Volume 180 Issue 8

We need a deep and broad international debate to begin The BMJ and a range of partners, including other journals published by the BMJ Publishing Group, The Lancet, the Canadian Medical Association Journal, the Dutch Journal of Medicine, the Medical Journal of Australia, the Croatian Medical Journal, the Academy of Medical Sciences, and many others, have initiated a project to bring people together to debate whether the existing structure of academic medicine is still fundamentally sound and, if not, to propose alternatives to it.1 I have taken on the challenge of coordinating this project, and I extend an invitation to readers all over the world to join me in this exciting enterprise. We are especially interested in the views of the “customers” of academic medicine — patients, politicians, the public, professionals. To achieve the project’s broad goals (Box 1) we begin from the position that “more of the same” is not enough. We need to be free to propose radical changes to the fundamental nature of academic medicine (is the balance between bench and applied research all wrong?); its name (should it become “academic healthcare” or should we drop “academic”?); its home base (are hospitals the wrong place to train doctors?); its relation to service (why are they so often far apart?); its methods of training and certification (should medical education be lecture based and far shorter?); and its responsibilities (should it be held accountable for inequities in healthcare at the global level?). Our approach will be inclusive and is designed to ensure a broad input of opinions. Rather than allowing the process to be taken over by a few experts with vested interests, we will build consensus by inviting an exhaustive range of global stakeholders to contribute their views. We are especially interested in the views of the “customers” of academic medicine — patients, politicians, the public, professionals. Anyone can contribute their views right now, today, as a rapid response to this article at bmj.com. In addition, our new project webpage is under development (www.bmj.com/academicmedicine), and this will contain regular campaign updates, news, and collected resources. The proposed structure is as follows. The pivotal group will be an international working party whose composition will include knowledge and competency across the dimensions of global health and basic to applied healthcare research, representing the range of constituents (medical students, postgraduates, junior faculty, established academics — especially women). Supported by four advisory groups (Box 2) and made up of about eight individuals, the working party will begin by answering four questions. Firstly, what are the roles of academic medicine? Secondly, how well is academic medicine carrying out these roles? Responses to the earlier BMJ editorial launching this initiative have already nominated a wide array of (but no clear consensus about) perceived failures, including failing to serve the public good, lack of a global perspective, an unnecessary dichotomy between education and research, various shortcomings in medical education, and inadequate numbers of and career paths for well-trained medical academics.2 Thirdly, why is academic medicine failing to fulfil its roles? Reasons might include inadequate leadership, a failure to translate basic discoveries into benefits for patients, inappropriate incentives to take up or maintain an academic career (especially among women), deficient mentoring for aspiring academics, lack of appreciation of the benefits of academic medicine by elected representatives, and poor integration with other health services. Many of the reasons will be economic — the salaries and resources needed for research and teaching make academic medicine currently unattractive — but we need to examine ethical and moral explanations as well. Finally, for each failure, what ought to be done about it? Given current economic constraints in countries with high and low income, special attention will go to strategies that call for no additional funding. We will, however, welcome strategies that call for the reallocation of current funding. At the policy level, we welcome strategies for how academic medicine can contribute to national and global health. These strategies will be combined and formulated into concrete proposals for action. We need your support and input. To nominate a member of the working party, join an advisory group, or register your experiences and views, send a rapid response to bmj.com or contact our project manager, Jocalyn Clark, at jclarkATbmj.com. 1: Goals of the project Development of strategy on the following issues: How should academic medicine look in the 21st century? How can we increase the impact of academic medicine on the rest of medicine and on health and healthcare? How should academic medicine be positioned internationally within medicine and also in the wider intellectual arena? How can recruitment to and job sati sfaction of those working in academic medicine be increased? 2: Four advisory groups Perspectives forum — patients, health professionals, government representatives, and medical unions. Ad hoc consultants — providing systematic reviews and other factual summaries about the efficacy of different educational, organisational, and administrative approaches, and trends in human resources in academic medicine. Communications consortium — disseminating surveys, drafts, and reports to everybody who is joined up to the campaign or may want to give input. International advisory panels — deans and chairs whose support could help establish funding, profile, and implementation; also used as an ongoing sounding board.

Peter Tugwell

Possible protection against cancer and improved immune function make supplementation with selenium attractive, but its toxicity and other unknown effects urge caution Selenium presents a nutritional conundrum because of its dual status as a highly toxic, but essential, trace element.1 The eightfold gap between the estimated average requirement2 and the upper limit of safe intake is relatively narrow, so questions of too much and too little are important. Additional key questions pertain to adequate versus optimal status, and reflect the shift in focus of nutrition from preventing deficiency towards promoting optimal health. As is the case for many micronutrients, the quest for protective effects of selenium (Se) intakes above requirements is rapidly gaining momentum. Ever since the biological role of Se in humans was first delineated less than 30 years ago, evidence for its increasing scope and importance to human health has been rapidly accumulating. Increasingly, Se depletion, as opposed to “deficiency”, is being associated with a range of health outcomes, including viral infection, reproduction, mood, thyroid function, cardiovascular disease, inflammatory conditions, immune function and cancer protection. 3,4 It is possible to advance a range of theoretical arguments that suboptimal Se status may have an effect on health, but evidence of a direct relationship to health outcomes is very limited. Se research is incipient and there is a paucity of data. For example, Se reference values that have been adopted in the United States2 are based on only two studies, one of which was a 1983 Chinese study of poor quality. Research is hampered by substantial difficulties in assessing and interpreting Se intakes and status, which become even more significant in the context of extreme global variations in the Se content of soil, food and human tissue.3,4 We do know that Se has key roles in redox regulation and antioxidant function, and hence in membrane integrity, energy metabolism and protection against DNA damage. 1,3,4 These and other functions are mediated through over 35 selenoproteins, which require adequate Se intake for synthesis and expression. Selenoproteins include several forms of the enzymes glutathione peroxidase (GPx), thioredoxin reductase and iodothyronine 5'-deiodinase. The number of known selenoproteins has almost trebled over the past 7 years,1,3 although the roles of several remain undefined. Plasma Se concentration is the most commonly used indicator of Se status.2 Low Se intakes, plasma Se concentrations and GPx activities have direct, linear associations up to a threshold plasma Se concentration (70–100 μg/L), beyond which GPx activity plateaus. This maximum GPx concentration is thought to represent repletion, and commensurate Se intake forms the basis of recommended dietary requirements.2,5 Concentrations of other selenoproteins are also influenced by Se intake and may have a role as functional indicators of Se status, 2,3,5 but assay methods and reference standards are at an early stage, and comparisons between studies are difficult. There is differential hierarchical expression of the selenoproteins, with relative preservation of the presumably more metabolically important at lower intakes of Se. 1,3 However, we do not clearly understand the health implications of submaximal expression of the selenoproteins. There are enormous geographical variations in the Se content of soil and food, and hence in Se intakes and concentrations in human blood and tissues.3,4,6 Thus, it is essential to use local data for monitoring and interpreting Se status.6 The 2000 US Recommended Dietary Allowance (RDA) is 55 μg/day.2 The 1987 Australian RDAs are 70 μg/day for women and 85 μg/day for men, but these are currently under review.7 Organic selenomethionine is the predominant form of Se in food. The most important dietary sources of Se are meat, poultry, fish and cereals (although brazil nuts are very high in Se and certain fish also have particularly high levels). Accurate assessment of intake is exceptionally difficult because the Se content of food is so variable. 2,3,6,8 Estimates of Se intakes include 106 μg/day in a large representative US sample,2 and a range of 29–70 μg/day in Europe.3 Extremely limited Australian data suggest intakes of around 90 μg/day,6 while more comprehensive New Zealand data show intakes as low as 28 μg/day, and indicate that conventional dietary intake methods are inadequate for estimating Se intake.8 Inorganic Se (selenite and selenate) is only available through supplementation, is generally less bioavailable and produces a different physiological response than organic forms of Se. 1,2 Environmental changes and agricultural practices may be reducing Se concentrations in soil.4 These factors, in conjunction with trade barriers (eg, the cessation of importing high-Se US wheat to the European Union), appear to be associated with a decline in the availability of Se through the food chain and in human Se status, particularly in Europe.3 Changes in food supply and habits, including the importation of Australian wheat, have improved the previously marginal Se status of New Zealanders.9 Twenty-six European studies since 1990 all reported mean plasma Se concentrations below 100 μg/L, the level postulated to be required for GPx saturation and cancer protection. 3,10 Ten of these studies reported plasma Se levels under 70 μg/L,3 postulated by others to be associated with GPx saturation.11 A representative US plasma Se level was 124 μg/L.2 In this issue of the Journal (page 383), Lyons and colleagues present evidence that although mean plasma Se concentrations of South Australians are relatively high by European standards, they may be declining, and over a third of their sample had levels below 100 μg/L.12 Overt human Se deficiency is rare. It is manifested as Keshan disease, an endemic fatal cardiomyopathy, which is virtually unknown outside areas of China, where the levels of Se in soil and dietary Se intake are extremely low. A few studies have reported Se deficiency as a result of long-term total parenteral nutrition.1 Despite myriad claims for potential relationships between a range of diseases and Se status, there are no clear population health outcomes that can be attributed to Se status in countries like New Zealand, where intakes are very low. 1,9 The evidence for an effect of Se on health outcomes is strongest in cancer prevention. Secondary findings from the 10-year US Nutritional Prevention of Cancer Trial demonstrated a protective effect of supplementation with 200 μg/day of organic Se (from yeast) on total cancer incidence and mortality, and on prostrate cancer incidence (relative risk, 0.75, 0.59, and 0.48, respectively).10 The effects were stronger in men and in those with lower baseline plasma Se levels (< 105 μg/L), and were not found for a range of other site-specific cancers. Of concern is that in the top tertile for baseline plasma Se level there may be an association between supplementation and increased risk of breast cancer and melanoma, as well as overall cancer incidence.10 There are numerous limitations to what was a small study, and the relatively high baseline plasma Se levels (114 μg/L) make it difficult to generalise the findings. It appears that protection from cancer may require supplementation beyond correction of depletion and maximal expression of the selenoproteins. Several large trials are under way to clarify the benefits and risks of Se supplementation with respect to tumorigenesis. More speculative and tantalising is the potential association between Se and immune function. Evidence suggests that reduced Se status may be associated with the incidence of clinical infection in adults,13 and supplementation of apparently Se-replete individuals potentially enhances immune function.3 Animal studies indicate that the Se status of the host can genetically alter invading viral pathogens, so that a normally benign strain may become virulent in an Se-deficient host.14 This is of interest given the emergence of new influenza virus strains from China, where there are significant areas of overt Se deficiency, and given the decline in Se status associated with progression of HIV infection.3 In summary, there has been an explosion of interest in the biological role of Se and the potential health implications of Se status. Much of the evidence in humans is descriptive, and the dearth of quality prospective trials means the links with many diseases are still controversial and, in many cases, speculative. There are very limited representative data on Se content of the food supply and Se status in many populous parts of the world, and no nationally representative Australian data. Lyons and colleagues provide the most comprehensive Australian plasma Se data to date,12 but they are neither prospective nor representative, and there may be variations according to states.6 Outcomes of research on Se in the next decade are likely to be important, and we urgently need more Australian data. Meanwhile, it is necessary to remember that selenium is toxic.1-3 Intakes below 400 μg/day are considered safe for almost all individuals.2 As illustrated by the Nutritional Prevention of Cancer Trial,10 outcomes of Se supplementation are variable and may not be without risk. Benefits and an appropriate dose for supplementation remain controversial. Until further evidence is available, supplementation should be recommended with caution, and overconsumption should be avoided.3

