Volume 183 Issue 9

We urgently need to expand clinical teaching into the private sector In clinical school common rooms around the country, a common refrain of frustrated medical students is “ There aren’t any patients in the wards we can see!” In this issue of the Journal, Olson and colleagues (page 461) report an investigation of hospital inpatients’ accessibility to medical students that strongly suggests that our students’ complaints are real.1 . . . there are not enough suitable public hospital inpatients for the clinical teaching programs of the new medical schools The study simulated the experience of students attempting to see patients without the assistance of junior or senior medical staff. Four University of Newcastle medical students audited the wards of four public hospitals on three separate days, each 2 months apart. Inpatients were classified as present, present but not accessible, unfit to be seen on clinical grounds, or absent. Those who were present and accessible were asked if they would agree to a student taking a history and performing a physical examination. Of 1960 patients, 959 (49%) were present and accessible and, of these, 673 (70%) said they would allow a student to take a history and 645 (67%) would allow a student to perform a physical examination. Half of all patients not available to be seen were classified as unsuitable on clinical grounds, either by nursing staff or by the students. In some wards the students were told by nursing staff that all patients were unsuitable. In short, just over a third of the inpatients in these four hospitals were accessible to medical students.1 Those responsible for clinical teaching programs in public hospitals are only too aware of this problem, which is caused by several factors. Reduced length of stay and “hospital in the home” programs designed to avoid or shorten admissions mean that inpatients are sicker and less inclined to see students. Moreover, as the average age of inpatients rises, an increasing proportion of inpatients are unable to give a history because of confusion or cognitive impairment. Another factor is that most elective surgical patients are now admitted on the day of their operation, leaving little time for students to make contact, and many are discharged the same day. In addition, some routine elective surgical procedures that students need to learn about are now very rarely performed in public hospitals. Finally, privatisation of hospital outpatient clinics has significantly reduced students’ exposure to ambulatory care. Thus, there is increasing competition for scarce “clinical material”. Medical students must also compete with early postgraduate and vocational trainees, especially before postgraduate exams, and with overseas-trained doctors preparing for the Australian Medical Council exam. The recent expansion of medical school places provides a major challenge for clinical educators.2 Australia urgently needs more medical graduates to deal with patently obvious workforce shortages, but there are not enough suitable public hospital inpatients for the clinical teaching programs of the new medical schools, or for their graduates to complete postgraduate training programs. The apparent lack of planning in decisions about the new medical schools will almost certainly exacerbate the problem identified by Olson and colleagues.1 It is difficult to see how the clinical resources in New South Wales will be adequate for the projected increase in student numbers; yet, in Victoria, there has been virtually no increase despite a need for more graduates and capacity to train them. This might have been avoided if the recent spate of medical school expansion had been based on consultation with educators rather than driven by political considerations. Are there any solutions? Olson and colleagues recommend better integration of students into clinical teams. This is sensible, but the magnitude of the problem demands more fundamental changes. The most obvious is to provide exposure to patients in other settings: general practice, specialists’ private rooms, privatised clinics and private hospitals. Many of the patients who used to be available for teaching in ambulatory settings in public hospitals have been diverted to these sites by state government cost-shifting. The Practice Incentives Program (PIP) has been an effective incentive for general practitioners to take on an enhanced role in clinical teaching, but very few students have access to patients seen in specialists’ rooms or privatised outpatient clinics, where there are significant financial disincentives to teaching.3 We urgently need to explore ways of delivering and funding clinical teaching in these locations. Pilot programs that address the financial disincentives would be an excellent place to start, but would require a level of collaboration between federal and state governments, hospitals and universities that has been conspicuously absent in the decisions on new medical school places. Private hospitals are major beneficiaries of the Australian medical education system yet most contribute little to the training of their medical staff. A few have made arrangements to accept students, but there is clearly capacity to provide clinical teaching for many more.4 Australian taxpayers provide large sums of money to support the private health system. We should insist that some of this money is allocated to training its future workforce. Another potential solution is to expand the use of simulation-based clinical teaching.5 Simulation-based teaching is no substitute for direct contact with patients, but it is an effective way to impart some clinical skills and may have some advantages; it can be delivered at the appropriate stage of the curriculum, students have more opportunity to practise in a non-threatening environment, and it is safer, particularly for procedural skills. Australian medical schools make extensive use of clinical skills laboratories in the early years of training, but our hospitals have been slow to acquire these facilities and have often developed them for nursing staff or postgraduate medical trainees rather than for the resource-deprived medical students. The high fidelity simulation centres, which have been developed in capital cities, are not accessible or affordable for day-to-day medical student teaching. Hospital-based clinical skills laboratories are expensive to build and equip and require substantial funding for recurrent costs: teaching staff, surrogate patients, equipment and disposables. International experience suggests that they can help to compensate for declining numbers of accessible inpatients, but this won’t occur without adequate funding or systematic planning by hospitals, universities and both levels of government.5 Australia has begun a long overdue, but poorly planned, expansion of medical schools. Olson and colleagues’ report suggests that we are already struggling to provide clinical teaching for our current students in public hospitals.1 If tomorrow’s doctors are to graduate with adequate clinical skills, we urgently need to expand clinical teaching into other sites — specialists’ private rooms, privatised clinics and private hospitals — and to develop multidisciplinary clinical skills laboratories in all training hospitals.

Brendan J Crotty MB BS, FRACP, MD

A recent report outlines the good and the bad news about asthma Asthma is a common chronic condition among Australians, particularly children. In recent years, federal and state governments have responded to community and health professionals’ concerns by investing in strategies to improve asthma management.1 Coinciding with this, new pharmaceutical formulations have become available for managing asthma. The latest publication from the Australian Centre for Asthma Monitoring and the Australian Institute of Health and Welfare, Asthma in Australia 2005,2 provides a timely review of the good and the bad news about asthma over the past few years (Box). The prevalence of asthma is high in Australia compared with other countries,3 affecting 14%–16% of children and 10%–12% of adults. However, Asthma in Australia 2005 shows that, after a substantial rise in the number of children with asthma during the 1980s and early 1990s, this trend has reached a plateau. Although this pattern is consistent with observations in other countries, including Hong Kong, Switzerland and the United Kingdom,4 the reasons for this rise and subsequent plateau remain unknown. Nevertheless, the observation highlights the value of ongoing surveillance for asthma. Over the past 5–10 years, rates of general practitioner visits and hospitalisations for asthma have declined substantially. Furthermore, deaths due to asthma have fallen by more than 50% since the early 1990s. Despite these overall gains, there are important inequalities in the outcomes of asthma among Australians. Aboriginal and Torres Strait Islander people, particularly adults, have more asthma and higher rates of hospitalisation for asthma than other Australians. Adults living in rural or remote areas and people living in the most socioeconomically disadvantaged localities also have higher rates of hospitalisation for asthma. The reasons for these inequalities need exploring. The burden of GP consultations, emergency department visits and hospitalisations for asthma is highest among children and probably reflects their higher rate of disease exacerbations. At the beginning of school terms, particularly in February, rates of emergency department attendance for asthma are higher than usual and the episodes are more severe than usual among pre- and primary-school-age children. A similar return-to-school increase has been observed in other countries, and has been attributed to increased transmission of respiratory infections.5 This observation highlights the need to develop and test interventions to prevent exacerbations. Regular use of inhaled corticosteroids can reduce asthma symptoms and prevent severe episodes of worsening asthma.6,7 However, Asthma in Australia 2005 highlights evidence that inhaled corticosteroid therapy, the cornerstone of drug therapy for asthma, is not well targeted. Many people who would benefit from using them regularly are not doing so. Furthermore, most formulations are prescribed at the highest doses, in spite of evidence that many people with asthma can be well controlled, with fewer side effects, at lower doses of inhaled corticosteroids.8 This discrepancy with current evidence is further highlighted by the rapid market penetration of inhaled formulations that combine long-acting β-agonists with corticosteroids, a combination which achieves effective asthma control in most people with moderate to severe asthma with lower doses of inhaled corticosteroids.9 These combined formulations accounted for 64% of inhaled corticosteroids distributed in Australia in 2004. Hence, more work is needed to improve appropriate prescribing of inhaled corticosteroid therapy for people with asthma. The Asthma 3+ Visit Plan is an Australian Government initiative introduced to improve the quality of care for people with moderate to severe asthma by promoting structured care of asthma in general practice. However, it is estimated that only 14.1% of eligible people have used this program since its introduction in 2002. Respondents to a survey of GPs in Sydney indicated that the administrative complexity of the program acted as barrier to its uptake.10 Another cause for concern is the limited use of written asthma action plans. Despite evidence that these improve the outcomes of asthma,11 their use has decreased in recent years.12 Asthma in Australia 2005 shows that the outcomes of asthma in Australia are improving, but there is still a long way to go to ensure access to the best quality care for all Australians. We need to understand more about the barriers to effective care and the basis for inequalities in health outcomes for people with asthma.10,13 To investigate these issues, we need more detailed asthma-specific data at a population level, qualitative research in specific populations of health care users and providers, and randomised controlled trials of interventions designed to improve care and outcomes, particularly in disadvantaged groups. Major findings of the Asthma in Australia 2005 report Gains The rising trend in the prevalence of asthma among children during the 1980s and early 1990s has reached a plateau. Currently, 14%–16% of children and 10%–12% of adults have asthma. In 1990, there were 822 deaths attributed to asthma in Australia (5.6 per 100 000), whereas in 2003 there were 314 deaths (1.5 per 100 000). Hospitalisation rates for asthma have declined from 920 patient-days per 100 000 in 1993–94 to 419 patient-days per 100 000 in 2003–04. No gains Hospitalisation rates for asthma in 2002–03 were higher among: Aboriginal and Torres Strait Islander people compared with others in Australia (1003 v 418 patient-days per 100 000); Adults in rural and remote areas compared with adults in major cities and regional areas (728 v 331 patient-days per 100 000); and People with greater levels of socioeconomic disadvantage (528 patient-days per 100 000 in the most disadvantaged quintile v 309 patient-days per 100 000 in the most advantaged quintile). Only 34% of people with asthma aged 15 years and over are using inhaled corticosteroids, but 71% of inhaled corticosteroids are supplied in the highest dose formulations. In South Australia, the proportion of people with asthma who stated that they owned a written asthma action plan declined from 42% in 1995 to 22% in 2001.

