Volume 183 Issue 1

Treating the paradox of an important emerging public health problem The international perception of bronzed Australians inhabiting a “sunburnt country” is under threat. Most Australians, including children, now sensibly avoid excessive sun exposure to reduce the risk of skin cancer. However, other Australians, particularly those who are older, disabled or institutionalised often do not receive even modest levels of sunlight exposure. This has led to the paradox of vitamin D deficiency emerging as a public health issue in sunny Australia. . . . despite Australia being a “sunburnt country”, vitamin D deficiency is common. But why is it important? Besides older and institutionalised Australians, others particularly at risk of vitamin D deficiency are people with pigmented skin from Africa, India and Pakistan; women who practise veiling; those on certain medications (eg, anti-epileptic drugs); and those with malabsorption or a low vitamin D intake. Even young Australians, pregnant women and their infants are at risk of this emerging health problem.1 The prevalence of vitamin D deficiency among Indigenous Australians has not been determined, but is likely to be high. The problem was highlighted recently in the Journal in a position statement on vitamin D and bone health in adults.2 Vitamin D deficiency is usually classified as mild (25-hydroxyvitamin D [25OHD] level, 25–49 nmol/L), moderate (12.5–24 nmol/L) or severe (< 12.5 nmol/L). The Geelong Osteoporosis Study detected mild or moderate deficiency in more than one in three women surveyed in summer, which rose to one in two in winter.3 Even in south-east Queensland, Western Australia, New South Wales and Victoria, nearly a third of men and women have mild to moderate vitamin D deficiency.4 Almost half of nursing home patients, and almost all patients in aged care facilities surveyed have at least mild vitamin D deficiency. Thus, despite Australia being a “sunburnt country”, vitamin D deficiency is common. But why is it important? Severe vitamin D deficiency results in osteomalacia in adults and rickets in children. Milder vitamin D deficiency results in secondary hyperparathyroidism and increased bone turnover, predisposing to osteoporosis. Proximal myopathy and muscle pains may occur in moderate or severe vitamin D deficiency, and the incidence of falls is increased.5 Less well known is the impact of vitamin D deficiency on depression, immunity and autoimmunity, obesity, and the progression of type 2 diabetes mellitus. It is also important to correct vitamin D deficiency to optimise the effects of other anti-osteoporotic drugs. In a recent United States study of 1536 women receiving anti-osteoporotic therapy, 52% had vitamin D deficiency.6 Treatment with intravenous or (more rarely) oral bisphosphonates may also cause severe hypocalcaemia in people with severe vitamin D deficiency,7,8 so it is prudent to screen for vitamin D deficiencies before initiating bisphosphonate therapy. In the broad context of vitamin D deficiency as an emerging public health issue, the article by Diamond et al in this issue of the Journal (page 10)9 is timely. Their prospective open label study of 50 elderly women and men with vitamin D deficiency showed that a single intramuscular injection of 600 000 IU (or 15 mg) of cholecalciferol (vitamin D3) increased serum 25OHD concentrations to above 50 nmol/L in all patients. Over 12 months, serum 25OHD concentration rose, on average, by 128% to 73 nmol/L — a level most would consider to be optimal. Secondary hyperparathyroidism, present in about 50% of participants, was abolished in most. The complications of therapy were mild hypercalcaemia in two participants (4%) and fasting hypercalciuria in 10 participants (20%) tested at 12 months. The study by Diamond and colleagues represents a step forward in currently available treatment options for vitamin D deficiency. Currently, this is limited to doses of 200–1000 IU of either vitamin D2 (ergocalciferol) or vitamin D3 (cholecalciferol). The commonest form is 1000 IU of ergocalciferol (Ostelin; Boots Healthcare Australia). Loading doses of 3000–5000 IU per day are required to treat severe vitamin D deficiency and, as commercially available radioimmunoassays do not always measure vitamin D2 as well as vitamin D3, measuring treatment response is difficult. Daily dosing is also difficult or unrealistic for many community-dwelling older people in whom compliance would be expected to be poor. A single intramuscular “megadose” of cholecalciferol would overcome this compliance issue in a simple and cost-effective manner. The mild hypercalcaemia and fasting hypercalciuria are of concern, but further controlled trials are planned, which will include 24-hour urine calcium excretion measurements, to evaluate the safety of “megadose” cholecalciferol therapy. The effect of this treatment on fracture risk is not established. A recent British study of 9440 community-dwelling participants aged 75–100 years, randomly allocated to receive either an annual injection of 300 000 IU cholecalciferol or placebo, showed no reduction in fracture rate.10 Nevertheless, the greatest clinical utility of an annual megadose injection is likely to be in older institutionalised people, most of whom are vitamin D deficient. The most important outcome in osteoporosis prevention or treatment is a reduction in fracture risk. Some data suggest treating vitamin D deficiency may prevent low-trauma fractures. A large French study in institutionalised, ambulatory older women found that daily doses of 800 IU of cholecalciferol and 1.2 g of calcium significantly decreased the incidence of hip and non-vertebral fractures compared with placebo after 18 months.11 Daily vitamin D and calcium treatment also reduced non-vertebral fractures in community-dwelling older American men and women.12 A recent large trial in community-dwelling British men and women aged over 65 years showed that a large oral dose of cholecalciferol (100 000 IU) every 4 months reduced osteoporotic fractures by 33%.13 The RECORD trial attempted to determine the relative contribution of calcium versus vitamin D on fractures. Ambulatory patients (5292) who had sustained a low-trauma fracture were randomly allocated to receive calcium (1000 mg/day), vitamin D3 (800 IU/day), a combination of the two, or placebo. After at least 24 months, fracture rates did not differ between the four groups. However, compliance at 2 years was poor.14 Further large studies of vitamin D and its effects on fractures and falls are still needed, particularly in populations at risk of vitamin D deficiency; these studies need to use varying oral doses of vitamin D and to include men. The treatment described by Diamond et al is a good start to introducing new alternatives for treatment of vitamin D deficiency in targeted people. However, much more work is needed to identify successful public health approaches that can be more broadly applied to this emerging public health problem.

Peter R Ebeling MD, FRACP

Canteens are not the main source of food for Australian school kids, but their symbolism is big There is widespread awareness of the obesity epidemic in Australian children,1 and the focus has now, quite appropriately, turned to action. In the United Kingdom, celebrity chef Jamie Oliver is trying to transform a 100-year-old school lunch service from “soggy and fried” to “crisp and fresh”. In Australia, the question is whether school canteens should be a high priority for action, because of their accessibility and visibility, or a low priority, on the grounds that canteen foods contribute little to children’s energy intake. Negative ripples from canteensOver the period of a year, children aged 5–15 years obtain only about 16% of their total energy intake from food eaten at school, and probably less than 3% comes from canteens.2 But while the energy contribution is small, the symbolism is big. Canteen users consume significantly greater amounts of foods likely to promote unhealthy weight gain, such as fast foods, confectionery and packaged snacks.2 The types of foods and beverages that predominate in school canteens not only undermine the health and nutrition curriculum, but also create the impression that foods and drinks that are high in fat, sugar and salt belong on the plate as “everyday foods”, rather than on the side as “occasional foods”. Other common practices in schools that undermine healthy eating messages include rewarding children with sweets, having soft-drink and confectionery vending machines, holding sporting events with fast-food vouchers as prizes, and using chocolate drives for fundraising. All these practices create negative ripple effects on Australian family eating practices and beliefs.3 Children are developing the food preferences that they will carry with them into adulthood, so strengthening family and school environments for enjoying healthier food choices is critical. In a 2004 survey of 18 Victorian primary schools (unpublished data), we found that, of the 17 with a food service, all sold meat pies, but only five sold fruit on a regular basis. As a rule, canteen managers provided foods that sold well and had a long shelf life. They usually had no mandate or support to do otherwise. A reliance on profits from canteens, vending machines and “junk food fundraising” also makes it hard for schools, particularly high schools, to model healthy eating. In common with a survey of 500 New Zealand schools,4 we found that schools readily recognise the rather poor job they do of providing a healthy food environment. Most schools do not see food provision as part of their core business and lack the inclination or resources to take on this “added” responsibility. Private enterprise fills this vacuum, with the result that the health of profits increasingly dominates the health of pupils. An extreme example is the “cola war” in the United States, in which the weapons of choice have been contracts with schools to sell minimum volumes of Coca Cola or Pepsi.5 Creating a new epidemic?Perhaps we should consider the task ahead of us as the creation of a new epidemic of healthy eating rather than reducing an obesity epidemic. Using the principles in Gladwell’s recent bestseller The tipping point,6 the school canteen and students themselves could be the catalyst for healthier eating among children and adolescents — turning negative ripples into positive waves. Can a “tipping point” be created from a handful of champion schools that decide to embrace the whole-of-school policies and strategies needed to get their canteens right (healthy, enjoyable, profitable and supported), hoping that others will follow their lead? This is almost certainly too much to expect to happen in 9000 schools across Australia, which tend to function semi-autonomously on these matters. Lessons from successful public health programs, such as sun protection and injury prevention, show that tipping the balance in targeted behaviours from unhealthy to healthy requires a backbone of strong central policy, ongoing social marketing, and supported and coordinated implementation of programs. Some Australian modelsVarious government-supported models influence how school canteens operate in Australia. Probably the least effective include the Victorian model of simply disseminating canteen guidelines7 and the Australian Government model from the pre-election spending spree, wherein each school could apply for $1500 to reinvent the “healthy canteen” wheel. Neither has policy, social marketing or implementation support. A third model, which has some merit, is exemplified by the Western Australian (StarCAP8) and Tasmanian (Cool CAP9) school canteen accreditation programs. Both have well developed criteria and processes for schools to work through to achieve program accreditation. StarCAP is backed by the WA government, but is managed on a shoestring budget, without policy and social marketing support, and thus has a low accreditation rate (7% of schools) and declining reach.10 Cool CAP is newer, with a higher accreditation rate (42% of schools accredited or working towards it), and so far has been successful in securing legislative and monetary support. Ultimately, however, the impact of these types of programs will probably be modest as long as the impetus to change remains with each individual school. Because they are well supported and centrally driven, the most promising models come from New South Wales and South Australia. The NSW Healthy School Canteen Strategy (“Fresh Tastes @ School”)11 grew out of the NSW Government Childhood Obesity Summit in 2002. It is now mandatory for state schools to provide food and beverage choices consistent with the Australian guide to healthy eating.12 NSW Health has also boosted support for the NSW Canteen Association so that it, in turn, can support schools to operate economically viable, nutrition-oriented school canteens. Early positive waves include support from parents, canteen managers, some food companies and, increasingly, local health and education services. A similar model released in 2004 in South Australia brings SA government backing to a set of healthy eating guidelines.13 The guidelines encourage links between the canteen, the community and teaching about nutrition food skills. Both the NSW and SA government models would now benefit from social marketing explaining the rationale, processes and support for the program. It would make sense, for example, to link these strategies with the national “Go for 2&5” (2 serves of fruit and 5 serves of vegetables) campaign.14 If we are serious about the childhood obesity epidemic, school canteens are a good place to start, because they carry a symbolism that ripples into the Australian diet far beyond their contribution to energy intake. At the moment, the ripples are a negative and undermining force. However, full implementation of the NSW or SA models for school canteens throughout the country could just tip the balance towards an outbreak of healthier eating.

A Colin Bell BSc(Hons), MSc, PhD · Boyd A Swinburn MB ChB, MD, FRACP

Not so long ago, the International Committee of Medical Journal Editors (ICMJE) — represented by 11 general medical journals including The Medical Journal of Australia — took a fairly passive and advisory role in medical publishing. The major outcome of its efforts was the Uniform requirements for manuscripts submitted to biomedical journals, which is an internationally accepted reference for biomedical publishing. It gives recommendations for preparing manuscripts for submission, and includes statements on editorial roles and responsibilities, authorship, and ethical issues governing biomedical publication.1 Recently, the ICMJE has adopted a more aggressive, interventional role. This new function first surfaced with the ICMJE’s 2001 statement Sponsorship, authorship and accountability, which conveyed the requirements for publishing clinical trials conducted with corporate sponsorship.2 The statement’s bottom line was that publication of such trials depended on compliance with transparent processes regarding responsibility for the trial, access to and control of data, and control of publication by researchers. In short, transparency and independence were stressed. The next ICMJE foray came with its 2004 statement on Clinical trial registration,3 which, despite being cautiously welcomed by research and media commentators,4,5 has reverberated in the research community, and in particular in the pharmaceutical industry, ever since.6 This statement was a response to the pharmaceutical industry’s longstanding unethical practice of “silent” clinical trials. It decreed that ICMJE journals would only consider publishing reports of trials that had been registered before enrolling the first participant. This policy came into operation on or after 1 July 2005 for new trials, and any ongoing trials are to be registered before 13 September 2005. The need for prospective registration of clinical trials is not a new idea.7,8 Almost a decade ago, for example, the Australian Health Ethics Committee first acknowledged the need to establish a clinical trials register in Australia.9 Now, in one swoop, the ICMJE has provided the impetus to move trial registration from the realm of theoretical nicety to its rightful place on various ethical and political agendas. In a follow-up statement in May this year, Is this clinical trial fully registered?,10 the ICMJE reaffirmed its clinical trial registration policy and endorsed the World Health Organization’s minimal registration data set of 20 fields. It also reaffirmed its requirements for an acceptable clinical trial registry: it must be electronically searchable, with free access; it must be open to all registrants; the trial data must be validated; and it must be a not-for-profit concern. The clinical trial registry site currently endorsed by the ICMJE is sponsored by the United States National Library of Medicine (http://www.clinicaltrials.gov), but the committee acknowledges that further registries will come on stream. These are under development in Japan, India and South Africa.11 In May this year, the Australian Government announced a grant of $1.5 million for the establishment of The Australian Clinical Trial Registry at the National Health and Medical Research Council Clinical Trials Centre at Sydney University.12 The Australian Registry (http://www.actr.org.au) complies with ICMJE and WHO requirements and became available for registrations in late June 2005. It is highly likely that more national trial registries will emerge. The WHO is currently developing an approval process to assess compliance of registers with ICMJE and WHO requirements.11 The WHO also plans to provide a web-based portal to all registries. These developments make sense: a cluster of national and regional clinical trial registries linked by an international agency. The WHO is ideally suited to assume this role and it will free the ICMJE to do what it does best — formulate publication policy.

