Volume 182 Issue 1

Modern medicine’s picture of human nature offers challenges and opportunities to the humanities There is much talk these days about “the medical humanities”, although we still await agreement on its meaning and importance. I think the key lies in appreciating how medicine and the humanities share in an endeavour larger than either alone — the endeavour of understanding the human condition. In this, medicine and the humanities have much to offer each other. My framework begins with an observation about knowledge, scientific and otherwise. All knowledge is to some extent concerned with the knower: our attempts to know things about the natural world are also part of a much larger attempt to understand ourselves (Box 1). Sometimes, this is obvious. For instance, in economics, the laws of supply and demand tell us about how we, as consumers, can be predicted to behave. It is still more obvious in the arts and humanities. Knowledge — about musical forms, the rise of impressionism in painting, Aristotelian influence on medieval Church scholars, or the ambiguous role of the narrator in the psychological novel — is knowledge about how people have tried to make sense of the world, how they saw themselves in the natural order, whether they liked what they saw, and whether they were going to “come along quietly” or were going to struggle. This is true in the natural sciences as well, even if only implicitly. When physiologists study the relations between form and function, when scientists of virtually any discipline attempt to create models of the world, they construct knowledge which not only tells us something about the world, but also something about us. They disclose and specify our need for explanation and prediction: our material need to govern our environment and to harness Nature, and our inner compulsion to understand, dissect and demystify it (Box 2). Enquiries in the natural and life sciences also raise questions about us. What is the nature of observation? How can we contain observer bias? Why do we crave simple explanations? Why do we derive such pleasure from making satisfying theoretical models? This relationship between the known and the knower has important implications for medicine’s role in our culture. Following Raymond Williams, 20th-century pioneer of cultural studies,1 I take “culture” to be the stock of meanings and purposes and shapes in a particular society (which we learn in our education and upbringing) and also the process of challenging these meanings and purposes, and making new ones. So, a “cultural good” is something that helps us learn the meanings, purposes and shapes that our society already embodies, or that helps us create new meanings, purposes and shapes. Medicine itself has a big role in this today. If knowledge implies something about the knower as well as the known, then equally a society’s meanings and purposes tell a story about that society and its members, collectively and individually. Medicine today makes a powerful, uncomfortable and as yet unchallenged claim to supplying part of that story. For me, this conclusion emerges from analysing medicine as a “cultural good”, by which I mean something that gives us resources in reflecting upon ourselves, or in articulating or expressing ourselves, or in developing ourselves, or in criticising ourselves, or in encountering ourselves — all key aspects of what it is to “tell our story”. Art or literature, history or philosophy, politics or theology are initially more obvious resources for doing these things. For instance, to reflect upon ourselves we might read a psychological novel, or study the conventions of classical Greek tragedy. To articulate or express ourselves, we might turn to social history, or to popular music, or to newly commissioned writings or public art. To develop or to criticise ourselves we might cultivate a taste for philosophy, or study the work of dramatists from Aristophanes to Arden. To encounter ourselves we might grapple with expressionist painting, and so on. Western cultures are partly defined by our habitual turning to these particular resources or cultural goods. However, I think that less obvious resources are all around us in scientific and other practices — but they are usually overlooked. And the practice that strikes me most forcefully in this regard is modern technological medical and health care (hereinafter “medicine”). So, how does medicine do these things? Reflecting upon ourselves: Modern medicine has given us new models of our own nature, seen in molecular genetics and in biological psychiatry’s story about our behaviour and character traits. Public health and preventive medicine purport to prescribe our “proper” conduct and spell out our individual responsibility, in line with the unargued assumption that good health is a self-evident benefit, rather than a contingent or instrumental one. The values that medicine presumes — such as the absolute benefit of health — show its heritage and its potency as a “cultural good”. Articulating or expressing ourselves: Medical practice has given us abundant material for artistic, literary or other creative purposes, arising, perhaps naturally, from the linear and “narrative” form that illness, disability, treatment and recovery seem to take. Thanks to the episodic form that clinical medicine acquires in individual clinical cases, intimate and compelling aspects of the experience of being human are explored in literature as diverse as Chekhov’s A case history,2 Camus’ allegorical The plague,3 and John Sayles’ film Passion fish.4 Of course, medicine is not unique in providing material for creative reflection on life’s conditions: all of lived experience does this. I simply want to note that medicine amply satisfies this characteristic of a “cultural good”. Developing ourselves: By contrast with the dominant theological determinism of earlier ages, according to which bodily suffering was seen as a necessary part of our journey through “this vale of tears”, medicine apparently offers a reassuring alternative, placing us within a flawed but eminently improvable natural world, from which we could in principle remove the deadlier stains, be they smallpox or polio or, in utopian mood, congenital anomalies. If, for most humans, life in the time of Thomas Hobbes was truly poor, nasty, brutish and short,5 medicine has already improved the odds and has ambitions to do vastly more. In the process, it has extended the range of stories we can tell about ourselves and about the human condition. It confirms our development beyond fatalism (Box 3). Criticising ourselves: Medicine has given us a vocabulary of criticism, whereby we draw on health, sickness, diagnosis and treatment for images that capture larger areas of our experience — think of “the body politic”, of “healthy” and “unhealthy” behaviour, societies or subcultures. The general idea of “diagnosis” has colonised human affairs, giving us a model of what it is to function well or badly in the social and cultural arena; we commend processes, teams and institutions for their “organic” development, and condemn them for their atrophy, decay or paralysis. Of course, this — sometimes dangerously — implies a rhetoric for action:6 to call one thing a treatment, remedy or therapy is to impugn some other things as a pathological problem in need of change. We now have “remedial” processes in education, in management, in urban regeneration. Certainly, there are grievous problems in these areas, but the vocabulary of remedy and therapy spuriously distinguishes expert agents from lay “patients” in matters where public dispute ought to remain legitimate. Encountering ourselves: This final aspect is perhaps the most interesting and suggestive. One of the conceptual foundations of medicine is the assumption that what lies beneath, or inside, holds the key to what lies outside or on the surface. Gross clinical pathology is explained by disruptive processes at the cellular or even molecular level. The once-astounding optical microscope now seems no more than a feeble and naive beginning: the slice-by-slice scanning of computed tomography, and the “unpeeling” made possible by magnetic resonance imaging, give us a new visual vocabulary for human nature (Box 4). By making the invisible become visible, we invert surface and substrate, seeming to locate the truth about ourselves at the level of physiology and neurology — rather than at the level of the ordinarily visible face and whole body, where we as selves ordinarily function and experience. The “medical body”7,8 is itself a substantial, if incomplete, story of encounter with the human condition, and one that invites critical interpretation and imaginative response. In all these respects, modern medicine is indeed a “cultural good”. The challenge that we face is to find an adequate response to the persuasive power of its reductionist picture of human nature and the human condition. Today, in the West, this picture is virtually unopposed by earlier claimants for our adherence: religious, Marxist or psychoanalytic world-views. We have an opportunity to reinvigorate enquiries into human nature within the established humanities disciplines — prominent among them being philosophy, recently rather coy about asking the real “meaning of life” questions.9 As a philosopher, it seems to me that coyness is no longer a serious option in the face of a story of human nature rooted at the molecular level. If we are to create a more satisfying conception of the human condition, it is time we recognised the need for a re-engagement between the humanities and medicine. All illustrations reprinted with permission from The illustrated history of medicine, by Jean-Charles Sournia. Published by Harold Starke. 1 The anatomist Vesalius, by Pierre Pons All knowledge is partly concerned with the knower. 2 Insulin molecule We have an inner compulsion to understand and demystify Nature. 3 Public health poster, post World War II Medicine’s promise to improve the human condition confirms our development beyond fatalism. 4 Magnetic resonance image of the brain Grey matter appears reddish-brown, and white matter green and blue.

H Martyn Evans BA, PhD

The medical humanities are concerned with “the science of the human”, and bring the perspectives of disciplines such as history, philosophy, literature, art and music to understanding health, illness and medicine. The medical humanities are designed to overcome the separation of clinical care from the “human sciences” and to foster interdisciplinary teaching and research to optimise patient care. Medical humanities have become part of the mainstream in medical education in North America and the United Kingdom, and are now integrated into many medical curricula in Australia. The Australasian Association for Medical Humanities was inaugurated in November 2004; a postgraduate program in the medical humanities began at the University of Sydney in 2003.