Guy B Marks MB BS, PhD, FRACP · Patricia K Correll MPH · Margaret Williamson MPH

There is clear evidence of long-term benefits The Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) 2000 overview of adjuvant systemic treatment trials for early breast cancer has demonstrated clear evidence of substantial and significant reductions in both recurrence and mortality, with follow-up now to 15 years.1 This is the fourth EBCTCG overview of adjuvant systemic therapies, conducted at 5-year intervals since 1985.2-6 The EBCTCG 2000 analysis, based on individual patient data from 145 000 women diagnosed with early breast cancer, involved 194 trials started by 1995 in which chemotherapy and hormonal therapy were evaluated alone and in combination for their effects on recurrence, breast cancer mortality and total mortality. This overview, with data from more trials than the earlier overviews, more patients and more years of follow-up, provided new and long-term information on adjuvant chemotherapy in women aged 50–69 years, tamoxifen duration, combined modality therapy, and cause-specific mortality (Box). What were the benefits?Chemotherapy regimens included single agents or polychemotherapy, either cyclophosphamide, methotrexate and fluorouracil (CMF), or anthracycline-containing regimens, mostly fluorouracil, adriamycin, and cyclophosphamide or substituting epirubicin for adriamycin. Anthracycline-containing regimens of about 6 months’ duration reduced the annual breast cancer death rate by 38% in women younger than 50 years, and by 20% in women aged 50–69 years. Similar reductions in annual recurrence rates were seen. The benefits were largely independent of the use of tamoxifen, oestrogen receptor status, or nodal status. Anthracycline-containing regimens were significantly better than CMF regimens for recurrence (2P = 0.0001 [2P is a two-sided P value]) and mortality (2P = 0.00001). There were insufficient trials involving women older than 69 years (< 5% of women) to reliably determine treatment effects. Hormonal therapies studied were tamoxifen (in most trials), ovarian ablation or ovarian suppression. The 15-year follow-up provided an opportunity to evaluate both early and late effects on recurrence and breast cancer mortality for each modality, given alone or in combination with chemotherapy. With respect to mortality, in women with oestrogen-receptor-positive tumours, 5 years of tamoxifen use reduced the annual breast cancer death rate by 31% and the annual recurrence rate by 40%, independent of patient age, the use of chemotherapy, progesterone receptor status or tumour characteristics. However, there was no advantage for a higher dose of tamoxifen than 20 mg per day. Tamoxifen given for 5 years was significantly superior to 1–2 years of therapy, but the evidence for any effect of continuing tamoxifen for more than 5 years remained inconclusive. With respect to recurrence, a significant trend was seen with increasing reduction of annual recurrence rates with increasing age (40–49 years, 29%; ≥ 70 years, 51%; age trend 2P = 0.05). The overview did not include any trials in which tamoxifen and chemotherapy given concurrently were compared with one modality followed by the other. However, as the benefits of tamoxifen and of chemotherapy were largely independent of whether treatment included the other modality, a mortality reduction of 57% for women younger than 50 years and 45% for women aged 50–69 years could be expected by using both modalities together. Do benefits occur early or late?Most of the benefit of polychemotherapy on recurrence was seen in the first 5 years (absolute reductions of recurrence of 12.5%, 12.4% and 12.4% at 5, 10 and 15 years follow-up, respectively, for women younger than 50 years), whereas the benefit for mortality continued to increase for 15 years (absolute reductions in breast cancer mortality of 4.7%, 7.9% and 10.0% at 5, 10 and 15 years, respectively). The early effect of chemotherapy on recurrence had been well established in the previous overview,6 but the continuing late mortality benefit has only now been established by the longer follow-up. The late mortality benefit was less apparent for chemotherapy in women aged 50–69 years. The pattern of benefit from 5 years of tamoxifen was similar to that seen with chemotherapy for women aged less than 50 years, but was apparent in all age groups. Again, most of the effect on recurrence occurred in the first 5 years (absolute reductions for recurrence: 10.4%, 13.6% and 11.8% at 5, 10 and 15 years), whereas much of the benefit on breast cancer mortality occurred after the first 5 years (absolute reductions of 3.6%, 7.9% and 9.2% at 5, 10 and 15 years). This extended mortality benefit, seen with both chemotherapy and tamoxifen, is striking and suggests that an important number of patients with residual disease after primary therapy are cured of their original tumour by adjuvant tamoxifen or chemotherapy, although they remain at continuing risk of new contralateral breast cancer in the long term. Given the similar pattern for clinical benefits observed for the two treatment modalities, the biological outcomes of their effects at the cellular level may have more in common than has previously been recognised. Ovarian ablation or suppression also had a significant, beneficial effect on recurrence (2P < 0.00001) and mortality (2P < 0.004). The pattern of benefit — an early effect on recurrence and a later effect on mortality — was similar to tamoxifen. However, in contrast to tamoxifen, the effect of suppression or ablation was less in trials where all women also received chemotherapy, perhaps because the chemotherapy also suppressed ovarian function. This question is being addressed in current trials. What were the harms?There were minimal long-term effects of all of these agents on non-breast cancer mortality. Chemotherapy was associated with a small, non-significant increase in mortality from heart disease, leukaemia and lymphoma (0.2%); tamoxifen was associated with a small excess mortality from uterine cancer and pulmonary embolus (0.2%). However, the small increase in non-cancer deaths (a few per 10 000 patients per year) was very much less than the reduction in breast cancer deaths seen for each treatment modality. What are the implications?The data from the earlier EBCTCG overviews have already contributed to widespread changes in practice and a recent fall in breast cancer mortality of around 20% in several developed countries. The findings of the 2000 overview will encourage an even wider use of systemic therapies and should contribute to further reductions in mortality.7 Overall, the most important finding from the 2000 overview is that important practical and biological information is gained from long periods of follow-up. Not only has this overview produced definitive results relevant to breast cancer management but, importantly, it has clearly demonstrated two important biological principles. First, that an early reduction in recurrence rates is invariably followed by a reduction in mortality. Hence, recurrence rate reduction may be an acceptable basis on which to recommend changes in practice before survival data is obtain-able. Second, despite the substantial benefits of 5 years of tamoxifen, 2% of patients continue to have a breast cancer recurrence each year from years 5 to 15 after diagnosis. This is a several-fold greater risk of new breast cancer events than was required for the “high risk” women to be eligible for the tamoxifen prevention trials.8 New strategies for ongoing management of these women should be considered. Further, other questions will need to be addressed by the overview process, including the value of tamoxifen or other endocrine therapies beyond 5 years and addition of a taxane to chemotherapy regimens.9 What are the limitations?The current overview only encompassed therapies used up to 1995, which — although clearly effective — are not optimal for all patients in 2005. The 2000 overview did not involve taxanes (there are now more than 10 000 patients in several trials) or aromatase inhibitors (about 30 000 patients in seven trials).10,11 Nor did it include trials with trastuzumab (Herceptin) for women with tumours expressing HER2.12 However, answers to other specific questions such as the value of long-term aromatase inhibitors and of targeted therapies will likely be based on a smaller number of larger trials rather than an overview of many smaller trials. Many such trials, including the important “SOFT”, “TEXT”, and “PERCHE” trials of different combinations of chemotherapy, aromatase inhibitor and tamoxifen for younger women, as well as trials for older women, and trials of taxanes and of trastuzumab, are being conducted in Australia by the Australian New Zealand Breast Cancer Trials Group through international collaboration. These trials should be the subject of separate meta-analyses, conducted in a timely manner to facilitate rapid dissemination of the results. However, long-term follow-up is a particularly valuable feature of the EBCTCG overviews, and the EBCTCG investigators are pursuing strategies to ensure that data from the 2005 overview will be made available sooner and more widely. Key findings of the Early Breast Cancer Trialists’ Collaborative Group 2000 overview Overview of 194 randomised trials of systemic therapies for early breast cancer started by 1995, including data at 10 and 15 years follow-up. Anthracycline-containing regimens are superior to cyclophosphamide, methotrexate and fluorouracil (CMF). Anthracycline-based polychemotherapy reduced annual death rates by 38% (standard error [SE], 5) for women younger than 50 years, and by 20% (SE, 4) for women aged 50–69 years. Tamoxifen reduced annual mortality rates for oestrogen-receptor-positive tumours in all age groups (31%; SE, 3). Combination therapy with tamoxifen and chemotherapy may produce a larger mortality reduction (45%–57%). Effects on recurrence occur early; effects on mortality occur later. Long-term benefits maintained to 15 years. Long-term non-breast cancer deaths from treatment are a few per 10 000 per year, and are greatly outweighed by the reduction in breast cancer deaths. More rapid data dissemination from overviews is required.

John F Forbes FRACS, FRCS, MS · Jack Cuzick PhD

Objective: To estimate the incremental effects on cost and quality of life of cardiac rehabilitation after an acute coronary syndrome.Design: Open randomised controlled trial with 1 year’s follow-up. Analysis was on an intention-to-treat basis.Setting: Two tertiary hospitals in Sydney.Intervention: 18 sessions of comprehensive exercise-based outpatient cardiac rehabilitation or conventional care as provided by the treating doctor.Participants: 113 patients aged 41–75 years who were self-caring and literate in English. Patients with uncompensated heart failure, uncontrolled arrhythmias, severe and symptomatic aortic stenosis or physical impairment were excluded.Main outcome measures: Costs (hospitalisations, medication use, outpatient visits, investigations, and personal expenses); and measures of quality of life. Incremental cost per quality-adjusted life year (QALY) saved at 1 year (this estimate combines within-study utility effects with reported 1-year risk of survival and treatment effects of rehabilitation on mortality). Sensitivity analyses around a base case estimate included alternative assumptions of no treatment effect on survival, 3 years of treatment effect on survival and variations in utility.Results: The estimated incremental cost per QALY saved for rehabilitation relative to standard care was $42 535 when modelling included the reported treatment effect on survival. This increased to $70 580 per QALY saved if treatment effect on survival was not included. The results were sensitive to variations in utility and ranged from $19 685 per QALY saved to rehabilitation not being cost-effective.Conclusions: The effects on quality of life tend to reinforce treatment advantages on survival for patients having postdischarge rehabilitation after an acute coronary syndrome. The estimated base case incremental cost per QALY saved is consistent with those historically accepted by decision making authorities such as the Pharmaceutical Benefits Advisory Committee.

Tom G Briffa PhD, MSc · Simon D Eckermann PhD(Ec), MSc, GradDipHEc · Alison D Griffiths BA Hons · Anthony C Keech MB BS, MScEpid, FRACP · Phillip J Harris MB BS, DPhil, FRACP · M Rose Heath RN · Saul B Freedman PhD, FRACP, FACC, FESC · Lana T Donaldson RN, MPH · N Kathryn Briffa BAppSc(Physio), PhD

Objectives: To ascertain what general practitioners’ priorities are for achieving optimal outcomes in people with asthma, and the barriers they face in delivering this care.Design: A qualitative study using the Nominal Group Technique (a highly structured meeting to gain information from experts about a particular issue) was conducted between August 2002 and September 2003. GPs in six discussion groups were asked “What do you think is needed to achieve best outcomes for asthma care?” To augment analysis of the discussion, sessions were taped and transcribed.Participants: Forty-nine GPs were recruited: 34 from metropolitan and 15 from rural areas.Results: All groups nominated asthma education for patients and continuing professional education for GPs as major priorities, but they also described educational and structural barriers to achieving these priorities. Other priorities were: medication adherence, facilitating regular patient review, negotiated treatment/management plans, making the correct diagnosis, increased remuneration and consultation time, and safer asthma medications and access to these. Health promotion initiatives and increased public awareness were also priorities. Spirometry was a significant cause of uncertainty. Overall, written asthma action plans were not considered a high priority.Conclusions: Remarkable consistency was found between GPs’ priorities for delivering best asthma care. Our study identified barriers to asthma guideline adherence, including accessible, relevant education for GPs, and structural, time and cost barriers GPs must overcome in providing asthma treatment and patient education.

Dianne P Goeman MA, DipSoc · Jo A Douglass MD, FRACP · Chris D Hogan MB BS, FRACGP · Rosalie A Aroni PhD · Michael J Abramson PhD, FRACP · Susan M Sawyer MD, FRACP · Kay Stewart PhD · Lena A Sanci MB BS, FRACGP, PhD

Objectives: To determine the number of patients in our teaching hospitals who were, on any given day, both available and willing to see medical students.Design and setting: Repeated cross-sectional audit in four teaching hospitals in the greater Newcastle area of New South Wales (one tertiary referral hospital, two district general hospitals, and one hospital combining general medicine and surgery with specialised oncology services). Audits were conducted three times, 2 months apart.Participants: All adult inpatients in the four hospitals.Main outcome measures: Numbers of patients present and accessible to students, present but inaccessible, absent, or unfit to be seen for clinical reasons; numbers of patients who agreed to history-taking and physical examination by a medical student.Results: Of 1960 patients, 959 (49%) were present and accessible to students. Only 11% were absent, and the most common reason students could not see patients was that the patients were said by nursing staff to be unfit to see medical students (25%). Of those present and accessible, 70% said they would agree to provide a history, and 67% that they would agree to physical examination.Conclusions: Across all four teaching hospitals about 200–250 patients are available and willing to see medical students on any given day. This is too few to provide our current student population of 500 with extensive clinical experience.