Martin B Van Der Weyden MD, FRACP, FRCPA · Davina Ghersi BAppSc, MPH

No single voice nor one perspective can claim to represent the whole of bioethics “Deep listening: bridging divides in local and global ethics” was the theme of the 7th World Congress of Bioethics, held in Sydney in November 2004. Preceded by the 5th Feminist Approaches to Bioethics Congress and followed by the 10th Australasian Bioethics Association Conference, the conference had 550 registered attendees from 35 different countries.1 The three conferences, running over 8 days, provided the biggest event in bioethics thus far in Australia and the Asia–Pacific region and demonstrated the breadth and heterogeneity of bioethics. The theme of the Congress — suggested by the word “dadirri”, meaning “deep listening”, from an Australian Aboriginal language — expressed the intention of the Planning Committee to explore a wide range of approaches to ethics in relation to health care and to provoke vigorous and productive discussion of the issues from different perspectives. The approaches ranged from those with a traditional focus on local issues in a clinical setting to broader reflections on bioethics at a global level. Emphasising the central importance of the indigenous theme, the keynote address of the Congress was delivered by Marcia Langton (Professor of Australian Indigenous Studies, University of Melbourne) on “Aboriginal intellectual and property rights”. Speakers at major plenary sessions included Thomas Pogge (Professor of Philosophy, Columbia University) on “World poverty”; Daniel Wikler (Professor of Public Health, Harvard University) and Daniel Brock (Professor of Social Medicine, Harvard University) on “Ethical issues in population health”; and Catriona MacKenzie (Associate Professor of Philosophy, Macquarie University) on “Conceptions of the body and autonomy”. There were 15 special symposia presented by specialist groups covering a wide range of subjects, including equity, refugees, torture, genetics, stem cells, biopolitics and HIV/AIDS, in addition to over 200 individual oral and poster presentations. The Congress program covered many topics of intense current interest — most notably cloning and stem cell research — and included many styles of presentation, such as talks, debates, panel presentations and group discussions. There was a program of Australian Indigenous dance and music, storytelling, poetry and art. There were also events for the general public that were well attended and aroused considerable interest, such as an open forum on biotechnology, stem cells and cloning and a debate between George Annas (Professor of Health, Law and Bioethics, Boston University) and Alex Capron (Director, Department of Ethics, Trade, Human Rights and Health Law, World Health Organization) on human rights and bioethics.2,3 A broader view of bioethicsThe Congress deliberately sought to extend the focus of bioethics discussions from traditional and important concerns about problems arising between doctors and patients to issues of wider compass, such as the broad social, cultural and political contexts that affect health and shape health care delivery. Also on the agenda were concerns about public health programs and the responsibilities of developed countries to contribute to health care in the developing world, as well as feminist and indigenous perspectives on bioethics. This combination of approaches precipitated some trenchant critical reflections on the philosophical assumptions on which bioethics itself has been based and revealed some tensions between differing views. Feminist perspectiveMany feminist writers have been critical of a prevailing assumption that individuals are autonomous decision-makers. From this perspective, Catriona MacKenzie argued that bioethics developed with a narrow, highly individualistic conception of personhood and autonomy. As an alternative, she outlined a “relational” approach to autonomy, according to which individuals and the decisions they make are understood as constituted within relationships of interdependence and embedded in complex social situations. Such a model necessarily draws attention to power relations within intimate and familial relationships and to oppressive or unequal social structures.4 Responsibility for health in the developing worldSome speakers built on this critique of power relations by drawing attention to power inequalities at a global level. For example, Solomon Benatar (Professor of Medicine, University of Capetown) proposed that HIV/AIDS be viewed not in isolation but as symptomatic of problems of poverty and injustice afflicting the developing world.5 Thomas Pogge argued that trade agreements between affluent countries disadvantage poorer countries and lead to systematic impoverishment and poor health of many people living in the developing world. As a result of this, he claimed, citizens in Western countries are not just innocent bystanders, but carry an unavoidable responsibility.6 One practical measure he proposed was to establish a system of financial incentives to encourage pharmaceutical companies to develop effective and inexpensive treatments for the major illnesses afflicting these countries. Tension between population health and individual perspectivesIn a controversial presentation that stimulated vigorous and sometimes heated debate, Daniel Brock and Daniel Wikler, using a rights-based framework, drew attention to the particular concerns of population health (rather than health care) and argued for a shift of emphasis away from managing disease to promoting health. While those who responded accepted the importance of a population perspective, they suggested that it did not go far enough in dealing with the problems of impoverished countries, and challenged those who engage in bioethical debates to become personally and politically engaged. One participant expressed concern that the proposed new focus on public and population health would lead to a diminished appreciation of the importance of issues affecting individuals. This brought to the surface a tension between those concerned with issues of individual freedom (including individual autonomy and human rights) and those who emphasise the role of society and culture in establishing ethical conduct and relationships. Human rights and bioethicsA further tension, expressed in the public debate, was between a human rights approach and more traditional approaches to topics in bioethics. In essence, the question became whether bioethics can (and should) be properly understood and addressed entirely in its own language and concepts, or whether it needs to be supplemented (or even replaced) by a human rights perspective. Indigenous ethics Aboriginal dancer: Clarence Slockee, Mindgingbal Clan of the Bundjalung Tribe, Northern NSW. There were also tensions evident in discussing the experiences of indigenous people in relation to majority cultures within their countries, and tensions surrounding issues of cultural difference. In her address, Marcia Langton adopted a broad approach to these issues and raised fundamental questions about knowledge and its dependence on culture, power and economic forms of relationship.7,8 Speakers from India, Sri Lanka, South Africa, New Zealand and Australia showed that indigenous populations face challenges in the delivery of health care that are in common across the world, such as disenfranchisement, lack of control over health programs and research, imposition of programs from outside, displacement from the land, prejudice and poverty. Nonetheless, there was a recognition of irreducible differences between cultures that require effective responses to be based on specific local needs and conditions. The discussion of indigenous issues, perhaps more than any other topic, made evident the need for openness to multiple perspectives. The challenge of accommodating diversityWhat can be concluded from this Congress, with its emphasis on listening across broad divides? One obvious conclusion is that there is no single voice nor one perspective that can claim to represent the whole of bioethics. There is no predominant theory or homogeneous position, nor is it constituted by just one focus. There are many areas of bioethical interest, including issues in the clinic, issues arising from new understandings in medicine (such as genetics) or possibilities presented by new technologies (such as stem cell research), and issues arising from feminist (and other) theoretical perspectives. Moreover, different levels of approach, ranging from a focus on individuals to a focus on populations (such as public health and indigenous health) raise different sets of ethical interests and concerns. In this context, “deep listening” can be understood as listening to each other, listening to different groups and listening to those with different voices. It implies an openness to a multiplicity of approaches. In drawing on a variety of perspectives on a health care issue, it is possible that some central concerns may rise above and be strengthened by this multiplicity, leading to an outcome that is recognised as ethical by all interested parties. It is also possible that some views will be incommensurable, some voices discordant, and decision-makers will have to determine that one set of values needs to take precedence over another. Nevertheless, we believe that many perspectives are needed to provide a wide vista and adequate understanding in preparation for informed, appropriate and nuanced decisions in health care. Human rights, population health and indigenous ethics can complement traditional perspectives. There is a need, both within health care education and in policy development, to consider issues from individual as well as wider social and cultural perspectives and to address disparities in power as part of a broader understanding of bioethics. The Congress demonstrated that diverse views can be accommodated, even when they are held passionately and discussion is vigorous. Listening for, and openness to, differences and commonalities worked well as a theme for the Congress. It is a capacity that remains to be encouraged in bioethics and applied in health care more generally.

Paul M McNeill MA, LLB, PhD · Ruth Macklin PhD · Angela Wasunna LLM · Paul A Komesaroff MB BS, PhD, FRACP

Aim: To evaluate the efficacy and safety of an annual intramuscular injection of cholecalciferol for vitamin D deficiency.Design: Prospective open-label study.Participants: Five men and 45 women (mean age 66.3 years) with vitamin D deficiency who were given a single therapeutic intramuscular injection of 600 000 IU (15 mg) cholecalciferol (vitamin D3).Outcome measures: Serum levels of calcium, creatinine, 25-hydroxyvitamin D3 (25OHD3) and parathyroid hormone, as well as early morning 2-hour urine calcium/creatinine excretion index. Specimens were collected at baseline and after 4 and 12 months of therapy. Data are reported as mean ± 1 SD.Results: Vitamin D deficiency was severe (< 12.5 nmol/L) in one participant, moderate (12.5–24 nmol/L) in 14, and mild (25–49 nmol/L) in 35. Twenty-four participants (48%) had secondary hyperparathyroidism. Following intramuscular cholecalciferol injection, serum 25OHD3 levels normalised in all participants and remained above 50 nmol/L throughout the study. Serum 25OHD3 levels were significantly higher at 4 months (114 ± 35 nmol/L), and 12 months (73 ± 13 nmol/L) compared with baseline (32 ± 8 nmol/L) (P < 0.001), increasing by an average of 128% over the 12 months. There was a corresponding decrease in serum parathyroid hormone levels at 4 months (6 ± 3 pmol/L) and at 12 months (5.2 ± 3 pmol/L), with a 30% decrease at 12 months from baseline (7.4 ± 4 pmol/L) (P < 0.01). Primary hyperparathyroidism was unmasked in one participant at 4 months and mild hypercalcaemia (serum calcium, < 2.70 mmol/L) was noted in two participants (4%) at 12 months. Serum creatinine levels remained normal in all participants throughout the study, while increases in 2-hour urine calcium/creatinine excretion index were seen in 10 participants (20%) at 12 months, three of whom had had elevated values at baseline.Conclusions: Once-yearly intramuscular cholecalciferol injection (600 000 IU) is effective therapy for vitamin D deficiency. While this therapy appears to be safe, the potential for developing hypercalciuria needs to be examined in a large randomised controlled trial.

Terrence H Diamond MB ChB, MRCP, FRACP · Kenneth W Ho MB BS · Peter G Rohl MB BS, FRACP · Matthew Meerkin FRCPA, FAACB, FACB

Objective: To estimate the short-term benefits of a reduction in smoking on acute myocardial infarction (AMI) and stroke hospitalisations and costs.Design and setting: Epidemiological study which applied functions describing reductions over time in risk of AMI and stroke in people quitting smoking to hospitalisation rates and costs for Australia.Main outcome measures: The numbers of AMI and stroke hospitalisations in 35–64-year-olds and the associated costs that could have been avoided over a 7-year period from 2001–02 if smoking prevalence had decreased by 1% in the first year (Scenario 1) or by 1% per annum for 5 consecutive years (Scenario 2).Results: Under Scenario 1, almost 1000 hospitalisations for AMI and about 350 hospitalisations for stroke would have been avoided over 7 years, saving about $20.4 million in health care costs. Under Scenario 2, over 3000 AMI hospitalisations and over 1000 stroke hospitalisations would be avoided, and health care costs could be reduced by $61.6 million (2.75% of costs for AMI and stroke over the period).Conclusions: This study provides further support for the proposition that modest and achievable reductions in smoking rates can substantially improve health outcomes and reduce health care costs, even in the short term.

Susan F Hurley MPharm, MS(Biostatistics), PhD

Objectives: To assess young people’s ability to recognise clinically defined depression and psychosis, the types of help they thought appropriate for these problems, their knowledge of appropriate treatments, and their perceptions regarding prognosis.Design: A cross-sectional telephone survey using structured interviews. Vignettes of a person with either depression or psychosis were presented, followed by questions related to recognition of the disorder, best forms of treatment and the prognosis.Participants: A randomly selected sample of 1207 young people aged 12–25 years.Setting: Melbourne, Victoria, and surrounding regional and rural areas.Outcome measures: Responses to a mental health literacy questionnaire.Results: Almost half the respondents were able to identify depression correctly, whereas only a quarter identified psychosis correctly. Counsellors and family or friends were the most commonly cited forms of best help, with family or friends preferred by the younger age group for depression. General practitioners were considered more helpful for depression, and psychiatrists and psychologists more helpful for psychosis. Most respondents considered counselling and psychotherapy to be helpful. However, more than half the respondents expressed negative or equivocal views regarding the helpfulness of recommended pharmacological treatments.Conclusions: The limitations we identified in youth mental health literacy may contribute to the low rates of treatment and the long duration of untreated illness reported in other studies. There is a need for initiatives to enhance mental health literacy among young people, and those close to them, if benefits of early treatment are to be realised.

Annemarie Wright BAppSc(OT), MMedSc(HProm) · Meredith G Harris MPH, MPASR, BA(Hons) · Anthony F Jorm DSc · Sue M Cotton BBSc(Hons), GradDipAppSci (Statistics), MAppSci (Statistics) · Susy M Harrigan BA, GradDipAppSci, MSc · Patrick D McGorry MD, PhD, FRANZCP · John H Wiggers BA(Hons), PhD · Rosalind E Hurworth PhD, MEd, PostGradDipSoc

The aromatase inhibitors deplete oestrogen by inhibiting aromatase, the enzyme that synthesises oestrogen from androgens. They are effective as therapies for breast cancer only in postmenopausal women whose tumours express oestrogen or progesterone receptors. As adjuvant therapy, tamoxifen and the aromatase inhibitors have similar efficacy in the first 5 years of treatment. Aromatase inhibitors can be used as an alternative to tamoxifen in women with symptomatic intolerance or a contraindication to tamoxifen. Early data suggest that switching to an aromatase inhibitor after 2–5 years of tamoxifen therapy is beneficial in women with high-risk disease. Aromatase inhibitors are associated with more hot flushes than placebo, but with fewer hot flushes, less endometrial toxicity and venous thromboembolism, and more arthralgia, myalgia and bone fracture than tamoxifen.