Jill Gordon MPsychMed, PhD, FRACGP

Story-telling can help doctors cope with the great catastrophe of illness and death Recently, I was involved in the diagnosis, suffering and, ultimately, death of my friend and patient, “Christie”. When I began to write about this experience, I thought that I was writing her story. But soon, I realised that this is my own story. Narrative, a recital of facts in the first person, has been used as a tool for people who personally experience illness. However, I believe it can be used by doctors as they try to understand the illnesses and sufferings of their patients. Christie’s storyI met Christie in my daughter’s school playground in 1989. She had recently arrived from Melbourne, and, apart from having daughters of the same age, we shared many interests. There was an instant spark. Several years after we met, I opened my own general practice and Christie came to see me as a patient. When I asked her whether she would be willing for me to do her Pap smear, she remarked that had we not already been friends, we would have become friends. She was such a warm, friendly and outgoing person that this theory of hers was probably right, although I think that when someone has been a patient first there is more reserve in the doctor–patient relationship. In September 2000, I fled the sporting mania of the Sydney Olympics and went to New York with a friend. We wined and dined, went to live theatre, saw all the tourist attractions and climbed the World Trade Center. It was a wonderful holiday. It was an abrupt return to reality when, on my first day back at work, I learned that, in my absence, my colleague had seen Christie — and had found a lump in her breast. The biopsy report was on my desk. I knew as soon as I read it that she was going to die. There was not one redeeming feature. The tumour was anaplastic, there were 38 positive nodes in the axilla, and the tumour was oestrogen-receptor negative. Not only did I anticipate Christie’s early death but I also realised that I was going to have to play a difficult, painful role in the process. Already, my self-pity was threatening to overshadow my grief for my friend and her family. The next three-and-a-half years were, for me, a tragic example of the way an aggressive tumour can destroy a human being. Christie, of course, handled the whole affair with flair. She had surgery, radiotherapy and chemotherapy. She passed through an era of hats and scarves that hid her hair loss. Through it all, she remained cheerful and optimistic. I do not try to hide the truth of a difficult prognosis with my patients, but do make an effort to break the news gradually. I also think it important to maintain hope and optimism. So, for me, making sure that Christie understood the hopeless nature of her cause was incredibly difficult for me. After the initial flurry of medical intervention, there was a period of relative calm. For about 12 months the only medical treatment Christie received was trastuzumab (Herceptin), known to slow the growth of oestrogen-receptor-negative breast cancer. She resumed her previously hectic social schedule, and her friends would tell me how wonderful it was that Christie had made such a great recovery from her breast cancer. My secret knowledge ate at me like a personal malignancy. She came to see me as her doctor again in May 2002. She had just had a routine follow-up CT scan and wanted to discuss the result with me rather than her oncologist. There was a mass of enlarged lymph nodes in the left supraclavicular space. The cancer was back. I broke the news as gently as I could, but she was devastated. Her fear for the future was written all over her face. I referred her for radiotherapy and she went through another period of intensive treatment. Without complaint, Christie suffered the accompanying fatigue and the skin burns. This period of intense treatment was followed, once more, by relative calm. I did not know which of Christie’s initial visible fear or her later cheerful front was the more difficult for me to witness. But the gaps between crises were shortening. The next problem arose less than six months after the radiotherapy. Christie was getting short of breath. A simple chest x-ray revealed the problem — fluid in the left side of the chest cavity. A day-trip to hospital was all that was required to drain the fluid, but pathology analysis confirmed the presence of malignant cells. The cancer was on the march again. In July 2003, I made arrangements for my own family to have a holiday — two weeks in the surfer’s paradise of Angourie, on the north coast of NSW. On my last day at work, Christie came to see me. This time, she was really in trouble: she had a constant burning pain in her left arm and marked weakness. The cancer had begun to invade her brachial plexus. Christie wept uncontrollably in my office. I held her and comforted her as she explained the frustration of having a useless arm. She couldn’t cook or hang out the washing. She couldn’t do up her bra or pull up her underpants. I did what I could for her neuropathic pain and referred her to the pain clinic. Then, I went on holiday. During that holiday, I spent many moments thinking about what Christie was going through. Sometimes when I was enjoying a moment in the sun, a walk on the beach, a card game with the family and, once, as I was pulling up my underpants, I thought of her and wept. I wept for her pain and frustration, for the bitterness of terminal illness in those too young, and my frustration in being able to do no more than observe, pity and weep. Over the next three months, I saw less of Christie. She was deep in the clutches of the medical machine. The most important person was her pain specialist. Every possible pain-relieving drug, including huge doses of morphine, failed to relieve her pain. Finally, her oncologist decided that depression was exacerbating the pain and she should see a counsellor. She went once, but informed the oncologist that, although the counsellor was lovely, she would find it much more helpful to talk to her GP. So began for me the most difficult period of all. Christie came to see me once a week. We spent at least half an hour together as she discussed the pain and practical difficulties of her situation, as well as the worsening prognosis. Sometimes we met at my surgery; sometimes I would go to her house. At about this time, she was going away for a weekend with her husband. I think they knew that the end was not far away and wanted some time alone. The day before they left was our counselling day. Christie told me how much she wanted to be sexy one last time for David, but how she was unable to get comfortable enough even to think about making love. Never before had I been required to help anyone with this dilemma and never had I felt so useless. In the following month, the cancer spread under the skin of Christie’s chest and the tumour broke through the skin, erupting into a foul-smelling sore. Nurses came daily to dress the wound and apply antibiotic gel to try to control the smell. I was unable to offer any way of preventing this from getting worse, and I was appalled at the ability of uncontrolled cancer to eat away at the flesh and dignity of such a lovely lady. Christie’s youngest child, “Henry”, who was seventeen, came to see me to talk about the way he was feeling. He had clinical depression. Although the management of his depression was within the scope of my expertise, it was beyond my coping skills. I referred him to an adolescent psychiatrist. Christie was severely distressed about her son’s depression and we discussed her guilt and grief about it. Her worry about dying and leaving the family was now compounded by her fear that something would happen to Henry. She felt it was all her fault. As a mother of teenage children, I knew what it was to worry about the effect that your life might have on them. I had spent a lot of energy dealing with the guilt that my commitment to my patients might have interfered with their capacity to become well-adjusted adults. Over Christmas 2003, Christie’s whole family went to their holiday house at Avoca on the NSW Central Coast. They rang me on Christmas Day and again the following day for help to try to keep her pain under control, but we all had to admit defeat and Christie went back into hospital. Finally, the decision was taken to install a ventricular pump to put narcotics and local anaesthetic directly into the central nervous system. The pain specialist had been promoting this idea for some time but Christie had been reluctant to submit to a procedure that was both invasive and irreversible. Thankfully, it was a successful exercise and, at last, her pain was controlled. Within a month of this step forward, Christie’s oncologist rang me. The tumour was spreading into the epidural space in Christie’s neck and the decision had been made to stop chemotherapy and admit defeat. Despite my knowledge at all times of this inevitable outcome, the news, when I heard it, made my heart race and my spirits sink. The end would arrive within a few weeks, and I was not ready to face that. As I grappled with this news, I found myself able to discuss the theoretical implications of certain types of treatment with the oncologist as though Christie were no more to me than any other patient. It made me angry with myself even while I recognised that I was displacing my anger at her impending death in the only way I knew. Christie died, aged 52. CommentaryIn a society that has attempted to remove much of the pain associated with living our lives, illness and death remain the great catastrophe. There has been a recent explosion in illness narrative — the telling of the facts that relate to a personal experience of illness. Broyard wrote: Always in emergencies we invent narratives. We describe what is happening as if to confine the catastrophe.1 It would also seem that, with patients, this may be because they need to reclaim their illnesses from our increasingly complex, technological and hospital-based health systems, which consider all illness within a biomedical model. Illness narrative can help patients to create meaning from memory, validate themselves as people in the role of patient, and reflect on the significance of the experience on their lives. It also helps them to come to terms with pain, whether the pain is physical, emotional or existential. Illness narrative may also have a therapeutic role to play in their illness, although this is not proven. In The Wounded Storyteller, Frank broke illness narrative down into three different types of stories — the restitution narrative (illness interrupts a life, is fought successfully and life resumes), the chaos narrative (no discernible narrative order, no happy outcome and the most difficult kind to read) and the quest narrative, in which not only does the patient overcome their illness but in the process something is gained either for the patient themselves or for the wider good.2 Chandler, in her essay on autobiography, describes three aspects of healing which flow from the writing: catharsis, restoration and transformation.3 These can be seen to fit into either restoration or quest narratives in the Frank model. Narrative can also be used by doctors. Hunter explains how, from the earliest days of medical training, doctors are taught to use narrative, both verbal and written, to understand and interpret the story of a patient’s illness.4 Medicine is fundamentally narrative...and its daily practice is filled with stories... Much of the central business of caring for patients is transacted by means of narrative... Medical stories are a well established way of sorting through and tackling problems of diagnosis and treatment... In such a scientific discipline it is surprising to find this unexpectedly familiar way of making sense of the facts. 4 True narrative, rather than case history, can be used to understand and explain the complexities of the person and their reaction to illness, as it affects their lives and the lives of those around them. Of course, the doctor will tell a different version of the story than the patient. The patient tells of the effect of the illness on a life, where the doctor tells, at least, the story of the identification and treatment, but perhaps can tell much more. In the same way that the 20th century has hospitalised illness, death and dying have also been taken out of the community and relegated to the hospital or hospice. Segal discusses the way in which the public sees death as part of the human experience, while the medical profession sees death as the failure of modern medicine.5 It is not only hard for patients and their families to face death and dying — it is also hard for doctors: The ability to cope with dying patients does not come easily. Society has not prepared one for such interaction.6 Medical education does not prepare doctors to deal with death and dying. Remen talks about the way in which medical training may even undo some of the inherent life skills that we have to deal with death and dying.7 The emphasis of modern medicine is on cure; and, in a narrative sense, doctors may only want to tell restitution stories. Accepting that death is inevitable for a particular patient usually invokes a sense of failure: People enter the medical profession to help; when they find that they cannot give good news, they often feel terrible and impotent and they tend to retreat.8 Further, discussing the issues that relate to dying and death is hard to reconcile with a professional relationship that emphasises the importance of an emotional distance between doctor and patient. Although there is a more general acceptance of death as a natural part of life in general practice than in hospitals, the myth that modern medicine can always find an answer persists for both doctors and their patients. Kübler-Ross found that specialists in her hospital were reluctant to refer patients to her program because to admit that the patients were dying was to acknowledge a failure to cure.9 It is true that “most of us learn to cope with the life and death scenario with denial”10; but there is a need for doctors to be taught other, better coping mechanisms. Dealing with the dying and death of someone close to you creates special dilemmas. Working with a dying patient can create a special relationship. Contact becomes more frequent as death approaches and there are more physical problems to solve. Contact often takes place in the patient’s home, which can create an emotional closeness, and there is often more involvement with the patient’s family members. McNamara wrote: Facing death, whether it be our own, that of someone we love dearly or someone we feel responsible for, presents us with a unique challenge... Inevitably the frequent contacts with dying people awaken some personal response...if you’ve given a bit of yourself to them, you lose that something when they die.11 Loss and disappointment are common experiences in the practice of medicine, and acknowledging this is important. I think narrative can be a good way to express the loss and at the same time to put it in perspective. Remen strongly believes that grieving is necessary, and not readily undertaken by doctors.7 Crying alone or with the patient is the method that she proposes. I believe that writing the story is another way in which the caring professional can come to terms with the grief and distress. I certainly found the writing of Christie’s story to be both cathartic and helpful in organising my memories. There is a strong sense in which writing it all down allows one to think about it less. Faber-Langendoen obviously shared that experience with me. Even though she was an oncologist and dealt regularly with dying patients, when confronted by the imminent death of her own mother she found herself ill-prepared to face the issues.12 She wrote a narrative as part of the “coming to terms” process, but failed to decide whether she had been able to successfully combine her roles as doctor and daughter. I believe narrative can also help professionals reclaim their caring role in the care of suffering patients. If doctors were to write more accounts of their dealings with patients, it would help people to better understand the issues faced by them as they attempt to manage the burden of sickness. And, doctors who do not write might take comfort from reading what other doctors have written.

Anne P Hellman MB BS

Robust safety specifications and funding arrangements are needed A recent review of the safety of helicopter emergency medical services (HEMS) in the United States found that the risk of death for a HEMS crewmember (per hour engaged in the activity) was similar to that of rock climbers and skydivers.1 The study on the accident and fatality rate of HEMS by Holland and Cooksley (page 17) in this issue of the Journal2 is a timely reminder of the risks faced by HEMS crew in Australia. . . . at least one Australian state government is yet to conduct any independent audits of its contracted HEMS operators . . . Aviation safety, like patient safety, is a complex interaction of systems, human factors and technology. Many of the lessons learned in aviation in improving safety and management of risk, such as incident reporting, crew resource management and simulator training, have crossed over into medical practice. The underlying issues affecting safety are similar, and are frequently unrelated to operator error. Investigation of major incidents and accidents worldwide, in industries such as transport, mining, and indeed health, has revealed many common contributing factors identified as “latent conditions”, or failures of the system.3 These include the lack of a positive safety culture through poor governance, limited resources or misallocation of resources. Blame for accidents often lies with operator error, or active failures (slips, lapses and mistakes — errors at the level of the frontline operator), but it is the mitigation of latent failures that is likely to have the biggest impact on safety. HEMS in Australia operate in a risky environment for flight crew, medical crew and patients alike, for several reasons. First, HEMS in Australia are generally required to fulfil multiple roles, performing critical care interhospital transfer, land-on-scene response, hoist operations and search and rescue (SAR). In North America and Europe, there is generally a distinction between hoist and SAR operators and those who undertake interhospital transfers and land-on-scene response. Second, Australian HEMS operations are further complicated by the vast distances and the predominantly hot conditions, which challenge both aircraft and crew performance. All incidents with injuries or fatalities reported by Holland and Cooksley2 were flights conducted in helicopters without sufficient instrumentation for flight in cloud. Under the current regulatory requirements, flight in such aircraft over water or in rural areas at night is acceptable but is not viewed as best practice. Aircraft not equipped to fly in cloud have much lower acquisition costs than aircraft that are so equipped. Crew training and experience levels are also substantially less. Such aircraft continue to be used for HEMS in Australia, operating with minimal safety margins, as a result of inadequate funding arrangements. In Australia, the Civil Aviation Safety Authority (CASA) certifies aircraft operators to provide specified levels of service. However, CASA certification does not necessarily mean a safe operator, any more than accreditation by the Australian Council on Health Care Standards means a safe hospital. Furthermore, the supervision provided by CASA varies with the category of operation. HEMS is situated at the lower end of the oversight spectrum by virtue of the category of operations in which CASA has placed it, resulting in a level of scrutiny that, given the complexity and risk involved, is lower than perhaps required. Recategorisation of HEMS into a higher category requiring higher standards of compliance, and hence scrutiny by CASA, is probably appropriate. However, effecting regulatory change is a slow process. Given the low level of regulator scrutiny in some categories of aviation operations, the industry has recognised a need to enforce its own standards by commissioning aviation safety experts to conduct independent safety audits. For example, in high-risk areas, such as the off-shore oil industry, oil companies conduct independent safety audits of contracted helicopter operators as frequently as every couple of months. Although HEMS carry greater risk than off-shore oil work, at least one Australian state government is yet to conduct any independent audits of its contracted HEMS operators, despite this being a requirement of contract. Recent accidents in Australia2 have highlighted latent factors, such as equipment and crewing issues. However, to operate the equipment specified by either regulations or contracts, operators will only put in place systems they can afford. Maintaining the high standards mandated by this complex operating environment requires that health systems work in partnership with HEMS providers to ensure robust contract and auditing processes. This does not come without cost, and adequate funding of HEMS needs to be accepted and achieved. Cost cutting to ensure financial survival compromises the safety systems that HEMS operators endeavour to put in place. These are designed to mitigate error, and include hazard and incident reporting, training and education, audit programs, and safety officer appointment. Against this background, a group of community HEMS providers in NSW and Queensland have commissioned, at their own expense, the development of a safety and integrated risk-management framework for HEMS. This is being facilitated by a specialised aviation risk-management company, which has been responsible for the development of similar programs for the Royal Australian Air Force, commercial airlines, airports and other aviation organisations. This program is a collaborative effort by HEMS operators to exceed regulatory compliance and lead the way for best practice. The program has subsequently expanded to a trans-Tasman initiative, with a number of New Zealand operators joining the consortium. The framework will be formally launched in February 2005. Robust safety specifications and funding arrangements are essential to ensure that HEMS operations in Australia are performed at a more appropriate level.