Leslie G Olson PhD, FRACP · Suzanne R Hill PhD, FAFPHM · David A Newby PhD

Objectives: To compare the safety, effectiveness and cost-effectiveness of drug-eluting coronary stents used in Australia with bare-metal stents and determine whether the benefits are greater for high-risk subgroups.Data sources: MEDLINE, Pre-Medline, EMBASE, Current Contents, CINAHL and the Cochrane Library database were searched to identify eligible randomised controlled trials and systematic reviews published in English between January 1966 and June 2004.Study selection: Seven randomised controlled trials that assessed polymer-based paclitaxel- or sirolimus-eluting stents versus bare-metal stents in patients with coronary atherosclerosis and reported on stent thrombosis, mortality, myocardial infarction, coronary artery bypass grafting or target lesion revascularisation.Data extraction: Two independent reviewers appraised eligible studies and extracted data. Relative risks (RRs) were calculated for each outcome and pooled using the Mantel–Haenszel method.Data synthesis: Rates of stent thrombosis, mortality, myocardial infarction and bypass grafts did not differ by stent type. Drug-eluting stents (DESs) resulted in a 71%–80% lower risk of revascularisation at 12 months (RR 0.29 [95% CI, 0.20–0.43] for paclitaxel-eluting stents [n = 1593 patients]; RR 0.20 [95% CI, 0.13–0.29] for sirolimus-eluting stents [n = 1296 patients]). Similar benefits were seen in several high-risk subgroups of patients: those with diabetes, lesion length > 20 mm and target-vessel diameter ≤ 2.5 mm. The benefits of DESs in these high-risk groups over lower-risk groups were inconclusive because of low numbers. The cost per revascularisation avoided by using DESs was A$3750–$6100, with an estimated cost per quality-adjusted-life-year (QALY) gained of A$46 829–$76 467. In sensitivity analyses, estimates varied from DESs being cost-saving to costing an additional $314 385 per QALY gained.Conclusions: DESs are effective in reducing revascularisation. Estimates of cost-effectiveness are very sensitive to changes in estimates of their true effects in clinical practice, market price and the number of stents used per patient. Decisions to limit DESs to only patients at the highest risk of restenosis may improve their cost-effectiveness but will need to be reassessed when evidence is available to compare absolute benefits between patient groups.

Sarah J Lord MB BS, MS(Epi), FRACGP · Felicity Allen BVSc(Hons), MPH · Luke Marinovich BA(Hons) · David C Burgess BMed, FRACP · Kirsten Howard MAppSc(Biopharm), MPH, MHlthEcon · Richard King MB BS, FRACP · John J Atherton MB BS, PhD, FRACP

As I recently walked around Canberra’s Lake Burley Griffin in an air temperature of 5°C, I had plenty of time to contemplate the position statement on acute domiciliary oxygen therapy recently published in the Journal.1 I have fibrosing alveolitis and am awaiting a lung transplant. I am on domiciliary oxygen therapy 24 hours a day. There is much in the position statement to congratulate the authors on. They have rightly identified the importance for people like me of maintaining an increased level of fitness, which incorporates the use of ambulatory oxygen therapy to improve our prognosis. They have also identified contraindications for oxygen therapy, cited the appropriate levels of evidence as prescribed by the National Health and Medical Research Council, searched MEDLINE, and undoubtedly worked their way through the various committees of the Thoracic Society of Australia and New Zealand (TSANZ). What then is missing? The patients! Perhaps I am being unfair to the authors and perhaps there is a process within the TSANZ structure whereby consumers were consulted on the position statement, but this is not immediately evident. If consumers were partners in the development of this statement, it might have been possible to address its four glaring omissions: The issues of access to and equity of oxygen supplies across Australia; Portability and comfort; Assessment and review; and Quality of life. Access and equityWhile it is well known among respiratory and thoracic physicians that not all Australians have access to free or subsidised oxygen, it is not well known in the community. Different states and territories have differing rules for patients who are on oxygen therapy. Victoria, Tasmania, South Australia and Western Australia routinely provide free oxygen, based on clinical need, irrespective of the patient’s financial position. Queensland will generally provide the service if the patient is on a lung transplant waiting list, but otherwise its approach is similar to that in New South Wales, where all patients are vetted by a means test. The means test is particularly harsh, and patients must have a government Health Care Card. The Australian Capital Territory changed its rules from 1 July 2004 to bring it into line with Victoria, Tasmania, South Australia and Western Australia. Why is it that some people in Australia have access to free or subsidised oxygen supplies and others do not? I often hear health ministers, state and federal, boasting about the wonderful universal health system we have in Australia. Everyone pays their taxes and their Medicare levies — yet, at the whim of a postcode, some people do not have access to a basic supply such as oxygen. Another access and equity issue is whether the supply of oxygen is capped (ie, whether patients have access to unlimited supplies of cylinders per week or per month). While, for example, the ACT Health Minister recently explained that access would not be capped when the new system was introduced, in reality oxygen therapy is restricted by a contract. I am in the lucky position of being on a lung transplant list, and therefore my access is not capped. However, there are other (generally elderly) patients who are limited to small supplies of oxygen each month because their disease, prognosis or age precludes them from the opportunity of a lung transplant. A further difficulty is that there are currently only three lung transplant units in Australia (in New South Wales, Victoria and Queensland). I am required to attend a lung transplant unit interstate every 6–8 weeks, as are other patients. Some ACT patients have been told that, if they travel interstate, they will not have access to the ACT government-funded oxygen supply while they are travelling or staying interstate. The limited number of lung transplant units means that the chances of patients having to travel with oxygen are quite high. Yet, because they are travelling and not resident in the state with the lung transplant unit, they are required to pay for their own oxygen. There is surely a better way of managing all patients, irrespective of their state of residence. Portability and comfortThe position statement mentions a range of oxygen delivery modes. The most commonly used portable cylinder in Australia is the “C” cylinder, which weighs over 4 kg when full. This is far too heavy to allow me to maintain an independent lifestyle, and I have been able to obtain CFR (carbon fibre wrap) fibreglass cylinders, which weigh less than 4 kg when full and fit neatly into a backpack. I use one when out exercising and for most of my daily life. However, even the CFR cylinder is too heavy for the long walk around the Lake, especially on chilly days. Oxygen suppliers have rentable lightweight trolleys, but these are unstable on any surface other than a smooth surface. My husband has therefore redesigned a golf buggy (I hate golf anyway) so that my cylinder can fit neatly into that. The buggy’s wheel base is wide enough to allow it to cross all sorts of terrain. Stairs, however, are a problem. What a joy it would be to all Australians needing oxygen therapy to have access to lightweight, longlasting liquid oxygen systems that weighed less than gas cylinders and did not require constant visits to oxygen suppliers for refilling. Patients in the United States and now the United Kingdom (a new system was announced in June 2005) have access to liquid oxygen, but suppliers in Australia do not provide such a system. I am told that this is because clinicians do not want to prescribe liquid oxygen. While the position statement gives a thorough analysis of systems available, it might have been useful if some comment were made about what patients would prefer, as the inconvenience of the accoutrements available to enhance or prolong our lives makes the whole illness process much worse than it needs to be. Assessment and reviewThe position statement correctly suggests that patients should be reviewed within 1–2 months of beginning oxygen therapy, and thereafter at 12-monthly intervals. However, there is no mention of who should undertake these reviews. The logical assumption — and, indeed, good clinical practice — would be that thoracic/respiratory physicians would fulfil this role. However, recently in the ACT I was contacted by the oxygen supplier who has the government contract and told it was time for my respiratory review, which would be undertaken by the oxygen supplier! I have to wonder at the appropriateness of such an arrangement, in view of the following: Conflict of interest. It is in the oxygen supplier’s interest to increase sales of oxygen. Clinical governance. Oxygen suppliers are generally just that. They do not have a clinical governance structure in place to ensure that their ability to undertake clinical assessment is appropriate. Issues such as calibration of equipment and competence and currency of staff are also key concerns. As is privacy: I was told that my results would be passed on to the administration of my local health department, an organisation whose role does not include the maintenance of patient records. Repetitive assessment. All patients being prescribed oxygen are assessed by appropriate thoracic/respiratory physicians. Their lung function and other indicators are assessed at regular intervals. To incorporate another layer of review by an oxygen supplier is demeaning and disruptive to patients. Quality of lifeThe authors of the position statement touch briefly on quality-of-life issues, but seem to have little understanding of what quality of life means for people dependant on oxygen therapy. Rarely does a patient wish to remain confined to barracks, tied to an oxygen concentrator. Patients’ outlook on life is greatly enhanced by making some attempt to lead as normal a life as possible. In my own case, I am relatively young and it is essential that I maintain an active lifestyle to help me look after a young family and to ensure readiness for lung transplantation. Debilitating diseases such as fibrosing alveolitis and cystic fibrosis have a huge impact on family life. Regular and uncapped supply of an extremely basic commodity like oxygen goes some way towards alleviating the stress on families and individuals in coping with the psychosocial aspects of the disease. Issues and suggestionsOne might argue that the authors were trying to provide evidence-based guidelines for the clinical aspects of oxygen therapy — that they never claimed to be doing more than that, and wouldn’t presume to speak for patients or funding bodies. But is that good enough? Can the quality of life of patients (as they see it) and the appropriateness of reviews of their need for oxygen therapy really be irrelevant to their doctors? And there are other issues. I have met people who have struggled out of their vehicles, put their cigarettes out, and wheezed their way in to the “oxygen shop” for their free oxygen because they fulfil the requirements of the means test (while others, equally or more deserving, have to wait in line to pay for theirs). Does it seem right that patients who are not committed to improving their health outcomes should have ready access to such a scarce resource? Perhaps it is time for some of the tobacco tax to be put into funding oxygen supplies. While cigarette smoking does not cause all of the lung disease occurring in Australia, it is responsible for a large burden of disease and death, including death from lung cancer, chronic obstructive pulmonary disease and heart disease. It is also evident that the multilayered federal/state government arrangements for managing health care in Australia are totally inappropriate for managing something as basic as oxygen. Perhaps it is time for individual states and territories to relinquish the funds they are currently using for oxygen therapy and for the federal government to assume a management role, as they do with pharmaceuticals. This seems to me to be the only equitable way of allocating oxygen on the basis of need, rather than state of residence. Indeed, the United Kingdom has just introduced a centrally managed system for providing oxygen therapy, recognising the fragmented nature of the previous system. In common with other patients, I will no doubt shortly become an orthopaedic surgical patient as a result of an aching back due to carting around heavy oxygen cylinders. Although I have the lighter oxygen cylinders, they become quite heavy on my back and shoulders. Perhaps it is time for physicians to start advocating for the comfort of their patients through the medical colleges or the TSANZ. A shift towards liquid oxygen systems would be welcomed by many who have lung disease and require oxygen therapy. Surely it is also time for the medical colleges and/or the TSANZ to agree on some basic forms that physicians could use for prescribing and reviewing oxygen requirements. This would ensure that patient dignity and privacy issues were maintained. Quality-of-life issues for patients requiring oxygen therapy should also receive more than passing attention from clinicians. I am told that there is an extremely high number of patients awaiting lung transplantation who are also taking antidepressants. This is hardly surprising, given that such patients have so much of their independent lifestyle removed so quickly. Surely this issue should also be discussed when considering how best to provide domiciliary oxygen therapy. A final commentPatients (or consumers, as we are sometimes called) are central to the business of illness. They know a lot about their diseases. This is not to say that some are not ill informed. However, there is a vast wealth of knowledge and experience to be tapped in having patients as partners in the development of position statements such as the recent one on domiciliary oxygen therapy.1 The TSANZ’s position statement is a good, solid, clinical paper. It could have been a great, patient-friendly statement if the views of patients had been sought and incorporated.

