Volume 183 Issue 7

The NHMRC is at a fork in the road — which route will the government take? When the then Commonwealth Minister for Health, William (Billy) Hughes defined the role of the newly formed National Health and Medical Research Council (NHMRC) in 1936, he noted that:1 . . . the new Council will stimulate a national vision of the infinite possibilities in human health and happiness as the underlying factor in social welfare . . . [and] . . . the new Council must have regard to a balanced policy in which the application of existing knowledge will be steadily maintained, and at the same time all possible efforts towards the acquisition of new knowledge must be made. Research must be actively pursued and developed and as fast as new knowledge is acquired it must be applied. The new Council had 15 members and an initial research budget of £30 000.1 Like its immediate predecessor, the Federal Health Council,1 it was embedded within the structure of the Federal Department of Health. Today, almost 70 years later, an announcement on changes to the governance of the NHMRC is imminent. The pathway that the Australian Government chooses to take to modernise the NHMRC is as critical for the Australian community as the decision that marked its establishment. In 1992, empowered by an Act of parliament, the NHMRC became a statutory body. It has an annual research budget of close to $400 million, and is governed by a council of about 30 members who are elected every 3 years.2 However, its scope and function have remained unchanged, as witnessed by the Council’s current mission statement: “to ensure that excellence in research, research and health ethics, and health advice improves the health of all Australians.”2 Now, 5 years into the 21st century and at the end of another NHMRC triennium, questions are being raised about whether the NHMRC can meet the challenges of delivering its mission in the new century.3 There is a view that the time has come for the NHMRC to modernise and mirror itself on the National Institutes of Health in the United States, the Canadian Institute of Health Research, and other organisations such as the Wellcome Trust in the United Kingdom.3 The attributes these organisations share include a high public and political profile, dynamic leadership, effective and accountable governance, strategies to achieve clearly defined goals, and a cadre of health and research professionals who communicate consistently and widely with other research and health organisations, universities, and the private sector. In contrast, the mould and modus operandi of the NHMRC have remained largely unchanged over the past 30 years.3 The three areas of responsibility of the NHMRC are ethics of research, health more generally, and health and medical research. The ethics component of the NHMRC function is world class, but recently the other areas have drawn increasing, albeit muted, criticism. There are perceptions that the NHMRC is arthritically conservative and has difficulty in establishing a national and international profile; is tangled up in Canberra’s bureaucratic culture of self preservation and political manoeuvring; and is bereft of executive power because of a lack of clarity in the roles of the Chair of Council and the Chief Executive Officer, with the latter having conflicting reporting responsibilities (Box 1).4 There are also perceptions that the purpose and strategy of the NHMRC are driven by crowded committees that have an apparent consensus orientation and undercurrents of the tensions that exist between investigator-driven curiosity research and practice- and policy-driven priority research; and that it has difficulty recruiting and retaining suitable staff.4 Furthermore, there have been assertions that the NHMRC’s health advice is protracted and bogged down by red tape and statutory requirements; that its processes for policy development and priority determinations are slow and at times suboptimal — as instanced by the recent attempts to develop a policy on chronic disease5 and enact one of the Australian Government’s four National Research Priorities proclaimed in 2002: “Promoting and maintaining good health”;6 and, finally, that it has no overt accountability to society for its policy and research directions and its expenditure of what is essentially the public’s money. In some ways it casts an image of an elitist organisation, but overriding all is a sense that its governance and structure is outmoded.3,4 What can be done? A radical option I would suggest is for the NHMRC to shed all its functions except health and medical research and in so doing emulate the National Institutes of Health, the Canadian Institute of Health Research and the UK Medical Research Council. But the Australian research psyche shuns the revolutionary in favour of incremental change. In this context are the excellent governance recommendations advanced in the report Sustaining the virtuous cycle for a healthy, competitive Australia4 delivered to the government nearly a year ago, but which have elicited no response. The review recommended that the NHMRC should be an independent and stand-alone entity, directly responsible to the Federal Minister for Health. It also recommended that it should be governed by a small board of 10–12 members, who could be drawn from society as well as the public health, medical research, and private sectors. The board should be led by a dynamic Executive Chair who might also assume the responsibilities of the Chief Executive Officer (Box 1). Added to this framework, there should be a delineation of the organisation into separate but cohesive units, with overriding responsibilities for research ethics, national health, health research, and medical research. These separate units should be staffed by health and research professionals recruited and retained by challenging work, attractive career pathways, and remunerations not hobbled by public service guidelines. The NHMRC Board and its units should be supported and advised by appropriate committees, including an overarching health and research advisory council of 10–15 members, addressing strategies, policies and priorities for the nation’s health and for curiosity and priority-driven health research. The latter need to focus on the prevailing national health problems in Indigenous health, disease prevention, chronic disease and health care delivery. The NHMRC should also develop innovative approaches to forging research partnerships, such as those pioneered by the Canadian Health Services Research Foundation and the Health Research Council of New Zealand. The overriding aim should be that all policy and practice must be supported by evidence, and, in the absence of evidence, this should be acquired through research. The activation of ad-hoc working committees (Box 1) should be on a needs basis. Ideally, these would be task- and outcome-focused, time limited and made up of experts drawn from an approved “College of experts”. Out of necessity, this College would be continually rejuvenated by “young blood”. This modern NHMRC could also shed some of its current functions. Health advice, particularly regarding acute threats to the nations’ health, could be the business of an Acute Response Taskforce of experts, including representatives from federal, state and territory health departments. Australia’s response to the bovine spongiform encephalitis threat is an exemplar of this approach. The ad-hoc Taskforce would obtain its research capacity from the NHMRC. The NHMRC’s role in clinical guidelines development and dissemination could be devolved to the National Institute of Clinical Studies, as is the case in the UK, where elaboration of guidelines is a function of the National Institute of Clinical Excellence.7 Long overdue questions as to the purpose of guidelines, the processes for their development and dissemination, and the nature of the final product, need to be addressed. The Board could take a radical approach and assess the success of its sponsored research not only by the traditional methods of published articles and granted patents, but also by asking “what exactly is society getting for its money?”8 Three UK bodies — The Medical Research Council, The Academy of Medical Sciences (a non-grant-giving body that promotes medical science) and The Wellcome Trust — are addressing the question of the societal value of health and medical research, to justify escalating government expenditure on this research and convince the public that these vast amounts of money contribute to individual and national health.8 The Board could even be so bold as to invite the public and policy makers to determine research priorities.9 These suggestions for modernising NHMRC governance have one purpose: to ensure that the organisation is clearly accountable to the Minister and is dynamic, flexible, adaptive, effective, and in tune with the 21st century. The recent achievements of the National Institutes of Health10 and Canada’s Institute of Health Research11 indicate that, with the right individuals and culture, all this is achievable. Above all, these changes would fulfil the goal of Billy Hughes that: “Research must be actively pursued and developed and as fast as new knowledge is acquired it must be applied.”1 However, all this discourse on modernisation is academic in the absence of a commitment by the Australian Government to provide appropriate research funding for the NHMRC with built-in annual growth. After all, who would want to lead an enterprise that by world standards is static or falling behind? PostscriptThree days after this editorial was published online on 4 September 2005, the Federal Minister for Health and Ageing announced that from 1 July 2006, the NHMRC will become a fully independent statutory agency within the Health and Ageing portfolio, and that this change “will streamline the council’s governance arrangements and improve its ability to respond to emerging health and research priorities”.12 The newly announced governance structure (Box 2) — a hybrid of the recommendations made by the Grant Report4 and those of the 2004 report of the National Audit Office on NHMRC governance13 — is undoubtedly an improvement compared with the present governance arrangements. There is a clearer delineation of responsibility, and accountability in management, advice and strategic development. However, there are good reasons for the medical and research community to vigorously oppose the suggested governance structure. It will potentially place the NHMRC under the complete control of the Minister and, indirectly, his political or departmental advisors. Under these circumstances, only a very strong CEO, a person with considerable power and influence, would be able to take the NHMRC and its agenda forward, and people of this calibre are hard to find. To improve the proposed new NHMRC governance structure, there should be a Board, a small statutory body operating in classical corporate governance mode, with the CEO responsible to the Chair and the Board, and the CEO corporately responsible to the Minister. In the new governance structure as depicted in Box 2, the Management Advisory Committee would be omitted and the Board would be placed between the CEO and the Minister, with an advisory connection between the Council and the Board. A framework for the modernisation of the NHMRC has been put in place. But, with the potential for political control of the modernised NHMRC, will it become “dynamic, flexible, adaptive, effective, and in tune with the 21st century”? There are 9 months remaining before the new governance structure is activated. During this time, the government might reconsider the governance issue and put in place a structure that will ensure the NHMRC’s independence. For advice on this matter, there is a wealth of interest, expertise and experience available, and the time has surely come for the government to move beyond the GOBSAT (Good Old Boys Sat Around a Table) principle. By embracing a commitment to consultation, communication and change, modernisation of the NHMRC might ultimately be achieved. But it will require leadership and a clear vision, and a commitment to what is good for the community rather than for politicians. 1 Current and proposed National Health and Medical Research Council (NHMRC) structure 2 New governance structure of the NHMRC

