Volume 183 Issue 5

It is time to focus on issues of roll-out and quality control “Hospital in the home” can mean different things in different countries and contexts. A Cochrane review defined it as “a service that provides active treatment . . . in the patient’s home of a condition that otherwise would require acute hospital in-patient care”.1 This definition includes services that substitute acute care by home-based management (admission avoidance) and those that support discharge with community-based post-acute care and rehabilitation (discharge support). The review found “insufficient evidence to support expansion or contraction” of home-based alternatives to inpatient hospital care.1 Two articles in this issue of the Journal contribute to the clinical evidence base for home care as an admission-avoidance service. There is a growing list of well-defined conditions that have been shown. . . to be manageable in home care. . . There is less consensus about whether treatment at home saves money. . . In a randomised controlled trial of an admission-avoidance hospital-in-the-home scheme in patients with mild to moderate community-acquired pneumonia, Richards et al (page 235) in New Zealand found no clinically important differences in time to discharge, duration of intravenous and oral antibiotic use or general functioning, but higher levels of satisfaction and lower costs for patients treated at home.2 In a retrospective case series of patients with pulmonary embolism in an admission-avoidance hospital-in-the-home scheme conducted in New South Wales, Ong et al (page 239) found outcomes similar to those in hospital cohorts, but acknowledged these results need to be confirmed in a trial.3 There is a growing list of well-defined conditions that have been shown in adequately powered trials or meta-analyses to be manageable in home care, provided either as a complete alternative to hospital admission or to support early discharge from inpatient care. These include cellulitis,4 chronic obstructive pulmonary disease5 and deep vein thrombosis.6 These findings should reassure clinicians who had concerns that similar overall outcomes in trials with a varied casemix may have masked important differences in outcomes for specific conditions. There is also consistent evidence from these studies that patients and carers prefer treatment at home. There is less consensus about whether treatment at home saves money, partly because of the difficulty of measuring costs realistically within a trial rather than a “real world” context,7 but also because costs are highly influenced by the health care system in which hospital in the home operates. A recent study from Victoria of 924 patients treated at home and matched hospital controls showed that home care was cheaper — especially if inpatient admission was completely avoided, in which case costs were 38% less.8 Costs also need to be considered as part of a whole system of health and social care provision. For example, it has been estimated that the Victorian hospital-in-the-home scheme provides the equivalent of more than 400 beds, and so has effectively provided care that would otherwise require the building and maintenance of a large metropolitan hospital.9 In contrast, in the United Kingdom, schemes are generally too small to have a detectable effect on hospital provision. If the evidence does support expansion of the scheme, clinicians and policymakers will need to know which key elements need to be replicated. Nearly all the evidence cited above relates to models with specific admission criteria, which include medical assessment by a specialist, generalist or both, either at home, in an accident and emergency department, or before transfer from inpatient care. Care is also supported by ongoing medical review, provided either in primary care or as hospital outreach. These schemes explicitly provide substitute, not additional, care and require detailed cooperation between the acute and community care providers. Interestingly, the development of hospital at home and other forms of intermediate care in the UK is going largely in the opposite direction. Since publication of the National service framework for older people in 2001,10 the emphasis has been on providing a wide range of schemes in response to local need, in part to prevent “avoidable admissions” (ie, those whose needs are primarily non-medical).11 Many schemes adopt low technology, and are nurse- or therapist-led, with admission rights extended to community nursing and social work teams.12 These developments have contributed to resistance, especially from physicians involved in the care of older people, who are concerned that inadequate assessment of geriatric clinical syndromes will disadvantage frail older people and reverse advances in clinical care made in the second half of the 20th century.13 These concerns are accompanied by fears held by general practitioners that they are neither equipped nor available to provide medical support to intermediate care. Although Richards et al point to the opportunities for involvement in home care schemes to increase the skills and experience of GPs,2 it seems only a minority of GPs in the UK will use the service if they have to assume medical responsibility. This proportion is likely to decline as most urban practices opt out of providing out-of-hours care.14 A national evaluation of intermediate care has recently been completed, but results have yet to be published. It seems likely that recent trial evidence will influence an updated Cochrane review, but problems appraising the evidence remain. Firstly, it may not be useful to combine data from intensive outreach interventions designed to substitute for inpatient hospital care (as seen in Australia and New Zealand) with more rehabilitative approaches designed to avoid unnecessary admissions and support discharge from inpatient hospital care. Furthermore, many of the advantages of hospital in the home, such as reducing risk of hospital-acquired infection and delirium and the social and psychological consequences of a hospital stay, occur only if admission is avoided, again suggesting that pooling data including supported discharge is not helpful. Finally, the Cochrane review will not include important evidence from large observational studies, which are more able than trials to detect uncommon complications and provide realistic estimates of cost. The articles by Richards et al and Ong et al add to the evidence for the effectiveness of a model of hospital in the home in which Australia and New Zealand are leading the world by providing services of sufficient scale to offer a real alternative to inpatient care. The evidence needed now goes beyond the remit of a Cochrane review, and should focus on issues of roll-out and quality control.

Andrew D Wilson MD, FRCGP · Stuart G Parker MD, FRCP

We need to acknowledge the inevitability of death to have some choice in the manner of our dying The tragic story of Maria Korp, the Victorian woman with severe irreversible hypoxic brain damage after an alleged murder attempt, has been prominent in the Australian media over the past few weeks. The clear, considered, and humane intervention by the state’s Public Advocate to authorise the cessation of artificial feeding has drawn both widespread praise, and some condemnation, especially from right-to-life activists.1 Once again, care and decision-making at the end of life is in the public arena. Earlier this year, world media attention focused on a young American woman, Theresa Marie Schiavo, who had been in a permanent vegetative state for more than 15 years. A prolonged legal and political battle in state and federal jurisdictions of the United States eventually led to the cessation of tube feeding, and her death. Interestingly, there was broad agreement between the courts and medical opinion that feeding should stop.2 In the preceding November, a much less publicised case was played out in Australia. The Supreme Court of New South Wales ruled that treatment could be withdrawn from Isaac Messiha, a man whose life was supported by ventilation and tube feeding, after he had experienced severe cortical brain damage resulting from a cardiac arrest. Faunce and Stewart review the Messiha and Schiavo cases concerning treatment abatement (a term adopted by Weir3 to encompass both stopping and not starting treatment) for incompetent persons (page 261) and weigh up two options for dispute resolution: an institutional clinical ethics committee ruling, and a judicial declaration on futility.4 Although both may occasionally have their place, basic process questions need to be posed by clinicians5 (Box 1) before recourse to external arbitration. It is noteworthy that in neither case was an advance directive in place. An important difference between the two cases lies in the time that elapsed after catastrophic hypoxic brain injury before treatment abatement was considered — years for Theresa Schiavo, and initially only 4 days for Isaac Messiha. It is clearly essential that abatement decisions should not be made prematurely. They should only be made after the patient’s failure to improve has been demonstrated over a period of observation and care that is widely agreed (by appropriate specialist neurological opinion, and supported by any relevant clinical evidence) to be reasonable for the diagnostic category concerned (stroke, post-coma unresponsive state, or brain death). Patients in a post-coma unresponsive state (previously known as permanent or persistent vegetative state) constitute a small subset of those who are incompetent to make medical decisions for themselves, and can be further subdivided into those whose condition is the end-stage of a terminal (albeit slowly progressive) illness (for example, the Victorian BWV case6), and those who are the victim of anoxic insult or trauma and are being maintained by nutritional support indefinitely, as in the Messiha and Schiavo cases, and the United Kingdom case of Anthony Bland.7 Leaving questions of advance directives to one side (their uptake rate has been poor nearly everywhere), Australian health legislation is not obviously helpful with the Bland-type cases, whereas some headway has been made with the first subset, as seen in the BWV case, and the drafting of the Consent to Medical Treatment and Palliative Care Act 1995 (SA). Whether the underlying condition is progressive or static, nobody should be locked indefinitely into an existence on life support, often without consent, and usually with no prospect of recovery. Treatment abatement decisions for those who are unable to speak for themselves should usually be resolved where they traditionally have been, between clinicians and families or duly appointed agents. Recourse to public tribunals and courts should be minimised, reserved for situations of intractable disagreement, if only because such processes address, but can also encourage, adversarial style mediation. Reducing the amount of futile medical treatment and introducing the timely deployment of appropriate palliative care to all who need it should be our preferred process. In bioethics, the concept of “futile” treatment has had a rough ride, mainly because of the inevitable uncertainties of medical prognostication. However, the “prognostic paralysis” described by Murray and colleagues is a real challenge,8 and we cannot ignore the fact that medicine has its limits. Despite polls reporting a widespread public pragmatism about death and dying (“I would never want to be a vegetable”, “When my time comes I do not want to be kept alive artificially”), when clinicians do try to discuss treatment abatement with patients and families, they often meet disbelief, even hostility. Clearly, polls reflect public attitudes as distinct from personal situations. In personal health care encounters, the idea that cure is improbable or impossible, or that continued life support is inappropriate or unkind, is unacceptable to many families. The wider problem here is that acknowledgement of the inevitability of death, and preparation for it, have largely lost their place in our culture. For many, an almost child-like faith in medicine and science has taken its place. We need to take up the challenges, and solutions, offered by health-promoting palliative care (Box 2).9,10 We need to shift from seeing the treatment of dying people, and the maintenance of those who are permanently unconscious but biologically alive, as “curative”. Instead, treatment of dying people with curative intent should be seen as an inappropriate and unkind obstruction of the natural dying process (given that our natural biological inheritance is to die) and a misuse of medicine.11 Thus, we should first try to save the lives of those who are sick and injured, but when this is no longer a reasonable prospect, the goals of care need to reflect that reality (Box 3).12 Mere emphasis on individual choice, important as it is, is not enough. A wider social understanding about the anticipated results of treatment of the dying and comatose person is essential, not medical heroics or legal and moral gymnastics. Health care workers and society need to move beyond curative domination and a view of death as medical defeat or failure. We need to question the place of death in the culture and processes of hospitals and aged care facilities, where most of these treatment abatement decisions occur. Appropriate care and decision-making at the end of life can only occur when death and the dying process are acknowledged, worked with, and regarded as an integral part of modern health care. Research into policy-based approaches, such as advance directives13 and care pathways for the dying in hospitals,14 is important. Results of their evaluation in Australia are eagerly awaited. In the meantime, many hospitals in Australia still do not have adequate consultative palliative care resources. When in place, and adequately funded, they can assist with imparting bad news, adapting to impending death, providing holistic care for patient and family, and with the transition, where appropriate, to community-based palliative care, or a palliative care bed. Evidence concerning good practice in communication about these issues is now well established.15,16 Death and dying is everyone’s business. Good clinical practice, integrating all we have learnt about communication and support for patients and families facing death, will go a long way to easing these tough journeys. But clinical approaches are not enough. We need to work with the policy-makers to place death and loss back on the public health and community agenda. We cannot control the fact of death, but we can have some influence on the manner of our dying. Medicine can make a wonderful contribution to quality of life until death; and it can make it miserable. This choice is ours. 1 Key questions to be addressed by a health care team if treatment abatement is considered Are the clinical facts of the case well established? Is the diagnosis correct? Has sufficient time elapsed to be reasonably confident that there is no reasonable prospect of substantial improvement or recovery? Is there consensus among the clinicians about the diagnosis, prognosis and most appropriate course of medical action? Is a case conference necessary? Identify the key decision maker(s) in the family, or friends. Have the patient’s family, carer(s) or legally appointed agent been advised of the above? Have they had a chance to express their opinions, and been involved in the decision-making process? Has the patient’s general practitioner been involved? Has the abatement decision been documented? The plan for implementing it may involve a “time trial” of continued life-sustaining treatment. How will subsequent objections to the decision be dealt with? Has a consultative palliative care team referral been considered? 2 Goals of health-promoting palliative care Provide education and information for health, dying and death Provide both personal and social supports Encourage interpersonal reorientation towards a “natural” death Encourage reorientation of palliative care services towards public health ideas of prevention, harm-reduction and community participation Combat death-denying health policies and attitudes 3 Goals of care Curative (“beating it”) Cure or durable remission Prognosis: years Palliative (“living with disease, anticipating death”) Disease incurable and progressive Prognosis: weeks, months (but can be years) Terminal (“dying very soon”) Death imminent Prognosis: hours or days Modified from Ashby and Stoffell.12

