Volume 184 Issue 3

The profession should speak with one voice in the debate about task transfer In mid December last year, a group of senior doctors, nurses, allied health professionals, hospital administrators and consumers in New South Wales publicly announced that they had had enough. So great was their frustration with the failure of the government to creatively confront the continuing workforce crisis in NSW public hospitals that they had banded together as the Hospital Reform Group to initiate open debate in the community and to find solutions. The media dubbed them the “health rebels”.1 Listed in the group’s manifesto is the statement: We see an urgent need for major workforce reform. The health workforce and workplace practices must be modernised. The traditional divide between professional disciplines and responsibilities is not necessarily appropriate for the future.2 In short, the group believes that public hospitals need to be dragged into the 21st century and their workplaces need to capitalise on current professional capabilities and not be bogged down by 19th century professional boundaries.3 . . . it is patients and the public who need to be convinced. The Hospital Reform Group workforce challenge follows closely on the back of similar calls from: the Australian Government Productivity Commission, which, in its draft report Australia’s health workforce (released in September 2005), called for an independent assessment of the opportunities to extend the role of some health workers so as to make best use of their skills while maintaining safety and quality.4 the Health Workforce Innovation Conference organised by the University of Queensland and Queensland Health and held in Brisbane in November 2005. A report of the conference is published in this issue of the Journal (page 105).5 Speakers from the United Kingdom and the United States described how their respective countries have responded to health workforce crises by introducing task transfer roles. These roles are played by nurse practitioners, physician assistants and a new professional species in the UK — the medical care practitioner. To the cynic, this is a watered-down version of a general practitioner. The UK speakers also outlined a new model for health care education — an education escalator, based on competence rather than time spent in training. Health care workers can “jump on” the escalator at different levels, depending on previous attainment of knowledge, skill and work experience, acquire further expertise, and then “jump off” the escalator at a higher level. The system’s apparent value is its capacity to encourage flexibility and multiskilling. Australia is traditionally an importer of educational and health care ideas. There is no doubt that debate about the education escalator concept, along with the push for medical task transfer to other health care professionals, will escalate. This will be especially so if the Council of Australian Governments (COAG) endorses the major recommendations of the Productivity Commission’s report. These developments should come as no surprise, as the drivers for changes have been with us for some time. These include: the prevailing shortage of doctors, exacerbated by the federal government’s cap on medical graduates in the 1990s, early retirement of doctors, shortened working hours, the feminisation of the workforce, and generational attitudes to work;6 the continual increasing demands for medical services, driven by the increasing burdens of ageing and chronic diseases, along with new technology and the medicalisation of daily living; the ascendancy of multidisciplinary and multiskilled teams, which already blur some professional boundaries;7 and ever-narrowing subspecialisation, in which many medical tasks are reduced to discrete and limited knowledge and skill bytes which, it is argued, do not require a broad clinical perspective and have the potential to be undertaken by other health workers at lower costs.8,9 But there are deeper undercurrents. Sir Graeme Catto, President of the UK General Medical Council, recently observed that: . . . the exclusivity of medical knowledge and skill is being broken down. Interprofessional learning is now commonplace in medical education and seems likely to increase. Professional boundaries are being blurred as more and more of the things that were once the sole domain of doctors are being undertaken by other healthcare professionals. None of us works alone any longer, but in multidisciplinary teams in which we depend upon the expertise of others. This is not a diminution of medicine, but a strengthening of healthcare. We must also acknowledge that, more than ever before, knowledge is available to patients and the public.10 So how should the profession respond to the inevitable debate on task transfer? Most of the doctors who attended the plenary sessions of the Brisbane conference were surprisingly silent. Others were singularly dismissive of any encroachment by other health care professionals into the traditional domains of doctors. And the limited evidence for, and the value-laden opinions surrounding, task transfer came to the fore in the conference’s breakout sessions. It was the epitome of tribalism! In this context, it is worth noting that: The most common temptation facing any long-established profession is to cling on too long to practices, privileges and traditional craft skills that have simply become outmoded. This can happen for many reasons including changes in demand or technology. It is an uncomfortable experience for a professional when technical mastery is commoditised and overtaken by some creative innovation. But the wise professional should not feel threatened by the impact of, for example, paralegals or paramedics, or simply computers. It is the task of the true professional to remain intellectually curious and to continue acquiring new skills. That said, knowing when to let go and to delegate responsibilities hitherto reserved to the profession is a task not just for the individual practitioner to face alone, but for the profession as a whole to confront.11 And therein lies a problem. To be effective, the profession needs to speak with one voice and not in the babble of its many tribes. The latter will only be seen by the public as negative, defensive and self-serving. The profession needs to unite and develop a position that is evidence-based and has at its centre quality and safety for patients. In this debate, it is patients and the public who need to be convinced.