Ilona C Nordman MB BS · Andrew J Spillane BM BS, MD, FRACS · Anne L Hamilton MB BS, FRACP

Medical education in Australia is about to undergo major changes, with the founding of six new medical schools, including the first private medical school and the first religiously affiliated medical school in Australia. The establishment of medical schools at Bond University on the Gold Coast, Queensland, and the University of Notre Dame in Fremantle, Western Australia, are particularly noteworthy developments. A recent article in the Journal claimed the new medical schools will foster diversity and are commited to fill “particular workforce needs”.1 We argue that increasing the range of options for medical education is not an unquestionable good, as it may threaten academic freedom and equity in medical education as well as just provision of health care. This article aims to stimulate awareness, conversation and debate on these issues, not only within the medical community but in the wider Australian community. While there are no prima facie reasons why religiously affiliated or private medical schools should not exist, in practice there are a series of curricular and administrative concerns that should be addressed before the establishment of any medical school — religiously affiliated, private or otherwise. There are important ethical and sociocultural issues associated with establishing religiously affiliated medical schools, and the principles underlying such schools must be made clear, particularly as interest may develop in establishing additional religiously affiliated medical schools (eg, based in the Islamic, Jewish or Hindu faiths). The recent article in the Journal outlined concerns raised about the Notre Dame program, including the inclusion of a mandatory theology course, and more generally how the institution’s Catholic ethos may affect the medical education provided and the skills and attitudes of physicians being trained.1 While many factors, including postgraduate education and clinical experience, may influence a doctor’s values or practice, it is undeniable that medical education is formative. Thus we concentrate here primarily on the issues raised by the establishment of religiously affiliated medical schools, and the University of Notre Dame’s medical school in particular. The important issue is not whether spirituality and religion are valid fields of enquiry within medical teaching, as there would seem to be little argument about including consideration of these in medical education.2,3 Both have been increasingly recognised as determinants of the values that people attach to their lives, the manner in which they understand and cope with illness, the health care decisions they make and the care they receive.4 Nor do we deny that values have a central role in medical education. Indeed, a general consensus has emerged over the past decade that examining values is fundamental to developing an understanding of ethics and professional responsibility in medicine.5,6 All Australian medical schools in fact now incorporate study of professionalism, values and ethics within their medical curricula.5 Furthermore, it is clear that different medical schools will have special emphases depending, in part, on their student and local populations. For instance, the private medical school at Bond University will emphasise organisation, administration, and information technology skills, along with communication, law, and ethics.1 Indeed, provided there are structural safeguards, it may be desirable for different schools to produce graduates with not only core attributes necessary for the practice of medicine, but also additional specialised skills suited to particular fields of practice or sociocultural contexts. There are, however, at least three major areas of concern with regard to religiously affiliated medical schools: (1) the adequacy of the medical education provided and potential resulting limitations on patient access to health services and provision of comprehensive care; (2) equitable access to medical education in an increasingly competitive environment; and (3) issues associated with academic freedom and tolerance of diverse beliefs. In theory, none of these problems are insurmountable, but all should be acknowledged and addressed. First, it has been well documented that patient access to health care services can be limited either directly (because of explicit religious concerns) or indirectly (by inadequate postgraduate education provided to health care practitioners).7,8 The restriction of health care services and the limitation of exposure to the full range of health care services required for professional competency have been major issues worldwide, particularly in obstetrics and gynaecology, and have resulted in legal action in the United States.9,10 Although individual physicians can conscientiously object to involvement in procedures that violate their own religious/moral values, it is reasonable to assume that all physicians should receive appropriate education about the range of health care services publicly available in Australia, including termination of pregnancy, provision of contraception, assisted reproductive technologies, genetic counselling, prenatal diagnosis and end-of-life care, as well as about the mechanisms for and limits to expressing conscientious objections. The existence of conscience clauses in codes of professional conduct is indicative of the fact that guidance is needed to mitigate the impact of religious beliefs on medical judgement and the delivery of care. Although Notre Dame officials have stated that their graduates will be educated to discuss these issues in a “non-judgemental, respectful and ethical manner . . . in relation to [the patient’s] needs and circumstances”,1 they also note1 that use of contraception is an immoral act according to Catholic doctrine (as, of course, are termination of pregnancy and many forms of cessation of life-sustaining treatment, particularly in light of the recent Papal allocution that artificial nutrition should not be withdrawn from patients in a persistent vegetative state except where it is of insufficient therapeutic benefit or overly burdensome to them).11 It is important to acknowledge that there may be a difference, or disjunction, between Catholic teaching and the behaviour and beliefs of many Catholics, including Catholic doctors, and that this may provide some reassurance to non-Catholics that their own beliefs and needs may be respected. Similarly, many religious hospitals often demonstrate a deep commitment to care, equity, social justice and service that may seem to be lacking in many secular institutions, as evidenced by the care of the indigent, the dying and those with HIV/AIDS in this country by religious hospitals and clinics. But, despite the evident commitment to care by many Catholic institutions and clinicians, it remains the case that there is a problematic tension between the teachings of the Church and the services and information provided by medical institutions and practitioners. Physicians may limit the health care options available to their patients (even those services that Australian society has determined should be publicly available), especially in rural and remote areas, where choice of medical practitioner is extremely limited. Doctors are the gatekeepers of all medical services and, as such, their knowledge, training, experience, values and beliefs, as well as the manner in which they resolve tensions between their own moral standpoints and their professional obligations, should be a central concern for the Australian public and any medical school seeking to train medical practitioners able to meet the diverse needs of Australian society. Simple assertions that a religious medical school or other tertiary institution will offer training according to the needs of the community do not adequately acknowledge the potential for conflict with religious teachings or mission, or the impact of such conflict. Nor do they acknowledge that there are multiple communities in which graduates may eventually practise. Second, although it is recognised that religious beliefs may contribute to or influence medical judgement, they are not required for clinical practice. Religious influence in education may discriminate against those who do not share those beliefs. Incorporating religious traditions into medical education, for instance through obligatory courses in Catholic theology (with limited discussion of contemporary ethics, secular moral philosophy, or comparative religious perspectives, and no options for substitution of other courses), or promotion of the work of the Catholic and other Christian churches as a core institutional value, may create an alienating atmosphere for potential students from divergent religious backgrounds. It may also influence access and choice to pursue medical education at such institutions. The assumption that students who hold conflicting values simply will not apply to religiously affiliated medical schools is fundamentally discriminatory, particularly where such schools include federal government-subsidised places. Moreover, the assumption that differences or conflicts could not arise is naive and inconsistent with recognition of the moral and religious pluralism that is a central feature of Australian society. There appears to be at least the possibility for discrimination along these lines at Notre Dame. While admission is open to students of any denomination (or presumably those with no religious affiliation), it is specifically noted that applicants should manifest personal qualities consistent with the mission of the University, which is “the advancement of learning, knowledge, and the professions, and the provision of university education, within a context of Catholic faith and values”.12 It is unclear how this could be assessed or enforced in a non-discriminatory manner. Given that discrimination against applicants to medical school has been documented to occur even at secular medical schools, in our view it is highly likely that such issues will arise more frequently in a religiously affiliated tertiary institution.13,14 The question of access to medical education is an important one, particularly as there are always more applicants to medical schools than there are places available in Australia, and as there is a desire to create a medical workforce able to meet the diverse needs of our multicultural community. The question that any proposal for a religiously affiliated medical school should address is not only whether its education is likely to increase the number of medical students and physicians in Australia, but also whether it will truly diversify the physician pool in terms of values, beliefs and professional behaviours. For instance, a selection process that may be intimidating for non-Catholic students and a mandatory curriculum emphasising Catholic beliefs, moral philosophy and values suggests that diversity may not be fostered and may well be reduced, which is ethically problematic. Finally, in a secular, pluralist society, there are well founded fears that rigid institutional commitment to a particular religious tradition can encourage discrimination and bias, as well as limiting academic and scientific freedom. These concerns are affirmed by well publicised instances of academics being dismissed by religious institutions because of theological or philosophical differences (eg, Hans Küng from the Catholic University at Tübingen, Gerd Lüdemann from the Protestant University at Göttingen, and Debora Diniz from the Catholic University of Brasilia).15-17 In the event of conflicts arising between Catholic ethos/values and the medical curriculum, it is unclear how a Catholic medical school would react to intervention by the university or the Church seeking to silence or remove a student or staff member because of beliefs that diverge from accepted Catholic doctrine or the university’s mission. It is of note that one of the goals of the University of Notre Dame is “. . . to support the role and work of the Catholic and other Christian churches”.18 Therefore, the question is not whether there can be any involvement of the Catholic church or other religious institutions in medical education, but what structural safeguards should be required for religious involvement in medical education to be morally, educationally and sociopolitically justifiable, particularly where student positions are to be subsidised by the federal government. Education at secular as well as religious medical schools should always be grounded in dominant and morally-justifiable societal norms, such as tolerance, equity, justice and care, the importance of which can be seen in our laws and practices. Australians live with relative ease with religious hospitals and schools (although there is ongoing debate as to whether these institutions should receive public funding). The value that Australian society attaches to religious tolerance is reflected in Section 116 of the Constitution, which prohibits the federal government from making any law prohibiting the free exercise of any religion.19 While, as a community, we acknowledge that religiously affiliated hospitals and schools may create tensions, we also believe that their existence does not, in principle, undermine society. Indeed, the potential value of a religious medical school may lie in the fact that its values and norms are more transparent and more clearly articulated than those of a secular medical school. But, in order to put safeguards in place to mitigate the concerns outlined above, the following issues should be addressed. First, religiously affiliated medical schools must actively recognise that conflicts are possible (and even likely) as a result of differences in religious beliefs or values. Accordingly, processes should be in place to identify and manage differences and conflicts arising between a medical school and its founder institution (for instance, the broader university or the Church), between the medical school and its staff or students, and within the medical school itself. There should be clear policies stating that expressing views inconsistent with the institution’s religious values will not prejudice a student’s continuing education or a staff member’s employment. Second, selection of applicants should proceed in a manner that is non-discriminatory and that actively seeks to promote diversity of beliefs and values. Third, the adequacy of the education provided should be assessed by independent observers in terms of the abilities of graduates to deliver care that is consistent with the varying needs, beliefs, and values of the broader Australian community. This is a valid expectation, particularly in view of the significant number of federal government-subsidised student positions that will be available (50 of 80 positions at Notre Dame will be funded by HECS [the Higher Education Contribution Scheme]).1 These processes are essential for any medical school to deal effectively with moral and religious pluralism and to ensure academic, scientific and religious/moral freedom. The Australian Medical Council (AMC), through its accreditation processes, has responsibility for the adequacy and quality of medical education. However, assessment of the impact of medical education on the delivery of health care services sufficient to meet the needs of Australians, and in accordance with their values, falls outside the remit of the AMC, and so should be of concern to the wider Australian community. While religiously affiliated medical schools may increase the range of options available for some students, they may narrow the diversity of values expressed and therapeutic options made available by physicians, thus reducing options for patients. Religious involvement in medical education in a pluralistic society is only morally and socially acceptable where it emphasises the rights of others to have and choose different beliefs, and be no less worthy of compassionate and skilled medical care as a result; where it demonstrates respect for other accepted and morally justifiable beliefs and practices within the community; and where it provides cultural security not only to members of its own religion, but to those with differing or no religious affiliation. All medical schools should seek to foster and attract the trust and respect of anyone who may need the services of their graduates. We do not have any objection, in principle, to religiously affiliated medical schools. What we seek is awareness, discussion and debate among members of the Australian public, particularly patients and policymakers.

Ian H Kerridge MPhil, FRACP, FRCPA · Christopher F C Jordens PhD · Wendy L Lipworth BSc(Med)(Hons), MB BS · Rachel A X Ankeny PhD

To the Editor: Thank you very much for the opportunity to respond to the article by Kerridge et al (page 28)1 on religiously affiliated medical schools. After careful consideration, the University of Notre Dame does not wish to take up your offer. You can be assured that we had many long discussions with the Australian Medical Council team charged with examining whether Notre Dame could be accredited as a medical school. The result of those discussions was that the team was fully satisfied that we could achieve all the outcomes expected of a graduate from an Australian medical school. Therefore we do not see a need to respond to this article. No doubt the same questions have been asked in good faith of all the great Catholic medical schools, found on all continents, which have been educating medical students for generations.