Michael A Ashby MD, FRACP · Allan Kellehear BA, PhD · Brian F Stoffell PhD

Millennium Development Goals for the world’s poorest nations need to be matched by Health Priority Goals for prosperous nations, to relieve the burden of wealth-related disease We have a set of clear and challenging goals — the Millennium Development Goals, adopted by the United Nations in 2000 — to improve the health of the poorest 760 million people on earth,1 but none for health development for the rest of us, and it is time that we did. Twelve per cent of the world’s population, inhabiting 50 countries, live on US$3 a day or less.2 Four and a half billion people live in less impoverished circumstances in Asia (excluding Japan), Latin South America, the Caribbean and some of Africa.1 Their countries have built the economic, legal and political infrastructure to attract investment, and they have achieved prosperity through the commercial, industrial and financial processes of global market participation. Birth rates and infant mortality have fallen, life expectancy has risen, and infectious diseases have been brought more or less under control. A further 1.2 billion people live long and prosperous lives in economically sound nations. Let us call these three groups Worlds A, B and C. The health needs of World A are those of people caught in desperate poverty, where infant and maternal mortality is high, infectious disease is out of control, and essential medical care for readily cured life-threatening illness is hard or impossible to obtain. HIV, malaria, respiratory and gastrointestinal infections and tuberculosis are the warlords that molest and kill. In 2000, the UN adopted the Millennium Development Goals to help World A gain its feet. The Millennium Development Goals called for global assistance through debt relief, direct aid, and scaling up of critical infrastructure, to cut in half the prevalence of abject poverty by 2015.3 The Millennium Development Goals correctly and appropriately concentrate on infant and maternal deaths, HIV and other diseases, but there are things that should be done now to prevent future chronic disease epidemics, for example, in tobacco control. For US$70 billion a year, less than the cost to the United States of the Iraq war, it would be possible to put in place a graded program of infrastructure development and community strengthening as a springboard for health gain and development. Part of poverty entrapment is health entrapment, and it may be easier to tackle this than try regime change as a means of social uplift. Although World A struggles desperately, it is now on the global radar. International aid agencies commit most of their resources to its relief. The Group of Eight (G8) summit recently agreed to a doubling of aid for Africa by US$25 billion a year by 2010, as part of an overall increase of US$50 billion for all developing countries. The G8 partners also cancelled 100% of the multilateral debts of the Highly Indebted Poor Countries.4 No one who understands the Millennium Development Goals claims that money is the whole answer, but while not sufficient, it is necessary. World B, meanwhile, is coming to terms with the impact of diseases that stem from the urbanisation, changing diet, tobacco, and transport changes that characterise their growing prosperity. Birth rates and infant mortality have fallen, and life expectancy is converging on that of World C, so that the global average life expectancy today is 65 years.1 Cardiovascular disease is now the truly global disease, evenly spread through Worlds A, B and C. World C has succeeded in pushing cardiovascular disease (both its death toll and much of its morbidity) into people’s late 70s and beyond. Not so in World B, where a third of deaths and suffering from cardiovascular disease occur among men and women, of working age.5 While the needs of World A are now on aid agendas, those of World B receive scant attention. Heart disease and stroke top the list of causes of disease burden worldwide. While the World Health Organization, the World Bank and the International Monetary Fund (to a lesser extent) have been steadily producing regional and national reports on the continuing and serious illnesses afflicting World B, no global commitment equivalent to the Millennium Development Goals has yet been proposed. As a result, efforts to control these problems are poorly directed and effective interventions all too rarely applied. A different set of goals — Health Prosperity Goals — is needed for World B. These goals should specify cuts in the toll of chronic disease, which is rising in developing countries. Specifically, smoking should be reduced by 20% in 10 years, and death from cardiovascular disease among people aged under 65 should be reduced by 15%. These goals could be discussed with town planners, food producers and retailers, insurers, employers (whose workforces cardiovascular disease adversely affects), unions (whose members suffer from cardiovascular disease), doctors and nurses, ministries of finance, educators, and the other people who must help us define the problem and solve it. Four benefits would follow from articulating a set of Health Prosperity Goals that would clearly define our intentions and bring to global attention the need to act on these conditions. First, Health Prosperity Goals would redirect us from repeatedly describing the size of our current health problems to concentrating thought on how to relieve them. To take cardiovascular disease again, we do not need to prove repeatedly that it is a serious problem. More to the point, we know we can achieve much through programs that manage people at elevated risk medically, combined with efforts to modulate the social and economic forces that promote those risks. Let us therefore aim for a 15% reduction in death from heart disease in people aged less than 65 by 2015 throughout Worlds B and C. Second, Health Prosperity Goals would establish accountability. Those who manage health programs then have an aim for which the community can hold them accountable. Third, we might frame the Health Prosperity Goals so that they specify broad strategies, based on evidence of effectiveness, but leave the details to individual nations to determine. Fourth, by concentrating on intervention, we will see how crucial it is that those involved in producing prosperity and its untoward side-effects contribute ideas and support to preventing and relieving those side effects. Discussion with city planners, developers, insurers, employers, union representatives, and non-government organisations may lead to a redefinition of health problems such as cardiovascular disease and proposals for their solution that introverted public health professionals, meeting in closed seminar rooms, might not think of in a decade.

Stephen R Leeder PhD, FRACP, FFAPHM

Objective: To determine whether community management of mild to moderate community-acquired pneumonia (CAP) is as effective and acceptable as standard hospital management of CAP.Design: Randomised controlled trial.Setting: Christchurch, New Zealand, primary and secondary care.Participants: 55 patients presenting or referred to the emergency department at Christchurch Hospital with mild to moderately severe pneumonia, assessed using a validated pneumonia severity assessment score, from July 2002 to October 2003.Interventions: Hospital treatment as usual or comprehensive care in the home delivered by primary care teams.Main outcome measures: Primary: days to discharge, days on intravenous (IV) antibiotics, patient-rated symptom scores. Secondary: health status measured using level of functioning at 2 and 6 weeks, patient satisfaction.Results: The median number of days to discharge was higher in the home care group (4 days; range, 1–14) than in the hospital groups (2 days; range, 0–10; P = 0.004). There was no difference in the number of days on IV antibiotics or on subsequent oral antibiotics. Patient-rated symptom scores at 2 and 6 weeks, median change in symptom severity from baseline to 6 weeks, and general functioning at 2 and 6 weeks did not differ between the groups. Patients in both groups were satisfied with their treatment, with a clear preference for community treatment (P < 0.001).Conclusions: Mild to moderately severe CAP can be managed effectively in the community by primary care teams. This model of comprehensive care at home can be implemented by primary care teams with suitable funding structures.