Alan A Garner FACEM, MSc · Jeff Konemann CFS · Deanne M Keetelaar

We need improved primary care, access to expert multidisciplinary services, and appropriate coordination of the two More than a third of Australians live outside major cities, with 3% living in remote or very remote areas.1 The health disadvantage of rural and remote Australians is well documented, and includes poorer survival after a diagnosis of cancer.2 Both more advanced cancer at diagnosis and poorer treatment appear to contribute.3 Documented instances of poorer cancer care in rural and remote Australia, though not necessarily all with survival implications, include less “state of the art” diagnosis, staging and treatment of prostate cancer;4 less breast-conserving surgery for breast cancer;5 and an apparently lower probability of completing treatment when referred for radiotherapy for rectal cancer.6 Surprisingly, there appears to be little difference in women’s use of breast and cervical screening by area of residence.7 Remoteness of residence is not the only axis of disadvantage that may contribute to poorer cancer outcome in remote areas. Indigenous Australians account for 26% of the population in these areas, and have poorer survival from cancer than other Australians.1,8 Lower socioeconomic status is also associated with rural and remote residence and poorer survival.2 Poorer treatment may explain these worse outcomes. Analysis of linked cancer registry and hospital inpatient records in Western Australia suggests that Indigenous cancer patients are less likely to have surgery for lung cancer or radical surgery for prostate cancer,9 but there was no significant difference in breast-conserving surgery for breast cancer.9 Although that study could not address the possibility that differences in stage at diagnosis explained the observed treatment differences, a Sydney study has shown, after adjustment for size and stage of cancer, that socially disadvantaged women with breast cancer are still less likely to have breast-conserving surgery.10 Factors that underlie Indigenous and socioeconomic disadvantage in cancer survival, and possibly treatment, may go beyond just remoteness of residence and inability to pay. They could include knowledge, attitudes and beliefs about cancer (which may influence presentation for and acceptance or completion of recommended treatment), communication difficulties, and discrimination on the basis of race or socioeconomic status for access to travel support or more expensive care.9,11 In principle, tackling rural inequality in cancer care and outcome requires a combination of improved primary healthcare, access to expert multidisciplinary services, and coordination of the two. Evidence that could guide investment decision-making is limited. Present rural health policy is underpinned by the principle that patients should have access to high quality services as close to their homes as is clinically and geographically feasible. This policy should improve access to primary healthcare and aid in obtaining earlier diagnosis of cancer and quicker referral to expert care. That these factors will improve cancer outcomes is, however, more an article of faith than supported by evidence. Increasing specialist healthcare services in rural areas may also run counter to evidence that, for some cancers at least, the best outcome is obtained by practitioners and institutions that have high caseloads.12 Specialist medical services of all kinds are rare outside cities and large rural centres in Australia and are likely to remain so, and cancer surgery caseloads are low in a high proportion of hospitals in rural New South Wales and Victoria.6,13 Problems of low caseloads can be overcome to some degree by specialist outreach services and shared-care arrangements, in which initial treatment often requires travel to a major centre, but subsequent treatment can be delivered effectively closer to home and partly by local healthcare practitioners. Available evidence suggests that specialist outreach services can increase the proportion of patients receiving breast cancer care consistent with evidence-based guidelines.14 More generally, it appears that specialist outreach services that interact in a shared-care model with primary healthcare providers, such as Aboriginal health workers, can improve healthcare access for remote Aboriginal communities.15 A trial of breast cancer nurses in rural settings has also shown clear psychological and physical benefits to women and more coordinated care among practitioners.16 Developing the role of specialty oncology nurses in care coordination and administration of chemotherapy in rural areas is supported by oncologists, but has not been fully evaluated.17 Moves have been made to define a more coherent approach to cancer service delivery,18 but there is little evidence of successful implementation. So what, in principle, do we need? Conceptually, a well-defined pathway, appropriately tailored to needs, that each person with cancer can easily follow to timely expert care. Practically, this requires that the person and their primary care provider know how to access the pathway, that the person’s journey along it is carefully guided to ensure he or she does not get lost, and that there is effective communication between all places visited. Successful development of such pathways would require innovative information systems, effective interaction between the many services involved in cancer care, and cooperation between governments. The challenge in establishing them will be greatest in rural and remote areas. Distance and low service density may make them more difficult to operate; the social and cultural adaptations required may be a hurdle; and they will need to draw more on special provisions, such as shared and outreach care. But the broad principles will be the same. The additional costs, for pathway creation and maintenance, information provision, journey coordination and communication, should not be great, and would probably be repaid by more efficient care and a better outcome. Food for thought?

Katharine E Jong MPH · Paula J Vale GradDipIHP · Bruce K Armstrong AM, FAA, FRACP

A stocktake of vaccination strategies and challenges The 9th National Immunisation Conference of the Public Health Association of Australia was held in August 2004 in Cairns, Queensland, in conjunction with the 1st Asia–Pacific Vaccine Preventable Diseases Conference. The conference was attended by more than 400 delegates, predominantly from the Asia–Pacific region. A theme of the conference was the potential of vaccines to achieve greater equity in health outcomes. A session on the Australian recommended immunisation schedule generated vigorous discussion, highlighting the difficulty of dealing with a schedule that includes vaccines not funded for universal use. Meningococcal diseaseThe epidemiology of meningococcal disease differs substantially around the world, with variation in both incidence and predominant serogroups. In parts of Africa, serogroup A causes regular epidemics. New Zealand has experienced a serogroup B epidemic for more than a decade, focused on the Maori–Pacific Islander community. In Australia, serogroup C has caused about 50%–70% of cases in Victoria and Tasmania since 2000, while serogroup B has been more common elsewhere.1,2 Serogroup C has also emerged as a significant problem in the United Kingdom and parts of Europe, especially in older children and adolescents. Mary Ramsay (Communicable Diseases Surveillance Centre, UK) provided an overview of the European experience of meningococcal disease, comparing vaccine schedules and outcomes. Use of meningococcal C conjugate vaccines, which provide more predictable and long-lasting immunity than polysaccharide vaccines, was pioneered in the UK with a national campaign beginning in 1999. Following the UK success, other European Union countries have begun programs, but schedules differ. In the UK, the vaccine is given at 2, 3 and 4 months; in Spain, at 2, 4 and 6 months; while, in The Netherlands, a single dose is given at 12 months. The last schedule, identical to that in Australia, was chosen because serogroup C is uncommon under the age of 12 months, and a single dose is sufficient for protection over this age. Preliminary data suggest that immunity persists longer when the last dose is given after 5 months of age.3 As outlined by Rosemary Lester (Department of Human Services, Victoria), meningococcal C conjugate vaccine was funded in Australia for children at age 12 months from 1 January 2003, and was accompanied by a catch-up program for children and adolescents aged 1–19 years. The school-based component of the catch-up program achieved good coverage across Australia in 2003–2004. Data on disease impact will be available in subsequent years. While a polysaccharide vaccine protects against meningococcal serogroups A, C, W135 and Y, and a conjugate vaccine protects against serogroup C, there is no commercially available vaccine against serogroup B. Since 1990, New Zealand has experienced a prolonged meningococcal epidemic thought to be attributable to a specific strain of serogroup B, combined with crowding and exposure to tobacco smoke. In response to this epidemic, and in partnership with the Norwegian Institute for Public Health and Chiron Vaccines, the New Zealand government has sponsored development of a vaccine for the New Zealand strain (MeNZB). After demonstration of adequate immune responses, a national rollout of this vaccine began in July 2004. Because of the unique nature of this program, assuring vaccine safety is critical. Stewart Reid (Chair of the New Zealand vaccine advisory committee) described a national safety monitoring program which, in scope and comprehensiveness, is at the level of world’s best practice. Pneumococcal diseaseKim Mulholland (Centre for International Child Health, University of Melbourne) gave an overview of the rapid and varied developments in conjugate pneumococcal vaccine trials around the world. Use of the polysaccharide pneumococcal vaccine was shown over 20 years ago in Papua New Guinea to reduce deaths, but neither this vaccine nor the newly available conjugate vaccine is used in any country with high death rates from childhood pneumonia. Although the current conjugate pneumococcal vaccine covers only seven serotypes, this vaccine, with two additional serotypes, has been shown to prevent invasive pneumococcal disease (IPD) and non-bacteraemic pneumonia in children from Soweto, South Africa.4 Peter McIntyre (National Centre for Immunisation Research and Surveillance, Sydney) and Vicki Krause (Centre for Disease Control, Northern Territory) outlined vaccine programs to control pneumococcal disease in Australian adults and children. Since the late 1990s, the 23-valent polysaccharide pneumococcal vaccine has been funded nationally for Indigenous adults aged 50 years and over and, in Victoria, for all adults aged 65 years and over. There is now convincing evidence from north Queensland of a decrease in IPD among Indigenous adults. Among the elderly, recent data have also shown a greater reduction in IPD in Victoria than in New South Wales, where there is no funded program for this age group.5 The polysaccharide vaccine will be funded for all adults aged 65 years and over from January 2005. Since 2001, the seven-valent pneumococcal conjugate vaccine has been funded only for Indigenous children and for others with specified medical conditions. From January 2005, it will be funded for all children under 2 years of age. Data from national surveillance of IPD for 2003, presented for the first time at the conference, show a measurable decrease in IPD in Indigenous children, so that the incidence in these children is now below that in non-Indigenous children. It is clear that universal funding is timely, and that vaccination has contributed to greater equity in health outcomes between Indigenous and non-Indigenous children in Australia, as previously shown for black children and white children in the United States.6 Immunisation in the PacificViliame Sotutu (Fiji School of Medicine) and Rob Condon (Public Health Physician, Fiji) highlighted the problems in providing vaccines to children in the 22 countries and territories in the Pacific, most of which are small and separated by vast distances. Many of the countries have young, growing populations with low living standards and high unemployment rates. Health status is variable, and political instability is not uncommon. The Expanded Programme on Immunization was introduced in 1977, jointly funded by the World Health Organization and individual countries. However, immunisation schedules vary between countries, and procurement and logistic strategies are often inefficient. Recent outbreaks of measles in Papua New Guinea and the Solomon Islands, with high death rates, and outbreaks of rubella in Samoa, with cases of encephalitis, highlight the fragility of control of vaccine-preventable diseases in the Pacific. More emphasis should be placed on vaccine delivery to island communities, and Australia can make an important contribution to this effort. Haemophilus influenzae type b diseaseAgustinus Sutanto (Catholic Hospital in Ampenan, Lombok, Indonesia) presented the results of a recently completed randomised controlled trial of the Haemophilus influenzae type b (Hib) vaccine PRP-T on the Indonesian island of Lombok. The trial, which enrolled 55 000 children aged under 2 years and was randomised by hamlet, produced evidence of a substantial, unrecognised burden of Hib disease. This type of “vaccine probe” study, pioneered in Gambia, is able to measure disease burden through differential vaccine impact, where routine data on disease notification and hospitalisation are not available.7 Mary Ramsay (Communicable Diseases Surveillance Centre, UK) presented the results of a series of studies, including seroepidemiology, nasopharyngeal Hib colonisation and routine measurement of disease frequency, to explore reasons for a resurgence of Hib disease in the UK. First, herd immunity, resulting from the 1992–1993 national catch-up program for children up to 5 years of age, had waned because no booster dose had been given in the second year. Second, this effect was exacerbated by the introduction of a less immunogenic vaccine combination. This resulted in an increase in cases among children aged 1–4 years, who were consequently targeted by a national booster campaign. The UK experience emphasised the importance of maintaining high-quality surveillance in order to rapidly assess unexpected problems, which may emerge even in apparently very successful vaccination programs.8 New vaccinesGraham Barnes (Gastroenterology Department, Royal Children’s Hospital, Melbourne) is involved in developing an Australian candidate rotavirus vaccine. The first licensed vaccine was withdrawn from the US market in 1999, after identification of a small but definite increased risk of intussusception. Following this experience, trials of new vaccine candidates have needed to be large enough to exclude any significant increased risk of intussusception. Two new candidate vaccines appear to have achieved this goal, one of which was recently licensed in Mexico. Terry Nolan (School of Population Health, University of Melbourne) described progress with vaccines against human papillomavirus (HPV), the major cause of cervical cancer worldwide. It is now established that these vaccines prevent HPV infection, and long-term studies will determine their impact on cancer. The potential availability of HPV vaccines has raised new issues of timing of vaccination and communication of the rationale to parents, who may not appreciate the risk of sexually acquired infections during adolescence. Both rotavirus and HPV vaccines are likely to be available in Australia within the next 3–5 years. Conference themes and resolutionsTraditionally, the final session of the conference is devoted to developing resolutions, many of which have been implemented. On the basis of public health benefit, the Australian Technical Advisory Group on Immunisation and the National Health and Medical Research Council recommend vaccines for inclusion in the Australian Standard Vaccination Schedule. Conference resolutions were dominated by the strong feeling that the Australian government should fund all vaccines that have been recommended by these two bodies.

Peter B McIntyre PhD, FRACP, FAFPHM · Heath A Kelly MPH, FAFPHM · E Kim Mulholland MD, FRACP

Objectives: To determine the accident rate for Australian helicopter emergency medical services (HEMS) per 100 000 flying hours and to determine the patient mortality risk per mission from a HEMS accident.Method: Retrospective observational study of Australian HEMS flying hours and accidents from 1992–2002.Results: The calculated accident rate for Australian HEMS is 4.38 per 100 000 flying hours. One patient died as a direct result of helicopter accident in 50 164 missions. Overall, one accident occurred every 16 721 missions.Conclusions: The overall Australian HEMS accident rate is similar to that reported from other countries, with all accidents occurring in Queensland community HEMS. Helicopters flown at night under Visual Flight Rules (VFR) appear to represent a high-risk subgroup. HEMS flights do not appear to present significant mortality risk to patients being transported.

Jim Holland MB BS · David G Cooksley MB ChB, FACEM

Objective: To examine the impact of a sudden and dramatic decrease in heroin availability, concomitant with increases in price and decreases in purity, on fatal and non-fatal drug overdoses in New South Wales, Australia.Design and setting: Time-series analysis was conducted where possible on data on overdoses collected from NSW hospital emergency departments, the NSW Ambulance Service, and all suspected drug-related deaths referred to the NSW Coroner’s court.Main outcome measures: The number of suspected drug-related deaths where heroin and other drugs were mentioned; ambulance calls to suspected opioid overdoses; and emergency department admissions for overdoses on heroin and other drugs.Results: Both fatal and non-fatal heroin overdoses decreased significantly after heroin supply reduced; the reductions were greater among younger age groups than older age groups. There were no clear increases in non-fatal overdoses with cocaine, methamphetamines or benzodiazepines recorded at hospital emergency departments after the reduction in heroin supply. Data on drug-related deaths suggested that heroin use was the predominant driver of drug-related deaths in NSW, and that when heroin supply was reduced overdose deaths were more likely to involve a wider combination of drugs.Conclusion: A reduction in heroin supply reduced heroin-related deaths, and did not result in a concomitant increase, to the same degree, in deaths relating to other drugs. Younger people were more affected by the reduction in supply.