Adrian Bower MB ChB, PhD

The article by Kerridge et al in this issue of the Journal (page 28)1 raises a number of important issues for the University of Notre Dame Australia and the community in general. The role of the Australian Medical Council (AMC) is to assess whether a medical school has appropriate structures and resources and is proposing a curriculum that meets the AMC’s set standards. The AMC also guides schools on changes that may be necessary and on the issues that will be monitored in future reports and visits. The purpose of AMC accreditation is “the recognition of medical courses that produce graduates competent to practise safely and effectively under supervision as interns in Australia and New Zealand, and with an appropriate foundation for lifelong learning and for further training in any branch of medicine”.2 The AMC assesses medical courses against explicit accreditation standards2 that outline the goals of medical education and describe the institutional settings, student selection and support processes, and resources required to achieve the objectives. The AMC supports diversity and does not prescribe core subjects or topics. AMC standards worth noting in the context of the article by Kerridge et al include the following: Graduates should have knowledge and understanding of normal pregnancy and childbirth, the more common obstetrical emergencies, the principles of antenatal and postnatal care, and medical aspects of family planning. Students should demonstrate a realisation that one’s personal or religious beliefs should not prevent the provision of adequate and appropriate information to the patient and/or the patient’s family, or the provision of appropriate management, including referral to another practitioner. The medical school is required to have a clearly defined admission policy that is consistently applied and is free of discrimination and bias, other than explicit affirmative action in favour of nominated disadvantaged groups. To be accredited, the school must satisfy the AMC that it can implement and deliver the complete course at a level consistent with AMC standards. In 2002, the University of Notre Dame Australia sought accreditation of a new medical school at its campus in Fremantle, Western Australia. The AMC agreed, in November 2003, to invite the University of Notre Dame Australia to submit the course details for assessment by an AMC team, and chose the team to conduct the assessment. Early in the AMC’s assessment, questions were raised about the explicit association of a medical school with a set of religious values. In selecting an assessment team to evaluate the proposal, the AMC included a community (non-medical) member. It also sought advice for the AMC assessment team to develop a framework for considering the explicit association of the medical school with a set of religious values. The assessment followed the standard process. The team considered the school’s accreditation submission and sought and received further information. The team then spent a week in discussions with university officers, curriculum committees and planners, students of the University of Notre Dame, clinicians who would teach and supervise students, and health services representatives. In November 2004, the AMC granted accreditation of the University of Notre Dame’s medical course until 2 years after the first cohorts of students have graduated (2010). Among the strengths identified in the accreditation report were: The extensive community consultation associated with establishing the medical school, and the support offered from the medical and other health professions. The clear commitment to emphasising the psychosocial dimension of medical care and its underpinning by a solid grounding in medical ethics. The proposed units in philosophy and ethics, and the inclusion of broad perspectives on spirituality in the medical course. Issues marked for attention included the following: Concerns over the theological context of the medical course, including the compulsory nature of the theology unit in the curriculum, need to be resolved. The unit should either be made optional or should be modified to enhance its utility to medical students in their future contact with patients of all beliefs. Although the AMC team received assurances about teaching and learning in areas such as contraception, termination of pregnancy, in-vitro fertilisation, sexuality, end-of-life decisions and embryonic stem cell research, the University is required to develop a process for handling potential conflicts over the inconsistency between the medical school’s teaching program and the canonical statute defining the purpose of the University. Given the religious milieu of the medical school and the current requirement to study theology, it was reported that students of some backgrounds may perceive themselves to be effectively discriminated against on the basis of their own religious conviction (or lack thereof). The school is required to report annually on the development of the medical course, and AMC teams will visit the school again in 2005 and 2006. Following these visits, the AMC will consider the medical school’s responses to the issues raised here and to others identified in the accreditation report.

Ian B Frank · Theanne Walters

Setting Every few weeks produces yet another assessment form to fill out on the junior medical officer, student or registrar. It becomes a bit of a blur and you default to ticking the boxes down the middle of the form. They’re all pretty bright — maybe putting in more effort wouldn’t make much difference to the result anyway? Medical schools, clinical colleges and other groups are committed to improving the measurement of trainees’ clinical skills by using specific assessments such as OSCEs (objective structured clinical examinations),1,2 simulated patients,1 mini-short cases3 or portfolios1,2 (the latter a collection of evidence of ability, such as supervisor reports, audit of procedures or publications). However, as Miller has noted,4 “no single assessment method can provide all the data required for judgement of anything so complex as the delivery of professional services by a successful physician”. Most of us contribute by assessing trainees as they work with us — so-called “in-training assessment”.2,5,6 Our judgments are based on observing their performance (how they are “doing” the job) — ie, the highest level of Miller’s four-level clinical assessment pyramid4,5 (see “Tips 6”7). What we need to judge is broad — covering clinical competence, communication and professional skills. Unless we plan in advance, we could find ourselves lost at the end of a 12-week attachment, not really sure how well trainees are doing in these areas. Although there are many problems with the reliability of in-training assessments,2,6 they are extensively used and there are strategies for improving their reliability. How do we measure performance?5There are several ways to measure performance: Outcomes — eg, patient outcomes. However, this is difficult, as many factors influence patient outcomes. Process — eg, how well trainees have carried out a task, communicated, assessed a patient or written in the notes. Volume — eg, how many procedures the trainee has done. In most circumstances, we measure performance based on how well trainees are working (ie, the “process”, as noted above), which is feasible and simple. Measuring patient outcomes or volume of work is more difficult. Challenges with in-training assessment6,8As raters, we aren’t very good at being objective. Comparing results across examiners shows we tend to be either “hawks” (marking hard) or “doves” (marking easily). We tend not to distinguish between items — if trainees perform well in one area, we tend to assess them well in other areas (the “halo” effect). Personality traits (eg, extroversion, introversion) or poor command of English may have either a positive or negative impact on our assessment, irrespective of the trainee’s ability. If we do the trainee assessment long after the actual training period has taken place, we tend to forget the details and mark towards the mean. Interaction with the trainee is important. If you are both the teacher and assessor, marks tend to be higher. How can we improve?8-10Be familiar with the outcomes expected for trainees — in clinical competence, communication and professionalism. Turn these outcomes into observable behaviours: Clinical competence — observe trainees doing an examination or taking a history, test their knowledge, review the inpatient notes or discharge summaries; Communication — observe trainees speaking to patients, and require them to present to you; Professional skills — note punctuality, time-management skills, whether trainees can cope with responsibility and whether they are interested in learning. Set expectations at the beginning of the rotation. Get trainees to take some responsibility for the assessment, such as bringing case notes for discussion. Find “assessable moments”, such as on rounds, in which trainees examine or talk to the patients and you watch. Write down your thoughts at the time and accumulate results across the term.9 Assess multiple events during the training period, to make assessment more reliable.2,9 Involve multiple people — ask other doctors, nurses or patients for their opinions (“360° assessment”).8,10 FeedbackPerhaps more important than the assessment per se is using the information we have gathered to give feedback (such as in appraisal). In assessment, although rating by means of a global score (“overall pass”, “borderline” or “fail”) works well,6 junior medical officers also want detailed feedback, not simply broad comments like “overall, you are very good”. Self-assessmentIt is useful to encourage a habit of self-assessment.11 Children tend to overestimate their abilities, whereas adults underestimate their own abilities. Poor students often overestimate their abilities. However, if feedback is given, a side effect is that we get better at our self-assessment. So, before giving your feedback, ask trainees to fill in the assessment form before you do (self-assessment), or ask how they feel they are going. Take-home message When considering in-training assessment Consider assessable moments, looking at clinical competence, communication and professionalism. Assess multiple events by multiple people. Note down what you thought at the time — otherwise you will forget. Give feedback — that is what junior medical officers want.

Fiona R Lake MD, FRACP

A dengue fever epidemic was recognised in the Torres Strait Islands of Queensland in late 2003. Two fatal cases of dengue haemorrhagic fever occurred in early 2004. This severe manifestation is more common when a patient is infected a second time, with a different virus serotype to the first infection. These are the first fatalities related to dengue fever in Australia in over a century. Clinical recordsPatient 1A 40-year-old woman from Thursday Island in the Torres Strait, north Queensland (Box 1), presented to a local hospital in February 2004 with a 6-day history of feeling generally unwell, plus generalised body aches and fevers, and 3 days of vomiting and diarrhoea. She had type 2 diabetes and was taking metformin. She had been seen at a primary health care clinic on Days 2 and 5 of the illness and was diagnosed clinically with dengue fever based on the typical symptoms, as this infection was epidemic at the location. Blood samples were taken on both occasions. On admission to hospital, she was delirious and restless, with a pulse rate of 120 beats/min and blood pressure of 100 mmHg systolic by palpation only. Petechiae were noted around the right elbow. She was given 2 L of intravenous fluid. Six hours after admission, she became more agitated and restless, with blood pressure of 123/55 mmHg and pulse rate of 150 beats/min. She was given a small dose of morphine. Thirty minutes later, her blood pressure became unrecordable. Despite 5 L of intravenous fluids over the next 7 hours, together with adrenaline and metaraminol, the blood pressure remained very low. A single dose of ceftriaxone (2 g) was given, and evacuation to a referral hospital was arranged. The retrieval team noted that the patient’s skin was cold and clammy and recorded a blood pressure of 90/55 mmHg. The pulse rate fell, and blood pressure became unrecordable before arrival at the referral hospital, and she could not be resuscitated. An autopsy was not performed. Between Days 2 and 6 of the illness, the patient’s haematocrit rose from 0.42 to 0.55 (reference range [RR], 0.36–0.52), and her platelet count fell from 144 × 109/L to 4 × 109/L (RR, 150–400 × 109/L). There was a moderate increase in hepatic enzyme levels: aspartate aminotransferase (AST), 1270 U/L; and alanine aminotransferase (ALT), 310 U/L (RR, < 40 U/L for both). Dengue virus type 2 was detected by both reverse transcriptase polymerase chain reaction (RT-PCR) testing and viral culture. Previous tests for dengue antibody, in 1998, were positive for IgG. The pattern of antibody response during the current illness was that of secondary infection. Culture of blood taken at the time of admission to the local hospital grew Escherichia coli. A diagnosis of dengue haemorrhagic fever was made, based on World Health Organization criteria1 (Box 2). Patient 2In March 2004, a 70-year-old man from an island north of Thursday Island had a 1-day history of dyspnoea, cough and a low-grade fever. He had type 2 diabetes, raised cholesterol level and hypertension. His wife called the local medical clinic during the night as he was agitated and semiconscious. His blood sugar level was noted to be low. Glucagon was administered on the advice of medical staff on Thursday Island, and his mental state improved slightly. His blood pressure was 80/60 mmHg. The patient was evacuated to Thursday Island the following day. On arrival, his temperature was 37.1°C, pulse rate was 93 beats/min, and blood pressure was 120/70 mmHg. His respiratory rate was 28 breaths per minute, oxygen saturation was 93% breathing room air, and he had several episodes of diarrhoea. He was given 2 L of intravenous fluid. He continued to complain of dyspnoea, and a chest x-ray showed hyperinflated lungs. A provisional diagnosis was made of an acute exacerbation of airways disease, and treatment was begun with prednisolone (50 mg per day). His blood pressure remained low (90–100 mmHg systolic). Thrombocytopenia (11 × 109 cells/L) was noted on a blood film, and the possibility of dengue fever was raised, although the infection was not then known to have spread to the patient’s home island. Hepatic enzyme levels were mildly elevated (AST, 126 U/L; ALT, 99 U/L). The following day, the patient had a sudden large melaena and became hypotensive. This was followed by bradycardia and cardiac arrest. He was resuscitated, intubated and ventilated, and then evacuated to a referral hospital. He received a blood transfusion but had further melaena, and was dependent on inotropic support in the intensive care unit. Blood was noted in his stomach after insertion of a nasogastric tube. Despite receiving antibiotics for presumed sepsis, he died later the same day. An autopsy was not performed. A retrospective diagnosis was made of probable dengue haemorrhagic fever. Dengue virus type 2 was cultured from blood taken on Day 4 of the illness. Dengue IgG, but not IgM, antibodies were detected in serum taken on Day 2, consistent with a secondary dengue infection. There was a fall in haematocrit from 0.48 to 0.39 between Days 4 and 5 of the illness. A chest x-ray done in the intensive care unit showed a right upper lobe infiltrate, but no evidence of pleural effusions. DiscussionThese two cases are, to my knowledge, the first fatalities related to dengue fever in Australia in over a century. Previous fatalities were described during a large epidemic of dengue fever in Charters Towers (north Queensland) in 1897.2 Dengue fever is caused by infection with one of four serotypes of dengue virus and is transmitted from human to human through the bite of the mosquito vector Aedes aegypti. Clinically, the infection is characterised by a febrile illness associated with generalised body aches, and occasional minor bleeding manifestations. A more severe form of the disease, dengue haemorrhagic fever, has become an increasing cause of morbidity and mortality throughout the tropical world. There are an estimated 50–100 million cases of dengue infection each year, including about half a million cases of dengue haemorrhagic fever. The number of cases of both dengue fever and dengue haemorrhagic fever has increased dramatically over the past few decades, and the geographical range has extended to involve most tropical countries.3 The frequency of dengue haemorrhagic fever is much greater during secondary dengue infections than during primary infection. As immunity to infection with the same dengue serotype is probably lifelong, secondary infections are usually caused by a different virus serotype. Antibodies raised in the initial dengue infection may cause an immune enhancement in a subsequent infection with a different dengue serotype.4 Epidemics of dengue haemorrhagic fever can occur when a particular population is subject to sequential epidemics caused by different serotypes.5 Cases of dengue haemorrhagic fever, including some fatal cases, were first described in Australia during the 1897 epidemic in Charters Towers.2 This followed another large epidemic in the town in 1894–1895. As individuals were described with symptoms during both epidemics, they were probably caused by different serotypes. A large epidemic of dengue fever in Townsville and Charters Towers in 1992–1993 raised the possibility of the re-emergence of dengue haemorrhagic fever in Australia.6 These fears have been repeated with each subsequent epidemic.7 Diagnosis of dengue haemorrhagic fever is based on clinical and laboratory findings (Box 2), and severity is graded 1 to 4.1 Grade 3 is defined as circulatory failure manifested by rapid and weak pulse, and narrowing of pulse pressure (20 mmHg or less) or hypotension, with the presence of cold clammy skin and restlessness. Grade 4 is defined as profound shock with undetectable blood pressure and pulse. Grades 3 and 4 dengue haemorrhagic fever are termed dengue shock syndrome.1 Both Patient 1 and Patient 2 were classified with grade 4 dengue haemorrhagic fever. Patient 1 had skin petechiae, haemoconcentration, thrombocytopenia, and fever. The presence of E. coli in the blood may have contributed to her death, but the pattern of illness was otherwise typical of dengue haemorrhagic fever. She was treated with an antibiotic with activity against E. coli. Concurrent bacterial infection may occur in dengue haemorrhagic fever and is more common in older patients.8 The death generated considerable publicity and has heightened awareness of the condition among clinical staff in the Torres Strait Islands. Patient 2 had a fall in haematocrit of about 20% between Days 4 and 5 of the illness, but evaluation of the degree of haemoconcentration was complicated by haemorrhage and transfusion. Although a chest x-ray did not demonstrate pleural effusion (which would have provided evidence of vascular permeability), the clinical endpoint of vascular permeability — hypotension and shock — was certainly evident. Both patients had evidence of recent infection with dengue virus type 2. A dengue 2 epidemic was recognised in the Torres Strait Islands in late 2003, following the admission of two patients (aged 32 and 42 years, respectively) to the intensive care unit at Cairns Base Hospital with severe hepatitis. Both these patients fulfilled the clinical criteria for dengue haemorrhagic fever and had serological evidence of secondary dengue infection. From November 2003 to April 2004, there were 176 laboratory-confirmed cases of dengue fever in the Torres Strait, mostly on Yam Island and Thursday Island (Alyssa Pyke, Queensland Health Scientific Services, personal communication). Smaller epidemics, also caused by dengue virus type 2, occurred concurrently in Cairns and Townsville. Previous epidemics of dengue fever in the Torres Strait Islands occurred in 1996 (dengue 2) and 1981 (dengue 1).9 The latter was the only non-dengue 2 epidemic that has been well documented in the Torres Strait Islands.10 The most plausible scenario in the four cases of dengue haemorrhagic fever in 2003–2004 is that primary infection occurred in 1981. This implies that secondary infection more than 20 years after primary infection may still produce severe manifestations. The same observation was made after an epidemic of dengue 2 in Cuba, 20 years after a dengue 1 epidemic.11 The patients with dengue haemorrhagic fever described here were aged 32 to 70 years. In contrast, in south-east Asia, dengue haemorrhagic fever is predominantly a paediatric condition. A possible explanation for the older age of the Queensland patients is that the interval between the dengue 1 and dengue 2 epidemics meant that only older people had dengue 1 antibodies. Epidemics of dengue fever appear to have become more frequent in north Queensland, with five major epidemics (three affecting the Torres Strait) and many smaller epidemics between 1992 and 2004. Control measures instituted by public health authorities may have averted more frequent larger epidemics.12 In contrast, the previous five major epidemics occurred over a period of 90 years. Increasing international travel into north Queensland and global increase in dengue activity will inevitably lead to further introductions of the virus into north Queensland. Indeed, another outbreak — of dengue type 4 — was declared in the Torres Strait in March of this year.13 Aggressive case-finding and mosquito control are our major defences against further epidemics and the attendant risk of dengue haemorrhagic fever. The major clinical feature of dengue haemorrhagic fever is intravascular fluid loss. Expert clinical management of dengue haemorrhagic fever with aggressive intravenous fluid replacement has reduced the mortality rate to less than 1% in centres experienced in fluid resuscitation.14 This compares with mortality rates up to 30% in some series.3 Medical staff in high-risk areas are now alert to the possible future occurrence of this syndrome. 1 Location of the Torres Strait Islands The Torres Strait Islands lie between mainland Papua New Guinea and the tip of Cape York in Australia. The two major foci of the dengue epidemic were Yam Island and Thursday Island. 2 Diagnostic criteria for dengue haemorrhagic fever (World Health Organization)1 Clinical findings Fever lasting 2–7 days; and Haemorrhagic manifestations, ranging in severity from a positive tourniquet test through to clinically obvious bleeding. Laboratory findings Platelet count < 100 × 109 cells/L; and Haemoconcentration, as evidenced by a 20% rise in haematocrit (or a 20% fall after rehydration).

