Volume 184 Issue 12

Caring for those who cannot or will not care for themselves In discussions and studies about access to health care — from prevention to inpatient management — the lower end of the socioeconomic spectrum rarely rates a mention. This sizeable subgroup, especially in cities but also in rural settings, is over-represented among people attending emergency departments.1 Frequent attenders to emergency departments are a heterogeneous group — a mix of patients with chronic medical, mental health, alcohol and drug problems, as well as other psychosocial issues.2,3 Individual patients often have a combination of some or all of the above problems. Interestingly, the frequency of attendance may change with time, although patients with psychiatric and substance misuse issues tend to be persistent heavy users.4 Despite the fact that they may be as sick as other, non-frequent attenders, frequent attenders are often perceived as time-consuming “illegitimate” users of emergency department resources.1 From the patient’s viewpoint, despite having good access to primary health care, the emergency department is seen as the most appropriate place to seek help because of a perceived need for urgent care.5 Rather than as a substitute, emergency departments are often used in conjunction with primary care services, with the emergency department providing appropriate higher level care.6,7 Some of the debate about the resourcing of very expensive 24-hour services, such as stressed emergency departments, focuses on “diverting” patients away or “streaming” them somewhere else (eg, general practice) after appropriate triage. Multidisciplinary teams (including allied health workers) that target high-risk patient subgroups — the elderly, patients with respiratory illnesses, patients with mental health problems — have been introduced in many hospitals to address the swamping of emergency services. But does all this actually make a difference? In this issue of the Journal, Phillips et al (page 602)8 evaluated the effect of multidisciplinary team case management on frequent attenders’ utilisation of an inner city emergency department in Melbourne, compared with their utilisation before case management (ie, the study population acted as their own historical controls). Emergency department utilisation and scores for housing stability, alcohol and drug use, and primary and community care engagement were determined. Perhaps surprisingly and paradoxically, despite intensive case management, Phillips et al found an increase in emergency department utilisation and overnight stays. A potential interpretation of this increased utilisation is that it may well reflect an increase in engagement of these patients, with the desired increased attention and improvement in their health. Furthermore, the study found that linkage with primary care and community services improved. Interestingly, in 2002, Moss et al, at another Melbourne inner city emergency department, found that a similar strategy produced a significant fall in hospital admissions.9 In an ideal world, there would be no debate about allocation of care teams to sick patients or the effectiveness of preventing health deterioration. Nor would certain groups of patients only be really visible once they have deteriorated — and then only mainly visible to certain parts of the health care system (eg, emergency departments, and community and mental health services). In health care, as elsewhere, planners can largely underestimate the need for, and the effect of, a new service where none previously existed. This would be easy to imagine when dealing with a marginalised, and at times psychosocially challenged, group of people. Quoting Malone: . . . reducing unwarranted or unwanted emergency services utilisation is not merely a matter of redirecting individuals to other medical care providers but is lodged within the larger and far more complex issue of how and where we as a society and as individuals care (or fail to care) for those who cannot or will not care for themselves in socially sanctioned ways . . .1 Research, measuring appropriate outcomes including accurate assessments of cost, has to be increased to allow resources to be rationally allocated.

Gordian W O Fulde FRACS, FRCS, FACEM · Martin Duffy MB BS, FACEM

The responsibility lies with the scientific community Since, both in importance and in time, health precedes disease, so we ought to consider first how health may be preserved, and then how one may best cure disease. Galen, AD 130–200 The article on scientific misconduct by Gerber in this issue of the Journal calls for more vigilance on the part of editors and peer reviewers in exposing fraudulent research.1 A recent commentary in the New York Times also vigorously questions the merits of peer review and the role of scientific journals in light of recent disclosures of fraudulent research published in high level journals and asks for more credibility on the part of editors as science gatekeepers.2 All this begs the question: why do editors and scientific journals come into the spotlight each time there is a new and shocking discovery of scientific fraud? Are they really the guilty party for publishing fraudulent research articles? As articles in scientific journals are the main form of scientific communication and documentation of research,3 members of the public mostly see scientific fraud as a deficiency in the publication process and focus on “the messenger” rather than on the true causes of scientific fraud. Instead of considering how to preserve the “health” (ie, responsible conduct) of research,4 it is left to editors and peer reviewers to look for ways to treat the “disease”. Is this fair, especially in view of the fact that scientific journals have been instrumental in gathering evidence about fraudulent science3 and in detailing problems of peer review and publication?5 Their evidence, and the exposure of each new case of scientific fraud, increases the awareness that this issue must be very seriously and creatively considered by the whole research community — not only at the end stage of the research by those involved in the publication process. Although many say that fraud is a substantial problem and blame editors for downplaying its significance,1,2 when we look for evidence, the estimated prevalence of fraudulent articles in international journals is about 0.2% of published articles.3 The prevalence of fraudulent articles may be higher in smaller journals with little scientific impact,6 but their authors rarely get discovered because the articles are either not read or not cited by the wider scientific community. An important element of scientific misconduct is the personal responsibility of individual scientists who are involved in the research and whose names ultimately appear on the published article. The Hwang scandal clearly illustrates that, although all authors usually get the same or similar benefits from a published article, the authors are not the same in the face of scientific fraud: many are quick to accept praise and benefits flowing from a high-profile publication, but many also evade the responsibility we expect from all authors — responsibility for their published work.1 Even the International Committee of Medical Journal Editors (ICMJE) has pulled back from its strict requirement, in the 1988 revision of the Uniform requirements for manuscripts submitted to biomedical journals (URM), that “each author should have participated sufficiently in the work to take public responsibility for the content”.7 The requirement in the current edition of the URM8 is that “each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content”. The move away from requiring shared responsibility of all authors for the whole manuscript opened a loophole for authors of fraudulent articles to escape embarrassment and perhaps legal action, as they can always claim that they were not responsible for the questionable part of the research. This was the case with Professor Schatten and the University of Pittsburgh in the Hwang case.1 Schatten was an advisor in the research conducted by Hwang and colleagues. Although he was listed as a co-author on the offending articles, he, unlike Hwang, was found guilty of scientific misconduct rather than fraud. We believe that the change to the ICMJE authorship criteria was a wrong move by the editors who defined such criteria. Wouldn’t it be better and more natural for all authors of a manuscript to meticulously analyse data produced by their team and ensure the veracity of the evidence presented, rather than transferring this responsibility to editors and reviewers? In the absence of this process, it is not surprising to see strong criticism of journals, editors and the peer review process and to hear demands that key data for most manuscripts be made available to reviewers.1,2 Although this seems like a rational proposal, it would have to be counterbalanced by ensuring that the reviewers, who are often the authors’ competitors in the field, do not misuse their privileged access to the data. The process of scientific discovery is a human endeavour and, as such, is burdened by the imperfections of human nature and ability. In other words, a degree of dishonesty can and perhaps must be expected in this process. The system of entrusting money to someone (a scientist or group of scientists) to do research contains an inherent imperfection: there is no guarantee that the endeavour will succeed, because it aims towards the unknown. Consequently, the key principle of scientific research is relatively poorly founded trust. Having trust as the only safety mechanism leaves the research process open to the risk of failure — and fraud. Trust and honesty present one side of the equilibrium of scientific integrity, and have to be balanced against pressures for publication output. To use an analogy with the economic rationalisation for crime,9 scientific fraud can be considered as a rational act of balancing the expected utility of scientific promotion against the expected cost of punishment. If we want a fraud-free equilibrium, the scientific community must find ways to ensure that the costs of fraud and assisting in fraud are high while the cost of informing about fraud is low.10 That is why the problem of scientific fraud cannot ultimately be solved by better peer review or more stringent editorial processes.11 It requires active and preventive work by all those involved or affected, starting with the research and academic community itself.4,12