Dee A Richards MB ChB, DPH(Dist) · Les J Toop MD, MRCGP, FRNZCGP · Michael J Epton MRCP, FRACP, PhD · G Ian Town MB ChB, FRACP, DM · Robin D Dawson MB ChB, MRCGP, DCH · Michael C Hlavac MB ChB, FRACP · Graham R B McGeoch MB ChB, FRNZCGP · Simon M H Wynn-Thomas BM BS, MRCGP, FRNZCGP · Paul D Abernethy BA(Psych), RN · Anja M Werno MD, FRCPA

Aim: To describe the characteristics, outcomes and treatment complications of patients with pulmonary embolism (PE) who were treated at home and as outpatients in an ambulatory care program.Methods: Retrospective descriptive study of patients with PE who were treated in the ambulatory care unit during 2003. Ambulatory care unit data and medical record information were reviewed. Data collected included demographic and clinical data, standard clinical indicators of unplanned admission during treatment program, incidence of major bleeding, recurrent venous thromboembolism (VTE), and death within 3 months of admission into the ambulatory care program.Results: 130 patients with PE were treated: 46% were treated totally as outpatients and 54% as early discharge patients. Mean age was 66.4 years; 61% were women. The program was successfully completed for 89% of patients; one patient was lost to follow-up. There were three episodes of major bleeding (2%; 95% CI, 0.5%–7%), all in patients aged > 70 years. Four patients died (3%; 95% CI, 0.8%–8%) within 3 months of admission into the program, but none in the first week, no death being directly attributable to PE. There were seven episodes of recurrent VTE (5%; 95% CI, 2%–11%).Conclusion: Appropriately selected patients with sub-massive PE can be treated as outpatients and in the home. Although the outcome is good in most patients, a significant proportion will require admission, emphasising the need for a well defined protocol and close medical supervision. Further study will more closely define at-risk patients and refine the care pathways.

Bin S Ong MB BS, FRACP · Margaret A Karr MPH, MSc(Med) · Daniel K Y Chan MD, FRACP, MHA · Anthony Frankel MB BCh(Wits), FCP(SA), FRACP · Qing Shen BMed, MSc

Objectives: To determine the incidence of childhood type 1 diabetes mellitus (T1DM) in New South Wales from 1997 to 2002; to compare with previously published rates (1990–1996); and to analyse trends in incidence from 1990 to 2002.Design, setting and participants: Prospective population-based incidence study. Primary ascertainment of incident cases aged < 15 years was from the Australasian Paediatric Endocrine Group NSW children’s diabetes register. Secondary ascertainment was from the National Diabetes Supply Scheme until 1999 and from the Australian Institute of Health and Welfare thereafter. Childhood population data were obtained from the Australian Bureau of Statistics.Main outcome measures: Age-standardised incidence; trends in incidence by calendar year, and sex and age at diagnosis.Results: There were 3260 incident cases (1629 boys, 1631 girls) in the 13 years. Case ascertainment was 99.7% complete using the capture–recapture method. Mean age-standardised incidence per 100 000 person-years was 20.9 (95% CI, 19.9 to 21.9) from 1997 to 2002 compared with 17.8 (95% CI, 17.0 to 18.7) from 1990 to 1996; there was a plateau in incidence between 1997 and 2002. Overall, the incidence increased on average by 2.8% per year (95% CI, 1.9% to 3.8%, P < 0.001) and increased with age, being 12.2 (95% CI, 11.3 to 13.1) in 0–4 year olds; 18.9 (95% CI, 17.8 to 20.0) in 5–9 year olds and 26.7 (95% CI, 25.4 to 28.1) in 10–14 year olds. The increase per year in 0–4 year olds (3.9%) was not significantly higher than in older children. The mean incidence of T1DM was 19.8 (95% CI, 18.8 to 20.7) in girls and 18.8 (95% CI, 17.9 to 19.7) in boys (P = 0.02).Conclusions: The incidence of childhood-onset T1DM has increased significantly in all age groups in NSW since 1990. Resource planning in the management of childhood diabetes in NSW should take these findings into account.

Craig E Taplin MB BS · Maria E Craig PhD, FRACP, MMed(ClinEpid) · Margaret Lloyd RN · Martin Silink AM, MD, FRACP · Neville J Howard FRACP, FRCP · Claire Taylor MB ChB · Patricia Crock FRACP

Objectives: To describe the main media narratives in the reportage of singer Kylie Minogue’s illness with breast cancer; and to assess the impact of this coverage on bookings for screening for breast cancer by mammography in four Australian states.Setting: Government sponsored BreastScreen programs in Queensland, Victoria, Tasmania and Western Australia.Main outcome measures: Narratives on breast cancer in television news programs 17–27 May 2005; initial and re-screening bookings for mammograms.Participants: Women aged ≥ 40 years who booked for mammograms in BreastScreen programs in the 19 weeks before, the 2 weeks during, and the 6 weeks after the publicity.Results: There was a 20-fold increase in news coverage of breast cancer, which emphasised that young women do get breast cancer and that early detection was critical. Overall screening bookings rose 40% in the 2 weeks of the publicity, with a 101% increase in non-screened women in the eligible age-group 40–69 years. Six weeks after the publicity, bookings remained more than a third higher in non-screened women.Conclusions: News coverage of Kylie Minogue’s breast cancer diagnosis caused an unprecedented increase in bookings for mammography. Health advocates should develop anticipatory strategies for responding to news coverage of celebrity illness.

Simon Chapman PhD · Simon Holding BA · Kim McLeod BA(Hons) · Melanie Wakefield PhD

Objective: To determine the extent of self-reported use of prescription medications in an Australian community sample.Design, setting and participants: Face-to-face interviews with a random, representative sample of the South Australian population (aged ≥ 15 years) living in metropolitan and rural areas. The study, a Health Omnibus Survey, was conducted between March and June 2004.Main outcome measures: Reported number of prescribed medications used per person, most common categories of medication, and use by individuals of multiple medications for the same body system.Results: From 4700 households selected, 3015 participants were interviewed (65.9% response rate). Of respondents, 46.8% were using prescribed medications; 171 respondents (5.7%) were taking six or more medications, and four were taking 16 or more; 23.2% were using medications for the cardiovascular system, with 11.9% using agents acting on the renin–angiotensin system. Prescription medication use increased with age, with over 10% of respondents aged ≥ 55 years using six or more medications.Conclusions: Use of multiple prescribed medications was common, with the potential for significant drug interactions. Assuming a similar pattern of medication use Australia-wide, reducing the number of prescribed medications by one for people taking six or more medications would save the federal government about $380 million a year.

Robert D Goldney MD, FRANZCP, FRCPsych · Laura J Fisher BA(Hons)

The obesity epidemic has been described as a catastrophic failure of government and public health authorities to devise and implement concerted, effective evidence-based action. To respond effectively to major public health challenges such as this, Australia needs a Ministry for the Public’s Health, with a budget and accountability to parliament separate from the Health Minister. This Ministry would be better able than current health departments to develop and implement health — rather than health care — policy, to build partnerships across tiers of government, and to present the health and economic arguments for disease prevention to state and federal treasuries. Such a Ministry has international precedents, with dedicated public health agencies created in Canada, Sweden and the United Kingdom, although it is, as yet, too early to gauge their effectiveness. The Ministry would be best placed within state and territory governments, as it is at this level that partnership building and whole-of-government cooperation would have the greatest impact.

Stephen J Corbett MPH, FAFPHM

The demand to implement clinical and educational strategies based on evidence has increased in the past two decades. Over a similar time frame, the problem-based learning (PBL) approach has been widely adopted by undergraduate medical schools, in spite of empirical reviews suggesting that its effectiveness may be limited. Students claim that PBL provides a more satisfying learning experience than traditional methods. While such an outcome is desirable, it is substantively less than the original promise of the approach. We hypothesise that the widespread adoption of PBL may be more a consequence of the approach meeting criteria for successful dissemination than of demonstrable positive educational outcomes. We suggest that greater effort should be taken to articulate and measure important undergraduate educational outcomes. Alternatives to the PBL approach should be actively considered.

Robert W Sanson-Fisher PhD · Marita C Lynagh PhD

Relatives may increasingly demand that an incompetent patient’s treatment be continued indefinitely, despite clinical advice that it is technically “futile” (offering no reasonable prospect of return to a meaningful quality of life). Third-party interventions may become a more frequent part of attempts to resolve such disputes where there is no formal advance directive. In the Messiha case, the Supreme Court of New South Wales upheld clinical judgement regarding the patient’s best interests as most important. In the Schiavo case in the United States, clinicians’ decisions on futility of treatment had received unwavering judicial support in more than 20 proceedings. Political differences between the US and Australia make it unlikely clinicians in this country will face Schiavo-type legislative challenges to individual clinical decisions and the judicial rulings upholding them. Consulting a clinical ethics committee in such scenarios is both legally recommended and clinically warranted as an important device for diffusing tensions between relatives and clinicians, as well as clarifying their respective ethical and legal responsibilities. In protracted or apparently irresolvable disputes with relatives, applying for a judicial declaration on futility of treatment has become a practical option for intensivists in Australia and should be a recognised part of their training.