Anne E Cahill Lambert AM, MPubAdmin, BHA

We welcome the incisive comments from Cahill Lambert (page 472).1 The remit of our position statement2 was to update our previous evidence-based guidelines for the prescription of oxygen in Australia and New Zealand by reviewing the currently available literature. Informal consultation with consumers was made through the Australian Lung Foundation’s COPD (chronic obstructive pulmonary disease) Consultative Group, but no funding was available to seek broader community comment. Our position statement supports the use of ambulatory oxygen as part of continuous oxygen therapy in patients who fulfil criteria for long-term oxygen therapy — both to maximise the duration of normal blood oxygen concentrations and to maximise exercise capacity. Two of us (A J C, C F M) have been actively involved in research around the issue of quality of life of patients on long-term oxygen therapy.3-6 It has not yet been confirmed whether ambulatory oxygen is of significant benefit in this area.7,8 The unwieldiness of some of the currently available portable cylinders may counteract some of the potential gains of using ambulatory oxygen, but we have not been successful in securing the widespread use of liquid oxygen in Australia. It is yet to be demonstrated that the extra costs associated with a liquid oxygen system are balanced by greater benefits in useability (portability and comfort) and quality of life. Although we are keenly aware that there are major issues of equity and access to ambulatory oxygen therapy across Australia, as Cahill Lambert correctly asserts, discussing these issues was outside the parameters (and space constraints) of our position statement. While we may consider oxygen to be equivalent to a “drug” for the purposes of this discussion, oxygen, unlike pharmaceuticals, is not a federally-funded commodity but is provided on a state-by-state basis through programs such as the Victorian Aids and Equipment Program (except in the case of war veterans, who are funded through the Department of Veterans’ Affairs). Individual state funding arrangements have led to inequalities in the provision of this service. It is our understanding that New South Wales and Queensland do not currently supply portable oxygen to adults requiring long-term continuous oxygen therapy delivered by concentrator. However, Victoria, Tasmania, Western Australia and South Australia provide portable oxygen cylinders to such patients and to others who have demonstrable evidence of desat-uration on exertion and measurable benefit from portable oxygen therapy (in terms of improved exercise capacity or reduced breathlessness). There are caps on supply, with only a certain number of cylinders allowed per month in most instances. Capping, although understandable in fiscal terms, makes little sense to patients trying to maximise their exercise capacity (and quality of life) by exercising regularly with the help of ambulatory oxygen. We recommended in our position statement that patients requiring oxygen therapy should be assessed and reviewed on a regular basis. Although not explicitly stated in our position statement, we believe this review should be undertaken by the clinician managing the patient. We agree with Cahill Lambert that there is a potential conflict of interest in the review being conducted by the company supplying the oxygen. We support her call for more advocacy in this area, but assure her that we have personally been advocating for a fairer and more equitable system for many years. Patient advocacy groups, such as those run through the Australian Lung Foundation, as well as organisations such as the Thoracic Society of Australia and New Zealand clearly have an important role to play in ensuring that this issue makes its way onto the political agenda. We believe that further research is the key to providing more definitive answers to some of the more contentious questions around oxygen provision. Specific areas of research should include portable oxygen use in patients not requiring continuous oxygen therapy, nocturnal oxygen use in patients whose daytime resting arterial blood gas levels would preclude them from receiving continuous oxygen therapy, and the use of palliative oxygen therapy in non-hypoxaemic patients. A more extensive body of data in these areas would allow future updates of our position statement to provide higher levels of evidence, which we hope would translate into a more consistent approach to oxygen provision in Australia.

Christine F McDonald MB BS, FRACP, PhD · Alan J Crockett PSM, MPH · Iven H Young PhD, FRACP

Setting Your junior medical officer (JMO) has been with you for 5 of his 10 weeks and you are not happy with how things are going. He is disorganised on ward rounds, makes few chart notes and often doesn’t have a grasp of patients’ problems, leaving things mostly to the registrar. This is his fourth term and he should be performing better. You think it’s time for a chat. Working as a junior doctor is stressful — 25% of interns show signs of “burnout” and 25% are mildly depressed.1-4 Senior doctors, as their teachers and supervisors, are in an ideal position to care for JMOs.5 While a small proportion (3%–7%) of JMOs in training programs are “difficult” or “problem” doctors who require the intervention of someone in authority,1,6,7 a higher proportion of JMOs are simply unable to cope with the stress of the job and exhibit signs of being “in difficulty”, “stressed” or “distressed”.1,2,4,6 Helping the “JMO in difficulty” has important flow-on effects, such as optimising patient safety and care, reducing self-harm of doctors and reducing the number of doctors who drop out of medicine.2 Despite these benefits, consultants (and registrars) often avoid addressing the problems because they: Are embarrassed, lack the skills, and fear it may expose their own inadequacies; Don’t like upsetting people; Believe it will only make matters worse; Fear reprisals through legal action against their judgement; and/or Feel they have no time to deal with the problem because they are already overstretched. However, it is incumbent on senior clinical staff to play a major role in managing problems and preventing poor outcomes. Indeed, it is part of their obligation to the profession. A framework for approaching a JMO who you think may have a problem is to ask yourself the following questions: Is there a problem and, if so, what is it? What are the underlying causes? What is the best way to manage the problem, and what documentation is needed? Is there a problem and, if so, what is it?Most junior doctors in difficulty are identified either through direct observation (82%), such as poor presentations in the clinical setting, or critical incidents (59%), such as inappropriate prescribing or failure to organise investigations.1,8 The most important first step is to be sure that there really is a problem. Observe and gather information confidentially from all relevant sources: previous supervisors, the Director of Clinical Training, and at some stage, the trainee. Doctors who have significant problems are usually identified through what appears to be insufficient knowledge (48%), poor clinical judgement (44%), inefficient use of time (44%), poor communication (39%) and/or unethical behaviour (15%).1,8 It is important to recognise that there may be self-denial and that stressed doctors who are performing adequately may not admit to problems unless asked in a supportive environment. What are the underlying causes?When someone is performing poorly, contributing factors (and therefore solutions) are usually multiple (Box). It may be difficult to be sure of the cause(s). As it is essential to ensure the JMO is treated fairly and confidentially, particularly if sharing information may have an impact on assessment, the ideal time to deal with the problem is while the JMO is working with you. Ask yourself, Am I supporting my trainee? Have I ever given feedback? How is the team working? Take-home message For the junior medical officer (JMO) in difficulty: Define early whether there is a problem and the nature of the problem. Consider underlying causes — personal factors (the “Bs”*) or institutional (supervisor or system) factors. When having a chat, make it confidential, let the JMO speak first, and agree on a plan. Provide frequent follow-up and feedback. * Blues, birds/blokes, banks, babies, booze, bilingual background. What is the best way to manage the problem, and what documentation is needed?The best way to help doctors in difficulty depends on the underlying problem(s). Management may range from support, change of attachment, or time off, to referral to a general practitioner or psychiatrist. It is important to separate the roles of “therapist” and “supervisor” and ensure that appropriate referral occurs. For major problems, the Director of Clinical Training should provide supervisors with support. Early intervention, involving information gathering and discussion with the JMO, is essential. Documentation may be necessary, even if it remains confidential and may only be used if called upon later. The “quiet chat” — discussing the problem with the JMOThe critical intervention of having a private discussion with the JMO (see “Tips 10”)11 requires: Setting aside time in a confidential setting; Getting the JMO to speak first (positive critique); Defining the issues involved (are they important, measurable, reproducible?); Determining the remediable cause(s); Agreeing on an action plan; and Monitoring outcomes and following up with frequent feedback. Factors that may contribute to poor performance in JMOs1,2,5,7-9 Personal factors* Stress (eg, relating to career concerns, poor self-esteem, relationship or financial problems) is frequent. Medical/psychiatric factors. About 25% of interns are mildly depressed. Substance abuse. In one study, 12.6% of JMOs were misusing alcohol, based on the CAGE† questions, but consultants only suspected it in 1%. Cultural differences. Doctors from a different culture are at high risk of having difficulties. Poor communication skills. Lack of clinical knowledge (this is relatively uncommon). Supervisor or system factors Receiving no feedback or support, or being given responsibilities beyond their level of competence. Interpersonal problems (eg, in dealing with the registrar, in breaking bad news to patients). Overwork (hours, intensity, menial tasks, conflicting demands). Exposure to patients with serious illness and death, often for the first time — especially patients of their own age. * Remember the “Bs” (blues, birds/blokes, banks, babies, booze, bilingual background). † CAGE = Cutting down, Annoyed by criticism, Guilty about drinking, Eye-opener drinks.10