Louisa J Degenhardt PhD, MPsych(Clinical) · Elizabeth Conroy BA · Stuart Gilmour BSc · Wayne D Hall PhD

Objective: To determine the effectiveness of intranasal (IN) naloxone compared with intramuscular (IM) naloxone for treatment of respiratory depression due to suspected opiate overdose in the prehospital setting.Design: Prospective, randomised, unblinded trial of either 2 mg naloxone injected intramuscularly or 2 mg naloxone delivered intranasally with a mucosal atomiser.Participants and setting: 155 patients (71 IM and 84 IN) requiring treatment for suspected opiate overdose and attended by paramedics of the Metropolitan Ambulance Service (MAS) and Rural Ambulance Victoria (RAV) in Victoria.Main outcome measures: Response time to regain a respiratory rate greater than 10 per minute. Secondary outcome measures were proportion of patients with respiratory rate greater than 10 per minute at 8 minutes and/or a GCS score over 11 at 8 minutes; proportion requiring rescue naloxone; rate of adverse events; proportion of the IN group for whom IN naloxone alone was sufficient treatment.Results: The IM group had more rapid response than the IN group, and were more likely to have more than 10 spontaneous respirations per minute within 8 minutes (82% v 63%; P = 0.0173). There was no statistically significant difference between the IM and IN groups for needing rescue naloxone (13% [IM group] v 26% [IN group]; P = 0.0558). There were no major adverse events. For patients treated with IN naloxone, this was sufficient to reverse opiate toxicity in 74%.Conclusion: IN naloxone is effective in treating opiate-induced respiratory depression, but is not as effective as IM naloxone. IN delivery of naxolone could reduce the risk of needlestick injury to ambulance officers and, being relatively safe to make more widely available, could increase access to life-saving treatment in the community.

Anne-Maree Kelly MD, MClinEd, FACEM · Debra Kerr RN, MBL · Zeff Koutsogiannis MB BS, FACEM · Paul Dietze PhD · Ian Patrick · Tony Walker

Allergic rhinitis (AR) is one of the most prevalent medical conditions. It has significant effects on quality of life and can have considerable socioeconomic effects. The traditional classification of perennial and seasonal rhinitis does not distinguish between provoking factors, nor does it indicate the most appropriate treatment. A more useful classification is based on symptoms, which may be intermittent or persistent, and vary widely in severity. The goal of management is to achieve optimal symptom control. Therapeutic options include allergen avoidance, pharmacotherapy and immunotherapy. Antihistamines and intranasal corticosteroids (INCS) have become the cornerstones of therapy. A variety of effective treatments are available for consumers to self-select, without the advice of a doctor or pharmacist. INCS are widely recognised as the most effective pharmacotherapy for AR, in both adults and children. The efficacy of various preparations is similar, but those with low systemic bioavailability are preferred for children and for patients who are also receiving inhaled, topical or systemic corticosteroids.

Ronald S Walls DPhil, FRACP, FRCPA · Robert J Heddle PhD, FRACP, FRCPA · Mimi L K Tang MBBS, PhD, FRACP, FRCPA · Ben J Basger MSc, BPharm, DipHPharm · Graham O Solley MBBS FACP · Guan T Yeo FRACGP, MBBS

Linda Mann, a Sydney GP, proposes ways of potentially enhancing patient care and reducing hospital stays, without increasing overall healthcare costs. Her suggested solutions include making it simpler for all healthcare practitioners involved in caring for the same patient to share (rather than not share) all patient information by applying the information technology of today (rather than tomorrow). Also, pooling some funding from state and federal sources could allow for further “seamless care” at areas of reasonable overlap between the current “silos” of hospital-based and community-based care. The type of scenario described in Box 1 is not uncommon. Contemporary healthcare cuts patient care into separate events by erecting barriers at the boundaries of what we have come to see as “hospital practice” and “general practice”. As a result, Mr A and his doctors face several barriers to optimal care: Patient information can be found in many places. Individual carers may not be aware of all the other places where patient information is held; Information about patients may not be shared within, let alone outside of, an institution; If a practitioner is not “within” an institution, the institution has no easy way of sharing care with the practitioner. It may be easier to duplicate not only clinical notes, but also tests and procedures, rather than look for information kept elsewhere; Institutions guard their healthcare resources and limit access to them. This is because they cannot afford to provide all the healthcare needs of all of their patients, irrespective of whether the care is delivered in the hospital or the community. Fragmentation of healthcare leads to poorer patient outcomesThe claim that patient care suffers because of the fragmentation of healthcare delivery is not new. In 1994, the US Primary Care Policy Fellowship observed: “Three barriers to health care are shared by all vulnerable populations: inaccessibility of care, fragmentation of care, and cultural insensitivity on the part of care providers”.1 Patients can get different forms of treatment from institutional sources or community sources (each funded from a different arm of government) for the same condition, with the same outcome but different costs.2 Fragmentation of care, which occurs even within institutions, is inefficient.3 Care is often discontinuous,4 with knowledge, culture and activity being housed in separate “silos”.5 Institutions guard their resources for good reasons: they must account for every dollar and relate the money spent to health activity and occasions of care of the patients within their boundaries. We are all required to “do more with less”. As a result, in order to benefit from resources provided by an institution, a patient must become a patient of that institution — leading, inadvertently, to potential fragmentation of healthcare. Communication between an institution and other people or organisations is sometimes distorted, leading to errors such as prescription critical incidents. For example, hand-written medical instructions can be misinterpreted, with 12 units of insulin being misread as 120 units if the prescriber uses the abbreviation “u” instead of writing out the word “unit”.6 Different funding sources for curative care (usually institution-based) and chronic care (usually community-based) create tension in the provision of medical care and in decisions about how that care should be funded.7 I believe general practitioners (GPs) are willing to provide whole-patient care, but are frustrated by barriers dictated by the “origin” of funding. In New South Wales, for example, interpreters are available in person for a patient attending a hospital clinic after a sexual assault, but not for a patient attending a GP or a sexually transmitted diseases clinic. In my own experience, patients who have been seen and diagnosed with a fracture in a general practice had to be seen by junior staff at a central Sydney teaching hospital before they could gain access to the hospital fracture clinic, because the clinic did not accept GP referral. I fully acknowledge that while some patients are well served economically and socially with care provided outside an institution, achieving the same clinical outcomes,2 certain forms of care can only occur inside institutions. We know that many conditions (eg, breast cancer, acute stroke and diabetes in pregnancy) respond better to care provided by a dedicated team.8 However, medical advances do allow care for some conditions to be appropriately resited from one side of the institution/community barrier to the other. For example, Doppler diagnosis of thromboembolism and the availability of new anticoagulants have allowed some patients to be diagnosed and treated in the community without requiring hospital admission, and community-acquired pneumonia is now most usually diagnosed, assessed clinically and treated out of hospital, facilitated by the use of small, portable oximeters. However, once care occurs outside an institution, patients with such conditions lose their access to institutional services such as specialised physiotherapy (eg, of the hand), social work and occupational therapy. How can we change this scenario for the better?I think we could reduce this fragmentation of healthcare by improving communication and sharing resources within the healthcare system. It would involve the patient, rather than interventions or healthcare practitioners, becoming the centre of care; however, it would not involve increased overall funding but rather a funding readjustment. And yes — even shorter hospital stays would result. Make it simpler to share (rather than not share) informationThe late Dr John Paterson, former Secretary of the Victorian Department of Health and Community Services, dreamed of a unified medical record and patient-centred medical economics. Paterson envisioned three important principles for streamlining the healthcare system:9 Develop a longitudinal patient record for each patient. At each contact, the provider would add new data to a centralised patient record and get paid for the service. Thus, a cumulative record would build up for each patient. Gradually roll funds into one budget pool. Cap pooled funds as a whole and then regulate entitlements at the patient end, rather than at the source of funding. Along similar lines, the concept of teams that deliver “seamless care”, overcoming gaps in information sharing and making the duplication of tests or medical effort unnecessary, has arisen. Genuine seamless care10 depends on a host of characteristics, including the culture of the “actors”,7 their previous investment in knowledge management processes11 that encourage movement (rather than hoarding) of knowledge, and the promise of access to new funding sources. If we could change the emphasis from “craft”-centred teams (eg, with a melanoma social worker and an orthopaedic physiotherapist and so on) to a patient-centred team (made up of an in-hospital specialist, a GP, a pharmacist, and a physiotherapist — either within or outside the institution), we may find workable new combinations of teams that benefit the patient by crossing current boundaries. Current examples of this are the “smart card” trial for patients with heart disease in Brisbane Waters12 (where hospital discharge records provide core information that is accessible on-line by GPs and other health providers), and trials of information sharing in central Sydney.13 In Sydney, use of an existing web platform (Ozdocsonline) allows patients, carers and institutional outreach nurses and GPs to develop interactive management for patients with heart failure. Coordinated care trials are under way to assess whether such “seamless care” is cost-effective and whether it delivers equivalent health outcomes.14,15 (The results from the second round of these trials, which began in 2001, are awaited.) The trials involve service providers working in public, private, and non-government organisations; community and institutional healthcare settings; community support services (such as Home and Community Care); and residential aged care. The trials “will be supported by improved data systems between participating services, and more flexible funding arrangements to enable movement of funds between services as required by an individual’s care plan”.14,15 Use information technology to enhance communicationExisting hospital and state area sector intranets, currently protected by firewalls, could be changed to Internet-based systems using PKI (public key infrastructure) or some other secure entrance to the platform. This would permit off-site, secure access to notes, results, messaging and communication. Such access systems are already being introduced in the United Kingdom.16 Health workers on home visits could use handheld devices to download patient information from a central source, allowing each and every team member caring for a patient to have access to all available information. Information Technology Online grants, from the Commonwealth Department of Communication, Information Technology and the Arts, were given in 2004 to support three separate trials of various methods of caring for patients whose conditions require treatment in the community, then in hospital, then back in the community.13 Subsets of such a process are being rolled out via HealthConnect17 in Tasmania and South Australia. Overlap healthcare boundaries to allow for “seamless care”Overlapping the line where primary care begins and institutional care stops could be achieved without insult to any medical craft — specialists are, and can remain, the designated “bed-holders” and technologists,18 while medical generalists3 (often GPs, but also geriatricians and, especially in rural areas, physicians and surgeons) maintain patient health before and after intervention, and “stream” patients for specialist care. However, patients receiving primary care from medical generalists should be included in the definition of those entitled to access services from state-funded hospitals. This intersection should be made a common ground, not a boundary to be fought over. Patients who are receiving a state-funded phase of healthcare should be guaranteed access to federally funded care, if needed — for example, via their GPs or federally granted allied healthcare. Patients would then have better-targeted services, allowing specialists to do more for patients at their level, while liberating funds to provide resources in the community. Specialists’ and GPs’ legal and fiscal responsibilities should be re-delineated, as is already done in shared-care programs. Doctor and patient satisfaction, costs and clinical outcomes should all be audited to assess whether the desired outcomes are being achieved. Pool some funds and then apply the “health bunyas” conceptState departments of health have suggested pooling of funds19 to allow healthcare activity to follow patients regardless of where they receive care. Fund pooling has been advocated internationally to support intersectoral service supply.11 Although not a health economist, I have found myself wondering whether one effective way of using pooled funds would be to apply the concept of “health bunyas”. A bunya is a unit of goods or work used in a “local energy transfer system”, such as the one currently being used in Maleny, Queensland.20 In that town, an individual’s work or goods are exchanged in local units or tokens (called “bunyas” — after the local pine tree) which can be traded for needed goods or services organised via a directory listing of what is wanted and what is available. In the healthcare setting, an item of care, or the complications of that item of care, could be valued in health bunyas, which would then be redeemable in either the state or federal arena. The money value of health bunyas in this system could be set at levels already calculated for medical care activity — for example, the Medicare rebate for the medical component of care, or the private insurance rebate for items of allied healthcare in the community. A similar system proposed for community-oriented “shopfront” projects21 already blurs the boundaries between state and federal funding. One such project is the NSW Community Options Project, providing case management services for individuals who need services across the state/federal divide not provided by home and community care services. “Silo”-type boundaries would be re-formed to allow for “seamless care”, and might look something like those presented in Box 2. Using the alternative healthcare model I have outlined in this article, Mr A’s care could follow a very different and, I believe, more desirable path (Box 3). 1 Scenario: “How things are today” Mr A, a 70-year-old Maltese migrant with limited English, has diabetes and vascular compromise of his right foot. He also has a longstanding but stable mental illness, managed by his Maltese-speaking psychiatrist, Dr B, and his general practitioner, Dr C. Mr A attends the combined diabetic, surgical and foot clinic at the nearest teaching hospital. The clinic sends its reports about Mr A to Dr C, who scans them into her paperless patient record, but she has no direct access to the results of Doppler imaging or pathology tests. Dr C continues standard diabetes monitoring between Mr A’s clinic attendances, sending results to the clinic. The various consultants at the hospital clinic decide that Mr A needs to have a below-knee amputation. Although Mr A tells Dr C of the planned surgery, the relevant letter does not arrive until three weeks after the operation. Only then does Dr C learn that Mr A was referred to a rehabilitation hospital. Dr C does not get a discharge summary from the rehabilitation hospital, as it goes to the referring surgical registrar from the vascular team at the hospital. Mr A spends 6 weeks in the rehabilitation hospital. The patient’s family asks Dr C to intervene because Mr A is becoming depressed. Dr C contacts the rehabilitation registrar, who tells her about an impending psychiatric referral with an interpreter. The registrar is surprised to learn of the existing arrangements for Mr A’s psychiatric care, as the referral from the hospital made no mention of this. As Mr A is still in the rehabilitation hospital, the decision to continue with the new, separate stream of psychiatric care stands. Long-term effect of fragmented healthcare delivery Because of increasing allied health costs and lengths of stay when healthcare delivery for individual patients is fragmented, the wait for hospital beds for patients with vascular conditions doubles, within the space of a year, from 3 weeks to 6 weeks. 2 A suggested patient-centred model of healthcare delivery and funding 3 Scenario: “How things could be today” Mr A (the patient with diabetes and a mental illness, described in Box 1) sees his general practitioner, Dr C, regularly. On each visit, using a smart card,12 Dr C accesses a database of hospital-derived results via the Internet. Dr C adds to the Internet-based history she maintains for Mr A. She receives email notification of Mr A’s attendance at the diabetes clinic, and sends email notification to his hospital team leader when he is seen at her surgery, so that the team leader can access her information and, if desired, add it to the hospital notes. The hospital clinic consultants decide that Mr A needs to have a below-knee amputation. When alerted by email of Mr A’s latest hospital assessment, Dr C learns of the decision to amputate. She undertakes preoperative testing as per the hospital protocol (detailed on its website), and sends all results directly to the hospital — downloaded from the private pathology company. This care is funded through the federal government (via Medicare). When Mr A is admitted for his operation, the “health bunyas” system commences as part of discharge planning. Money previously dedicated to late postoperative care by nurses, occupational therapists and physiotherapists in the hospital is now pooled in a health bunyas fund. (Pharmaceutical Benefits Scheme funding of Mr A’s usual medications is also pooled into this fund during his hospital stay.) The area discharge planner adds up the bunyas that Mr A’s condition attracts, consults her list of community bodies that take part in the bunya system, and advises them of Mr A’s hospital admission. As he progresses through his stay, she writes up the plan. Dr C warns Dr B, Mr A’s psychiatrist, of his admission and makes an early appointment for him to be seen after discharge. Mr A goes home on the early discharge program to have care at home. Money from community health services, local government and Medicare is added to his bunya pool. He is attended by hospital-in-the-home nurses, who record their visits on hand-held devices and download their data daily to the Internet-based patient record, which is also accessible to Mr A’s specialist and GP members of Mr A’s team. Community resources are costed at community rates. Bunyas buy home-visit physiotherapy, a prosthesis, community transport to the day hospital rehabilitation gym and to Dr B, dressings, medications, social worker support for accessing benefits, regular specialist follow-up consultations in the hospital outpatient department or the specialist’s rooms, and postoperative home-based medical care from Dr C. Dr C works together with Mr A’s specialist via the Internet and phone to manage Mr A’s progress. Long-term effect of integrated healthcare delivery Because of cost sharing, care in the community and use of private allied health workers, the wait for vascular beds falls, within the space of a year, from three weeks to one week.

