospital for pamidronate infusion complaining of a 2-week history of shortness of breath, especially on exertion. There was no oedema present, and her blood pressure was 135/70 mmHg. Electrocardiography showed sinus bradycardia, with a heart rate of 46 beats/min. The dose of thalidomide had been titrated to 200 mg at night. Thalidomide was stopped, and the patient was referred to a cardiologist, who performed an echocardiogram, 24-hour Holter monitoring and a stress test. The results from these tests showed no underlying cardiac disease or abnormalities. Six weeks later, on review, the bradycardia had resolved (heart rate, 60 beats/min). Thalidomide was recommenced at 100 mg daily. However, after a further 6 weeks, her heart rate had decreased again to 45 beats/min, and the dose of thalidomide was reduced to 100 mg on alternate days. Thalidomide therapy has been continued in this patient at 100 mg on alternate days. Her heart rate has stabilised between 50 and 55 beats/min, and she has remained asymptomatic. The multiple myeloma is responding to treatment, as indicated by symptom control and serial measurements of IgG kappa. She continues to take hydroxychloroquine, rofecoxib and sertraline. Bradycardia is a rare side effect of thalidomide therapy, with an incidence of 0.12%.1,2 The mechanism is unknown, but could be related to thalidomide’s central sedative effect.1 There are isolated published case reports of thalidomide-induced bradycardia; in all cases the drug was stopped.2-5 Thalidomide is being used for various conditions for which no alternative therapy exists. As the drug is now commercially available in Australia, its use is likely to increase. In all patients taking thalidomide, we recommend measuring heart rate; and in those with underlying heart disease, or who are taking medications that can precipitate bradycardia, we recommend electrocardiographic monitoring. Our findings in this patient suggest that thalidomide-induced bradycardia can be successfully managed with dose reduction and regular monitoring.

John Coutsouvelis · Carmela E Corallo

John B Dixon Senior Research Fellow, Monash University Department of Surgery, Alfred Hospital, Commercial Road, Melbourne, VIC 3181. john.dixonATmed.monash.edu.au To the Editor: I am concerned about a possible misrepresentation in the Journal. A recent Practice Essentials article included a case report describing the management of type 2 diabetes.1 The case involved a 51-year-old man with a 6-year history of type 2 diabetes and body mass index (BMI) of 32 kg/m2. The case report included a photograph, but this was not of a man with a BMI of 32 kg/m2. Ten consecutive professional staff working at a large Melbourne centre for bariatric (obesity) surgery were asked to estimate the man’s BMI. Estimates varied from 50 to 65 kg/m2. None accepted that his BMI was 32 kg/m2. All estimates placed this gentleman in the obesity class III category (BMI > 40 kg/m2). A man with a true BMI of 32 kg/m2 is shown in the Box. If indeed the man depicted previously has class III obesity, he is likely to suffer significant obstructive sleep apnoea,2 physical disability and poor quality of life, in addition to the metabolic syndrome and type 2 diabetes. The case report focused on the management of an unacceptable level of glycosylated haemoglobin (HbA1c) of 8.9%. The management may, arguably, be appropriate if his BMI were 32 kg/m2, although treatment options may promote weight gain. Unfortunately, the options and discussion were inadequate for the man depicted. This ill, disabled man deserves better assessment and care. His obesity-related conditions should be fully explored. The only management likely to have a significant effect on conditions related to class III obesity (diabetes, metabolic syndrome, sleep apnoea, physical disability and poor quality of life) is significant weight loss. The only treatment that reliably provides significant sustained weight loss for those with class III obesity is surgery. Obesity surgery therefore should be an essential inclusion in his treatment options. The beneficial effects of modern obesity surgery on type 2 diabetes, the metabolic syndrome, sleep and quality of life are well documented.3,4 I believe the inclusion of this illustration is a serious misrepresentation. Editor's note: We agree with Dr Nixon's remarks, and have replaced the inappropriate illustration in the article with the image he has kindly supplied. Patient with a body mass index of 32 kg/m2 (height, 172 cm; weight, 96 kg)