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

Clinical records Patient 1 A 30-year-old woman presented to hospital with bilateral hand paraesthesia and a serum potassium level of 2.9 mmol/L (reference range [RR], 3.5–5.0 mmol/L). She denied taking medications and had no significant past medical history. However, 3 months before admission, she had presented to her general practitioner complaining of anorexia, nausea, lethargy, fevers and aches. An erythrocyte sedimentation rate (ESR) of 91 mm/h (RR, 7–18 mm/h) and a serum creatinine level of 0.106 mmol/L (RR, 0.030–0.110 mmol/L) were noted. (Twelve months previously, her serum creatinine level had been 0.073 mmol/L.) Then, 1 month before admission, she had developed blurred vision due to anterior uveitis, diagnosed by an ophthalmologist, and was treated with topical steroids. In the intervening period, she had lost 12 kg in weight. A normochromic, normocytic anaemia was now present (haemoglobin level, 103 g/L; RR, 115–165 g/L), and her serum creatinine level was 0.230 mmol/L. The hypokalaemia was corrected, and she was discharged with a referral to the renal outpatient clinic. In clinic, her blood pressure was 140/85 mmHg, but the physical examination was otherwise normal. Repeat laboratory tests showed: creatinine, 0.250 mmol/L; potassium, 3.1 mmol/L; bicarbonate, 17 mmol/L (RR, 23–31 mmol/L); and phosphate, 0.64 mmol/L (RR, 0.60–1.40 mmol/L). Urine microscopy showed no leukocytes, erythrocytes or casts. Urine pH was 7.0, with glucosuria on dipstick. Protein excretion was 0.9 g/day (RR, < 0.15 g/day). Autoimmune markers were negative, including antinuclear antibody, antineutrophil cytoplasmic antibody, antidouble-stranded DNA antibody, and antibodies to extractable nuclear antigens. Serum calcium and angiotensin-converting enzyme (ACE) levels were normal. A chest x-ray and renal ultrasound were unremarkable. A renal biopsy showed acute interstitial nephritis and chronic renal damage (Figure A). After taking prednisolone 60 mg/day and concurrent phosphate, bicarbonate and potassium supplements for 4 weeks, her serum creatinine level fell to 0.130 mmol/L. The dose of steroids was reduced gradually over 4 months and renal function remained stable. Shortly after stopping prednisolone, her eye symptoms recurred. Ophthalmological examination revealed a bilateral visual acuity of 6/4, keratic precipitates, posterior synechiae and perilimbal injection, consistent with anterior uveitis (Figure B). This responded to topical steroids. Patient 2 A 34-year-old woman was referred to the renal clinic by her general practitioner, with a creatinine level of 0.190 mmol/L, normochromic, normocytic anaemia (haemoglobin level, 110 g/L), and an elevated ESR (120 mm/h). She gave a 1-month history of weight loss (15 kg), with anorexia, nausea, arthralgias, myalgias, fatigue and fevers. She had mild asthma, which was being treated with salbutamol, and took no other medications. Physical examination was unremarkable. Repeat laboratory tests 1 week later showed a serum creatinine level of 0.250 mmol/L. Urine microscopy showed no leukocytes, erythrocytes or casts. Proteinuria was absent and a renal ultrasound gave normal results. A renal biopsy revealed granulomatous acute interstitial nephritis with multinucleated giant cells (Figure C). Her serum calcium and ACE levels were normal, and a chest x-ray was unremarkable. Oral prednisolone 60 mg/day was commenced. One week later, her constitutional symptoms and renal function markedly improved. Repeat tests showed: creatinine, 0.120 mmol/L; potassium, 2.9 mmol/L; and phosphate, 0.40 mmol/L. Glucosuria was detected on urine dipstick analysis. All autoimmune markers and HLA-B27 were negative. Potassium supplementation was commenced. After the prednisolone dose was reduced to 2.5 mg/day over 2 months, she developed bilateral red and painful eyes, photophobia and watery discharge. Ophthalmological examination showed bilateral anterior uveitis, with a visual acuity of 6/9 bilaterally, perilimbal injection, keratic precipitates, anterior chamber cells 3+, and posterior synechiae. The uveitis resolved with topical steroids and cycloplegic agents. Her serum creatinine level remained stable without steroid dose adjustment. A: Renal biopsy specimen (Patient 1) showing an interstitial infiltrate of lymphocytes, plasma cells, histiocytes and eosinophils, without granulomas. There is prominent tubular atrophy and wide separation of tubular structures due to interstitial fibrosis (haematoxylin–eosin stain, original magnification x 200). B: Photograph of the right eye of Patient 1, with the thick arrow showing pupil irregularity and posterior synechiae, and thin arrows showing inflammatory perilimbal injection. Keratic precipitates and anterior chamber cells are best appreciated on slit lamp examination. C: Renal biopsy specimen (Patient 2) showing tubulointerstitial mononuclear infiltrate with non-caseating granulomas and multinucleated giant cells (large arrows) (haematoxylin–eosin stain, original magnification x 200). Inset: Small arrows highlight eosinophils with typical bilobed nuclei (x 400). Tubulointerstitial nephritis and uveitis syndrome (TINU) was first reported in 1975.1 Diagnosis of TINU requires identification of acute interstitial nephritis and uveitis, in the absence of systemic diseases associated with either condition. TINU occurs more frequently in females (3 : 1), with the median age of onset being 15 years, and has no racial association.2 At least 50% of cases are probably idiopathic based on the absence of risk factors for acute interstitial nephritis.2 Associations that have been reported include: drugs (antibiotics, non-steroidal anti-inflammatory drugs), infections (herpes zoster, Epstein–Barr virus, toxoplasmosis), and systemic diseases (hyperthyroidism, hypoparathyroidism, rheumatoid arthritis).2 The main differential diagnosis is sarcoidosis. Although uveitis associated with sarcoidosis is typically granulomatous, uveitis associated with TINU is mostly non-granulomatous. Sarcoidosis rarely causes acute interstitial nephritis and frequently affects the lungs, whereas lung involvement has not been reported with TINU. Sjögren’s syndrome is not a differential diagnosis because patients with Sjögren’s syndrome do not develop uveitis despite having sore eyes (sicca). Neither patient was taking medications known to cause acute interstitial nephritis. There is often a time interval between the diagnosis of uveitis and that of acute interstitial nephritis, making the diagnosis of TINU difficult. In 35% of patients with TINU, ocular findings precede or develop concurrently with acute interstitial nephritis. In 65% of patients, ocular symptoms follow acute interstitial nephritis by a median time of 1 month, but can occur up to 14 months later.2 The most common systemic features are fever, weight loss, fatigue and malaise (50%); and eye pain and redness are the most usual ocular symptoms (77%).2 Acute anterior uveitis is the typical finding (80%) and is usually bilateral. About 20% of patients develop ocular complications, such as posterior synechiae (most common), cataracts and glaucoma. Patient 1 developed recurrence of uveitis despite quiescent renal disease, showing that the course of ocular disease can be independent of renal disease.2,3 Uveitis recurs or becomes chronic in about 50% of patients. It is commonly treated with topical or systemic steroids, and cycloplegic agents. Methotrexate, cyclosporin or azathioprine may prevent relapses in steroid-resistant, recurrent or persistent uveitis, but randomised trials are lacking.2,4 Both patients demonstrated features of proximal tubular dysfunction consistent with Fanconi’s syndrome. This syndrome causes aminoaciduria, glucosuria, metabolic acidosis (bicarbonate wasting), hypophosphataemia, natriuresis, kaliuresis, polyuria and proteinuria. It has been reported in idiopathic interstitial nephritis,3 drug-related interstitial nephritis,5 and TINU.6,7 Incomplete Fanconi’s syndrome and distal tubular defects with hyperkalaemia have also been reported.8 Urinary electrolyte losses can be significant and symptomatic, as in Patient 1. Lessons from practice Beware of red eyes — check for interstitial nephritis and renal failure. In patients with uveitis, acute interstitial nephritis may not develop concurrently and may be asymptomatic. In tubulointerstitial nephritis and uveitis syndrome, complications of proximal tubular dysfunction (leading to metabolic acidosis and serious electrolyte disorders) and chronic renal damage can occur. Potassium, bicarbonate and phosphate supplementation may be needed. Steroid treatment may prevent chronic renal damage. Another complication that has been found is chronic renal damage. Some authors consider renal disease in TINU to be benign,9 but the renal biopsy from Patient 1 suggests that TINU produces chronic damage. Renal failure may resolve spontan-eously and almost always responds to steroids.2 Persistent renal dysfunction occurs in about 10% of patients, with few needing dialysis. Renal biopsy findings are typical of acute interstitial nephritis, with eosinophils seen in 34% and non-caseating granulomas in 13%.2 Granulomas have been described in lymph nodes and bone marrow.1 Despite its propensity to affect the young, TINU is not limited to paediatric patients, as these cases demonstrate. TINU may be underreported, given the frequent temporal dissociation between uveitis and acute interstitial nephritis. Chronic renal damage and electrolyte abnormalities do occur; hence, patients with uveitis should be evaluated for renal involvement. If any abnormalities are detected, a renal biopsy may be indicated. Early detection and steroid treatment may prevent renal complications.

Andy K H Lim MB BS · Vicki Levidiotis MB BS, FRACP, PhD · Matthew A Roberts MB BS, FRACP · Troy Lim Joon MB BS, FRANZCO, FRACS

With the demise of the Aboriginal and Torres Strait Islander Commission in 2004 after a long and painful 8-year illness, a new council to represent the views of Indigenous people, the National Indigenous Council, has been chosen for us. One of the first viewpoints expressed by one of the new council members concerned the “Sorry” debate.1 The council member stated that an apology for past injustice was important, “but does not address domestic violence in our homes”, and went on to say that the need to address poverty, poor health and lack of education were a higher priority than statements of regret. In my view, this comment was a disappointment, not only because of the leverage this kind of statement gives to the “anti-bleeding heart” brigade, but also because a true apology — and, more importantly, the actions that go with it — would address exactly these conditions in our communities. Genuine measures would go some way towards making holistic health gains and dealing with health inequities experienced by Aboriginal and Torres Strait Islander people. To be truly effective, any actions taken should be based on the existing framework of the recommendations of the Human Rights and Equal Opportunity Commission’s report, Bringing them home.2 A little background: the Bringing them home inquiry traced the history of the forcible removal of Aboriginal and Torres Strait Islander children from their families from the earliest days of colonisation to contemporary removals that took place in the 1990s. In New South Wales, the Aborigines Protection Act 1909 allowed the Aboriginal Protection Board (APB) to “assume full custody and control of the child of any Aborigine”. Intimidation and influence hadn’t been effective in getting families to hand their kids over, so the law was brought in. The justifications for removal included claims that children would receive a better education or that it would help them gain good employment (the reality was that education was often discouraged and adolescents were sent off to do menial domestic and farm or labouring jobs). However, what isn’t so well known is the reasoning at the time, which was simple, and may explain why many who were connected personally and professionally with the issue called the policies and practices “genocide”. The architects of the Aborigines Protection Act had an aim of making the Aboriginal race cease to be a problem to settlers and townspeople: In the course of a few years there will be no need for the camps and stations; the old people will have passed away, and their progeny will be absorbed in the industrial classes of the country.3 An amendment to the Act came into force when the APB desired the power to remove children without having to go through a court and without having to establish neglect (Aborigines Protection Amending Act 1915). Reasons for removal found on files in the NSW state archives include “to send to service”, “at risk of immorality”, “to get her away from surroundings of Aboriginal station/removal from idle reserve life” and “being Aboriginal”.2 Mostly, children were sent to institutions such as the Bomaderry Childrens Home, Cootamundra Girls Home or Kinchela Boys Home. The experiences of these children were often brutal, with assimilation into white society the main aim. Experiences such as that recounted below are detailed in the Bringing them home report. Most of us girls were thinking white in the head but were feeling black inside. We weren’t black or white. We were a very lonely, lost and sad displaced group of people . . . We didn’t know anything about our culture. We were completely brainwashed to think only like a white person. When they went to mix in white society, they found they were not accepted [because] they were Aboriginal. When they went and mixed with Aborigines, some found they couldn’t identify with them either, because they had too much white ways in them. So that they were neither black nor white. They were simply a lost generation of children. I know. I was one of them.”2 The APB evolved into the Aboriginal Welfare Board, and the amended Act became the Child Welfare Act 1939 (NSW), which had one system of regulation for Aboriginal children and another for non-Aboriginal children. While the Child Welfare Act returned removal matters to the court system, most parents were excluded from procedures because of physical isolation from the towns where children’s courts were located and a lack of money to pay for legal representation. Added to the legislation at this stage were the terms “neglected” and “uncontrollable”, with all the race and class subjectivity that goes along with interpreting the definitions. The Aboriginal Welfare Board finally ceased to exist in NSW in 1969, but not before the institutionalisation of removed children had been slowly phased out over the years in favour of adoption and fostering into non-Aboriginal family homes. By this time, the fine art of coercion by Welfare staff had been honed — much more “civilised” than driving in and rounding up kids with a truck while their parents tried to hide them in flour bags. This trend, reinforced by adoption laws, gave children little chance of finding out who they were and where they were from or even that they were Aboriginal, unless they were fortunate enough to be told by caring adoptive families. Even today, Aboriginal children are placed in out-of-home care at rates up to 13 times greater than those for non-Aboriginal children.4 Contrary to recent claims made in public discourse and media reports, Aboriginal children, unlike other children, are removed for neglect more often than they are for abuse.4 The well publicised high rates of incarceration also bear witness to the continued institutionalisation of Aboriginal and Torres Strait Islander people, well after the shift away from assimilationist policies. If the seeds of future ill health are indeed present before birth,5 what could be the cumulative consequences of several generations’ worth of control by the government? I would suggest you need look only as far as your Aboriginal patients who present for treatment. The likelihood is that these policies, or their equivalents in other states, have affected them in some way. The Bringing them home inquiry estimated there would barely have been a family untouched by these practices. If your patient was not taken, he or she may have parents, siblings, aunts, uncles, cousins, grandparents or great grandparents who were taken. The patient’s own children may have been removed or temporarily separated. Or the patient’s family may have lived in fear after witnessing friends’ children being taken and grown up denying their own Aboriginality to avoid the same fate. How could these removal policies have had such an effect on such a great number of individuals across Australia, and could that explain the poor health, educational and socioeconomic status and the social problems of Indigenous people so visible today? The effects of the policies are numerous and include: The grief of parents and family for the child or children removed; The interruption to family and community structure when children have been taken; The loss of identity, of rightful place in family, of ties with family, community and culture of the children removed; The anxiety of the search for family and identity; The turmoil, for all, of trying to fit each other back in each other’s lives; and The pain and anger when this doesn’t happen as it was hoped, or if it can’t happen at all. Each of these effects manifests itself in various ways, leaving its impact on relationships, physical and mental health, family structure, parenting skills and social and criminal behaviour. Perhaps here it’s best to let one of the many hundreds of people who submitted evidence to the Bringing them home report tell you her story in her own words: After the kids had gone to the home Mum and Dad hit the grog hard as they had done everything in their power and in their hearts to keep us away from . . . the Welfare. But they sniffed us out of the bush like dogs. My parents couldn’t handle the trauma of not having the closest warmth loving caring family we were. They separated. My Mum went one way; my Dad went his way . . . Eventually I got married when I was 21 years old. I thought maybe I could get my brothers and sisters and give them the home that the Welfare said my parents had to do . . . After about 14 years my [eldest] brother came to live with us. One sister found us through the Salvation Army about 16 years later. Then my brother [the baby] who died last year, who was caught up in the System was like a lost street kid and was bashed by the police in Melbourne a couple of years ago, ended up with a tumour on the brain and was never the same again. My second sister who I or my family didn’t see for 27 years. What could anyone do now to make up for those 27 years of not having their sister a part of their life? A terrible big hole in my heart that will never be filled. We all are in contact with each other now and we try to make up for all those lost years. But something’s missing. Could you put yourself in the situation that we were put through?2 The view that an apology for past injustice is important “but does not address domestic violence in our homes” is mistaken. The impact of removal policies goes on down the line and will continue to do so for as long as child welfare policies are directed at removal rather than prevention, with Indigenous families bearing the brunt. Professor Beverly Raphael spoke to the Inquiry of the reaction people had to the kind of trauma described above. She described it as: . . . a high level of arousal . . . that heightened arousal can stay on a heightened level with physiological responsiveness for the rest of one’s life . . . And one reason they take alcohol and other substances is often to dampen this down and they don’t know its cause.2 The Bringing them home report also discussed research into the effects of adoption on relinquishing parents and the impact of bereavement on mortality and morbidity. The researchers stated that there were a number of matters affecting recovery: Perceived social support facilitates adjustment; The opportunity for free expression of feelings facilitates adjustment; The ability to find meaning in the outcome facilitates adjustment; and The presence of other life stressors impedes adjustment.6 If this is a framework upon which to base the healing of those affected, it surely can be seen how genuine apology and practical support (or lack thereof) for survivors could have an impact on health and wellbeing. When families have been torn apart and parenting and familial roles undermined, damage is done and lives continue to be interrupted. Aboriginal people can grow up with emotional scars and cultural identity issues, leading to deep and highly visible “practical” problems such as family violence, social and emotional wellbeing issues, and substance and alcohol abuse problems. Many people affected have shown great resilience to overcome such problems and emerge with their families safe and intact, but many more have not and are still trying. There are services to help, such as Link-Up7 and the many “Bringing Them Home” counsellors, Aboriginal social and emotional wellbeing workers, Aboriginal health workers and many other concerned professionals. These positions, their integrity, and the existence of these organisations must be assured. * While state governments around the country made apologies around the time of the release of the report, the federal government has failed to do so. Furthermore, if the cycle of trauma that the “Stolen Generations” has created is to be halted, there are numerous recommendations from the Bringing them home report that must be put into action. The proposals range from acknowledgement and apology* to guarantees against repetition, implementation in federal legislation of the Genocide Convention,8 restitution and rehabilitation (including medical and psychological care, legal and social services), to parenting skills training and health professional training regarding the effects of removal. Unfortunately, until the underlying problems are appropriately addressed, existing services guaranteed and the required new services implemented, the cycle will continue and we’ll struggle to deal with the important issues such as poverty, poor health and lack of education that this new National Indigenous Council member rightly spoke of.