Linda Mann FRACGP

We report two elderly women who presented with hypertensive crisis and acute pulmonary oedema, which responded poorly to antihypertensive therapy. The patients were later diagnosed as having hepatitis C virus-related cryoglobulinaemia. Acute pulmonary oedema is a well-known complication of severe hypertension,1 but, to our knowledge, has never been reported in association with mixed cryoglobulinaemia. We report two patients with severe hypertension who presented with pulmonary oedema which was not controlled until cryoglobulinaemia was diagnosed and treated with plasmapheresis and methylprednisolone. Clinical recordsPatient 1Presentation: A 66-year-old woman presented to our emergency department in late February (winter) with severe dyspnoea of 2 hours’ duration. She had a 10-year history of hypertension, and had had a stroke 3 months before, but had recovered. Over the previous month, her blood pressure had been over 210/120 mmHg, and she had intermittent dyspnoea, orthopnoea and leg oedema. On examination, she was orthopnoeic, with blood pressure of 218/124 mmHg, regular pulse of 126 bpm, and respiratory rate of 36 breaths per minute. She had engorged jugular veins, bilateral chest crackles, hyperpigmentation of the legs and marked bipedal pitting oedema. A chest radiograph showed diffuse haziness over both lungs. Electrocardiography (ECG) showed inverted T waves in leads V4 to V6. Oxygen saturation was 77% while breathing 100% O2 (reference range [RR], 95%–100%). Initial management: The patient was intubated and mechanically ventilated. Her central venous pressure was 13 cmH2O (RR, 3–11 cmH2O), and pulmonary wedge pressure was 19 mmHg (RR, 6–12mmHg). She was treated with intravenous glyceryl trinitrate and diuretics, but over the next 48 hours her blood pressure fluctuated between 300/130 mmHg and 200/90 mmHg, and pulmonary oedema persisted. After 2 days, the patient was extubated. Over the next 24 hours, she developed massive bilateral pleural effusions and numerous petechiae over the legs. Echocardiography revealed a normal left ventricular (LV) ejection fraction (72%) and diastolic dysfunction. Radionuclide angiography confirmed these findings. Laboratory tests showed hypoalbuminaemia, proteinuria (daily protein loss, 9.3 g), haematuria with granular casts, impaired renal function, anaemia and thrombocytopenia (Box 1). Nephrotic syndrome was diagnosed. Further tests revealed a decreased serum concentration of complement components C3 and particularly C4, and markedly raised concentration of rheumatoid factor. However, tests were negative for antinuclear (ANA), anti-double-strand-DNA (anti-ds-DNA), antiglomerulo-basement-membrane and antineutrophil-cytoplasmic antibodies. A cryoglobulin test was positive (Box 2). Immunofixation electrophoresis of the cryoprecipitates showed monoclonal IgM/kappa and polyclonal IgG. A test for hepatitis C virus antibodies (anti-HCV) was then performed and was positive. Diagnosis: On Day 27 of admission, the patient was diagnosed with type II mixed cryoglobulinaemia associated with HCV infection. At that time, her blood pressure was still fluctuating between 230/130 mmHg and 180/100 mmHg, and pulmonary oedema and massive pleural effusions persisted, despite vigorous antihypertensive therapy with frusemide, intravenous glyceryl trinitrate, an α-adrenergic blocker and angiotensin-converting enzyme inhibitors. Repeated thoracocentesis was required to release massive effusions (initially transudative, but later haemorrhagic). Renal biopsy revealed diffuse glomerulonephritis with crescent formation. Management: Plasmapheresis was started on Day 27, along with pulse therapy of intravenous methylprednisolone (500 mg daily for 3 days). After five courses of plasmapheresis in 12 days, the hypertension and pulmonary oedema were controlled. The patient was discharged from hospital on Day 57 of admission. At discharge, serum creatinine level was 141 μmol/L (reference range [RR], 53–106 μmol/L), and she was taking prednisolone (25 mg), diltiazem (180 mg), spironolactone (75 mg) and doxazosin (8 mg) per day. Patient 2Presentation: In February, 2 years after Patient 1, a 77-year-old woman presented to our emergency department with a 1-day history of severe dyspnoea and orthopnoea. She had had hypertension for 3 years. On several occasions during the previous month, her blood pressure had risen to 200/120 mmHg. On examination, she was stuporous, with blood pressure of 200/110 mmHg, regular pulse of 112 bpm, and respiratory rate of 36 breaths per minute. She had engorged jugular veins, bilateral chest crackles, hepatomegaly, ascites and bipedal oedema. A chest radiograph showed bilateral diffuse haziness, and ECG showed a generalised low QRS complex. Blood gas analysis showed pH, 7.43 (RR, 7.35–7.45); Paco2, 3.9 kPa (RR, 4.7–5.3 kPa) and Pao2, 11.2 kPa (RR, 12.7–13.3 kPa) while breathing oxygen through a mask. Initial management: The patient was intubated and mechanically ventilated. Central venous pressure was 12 cmH2O. Echocardiography revealed concentric LV hypertrophy, normal LV ejection fraction, but impaired LV diastolic function. Blood pressure fell to 170–200/90–100 mmHg in 2 days, after diuretic and nitroprusside therapy, but pulmonary oedema and respiratory failure did not decrease, even after haemodialysis. She had massive ascites, bilateral pleural effusions, hypoalbuminaemia, proteinuria (daily protein loss, 3.5 g), haematuria, poor renal function, anaemia and thrombocytopenia (Box 1). Nephrotic syndrome was diagnosed. Levels of both C3 and C4 were markedly low. ANA and anti-ds-DNA antibodies were negative, but rheumatoid-factor titre was markedly high. Cryoglobulin tests on Days 14 and 16 of admission were positive. Immunofixation electrophoresis of serum cryoprecipitates showed polyclonal IgG. HCV tests were negative for anti-HCV antibody but positive for serum HCV RNA. Diagnosis: The diagnosis of type III mixed cryoglobulinaemia associated with HCV infection was thus established on Day 16 of admission. At that time, the patient was still being mechanically ventilated and needed repeated thoracocentesis (effusions were initially yellow, but later became haemorrhagic). Computed tomography of the head showed multiple ischaemic infarcts. Management: Plasmapheresis and methylprednisolone pulse therapy (1 g intravenously daily for 3 days) were started on Day 17 of admission. The patient was extubated the next day and discharged from hospital 2 weeks later, after two courses of plasmapheresis. Serum creatinine level at discharge was 291.5 μmol/L. DiscussionHypertensive crisis with rapid-onset pulmonary oedema has been associated with coronary artery disease,2 renal artery stenosis3,4 and phaeochromocytoma,5 but a search of English-language articles in PubMed revealed no previous reports of an association with mixed cryoglobulinaemia. The latter is characterised by the presence of cold-precipitable cryoglobulins in serum. Underlying diseases include autoimmune and infectious diseases, especially hepatitis C.6-9 “Mixed” indicates that the cryoglobulins in these patients contain either monoclonal plus polyclonal immunoglobulins (type II cryoglobulinaemia), or polyclonal immunoglobulins (type III cryoglobulinaemia).7 In hepatitis C, cryoglobulins usually contain anti-HCV antibody, HCV RNA and IgM rheumatoid factor (ie, anti-IgG autoantibody).9 Cryoglobulins often trigger the formation of immune complexes, leading to immune-complex-type vasculitis, and produce cutaneous, vasomotor, renal and neurological symptoms.7-9 In our patients, factors precipitating the acute pulmonary oedema included hypertensive crisis, renal insufficiency and probably coronary insufficiency. The hypertensive crisis and pulmonary oedema had abrupt onset, progressed rapidly to respiratory failure, were accompanied by nephrotic syndrome, and responded poorly to antihypertensive and diuretic therapy. Our patients had had moderate hypertension for 3–10 years before their blood pressure suddenly rose markedly 2 to 3 months before the development of pulmonary oedema. Hypertension has been found in 37% of patients with cryoglobulinaemia.6 When the underlying disease of cryoglobulinaemia (eg, hepatitis C) flares up, levels of cryoglobulins (which contain HCV-RNA) increase, resulting in higher levels of circulating immune complexes, acute vasculitis and raised blood viscosity. These factors all precipitate the abrupt rise in blood pressure and pulmonary oedema, and explain the failure of conventional antihypertensive agents. Treating cryoglobulinaemia in our patients decreased renal vasculitis and ischaemia, fluid overload, and ultimately hypertension and pulmonary oedema. Coronary vasculitis, found at autopsy in 22% of patients with mixed cryoglobulinaemia,6 could contribute to pulmonary oedema. However, both our patients had a normal LV ejection fraction, suggesting that neither had significant coronary vasculitis. In both patients, acute pulmonary oedema developed in winter. Whether cold weather worsens hypertension by precipitating more cryoglobulins and increasing viscosity awaits further observation. In our patients, the initial features that led to the suspicion of vasculitis were petechiae, proteinuria and haematuria. Further testing revealed decreased complement levels (especially C4). These and other manifestations, including oedema, ascites, recurrent pleural effusions, cerebral infarction and glomerulonephritis, were caused by circulating cold-precipitable immune complexes and resulting vasculitis.6-9 Chronic HCV infection stimulates B-cell clones to proliferate and produce cryoprecipitable IgM antibody with rheumatoid-factor activity10 — an important laboratory index of HCV-related mixed cryoglobulinaemia. However, Patient 2 was negative for anti-HCV antibody, possibly because the sensitivity of the anti-HCV immunoassay, although high, is still suboptimal,11 or because the anti-HCV antibodies were concentrated in cryoprecipitates, and therefore not detectable by the serum assay.7 In both patients, the refractory hypertension and pulmonary oedema responded to plasmapheresis and methylprednisolone therapy. Conventional treatment of mixed cryoglobulinaemia aims to reduce circulating immune complexes through immunosuppression and plasmapheresis.8 Although immunosuppressive therapy alone could ameliorate vasculitis,12 plasmapheresis has shown hypotensive effect in immune-complex nephritis, including mixed cryoglobulinaemia.13 It also reduces plasma viscosity and improves perfusion of the affected organs,14 thus helping in patients with hypertension, encephalopathy or severe renal impairment. Neither patient had a history of blood transfusion, surgery, intravenous drug use or tattooing. They probably acquired HCV infection through non-sterile injections or acupuncture in local clinics, the most common source of HCV infection in Taiwan.15,16 With the increasing prevalence of hepatitis C,17 knowledge of its extrahepatic manifestations is important. Our two patients illustrate the association with mixed cryoglobulinaemia presenting with hypertensive crisis and acute pulmonary oedema. 1 Blood test results before diagnosis of cryoglobulinaemia Test Patient 1 Patient 2 Reference range Serum albumin (g/L) 24 24 32–45 Serum urea nitrogen (mmol/L) 13.9 36.8 2.9–8.2 Serum creatinine (μmol/L) 230 412 53–106 Haemoglobin (g/L) 59 98 120–160 Platelet count (× 109/L) 105 69 150–450 Complement 3 (g/L) 0.62 0.30 0.79–1.19 Complement 4 (g/L) 0.02 0.07 0.17–0.37 Rheumatoid factor 1:10 240 > 1:20 480 < 1:40 2 Cryoglobulin test Cryoglobulin particles float in the serum and precipitate at the bottom of the test tube at 4°C. The particles dissolve on rewarming of serum to body temperature.