Lynne A Daniels PhD, APD

Can chemoprevention reduce the risk of progression to malignancy? Once a rare tumour, adenocarcinoma of the oesophagus has tripled in incidence in Australia over the past 20 years (Ian McDermid, Australian Institute of Health and Welfare, personal communication). This increase, together with the dismal 5-year survival of patients with this cancer, has focused attention on its risk factors. The strongest of these are symptomatic gastro-oesophageal reflux disease and Barrett’s oesophagus, a condition in which the squamous lining of the lower oesophagus is replaced by metaplastic columnar epithelium. Based on postmortem studies, Barrett’s oesophagus probably affects about 1% of the population in the United States and, at endoscopy, one in five to 10 patients with gastro-oesophageal reflux.1 Evidence of Barrett’s oesophagus (or at least intestinal metaplasia) is commonly found in resection specimens for oesophageal cancer.1 When Barrett’s oesophagus is found at endoscopy, the appropriateness of the patient entering a surveillance program may be considered, with the aim of reducing the risk of death from oesophageal adenocarcinoma. These programs involve regular endoscopy with multiple biopsies from the metaplastic epithelium and interpretation by a skilled pathologist. The rate at which malignancy develops in patients undergoing surveillance has been overestimated in the past because of publication bias; a reasonable estimate appears to be about 1 tumour in 200 patient-years of surveillance.2 The absolute lifetime risk of an individual with Barrett’s oesophagus developing oesophageal adenocarcinoma is probably about 1 in 20, which is comparable to the community risk for developing colorectal cancer. The average age for developing oesophageal adenocarcinoma is the mid to late 60s, but only a few patients with Barrett’s oesophagus die of oesophageal cancer, as comorbidities are common.3 Given these facts, and the problem of ensuring compliance with surveillance, it is not surprising that it has been difficult to demonstrate that surveillance programs reduce mortality, either overall or from oesophageal cancer. The only positive evidence that surveillance improves outcomes derives from the results of surgery on patients with surveillance-detected tumours. These patients generally fare better than those who are diagnosed after presenting with symptoms. Although individual patients may benefit from surveillance, the overall community benefit and cost-effectiveness of these programs is still debated (particularly for programs not conducted in well organised centres by enthusiasts with access to specialist pathologists).4 The use of biomarkers, such as aneuploidy or molecular markers, may help predict the risk of malignancy and may be useful in targeting surveillance programs.5 If surveillance of patients with Barrett’s oesophagus is unrewarding, are there ways to retard the neoplastic process? Recently, the pathobiology of Barrett’s oesophagus has come under intense scrutiny, and it is likely that repeated exposure of the lower oesophagus to reflux of acid and bile is a major factor resulting in metaplasia and subsequent dysplasia.6 Molecular changes in the pathway to malignancy have been identified, including upregulation of cyclo-oxygenase-2 (COX-2).7 The study reported by Hillman and colleagues in this issue of the Journal (page 387) examines the effect of acid suppression on the development of dysplasia in Barrett’s oesophagus.8 The authors analysed the pathology findings from a group of patients enrolled in a surveillance program over the period of time during which proton-pump inhibitors (PPIs) were introduced. The rates of development of dysplasia and malignancy were examined before and after patients started taking PPIs. Although the results must be interpreted in the light of the lack of randomisation, the time effects, and difficulties in distinguishing low-grade dysplasia from inflammatory atypia (problems which the authors recognised and corrected for as far as possible), the study does demonstrate an effect of acid suppression on the development of dysplasia and malignancy. Over 50% of patients (a somewhat high figure) developed low-grade dysplasia within 3 years while not taking PPIs, but this percentage was reduced by almost two-thirds in patients taking PPIs. Interestingly, the dysplasia-free survival curves diverged after only months, suggesting that the effect was rapid. If acid suppression were efficacious in reducing the risk of malignancy, it would be an attractive chemopreventive option, as: it is the cornerstone of therapy for gastro-oesophageal reflux disease, with which Barrett’s oesophagus is closely associated; powerful acid-suppressant drugs are available; and a reduction in gastric acid exposure leads to a concomitant reduction in bile exposure. Combining acid suppression with COX inhibitors (especially aspirin) has further attractions, as COX inhibition alone may reduce the incidence of oesophageal carcinoma by up to half,9 and some of its risks would be ameliorated by acid suppression. COX inhibitors may have an additional benefit on cardiovascular risk in this group of patients. Studies to investigate these issues are under way. So how will this information help us control oesophageal adenocarcinoma? In particular, if acid suppression does reduce the rate of progression of Barrett’s oesophagus to low-grade dysplasia, will this translate into a reduction in the incidence of oesophageal adenocarcinoma? The natural history of low-grade dysplasia is not well defined, while even that of high-grade dysplasia has been debated,10 with the estimated cumulative incidence of cancer varying dramatically between studies, from 56% at 3 years to only 9% at 5 years. The most efficacious method of preventing gastro-oesophageal reflux is good antireflux surgery, so, if control of acid and bile reflux alone were the answer, one might expect to see a dramatic reduction in the rate of oesophageal adenocarcinoma after fundoplication. Unfortunately, this has not been the case.11 One might also predict that the increasing use of proton-pump inhibitors in the past decade, and particularly in the past few years, would reduce the rate of oesophageal adenocarcinoma. However, this effect is not yet evident either in follow-up of patients prescribed omeprazole,12 or in national cancer monitoring (Ian McDermid, Australian Institute of Health and Welfare, personal communication). Even if chemoprevention using potent acid suppression, with or without COX inhibition, can be shown to slow development of malignancy, given the modest absolute risks (1 per 20 patients with Barrett’s oesophagus and perhaps 1 per 200 of those with gastro-oesophageal reflux), we must still identify and target appropriate groups for this or other interventions. We must also carefully examine strategies for efficacy and cost effectiveness. Low-risk strategies, such as chemoprevention, may be broadly applicable, whereas intensive strategies, such as endoscopic surveillance with examination of biopsy specimens for biomarkers of malignancy, will need to be targeted to high-risk groups.13 The jury is still out.

Geoffrey S Hebbard PhD, FRACP · Sanjay Nandurkar FRACP

Tips for teaching in tough times Patients, families, carers and our communities expect high-quality, safe, efficient, acceptable health services in which advice and interventions are based on evidence. The quality of undergraduate, postgraduate and continuing education is a key determinant of the capacity of clinicians to work with patients, administrators and other health professionals to fulfil such expectations. Successful teaching programs recognise and address the needs of students and teachers within particular educational settings. They use techniques that are likely to be effective, efficient and acceptable. This issue of the Journal features the beginning of a series called “Teaching on the run tips”. The first article, “Doctors as teachers”1 (page 415), outlines barriers to quality medical education and offers practical solutions. The title of the new series is particularly apt, as it highlights two causes of anguish among teachers: lack of time, because of expanding clinical and administrative workload, and lack of know-ledge of teaching techniques. Teachers’ anguish is increased by changes that have occurred within hospitals, such as reductions in junior-doctor working hours and shortened lengths of stay. These changes have resulted in fewer learning opportunities with inpatients and hence an even greater need for comprehensive and efficient teaching. To compound the problem, increasing specialisation means that a smaller pool of clinicians is both available and willing to teach across the breadth of clinical areas. Furthermore, clinician-teachers feel unsupported — a recent survey across US teaching hospitals reported that only a minority offer faculty development in teaching skills.2 Thirty years of research in medical education has provided some valuable insights.3 Much is now known about the attributes of effective clinical teachers,4 but knowledge of these advances is limited to a relatively small number of clinical teachers. The “Teaching on the run tips” series aims to improve dissemination of knowledge by providing practical tips on undergraduate and postgraduate clinical teaching. One barrier to the uptake of advice about teaching is the fact that some teachers are sceptical about the effectiveness of recommendations for changing teaching techniques. This is especially relevant for clinicians supporting evidence-based practice, who may seek the same standards for recommendations about teaching that they have learned to expect for recommendations about treatment and diagnosis. Unrealistic expectations for high “levels of evidence” may lead to disappointment, as there are fewer randomised trials and systematic reviews of educational interventions than there are of clinical interventions. Clinician teachers may also be concerned about the applicability of teaching recommendations derived from other settings to their own situation. The essential problem is that we have not yet developed “best practice” for assessing recommendations about teaching. The ultimate “outcomes” should be clinical and should reflect the needs of patients. These largely relate to the quality, safety, acceptability, appropriateness and accessibility of healthcare services. The problem is that such outcomes are all difficult to measure, and changes in them often reflect factors other than the uptake of teaching recommendations. Furthermore, the protracted time between uptake of educational initiatives and clinical outcomes makes it difficult to establish associations and causal relationships. Three developments might serve to reduce such scepticism. Firstly, in teaching, as in clinical areas, where outcomes prove too difficult to assess it may be possible to develop surrogate markers of process that reliably predict clinical outcomes of educational interventions. Secondly, pleas for more evidence in medical education5,6 are being heard. In recent years, several guides to “best evidence medical education” (BEME) have been published in Medical Teacher,7 BEME has become an established international collaboration of medical educationalists,8 research directions in medical education have been defined,3 and an educational section has been established in the BMJ.9 The third development offers great promise. The recognition of the limitations of randomised controlled trials in many educational areas10 is an incentive to switch the focus towards scientific evaluations of educational initiatives using studies specifically designed for this purpose. 11,12 Although “level-of-evidence” hierarchies are essential for assessing research quality, in themselves they are insufficient. They should be considered along with other dimensions of scientific quality, including the magnitude of the effect; applicability in different settings; and the extent to which bias, confounding and statistical error are minimised. Scientific rationality, educational reasonableness, resource implications and ethics13 should also be taken into account, and evidence across a range of research strategies must be sought.12 Good clinical teaching improves student performance.14 It clearly has the potential to improve clinical outcomes and to help satisfy the community’s expectations of a high-quality healthcare system. The recent recommendation for medical graduates in the United Kingdom to “understand the principles of education as they are applied to medicine”15 may help to enhance teaching skills in the United Kingdom and elsewhere. Along with other recently published resources for teachers, such as the BMJ’s “ABC of learning and teaching medicine” section, this MJA series is enthusiastically welcomed.

