Volume 181 Issue 3

Hot topics. Exercise. Manu V Chakravarthy, Frank W Booth. Philadelphia: Hanley and Belfus, 2003 (x + 326 pp). ISBN 1 56053 568 7. Tobacco smoking is still the leading preventable health risk in Australia, but the risk associated with a sedentary lifestyle is similar to that of smoking. For those Australians who do not smoke, physical inactivity is now by far the greatest health risk. Hot Topics. Exercise defines the key role that a sedentary lifestyle plays in the development of many common chronic health disorders and provides practical solutions to reversing this major trend in contemporary public health. The authors are two Americans whose professional lives are dedicated to increasing our understanding of the role of exercise in preserving human health. Chakravarthy is a physician and Booth a well-known clinical exercise scientist. The book provides a comprehensive account of the epidemiology, the biological mechanisms and the all-important randomised controlled trials that show that regular physical activity can prevent or delay the onset of chronic health disorders. In addition, the authors review the clinical evidence that exercise can reduce morbidity and enhance the quality of life of patients with a variety of chronic diseases. Through these various lines of evidence they establish clearly the health risk associated with a sedentary lifestyle. However, their purpose is not simply to extol the benefits of exercise. About one third of the book is devoted to sensible, practical exercise prescription and strategies to assist practitioners in guiding their clients and patients to more active lifestyles. Although medical practitioners may not be able to administer some of the types of exercise described, the section is important because it informs them about what is required and the advice they can expect their patients to receive from exercise specialists. The text is dense with information, but enjoyable to read and generously supported by tables, clear diagrams and flow charts. If we all act on the compelling arguments advanced in Hot Topics. Exercise we could reduce the health burden of sedentariness as we have reduced smoking-related diseases. The book will do much to encourage a vanguard. John R BrotherhoodSenior Lecturer School of Exercise and Sport Science University of Sydney, NSW

John R Brotherhood

A small number of Australian babies continue to acquire HIV infection unnecessarily The World Health Organization estimates that each year worldwide about 700 000 children are infected with HIV.1 Most of these infections occur through mother-to-child transmission in resource-poor settings, predominantly in Africa and Asia. Mother-to-child transmission rates of 30% continue to occur, despite the fact that this form of transmission is almost entirely preventable with antiretroviral therapy and formula feeding. The barriers to implementation of prevention strategies include restricted access to antenatal testing, cost and limited availability of antiretroviral therapy, poor workforce resources, and political obstacles, such as have occurred in South Africa.2 . . . the concerns about cost-effectiveness have largely been resolved . . . The outlook for babies born to HIV-positive mothers in high-income settings has improved dramatically. Most pregnant women with HIV infection in Western Europe or North America can expect an infection risk for their infant of less than 2%.3,4 This ability to interrupt perinatal transmission of HIV is, of course, only possible if the mother’s status is known. From 1998 to 2002, 103 pregnant Australian women were aware of their HIV-positive status. None of their infants was infected. During the same period, HIV was diagnosed in eight of the 15 infants born to mothers who became aware of their status only after giving birth.5 Overall, almost half the women in Australia with HIV infection known to have completed a pregnancy were unaware of their status before the birth of their baby.6 With this ignorance, no interventions can be offered. Despite the ready availability of prevention strategies, it appears that a small number of Australian babies continue to acquire HIV infection unnecessarily. The solution to this calamity is to prevent HIV infection in women and, when it does occur, to identify it before or during pregnancy. Unfortunately, national policies on antenatal screening are flawed. The Australian National Council on AIDS and Related Diseases recommends that “[pregnant] women found to be at higher risk of HIV . . . should be encouraged to undergo HIV antibody screening”, but does not explain the term “higher”.7 HIV antibody testing is now recommended for all pregnant women in the Northern Territory, New South Wales and Queensland, but the national guidelines continue to be followed in South Australia, Western Australia and Victoria. However, the facts show that existing practice fails to identify a number of preventable cases of mother-to-child transmission.8 The policy of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists is that HIV testing of pregnant women is the standard of care.9 Between 1995 and 1999, surveys indicated that rates of antenatal testing in Australia increased from 20%10 to 33%,11 and a recent survey suggests that the rate continues to increase slowly.12 Routine testing has been opposed on several grounds. There are quite reasonable concerns that routine testing might result in a degree of coercion and the conduct of testing without proper pre- and post-test counselling. Clearly, any recommendation to offer testing to all pregnant women would need to be accompanied by systematic strengthening of counselling and consent procedures. However, the strongest argument against routine antenatal testing has been that, given the low prevalence of diagnosed HIV infection in women, it is unlikely to be cost-effective. Our recent report challenges this position.13 We evaluated the cost-effectiveness of universal antenatal testing. We assumed that society would pay $39 000 per life-year gained, about twice the national average per-capita income. This value has been shown to result in efficient resource allocation.14 This is less than the cost per life-year gained for other screening programs currently under way in Australia, and is the valuation of a life-year gain used implicitly by the Australian Pharmaceutical Benefits Advisory Committee.15 The costs of universal testing — about $1.8 million — are offset by economic benefits for a prevalence of undiagnosed HIV of 0.0044%, or 1 in 23 000. The true prevalence is unknown, but available data suggest it is of this order. The major costs taken into account in our model were the training and time required for counselling about testing, and the pathology costs. The major benefit is that a young life might be extended by 60 or 70 healthy years. Many women in Australia with HIV infection were born overseas and are less likely to have comprehensive health insurance than those born here. Their access to antenatal care is thus limited. It is possible that women with undiagnosed HIV infection are currently over-represented among those missing the testing currently being done. If there were to be a uniform national approach to HIV testing, then education of the public, providers and clinic populations could be expected to improve the consent process. In the United States and Europe, anonymous HIV serological surveys among women giving birth in the 1980s gave way to recommendations for routine testing. Such surveillance of women giving birth has been seen as politically difficult in Australia.16 Given that concerns about cost-effectiveness have largely been resolved, the time has now come for public health and political courage to make it national policy that HIV testing be recommended for all women receiving antenatal care.

John B Ziegler FRACP, MD · Nicholas Graves PhD

A more efficient system of governance is needed to safeguard individual privacy while allowing registries to operate for the public good The recent controversy about cancer registries and patient privacy in the United Kingdom highlights the need for more debate about the governance of medical registries.1 For 40 years, identified data from UK patients with cancer have been transmitted to cancer registries without the patients’ express knowledge or consent. Although many benefits have flowed from analysis of these data, societal conventions have now changed, and questions are being asked in the UK and other countries, including Australia, about the privacy issues involved in the governance of medical registries in particular2-4 and medical research in general.5,6 Medical registries were traditionally established by public health authorities to monitor trends in the incidence of conditions such as infectious diseases and cancer. However, registries have become increasingly important in monitoring outcomes after the implementation of disease-prevention and treatment programs. They are now vital to quality-improvement programs that assess the safety of new drugs and procedures, identify best clinical practice and compare healthcare systems. For example, the Australian Orthopaedic Association National Joint Replacement Register currently monitors the use and survivorship of artificial hip- and knee-replacement prostheses,7 while the Victorian State Trauma Registry (VSTR) was established largely to monitor the effects of changes to the state trauma system.8 For registries to be effective, they must include all eligible participants so as to avoid biases that would affect the applicability and generalisability of results, and they must collect patient-specific data so as to adjust outcomes for risk and management factors. Further, in the absence of a unique national identification number, registries require name-based identification if participants are to be contacted for follow-up, or if registry data are to be validated against those held in other databases. The need for identified data raises consent and privacy issues. Registries must be established and governed in compliance with both federal and state legislation on privacy. Current requirements of this legislation have necessitated the development of consent procedures that maintain the effectiveness of medical registries, while informing patients and protecting their personal medical information. However, obtaining patient consent before participation in broad-based registries is often impractical and results in poor enrolment rates.,4 A more practical approach is to inform participants of their registration but to allow them to opt out of the registry. This approach resulted in the loss of fewer than 0.5% of eligible participants from the VSTR (unpublished data). This both complies with privacy legislation and achieves enrolment levels sufficient to maintain the scientific integrity of registries. Privacy legislation also sets down the circumstances under which privacy principles may be waived. For example, a human research ethics committee (HREC) may determine that the public benefit in allowing access to identified data substantially outweighs individuals’ right to privacy. However, as broad-based registries collect identified data from many sources, they are currently required to seek approval from many individual HRECs. This process is both time consuming and expensive. Further, many local HRECs have insufficient resources or expertise to evaluate the scientific merit of epidemiological research or to interpret privacy legislation,4,8,9 and consequently may reject legitimate research proposals. Registries could be established by legislation that overrides privacy provisions, but this approach lacks flexibility. A more workable system is required for establishing and governing medical registries that both safeguards individual privacy and allows the registries to continue to provide the foundations for quality-improvement programs and epidemiological research. No general guidelines for establishing and governing registries have been published, either in Australia or overseas. However, the National Health and Medical Research Council (NHMRC) has produced guidelines for genetic registers,10 which complement the National Privacy Principles11 with respect to the collection, use and disclosure of sensitive information, data quality and security, and the use of unique identifiers. After further development by the NHMRC in conjunction with federal and state privacy commissions, this model might be applied to other medical registries. We also propose that the NHMRC acts as an accrediting authority for institutions maintaining medical registries. This would ensure that the institutions comply with privacy legislation, maintain independence from the agencies that directly manage participating patients’ healthcare, and have the personnel, facilities and funding to maintain the registry and achieve its purpose. Institutions could be encouraged to seek accreditation by linking it to ongoing funding for registries. Further, a centralised HREC with scientific, ethical and legal expertise might be better able than local HRECs to ensure that registries can achieve their public health aims while maintaining patient privacy. Such a centralised committee should include patient advocates, as well as experts in epidemiology, ethics and privacy law. It could also provide guidance to local HRECs, if current legislation requires that they make their own determination, to avoid unnecessary duplication of review processes. Good registry governance involves developing a structure that includes stakeholders in management of institutions that analyse personal medical information; has a management independent of the institutions that provide healthcare; provides a research environment that maximises scientific benefit to patients and the wider community; and receives adequate funding to ensure continuity of data collection and quality assurance. We hope that developing processes to ensure good registry governance will allay public concerns about privacy and allow registries to continue to underpin programs of healthcare quality improvement and epidemiological research.