Li-Na Lee MD, PhD · Shyh-Chyi Lo MD · Fu-Chi Lin BS · Hon-Ping Lau MD · Jih-Shuin Jerng MD · Pan-Chyr Yang MD, PhD

Re: “Warfarin reversal: consensus guidelines, on behalf of the Australasian Society of Haemostasis and Thrombosis”, by Ross I Baker, Paul B Coughlin, Alex S Gallus, et al on behalf of the Warfarin Reversal Consensus Group (Med J Aust 2004; 181: 492-497). In Box 5, an asterisk in the Box title should have attributed Prothombinex-HT to CSL Limited, the manufacturer of all plasma-derived therapeutic products fractionated from Australian plasma. The error only appeared in the printed edition. The html and pdf versions of the article published in the eMJA were correct on publication.

Ross I Baker PhD, FRACP · Paul B Coughlin PhD, FRACP, FRCPA · Hatem H Salem MD, FRACP, FRCPA · Alex S Gallus FRACP, FRCPA, FRCP · Paul L Harper MD, FRACP, FRCPA · Erica M Wood FRACP, FRCPA

Re: “The hidden tragedy of offender deaths”, the editorial by Stuart Ross in the 1 November issue of the Journal (Med J Aust 2004; 181: 469-470). The reference numbering in the text is incorrect because of a computer error. In the first 3 paragraphs, references 12, 13, 14 and 15 should be references 1, 2, 3 and 4, respectively. All other references are correct, except for reference 13 in the last paragraph of the text, which, again, should be reference 2. The html and pdf versions of the article published in the eMJA were corrected on 17 December 2004.

Stuart Ross

Re: “Postnatal evaluation of vitamin D and bone health in women who were vitamin D-deficient in pregnancy, and in their infants”, by Thomson K, Morley R, Grover SR and Zacharin MR in the 1 November 2004 issue of the Journal (Med J Aust 2004; 181: 486-488). The first author’s name was incorrectly given as “Katherine Thompson”. The correct name is “Katherine Thomson”. The html and pdf versions of the article published in the eMJA were corrected on 30 November 2004.

Katherine Thomson MB BS · Margaret R Zacharin MB BS, FRACP · Ruth Morley BA, MB BChir, FRCPCH · Sonia R Grover MB BS, FRACOG

Llew Wheeler was born in South Strathfield, Sydney, on 23 October 1919. He was educated at Fort Street Boys’ High School, and began his medical course at the University of Sydney in 1939. After graduating in 1943 and doing a period of residency at the Royal Prince Alfred Hospital (RPAH), he joined the Army and served within Australia. After the war he “marked time” medically for a few years, doing various jobs, including a locum in Bathurst. Llew was Gordon Craig Fellow in Urology at RPAH from 1950 to 1953. In 1952, he acquired the postgraduate qualifications of Master of Surgery and Fellowship of the Royal Australasian College of Surgeons. He then went into specialist urological practice in Macquarie Street, Sydney, for a number of years. In 1956, he married Jacqueline, daughter of John Maude, an ophthalmologist. After the death of one of the practice partners, he entered solo urological practice at the new RPAH Medical Centre in Newtown in 1957. He became a Senior Urologist at RPAH and, finally, Head of Department. Llew was Honorary Secretary (1955–1958) and President (1963–1964) of the Urological Society of Australia, and was Consultant Urologist to the Royal Australian Navy. He was a life member of the Australian Medical Association. The only child of strict Presbyterian parents, Llew was himself deeply religious, but his feelings led him along a different path from that of his parents — he became a High Church Anglican. While still in active urological practice, he took up formal religious studies and obtained the degree of Bachelor of Divinity in 1978. A supporter of the movement to preserve the old Prayer Book, he became one of the founders of the Prayer Book Society in Australia, and was its NSW Chairman until the year 2000. He gave up specialist urological practice in 1979 to immerse himself in his religious and general interests, although he maintained some involvement in lower-key medical practice. Llew was also an accomplished organist. He loved humanity and took on a pastoral role. He was frequently consulted by people with medical difficulties of all kinds and by a wide variety of “lame ducks”, whom he would refer to his medical friends to sort out. The last years of his life were not easy. He had a resection of an upper gastric carcinoma in 1998 and knee surgery in 2001. He then fell victim to diffuse Lewy-body disease, becoming progressively and severely disabled. Llew died peacefully on 17 April 2004 and is survived by his wife Jacqueline and children Andrew, Daniel and Frances.

John L Allsop

Gwendolyn L Gilbert,* Heather F Gidding,† Josephine Backhouse,‡ Peter B McIntyre§ * Director, ‡ Serology Project Officer, Centre for Infectious Diseases and Microbiology, Institute of Clinical Pathology and Medical Research, PO Box 533, Wentworthville, NSW 2145. † Epidemiologist, § Director, National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases, University of Sydney, Westmead, NSW. LyngATicpmr.wsahs.nsw.gov.au To the Editor: Varicella vaccine was licensed in Australia in 2000. It is safe and efficacious and can prevent significant acute morbidity, significant out-of-pocket expenses for parents of affected children and, in Australia, prevents an estimated 450 admissions to hospital and one death per year.1 In September 2003, the National Health and Medical Research Council (NHMRC) recommended giving varicella vaccine to all children at 18 months of age.2 The net effect of childhood immunisation on varicella morbidity will depend on vaccination coverage. Modelling of Australian (unpublished National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases data) and UK3 seroprevalence data suggests that, for a range of vaccine efficacy estimates, 80% coverage is required before morbidity is reduced in adults. Accurate Australian coverage data are unavailable, as varicella vaccine is not funded under the National Immunisation Program.2 National serosurveillance can provide a practical alternative estimate of vaccine uptake. The first Australian national serosurvey of vaccine-preventable diseases, for which sera were collected between July 1996 and February 1999, established baseline seroprevalence for future assessment of the effects of changes in the vaccination schedule. It showed that the incidence of varicella was highest in 5–9-year-old children,4 indicating that infant vaccination would provide optimal protection. The second national serosurvey (with sera collected in 2002) is under way, with methods identical to those of the first.4 We compared varicella IgG levels in children aged 1–5 years, testing 459 sera in the first serosurvey and 380 in the second (see Box). The proportion with protective or equivocal antibody levels increased between the two serosurveys. The difference was statistically significant only in 3–4-year-olds, which is consistent with the greatest uptake when children enter childcare. Although there is some variation in varicella incidence over time, the changes are consistent with only modest vaccine uptake in the time that varicella vaccine has been available in Australia. The only other available estimates of varicella vaccine uptake are from GP consultations5 and reports to the Australian Childhood Immunisation Register (ACIR), which also indicate it is modest. For example, only 6.2% of children aged 4 years were reported to the ACIR to have received varicella vaccine (Brynley Hull, Epidemiologist, National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases, personal communication). This is probably an underestimate, as there is no incentive for notifying varicella vaccination. However, a low vaccination uptake is consistent with use only in the private sector, and could lead to an increase in adult morbidity (despite an overall reduction in infection rates) because of a higher average age of infection (unpublished National Centre for Immunisation Research data). Unless vaccine is provided in the routine immunisation program at no cost to parents, uptake is unlikely to meet the 80% target required to reduce disease burden in all ages.3 Varicella IgG seroprevalence in preschool children in the 1st and 2nd national serosurveys 1st serosurvey, July 1996 to February 1999 2nd serosurvey, 2002 Age group No. Positive Negative Equivocal* No. Positive Negative Equivocal* Increase in positive and equivocal (95% CI) P 1 to < 3 years 138 27 (19.6%) 111 (80.4%) 0 152 34 (22.4%) 118 (77.6%) 0 2.8% (−6.6 to 12.2) 0.6 3 to < 5 years 214 72 (33.6%) 140 (65.4%) 2 (0.9%) 152 73 (48.0%) 79 (52.0%) 0 13.4% (3.3 to 23.6) 0.01 5 years 107 61 (57.0%) 46 (43.0%) 0 76 43 (56.6%) 33 (43.4%) 0 −0.4% (−15.0 to 14.1) 1.0 Total 459 160 (34.9%) 297 (64.7%) 2 (0.4%) 380 150 (39.5%) 230 (60.5%) 0 4.2% (-2.4 to 10.8) 0.2 *Sera giving equivocal results by enzyme immunoassay were retested and most were resolved by immunofluorescence (IF). These results represent the few that were still equivocal by IF and are probably low-titre positive results.

Gwendolyn L Gilbert · Heather F Gidding · Josephine Backhouse · Peter B McIntyre

Angelo Labate,* Mark R Newton,† Graeme M Vernon,‡ Samuel F Berkovic§ * Research Fellow, Brain Research Institute, † Neurologist, § Director, Epilepsy Research Centre, ‡ Drug Information Pharmacist, Austin Health, Heidelberg West, VIC 3081. s.berkovicATunimelb.edu.au To the Editor: Tramadol is a synthetic, centrally acting analgesic that was approved for use in Australia in 1998. Seizures have been reported in patients receiving the drug in overdose and, rarely, at the recommended dose.1-4 Over a one-year period, we observed a number of tramadol-associated seizures in the First Seizure Clinic at Austin Health, an outpatient service for rapid evaluation and diagnosis of patients with new-onset seizures.5 We evaluated 197 patients from April 2003 to April 2004. One hundred had alternative diagnoses to epileptic seizures: syncope (n = 56), convulsive syncope (n = 27), panic attacks (n = 3) and other events (n = 14). Of 97 patients with confirmed seizures, 8 (5 male; median age, 34 years [range, 18–51 years]) were associated with tramadol (Box). Two patients who had received high doses of tramadol (600–750 mg/day [maximum recommended dose, 400 mg/day]) had developed seizures within 24–48 hours. Among the other six patients, who had received tramadol in the recommended dose range (50–300 mg/day), seizures had occurred 2–365 days after commencing therapy. Long-term psychotropic medication was taken by two patients. Seizures were generalised tonic–clonic seizures, without auras or focal features. No patient had a prior history of seizures, and none had a recurrence after they had ceased taking tramadol for a median of 9 months’ follow-up (range, 2–14 months). Electroencephalographic studies were normal in seven patients, with only one isolated sharp slow-wave in one patient. Computed tomography scans were all normal, and magnetic resonance imaging was normal in five patients. Previous US studies suggest a relatively low risk of seizures with tramadol, unless it is taken by people with epilepsy or taken with other drugs that reduce the seizure threshold.2-4 Tramadol is now widely prescribed in Australia, with 1.65 million prescriptions for oral tramadol issued under the Pharmaceutical Benefits Scheme in 2003.6 The Australian Adverse Drug Reactions Advisory Committee had received 83 reports of convulsions associated with tramadol to March 2004, although in only three cases was the association classified as “certain”. In our First Seizure Clinic, tramadol is the most frequently suspected cause of provoked seizures. We cannot calculate the exposure risk in our population, but the frequency of tramadol-related seizures suggests that they may be under-reported. It is important to consider tramadol as a possible cause of seizures — even when used at recommended doses. This may avoid inappropriate use of anti-epileptic drugs and unnecessary restrictions on driving and choice of vocation that might apply in cases of new-onset epilepsy. Details of eight patients with tramadol-related seizures at the First Seizure Clinic, Austin Health, April 2003–April 2004 Patient 1 2 3 4 5 6 7 8 Age (years) 18 35 31 33 48 51 25 45 Sex M F F M M M F F Tramadol dosage (mg/day) 750 600 100 300 100 50 100 300 Treatment duration (days) 1 2 7 365 21 90 2 180 Concomitant psychotropic drug taken No No No Yes* Yes† No No No Duration of follow-up (months) 12 9 14 9 9 3 3 2 * Chlorpromazine hydrochloride 200 mg/day. † Haloperidol 1 mg/day.