Martin B Van Der Weyden MD FRACP FRCPA

The scientific benefit is clear, but translating this into practice requires advocacy Fourteen years ago, randomised controlled studies in the United Kingdom1 confirmed observational studies from Australia,2 the United States,3 and elsewhere, showing that an adequate intake of folic acid by women at around conception prevents most neural tube defects in their babies.4 These three countries now (i) have government-sponsored public health campaigns which encourage women of childbearing age to increase their daily intake of folic acid; (ii) have food standards permitting the food industry to voluntarily add folic acid to cereal and other foods; and (iii) have health benefit claims related to the prevention of birth defects. In 1996, the US (along with Canada) introduced mandatory fortification of virtually all wheat flour products. Despite recommendations by the National Health and Medical Research Council in Australia and other scientific bodies and scientists in the UK, mandatory fortification has yet to be introduced in these countries. Why should this be? After mandatory wheat flour fortification in the US, median serum folate levels in non-pregnant women of reproductive age more than doubled.3 Mandatory fortification has resulted in a 30% reduction of neural tube defects, or 1000 fewer cases every year.2 Each case of spina bifida prevented saves an estimated US$500 000 in lifetime costs.5 Even so, more could be achieved in the US compared with other countries where mandatory fortification requires higher amounts of folic acid to be added to flour than in the US.6 Examples include Canada7 (50% reduction in neural tube defects) and Chile8 (70% reduction). It is well past the time that the Australian and the UK governments should have drafted food standards with sufficient folic acid to provide 400 μg of synthetic folic acid a day to women of child-bearing age. In Australia, while the number of preventable cases (about 500 a year) has been reduced by voluntary fortification,2 this has not occurred across all of society, with resulting inequities.9,10 The reduction of cases of lifelong disability from neural tube defects has largely resulted from antenatal detection, with pregnancies being terminated (now the leading cause for late-stage termination of pregnancy in Australia and the UK). Preventing 500 neural tube defect cases each year in Australia would relieve the huge time commitment, financial cost and emotional burden from not only the affected individual, but his or her network of family, friends, work colleagues and other associates and caregivers. In the 10 years since we have known how to prevent neural tube defects, this would have meant 50 000 highly affected people in Australia alone. Folic acid fortification of flour is cheap — less than 0.1% the cost of flour (ie, less than 20 cents Australian per ton of flour). As thiamine is already a required additive, the costs of preparation and of administering quality control of the process, as well as of changing the labels on some foods, are small. Some millers and grocery companies in Australia do not favour mandatory flour fortification because they fear loss of market share for already fortified foods. However, a number of the largest milling companies, including Allied Mills and the Manildra Group, have publicly stated their support for mandatory flour fortification. The mandatory fortification of flour in the US not only prevents neural tube defects, but has also brought a wider benefit to the population, especially to older people beset with chronic and degenerative diseases. The exact degree of this benefit is still being defined, but current evidence indicates the increase in serum folate concentrations in the population is sufficient to prevent almost all folate deficiency anaemia.7 The association between lower risks for heart attack and stroke with lower homocysteine concentrations has been established.7 Since mandatory flour fortification with folic acid in the US, there have been about 17 000 fewer heart attacks and 31 000 fewer strokes.7 In addition, several recent scientific articles have credited folic acid supplementation with protection against loss of cognitive function in the elderly and Alzheimer’s disease,11 and against several cancers (including neuroblastomas). The benefits described above are clear and significant, but what are the perceived risks? One is the possibility of masking pernicious anaemia (the result of vitamin B12 deficiency) in the elderly and evolution of its neurological manifestations. Mild forms of dietary vitamin B12 deficiency in the elderly do occur, but there is no relationship between folate and vitamin B12 deficiencies. A second perceived risk is an increased risk of certain cancers, such as colon and breast cancer; however, there is mounting evidence that the overall risk of cancer is reduced, as the genome is less stable and at higher risk of mutagenesis when people are deficient in certain micronutrients, including folic acid.12 Since the US first demonstrated the benefits of flour fortification, more than 40 countries around the world have made it mandatory.13 Recently, leaders from over 50 key organisations formed The Flour Fortification Initiative, a United Nations-registered public, private, and civic alliance in support of the UN Millennium goals. With Australians in the forefront of this global movement, it is time that Australians at home also gain the benefit of this substantial public health measure. If there were a toxin (such as lead and mercury) or an infectious agent (such as the mad cow product) in the nation’s food supply, action would be swift and decisive. The ethical issue here is not what harm the mandatory fortification of flour with folic acid would do; rather, it is the harm inflicted each day that fortification is delayed by those who know how to prevent the damage from folic acid deficiency. In 2005, The National Institute of Clinical Studies Evidence-Practice Gaps Report14 identified mandatory folate fortification of flour as a key issue, and the Australian, New Zealand and UK governments will decide for or against this measure during the next 6 months. If the medical community will not rally and become advocates for this public health issue, who will? And at whose expense?

Glen F Maberly BSc(Med), MD, FRACP · Fiona J Stanley AC, FAFPHM, FRACP, FRANZCOG

Major advances continue apace in therapy and in understanding its molecular pathogenesis Myeloma is a malignancy of plasma cells in the bone marrow and presents with bone lesions, renal failure, anaemia and hypercalcaemia. Back pain, often associated with vertebral body collapse, is the most common presenting feature. In Australia, about 1200 new patients are diagnosed with multiple myeloma each year, with a median age at diagnosis in the early 60s. The aetiology of myeloma remains essentially unknown, although recent studies suggest links to agricultural exposures and lifestyle factors, such as low socioeconomic status and obesity.1 The major risk factor is the presence of a monoclonal immunoglobulin (paraprotein) in the blood. The incidence of paraproteins increases with age, and they are found in up to 3%–5% of people aged over 80 years. They are termed “benign paraproteins” or, more commonly, MGUS (monoclonal gammopathy of undetermined significance). By definition, this condition is not associated with other myeloma abnormalities. A patient with this type of gammopathy has an annual risk of about 1%–1.5% of developing active myeloma.2 A variant of myeloma — smouldering or indolent multiple myeloma — is associated with an infiltrate of over 10% monoclonal plasma cells in the bone marrow, but no organ dysfunction. Patients with this variant can be safely monitored for the onset of increasing paraprotein levels or organ dysfunction, suggesting transformation from smouldering myeloma to active disease. Melphalan chemotherapy was introduced in the 1960s, but there was little further change in our ability to affect the natural history of myeloma until the past decade, which has witnessed dramatic therapeutic advances. Currently, all patients aged under 65 years are offered autologous stem cell transplantation, using bone marrow stem cells harvested from the peripheral blood, unless precluded by other comorbidities. Stem cell transplantation is usually preceded by 3–6 months of induction therapy aimed at reducing tumour load and contamination of stem cell harvests by malignant cells.3 The role of a second stem cell transplant 3–6 months after the first is under investigation; it appears to benefit patients who do not have a full response to the initial transplant.4 The effect of a second transplant is also being compared with the new targeted drug therapies (see below). While allogeneic transplantation is usually precluded by age at presentation of myeloma, new techniques that require less intensive chemotherapy and gain their efficacy from the immunological effect of the stem cell graft on the malignant plasma cells (so-called “non-myeloablative” transplants) are now being used for patients who have a suitable matched sibling donor, are young, and have relapsed after autologous stem cell transplantation. The role of ongoing chemotherapy after transplant is unknown at present and the subject of a number of clinical trials. Lytic bone disease, bone pain and hypercalcaemia are major clinical manifestations of myeloma. In the past, no effective therapy was available for bone disease, but now all patients with myeloma receiving chemotherapy are also treated with a bisphosphonate. This reduces the number of skeletal events, such as vertebral collapse and pathological fracture of long bones, and reduces bone pain. Despite the increasing recognition of the uncommon side effect of osteonecrosis of the jaw, bisphosphonate therapy continues to be a standard intervention for all patients with myeloma who are receiving active chemotherapy.5,6 Of great interest are the new targeted therapies. Currently, three drugs — thalidomide, its analogue lenalidomide, and the proteasome-inhibitor bortezomib — are available for use in North America and are undergoing clinical trials in Australia. Extensive clinical experience with these drugs in refractory disease shows that they have a response rate of about 30%, which rises to 60%–70% when combined with dexamethasone.7 Major side effects include neuropathy (thalidomide and bortezomib) and myelotoxicity (lenalidomide). Current investigations are assessing the value of these drugs at initial diagnosis and as maintenance therapy after stem cell transplantation.7-9 Thalidomide and dexamethasone have been shown to be as effective for induction before stem cell transplantation as standard therapies. However, as they may be administered orally they are considered more convenient than therapies requiring venous access. Current studies involve the use of lenalidomide and bortezomib in induction therapy, while a recent French study has shown that thalidomide taken after stem cell transplantation both prolongs event-free survival and prevents relapse compared with no therapy.10 In April this year, the 10th International Myeloma Workshop in Sydney was attended by over 1000 experts in myeloma, indicating the current research interest in this condition. Abstracts and presentations of the meeting are available at the Haematologica website (www.haematologica-thj.org/supplements.html). The work presented at the meeting offered great hope for the future, both in our understanding of the molecular pathogenesis of multiple myeloma and, more importantly, in new therapies for our patients.

