Volume 184 Issue 1

Artesunate reduces mortality and should now be the treatment of choice in severe malaria in adults: good news for countries in our region, but registration in Australia must wait For nearly 400 years quinine has been the principal drug used to treat severe malaria. Despite its long history of efficacy, quinine has significant limitations. Even with prompt administration, case-fatality rates in severe malaria often exceed 20%.1 Furthermore, quinine requires three-times-daily administration and has a number of adverse effects including hypoglycaemia, vomiting, headache and tinnitus.1 The identification of artemisinin from sweet wormwood (Artemisia annua) in China in the 1970s focused attention on the most rapidly acting of all antimalarial drugs,1 and raised hopes that artemisinin derivatives would reduce the high case-fatality rate in severe malaria. Initial trials using intramuscular artemether demonstrated less toxicity but no clear mortality benefit over quinine,1 most likely due to the erratic absorption of the intramuscularly administered oil-based preparation of artemether.2,3 More recent trials have used intravenous artesunate, a water-soluble derivative with a more favourable pharmacokinetic profile.3,4 The SEAQUAMAT trial, a multicentre randomised trial conducted in Bangladesh, Myanmar, Indonesia and India, recently reported a 34.7% reduction in mortality associated with intravenous artesunate compared with intravenous quinine.5 This is the largest trial ever performed in severe malaria and the first to demonstrate conclusively a mortality reduction over standard quinine therapy. This is good news for malaria-endemic areas in South-East Asia. The burden of malaria in our region is far worse than previously thought, with over 120 million cases each year in south/south-east Asia.6 The World Health Organization now advocates the use of artemisinin combination therapy for uncomplicated malaria,7 a move that is likely to reduce the number of people developing severe disease. Now there is convincing evidence that for those who do develop severe malaria, intravenous artesunate will reduce the risk of death by one-third.5 It is also safer and easier to use than quinine. What about children? In the 202 children in SEAQUAMAT, artesunate was equally safe and effective.5 But the study did not have the statistical power to demonstrate a mortality benefit in the paediatric age group. In the Asian countries that have changed policy, artesunate is first-line treatment for both adults and children. However, because the clinical pattern and rapidity of death is different in paediatric severe malaria in high transmission areas, a randomised trial comparing mortality in African children treated with artesunate and quinine has recently commenced. Several countries in our region recommend parenteral artemisinin derivatives as first-line therapy for severe malaria, including Vietnam, Thailand, Papua New Guinea and Cambodia.8 As a result of SEAQUAMAT, Indonesia has now also changed national policy from quinine to artesunate. However, quinine is still national policy for severe malaria in most other Asia–Pacific countries.8 At US85c–$1 per 60 mg vial when purchased in bulk, artesunate is only modestly more expensive than quinine. And this does not take into account the intravenous infusions and additional nursing required for quinine. The number needed to treat to save one life was between 11 and 20 in the SEAQUAMAT study, making this a very cost-effective policy change. A major issue for many national bodies faced with licensing parenteral artesunate is that neither of the current manufacturers in China and Vietnam produce a formulation approved as compliant with international Good Manufacturing Practice (GMP) speci-fications. Support from the developed country pharmaceutical industry does not appear likely. United States Army plans for independently developing a GMP-compliant formulation have been delayed by the lack of a commercial co-development partner.9 Absence of GMP certification does not necessarily mean poor quality: independent analysis of the lots used in the SEAQUAMAT trial demonstrated satisfactory quality of this drug. However, neither of the current manufacturers has yet received WHO prequalification certification, a requirement for the WHO and several other international agencies to purchase drugs centrally and distribute large quantities at low cost to ministries of health. Nevertheless, forthcoming WHO guidelines will recommend artesunate be made the treatment of choice for severe malaria in adults.10 What about Australia and other developed countries? In settings with well resourced intensive care facilities, the mortality rate from severe malaria is less than that seen in most sites involved in the SEAQUAMAT trial.11 It is possible that the benefit with artesunate (seen after 24–48 hours in the SEAQUAMAT trial) could be attenuated by better treatment of late complications in a developed country setting. However, the magnitude of the mortality reduction was remarkably consistent among the SEAQUAMAT sites, despite varying mortalities and levels of ancillary care. Parenteral artesunate should therefore be the treatment of choice for adult severe malaria in all countries.10 The lack of a GMP-compliant formulation is, however, a major hurdle and means that artesunate cannot be registered in Australia by the Therapeutic Goods Administration12 or in other countries, including the European Union and United States. This creates a paradox. In contrast to the usual situation, a life-saving drug is available and being used in many developing countries, yet cannot be registered in developed countries. Although it is clearly far more important that these drugs are available in malaria-endemic countries, and the number of Australians developing severe malaria each year is small, it is unacceptable that we must continue to use quinine when a drug that reduces mortality by one-third is available elsewhere. Pending the availability of a GMP-compliant product that can be registered, an interim strategy is available in Australia. Hospital pharmacies can import and hold artesunate for category A usage in named patients with severe malaria under the Special Access Scheme, reserved for “very seriously ill patients” with a high short-term likelihood of death in the absence of early treatment.13 This strategy could be coordinated by a consortium of state/territory hospital pharmacies in capital cities and supported by the relevant national professional bodies. Ideally, the quality of an imported lot of non-GMP artesunate should have been confirmed at a Good Laboratory Practice-compliant laboratory. From a global perspective, registration and availability of parenteral artesunate in both malaria-endemic and developed countries would be maximised if current manufacturers were given assistance to become GMP-compliant without delay.

Nicholas M Anstey PhD, FRACP · Ric N Price MD, FRACP · Nicholas J White FRCP, DSc