Angelo Labate · Mark R Newton · Graeme M Vernon · Samuel F Berkovic

Barbara A Hawkshaw,* Yeqin Zuo† * Planning and Evaluation Officer, Health Promotion Unit, Central Sydney Area Health Service, Level 9 North, King George V Building, RPAH, Missenden Rd, Camperdown, NSW 2050; † Currently Tobacco Control Program Coordinator, Cancer Institute NSW, Sydney, NSW barbara.hawkshawATemail.cs.nsw.gov.au To the Editor: The World Health Organization recommends that hospital staff ask about the smoking status of every patient, and offer brief quit advice and pharmacotherapy.1 These effective strategies2 underlie the Central Sydney Area Health Service (CSAHS) Smoke Free Environment Policy,3 which specifies the use of nicotine replacement therapy (NRT) in managing nicotine dependence of inpatients. Recording quit advice is yet to become a regular feature of medical records, but documentation of smoking status and NRT prescribing is evidence of compliance with the policy. To monitor the implementation of this policy in CSAHS, we examined the medical records of smokers for evidence of NRT prescribing in hospital or at discharge. A small sample was chosen to provide a “snapshot” of NRT use. First, we identified 2718 patients admitted to Royal Prince Alfred Hospital and Canterbury Hospital between 1 July 2001 and 30 June 2002 who were single admissions, stayed 48 hours or longer, and were current smokers (ICD-10 code Z720).4 Current smokers were defined as those who had smoked any tobacco in the past month.4 Sixty medical and 60 surgical patients from each hospital were selected randomly by random number generation (medical/surgical status was based on the specialty of the admitting doctor). After excluding 33 patients who were either ex-smokers or smokers who died during admission, the sample included 207 patients. Records were examined for smoking history, NRT prescribing during hospitalisation, and documentation of smoking status or NRT prescribing on discharge summary. NRT was prescribed to 13 patients (6.3%) during their hospitalisation (Box). All 13 received patches. A larger proportion of medical patients than surgical patients had NRT prescribed in hospital (8.1% v 4.6%) and at discharge (7.1% v 2.8%). In 8% of records, smoking was identified on the discharge summary. Most records (80%) provided numerical information about daily cigarette consumption. Seventy per cent of our sample smoked more than 10 cigarettes per day. Other records described consumption in subjective terms only, such as “heavy”. We believe that this is the first study in Australia to estimate the NRT prescribing rate for inpatients using medical record audit. Very few patients who were smokers were prescribed NRT. It is encouraging that most patients who were prescribed NRT were given a supply of patches at discharge. The NSW Health Department’s Guide for the management of nicotine dependent inpatients is a commitment to assisting people to quit.5 Implementation of the CSAHS Smoke Free Environment Policy3 by hospital staff requires a greater knowledge of the barriers to prescribing NRT and documenting quit activities at all levels of the hospital system. Nicotine replacement therapy (NRT) prescribing and smoking history Medical* Surgical* Total NRT prescribing (n = 99) (n = 108) (n = 207) During hospital stay 8 5 13 (6%) At discharge 7 3 10 (5%) Smoking history (n = 99) (n = 108) (n = 207) Number of cigarettes recorded 76 90 166 (80%) Years of smoking recorded 26 41 67 (32%) Cigarettes per day (n = 76) (n = 90) (n = 166)† 1–10 25 24 49 (30%) > 10 51 66 117 (70%) * Admission categorised according to specialty of admitting doctor. † Only 80% of total sample indicated number of cigarettes per day.

Barbara A Hawkshaw · Yeqin Zuo

Desmond O’Brien Emeritus Honorary Anaesthetist, The Prince of Wales Hospital, Randwick, NSW 2031. hdobrienATbigpond.com.au To the Editor: Tonti-Filippini condemns denial of elective surgery to smokers as discriminatory.1 He disregards the fact that surgery requires anaesthesia, which may require serious consideration before undertaking non-urgent surgery, and in no way involves discrimination. He mistakenly regards denying elective surgery to those who continue to smoke as discrimination, in breach of the Hippocratic Oath, and the Australian Medical Association (AMA) Code of Ethics. In fact, to proceed with elective, especially cosmetic, surgery in a heavy smoker is more in breach of the Oath and the AMA Code than not proceeding, for the following reasons. Smokers are at a significantly greater risk under anaesthesia than non-smokers because, firstly, smoking reduces the capacity of the lungs to take up oxygen, thus increasing the risk of hypoxia and its consequences to heart and brain.2 It also causes coughing and breath-holding during anaesthesia,2,3 creating surgical difficulties, and the risk of error. Postoperative coughing causes additional pain (especially after thoracic and abdominal operations), and increases the risk of postoperative bleeding, infection, delayed healing and even wound breakdown.4,5 Rather than being discriminatory, delaying elective and cosmetic surgery until he or she stops smoking is very much in the patient’s interests.

Desmond O’Brien

Daniel M Fatovich Specialist in Emergency Medicine, Royal Perth Hospital, GPO Box X2213, Perth, WA 6847 daniel.fatovichAThealth.wa.gov.au To the Editor: I have read with interest the debate in the MJA on the use of tPA in acute ischaemic stroke. Most recently, Levi et al published a position statement stating that it is a major advance.1 This was probably in response to Hoffman’s critical editorial.2 At the 10th International Conference on Emergency Medicine in June 2004, a session on the use of tPA in acute ischaemic stroke clearly portrayed thrombolysis as not standard care.3 I have attended other emergency medicine conferences where thrombolysis was seen as risking more harm than good. Conversely, I expect that stroke physicians attend stroke conferences that endorse thrombolysis. In my experience, when such divergent views exist, it usually means that we don’t have enough answers. I would like to outline here some other viewpoints that are not often considered. Number needed to harm (NNH): The best results to date were from the NINDS study that reported a number needed to treat (NNT) of 8.4 With their findings of an intracranial haemorrhage rate of 6.4%, the NNH is about 16. Hence, for every 16 patients treated with tPA, two may derive much benefit, but one much harm. These odds are worse than Russian roulette. The Cleveland study reported an intracranial haemorrhage rate of 22%.5 Hence, the worst possible NNH is about 5. Other authors have expressed similar ethical concerns.6 Risk tolerance is an individual judgement, but, when faced with the above issues, my practice is to ask what I would want for myself. Knowing that the earlier thrombolysis is given the better,7 my personal choice would be to only have thrombolysis if it is administered within 90 minutes of stroke onset (ie, maximal benefit and minimal risk). Unfortunately, it is rare for patients to present early enough for this to occur. Furthermore, many of my colleagues do not know what they would want for themselves, so how can we advise our patients? Pathophysiology: Heart muscle is relatively robust, whereas the brain is a softer structure. A haemorrhagic complication is very different in the two organs. Mode of thrombolysis: Giving thrombolysis by infusion is an outdated approach. Furthermore, thrombolysis is almost a forgotten therapy for acute myocardial infarction in tertiary centres because of the use of primary angioplasty. When thrombolysis is used, the agent is given as a bolus. Uptake of this mode of administration would be rapid if it were shown to be effective and safe for acute ischaemic stroke. Obviously, consensus among care providers on the use of tPA does not exist. This means that more research needs to be done to work out the answers to these difficult questions. I believe there is much support for this, as we need to define who should be receiving thrombolysis, and, perhaps more importantly, who should not. We all want something that works! However, we need greater knowledge to overcome the safety issues. The answer to Levi’s question “Why did it take so long?” is “Because it is a complex problem”.

Daniel M Fatovich

Ian R Rogers,* George A Jelinek,† Ian Jacobs* * Associate Professor, † Professor, Discipline of Emergency Medicine, Queen Elizabeth II Medical Centre, Nedlands, WA 6009. Ian. RogersAThealth.wa.gov.au To the Editor: We applaud the call of Levi and his co-contributors for collegiate communication and consensus regarding the use of tissue plasminogen activator in acute ischaemic stroke.1 Emergency care providers are acutely aware of their role at the centre of the acute healthcare system. Daily, we interact with colleagues from other disciplines in the course of seeking the best clinical care for our patients. However, the views expressed by Hoffman2 are shared by many emergency physicians and prehospital care providers. We remain unconvinced of the role of thrombolysis in acute ischaemic stroke outside the setting of properly constituted clinical trials. On review of the contributors list in Levi’s article, we are unable to identify a single specialist emergency medicine or prehospital care provider. Consensus is not likely to be achieved until position statements from expert groups include a strong representation from all the specialty disciplines involved in the care of stroke patients. We look forward to developments in this direction.

Ian R Rogers · George A Jelinek · Ian Jacobs

Christopher R Levi (on behalf of the Australasian Stroke Unit Network, the New South Wales Greater Metropolitan Clinical Taskforce Stroke Initiative, and the Towards A Safer Culture Stroke Expert Working Group) Director, Acute Stroke Services, John Hunter Hospital, Locked Bag No. 1, Hunter Region Mail Centre, NSW 2310. christopher.leviAThunter.health.nsw.gov.au In reply: We thank the authors for their comments on our recent position statement.1 We fully agree and accept the view of Rogers and colleagues that emergency physicians are central to the timely and safe delivery of emergency medical care in our health system. This is especially the case for a therapy such as intravenous tPA, given the narrow therapeutic window and coordination challenges. We view the development of linkages with our colleagues in emergency medicine as crucial in implementing not only tPA but also a number of acute stroke therapies showing great promise in the advanced stages of development.2 Our position statement is a starting point for broader discussion, and we are pleased that discussions between the key groups are under way. We agree that, when considering patient suitability for intravenous tPA, a number of uncertainties remain, and we fully support the rationale for the ongoing clinical trials of thrombolysis in acute ischaemic stroke (see www.astn.org.au/epithet/index.html and www.ist3.com/). The risk–benefit ratio will be improved in the 0–90-minute window, as indicated by Fatovich. However, it is likely that some patients at much later time points will also gain benefit. We would emphasise, however, that according to Australia’s independent arbiter of therapeutic safety and efficacy, the Therapeutic Goods Administration, intravenous tPA is an approved therapy if given within a 3-hour window, under appropriate clinical circumstances and within appropriate healthcare settings. Regarding the comments by Fatovich on number needed to harm, it is important to recognise that the most serious adverse outcome of intravenous tPA — fatal intracerebral haemorrhage — is already accounted for in the calculations of number needed to treat (for patients to survive free from dependency). Intra-arterial thrombolytic therapy in the form of prourokinase has been found to be effective in reducing dependency in acute ischaemic stroke, shown angiographically to be caused by middle cerebral artery occlusion.3 Feasibility issues, however, presently limit the application of the intra-arterial approach, and the relative risk of intracranial haemorrhage, even with this more targeted approach, is similar to that seen with intravenous therapy. The importance of cross-disciplinary teamwork in the effective application of current and future acute stroke therapies cannot be underestimated. Central to this is the need to develop an effective dialogue between the leaders of these teams — stroke physicians and emergency physicians. The Australasian Stroke Unit Network, the New South Wales Greater Metropolitan Clinical Taskforce Stroke Initiative, and the Towards A Safer Culture Stroke Expert Working Group are committed to the task of helping to build better links between stroke units and emergency departments.

Ron Borland,* Catherine J Segan† * Nigel Gray Distinguished Fellow, † Behavioural Scientist, The Cancer Council Victoria, 1 Rathdowne Street, Carlton, VIC 3053 ron.borlandATcancervic.org.au To the Editor: The editorial on web and telephone counselling in Australia1 has the capacity to seriously mislead readers. It asserts: Despite this extensive use, the review confirmed that no randomised controlled trials (RCTs) have been conducted of the efficacy of web or telecounselling either in Australia or internationally.1 The assertion was based on a review commissioned by the Commonwealth Department of Health and Ageing and from a review in the United Kingdom, but is simply not true. It may be true for services designed to deal with mental health problems, narrowly defined, but it is patently false if it is taken to include services to facilitate smoking cessation. We note that nicotine dependence is a recognised mental disorder,2 and thus, strictly speaking, even if the review asserted that it was restricted to mental health, it would still be wrong. We do not know about the accuracy of the statements in relation to other drug use problems, but for smoking cessation there are a number of randomised trials of telephone-based systems,3 and at least two web-based resources are translations to the Internet of tailored computer advice services shown to be effective in RCTs.4,5 Both include Australian examples of RCTs. Our group demonstrated that the Quitline callback service as operated by Quit Victoria (phone 131 848) enhances cessation outcomes.6 Another study showed that an interactive personalised computer advice program called the QuitCoach (www.theQuitCoach.org.au) is effective in facilitating cessation, particularly by reducing relapse.4 It is currently available through the Department of Health and Ageing’s website at www.quitnow.info.au. We wonder why this omission has happened. What makes a health issue as important as smoking so invisible? Are other drug and alcohol issues similarly invisible? Tobacco kills about 19 000 Australians each year, and disables many more. There is increasing evidence suggesting it plays an important aetiological role in the development of some mental disorders. Smoking rates among people with schizophrenia and depression are extraordinarily high.7-9 The Victorian Quitline has pioneered the integration of support for psychiatric conditions with smoking-cessation counselling,10 and, although this service has not yet been subject to outcome evaluation, it is apparent that it meets the proximal needs of both smokers with concurrent mental disorders and their carers. Telephone and web-based services hold tremendous potential both as stand-alone services and as integrable components of comprehensive, coordinated care. High quality evaluations are required, and they need to be seen as an integral part of service delivery. People in other healthcare areas could learn a lot from what has been achieved in smoking cessation.