Peter B Greenberg MD, PhD, FRACP · Susan L Elliott MB BS, MD, FRACP

The debate over prostate-specific antigen (PSA) testing for prostate cancer has been prolonged, public, and sometimes acrimonious. Despite this, a common theme is present in most evidence-based guidelines produced to date: while population-based screening cannot be advocated currently, individuals considering a test should be fully informed about the pros and cons and make their own decisions. 1-3 The US Preventive Services Taskforce adds that individuals “be assisted in considering their personal preference and risk profile”.4 However, none of these guidelines address the issue of how to ensure such “informed choice”. * The Australian Prostate Cancer Collaboration is a national organisation of clinicians, researchers, consumers and non-government organisations with an interest in prostate cancer. It receives project-based sponsorship from non-government organisations and commercial sources. The Australian Prostate Cancer Collaboration* (APCC), with support from the National Cancer Control Initiative, convened a workshop on informed choice for prostate cancer testing. The meeting was part of the Conjoint 4th National Prostate Cancer Symposium and the 5th Annual APCC Meeting held at Royal Melbourne Hospital in August 2003. The workshop participants (about 50 people) comprised urologists, GPs, nurses, members of non-government cancer organisations, patients and consumers. The diverse views presented at the workshop suggested that an active approach to managing the PSA testing issue in general practice is needed. What is currently happening?Jeanette Ward (Director, Division of Population Health, South West Area Health Service) summarised the current status — that PSA testing is widespread in general practice (in a Western Australian study, 48% of men aged 45 to 60 years had ever been tested).5 Furthermore, men overestimate their risk and make decisions without being fully informed. 5-7 Max Gardner (Chair, Prostate Cancer Foundation of Australia) and several workshop attendees made it clear that some men with prostate cancer felt they did not have an opportunity for informed testing when their cancer may have been localised. Paul Nisselle (Health-Law Consultant; formerly Chief Executive, Medical Indemnity Protection Society and general practitioner) described the medicolegal exposure arising from this situation, as well as when men feel that they have been harmed by unnecessary screening. A common theme was that a climate of anger, frustration and, increasingly, litigation is arising from men feeling inadequately informed about prostate cancer testing. Addressing this issue, speakers described barriers that prevent men being fully informed. These include: time constraints for the GP; lack of knowledge of the issues (Murray Barson, general practitioner with interest in men’s health; Debra Rowett, Chief Investigator, DATIS trial of academic detailing for PSA testing in general practice); lack of understanding of medicolegal obligations, particularly what is prudent and what is sufficient in terms of information provision (Nisselle); and wide ranges in patients’ awareness, concerns, levels of comprehension and life circumstances (Barson; Suzanne Steginga, Director, Community Services, Queensland Cancer Fund). Lack of understanding of how to communicate the complex areas of risk and uncertainty (Barson; Rowett; Ward) is also a barrier to fully informing men. What constitutes “informed choice”?Niselle revisited the medicolegal precedent set by Rogers v Whitaker and suggested that three tests are needed to determine if a patient has been fully informed: The reasonable patient test: information has been given that a reasonable person as a patient would think relevant; The reasonable doctor test: extra information has been given, which a reasonable doctor would add, having regard to the particular circumstances of the patient; and The individual patient test: additional information has been given, that that particular patient sought, having been given the opportunity to seek it. “Informed refusal” is as important as “informed consent”. A patient needs to be made aware that there is information he should consider before deciding not to have a test. How patients make decisions is crucial in determining how they should be informed. Steginga reported research which suggests that patients more commonly use non-systematic processes (eg, anecdotes or analogies, old beliefs, salient experiences and expert opinion) to make health-related decisions rather than systematic processing (the weighing up of the medical risks and benefits of the decision). As a consequence of these issues, Nisselle and Steginga maintained that providing a patient with written material and telling him to go away and make a decision is not enough. A discussion between doctor and patient has to take place, in which the patient’s views and beliefs are elicited, medical information is individualised to the patient’s circumstances (eg, age, family history), and the patient’s specific information needs are responded to. In short, “shared decision-making”. Pinnock outlined effective communication strategies to support this shared decision-making. These include establishing the preferred amount of information, the preferred role in decision-making,8 graphical representations of risk, and checking patient understanding. Ward noted that preference for a shared decision-making has been found in studies of men and GPs alike.9 Rowett reported results from the DATIS trial (a three-state study of academic detailing, which is a form of educational outreach as a means of informing GPs about issues concerning prostate cancer screening). Unprompted comments from GPs suggested that, although secondary, written materials can be useful in supporting the discussion. This was reinforced by Ward,9 who found that written materials increased knowledge gain by patients, particularly in those who prefer an active decision role. Pinnock discussed quality criteria for decision aids,10 including neutral framing, explicit evidence base, and evidence of effectiveness. High-quality written materials may reduce the length of the consultation (Rowett), improve patient knowledge,9 and reduce decisional conflict,9 but their effect on the decision outcome is variable (Steginga). The content of the informed-choice discussionGardner (providing a patient perspective), Pinnock (from the perspective of published research), and Ward (based on her group’s research) addressed the categories of information that should be presented in written materials. These include: Basic information on the prostate and its function, the individualised risk of developing prostate cancer and dying from it, and the way in which the man’s age, health status and family history may modify these risks; The potential benefits of early detection (can detect disease at a stage when treatment is potentially curative) and uncertainties (not sure whether active treatment prolongs life); and The performance of the PSA test in detecting prostate cancer (sensitivity, specificity and positive predictive value).9 The outcome of informed choicePinnock suggested that the outcome of this process of discussion and decision support is not a decision whether or not to test, but a management plan, which may involve review only, a single test, or testing at specified intervals. It should be individualised to the patient’s situation, sense of his risk, and preference when balancing the potential benefits, risks and uncertainties of early detection for prostate cancer. Providing resources and skills to GPsThe DATIS study suggests that academic detailing is successful in reaching GPs (80%–90% penetration), acceptable to GPs, and effective in increasing knowledge and perceived ability to inform patients. Ward revealed that a NSW trial of a peer-led 3-month education program will also look for improvements in understanding the evidence, perceived medicolegal risk and self-efficacy in promoting informed decision-making. Improved health literacy schemes in the community may reduce GP time required to explain basic background information. Furthermore, improving prostate health literacy is likely to improve decision-making regarding lower urinary tract symptoms,11 which are more common than prostate cancer. Sharing the educational task with non-government organisations, such as cancer councils, could spread the cost across sectors. These and other strategies to make the informed-choice discussion time-efficient need to be explored. Addressing inequity in accessWorkshop attendees raised the issue of men who are unconcerned about their health, who do not visit their doctor, and others (eg, rural men), who have poor access to medical services. These groups have an imposed, or default, uninformed refusal of prostate cancer testing. Education programs targeting general practice will not address this problem, but a community education program can reach such groups. Community education focusing on male reproductive and prostate health is also likely to promote a more active role for men in maintaining their health and reduce stigma associated with some of these disorders. Should this wait until 2008?Two speakers (Pinnock; Greg Neerhut, urologist, Victoria) addressed whether the need for informed choice will change once the results of the US and European randomised controlled trials on prostate cancer screening become available from 2008. Even if a screening benefit is detected in trials, the need for a man to make a fully informed decision will remain. This is because any survival benefit of active treatment of localised disease is likely to be evident only after 10 years or more.12 It is also likely that the poor performance of the PSA test, in particular the high rate of false positive results, will continue or increase with widespread early detection. In summary, the workshop established that there is a pressing need to support and resource GPs assisting men in making an informed choice about prostate cancer testing, to disseminate knowledge of how patients make these decisions, medicolegal issues, and provide access to decision support resources. A community education program on men’s prostate or reproductive health will help to reduce the burden on the GP as the sole agent responsible for community and patient understanding of these issues.

Carole B Pinnock PhD

Objective: To assess trends in selenium status in South Australians from 1977 to 2002.Design: Six cross-sectional surveys.Participants: 117 participants in 1977, 30 in 1979, 96 and 103 (separate surveys) in 1987, 200 in 1988, and 288 volunteer blood donors in 2002. A total of 834 healthy Australian adults (mean age, 42 years [range, 17–71 years]; 445 were male).Main outcome measures: Plasma and whole blood selenium concentrations.Results: The 2002 survey yielded a mean plasma selenium concentration of 103 μg/L (SE, 0.65), which reached the estimated nutritional adequacy level of 100 μg/L plasma selenium. Mean whole blood selenium declined 20% from the 1977 and 1979 surveys (mean whole blood selenium concentration, 153 μg/L) to the 1987, 1988 and 2002 surveys (mean whole blood selenium concentration, 122 μg/L). Plasma selenium was higher in men (P = 0.01), and increased with age in both men and women (P = 0.008).Conclusions: In healthy South Australian adults sampled from 1977 to 2002, whole blood and plasma selenium concentrations were above those reported for most other countries and in most previous Australian studies, notwithstanding an apparent decline in selenium status from the late 1970s to the late 1980s.