Ana Marušić MD, PhD · Matko Marušić MD, PhD

An innovative model for health planning has improved equity of access and outcomes Clinician frustration with marginalisation of their influence in the public hospitals and a growing mistrust of centralised bureaucracy reached boiling point in New South Wales in 1999. In response, the then Minister for Health established a program aimed at re-engaging clinicians in the governance of health services. One outcome of this engagement was the emergence of an entity, unique in the Australian context — the Greater Metropolitan Transition Taskforce (GMTT). At the core of this entity was clinician-led responsibility for the development of networks and plans for clinical services across a population of five million people. Two complimentary, independent reviews1,2 of the outcomes of the GMTT led to the permanent establishment of its successor, the Greater Metropolitan Clinical Taskforce (GMCT), in 2005, and the current search for a full-time clinician chief executive officer to carry it to the next phase. It is timely to review the achievements and outcomes of the GMTT (Box) and the relevance of these to future clinician involvement in health governance across Australia and, perhaps, beyond. At the heart of the GMTT experiment was the conviction that busy clinicians working under trying circumstances would, nonetheless, accept the challenge to join a collegial effort to network their services and accept responsibility for master planning for more equitable delivery of their particular specialty. The GMTT vision for clinician governance required doctors, nurses and allied health professionals in a particular specialty to meet and plan in a “first among equals” environment. Although many involved doctors knew their colleagues from scientific meetings, few had ever met to plan metropolitan-wide services and none had done this with nurses and allied health colleagues. An innovative aspect of the process was the appointment, as initial network chairs, of clinicians who did not belong to the discipline (eg, the cardiologists’ group was chaired by a gastrointestinal tract surgeon). After initial hesitancy, 17 designated networks formed and flourished. In 2002, the GMTT received $64 million from the NSW Government to deliver the 162 service improvements designed by the clinicians,3 on the condition that they function as metropolitan-wide networks. The money was necessary for change, but far from sufficient. Each network elected its chair and co-chairs. Critical to success, each was supported by clinician-managed infrastructure, including a senior network manager. Consumers were appointed as equal members to the executive committee of each network and to the GMTT committee, adding an important element of community scrutiny. The GMTT was strongly endorsed in an external review in 2003,1 and the activities of the GMCT have attracted interest from, and degrees of replication in, other states in Australia and in New Zealand. Internationally, there is growing interest in, and experience with, managed clinical networks as a means of counterbalancing some of the shortcomings of the current hierarchical systems of health service governance.4 The GMTT model and process were outlined in a commentary in the Lancet in 2004: “Turning the health system 90° down under”.5 In 2005, the networks were confirmed as the peak bodies advising NSW Health, the Director General of Health and the Minister for Health on all clinical matters relating to their field; this followed recommendations from a second external review (the Phelan review).2 Other essential ingredients of the success enjoyed by the taskforce include the commitment to meaningful consumer involvement and a continuing program aimed at increasing understanding and cooperation between “front line” clinicians and middle managers. Of particular importance have been partnerships with newly created organisations whose missions overlap with that of the GMCT: the Clinical Excellence Commission (CEC; a peak body established to improve quality and safety in health care in NSW), the Institute of Medical Education and Training (responsible for postgraduate training and a more equitable distribution of trainees) and the newly formed Cancer Institute NSW. The CEC in particular has valued the single point of entry to clinicians in a whole discipline that a GMCT network and program manager offers. Increasingly, the GMCT is working in concert with the Rural Health Taskforce to improve patient outcomes across NSW. Currently, more than 4000 clinicians are committed through the networks to the GMCT process and structure.6 They have used their networks to enhance equity of access, particularly in outer Sydney, with a range of new services from acute stroke units to interventional cardiology.6 There is good evidence that the stroke units have achieved significant improvements in the care of stroke patients. Similarly, the establishment of interventional cardiological procedures at several hospitals has led to a major improvement in the standard of care for patients presenting to those hospitals with acute coronary syndromes. Other clinicians have used their networks to eliminate waiting times for living related donor renal transplantation from 18 months to zero; to provide uniform clinical protocols across five million people (examples include web-published protocols for prioritisation and treatment for bone marrow transplantation7 and management of severe burns8); to attract substantial research funds from the National Health and Medical Research Council (NHMRC) and from the United Kingdom; and to implement data management programs they have designed. An important element of the success of the GMTT has been the process of peer review. A proposal that was generated within a specialty network did not progress unless it was supported by the medical, nursing and allied health peers within that network. Finally, to be adopted by the GMTT committee, the proposal had to be endorsed by peers from other specialties. This process added exceptional rigour to the resource allocation and ensured that it was not possible for specialists to make decisions that only benefited their own particular silo. For the future, is it better for a change agency such as the GMTT/GMCT to be inside or outside the tent? The GMTT was established as a ministerial advisory committee with regular and direct access to the Minister. This had the dual effect of energising the clinicians and alienating a sizeable section of the health bureaucracy. It created parallel processes — a circumstance that was considered necessary for change, but not viable in the long term. Following the Phelan review, it was agreed that the new GMCT should be integrated into the department, with dual reporting to the Director General and the Minister. This carries the opportunity for sustained influence, but the threat of demotivating some clinicians. Clinician vigilance will be required to ensure that the current genuine partnership with the bureaucracy is sustained. Time and achievements will tell. The next phase for the GMCT is challenging but exciting. Hospitals and their clinicians remain stressed by demands for services for which neither the dollars nor the available workforce are adequate. The GMCT must continue to expand its influence and reputation, develop further networks (orthopaedics, gastroenterology, respiratory medicine and urology are currently being targeted), and, most importantly, maintain the appropriate influence of clinicians on decision making. The challenge remains to ensure that the voices of those clinicians who are passionately committed to public hospital services are listened to as they should be. It has been a privilege to watch clinical colleagues respond so magnificently to the opportunities provided. This process for clinician governance merits recommendation to colleagues throughout Australia, where the benefits to patients and communities are likely to be the same. The Greater Metropolitan Transition Taskforce: achievements and outcomes For clinicians Involvement in making a difference for patients across greater metropolitan Sydney (five million people) Recognition of networks as peak advisory bodies for health service planning in their field Enhanced access for clinicians to Minister, Director General and Deputy Directors General of Health Dedicated infrastructure, including senior program manager and clinician-led data management Use of the networks for attracting research funds: Centres of Clinical Research Excellence, National Health and Medical Research Council (NHMRC) project grants, United Kingdom Medical Research Council trial funding Enhanced education and training, particularly for specialised nurses Enhanced communication and collegiality across professional and geographic boundaries For patients and communities Enhanced equity of access, particularly on the periphery of Sydney Greater equity of outcomes across the population Better clinical outcomes (eg, reduced morbidity and mortality [stroke network] and abolition of waiting times for living donor transplantation [renal network]) Representation on all clinical networks For government and Department of Health Better access to people who know where the solutions lie Safer, fairer and more cost-effective health care Assistance with identifying and addressing problems due to workforce shortages Details of the networks and their achievements can be viewed on http://www.health.nsw.gov.au/gmct.

Graeme J Stewart AM, PhD, FRACP, FRCPA · John M Dwyer AO, MB BS, PhD, FRACP · Kerry J Goulston AO, MB BS, MD, FRACP