Wendy A Hermeston BA(Psych)

Imaging should only be undertaken if it is likely to influence patient management. The dose of ionising radiation to the patient should be considered. Requesting the appropriate imaging method requires an understanding of the pathological process. Plain x-ray should still generally be the first imaging technique; exceptions include some forms of superficial tendinopathy, in which ultrasound may be more appropriate, and situations where radiation exposure is contraindicated, such as in a pregnant patient. The cost of the examination to the patient and the community should also be considered (eg, ultrasound v magnetic resonance imaging).

John W Orchard PhD, FACSP, FACSM · John W Read MB BS, FRANZCR, DDU · Ian (Jock) F Anderson MB BS, FRANZCR, FRACSP(Hon)

Born at Bombala, NSW, on 22 December 1912, Geoff was the son of a general practitioner. After early schooling in Kempsey, he attended The Armidale School and Sydney Grammar School. He graduated in medicine from the University of Sydney in 1936, and was appointed to Sydney Hospital as a Resident Medical Officer. He married Claire Probert in secret, the hospital appointment being then unavailable to a married man. In 1939, Geoff went to work in the Radiology Department, which was “a bit of a shambles”. His knowledge and interest grew as he learned from the visiting Honorary Radiologists, and his technical skills were honed, of necessity, after half of them enlisted in the armed forces in 1939. In 1942, Geoff left for New Guinea and the 9th Australian General Hospital, treating the wounded in tents during the Kokoda Trail retreat. On discharge in 1946, Geoff joined a private radiology practice in Macquarie Street, Sydney. He was accepted by the Australian and New Zealand Association of Radiologists and became a Foundation Member of the College on its formation in 1949. He worked as an Honorary Radiologist at Sydney Hospital, Crown Street Women’s Hospital and Royal North Shore Hospital. A shy and gentle man, Geoff was a mentor to other radiologists in the practice, John Cashman, Peter Geddes and Bruce Roberts. He was even-tempered, innovative, honest to a fault, widely read and a thoughtful and well regarded radiologist. He served on two NSW government committees, the Radiological Advisory Committee and the State X-ray Committee. In 1991, Geoff retired due to macular degeneration, but his mental acuity and memory remained sharp until his last illness. Geoff was fascinated by astronomy and built a 9-inch reflecting telescope, hand grinding and polishing the mirror himself. He played the flute and built two harpsichords from scratch. He also had an abiding love of the sea and all things nautical, sailing with his friend, Robert Scot Skirving, on “Phalarope” many times. His wife Claire died in August 2004, after 68 years of marriage. On 17 January 2005, Geoff succumbed to a stroke. They are survived by their four children, Michael, Phoebe, Anne and Lucy, and Geoff’s sister, Pamela Marsh.

John D Cashman DDR, DRACR, FRANZCR · H Michael Marsh FANZCA, FFICANZCA, FACA · Bruce A Roberts FRACP, FRACR

Benjamin C Cowie,* Alan Breschkin,† Heath Kelly‡ * Infectious Diseases Physician, † Senior Scientist, Infectious Disease Serology, ‡ Head of Epidemiology, Victorian Infectious Diseases Reference Laboratory, 10 Wreckyn Street, North Melbourne, VIC 3051. Benjamin. CowieATmh.org.au To the Editor: Hepatitis E virus (HEV) infection is uncommon in Australia. The HEV cases detected are almost always in patients who have recently arrived from HEV-endemic regions of the world.1 We previously reported a significant increase in highly reactive serology results for anti-HEV IgG antibodies measured by enzyme im-munoassay (EIA) at the Victorian Infectious Diseases Reference Laboratory (VIDRL) in the first 6 months of 2004.2 Nine of the 10 Victorian patients with highly reactive samples in the previous report had had a history of recent clinically compatible illness and travel in a disease-endemic region within the incubation period (2–9 weeks). This indicated a strong association between highly reactive anti-HEV IgG measured by EIA and acute HEV infection, as has been shown previously.3 At the time, we hypothesised an association with overseas HEV epidemics, particularly in India, as seven of the nine patients with acute HEV infection had travelled there. We have now reviewed HEV serology results at VIDRL for the subsequent 9 months and compared them with our ex-perience of the past 5 years (Box). In the first quarter of 2005, we recorded the highest quarterly number of highly reactive anti-HEV serology results since testing commenced at VIDRL. Also marked on the figure are the dates, over the same time period, when an outbreak of hepatitis in India (either suspected or confirmed to be caused by HEV) was reported on ProMED-mail, the global electronic reporting program for emerging diseases hosted by the International Society for Infectious Diseases (http://www.promedmail.org). It would appear that epidemic HEV activity in India is reflected in significant increases in the number of highly reactive anti-HEV serology results in our laboratory. In fact, as shown in the Box, increases in highly reactive anti-HEV serology at VIDRL have sometimes preceded an outbreak noti-fication on ProMED-mail, and may provide early warning of such an event. A similar association is not observed for epidemics in other countries. Travellers to developing countries must be advised of preventive measures against HEV and other enterically transmitted diseases, and a diagnosis of HEV infection should be considered in any febrile traveller recently arrived from an HEV-endemic area, particularly if jaundice or abnormal liver function tests are present. This is especially important in pregnant women because of the risk of fulminant hepatitis, with maternal mortality in excess of 20% in the third trimester.4 All cases should be notified to state health authorities. Highly reactive anti-HEV IgG EIA results at VIDRL per quarter, 1 Apr 2000 to 31 Mar 2005. Also marked are confirmed (in bold) or suspected epidemics of HEV in India listed on ProMED-mail* during the same period EIA = enzyme immunoassay. HEV = hepatitis E virus. VIDRL = Victorian Infectious Diseases Reference Laboratory. * Available at <http://www.promedmail.org>.

Benjamin C Cowie · Alan Breschkin · Heath Kelly

Noelene S O'Keefe,* Kristina A Heinrich-Morrison,† Bruce McLaren‡ * Project Officer, Legionella Program, Environmental Health, † Public Health Nurse, ‡ Medical Officer, Communicable Diseases Section, Department of Human Services, 17/120 Spencer Street, Melbourne, VIC 3000. bruce.mclarenATdhs.vic.gov.au To the Editor: A 23-year-old man presented to a Victorian hospital with a 4-day history of fever, rigors, confusion and malaise. A chest x-ray showed left lower-lobe pneumonia, and Legionella pneumophila serogroup 1 antigen was detected in his urine. No respiratory specimens were obtained. He recovered completely after treatment for community-acquired pneumonia, including intravenous ampicillin and oral roxithromycin, and returned to work 16 days after onset. Investigations for the source of the infection included environmental review and sampling of cooling towers near his workplace, home, and other sites visited during the incubation period. Active workplace surveillance prompted testing for and detection of L. pneumophila serogroup 1 urinary antigen in a second employee, a 53-year-old man who had presented 2 days earlier than the patient above to another Victorian hospital with fever, abdominal pain and diarrhoea. Legionellosis was not suspected on presentation. He had no symptoms, signs or radiological evidence of pneumonia. Treatment, including intravenous ampicillin and oral roxithromycin, began when the antigen result was obtained, and he was discharged after 10 days in hospital, although he felt unwell for 2 or 3 weeks after discharge. The two men worked near each other in a welding area. A water tank was placed at the entrance to the area, with the cover left open. This acted as a heat exchange for the welding cooling system. A high count of L. pneumophila serogroup 1 (1300 colony-forming units/mL) was grown from a sample of this water. It was common on hot days to cool the work place with an industrial fan. The open water tank was between the fan and the two employees during the incubation period. No L. pneumophila isolates were found in any linked cooling towers. Remedial action included commencing a disinfection program for the water reservoir, and a request to fit the cover correctly and move the fan. No further cases were detected. Because no clinical isolates were obtained, a direct subtype match between clinical and environmental specimens was not possible. Urine antigens are considered definitive laboratory tests given a compat-ible illness (fever or cough or pneumonia).1 Outbreaks of Legionnaire’s disease and Pontiac fever (legionellosis without pneumonia) with industrial sources other than cooling towers have been reported.2,3 This outbreak demonstrates that a simple change in the environment (adding a fan) and an apparently low-risk source (a warm water bath) have the potential to give rise to significant disease. It also shows the value of active workplace surveillance after a single case.