Graham H Lyons BAgricSc, MPH · James C R Stangoulis BAgricSc, PhD · Lyndon T Palmer BSc · Robin D Graham PhD, DAgricSc · Geoffrey J Judson BRurSc, PhD · Janine A Jones BCom/Eco, MStatSocAust

Objective: To examine whether proton-pump inhibitor (PPI) therapy influences the incidence and progression of dysplasia in patients with Barrett’s oesophagus.Design and setting: Review of prospective data on patients undergoing surveillance with regular endoscopy and biopsy at a private endoscopy centre in Canberra, ACT, between 1981 and 2001.Patients: 350 patients diagnosed with Barrett’s oesophagus.Interventions: PPI therapy was progressively introduced into clinical practice from late 1989. Once begun, PPI therapy was ongoing, with no attempt to reduce the dose.Main outcome measures: Relationship between development of dysplasia or adenocarcinoma and delay between diagnosis with Barrett’s oesophagus and starting PPI therapy was determined by Cox regression analyses, stratified by year of enrolment. Age, sex, presence of macroscopic markers (severe oesophagitis, nodularity, Barrett’s ulcer, stricture) and use of aspirin or non-steroidal anti-inflammatory drugs were considered as confounding factors in the regression analyses.Results: The 350 patients had 1422 surveillance endoscopies, with a median follow-up of 4.7 years. Patients who delayed using a PPI for 2 years or more after diagnosis with Barrett’s oesophagus had 5.6 times (95% CI, 2.0–15.7) the risk of developing low-grade dysplasia at any given time as those who used a PPI in the first year. Similar results were found for the risk of developing high-grade dysplasia or adenocarcinoma (hazard ratio, 20.9; 95% CI, 2.8–158).Conclusions: Use of ongoing PPI therapy appeared beneficial in the prevention of dysplasia and adenocarcinoma in patients with Barrett’s oesophagus. We suggest that all patients with this condition, even those with no oesophagitis or symptoms, should be encouraged to continue long term PPI therapy.

Lybus C Hillman MD, FRACP · Louise Chiragakis MA · Graham L Kaye FRACP · Anthony C Clarke FRCP, FRACP · Bruce Shadbolt PhD

Objective: To evaluate changes in quality of in-hospital care of patients with either acute coronary syndromes (ACS) or congestive heart failure (CHF) admitted to hospitals participating in a multisite quality improvement collaboration.Design: Before-and-after study of changes in quality indicators measured on representative patient samples between June 2001 and January 2003.Setting: Nine public hospitals in Queensland.Study populations: Consecutive or randomly selected patients admitted to study hospitals during the baseline period (June 2001 to January 2002; n = 807 for ACS, n = 357 for CHF) and post-intervention period (July 2002 to January 2003; n = 717 for ACS, n = 220 for CHF).Intervention: Provision of comparative baseline feedback at a facilitative workshop combined with hospital-specific quality-improvement interventions supported by on-site quality officers and a central program management group.Main outcome measure: Changes in process-of-care indicators between baseline and post-intervention periods.Results: Compared with baseline, more patients with ACS in the post-intervention period received therapeutic heparin regimens (84% v 72%; P < 0.001), angiotensin-converting enzyme inhibitors (64% v 56%; P = 0.02), lipid-lowering agents (72% v 62%; P < 0.001), early use of coronary angiography (52% v 39%; P < 0.001), in-hospital cardiac counselling (65% v 43%; P < 0.001), and referral to cardiac rehabilitation (15% v 5%; P < 0.001). The numbers of patients with CHF receiving β-blockers also increased (52% v 34%; P < 0.001), with fewer patients receiving deleterious agents (13% v 23%; P = 0.04). Same-cause 30-day readmission rate decreased from 7.2% to 2.4% (P = 0.02) in patients with CHF.Conclusion: Quality-improvement interventions conducted as multisite collaborations may improve in-hospital care of acute cardiac conditions within relatively short time frames.

for the CHI Cardiac Collaborative*

Viral bronchiolitis is the commonest cause of hospital admission in young infants. Respiratory syncytial virus is responsible for most cases of bronchiolitis. Secondary bacterial infection is rare and antibiotics are seldom necessary. Most children with bronchiolitis develop only mild illness and can be managed at home. Infants born prematurely, those with pre-existing cardiac or respiratory disease, and infants in the first three months of life are more likely to need hospital admission. On current evidence, nebulised adrenaline, inhaled and systemic corticosteroids, and inhaled bronchodilators do not have a role in the routine management of infants with bronchiolitis.

Dominic A Fitzgerald MB BS, PhD, FRACP · Henry A Kilham MB BS, FRACP

There is evidence that drug-marketing techniques affect doctors’ prescribing practices. This has ethical implications for doctors, as it affects the trust required in the doctor–patient relationship. Doctors need to recognise they are affected by drug marketing, and take steps to maintain their independence from the pharmaceutical industry. At a time when leaders of the medical profession in Europe and North America are calling for a critical re-evaluation of how the medical profession “dances with the porcupine”1 of the pharmaceutical industry2-6 it is disappointing that leaders of the profession in Australia appear in denial about the influence of the industry on such things as the prescribing patterns of doctors, the clinical research agenda, and bias in the publication of pharmaceutical research findings.7-9 The most striking denial is that of the effect of pharmaceutical promotion of various kinds on the prescribing practices of doctors. 8,9 Here I wish to: acknowledge that the issues surrounding the relations between the medical profession and industry are not unidimensional; draw attention to the overwhelming evidence that our prescribing habits are open to industry influence; remind doctors of the key ethical issues which are at stake; and offer pragmatic suggestions for finding ways of reducing the dependence of the medical profession on support from the industry. As remarked by an industry executive 40 years ago,10 the medical profession must look at its own conduct and not place responsibility on the pharmaceutical industry. Within the pharmaceutical industry, at least two independent sections interact with doctors and the healthcare system: the drug development/research section, and the drug promotion/advertising section. The former has made major contributions to health improvements in the developed world, and its role is more comfortably acknowledged by doctors than is the drug promotion section. More than half the biomedical research being done in the United States is now privately funded, with sponsors able to set the research agenda.4 The pharmaceutical industry has learnt to influence our prescribing behaviour indirectly, and uses “opinion leaders” from within the profession to promote its products and to help identify its research agenda. 11,12 There is also clear evidence of publication bias, selective publication and selective reporting of sponsored clinical trials. 3,13 However, I do not want to explore these and other important research-related issues here. Rather, I will focus on the very strong evidence regarding the effectiveness of industry activities on prescribing practices (Box). In identifying this compelling evidence, I accept that the pharmaceutical industry mostly consists of public companies with legally mandated responsibilities to shareholders and legitimate rights to promote their products. My criticism is of the naïveté of doctors and/or their unwillingness to accept overwhelming evidence that the techniques used by the industry to increase prescribing of their products actually work. Doctors interact with the pharmaceutical industry in various ways. Most common are direct face-to-face visits from company representatives (referred to as “drug reps” rather than “sales reps”). Also common are indirect interactions via a wide range of marketing techniques, including direct mailing, advertising in medical journals and medical newspapers, and sponsorship of medical conferences and medical products (such as computer software). For a smaller proportion of the profession, the interactions may be through involvement in clinical trials or in industry advisory groups, speakers’ panels and the like. Although only a select few play these latter roles, they are greatly valued by the pharmaceutical industry as “opinion leaders” in shaping the views of the rest of the profession, especially for new medications. 11,12 In addition to drug promotion, the industry seeks to alter our prescribing patterns by other means. These include “illness promotion” (using public awareness campaigns in the general media to encourage more people to seek new treatments) and support for patient-help organisations (again indirectly encouraging more patients to present to doctors identifying either their ailment or its desired drug treatment). 2,17-19 There is nothing inherently improper about any of these interactions, provided that the medical profession, collectively and individually, is fully and openly aware of the effect of the interactions, that all such interactions are transparent to the community, and that doctors are capable of negating any undesirable effects on their prescribing habits. At present, none of these provisions are being met. The ethical issues at stake here for most practising clinicians are simple to identify but complex to resolve. To be a medical “professional” implies that patients can rely upon the independence and trustworthiness of any advice or treatment proffered.20 It is a significant ethical failing to aspire to such independence and to the respect and trust that underpin an effective doctor–patient relationship while wilfully or ignorantly denying the evidence that the pharmaceutical industry does affect our prescribing behaviour. The impropriety of this stance is compounded by information asymmetry (where the patient is almost always dependent upon the doctor for information and guidance about medications) and by the fact that the prescribed drugs are usually subsidised by public funds.16 Most doctors seem to genuinely perceive they are immune to such influences, seeing themselves as acting only on the best available evidence in the interests of their patients.14 To change this perception, a new and systematic approach to these ethical issues is warranted. These issues are not new, but their significance has increased in parallel with the growth of the size, power and influence of the pharmaceutical industry. The medical profession needs to confront these issues before a concerned public forces us to do so. The pharmaceutical industry has had sufficient awareness of public opinion to see the need to strengthen its code;21 surely the medical profession might also have the initiative to re-examine its performance in this area? If we agree that these are significant ethical issues, what practical steps can the profession, and the institutions and healthcare structures in which we work, take to maintain community trust? Several writers have proposed a range of suggestions. 5,6,14,16,22 Ideas of special relevance include the Australian website that critically monitors drug advertising (www.healthyskepticism.org/adwatch.asp)10 and the American Medical Student Association’s campaign “PharmFree”, which is based on another US initiative, “No Free Lunch”.5 Apart from doctors choosing not to see pharmaceutical company representatives (a very simple step which I took a decade ago), readily achievable steps include adoption of policies by hospitals, colleges and professional associations to make those organisations and their staff or members more independent of the industry. Such policies might include: funding directly (from hospital budgets and doctors’ contributions) the catering and other facilities needed to promote continuing education of staff, more especially, but not solely, the education programs provided for junior doctors; taking formal, publicly announced decisions to reduce financial reliance on the pharmaceutical industry in all areas; and developing and policing procedures for identifying and dealing with conflicts of interest for staff and the organisation in regard to the use of pharmaceutical industry support. In addition, our medical school faculties and medical colleges must ensure that the ethical issues surrounding relationships with the pharmaceutical industry are included in medical student and postgraduate training programs, and that knowledge and attitudes of students and trainees to the industry are included in formal assessment. As the World Medical Association has reviewed its code of conduct about relationships with the industry,23 so too our responsible bodies (medical boards, medical colleges and professional associations) should critically review their codes and take whatever steps are available to them to enforce these codes. It is surely time for leaders of the profession to truly open their eyes to these issues. Some of the available evidence about doctors’ prescribing habits Most doctors deny that gifts from the industry influence their prescribing.14 The number of gifts received correlates with the belief that seeing representatives does not influence prescribing.14 80%–95% of doctors see industry representatives regularly.4 More frequent contact is linked to unnecessary prescribing and to increased use of new drugs. 14,15 Attendance at sponsored conferences is associated with increased prescribing of the sponsor’s product. This increase can be seen for the next 6 months.14 It is estimated that industry spends about $21 000 per year per practising doctor on drug promotion.16

Kerry J Breen MB BS, MD, FRACP

Little research has been done on the extent of the relationship between the pharmaceutical industry and medical students, and the effect on students of receiving gifts. Potential harms to patients are documented elsewhere; we focus on potential harms to students. Students who receive gifts may believe that they are receiving something for nothing, contributing to a sense of entitlement that is not in the best interests of their moral development as doctors. Alternatively, students may be subject to recognised or unrecognised reciprocal obligations that potentially influence their decision making. Medical educators have a duty of care to protect students from influence by pharmaceutical companies.