The debate on its efficacy has been reignited Improvements in technology and greater acceptability have narrowed the gap between care in the hospital and care in the home. More patients with more diagnoses are receiving a greater diversity of hospital-type treatments at home than ever. However, the schism that once existed between hospital and home for treatment has opened up within the “hospital in the home” (HITH) movement over whether the concept works at all. In the early days, anecdotes suggested better outcomes at home, the only plausible mechanism being avoiding the risks of hospital. Then, it was easy to consider the high rate of adverse events in hospital and believe that HITH must reduce these. Because hospital-related adverse events are more common in older patients,1 it seemed plausible that older patients may have more to gain from HITH. However, the wide variety of adverse events hinted at difficulties in capturing the difference. It seemed even more obvious that replacing care in hospital with care at home must be cheaper. But critics thundered that HITH offered inferior care at greater cost.2 Both sides spoke without fear of contradiction because evidence was absent. But now there is evidence, and the debate has been reignited: Is HITH a true advance on in-hospital treatment with reduced complications, better health outcomes and greater patient satisfaction? Is it even cost-saving, or just a waste of money? On one side sits the Cochrane review, Hospital at home versus in-patient hospital care.3 This meta-analysis of 22 randomised controlled trials (RCTs) clearly concluded that there is no difference in outcomes and no cost savings! However, the review grudgingly accepts that patient satisfaction is greater with HITH than with hospital. The Cochrane process carefully sifted the trials to determine methodological rigour — whether the patients were adequately randomised, etc. Unfortunately, this sifting process did not include a criterion as to whether the basic experiment succeeded. One may assume that a review entitled Hospital at home versus in-patient hospital care would include only trials where patients in the control arm received their treatment in hospital, while those in the other arm received treatment entirely or almost entirely at home as a substitute for in-hospital care, with a curative intent. Studies of intensive palliative care at home should properly be called “hospice in the home”. Unfortunately, in one large study included in the Cochrane review, there was no statistically or clinically significant substitution for care in hospital by care at home. The study recruited older medical patients and the control group stayed in hospital 13.20 days while the group randomised to “HITH” was discharged 0.36 days earlier from hospital and then received an additional 9.04 days of “HITH” care at home.4 If the patients in the treatment group were not discharged from hospital earlier than the control group, that study does not meet the Cochrane review’s own definition of HITH, namely “treatment . . . that otherwise would require hospital in-patient care”, and should clearly have been excluded. Clouding by a study that did not meet HITH criteria was not the only impediment to discovering whether there was an improvement in health outcomes. Where outcomes were assessed, this was almost always done after discharge, often 3 or more months later. To be fair though, no one knew exactly what the difference in outcomes was, and so what “instrument” to use, at what time (during or after the admission) and how frequently to look for it, and in what patient group. On the other side, and providing the first inkling that there may be a difference, but that we had been looking at the wrong time, was an article published in this Journal. An RCT of 100 emergency department patients found a 20% decrease in the incidence of confusion in HITH.5 Three subsequent studies have now confirmed this. A trial (not an RCT) of surgical patients found less postoperative cognitive dysfunction at 7 days after day surgery compared with inpatient surgery.6 A United States multicentre trial (not an RCT) and an Australian single-centre RCT both showed significant decreases in delirium using the Confusion Assessment Method during the admission (to either hospital or HITH) for medical patients in HITH compared with hospitalised patients.7,8 The manifestation of this phenomenon in both medical and surgical patients demonstrates that the underlying diagnosis is not important, but the substitution of HITH care for in-hospital care is critical. Delirium is the “canary in the coalmine” of aged care — a transient early warning of increased mortality, nursing home placement and impaired physical and cognitive function. So, if delirium is reduced by HITH keeping patients out of hospital, you would expect to find reduced mortality and placement, and improved function, though a very large study or meta-analysis might be needed, because these events are less common than delirium. The Cochrane review, interestingly for a meta-analysis, does not combine all the data for mortality, and produces two solidly non-statistically significant results. But, if you combine all the Cochrane studies that measured mortality, excluding the palliative care studies (as Cochrane does) and the no-substitution study that should have been excluded, the odds ratio for mortality in HITH becomes a near-statistically significant 0.76 (95% CI 0.57–1.01; P = 0.0599)! The fact that it is not significant is probably a type II error. Interestingly, both groups in the Cochrane analysis, after removing the failed HITH trial, show an odds ratio of about 0.76 for mortality, indicating homogeneity. Even with borderline statistical significance, a one-quarter reduction in mortality from 17.8% to 13.4%, with a number needed to treat in HITH to prevent one death in 25, is clinically significant. Assessment for function in HITH studies shows two patterns. Studies where HITH substituted for hospital admission found that physical and cognitive function were improved.9,10 In studies in which patients are discharged early to HITH, the general focus on rehabilitation means that both groups attain comparable function. There are insufficient data on nursing home placement to draw conclusions. The problems with the financial analyses are similar, but simpler. Services where HITH is not a substitute for in-hospital care, but merely add-on care, are bound to be more expensive, no matter how sophisticated the economic analysis.4 Where HITH substitutes for in-hospital care, and the service works at reasonable capacity, HITH is cheaper than hospital.11 All the pieces are in place, though more evidence is needed to achieve statistical significance. The evidence clearly leads towards a conclusion that HITH offers better health outcomes and a reduction in costs.

Gideon A Caplan MB BS, FRACP

New Australian evaluation guidelines will help inform the debate It takes something like 10 years for a new compound to go from laboratory to clinical trial, and many more before a drug’s safety and efficacy are proven. Why isn’t clinical software — which might check for drug–drug interactions and dosage errors and generate alerts and recommendations to influence prescriber behaviour — treated as rigorously?1 Today, anybody with programming skill could create a rudimentary electronic prescribing package and put it directly onto the desktop of a general practitioner without regulatory approval. No doubt the stand-alone software in routine clinical use has undergone rigorous evaluation by its developers, but in most countries there is no specific regulation that requires this. Commercial vendors still sometimes sell prescribing systems with significant gaps in functionality.2 Some hospital prescribing systems are even sold devoid of the decision rules that will check for errors or guide prescribing. The expectation is that a hospital drug committee will have expertise in the development and maintenance of computational knowledge bases, an arcane and highly specialised skill set if there ever was one. Evidence mounts from systematic reviews that there is manifest benefit associated with clinical information technologies.3,4 However, case reports are appearing that indicate clinical software can sometimes cause harm.5 A new debate is building between those who demand that we rapidly introduce new information systems to improve the safety and quality of clinical practice and those whose view is that the evidence supporting its introduction is still wanting, and that, in some situations, there is a real possibility that it may do more harm than good.6 Much of the science on both sides in this debate is questionable. A widely reported article in 2005 identified 22 types of possible medication error risk associated with a clinical order-entry system.7 Clinical outcomes were not measured, and no attempt was made to explore whether these potential errors were the result of a badly designed system. Recently, Han et al reported that a hospital electronic prescribing system produced a statistically significant increase in mortality from about 3% to 7%.8 However, assigning the blame for this startling outcome solely to the software is problematic. Introduction of the software altered traditional work patterns and increased the complexity and time taken to prescribe. Yet the new system was implemented in less than a week — an extremely short time to introduce a complex new organisational process. On the technology proponents’ side, systematic reviews of decision support systems often try to infer which features are beneficial by lumping together widely dissimilar systems used in very different contexts.4 However, local and sociocultural variables strongly influence the uptake and efficacy of such systems,9 and these are rarely controlled for or quantified in studies, making it hard to interpret this type of systematic review. Further, citing lack of evidence for the value of different software features in a review, when the original studies were never designed to test for these features, does not say much. What should be done? The process guiding the development and testing of most medical treatments and biomedical instrumentation, including software embedded in or linked to clinical devices, is tightly regulated. In contrast, the development of stand-alone clinical software is not. In Australia, stand-alone decision-support computer programs, such as electronic prescribing systems, are not considered “therapeutic goods” and are not subject to regulation. Similarly, in the United States, software that relies on manual data input and that is not directly used in diagnosis or treatment is usually exempt from the premarket regulatory requirements of the Food and Drug Administration to demonstrate that the device is as safe and as effective as devices already on the market.10 Even if there were strict regulations for clinical software, defining either the process of system development or the knowledge within and behaviours of a system, there is no guarantee that software would be implemented or used safely. Information technology is only one component of health services.9 For the whole system to be safe, certification might have to include the skills of those using the software and the organisational processes within which the software is embedded. Consequently, the most appropriate model of governance over the safety and quality of clinical software is far from clear, and may involve elements of industry self-regulation, legislation and best practice guidance. These models are currently a matter of debate among organisations such as the International Organization for Standardization and the European Committee for Standardization. Locally, the National E-Health Transition Authority is developing basic technical standards for clinical software that should lead to more uniform and better engineered systems, and early work by the General Practice Computing Group examined the broader need for software accreditation. The United Kingdom’s National Programme for IT has moved further — establishing a safety team — and has embedded a safety management approach into its procurement processes. The Australian Health Information Council recently published national guidelines for the evaluation of electronic clinical decision support systems, to promote evaluation using rigorous and validated methodologies.11 The guidelines recognise that it is difficult to propose a single evaluation methodology that meets the diverse needs of both the software and clinical communities. Different user groups have different evaluation tasks and objectives. Even the choice of evaluation method is sometimes unclear, given the complexities of health services and the limited opportunities to carry out rigorously controlled trials. The guidelines outline approaches to testing the clinical effectiveness of decision support systems, their integration into existing work practices, user acceptability, and technical evaluations of the software and knowledge bases. Urgent debate is needed to move this agenda forward,12 and these guidelines should provide a platform to inform that debate. We can move quickly to develop appropriate models of governance for clinical software, or we can step back and let the courts decide, when legal cases of negligence occur. Some will argue that regulation inhibits innovation, but there are good examples of regulation driving technology innovation in other industries. The airline industry is often presented to us as a safety role model, but that industry was forced to change only after a string of catastrophic disasters. We can do much better by anticipating the potential risks of these technologies, rather than reacting to mishap. Over the next few years, despite people’s lives being saved or improved by these new systems, some hard lessons may be learned about their safe and effective use.

Enrico W Coiera MB BS, PhD · Johanna I Westbrook PhD, FACMI

Objective: To evaluate the effects of multidisciplinary case management (CM) on emergency department (ED) utilisation and psychosocial variables for frequent attenders at the ED.Design: Retrospective cohort analysis, with the study population as historical controls and data analysed 12 months before and after CM intervention in the period 1 January 2000 – 31 December 2004. Subgroup analyses were performed according to primary problem categories: general medical, drug and alcohol, and psychosocial.Setting: Inner urban tertiary hospital ED.Participants: Frequent ED attenders who received CM.Main outcome measures: ED attendances: length of stay, triage category, ambulance transport, disposition, attendances at the only two EDs nearby. Psychosocial factors: housing status, drug and alcohol use, and primary and community care engagement.Results: 60 CM patients attended the ED on 1387 occasions. Total attendances increased after CM for the whole group (610 v 777, P = 0.055). Mean average length of stay (minutes) of the total study population and each subgroup was unaffected by CM (297 v 300, P = 0.8). Admissions for ED overnight observation increased as a result of CM (P = 0.025). CM increased scores for housing stability (P = 0.007), primary care linkage (P = 0.003), and community care engagement (P < 0.001) for the whole group and variously within subgroups. Drug and alcohol use was unaffected by CM.Conclusion: ED-initiated, multidisciplinary CM appears to increase ED utilisation and have a positive effect on some psychosocial factors for frequent attenders. A trend towards increased ED attendance and utilisation with CM may have implications for policies that seek to divert frequent attenders away from hospitals.