Contributing to health services research, implementation and effective health policy-making Some of the most pressing issues in Australian health care are not about the efficacy of particular treatments, but rather how health services can be organised to deliver optimal care. Examples of service-related initiatives familiar to most clinicians include: multidisciplinary teams to improve coordination of cancer care; designated trauma centres to optimise management of injured patients; financial incentives to encourage particular services; restricted licences for overseas medical graduates to increase the rural workforce; specialist outreach and telemedicine to improve access in remote areas; clinical audit and review to enhance care quality; and management and prescribing guidelines. Broadly speaking, these represent a spectrum of organisational, financial, regulatory and professional interventions aimed at improving service delivery and achieving best practice. Just as clinicians and patients are concerned with the effectiveness of clinical treatments, policy-makers and the public are interested in the effectiveness of health system interventions. For clinical treatments, questions about “what works” may be best answered using randomised controlled trials and other experimental designs. Those studying the effectiveness of health service interventions, however, face some specific methodological and analytical challenges, and often need to consider other types of designs. Is it possible to randomise communities to receive outreach visits, for example? What are the important outcomes of employing nurse practitioners in remote areas? Can we effectively control for other health service changes, such as closure of a hospital, or loss of staff, that may be unavoidable during a study period? In studies in which the intervention is delivered to a population, but the outcomes are measured in individual patients, how do we take clustering effects into account in the analysis? Australians have contributed to developing appropriate methods (some adapted from economics and social sciences) for addressing such questions in real-world situations. Support for the Australian health services research community has come from the Health Services Research Association of Australia and New Zealand (http://www.chere.uts.edu.au/hsraanz/), established in 2001, the longstanding interest of The Medical Journal of Australia, as well as other organisations, and the Australian and New Zealand Journal of Public Health, Australian Health Review, and a new open-access journal, Australia and New Zealand Health Policy (http://www.anzhealthpolicy.com). Syntheses of available research also contribute to rational health policy-making. The international Cochrane Collaboration maintains systematic reviews in which the research literature on a topic has been identified, selected, appraised and synthesised in a transparent way.1 Such reviews reduce the likelihood of people being misled by research findings, and increase the confidence in what outcomes can be expected from an intervention.2,3 However, reviews of health service interventions differ in that, to be useful for policy-makers and managers, the goal of methodological rigour that characterises Cochrane reviews needs to go hand in hand with an understanding of the challenges inherent in health services research. The Cochrane Collaboration’s Effective Practice and Organisation of Care (EPOC) Group, based in Ottawa, Canada, is dedicated to conducting reviews of interventions designed to improve professional practice and the delivery of effective health services, potentially spanning any clinical area.4 It has already produced 37 reviews on topics such as audit and feedback, discharge planning, hospital in the home, printed educational materials, telemedicine and specialist outreach. A particular focus of EPOC has also been how to broaden the types of included studies beyond blinded randomised trials, while at the same time optimising validity and generalisability. These include designs such as controlled before–after studies and interrupted time series studies. Recognising that evidence for policy-making is not always readily available, the Australian Government has provided for a new partnership between EPOC and the National Institute of Clinical Studies (NICS). The Australian EPOC satellite at the National Institute of Clinical Studies was officially announced at the Cochrane Colloquium in Melbourne on 22 October 2005. NICS is funded by the Australian Government to help improve uptake of evidence into clinical practice, and to use evidence about individual, organisational and system change in designing implementation programs. In addition, free access to the Cochrane Library (and a user’s guide) is available through the NICS website (http://www.nicsl.com.au). The overall goal of the satellite is to assist evidence-based policy-making through systematic reviews of interventions designed to improve health care practice and the delivery of effective health services relevant to Australia and our region. In particular, the satellite aims to: identify and help produce priority EPOC reviews relevant to Australia; support EPOC review activity through training and mentoring of researchers; and foster a culture of evidence-based health policy and knowledge translation by promoting the use of the Cochrane Library, and EPOC reviews in particular. In addition, the Australian satellite will: support the EPOC editorial base in Canada by editing, producing and updating EPOC reviews, especially reviews relevant to rural areas; collaborate with the Australasian Cochrane Centre and the other Australian-based Cochrane groups to further the work of the Cochrane Collaboration in the region; and contribute to the international effort of synthesising research to improve evidence uptake. We hope that the satellite will make an ongoing contribution to Australian health services research, implementation and effective health policy-making.

Russell L Gruen MB BS, PhD, FRACS · Heather Buchan MB ChB, MSc, FAFPHM · Jan Davies PhD, MBA · Alain Mayhew MSc · Jeremy M Grimshaw MB ChB, PhD, FRCGP

Objectives: To measure the incidence of treated non-melanoma skin cancer (NMSC) in Australia in 2002 and investigate trends since 1985 by histological type, sex, age group, latitude and skin type. Design: Face-to-face survey between 1 January and 31 December 2002 using stratified sampling of households to identify people treated for skin cancer in the previous 12 months. Self-reported diagnoses were confirmed with treatment providers. Data from similar surveys conducted in 1985, 1990 and 1995 were used to assess trends. Setting: Whole of Australia (population 19.6 million). Participants: Of 57 215 people interviewed, 4098 said they had been treated for skin cancer in the past year and 3198 gave permission for their diagnoses to be confirmed with their doctor. Results: 817 people were confirmed as having at least one skin cancer treated in the past year. The age-standardised rate per 100 000 population for NMSC was 1170, for basal cell carcinoma (BCC) 884, and for squamous cell carcinoma (SCC) 387. The estimated number of NMSC cases in Australia for 2002 was 374 000. Cumulative risks to age 70 years of having at least one NMSC were 70% for men and 58% for women. Rates of BCC and SCC have increased since 1985, and the increases greatest for people aged 60 years and older; rates for those younger than 60 years have stabilised. Conclusions: The incidence of treated NMSC in Australia in 2002 was more than five times the incidence of all other cancers combined. Although the overall NMSC rates have risen since 1985, the stabilisation of rates for people younger than 60 years who were exposed to skin cancer prevention programs in their youth highlights the importance of maintaining and strengthening these programs.

Margaret P Staples DipAppSc, BBSc, MSc · Mark Elwood MD, DSc, FRCPC, FAPHM · Robert C Burton FRACS, FRACP, FAFPHM · Jodie L Williams BBus · Robin Marks MPH, FRACP, FACD · Graham G Giles BSc, MSc, PhD

The number of skin cancer clinics functioning within Australia’s primary care environment is increasing rapidly, and significant concerns have been raised about the type and quality of work done by some doctors in some clinics. Mainstream general practice is threatened by perceived fragmentation, and specialist practice in dermatology and plastic surgery is threatened by encroachment into their domains of practice. We propose an agenda of training, standards, accreditation, audit and research to ensure that skin cancer clinics provide optimal health outcomes for patients.

David Wilkinson MB ChB, FRACGP, DSc · Scott Kitchener MB BS, DrPH, FAFPHM · Peter Bourne MB BS · Anthony Dixon MB BS, FACRRM

Research shows that a large proportion of shade structures provide insufficient protection against the sun’s ultraviolet light. Shade creation guidelines need to be updated. Community organisations such as child care centres and schools that need to provide effective shade are hindered by cost and building regulations. The protective function of shade structures is more important than their aesthetic appeal.

David J Turnbull PhD · Alfio V Parisi PhD

In view of the possibility of a human pandemic of avian influenza, a first-line strategy for many countries is stockpiling of antiviral neuraminidase inhibitors (oseltamivir [Tamiflu] and zanamivir [Relenza]), which can reduce mortality, morbidity and influenza transmission. However, global supply of the antivirals is controlled by the European-based patent owners, Roche and GlaxoSmithKline. This prevents competition in the manufacturing and distribution of antivirals and has reduced global supply capacity and affordability. The Australian Government has acknowledged that, in the event of a pandemic, its own stockpile of antivirals will be limited and reserved for those on a confidential rationing list. Pharmacies are running out of stocks, limiting opportunities for individuals to secure supplies privately. Compulsory licensing provisions, permitted under domestic patent law, would allow Australian generic manufacturers to start producing antivirals locally or import them from generic producers at affordable prices. Australia also has an opportunity and a responsibility to promote compulsory licensing and generic antiviral production in the Asian region, to ensure our neighbours can establish pandemic stockpiles in a timely and affordable manner.