Thomas A Faunce LLB(Hons), BMed, PhD · Cameron Stewart BEc, LLB(Hons), PhD

Randomised controlled trials are often not feasible or not appropriate in palliative care research In evaluating evidence for clinical care, study designs are graded according to their potential to eliminate bias,1 and the most robust evidence is considered to come from randomised controlled trials (RCTs).2,3 However, the reliance on study design as the main criterion for credibility of evidence has its critics,4 as does this view of what constitutes the “best” evidence.5,6 In public health in particular, there is debate about the primacy of the RCT for evaluating interventions and about the tendency to downgrade the contribution of observational studies.7,8 More recently, this debate has moved to emerging research areas, such as palliative care. This discipline urgently requires a wider evidence base, but acquiring this evidence presents particular problems. Evidence in palliative care researchIn palliative care research, methodological difficulties arise because of the complex physical, psychological, existential and spiritual problems faced by patients, families and professionals.9-13 These difficulties include patient recruitment, gate-keeping by professionals (ie, reluctance to enrol patients in research studies), small sample sizes, high attrition rates, rapidly changing clinical situations and limited survival times.10,12,13 Palliative care research often focuses on the effectiveness of services for populations, rather than the effect of treatments on individual patients.9 Trials of palliative care services are almost entirely pragmatic (ie, they compare a new service with current best practice).13 The difficulties in identifying, recruiting and retaining patients mean that study populations often comprise those who are best able to cope and least ill. As palliative care is by its nature holistic and often tailored towards the needs of individual patients (pain relief and improved quality of life), it may be difficult to define the intervention precisely and uniformly. Palliative care is also characterised by a multidisciplinary approach. It can be difficult, and possibly also inappropriate, to isolate an individual intervention from a multidisciplinary approach. In addition, treatments that involve various components, changes in services, and surgical or radiological interventions are harder to deliver in a blinded manner to all concerned. Because treatment packages are the mainstay of palliative care research, the ideal type of RCT is seriously compromised.13 It is also important to reflect on the outcomes that we wish to assess. In general, the outcomes of RCTs are to reduce mortality and morbidity and improve survival.14,15 However, extending life is not the central aim of palliative care services, and duration of survival may therefore be irrelevant. Instead, symptom management and health-related quality of life are important outcomes. The timing of measurements is also crucial for trials, yet timing in palliative care is problematic because of the short time between eligibility and death.13 Furthermore, RCTs have been considered inappropriate or unethical in palliative care.9 They are seldom acceptable to patients and their families, who may not wish to risk reducing the quality of life in their remaining days in a trial with a non-intervention arm. Deliberate withholding of support services from the control group has been deemed unethical,16 and it is difficult for researchers to easily gain control “within ethically defensible limits”.13 For example, the Cambridge Hospital at Home study compared 186 patients randomised to receive up to 2 weeks of 24-hour nursing care when nearing death, with 43 control patients on an intention-to-treat basis.17 Problems included the limited power of the study to show differences, service resource constraint of 2 weeks, doctors not wanting to withdraw a desirable service before a patient’s death, 39% of the intervention group dying before receiving the intervention, and the control group receiving an alternative good nursing service. These problems made it difficult to show the worth of the intervention. A new system for classifying evidenceIt is difficult to grade published studies in palliative care using the traditional taxonomies for levels of evidence. Our recent literature review during the preparation of evidence-based guidelines for palliative care in aged care18 revealed numerous problems; many publications fell into evidence levels III (non-randomised comparative studies) and IV (case series),15 and many of the studies could not have been ethically conducted as RCTs. Consequently, to ensure a consistent, defensible approach to evaluating the available studies, we adapted traditional taxonomies in accord with recommendations of the National Health and Medical Research Council (NHMRC).19 We scored studies for quality of methods used to minimise bias, strength and relevance and, based on these scores, defined two new levels of evidence — qualitative evidence and consensus opinion of experts in the field (Box). Although some may consider these levels of evidence less rigorous, we believe that, given the limitations of the study designs, they are the most appropriate criteria for assessing evidence to guide palliative care practice. Alternative approaches to study designThere have been calls in both public health and palliative care for study designs to incorporate the social, economic and political factors that usually influence the effectiveness of the intervention.4,5,14,20,21 The NHMRC has recognised that clinical practice guidelines may improve health more readily for the relatively health-advantaged than for the relatively disadvantaged, potentially increasing health inequalities.22 In response, the NHMRC has developed a framework for incorporating evidence about socioeconomic position and health into these guidelines.14 The tendency for evidence classified as “best” (based on study design) to have been gathered on simple interventions and from groups that are easy to reach in a population raises issues about its relevance and transferability to other groups. Assessing evidence on multiple dimensions would better allow these issues to be taken into account For example, it has been suggested that evidence on the effectiveness of public health interventions should be assessed on three dimensions, similar to those we devised for palliative care interventions, namely: strength of the evidence, which is determined by a combination of study design (level), methodological quality and statistical precision; magnitude of the measured effects; and relevance of the measured effects to the context in which the intervention is to be implemented.4 A pragmatic approach is recommended when considering the importance of study design relative to the other dimensions.4 Study design should not be seen as synonymous with quality of evidence, as it is only one aspect. There are many useful observational designs, including, in particular, prospective open-label studies.23,24 These have a more realistic methodology for palliative care research, with each patient acting as as his or her own control, and data compared before and after the intervention. For example, the efficacy of ketamine as an analgesic was investigated with a prospective, multicentre, unblinded, open-label audit: 39 patients received a 3–5 day continuous subcutaneous infusion of ketamine, in addition to their existing analgesic regimen.23 Patients who achieved a 50% or greater reduction in mean pain scores were designated responders. The responder rate was 67%. A second trial on 43 patients in eight centres found a responder rate of 51%.24 The authors concluded that such data can be used to inform practice, if input and output data are rigorously recorded, and patients act as their own controls.23,24 Quality improvement methods are emerging as a way of obtaining evidence in palliative care. These methods involve stating an aim, measuring success, and testing possible improvements, for example through a PDSA (“Plan, Do, Study, and Act on new insights”) cycle. These cycles can generate deep understanding of complex systems and make sustainable improvements rapidly.25 Although RCTs have their place whenever possible,10,26 the above alternative designs may offer more feasible research protocols that can be successfully implemented in palliative care. If studies are to be fairly and accurately graded for the development of evidence-based guidelines, a second look at this taxonomy is warranted. Rating system for qualitative evidence This system was devised by the Australian Palliative Residential Aged Care (APRAC) project to classify qualitative evidence.* Studies were scored for: Quality of evidence (quality of methods used to minimise bias): This was assessed with eight questions, each with a yes or no answer (scored as 1 or 0, respectively): Was the aim of the study clear? Was the paradigm (philosophical and scientific approach, such as logical positivistic, qualitative) appropriate to the aim? Was the methodology (overall qualitative approach, such as phenomenological, grounded theory, critical theory) appropriate to the paradigm? Were the methods (eg, sampling, data collection, analysis) appropriate to the methodology? Could the rigour of the study be established? (ie, were the methods explicit and transparent, did researchers make explicit their own beliefs, did the analysis search for “negative” cases?) Did the sampling strategy address the aim? Was the data analysis appropriately rigorous? Were the findings clearly stated and relevant to the aim? Strength of evidence (magnitude of intervention effect): 4 = very high; 3 = high; 2 = low; and 1 = very low. Relevance to APRAC project (relevance of outcome measures and the applicability of the study results to the clinical question): 4 = very relevant; 3 = relevant; 2 = of some relevance; and 1 = of little or no relevance. Studies were classified as: Level QE (qualitative evidence) and were considered appropriate for development into guidelines if they had a quality rating of 6 or higher (out of a total of 8) and both a strength and a relevance rating of 3 or 4 (out of a total of 4). These studies are usually descriptive and include detailed, rich and “integrative” analysis, including observational or case studies. Level EO (expert opinion), if they contained no quantitative or qualitative evidence, but provided information about best practice from an expert or experts in that field, as agreed by the project team. Because expert opinion is generally the result of experiential knowledge, it was considered helpful to the development of the guidelines and, accordingly, was included in the preamble for each chapter. However, as it was not research-based, it was not used as the basis for any guidelines. * The first edition of the APRAC guideline document was made available for public comment.18 This description is based on the second edition, currently undergoing evaluation by the National Health and Medical Research Council.

Samar M Aoun PhD · Linda J Kristjanson PhD

Setting Your intern presents three cases on the ward round. You are nearing the middle of term and you have time before the afternoon clinic to give some informal feedback as to how she went on those cases and how the term is progressing. Giving trainees feedback means letting them know, in a timely and ongoing way, how they are performing. Providing feedback is an essential part of training junior doctors.1-4 Most trainees welcome the opportunity to discuss their strengths and areas for improvement. Feedback should encourage self-reflection, raise self-awareness and help students plan for future learning and practice. Medical students and junior medical officers report that feedback doesn’t occur frequently enough and that it is not always conveyed effectively.5 In contrast, teachers feel they give more feedback than learners claim to receive.6 Perhaps we can do better. The Confederation of Postgraduate Medical Education Councils recommended in 2001 that effective feedback should be given to students and junior doctors as a strategy for preventing distress.7 Feedback may be formal or informal. Formal feedback is planned as part of appraisal and assessment1,4 and occurs episodically (eg, at the middle and end of a rotation). It may cover specific areas or outcomes as set down by the hospital or a clinical college. Informal feedback should be given on a daily basis in relation to specific events (eg, managing a case or doing a procedure). Indeed, daily feedback should be part of the culture of our hospitals and other sites of training. Ensuring good feedback requires:1-4 Adequate time; Clear goals and outcomes — so you know what you are appraising or assessing; Direct observation of learners — so you know how well they are doing; and Skills in giving positive and negative feedback — so you are an effective facilitator of junior doctors’ development. Positive critique3,8Positive critique, in which the trainee is asked to speak first, is a powerful framework for giving feedback (Box). This approach, while not avoiding negative feedback, emphasises the positive and encourages self-reflection. Often the positive critique approach is easier on the supervisor, as the trainee may bring up areas of concern first, so you can agree rather than break the bad news! A mismatch in trainer/trainee understanding revealed by feedback raises flags as to trainees’ insights. Best practiceAs outlined in “Tips 8”,4 when giving feedback, make sure you cover all important areas of professional competence (knowledge, skills, communication, attitudes) and collect good data (from multiple people on multiple occasions) on which to base your feedback. Feedback should not skim across the surface task. Good feedback should: Be timely. Give feedback soon after an event and as regularly as possible (preferably daily or weekly). Waiting till the end of a rotation is too late. Don’t give feedback at times when you or the trainee are tired or emotionally charged. Be specific. Trainees want the specifics, rather than a global “overall, you are doing fine”. Be constructive. Help provide solutions for areas of weakness. The positive critique, which looks at “what can be improved” rather than “what is wrong”, encourages looking for solutions. Be in an appropriate setting. Positive feedback is effective when highlighted in the presence of peers or patients. Constructive criticism should be given in private — an office or some neutral territory where you are undisturbed is ideal. Phones should be off the hook, mobiles and pagers turned off. Allow the trainee input. Trainees should be given the chance to comment on the fairness of the feedback and to provide explanations. Involve attentive listening. Focus on the positive. Avoid jokes, hyperbole or personal remarks (concentrate on the act or behaviour, not the person). Try not to dampen positive feedback by qualifying it with a negative statement (“I was very happy with your presentation, Sharon, BUT . . .”; “Overall, James, we are pleased with your performance, HOWEVER . . .”). Impact of feedbackUsing regular feedback to encourage, enthuse and correct learning9 improves outcomes and helps to define goals. A survey of junior doctors on interactions with their supervisors showed that when feedback (especially when given in a positive fashion) was an integral part of the solution it was more likely to be associated with a positive view of medicine as a career and junior doctors having confidence in themselves as doctors.10 And remember, it is not just poorly performing doctors who want feedback — good doctors want to know how to be even better. Principles of the positive critique3,7 As a supervisor, you should: ask the trainee what went well; list the tasks you thought the trainee did well; ask the trainee what could be improved; and add any other things you think could be improved. Take-home message Feedback should be: both formal (regular and covering term outcomes) and informal (daily); given as a positive critique (ie, trainee lists good points, supervisor lists good points, trainee lists areas to improve, supervisor lists areas to improve) to encourage self-assessment and emphasise the positive; specific and constructive, and done at the right time, in the right place. For senior doctors, a good question to ask at the end of the day is, “Have I given my trainees any feedback today?”.