Georgina Ann Phillips MB BS, FACEM · David S Brophy BA, BSW · Tracey J Weiland BBSc(Hons), PhD · Antony J Chenhall MB BS, FACEM · Andrew W Dent FACEM, FRCS, MPH

Objective: To compare patterns of epilepsy in Indigenous and non-Indigenous people presenting to hospital.Study design: Retrospective cross-sectional survey of individuals admitted to hospital with a diagnosis of epilepsy (1 January 2001 – 31 December 2004); presenting to the emergency department with a seizure (2004); or presenting to the epilepsy clinic (1 September 2002 – 31 March 2005).Setting: Cairns Base Hospital, the major referral centre for Far North Queensland, including Cape York and the Torres Strait, with a population of 230 000 (13% Indigenous).Main outcome measures: Proportion of Indigenous patients presenting for epilepsy; proportion of Indigenous and non-Indigenous groups affected by each of the main epilepsy syndromes.Results: Of 359 patients attending the epilepsy clinic and 918 patients having electroencephalography (EEG), 11% and 13% were Indigenous, respectively (in proportion with the catchment population). However, 30% (146/486) of patients presenting to the emergency department with seizure, 31% (130/418) of inpatient admissions with epilepsy, and 44% (28/63) of patients admitted with status epilepticus were Indigenous. Indigenous patients were more likely to have an abnormal EEG result (P = 0.025), while non-Indigenous patients presenting to the clinic were more likely to be classified as non-epileptic (31% v 18%). In those with abnormal EEG, the frequency distribution of abnormalities was similar, and, in those with epilepsy, syndrome classification also showed similar frequencies. There was no significant difference in occurrence of epileptogenic abnormalities detected by imaging (13% non-Indigenous v 18% Indigenous) or in alcohol consumption (38% v 37%).Conclusions: Indigenous Australians have similar epilepsy syndromes to the non-Indigenous population, but they present with more serious disease. This discrepancy may relate to inequitable health care utilisation due to cultural issues or geographic isolation.

John Archer FRACP, PhD · Ruth Bunby BAppSc

Objective: To assess the potential for dose-reduction of prophylactic anti-D postpartum.Design: Retrospective audit of fetomaternal haemorrhage (FMH) quantitation by flow cytometry.Participants and setting: 5148 consecutive Rhesus D-negative women aged 15–45 years who had FMH estimation by flow cytometry at a central laboratory in Western Australia in the 65 months between 1 August 1999 and 31 January 2005.Main outcome measures: Quantitation of FMH volume for adequate prophylactic anti-D administration in a timely fashion.Results: 90.4% (4651/5148) of the women had an FMH volume of 1.0 mL or less of Rh D-positive red cells, and 98.5% (5072/5148) had a volume of less than 2.5 mL. Only 0.4% of cases had an FMH volume of 6.0 mL or greater (range, 6.0–92.4 mL).Conclusions: This large retrospective audit shows that a currently available dose of 250 IU (50 mg) of anti-D would have been sufficient for 98.5% of the 5148 Rh D-negative women. On the basis of this evidence, a reduction in the recommended routine postpartum dose of anti-D from 625 IU to 250 IU when flow cytometric quantitation for FMH is available should be considered. Adopting such a strategy would ensure the ongoing provision of a valuable human blood product currently in limited supply.

Bradley M Augustson FRACP, FRCPA · Elizabeth A Fong BappSc, PGradDip(MBiol), GradDip(BCom) · Dianne E Grey FAIMS, BAppSc · Janine I Davies BAppSc, PGradDip(MSc) · Wendy N Erber MD, FRCPA

Objective: To determine the usefulness of abdominal ultrasonography for diagnosing colorectal cancer in patients presenting with abdominal distension.Design, setting and participants: A prospective case series of consecutive adult patients with abdominal distension admitted to the National Taiwan University Hospital between January 2001 and July 2004. All participants were examined by abdominal ultrasonography. Those with suspected colorectal tumours on ultrasonography had follow-up colonoscopy, while all other patients had computed tomography scans.Main outcome measures: Accuracy of abdominal ultrasonography for diagnosing colorectal cancer in patients with abdominal distension; incidence of colorectal cancer.Results: Of 511 patients eligible for inclusion in our study, 97 (19.0%) were confirmed to have colorectal cancer. For diagnosis of colorectal cancer, ultrasonography had a sensitivity of 92.8% (95% CI, 85.2%–96.8%); a specificity of 98.8% (95% CI, 97.0%–99.6%); a positive predictive value of 94.7% (95% CI, 87.6%–98.0%); a negative predictive value of 98.3% (95% CI 96.4%–99.3%); and an accuracy of 97.7%.Conclusion: Ultrasonography is a sensitive tool for diagnosing colorectal cancer in patients presenting with abdominal distension.

Shyr-Chyr Chen MD, MBA · Zui-Shen Yen MD, MPH · Hsiu-Po Wang MD · Chien-Chang Lee MD, MPH · Chiung-Yuan Hsu MD · Wen-Jone Chen MD, PhD · Chien-Yao Hsu MD · Hong-Shiee Lai MD, PhD · Fang-Yue Lin MD, PhD · Wei-Jao Chen MD, PhD

Objectives: To determine whether pregnant women and their newborns show evidence of iodine deficiency, and to examine the correlation between maternal urine iodine concentration (UIC) and newborn thyroid-stimulating hormone (TSH) level.Design: A cross-sectional study.Setting: Hospital antenatal care services (March–May 2004) and private obstetrician clinics (June 2004) in the Central Coast area of New South Wales.Participants: 815 pregnant women (≥ 28 weeks’ gestation) and 824 newborns.Main outcome measures: World Health Organization/International Council for the Control of Iodine Deficiency Disorders criteria for assessing severity of iodine deficiency (recommended levels: < 20% of urine samples in a population with UIC < 50 μg/L; and < 3% of newborns with whole-blood TSH level > 5 mIU/L).Results: The median UIC for pregnant women was 85 μg/L, indicating mild iodine deficiency. Almost 17% of pregnant women had a UIC < 50 μg/L, and 18 newborns (2.2%) had TSH values > 5 mIU/L. There was no statistically significant linear correlation between neonatal whole-blood TSH level and maternal UIC (r = − 0.03; P = 0.4). Mothers with a UIC < 50 μg/L were 2.6 times (relative risk = 2.65; 95% CI, 1.49–4.73; P = 0.01) more likely to have a baby with a TSH level > 5 mIU/L.Conclusion: The pregnant women surveyed were mildly iodine deficient. TSH values for their newborns were mostly within acceptable limits. Ongoing surveillance of the iodine status of NSW communities to establish trends over time is recommended.

Cheryl A Travers BSc, MPH · Kamala Guttikonda MB BS, FRACP · Carol A Norton BHSc, GDMid, MMid · Peter R Lewis MB BS, MPH, FAFPHM · Lyndall J Mollart RN, RM, MMid Studies · Veronica Wiley PhD, FHGSA · Bridget Wilcken AM, MB ChB, FRACP · Creswell J Eastman AM, MD, FRCPA, FRACP · Steven C Boyages PhD, DDU, FRACP

Objective: To identify characteristics of submitted manuscripts that are associated with acceptance for publication by major biomedical journals.Design, setting and participants: A prospective cohort study of manuscripts reporting original research submitted to three major biomedical journals (BMJ and the Lancet [UK] and Annals of Internal Medicine [USA]) between January and April 2003 and between November 2003 and February 2004. Case reports on single patients were excluded.Main outcome measures: Publication outcome, methodological quality, predictors of publication.Results: Of 1107 manuscripts enrolled in the study, 68 (6%) were accepted, 777 (70%) were rejected outright, and 262 (24%) were rejected after peer review. Higher methodological quality scores were associated with an increased chance of acceptance (odds ratio [OR], 1.39 per 0.1 point increase in quality score; 95% CI, 1.16–1.67; P < 0.001), after controlling for study design and journal. In a multivariate logistic regression model, manuscripts were more likely to be published if they reported a randomised controlled trial (RCT) (OR, 2.40; 95% CI, 1.21–4.80); used descriptive or qualitative analytical methods (OR, 2.85; 95% CI, 1.51–5.37); disclosed any funding source (OR, 1.90; 95% CI, 1.01–3.60); or had a corresponding author living in the same country as that of the publishing journal (OR, 1.99; 95% CI, 1.14–3.46). There was a non-significant trend towards manuscripts with larger sample size (≥ 73) being published (OR, 2.01; 95% CI, 0.94–4.32). After adjustment for other study characteristics, having statistically significant results did not improve the chance of a study being published (OR, 0.83; 95% CI, 0.34–1.96).Conclusions: Submitted manuscripts are more likely to be published if they have high methodological quality, RCT study design, descriptive or qualitative analytical methods and disclosure of any funding source, and if the corresponding author lives in the same country as that of the publishing journal. Larger sample size may also increase the chance of acceptance for publication.