Martin B Van Der Weyden MD, FRACP, FRCPA

An Australian document now has an important role in acute pain management worldwide More than 50% of patients continue to have severe pain after surgery and trauma.1 This situation not only results in unnecessary suffering, but occurs despite evidence that inadequate treatment of acute pain increases the risk of postoperative complications and may lead to persistent (chronic) pain. Indeed, operations and injuries are considered to contribute to at least 25% of the burden of chronic pain.1 These points were highlighted at a forum cosponsored by the International Association for the Study of Pain (IASP), the European Federation of IASP Chapters, and the World Health Organization on 11 October 2004. This forum launched the Global Day Against Pain in support of the declaration that in acute, chronic non-cancer and cancer pain, “the relief of pain should be a human right”, and that improvements in the management of pain, including acute pain, require “global education of health professionals, patients and their families”.1 In Australia, there has been long-standing awareness of the need to improve the management of acute pain. This was supported by the publication of the first edition of Acute pain management: scientific evidence by the National Health and Medical Research Council (NHMRC) in 1999.2 At that time, the NHMRC and the Agency for Health Care Policy and Research in the United States were the only organisations worldwide to have produced evidence-based documents on the treatment of acute pain. More recently, this awareness has been highlighted by a number of high-level activities including the Pain Management Project of the National Institute of Clinical Studies,3 the development of the Operational principles for acute pain management by the Victorian Quality Council4 and the release of a Statement on patients’ rights to pain management by the Australian and New Zealand College of Anaesthetists (ANZCA) and the Faculty of Pain Medicine (FPM), a multicollegiate Faculty under ANZCA.5 International awareness of the need to improve the management of pain also continues to grow. The IASP held another Global Day Against Pain on 17 October 2005, which focused on pain in children.6 The Global Day Against Pain is to become an annual event. The IASP is also forming a special interest group on acute pain, which will further promote better management.7 Over recent years there has been an enormous increase in the amount of evidence available on the management of acute pain. Therefore, ANZCA and the FPM convened a working party to oversee a revision of the 1999 NHMRC acute pain document. To summarise the substantial amount of new evidence in a concise and easily readable form to help health care professionals and consumers, a large panel of contributors was appointed to draft sections of the document, and a multidisciplinary consultative committee (including medical, nursing, allied health and complementary medicine providers as well as consumers) was chosen to review drafts of the document and contribute more broadly as required. Evidence was annotated according to the levels recommended by the NHMRC.8 In addition, many practical recommendations for the treatment of aspects of acute pain were included by the working party as “clinical practice points” because of their clinical relevance, even though they are not purely evidence-based. The revised document9 was approved by the NHMRC in June 2005 and launched at the World Pain Congress in Sydney in August 2005. It has already received widespread recognition with formal endorsement by the IASP and the Australian Pain Society. As it forms the basis for the section on acute and postoperative pain in the third edition of the IASP’s Core curriculum for professional education in pain, its use worldwide is ensured.10 It has also been endorsed by the Royal College of Anaesthetists in Britain and recommended by the American Academy of Pain Medicine to its members. Much of the evidence relating to acute pain management comes from the hospital setting, but many of the principles can be extrapol-ated to other acute pain settings, such as managing pain from renal colic or migraine or the use of opioids and non-steroidal antiinflammatory drugs (NSAIDs). Examples of updated key messages and clinical practice points for the use of opioids, paracetamol, NSAIDs and cyclo-oxygenase-2 (COX-2) inhibitors are listed in the Box. As the field of acute pain medicine is changing rapidly, new information emerging in areas considered to be of importance will be reviewed by the working party and posted periodically on the ANZCA website (http://www.anzca.edu.au/publications/acutepain.htm). A third edition of Acute pain management: scientific evidence is planned for 2010. A revision of the consumer guide to acute pain management will also be available shortly at the above website. Knowledge about acute pain medicine is growing too rapidly for individuals to keep abreast of it unaided. It is hoped that the updated guidelines will help clinicians and others approach acute pain treatment more effectively and safely, thus going some way towards reducing the suffering and improving outcomes of patients in our community. Selected updated key messages and clinical practice points*9 Opioids Dextropropoxyphene has low analgesic efficacy (Level I evidence). In the management of acute pain, one opioid is not superior over others but some opioids are better in some patients (Level II evidence). Tramadol has a lower risk of respiratory depression and impairs gastrointestinal motor function less than other opioids at equi-analgesic doses (Level II evidence). Pethidine is not superior to morphine for treating pain of renal or biliary colic (Level II evidence). In adults, age is a better predictor of opioid requirements than weight, although there is a large interpatient variation (Level IV evidence). Assessing sedation level is a more reliable way of detecting early opioid-induced respiratory depression than a decreased respiratory rate (clinical practice point). The use of pethidine should be discouraged in favour of other opioids (clinical practice point). Paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and cyclo-oxygenase-2 (COX-2) inhibitors Paracetamol is an effective analgesic for acute pain (Level I evidence). NSAIDs and COX-2 inhibitors are effective analgesics with similar efficacy for acute pain (Level I evidence). NSAIDs given in addition to paracetamol improve analgesia (Level I evidence). COX-2 inhibitors and NSAIDs have similar adverse effects on renal function (Level I evidence). Paracetamol, NSAIDs and COX-2 inhibitors are valuable components of multimodal analgesia (Level II evidence). COX-2 inhibitors do not impair platelet function (Level II evidence). Gastric ulceration rates with short-term use of COX-2 inhibitors are similar to those for placebo (Level II evidence). Adverse effects of NSAIDs are significant and may limit their use (clinical practice point). The risk of adverse renal effects of NSAIDs and COX-2 inhibitors is increased in the presence of factors such as pre-existing renal impairment, hypovolaemia, hypotension, use of other nephrotoxic agents and angiotensin-converting enzyme inhibitors (clinical practice point). Levels of evidence designated according to those recommended by the National Health and Medical Research Council.8 * Reproduced with permission from the Australian and New Zealand College of Anaesthetists.