Owen D Williamson GradDipClinEpi, FRACS · Peter A Cameron MD, FACEM · John J McNeil PhD, FRACP

The NHS was founded on the principle of access to adequate healthcare for all Roman society in Britain was highly classified. At the top were . . . the legions, the provincial administration, the government of towns and the wealthy traders and commercial classes who enjoyed legal privileges not generally accorded to the majority of the population. In 212 AD, the Emperor Caracalla extended citizenship to all free-born inhabitants of the empire, but social and legal distinctions remained rigidly set between the upper rank of citizens known as honestiores and the masses, known as humiliores. At the lowest end of the scale were the slaves . . .1 In the United Kingdom today, the widening gap between upper and lower “social classes” is regularly presented by politicians and health bureaucrats to professional and lay audiences alike, and used to justify the public health agenda. Health inequalities have become the driving force for public health initiatives. The government under Thatcher explored “variations” in health outcomes and in health service provision. Subsequently, the Blair government replaced “variations” with the more class-oriented “inequalities”. All too often, however, attempts to deal with the real and frequently demonstrated social gradient in disease and in health service provision is limited to “hand-wringing epidemiology”. In any case, discussion of a widening gap reflects a failure to understand the difference between relative and absolute risk, as well as demographic change and the type of outcomes amenable to prevention. . . . unless public health programs are based on sound theoretical bases, they will fail. The debate in Australia is rather more sophisticated: for example, in the report of the Chief Health Officer of New South Wales,2 trends over time in the social gradient are presented in terms of absolute risk, as well as for diseases in which social interventions are likely to be effective. Presented in this way, the social gradient persists, but does not necessarily appear to widen over time, and some improvement in the experience of the least affluent may also be apparent. Are we carping and nit-picking to criticise the UK approach? No, because unless public health programs are based on sound theoretical bases they will fail. Implausible and non-achievable targets aimed at “narrowing the gap” have been established. These include: reducing, by 10%, the difference in infant mortality between the children of manual workers and the whole population; and reducing, by 10%, the gap in life expectancy at birth between the quintile of local council areas with the lowest life expectancy and the whole population. Far better would be to aim at the more important goal of improving the health of the whole community, as well as the disadvantaged part. The NHS was founded on the principle of access to adequate healthcare for all. Selectivity, even well intentioned selectivity, not only flies in the face of this ideal, it ignores the late Geoffrey Rose’s astute observation3 that small changes in the average for the whole population can bring great benefits to those at greatest risk, provided the change involves the whole population. People in the UK still talk about, and measure, social class. Although the use of the term “socioeconomic status” may be an example of political correctness, the fact that “class” is still an acceptable form of scientific terminology in the UK reflects the underlying acceptance of its existence. People typically “know their place”. They measure themselves against a social standard. Those who are “working class” stoutly defend their place in the social hierarchy and are proud of it. Expectations of health and of access to healthcare are firmly rooted in the class system. It is “posh” to eat healthy food, and “posh” is a derogatory term. If men (and women) are born into such shackles of social convention, their freedom to improve their health is distinctly limited. The claim that Australian society is classless is oft made but open to challenge. The concept of social class, as developed by Weber and Marx, is a complex one that involves consciousness of social position and sharing of values and outlooks within the group. If Australia has social classes, they are probably blue collar, white collar, “squattocracy” and those on the dole, but ranged against this are the acknowledged rights of all to “have a go” and to “a fair go”. These maxims make attempts to improve everyone’s health possible, as well as socially and politically legitimate. Why should we care if socially entrenched self-denial of the chance for better health exists in the UK? The reason is that attempts to deal with health inequalities are doomed to failure in such a climate. The debate about equity and health is complex and wide-ranging, and has an international component — all countries have inequality and inequity. The ancient Romans introduced a rigid social class structure into Britain, but the current inhabitants of the British Isles have made its perpetuation an art form.

Richard F Heller MD, FRCP, FRACP, FAFPHM · David P Weller MPH, PhD, FRACGP, FAFPHM · Konrad Jamrozik DPhil, FAFPHM, MFPH

Objective: To compare differences in functional outcomes between urban and rural patients with traumatic brain injury (TBI).Design: A longitudinal, prospective, multicentre study of a 2-year cohort from the Brain Injury Rehabilitation Program (BIRP) for New South Wales, with follow-up at 18 months after injury.Participants: 198 patients (147 urban, 51 rural) with severe TBI from the 11 participating rehabilitation units.Main outcome measures: Demographic and injury details collected prospectively using a standardised questionnaire, and measures from five validated instruments (Disability Rating Scale, Mayo–Portland Adaptability Inventory, Sydney Psychosocial Reintegration Scale, Medical Outcomes Study Short Form and the General Health Questionnaire – 28-item version) administered at follow-up to document functional, psychosocial, emotional and vocational outcomes.Results: Demographic details, injury severity, lengths of stay in intensive and acute care wards were similar for both rural and urban groups. There were no significant group differences in functional outcomes, including return to work, at follow-up.Conclusions: Our findings contrast with previous research that has reported poorer outcomes after TBI for rural residents, and suggest that the integrated network of inpatient, outpatient and outreach services provided throughout NSW through the BIRP provides effective rehabilitation for people with severe TBI regardless of where they live.

Peter G Harradine MB BS, FAFRM (RACP) · Julie B Winstanley PhD, CStat · Robyn Tate MPsychol, PhD · Ian D Cameron MB BS, PhD · Ian J Baguley MB BS, FAFRM · Ross D Harris PhD, MA

Objective: To determine the changes in availability of neonatal intensive care for extremely low birthweight (ELBW) infants, and the consequences of a lack of availability.Design and setting: Population-based cohort study of consecutive ELBW infants born in the state of Victoria during four distinct eras.Participants: All livebirths weighing 500–999 g in Victoria in the calendar years 1979–1980 (n = 351), 1985–1987 (n = 560), 1991–1992 (n = 429), and 1997 (n = 233).Main outcome measures: Changes over time in the proportions of ELBW infants offered intensive care, the proportions that were “outborn” (born outside level 3 perinatal centres), and their survival rates and quality of survival compared with “inborn” infants.Results: The proportions of ELBW infants offered intensive care increased over time and were significantly higher in heavier infants. The proportion of outborn ELBW infants was 30% in 1979–1980, falling to 9% by 1997. The difference in survival rates between inborn and outborn infants widened progressively over time: the survival advantages for inborn infants over outborn infants were 12.0% in 1979–1980, 30.1% in 1985–1987, 36.5% in 1991–1992, and 43.6% in 1997. For survivors, the quality of life was significantly better for inborn infants in two of the four eras.Conclusions: Neonatal intensive care has been increasingly available for ELBW infants in Victoria over the period 1979 to 1997. The gap in survival rates between outborn and inborn infants has widened, and the quality of life of outborn survivors is inferior.

for the Victorian Infant Collaborative Study Group*

Objective: To determine the prevalence and types of deliberate self-harm (DSH) in adolescents, and associated factors.Design: A cross-sectional questionnaire study.Participants and setting: 3757 of 4097 Year 10 and Year 11 students (91.7%) from 14 high schools on the Gold Coast, Queensland, during September 2002.Main outcome measures: DSH behaviour, including descriptions of the last act, psychological symptoms, recent stressors, coping styles, help-seeking behaviour, lifestyle choices, and self-prescribing of medications.Results: 233 students (6.2%) met the criteria for DSH in the previous 12 months, with DSH more prevalent in females than males (OR, 7.5; 95% CI, 5.1–10.9). The main methods were self-cutting (138 respondents; 59.2%) and overdosing with medication (69 respondents; 29.6%). Factors associated with DSH included similar behaviours in friends or family, coping by self-blame, and self-prescribing of medications. Most self-harmers did not seek help before or after their most recent action, with those who did primarily consulting friends.Conclusions: DSH is common in Australian youth, especially in females. Preventive programs should encourage young people to consult health professionals in stressful situations.