Ron Borland · Catherine J Segan

Helen Christensen,* Barbara Hocking,† Dawn Smith‡ * Deputy Director, Centre for Mental Health Research, Australian National University, Canberra, ACT 0200; † Executive Director, SANE Australia, Melbourne, VIC; ‡ Chief Executive Officer, Lifeline Australia, Canberra, ACT. helen.christensenATanu.edu.au In reply: Borland and Segan are correct in assuming that we did not include substance disorder randomised controlled trials (RCTs) in the assessment of the efficacy of web and telecounselling services in our editorial.1 Our definition of web and telecounselling was also strict in that we included only contact that involved a person (a counsellor) online or by telephone. We specifically excluded interactive personalised web programs such as www.theQuitCoach.org.au or others specifically in mental health (narrowly defined), which have been found effective when delivered by the Internet. (Such programs include Panic Online,2 MoodGYM and BluePages.3) The use of RCTs in evaluating the areas of substance use, anxiety, depression and other mental health problems is to be applauded. Borland and Segan’s letter is also instructive in reminding us of the importance of coexistent substance-use disorders and mental health problems. Organisations such as SANE are committed to reducing the health costs of smoking in people with mental health problems and have developed specific programs for this purpose. Importantly, we are in agreement with Borland and Segan that telephone and web-based services “hold tremendous potential both as stand-alone services and as integrable components of comprehensive, coordinated care”. However, our editorial reported that web and telecounselling (not integrated web-based management systems) have yet to be evaluated through RCTs. One point we contest is the view that smoking is invisible. Our systematic review of funding allocations to mental health research has found that the category of substance-use disorders, of which smoking was the third-largest component (below alcohol and opioids), received the most Australian research funding in 2000.4 The level of funding for substance use exceeded that for childhood disorders and dementia. Compared with substance-use research, depression research received less than half, and psychosis and anxiety less than a third, of funding. Affective disorders contribute the highest disease burden, and dementia has the highest health system costs. Although all our projects in these important areas require proportionately more funding, it is not helpful to claim that the omission of smoking outcome research is due to failure to recognise its importance.

Helen Christensen · Barbara Hocking · Dawn Smith

Ailsa Goulding,* Andrea M Grant,† Peter L Davidson‡ * Professorial Research Fellow, † Assistant Research Fellow, Department of Medical and Surgical Sciences, ‡ Research Fellow, Injury Prevention Research Unit, University of Otago, Dunedin, New Zealand. Ailsa. GouldingATstonebow.otago.ac.nz To the Editor: The interesting article on playground safety and arm fractures by Sherker and Ozanne-Smith1 documents a steady increase in hospitalisation rates for arm fractures among Victorian children between 1987 and 2002. It would appear that the increase over this 15-year period was about 45%. These figures may represent the tip of the iceberg, as few children with arm fractures are admitted to hospital and most are treated on an outpatient basis. Increases of similar magnitude in forearm fractures in adolescence have also been reported recently in the United States.2 It would seem that children are becoming more vulnerable to such fractures. This is a concern, as fractures of the distal forearm are extremely common during growth. Indeed, about a quarter of all fractures during childhood and adolescence occur at this site. One factor that might be contributing to this rising incidence of arm fractures during growth is increasing childhood adiposity. Childhood obesity has increased sharply in Australian children over recent years.3 Obese children fall with more force, and, although they may have more bone for chronological age than children of healthy bodyweight, adaptive increases in bone mass are not enough to accommodate their high bodyweight gain, placing them at a biomechanical disadvantage during falls on the outstretched arm.4 Our studies of consecutive series of girls and boys with distal forearm fractures indicate that a high proportion of these children are overweight. Moreover, in a 4-year prospective study of 170 girls, we found that high bodyweight at baseline increased the risk of new fractures.5 In their study, Sherker and Ozanne-Smith measured the heights and weights of 402 children under 13 years of age who had broken their arm falling from playground equipment between 2000 and 2002. We wonder how many of these children were overweight or obese for their age. Examination of the body mass index values would provide this information, and we ask that the authors report these data for both girls and boys using international cut-off points. We would like to know whether or not overweight is contributing to rising rates of arm fracture in Australian playgrounds.

Ailsa Goulding · Andrea M Grant · Peter L Davidson

Shauna Sherker,* Joan Ozanne-Smith† * Postdoctoral Research Fellow, NSW Injury Risk Management Research Centre, University of New South Wales, Sydney, NSW; † Chair of Injury Prevention, Accident Research Centre, Monash University, Melbourne, VIC. Shauna. SherkerATunsw.edu.au In reply: The prevalence of obesity has increased dramatically among Australian children, particularly over the past 2 decades.1 However, the role of obesity as a risk factor for fall-related arm fracture remains unclear. Using standard definitions for child overweight and obesity,2 our study population3 (Box) did not demonstrate quite as high a prevalence of obesity as had been previously reported for Victorian schoolchildren.1 This case series was part of a larger, yet to be published case–control study, the results of which indicate no significant difference in body mass index between children who fell from playground equipment and fractured their arm (cases) and those who fell and landed on their arm with no significant injury (controls). The negative public health effects of increasing prevalence of obesity among Australian children highlight the need to promote safe and enjoyable physical activity. Playground equipment provides a very popular means of physical activity for children. Improving playground safety standards to minimise the risk of arm fracture — a traumatic, costly and preventable childhood injury — has never been more urgent. Children with arm fracture caused by falls from playground equipment, showing proportion of children who were normal weight, overweight or obese.* * Based on unpublished data from Sherker and Ozanne-Smith.3

Shauna Sherker · Joan Ozanne-Smith

Erica L Mann Managing Director, Wyeth Australia and New Zealand, 17-19 Solent Circuit, Norwest Business Park, Baulkham Hills, NSW 2153. To the Editor: Wyeth Australia welcomes the opportunity to comment on Lu and colleagues’ discussion of whether rheumatoid factor status is a predictor of tumour necrosis factor-α (TNFα)-inhibitor response in rheumatoid arthritis (RA).1 Wyeth provided the data used by the Pharmaceutical Benefits Advisory Committee (PBAC) to originally exclude patients who test negative for rheumatoid factor from access to TNF-α inhibitors. Although Wyeth agreed with the PBAC’s interpretation that only patients with positive rheumatoid factor status may benefit from etanercept, efficacy in those testing negative for rheumatoid factor was not clearly established because of the small number of patients in these subgroups. Importantly, the subgroup analysis divided all study participants into two groups depending on their rheumatoid factor status and only included ACR 20 response (a standard from the American College of Rheumatology which requires at least 20% reduction in swollen joint count, tender joint count, and in three out of five of patient’s assessment of pain, patient’s assessment of disease activity, investigator’s assessment of disease activity, acute phase reactant levels and patient’s assessment of disability). This analysis may not represent the likely response of patients who test negative for rheumatoid factor, but who develop severe, progressive rheumatoid arthritis and otherwise meet the stringent eligibility criteria associated with Pharmaceutical Benefits Schedule listing (excluding positive rheumatoid factor status). It is possible that the small number of unique rheumatoid-factor-negative patients who have severe disease will not have a different response to etanercept from similar patients who are rheumatoid-factor positive. More recent data are available from a large multicentre study that compared treatment with etanercept in combination with methotrexate to either monotherapy alone for control of RA disease activity.2 Subgroup analysis for the effect of rheumatoid factor on treatment responses showed that the presence of rheumatoid factor in the circulation of study patients did not significantly affect the responses to therapy among treatment groups. Although these new data have yet to be presented to the PBAC for reconsideration, a submission on this matter is under way.

Erica L Mann

Australian health care system. 2nd ed. Stephen J Duckett. Melbourne: Oxford University Press, 2004 (xxv + 341 pp). ISBN 0 19 5517458. THE AUSTRALIAN HEALTHCARE SYSTEM The Australian healthcare system is dauntingly complex. To understand it you need a good map, and this book, now updated to a 2nd edition, is an excellent map. Most structural aspects, such as funding arrangements; provider configuration including hospitals, primary care and public health; and policy issues such as workforce and health system design, are described clearly and concisely using a systems framework. Arguably, there is no one else who has had the range of experience of travelling through and, on occasion, steering the Australian healthcare system than the author. Professor Duckett is a leading health services academic and has been our most senior health bureaucrat. He brings an operations research, economic, managerial, policy and a particular political perspective to the task. No one, of course, writes a book exactly as a reviewer would have. Given the author’s background, I would have appreciated more on his perspective of the role of politics and process in shaping the health system over the past 20 years. Perhaps that will be another book — a 21st-century version of the seminal 1984 book by the late Sydney Sax, A strife of interests: politics and policies in Australian health services (Sydney: Allen and Unwin, 1984). The present work will contribute most as a textbook for postgraduate students in public health and health services management, for whom it is already a standard text. However, all clinicians would benefit from a deeper understanding of the Australian healthcare system and how it provides the construct for their clinical work. This book is a good place for them to start that journey. Johannes U StoelwinderOrthopaedic Surgeon Chair of Health Services Management Alfred Hospital, Melbourne, VIC

Johannes U Stoelwinder

Weight of evidence Looking for another reason to encourage obese patients to try to reduce their weight? Along with obesity, the prevalence of atrial fibrillation (AF), the most common dysrhythmia, has also been on the increase. Now, an analysis of Framingham Heart Study data suggests that obesity may be a potentially modifiable risk factor for AF. Wang and colleagues studied data from more than 5000 study participants who were followed for an average of 13.7 years. They found that obesity was associated with a 50% increase in the risk of new-onset AF. Further, for both men and women, there was a 4% increase in risk of AF for each 1-unit increase in body mass index. Left atrial dilatation may be responsible for the link between obesity and AF. JAMA 2004; 292: 2471-2477 Venereal vaccine A human papillomavirus (HPV) vaccine will probably be the first licensed vaccine against a common sexually transmitted infection, say Finnish authors.1 They were commenting on the GlaxoSmithKline HPV Vaccine Study Group’s report of an efficacious HPV vaccine.2 The study randomised 1113 women between 15-25 years of age to receive 3 doses of either a bivalent HPV-16/18 virus-like particle vaccine or placebo at 0, 1 month and 6 months. In analyses, vaccine efficacy against incident and persistent cervical infection was greater than 90%. The vaccine was generally safe, well tolerated and highly immunogenic. However, a protective antibody level has not yet been established, nor are there sufficient data to estimate the duration of vaccine-induced protection. 1. Lancet 2004; 364: 1731 2. Lancet 2004; 364: 1757-1765 Seniors on the sea? Some elderly people should consider living on a cruise ship when they can no longer manage to live independently, say US authors. They compared the features and costs of long-term cruising with those of moving into an assisted living centre (hostel) in the US, where government assistance with the cost of care is limited. Cruises were similarly priced but more cost-effective. As well as offering three meals a day with escorts, and housekeeping and laundering services, added benefits of cruise ship care included on-site doctors and nurses, and emergency care facilities. The authors said the ideal candidates for cruise ship care were seniors who enjoy travel and have good cognitive function but need some help in daily living. J Am Geriatr Soc 2004; 52: 1951-1954 From the Age of reason Some 18th-century data give us pause to reflect on the current high rates of childbirth intervention, according to a UK author. Emeritus Professor Dunn says that a Dutch midwife, Catherina Schrader, kept notes on about 4000 confinements which she attended between 1693 and 1745, including 64 twins and three triplets. Although she recorded some manual extractions and a few instrumental deliveries, 95% of deliveries were spontaneous and without intervention. Overall, maternal mortality was about 1 in 200, and 95% of the neonates survived childbirth. Arch Dis Child 2004; 89: F560-F562 To the final frontier Remote medicine, particularly in developed countries, may receive a boost after a special report of a recent, successful project conducted on, of all places, the International Space Station. US researchers said that, with minimal pre-flight training, an on-board "refresher" course and (almost) real-time, Earth-based expert guidance, non-experienced personnel could be trained to conduct a complex, clinically useful ultrasound examination of the shoulder in space. The total examination time required was about 15 minutes. The researchers said that, in space, this technique could be used to evaluate shoulder integrity in symptomatic astronauts after strenuous extravehicular activities, or to monitor microgravity-associated changes in musculoskeletal anatomy. However, this spaceflight-derived technique is also readily transferable to Earth, including for rural, military and emergency medical care. Radiology 2004, 10.1148/radiol.2342041680 Acupuncture advantage Acupuncture, used in addition to an NSAID, may assist in managing osteoarthritis of the knee, say Spanish researchers. In a controlled trial involving 97 outpatients with osteoarthritis of the knee, they randomised subjects to receive 12 weekly sessions of either acupuncture or placebo acupuncture. In placebo acupuncture, supported needles were placed over the same points as for acupuncture, but did not perforate the skin. All study subjects were prescribed diclofenac (50 mg, 8-hourly) with instructions to reduce the dose if symptoms improved. At trial completion, outpatients who received acupuncture took less diclofenac and had less stiffness and better physical function of the knee. Bruising after acupuncture occurred in three patients (at the same local point). BMJ 2004; 329: 1216-1219 Dr Ann Gregory, MJA

Ann Gregory