Buddhima Lokuge MB BS, MPH · Peter Drahos GDLP, LLM, PhD · Warwick Neville BA, LLB, STD

They call it the “Rat Village” — a small community of 17 families in south-eastern India’s Tamil Nadu province, which gained its unenviable name as a consequence of dietary necessity. Indirectly affected by the Boxing Day tsunami of 2004, Vadapattanam has no claim to receive help from government organisations. With no employment, no income, no funds for schooling and no aid, the people of this small village captivated us with their resilience, optimism and friendship. The rat catcher uses a small earthen pot stuffed with dry wooden debris. A small fire is started inside and the mouth of the pot is aimed towards the rats’ burrow. By blowing through a mouthpiece at the opposite end, a steady stream of smoke is forced into the rats’ sanctuary, eventually suffocating them. The burrow is raided not just for the meat within, but also the rice that the rats have sequestered from nearby paddies. These are the staple foods of Vadapattanam, one small meal a day sustaining the residents. One month volunteering as a doctor with the non-government organisation Earthaid introduced me to this community and many similar ones. Earthaid’s post-tsunami relief efforts are concentrated on several small communities that were devastated by the disaster but do not meet the criteria for receiving foreign donations. This village never saw the rising water and no one drowned. However, the occasional employment from farmers and nearby villages that they relied on for income dissipated with the destruction caused by the tsunami. Five months later, most villages directly affected by the tsunami have received government relief and are faring well with adequate food, access to health facilities and a higher than ever proportion of children attending school. Villages like Vadapattanam, which was indirectly affected, are still suffering. Vadapattanam would be described by a real estate agent as “rustic”, consisting of 20 clay huts with thatched roofing on one side of a dirt track and a small, stagnant backwater lake on the other. This water is shared by villagers for bathing, attempts at catching seafood, toileting, and the washing of clothes, vegetables and rice. A shallow bore providing precious, unsalinated drinking water is only a kilometre away and, thankfully, separate from backwater run-off. On a typically stifling, hot, pre-monsoonal afternoon, we were dropped off by our driver for the first time on the dirt road that ran alongside Vadapattanam — one nurse, one doctor, an Indian translator, six large bottles of drinking water and a suitcase stocked with precious donated pharmaceuticals and other basic medical provisions. We were provided with mats in a shady area where we spent the next few hours assessing the community and providing basic medical aid. Our first patient was the village head, who had an open fracture of his middle finger on the dominant hand, sustained a month previously. The finger was almost as wide as it was long, green with frank pus and excruciating just to look at. He seemed impervious to the pain but genuinely concerned that it was preventing him from attending to his normal working activities within the village at its most desperate time. After being slightly miffed that we couldn’t fix his finger on the spot, he gave us an interesting history of Vadapattanam and an insight into the villagers’ way of life and their current problems. The villagers of Vadapattanam are descendents of Indian tribes who were once famed for cultivating herbs and producing traditional medicines. This industry was gradually lost over generations, with displacement. In more recent times, occasional woodcutting and farmhand jobs have provided a meagre income. After the tsunami, the loss of sporadic employment meant things got worse very quickly. Regular meals ceased and education became unaffordable. The ailments seen by the mobile medical clinic over the next month were generally infectious or traumatic in nature, with Vadapattanam the only village in the area to have obvious nutritional deficiencies. Not surprisingly, given the poor community knowledge about links between poor hygiene and disease, typhoid fever was present and parasite infestations seemed ubiquitous. One young patient dutifully self-diagnosed his intestinal infestation by coughing up a sample of his resident worms. Skin infections (scabies, fungal infections or infected wounds) and otitis media and externa were also relatively common, particularly in the children. Occasionally, we encountered infectious diseases interesting enough to excite a microbiologist, including filariasis, malaria and leishmaniasis. A large component of the mobile clinic’s time was allocated to community health education on issues such as hygienic toileting, safe methods to prepare water for drinking and washing of food, methods of transmission of intestinal worms and typhoid fever, and many other topics aimed at disease prevention. All the villages we were involved with seemed keen to adopt our recommendations, and in Vadapattanam, after one particular education session, separate areas for toileting and washing of food were introduced immediately. While food donations and mobile medical clinics from non-government organisations help in the short term, they are not sustainable and do little to encourage self-sufficiency. The other arms of Earthaid address these issues by attempting to place children in education and train the adults in income-producing activities. On initial assessment, the most senior villagers in Vadapattanam expressed a strong desire to return to the industry of their ancestors. It was difficult not to be impressed by the motivation and determination of this community. In partnership with another non-government organisation and after appropriate soil testing, funds were set aside to purchase land on the opposite side of the backwater to be used for cultivating herbs and vegetables. Equipment for working the land and the initial crops is being organised, and education sessions by experienced farmers have begun. With these major hurdles breached and with some good fortune in weather patterns, the community of Vadapattanam will hopefully be less reliant on outside help in coming years. However, in the short term, necessities remain unaffordable and need to be provided by outside aid agencies. A gift of 16 goats and a regular, once-weekly rice donation were organised by Earthaid to address the immediate food shortage. The children have also been provided with tuition fees, bags, schoolbooks, and footwear for the 2-kilometre walk to school. With further short- and long-term support, it is hoped that the village of Vadapattanam will once again begin to deserve its currently ironic name, “vada” meaning “food” and “pattanam” meaning “town” in the local Tamil dialect.

Rohen White MB BS

The Indian Ocean tsunami of 26 December 2004 has drawn attention to the need for a process to ensure that health aid is provided in an efficient, coordinated and appropriate manner. In response to this, and with support from various medical colleges and the Australian Government, we have established the Australian Health Alliance to Assist with Post-tsunami Reconstruction. In Sri Lanka, some of the current challenges include shortages of medical staff, damaged infrastructure and changing demands due to population shifts. Psychological services are particularly scarce. The psychological and cultural implications of disaster require specific attention when designing aid programs. The goals of the Health Alliance include providing a forum for discussion, identifying specific local needs, coordinating health services and helping local organisations to develop action plans.