Diego De Leo MD, PhD, FRANZCP · Travis S Heller BSc(Hons), BA

Objective: To conduct a systematic review of studies on clinically relevant digital mobile phone electromagnetic interference with medical equipment.Data sources: MEDLINE and SUMSEARCH were searched for the period 1966–2004. The Cochrane Library and Database of Abstracts of Reviews of Effects were also searched for systematic reviews.Study selection: Studies were eligible if published in a peer-reviewed journal in English, and if they included testing of digital mobile phones for clinically relevant interference with medical equipment used to monitor or treat patients, but not implantable medical devices.Data synthesis: As there was considerable heterogeneity in medical equipment studied and the conduct of testing, results were summarised rather than subjected to meta-analysis.Results: Clinically relevant electromagnetic interference (EMI) secondary to mobile phones potentially endangering patients occurred in 45 of 479 devices tested at 900 MHz and 14 of 457 devices tested at 1800 MHz. However, in the largest studies, the prevalence of clinically relevant EMI was low. Most clinically relevant EMI occurred when mobile phones were used within 1 m of medical equipment.Conclusions: Although testing was not standardised between studies and equipment tested was not identical, it is of concern that at least 4% of devices tested in any study were susceptible to clinically relevant EMI. All studies recommend some type of restriction of mobile phone use in hospitals, with use greater than 1 m from equipment and restrictions in clinical areas being the most common.

Nathan Lawrentschuk MB BS · Damien M Bolton FRACS, MD

The prevalence of peripheral arterial disease (PAD) in people aged over 55 years is 10%–25% and increases with age; 70%–80% of affected individuals are asymptomatic; only a minority ever require revascularisation or amputation. Patients with PAD alone have the same relative risk of death from cardiovascular causes as those with coronary or cerebrovascular disease, and are four times more likely to die within 10 years than patients without the disease. The ankle–brachial pressure index (ABPI) is a simple, non-invasive bedside tool for diagnosing PAD — an ABPI less than 0.9 is considered diagnostic of PAD. About half of patients with PAD (defined by an abnormal ABPI) have symptomatic coronary or cerebral vascular disease. The ABPI is an independent predictor of coronary and cerebrovascular morbidity and mortality. Patients with PAD require medical management to prevent future coronary and cerebral vascular events. There are currently insufficient data to recommend routine population screening for asymptomatic PAD using the ABPI.

Paul E Norman DS, FRACS · John W Eikelboom MB BS, FRACP · Graeme J Hankey MD, FRACP

Arc welding produces the full spectrum of ultraviolet radiation (UVR). It is possible that welders are at greater risk of developing skin cancer than the general population, but there is a dearth of well designed studies in this area. The only major study of the relationship between arc welding and skin cancer risk did not reveal an increased incidence of skin cancer in welders. As the welders examined were all well protected and the length-of-exposure period was limited, the findings cannot be generalised to all welders. Studies have demonstrated that welding increases the risk of ocular melanoma. Just as we urge the public to protect themselves from UVR, we need to consider similar advice for arc welders.

Anthony J Dixon FACRRM · Brian F Dixon PhD

Setting You usually see your patients and then teach outside their room. You do this because you worry that the junior medical officer or student might come up with something that will upset the patient. But recent reports suggest your concern may be unfounded. There should be no teaching without the patient for a text, and the best teaching is often that taught by the patient himself.1 This advice by William Osler, at the beginning of the 20th century, has been continually handed down since then. Osler’s style wouldn’t be acceptable today, with large rounds, and consent rarely obtained from the patient. Now, simulation is being used for teaching, but teaching that involves patients remains invaluable. Teaching with the patient rather than about the patient should be considered vital for students, junior medical officers and registrars to learn the practice of medicine. Benefits of teaching with the patientPatients like to be included in the teaching process. Case presentations by junior staff at the bedside significantly increase the time doctors spend with patients, and such patients are more likely to be satisfied with their inpatient stay.2 They prefer having students present their history in front of them than outside the door.3 Teaching with patients allows the important domains of learning to be integrated through teaching, observation and role modelling.4,5 These domains include: Clinical (knowledge, decisions, skills) Professionalism (ethics, teamwork) Communication (with patients, families and other staff).5 Teaching with the patient incorporates adult learning principles, as it is meaningful, relevant to work, and allows active involvement (see “Tips 2”6). Downsides of teaching with the patientPatients may be adversely affected by teaching in their presence if their rights are not respected,4,7 or if the teacher fails to recognise that patients may have conditions not appropriate to be discussed in front of a group.7 The patient’s perception as to the competence of the junior medical officer or registrar may be harmed by negative feedback that senior clinicians give in front of the patient. Remember that the doctors in training are the ones the patient sees on a daily basis. In some instances, the patient may be upset and confused by the discussion.2,7 Patients want to be asked for consent beforehand and to be introduced to people. They appreciate an approachable tutor, clear explanations, the opportunity to ask questions, and the feeling that their feedback is valuable.2,4 How to teach with patients in the clinical settingPlan your teaching using the “Set, Dialogue and Closure” framework (see “Tips 3”8). Important factors in teaching with patients include choosing the correct patient, obtaining consent, and explaining the patient’s role. Structure your dialogue using methods described such as the “One-minute teacher” and SNAPPS (see below). These have been shown to significantly increase learners’ motivation, their involvement in decision-making, evaluation of their knowledge, and provision of feedback.9,10 Aids to teaching with patientsThe “one-minute teacher”The “one-minute teacher”9 uses five steps to direct the learner’s focus to a key aspect of a case, and the clinician teaches around that issue. Feedback is explicitly given (a step we often omit when busy). The clinician Asks the learner to outline his or her diagnosis or management plan; Questions the learner for reasoning; Teaches general rules (take-home points); Provides feedback on what was done well; and Corrects errors and suggests what could be improved. SNAPPSIn the “SNAPPS” approach,10 the learner Summarises the case; Narrows the differential diagnosis; Analyses the differential diagnosis; Probes (asks the teacher about areas not understood); Plans management; and Selects an issue for self-directed learning. SNAPPS makes learners do most of the work, through justifying their thinking and exploring what they don’t know (rather than questioning them on what they do know!). A pilot study of SNAPPS showed that learners were more actively involved and readily came up with questions, whereas in more traditional interactions they rarely did. The teachers were relieved of having to think up questions and, instead, could respond to the learner.10 Before you try out the “one-minute teacher” or SNAPPS, orient your learners so they know what to do and expect. Take-home message When teaching with patients, remember that: Patients like being involved in teaching sessions (as long as their rights and wishes are respected). Teaching with patients incorporates adult learning principles, in that it is meaningful, relevant to work, and allows active involvement. Good communication with patients is important: ask for their consent, ensure understanding, and ask for questions and feedback. Teaching methods like the “one-minute teacher” or SNAPPS can make teaching and learning more efficient.