Douglas E Joshua DPhil(Oxon), FRACP, FRCPA

The challenge for health authorities is to implement effective preventive strategies and a zero-tolerance policy Although in Australia the risk of death or serious physical injury from a violent workplace incident is quite remote, each year about one Australian health worker is murdered at work1 and large numbers are either verbally abused, bullied or assaulted.2 Claire Mayhew and Duncan Chappell have been involved with research and public policy development related to workplace violence for over a decade. They both worked at the Australian Institute of Criminology (Canberra); they were involved in the NSW Health “Taskforce on prevention and management of violence in the health workforce”; they conducted the most extensive study on violence in the health industry in Australia to date and have collaborated in the development of publications for the International Labour Office in Geneva. Workplace violence has been defined in various ways, and behaviours ranging from verbal abuse and threats to sexual harassment, physical assaults and homicide may be included. The precise definition adopted will affect incidence and severity rates of workplace violence. An inclusive definition developed specifically for the health sector is: Incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.3 There are two core risk factors for violence in any workplace: face-to-face contact with clients or customers; and cash or high-value goods on site which may attract perpetrators of instrumental violence.4 Marked variations in risk exist between different occupational groups, reflecting the relative presence or absence of these two core risk factors.5 These patterns generally hold across different countries so that high-risk jobs in one country tend to also be high-risk jobs in others. For example, throughout the industrialised world there is a very high rate of homicide of taxi drivers, who also experience high levels of verbal abuse and assault. Conversely, white collar workers, with little face-to-face contact with members of the public, generally have very low incidence and severity rate. Fast-food outlet workers tend to experience high levels of verbal abuse but homicide is rare (apart from those located in suburbs with a high risk of hold-ups). Other occupational groups have diverse experiences essentially determined by levels of exposure to known risk factors. In health care settings, one of the two core risk factors — face-to-face contact with patients and visitors — is particularly common. The Box gives workplace verbal abuse, bullying and assault rates for various Australian industry sectors. These estimates were collated after separate face-to-face surveys conducted with representative samples of employees. In each case, interviewees were requested to state precisely what, if any, form of workplace violence they had experienced over the previous 12-month period. While space prohibits an exposé of these different studies here, it is clear that health care ranks fairly highly compared with many of the groups.6 Almost all the cited “bullying” events were from one staff member to another (Box). A similar pattern of variable risk across industry sectors and occupational groups is also evident in Britain.4 In 2001–02, representatives from the International Labour Office, International Council of Nurses, World Health Organization and Public Services International initiated an international collaborative program to develop policies and approaches to prevent and eliminate violence in the health sector. Outcomes included: a series of country-specific research studies (Brazil, Bulgaria, Lebanon, Portugal, South Africa, and Thailand and a linked Australian study; see <http://www.icn.ch/sewworkplace.htm>); a Synthesis report of the commissioned country reports;3 and finally the drafting of Framework guidelines for addressing workplace violence in the health sector.7 Across the various country-specific research studies, more than 50% of health workers reported experiencing one or other form of workplace violence in the previous 12 months; ambulance officers were at greatest risk, followed by nurses. The linked Australian health study involved face-to-face interviews with a representative sample of 400 public health employees, including medical officers, nurses, allied health, ancillary and ambulance workers.2,6 About two-thirds (67%) of all interviewees said they had been verbally abused in the previous 12-month period, 10.5% had been bullied, and 12% assaulted, rarely resulting in physical injury. As in other countries, incidence rates varied between and within health occupations, with ambulance officers most at risk, followed by nurses. Among medical officers interviewed, 62% had been verbally abused, 15% bullied and 17% assaulted over this period. The perpetrators of verbal abuse and assaults were predominantly clients and visitors, however, other staff members were responsible for almost all bullying events. Nevertheless, only a small proportion (between 8% and 10%) of these events had been formally reported — providing health authorities with limited evidence on which to base preventive planning. Similar incidence rates have been reported in general medical practice,8 including the study by Magin et al in this issue of the Journal (page 352).9 Comprehensive workplace violence prevention strategies have been developed and are available.4,10-12 However, in our experience, there is a tendency among health workers to favour preventive strategies that have only been trialled at other health sites. We would encourage health workers to consider the full range of prevention strategies, many of which have been well documented and evaluated in other industry sectors — including, in particular, those published in the scientific literature for criminology and occupational health and safety (OHS). All workplace violence prevention strategies — regardless of the setting, health care or otherwise — should be multifaceted and organisation-wide, and involve widespread consultation with all workers (including casuals and those off-site) in their development and implementation. In health care settings, this may involve nursing agencies, ambulance officers, and workers in the community and remote locations. In the OHS “hierarchy of control” approach to violence, designing out risk is the preferred action in all workplace environments, and should include health care settings such as hospitals, clinics, general practices, and ambulances and other vehicles. For example, to remove or minimise risk, careful attention can be paid to the design of buildings (eg, placement of windows) and their fittings (eg, counter height and width, and choosing chairs for waiting areas that cannot be easily lifted and thrown).2,10,13 The least preferred action is sole reliance on staff training, as the causes of workplace violence are multifactorial and hence simplistic solutions are unlikely to be effective in prevention. Chief executive officers (CEOs) should demonstrate commitment to zero tolerance of workplace violence. They should encourage cultural change and show enhanced concern for workers’ safety. Strong encouragement should be given to formal reporting of workplace violence, including the removal of covert penalties and the excessive filling in of forms. Regular violence vulnerability audits should be conducted by independent OHS professionals. The files of serial perpetrator patients should be “flagged” to forewarn other staff (the best predictor of violence is past aggression), and, ultimately, such patients should be sanctioned, which, although difficult, is an essential component of a comprehensive workplace violence prevention strategy.14 Particularly in the UK National Health Service, the sanctioning of perpetrators of violence has become increasingly common; however, the deterrent reach of penalties can be limited by the lack of capacity of certain patients to control their behaviour, including those suffering from mental illness and dementia. Under the OHS legislative framework in each Australian state and territory, primary responsibility rests with employers and CEOs to provide a safe place and a safe process of work for their employees, including those who work off-site. OHS obligations are not diminished by the rights of patients to confidentiality or to treatment. Employers (including public health departments) and CEOs may be prosecuted for a breach of this “duty of care” with respect to their employees, as well as being liable under common law.15 The core challenges for health authorities will be to: implement a zero-tolerance policy with effective prevention strategies encompassing all health occupational groups, and especially those working off-site and in general medical practice; adopt preventive strategies which have been successful in other industry sectors; and develop and implement a deterrent sanctioning policy for perpetrators. The group of articles in this issue of the Journal will further assist the health industry to recognise the potential benefits from involvement with the Australian Patient Safety Foundation (APSF) database (Benveniste et al, page 348);16 identify verbal cues of imminent overt aggression in mental health settings (Forster et al, page 357);17 understand possible causes of under-reporting of violence against emergency department staff (Kennedy, page 362),18 and to also recognise the particular vulnerabilities faced by those working in general medical practice.9 Workplace violence experiences of 1362 workers over a 12-month period (% of respondents) in Australia6 Workplace Verbal abuse Bullying Physical assault Juvenile justice 68% 12% 17% Tertiary education 50% 65% 1% Health care 67% 10.5% 12% Seafaring 19% — 1% Long-haul transport 33% — 1% Fast-food 48% — 1% Taxis 81% — 10%