Kirby P Lee PharmD, MA · Elizabeth A Boyd PhD · Jayna M Holroyd-Leduc MD · Peter Bacchetti PhD · Lisa A Bero PhD

Marfan syndrome (MFS) is a multisystem disorder of connective tissue that is inherited in an autosomal dominant fashion, and results from mutations in the FBN1 gene on chromosome 15. Diagnosis is challenging as it requires definition of diverse clinical features and input from a variety of specialists. Genetic testing of FBN1 is time consuming, expensive and complex, and may not solve the diagnostic dilemma. Failure to make a diagnosis or making an inappropriate diagnosis of MFS has social, lifestyle and medical consequences for the individual as well as the family.

Kim M Summers BSc(Hons), PhD · Jennifer A West RN · Madelyn M Peterson BPharm, MA(Ethics) · Denis Stark MB BS, FRCS, FRACO · James J McGill MB BS, FRACP · Malcolm J West MB BS, FRACP, PhD

The recent publication, in prestigious scientific journals, of two major studies that were subsequently shown to contain fabricated data may compel reviewers and editors to adopt a more rigorous policy in accepting articles for publication. The current manner of peer reviewing research articles provides no assurance that the proffered work is not the result of fraud. The present guidelines for contributors in large team investigations may need to be updated to avoid giving credit to co-authors who may have made little, if any, contribution to the work.

Paul Gerber LLB, DJur

The fortification of staple foods has eliminated many deficiency diseases. Despite this, “tampering” with people’s food always provokes opposition, much of it from health professionals. Opposition is often based on self-interest, tunnel vision and theory rather than research. A historical perspective of the patterns of objections to fortification and its outcomes may help resolve the anxieties and opposing ethical positions of advocates and opponents of fortification.

Max Kamien FRACP, FRACGP, FACRRM

CorrectionRe: “The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments”, by Peter C Sprivulis, Julie-Ann Da Silva, Ian G Jacobs, Amanda R L Frazer and George A Jelinek, in the 6 March issue of the Journal (Med J Aust 2006; 184: 208-212). Sprivulis et al wrote that they obtained ethics approval from the “Western Australian Department of Health Confidentiality of Health Information Committee”. This description is incorrect. The Confidentiality of Health Information Committee of Western Australia is an independent committee appointed by the Minister for Health and is not part of the WA Department of Health. We thank Dr David G Blackledge (a member of the committee in question) for pointing out this error. The html and pdf versions of this article were corrected on 23 May 2006.

Peter C Sprivulis · Julie-Ann Da Silva · Ian G Jacobs · Amanda R L Frazer · George A Jelinek

Edwin (“Eddie”) Young was born on 25 October 1938 in Brisbane. He attended Brisbane Boys’ College as a boarder, his parents being stationed in Colombo, where his father was Director of Ceylon’s Rubber Research Station. At school, Edwin proved to be not only an outstanding scholar, but also a highly talented gymnast, a sport he pursued throughout his life, leading Queensland’s gymnastics team for 2 years before becoming its coach. Eddie graduated in medicine from the University of Queensland in 1965. In 1968, he took up a position as Psychiatrist (later, Senior Psychiatrist) at Wolston Park Hospital, Brisbane, one of Australia’s oldest psychiatric hospitals (founded in 1865 as the Woogaroo Lunatic Asylum). He completed a Diploma in Psychological Medicine in 1969 and obtained his Fellowship of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) in 1975. The family lived in one of Queensland’s most significant residences, Ellerton House, which was built in 1916 by the Queensland Government. It was here that Eddie developed his love of teaching, soon becoming a member of what was then the Faculty of Medicine, University of Queensland, lecturing in neuropsychiatry in the preclinical years and giving lectures to medical students at Wolston Park and Ipswich hospitals. He also regularly organised pre-fellowship courses for psychiatrists-in-training, which are now being provided by Queensland Health and called the “Eddie Young Annual Psychiatric Registrars weekend”. In 1981, Eddie entered private practice, although he retained a connection with Wolston Park as Visiting Senior Specialist until his death. He was instrumental in establishing Queensland’s first methadone clinic, which included an injection program for opiate addicts — the first of its kind in Australia. Eddie was a true neuropsychopharmacologist at a time when Brisbane was still overpopulated with Freudian or Kleinian analysts. He took a scientific interest in the condition that became known as attention deficit hyperactivity disorder, publishing as lead author a major article on the condition.1 He also established the first Computer Bulletin Board for the RANZCP. In late 1999, Eddie was first diagnosed with multiple myeloma. He went into remission after receiving autologous stem cell transplants, but by the beginning of 2005, despite treatment with thalidomide, his condition had declined rapidly. He bore his suffering stoically, continuing to see patients and lecturing in the medical school. His last words to his secretary were, “I’ll be in the office tomorrow to go through the mail”. Alas, tomorrow never came. Eddie died on 12 October 2005 and will be deeply missed by colleagues and friends. He is survived by his wife Barbara and children Marcus, Marina and Victoria.