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

Clinical record A 33-year-old woman presented to the emergency department with a 10-day history of vesicular rash, 2 days of cough and fever, and 12 hours of dyspnoea, malaise and facial swelling. Her three children were recovering uneventfully from chickenpox. She had no past history of varicella infection or vaccination. She was a non-smoker, had no pre-existing medical conditions and was not known to be pregnant at the time of presentation. On presentation, the patient was in respiratory distress, with a respiratory rate of 36 per minute, pulse of 140 bpm, and oxygen saturation of 72% in room air. Subcutaneous emphysema was noted over the upper chest wall. Multiple healing and healed vesicles were present. The provisional clinical diagnosis was pneumonia, in the presence of resolving varicella. Results of blood tests on admission are shown in Box 1. Blood film demonstrated neutrophilia with toxic changes. Chest x-ray revealed pneumomediastinum and subcutaneous emphysema, while computed tomography showed pneumomediastinum and consolidation in the left upper lobe with cavitation (Box 2A). Electrocardiography revealed sinus tachycardia with paroxysmal atrial fibrillation. The patient was admitted to the intensive care unit with acute respiratory failure. Antimicrobial therapy was begun with ceftriaxone, flucloxacillin and aciclovir based on the clinical diagnosis of pneumonia with cavitation in a patient with active varicella. Blood cultures revealed gram-positive cocci in chains after 24 hours of incubation; intravenous clindamycin was added to the antibiotic regimen. The next morning cultures of blood and bronchoalveolar fluid confirmed the presence of Streptococcus pyogenes (group A streptococcus). Uncontrolled sepsis progressed within hours to multiorgan failure, precipitated by an overwhelming systemic inflammatory response syndrome. Clinical features were consistent with streptococcal toxic shock syndrome, with the primary streptococcal infection being pneumonia. Intensive care management included haemofiltration for acute renal failure; inotropic support for septic shock; invasive lung ventilation for respiratory failure (acute respiratory distress syndrome); activated protein C for the systemic inflammatory response syndrome; and infusion of intravenous gamma globulin for toxic shock syndrome, and fresh frozen plasma and platelets for coagulation dysfunction and thrombocytopenia. Despite maximal support, the patient died 44 hours after presentation. An autopsy confined to the chest and abdomen showed interstitial emphysema involving the mediastinum, pericardium and left upper lobe of the lung, and extensive necrotising left bronchopneumonia with abscess formation, but no signs of pneumothorax (Box 2B). Numerous gram-positive cocci consistent with streptococci were evident on microscopy of lung sections. Varicella zoster virus DNA was detected by polymerase chain reaction in one of three tissue samples tested, but no viral cytopathic changes were seen, and no virus was detected by culture. Varicella (chickenpox) is a highly infectious disease caused by varicella zoster virus. Monthly notifications in Australia fluctuate from 40 to 180, with three to four deaths yearly.1 Varicella zoster pneumonia with interstitial pneumonitis and respiratory distress syndrome is a well recognised complication which occurs more frequently in adults than children (particularly smokers, pregnant women and those who are immunocompromised). Despite the presence of varicella zoster virus DNA, there was no histological evidence that varicella pneumonia predisposed to the development of secondary group A streptococcal pneumonia in this case. In children, varicella is a well recognised predisposing condition for invasive group A streptococcal infection, preceding 15% of recorded cases of this infection in a recent Canadian study.2 The most common manifestation of invasive group A streptococcal infection is necrotising fasciitis, a serious but rare infection of the deeper layers of skin and fatty subcutaneous tissues. This is one of the fastest-spreading infections known, consuming tissue at a rate of up to 3 cm per hour.3 Pneumonia is a less common manifestation but has a higher fatality rate (38% versus 12% for necrotising fasciitis), with a reported median survival of 2 days.4 In adults, varicella is less common as a predisposing condition for invasive group A streptococcal infection, but cases have been reported of varicella gangrenosum with limb-necrotising fasciitis and toxic shock syndrome5 and of septic arthritis6 secondary to group A streptococcal infection after chickenpox. The speed of the patient’s demise and the presence of streptococcal bacteraemia and streptococci in postmortem lung tissue supports S. pyogenes as the pathogen causing death in this patient. Pneumomediastinum has many causes, particularly barotrauma and other forms of trauma, but is rare secondary to pneumonia and pulmonary abscess. We believe that this is the first case of group A streptococcal pneumonia with mediastinal gas leakage recorded in Australia. Pneumomediastinum occurring ultimately as a complication of varicella has similarly not been reported previously in this country. Primary vaccination of children is now recommended,7 but is not federally funded. Vaccination of adolescents and adults should also be strongly considered, as these age groups are more at risk of severe or lethal complications, including overwhelming secondary infection. Once invasive group A streptococcal infection is clinically suspected, it can be confirmed bacteriologically by culture of blood or affected tissue. Early medical treatment with intravenous penicillin and clindamycin is indicated. When infection is associated with streptococcal toxic shock syndrome, normal human immunoglobulin reduces organ failure and possibly mortality.8 Aggressive surgical debridement is critical for invasive fasciitis or myositis. However, in our patient, surgical debridement of affected pulmonary and mediastinal tissue was not an option. The prognosis was clearly extremely poor at presentation. The illness could have been prevented by varicella vaccination. Lessons from practice Varicella in adults is potentially serious, with a significant risk of very severe secondary bacterial infection. Varicella zoster pneumonia with interstitial pneumonitis and respiratory distress syndrome is a well recognised complication of varicella, and is more common in adults than children, particularly smokers, pregnant women and those who are immunocompromised. Varicella vaccination, although not federally funded, is recommended for children and should be strongly considered in adolescents and adults because of their higher risk of severe and lethal complications. Invasive group A streptococcal infection spreads rapidly and is often fatal; if suspected clinically, treatment should be begun urgently with intravenous penicillin and clindamycin; the addition of intravenous immunoglobulin for toxic shock should be considered, and surgical debridement for invasive fasciitis or myositis. 1 Results of blood tests in a patient with complications from varicella Test Result Normal range On admission Serum sodium (mmol/L) 121 135–145 Serum potassium (mmol/L) 3.4 3.2–4.5 Serum chloride (mmol/L) 79 100–110 Urea (mmol/L) 47.7 3.0–8.0 Creatinine (mmol/L) 0.48 0.05–0.10 Albumin (g/L) 21 33–47 Globulins (g/L) 50 25–45 Bilirubin (μmol/L) 31 < 20 Alkaline phosphatase (U/L) 144 30–120 γ-Glutamyl transferase (U/L) 308 < 50 Aspartate aminotransferase (U/L) 89 < 40 Lactate dehydrogenase (U/L) 425 110–250 Prothrombin time (s) 19 8–14 Fibrinogen (g/L) 9.9 1.5–4.0 Haemoglobin (g/L) 127 110–165 White blood cell count (cells/L) 17.3 x 109 3.5–11.0 x 109 Neutrophils (cells/L) 16.2 x 109 2.0–8.0 x 109 Platelets (cells/L) 113 x 109 140–400 x 109 6 h after admission* pH 7.01 7.35–7.45 pco2 (mmHg) 54 35–45 po2 (mmHg) 87 75–100 * After intubation and ventilation. 2 Appearance of the lungs in a patient with group A streptococcal pneumonia A: Computed tomography of the chest on admission showed subcutaneous emphysema, pneumomediastinum and consolidation in the left upper lobe with cavitation. B: Postmortem examination showed extensive necrotising left bronchopneumonia with abscess formation.

Peter JO Stride FRACP, FRCP · Matthys JJ Campher FANZCA · Janice M Geary RN, GradDipInfectionControl, GradCertHealthManagement · Christopher Coulter FRACP, FRCPA · Edwina E Duhig BMedSci, FRCPA

Doctors should:

Ian H Kerridge BMed(Hons), MPhil, FRACP, FRCPA · John R McPhee BCom(Hons)(LegStud)