Paul A Komesaroff MA, PhD, FRACP · Suresh Sundram PhD, FRANZCP

Objective: To survey the use, cost, beliefs and quality of life of users of complementary and alternative medicine (CAM).Design: A representative population survey conducted in 2004 with longitudinal comparison to similar 1993 and 2000 surveys.Participants: 3015 South Australian respondents over the age of 15 years (71.7% participation).Results: In 2004, CAMs were used by 52.2% of the population. Greatest use was in women aged 25–34 years, with higher income and education levels. CAM therapists had been visited by 26.5% of the population. In those with children, 29.9% administered CAMs to them and 17.5% of the children had visited CAM therapists. The total extrapolated cost in Australia of CAMs and CAM therapists in 2004 was AUD$1.8 billion, which was a decrease from AUD$2.3 billion in 2000. CAMs were used mostly to maintain general health. The users of CAM had lower quality-of-life scores than non-users. Among CAM users, 49.7% used conventional medicines on the same day and 57.2% did not report the use of CAMs to their doctor. About half of the respondents assumed that CAMs were independently tested by a government agency; of these, 74.8% believed they were tested for quality and safety, 21.8% for what they claimed, and 17.9% for efficacy.Conclusions: Australians continue to use high levels of CAMs and CAM therapists. The public is often unaware that CAMs are not tested by the Therapeutic Goods Administration for efficacy or safety.

Alastair H MacLennan MD, FRCOG, FRANZCOG · Stephen P Myers PhD, BMed, ND · Anne W Taylor BA, MPH

Objectives: To examine the commercial development of Australian medical patents and identify the determinants of their being used in innovations (new or improved products or production processes).Design: Cross-sectional survey with a nested case–control study.Participants and setting: 177 inventors listed as the first Australian on medical patents granted in the United States between 1 January 1984 and 30 December 1994, and surveyed in 1998–1999.Main outcome measure: A series of predictor variables (including characteristics of the patents; characteristics of the inventors; ideas, advice and funding during commercialisation; and the process of commercialisation) for whether or not a patent became an innovation.Results: Half (89/177) of the medical patents became innovations, with 34% generating a total of A $287 million (13% over $1 million) in annual sales a median of 8 years after the patent had been granted. A patent was more likely to become an innovation if the inventor was employed by industry at the time of invention (odds ratio [OR], 3.2; 95% CI, 1.1–9.2), had invested their own finances (OR, 2.8; 95% CI, 1.0–7.4), and if the patent had been licensed (OR, 4.6; 95% CI 1.7–12.7), led to further patents (OR, 3.2; 95% CI, 1.0–10.4) and involved an industry partner in its commercial development (OR, 10.1; 95% CI, 3.6–27.7). It was less likely to become an innovation if finance came from a research funding agency (OR, 0.3; 95% CI, 0.1–0.8) and if interest from Australian industry was judged by inventors as “poor” (OR, 0.6; 95% CI, 0.4–0.9).Conclusions: Medical patents in the US listing Australian inventors are more likely to become innovations if they originate from industry rather than the public sector, and if inventors are willing to invest their own finances.

Eugen Mattes MPH, PhD, FRACGP · Michael C Stacey DS, FRACS · Dora Marinova BEng, MSc, PhD

An ophthalmologist who made an enormous contribution to improving eye care in Central Australia, Wilfred Win Law died suddenly on 11 October 2005 as the result of a stroke. Wilfred was born on 11 June 1930 in Rangoon, Burma. He graduated from Rangoon University in 1955, after which he received postgraduate training in ophthalmology in London. After working at the Royal Victorian Eye and Ear Hospital, Melbourne, in 1977, he spent 6 years in Hong Kong before moving to Alice Springs in 1984 to take up the position of Senior Specialist Ophthalmologist at Alice Springs Hospital. For the next 21 years, until his death, he devoted himself to establishing a sustainable eye care service in Central Australia — a service that was badly needed. Through his considerable energy and dogged persistence, Wilfred built up a substantial ophthalmology service based in Alice Springs. Recognising the paramount need to achieve a sustainable pattern of activity, he committed himself to stay for the long term. He realised that a resident specialist would always be able to achieve more than a visitor. He also recognised the value of teaching and training the next generation. Like all good teachers, he was a generous man, prepared to pass on in a few minutes something that he may have taken decades to learn. He also had a well developed sense of responsibility. This he attributed to his traditional oriental upbringing. He felt he was fortunate to have been given the talent to study medicine and the opportunity to do so. In recognition of this privilege, he chose to practise medicine for as long as he could do it well — and he did, until the day he died. Wilfred taught not by preaching but by example. If he was consulted by junior emergency staff, even in the middle of the night (as was often the case), he was always prepared to attend the hospital — replete in coat and tie. The junior staff loved him for his generosity, wisdom and after-hours support. To them he was more a mentor than a clinical supervisor. Wilfred is survived by his wife Elizabeth, children Justus and Maria, and two much-loved grandchildren.

Douglas J Coster

CorrectionRe: “Long-term trends in cancer mortality for Indigenous Australians in the Northern Territory”, by John R Condon, Tony Barnes, Joan Cunningham and Bruce K Armstrong, in the 17 May 2004 issue of the Journal (Med J Aust 2004; 180: 504-507). Box 1 on page 505 of this article inadvertently included some incorrect data. The corrected table is shown with the changes in bold text. The html and pdf versions of this article were corrected on 1 December 2005. In summary: for oesophageal cancer, the corrected mortality rate ratios (NT Indigenous to total Australian) are higher than the published results in all age categories; for stomach cancer, the corrected rate ratio for the 0–64 age group is lower than the published figure, and the all-ages result is now reported because the difference between the younger and older age groups is no longer statistically significant (P = 0.06); for cancer of the liver and gallbladder, the corrected rate ratios are lower in the 0–64 years and all-ages groups; and there are also very slight changes for breast and lung cancers. These changes do not alter the inferences that might reasonably be drawn from the results in the table, or the overall findings of the study and their interpretation. Cancer mortality rate ratios* (NT Indigenous population compared with the total Australian population), by age group, 1991–2000 Site/type of cancer 0–64 years 65 years and over All ages† Interaction P value† Oropharynx 8.0 (5.5, 11.6) 2.0 (0.8, 4.8) — < 0.01 Oesophagus 2.9 (1.5, 5.6) 1.2 (0.5, 2.9) 1.9 (1.1, 3.2) 0.11 Stomach 1.4 (0.6, 3.0) 0.2 (0.0, 1.2) 0.7 (0.3, 1.4) 0.06 Colon and rectum 0.9 (0.5, 1.4) 0.2 (0.1, 0.6) — 0.01 Liver and gallbladder 5.5 (3.6, 8.6) 5.8 (3.9, 8.6) 5.7 (4.2, 7.6) 0.88 Pancreas 4.1 (2.7, 6.3) 1.1 (0.5, 2.2) — < 0.001 Lung 3.6 (2.9, 4.5) 1.4 (1.0, 1.9) — < 0.001 Melanoma 0.0 0.0 0.0 na Breast 0.8 (0.5, 1.3) 0.9 (0.4, 1.8) 0.8 (0.6, 1.3) 0.86 Uterus‡ 3.4 (1.1, 10.7) 2.5 (0.8, 7.6) 2.9 (1.3, 6.4) 0.68 Cervix 8.0 (5.2, 12.4) 10.1 (5.4, 19.1) 8.6 (6.0, 12.3) 0.56 Ovary 1.0 (0.4, 2.6) 1.3 (0.5, 3.5) 1.1 (0.6, 2.2) 0.67 Prostate 0.9 (0.2, 3.6) 0.3 (0.1, 0.8) 0.4 (0.2, 0.8) 0.23 Bladder 1.5 (0.4, 6.1) 0.5 (0.1, 1.9) 0.7 (0.3, 1.9) 0.24 Kidney 0.3 (0.0, 2.2) 0.0 0.1 (0.0, 1.0) 1.00 Thyroid 12.9 (4.8, 34.7) 6.1 (1.5, 24.7) 9.4 (4.2, 21.1) 0.40 Unknown primary 3.2 (2.1, 4.7) 1.7 (1.0, 2.6) — 0.04 Non-Hodgkin’s lymphoma 1.1 (0.5, 2.2) 0.7 (0.2, 1.7) 0.9 (0.5, 1.6) 0.40 Leukaemia 1.5 (0.9, 2.5) 0.8 (0.3, 2.0) 1.2 (0.8, 1.9) 0.25 * Mortality rate ratio estimated by negative binomial regression. † Mortality rate ratios are reported separately for age groups 0–64 and 65 years and over; the rate ratio for all ages combined is reported only where the P value of an interaction term testing for difference in mortality rate between younger and older age groups was > 0.05. ‡ Not including cervix. na = not applicable because rate ratio was zero (no NT Indigenous deaths from this cancer in 1991–2000).