Claire Mayhew BAdmin(Hons), PhD · Duncan Chappell LLB, PhD

Frustration and anger arising out of illness and pain, psychiatric disorders, alcohol and substance abuse, can affect behaviour and make people verbally or physically violent. The incidence of violence faced by workers in contact with people in distress is so common that it is often considered an inevitable part of the job. Health care workers are at the forefront of this situation.1 In 1996, the World Health Organization declared violence a leading worldwide public health problem.2 Its subsequent publication World report on violence and health confirmed that violence had become a global phenomenon of epidemic proportions in all societies.3 In the European Union, for example, an estimated three million workers, or 2% of the labour force, have been subjected to physical aggression and violence at work.3 We already know from a number of studies conducted among health professionals that Australian health care workers frequently experience violence (Box 1). However, collection and aggregation of incident data reported by health professionals from multiple hospitals can reveal information not available from single hospital or single study reports. The purpose of such a patient safety reporting system is “to ferret out and correct vulnerabilities, not to count them”.11 The Australian Patient Safety Foundation (APSF), a non-profit research organisation, has played an important role in developing systems to collect, aggregate, monitor and analyse incidents related to patient safety since its formation in 1988, when it received its first reports of anaesthetic-related events for the Australian Incident Monitoring Study in anaesthesia. In 1998, to re-analyse data from the Quality in Australian Health Care Study,12 the APSF created a taxonomy and software which became the Australian Incident Monitoring System (AIMS). This involved developing a classification of health care incidents — both adverse events and near misses — an incident being “any event or circumstance which could have led, or did lead, to damage, loss or harm”.13 Incident reporting to AIMS has always been voluntary. Reports have been made by all types of health care professionals from a varying number of participating hospitals and other health facilities within Australia and New Zealand. Data are de-identified before aggregation and analysis, and thus cannot be used to determine incidence rates. However, their value lies in understanding the contributing, minimising and preventive factors involved, which can then be used in devising corrective strategies and action plans for incidents affecting patient safety. Violence is one major category of incident classified within AIMS. Because of growing concern about violence in health care in Australia, we reviewed the relevant data collected using AIMS.14 Here, we present and discuss some of the summary data relating to reported incidents of violence. What has been reported? The complete AIMS collection of patient-safety-related incidents from January 1998 to June 2002 contains nearly 80 000 coded reports. The data include contributing factors, action taken and outcome, when available. Among 42 338 incidents reported from 1 July 2000 to 30 June 2002, 3621 (9% of all incidents) involved patients and physical violence (for example, assaults or throwing objects) or violent verbal exchange (abuse or threats) occurred.14 Staff injury was reported in 5% of cases. Box 2 summarises the key findings. Although 9% of reported incidents in all health units involved violence, the proportion was higher in emergency departments (16%) and higher still in mental health units (28%). Incidents in these two areas have their own characteristic patterns of contributing and precipitating factors. In reports from 12 emergency departments, 16% of all reported incidents (190 of 1214 incidents) involved violence. Mental health problems were patient-related contributing factors for over half of the violent incidents, with alcohol or drug intoxication contributing to more than 25%. The most common staff-related contributing factors were “communication problems” and “insufficient or inadequate [numbers of] staff”. Precipitating factors included dissatisfaction with staff decisions to admit or discharge a patient from hospital, lack of support on discharge, or non-prescription of a patient-requested medication. Weapons used in incidents included hospital equipment, razor blades, scissors and blood-filled syringes. In reports from 10 mental health services, 28% of all incidents reported (1467 of 5326 reports) involved violence. In violent incidents in which the patient’s status (voluntary or involuntary admission) was known, 79% involved patients who were legally detained. There was often a precipitating factor, such as refusal of privileges. What are the issues? Health services are provided in a changing environment where new policies and programs are often needed in response to changing patient demand — such as varying demographic characteristics of patients and the nature of their presenting symptoms — but these policy changes have to be balanced against the obligation to provide a safe environment for both health professionals and patients. Mental health services The violence seen in our health services reflects changes in our society, including changes in mental health service provision. Over the past decade, deinstitutionalisation of patients with mental illness has had an impact on public hospital emergency departments. Between 1998–99 and 2002–03, mental-health-related separations (that is, deaths and discharges) from public acute hospitals increased by 11%, whereas those from public psychiatric hospitals decreased by 24%.15 Secure rooms have been built in general hospitals to seclude violent patients presenting to public hospital emergency departments. However, psychiatric patients, including prisoners with mental illness, have been detained in public hospital wards that did not have appropriate resources to cope with them, posing a potential risk to other patients.16 In one incident, an entire ward of a NSW district hospital was closed when an elderly woman inpatient died after being attacked in her bed by a patient with mental illness.17 In South Australia, the potential risk to emergency staff may increase as the last public psychiatric hospital is scheduled for closure in 2007, and patients with acute psychiatric conditions are to be directed to general hospitals.18 Such health system changes have major implications for risk management and injury litigation in all acute health services. Staff protection Medical practitioners working in psychiatry, emergency medicine, general practice or rural and remote health need to develop protective behaviours, both for their own safety and that of their patients. Since 1992, in South Australia alone, there have been two workplace deaths of psychiatrists associated with patient violence.19,20 These and other incidents of violence indicate the importance of staff access to duress alarms, escape routes and back-up support, as illustrated in the incident described in Box 3. Preventive strategies AIMS analysis highlights the importance of understanding the contributing and precipitating factors in violent incidents to determine the vulnerability of a health facility. Our review supports a variety of initiatives that are being developed and adopted to reduce violent incidents. These include: de-escalation training for staff, and introduction of violence management plans;21 improved design of buildings to enhance safety of staff and patients;22 initiatives for emergency department fast-tracking of patients with mental health problems;23 and initiatives to improve waiting times in public hospital emergency services using a clinical initiatives nurse (whose priority will be emergency department patients waiting for care, and their families/carers).21 Some hospitals have developed comprehensive aggression management programs to integrate strategies involving environmental design, staff training and team response.24 An Aggression Risk Assessment tool has been developed by Consultation and Liaison Psychiatry at Austin Health in Victoria for use in initial assessment of patients in a variety of inpatient settings (see Forster et al, page 357).25 The National Health and Medical Research Council has developed a resource manual for rural and remote practitioners.26 Further, the Australian National Institute of Clinical Studies has a program to assist emergency department staff to improve care of patients with mental health conditions — the Mental Health Emergency Care Interface Project.27 Incident analysis: the way forward AIMS has continued to evolve since an early version was evaluated in November 2002.28 It is now capable of analysing incidents from all sources in health care including investigative analyses, coroners’ reports, and mortality and morbidity reviews as well as incident reports. Importantly, it now also allows for consumer complaints. AIMS is now used on a state-wide basis by the health departments of New South Wales, Western Australia, South Australia and the Australian Capital Territory, as well as by some health facilities in the Northern Territory, Victoria and Queensland. States collect and analyse their own data to aid state-based decision-making. Incident monitoring also has the potential to enable health services to collect local data on patient, staffing and system factors that contribute to incidents, and to develop and evaluate local management plans. However, there is currently no national system to aggregate incident monitoring data. We recommend that a national system be developed to share and compare incident monitoring data, to monitor trends, and to facilitate learning and thinking at all levels — ward, department, hospital, state and national. At all levels, intelligent interrogation of data and imaginative initiatives will be needed to improve care. 1 Experience of violence by Australian health professionals4-10 A survey conducted in 1999 of 266 emergency department nurses in metropolitan and regional hospitals in New South Wales revealed that all had experienced some form of violence at work at least weekly, but over 70% of incidents were not reported to authorities.4 In a 2002 survey of all Tasmanian nurses, 64% of over 2400 respondents had experienced violence in the past 4 weeks.5 In another survey conducted in 2001–2002 of 400 Australian health care workers interviewed to provide baseline data for the “Taskforce on the prevention and management of violence in the health workplace”, three-quarters of the 200 nurses involved had experienced some form of violence in the past 12 months; the highest rate of events per worker was among ambulance officers.6 Exposure to violence is particularly high for nurses in inpatient psychiatric facilities7 and remote area nursing.8 Situations of increased risk for medical practitioners include working in emergency departments, treating clients affected by drugs or alcohol, and dealing with high-stress situations in delivery suites, intensive care or coronary care units.6 Violence towards medical practitioners is not confined to hospital services; 73% of rural general practitioners in Western Australia, New South Wales and Victoria reported experiencing some form of aggressive behaviour from patients and 20% had been subjected to physical abuse during their careers as rural doctors.9 Urban GPs have reported that providing after-hours care now puts them at increased risk of assault, and some have restricted provision of after-hours care as a result.10 2 Key findings in 3621 incidents involving patients becoming violent in Australian hospitals and health services, 1 July 2000 – 30 June 2002 Any health care setting Number of incidents 3621 incidents, 9% of all health care incidents (n = 42 338) Most common contributing factors Patient-related — mental health conditions, 40% of incidents; dementia, 15%; pathophysiological factors, 13%; confusion, 9%; alcohol or drug intoxication, 6% Staff-related — “insufficient or inadequate [numbers of] staff”; “communication problems”; “inadequate knowledge or inexperience” System-related — “security problems” Most common outcomes Change of treatment, over 40%; informing a medical practitioner, 25%; patient transfer, 16%; restraint team called, 15%; police or security called, 15%; staff injury, 5% Accident and emergency services (reports from 12 services) Number of incidents 190 incidents, 16% of all incidents in this setting (n = 1214) Most common contributing factors Patient-related — mental health conditions, more than 50% of incidents; alcohol or drug intoxication, more than 25% of incidents Staff-related — “insufficient staffing”; “communication problems” Most common precipitating factor Dissatisfaction with staff decisions Mental health services (reports from 10 services) Number of incidents 1467 incidents, 28% of all incidents in this setting (n = 5326) Most common contributing factors Patient-related — mental health conditions; where admission status was specified, 79% were involuntary admissions Most common precipitating factor Refusal of privileges 3 Incident reported to the Australian Incident Monitoring System (AIMS) A doctor was interviewing a patient with a psychiatric condition in an interview room of an emergency department. The patient was in a psychotic state and became agitated and violent. The doctor tried unsuccessfully to press the duress alarm, but managed to escape from the room. The patient followed the doctor into the triage section, lunging and pinning the doctor against the wall and tearing clothing. The patient was eventually calmed by other staff and urgent restraint was requested. Security personnel arrived after the patient had been calmed by another doctor.

Klee A Benveniste PhD, MAPS · Peter D Hibbert BAppSc(Physio), GradDipComp, CertHlthProgEval · William B Runciman MB BCh, PhD, FJFICM

Objective: To establish the prevalence and characteristics of occupational violence in Australian urban general practice, and examine practitioner correlates of violence.Design, setting and participants: Cross-sectional questionnaire survey mailed to all members (n = 1085) of three urban divisions of general practice in New South Wales in August and September 2004. The three divisions were chosen to provide a range of socioeconomic status (SES) demographics.Main outcome measures: Occupational violence towards general practitioners during the previous 12 months.Results: 528 GPs returned questionnaires (49% response rate). Of these, 63.7% had experienced violence in the previous year. The most common forms of violence were “low level” violence — verbal abuse (42.1%), property damage/theft (28.6%) and threats (23.1%). A smaller proportion of GPs had experienced “high level” violence, such as sexual harassment (9.3%) and physical abuse (2.7%). On univariate analysis, violence was significantly more likely towards female GPs (P < 0.001), less experienced GPs (P = 0.003) and GPs working in a lower SES status area (P < 0.001), and among practice populations encompassing greater social disadvantage (P = 0.006), mental health problems (P < 0.001), and drug- and alcohol-related problems (P < 0.001). Experience of violence was greater for younger GPs (P = 0.005) and those providing after-hours care (P = 0.033 for after-hours home visits). On multivariate analysis, a significant association persisted between high level violence and lower SES area (odds ratio [OR], 2.86), being female (OR, 5.87), having practice populations with more drug-related problems (OR, 5.77), and providing home visits during business hours (OR, 4.76). More experienced GPs encountered less violence (OR, 0.77) for every additional 5 years of practice.Conclusion: Occupational violence is a considerable problem in Australian urban general practice. Formal education programs in preventing and managing violence would be appropriate for GPs and doctors-in-training.

Parker J Magin MB BS · Elyssa Joy BA · Malcolm C Ireland MB BS · Jon Adams PhD · David W Sibbritt PhD

Strategies to prevent and manage violence and aggression in the health care setting have become a primary health and safety issue. A series of vignettes are provided to highlight key elements in developing a program for preventing behavioural violence and aggression in a tertiary hospital. Key components of the program include staff education and training, risk assessment and management practices, the use of patient contracts and policy development. The program aims to integrate and balance occupational health and safety obligations to staff with the duty of care owed to patients.

John A Forster RN, RPN, GradDipPsychNurs · Mark T Petty RN, BAppSci(Nurs Admin), GradDipCompSci, MHA, FRCNA · Colin Schleiger GradDipOccupHazMan, DipPublHealth · Helen C Walters CPN, BPN, GradDipPsychNurs

Violence in emergency departments (EDs) has reached a level that requires concerted action and a shift in attitude — to eradicate a socially and professionally unacceptable peril. In some EDs, violence is a daily occurrence, with nursing staff reporting several episodes each week. Increased societal violence results in an increase in presentations for injury. Anger and pain and the influence of alcohol and drugs contribute to violence spilling over into the ED. The well known “system blockers” to reporting adverse events in hospitals result in under-reporting of violence episodes. Violence in EDs is different from other forms of violence — the aggressor has no overt dominance or power status and, in a setting of care, victims are likely to excuse the behaviour. Strategies to curb violence in EDs include modifying building design, providing security systems and personnel, and training staff in aggression management. The key to successful intervention is a strong preventive orientation that looks for high-risk indicators, and may extend to active physical and behavioural screening.