John B Dixon

Former Director General of Public Health and a loyal and long-serving member of the New South Wales medical fraternity, Cyril Joseph Cummins spent more than 30 years committed to improving public health and health services. Cyril was born in Sydney on 10 November 1914. He attended Marist Brothers High School, Darlinghurst, where he excelled academically and at sport, completing his studies at the age of 16. Too young for university, he began a cadetship in journalism, but later enrolled in medicine at the University of Sydney to pursue his interest in health issues. After graduation in 1937, Cyril began his residency at St Vincent’s Hospital, where he later became Medical Superintendent. It was there that he met Eileen, a nurse, whom he later married. In 1939, Cyril joined the Royal Australian Air Force and rose to the rank of Wing Commander in charge of the No. 3 RAAF Hospital. While holding an administrative position in New Guinea during the war, he was often called upon to give anaesthesia during busy surgical periods. After the war, he worked for 3 years in a specialist practice in occupational health and was also a consultant in industrial medicine to the Department of Post-War Reconstruction before completing a Diploma of Public Health at the University of Sydney. In 1950, Cyril became Director of Industrial Hygiene at the Department of Public Health, where he was later promoted to the positions of Deputy Director of Public Health and Director General of Public Health. Cyril was passionate about his work and had a tremendous ability to organise and influence committees. His keen interest in mental health led him to take on the position of Director General of State Psychiatric Services in 1961, in addition to his role as Director General of Public Health. Cyril also held appointments in a number of healthcare organisations, including the World Health Organization, the Nurses Registration Board and the Board of Health, and acted as Commissioner under the Venereal Diseases Act. Cyril produced more than 25 publications spanning a range of health-related issues, including mental health, aged care and infectious diseases. His article outlining the history of the Colonial Medical Service in NSW has been recognised as a valuable public resource and is now available on the NSW Health website (www.health.nsw.gov.au/history/med_admin). Cyril retired at the age of 60 to spend time with his family and to follow his great interest in horse-racing. Sadly, Eileen died in 1992, and some 6 years later Cyril moved to the Central Coast to be nearer his daughter and grandchildren. He died peacefully in his Woy Woy home on 19 July 2003. Kimberley Moore

Kimberley Moore

Psychiatry and the specialised field of eating disorders lost one of its most respected practitioners at the end of 2003 with the death of Pierre (“Peter”) Beumont. Peter was a world-renowned psychiatrist, an innovative educator, a brilliant scientist and author, and a larger-than-life role model to his colleagues. He was one of the foremost authorities in the field of eating disorders, identifying early in his research that anorexia was a psychological disorder, not an endocrinological one. He was the first scientist to classify anorexia nervosa into clearly identifiable subtypes. This work still forms the basis for the classification of eating disorders today. Peter was born in South Africa in 1937. He was educated there and in the United Kingdom. He lectured at Merton College, Oxford, before returning to South Africa in 1971 to become Acting Head of Psychiatry at Groote Schuur Hospital and the University of Cape Town. During this time he was adviser on medical matters to Mrs Helen Suzman, the sole Member of Parliament for the anti-apartheid Progressive Party. He settled in Australia in 1975 when he took up the position of Professor and Head of Psychological Medicine at the University of Sydney. He is credited with creating a strong and integrated department with eclectic interests and excellence in teaching, research, clinical work and work in the community. Peter was a gifted teacher, and generations of medical students benefited from his encyclopaedic knowledge of psychiatry and medicine, as well as philosophy, religious studies, ancient and modern history, the arts, and his special love — Egyptology. In 1975, he founded New South Wales’ first specialist unit for anorexia nervosa, at the Royal Prince Alfred Hospital, and remained as its Director until illness forced him to retire. He was a tireless campaigner for better treatment facilities for patients with eating disorders and a devoted clinician who provided exemplary care for his patients. He also trained many of the specialists who now practise in this area. Peter was awarded the Gaskell Gold Medal and Prize by the Royal College of Psychiatrists (in 1975) and the Max Planck Prize by the Humboldt Foundation (in 1995) for his work in psychosomatic medicine. In 2001, he was made a Member of the Order of Australia. Peter is survived by his wife Daphne, his three daughters and their extended families. Stephen W Touyz