John R Condon MPH, FAFPHM PhD · Joan Cunningham ScD · Tony Barnes MSc · Bruce K Armstrong DPhil

A recent position statement issued by the Australasian Creatinine Consensus Working Group sparked a lively response from our readers (Med J Aust 2005; 183: 138-141)

Christopher M Florkowski · Wolf W Woltersdorf · Peter M George · Mohammed Saleem

Biswadev Mitra,* Peter A Cameron† * Registrar in Emergency Medicine, Emergency and Trauma Centre, The Alfred Hospital, Commercial Road, Melbourne, VIC 3004. † Professor of Emergency Medicine, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC. b.mitraATalfred.org.au To the Editor: We congratulate Kaye and colleagues on their efforts to educate and influence prescribing practice in reducing the use of pethidine.1 The adverse effects of pethidine and its lack of efficacy over other opiates have been known and taught since the early 1990s.2 A decade on, we are still seeing significant use of this drug,3 which has multiple disadvantages when compared with other opioid analgesics. The difficulty lies in doctors’ attitudes to quality improvement and change in health care. It has been noted that doctors’ responses to concern about the quality of health care range widely, from opposition to whole-heartedly embracing legitimate opportunities for improvement.4 While there is such variance, the implementation of evidence-based medicine into practice will lag, sometimes by decades, resulting in unnecessary adverse effects in patients. With clinical guidelines in place, a rigorous education campaign and many hours of research time and resources, Kaye and colleagues have significantly reduced, but not eradicated, pethidine prescribing in New South Wales. In comparison, O’Connor et al report combining a similar educational program with formulary restrictions to effectively eliminate the use of meperidine (pethidine) in their single centre study.5 We can only conclude that clinical evidence, even when combined with quality improvement campaigns, remains less effective than policy changes which restrict doctors’ behaviour. From available evidence, the liberal use of pethidine may cause adverse effects which are preventable by a simple system-oriented approach — in this case, the appropriate risk-management step is restricting pethidine use to very limited situations. We cannot continue to justify use of a drug with poor efficacy, toxicity and serious drug interactions. Pethidine prescribing as a percentage of total narcotics in Launceston General Hospital emergency department, 1992–2004 Note: data not available for some quarters.

Biswadev Mitra · Peter A Cameron

Paul Pielage Director of Emergency Medicine, Launceston General Hospital, Charles Street, Launceston, TAS 7250. paul.pielageATdchs.tas.gov.au To the Editor: I was interested to read the article by Kaye and colleagues about reducing pethidine use in the emergency department by means of evidence-based prescribing.1 In view of published reports describing the disadvantages of pethidine, it was decided in late 1996 to attempt to reduce the amount of pethidine prescribed in the emergency department of Launceston General Hospital. Narcotics were supplied as ampoules of 100 mg pethidine, 10 mg morphine, 15 mg papaveretum (the use of which was trivial) and fentanyl, which was used mainly for anaesthetic induction. Before mid-1996, 50%–72% of all ampoules of narcotics used in the emergency department were of pethidine. Of narcotics used for acute pain management, pethidine would have been much higher as a proportion because it was not used for acute pulmonary oedema, ischaemic myocardial pain, anaesthetic induction and in patients being ventilated. The use of narcotics was monitored by quarterly reports from the pharmacy department of the quantities of the various parenteral narcotics supplied to the emergency department. Papaveretum was removed from the pharmacopoeia in 1999. In 1996, an informal education program was instituted within the emergency department, strongly supported by the nurses, with the aim of convincing junior medical staff on rotation from other areas within the hospital to prescribe morphine rather than pethidine. It had long been observed that such staff prescribed pethidine almost exclusively for acute pain management, and a cultural change was required. As shown in the Box, the percentage of narcotics dispensed as pethidine was steadily reduced over the following years, reaching 5% in 2002. After 2 years at this level it was decided to remove pethidine from the pharmacopoeia. In February of 2005, hydromorphone was introduced and pethidine removed. There have been no complaints or problems as a result, and the whole process was unexpectedly painless and successful.

Paul Pielage

Karen I Kaye,* Susan A Welch,† Linda V Graudins,‡ Andis Graudins,§ Tai Rotem,¶ Sharon R Davis,** Richard O Day†† * Executive Officer, ** Research and Liaison Officer, NSW Therapeutic Advisory Group, PO Box 766, Darlinghurst, NSW 2010. † Senior Pharmacist, †† Director, Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW. ‡ Medication Safety and Quality use of Medicines Pharmacist, Sydney Children's Hospital, Sydney, NSW. § Emergency Physician and Director, Clinical and Experimental Toxicology Unit, Prince of Wales Hospital, Sydney, NSW; and Senior Lecturer (Conjoint), University of New South Wales. ¶ Statistician, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW. nswtagATstvincents.com.au In reply: As Mitra and Cameron point out, policy change can be effective in influencing prescribing practice. Indeed, use of a restrictive formulary is a strategy used by drug and therapeutics committees in most Australian hospitals. However, where support among clinicians for policy change is lacking, significant time and effort is required by those responsible for policy implementation. Confrontation and lack of interdisciplinary cooperation can be expected. Quality use of medicines (QUM) means selecting management options wisely, choosing suitable medicines if a medicine is considered necessary, and using medicines safely and effectively. Australia is fortunate in having a National Medicines Policy1 and a national strategy for QUM.2 This strategy recognises the importance of active and respectful partnerships, and of consultative, collaborative, multidisciplinary activity to improve the quality use of medicines. To attain QUM, “. . . key partners must be involved at all stages in designing, implementing and evaluating QUM programs . . . Multiple activities and strategies are needed to raise awareness about issues related to QUM. Attitudes, knowledge, skills and behaviours that support QUM need to be developed and maintained”.2 Our approach was based on these principles. Pielage provides another example of the successful use of this approach to limit pethidine prescribing in a large teaching hospital, which should be applauded. Doctors, pharmacists, nurses and consumers are important partners in QUM. An educative, multidisciplinary approach that respects each partner is the most appropriate way to ensure sustained practice change and promote QUM in hospitals and the wider community.