Paul Gerber

Clinical records The details of four patients treated at the Head and Neck Unit, Princess Alexandra Hospital, Brisbane, over a 1-year period are summarised in the table. All four patients presented with progressive trigeminal or facial nerve palsies following excision of cutaneous lesions from the head and neck. Patient Age (years) Sex Presentation History of cutaneous head and neck malignancy Specialties involved Delay in diagnosis Investigations Final diagnosis Management Patient 1 40 male 3 years’ progressive paraesthesia of the left upper lip and cheek Nasal tip lesion removed with cryotherapy: no histology available General practice, dermatology, otolaryngology 3 years MRI PNS (SCC) along V2 Intracranial/skull base surgery with postoperative radiotherapy Patient 2 41 male 8 months’ progressive left cheek paraesthesia, jaw pain and trismus Excision of a left lower lip SCC 2 years previously: histology showed small nerve PNS, so postoperative radiotherapy given General practice, maxillofacial, neurology, otolaryngology 6 months MRI (showed hyperintensity of the left masseter consistent with denervation changes) Masseteric muscle biopsy PNS (SCC) along V2 and V3 extending to the pons Palliative radiotherapy Patient 3 67 female 2.5 years’ progressive left facial nerve palsy Extensive facial SCCs, including an aggressive recurrent right cheek SCC treated with radical excision and radiotherapy Neurology, ophthalmology, otolaryngology 2.5 years MRI PNS (SCC) along VII and V2 Intracranial/skull base surgery with postoperative radiotherapy Patient 4 72 female 5 months’ progressive left facial nerve palsy and left forehead and cheek paraesthesia Two skin lesions excised from the right (contralateral to nerve palsies) nasolabial sulcus 20 years previously: no histology available Otolaryngology 5 months Initial MRI (Box 1) reported as “normal”, although on retrospective review PNS was seen. Subsequent MRI (Box 2) showed extension of the tumour to the pons. PNS (melanoma) along V2 and V3 extending to the pons Palliative care MRI = magnetic resonance imaging. PNS = perineural spread. SCC = squamous cell carcinoma. V2 = maxillary division of trigeminal nerve. V3 = mandibular division of trigeminal nerve. VII = facial nerve. The incidence of non-melanotic head and neck skin cancers in Queensland is among the highest in the world.1 Perineural spread (PNS) from these lesions involves either small nerves, identified at pathological examination (incidental), or large nerves, presenting clinically as cranial nerve palsies. Basal cell carcinoma is the more common skin cancer, but incidental PNS is most frequently associated with squamous cell carcinoma.2 In 32 out of 34 patients over a 5-year period, isolated major nerve PNS was due to squamous cell carcinoma (unpublished data). PNS from melanoma and microcystic adnexal carcinoma has also been described.3,4 Because many clinicians are not familiar with PNS involving large cranial nerves, the diagnosis can easily be missed or delayed. The disease is associated with high treatment morbidity and poor prognosis once clinical or radiological evidence becomes apparent, with a 5-year survival rate of 20%–30%.5 Early detection of PNS in large cranial nerves is essential, as the condition is often unsalvageable once the tumour has spread through the skull base. The facial and trigeminal nerves are most commonly affected,6 although forehead tumours can gain access to the orbit via the ophthalmic nerve.7 Symptoms of trigeminal nerve infiltration include formication, dysaethesia, paraesthesia, numbness and pain (often severe and “electric shock-like” in nature).8 Slowly progressive facial nerve palsy may represent seventh cranial nerve infiltration or infiltration within the parotid, whereas diplopia and visual impairment indicate advanced orbital disease. These symptoms can mimic other diagnoses, such as Bell’s palsy or trigeminal neuralgia, but almost always manifest as slowly progressive and irreversible palsies. Close follow-up of patients to ensure resolution of symptoms is mandatory. The four patients we have described illustrate delays between clinical presentation and diagnosis. These delays could have been avoided by establishing the link between unresolving cranial nerve palsies and excision of cutaneous lesions from the head and neck. Patients 2 and 3 had a history of aggressive squamous cell carcinoma of the face treated with radical excision and postoperative radiotherapy. Advanced, recurrent skin squamous cell carcinomas have a higher incidence of PNS, particularly when located close to a cranial nerve, and should alert the clinician to the possibility of neural metastasis.9 Tumour size before excision, postoperative defect size, subclinical extension and Moh’s micrographic surgery levels are significantly larger in patients with PNS than in patients without PNS.10 PNS can be subtle and missed on initial pathology but, because of the propensity for local recurrence, most specialist multidisciplinary units that deal with skin cancer will recommend adjuvant radiotherapy, particularly if the lesion is excised from the trigeminal nerve distribution. In Patients 1 and 4, no histology was available. Small skin lesions are often treated with cryotherapy or curettage, resulting in no pathological report. However, these lesions may still have a propensity for PNS, so their excision should be elicited in the history. In Patient 4, the skin lesions were excised from the side of the face contralateral to the cranial nerve palsies and were unlikely to represent the primary disease. Nevertheless, this case illustrates that patients with a history of cutaneous lesions from any site on the head and neck are at risk of developing PNS. These cases also illustrate that the interval between excision of a lesion and presentation of PNS can be long.11 Clinicians should hold a high index of suspicion even if the interval is several years. A further source of delay is that patients are seen by a variety of clinicians before diagnosis. Cross-referral for second opinions is common, resulting in further delay. Patients 1–3 illustrate how the unfamiliarity of clinicians with the disease process resulted in patients seeking opinions from several specialties before definitive diagnosis. In addition, investigations may be performed to exclude a different pathology or misinterpreted because the clinician is unaware of the phenomenon, resulting in further delay. In Patients 2 and 4, initial imaging revealed changes compatible with PNS, but these were not recognised, either because the radiologist was not familiar with the entity or because the referring clinician may not have raised the possibility of PNS. In Patient 2, the hyperintensity of the masseter muscle on magnetic resonance imaging (MRI) led the clinician to suspect a primary muscular disorder, instead of the correct interpretation of denervation changes from trigeminal nerve involvement. The patient underwent an unnecessary muscle biopsy. Earlier detection may have resulted in Patients 2 and 4 being treated with curative intent instead of palliative care. High resolution MRI is the investigation of choice, and may identify the earliest changes of PNS. However, disease may not be radiologically apparent until it has reached the orbit, cranial fossa or the skull base foramina. Computed tomography (CT) identifies the disease at a late stage when the tumour has eroded adjacent bony margins. MRI has the added advantage of defining the relationship of the perineural tumour to important anatomical landmarks such as the cavernous internal carotid artery; this is important when planning a resection or biopsy. However, subtle changes on MRI may be missed even by experienced radiologists and, given a strong clinical suspicion with normal imaging, nerve biopsies should be performed. Presently, positron emission tomograph (PET) scanning has no role to play in the staging of PNS. Delayed diagnosis of major cranial nerve PNS may result in devastating outcomes for patients, so early detection is crucial. Patients who present with slowly progressive cranial nerve palsies with a history of head and neck cutaneous malignancies should be investigated for PNS with a high index of suspicion. We recommend that all patients who undergo excision of high risk skin malignancies should be advised to seek a medical opinion if they develop facial numbness or weakness in subsequent years. 1 Coronal T2-weighted MRI images of Patient 4 These images were reported as “normal”, although retrospective review shows perineural spread of melanoma with thickening and nodularity along the left V2 (A), V3 (B) and the trigeminal ganglion (C). MRI = magnetic resonance imaging. 2 Contrast-enhanced T1-weighted MRI images of Patient 4 The images show perineural spread of melanoma with perineural thickening and enhancement along the left V2 (A), V3 (B), the trigeminal ganglion (C) and the trigeminal nerve as it exits the pons (D). MRI = magnetic resonance imaging.

Giles C Warner MSc, MD, FRCS · Mitesh Gandhi MRCP(UK), FRCR, FRANZCR · Benidict Panizza MB BS, MBA, FRACS

A 54-year-old man presented with a 3-year history of non-inflammatory pain in his lower back, and his hip and knee joints. He also had black discolouration of the palms, cheeks and sclerae (Box 1A) and his urine turned black on alkalinisation (Box 1B). Spinal x-rays showed intervertebral disc calcification (Box 1C). A diagnosis of alkaptonuria (ochronosis) was made. The calcification of intervertebral discs is caused by calcium hydroxyapatite. Knee, shoulder and hip joints may also be affected, but small joints of the hands and feet are spared. This condition differs from ankylosing spondylitis in that there is no annular ossification. Sacroiliac joint changes differ — patients with ochronosis have narrowing and extensive sclerosis, while those with ankylosing spondylitis have erosive changes followed by ankylosis. The diagnosis of ochronosis can be confirmed by detection of urinary homogentisic acid. Features pointing to the diagnosis of ochronosis A: Discolouration of the sclerae. B: Urine sample before (left) and after (right) alkalinisation. C: Spinal x-ray showing intervertebral disc calcification.

Aman Sharma MD · Shefali K Sharma MD · Ajay Wanchu DM · Manish Kumar MD · Surjit Singh MD · Pradeep Bambery MD

To the Editor: There has been much public discussion recently about comorbidity between substance misuse and psychiatric disorders.1,2 Drug and alcohol misuse can precipitate, exacerbate and prolong psychiatric disorders, and is often accompanied by a range of social problems. Here we report on the prevalence of substance misuse in an unselected group of patients admitted to the 20-bed acute psychiatric facility at Lyell McEwin Health Service, situated in an underprivileged region of northern Adelaide. The facility has five closed beds and 15 open beds. In October 2005, 45 patients (23 men, 22 women; mean age, 39 years) were admitted to the unit, of whom 28 (62%) were detained involuntarily. Semi-structured interviews, clinical history taking and collateral information gathering revealed that 27 patients (60%) had a comorbid substance misuse disorder. The most common substance misused was cannabis (20 patients [44%]), followed by alcohol (16 patients [36%]), amphetamines (15 patients [33%]), opiates (6 patients [13%]) and benzodiazepines (5 patients [11%]). Misuse of more than one substance was common — for example, all 15 patients diagnosed with amphetamine misuse also misused cannabis. Patients who misused cannabis were younger (mean age, 33 years) than those who did not (mean age, 44 years) (t43 = 0.23; P = 0.023) and were more likely to be male (61% of male patients misused cannabis compared with 27% of female patients; χ2 = 5.14; P = 0.036). Of 19 patients with psychotic disorders, 11 misused cannabis. These results indicate high rates of substance misuse in patients admitted to a psychiatric facility. Cannabis misuse by young men is a particular concern. It is apparent that more than half of inpatients with acute psychiatric conditions could benefit from interventions to address their substance misuse. The extent of cooperation between drug and alcohol services and mental health services varies between different localities and between the private and public sectors. In states such as South Australia, where there is a historical separation between drug and alcohol services and mental health services, the treatment of these disorders is regarded as outside the role of mental health services. Patients considered to have a primary problem with substance misuse are treated by specialised drug and alcohol services. This service divide does not reflect clinical reality. Patients with comorbidity can “fall through the cracks”, each service regarding them as someone else’s responsibility. Postgraduate training in psychiatry includes both academic input and the submission of case logs describing 10 patients with addiction disorders, but this aspect of training may need to be expanded in response to changes in the pattern of disorders in the patient population. Mental health clinicians, along with general practitioners and doctors working in settings such as emergency departments, will increasingly need to be highly skilled in diagnosing and managing comorbid drug and alcohol and psychiatric disorders.