Marcus P Kennedy FACEM, FRACGP, DA(UK)

Objective: To evaluate the effect of appointment reminders sent as short message service (SMS) text messages to patients’ mobile telephones on attendance at outpatient clinics.Design: Cohort study with historical control.Setting: Royal Children’s Hospital, Melbourne, Victoria.Patients: Patients who gave a mobile telephone contact number and were scheduled to attend any of five outpatient clinics (dermatology, gastroenterology, general medicine, paediatric dentistry and plastic surgery) in September (trial group) or August (control group), 2004.Main outcome measures: Failure to attend (FTA) rate compared between the group sent a reminder and those who were not.Results: 2151 patients were scheduled to attend a clinic in September; 1382 of these (64.2%) gave a mobile telephone contact number and were sent an SMS reminder (trial group). Corresponding numbers in the control group were 2276 scheduled to attend and 1482 (65.1%) who gave a mobile telephone number. The FTA rate for individual clinics was 12%–16% for the trial group, and 19%–39% for the control group. Overall FTA rate was significantly lower in the trial group than in the control group (14.2% v 23.4%; P < 0.001).Conclusions: The observed reduction in failure to attend rate was in line with that found using traditional reminder methods. The ease with which large numbers of messages can be customised and sent by SMS text messaging, along with its availability and comparatively low cost, suggest it may be a suitable means of improving patient attendance.

Sean R Downer MBA · John G Meara FRACS · Annette C Da Costa BA, GradDip(Psych), GradCert(AppSc)

As the working hours of junior doctors decrease, adequate handover of patients becomes more important to maintain continuity of care and avoid errors caused by information gaps. A minimum dataset for surgical handover should include the patient’s name, location (ward and bed number), date of admission, diagnosis, procedure (with date), complications and progress, management plan, resuscitation plan, consultant availability (and instructions if not available), expected need for review, and name of doctor completing handover and date to confirm that information is current. An electronic handover system is a potential solution, but our survey shows that free-text entry into such systems may be inadequate; prompts or predefined fields for handover content are possible solutions.

Lean-Peng Cheah MB BS(Hons), MRCS · Debbie H Amott MB BS(Hons) · James Pollard MB BS · David A K Watters FRCS, FRACS

Strict control of blood glucose levels should be pursued before conception and maintained throughout the pregnancy (glycohaemoglobin [HbA1c] level as close as possible to the reference range). Before conception: high-dose (5 mg daily) folate supplementation should be commenced; oral hypoglycaemic agents should be ceased; and diabetes complications screening should take place. Management should be by a multidisciplinary team experienced in the management of diabetes in pregnancy. Blood glucose monitoring is mandatory during pregnancy, and targets are: fasting 4.0–5.5 mmol/L; postprandial < 8.0 mmol/L at 1 hour; < 7 mmol/L at 2 hours. A first trimester nuchal translucency (possibly with first trimester biochemical screening with pregnancy-associated plasma protein A and β-human chorionic gonadotropin) should be offered. Ultrasound should be performed for fetal morphology at 18–20 weeks, if required, for cardiac views at 24 weeks and for fetal growth at 28–30 and 34–36 weeks. Induction of labour or operative delivery should be based on obstetric and/or fetal indications. Level 3 neonatal nursing facilities may be required and should be anticipated when birth occurs before 36 weeks, or if there has been poor glycaemic control. Insulin requirements fall rapidly during labour and in the puerperium. At this time, close monitoring and adjustment of insulin therapy is necessary.

Aidan McElduff MB BS, PhD, FRACP · N Wah Cheung MB BS, FRACP, PhD · H David McIntyre MB BS, FRACP · Janet A Lagström BSc, RM, GradCertDiabetesEd · Barry N J Walters FRACP, FRANZCOG · Jeremy J N Oats MB BS, DM, FRANZCOG · Peter Wein MB BS, FRANZCOG · Glynis P Ross MB BS(Hons), FRACP · David Simmons MD, FRACP

Medical termination of pregnancy with mifepristone, a progesterone antagonist, is available to women in North America, the United Kingdom, much of Western Europe, Russia, China, Israel, New Zealand, Turkey and Tunisia, but not Australia. Experience of mifepristone use in around two million abortions has shown that it is safe, effective, cheap to produce, and highly acceptable to women. Mifepristone is usually used in combination with a prostaglandin analogue, such as misoprostol; these drugs have been added to the World Health Organization’s list of essential medicines for developing countries. Availability of this drug in Australia might largely overcome many of the inequities of access to abortion, and is critical for many women in rural areas and women in some ethnic groups whose access to surgical abortion is limited.

Caroline M De Costa FRANZCOG, FRCOG

Anthony Proust was born in Sydney on 23 February 1924 and graduated in medicine from the University of Sydney in 1948. After doing his residency at the Royal Prince Alfred Hospital, he studied and worked overseas from 1950 to 1953, first at Winnipeg General Hospital and the Manitoba Sanatorium in Canada, then at Johns Hopkins Hospital in Baltimore, and finally in Edinburgh and London. In 1953 he gained membership of both the London and Edinburgh colleges of physicians. As a well trained general physician with expertise in thoracic medicine and diabetes mellitus, Tony moved to Canberra in 1954. He first practised medicine in a partnership and later entered full-time consultant practice. Tony’s expertise in tuberculosis and lung disease led to an invitation to become foundation Director of Tuberculosis for the Australian Capital Territory and Director of the Canberra Chest Clinic, a position he held from 1967 until his retirement in 1985. He was elected Fellow of the Royal College of Physicians (Edinburgh) (1971), the Royal Australasian College of Physicians (1978) and the Royal College of Physicians (London) (1981). One of Tony’s major contributions to medical research was as coordinator of the Australian Rifampicin Trial (published in 1971 and 1972), a trial that led to the drug becoming the mainstay of antituberculosis treatment, which it remains to this day. In 1984, he founded a medical periodical, the Australian Tuberculosis Newsletter, a publication that remains alive and well. He was a longstanding member of both the Thoracic Society of Australia and New Zealand and the Australian Society of the History of Medicine. Tony’s reputation also extended outside Australia. In 1981, Sr Mary Aquinas invited him to work with her at the world famous Ruttonjee Hospital for tuberculosis in Hong Kong. In 1991, St John’s Medical College, Bangalore, appointed him Visiting Professor of Medicine. Tony’s interest in diabetes continued, and his passion for the history of medicine grew with age. His History of tuberculosis in Australia, New Zealand and Papua New Guinea was published in 1991, and his final book, A companion of the history of medicine in Australia 1788–1939, appeared in 2003. He was contemplating another work, on medical women in Australia, when his last illness, cryptogenic fibrosing alveolitis, overtook him on 16 May 2005. He is remembered by his wife Moya, their five children and eight grandchildren. -->

John Thompson FRACP, FRCPE, FCCP

The recent epidemic of sleep deprivation during the dramatic Ashes cricket series has once again highlighted the Australian passion for sport. A drive around city suburbs or country towns on a weekend may reassure one that thousands of Australians are still playing sport. However, such reassurance should be tempered by data which suggest that we are increasingly doing the driving rather than the playing.1-3 For example, the proportion of children and their parents who were physically active in Australia dropped between 5% and 11% from 1985 to the late 1990s.4 The importance of physical activity in the fight against obesity and its associated negative effects on health is becoming more evident. The role of exercise in preventing diseases such as coronary heart disease, diabetes, various forms of cancer, osteo-porosis and mental health problems is well documented, and rivals smoking cessation as a preventive measure.3 Although experts agree that many people should exercise more, injury and disability are consistent barriers to achieving this aim.5,6 The medical discipline of sports medicine has emerged over the past two decades and evolved from being a service to elite sportspeople into “the medicine of exercise”. While many of the advances in treating sporting injuries have come from the world of professional sport (where it is most costly to rest), these benefits, and the mentality of “keeping the player on the field”, are now available to the broader community. As a relatively young area of medicine, sports medicine lags somewhat behind some of the more traditional specialties in the amount of evidence-based medicine it can offer, but it is making rapid progress. In one article in this series, the overall evidence in favour of participation in sports and exercise is weighed up against the costs of long-term health problems that vigorous exercise can bring. Other articles look at some of the recent advances in sports medicine and practicalities such as the role of the “doctor on the sidelines”. In selecting the topics for this series, we have tried to balance the areas where sports medicine has made most progress in recent years (eg, use of therapeutic drugs in sport, and radiological imaging) with those where it must make most progress in the next few (eg, sports medicine in special groups such as older athletes and children). The increasing demand from the community for sports medicine expertise has led to the development of medical specialisation in this area. The Australasian (formerly, Australian) College of Sports Physicians (ACSP) was formed in 1985 with the aim of developing the specialty in this country. Over the past 20 years, this has been achieved with the development of a curriculum, entrance and exit examinations, and the creation in 1992 of a 4-year full-time training program in sports medicine, which is regarded as a world leader in the field.7,8 There are now about 110 Fellows of the College practising in Australasia and overseas. Fellows may be in private practice (either solo or in a multidisciplinary environment), may service professional and national sporting teams or may work for Institutes of Sport, the Australian Defence Force or for private bodies such as workers compensation insurers. It must be said that other professional bodies such as medical schools, the Royal Australian College of General Practitioners, the Australian Medical Council and the Health Insurance Commission have been slow to acknowledge the existence of the specialty and its accompanying high-quality training program.7,8 The resultant “out of pocket” expenses for consulting sports physicians (resulting from lower-tier Medicare recognition) mean that the benefits of this specialty have not been realistically available to those in the community who rely on the public system. If the specialty of sports medicine in Australia is finally recognised by the appropriate authorities, the next major challenge in Australia is the establishment of a national sports injury surveillance system.9 Managing sports injuries as they occur is important, but preventing them (which starts with surveillance10) is perhaps more important, and other countries like New Zealand and Norway are much further advanced in this regard.9,11 We trust that readers will read and enjoy these summaries of recent research in sports medicine, a new and exciting field of medicine which is attracting graduates with an interest not only in sport, but in the benefits of exercise to the community.