Stephen W Touyz

Ross Webster served Australian medicine for 55 years — 20 as a rural general practitioner, 15 as Professor of Community Medicine, and 15 with the Medical Indemnity Protection Society. Son of Reginald Webster, the first Victorian public hospital pathologist, Ross was born on 5 January 1924 in Melbourne. He studied medicine at the University of Melbourne, graduating in 1947. After graduation, Ross served in the Occupation Force in Japan as a member of the Royal Australian Army Medical Corps. Returning to Australia in 1950, he did postgraduate training in Melbourne, then moved to Horsham, in north-west Victoria, to join a multidisciplinary clinic and to be Honorary Medical Superintendent of the Wimmera Base Hospital. He served 6 years on the Horsham City Council, including one year as Mayor. After his wife Marjory’s death in 1972, and with three children to care for, Ross opted for regular hours of work at the Cancer Institute in Melbourne. In 1975, he was appointed Foundation Professor of Community Medicine at the University of Melbourne. In 1985, he married Jill, who was at the time Director of Nursing Education at the Cancer Institute. Ross was a tireless worker for the University community. He chaired the University’s Board of Social Studies, the Academic Committee and the Social Biology Resources Centre. He also chaired accreditation committees for nursing courses and the Victorian Health Advisory Council. He served on the Health Services Review Council and on the Federal Administrative Appeals Tribunal. Ross was an active and dedicated member of the Australian Medical Association (AMA), being a Councillor of the Victorian Branch for 33 years, President in 1977 and Chairman for 14 years. He is the only recipient of AMA Victoria’s Medal of Merit. He chaired the AMA Federal Council and Assembly for 6 years and was elected a Fellow of the AMA in 1979. Ross was Chairman of the Australian Medical Agency, the Victorian Medical Insurance Agency, the AMA Friendly Society, AMA Financial Services and the AMA Health Fund. From 1983 to 1988, he was Chairman of the Australasian Medical Publishing Company, publisher of the Medical Journal of Australia. Although he retired from the University in 1989, Ross did not stop working. In 1990, he became a part-time Director of Medical Services at Werribee and Broken Hill hospitals. He was also Foundation Chairman of the Medical Indemnity Protection Society (1988–1998), and continued to manage legal claims until his retirement in 2002. Ross was a man of great integrity. He was intolerant of questionable corporate behaviour and conflicts of interest, and had no time for specious arguments “justifying” such behaviour. He was friend, mentor and, above all, exemplar to many doctors. He died on 26 November 2003, of multiple myeloma. The profession and the community at large celebrate his lifetime of achievement and service. Paul Nisselle

Paul Nisselle

Communicating with vulnerable children: A guide for practitioners. David P H Jones. London: Gaskell, 2003 ($72.00, xvi + 188 pp). ISBN 1 901242 91 9. David Jones is well recognised for his research into the reliability of child testimony. This text provides a primer on good professional practice for interviewing children, based on current scientific evidence. This is an essential area of competence for the ever-increasing range of professionals working with children who have experienced adversity or abuse. This book provides a comprehensive and well-organised summary of the area, and is relevant to all those who may communicate with vulnerable children, including professionals from health, education, welfare and the law. It describes the process of enabling children to communicate freely and honestly, and to impart reliable and accurate information. The book is based on relevant research and clinical experience. As well, it has been carefully edited by an advisory board from the Department of Health and the Family Division of the High Court of Justice in the United Kingdom, with the aim of improving practice and reducing the amount of malpractice in communication with children. The first section covers the knowledge base of influences on childhood communication and interviewing style. It includes developmental limitations and considerations, especially regarding memory and language, and the influence of social context, including disability and culture. Childhood reliability in providing information is a small, though important, part of the problem of “erroneous concerns” in the system of child protection and notification, and the chapter about these issues helps refocus on the practitioner’s responsibility for unreliability. The second section guides practice at the different stages of communication, including response to first concerns, initial assessment and in-depth interviews. It also contains helpful chapters on the problems of using communication aids such as anatomically correct dolls, and advice on coping for parents. Medicolegal sensitivity means that this book is not always light reading and more case examples and diagrams would help improve accessibility. While full of useful details for even the most experienced clinicians, problems of development and mental health require more knowledge and expertise than is provided here. On the whole, a wide range of detailed information and practical advice is clearly presented, and we would recommend this as a comprehensive and common sense introductory text for all those who understand children, and essential reading for those who don’t. Emma HartwellPsychologist David R DossetorDirector of Mental Health Children’s Hospital at Westmead, Sydney, NSW