Wendy A Rogers PhD, FRACGP · Peter R Mansfield BMBS · Annette J Braunack-Mayer BMedSci(Hons), PhD · Jon N Jureidini MB BS, PhD

To quote from Rogers’s article in this issue of the Journal, “There is growing debate about the ethics of relationships between the pharmaceutical industry and the medical profession”.1 Nothing could be more true. However, if this debate is raging for doctors, then it is sizzling for medical students. While doctors might not have the time or the inclination to voice their opinions on the pharmaceutical industry publicly, Australian medical students seem to have both. The relationship between medical students and the pharmaceutical industry has been hotly debated by the National Council of the Australian Medical Students’ Association (AMSA) for years. Yet tangible outcomes and policy have been less palpable, evidence of just how complex this issue is. Medicines Australia has imposed self-regulation upon the industry through its own code of conduct (www.medicinesaustralia.com.au). This is an important document in various ways, but, most importantly, it sets practical boundaries within which the industry can ethically operate. So why should medical students bother tackling this issue? We don’t have script pads or the status to influence prescribing habits of those who do. Furthermore, with so many codes of conduct floating around, surely we fall under these somewhere? Surprisingly not. Medical students appear to occupy a loophole in an otherwise highly regulated environment. Codes commonly use the terms “medical professional” (health professionals who are unable to prescribe [eg, nurses]) and “non-prescriber” (people without degrees in health fields and who are unable to prescribe), but do not mention medical students. As students, and thus non-prescribers, we sit outside these codes, yet we will prescribe in years to come. For this reason, AMSA is taking proactive steps to formulate policy and produce its own code of conduct for medical students. At the recent meeting (Adelaide, 12–15 March 2004) of the AMSA National Council (which comprises one elected representative from each of the 12 medical schools in Australia), various speakers were invited to give the full spectrum of opinions on the topic. These guest speakers included a physician and a professor of clinical pharmacology, along with representatives from Medicines Australia, a pharmaceutical company and Healthy Skepticism. After several very informative presentations, the AMSA Council met in private to discuss the best way forward. Feedback from the Council varied greatly, but it was decided that AMSA’s main responsibility at this stage is to educate medical students about the differing opinions on this controversial issue. Following this education campaign, a nationwide survey will be conducted to gauge medical students’ opinions at the grass roots. Data from this survey will then be used, with assistance from the AMSA Council, to formulate policy and a code of conduct. Although not binding, this code of conduct will act as a practical guide for medical students and their societies. AMSA feels very strongly that, while individual opinions on this issue may vary greatly, our responsibility is, at the very least, to educate medical students about the pros and cons. In this way, medical students can make better-informed decisions about how far they take their relationships with the pharmaceutical industry.

Matthew S Hutchinson

Setting The new intern and registrar are about to commence. The students are also starting soon. These days, the hospital is pushing you to do more for the junior medical officers, the clinical colleges’ forms are getting longer, and the medical school has not only changed its course but increased the intake of students. You like teaching, but it is stressful fitting it in with your other duties. Looking around, you realise there are some good teachers. You wonder what they do that you don’t. There is a tradition for doctors to teach their colleagues and students. The Hippocratic oath states, in part, that the duties of a doctor are “. . . to teach them this art, if they want to learn it, without fee or indenture”.1 Sharing expertise is regarded as a rewarding and enjoyable aspect of medicine. But it is becoming harder. The task is to maintain our teaching commitments while improving the quality of teaching and keeping it rewarding and enjoyable.2 ProblemsLack of time. With increased patient and administrative loads, the single most important factor clinicians cite is lack of time. The fact that there are fewer patients to teach on, shorter hospital stays and sicker patients also contributes to the problem. These pressures are unlikely to lessen.2 Lack of knowledge. Clinicians need to increase their knowledge about how to motivate the learner, assess competence, give constructive feedback, teach multiple trainee levels at the same time and deal with competing demands of patient care and education.3 Lack of training. Most of us who teach have never been taught how to teach, supervise or assess students, junior doctors or trainees.3 Criticism of teaching. Although we do our best to teach, we are told we do it poorly. Evidence suggests, even today, that there is still teaching by humiliation and sarcasm, teaching that is variable and unpredictable, and poor supervision and assessment, with little feedback.4 A recent inquiry into the clinical services at a tertiary hospital in Western Australia noted poor supervision and training and recommended all senior doctors should partake in “train the trainer”-type courses.5 Lack of rewards. Material rewards and recognition for the teaching we do are poor. To cope with these challenges, we, as teachers, need knowledge and skills2,6 to teach effectively in the clinical setting “on the run”. SolutionsTeachers’ goalsResearch confirms that the performance of students, as measured by knowledge and skills assessments, is directly related to the prowess of their teachers.7 Good teachers are recognised not only by their teaching abilities (organisation and clarity of presentation, enthusiasm and stimulation of interest, group interaction skills) but also by their “doctoring” qualities (competence, clinical knowledge, analytic ability, professionalism) and their supervisory skills.8 The goals of an effective clinical teacher are:8,9 to provide a clinician role model: being knowledgeable, competent, caring and professional; to be a supervisor: giving direction in patient care when required; providing feedback; involving trainees, junior medical officers and students in clinical care; to provide support: mentoring, caring, showing an interest, and providing advice about careers; to be a dynamic teacher: planning, motivating, understanding the relevance for learners, and identifying learner needs. The teacher–learner relationship has an enormous impact on the quality of teaching and learning, with interpersonal variables accounting for half the variance in teaching effectiveness.10 The learning cycleJunior doctors learn while caring for patients. Mistakes may occur and clinical decisions could sometimes be better. As teachers, we need to anticipate mistakes, minimise them, and, when they occur, ensure that a supportive environment allows junior doctors to reflect on their practice and learn from it, rather than feel blamed.8 A framework for thinking about how students, junior doctors or trainees learn and how we can help them learn — either in a discrete session or across a clinical attachment — is embodied in the learning cycle. 9,11 We will be better teachers if we can address each component of the cycle. The series “Teaching on the run tips” as it unfolds will explore with clinicians basic educational principles to apply in the clinical setting for all phases of learning and teaching with students, junior doctors and specialty trainees. Take-home message Effective clinical teachers of students, junior doctors and specialty trainees are good clinicians; understand basic educational principles and have the skills to apply these in practice. A particular teaching tip may not suit all circumstances or all people — each of us has our own style. Different learners have different needs, and different circumstances require different actions. Therefore, we need a wide range of skills, together with flexibility in applying them at different times. So ... evaluate your own teaching; try new methods as suggested in this series and elsewhere, and evaluate their effectiveness; get feedback from others, and try again. Evidence suggests we can improve!

Fiona R Lake MD, FRACP

Pituitary adenomas are found in 10%–25% of unselected autopsy series and are evident in about 10% of asymptomatic individuals by magnetic resonance imaging. Diagnosis of pituitary disorders is often delayed by lack of awareness and the subtlety of symptoms and signs. Hypopituitarism is suspected when peripheral hormone concentrations are low without an elevation in the corresponding pituitary tropic hormone(s). Severe adult-onset growth-hormone deficiency results in reduced muscle mass, increased fat mass and diminished quality of life, which are reversed by growth hormone replacement therapy. While trans-sphenoidal surgery remains first-line treatment for acromegaly, drug treatment has an important role in controlling residual growth-hormone excess and, in some circumstances, as first-line treatment. Dopamine-agonist therapy (cabergoline or bromocriptine) is the treatment of choice for micro- and macroprolactinomas. In patients with suggestive clinical features, elevated 24-hour urine free cortisol level is usually sufficient to diagnose endogenous Cushing’s syndrome; careful additional investigation is needed to determine whether the cause is Cushing’s disease (pituitary adenoma secreting adrenocorticotropic hormone [ACTH]), ectopic ACTH secretion or adrenal disease.