John W Orchard MB BS, BA, FACSP · Peter D Brukner MB BS, DRCOG, LACSP

Soft-tissue injuries are injuries to skin, fascia, ligament, muscle, and tendon. Currently, many therapeutic medications are commonly used in the management of soft-tissue injuries, including: analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, prolotherapy sclerosant agents, aprotinin, glyceryl trinitrate, botulinum toxin, and glucosamine. Despite their regular use for soft-tissue injury, few medications have strong evidence of a consistent therapeutic effect. In this article, we review the proposed mechanisms of action, side effects, and the evidence base (based on National Health and Medical Research Council levels of evidence1) for common soft-tissue injury treatments. We also suggest appropriate circumstances for using therapeutic medications, with emphasis on the Hippocratic principle of primum non nocere (first do no harm). Non-steroidal anti-inflammatory drugs for ligament and muscle injuryNSAIDs are among the most widely used medications for common soft-tissue injuries such as muscle contusions, muscle tears, and ligament tears. The mechanism of action of NSAIDs is through non-specific cyclo-oxygenase inhibition, thereby blocking the production of prostaglandins from arachidonic acid. Prostaglandin inhibition by NSAIDs decreases the inflammatory response, which can have both positive and negative effects. For example, the arachidonic acid “overflow” pathway may lead to increased leukotriene production and potential tissue damage. Other known negative NSAID class side effects include hypertension, altered renal function, gastrointestinal disturbance (including peptic ulceration), and the recently discovered increased rates of myocardial infarction with non-selective NSAIDs, such as diclofenac and ibuprofen (evidence level III-2 [E32]).2 Potentially desirable class effects of NSAIDs include reduced risk of bowel cancer and increased blood clotting times. Side effects, whether positive or negative, are generally far more relevant for long-term use (such as in patients with rheumatoid arthritis) than with short-term use for sports injury. Many NSAIDs are available as topical preparations. Although the results of tissue penetration studies are variable, for injured body structures which are close to the surface (eg, limbs), topical NSAIDs may offer the advantages of higher local tissue concentrations with reduced risk of systemic side effects. The balance of evidence suggests that NSAID use is associated with a short-term mild to moderate decrease in pain in “minor sports injury” (E2),3 ankle sprains and knee pain (E2),4 and shoulder pain (E1).5 The number needed to treat (NNT) for a positive effect greater than placebo for most conditions is 3–4 patients. There is no evidence that NSAIDs improve muscle function after injury. NSAIDs (and corticosteroids) are catabolic in nature, particularly having their effect on tissues such as the soft-tissue structures of muscles, ligaments, tendon, and fascia, with very little effect on neural tissue. Therefore, in conditions where the pathological disorder is entrapment or impingement of nerves because of soft-tissue proliferation, such as carpal tunnel syndrome, Morton’s neuroma, thoracic outlet syndrome, and intervertebral disc prolapse, there is a strong theoretical basis to support the use of anti-inflammatory medications like NSAIDs (and corticosteroids). There is level II evidence of efficacy of NSAIDs on the inflammatory components of disorders such as bursitis in rotator cuff disease or iliotibial band friction syndrome,6 and synovitis in Morton’s neuroma7 or carpal tunnel syndrome.8 Case study — a torn tendon and bursitis in the shoulder A 46-year-old left-handed woman with a 6-month history of left shoulder pain initially injured the shoulder while playing tennis. She felt a dull ache in the lateral arm immediately after the game, and now has night pain, and pain with activities of daily living. Examination showed restricted range of shoulder motion, muscle weakness, and positive impingement signs. Her x-rays were unremarkable. Ultrasound showed a supraspinatus tendon tear with bursal thickening, and supraspinatus tendon tear with supraspinatus bursitis was diagnosed. Therapy is dictated by the patient’s activity level. If she requires strong overhead function then the goal of treatment should be healing of the tendon tear. However, if she generally only requires use of the arm for activities below shoulder height, then relief of impingement is the primary goal of treatment. Anti-inflammatory treatment for 6 weeks and/or subacromial corticosteroid and local anaesthetic injections (Figure A) are among the best therapeutic options for giving pain relief. These will generally provide analgesia, but may have potentially deleterious effects on tendon healing. Regular use of ice and paracetamol may be used for analgesia as alternatives if healing is considered important. Topical glyceryl trinitrate patches (1.25 mg/24 h) are an appropriate option to help relieve symptoms and increase function with chronic injury (Figure B). Exercise rehabilitation is the cornerstone of managing tendinopathies to regain function — in this situation, concentrating on scapula stabilisation and rotator cuff strengthening. This may be managed by the general practitioner confident in exercise prescription for this shoulder injury, or with the assistance of a sports physician or physiotherapist with experience in rehabilitating such injuries. Surgery may have a role if other treatments are not successful. If the patient requires high levels of shoulder function, direct repair of a tendon tear has a good rate of success, but requires prolonged rehabilitation. Arthroscopic acromioplasty is a procedure with quicker recovery which, like anti-inflammatory agents, is directed at providing pain relief rather than maximising shoulder function. A: Corticosteroid injections for tendon injuries, such as this subacromial injection, provide a short term reduction in pain of 6–8 weeks duration in most soft-tissue conditions. B: Quartered 5 mg/24 h glyceryl trinitrate patch, used for treatment of shoulder tendinopathy. Thus, current evidence does not support NSAID use as solo therapy or long-term therapy for soft-tissue injury, except when the primary disorder is soft-tissue impingement, or predominantly inflammatory (such as bursitis or synovitis). NSAIDs should not be used routinely in soft-tissue injury, as they are, at best, an adjunct to treatment through symptom relief, most notably analgesia (see Case study), and these benefits must be weighed against the risks of gastrointestinal side effects, especially with prolonged use. Non-steroidal anti-inflammatory drugs for tendinopathyThe abnormality in chronic tendinopathy in most cases is degeneration, with no evidence of inflammation (Box 1). Despite this, there is level II evidence that NSAIDs provide short-term mild to moderate decreases in pain in lateral epicondylosis,9 increased abduction in rotator cuff disease,10 but have no efficacy in treating Achilles tendinopathy.11 The mechanism of action of NSAIDs in tendinopathy is unclear. NSAID use decreases fibroblast proliferation and increases “overflow” leukotriene production in tendon both at rest and during exercise, which is additive to the normal effect of increased leukotriene production with cyclic tendon loading. So, there is potential for NSAIDs to cause tendon damage through increased leukotriene formation. Further, as tendinopathies have a tendency to chronicity, the side effects of NSAIDs with prolonged use are an even greater limitation than with other soft-tissue injuries. Thus, the evidence does not support the use of NSAIDs in pure tendinopathy, given their small effect on relieving symptoms and potential adverse effects. Short-term use of ice and paracetamol should provide an equivalent analgesic effect without serious side effects. Non-steroidal anti-inflammatory drugs compared with paracetamol for soft-tissue injuryParacetamol is an analgesic with a centrally mediated mechanism of action. With comparable efficacy to NSAIDs for pain in soft-tissue injury (E2),12 and being both opioid-sparing and NSAID-sparing, it can be used in combination analgesia. It also has a low cost, low side-effect profile, and no risk of local soft-tissue injury. It is often the analgesic of choice for soft-tissue injury. Cyclo-oxygenase-2 (COX-2) inhibitors for soft-tissue injuryCOX-2 inhibitors were developed to selectively block the COX-2 enzyme and the inflammatory process without inhibiting the effects of prostaglandins on gastroprotection or the effects of thromboxane on bleeding time and platelet aggregation. The use of these agents is currently under review because of increased rates of myocardial infarction, with rofecoxib withdrawn from the market and celecoxib only recommended for use in rheumatoid arthritis and osteoarthritis at low dosages. Given the lack of evidence of efficacy for these agents in soft-tissue injury, and significant cardiovascular safety concerns that are yet to be adequately researched, COX-2 inhibitors should generally not be used for treating soft-tissue injuries. They would only be recommended for patients in whom nerve or mechanical impingement is predominant, and non-specific NSAIDs are contraindicated because of a coexisting gastric disorder. They should not be used in patients at high risk of cardiovascular disease. Corticosteroid injections for tendinopathyCorticosteroids are injectable anti-inflammatory medications that inhibit the accumulation of neutrophils and the synthesis of inflammatory mediators, and prevent phagocytosis and lysosomal enzyme release. They have short-term efficacy in symptom relief for degenerative tendinopathies, bringing decreased pain in lateral epicondylosis (E1),13 decreased pain and increased abduction in rotator cuff tendinopathy (E1),14 and decreased pain and increased function in trigger finger (E2).15 However, there does not appear to be a positive effect of peritendinous injections in Achilles tendinopathy (E2).16 Positive results noted in studies occur in, at most, 80% of patients, and are generally limited to 6–8 weeks after injection (Box 1). Longer-term studies (12 months’ follow-up) of the effects of corticosteroid injections in lateral epicondylitis show inferior results to physiotherapy (E2).17 Studies have not shown clinically significant improvements in function with corticosteroid injections (E1) or greater efficacy than NSAIDs for shoulder pain. The demonstrated effect of corticosteroids in decreasing pain of tendinopathies may be the result of improvements in the inflammatory components of tendon injuries such as bursitis in shoulder tendinopathy, and tenosynovitis in trigger finger. The mechanism of any effect of corticosteroid injections in reducing symptoms in purely degenerative tendinopathies is unknown. There is Level IV evidence of tendon rupture with both local corticosteroid injection and oral corticosteroid treatment. This risk may be overstated in view of the frequent use of corticosteroid injections, a lack of evidence of increased rates of tendon rupture with corticosteroid use, and the endstage tendon degeneration noted in tendon ruptures.18 Animal studies indicate that cortico-steroids weaken tendon whether injected into or proximal to the tendon, and it is possible that corticosteroid injections do lead to partial rupture of tendon substance. In non-weight-bearing tendons or patients who place little demand on the affected tendon through heavy loading at work or playing sport, this may lead to symptom abatement through a “medical tenotomy”, with surprisingly little functional loss. Partial tendon rupture in weight-bearing tendons or patients who place higher demand on the tendon is much more significant, and frequently necessitates surgery. Thus, the evidence suggests that a single corticosteroid injection for symptomatic tendon injuries may achieve a mild, short-term reduction in pain for up to 6 weeks, particularly for “non-critical” tendons where rupture may not be a deleterious outcome. This injection should be coupled with a tendon-specific rehabilitation program. Where actual tendon healing is critical to a good outcome, such as overuse injuries to major weight-bearing tendons like the Achilles, corticosteroid injections are probably contraindicated. Prolotherapy and aprotinin injectionsProlotherapy generally refers to the injection of a sclerosant such as phenol, or hypertonic glucose. Theoretically, sclerosants may be useful for soft-tissue conditions, such as ligament injuries, in which joint laxity is an issue. There are no controlled studies examining prolotherapy as a treatment for soft-tissue injury, although there is some low-level evidence supporting prolotherapy for back pack pain and osteoarthritis.19 Given the lack of evidence of efficacy, prolotherapy cannot yet be recommended for treating soft-tissue injury. Its major advantage is that side effects of treatment are likely to be minimal. Aprotinin is a broad-spectrum metalloprotease (MMP) inhibitor used to treat many conditions, but particularly in preventing blood loss during cardiac surgery. Its use in chronic tendinopathy is attractive, as aprotinin may act as a collagenase inhibitor. Certain MMPs have been shown to be present in excessive proportions in patellar tendinopathy and rotator cuff tendinopathy, and aprotinin could potentially normalise the concentration of MMPs in chronic tendinopathy, which may help healing. In treatment for tendino-pathy as a series of two to four injections into the peritendinous space, aprotinin provides superior analgesia when compared with corticosteroid injections and placebo in patella tendinopathy (E2),20 and in Achilles tendinopathy (E3).21 Potential side effects include allergy and anaphylaxis, although death has only been reported when used intravenously for cardiac surgery; the “test dose” of 3–5 mL for major procedures is similar to the therapeutic dose for tendinopathy.22 The use of aprotinin injections for tendon injuries is currently an “off-label” indication. Botulinum toxin for tendinopathyBotulinum toxin type A is a neurotoxin which inhibits the release of the neurotransmitter acetylcholine at the neuromuscular junction, and inhibits skeletal muscle contraction. It results in reduced muscular spasticity, reduces pain and increased function in “whiplash-associated disorder” (E2).23 The use of multiple botulinum injections around the musculotendinous junction as a “last option” in the treatment of lateral epicondylosis has comparable results to extensor release surgery (E2);24 however, placebo injections demonstrate equal efficacy.25 These treatments may all induce local tissue healing responses. Side effects of botulinum injections include allergic reactions, and permanent muscle and tendon injury. Current evidence does not support the use of botulinum toxin injections for tendon injuries. An exception may be in chronic recalcitrant cases of lateral epicondylosis where surgery is considered. Glyceryl trinitrate treatment for tendinopathyGlyceryl trinitrate is a donor of nitric oxide (the endothelium-derived relaxing factor), but the mechanism of action of topical glyceryl trinitrate therapy on tendon is unknown. Nitric oxide inhibition decreases collagen content and collagen synthesis by fibroblasts,26 and nitric oxide donation may stimulate collagen synthesis by fibroblasts. In acute shoulder pain, there is evidence of an analgesic effect of 3 days duration (E2),27 which is of lesser efficacy than corticosteroid injections (E2).28 In chronic tendinopathies, topical glyceryl trinitrate therapy with 1.25 mg per 24 hours has level II clinical evidence of decreased pain, increased tendon force, improved functional measures, and improved symptom resolution in Achilles tendinopathy,29 lateral epicondylosis,30 and supraspinatus tendinopathy.31 Glyceryl trinitrate has a long history of therapeutic use in humans, and the common side effects of rash and headache are rapidly reversible on discontinuation of topical treatment. It should not be used concomitantly in patients taking phosphodiesterase inhibitors such as sildenafil (Viagra; Pfizer), as the additive effect may cause life-threatening hypotension. The use of topical glyceryl trinitrate for tendon injuries is currently an “off-label” indication, although medical practitioners may legally exercise discretion in prescribing this treatment for tendon conditions, provided likely effects, and side effects, such as rash and headache, are explained to the patient. Topical glyceryl trinitrate therapy has robust evidence of efficacy in treating common chronic tendinopathies, the side-effect profile is known and reversible, and this therapy should be used as an adjunct to tendon rehabilitation in chronic tendinopathies (Box 1). Glucosamine and soft-tissue injuriesGlucosamine has a significant analgesic effect in treating osteoarthritis, and it has been suggested that it may aid wound healing through enhanced fibroblastic production of hyaluronate (E5).32 There are no studies on glucosamine in treating soft-tissue injury. ConclusionBox 2 provides a flowchart summarising the evidence-based options for medical treatment of soft-tissue injuries. The widespread use of NSAIDs and corticosteroid injections in the treatment of most soft-tissue injuries requires reassessment based on current evidence, while new drugs such as aprotinin and glyceryl trinitrate hold promise as effective adjunctive treatment for chronic tendinopathies. Evidence-based guidelines on newer therapies There is evidence for the efficacy of topical glyceryl trinitrate therapy in treating common chronic tendinopathies (Achilles tendinopathy, lateral epicondylosis, and supraspinatus tendinopathy) (E2),27-29 and it can be used as an adjunct to tendon rehabilitation. Aprotinin provides superior analgesia compared with corticosteroid injections and placebo in patella tendinopathy (E2).18 This therapy may be particularly useful for chronic tendinopathy of the major weightbearing tendons, where the use of cortisone is contraindicated. Given the lack of controlled efficacy studies, prolotherapy cannot yet be recommended for treating soft-tissue injuries. Current evidence does not support the use of botulinum toxin injections for tendon injuries.23 There are no studies on the use of glucosamine in treating soft-tissue injuries. 1 Tendinopathies Tendon injuries, such as in lateral epicondylosis (tennis elbow, top) and tibialis posterior tenosynovitis (bottom), can be recalcitrant to treatment; conventional treatments such as non-steroidal anti-inflammatory drugs and corticosteroid injections may have a short term analgesic effect, while there is some evidence of efficacy with newer treatments such as topical glyceryl trinitrate therapy. 2 Evidence-based medical management of soft–tissue injuries NSAIDs = non-steroidal anti-inflammatory drugs.