William J H McBride FRACP, FRCPA, PhD

From left: Bill Glasson, Geoffrey Angeles, Ruth Armstrong, Martin Van Der Weyden. The 2005 Dr Ross Ingram Memorial Essay Prize was presented to Geoffrey Angeles (Indigenous Health Researcher, Menzies School of Health Research, Northern Territory) at the national AMA conference in Darwin in May. Outgoing AMA president Bill Glasson presented the award, with Martin Van Der Weyden and Ruth Armstrong present from the Journal to hand over the $5000 prize money on behalf of the Australasian Medical Publishing Company. Geoffrey Angeles emerged from a strong field to win the competition with his essay Fish traps — a significant part of our health and wellbeing, which was published in the 16 May 2005 Indigenous health issue of the Journal. In accepting his prize, Geoffrey thanked Dr Ross Ingram and his family, and the Journal, for providing him (and many others across the nation) with the inspiration to share their stories. He also thanked his own family and community in Darwin for their wisdom and support. We wish him all the best with his work, his writing and his fishing. Entries for the 2006 Dr Ross Ingram Memorial Essay Competition close on 16 January 2006. The competition is open to any Aboriginal or Torres Strait Islander person who is working, researching or training in a health-related field. See the eMJA for details (http://www.mja.com.au/public/issues/180_10_170504/arm10277_fm.html).

Ruth M Armstrong BMed

My career in Indigenous health was first ignited in my teenage years as part of an overall desire to “work among my own people”. At that point in my life, I never really felt “Aboriginal”, owing, in part, to my being of “mixed descent”, light-skinned and having been raised in a predominantly white neighbourhood in an urban area. My claim to Aboriginality somehow felt a little inauthentic in light of the public imaginings of Aboriginality that I had been exposed to growing up. My perception of the “real” Aboriginal people were those who possessed dark skin, occupied the remotest parts of our country, and had retained a “pure” and “uncontaminated” Aboriginal culture. Rather naively, I had imagined that I would graduate from university and work with those people, sharing my expert wisdom of health knowledge and, in return, finding a connection with my “true” self — my Aboriginality. Funnily enough, I did achieve my goal of finding myself and my sense of Aboriginality. It was just not in the place, and not in the form, that I had first anticipated several years earlier. Commitment to family and community among Indigenous people (quotes from a study by Brough et al4) “My wife’s cousin rings up from Cairns, said, oh some fellas come down for hospital and they want a place to stay. . . . They all say [name’s] daughter, down there in Brisbane, you go stay with her anytime. Because dad was always taking in the homeless up in Cairns.” “To me, being involved in the community is something that, if you identify as being Aboriginal, then that’s part and parcel of what you give back to it by being involved in your community.” “Weddings, sporting events, NAIDOC Week. Sometimes it can be as little as a performing arts thing. People will turn up . . . especially if it’s got some Indigenous input in there . . . they’ll turn up to those events. They’re good events because usually people are feeling high in spirit because it’s something that . . . because there’s an Indigenous input (might be Indigenous actors), so they feel proud and good about themselves. This person put on a good play and there’s lots of white people there too, so that this white person can see black fellows from a different side and it makes black fellows proud and feel good.” NAIDOC = National Aboriginal and Islander Day Observance Committee. The chronicling of this journey is not meant to be a purely narcissistic endeavour. It revolves around two plights — one personal and one professional — which together describe the disjuncture between the lived experience of being an Aboriginal person and the described experience of Aboriginality that is manifest within public health practices and hampers our ability, as health professionals, to have a meaningful and positive impact on Indigenous health. It was upon undertaking a degree in Indigenous health that my romanticised ideas of a noble people quickly came crashing down. I soon learnt that Aboriginal communities were fraught with appalling levels of ill health, disease, despair and dysfunction, a situation that would invoke moral indignation from even the most casual and distant observer. Spurred on by the desire to “save my people”, I successfully obtained a rural health scholarship, which (I imagined) would see me stationed within a rural or remote Aboriginal community upon graduation from university. As it turned out, my placement was in a large rural community just 3 hours west of Brisbane. I was initially a little discouraged, as I didn’t view that placement as capable of providing me with the personal and professional prestige of having proven myself in a more “authentic” Aboriginal community in some far-flung region of the state. Nonetheless, I still found myself in a place with a sizeable Aboriginal population and a sense of community that I thought had eluded me in all my years growing up in Brisbane. Upon starting there, I threw myself into the role of Aboriginal health worker, conducting hospital visits to clients, assisting the community medical centre, liaising with non-Indigenous health providers in a cultural brokerage role, and uncritically, week after week, churning out the employer-sanctioned Aboriginal and Torres Strait Islander cultural awareness program. As each workshop went by, I began to notice that there were increasing numbers of local Indigenous community members in attendance, who were interested not so much in teaching others about specific Aboriginal cultural practices and protocols as in learning, sharing and reflecting upon their own experiences as Aboriginal people. Ironically, the task of educating white health professionals about the local Aboriginal community was inadvertently replaced by an ever more important task of connecting local Indigenous people with their own experiences, their own histories and their own cultures. Similarly, most community members appeared less interested in engaging in the traditional health education campaign of our health service, and instead were much more enthused about cultural revival in the form of NAIDOC Week* celebrations, cultural programs for young people, and sharing their own stories of strength and survival. At the time, I was a little troubled by this because, as a health worker, I was meant to be talking up health, not culture. The two seemed to lie in opposition to each other. My supervisor — a non-Indigenous nurse who had never engaged with the local Aboriginal community outside of a nurse–patient relationship at the local hospital — appeared annoyed and concerned about my inability to persuade the community to engage in the “real” health work. Rather than reflect upon the failings of our health service, she, and many of my non-Indigenous colleagues, saw this predicament as just further “evidence” of the passivity, dependency, and non-compliant nature of our mob, which in turn could be explained away as the “real” cause of our ill health. Any efforts on my part to celebrate Aboriginal culture and community were considered a contradiction within our health service, because of the assumed unhealthiness of the Aboriginal experience. I began to reflect upon the reasons for the Indigenous community’s disengagement with health education and started to question the way in which our communities had been constructed within this practice. Within the health care system, no value or worth was attached to being Aboriginal, as the success of the system was measured solely by its ability to bring the health of Indigenous people up to the same level as that experienced by non-Indigenous Australians. Underlying the quest to reduce health inequalities lay first the assignment of inferior status to Aboriginal people within health education programs. Is it actually any wonder, then, that we’d have to beg “Aunty” to come along to a presentation where she was depicted as nothing more than a subset of problems and unhealthy afflictions that could be remedied by simply telling her to eat better and exercise more? I remember feeling shame about having enticed community members to a workshop for a free feed, only to have them subjected to the paternalism of visiting health professionals, who, by virtue of their occupation alone, assumed they could completely disregard cultural and community protocols and that they were instantaneously authorised to speak to our old people as a parent would to a child. As time went by, I began to feel that health promotion in the form of health education was not empowering, but rather disempowering, to our mob. Under this system, we are seen as nothing more than a group of people who just don’t know what is good for us. And herein lay a strong contradiction between what I had been taught as a health professional and what I had learnt and experienced as an Aboriginal person. Health promotion was, I thought as a health professional, meant to empower people.1 Aboriginality, I thought as an Aboriginal person, was about pride, strength, determination and survival — survival of our people, our communities and our cultures. Why then does Indigenous health discursively reverberate around the inadequacies, impairment and hopelessness of our people, families and communities? Yes, sure, the status of Indigenous health is “appalling”. We have countless reports, studies, investigations and inquiries to remind us and reinforce the nature and breadth of these problems.2,3 But my question remains — so then what? What is left of us that we can draw from to make some improvement to our lot in life? I find it hard to just passively accept, as both an Indigenous person and as a health professional, that Indigenous communities have nothing to bring to the table in efforts to improve our own health. A few years after I began my rural placement, on returning home to Brisbane, I continued working in the field of Indigenous health, this time in the role of project officer for an urban Indigenous health promotion project that critically challenged these assumptions. It was through this project that I was able to realise how health promotion could equate to more than just health education. Here I was able to work in a manner that sought to uncover and support the true assets of our communities. Perhaps one of the most conspicuous strengths, which community members continually spoke of, was strength in identity — the persistence of Aboriginality within ourselves, our families and our communities.4 Here identity was not simply a label or name, a series of health issues, or even a stereotypical depiction, but a very complex, dynamic and fluid entity that provided a resource for everyday living. For instance, a vast number of social resources were derived from large family and community networks, and the values attributed to one’s Aboriginal identity produced a reciprocal exchange whereby individuals felt a strong sense of commitment to their community (Box). The result of this participation, such as community organisations and community events, was a source of strength and pride for many of the respondents. It should hardly be surprising, however, that there is something resourceful about Aboriginal identity, given that it has endured over 200 years of active attempts to remove, deny and delegitimise it. It was here that I made my connection. What resonated most with me was the persistence and diversity of our Aboriginality, which I had witnessed and experienced myself as an Aboriginal person, having lived and worked in both rural and urban Aboriginal communities. All this time, I had been seeking a version of Aboriginality that was simply not mine. So, exactly whose version of Aboriginality was it? My search for answers has led me to undertake a PhD in Indigenous health, to examine how the concept of Aboriginality has been constructed within public health practice. As I’ve reflected on my own culture as an Aboriginal person, I’ve been forced to examine the professional culture of public health that I am also a part of. In so doing, I have realised that my own naive and romanticised understanding of the “authentic Aboriginal” was not unique to me. In fact, I have found that these very images are supported and reproduced within much of Indigenous public health practice. For instance, there has to be some explanation for why the epidemiological gaze in Indigenous health research still disproportionately focuses on rural and remote Aboriginal communities,5 when the majority of Aboriginal people reside in urban centres.6 One must also question the practice of continually highlighting the health inequalities facing Aboriginal people without explaining the precise causal pathways — thus perpetuating assumptions about “innate characteristics related to ‘ethnic’ or ‘racial’ difference”.7 The perception of Aboriginality as nothing more than a label, a health risk, and predicator of unhealthy behaviours within Indigenous public health practice reinforces stereotypical ideas of Aboriginality, demonises those who possess it, and disconnects Aboriginal people from their own identities in a manner similar to past oppressive policies of colonisation, assimilation, segregation and integration. Critically examining such practices is not just a matter of “political correctness”, but a vital step that will have profound and meaningful implications for the health of Aboriginal people. Such depictions fuel the very racism that creates and compounds health inequality,8-10 and may also result in Aboriginal people internalising such negative depictions.11 Internalised racism has been linked to increased drug use, behavioural problems,12 increased rates of depression and obesity, and lower academic aspirations.13 Numerous studies have also demonstrated the association between social status and health inequality,14 the relationship between community integration and health,15 and the influence of factors such as social exclusion, support, isolation, participation and autonomy.16 It has been argued that notions of identity and culture are an important resource for empowering minority or marginalised communities — a goal that accords with the broader global health promotion agenda.17 It is not the quantification or authentication of culture by the dominant group, but rather the process of enabling such communities to define, express and represent themselves that is empowering and conducive to better health outcomes. Bearing this in mind, I have sought to develop my research agenda around examining and validating the way in which Aboriginal people define themselves, without the distraction of a predetermined health agenda guiding or hijacking every activity that I engage in. Importantly, despite my apparent rejection of the way public health is practised and health care delivered to Indigenous people, I do not view my current journey as contradictory to the overall goal of public health practice — which is to improve the health and wellbeing of Aboriginal people. All that differs is the construction of meanings around our own notions of health and Aboriginality. Public health and medicine are themselves cultural practices that have been influenced heavily by the politics of colonialism.18 Rather than claiming to be neutral, objective observers of the cultural domain occupied by Aboriginal people, we, as health professionals, need to be prepared to place our own cultural practices under the microscope and examine their effect on the health of Aboriginal people. For Aboriginal people, health is “not just the physical well being of the individual, but the social, emotional and cultural well being of the whole community . . . [and] a matter of determining all aspects of their life, including control over their physical environment, of dignity, of community self esteem and of justice. It is not merely a matter of the provision of doctors, hospitals, medicines or the absence of disease and incapacity.19 I am currently conducting my fieldwork, the chosen site of which is itself somewhat poignant. It is not in some far-off exotic location, but just a few suburbs over from where I grew up. Through my journey so far, I have found the strength in my identity as an Aboriginal person, in all of its “inauthenticity”, and the strength in my community, in all of its unhealthiness, to see a way forward to improving the health of our people. For me, inherent in the task of improving Indigenous health and in achieving wellbeing as an Indigenous person is providing a space within public health practice and in our own minds that allows us, the “public”, to define and redefine our experiences of our identity.