Alistair W Vickery MB BS, FRACGP · Fiona R Lake MD, FRACP

As Indigenous Australians, our health lags behind that of indigenous groups in other settler colonial nations such as the United States, Canada and New Zealand.1 Similarly, we are far behind these nations in relation to Indigenous participation in the health workforce and the professions generally. A compelling illustration of this is the fact that the first indigenous doctors in North America and New Zealand graduated in 1889 and 1899, respectively, while the first Indigenous doctor in Australia graduated almost a century later, in 1984.2,3 It is undeniable that our poor health and our low participation in the health workforce are related. Increasing recognition of this has led to a situation in which there are now over 80 qualified Indigenous doctors and almost 100 Indigenous medical students in Australia.4 This achievement has only been possible because we live in the era of “self-determination” that was born, as was I, during the 1970s. I am a multiracial Australian, with Aboriginal, Anglo and Asian ancestry. Because my grandmother (being my only Indigenous ancestor) was a member of the “stolen generations”, and because I am fair-skinned, I started life with an ambivalent Indigenous identity which has been profoundly shaped by the policies of affirmative action (or positive discrimination) that epitomise the era of self-determination. My first experiences with affirmative action occurred in high school, when I was showcased as a role model for other Indigenous students. I went on to gain a degree in science and start a career in health research through an Indigenous cadetship. Affirmative action also provided me with the financial means to complete a Master of Medical Statistics — the first Indigenous Australian to do so — and with preferential access to scholarships, which allowed me to complete a Master of Public Health and to undertake a PhD. In return for this assistance, I have spoken at Indigenous youth summits and school career days, tutored, taught, and donated prize money to Indigenous tertiary students, and conducted research and teaching in Indigenous health on topics of importance to Indigenous people (such as the health effects of racism).5 In addition, I have brought an “Indigenous” perspective to a range of committees, forums, round tables, community groups, conferences, colleagues and students. These experiences are in keeping with the goals of affirmative action, which are to create equality of opportunity and outcome for Indigenous Australians and, for the benefit of all Australians, to promote diversity through equitable representation of Indigenous people in society. Affirmative action is achieved, in practice, by assisting individual Indigenous people to become more “successful”. In addition, there is often an implicit assumption that the Indigenous recipients of affirmative action will themselves strive to reduce social inequities, promote opportunities for and enhance representation of Indigenous people, and act as role models. While medicine has made some progress towards these goals, and the role played by Aboriginal and Torres Strait Islander health workers has been crucial, other areas of health have not fared as well. There has been little government support for increasing the number of Indigenous nurses or allied health professionals,2 with the notable exception of the recent Puggy Hunter Memorial Scholarships.6 Health research is a particularly lonely field. I knew of no other Indigenous person studying at my institution in the same degree program as me. Also, milestones such as the first Indigenous doctor and the first Indigenous clinical psychologist to gain a PhD have only been achieved in the 21st century. Clearly, there is still considerable scope for applying affirmative action in health and other sectors in which Indigenous people continue to suffer from disadvantage. However, I believe there are complexities inherent in both the aims and practice of affirmative action that need to be considered in order to improve social outcomes for Indigenous Australians and allow our diversity to contribute to Australia’s future. In this essay, I will share with you what I have learnt about the benefits and pitfalls of affirmative action as an Indigenous health professional during the past decade. The most obvious difficulty faced by Indigenous people who are beneficiaries of affirmative action is the self-doubt stemming from accusations that we do not merit such support. Unfortunately, it appears that many Australians still think Indigenous people get “too many benefits”. In one survey, almost a third of participants believed that car loans are paid for us by the government, and almost two-thirds thought that we receive more social security benefits than non-Indigenous people.7 In another survey, more than half of respondents believed Indigenous people were “treated over generously by the government”.8 The hostility to affirmative action programs, which is compounded by these misconceptions, can only be reduced through education that explains the benefits of diversity and the need to remedy historical injustice.9 There is also an urgent and profound need to tackle systemic racism in Australia, which, in its most extreme form, led to the death of Private Damien Palmer. After entering the army through an affirmative action policy, he committed suicide following racist taunts and intense ridicule from fellow soldiers and instructors.10 Systemic racism is something that white Australians, as those who benefit most from the system of racial oppression, are in the best position to combat. Indigenous people, in contrast, face anguish and rapid “burnout” when leading the fight against this insidious form of racism. The intense doubt of our self-worth which some Indigenous people experience as a result of affirmative action can be reduced by ensuring that Indigenous people are only placed in positions and given training or learning opportunities for which they have the appropriate commitment, skills, abilities and qualifications. If we cannot do a job or don’t have the capacity to benefit from a program, this is no doubt due to a legacy of oppression and colonisation. However, this situation is not remedied by the tokenism being engaged in by far too many organisations around Australia. Not only are those caught up in tokenism unable to effectively advance the goals of affirmative action, but they are also being set up to fail or, worse, set up as ever more prominent “tokens”, whose increasing visibility as such severely hampers ongoing efforts to redress Indigenous disadvantage. It is clear that affirmative action, no matter which segment of the Indigenous population is targeted, is most helpful to those who are most advantaged to begin with.11 It is easiest, and perhaps most appropriate, for those who have the most capacity to benefit to take up whatever opportunities are on offer. However, there is still a tendency for both Indigenous and non-Indigenous people to assume that being Indigenous is synonymous with a certain “marginality or victimage”.12,13 This misconception can leave Indigenous recipients of affirmative action not only doubting their self-worth but also being seen as threatening “tall poppies”2 and having their Indigenous identity questioned. I have certainly been accused of taking positions that should have been given to “real blacks” who weren’t as acculturated to white society as me and/or who had darker skin. These issues need to be brought into the open, so that Indigenous people who are beneficiaries of affirmative action can share these difficult experiences and learn from each other about effective coping strategies. In implementing affirmative action policies, we need to stop simply seeing “Indigenous people” as a single entity and instead see individuals with multiple personal and professional identities, including Indigeneity. We need to believe in and respect Indigenous people as individuals who have their own goals, principles, flaws and foibles and who may or may not be interested in, capable of, or suitable for a specific affirmative action policy or program. Despite what is often assumed, some Indigenous people — just like some non-Indigenous people — are not effective role models or interested in working towards emancipatory goals. Therefore, it is vital to consider, in every case, whether, and to what degree, affirmative action is aimed at helping an individual become more successful, at increasing diversity, or at aiding recipients who will then contribute to the goals of affirmative action themselves. These questions need to be addressed by all Australians and will require us to grapple with the historical baggage that accompanies the stereotyped Indigenous identity we have inherited as a nation.14 All of us need to truly come to terms with the diversity of Indigenous people in Australia, rather than just paying lip service to this notion. To do this, non-Indigenous Australians must overcome their reluctance to engage in debate about Indigenous affairs,15 and Indigenous Australians must stop acting as if dissenting views are nothing more than simplistic attacks on Indigenous people.2 If there is one thing that most people agree on, it is that there is no simple solution to the complex problems in Indigenous health.2 In relation to our history as a nation, the struggle to improve the lives of Indigenous people in Australia has only just begun and has a long way to go before equity is achieved. In the field of Indigenous health research, in which I work (and, I suggest, in many other fields), we require a greater clarity of purpose and increased patience in relation to affirmative action if we are to avoid jeopardising our efforts at improving the plight of Indigenous people. Not all health research can involve Indigenous researchers, because those with sufficient training and experience are few and far between. We are not well served by setting up Indigenous people as “researchers” when they are not, or by prioritising affirmative action to such an extent that the very research we do is compromised. Let us hope that the spectacular rise in the number of Indigenous doctors continues until equity in medicine is reached and that we can match this achievement in Indigenous health research. In working towards these goals we need to recognise that the era of self-determination, like those before it, won’t last forever. What could perhaps be called the “partnership era” may already be replacing it, as exemplified by policy approaches such as shared responsibility agreements.16 The role of affirmative action in this new era is not assured and will only be maintained by addressing the difficult issues now, so that Australia may one day become an inclusive nation where, as Indigenous people, we can maintain our unique identity while playing a full role in society and enjoying the same level of health as other Australians.