Justin A Paoloni PhD, MSpMed, FACSP · John W Orchard MB BS, PhD, FACSP

Peter M Herriot OACIS Clinical Sponsor, Noarlunga Health Services, Alexander Kelly Drive, Noarlunga Centre, SA 5168. herriot.peterATsaugov.sa.gov.au To the Editor: Readers may be interested to learn of an SMS notification system introduced in South Australia to facilitate the retrieval of cornea donations. The South Australian Department of Health has recently completed the 5-year implementation of its “careconnect.sa” clinical information system (formerly known as the OACIS program), a system which supports clinical activities across the eight major Adelaide metropolitan public hospitals.1 A relatively simple and inexpensive enhancement to the system has been the use of short message service (SMS) text messaging to notify the Eye Bank of South Australia of a potential corneal donor. Following the recording of an inpatient death in the hospital patient administration system, an SMS death notification comprising the relevant medical record number, hospital location and time of death is automatically generated by the OACIS gateway and sent to selected recipients, including the Eye Bank of South Australia. Staff can then check the potential donor’s clinical details online via OACIS to obtain accurate information on the person’s suitability as a donor and also to cross check the National Organ Donor Registry to determine whether the person is registered as a donor. Before SMS notification, Eye Bank staff made many calls daily to the major public hospitals to obtain information on recent deaths. Medical or nursing staff would then sift through the medical record to determine whether the patient might be a potential donor and to obtain next-of-kin details. SMS notification has resulted in less disruption to hospital staff, as well as considerable time savings. The whole process of retrieval is now easier and timelier. The actual number of corneal retrievals has increased since the introduction of the new SMS notification system. There has also been a substantial reduction in the number of corneal transplants postponed because no cornea was available. Donations are now retrieved earlier and more efficiently. The development of the system also corresponds with a shift to South Australia becoming a net exporter of corneal tissue. The SMS notification system demonstrates how relatively simple information and communications technology can be applied to make a substantial impact on clinical practice and outcomes.

Peter M Herriot

Peter C Arnold Former General Practitioner, PO Box 280, Edgecliff NSW 2027. peterATarnold.name To the Editor: Schofield and Beard,1 discussing demographic shifts among doctors, raise the spectre of “workforce shortages within the next 5 years”. For decades, Australian health authorities have used various proxy indicators, ranging from Medicare utilisation to World Health Organization and other comparative data, to deny the existence of shortages of doctors. Based on those faulty premises, government policies have aggravated these shortages. The Oxford English Dictionary defines a “shortage” as “a deficiency”. For many years, there have been deficiencies in services provided by Australia’s doctors, including, among others: General practitioners available for house calls and visits to nursing homes; working past 6:00 pm on weeknights or on Saturday mornings; available at nights and on weekends; offering prompt appointments; and being available in locum tenens. Specialist initial consultations within a week or two, especially dermatologists, oncologists, neurologists, and, more recently, neurosurgeons and obstetricians. And all this in our cities and large towns. The sho rtages of all medical personnel in rural and remote areas has long been obvious. Our current reliance on overseas-trained doctors is undeniable proof of the existence of those shortages. For more than three decades, the general practice “positions available” advertisements in the medical newspapers have far outnumbered advertisements from doctors seeking GP positions.2 None of the proxy indicators of workforce adequacy, so beloved of politicians and bureaucrats, can rival the plain truth that the supply of doctors, probably in every field of medicine and in every region of Australia, is plainly insufficient to meet reasonable demand, and has been so for at least 30 years.