David M Hurley PhD, FRACP · Ken K Y Ho MD, FRACP

Re: “Overweight and obesity in Australia: the 1999–2000 Australian Diabetes, Obesity and Lifestyle Study (AusDiab)”, by Adrian J Cameron, Timothy A Welborn, Paul Z Zimmet et al in the 5 May 2003 issue of the Journal (Med J Aust 2003; 178: 427-432). In Box 3 and Box 4 (pages 429 and 430), the row headings for the weekly income categories were reversed — the reference category should have been the lowest (rather than the highest) income group. These sections of Boxes 3 and 4, as they should have appeared, are shown below. This reversal affected our interpretation of the results of the study. In the Results section (page 431), we stated that “Increasing income increased the risk of obesity in women. Although no such association was significant for men, both the BMI and waist circumference data suggested that middle-income men tended to be more obese than the lowest income group.” This should have read: “Increasing income decreased the risk of obesity in women. Although no such association was significant for men, both the BMI and waist circumference data suggested that middle-income men tended to be more obese than the highest income group.” In the Discussion section (page 432), we stated that “In men, minor trends for middle-income groups to be more obese and the least affluent to be thin were observed, although these were not significant. Women, by contrast, showed a strong positive graded association between income and obesity.” This should have read: “In men, minor trends for middle-income groups to be more obese and the most affluent to be thin were observed, although these were not significant. Women, by contrast, showed a strong negative graded association between income and obesity.” The association between obesity and income was not a major outcome of the study, with the results focusing on the prevalence of obesity and the association of obesity with physical activity and television viewing time. The html and pdf versions of the article published in the eMJA were corrected on 20 March 2004. 3: Association between obesity (measured using body mass index [BMI]* [n = 4996] and waist circumference* [n = 4984]) and potential risk factors among Australian men Body mass index Waist circumference n Adjusted odds ratio† (95% CI) n Adjusted odds ratio† (95% CI) Smoking status Non/ex-smoker 4048 1.00 4041 1.00 Smoker 865 0.71 (0.48–1.04) 860 0.63 (0.51–0.78)‡ Physical activity§ Lowest quintile 946 1.00 946 1.00 Highest quintile 1021 0.70 (0.46–1.06) 1022 0.56 (0.42–0.75)‡ Television viewing¶ Lowest quintile 784 1.00 783 1.00 Highest quintile 1094 1.86 (1.30–2.67)‡ 1093 1.97 (1.48–2.63)‡ Education University/Further education 2089 1.00 2086 1.00 Completed high school 901 1.14 (0.92–1.42) 900 0.93 (0.69–1.27) Some high school completed 1693 2.19 (1.6–3.01)‡ 1684 1.65 (1.17–2.33)‡ Primary school/never attended school 309 2.40 (1.59–3.61)‡ 310 2.31 (1.69–3.15) ‡ Country of birth Australia/New Zealand 3727 1.00 3713 1.00 United Kingdom/Northern Ireland 612 0.92 (0.65–1.29) 611 0.89 (0.68–1.16) Rest of world 653 0.85 (0.67–1.08) 656 0.60 (0.40–0.92)‡ Weekly income (A$) 0–199 502 1.00 502 1.00 200–399 1541 1.18 (0.80–1.74) 1533 1.30 (0.93–1.81) 400–599 1162 1.12 (0.78–1.60) 1157 1.29 (0.91–1.82) 600–799 1133 1.07 (0.77–1.50) 1134 1.23 (0.84–1.80) 800–1499 571 1.06 (0.70–1.62) 573 0.97 (0.69–1.36) 1500+ 37 0 .68 (0.22–2.07) 36 0.51 (0.17–1.54) Occupation** Skill level 1 1243 1.00 1244 1.00 Skill level 2 540 0.65 (0.46–0.93)‡ 534 0.74 (0.49–1.14) Skill level 3 658 0.48 (0.32–0.72)‡ 659 0.43 (0.26–0.70)‡ Skill level 4 604 0.95 (0.63–1.43) 602 0.84 (0.58–1.21) Skill level 5 304 0.93 (0.52–1.63) 304 0.92 (0.46–1.84) Others 1629 0.56 (0.35–0.89)‡ 1623 1.07 (0.66–1.72) * Obesity defined as BMI ≥ 30 kg/m2, or waist circumference ≥ 102 cm. † Model adjusted for age and all other risk factors in the table. ‡ Significantly different from reference (P < 0.05). § Quintiles of physical activity: < 30 minutes = lowest, ≥ 550 minutes = highest. ¶ Quintiles of television viewing: < 300 minutes = lowest, ≥ 1260 minutes = highest. ** Skill levels: 1 — managers, administrators and professionals; 2 — associate professionals; 3 — tradespersons, advanced clerical and service workers; 4 — intermediate clerical, sales and service workers, intermediate production and transport workers; 5 — elementary clerical, sales and service workers and labourers; and others — students, retirees, pensioners and unemployed. 4: Association between obesity (measured using body mass index [BMI]* [n = 6071] and waist circumference* [n = 6075]) and each of the potential risk factors among Australian women Body mass index Waist circumference n Adjusted odds ratio† (95% CI) n Adjusted odds ratio† (95% CI) Smoking status Non/ex-smoker 5123 1.00 5128 1.00 Smoker 857 0.70 (0.51–0.97)‡ 858 1.03 (0.76–1.39) Physical activity§ Lowest quintile 1254 1.00 1255 1.00 Highest quintile 1221 0.47 (0.31–0.72)‡ 1221 0.53 (0.34–0.80)‡ Television viewing¶ Lowest quintile 992 1.00 994 1.00 Highest quintile 1292 1.82 (1.19–2.76)‡ 1295 2.27 (1.55–3.32)‡ Education University/Further education 1985 1.00 1985 1.00 Completed high school 1185 1.04 (0.77–1.40) 1185 1.31 (1.01–1.70)‡ Some high school completed 2481 1.48 (1.19–1.83)‡ 2487 1.47 (1.19–1.82)‡ Primary school/never attended school 419 2.12 (1.18–3.80)‡ 417 2.68 (1.64–4.36)‡ Country of birth Australia/New Zealand 4672 1.00 4677 1.00 United Kingdom/Northern Ireland 644 0.95 (0.68–1.34) 646 1.01 (0.69–1.49) Rest of world 754 0.80 (0.66–0.97)‡ 751 0.72 (0.57–0.92)‡ Weekly income (A$) 0–199 1034 1.00 1034 1.00 200–399 2046 0.85 (0.67–1.08) 2046 0.93 (0.74–1.19) 400–599 1270 0.87 (0.66–1.15) 1274 0.79 (0.62–1.02) 600–799 1064 0.57 (0.40–0.82)‡ 1062 0.62 (0.46–0.83)‡ 800–1499 499 0.67 (0.48–0.93)‡ 501 0.59 (0.37–0.94)‡ 1500+ 20 0.63 (0.19–2.11) 20 0.46 (0.13–1.65) Occupation** Skill level 1 990 1.00 989 1.00 Skill level 2 390 0.82 (0.41–1.65) 389 0.80 (0.48–1.34) Skill level 3 354 0.88 (0.55–1.40) 355 0.93 (0.58–1.48) Skill level 4 886 1.11 (0.72–1.71) 884 0.74 (0.53–1.05) Skill level 5 549 0.84 (0.45–1.57) 551 0.90 (0.60–1.36) Others 2869 0.94 (0.54–1.63) 2874 1.08 (0.71–1.64) * Obesity defined as BMI ≥ 30 kg/m2, or waist circumference ≥ 88 cm. † Model adjusted for age and all other risk factors in the table. ‡ Significantly different from reference (P < 0.05). § Quintiles of physical activity: < 20 minutes = lowest, ≥ 390 minutes = highest. ¶ Quintiles of television viewing: < 240 minutes = lowest, ≥ 1200 minutes = highest. ** Skill levels: 1 — managers, administrators and professionals; 2 — associate professionals; 3 — tradespersons, advanced clerical and service workers; 4 — intermediate clerical, sales and service workers, intermediate production and transport workers; 5 — elementary clerical, sales and service workers and labourers; and others — students, retirees, pensioners and unemployed.

Adrian J Cameron MPH · Paul Z Zimmet MD, FRACP FAFPHM · David W Dunstan PhD · Marita Dalton GradDipEpidemiol · Jonathan E Shaw MD, MRCP · Timothy A Welborn MB BS, PhD · Neville Owen PhD · Jo Salmon PhD · Damien Jolley MSc

Re: “Bone and Joint Disorders: Prevention and Control”, the Supplement to the 1 March 2004 issue of the Journal (Med J Aust 2004; 180 (5 Suppl): S1-S40). Three errors have been noted. Firstly, on page S2, the funding for the Supplement was incorrectly attributed to the Department of Health and Ageing alone, and the text should have read: “The Australian Government Department of Health and Ageing sponsored the summit — Bone and Joint Decade Approach, Canberra November 15, 2002. Merck Sharp & Dohme, the Department of Health and Ageing and the Australian Rheumatology Association funded the publication of this Supplement. The views expressed in this Supplement are those of the authors and do not necessarily reflect those of the funding organisations.” Secondly, there is incorrect reference numbering in the article “Can we reduce disease burden from osteoarthritis? An evidence-based priority-setting model”, by Segal L, Day SE, Chapman AB and Osborne RH. In the section on primary prevention, on page S14, the reference numbers should have read 1,8-10,12, and not 1,12-9. Finally, in the article “The Australian Orthopaedic Association National Joint Replacement Registry”, by Graves SE, Davidson D, Ingerson L, et al, the details for one author were omitted from the authors’ address box on page S31. These details are as follows: Heather J McElroy, BSc(Hons), GradDipApplStat, Statistician, Data Management and Analysis Centre, Department of Public Health and General Practice, University of Adelaide, Adelaide, SA. These errors appeared in the printed edition of the supplement but were corrected before the html and pdf versions appeared in the eMJA.

Peter M Brooks MD, FRACP, FAFRM · Michael J Hooper MB BS, FRACP · Richard A Smallwood AO, MD, FRACP, FRCP

Re: “Parallel infusion of hydrocortisone ± chlorpheniramine bolus injection to prevent acute adverse reactions to antivenom for snakebites”, by Gawarammana I B, et al in the 5 January issue of the Journal (Med J Aust 2004; 180: 20-23). As a result of a programming error, the confidence intervals in Box 3 of the article were incorrect. Box 3 should be as follows. 3: Reactions to antivenom and time from antivenom infusion to reaction Reaction Treatment A (n = 10) Treatment B (n = 21) Treatment C (n = 16) Mean time (min) Patients Mean time (min) Patients Mean time (min) Patients No. % (95% CI) No. % (95% CI) No. % (95% CI) Hypotension (< 120/80 mmHg) 43 5 33% (15%–58%) 26 8 38% (21%–59%) 22 9 56% (33%–77%) Tachycardia (> 80/min) 42 5 33% (15%–58%) 18 7 33% (17%–55%) 16 10 63% (39%–82%) Rigors 90 1 7% (1%–30%) 38 6 29% (14%–50%) 16 3 19% (7%–43%) Itching 25 10 67% (42%–85%) 16 10 48% (28%–68%) 13 10 63% (39%–82%) Urticaria 32 10 67% (42%–85%) 19 8 38% (21%–59%) 15 12 75% (51%–90%) Dyspnoea 15 2 13% (4%–38%) — 0 — — 16 5 31% (14%–56%) Treatments: A, hydrocortisone and placebo; B, hydrocortisone and chlorpheniramine; C, placebo and placebo. The html and pdf versions of the article appearing in the eMJA were corrected on 19 April 2004.