Emma Hartwell

Medical orthopaedics. Conservative management of musculoskeletal impairments. Rene Cailliet. Chicago: AMA Press, 2004 ($106.30, xix + 217 pp). ISBN 1 57947 409 8. It is a monumental task to cover this huge topic in 200 pages. Professor Cailliet, however, has been writing about musculoskeletal impairments for the past three decades and has a knack for simplifying complex topics. He has previously found a receptive audience of over a million people. Undoubtedly, there is a thirst for knowledge in this field, as it is a common reason for seeking healthcare, but it is largely ignored by undergraduate training and hospital medicine, especially in Australia. This is a great pity, as a recent article in the Medical Journal of Australia1 revealed that musculoskeletal disability is the commonest cause of disability across all age groups in Australia. In the current "Decade of the Bone and Joint" it is encouraging to see that this black hole of medical education is receiving increasing attention. This book would be most attractive to the novice with little previous exposure to the field. It is easy to read, well illustrated and directive. The perspicacious reader will, however, be left unfulfilled. The peripheral joints are touched on so briefly I was left wondering why the author bothered at all. No mention was made of tendinopathies or frozen shoulder syndrome and the knee chapter was five pages long. On the positive side there is reasonable coverage of low back and neck pain, with an emphasis on the importance of ruling out red flags, avoiding rest, confident explanation, attention to psychosocial factors and limiting radiological exposure. Chronic regional pain and fibromyalgia are awarded a chapter each. The pathophysiology of these two syndromes is yet to be unravelled, but patients with these conditions seek help frequently and widely. Dissemination of quality information about both these topics is vital and this book helps in this task. Strangely, there is little reference throughout the text about the level of evidence for statements. Instead, we are given statements such as "therapists agree", "exercises are desirable" and "salicylates are of value". I suspect many readers would like to know more about the effect size of treatments rather than these global proclamations. C Scott MastersGeneral PractitionerCaloundra Sports Medicine Centre, QLD 1. Giles LC, Cameron ID, Crotty M. Disability in older Australians. Med J Aust 2003; 179: 130-133. Order this book New books | All books | Search | Information | Contact | eMJA Home © 2004 Medical Journal of Australia

C Scott Masters

The art of living ... the art of medicine. The wit and wisdom of life and medicine: a physician’s perspective. Edward C Rosenow. Victoria, BC: Trafford Publishing, 2003 (140 pp). ISBN 1 4120 9262 1. Edward Rosenow III is an experienced physician who is seeking to pass on his skills in how best to relate to patients as well as to other professional staff. The book can be dipped into and enjoyed in small portions or it can be consumed in more substantial quantities. However you approach it, this book has something to offer most people. Written in a pithy and humorous style, with many quotations, it is easy to read. At the same time the author has some important messages that he is offering to the younger physician in particular. The very full curriculum provided for medical students today allows little time to deal with the more qualitative aspects of how to balance the pressures of a professional career with one's needs as a whole person and one's responsibilities to family and community. The value of role models and mentoring in supporting, and gently nurturing, the inherent skill of the young physician certainly strikes a chord with my own views. The author is quite concerned about the public image of the physician and is aware that there has been a decline in the level of trust of physicians generally. It is no surprise that the longest chapter in the book is called "Qualities of the respected person", in which he works his way through many qualities, such as trustworthiness, humility, communication skills, collegiality and professionalism. The more serious section of the book deals with how to avoid stress, "burnout", and depression, suggesting a range of practical and cognitive strategies. The chapter on end-of-life issues clearly demonstrates his compassion and sensitivity, and provides poignant reminders of the importance of the good physician’s role and obligations at this time. This slim volume is certainly value for money and will empower the reader to focus attention on the human elements of our work that have become endangered in the modern world. Chris MileshkinDirector of Clinical Services St Vincent’s Mental Health Services Melbourne, VIC