Chelsea J Bond

Brain development from late pregnancy to 3 years of age affects a child’s learning, behaviour and health throughout life. Behavioural difficulties in children are usually symptoms of underlying problems. Observing a child’s appearance and performance, and taking a detailed history (considering factors in the child, the home, the school and the wider environment) provide most of the information needed for diagnosing behavioural problems. It is important to know what is “normal” for all stages of a child’s development, but equally important not to confuse behavioural difficulties with normal variations and behaviours associated with developmental stages. Assessment and early intervention for behavioural and learning difficulties in children require a multidisciplinary team approach. As well as the recommended “multimodal” approach for managing attention deficit hyperactivity disorder, shared care with a general practitioner is available in some states, but medication is likely to be the trigger for a positive outcome.

Trevor S Parry FRACP, DCH, DPH, FRACMA

Ashwin Swaminathan,* Iain B Gosbell,† Nicholas A Zwar,‡Mark W Douglas§ * Infectious Diseases Registrar, † Director and Associate Professor, § Infectious Diseases Physician, Department of Microbiology and Infectious Diseases, Liverpool Hospital, South Western Area Pathology Service, Locked Bag 7090, Liverpool, NSW 1871; ‡ Director and Professor of General Practice, Sydney South West Area Health Service General Practice Unit, Fairfield Hospital, Sydney, NSW. Iain. GosbellATswsahs.nsw.gov.au To the Editor: Infestation with the sandflea Tunga penetrans, or “chigoe flea”, is rarely encountered in Australia, but has been noted in children recently arrived from Central–East Africa. There have been only two previous Australian case reports of this parasitic infection, both in adult travellers returning from Africa.1,2 Several families who had been living in crowded refugee camps in Tanzania underwent routine screening for infection within 2 weeks of arrival in Australia. Four of 14 children examined had cutaneous lesions on their feet — mainly on the toes, nail beds and interdigital spaces (Box). These lesions were papular, less than 1 cm in diameter, pale yellow with dark centres, and were variably painful and/or itchy. Chronic, adjacent skin and nail bed changes were evident, as were small, loosely attached seed-like objects. Papules could be lifted with a sterile needle, leaving a small, non-bleeding cavity. Tunga penetrans, with numerous attached eggs, was identified by microscopy. Tungiasis occurs when an impregnated female sandflea burrows into the unprotected skin of a warm-blooded host. There is a predilection for the feet, although the perineum, buttocks and arms may also be infected.3 The head of the sandflea breaches the upper dermis to feed on blood vessels, while the abdomen traverses the epidermis, with its posterior components (anus, genital opening and respiratory spiracle) reaching the surface, forming a papule. Over several weeks, the flea releases hundreds of eggs before dying. After hatching, the larvae thrive in dust, soil and sand; they are found on beaches and in animal stockyards of tropical countries.3,4 Infection of pigs and other livestock, the usual host reservoirs, has led to significant problems in the livestock industry.1,4 Apart from pruritis and pain caused by local inflammation, morbidity results from ulceration and secondary bacterial infection, including tetanus and gas gangrene.1,2,4 Fleas can be removed using a sterile needle and forceps, and secondary complications prevented with tetanus prophylaxis, and antibiotics as appropriate. Successful outcomes with antiparasitic agents, such as ivermectin and thiabendazole, have also been recently reported.5 Tungiasis is indigenous to Latin America and the Caribbean, but was introduced to Africa, where it is now endemic, and to parts of South Asia.4 Given the current influx of African refugees into Australia, including the tropical north, the obvious concern is whether Tunga penetrans could establish itself here. We encourage medical practitioners dealing with newly arrived African refugees to examine for tungiasis in their screening evaluation. If, as suspected, this condition is prevalent, national infection control guidelines aimed at preventing establishment of the disease in Australia may be needed. Lesions caused by Tunga penetrans, the “chigoe” sandflea A characteristic Tunga penetrans lesion (thick arrow), with pale-yellow papule and dark centre, and a less obvious lesion (thin arrow) with surrounding chronic skin changes and multiple, loosely attached eggs.

Ashwin Swaminathan · Iain B Gosbell · Nicholas A Zwar · Mark W Douglas

Tulsi Menon Resident Medical Officer, Department of Orthopaedic Surgery, Royal Perth Hospital, 19 Morgan Road, Redcliffe, WA 6104 kaltulAToptusnet.com.au To the Editor: I report an infection with Dracunculus medinensis diagnosed incidentally on x-ray. The patient was a Sudanese immigrant, who had sustained a left knee joint effusion after falling. During management at Royal Perth Hospital, a calcified lesion with a serpentine appearance was seen on x-ray within soft tissues near the left knee joint. Its characteristic appearance, combined with the patient’s background, led to a diagnosis of D. medinensis (known as guinea-worm), a nematode parasite which causes dracunculiasis. The patient’s knee effusion was managed conservatively and improved within a few weeks. The effusion was secondary to the fall and believed to be unrelated to the calcified D. medinensis. Transmission of dracunculiasis is through consumption of contaminated water. The guinea-worm larvae mature and migrate towards the skin surface over 1 year (during which the patient remains asymptomatic), with over 90% of the worms appearing from the lower limbs. When in contact with water, the exposed guinea-worm releases larvae, and the lifecycle is completed when people ingest contaminated water.1 If the guinea-worms die before maturation, they usually calcify. The Global Dracunculiasis Eradication Campaign was established in 1981 with the aim of eliminating dracunculiasis through water sanitation efforts.1 With no vaccine or treatment, prevention is the only method of eliminating dracunculiasis. Since the campaign was established, the number of people affected by dracunculiasis has decreased by 98%. Currently, Sudan alone accounts for 73% of cases.1 Our patient migrated to Australia as a refugee from Sudan during the civil war. Her village in Sudan had only one source of water used for daily activities, including drinking. The patient knew many people with dracunculiasis, but did not know she had been infected. When calcified guinea-worms are discovered during routine radiological examination, they usually do not need treatment. Many people are not aware they have been infected. Muller reported 89% of patients with calcified guinea-worms were asymptomatic.2 No known previous case of a radiologically diagnosed calcified guinea-worm has been reported in Australia. The consequences of war and famine, with a resultant increase in refugees and immigrants from affected nations, is likely to increase the number of incidental calcified guinea-worms found in non-endemic countries. This disease may have a significant impact if affected immigrants arrive during the incubation period (when asymptomatic) and the parasite emerges from the skin after immigration (rather than calcifying), similar to the patient described by Spring.3 Thus, it is important for health personnel to be aware of dracunculiasis, including its radiological manifestations. Lateral view of left knee joint and distal left thigh A calcified lesion, representing Dracunculus medinensis within the soft tissues, is visible posterior and lateral to the distal femur near the knee joint. The calcification has a serpentine appearance: the proximal part coiled in appearance, the middle having a string-like linear appearance, and the distal part having dense curvilinear opacity.

Tulsi Menon

Simon J Vanlint Lecturer, Department of General Practice, University of Adelaide, SA 5005. simon.vanlintATadelaide.edu.au To the Editor: The Working Group of the Australian and New Zealand Bone and Mineral Society, Endocrine Society of Australia and Osteoporosis Australia are to be commended for their clear and succinct position statement on vitamin D and bone health.1 This statement highlights an important public health issue which is under-recognised in this country. Of particular value is the box of recommendations on high-risk groups, testing and treatment. However, I believe an important high-risk group has been omitted, a group which too often escapes the notice of the broader medical community. People with intellectual disability have been shown to be at particularly high risk of low vitamin D levels, reduced bone density and fractures.2-5 The reasons for this are multifactorial and include poor mobility, insufficient sun exposure, reduced muscle mass and strength, problems with dietary intake, and medications which interfere with vitamin D metabolism.3,4 There is also some evidence that people with intellectual disability are prone to premature ageing, together with the health problems associated with older age in the general population.3 Some conditions which cause or are associated with intellectual disability are also linked with hypogonadism and reduced peak bone mass.4 To add to all of this, several of the above risk factors, vitamin D deficiency itself, and the increased incidence of epilepsy in the population with intellectual disability, also result in an increased incidence of falls and trauma.5 This unfortunate combination of poor bone health and increased risk of falls and trauma results in a markedly increased incidence of fracture when compared with age- and sex-matched controls from the general population.2-5 In conclusion, people with intellectual disability, particularly those with poor mobility or who are also being treated for epilepsy, should be added to the list of high risk groups. It is likely that the relatively simple steps set out in the position statement (screening for vitamin D deficiency and supplementation) will result in substantial health benefits for this small but particularly vulnerable group of people.

Simon J Vanlint

Alvin L K Chia,* Stephen Shumack,† Peter Foley‡ * Research Fellow, † Dermatologist, St George Dermatology and Skin Cancer Centre, Level 3, 22 Belgrave St, Kogarah, NSW 2217; ‡ Dermatologist, St Vincent’s Hospital, Melbourne, VIC. sshumackATbigpond.com To the Editor: We read with alarm the extraordinary statements in the position statement on vitamin D and adult bone health published recently in the Journal.1 The suggestion that “it is a fallacy that Australians receive adequate vitamin D from casual exposure to sunlight” is not true. The suggested basis for this statement is an extraordinary extrapolation from a single study in which a small number of volunteers had whole body exposure on one occasion for 10–15 minutes to midday summer sun in Boston. It is not possible to extrapolate in such a way from this single demonstration, as the effect of shorter exposure times or repeated daily exposures were not examined. In fact, a study in Australia showed that the adult population (including those aged over 70 years) received sufficient sunlight while using sunscreen to ensure that no-one was found to have vitamin D deficiency during the study period.2 While it is well accepted that ultraviolet B (UVB) radiation is essential for the formation of vitamin D3 in the skin, it is equally well established that continued exposure of vitamin D to UVB radiation results in its degradation. Hence, the importance of knowing the effect of lower sun exposures on vitamin D production. It is intriguing that the authors of the position statement recommended a daily sun exposure dose that they calculate will produce 1000 IU of vitamin D, but, if sun exposure is not possible, a vitamin D supplement of at least 400 IU per day. The high prevalence of vitamin D deficiency among institutionalised older Australians is a tragedy, but this cannot be used as the basis of advice for the general population who do receive daily sun exposure and appear to be the target of the statement. Nor can the mild vitamin D deficiency found in a single study in southern Victoria be used to recommend sun exposure in more northern Australian climes. Finally, while vitamin D supplementation has been shown to reduce the risk of fractures in the elderly, the proposed beneficial effect of deliberate sun exposure has not been demonstrated. Recently, a joint position statement was approved by the Australian and New Zealand Bone and Mineral Society, Osteoporosis Australia, the Australasian College of Dermatologists and the Cancer Council Australia. This included the statement that “The majority of Australians generally have sufficient ultraviolet radiation exposure to enable adequate vitamin D production . . . to form and maintain healthy, strong bones”.3 This statement, endorsed only a few weeks ago, is in obvious conflict with the position statement from the same organisations that was published in this Journal. The latter puts the vast majority of Australians at further risk of skin cancers, which are already epidemic in our country.4