The way forward involves not only preventing negligence and fraud, but also facilitating therapeutic exchanges between various healthcare providers and their patients United States physicians, like their Australian counterparts, are deeply interested in the legal and ethical issues surrounding patient use of complementary and alternative medicine (CAM) therapies.1-3 Key legal questions of concern to physicians include (i) malpractice liability for negligent care and for inadequate informed consent; (ii) licensure and credentialling; (iii) scope of practice (the legally authorised practice boundaries for non-physicians, including CAM providers); (iv) regulation of dietary supplements; (v) professional discipline; (vi) third-party reimbursement; and (vii) healthcare fraud.1 This article briefly highlights key aspects of the first and second issues, comparing them, where possible, with the situation in Australia, and then brings an ethical perspective to the discussion. Duty of care regarding informed consentA major issue confronting physicians in everyday clinical practice is the extent to which they have a duty to discuss CAM therapies with their patients. Kerridge and McPhee’s article (page 164) argues that, in Australia, physicians have a “proactive and reactive” duty to do so.4 In the US, as part of the legal and ethical obligation of informed consent, physicians have a duty to disclose and discuss reasonable and feasible treatment alternatives, together with the risks and benefits of each option.2,3 While no court has yet held a physician liable for failure to disclose a CAM option, such a rule would be the logical extension of a 1993 federal appeals court case involving a patient’s claim that the physician should have disclosed the possibility of trying EDTA chelation therapy rather than bypass surgery to treat a carotid artery. The court stated that disclosure of such a therapeutic alternative would be required if the CAM therapy in question were generally accepted within the medical community.5 The question of liability connected with referring patients to CAM providers has also been of concern within the US medical community. In the US, mere referral to a medical specialist does not generate malpractice liability for the specialist’s negligence; similarly, mere referral to a CAM provider should not leave the referring physician liable for subsequent negligence by that provider.6,7 There are, however, a number of potentially applicable exceptions to this rule. The first involves delay of necessary medical treatment, resulting in patient harm.6,7 The second involves referral to a CAM provider that the referring physician knew or “should have known” might be “incompetent” (this rule suggests an obligation of due diligence in vetting both the provider’s credentials and, through reasonable inquiry, the provider’s general competence, skill, and practice).6,7 A third exception involves “joint treatment” of the patient, a fairly ambiguous term that could conceivably encompass situations in which the physician and CAM provider share information by telephone or email as part of the treatment plan.2,8 The possibility of such shared liability suggests exercising great care in selecting CAM providers to whom one will refer, and moving from a posture of distance from the CAM provider to one of closeness, in the hope of gaining a clear clinical understanding of the potential contribution — and risks — of the CAM therapeutic route and/or its interaction with conventional care. Licensure and credentiallingA second issue of concern to physicians in everyday clinical practice is understanding the legal authority that CAM providers have to deliver healthcare services. In the US, healthcare licensure is a matter of state law. Thus, there is great diversity among the states as to who can be licensed, and the scope of practice authority allocated to each class of provider by the licensing laws in each state. Across the US, the four professional groups which are licensed in most states are chiropractors (every state), practitioners of acupuncture and traditional oriental medicine (over 40 states), massage therapists (over 30 states), and naturopathic physicians (about 12 states).9,10 The numbers vary depending on what legal authority one counts as licensure to practise. For example, different forms of licensure include mandatory licensure, title licensure, mere registration, and combinations of these. In addition, a number of states allow a wide variety of unlicensed CAM providers to practise under certain circumstances.11 Further, compared with the limited scope of practice allocated by licensing laws to both allied health professionals (such as nurses and physical therapists) and CAM providers (such as chiropractors and acupuncturists), physicians in the US have an “unlimited” scope of practice, which means they can generally use all methods that their profession generally accepts as safe and effective to treat a given disease.1 However, there are several caveats. When physicians practise CAM therapies such as acupuncture, they must be properly trained and appropriately credentialled (although such training and credentialling requirements tend to be far less extensive than for non-physician acupuncturists);6,10 and, if they provide the patient with CAM therapies that are unsafe and ineffective, they are likely to be sued for medical malpractice and be disciplined by the state medical board.1,6 Ethical considerationsWhether or not liability results, physicians may find, at times, that their beliefs and commitment to the kind of evidence-based practice they practise in conventional care conflicts with patient interest in some CAM therapies. One useful approach to help negotiate such conflicts involves balancing the major bioethical principles (eg, non-maleficence, autonomy, beneficence, and justice) on a case-by-case basis,12 bearing in mind that shared decision-making is preferred to the older, more authoritarian model in which doctors simply disclose options without engaging patients in negotiated conversations.13 Thus, there may be a trade-off between granting the physician’s desire to avoid all harm to the patient (expressing non-maleficence), and honouring the patient’s persistent desire to try a CAM therapy for a time (expressing an autonomy interest) while continuing conventional monitoring.1,6,13 A slightly more sophisticated approach involves balancing seven factors (Box), to draw an appropriate ethical conclusion about the best course of action. This framework somewhat parallels the analysis of liability considerations in the US.6,13 For example, consider the following two cases taken from clinical practice. The patient has a premalignant condition that can be completely cured through surgery, but, if left untreated, can progress to invasive cancer. The patient tells her MD that she plans to pursue meditation, colonics and yoga, and to work with her Reiki master, rather than have surgery.13 The patient, a woman with recurrent metastatic ovarian adenocarcinoma, asks her oncologist to provide her with conventional treatment, but to be open to evaluating and guiding her regarding available CAM therapies.13 In the first case, the patient’s illness can be cured with conventional, although invasive, treatment (surgery); the evidence for CAM is low, but the patient understands and accepts the risks, and insists on trying CAM therapies. It would be ethical for the physician to allow the patient to try her regimen of CAM therapies, as long as she continues to monitor her condition conventionally.13 If the risk of cancer increases past a tolerable threshold, the physician should intensify attempts to persuade the patient that it is time to return to conventional methods of treatment.13 In the second case, the clinician should be aware of pertinent evidence and be willing to consider any intervention (CAM or allopathic) that has an acceptable risk–benefit balance.13 Whatever approach is used, physicians are still learning ways to fruitfully discuss integration of CAM therapies with their patients, as differing value systems and bases of knowledge about these therapies may leave a gap that only skilful negotiation can bridge.14 In this respect, the question is less about legal rules alone and more about relationship, conversation, and how the law may help or hinder these. The way forward for Australian legislators, judges and policymakers, as for their US and international counterparts, involves focusing not only on preventing negligence and fraud, but also on finding ways to facilitate therapeutic exchanges between a variety of healthcare providers and their patients.8 Framed in this light, the need for international dialogue around common legal and ethical issues pertinent to CAM therapies becomes ever clearer. Framework of considerations for drawing ethical conclusions Severity and acuteness of illness Curability with conventional treatment Invasiveness, toxicities, and side effects of conventional treatment Quality of evidence of safety and efficacy of the CAM treatment Degree of understanding of the risks and benefits of conventional and CAM treatments Knowledge and voluntary acceptance of those risks by the patient Persistence of patient’s intention to use CAM treatment

Michael H Cohen JD

Christine B Phillips,* Suzanne Manning† * Senior Lecturer, Academic Unit of General Practice and Community Health, Australian National University Medical School, PO Box 254, Jamison Centre, Jamison, ACT 2614; † Intern, Department of Psychology, Australian National University, Acton, ACT. christine.phillipsATcalvary-act.com.au To the Editor: Since 1999, most asylum seekers in Australia who have been detained and subsequently found to be genuine refugees have been issued temporary protection visas (TPVs). Missing from much of the debate about management of asylum seekers has been the impact of the provisions of TPVs on children. A comparison of the entitlements of refugees on permanent and temporary protection visas is given in Box 1. To estimate the proportion of TPVs issued to children under 18 years of age, we analysed data provided by the Department of Immigration and Multicultural and Indigenous Affairs (DIMIA). The denominator population was drawn from data on numbers of temporary and permanent protection visas issued between June 1999 and June 2002.1,2 Numerator data were drawn from information provided by DIMIA on request.3 As shown in Box 2, we found that between October 1999 and June 2002, 23% of all TPVs were issued to children under the age of 18. Some of these children are now over 18 years of age. However, as children born to TPV holders in Australia are also given TPV status, more children will be recruited into this visa category. Australia is a signatory to the UN Convention on the Rights of the Child, which enshrines key rights for children, such as the right to health and safety.4 However, we believe that several of these basic rights are undermined by the lack of provisions afforded to TPV holders: they are prohibited from sponsoring family members, and they have limited access to settlement services for refugees (Box 1). Withholding of family reunion provisions increases the risks for children, as it makes it more likely that parents will take their children with them when they undertake hazardous travel to seek asylum. This is in contrast to the traditional model of families sending an index person, who then sponsors other family members. The lack of a comprehensive settlement package for TPV holders, and the temporary and indeterminate nature of the visas, is likely to compound the psychological distress experienced by both adult and child refugees. Children who have experienced ongoing adversity are vulnerable to developing psychological disorders.5 The children of TPV holders must also live in families where the parents bear an ongoing burden of fear and destabilisation. The effects of TPVs are borne by large numbers of children. There is a need for concerted advocacy by health professionals to ensure that the health consequences of TPVs for children are recognised and addressed. Addendum 13/07/04. While a recent federal government initiative will allow current Temporary Protection Visa holders to apply for permanent Australian residency, we urge ongoing review of refugee visas. 1 Comparison of entitlements of refugees on permanent and temporary protection visas Services funded by the Australian Government Refugees with permanent visas Refugees with temporary protection visas Settlement services Translating and interpreting service Eligible Not eligible Accommodation support Eligible Not eligible Assistance from Migrant Resource Centre Eligible Not eligible Early health and intervention service Eligible Eligible Torture and trauma counselling Eligible Eligible English language tuition Free tuition for adults and children Adults not eligible. Children eligible from July 2002 Family reunion May apply to sponsor family members Not eligible Employment Access to all assistance programs Not eligible except for most basic services Income support Eligible for full range of social security benefits Restricted entitlements Medicare Eligible Eligible Education Primary and secondary education Eligible Eligible Tertiary education Eligible for HECS Must pay upfront fees Travel Right of return if holder travels overseas No right of return if holder leaves country HECS = Higher Education Contribution Scheme. 2 Proportion of temporary protection visa (TPV) holders who were children when visa was granted (1999–2002) Years* No. of TPVs granted No. (%) < 18 years when TPV granted 1999–2000 871 108 (12.4%) 2000–01 4456 907 (20.3%) 2001–02 3196 952 (29.8%) Total 8523 1967 (23.1%) * Financial years.