Pamela E Macintyre MB BS, FANZCA, FFPMANZCA · Stephan A Schug MD, FANZCA, FFPMANZCA · David A Scott MB BS, PhD, FANZCA

We ignore global inequalities at our peril Nearly 10 years ago, the Simons Review of the Australian Aid Program proposed that eradicating poverty should be a major focus, that the voices of recipient countries should be heard, and that greater accountability, as well as evaluation, information sharing and research, were crucial.1 Fast forward to 2005, to a globalised world with the “war on terror” and national security at centre stage. From the Indian Ocean tsunami to Hurricane Katrina, from the Kashmir earthquakes to the silent emergencies in Darfur, Niger and Uganda, disasters disproportionately affect the poor and marginalised. There are now increasing inequalities within and between states, heightened concerns about peace, security and development, and threats to human rights and fundamental freedoms. In September 2005, world leaders assessed the progress made towards meeting the Millennium Development Goals (MDGs), a set of globally agreed development objectives for the year 2015. Three goals — reducing child mortality, improving maternal health and combating HIV/AIDS, malaria and other diseases — have a specific health focus. For each goal, targets have been established, but are unlikely to be met (Box).2 The United Nations Development Program identifies aid, trade and security as crucial to achieving the MDGs.3 AidAs the federal government is preparing a White Paper on its aid program, Australia has an opportunity to reshape its role as a global citizen. The Prime Minister, John Howard, announced on 13 September 2005 that Australia’s official development assistance will be increased to $4 billion by 2010. While this commitment is welcome, Australia’s contribution will still be only 0.35% of its Gross National Income in that year, well below the UN-proposed target of 0.7% by 2015. It is particularly important to ensure that the available funds are used to eliminate poverty and support development, the objectives of the MDGs. This will mean focusing on the core issues of poverty eradication, enhancing social justice, promoting equity, and delivering basic health and education services. In Asia and the Pacific, five countries, including Timor-Leste and Papua New Guinea, are not expected to achieve even one of their targets for the high priority indicators — and 14 other countries are not on track for more than half of them.4 TradeTrade and the economy influence a state’s ability to meet basic needs and redress inequalities. Eighteen countries, with a combined population of 460 million people, have shown declines in the Human Development Index (a comparative measure of poverty, life expectancy, education, literacy, and other factors) — revealing poorer health, education and wellbeing since 1990.3 Trade should be seen as a means to development and not as an end in itself. Structural inequalities in international trade must be addressed; fair trade rules should be put in place and tariff barriers inhibiting trade with developing nations removed. Trade concerns in the health sector range from access to pharmaceuticals to establishing and retaining an adequate health workforce. A key MDG indicator is the “proportion of the population with access to affordable essential drugs” on a sustainable basis. Australia’s Department of Foreign Affairs and Trade is promoting bilateral free-trade agreements that jeopardise developing countries’ access to affordable pharmaceuticals, including antiretrovirals, by strengthening and enforcing patent monopolies globally.5 Bilateral agreements have been described as a covert form of private governance, threatening to undermine hard-won public gains in health regulation.6 Failure to ensure access to drug therapy and combat neglected diseases will lead to widening gaps in health status, and the threat of emergent disease. A valuable intervention would be to support countries to collectively procure drugs at competitive prices. Australia benefits greatly from the immigration of skilled health workers, including those from developing countries. While AusAID spends aid monies on building human resource capacity in the health sector in developing countries, Australia’s immigration system, by design, attracts doctors, nurses and other scarce health professionals from these countries to overcome skills shortages in our own health workforce. More engagement with the countries providing personnel is needed: recruitment and migration should be accompanied by government-to-government negotiation, and commitments to strengthening the health workforce in developing nations in our region and investing in developing our own health capacity. In addition, long-term twinning and partnership agreements to build capacity, and the use of new technologies to facilitate training and bridge geographic divides, are likely to be of value. SecurityThe recent UN publication, Report on the world social situation 2005. The inequality predicament,7 highlights the significant links between poverty and conflict: social disintegration and violence increase where inequalities are extreme and competition over scarce resources is greatest. Countries with high rates of poverty and inequality generally have poorer social supports, more unequal access to health and education, and fewer opportunities for young people, contributing to heightened risks of armed conflict. Moving from a narrow framework of national security to considering human security in its broadest sense is a fundamental challenge;8 ultimately, human security will be achieved only if there is equitable development in the region, support for governance structures, and increasing responsiveness to community needs. In Australia, establishment of a dedicated unit within AusAID to concentrate on fragile states recognises the potential threat they pose to health and security in the region, and the need to understand and work more closely with them. Fragile states are those which are hard-pressed to govern, to deliver services, and to ensure the safety and security of their citizenry. The Solomon Islands has one of the fastest growing youth populations, lacks educational and employment opportunities and, until recently, was flooded with small arms. Papua New Guinea struggles with corruption, governance, and the difficulty of delivering basic services. Timor-Leste, while making massive strides in building a new nation, remains fragile, with the government under enormous pressure to rapidly bring the benefits of independence to the majority rural population. While previous policy advice was to stay away from fragile states and donors withdrew to avoid “wasting” aid, it is increasingly recognised that maintaining service delivery and governance are crucial. “Strengthening weak states against failure is far easier than reviving them after they have definitively failed or collapsed.”9 For the health sector, supporting the resilience of health professionals and peripheral services, and assuring the delivery of essential care, must be a priority. This better positions the sector to move forward from a more secure base when violence and instability recede. In the longer term, this may position the health sector to lead in promoting quality, responsiveness and good governance in these fragile states. ConclusionBy articulating more equitable, whole-of-government responses that take account of national and regional interests, Australian engagement can make a difference. Meeting the MDGs and tackling poverty remain central.10 Identifying and mitigating the adverse effects of globalisation — the widening gaps between those with and without access to resources — and strengthening the economies of marginalised countries, deserve attention. Australia can be innovative, progressive, strategic and ethical at the same time. Doing so requires more explicit support for the MDGs, as well as: A long-term view which places constructive global citizenship at the core; Appreciation that national security rests on human security and more equitable arrangements within and between states; A commitment to linking aid, trade and security and adopting whole-of-government approaches; A commitment to building system capacity in public health, supporting human resources and securing health in fragile states; and An investment in development-related research — monitoring trends, evaluating interventions, and learning and sharing lessons from aid delivery and its effects. Millennium Development Goals — update on progress and achievements, May 2005 1. Eradicate extreme poverty and hunger Global poverty rates are falling — however, in sub-Saharan Africa, millions more people are now experiencing extreme poverty and the poor are getting poorer. 2. Achieve universal primary education Five developing regions are approaching universal enrolment; however, sub-Sahara, Southern Asia and Oceania have a long way to go. School enrolment among the most disadvantaged groups (low-income households, indigenous communities) is much worse. 3. Promote gender equality and empower women The gender gap is closing — albeit slowly — in primary school enrolment. However, women represent a smaller share of wage earners, are more likely to be relegated to insecure and poorly paid jobs, and lack equal representation at the highest levels of government. 4. Reduce child mortality Death rates in children under 5 are dropping, but not fast enough. 30 000 children die every day from preventable or treatable causes. 5. Improve maternal health Some progress has been made in reducing maternal deaths, but not in those countries where giving birth is most risky. 6. Combat HIV/AIDS, malaria and other diseases AIDS is the leading cause of premature death in sub-Saharan Africa and the fourth largest killer worldwide. Tuberculosis is on the rise, partly as a result of HIV/AIDS. 7. Ensure environmental sustainability Access to safe drinking water has increased, but half the developing world still lacks toilets or other forms of basic sanitation. Urban slums are an increasing problem — nearly one in three city dwellers live in slum conditions characterised by overcrowding, scarce employment, poor water, sanitation and health services and insecurity, including violence against women. 8. Develop a global partnership for development Developed countries have fallen short of targets they have set for themselves. To achieve the MDGs, increased aid and debt relief must be accompanied by further opening of trade, accelerated transfer of technology, and improved employment opportunities for young people in the developing world. Source: The Millennium Development Goals Report 2005.2