Cherrie Ann Galletly DPM, FRANZCP, PhD · Darryl P Watson MB BS, FRANZCP

To the Editor: Much has been written to describe the best clinical protocols to improve patient outcome following a medical emergency in hospital.1-4 However, one simple step in the process has not been clearly articulated: what is the hospital internal emergency number to ring to summon the medical emergency or “code blue” team? Each hospital in Australia sets its own emergency phone number. Examples include 333, 444, 555, 666, 777 and 2333 — there are probably others. For the highly mobile workforce in our hospitals, it is often difficult to recall which number to ring when challenged by the immediacy of a situation. All hospitals should upgrade their phone systems to have a single standard phone number for internal emergencies. This solution has been successfully applied in the broader community. In the Australian community an emergency call is 000, in the United States it is 911, and in the United Kingdom it is 999. It ought to be possible for all Australian hospitals to use a standard emergency telephone number to initiate an internal emergency response. I have only been able to find one health service internationally that has attempted this solution — the UK National Health Service advises trusts to use the number 2222.5 Technical advice on what number would be most suitable in Australia would be required. Telecommunications experts should advise on the technical aspects, cost and a reasonable time frame for all hospitals. State and federal health services would need to direct all hospitals to move to the new number, either as able or by a date to be determined. I hope to raise the debate on what appears, at a superficial level, to be a very simple initiative that could save lives, or at least remove one more cause of error and delay in the internal emergency response of each hospital.5 I have written to various authorities asking that this concept be explored. Those that have responded agree in principle, but have not taken responsibility for its progression. If this is a good idea, who should or could take control of it? It would be helpful to find an authority to back this proposal. This is a call for help.

Gerald F Williams

To the Editor: I am not a regular correspondent, as, with three children and a career, I rarely have the time. But, having read the recent personal perspective on missed conception1 and the accompanying commentary,2 I felt compelled to offer my own personal perspective on how, in medicine as a profession, we value (or don’t value) childbearing. Chapman and colleagues2 discuss the need for workplace reforms as a means of reducing barriers to earlier childbearing. If we, as doctors, are serious about this issue we need to lead by example and address workplace difficulties in promoting childbearing as a positive choice in our own profession. Despite women comprising at least half the medical students, they are still under-represented in most specialties, principally because training and childbearing are realistically seen by many women as “either/or” options. From my own experience, I can offer some illustrations of very real ways childbearing is devalued or discouraged in medicine. In my interview (around 1990) to gain admission to a physician training scheme, I was asked about my plans for a family, with the clear implication that, if I was considering having children, I should reconsider my options. Once a trainee, at the same hospital, I was advised by a senior (female) physician to delay pregnancy as long as possible, as it would mean death to any career aspirations. In my final year of advanced training, I was offered a job at one hospital, only to be un-offered the job days later when they heard, on the “grapevine”, that I was pregnant. When, as a National Health and Medical Research Council Research Scholar, I became pregnant with my second child and wanted to reduce my hours to part-time, I found the scholarship income became taxable — as it was assumed that part-timers were topping up income with private work. This significantly devalued the scholarship and went nowhere near covering childcare costs! After completing my PhD, in the course of applying for research funds while still working part-time, I discovered that granting bodies in Australia have no standard methodology for assessing curricula vitae of part-timers. With mothers comprising a large proportion of the medical part-time workforce, this effectively excludes us from competing for funds unless we wish to outsource our children. As recently as 2 years ago, when discussing these sources of inbuilt bias against medical mothers with a colleague, I was told my comments were inappropriate and offensive. If we, as a profession, can’t even discuss these stories, how can we set an example of positive family planning to the community at large? In listing the events described, I am not seeking sympathy or redress or claiming my path has been unusually difficult. Nor do I regret having my three lovely children! If one speaks to any working mother, similar stories emerge. As long as women feel the problems are their individual issues to grapple with in silence and embarrassment, rather than system failures, women embarking on any career will continue to be faced with a very real choice between children and a career (as opposed to a “job”). We may not be able to solve these issues on a community-wide basis, but let’s at least look in our own backyard.

Jane M Andrews

To the Editor: In an editorial in the 3 April 2006 issue of the Journal,1 Roughead and Lexchin estimated the annual incidence of adverse drug events (ADEs) in patients presenting to general practitioners, based on our data presented in the same issue.2 Calculating the incidence of ADEs from general practice encounter data is fraught with difficulties. Roughead and Lexchin’s calculation depends on all general practice patients having an equal chance of being in the sample. This would only hold true if all patients attended their GP an equal number of times. However, in our study, the age distribution of patients with ADEs shows that they are more likely to belong to older patient groups with a much higher than average general practice attendance rate. They thus represent a smaller proportion of all general practice patients, as their chance of being in the sample is much higher. Adjusting for the age and sex distribution results in an estimated incidence of about 1.6 million people. Further, these 1.6 million would, if asked, have reported an ADE in the previous 6 months. This cannot be extrapolated to an annual incidence of ADEs. The annual incidence figure could in fact be larger than that suggested by Roughead and Lexchin. We believe that recurrent monitoring of ADEs in patients attending general practice is a useful way of measuring the impact of the interventions suggested by Roughead and Lexchin, regardless of the difficulty of extrapolating to population incidence.

Graeme C Miller, Associate Professor and · Helena C Britt · Lisa Valenti · Stephanie Knox

To the Editor: We read with great interest the editorial by Gruen and colleagues on the recent developments in health services research and the establishment of an EPOC (Effective Practice and Organisation of Care) satellite at the National Institute of Clinical Studies in Australia.1 Before the social and political changes in Central and Eastern Europe in the 1990s, policymakers in Hungary (population 10 million) and many other former socialist countries had little interest in the effectiveness of health service interventions.2 Important tools of health policy decision making were missing from the health care system. Over the past 16 years, efforts have been made in Hungary to strengthen the institutional background and tools of health policy decision making. We would like to highlight some milestones of this process. During the 1990s, Hungarian researchers were sent to foreign universities to receive formal training in subjects related to health services research. Later, academic institutions and departments were established (Health Services Management Training Centre at Semmelweis University [Budapest], School of Public Health at the University of Debrecen [eastern Hungary], Unit of Health Economics and Health Technology Assessment at Corvinus University [Budapest], and Department of Health Insurance and Health Policy at the University of Pécs [southern Hungary]). In 2004, the National Institute for Strategic Health Research was established to guide governmental health policy decision making by undertaking activities in four main areas: health informatics and information policy; health economics; health services and health system research; and health technology assessment and coverage policy. A key issue of Hungarian health policy was the introduction of the “fourth hurdle” (cost-effectiveness) into the decision-making process.3 In a first step towards achieving this, methodology standards were published by the Ministry of Health, which regulates the guidelines for conducting economic evaluation.4,5 During the development of health services research in Hungary, we carefully studied many aspects of the Australian experience, published in the international literature or presented at scientific meetings, including: coverage policy, drug pricing and reimbursement, health technology assessment, price/volume agreements, diagnosis-related groups, evidence-based guidelines, the National Health and Medical Research Council, the Pharmaceutical Benefits Advisory Committee and the Pharmaceutical Benefits Scheme, and performance measurement. Several of these (coverage policy, drug pricing and reimbursement, and diagnosis-related groups) had a significant effect on Hungarian health policy decision making. We found the main advantages of the Australian system, compared with other countries, to be the strong scientific and professional background (evidence-based medicine) and the transparency of decision making. Although we did not make any formal ranking of countries, the Australian experiences were evaluated as worthwhile for local application, together with those of the Netherlands, Sweden and the United Kingdom. Notwithstanding the considerable distance between Australia and Hungary, we look forward to reading about further developments in health services research and the Australian EPOC satellite, and hope that we can also benefit from your experience with the appropriate implementation of research findings throughout health policy decision making and into everyday medical practice.

Imre Boncz · Andor Sebestyén

To the Editor: Shewan and Coats1 are right to draw attention to the shortcomings of the Research Assessment Exercise (RAE) in the United Kingdom in relation to the formulation of the Research Quality Framework in Australia. The impact of the RAE on clinical academic medicine in the UK has been disastrous, and it will take years to recover. Driven by the imperatives of the RAE, gross distortions of the role of medical schools have occurred. Many major departments, particularly in the surgical disciplines, have been closed, irrespective of the service and teaching implications. Over the past 6 years, some 20% of clinical lecturer posts have been abolished.2 These are training-grade posts that inevitably make only a limited contribution to the RAE returns. However, these posts provide the seed corn for future academic staffing in clinical medicine. In academic pathology, 40% of all academic posts have been lost and there are now only 12 remaining lecturer posts in England and Wales. All these changes have occurred in the midst of a substantial increase in medical student numbers, when academic staff numbers should have been increased. Those responsible for funding tertiary education in the UK have consistently failed to understand that the role of clinical academic staff is to integrate the practice of medicine with research and teaching. This means that at least a third of their working hours will be taken up with clinical practice; therein lies the strength of clinical academic medicine. The RAE has effectively engendered a split in the roles of clinical academics and, by so doing, has seriously jeopardised the future existence of clinical academic medicine.3 The damage that this exercise in academic self-interest has caused has now been recognised at the highest political level, with a recommendation that the RAE be discontinued as from 2008.