Chris Mileshkin

Building better health. A handbook of behavioural change. C David Jenkins. Washington DC: Pan American Health Organisation, 2003 (Available free, xvii + 378 pp). ISBN 92 75 11590 7. David Jenkins set out to produce an easy-to-read introductory text on behaviour change in support of health promotion, and to a large extent he has succeeded. The style is readable and the text provides a theoretical framework, a clear examination of the epidemiology of common problems, and plenty of practical examples. It steers clear of scientific controversy, as befits a book intended for, among others, "a school teacher, a town council member, a dedicated parent". The disappointing aspect is what he does not include, given the role of the World Health Organization in such radical rethinking of health strategies as the Declaration of Alma Ata and the Ottowa Charter. The authors of those statements would be disappointed — health promotion is much more than just behaviour change. Despite the history of Latin American radicalism throughout the 20th century, Professor Jenkins charts a rather safe and conservative course. Tackling "hunger epidemics", he suggests better methods of food storage and handling, the introduction of new crops, cooking classes, and more productive fertilisers. All well and good, but what of the basic problem of landlessness throughout the Americas? Why no mention of people like Paulo Freire, who used basic literacy work to enhance political awareness in precisely the way that this book does not? Jenkins suggests reducing firearms-related injuries by keeping guns locked away, to add "cooling-down" time to the process readying them for use. He never mentions what might seem obvious to everyone outside the United States — limiting ownership of firearms by the citizenry in the first place. I would recommend this book to the health workers and community members who are its target audience — but with the proviso that they do not read only this book, and that they use it for reference and not as their primary inspiration. James F P BlackHead of Epidemiology Victorian Infectious Diseases ServiceMelbourne, VIC

James F P Black

Migraine and other headaches. Your questions answered. Andrew J Dowson. Edinburgh: Churchill Livingstone, 2003 (256 pp). ISBN 0 443 07339 2. Andrew Dowson is a general practitioner and Director of Headache Service at King's College Hospital, London. This puts him in a good position to write a book that answers questions about headaches that patients present with in the course of a busy practice. His pocket-sized book is part of a Churchill Livingstone series called Questions answered. The emphasis is naturally on migraine, which can be a burden for doctors as well as for their patients. A key question posed is “How well is migraine managed in primary care today?” and the answer given is “less than 50% of migraine sufferers receive effective treatment from their healthcare provider”. This deplorable situation probably applies in Australia as well as in the United Kingdom. The author intends this book to be delved into when required, rather than read from cover to cover. Most answers are not supported by references to original sources, and this makes one apprehensive at times, but in general they reflect current opinion. Some answers are deceptively simple. For example, “thunderclap headache” at orgasm is not always benign, or an occasion for “a certain amount of amusement”, but may signal a subarachnoid haemorrhage and requires immediate investigation when it happens for the first time. I found a particularly helpful table in the Appendix summarising the many medications used in the treatment of headache with their trade names, dosages and side-effects. On the other hand, I found some illustrations unnecessarily complex: for example, the multiple diagrams included in Figure 2.7 do not clarify the mechanism of migraine. However, my overall impression is that it will prove interesting and useful in the care of headache patients. The price is higher than one might wish, but, if every doctor had the answers to these questions at his or her fingertips, there would be far fewer disgruntled patients in the community. James W LanceNeurologist Woollahra, NSW