Anthony B Zwi MB BCh, PhD, FFPHM, AFPHM · Natalie J Grove MPH, BOccThy

We need to create a range of new health practitioners who can deliver patient-friendly care On 22 and 23 November 2005, some 200 health professionals, including doctors, nurses and other health professionals, met in Brisbane to discuss education and training issues for the future health workforce. The meeting, sponsored by the University of Queensland and Queensland Health, accepted that providing health care for an ageing population afflicted with chronic disease requires a health workforce that is more flexible, mobile and multiskilled than our current one, and this will require creative thinking about future workforce requirements. Key issues addressed at the meeting included: What will be the health care requirements in 2010–2020? Who is going to deliver these services, and how? How are these health care practitioners to be trained? What are the issues of accreditation of these practitioners? How are we going to pay for these services? William Doe (Dean of the Faculty of Medicine, University of Birmingham) discussed some of the changes that are occurring in the United Kingdom’s National Health Service (NHS). These relate to the National Practitioner Program, which tackles traditional and longstanding barriers to change, such as professional boundaries, team structure, hierarchies and existing care processes. The program involves expanding the depth and breadth of roles and creating new job descriptions so that different health professionals at similar levels of responsibility can share a number of care competencies in addition to those unique to their own role. An important enabler in the NHS has been the establishment of a generic competency-based skills escalator, involving all non-medical health professions. This framework has eight steps, beginning with a Junior Assistant and ascending to a consultant Health Professional Practitioner. Foundation degrees allow a broader range of people access to health careers, commencing in the newer roles lower on the skills escalator. New roles described by Doe include the Medical Care Practitioner, which is based on the physician assistant model in the United States and will have a skill and knowledge base to deliver most generalist diagnoses, treatment and care within general medical and family practice. Science graduates, NHS staff and armed health services staff are the expected source of recruits, and there are plans for a 2-year university degree course, developed with input from universities and royal colleges. This course will lead to a statutory registered qualification and registration, probably on the health professions register. Although there will be considerable autonomy for Medical Care Practitioners, they will work under the supervision of a qualified medical practitioner. Surgical Care Practitioners will tend to be drawn from nurses and other health care practitioners, and will assist in delivering surgical services to patients under the supervision of a consultant surgeon. Again, this role is being developed in collaboration with the Royal Colleges of Surgeons and Nursing. Anaesthesia Practitioners will perform pre- and postoperative assessment care, maintain anaesthesia and, under direct supervision of a specialist anaesthetist, conduct the induction of and emergence from anaesthesia. Debra Humphris (Director of the Health Care Innovation Unit at the University of Southampton) described significant changes that are occurring in southern England in relation to the delivery of primary care. She noted that patients’ needs may be much simpler than what we wish to provide. The new models of care increasingly reflect the importance of effective teamwork, collaboration and real role change, coupled with improvements in productivity, but can only be developed through a close relationship between the academic institutions, local policymakers, service providers and patients. Jane Barnacle (Health Care Innovation Unit, University of Southampton) described the development of a new role: Community-Based Rehabilitation Assistant. This role is level 4 on the NHS skills escalator (Assistant Practitioner). The role was designed after a task analysis of the delivery of post-hospital care at home showed that 80% of the care delivered was not discipline-specific, was poorly coordinated (in one case by 17 different providers) and of poor productivity, with much time spent in driving. The training required is a foundation degree, developed in close association with local employers, which includes a generic first year and more specific second year, and emphasises structured competency-based training in the field. Bonnie Sibbald (Chair of Health Services (Research), University of Manchester) presented data on nurse practitioner experience in the United Kingdom. Nurses are increasingly working alongside doctors in primary care, assisting doctors in tasks ranging from blood sampling or syringing ears to more advanced roles in health care promotion and management of patients with stable chronic conditions such as asthma, diabetes, cardiovascular disease and arthritis. Sibbald also presented the details of a Cochrane review of nurse practitioners.1 The review showed the same or better outcomes for patients in services delivered by nurse practitioners or by general practitioners, and showed that nurse practitioners are well accepted by patients. Issues that need to be carefully addressed in using nurse practitioners include continuity and coordination of care, which may be an issue particularly if the team becomes too big (greater than 10). There may be significant initial capital costs in terms of producing nurse practitioners and, of course, the nursing profession is as much in short supply as the medical profession. Rod Hooker (Associate Professor, Department of Physician Assistant Studies, University of Texas, Southwestern Medical Center Dallas, Tex) presented the US experience with physician assistants. There are now some 65 000 physician assistants in the US, graduating from some 130 programs, mostly attached to Faculties of Medicine or Health Sciences. The physician assistants cover a vast range of tasks from anaesthesia, acute care, public health, surgery, pathology, radiology, chronic disease management and primary care. He presented data that suggest that physician assistants take up about 10% of the time of the supervising doctor but can address 85% of the caseload of the physician in most situations. The educational programs run for around 24 months and the cost of educating a physician assistant is about 20% of that of a medical practitioner. It was felt that physician assistants could address a number of the problems currently facing the Australian health care system, particularly in primary care, chronic disease, some procedures (colonoscopies, etc), and in rural and remote Australia. Amanda Adrian (Health Care Consultant, NSW) discussed the issues of nurse practitioner legislation in Australia and pointed out some of the complexities of the legislative process for health practitioners (the Productivity Commission recently noted that there are more than 90 registration bodies for health practitioners in Australia2) and the difficulties for health practitioners in moving between jurisdictions. She highlighted that much legislation can be disabling (rather than enabling), and this may be why so few nurse practitioners are actually working in Australia. Tony Austin (Head, Defence Health) presented the final formal presentation. He noted that the military has a long tradition of innovation in health care delivery and gave particular emphasis to the important roles of medics (medical assistants). One feature of the military medic group is their variation — to meet the differing needs of the three Services (Army, Navy and Airforce). A major concern at the moment is the lack of articulation for medics with the civilian community. Although there is some scope for this with paramedics and nursing, there are also significant limitations. The development of a physician assistant program in civilian life would provide a valuable opportunity for army medics on discharge from the Defence forces. Peter Brooks then gave a brief overview of the Productivity Commission’s draft report,2 emphasising its recommendation for the establishment of an Advisory Health Workforce Improvement Agency to facilitate workplace innovation, and the possibility of shifting the primary responsibility of funding from the education sector to the health sector to allow more responsive education and training arrangements. The report discussed the need for a consolidated national accreditation regime and the establishment of uniform national registration standards and improved mutual recognition. The report also recommended the establishment of an independent review body to advise on services to be covered by the Medicare Benefits Schedule and on referral and prescribing rules. In addition, the report recognised the importance of an adequate database on workforce and of creating better solutions to the problems of rural and remote areas and groups with special needs. Discussion took place in relation to the importance of addressing remuneration for health services and particularly a revisitation of the Relative Value Study with a redistribution of funding away from procedures and towards the “considered opinion”. Wide-ranging discussion on Day 2 of the conference covered areas supporting the development of integrated care models, the importance of getting general practitioners more involved in preventive care, and a focus on health professionals and creating meaningful work environments for these individuals. The meeting reflected a groundswell of feeling within the Australian health system that change must happen and that we, as key players in that system, must help to drive that change. We need to create a health system (not an ill system, as we currently have), continue to develop partnerships to break down the professional silos, and create a range of new health practitioners who can deliver care in a patient-friendly fashion. Many participants considered that a key to workforce innovation is a back-to-basics review of what consumers want and what services should be provided. It was proposed that a key question is the level of skill required of the person providing the initial assessment in primary care. Is it someone who should be able to handle 100% of conditions presenting? Or is someone who can handle 70% and refer the other 30% acceptable? There was general support for the concept of a wide range of delegated care, especially physician assistants and nurse practitioners. The associated changes to the Medical Acts which this would require were felt to be an important area of reform that needs to be urgently addressed. Delegated payment systems, where payment could be made to a practice rather than an individual, were preferred. Many speakers supported streamlining of the regulatory processes and the development of a competency-based modular education system. There was support for a better aligning of the health and education sectors, particularly in regards to policy. Although there was support for the Productivity Commission’s draft document, some participants that felt that it would be difficult to implement many of the suggested changes. There was strong support for local action to introduce appropriate innovations, and a sense that this could and should be done, with or without central reform. Participants were keen to continue the health workforce innovation agenda in the future.