Yin C Paradies BSc, MMedStats, MPH

Robert D Goldney Professor of Psychiatry, University of Adelaide, The Adelaide Clinic, 33 Park Terrace, Gilberton, SA 5081. Robert.goldneyATadelaide.edu.au To the Editor: Two recent items in the Journal might potentially lead to misinterpretation of the evidence on managing depression in young people. The first was the book review entitled Darker side of “wonder drugs” by Jureidini1 in which there was no disclosure that the author of the review is president of Healthy Skepticism, a body which has been quite strident in its opposition to antidepressant therapy. The second was the unattributed comment in the editorial by Rey and Dudley describing “parents who believe their children killed themselves because they were taking SSRIs [selective serotonin reuptake inhibitors] . . .”,2 which may imply subtly that this has occurred frequently. In a review of the United Kingdom General Practice Research Database of more than three million people,3 there were no suicides among the 6976 aged 10–19 years who had been prescribed one of two SSRIs or two tricyclic antidepressants; however, 15 people in that age group who had not received an antidepressant drug died by suicide. Furthermore, in a review of 14 857 suicides in Sweden, of the 52 involving people under 15 years, no SSRIs were detected, and in the 15–19-years age group, those taking SSRIs had a lower relative risk of commiting suicide than those taking other antidepressants.4 Clinicians with responsibility for children and adolescents can be reassured by these data, and also by the fact that the American Food and Drug Administration “black box” warning (their most potent warning) about antidepressants has recently been modified.5 Furthermore, the American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association have provided a new resource about the use of medication in treating childhood and adolescent depression,6 which has been endorsed by over a dozen United States organisations comprising a “national coalition of concerned parents, providers, and professional associations”. This should allay questions that have rightly been raised, but that have been answered in favour of the judicious use of antidepressants, along with other therapeutic measures for children and adolescents with severe depression. In view of the strong association between child and adolescent mood disorders and suicide,7 the above research findings and the recommendations of respected professional bodies raise the issue of potential legal action for not at least trialling antidepressant medication in young people with severe depression if non-pharmacological measures are ineffective.

Robert D Goldney

Peter R Mansfield,* Melissa K Raven,† Jon N Jureidini‡ * Research Fellow, University of Adelaide, SA; † Lecturer, Flinders University, Adelaide, SA; ‡ Head, Department of Psychological Medicine Women's and Children's Hospital, Adelaide, SA. peter.mansfieldATadelaide.edu.au To the Editor: Rey and Dudley cite clinical experience as the basis of their recommendation of selective serotonin reuptake inhibitors (SSRIs) — chiefly fluoxetine — for youth with severe depression plus severe impairment or failure of non-drug therapy.1 They do not discuss the evidence on efficacy because they claim that it is “ambiguous enough for scholars to be divided”. It is true that industry-funded scholars are continuing to suggest that SSRIs (chiefly fluoxetine) provide a worthwhile benefit.2 However, the evidence is unambiguous. The four published comparisons of fluoxetine versus placebo for children and adolescents have all been negative on their pre-specified primary endpoints.3,4 A tiny average benefit is likely, but the magnitude of this benefit is unlikely to exceed the magnitude of less frequent but more severe harms. Furthermore, the common clinical impression of worthwhile benefit is to be expected given the large average improvements seen in placebo groups. Rey and Dudley speculate that psychosocial treatments may be less effective with uncooperative teenagers.1 However, that group may also be at higher risk of the dangers of intermittent use of, and overdosing with, antidepressant drugs. Rey and Dudley cite Timimi’s critique of the concept of childhood depression5 as supporting “treating depression primarily as a moral or social problem”. However, Timimi did not even allude to depression as a moral problem, and advocated a multi-perspective approach that normalises emotional responses to adverse life experiences and includes interventions addressing biological factors, such as diet, exercise, and cognitive abilities. Rey and Dudley use a related straw-man argument in their final sentence when they suggest that the only alternatives to SSRIs are tricyclic antidepressants, victim blaming, and non-treatment. Rey and Dudley deny being influenced by the gifts and funding that they have received from drug companies. There is compelling evidence that gifts and funding are effective, on average, for influencing beliefs, especially among people who have an illusion of invulnerability.6 We are not aware of any way that any individual can know that he or she has not been influenced.

Peter R Mansfield · Melissa K Raven · Jon N Jureidini

Joseph M Rey,* Michael J Dudley† * Professor, Psychological Medicine, University of Sydney, PO Box 142, North Ryde, NSW 1670. † Senior Lecturer in Psychiatry, University of New South Wales, Randwick, NSW. jreyATmail.usyd.edu.au In reply: The data available are inconclusive, but suggest that treatment with selective serotonin reuptake inhibitors (SSRIs) may increase the short-term (less than 14 weeks) risk of suicidal thoughts or self-harm in children and adolescents slightly, by about 2%. However, SSRI treatment may actually decrease the number of completed suicides,1 as Goldney also highlights. To show whether SSRIs influence the risk of completed suicide, a rare event, requires a randomised trial including up to two million individuals.2 This will not happen. Hence, clinicians must rely on accumulated data from experimental, epidemiological, and observational studies. Disagreements about interpretation will doubtless continue. In response to Mansfield and colleagues, we personally know of media reports influencing some practitioners to revert to using tricyclic antidepressants, and child psychiatrists to avoid treating depressed adolescents. We do not shrink from our interpretation of the implications of Timimi’s reconceptualisation of “depression” as “unhappiness”. Regardless of how childhood depression is classified or named, we remain concerned that the impetus for clinicians to diagnose and treat it not be lost. Its social correlates include stigma and racism, which often involve seeing mental health problems as moral failures of character. Our view is that fluoxetine shows a favourable harm–benefit profile in moderate to severe depression. According to the Treatment for Adolescents with Depression study,3 which was not funded by drug companies, four children need to be treated with fluoxetine for one to show much or very much improvement attributable to medication. This compares with having to treat 21 children for one to display a widely defined harm-related event. The numbers improve further when fluoxetine is combined with cognitve behavioural therapy (3 and 50, respectively). Pending new studies, clinicians would be unwise to ignore these data when treating serious depression in young people, a recurring illness that produces much suffering, physical and psychosocial disability, and suicide (odds ratio estimates ranging from 11.0 to 27.0).4 Our opinions are consistent with those of the recently released joint clinical guidance by the colleges of psychiatrists, general practitioners, and physicians.5 Mansfield and colleagues suggest that our editorial’s content might have been influenced by drug company gifts. We provided the educated readers of the Journal with information to judge this for themselves.

Joseph M Rey · Michael J Dudley

Duncan Topliss Chairman, Adverse Drug Reactions Advisory Committee, Therapeutic Goods Administration, Department of Health and Ageing, Canberra, ACT 2601. adracAThealth.gov.au Comment: Three essentially independent reviews of the use of selective serotonin reuptake inhibitor (SSRI) antidepressants in children and adolescents have been undertaken in Australia in the past 9 months.1-3 The review by the Adverse Drug Reactions Advisory Committee1 had input from representatives of the Royal Australian and New Zealand College of Psychiatrists and the Division of Paediatric and Child Health, Royal Australasian College of Physicians (RACP). All three reviews noted the paucity of information to support the efficacy of these and other antidepressants in children and adolescents, and the frequent observation of increased suicidal thoughts and self-harm in clinical trials. The colleges’ review2 and the National Prescribing Service Rational Assessment of Drugs And Research (RADAR) review3 support the ADRAC advice that: Any use of SSRIs in children and adolescents with MDD [major depressive disorder] and other psychiatric conditions should be undertaken only within the context of comprehensive management of the patient. Management should include careful monitoring for the emergence of suicidal ideation and behaviour which may particularly develop early in therapy, or if therapy is interrupted or irregular because of poor compliance. Cognitive behaviour therapy, if it is available, may enhance the outcome in MDD. An SSRI should be chosen for a child or adolescent with MDD or other psychiatric condition only after taking into account the recent evaluations of clinical trial data and the Australian product information. Prescribers should be aware that the marketers of fluvoxamine and sertraline (indicated for obsessive compulsive disorder) advise against their use in children and adolescents with MDD, and the marketers of citalopram, escitalopram, paroxetine, venlafaxine and fluoxetine warn or caution against their use in patients aged less than 18 years for any indication. It is important to note that children and adolescents who are being treated for MDD with an SSRI should not have their medication ceased abruptly.

Duncan Topliss

Gordon R W Davies Psychiatrist, 33 Smith Street, Wollongong, NSW 2500. alienistATihug.com.au To the Editor: The recent editorial by Andrews1 quotes a report suggesting that the integration projects funded by the Australian Government produced substantial benefits to patient care at no extra cost. Working in an area in which one of these projects was funded, I suggest that such an inference is unwarranted, particularly as many patients report increased difficulty in accessing public mental health services. The Illawarra, being geographically circumscribed and with a relatively small medical population, has always had a high degree of interaction between services, although it is true to say that these have somewhat declined in recent years with larger bureaucracies and increased privacy concerns. In my early days in the area, there was a monthly meeting involving police, Youth and Community Services, the Housing Commission, school counsellors, and hospital and community social and mental health workers to coordinate the management of problem families. Sadly, this no longer occurs. Unfortunately, the major effect of the integration project was simply to add a management structure to the prior interaction, and not to significantly increase it. It seemed that the core issue was control and not service provision. Useful coordination projects, such as some commonality of core records, never seemed to happen, and with the passing of the project, things have, in fact, been worse, as fundamental community services such as the crisis team and chronic care components have been cut. I have always been a strong supporter of a more integrated approach to care, but one that does not grow primarily from the workers involved in day-to-day clinical care and that addresses their needs is unlikely to be lasting and successful.