S Abeysingha M Kularatne MB BS, MD, MRCP(UK) · Indika B Gawarammana MB BS, MD

Simon G A Brown Emergency Physician, Fremantle Hospital & Health Service, and Clinical Senior Lecturer in Emergency Medicine, University of Western Australia, Department of Emergency Medicine, Fremantle Hospital, Alma Street, Fremantle, WA 6160. simon.brownAThealth.wa.gov.au To the Editor: Gawarammana et al present an interesting study of premedication to prevent adverse reactions to snake antivenom,1 but I have concerns with the data presentation and analysis. The 95% confidence intervals presented in Box 3 of their article are impossibly narrow. For example, recalculation of the first cell (hypotension rate for treatment A) by the binomial method gives a 95% confidence interval of 12%–62%, not 30%–36% as presented. Also, my analysis of the aggregate endpoint differs. Using the Fisher exact test to compare reaction rates in the hydrocortisone + antihistamine group (11/21) with placebo (13/16), for the difference in proportions of 0.29 I obtain a 95% confidence interval of 2 0.04 to 0.58. This has a P value of 0.14 using a 2-tailed test, according to the program Analyse-it.2 This comes as no surprise given that steroids take hours to work, and that histamine is just one of many mediators released during anaphylaxis, rising early and only transiently during severe and protracted anaphylactic reactions.3 Although antihistamines reverse the effects of histamine infusions which mimic anaphylaxis, animal studies indicate that they are ineffective for treating anaphylaxis mediated by mast-cell degranulation.4,5 Human studies have shown that H1 blockade is useful in preventing mild reactions to immunotherapy that are confined to the skin, but do not appear to prevent severe reactions.6,7 One human study has compared H1 + H2 blockade with H1-only blockade for the management of mild allergic reactions, finding a small benefit of combined H1 + H2 blockade.8 However, a confounder was that adrenaline was administered more frequently in the combined H1 + H2 antihistamine treatment group. A study of reactions to immunotherapy has failed to show any benefit from H1 + H2 blockade.7 I suspect that, instead of proceeding to study combination prophylaxis with antihistamines, steroids and adrenaline, it might be better to examine the preparation for and management of allergic reactions to antivenom. Many doctors fear intravenous adrenaline infusions, but in our experience this approach to managing anaphylaxis is safe, well tolerated and immediately effective, without the unpredictable, unpleasant, and (in the setting of venom-induced coagulopathy) potentially dangerous side effects sometimes seen with intramuscular, subcutaneous and intravenous bolus injections.9 Perhaps it is time for a trial of premedication with subcutaneous adrenaline versus an “as required” approach using a carefully titrated intravenous infusion.

Simon G A Brown

S Abeysingha M Kularatne,* Indika B Gawarammana† * Senior Lecturer, † Lecturer, Department of Medicine, Peradeniya University, Sri Lanka. samkulATsitnet.lk In reply: Brown has pointed out some interesting observations about antihistamines and mediators such as histamine, released during anaphylactic reactions. First, we must address the statistical issues. We are grateful to Brown for detecting an important error in Box 3 of our article.1 When we were asked to calculate confidence intervals for the percentages, we used a formula recommended by Spiegel.2 As this formula was not available in our software packages, we programmed it ourselves. We made an error in our programming and we apologise for this. (See Correction, page 428.) For the difference in reaction rates for the treatment regimens, we used the following calculation. The difference P1 – P2 = − 0.2887 To calculate the confidence interval, we calculated the standard error (SE) of the difference by the following formula. This interval does not include 0, so Brown’s P value of 0.14 is not reasonable. We do accept that the statistical significance is marginal. We agree that antihistamine is ineffective as a prophylactic agent in anaphylaxis. This was observed in studies in Sri Lanka and Brazil, where chlorpheniramine and promethazine, respectively, were used to prevent reactions to antivenom.3,4 However, we defended the observed reduction of mild to moderate acute reactions to antivenom in our study by highlighting the counter-effect of antihistamine on released histamine after mast-cell degranulation.1 Our study was to test the usefulness of an established practice in Sri Lanka, where steroid infusion is used to counter reactions to antivenom. The crux of the problem is the highly antigenic antivenom preparations used in Sri Lanka, despite ever-increasing reaction rates, because of the lack of facilities for developing purified antivenom. The proposal of using intravenous adrenaline infusion to reduce allergic reactions is novel and exciting. This should be tested by randomised controlled trials.

Indika B Gawarammana

Val J Gebski Principal Research Fellow, NHMRC Clinical Trials Centre, Level 5, Building MO5, Mallett Street Campus, University of Sydney, NSW 2006. valATctc.usyd.edu.au Comment: Kularatne and Gawarammana compared the proportion of side-effects given in their table above using the well-known (and easily understood) test of the difference between two proportions using the normal distribution. However, as each of these proportions follows a binomial distribution (13 “successes” out of 16 trials and 11 “successes” out of 21 trials), the normal approximation is only useful if the number of trials is greater than 30. Because of the small sample sizes, “exact” methods better reflect the true difference (in terms of P values and confidence intervals) between the two proportions. The more complicated methods (different formulations of the exact test) and the resulting confidence intervals provide a clearer indication of whether the proportions are indeed different (statistically). In this instance, the evidence is not sufficient to declare the two proportions statistically different.

Val J Gebski

Michael A Quinn Director, Oncology and Dysplasia Unit, Royal Women's Hospital, 5th Floor, 132 Grattan Street, Carlton, VIC 3053. michael.quinnATmaynegroup.com To the Editor: A recent article by Zorbas et al1 highlights some of the many difficulties experienced by Australian women in accessing multidisciplinary care after they have been diagnosed with breast cancer. A multidisciplinary approach to women with gynaecological cancer has been the cornerstone of care since the establishment of gynaecologic oncology units in Australia in the early 1980s. Over 20 years’ experience has reinforced the value of this approach. By and large, however, the success of this model has very much depended not only on the skills of the multidisciplinary team but also on the readiness of referring doctors — in this case, specialist gynaecologists — to refer patients for management that is often surgical and could easily be done by themselves. Reinforcing the concept that care of the patient is holistic and that surgery plays an important (but not definitive) role in overall care has led to increased referrals, but there are still many to convince. For instance, a survey published in the Journal in 20022 showed that in the late 1990s more than half the women with ovarian cancer in Victoria were still being operated on outside established gynaecologic oncology units or by a non-gynaecological oncologist. It is to be hoped that new National Health and Medical Research Council guidelines on the management of ovarian cancer (soon to be released) will reduce this deficit and thereby improve outcomes for women with ovarian cancer. Much of the development of this benchmark care has come from patients, who, thankfully, are becoming increasingly articulate in their expectations of optimal clinical outcomes. The question of rural patients is an extremely important one. In Victoria, over a period of more than 10 years, the three major metropolitan gynaecologic oncology centres have established satellite clinics in country towns to facilitate patient follow-up, often involving local specialists and family doctors. This system seems to have worked well and is worthy of assessment as a model that might be transferable to other specialties. In conclusion, it is all very well setting up multidisciplinary teams, but the key to their success has to be the recognition of professional equality. If teams are based on a hierarchical setup they are likely to fail in their major aim, which is to provide the best care available based on input from a broad range of professionals and from patients themselves.

Michael A Quinn

Susan C Pendlebury,* Katherine J Clark,† Martin H N Tattersall‡ * Radiation Oncologist, † Palliative Care Physician, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050; ‡ Professor of Cancer Medicine, University of Sydney, Sydney, NSW. spendlebATemail.cs.nsw.gov.au To the Editor: Zorbas et al1 have highlighted both the complexities and resource intensiveness of multidisciplinary care for women with early-stage breast cancer. The same arguments exist in advanced disease, where input from many disciplines is the norm. However, there is no evidence that such a process improves outcomes in the Australian setting. The references the authors draw upon relate to regions in which breast cancer outcomes have historically been poor. Evidence from Australian studies suggests higher standards of care and appropriate changes over time. 2,3,4 The National Health and Medical Research Council (NHMRC) Clinical practice guidelines for the management of early breast cancer5 provide an evidence-based strategy for managing the disease. Enshrined within them is the concept that many different treatment approaches are equivalent and that patient preferences are important. Patient input into multidisciplinary case conferences is frequently minimal. Case conferences can be confusing for patients, and it may not be clear to them who is their doctor. Many clinics include a breast nurse, who commonly acts as a patient advocate. Zorbas and colleagues note the different models of multidisciplinary care, but the minimum approach required to achieve good outcomes has not been established. It is not surprising that 34% of rural surgeons find it difficult to implement a service in which all women have access to a full range of treatment options in a multidisciplinary setting. There is no evidence, however, that their patients are more unhappy or that management outcomes are inferior. Similarly, the guidelines correctly promote the importance of psychosocial support for patients, but the suggestion that this can be better achieved by a psychologist via teleconferencing rather than by the patient’s general practitioner is purely speculative. None of the multidisciplinary models suggested by Zorbas et al addresses the management of patients at relapse, and yet data and clinical experience indicate this is the time of greatest stress for patients, 6 a time when input from a number of specialties — medical care, radiation oncology, palliative care — is the norm. Multidisciplinary care appears to be beneficial regardless of the stage of disease. However, the execution of some of the models is resource-intensive. We need to evaluate not only whether the objectives of the NHMRC guidelines are met, but whether patient satisfaction and participation are enhanced, survival outcomes are improved and care through all stages of the disease is optimal. Currently, by such measures, multidisciplinary care has not been shown to be superior to a small number of well-directed, evidence-based selective consultations.

Susan C Pendlebury · Katherine J Clark · Martin H N Tattersall

Helen M Zorbas,* Bruce H Barraclough,† Katherine J Rainbird,‡ Karen A Luxford,§ Sally Redman¶ * Clinical Director, ‡ Manager, Treatment Program, § Program Director, National Breast Cancer Centre, Locked Bag 16, Camperdown, NSW 1450; † Director of Cancer Services, Department of Surgery, Royal North Shore Hospital, St Leonards, NSW; ¶ Director, Institute for Health Research, Sydney, NSW. karenlATnbcc.org.au In reply: We agree with the comments by Pendlebury et al that knowledge about outcomes for patients receiving multidisciplinary care in Australia is limited. Hence, the National Breast Cancer Centre has investigated the application of multidisciplinary care and outcomes for women with breast cancer. Our article focused on the “Principles of multidisciplinary care” developed as a basis for a subsequent project (outcomes yet to be published). It was necessary to define such principles at the outset, as there is not yet an agreed view about what constitutes “multidisciplinary care” within the Australian healthcare context. We also agree that the standard of clinical care in Australia is generally good. However, delivery of care is often fragmented and inconsistent.1 In other countries with high quality services, multidisciplinary meetings have been found to result in care that is more in accord with the evidence than non-multidisciplinary care.2 The Principles emphasise the role of the general practitioner, while recognising that some patients will require appropriate specialist referral.3 They also state that living in a rural area should be no impediment to accessing care. We agree that multidisciplinary care is as important in advanced breast cancer as it is in early disease. The Principles were developed before the release of the guidelines for advanced breast cancer and it would be useful to extend them in the future. The importance of one main contact for women is acknowledged. The purpose of a multidisciplinary case conference is to identify treatment options and their relative merits. This ought to assist communication with women and enable them to make a more informed choice.