Peter M Brooks FRACP, FAFRM, FAFPHM · Niki Ellis MB BS, FAFOM

Objective: To evaluate the efficacy of supplementation with zinc and vitamin A in Indigenous children hospitalised with acute lower respiratory infection (ALRI).Design: Randomised controlled, 2-by-2 factorial trial of supplementation with zinc and vitamin A.Setting and participants: 187 Indigenous children aged < 11 years hospitalised with 215 ALRI episodes at Alice Springs Hospital (April 2001 to July 2002).Interventions: Vitamin A was administered on Days 1 and 5 of admission at a dose of 50 000 IU (infants under 12 months), or 100 000 IU; and zinc sulfate was administered daily for 5 days at a daily dose of 20 mg (infants under 12 months) or 40 mg.Main outcome measure: Time to clinical recovery from fever and tachypnoea, duration of hospitalisation, and readmission for ALRI within 120 days.Results: There was no clinical benefit of supplementation with vitamin A, zinc or the two combined, with no significant difference between zinc and no-zinc, vitamin A and no-vitamin A or zinc + vitamin A and placebo groups in time to resolution of fever or tachypnoea, or duration of hospitalisation. Instead, we found increased morbidity; children given zinc had increased risk of readmission for ALRI within 120 days (relative risk, 2.4; 95% CI, 1.003–6.1).Conclusion: This study does not support the use of vitamin A or zinc supplementation in the management of ALRI requiring hospitalisation in Indigenous children living in remote areas. Even in populations with high rates of ALRI and poor living conditions, vitamin A and zinc therapy may not be useful. The effect of supplementation may depend on the prevalence of deficiency of these micronutrients in the population.

Anne B Chang MPHTM, FRACP, PhD · Paul J Torzillo FRACP, FFICM · Peter M Stewart FRCPA · Naomi C Boyce BNurs · Andrew V White FRACP · Gavin R Wheaton FRACP · David M Purdie BSc(Hons), PhD · John Wakerman MB BS, MPH · Patricia C Valery MD, MPH, PhD

Objective: To assess the safety and efficacy of percutaneous vertebroplasty for the treatment of acute osteoporotic vertebral fractures.Design: A prospective, non-randomised, “intention-to-treat” 2-year study.Patients and setting: 126 consecutive patients (39 men and 87 women, aged 51–95 years) with acute osteoporotic vertebral fractures presenting to St George Hospital from November 2000 to December 2002. They comprised 88 patients treated by percutaneous vertebroplasty and 38 by conservative therapy.Main outcome measures: Primary outcomes — changes in patients’ pain score and level of function recorded at 24 hours, 6 weeks, 6–12 months and 24 months after therapy. Secondary outcomes — occurrence of new clinical or radiological vertebral fractures and survival at 2 years.Results: Three minor complications (fractured pedicle and psoas muscle haemorrhage) occurred in the vertebroplasty group during the first year of the study. Outcomes in vertebroplasty-treated patients (60% reduction in visual analogue pain scores from 20 to 8; P < 0.001), a rapid return to normal function (29% improvement in physical functioning from 14 to 18; P < 0.001) and lower rates of hospitalisation (43% reduction in the mean number of hospital bed-days occupied) were better than those treated conservatively (P < 0.001 for the comparison of all variables at 24 hours). Lower pain scores persisted in the vertebroplasty-treated group at 6 weeks (P < 0.001), but no differences between the two groups were evident at 12 and 24 months. In the vertebroplasty-treated group compared with the control group, the rates of new vertebral fractures (clinically and by radiographic assessment) (hazard ratio, 1.13; 95% CI, 0.52–2.46; P = 0.76) and death (hazard ratio, 1.07; 95% CI, 0.42–2.76; P = 0.89) showed no significant difference.Conclusion: The analgesic benefit of percutaneous vertebroplasty and the low complication rates suggest that it is a useful therapy for acute painful osteoporotic vertebral fractures.