Alvin L K Chia · Stephen Shumack · Peter Foley

Terrence H Diamond,* John A Eisman,† Rebecca S Mason,‡ Caryl A Nowson,§ Julie A Pasco,¶ Philip N Sambrook,** John D Wark†† * Associate Professor, Endocrinology, University of NSW, Sydney, NSW; † Professor and Director, Bone and Mineral Research Program, Garvan Institute of Medical Research, Sydney, NSW; ‡ Associate Professor of Physiology, ** Professor of Rheumatology, University of Sydney, NSW; § Associate Professor, School of Health Sciences, Deakin University, Melbourne, VIC; ¶ Senior Research Fellow, Clinical and Biomedical Sciences: Barwon Health, The University of Melbourne, PO Box 281, Geelong, VIC 3220; †† Professor of Medicine, The University of Melbourne, VIC. juliepATbarwonhealth.org.au In reply: We agree with Vanlint that any individual who has limited mobility, or is housebound or institutionalised, is at risk of vitamin D deficiency, as highlighted in Box 3 of the position statement.1 Disability in general is likely to be a risk, with motor disability as well as intellectual disability liable to limit sun exposure. The problem may be further exaggerated by any increased risk of falls or convulsions. Chia and colleagues have raised important issues. After a number of meetings, the Cancer Council of Australia, the Australasian College of Dermatologists and the Australian and New Zealand Bone and Mineral Society developed a considered consensus statement on vitamin D deficiency, risk of skin cancers and sunlight exposure, which was published at <http://www.cancer.org.au/documents/Risks_Benefits_Sun_Exposure_MAR05.pdf>. This document refers to the position statement published in this Journal in relation to sun-exposure guidelines for vitamin D. Chia and colleagues’ objection to the abstract of this position statement appears ill-founded. If “a significant number of Australians are deficient in vitamin D”, then it follows logically that “it is a fallacy that Australians receive adequate vitamin D from casual exposure to sunlight”, as sunlight is the main source of vitamin D in Australia. The significant number of Australians deficient in vitamin D are not the majority, as was clearly shown in the article, so this statement does not conflict with the complementary statement in the risks and benefits statement. We stand by our original claim that a number of groups in the Australian community have a high prevalence of vitamin D deficiency, including elderly men with hip fracture (63%), Muslim women (68%), elderly ambulant men with prostate cancer (34%), “healthy” elderly men living in Southern Sydney (16%), healthy community-dwelling, ambulatory women in Geelong (20% in the age group 20–39 years, increasing to 53% in older age groups), men and women (some with psychiatric disorders) in south-east Queensland (23%), and even pregnant women in south-eastern Australia (7%) (references are available from the authors on request). As noted in the position statement, and by Chia and colleagues, continued exposure to ultraviolet (UV) radiation may lead to degradation of pre-vitamin D, so that short exposures are likely to be more efficient. This degradation is marked only at relatively high UV doses.2 Studies that used lower UV doses2,3 produced indirect UV equivalence data similar to those quoted in the position statement.1 As the relationship between UV exposure and vitamin D dosage varies from person to person, and as sun exposure is also likely to be variable and on most days, rather than every day, the recommendation that vitamin D supplementation be at least 400 IU/day in people likely to be at risk of inadequate skin-derived vitamin D is entirely appropriate. We strongly agree with Chia and colleagues about the need to avoid sun damage while still obtaining the small amount of sun exposure needed to make adequate vitamin D, which is why the position statement advocates short exposures, easily achieved by casual exposure, and reiterates other Sun-Safe messages, such as avoidance of exposure in peak UV periods and the use of sunscreens where appropriate.

Terrence H Diamond · John A Eisman · Rebecca S Mason · Caryl A Nowson · Julie A Pasco · Philip N Sambrook · John D Wark

Deborah J Verran Senior Transplant Surgeon, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050. deborahATemail.cs.nsw.gov.au To the Editor: A recent editorial by Mathew et al1 and an article by Kennedy et al2 tackle the issue of commercial kidney transplantation. In their editorial, Mathew and colleagues conclude that if the nationwide Australian deceased donor organ donation rate approached South Australian levels, dialysis patients would not travel overseas to purchase renal allografts.1 I believe that this statement oversimplifies the situation with respect to organ trafficking and the motives behind patients’ acceptance of this option. Organ trafficking is illegal under all state and territory laws within Australia and hence cannot occur. In a number of other countries around the world this is not the case. Although laws have been introduced in India, this has not necessarily led to cessation of trafficking in kidneys.3 Compounding this, the option of purchasing an organ is becoming more readily accessible by means of an increasing number of Internet sites.4,5 What motivates patients to go through with purchasing an organ overseas is not explored either in the editorial by Mathew et al1 or the article by Kennedy et al.2 Kennedy et al do not state whether any of the patients who travelled overseas for a kidney had been deemed not fit to be on the renal transplant waiting list in New South Wales. They also do not give the waiting time on dialysis for each patient before he or she decided to travel overseas. What is clear is that only patients who can afford to pay the US$70 000 or more currently quoted for a renal allograft will be the ones who end up travelling overseas. It would be nice to think that, with an increased organ donor rate in Australia, patients will no longer travel overseas to purchase organs. However, the ready availability of the commodity in not-too-distant countries and the increasing ease of access to this organ trade, combined with sufficient cash, will mean that there is no major barrier to some individuals.

Deborah J Verran

Sean E Kennedy,* Yvonne Shen,* John A Charlesworth,† James D Mackie,‡ John D Mahony,§ John J P Kelly,¶ Bruce A Pussell** * Renal Registrar, † Professor of Renal Medicine, Prince of Wales Hospital, Sydney, NSW. ‡ Renal Physician, Prince of Wales Hospital, Sydney, and Illawarra Regional Hospital, Wollongong, NSW. § Renal Physician, Royal North Shore Hospital, Sydney, NSW. ¶ Renal Physician, St George Hospital, Sydney, NSW. ** Professor of Medicine, Department of Nephrology, Prince of Wales Hospital, Sydney NSW 2031. b.pussellATunsw.edu.au In reply: We agree that the motives for organ trafficking are complex. The reasons that people choose to travel overseas to obtain an organ was not addressed in our article on this occasion, but some possible reasons may be self evident given the long waiting time, especially in New South Wales. Our aim was to alert our colleagues to the increased risks associated with overseas commercial transplant procedures so that they could ensure that their patients were fully informed when making a decision. Most of our patients were on the waiting list, and the time on dialysis was detailed in Box 2 in our article.1 However, two were not on the waiting list — one had a pre-emptive transplant and another was not on the list because of age-related medical problems.

Sean E Kennedy · Yvonne Shen · John A Charlesworth · James D Mackie · John D Mahony · John J P Kelly · Bruce A Pussell

Raymond F Raper,* Elizabeth Fugaccia,† Yahya Shehabi‡ * Board Member, † Member, ‡ Chairman, NSW Regional Committee, Joint Faculty of Intensive Care Medicine, 117 Alexander Street, Crows Nest, NSW 2065. yshehabiATozemail.com.au To the Editor: We are writing in response to the pejorative, unhelpful and somewhat misleading editorial “The shortage of kidneys for transplantation in Australia”.1 There are many possible reasons for lower organ donation rates in Australia. Several Australian initiatives have led the way in reducing the incidence of severe, traumatic brain injuries. These include the compulsory wearing of seat belts and helmets, random breath testing, and a zero blood alcohol limit for inexperienced drivers. Intensive care medicine is better structured and organised in Australia and New Zealand than in most of the countries cited by Mathew et al, with higher organ donation rates. Intensive care outcomes in Australia are world-leading. So the donor rate may be lower because patient outcomes are better. A comprehensive chart audit of donor potential in New South Wales carried out under the supervision of the Organ Donation Network NSW/ACT, identified very few missed donors (T Wills, Manager, Organ Donation Network NSW/ACT, personal communication), and a Victorian audit has suggested that the donor pool may be much lower in Australia than previously estimated.2 Similarly, organ donation rates will appropriately vary considerably among hospitals. To improve outcomes, critically ill patients are transported to centres with specific experience and expertise, resulting in a preponderance of potential donors in hospitals with trauma and neurosurgical services compared with hospitals lacking these. The intensive care community supports these life-saving initiatives, notwithstanding the effect they may have on organ donation potential. In fact, the principal “barrier” to organ donation in Australia appears to be the consent rate. From 2000 to 2004, 44% of families declined organ donation when faced with an actual rather than a hypothetical request.3 The intensive care community represents the interests of critically ill patients and their families. We will continue our best endeavours to improve both the survival and quality of life of patients suffering devastating brain injuries (our performance standard). When all brain function ceases, despite our best efforts, we will continue to facilitate organ donation, in discussion with the family, and in consideration of the patient’s known or projected wish. The intensive care community has led the way in developing organ donation-related practice guidelines4 and in related education. Australian Donor Awareness Program — Training (ADAPT) workshops are now a compulsory component of Fellowship of the Joint Faculty of Intensive Care Medicine training. The editorial implication of poor performance and lack of commitment is inaccurate and offensive.

Raymond F Raper · Elizabeth Fugaccia · Yahya Shehabi

Timothy H Mathew,* Randall J Faull,† Paul L Snelling‡ * Medical Director, Kidney Health Australia, GPO Box 9993, Adelaide, SA 5001; † Nephrologist, Royal Adelaide Hospital, Adelaide, SA; ‡ Nephrologist, Royal Prince Alfred Hospital, Camperdown, NSW. tim.mathewATkidney.org.au In reply: We regret that Raper et al have misinterpreted our editorial on the shortage of donor kidneys in Australia.1 We are particularly concerned and indeed mystified by their last statement, where they state that we implied that “poor performance and . . . lack of commitment” were to blame. This was in no manner our message. Rather, we sought to emphasise that all possibilities to optimise local donation rates should be explored, so desperate patients seeking grafts from potentially dangerous overseas sources need not expose themselves to serious potential morbidity and mortality. We consider that our intensive care colleagues perform superbly under the most difficult of circumstances when managing potential organ donation. We understand they are often unsupported with managing potential donations while they must at the same time deal with the grieving family, and the immediate demands of treating other seriously ill patients. We simply suggest that problems within the system (for example, differences between states in the number of intensive care beds per head of population or in the provision of specifically funded donor coordinators) that might hinder increasing organ donation should be carefully examined. We believe it is unhelpful to suggest that the South Australian experience should simply remain unexplained. In the article by Opdam and Silvester (cited by Raper et al), of 112 potential donors, 46 were considered medically suitable unrealised potential donors, and their estimated maximal potential donor rate was 30 per million,2 remarkably similar to the rates seen in Spain (the country with the highest organ donor procurement rate) and South Australia. We agree with the conclusions of Opdam et al that “an increase in the organ donation rate may be possible through increasing consent and the identification and support of potential donors”. As they also state, this would require substantial changes in clinical practice, with resource and ethical complications We did not mean to offend our intensivist colleagues. We merely suggest that we all need to assess the systems in which donation occurs and attempt to improve donation rates, for the sake of the many desperate people awaiting organ transplants in this country.

Timothy H Mathew · Randall J Faull · Paul L Snelling

To the Editor: The article by Senanayake and Ferson1 on detention for tuberculosis included two case histories. In the case of “Patient 2”, we believe the details published were misleading and unnecessarily disclosed potentially identifying information. This case was presented in sufficient detail to allow identification of “Patient 2” by including date of admission, personal details, city of admission and details regarding his past history of alcohol addiction and attempts to self-discharge. All this information was not necessary and did not take into account all the relevant medical complicating factors. We were surprised that, as the primary treating team involved in this patient’s care over the inpatient stay of 3 months and the following 6-month outpatient follow-up, we were not informed of the authors’ plans for publication, nor requested to comment on the facts of the report. We were also surprised to read details of the article in The Sydney Morning Herald on the day of the article’s publication in the Journal.2 An individual’s right to privacy is a fundamental human right. It is unfortunate that the careful consideration that had been given to his detention was not extended to publishing his case details. As Senanayake and Ferson point out, “Patient 2” recognised that his human rights were being “infringed” because he was being held in a “jail cell”, which was a temporarily modified isolation room in a public hospital under 24-hour guard. In law, information provided to a medical practitioner by a patient becomes subject to a statutory duty to protect the patient’s privacy and a common-law duty of confidence is owed by the treating medical practitioner to the patient. The NHMRC Guidelines approved under Section 95A of the Privacy Act 1998 indicate that, when a patient history is published, an important principle is that a patient may not be identified or held up to ridicule.3 Furthermore, public access to medical journals on the Internet has allowed increased availability of such reports to the general public and increases the chance of family members and others identifying individuals. The principle of protecting patient privacy has previously been respected by the Journal. An article published in 1994 reported a 1979 outbreak of tuberculosis in medical students who attended an autopsy of an immunosuppressed patient with unsuspected active tuberculosis.4 A report of the incident was not published contemporaneously, mainly to protect the privacy of the students involved. As the report by Senanayake and Ferson suggests, our patient was socially disadvantaged, and several aspects of his behaviour were probably attributable to a Jarisch–Herxheimer reaction in conjunction with acute alcohol withdrawal. Although we recognise the need to serve the public interest in health service management activities, this must be balanced against the requirement for patient privacy regardless of social class. We suggest that the publisher has an obligation to ensure that patient consent is obtained, and that the primary treating team has been involved in the review of case details so that misleading and potentially identifying information is not released inappropriately.

Medical Registrar · Respiratory Physician

Ruth M Armstrong,* Martin B Van Der Weyden† * Deputy Editor, † Editor, The Medical Journal of Australia, Locked Bag 3030, Strawberry Hills, NSW 2012. medjaustATampco.com.au In reply: We concur with the principle that patient privacy should be protected in case reports. As recommended by the International Committee of Medical Journal Editors,1 measures in place at the Journal include asking authors to obtain patient permission for publication where possible, and directing authors to remove potentially identifying patient information. The article in question was not a case report. Case details were given to exemplify the circumstances that might lead to detention of a patient for public health reasons in New South Wales, and dates and some details were retained to illustrate the temporal flow of the story. We agree that this may have made the patient identifiable, if not to the general public, to himself or his family. We regret this editorial lapse, and have reworded the patient details in the electronic version of the article.2 Although chastened by our anonymous colleagues’ observations, we are somewhat puzzled as to why, given their concern about their patient’s privacy, they are determined to draw further attention to the exposing details. We assume that, in this case (as in the cases of detaining patients for treatment of tuberculosis), public interest prevails. We also agree that case reports of detailed clinical histories require the input of the primary treating team, but the question of authorship should be determined by the involved parties, not the Journal. Be that as it may, as the article was a public health report (and thus not meant to be a detailed clinical exposition), we do not believe that the input of the treating team was required.