Noelene S O'Keefe · Kristina A Heinrich-Morrison · Bruce McLaren

Osman Mansoor,* Nick Wilson† * Public Health Physician, Public Health Consulting Ltd, Wellington, New Zealand; † Senior Lecturer, Department of Public Health, Wellington School of Medicine, Otago University, PO Box 7343, Wellington South, New Zealand. nwilsonATactrix.gen.nz To the Editor: How marvellous to see the recent editorial by Zwi and colleagues on Australian overseas aid.1 They elegantly (and disturbingly) make the case for increasing development aid, and more specifically, for AusAID support of health programs. They suggest investments are needed in health and education primarily because we care about other people. But there are many other reasons (including enlightened self-interest) for Australia and New Zealand to increase health development assistance, especially in the South Pacific region.2 One reason for reluctance of donors to provide aid is concern that the aid will not be effective or sustainable. Therefore, we would like to briefly report about a joint Australian and New Zealand aid project that has not only been very successful and effective, but has probably saved the taxpayers of both countries millions of dollars in future costs. The two countries jointly funded a 5-year Pacific hepatitis B project that successfully integrated hepatitis B vaccine into the immunisation program of 10 Pacific island countries. The project provided technical support and 5 years’ funding for hepatitis B vaccine on a reducing scale: from 100% (1996–1998) to 75% (1999) to 50% (2000). Since 2001, the Pacific island countries have taken over the funding of hepatitis B vaccine (as they do for the other Expanded Programme on Immunization vaccines). Thus this short-term intervention has provided sustainable gains in hepatitis B control in the Pacific — one of the areas with the highest rates of hepatitis B infection in the world. An initial evaluation in four Pacific island countries demonstrated reduced transmission as a result of the project. For these four countries, the program was estimated to have reduced chronic hepatitis B virus (HBV) infection among preschool children by 81% (95% CI, 69%–88%), with an estimated cost of US$190 per premature death prevented.3 Reducing HBV transmission in the Pacific is likely to reduce disease transmission in Australia and New Zealand (associated with travel movements and migration). But it will also affect health services, as some people born in Pacific island countries will either become long-term residents of these developed countries or travel there for specialist care. The cost of a single case of chronic HBV infection to a developed country’s health services is likely to cover several years of vaccine cost for many of the smaller Pacific island countries. In summary, Australians and New Zealanders should be proud of this particular project. It supports Zwi and colleagues’ call for much more investment in development assistance in health.

Osman Mansoor · Nick Wilson

Stephen E Cains Medical Director, The Fred Hollows Foundation, Locked Bag 3100, Burwood, NSW 1805. scainsAThollows.org To the Editor: I read with interest the personal perspective by Baker, describing her recent visit as part of an ophthalmic surgical team.1 Such teams from Australia have a long and creditable record of service in the Pacific, and their work has been of great value to the people in the countries involved, and of considerable personal satisfaction to those who have taken part in them. The experience of ophthalmic surgeons working with The Fred Hollows Foundation in developing countries certainly confirms Baker’s observations that the density of the cataracts found in these circumstances commonly makes them unsuitable for phacoemulsification. This does not, however, lead to the conclusion that modern small-incision surgery is not suitable for cataract patients in the developing world. Sutureless small-incision cataract surgery (SSICS) by manual means has been practised in many parts of the developing world for many years, with a range of techniques being used to extract the nucleus without phacoemulsification.2,3 Such techniques have been shown to give better uncorrected vision when compared with standard extra-capsular surgery, and are quick4 and economical, with fewer problems requiring follow-up than extracapsular surgery.5 The Fred Hollows Foundation, along with many other non-government organisations and authorities, is actively teaching and promoting the use of SSICS in its programs as the operation of choice for cataract extraction in the developing world. In light of this, I was surprised to see mention of the introduction of phacoemulsification to the Solomons by the team. Not only is this procedure not suitable for a large proportion of the presenting cataracts, but the cost of equipment and consumables in phacoemulsification is several times that of SSICS, and the time taken for surgery is often longer. In an environment where people suffer vision impairment simply from lack of glasses, and where surgeons are available who can perform modern small-incision sutureless cataract surgery, I wonder if this is an appropriate technology to introduce to the region.

Stephen E Cains

John L Szetu Ophthalmologist, Vanuatu National Eye Care Program, Port Vila, Vanuatu. fhfvaneyeATvanuatu.com.vu To the Editor: I am the ophthalmologist from Vanuatu referred to in Baker’s recent article, Sight-seeing in the Solomon Islands,1 who teamed up with the Pacific Islands Project surgeon in Honiara. I am currently working in Vanuatu with the Fred Hollows Foundation (New Zealand) and the Ministry of Health, developing a national eye care program, and continue to make two Fred Hollows Foundation-funded ophthalmic service trips annually to the Solomon Islands. At the end of this year, I will be returning to Honiara to help set up a regional ophthalmic training centre, and again manage and develop the national eye program. The article’s title, while aimed at highlighting the rehabilitation of vision resulting from the visit of a Pacific Island Project ophthalmic team, points ironically to the problem of “medical tourism”. Medical tourism is common in the Pacific, and I speak for many indigenous Pacific doctors when I say that we are trying to discourage the practice because of the patient expectations it raises that cannot be fulfilled, the opportunity cost, and the post-visit cleanup that is often required. Medical tourism is usually well-intentioned and can be seen by those involved as a well earned break from private practice at home. However, it is often not anchored to the real needs and conditions of the countries in which it occurs. The use of phacoemulsification for cataract extraction, as reported in Baker’s article, is a case in point. With due respect, the Pacific Islands Project (PIP) surgeon managed to perform fewer than three phaco-emulsifications, while I did 116 “low technology” manual small-incision cataract surgeries during the 3 days available to us in Honiara. The appropriate backup was not available for “high technology” phacoemulsification. The unit could not be made fully functional, and the surgeon eventually resorted to a manual technique. While quantity is important, so is quality of outcome, for which there is no long-term difference between the high and low technology techniques used in Honiara. Before the civil unrest, the Solomon Islands Eyecare Program was a Pacific leader in terms of facilities, mid-level (nursing and refraction) human resources and overall productivity. I had trained a network of 14 ophthalmic nurses. These workers have held services together in my absence, and been largely responsible for “screening” and organising patients to be seen by visiting teams (PIP), New Zealand-based Volunteer Ophthalmic Services Overseas, and Surgical Eye Expeditions from the United States) and myself. Credit should also go to these workers and the other teams. Medical team visits are valuable, but many Pacific Island nations now see that resources could be better used if they targeted appropriate development of eye care systems and programs, and built local capacity (such as the Solomon Island ophthalmic nurses) rather than delivering services in an ad hoc manner. Visiting service teams need to become aware of this, be prepared to take direction from local authorities, take responsibility for monitoring and evaluating their own clinical activities and outcomes as they would at home, and contribute in an organised and agreed manner to building local resources.

John L Szetu

Michelle L Baker,* Geoffrey T Painter† * Resident Medical Officer, Neurosurgery Department, Royal Melbourne Hospital, 46-58 Drummond Street, Carlton, VIC 3053. † Ophthalmology Coordinator, Royal Australasian College of Surgeons Pacific Islands Project, Melbourne, VIC. michellelouisebakerATyahoo.com In reply: Despite increased efforts over the last decade, the burden of blindness due to cataract is still immense. With over 18 million people in the world blind because of cataract1 there is an obvious need for an affordable and efficient cataract surgery technique. We agree that sutureless small-incision cataract surgery (SSICS) does have an important place in cataract surgery in the developing world. It has advantages over extra-capsular cataract extraction (ECCE) in the longer term, such as decreased cost,2 reduced astigmatism and decreased surgery time.3 There is increasing interest in SSICS among Australian ophthalmologists, and instruction courses are to be held at the forthcoming Royal Australian and New Zealand College of Ophthalmologists meeting. On the other hand, SSICS can be more difficult to learn, and for inexperienced surgeons, there are risks of complications when it is used for a bulky dense cataract.3 ECCE is continuing to evolve, with modern surgical blades giving significantly shelved wounds, which are potentially safer and require fewer sutures, and still has a place. In the Solomon Islands, ECCE and SSICS are the predominant techniques because phacoemulsification is unsuitable for most patients as their cataracts are too dense.3 SSICS was used successfully for suitable cases by Szetu, who is very experienced in the technique. The phacoemulsification machine was brought to Honiara to perform vitrectomy (which the machine is capable of) for diabetic retinopathy in patients who otherwise would have needed expensive treatment in Australia. Phaco-emulsification was purposely used only as a trial (hence, in only three patients), but in the subsequent Pacific Islands Project (PIP) visit, six children with congenital and traumatic cataracts were successfully treated with with phacoemulsification/lensectomy and the insertion of folding intraocular lenses (these were six of a total of 260 operations). In this group it is an ideal technique.4 Currently, it is sustainable to use phacoemulsification because of generous donations. With the advent of low cost phacoemulsification machines (as presented at the Australasian Society of Catar-act and Refractive Surgeons conference in Broome in 2004) and low cost disposables, it is likely the technique will be increasingly used when the backlog of dense cataracts are reduced. Phacoemulsification is the accepted standard of care for cataract surgery in the developed world,2 and there are valid reasons for introducing it into developing countries. Professional development is important, and we must consider the aspirations of our colleagues; the appropriate introduction of phacoemulsification can aid this. We are pleased to hear of Szetu’s return to Honiara, and are sure this technology will have a small, but useful, place in his clinical practice in the future. We cannot agree more strongly that so-called “medical tourism” is wrong. It provides no significant benefit to the community and is disruptive, unhelpful and is, at worst, a burden to the local medical and nursing staff. Unrequested, unhelpful and short-term visits should not be undertaken. The PIP was specifically set up to avoid the abovementioned problems by providing aid that was substantial and well funded (by AusAID), and teaching trips to countries that have made specific requests at the government level for assistance. Such assistance is provided only with the total cooperation and support of local ophthalmic staff, and is run to the highest standards by experienced and committed volunteers. It has been well received in all Pacific countries visited. Ultimately, PIP was intended only as a transitory phase in Pacific development and, as each country achieves self-sufficiency through infrastructure development, visits will be scaled down. We are looking forward to the Solomon Islands regaining the place it once had in Pacific ophthalmology before the civil unrest, and look forward to continuing to help develop the Eye Department in the years ahead. We hope that the close to 1500 operations the PIP team have performed over the eight visits since 2000 have been of help during this troubled time.

Michelle L Baker · Geoffrey T Painter

Graham K Wong,* John W G Tiller† * Psychiatrist, † Professor of Psychiatry, Albert Road Clinic, University of Melbourne, 31 Albert Road, Melbourne, VIC 3004. wonggrahamATmh.org.au To the Editor: We were interested in the recent finding of Simpson and colleagues that a public hospital-based psychiatric assessment service was poorly utilised by general practitioners.1 We established a comparable service in a private setting, with very similar results. In 2002, the senior psychiatry trainee at the Albert Road Clinic (a private psychiatric hospital in Melbourne) established a GP psychiatric assessment service in response to a previously established need.2 The additional aim was to reduce waiting times and patient costs of seeing a private psychiatrist. There were no out-of-pocket expenses for patients. The service was promoted to 300 local GPs with an individually addressed flyer; a notification was published in the local Division of General Practice newsletter; and discussions were held with the local public mental health service to redirect appropriate referrals from GPs. A survey evaluated GPs’ subsequent satisfaction with the service after a patient was referred and seen. Over a recruitment period of 15 weeks, an average of only one patient per week was referred. The referring GPs were happy with waiting times (well within a week), the quality of the service, and the communication received by the assessing senior psychiatry trainee. The similarity between these independently established services and the findings are striking. Of note, was the paucity of referrals from GPs despite clearly expressed needs. We wonder to what extent GPs’ perceptions of difficulties accessing psychiatric assessment from the private sector are the result of a small subset of difficult patients, rather than the general rule. There are numerous GP and psychiatrist-focused initiatives to overcome reported difficulties accessing specialist psychiatric input for GPs. Most recent of these is a new Medicare Benefits Schedule item that increases remuneration for psychiatrists to outline a detailed management plan for the GP to continue care of the patient. The findings of these types of psychiatric services directed at GPs highlight the limitations of GP uptake of such incentives. At the very least, there is a requirement for adequate promotion, education and ongoing reinforcement of the referral model to psychiatrists, GPs and practice managers alike.