Karen I Kaye · Susan A Welch · Linda V Graudins · Andis Graudins · Tai Rotem · Sharon R Davis · Richard O Day

Susan F Hurley Associate Professor, School of Population Health, University of Melbourne; and Health Economics Consultant, Bainbridge Consultants, 532 Brunswick St, North Fitzroy, VIC 3068. susanhurleyATbainbridgeconsultants.com To the Editor: Previous analyses of costs to the Pharmaceutical Benefits Scheme and costs for stroke and acute myocardial infarction hospitalisations suggest that tobacco control programs are a good investment.1,2 To further highlight the economic benefits of reducing smoking rates, I estimated the hospitalisation costs attributable to cigarette smoking in Australia for 2001–2002 by applying aetiological fractions to hospitalisation data.3 Aetiological fractions were calculated using 2001 National Health Survey smoking prevalence data and relative risks of hospitalisation for current and former smokers, as previously calculated by English and colleagues through linkage of data from the Busselton health survey and the Western Australian Hospital Morbidity Data system.4 Counts of separations (hospitalisations), bed-days, and average costs for hospitalisations in Australia in 2001–2002, by sex and 5-year age category, were obtained from the Australian Institute of Health and Welfare. They had been sourced from the National Hospital Morbidity Database (http://www.aihw.gov.au/hospitals/nhm_database.cfm) and the National Hospital Cost Data Collection (http://www.health.gov.au/casemix), linked by the common variable “DRG4.2”. The results (Box) show that, in 2001–2002, almost 300 000 hospitalisations, costing $682 million, were attributable to cigarette smoking. English and colleagues estimated previously that, in 1992, 129 000 hospital separations and over 1.1 million bed-days were attributable to cigarette smoking.4 Although the proportion of the Australian population who are smokers has decreased since then, from 26% to 23% in 2001,5 cigarette smoking is still associated with substantial health care utilisation and costs. The actual costs are even greater than the $682 million per annum estimated by my analysis, as the following were not considered: hospitalisation costs for those aged 80 years and over; pharmaceutical costs (estimated at $126 million for cardiovascular drugs on the Pharmaceutical Benefits Scheme1); community care costs (such as general practitioner visits); and patient contributions to hospitalisation costs. In stark contrast to the $682 million spent on hospitalisations attributable to smoking, the Australian Government has committed an average of only $2 million per year over the last 10 years to tobacco harm minimisation programs.6 Hospitalisations, bed-days and costs attributable to cigarette smoking in Australia in 2001–2002* Hospitalisations Bed-days Costs† Proportion Number Proportion Number Proportion $ (millions) Men 7.6% 138 000 14.6% 891 000 7.6% $339 Women 8.6% 153 000 9.8% 581 000 8.6% $342 Total 8.1% 291 000 12.2% 1 472 000 8.1% $682 * For people aged 40–79 years. † Estimated costs are conservative, as they are based on average cost per hospitalisation for the total population. However, the higher proportion of bed-days than hospitalisations attributable to smoking suggests smokers tend to have longer stays and thus higher than average costs.

Susan F Hurley

Huy A Tran Director, Hunter Area Pathology Service; and Associate Professor, Department of Clinical Chemistry, University of Newcastle, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Centre, NSW 2310. huy.tranAThnehealth.nsw.gov.au To the Editor: The recent article by Roberts et al1 requires further comment. In anorexia nervosa, hypercalcaemia is extremely unusual because patients are likely to be under- or malnourished, with consequent hypocalcaemia and hypovitaminosis D, rather than the opposite, as implied by the authors. In one of their references,2 hypercalcaemia is only briefly included, and the mechanism is not discussed or substantiated. Another of their references3 does not include hypercalcaemia at all as a metabolic disturbance. In addition, hypercalcaemia in itself is not a diagnosis, and indicates a significant underlying pathophysiological disturbance whose differential diagnoses need to be carefully dissected. Where there are problems with the interpretation of calcium homoeostasis, such as renal impairment and hypoalbuminaemia, ionised calcium should be measured because it is the physiologically active agent. In the first patient described by Roberts et al, although the investigations are incomplete, primary hyperparathyroidism (PHPT) needs to be carefully considered, as the parathyroid hormone (PTH) level is not normal in the setting of hypercalcaemia. The normal physiological response would dictate that the PTH level should be low to suppressed. Nephrocalcinosis and renal impairment then fit snugly into the diagnosis of PHPT.4 Phosphate level, expected to be low in this condition, might have been masked by exogenous phosphate supplement. For Patient 2, stool electrolyte analysis could further support the presence of laxative misuse and aid in the interpretation of urinary results. Faecal fluid in this situation should be high in sodium, potassium and calcium concentrations. The low urinary sodium and calcium levels are therefore appropriate, and indicate relatively intact tubular function. The diagnosis of hypercalcaemia is thus difficult without a PTH measurement and in the presence of gastrointestinal confounders, even if all investigations were available. Nevertheless, familial benign hypocalciuric hypercalcaemia (FBHH) is a strong probability given the low urinary calcium excretion, especially before iatrogenic manipulation of calcium and phosphate homoeostasis. Nephrocalcinosis can theoretically occur in FBHH.5 It is important that the diagnosis is made in both cases, so that a familial study can be carried out if indicated given the patients’ age. One may also wonder if the intermittent hypercalcaemia contributed to or aggravated the psychiatric disturbance in both patients.