James W Lance

HABITS trial terminated Scandinavian researchers have pulled the plug on their own trial, HABITS (hormonal replacement therapy after breast cancer — is it safe?).1 An interim safety analysis found that breast cancer survivors allocated to receive 2 years of hormone replacement therapy (HRT) for menopausal symptoms were experiencing an "unacceptably high risk" of breast cancer compared with those allocated to best symptomatic treatment without hormones (26/174 v 7/171; relative hazard 3.5). Any participants currently receiving HRT were advised to discontinue. An accompanying commentary said that the HABITS finding was consistent with those from the Women’s Health Initiative (WHI) trial.2 1. Lancet 2004; 363: 453-455 2. Lancet 2004; 363: 410-411 Don't drink plenty of fluids "Pushing fluids" beyond satisfying thirst in patients with respiratory infections may cause serious harm, caution Australian authors. Their systematic review found that, although no randomised controlled trials have compared increased and restricted fluid intake in patients with respiratory infection, reports from two prevalence studies and several case series suggest that an increased fluid intake could lead to hyponatraemia, especially in lower respiratory tract infection. Long-held concerns about the risks of fluid loss from fever and respiratory tract evaporation may be unfounded, thanks to a compensatory increase in antidiuretic hormone secretion. BMJ 2004; 328: 499-500 When two betters one . . . . . . in HIV survival The US Multicenter AIDS Cohort Study has found that long-term persistent co-infection with the non-pathogenic GB virus C (GBV-C) — an RNA flavivirus closely related to hepatitis C — is associated with longer survival in men with HIV. The link between GBV-C viraemia and survival held at 5 to 6 years, but not at 12 to 18 months, after HIV seroconversion. The protective effect of co-infection is lost, and the clinical prognosis worse, once GBV-C is cleared. N Engl J Med 2004; 350: 981-990 . . . in rheumatoid remission Combined treatment of active, adult-onset rheumatoid arthritis with a subcutaneous tumour necrosis factor antagonist and an oral antimetabolite leads to better disease control than using either agent alone, according to an international study involving nearly 700 patients. In the double-blind, randomised controlled trial of etanercept and methotrexate with radiographic patient outcomes (TEMPO), patients receiving both agents concurrently were much more likely to achieve clinical remission at 1 year (35% v 16% for etanercept and 13% for methotrexate). Further, the scoring of serial joint x-rays not only found that joint damage could be slowed but also suggested that repair of structural damage may be achievable. Lancet 2004; 363: 675-681 How to tell if it’s bacterial A simple, sensitive assay can safely reduce unnecessary antibiotic use in lower respiratory tract infection (LRTI), say Swiss researchers. Levels of circulating calcitonin precursors, including procalcitonin, are raised in severe bacterial infections but stay fairly low in viral infections and non-specific inflammatory diseases. In a randomised study, they allocated 243 patients admitted with a suspected LRTI to either standard care or procalcitonin-guided treatment. Clinicians were advised about the likelihood of bacterial infection according to the serum procalcitonin level, ranging from "unlikely" if ≤ 0.1g/L to "suggestive" if ≥ 0.5g/L. The procalcitonin patient group were about half as likely to receive antibiotics as those receiving standard care, equating to 39 fewer courses per 100 patients with LRTI, with no difference in outcomes. The researchers tempered their enthusiasm for the procalcitonin assay by acknowledging that circulating levels can also be enhanced in non-infectious disorders, and may remain low even in sepsis. As always, consider all test results in light of the clinical context. Lancet 2004; 363: 600-607 Bright sparks burn longer Good cognitive ability in both childhood and as a mature adult may protect against mid-life cognitive decline, according to a longitudinal study. Richards et al analysed full sets of data from 2058 men and women, all born in England, Scotland or Wales in the same week in 1946; all had completed various cognitive tests at ages 15, 43 and 53 years. Childhood ability was inversely linked with the rate of decline in tasks of memory, speed and concentration as measured in mid-life. Adult ability was independently and similarly linked, leading to the researchers' suggestion that adult training and education may protect against cognitive decline in later life. BMJ 2004; 328: 552-556 — Dr Ann Gregory, MJA

Ann Gregory