Christine B Phillips · Suzanne Manning

Kim Hoe Chan,* Murugasu Segasothy† * Medical Registrar, † Associate Professor of Medicine, NT Clinical School of Medicine of Flinders University, Alice Springs Hospital, PO Box 2234, Alice Springs, NT 0871 m.segasothyATnt.gov.au To the Editor: A recent review suggests that acute rheumatic fever, osteoarthritis and systemic lupus erythematosus account for most rheumatic disease in Australian Aboriginals, and comments on the rarity of gout.1 Although the increased prevalence of hyperuricaemia in Aboriginals compared with non-Aboriginals has been described,2 clinical attacks of gout in Aboriginals have so far been extremely rare.1,3 This is in sharp contrast to various Polynesian and other indigenous populations, including Mäori in New Zealand, Filipinos in Hawaii and Alaska, Chamorros and Carolinians in the Marianas Islands, and Taiwanese aborigines. In these populations, increased prevalences of both hyperuricaemia and gout have been documented.4,5 In an extensive literature search, we found only one report of confirmed acute gouty arthritis in an Australian Aboriginal with normal renal function,3 although there have been several Aboriginals in the “Top End” with crystal-confirmed gout in association with chronic renal impairment.1 Between January 2001 and April 2004, we identified seven new cases of acute gouty arthritis in Aboriginals (Box), confirmed by joint aspiration revealing monosodium urate monohydrate crystals. Three of these patients had confirmed acute gouty arthritis without renal impairment. This series also includes the first reported cases of gouty arthritis in Aboriginal women. Our findings suggest that the prevalence of acute gouty arthritis in Australian Aboriginals is much higher than previously reported. Discussion with physicians at Alice Springs Hospital revealed that they too have encountered gouty arthritis in Aboriginals, but whether this was confirmed by joint aspiration is not known. It appears that gout has been misdiagnosed or under-reported, or both. Further epidemiological studies should be undertaken to confirm this hypothesis, and we must have a higher index of suspicion for gout when an Aboriginal patient presents with an arthropathy, as gout is a potentially disabling and yet easily treatable condition. Aboriginals with acute gouty arthritis, Alice Springs Hospital, January 2001 – April 2004 Age (years) Sex UA level (mmol/L) Site of joint aspiration Possible precipitating factors Joints involved 46 M 0.37 Right knee Alcohol Right knee 44 M 0.45 Right knee Acute renal failure, alcohol Right knee, left first metatarsophalangeal joint, left ankle 65 M 0.23 Right knee Renal transplant, cyclosporin Right knee, right foot 64 F 0.50 Right knee Chronic renal impairment Both ankles and first metatarsophalangeal joints, right knee 61 F N/A Right knee Acute-on-chronic renal failure, alcoholism Right knee 51 M 0.48 Left knee None identified Left knee 35 M 0.54 Right knee None identified Both ankles, right knee UA = uric acid. Reference range, 0.20–0.45 mmol/L. N/A = not available.

Kim Hoe Chan · Murugasu Segasothy

Michael J Sinnott Emergency Physician, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, QLD 4102 michael_sinnottAThealth.qld.gov.au To the Editor: In physiology, the Frank–Starling curve demonstrates that cardiac muscle initially responds to an increased workload with an increased force of contraction.1 However, after the point of maximum efficiency is reached, further workload produces a decrease in both the force of contraction and the ejection fraction, leading to cardiac failure. It now appears that the same curve could describe the current situation in many Australian emergency departments. We used to operate at point A on the curve (Box). If there was a mini-disaster or a moderately large number of victims of a road accident, the department was able to increase output to cope with the situation. The “adrenalin stimulation” experienced by all members of the team meant that the department coped, and that staff were left with a sense of satisfaction. Now our department finds itself at point B on the curve. Extra workload can result in a decrease in performance and output. The patients obviously suffer, but so do the staff. The once-challenging and enjoyable parts of the job now generate frustration and exacerbate the background dysfunction. On a recent weekend, the emergency department experienced an influx of sick elderly patients as a result of a local heatwave, with temperatures reaching 42°C. The problem was identified as a mini-disaster only in retrospect. At the time it was thought to only exemplify another bad day. This is an example of the syndrome of “learned helplessness”2 that staff are experiencing. Politicians and health administrators need to understand that our public hospital emergency departments are struggling with their daily workloads and are no longer equipped to deal with medium- to large-scale emergencies. Access block as a medical model At point A, an increase in workload leads to increased performance to cope (moving to point A1). At point B, an increase in workload leads to a decrease in performance (to point B1).

Michael J Sinnott

Stacey L Emmett,* Joseph E Ibrahim,† Amanda Charles,‡ David L Ranson§ * Research Officer, † Physician, ‡ Clinical Research Nurse, § Deputy Director, Clinical Liaison Service, Victorian Institute of Forensic Medicine and the State Coroner’s Office, 57–83 Kavanagh Street, Southbank, VIC 3006 staceyeATvifm.org To the Editor: The Royal College of Pathologists of Australasia Autopsy Working Party highlighted the decline in the numbers of hospital autopsies.1 Forensic and hospital autopsies are a valuable safety and quality tool for improving healthcare systems. Autopsies provide an accurate cause of death and are a valuable audit tool to evaluate medical diagnostic processes and therapeutic interventions. Declines in both types of autopsies are cause for concern. A forensic autopsy is an integral part of the coronial process. The Coroner’s role is to establish the identity of the deceased, where he or she died, the cause of death and, perhaps most importantly, how the person died.2 Without an autopsy, it can be difficult to determine the cause of death. At the Victorian Institute of Forensic Medicine (VIFM), about 80% of all deaths that are reported to the State Coroner (in Melbourne and Geelong) undergo a full forensic autopsy. Senior next-of-kin can object to an autopsy being performed. Section 29 of the Coroner’s Act 1985 (Vic) details the objection process.2 The decision to grant an objection is dependent on the opinion of the Coroner and his or her view on the circumstances of death. We reviewed the number and rate of forensic autopsies performed by the VIFM between 1992 and 2002, as well as the number and rate of objections under Section 29. The rate of forensic autopsies remained relatively stable over the decade, at 80% of deaths reported to the State Coroner. There were 94 successful Section 29 applications in 1992. This accounted for 3.25% of all deaths reported to the Coroner. Objections to autopsies have been steadily increasing since 1992. In 2002, there were 212 successful applications, accounting for 7.1% of all deaths reported to the Coroner and representing about a 4% rise over the decade. When a coronial autopsy has been requested, but not carried out because of a Section 29 objection, substantial additional work is required. This includes medical record reviews; external forensic examinations; reviews of statements from treating doctors, independent experts and family; and inquests. The other major ramification associated with objections to autopsies is the discrepancies between causes of death that are determined clinically and at autopsy (with 28% of presumed causes wrong in one study).3 Without an autopsy, important pathology may remain unrecognised, and this can substantially affect the accuracy of the stated cause of death. The inherent right of next-of-kin to object to coronial autopsies will remain. However, healthcare professionals and coroners need to be aware of the public health implications associated with objections to autopsies.

Stacey L Emmett · Joseph E Ibrahim · Amanda Charles · David L Ranson

Gaston R B Arnolda Honorary Associate, Department of Public Health, University of Sydney, QEII Institute for Mothers and Babies, Building DO2, Sydney, NSW 2006. garnoldaATperinatal.usyd.edu.au To the Editor: O’Grady and Noland, concerned about the consequences of privacy legislation,1 draw attention to “. . . the findings of an Australian survey in which 61% of adults believe that even their de-identified health information should not be used for research purposes without their consent”. Unfortunately, they do not point out that the survey,2 commissioned by the Office of the Federal Privacy Commissioner, had a 20% response rate, making it effectively useless in determining what Australian adults really think about the use of their de-identified health information. Alarmed at the possibility that “evidence” of this quality could be used to aid decision-making that had important implications for rigorous research, I turned to Google (<www.google.com>) for assistance. A Google search using the words “61% de-identified health information roy morgan” generated 21 hits, 15 of them unique, and only five related to the subject. One of the five was the letter by O’Grady and Noland, one was the report of the survey, and three specifically cited this survey result: Privacy Victoria,3 Privacy NSW,4 and the Office of the Federal Privacy Commissioner5 all used the result in formal submissions to reviews of privacy-related issues — without revealing the survey’s appalling response rate. We have privacy commissioners who are powerful advocates of the principles of respect for privacy and autonomy. Perhaps the time has come for Australia to have “public interest commissioners” who can powerfully advocate for the public interest in high-quality health research.