Huy A Tran

Matthew A Roberts,* Campbell R Thorpe,† Duncan P MacGregor,‡ Nick Paoletti,§ Francesco L Ierino¶ * Nephrologist, ‡ Director of Anatomical Pathology, § Psychiatrist, ¶ Deputy Director of Nephrology, Austin Health, Studley Road, Heidelberg, VIC 3084; † Psychiatrist, Child and Adolescent Mental Health Service, The Alfred Hospital, Melbourne, VIC. frank.ierinoATaustin.org.au In reply: Disturbances of calcium metabolism in anorexia nervosa are complex, particularly with associated renal insufficiency. Although hypocalcaemia is observed in patients with anorexia nervosa, our article attempted to highlight nephrocalcinosis and hypercalcaemia. We agree that hypercalcaemia is not in itself a diagnosis, and identifying the underlying pathology is essential. Ingestion of vitamin D preparation remains a likely explanation for the hypercalcaemia observed in Patient 1; however, primary hyperparathyroidism was considered as a possible differential diagnosis. Patient 1 had two normal parathyroid hormone tests in the setting of hypercalcaemia and renal impairment. This is consistent with secondary hyperparathyroidism and vitamin D ingestion as documented. The coexistence of primary hyperparathyroidism cannot be excluded. Ionised calcium may be a useful measure if the patient had hypoalbuminaemia, and this would be our normal practice. Patient 2 had ionised calcium measured twice (one result high, one low), but these added little to the case description and message of the article. Faecal electrolytes were not measured in Patient 2. However, we acknowledge the potential utility of this investigation when interpreting electrolyte disorders. We also agree that familial or genetic conditions should be considered if clinically appropriate.

Matthew A Roberts · Campbell R Thorpe · Duncan P MacGregor · Nick Paoletti · Francesco L Ierino

Alan Rodger Professor of Clinical Oncology, Beatson Oncology Centre, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, United Kingdom. alan.rodgerATnorthglasgow.scot.nhs.uk To the Editor: I note with concern that one of the authors of the article on aromatase inhibitors in early breast cancer (Nordman)1 declares under competing interests that she received an honorarium (in the form of financial support to attend a conference) “for writing this article” from a manufacturer of one of the current licensed aromatase inhibitors. It is reassuring to be informed that the company concerned had no role in the content of the article. However, is it wise and reasonable and, indeed, necessary for a medical oncology registrar to be financially rewarded by a pharmaceutical company for writing an article published in The Medical Journal of Australia about therapeutic products, one of which was developed and is now marketed by that company? Two other authors and reviewers and editorial staff were involved in this otherwise excellent article. I commend Nordman for her openness and declaration. However, I question the role of the pharmaceutical industry in rewarding medical authors in this way.

Alan Rodger

Glen Pater Director, Medical and Regulatory Affairs, AstraZeneca Australia, PO Box 131, North Ryde, NSW 1670. Glen. PaterATASTRAZENECA. COM In reply: In response to Rodger, AstraZeneca would like to reiterate that the company had no role in the content of the article published by Nordman and colleagues in the 4 July issue of The Medical Journal of Australia.1 AstraZeneca has provided Sydney Cancer Centre with an unrestricted educational grant. Along with Rodger, we commend the authors on their transparency about how this grant was applied.

Glen Pater

Duncan A Howard,* Sue D Waygood,* Sharon L Desmond† * General Practitioner, † Registered Nurse and Practice Manager, Brunswick Community Medical Centre, St Vincents Health, 11 Glenlyon Road, Brunswick, VIC 3056. duncan.howardATsvhm.org.au To the Editor: It is well known that people with serious mental health problems are more likely to suffer substantial physical health problems, or die younger, than those in the general population.1,2 We would like to report some early results from a program that is aiming to improve primary health care for people with serious mental health problems. The Stewart Lodge program was developed through cooperation between the local Moreland Community Health Service, two general practitioners and one registered nurse from the medical clinic collocated with the Community Health Service, the local area mental health service, and the managers of the Victorian Government Supported Residential Services program. The Stewart Lodge program includes a regular non-appointment doctor’s session, complete health assessments for all residents, and regular case conferences involving all carers and clinicians. Initial establishment was funded through a Victorian Government Department of Human Services GPs in Community Health Services strategy grant, which focused on improving integration and service coordination. There are around 85 people living in this community, most of whom have chronic schizophrenia or another serious mental health problem. We plan to report the findings from our program in more detail when we have completed the assessments of most Stewart Lodge residents. However, we would like to report our interim findings on vitamin D levels, which are likely to be relevant to many others in similar circumstances. Of the 30 residents tested so far, three have had vitamin D levels in the normal range (> 50 nmol/L), 20 in the deficient range, (25–50 nmol/L) and seven in the severely depleted range (< 25 nmol/L). An increased risk of low vitamin D levels has been previously reported in populations of older institutionalised people,3 and a recent position statement in the Journal on accepted levels of 25-hydroxyvitamin D (25-OHD) warned of risks of vitamin D deficiencyfor various groups in the community.4 We suggest that people with serious mental illness are another group that should be included in those at risk. The people we work with are at risk because of decreased exposure to the sun through inactivity, and because of their illness and medication. Of note, the median age of our residents is 49 years. We aim to tackle this issue by giving Vitamin D supplementation (although this is currently problematic because there is no suitable vitamin D supplement supported by the Pharmaceutical Benefits Scheme). We will be encouraging more physical activity, particularly outdoors, as this is most likely to be of overall benefit to our residents’ general health.

Duncan A Howard · Sue D Waygood · Sharon L Desmond

Biji T Kurien Senior Research Scientist, Arthritis and Immunology, Oklahoma Medical Research Foundation, 825 NE 13th Street, Oklahoma City, OK 73104, USA. biji-kurienATomrf.ouhsc.edu To the Editor: The smiley icon “ :) ” has been widely used to convey amusement, mirth or jollity in casual email communications. However, there seems to be a lack of simple icons for use by health professionals as email shorthand in different scenarios. I therefore submit the symbols shown in the Box for use by doctors and others involved in health care. All are derived by typing a combination of characters of various font sizes and other features (colour, superscript, subscript, italics, and bold), and all are in Times New Roman font except when stated otherwise. Note that it would be highly inadvisable to use a spell check feature in conjunction with these icons.1 Email icons (“emoticons”) for the health profession Symbol Meaning Bearded doctor with stethoscope around neck Curly-haired (red-haired) doctor/scientist with big moustache Nurse (face) [Characters: { in red, ital, f12; space; colon in black, bold, ital, Sp, f12; space; ” in red, bold, f8;) in red, bold, ital, f8.] Nurse (whole body) [Characters: { in red, ital, f12; space; colon in black, bold, ital, Sp, f12; space; ” in red, bold, f8;) in red, bold, ital, f8; = in yellow, f8; { in red bold f12; 3 in red f9; two colons in red, bold, f10; \ in red, ital, f8; = in green, f28; \ in green, bold, Sb, f8; = in dark red, Sb, f16; / in red, bold, Sb, f8.] Bearded doctor/scientist awestruck on having article accepted in MJA Bearded doctor/scientist awestruck on learning of receipt of Nobel Prize Mouth-to-mouth resuscitation [Characters for lips: “ in Sb, f11.] Identical twins Whole body x-ray [Characters: 8 in f9; space; O in f10; hyphen in f12; { in f12; | in f12; | in f11; | in f10; | in f8; () in f8; five colons in f12; full stop in f12; / in Sp, f12; / in f12. All in bold; convert font to white and highlight characters in black.] Acromegaly and gigantism (same as for twins, but use Courier New) Smoking [Characters for cigarette: [ and ] in bold, ital, f10; ~ in f24.] Obesity Healthy laboratory mice (Courier font) Dead laboratory mice Concerned doctors/scientists discussing experimental failure ital = italics. Sp = superscript. Sb = subscript. f = font.