Gordon R W Davies

Andrew S Kemp Professor, Allergy Immunology and Infectious Diseases, The Children’s Hospital at Westmead, Locked Bag 4001,Westmead, NSW 2145. andrewk5ATchw.edu.au To the Editor: Publicity such as that on the recently televised “Sunday” show (Channel 9) entitled “When food can be fatal” (http://sunday.ninemsn.com.au/sunday/cover_stories/transcript_1770.asp), which contained statements that “30 in every 1000 [3%] children in Australia are at risk of a severe allergic reaction [anaphylaxis] to a food”, and a reference to a “tsunami of children” with serious allergies, provokes understandable concern and anxiety. Some perspective on this issue is required. To determine the risk, it is essential to study a population-based cohort. Allergies to peanuts or tree-nuts are the most common cause of severe childhood food anaphylaxis and death.1 What is the risk for Australian children of peanut-induced anaphylaxis that is likely to require adrenaline? Of a population-based cohort of 456 Tasmanian children aged 7–8 years, none reacted to a peanut skin-prick test.2 In the Australian Childhood Asthma Prevention Study (CAPS),3 a high-risk cohort, 4.9% of 3 year olds were prick-test positive to peanut (unpublished data) using a liberal cut-off of ≥ 2 mm (for clinical testing the usual cut-off is ≥ 3 mm). Perhaps the most helpful information comes from a population-based study of 13 971 preschool children in the United Kingdom who were followed from birth to 6 years of age. Forty-nine (0.35%) children had an allergic reaction to peanut, of whom only two (0.014%) had what was described as anaphylaxis.4 Thirty-six of the children underwent formal peanut challenge, 23 reacted and three had reactions for which adrenaline was given. Combining these three with the previous two gives a severe reaction rate requiring adrenaline of 0.036%. This suggests that, of the 49 children in the UK study who had an allergic reaction to peanut, only 10% were at risk of a severe reaction requiring adrenaline. Only a third to a half of children with a positive peanut skin test will react if exposed.5 Applying these considerations to Australian children indicates that the proportion at risk of a severe peanut reaction is only 0.25% (4.9% × 1/2 × 5/49) even in a high-risk cohort such as the CAPS. This would be substantially lower in a population-based cohort. For the cohort of 7–8-year-old Tasmanian children referred to above, the risk would be much less than 0.2%, considering none of 500 children was prick-test positive to peanut allergen. There has been a substantial increase in childhood food allergy in recent decades;5 however, sensationalist statements and inaccurate figures are unlikely to be helpful in developing appropriate responses. The Australasian Society of Clinical Immunology and Allergy recently published guidelines for the prevention of food anaphylactic reactions,6 and has other useful information for patients and medical practitioners on its website (http://www.allergy.org.au/).

Andrew S Kemp

Grant A Mackenzie Paediatrician and Postgraduate Student, Ear Health and Education Unit, Menzies School of Health Research, PO Box 41096, Darwin, NT 0811. grantmacATmenzies.edu.au To the Editor: Funding of universal varicella zoster vaccine (VZV) at ages 18 months and 10–13 years was recently announced in Australia. Health professionals should be aware of a number of related issues. Varicella vaccination was recommended in the United States from 1996 for all children aged 12–18 months, with catch-up vaccination to age 13 years. US surveillance shows: Decreased varicella mortality in all age groups except those aged ≥ 50 years (average varicella deaths per year: 145 in 1990–1994 versus 66 in 1999–2001).1 Decreased varicella cases in all age groups, with a non-significant reduction in hospitalisations (average annual hospitalisations in three surveillance regions: 40 before vaccination versus 14 after vaccination).2 US data on herpes zoster have not yet been published. There are concerns that, in the longer term, universal varicella vaccination may increase the incidence of adult varicella and herpes zoster, similar to the effect of pertussis vaccination on adult pertussis. Modelling in the United Kingdom predicted that universal infant vaccination would initially reduce varicella, but would result in increases in herpes zoster 5–10 years later and adult varicella 20–40 years later.3 In contrast, modelling of adolescent vaccination predicted a small decrease in varicella, but no increase in later adult varicella.3 Varicella is generally perceived as a mild illness, while vaccination is largely valued for preventing serious, life-threatening conditions. Anecdotal reports of low levels of private purchase of VZV in Australia suggest it may not be a priority for some families. With 36% of general practitioners concerned about unknown side effects of VZV,4 and public concern about vaccine adverse events in the face of low disease rates, the level of acceptance of universal varicella vaccination by providers and consumers is uncertain. Alternatives to universal varicella vaccination were a high-risk strategy (vaccination of children with chronic illness and family members of high-risk individuals) or waiting until US disease patterns were established. These were real options as: A high-risk strategy may prevent up to 45% of paediatric hospitalisations.5 Hospitalisation and herpes zoster contribute more to health costs than treatment in the community or acute varicella.5 Natural infection, at the cost of disease, immunises most of the population. Any increase in adult varicella and herpes zoster caused by varicella vaccination may be alleviated by booster doses, but the added cost, difficulty in reaching the target population, and potential impact on community confidence in vaccination may be significant problems. The universal varicella vaccination program will test providers’ and consumers’ acceptance of vaccination against what is perceived as a mild illness.

Grant A Mackenzie

Kristine Macartney,* Peter McIntyre† * Senior Research Fellow, † Director, National Centre for Immunisation Research, The Children’s Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145. petermATchw.edu.au Comment: Recently published data have added considerably to the evidence about the impact of varicella vaccination programs, and address many of the concerns raised by Mackenzie. First, in the United States where universal varicella vaccination was recommended a decade ago, recent data show that — despite much slower implementation than is expected in Australia — varicella-related disease has declined by up to 90%, and hospitalisation rates and deaths from varicella by more than two-thirds, due to herd immunity.1,2 Second, data have now been published on the incidence of herpes zoster in areas of sentinel surveillance in the US, showing no change in age-specific rates to 2002.3 Along with the success of a recent trial of high-dose varicella vaccine in reducing herpes zoster in older adults,4 these data add to confidence that any increase in herpes zoster — as predicted in some models — will be detected and effectively combated by vaccinating people aged over 60 years. A substantial allowance for surveillance of both varicella and herpes zoster was included in the 2005 federal budget, to accompany the introduction of universal varicella vaccination in Australia. Mackenzie is correct that varicella is perceived by some as a mild illness, but it is important for general practitioners to emphasise to patients that this is incorrect.5 Each year in Australia, varicella causes around seven to eight deaths and more than 1500 hospitalisations,6 many associated with serious complications, such as invasive bacterial infection, pneumonia, and encephalitis. Although complications are more likely in adults and immunocompromised patients, 42% of hospitalisations are in children aged 0–4 years,6 most of whom are otherwise healthy.7 Patients can also be reassured about the safety of varicella vaccines, as clinical trials now date back 30 years, and more than 40 million doses of vaccine have been distributed in the US. Mackenzie suggests alternatives to universal childhood varicella vaccination, such as vaccination of “high risk” patients and their families, or of adolescents alone. However, these programs would not prevent morbidity among otherwise healthy young children and older age groups, as they would be insufficient to generate herd immunity. Moreover, age-based vaccination strategies have been shown to be easier to implement than more targeted programs. In the absence of a publicly funded universal program, the private market could sustain modest varicella vaccination rates of around 40%–50% in Australia.8 This would increase the number of adolescents and adults susceptible to varicella, because of reduced exposure to the virus and lack of vaccination; these groups also experience greater morbidity with infection than children. A universal program vaccinating young children and adolescents against varicella offers the best current option to reduce morbidity and mortality from this disease in Australia. Ongoing surveillance of varicella and herpes zoster in Australia and elsewhere will reveal whether there is a need for further interventions, such as a second dose of varicella vaccine in children and high-dose varicella vaccine to prevent herpes zoster in older adults.

Kristine Macartney · Peter McIntyre

Adam P Morton Physician, Department of Medicine, Mater Adult Hospital, Raymond Terrace, South Brisbane, QLD 4101. AmortonATmater.org.au To the Editor: The excellent report by Harding et al in the Diagnostic Dilemmas article in the Journal highlighted medications and conditions that may cause false positive results of biochemical tests for phaeochromocytoma.1 Another group of patients, those with obstructive sleep apnoea (OSA), may have raised urine noradrenaline levels in the absence of a phaeochromocytoma. Of about 170 patients seen at a hypertension screening service at the Mater Adult Hospital between 1998 and 2000, six had elevated levels of urine noradrenaline and normetadrenaline up to twice the upper limit of the normal range on repeated testing. Five were obese and were proven to have significant OSA. All required at least three antihypertensive drugs for reasonable control of their blood pressure, and had normal suppression of catecholamines with clonidine. A recent report described a series of five patients with OSA presenting as pseudophaeochromocytoma who had consistently elevated levels of noradrenaline on measurement of 24-hour urinary catecholamine levels; normetadrenaline levels were not measured.2 Noradrenaline levels became normal in all five patients after treatment with continuous positive airway pressure, and blood pressure levels improved significantly. Excess urinary noradrenaline, rather than being adrenal in origin, was thought most likely to be due to increased neuronal release of noradrenaline from small arteries and arterioles as a result of sympathetic nerve activity and synaptic overflow. In conclusion, OSA is an important reversible cause of elevated urine noradrenaline and normetadrenaline levels in patients with resistant hypertension.

Adam P Morton

Stan B Sidhu In reply: We thank Morton for his letter which highlights another group of patients in whom raised urinary noradrenaline levels exist in the absence of a phaeochromocytoma. His experience and our group of patients1 should serve as a note of caution when making the diagnosis of phaeochromocytoma. A combination of positive results of biochemical tests, along with results of anatomical and functional imaging, should serve to minimise false positive diagnoses.

Stan B Sidhu

Raymond W Cook Retired anaesthetist, PO Box 6135, O’Connor, ACT 2602. dcookATactonline.com.au To the Editor: A great deal has been said and written in recent years about inadequate numbers in the medical workforce. As a result, many scientific and political articles about the need to increase the number of medical students and how to train them for the workforce have been written.1,2 Yet there has been little discussion of how those already trained and in the workforce should be retained, or of the rate of attrition of those in the workforce. After 30 years as an anaesthetist, I can recall only one positive change in my conditions of work — the introduction of exhaust gas scavenging. All other changes have been negative: longer hours, greater stress (from multiple factors, such as increased complexity, day surgery and admission on day of surgery) and higher public expectations. My motives in suggesting the need for such research are purely selfish — having recently retired, and enjoying the lack of stress, I wish to be sure there is an adequate workforce in my old age.

Raymond W Cook

Re: the letter in reply “Achieving equal standards in medical student education: is a national exit examination the answer?”, by Bogda Koczwara, on behalf of the Cancer Council of Australia Oncology Education Committee, in the 1 August issue of the Journal (Med J Aust 2005; 183: 168). Part of the reference list was omitted from the printed version due to a technical error. The complete list of references is:

Re: the letter “Reliability of parental reports of head lice in their children”, by Megan L Counahan, Ross M Andrews and Rick Speare, in the 7 February issue of the Journal (Med J Aust 2005; 182: 137-138). There was an error in Box 2, Sensitivity and specificity of parental report versus screening. The specificity given as 94.0% (969/1030) should have been 98.8% (1018/1030). The html and pdf versions of this article published online were corrected on 5 August 2005.