E Malcolm Symonds

To the Editor: Now that Calver and colleagues have unequivocally established that “High costs appear to be needs-driven”,1 can we dispense with the Orwellian language used in this article? “High-cost users” can now become “high-needs patients”. The language in the article subtly reflects a view that is often adopted by senior non-clinical health service administrators, who are themselves usually in robust good health. This view is that people with high levels of health service need are merely rapacious consumers of rare health dollars, of which the administrators are guardians. For those of us providing services in primary (mostly ambulatory) care, life is complicated enough choosing between “patient”, “person with”, “client”, “consumer” or “punter”. Can we please avoid adding “user” to the already overcrowded lexicon of nominals used for patients? I am sure if we changed the terminology then those “high-cost users” would feel a bit more valued when they read this article.

Chris Holmwood

Primary care ophthalmology. 2nd ed. David A Palay, Jay H Krachmer. Philadelphia: Elsevier Mosby, 2005 (xvi + 395 pp). ISBN 0 323 03316 4. I was pleasantly surprised at the balanced approach achieved in this book by its American ophthalmologist authors. As a reference book, it delivers as much detail as most primary care practitioners would seek, without getting bogged down in minutiae. At about 400 pages, lightened by abundant photographs, Primary care ophthalmology goes a bit beyond being just a primer. Many of the segments invite browsing, whereas others would only be consulted for a specific topic. There is an emphasis on management at a general practice level, together with clear guidelines on when specialist referral is needed. The urgency of timing of referrals and the frequency of specialist reviews often seems a bit excessive, but this may reflect the American environment. Similarly, the range of medications reflects availability there, especially in antibiotics. The initial sections on examination, differential diagnosis, and the acute red eye are well presented and would also be useful to medical students. Skills varying from as mundane as everting eyelids up to applanation tonometry are clearly described. Much of the rest of the book is anatomically arranged, with brief anatomy refreshers and then succinct disease descriptions, each with differential diagnoses, investigation, treatment and follow-up recommendations. Ophthalmology has not completely seceded from the rest of medicine, and the excellent section on systemic disease reflects this. The systemic drug toxicity segment is clearer than I’ve seen anywhere else. Another highlight is the chapter on the manifestations of ocular trauma and its management. Overall, this is a very useable, good-value and readable reference with good photographic illustrations. Its main role would be in general practice, but emergency departments would also find it useful. The limitations of the American pharmacopoeia don’t really take away from the book, and I don’t think it will date quickly. Malcolm J BurvillOphthalmologist, Mount Lawley, WA

Malcolm J Burvill

Paediatric trauma manual. Catherine Bevan, Clara Officer (editors). Melbourne: Royal Children’s Hospital, 2004 (336 pp + CD-ROM). ISBN 192082431. Trauma continues to be the most common cause of death in children after the first six months of life, accounting for many paediatric hospital admissions in both Australia and overseas. Few would dispute the importance of this topic to the health of children, yet it is an area beyond the comfort zone of many doctors and allied health professionals, even those experienced in dealing with adult trauma patients or children with other diseases. Armed with appropriate information, many clinicians will at least feel better able to face a challenging situation when it arises. This manual and CD-ROM represent a collaboration between the Royal Children’s Hospital in Melbourne and the Victorian Trauma Foundation. The text has been edited by the hospital’s Trauma Fellow and Trauma Service Education Co-ordinator, and the majority of the authors are clinicians at that institution. The text centres on trauma management guidelines for the various body systems, with short sections on practical trauma procedures and the Victorian State Trauma System. In general, the text is clearly and simply written in a style that would be familiar to those who have read the manuals for the Emergency Management of Severe Trauma or Advanced Paediatric Life Support courses. In addition to the text of the manual, the CD-ROM contains a number of scenarios with multiple choice questions, as well as video demonstrations of practical procedures. In a style common to many manuals, I found the text dry and not immediately engaging. Although there were a number of illustrations, many in colour, most were far too small and several were duplicated in different chapters. The use of references was curiously sporadic throughout the book, with some chapters containing several useful review articles and others none at all. I did not agree with everything in the book. For example, I would challenge the authors’ recommendation restricting mobility after splenic trauma for three months, as there are considerable data from the United States confirming the safety of a much earlier return to normal activities. Overall, given the manual’s price, style and content, I would only see a place for it in the library and emergency department of hospitals dealing with paediatric trauma patients. Its price would preclude purchase by most junior clinical staff and general practitioners dealing with the occasional paediatric trauma patient. Andrew J A HollandAssociate Professor of Paediatric Surgery and UrologyThe Children’s Hospital at Westmead, NSW

Andrew J A Holland

Attacks in no time The cardiovascular risks associated with rofecoxib use are more acute than previously thought, according to Canadian researchers. Levesque and colleagues analysed data from 526 patients aged 66 years or older who were current users of either rofecoxib (n = 239) or celecoxib (n = 287) and who had had a first acute myocardial infarction (MI) during an average follow-up period of 2.4 years. The risk of a first MI was highest following first-time use of rofecoxib — about a quarter of those who had an MI experienced it within the first few weeks of use, corresponding to the highest period of risk for this agent. CMAJ 2006; 174: 1563-1569 From the BBC “diet trials” Resource-strapped GPs should discuss effective commercial weight loss programs with their overweight and obese patients, say UK researchers. They conducted a randomised controlled study, filmed in a BBC series on diet trials, which compared the effects of four such programs on weight and fat loss in 231 trial participants allocated to undertake one of the programs. Over a trial period of 6 months, all four programs — Dr Atkin’s new diet revolution, the Slim-Fast plan, Weight Watchers pure points program and Rosemary Conley’s eat yourself slim diet and fitness plan — led to a similar and clinically useful average weight loss of 5.9 kg and average fat loss of 4.4 kg. Some participants lost more then 25 kg over the study period, whereas others gained weight. BMJ Online First, 23 May 2006 How’s your dog? Australian Professor Lesley Campbell says she teaches all her registrars to ask patients with diabetes about the health of their dog. And not only because the dog forces the owner to walk and a fat family dog is a bad metabolic risk indicator. In an essay, Campbell advises: “Beware the day the dog dies”. In her considerable experience, real-life events, such as the death of a family pet, have been the root of a significant deterioration in a patient’s glycaemic control. Although such an observation has proven difficult to replicate in a controlled laboratory experiment, it nevertheless informs her clinical practice, as do other lessons learned from past patients — as Professor Campbell calls them, her “companionable ghosts”. Lancet 2006; 367: 1626-1627 More than aspirin The European/Australasian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT) may provide enough evidence to prefer aspirin plus dipyridamole over aspirin alone as secondary prevention for cerebral ischaemia of arterial origin. The trial assigned 2739 patients, within 6 months of a transient ischaemic attack or minor stroke of presumed arterial origin, to receive aspirin (30 - 325 mg daily) either with or without dipyridamole (200 mg twice daily). After an average follow-up period of 3.5 years, 389 participants had at least one primary outcome event (death from a vascular cause, a non-fatal stroke or myocardial infarction, or a major bleeding complication): 216 (16%) had been taking aspirin alone but 173 (13%) had been on combination therapy — an absolute risk reduction of 1.0% per year. Trial participants came from 14 countries; 23 were from Australia. Lancet 2006; 367: 1665-1673 Less surgically inclined New Zealand may face a shortage of trainee surgeons in the near future. So suggest the findings of a recent survey of senior students at one medical school. Insull and colleagues asked fourth and fifth year students at the University of Auckland Medical School to answer 25 questions in an online survey; five of the questions were designed to positively (but not obviously) identify a “surgically inclined” student. Only one in five respondents were deemed to be so inclined. Male students were more likely to be surgically inclined than females; however, males now make up less than 50% of the medical students in New Zealand. N Z Med J 2006; 119: U1983 Policosanol and lipids German researchers have raised doubts about the widely publicised putative lipid-lowering effects of policosanol — a natural substance derived from sugar cane. In a randomised controlled trial, 143 white patients with hypercholesterolaemia or combined hyperlipidaemia were allocated to five equal groups, to receive policosanol, at a usual daily dose (10 mg or 20 mg) or at a high dose (40 mg or 80 mg), or placebo for 12 weeks. The researchers were looking to find and document a dose-dependent lipid-lowering effect of policosanol. Instead, they found no evidence that policosanol, at usual or high doses, was more effective than placebo in reducing lipid levels. The researchers pointed out that most of the published literature supporting the beneficial effects of policosanol on lipids came from a single research group in Cuba; further, that there are still no data on relevant patient-related outcomes, such as cardiovascular morbidity and mortality. JAMA 2006; 295: 2262-2269

Ann Gregory