Terrence H Diamond MB BS, MB BCh, FRACP · Carl Bryant FRACR · Lois Browne PhD · William A Clark FRACR

Objective: To describe the epidemiology of invasive pneumococcal disease (IPD), and the impact of pneumococcal vaccines on IPD, in Indigenous people in north Queensland.Setting: North Queensland, 1999–2004; there are about 53 750 Indigenous people in the region, including nearly 6900 children < 5 years and nearly 5650 adults ≥ 50 years.Main outcome measures: Incidences of IPD in Indigenous children and in Indigenous adults compared between the 3 years before and after the introduction of a 7-valent pneumococcal conjugate vaccine (7vPCV) (1999–2001 versus 2002–2004).Results: Estimated annual incidence of IPD in Indigenous children < 5 years of age declined from 170 to 78 cases per 100 000 in the 3 years following the introduction of 7vPCV in 2001. The annual incidence of vaccine-preventable IPD in Indigenous adults had declined by 86% since a 23-valent pneumococcal polysaccharide vaccine (23vPPV) was introduced to the region in 1996, to 15 cases per 100 000 (95% CI, 8–25) in 2002–2004.Conclusion: Although there was a rapid decline in IPD in young Indigenous children, it is unlikely that the incidence will fall much further with the current 7-valent vaccine. There was a suggestion that vaccinating Indigenous children indirectly protected those aged 5–14 years and Indigenous adults ≥15 years of age. Incidence of IPD in Indigenous adults in 2002–2004 was the lowest on record in the region.

Jeffrey N Hanna MPH, FAFPHM · Jan L Humphreys · Denise M Murphy DipMedTech

Most people presenting with rheumatoid arthritis today can expect to achieve disease suppression, can avoid or substantially delay joint damage and deformities, and can maintain a good quality of life. Optimal management requires early diagnosis and treatment, usually with combinations of conventional disease modifying antirheumatic drugs (DMARDs). If these do not effect remission, biological DMARDs may be beneficial. Lack of recognition of the early signs of rheumatoid arthritis, ignorance of the benefits of early application of modern treatment regimens, and avoidable delays in securing specialist appointments may hinder achievement of best outcomes for many patients. Triage for recognising possible early rheumatoid arthritis must begin in primary care settings with the following pattern of presentation as a guide: involvement of three or more joints; early-morning joint stiffness of greater than 30 minutes; or bilateral squeeze tenderness at metacarpophalangeal or metatarsophalangeal joints.

Lynden J Roberts MB BS, PhD, FRACP · Leslie G Cleland MD, FRACP · Susanna M Proudman MB BS(Hons), FRACP · Ranjeny Thomas MB BS, MD, FRACP

The implications arising from the Inquiry into the Waterfall train crash for medical examinations of safety-critical workers are discussed. Examinations need to be appropriate for the level of risk in the job and apply current medical thinking. A careful balance is required between the various legal obligations, including duty of care, disability discrimination and privacy. The frequency of examinations depends on a combination of medical, economic and logistical factors. Health professionals who conduct examinations should be familiar with the occupation of the person being examined. Ethical relationships with the worker’s general practitioner or specialist(s) must be observed. The procedures associated with the examinations are as important in achieving safety as the actual examinations. These include complying with relevant standards; providing all relevant documentation with a referral for an examination; acting on the doctor’s report appropriately; and auditing the process.