Gaston R B Arnolda

Gary C Morgan Executive Chairman, Roy Morgan Research Pty Ltd, PO Box 2282U, Melbourne, VIC 3001. Gary. MorganATroymorgan.com In reply: In a world in which people are increasingly busy and mobile, increasingly concerned about invasions of privacy and increasingly approached to participate in surveys, survey response rates that could be readily achieved 25 years ago are now very much more difficult to attain. High response rates (ie, 60% and over) are still very desirable and can still be achieved. We have conducted surveys on sensitive issues, such as drug-taking, and achieved response rates that would probably satisfy even Arnolda. But this requires very intensive field activity that is not always justified by the nature of the project. The survey in question was not a health survey. It set out to provide general background information, exploring comparative levels of concern about, and the relationships between, a very wide range of privacy issues on a scale adequate to allow relatively small groups within the population to be examined. It was not intended to yield precise and critical measurements. Measures of “concern” or “reluctance” are highly context-dependent, “soft” measures, subject to interpretation, both by the respondents and by end-users. External validity is therefore not the issue: a response rate of 80% would not have made the figures demonstrably more “accurate”. Given the imprecise nature of the measures obtained, overengineering the sample relative to other components of the survey design would have been a waste of (public) money, better devoted to further research. The survey was part of a wider-ranging project and was planned in close consultation with the Office of the Privacy Commissioner in the light of their needs and priorities. It is appropriate that this issue arose out of a debate on privacy. As privacy constraints bite harder, whether imposed by statute or codes of practice, or arising through increasing resistance from subjects, medical researchers are going to have to come to terms with problems of non-response in the same way that social-survey researchers have. How are researchers going to react when only 20% of potential subjects consent to have their information used? Will they use words like “appalling” and “effectively useless” to dismiss any studies based on such a subset? Or will they perhaps learn to use them, with due caution, for the valuable information they nevertheless contain? One does not have to look very far in the history of medicine or public health to find major advances in knowledge using less than perfect statistics.

Gary C Morgan

Sharon J Gardiner,* Evan J Begg,† Carl M J Kirkpatrick,‡ Robert B Buckham¶ * Drug Information Pharmacist, † Professor of Medicine, Christchurch School of Medicine and Health Sciences, Private Bag 4345, Christchurch, NZ; ‡ Lecturer, School of Pharmacy, University of Queensland, Brisbane; ¶ Drug Information Pharmacist, Christchurch Hospital, NZ sharon.gardinerATcdhb.govt.nz To the Editor: We wish to commend the Australasian Diabetes in Pregnancy Society (ADIPS) ad hoc working party for providing an update on the safety of metformin in pregnancy.1 However, we would like to comment on the information they provided on the safety of this drug in breastfeeding. Metformin can be regarded as a well studied drug with respect to its distribution into human breastmilk;2,3 most drugs are not as well served in this regard. As Simmons et al indicated,1 the infant “dose” in breastmilk is small at less than 0.4% of the maternal dose, corrected for body weight. This is substantially lower than the arbitrary cut-off of 10% used to guide drug use during lactation and thus implies safety.4 Further evidence for the safety of this drug in breastfeeding arises from failure to detect metformin in blood sampled from four of six infants exposed via breastmilk (limit of detection, 5–10 μg/L) and lack of adverse effects noted in nine exposed infants.2,3 Simmons et al stated that infant exposure to metformin could be reduced by breastfeeding immediately before maternal dose ingestion and then avoiding feeding for at least 2–3 hours after the dose. For drugs with a short elimination half-life, this recommendation — avoiding feeding at peak drug concentrations in the milk — may reduce infant exposure. However, this is not the case for metformin. Two studies investigating metformin in breastfeeding have shown that the metformin peak plasma concentration occurs about 2–4 hours after the dose, while milk concentrations are “flat” across the entire dosing interval. This is distinctly different from most drugs, in which the drug concentrations in milk mimic the rise and fall of plasma concentrations, consistent with passive diffusion.2,3 The flat profile observed with metformin raises the possibility that the distribution of metformin into or out of breastmilk may involve an active process such as organic cation transporter(s), in addition to passive diffusion Given this unusual concentration profile in breastmilk, infant exposure (albeit small) will not be reduced by the practice of avoiding breastfeeding for a few hours after maternal dose ingestion, as suggested by Simmons et al. In other words, mothers may feed their infants at any time during the dosing interval and this will not affect infant exposure to metformin. We believe that there is sufficient evidence for metformin to be considered a safe therapeutic option in the treatment of diabetes or polycystic ovary syndrome in breastfeeding mothers, with the usual caveat of weighing up the risk–benefit ratio in each case.

Sharon J Gardiner · Evan J Begg · Carl M J Kirkpatrick · Robert B Buckham

David Simmons,* Barry N J Walters,† Janet A Rowan,‡ H David McIntyre§ * Professor of Medicine, Waikato Clinical School, Waikato Hospital, Hamilton, NZ; † Clinical Associate Professor, Department of Women’s and Children’s Health, King Edward Memorial Hospital, Subiaco, WA; ‡ Physician, Department of Obstetrics, National Women's Hospital, Auckland, NZ; § Director of Endocrinology, Mater Hospital, Brisbane, QLD. simmonsdATwaikatodhb.govt.nz In reply: We thank Gardiner et al for their commendation and support for our update on the safety of metformin in pregnancy.1 We agree with their analysis regarding the timing of the use of metformin during lactation. Nevertheless, we would like to highlight that the safety of metformin can not be assumed from the studies they quote, as these included very few subjects. Such studies, helpful as they may be, provide no imprimatur for the long-term safety for the growing infant and subsequent adult. While no babies had side effects reported during these studies, this may not be the case for other babies. Should a woman decide against the use of insulin to control hyperglycaemia postnatally, then the risk of potential known and unanticipated side effects of metformin should be discussed while obtaining informed consent for metformin use. However, during this discussion, it would also be prudent to weigh-up metformin use against breastfeeding with continued hyperglycaemia, an activity associated with greater obesity and impaired glucose tolerance in the offspring.2

David Simmons · Barry N J Walters · Janet A Rowan · H David McIntyre

Clive D Hadfield Gastroenterologist, 30 Megan Street, Cairns, QLD 4870. chadfieldATaustarnet.com.au To the Editor: In their recent study, Scott and colleagues demonstrated benefit from a program to standardise clinical management of cardiac conditions in Queensland hospitals.1 They found differences in the effect on “low-intensity intervention” hospitals compared with “high-intensity intervention” hospitals. The former were, by and large, district-type hospitals and the latter tertiary hospitals. The study found that about 50% more patients in the larger hospitals had assessments of left ventricular function. Three times as many patients in the larger hospitals accessed rehabilitation. Nearly three times as many patients in the smaller hospitals were readmitted with a diagnosis of acute coronary syndrome within 30 days, perhaps a surrogate for angiography rates, which were not reported differentially. It may be that the most urgent intervention required is “high-intensity” funding of district hospitals, so that they can achieve rates of echocardiography, rehabilitation and coronary angiography approaching those of tertiary hospitals. This intervention would need no further justification than that the population served by the district hospitals has paid its share for these treatments. Let us hope that the remaining comparative outcome data are published.

Clive D Hadfield

Ian A Scott,* Irene C Darwin,† Kathy H Harvey,‡ Andy B Duke,§ Nicholas D Buckmaster,¶ John Atherton,** Hazel E Harden,†† Michael Ward,‡‡ for the CHI Cardiac Collaborative * Director of Internal Medicine, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, QLD 4102; † Program Manager, ‡ Project Manager, § Senior Analyst, Collaborative for Healthcare Improvement, Queensland Health; ¶ Director of Medicine, Caboolture Hospital; ** Director of Cardiology, Royal Brisbane Hospital; †† Program Manager, Integrating Strategy and Performance, Queensland Health; ‡‡ Program Director, Queensland Health Skills Development Centre, Royal Brisbane Hospital. ian_scottAThealth.qld.gov.au In reply: We agree with Hadfield that optimising cardiac care may require extra resources targeted at increasing access of patients in regional Queensland to specific interventions, such as coronary angiography, cardiac rehabilitation and echocardiography, in addition to the quality-improvement strategies used within our collaborative. We contend that both approaches are necessary, and that the magnitude of improvement achieved by either will depend on the intensity with which they are applied. Indeed, the “high-intensity” quality-improvement hospitals in our study were defined on the basis of more funding being made available to undertake quality-improvement activities at those sites. We concede that some of the differences in quality indicators between “high-intensity” and “low-intensity” quality-improvement hospitals may be attributable to inequities in capital expenditure on service delivery that we did not measure. However, some of the differences may have also arisen from variation in systems for identifying and referring those patients who have most to gain from receiving the care targeted by our collaborative.