Peter C Arnold

Graham D Hocking Child Psychiatrist, 25 High St South, Kew, VIC 3101. ghockinATiprimus.com.au To the Editor: Catto-Smith gives a very good account of the medical management of constipation and soiling in children,1 but fails to mention psychological, interpersonal and social factors in the main part of his article. He does mention “behavioural abnormalities” towards the end, in the section “When to refer”. I think it is generally accepted among paediatricians and child psychiatrists that the problem of constipation and soiling, or encopresis, often has multiple determinants and varied psychological effects on the child and the family. Certainly, the older the child is, the more likely these effects will be present.2 If this condition is to be managed in general practice over a period of “6–12 months”, general practitioners need to be aware of these factors so they can be addressed. Twelve months is a long time in the life of a 5 year old, and in that time pathological patterns can become well established and hard to shift. Most children over 5 years with soiling have developed secondary psychological problems as a result of the soiling.3 At this stage, assessment by a child psychiatrist will often reveal that the child has developed a pathological fantasy world around what they believe is happening inside them. The physical management of constipation and soiling is an essential part of the management no matter what the aetiology, but addressing the psychological interpersonal and social factors is equally important. If these factors are obvious to the GP and are not responding to intervention, the family should be referred to a child psychiatrist. With children over 5 years, the secondary effects have almost always become significant, and I believe that all these families should be referred for assessment. Catto-Smith quotes a 30%–50% relapse rate,1 and “there is evidence that they do not improve on reaching puberty”. This is not my experience with families that have the benefit of a multidisciplinary approach to the disorder.

Graham D Hocking

Anthony G Catto-Smith Director, Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Flemington Road, Parkville, VIC 3052. tony.cattosmithATrch.org.au In reply: Hocking emphasises secondary behavioural and emotional effects that occur in some children with longstanding faecal soiling. Fortunately, there is good evidence that these tend to resolve with effective multimodal treatment of the constipation.1 The relatively high long-term relapse rate of soiling among children who have been treated in tertiary centres has only recently been recognised,2 but the psychological features of this relapsing group are not well defined. My review was directed toward general practitioners and was as much as possible evidence-based. I am unaware of any good quality evidence to support Hocking’s assertion of the benefits of automatic referral to a child psychiatrist of all children over the age of 5 years with ongoing faecal soiling. Given the beliefs of both myself and Hocking, that constipation and soiling are likely to have multiple determinants and varying psychological effects, it would seem to be appropriate to triage “problem” patients through a general paediatrician, with referral for psychological assistance if deemed appropriate. This is best summed up in my article in the section that Hocking mentions, “When to refer”.3

Anthony G Catto-Smith

Essential psychopharmacology. The prescriber’s guide. Stephen M Stahl. Cambridge: Cambridge University Press, 2005 (xv + 571 pp). ISBN 0 521 01169 8. Psychotropic drugs are heavily marketed and widely prescribed in general practice and Stephen Stahl, an internationally recognised clinician and teacher in psychopharmacology, is tapping into the need for a practical prescriber’s guide to psychotropic drug use. He has skilfully condensed essential information on individual psychotropic drugs and presented it in an attractive, user-friendly format. Information on each drug is broken down into five colour-coded sections: therapeutics; side effects; dosage and use; special populations; and the art of psychopharmacology, including how to get the best use out of a drug. The author also uses a list of icons to alert the reader to the class of drug, mechanism of action and concerns with drug interactions or major side effects. The drugs are listed in alphabetical order by their generic name and are supplemented by an index with generic and trade names allowing quick and easy reference for the busy clinician. For the Australian reader, approved indications for each of the drugs may differ from those in the United States so you may need to access “the yellow book” (Schedule of Pharmaceutical Benefits) to obtain information on PBS listings. Also, some medications are available in the US but are not approved for marketing in Australia. For example, since the book was published, regulatory decisions have led to the withdrawal of nefazodone from the market due to safety issues. There is considerable duplication of information for drugs of a similar class, such as the selective serotonin reuptake inhibitors (SSRIs). However, the advantage is that the prescriber can readily obtain all the information required on a particular drug without needing to access other chapters of the book. While the author clearly states in his introduction that certain drugs and combinations of drugs may be for the expert only, this is not always highlighted in the text, such as combination antidepressants with mirtazapine, venlafaxine or SSRIs, colloquially known as “Californian rocket fuel”. There is much in this book to recommend it to general practitioners, medical students and experts, but it is a glossy production and at $120 for the paperback, the cost is on the high side. Gordon F S JohnsonProfessor of Psychological Medicine University of Sydney, NSW

Gordon F S Johnson

CorrectionRe: “The Messiha and Schiavo cases: third-party ethical interventions in futile care disputes”, by Thomas A Faunce and Cameron Stewart, in the 5 September issue of the Journal (MJA 2005; 183: 261-263). Two words were omitted from the title. The title should read “The Messiha and Schiavo cases: third-party ethical and legal interventions in futile care disputes”. The html and pdf versions of the article were corrected on 8 September 2005.

Thomas A Faunce · Cameron Stewart

Is it a melanoma? Most new or changed naevi are unlikely to be melanomas, according to Australian researchers. However, a new or changed naevus in an older patient is much more likely to be a melanoma than one in a younger patient. Jeremy Banky and colleagues followed 309 patients (age range, 16-74 years) at high risk for melanoma for an average of nearly 3 years, using baseline photography and dermatoscopy. Overall, 262 new pigmented lesions, 311 changed naevi, 86 completely regressed naevi and 18 melanomas were detected. Patients younger than 50 years of age did have a higher rate of new pigmented lesions and of changed and regressed naevi compared with patients older than 50 years; however, they also had a lower incidence of melanomas. In patients younger than 50 years of age, less than 1% of all new lesions and 3% of changed lesions were melanomas, whereas in patients older than 50 years, 30% of all new lesions and 22% of changed lesions were melanomas. Arch Dermatol 2005; 141: 998-1006 Harry Potter helps out A familiarity with JK Rowling’s Harry Potter books could help younger children grasp some basic concepts of heredity and genetics, say Australian authors. Jeffrey Craig and colleagues say that the wizarding ability of various characters appears to have been inherited in a Mendelian fashion, with the wizard allele (W) being recessive to the muggle (non-wizarding) allele (M). Accordingly, all the wizards and witches in the book would have two copies of the wizard allele (WW). Harry’s best mate Ron Weasley is a “pure-blood” (WW with WW ancestors for generations back), whereas his other close friend Hermione Granger is a powerful muggle-born witch (WW with WM parents). Other characters can help to explain further concepts such as incomplete penetrance and possible mutations. Nature 2005; 436: 776 Birth: trial v mother’s choice A survey of UK obstetricians and midwives suggests that any proposed randomised controlled trial comparing planned caesarean section (without clinical indication) with planned vaginal birth would itself have a difficult birth. Although most of the survey respondents wished they had the evidence-based results of such a trial available to them, only a minority thought such a trial would be feasible, ethical or desirable, and would recruit to such a trial. Almost half of the obstetricians and a quarter of the midwives believed that a woman should choose her method of delivery. BMJ 2005; 331: 490-491 When HIV met an anticonvulsant A new approach to treating HIV, which involves an anticonsulvant drug, may help us to cure this disease in the future, suggest US researchers. They conducted a pilot study in four patients with HIV who, despite treatment with highly active antiretroviral therapies (HIV), had reservoirs of latent infection in resting CD4+ T cells. The patients received oral valproic acid, 500-750 mg twice daily for 3 months, together with intensified HAART. In three of the four patients, the frequency of resting cell infection declined. Lancet 2005; 366: 549-555 Kids on CAM Doctors should ask about child use of complementary and alternative medicine (CAM) as a part of routine history taking, say Australian researchers. Alissa Lim and colleagues conducted 503 face-to-face interviews with the parents of children and with adolescents attending the Royal Children’s Hospital in Melbourne, asking about the youngsters’ use of CAM. About half the children were reported to have used CAM in the preceding year; this proportion fell to a quarter when those using only vitamins or mineral supplements were excluded. Although most interviewees said they believed it was important for doctors to know about CAM use, in general, this use had not been disclosed to treating doctors. J Paediatr Child Health 2005; 41: 424-427 Lung cancer: to op, or not? A novel, minimally invasive procedure could improve the pre-operative staging of non-small cell lung cancer (NSCLC) and reduce unnecessary thoracotomies, say Dutch researchers. They compared the ability of trans-oesophageal ultrasound-guided fine-needle aspiration (EUS-FNA) to identify metastatic or invasive disease with that of mediastinoscopy in a series of about 100 patients with NSCLC. All patients had undergone thoracotomy with tumour resection after negative pre-operative mediastinoscopy. Pre-operative EUS-FNA had also been conducted in all patients for research purposes only. Combining the results of both techniques preoperatively would have identified more patients with lymph node metastases or tumour invasion than using either technique alone. The techniques have a complementary reach in assessing regional lymph node stations. One in six thoracotomies could have been avoided in this series if the EUS-FNA results had been taken into account in the clinical decision-making. On the downside, some false-positive EUS-FNA results were reported. JAMA 2005; 294: 931-936

Ann Gregory