Ruth M Armstrong · Martin B Van Der Weyden

A 76-year-old woman presented for a routine skin check in late spring. On examination, she was noted to have a marked purpuric rash involving her lower legs (Figure A). The rash was accompanied by a slight burning sensation. The patient had played golf the day before. A skin biopsy revealed limited changes suggestive of leukocytoclastic vasculitis (Figure B). The rash resolved over 3 days. As the patient was concerned about herbicides causing the rash, she was subsequently patch-tested to an extensive panel of contact allergens, but all tests were negative. In our experience, an erythematous-to-purpuric rash occurring on the legs and ankles of older people is not uncommon after prolonged exercise, such as golfing or hiking, in hot weather. It usually resolves within a week. Surprisingly, there have been very few published reports of this type of rash occurring. We recently reported a case series of 17 other patients,1 and suggested that the condition — a benign variant of cutaneous vasculitis, for which a combination of exercise, heat and stasis appears to be the most significant cause — be known as “golfer’s vasculitis”. However, a colleague who practises in Florida and who is familiar with the condition refers to it as “Disneyworld leg”! A: Purpuric rash on skin of lower leg. B: Skin biopsy of lower leg showing a perivascular infiltrate of predominantly lymphocytes with occasional eosinophils, endothelial swelling and some extravasated red blood cells.

Rosemary L Nixon FACD, FAFOM · Jacinta M Opie MB BS, DRANZCOG · Robert I Kelly MB BS, FACD

On 14 January 2005, Western Australia lost one of its finest paediatricians. Paul Carman died suddenly of acute myocardial infarction while on holiday with his family in Capel. The loss to the medical and Catholic community is immense. In the 19 years that Paul was in Western Australia, he made significant contributions in many fields. He was Chairman of the Paediatric Clinical Care Unit at Princess Margaret Hospital for Children. He ran regular remote paediatric clinics in the Pilbara region, serving the local mining and Aboriginal communities with compassion and care — qualities that he exercised in all other aspects of his professional life. He was a foundation member of the (now disbanded) Advisory and Coordinating Committee on Child Abuse, an advisor to the Christian Brothers commission to support the needs of former child migrants who had been under their care, and an active member of St Thomas’ parish and school, which his seven children attended and where his funeral was held. However, his lasting legacy for paediatric hospitals in Perth will be his vision to establish a Child Protection Unit to provide specialised medical and forensic services to children. Paul was born in Melbourne on 17 September 1950. When he was 4 years old, his family moved to Cairns, in Queensland, and then, 8 years later, to Warrnambool, in Victoria. In Warrnambool, his father established a very successful dental practice. Paul matriculated from St Joseph’s Christian Brothers College in Warrnambool. However, his university entrance score was not sufficient to enter medicine, which was his passion (a passion sparked by the television serial “Dr Finlay’s Casebook”). The following year, Paul repeated his matriculation exams and gained entrance to the University of Melbourne Medical School in 1969. During the fifth year of his course, he met Margaret, whom he married in 1977. Paul worked for 2 years at Queen’s Medical Centre in Nottingham under the guidance of Sir David Hull. It was here that Paul developed his interest in child protection. He obtained his Fellowship of the Royal Australasian College of Physicians in 1985 and, in the following year, took up an appointment as a staff paediatrician at the Princess Margaret Hospital in Perth and as a rural paediatrician in conjunction with the legendary Dr Rex Henderson. Paul’s ability to listen, discuss and draw on his vast knowledge of Russian and European history, ethics, philosophy and common sense was a driving force in the outstanding contribution he made to children’s health in Western Australia. The love, trust and enduring friendship in his relationship with Margaret is reflected in the lives of their seven children.

Peter M Winterton BA, MB BS, FRACGP

Trikojus: a scientist for interesting times. Ross Humphreys. Melbourne: Miegunyah Press, 2004 (xviii + 154 pp). ISBN 0 522 85095 2. Victor Trikojus (1902–1985) must surely rank among Australia's most controversial men of science. In this extended memoir, Ross Humphreys continues his studies of Australian scientists with an agreeable account of a man who, if not born to controversy, seems to have had controversy thrust upon him. Trikojus is credited with important wartime achievements in the production of drugs, including ascorbic acid (for vitamin C), sulphaguanidine for the treatment of dysentery, mersalyl for the control of wound sepsis, and Merthiosal for the prevention of tropical fungal growths on optical instruments. After the war he had important successes in the study of thyroid metabolism, including the discovery (with Frank Hird) of T3 (triiodothyronine). He was also well known for his dedication to the University of Melbourne where, between 1943 and 1967, he established Australia’s leading Department of Biochemistry, and for his contributions to the promotion of food quality, nutrition, and public health. Among the rare Sydney University graduates to receive an 1851 Exhibition, Trikojus returned from his doctoral years in Oxford and Munich with much to offer his alma mater. Notwithstanding his scientific reputation, he is perhaps best remembered for his wartime detention as an alleged pro-Nazi sympathiser, an image that was in 1999 wildly exaggerated by articles in The Age, The Sydney Morning Herald, and on SBS television. The son of a German-born, naturalised Australian father, Trikojus was caught up in the tide of anti-Nazi (mixed with anti-communist) hysteria that coursed through Australia in 1940, leading to his formal detention in 1941, and to restrictions on his movements until 1944. A less robust character might have given way before what now seems singularly misjudged persecution by ill-informed and ill-advised, if not actually incompetent, security services. During and after the war, Trikojus, whose European manner and conservative mannerisms conjured an image of the “other” in an Australia still deeply British in both form and appearance, attracted misunderstanding. To this image, his outspoken, Russian-born wife of mixed European descent, may have inadvertently contributed. At the same time, his dealings with leading Australian scientists were widely praised, and warmly supported. Humphreys makes good use of the Trikojus archives and, by restoring him to his context, makes fresh sense of his life. If, at times, the account reads like a brief for the defence, the outcome is no worse for that. The book goes well beyond the official biography,1 and recaptures a sense of what life in wartime (and Cold War) Australia could be like for those who differed from the familiar norm. At the same time, it reminds us what a difference a “foreigner” can make to Australian cultural and intellectual life. Trikojus: a Scientist for interesting times was released in time to coincide with the opening of the new Bio21 Institute at the University of Melbourne, and includes a prefatory appreciation by Australia’s most recent medical Nobel Prize winner, Peter Doherty. Roy MacLeodEmeritus Professor of History University of Sydney, NSW 1. Legge JW, Gibson F. Victor Martin Trikojus, 1902-1985. Hist Rec Aust Sci 1987; 6: 519-531.

Roy MacLeod

Dx/Rx: valvular heart disease. Dennis A Tighe, Theo E Meyer, Gerard P Aurigemma. Boston: Jones and Bartlett, 2005 (xi + 175pp). ISBN 0 7637 2385 1 This well presented pocket manual is part of the Dx/Rx Cardiology series. Written by clinicians from the Division of Cardiovascular Medicine at the University of Massachusetts Medical School, USA, it succeeds in providing, to quote the editor, “a clinical, concise and practical resource…” with which to approach cardiac valve disorders. Their aetiology, pathophysiology, natural history, clinical presentation and physical examination are discussed, followed by the diagnostic evaluation required and the suggested therapy — whether medical, interventional or surgical. The text is presented in a bullet-point format, aided by tables and figures throughout. Pertinent references are provided at the end of each chapter. Unfortunately, however, there are no illustrations of the various valvular abnormalities, which would have been helpful. The manual is more relevant to an adult population, although providing a considerable amount of information on congenital abnormalities of the valves. Aortic and mitral valve disease is reviewed in great detail with particular attention given to acquired valvular disease, especially rheumatic fever. Attention is also given to the less common disorders affecting the tricuspid and pulmonary valves. There is an excellent chapter on prosthetic valves, describing the types used, their specific clinical findings and the details of their assessment and follow-up requirements. Details of anticoagulation for mechanical valves are provided, including a special reference to difficulties associated with pregnancy. Homografts and autografts are briefly described. Infective endocarditis is referred to, where appropriate, throughout the text. Although aimed at postgraduate students, the manual may be a helpful resource for the busy clinician, whether general physician or family practitioner, as well as the practising cardiologist, for whom there is detailed information available related to less commonly used investigations, such as Doppler echocardiography to determine valve orifice size. While one could take issue with specific comments or details provided, I do think this well written manual achieves its goal. It may prove invaluable in the consulting room and may also become a welcome guide for interns, residents and registrars working in busy hospital settings. Within its small size, it contains a considerable amount of up-to-date information, clearly and concisely presented. Samuel MenahemCardiologist Monash Medical Centre and Royal Children’s Hospital, Melbourne, VIC

Samuel Menahem

Dx/Rx: heart failure. Theo E Meyer, Dennis A Tighe. Boston: Jones and Bartlett, 2005 (ix + 100pp). ISBN 0 7637 2309 6 This 100-page monograph on the diagnosis and management of heart failure, authored by two clinicians from the University of Massachusetts Medical School, USA, strikes a very good balance between the theoretical and practical aspects of this condition. An extremely well written, compact manual, it covers all aspects of heart failure in five sections. An introduction that deals with definition, classification, risk factors, prevalence and prognosis is followed by sections on the pathophysiology, clinical presentation, assessment and management of heart failure. Throughout the book, excellent tables and diagrams complement the text. I found the section about assessment very informative and thought the part on management contained useful practical information about the roles of different pharmacological and non-pharmacological agents used in the treatment of heart failure. Important results from various health failure trials are incorporated in a practical fashion, although in a book of this small size they cannot be presented or discussed in detail. I would highly recommend this book to all doctors who deal with patients who have heart failure, and am looking forward to reading other books in the Dx/Rx Cardiology series. Jitendra K VohraCardiologist Royal Melbourne Hospital, Melbourne, VIC

Jitendra K Vohra

Shingles vaccine A highly potent varicella-zoster vaccine has been reported to more than halve the incidence of herpes zoster and postherpetic neuralgia in healthy, older adults. In the US Shingles Prevention Study, 38 546 immunocompetent adults aged 60 years or older were randomised to receive either a live attenuated varicella-zoster vaccine derived from the Oka strain, or placebo, subcutaneously. The vaccine contained 18 700 to 60 000 plaque-forming units of virus, much more than the approximately 1350 plaque-forming units in the childhood vaccine. Over more than 3 years of follow-up, there were 957 cases of herpes zoster (315 among vaccine recipients and 642 among placebo recipients), and 107 cases of postherpetic neuralgia (27 among vaccine repicients and 80 among placebo recipients). Further, the vaccine reduced the severity of both conditions. At this stage, the "zoster vaccine" is investigational only. N Engl J Med 2005; 352: 2271-2284 Welcome to my Atopia More middle-aged men are atopic today than they were 25 years ago because those born in the 1950s were more likely to become atopic than those born in the 1930s, say London researchers. They measured markers of atopic sensitisation and childhood infection in stored serum samples collected from UK men over nearly a quarter of a century from 1975 to 1998. Year of birth rather than age at sampling was linked to the prevalence of atopy (later birth, more atopy). However, childhood infection was not linked to atopy, suggesting that the increase in atopy was not due to declining rates of childhood infection. Instead, the researchers wondered whether an increased exposure to both indoor and outdoor allergens in more recent decades may be responsible for the observed increase in atopy. BMJ 2005; 330: 1187-1188 Plane trouble Exposure to aircraft noise could have a negative effect on the reading comprehension of young schoolchildren, according to European researchers. They assessed the cognitive performance and general health status of 2844 children aged 9 or 10 years who attended 89 schools near major airports in The Netherlands, Spain or the UK. Although no effect on sustained attention or self-reported health was detected, each 5-decibel increase in aircraft noise at a school was found to equate with a 2-month reading delay in the UK and a 1-month reading delay in The Netherlands. The researchers concluded that schools exposed to high levels of aircraft noise are not healthy educational environments. Lancet 2005; 365: 1942-1949 Giving birth to a new rule? An Australian expert has dared to question the long-held obstetric practice of elective repeat caesarean section after a previous classical caesarean section (CCS), rather than a trial-of-scar. Professor de Costa reviewed the relevant literature after managing a woman who had inadvertently proceeded to four normal vaginal deliveries after a CCS. Although there is not enough evidence to be certain, de Costa concluded that some women who have had a CCS may be able to have a subsequent, uncomplicated vaginal birth — in particular, if the placenta in the current and the CCS pregnancy was not sited under the incision and there had been no postpartum fever after the CCS. Aust N Z J Obstet Gynaecol 2005; 45: 182-186 Beware the tag Another Australian case of small bowel perforation due to a swallowed plastic bread-bag clip has been reported. 1 This time, rather than the more typical elderly, edentulous person, 2 a younger, 50-year-old woman was affected — presenting with increasing epigastric pain and vomiting of relatively short duration. The offending non-degradable, non-radio-opaque bread tag was revealed at laparotomy for a distal small bowel obstruction of no obvious cause. The clip still sported its expiry date — more than 2 years before presentation; the patient did not recall ever having swallowed the clip. Could it be time to modify or replace bread-bag clips? 1. ANZ J Surg 2005; 75: 360-362 2. Med J Aust 2002; 176: 506 Antibiotics and the heart Antichlamydial antibiotic therapy does not reduce deaths or cardiovascular events in patients with coronary artery disease, according to US researchers. They conducted a systematic review and meta-analysis of 11 randomised controlled trials which compared macrolide antibiotics (and in one trial, a fluoroquinolone) with placebo in a total of 19 217 patients. Antibiotic therapy had no effect on all-cause mortality, on the rates of myocardial infarction or on a combined end-point of myocardial infarction and unstable angina. However, the researchers said their meta-analysis did not exclude Chlamydia pneumoniae infection as a potential cause of acute coronary events. They said eradication of this organism in vivo is extremely difficult, if not impossible, to achieve, even with long courses of antibiotics. JAMA 2005; 293: 2641-2647

Ann Gregory

Med J Aust 2005; 183 (1 Suppl).