Ian A Scott · Irene C Darwin · Kathy H Harvey · Andy B Duke · Nicholas D Buckmaster · John Atherton · Hazel E Harden · Michael Ward

Barry E Christophers Retired General Practitioner, 1/12 Tollington Avenue, East Malvern, VIC 3145 To the Editor: I write concerning the recent article about my letters to the MJA in the 1950s and 1960s drawing attention to Indigenous health issues.1 Mention is made in the article of the campaign waged by the Federal Council for the Advancement of Aborigines and Torres Strait Islanders concerning the exclusion of Queensland Aboriginal patients with tuberculosis from the generous allowance paid to other TB patients. This campaign was successful. The Tuberculosis Act was amended so that Aboriginal people were not excluded from receiving this allowance. The Australian Medical Association supported this campaign. Without its support it would have failed.

Barry E Christophers

Subhash C Arya,* Nirmala Agarwal† * Clinical Microbiologist; † Chief of Gynaecology and Obstetrics, Sant Parmanand Hospital, 18 Alipore Road, Delhi-110054, India. subhashjiAThotmail.com To the Editor: The recent editorial by Burgess and McIntyre on the recommended vaccination schedules in Australia1 points to the fiscal constraints on offering the new, costlier vaccines. Overcoming these constraints would not be insurmountable if vaccinations were to be linked with annual festivals and celebrations in the life of individuals and the community. Birthday celebrations are important for infants and preschool children. Rather than giving conventional birthday gifts, varicella vaccine, costing $40, would be most appropriate. For those in the sixth or higher decades of life, gifts of influenza vaccine, 23-valent pneumococcal polysaccharide vaccine or the adult formulation of the diphtheria–tetanus vaccine would be memorable on Mother’s Day or Father’s Day and silver, golden or platinum wedding anniversaries. Similarly, slight adjustments to the allocation of funds for celebrating festivals such as Christmas and New Year, Dewali or Eid could make costly vaccines available to all. Vaccine producers, like department stores, could gear up for a Christmas vaccine sale. The public should be motivated to consider vaccines the most appropriate gifts. This is bound to address any poor coverage of costlier vaccines, such as varicella or the pneumococcal polysaccharide vaccine.

Subhash C Arya · Nirmala Agarwal

Don Wurth died on 31 March 2004, after a 5-year decline with Lewy body dementia. He was a 50-year member of the Australian Medical Association. Don was born in Sydney on 1 January 1921, the oldest son of Wallace Wurth. He attended Fort Street High School and Sydney High School, and studied medicine at the University of Sydney, doing a compressed course during the war years. Don did his residency at Sydney Hospital, where all-night poker games featured prominently. His father, Director General of Manpower for the Commonwealth, keen to avoid any impression of privilege, made sure Don was one of the first in his year to enlist in the Army. After training at various camps, he was in the first wave landing at Balikpapan in Borneo. He gained valuable surgical experience in field hospitals. After demobilisation, Don worked his passage to England as a ship’s doctor, and gained his Fellowship of the Royal College of Surgeons in London in 1949. He married Ivy Field, a theatre sister at Barnet Hospital, in 1950, and returned to Sydney later that year. He settled in the Cronulla area, and performed the first operation at Sutherland District Hospital in 1958, where he was senior surgeon. He held appointments for many years at Prince Henry and Prince of Wales hospitals and the Royal Hospital for Women. Don was a clinical lecturer at the University of New South Wales, where his father, the University’s first President and Chancellor, had been instrumental in establishing the Wallace Wurth School of Medicine. Don trained many registrars and residents during his long career. His main love, after surgery, was jazz, and he used the opportunities opened up by admission to the American College of Surgeons to attend conferences and listen to jazz in many cities in the United States. However, his favourite city was always London, to which he returned many times. Don performed his last operation in 1986, but continued working in a consultant capacity for the next 5 years. He devoted the first part of his retirement to boating, his grandchildren, and his friend Val Derwin. He is survived by Val, his former wife Ivy, and children Graham, Peter, Jonathan and David. Peter Wurth

Peter Wurth

Diet variety A US expert includes a low-carbohydrate diet (with “healthy” fats and proteins as well as regular exercise) among the methods that doctors can encourage their overweight patients to experiment with for weight control.1 Dr Walter Willett was commenting on recent randomised controlled trials that have studied such diets. One study, by Yancy and colleagues, had found that, compared with a low-fat diet, a six-month low-carbohydrate ketogenic diet program led to greater weight loss (9.4 kg v 4.8 kg) and had better participant retention (76% v 57%).2 In the low-carbohydrate diet group, fat made up an average of two-thirds of the daily energy intake. Interestingly, the low-carbohydrate dieters seemed to voluntarily reduce their energy intake. Further, on average, their blood lipid levels were not “harmed”, as has been feared with such diets; however, the researchers advised that it would be prudent to monitor the serum lipid profiles of followers of low-carbohydrate diets. Willett pointed out that individual responses to a low-carbohydrate diet may vary widely — in this study, weight loss ranged from 0 to more than 20 kg. 1. Ann Intern Med 2004; 140: 836-837 2. Ann Intern Med 2004; 140: 769-777 Who’s the boss? Cognitive therapy may help high-risk patients deal with distressing auditory hallucinations that command them to, among other things, harm themselves (eg, “set yourself alight”) or others (eg, “kill the therapist”). A UK pilot study randomised 38 such patients to receive either treatment as usual or usual treatment plus cognitive therapy for command hallucinations. Although the frequency, loudness and content of the voices heard remained the same in both study groups, the 18 patients who received cognitive therapy (a median of 16 sessions) were less likely than those who received usual care to comply with or otherwise act to appease the commanding voice or voices. Br J Psychiatry 2004; 184: 312-320 Smoking doctors 50 years on About a half to two-thirds of all persistent cigarette smokers will eventually be killed by their habit, according to an editorialist in the BMJ.1 Epidemiologist Meir Stampfer was commenting on a report of 50 years of data (1951 - 2001) from a total of nearly 35 000 male doctors who participated in the British Doctors Study.2 The study also found that stopping smoking at any age confers a survival benefit: cessation at age 60, 50, 40 or 30 years gained about 3, 6, 9 and 10 years of life expectancy, respectively. 1. BMJ 2004; 328: 1507 2. BMJ 2004; 328: 1519-1528 Supersperm In 1979, a 17-year-old patient, who needed further cancer treatment after an orchidectomy for a malignant testicular teratoma, had five ampoules of sperm from four ejaculates cryopreserved. Thirteen years later, in 1992, after radiotherapy (including to the contralateral testicle), four courses of chemotherapy and a laparotomy with resection of a retroperitoneal mass, he was discharged from follow-up and he and his partner started planning a family. A decade later, in 2002, after 3 years of trying to conceive naturally, followed by a diagnosis of persistent azoospermia, and then four IVF/intracytoplasmic sperm injection cycles using up all five ampoules of cryopreserved sperm, a son was born (3.7 kg, and healthy). The UK authors of this case report say it provides evidence that long-term cryopreservation can successfully preserve sperm quality and fertility. In this case, post-thaw sperm quality was good in all but one of the banked ejaculates, and fertilisation and fresh embryo transfer were achieved in three of the four cycles, with a take-home baby resulting from the last one. Hum Reprod 2004; 19: 1448-1449 Relieving renal colic NSAIDs are better than opioids for relieving acute renal colic, according to a systematic review conducted by Australian authors. Holdgate and Pollock reviewed 20 trials involving a total of 1613 patients that compared any NSAID with any opioid in managing acute renal colic. Although results varied widely between the individual studies, possibly reflecting the wide range of agents, doses and routes of administration described, the review found that, overall, patients taking NSAIDs had slightly better pain relief and were less likely to need rescue analgesia. Further, patients receiving opioids, especially pethidine, were more likely than those receiving NSAIDs to experience vomiting. BMJ 2004; 328: 1401-1404 Kids who need kidneys Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry data collected over four decades (from April 1963 to March 2002) have shown that, despite a trend over time towards improved survival, mortality rates for children with end-stage renal disease are 30 times higher than for other children. The long-term survival rate for 1634 children and teenagers needing renal replacement therapy was 79% at 10 years and 66% at 20 years. Authors for the Australian and New Zealand Paediatric Nephrology Association say that treatment with transplantation, rather than dialysis, may improve overall survival further, and that the challenge ahead is to reduce the incidence of cardiovascular and malignant diseases that account for the bulk of long-term mortality in children with end-stage renal disease. N Engl J Med 2004; 350: 2654-2662 Dr Ann Gregory, MJA

Ann Gregory