Graham K Wong · John W G Tiller

Umberto Boffa Medical Director, BUPA Australia Health Insurance, 600 Glenferrie Rd, Hawthorn, VIC 3122. umberto.boffaAThba.com.au To the Editor: Taylor and colleagues have provided an excellent analysis of the prevalence and causes of vision loss in Australia.1 However, their conclusion that vision loss in Australia is a much bigger problem than is usually recognised and requires “save your sight” public promotion bears some discussion. The main outcome measure used was impairment in visual acuity. Impairment does not necessarily equate with disability. Disability has been defined as an alteration of an individual’s capacity to meet personal, social or occupational demands, or statutary or regulatory requirements, because of an impairment.2 An impaired person is not necessarily disabled. The study of Taylor et al did not use measures of visual disability, such as the VF-14 (Visual Function Index). Participants were asked to complete a questionnaire that included information about “symptoms of eye disease”, but it is not clear that the questionnaire explored self-perceived problems with vision. Nor does the study seem to have looked at the level of cognitive impairment within this aged population. Tielsch et al, in a similar study,3 made the point that whether people who have both a treatable loss of vision and cognitive impairment should receive ophthalmological intervention depends on the cause and severity of the cognitive deficit. Further, Taylor and colleagues stated that, after undercorrected refractive error, cataract is the most common cause of low vision and is also comparatively easily treated, but they did not objectively evaluate the relative risks and benefits of such interventions. The study provides interesting data on the extent of visual impairment in Australia, but the authors are presupposing that the uncovered prevalence of visual impairment necessarily constitutes a social problem requiring “save your sight” public health measures. Reference should be made to patient goals and needs, and an objective cost–benefit analysis, before such a conclusion can be reached.

Umberto Boffa

Konrad Pesudovs,* Douglas J Coster† * Deputy Director, † Director, NHMRC Centre for Clinical Eye Research, Department of Ophthalmology, Flinders Medical Centre and Flinders University, Bedford Park, SA 5042. Konrad. PesudovsATflinders.edu.au To the Editor: The timely report of Taylor and colleagues of large numbers of Australians suffering visual impairment caused by refractive error raises some important questions.1 Firstly, is it reasonable to assume that visual acuity of less than 6/12 is disabling and demands intervention? The correlation of visual acuity and visual disability is tenuous.2-4 This is not surprising. Visual acuity measures a narrow domain of visual function. Different abnormalities differentially impact across wide domains of visual function. Everyday sight-dependent functions will be affected differently. For example, people with cataracts may experience reduced contrast sensitivity and colour discrimination, while those with advanced glaucoma will lose visual field, but those losses will affect a person’s life independent of visual acuity. Conversely, myopia acquired in old age may reduce visual acuity to less than 6/12 but may also provide spectacle-free near vision adequate for reading and other daily tasks. This may not cause any disability for an elderly person whose life is spent predominantly indoors. Therefore, it seems inappropriate to assume that the 62% of people with visual impairment caused by refractive error suffer visual disability to the extent of those with glaucoma or age-related macular degeneration. A better approach to measuring visual impairment would be to use patient-centred measures, which consider the impact of eye disease on visual performance, rather than the convenient but narrow measure of visual acuity. If visual acuity is to be used, its limitations as an indicator of visual disability should be considered, and inferences about visual impairment should remain constrained by these limitations. The second question which follows from the report that uncorrected refractive error is responsible for 62% of visual loss below 6/12 is: why do people so affected not wear spectacles? Perhaps there are barriers to acquiring spectacles, such as access. However, this seems unlikely as there is an optometrist in every major shopping centre. Certainly, cost may be a barrier, and a study from our Centre has shown that spectacle correction may reduce quality of life in the domains of wellbeing, convenience, and economic concerns.5 Therefore, it seems likely that the cost–benefit balance is such that these people are not sufficiently dis-abled by their vision to go to the inconveni-ence and expense of acquiring spectacles. The authors have raised important issues which require clarification. Is it that visual acuity overestimates the impact of refractive error on visual disability, or is the system for supplying spectacles to Australians failing?

Konrad Pesudovs · Douglas J Coster

Jill E Keeffe,* Hugh R Taylor† * Director, Population Health Division, Department of Ophthalmology, University of Melbourne, and Royal Victorian Eye and Ear Hospital, Locked Bag 8, East Melbourne, VIC 8002; † Professor, Centre for Eye Research, University of Melbourne, VIC. jillekATunimelb.edu.au In reply: Boffa and Pesudovs and Coster all correctly point out that a reduction in visual acuity does not always lead to dis-ability, and that not all people with impaired vision are disabled or report impaired quality of life. Large Australian and American population-based studies have shown that visual acuity below a critical level of 6/12 is associated with disability and affects participation in chosen activities and quality of life.1 When compared with people with normal vision (≥ 6/12), those with impaired vision have an increased risk of falls and hip fractures, depression, difficulties with activities of daily living and social functioning.1 Not all people with reduced visual acuity are affected in the same way at any vision threshold, even if there is a demonstrated statistically significant association between poor vision and visual function and quality of life. For example, not all people with severe visual impairment (visual acuity < 6/60) report an impact on their own visual functioning or quality of life. The impact of poor vision on functional ability is similar for conditions such as cataract or acute macular degeneration as for refractive error. The impact has been shown with both correctable and uncorrectable vision impairment.2 The VF-14 (Visual Function Index) can be used as a measure of visual disability, as suggested by Boffa. It was used in the Melbourne Visual Impairment Project and confirmed the functional implications of vision impairment (visual acuity < 6/12).3 Studies show unequivocally that vision impairment is a social3 and economic4 problem, and suggest the need for health promotion campaigns. Pesudovs and Coster ask why, in a country such as Australia, with optometrists “in every major shopping centre”, do people with refractive error not have the correct spectacles? They suggest some barriers of access to care. The Brotherhood of St Laurence has shown that affordability of glasses and rural disadvantage are barriers to access and equity of use of eye care services.5 Our report highlighted the fact that catar-act is an important cause of vision loss that is highly amenable to surgical intervention.6 We did not discuss the relative risks and outcomes of cataract surgery, which is well documented to be highly successful, with low complication rates (< 2% for most complications),7 and very high cost-effectiveness.

Jill E Keeffe · Hugh R Taylor

Heather Cleland Director, Burns Unit, The Alfred Hospital, Commercial Road, Prahran, VIC 3181. burnsunitATalfred.org.au To the Editor: While mention is made in the recent position statement1 of the inappropriateness of home oxygen use in association with continued smoking, I wish to highlight the fact that the dangers of this activity — and indeed of any open flame in proximity to oxygen delivery units — constitutes significantly more than a theoretical hazard. In the past 4 months, the Victorian Adult Burns Service at The Alfred Hospital, Melbourne, has admitted two patients with severe burns sustained in fires caused by smoking in association with domiciliary oxygen use. Both these patients died of their burn injuries, and the cases have been reported to the coroner. I am aware of at least one other fatality that occurred under similar circumstances in the same time period in Victoria. If patients or people living with them continue to smoke, oxygen therapy should be withdrawn. I also suggest that the position statement should emphasise the need for adequate and regular domiciliary assessments of people using this therapy and the importance of ongoing education about the dangers of oxygen use in association with any open flame.

Heather Cleland

The sugar story continues The accepted normal fasting plasma level of glucose has been lowered, step-by-step, over the past two decades from 7.7 mmol/L (140 mg/dL) to less than 5.5 mmol/L (100 mg/dL). Now, a US expert suggests that fasting plasma glucose levels represent a continuum, and that the border between what is “normal” and “abnormal” is a shady zone, influenced by a range of factors, including weight, age and sex.1 Dr Ronald Arky was commenting on an Israeli study which followed a large military cohort for 12 years.2 Healthy young men with fasting plasma glucose levels at the high end of the normoglycaemic range were found to be more likely to develop type 2 diabetes. Together with other independent risk factors for diabetes, like body mass index (BMI) and serum triglyceride levels, this assay could help to identify apparently healthy men at increased risk of diabetes. 1. N Engl J Med 2005; 353: 1511-1513 2. N Engl J Med 2005; 353: 1454-1462 Don’t follow our lead An Australian expert has cautioned that Canada will face “similar ill effects” if it follows the Australian path of health organisation by allowing private health sector provision of some essential health services.1 Currently in Canada, there is a government monopoly of health care services but this public system is perceived to have several problems (eg, inefficiency, high costs) which need fixing.2 Professor Stephen Duckett, writing in the CMAJ, said that the dual system of public and private care had deleterious implications for the equity and efficiency of the Australian health care system. For example, those with health insurance have faster access to elective surgery than those without; and, due to subsidies, government expenditure for each additional patient treated in the private sector is well over the price paid for treating additional patients in the public sector. 1. CMAJ 2005; 173: 745-747 2. CMAJ 2005; 173: 565 High-toxin intruder alert A hypervirulent strain of Clostridium difficile has been identified as the agent responsible for the high mortality reported in the 2003-2004 outbreak in Sherbrooke in Quebec, Canada.1 Compared with non-epidemic strains, the epidemic strain (NAP1/027) produces 16 times the amount of toxin A and 23 times the amount of toxin B.2 The NAP1/027 strain has also been detected in the USA, the UK and the Netherlands. A commentator warned that we are feeling the cold wind of another threatening epidemic emerging in the face of our frequent use of broad-spectrum antibiotics.3 1. CMAJ Online, 29 Sept 2005 2. Lancet 2005; 366: 1079-1084 3. Lancet 2005; 366: 1053-1054 Exercise for the brain Leisure-related physical activity in midlife may decrease the risk of dementia in later life, according to Scandinavian researchers. They followed 1449 adults, with an initial mean age of 50 years for an average of 21 years, by which time 117 persons had dementia and 76 had Alzheimer’s disease. Participants had been asked, in midlife questionnaires, “How often do you participate in leisure-time physical activity that lasts at least 20-30 minutes and causes breathlessness and sweating?” Those who had engaged in leisure-time physical activity at least twice a week at midlife had 50% lower odds of dementia compared with sedentary participants. This protective effect seemed more pronounced for Alzheimer’s disease and among APOE ε4 carriers. Lancet Neurology Online, 4 Oct 2005 Weighing up for a lifetime The lifetime risk of becoming overweight or obese may be even higher than that previously estimated from cross-sectional surveys, according to data from the Framingham Offspring Study data. In this long-term longitudinal study, 4117 participants, aged 30 to 59 years of age at baseline, were followed for up to 30 years. It found that nine in 10 of these young to middle-aged adults were already overweight, or developed overweight over the three decades; and, that one in two adults were already obese or developed obesity. Ann Intern Med 2005; 143: 473-480 Postcards from the Edge Australian researchers have reported that a low-cost postcard-based intervention could reduce repetitions of deliberate self-poisoning. They randomised 772 patients, aged 16 years or older, who had presented with deliberate self-poisoning to either receive or not receive a postcard intervention, in addition to usual care. A total of eight postcards, conveying a simple message of good wishes, was sent to each patient in the intervention group (at 1, 2, 3, 4, 6, 8, 10 and 12 months after discharge). For the year after discharge, the proportion of “repeaters” was the same in both the intervention and control groups; however, the number of repeat episodes per person was lower in the intervention group. The intervention group occupied hospital beds for 129 days (101 repetitions) compared with 239 days (192 repetitions) in the control group — a total of 101 bed days saved. BMJ Online, 23 Sept 2005

Ann Gregory