Megan L Counahan · Ross M Andrews · Rick Speare

Hypertension Michael Schachter, David Monkman. Edinburgh: Churchill Livingstone, 2004 (v + 134pp). ISBN 044 307470 4. Hypertension is a short book aimed at primary care physicians and junior doctors. It provides a comprehensive summary of the major issues in the diagnosis and treatment of hypertension. Each volume of Churchill’s In clinical practice series is written by a specialist working with a primary care physician, and both authors of Hypertension have appropriate qualifications. The book is very topical, given the publication of hypertension guidelines by a number of national and international organisations in the past year, and the subsequent controversy about some of their recommendations. Differences in the guidelines are discussed and some of the authors’ own interpretations are provided. Opinion is clearly differentiated from evidence in the book. Importantly, several major hypertension trials have been published since the book was written, and the ASCOT (Anglo-Scandinavian Cardiac Outcomes Trial) results are soon to be published. This means that parts of the book will be out of date in a relatively short time. However, whether the results of these recent trials lead to changes in the recommended management of hypertension remains to be seen. The presentation and writing style are very user-friendly and I found this an enjoyable book to read. Important points are listed in italics in the margins. The table of antihypertensive drugs provides an easily accessible summary of doses, indications and side effects. The cost of the book seems reasonable. There are few who manage hypertension who would not glean some useful and practical information from this book. I would particularly recommend it to specialist physician trainees as well as primary care trainees. Roger PeverillCardiologist Monash University, Melbourne

Roger Peverill

Medical ethics manual. John R Williams. Ferney-Voltaire, France: World Medical Association, 2005 (134 pp, no charge, free download available at www.wma.net). ISBN 92 990028 1 9. The World Medical Association (WMA) has been active in promoting ethical standards in medicine for over 50 years, with notable publications including the Declarations of Geneva and Helsinki. With the Medical ethics manual, the WMA turns its attention to the practical ethical issues facing medical students and physicians. Despite its brevity, the Manual presents a fair introduction to medical ethics together with an argument for its inclusion in medical education. Three core values of compassion, competence and autonomy are identified in the first chapter, reflecting a general shift away from the “four principles” approach in medical ethics. Interestingly, the value of “autonomy” described here refers to both physician and patient autonomy. The three central chapters describe physicians’ relationships with patients, society and colleagues, respectively. The chapter on patients contains standard medical ethics fare: confidentiality, informed consent, incompetent patients, and issues at the beginning and end of life. Euthanasia and assisted suicide are condemned as unethical, while abortion is left to “individual conviction and conscience”. The chapters on society and colleagues discuss a range of issues including resource allocation, public and global health and the evolving role of doctors in the health care team. The international orientation of the WMA is reflected in sections on human rights, professional duties (such as avoiding participation in torture), and the need for countries to educate their own doctors rather than securing them from less advantaged places. Research ethics are covered in a brief but comprehensive discussion. Each chapter begins with a set of objectives. These are overly ambitious at times (for example, “deal with the ethical issues involved in allocating scarce medical resources”), but will be helpful for teaching, as will the case studies. The appendices contain a somewhat idiosyncratic glossary as well as various resources. The listed Internet resources are disappointing and do not reflect the nature and scope of current web offerings. I enjoyed reading the Manual; this attractively presented, pocket-sized text is a useful introduction to ethics for students. The emphases upon relationships, public health and the global context are particularly welcome. Wendy A RogersAssociate Professor of Medical Ethics and Health Law Flinders University, Adelaide, SA

Wendy A Rogers

The doctor in literature: satisfaction or resentment? Solomon Posen. Oxford: Radcliffe Publishing, 2005 (ix + 298 pp). ISBN 1 85775 609 6. The Doctor in Literature is physician–author Solomon Posen’s take on how the doctor, as received by patient and society, is represented in Western literature. It is the first of four volumes in the same vein, the others examining the doctor’s personal life, medical career choices, and selected issues such as physician–nurse interactions, abortion, male and female doctors, and sexual fantasies and encounters. Described as a reference guide highlighting 1500 passages from over 600 texts (virtually all available in English), this volume is compiled from Posen’s lifetime of reading with an eye toward literary portraits of physicians. He has identified eleven facets of the physician–patient–society encounter and organised the book around these, with chapters addressing, for example, physician fees, the doctor’s time, bedside manner, emotional distance between doctor and patient, and litigation, as played out by medical characters in literature across the ages. This is not an anthology, for excerpts from literature frequently run but a sentence or two and serve Posen’s points rather than those of cited texts’ authors. Nor is it an annotated bibliography of literature depicting doctors, or even the index that the author suggests medical scholars need, for references are embedded in Posen’s assertions and one must go to endnotes for full information. While documenting “astonishing” constancy in physician–patient relations over two and a half millennia (eg, patients like doctors who are willing to help, society resents doctors’ fees), Posen’s conclusions may be over-engineered. Having excluded texts that employ allegory or symbolism or that portray doctors who traffic in metaphor (psychiatrists, he says) or dark arts or who misbehave as criminals or clowns, he chiefly cites works in which doctors exhibit what he terms “recognizable medical behavior.” His readings of fictional doctors who meet his criteria are straightforward but sometimes sufficiently colored by his own lenses as to miss authors’ satire or social criticism. As a result, Posen’s composite view of medical practice is inherently conservative, and his typical doctor — even more than society’s — is white, male, paternalistic and active rather than contemplative, irreligious, devoted more to profession than family, socially powerful, and resentful of political or institutional control. More historically and culturally nuanced aspects and ethical tensions of the doctor–patient–society triad tend to go unaddressed here, even though many of the cited literary works do take them on. Marcia D ChildressDirector, Program of Humanities in Medicine University of Virginia School of Medicine Charlottesville, VA, USA

Marcia D Childress

Echinacea: the cold facts Is echinacea effective against the common cold? Not likely, according to a US expert who laments that further trials of implausible remedies are continuing because of their public popularity rather than some reasonable chance of efficacy.1 Sampson was commenting on a placebo-controlled study sponsored by the US National Center for Complementary and Alternative Medicine (NCCAM) which found three extracts from Echinacea augustifolia roots ineffective in preventing and/or treating a cold in about 400 healthy, young adult volunteers inoculated with rhinovirus type 39.2 The NCCAM is reported to have three more clinical trials of echinacea currently under way. 1. N Engl J Med 2005; 353: 337-339 2. N Engl J Med 2005; 353: 341-348 Doubting dementia drugs Questions about the scientific basis for treating Alzheimer’s disease with cholinesterase inhibitors have been raised by German authors. They conducted a systematic review of 22 randomised controlled trials that had compared donepezil, rivastigmine or galantamine with placebo in patients with Alzheimer’s disease. Two main concerns arose on review: variously flawed methods; and small benefits — too small to be considered clinically significant. The reviewers suggested that if, as clinicians may argue, only a sub-group of patients respond to treatment with cholinesterase inhibitors we should focus on defining these responders. BMJ 2005; 331: 321-327 About refugees Refugees resettled in permanent, private accommodation have significantly better mental health than refuges resettled in institutional and temporary private settings, according to the authors of an extensive meta-analysis. The study, co-authored by Australian researcher Nick Haslam, extracted data from 56 reports published from 1959 to 2002 that examined the experiences and mental health outcomes of 22 221 refugees. Among the many results of the study, post-displacement experiences were reported to affect mental health outcomes with, for example, worse outcomes observed for refugees who lived in institutional accommodation and those who experienced restricted economic opportunity. Refugees who were older, more educated and female also had worse outcomes. JAMA 2005; 294: 602-612 Reflux: the fat factor Overweight and obesity are risk factors for acid-related oesophageal disease, suggest US researchers. In a systematic review and meta-analysis of data from nine studies, they found that obesity was linked to increased risk for gastro-oesophageal reflux symptoms, erosive oesophagitis and oesophageal adenocarcinoma. The risk seemed to increase with increasing weight. The researchers suggested that, while we sort out the mechanism(s) behind the link, doctors could advise overweight patients with gastro-oesophageal reflux-related diseases that weight loss may help improve their symptoms. Ann Intern Med 2005; 143: 199-211 Head lice? Try “Bug Busting” Head lice infestations have the dubious reputation of being notoriously difficult to control. Now, UK researchers say that “Bug Busting” — a method of treating head lice developed by a UK charity — may be more effective at dealing with those pesky little pests than over-the-counter pediculicides. The method involves combing wet and conditioned hair from root to tip across the whole scalp with a fine toothed comb, repeating in rinsed hair, with this whole process being repeated another three times at 3-day intervals. In a community-based trial in 133 children aged 2 to 15 years, the researchers found that Bug Busting was four times more effective in eliminating head lice than the recommended (single) dose of either aqueous malathion or aqueous permethrin — a 57% versus 13% “cure” rate, that is, no more live lice. Ovicidal acitivity was not evaluated. BMJ Online In support of a switch Postmenopausal women with hormone-sensitive early breast cancer who initially receive tamoxifen as adjuvant therapy should be switched to the aromatase inhibitor anastrozole after 2 years of treatment, European researchers advise. They combined data from over 3000 such women in two trials which compared ongoing oral tamoxifen (20 or 30 mg daily) with oral anastrozole (1 mg daily) after 2 initial years of adjuvant tamoxifen, finding that the anastrozole group were more likely to experience event-free survival with, in particular, less distant metastasis detected. However, the researchers were careful to point out that their findings should not be used to support a treatment strategy of starting with tamoxifen and switching to an aromatase inhibitor in newly diagnosed women. Lancet 2005; 366: 455-462

Ann Gregory