Biji T Kurien

Diving and subaquatic medicine. 4th ed. Carl W Edmonds, Christopher Lowry, John Pennefather, Robyn M Walker. London: Arnold, 2002 (viii + 719 pp). ISBN 0 340 80630 3. One of the first books I was given to study when starting my hyperbaric term was the third edition of Diving and subaquatic medicine. It is still one of the few textbooks that I have literally read from cover to cover. The fourth edition builds on the success of the previous three editions as four of the most respected diving specialists in Australia have collaborated to produce an immensely readable book of a technically difficult subject. The contents include both the physics and physiology of diving medicine along with interspersed clinical vignettes of actual cases that are used to illustrate particular points. The book itself is well diagrammed and has extremely good photos (several in colour), which only enhance the clinical and theoretical discussions of each topic. I find it hard to think of a subject in diving medicine that this book has not covered very well, and the main topics (such as injuries to the ear) are covered in appropriate depth. The book also helpfully includes several common treatment tables and diving schedules, and it is still one of the most utilised books (as well as the most often liberated book) in the hyperbaric medicine unit. Diving and subaquatic medicine keeps to the topic well and is a reasonable size to keep readily available. It is probably the best all-round diving medicine book available, and its Australian origins make it particularly relevant. Even non-diving issues such as marine envenomation, near-drowning and underwater explosions (!) are covered in this comprehensive textbook. It is quite rightly known as the Diving Medicine Bible in Australia, and anyone who works in diving medicine, medically certifies divers or even has a mild interest in diving will enjoy this easy-to-read book.

Glen Hawkins

“Open artery” Dual antiplatelet therapy, with clopidogrel added to aspirin, presents a major advance with clear benefit in managing patients with acute myocardial infarction, according to a US expert.1 Sabatine, from the Thrombolysis in Myocardial Infarction (TIMI) Study Group, was commenting on findings from COMMIT — the ClOpidogrel and Metoprolol in Myocardial Infarction Trial; also known as the Second Chinese Cardiac Study.2,3 COMMIT was a randomised, placebo-controlled mega-trial, coordinated by the UK Oxford Clinical Service Unit and conducted in China, which involved more than 45 000 patients with suspected acute myocardial infarction. The trial found that, in a wide range of patients, adding 75 mg clopidogrel daily to aspirin and other standard treatments safely reduced mortality and major vascular events in hospital.2 Clopidogrel may work by preventing re-occlusion of coronary vessels, supporting the “open-artery hypothesis”. 1. Lancet 2005; 366: 1587-1589 2. Lancet 2005; 366: 1607-1621 3. Lancet 2005; 366: 1622-1632 Medicine by media? Although medical news reports are often castigated as alarmist or as raising unrealistic treatment expectations, Canadian authors say that accurate reporting can also help build a link between research evidence and clinical practice.1 They found that a Canadian Broadcasting Corporation television documentary about Diane-35 (cyproterone acetate) had a greater effect on subsequent prescription rates than a “Dear Health Professional” letter and a safety alert published in CMAJ.2 The documentary conveyed two key messages — that this oral contraceptive had: • a higher risk of venous thromboembolism than other, similar agents; and • widespread off-label use as an oral contraceptive agent in women who did not have severe acne. 1. CMAJ 2005; 173: 1313-1315 2. CMAJ 2003; 168: 455-456 Dolphins for depression Being with bottlenose dolphins is an effective treatment for mild to moderate depression, say UK researchers. They conducted a small, randomised single-blind trial in an appropriate natural setting — Honduras — which compared the anti-depressive effect of being with bottlenose dolphins (Tursiops truncatus) for an hour a day with that of similar water activities sans dolphins (ie, swimming and snorkelling in the coral reef). At 2 weeks, participants who played and swam with and took care of the dolphins had a greater reduction in their depressive symptoms than those who didn’t. BMJ 2005; 331: 1231 Weight loss and more Overweight and obese patients at high risk of cardiovascular disease may gain benefit from a new drug on the horizon — rimonabant, a selective cannabinoid-1 receptor blocker.1,2 This drug was studied in a randomised controlled trial involving more than 1000 overweight or obese subjects with untreated dyslipidaemia conducted at 67 sites in eight countries, including Australia. Rimonabant was found to not only lead to moderate weight loss but also to have a beneficial effect on several metabolic variables, including serum high-density lipoprotein cholesterol and triglyceride levels.2 Adverse effects of rimonabant included nausea, anxiety and insomnia. 1. N Engl J Med 2005; 353: 2187-2189 2. N Engl J Med 2005; 353: 2121-2134 Flight operations Would you fly on an aeroplane without a pilot? What about undergoing an operation without an anaesthesist in the theatre? New Zealand author Guise raised this interesting analogy, between a pilot flying a plane and an anaesthetist attending to a patient during a surgical procedure, when responding to a press report that the Chairman of a NZ government advisory group had claimed that doctors were no longer necessary to perform cataract surgery. Guise pointed out that to the inexperienced observer, a group of highly skilled professionals conducting their work in a quiet, efficient, safe manner — be it in a plane or an operating theatre — can give the impression that the procedure is simple and, therefore, does not require highly trained staff. However, the cost of complications in either setting, even if they occur infrequently, can be high. Clin Exp Ophthalmology 2005; 33: 451-452 A PBS for America? Recent US legislation (the Medicare Prescription Drug Improvement and Modernization Act) will introduce a voluntary program of prescription drug coverage to the States. However, drug price negotiations will be in the hands of managed care organisations and pharmacy benefit managers rather than government. By way of assistance and advice, Australian authors have compared and contrasted the well established drug evaluation systems in Australia (the Pharmaceutical Benefits Scheme, PBS) and the UK (The National Institute for Health and Clinical Excellence, NICE). Both the PBS and NICE make decisions using formal measures of cost-effectiveness. Advantages of NICE were considered to include its independence from government; and its ability to commission drug evaluations, whereas the Australian system is reliant on pharmaceutical companies to perform assessments of new drugs. However, neither system re-evaluates older, potentially cost-ineffective drugs. JAMA 2005; 294: 2630-2632

Ann Gregory