Helen M Zorbas · Bruce H Barraclough · Katherine J Rainbird · Karen A Luxford · Sally Redman

John Fraser,* Christian Alexander,† Berniece Simpkins‡ * Director, † Senior Research Fellow, ‡ Health Career Promotion Project Officer, New England Area Rural Training Unit, New England Area Health Service, PO Box 83, Tamworth, NSW 2340 jdfraserATdoh.health.nsw.gov.au To the Editor: We read with interest the recent article concerning Australian medical workforce issues.1 Brooks et al comment on feminisation, lifestyle changes, increased community demand and globalisation as major issues for the future medical workforce. Here, we present data from recent rural high school health career promotion activities, describing student interest in health careers. These data further support this trend in feminisation. Promotion of health careers in high schools is a core long-term rural workforce strategy in Australia.2 It is justified, as rural origin is an important predictor of medical graduates pursuing a rural health career.3 The New England Area Rural Training Unit (NEARTU) promotes rural health careers to school students, undergraduates and postgraduates in north-west New South Wales. Multidisciplinary regional health career expos were offered to all high school students in Years 9 to 12 from 2000 onwards in the regional centres of Armidale, Tamworth and Moree. Medical, nursing and allied health professionals and undergraduates (of both sexes) staffed the expos. Inquiries were recorded by sex, year at school and health career. Students could enquire about multiple careers. In 2000, 453 high school students (394 female; 59 male) expressed an interest in health careers at expos. The Box displays that, for both female and male Year 9 to Year 11 students, interest in a nursing career far exceeds interest in either allied health or medicine, and, for Year 12 students, an interest in allied health far exceeds interest in either nursing or medicine. Enquiries were more frequent from females than from males, ranging from just over four times (medicine) to eight times more frequent (nursing). In 2000, 60% of these students’ enquiries (270 enquiries) referred to nursing, 33% (151 enquiries) referred to allied health and 7% (32 enquiries) referred to medicine. Compared with the Australian Bureau of Statistics 2001 data, which showed a 50.4 to 49.6 ratio of females to males in the region’s high schools, our increased interest by females is statistically significant (P < 0.01). In other careers projects by NEARTU in 2000–2002 (eg, work experience placements, and health career promotion at local agricultural field days), similar sex differences were observed (female-to-male ratio range, 10:1 to 3.5:1). Increased interest by female high school students is consistent with other reports of high school students’ health career preferences in the United States. 4,5 Registering interest is only the first step in considering a health career. The higher proportion of females expressing this interest in rural high schools is important for rural workforce planning. Interest in health careers by high school students in 2000

John Fraser · Christian Alexander · Berniece Simpkins

Alex J Chamberlain,* John W Kelly† * Registrar, † Head, Victorian Melanoma Service, The Alfred, Prahran, VIC. alex_chamberlainAThotmail.com To the Editor: Janda and colleagues’ survey of skin screening by general practitioners in regional Queensland1 demonstrated that only 20% of participants had undergone a total-body skin examination in the previous 3 years and that examination rates were slightly lower for patients 50 years of age and older. They conclude that those at greatest risk (older people, especially men) will need to be targeted if screening programs are to reduce melanoma mortality. In the same issue of the Journal, a study by English and colleagues of excisional biopsies of pigmented lesions by Perth GPs showed that the excision rate for patients under the age of 50 years (62%) is nearly twice that for patients over 50 years (38%), and that in the younger cohort this is primarily harvesting benign naevi.2 They conclude by encouraging GPs to increase their suspicion and lower their biopsy threshold in older patients in order to detect more melanomas. These studies serve to remind us that it is predominantly older people (and especially men) who are at greatest risk of thick (and potentially lethal) melanoma.3 The evidence provided by these studies of mismatch between skin cancer risk and resource allocation to surveillance and excisional surgery might help explain why recent advances in early detection seem to have bypassed elderly men. It is of continuing concern that despite the fact that melanomas are currently diagnosed at an earlier stage when compared with 20 or 30 years ago, the background incidence of thick melanoma has remained stable, both in Australia and around the world. In a recent study conducted in Victoria,4 we found that thick melanomas (≥ 3 mm) were predominantly nodular melanomas, primarily affecting people over 50 years of age and especially men. This elusive subtype frequently fails to fulfil the “ABCD” (asymmetry, border, colour, diameter) diagnostic criteria in that they are more often uniform in colour, symmetric in shape and predominantly amelanotic.5 A possible aide-mémoire that we have suggested elsewhere for identifying nodular melanoma is the addition of “EFG” (“elevated, firm, growing for more than 1 month”) criteria.6 The observation that nodular melanomas grow quickly, leading to deep invasion within a few months, poses a significant obstacle to the potential success of community-based screening programs.1 It is likely that many nodular melanomas will escape early detection by such programs, as they will evolve significantly in the interval between screening examinations.4,5 It is important that all clinicians recognise this subtype if we hope to reduce melanoma mortality in Australia.

Alex J Chamberlain · John W Kelly

Erectile dysfunction and related disorders. William Alexander, Culley Carson. London: Mosby, 2003 (vi + 152 pp). ISBN 0 7234 3327 5. Understanding of erectile dysfunction has progressively increased over the years due to the development of new treatments. Much of the information available today to medical practitioners is provided by the pharmaceutical industry, particularly when a new product appears on the market. This book provides up-to-date and independent information to any medical practitioner who has an interest in assessing and treating erectile dysfunction. The book’s authors are experienced practitioners in this field and the book itself comes in the neat, pocket-size format usually reserved for emergency handbooks, although it is more likely that it would sit on a desk as a reference. The first chapters, covering anatomy, diagnosis and treatment, would suffice for most doctors’ needs. There are straightforward tables, figures and illustrations supporting the written information. The section on treatment is up-to-date and includes all the current products in the UK market, although not all are available in Australia. I particularly liked the emphasis on the psychological component of erectile dysfunction, a common secondary issue that is often overlooked. Other, more detailed issues, such as ejaculatory disorders and andrology, are well covered and relevant to those with an interest in sexual medicine. The list of resources and web sites is European based. I refer Australian readers to our local resource, Impotence Australia (www.impotenceaustralia.com.au. Phone 1800 800 614). With the increasing recognition of sexual dysfunction as a medical condition, I recommend Erectile dysfunction and related disorders as an excellent publication. Michael P LowyGeneral Practitioner Sydney Centre for Men’s Health Bondi Junction, NSW

Michael P Lowy

Aspirin-induced asthma alert Doctors should routinely advise their patients with asthma about the possibility of aspirin-induced asthma, as it occurs more commonly than previously thought, say the authors of a systematic review. The advice should be tailored to the patient (eg, those with nasal polyps or chronic rhinitis are at high risk of aspirin-induced asthma and should avoid all products that contain aspirin or NSAIDs indefinitely). Australian researcher Jenkins and colleagues analysed pooled data from 21 trials, finding an overall pooled incidence of 21% (95% confidence intervals, 14% to 29%) for aspirin-induced asthma — about twice as high as previously reported. Their review also determined that cross-sensitivity to three commonly used NSAIDs (ibuprofen, naproxen and diclofenac) was present in most patients with aspirin-induced asthma. Cross-sensitivity to paracetamol occurred in only 7% of patients, and tended to be less severe. BMJ 2004; 328: 434-437 Downsize, get sick, and die? Finnish research has found major oragnisational downsizing (>18%) during the recession of the 1990s was linked to more sick leave in full-time, permanent municipal employees of four towns. It was also linked with more cardiovascular deaths, especially in the first few years. The municipalities downsized to cut costs, but legislation did not allow parallel cuts in the services provided. BMJ 2004; 328: 555-589 Children’s voices The days of children being seen and not heard may be over. According to a news item in the BMJ, a report from the UK Commission for Health Improvement says that many children and teenagers want to learn and participate more in decisions about their treatment. Commenting on their level of involvement, children were quoted as saying: "[The doctor] only explained it to my dad", and "[I] did not really understand, nobody explained what is going to happen to you to make you better". BMJ 2004; 328: 600 Trafficking: the human cost The Lancet recently examined health and human rights issues relating to the "trafficking" of people for indentured servitude, and especially of women and girls for sexual exploitation. Trafficked people may fear retribution or deportation and avoid health services, despite the threat to their own health (and others, via HIV/AIDS). Well-meaning acts on behalf of trafficked women have sometimes landed them in even worse situations; each woman’s assessment of her situation and risks to her safety should be respected. Lancet 2004; 363: 564, 565, 566 . . . and would you like some gout with that, sir? The US Health Professionals Follow-up Study has confirmed that eating meat and seafood increases the risk of gout, whereas consuming dairy products reduces it. Over 12 years, the study found 730 new cases of gout had developed among 47 150 men. Gout was more likely in men who had eaten more meat (at just under two servings a day, on average) and more seafood (a little more than about half a serving a day) than unaffected men. Those who consumed more dairy products, especially low-fat ones (eg, two glasses of skim milk per day), were less likely to develop gout. However, intake of purine-rich vegetables and total protein intake were not linked to an increased risk of gout. An accompanying article said that gout should be considered part of the current global epidemic of obesity, hypertension and diabetes. 1. N Engl J Med 2004; 350: 1093-1103 2. N Engl J Med 2004; 350: 1071-1073 Clinical statistics put simply With the current emphasis on evidence-based medicine, we're rapidly reaching the point where all clinicians simply must have some kind of grip on statistics. But perhaps this lies more in understanding what each test is designed to measure and in interpreting what the result will mean in practice rather than in knowing how to do the calculations. For example: when is a median value preferable to a mean? When is a statistically significant result clinically significant? And, what are the dangers inherent in subset analyses? Those seeking a straightforward, practical approach to these kinds of questions might like to look at Guller and DeLong’s vade mecum, prepared for surgeons as a no-nonsense way of launching into a potentially tricky operating field. J Am Coll Surg 2004; 198: 441-458 — Dr Ann Gregory, MJA

Ann Gregory