Bruce Hocking FAFOM, FAFPHM, FRACGP

Clinical record A 37-year-old woman presented with a 2-month history of progressive restriction of movement of the left shoulder joint, associated with episodic pain over the region. She was unable to raise her left arm above the shoulder. The pain was mild, deep-seated, non-radiating and relieved by supporting the left elbow. She denied any weakness of the arm muscles. The patient also complained of diminished pain and temperature sensation over the affected limb, as evidenced by painless scalds of the fingers of her left hand — the first about 4 years previously, and the second, 7 days before presentation. She had had mild pain in the left shoulder region infrequently for the previous 17 years, and had noticed enlargement of her left arm since childhood. She had not noticed any lymphadenopathy. She had normal facial sensation and denied any history of diplopia, dysarthria, dysphagia, hoarseness, vertigo, sphincter abnormalities or weakness and ataxia of any extremity. There was no history of neck pain, trauma, radiation or prolonged fever. She had no hypertension or diabetes, and her family and obstetric history were unremarkable. Examination: The patient’s left upper limb was larger than the right (Box, A). The other limbs appeared normal. Girth of the left upper limb was 51.6 cm at the shoulder (right, 46.5 cm); 35.8 cm at the mid-arm (right, 31.4 cm); and 29.1 cm at the forearm (right, 25.2 cm). Wrist and fingers also had wider girth on the left compared with the right, but were equal in length. The swelling of the left upper limb was painless, non-pitting, with no colour change or abnormal sweating. Temperature of the limb was normal. Apart from evidence of a recent scald injury, no other superficial skin changes, vascular prominences or nerve thickening were observed. Loose bodies were present in the left shoulder joint, as evidenced by palpable crepitus. Left shoulder abduction was restricted beyond 90°. No hum, bruit or machinery murmur could be heard on auscultation in any part of the affected limb. The right breast was slightly larger than the left. Neurological examination revealed that pain, temperature and tactile sensation were diminished on the left side from C2 to T6 dermatomes anteriorly, and from C2 to T4 dermatomes posteriorly. Position and vibration senses were well preserved in these segments. All modalities of sensation in other parts of the body were normal. The patient had normal speech and higher functions. The hairline was at C2 level and the height–neck ratio was 11.67 (reference range, < 13). No meningism or cranial or spinal deformities could be identified. Examination of the cranial nerves gave results within normal limits. Apart from a mild weakness of the small muscles of the left upper limb, as evidenced by a positive card test and Grade 4/5 power in the left supraspinatus and deltoid muscles, the motor system appeared normal. Deep tendon reflexes in the left upper limb were present but grossly diminished. Plantar reflexes were bilaterally flexor, with preserved abdominal reflexes. The patient had normal coordination, stance and gait, with no evidence of nystagmus or Horner syndrome. Investigations: Complete blood count and routine biochemistry tests gave normal results. Fasting blood glucose level was 5.4 mmol/L (reference range [RR], < 6.1 mmol/L), and results of oral glucose tolerance were in the reference range. A serum VDRL (Venereal Disease Research Laboratory) test was negative. An x-ray of the left hand showed soft tissue swelling and a slight increase in the size of the metacarpals and proximal phalanges compared with the right (Box, B). X-ray of the left shoulder joint showed loss of normal architecture, multiple bony fragments and loose bodies (Box, C). Skeletal imaging showed no abnormalities of the skull, spine or other limbs. No abnormalities were seen in the affected limb on arteriovenous doppler examination, computed tomography, magnetic resonance imaging, angiography, lymphangiography and skin biopsy. Magnetic resonance imaging of the brain and spine showed a fairly large (12 mm) cerebellar tonsil dipping in the posterior portion of the foramen magnum, with a large syrinx involving the whole of the cervical and thoracic spine to level T8 (Box, D). Management: The patient was advised to undergo posterior fossa decompression, but was unwilling to have surgical intervention and is currently receiving regular follow-up. A syrinx is a cavity in the spinal cord (syringomyelia) or brain stem (syringobulbia).1 Syringomyelia is a chronic progressive degenerative or developmental disorder of the spinal cord, characterised clinically by brachial amyotrophy, cutaneous analgesia and thermoanaesthesia, with sparing of tactile, joint, position and vibration senses, and loss of deep tendon reflexes. Frequently, there are associated developmental abnormalities of the vertebral column, base of the skull, and particularly of the cerebellum and brain stem. About 90% of patients with syringomyelia have type I Chiari malformation (downward displacement of cerebellar tonsils). Patients with syringomyelia typically present with lower motor neurone signs at the level of the lesion, dissociated sensory loss in a cape or hemi-cape distribution on the arms or upper trunk, and spinal long tract dysfunction below the level of the lesion. Few patients show the complete picture, and the clinical features vary with the size, location and shape of the cavity, and the associated neurological condition.1 Common early signs are wasting and weakness of the small muscles of the hand, or loss of feeling in the hand and resulting injuries. Surprisingly, our patient — despite a relatively large syrinx — had no lower motor neurone signs in the upper limb, apart from diminished deep tendon reflexes and mild weakness, and no spinal long tract signs. Syringomyelia can also cause “neuropathic joint”, most commonly in the shoulder, elbow or wrist. The affected joint is often enlarged but painless, and movements evoke loud crepitus,2 as in our patient. While syringomyelia is more commonly associated with limb atrophy, hypertrophy can occur, involving bones, muscles and other tissues in one limb, one half of the body or even the tongue.2 Trophic changes in the skin can include cyanosis, hyperkeratosis and thickening of the subcutaneous tissue, leading to a swelling of the fingers described as “la main succulente”.2 Other findings associated with syringomyelia include increased ratio of arm to body length, size differences between the breasts, and curved fingers,2 (the latter two features documented in our patient). An association with hypertrophy of the limbs, hands or feet is also recognised in syringomyelia,3 and has been reported in four patients from Japan, including three of a series of 26,4,5 and in two patients from India. However, the latter two, in contrast to our patient, had prominent neurological features.6,7 Localised hypertrophy of the hand is also seen in syringomyelia: a radiological study of hand bones in four patients with syringomyelic chiromegaly found enlarged hand bones on the affected side.8 This feature was also evident in our patient. A range of mechanisms have been postulated to explain the segmental hypertrophy in syringomyelia, including stimulation of the sympathetic nervous system, causing defective circulation and oedema.9 An in-vitro study of muscle cells from patients with syringomyelia and muscle hypertrophy found the cells had accelerated growth in the presence of patient serum, suggesting involvement of serum factors and molecules released in response to neural lesions.10 To our knowledge, there are few other documented cases of syringomyelia presenting with both neuropathic joint and limb hypertrophy. Our case highlights this rare clinical presentation of a common spinal cord anomaly. It reminds clinicians that, although conventional teaching commonly associates syringomyelia with limb atrophy, it can be associated with limb hypertrophy. Hence, syringomyelia should be considered as a differential diagnosis in all cases of limb enlargement. Moreover, this case further emphasises the importance of considering a spinal cord anomaly as the aetiology of upper limb neuropathic joint. A patient with syringomyelia A: Hypertrophy of the left upper limb. B: X-ray of the hands showing bony and soft tisse enlargement on the left side. C: X-ray of the left shoulder showing gross disorganisation with multiple bony fragments. D: Magnetic resonance imaging of the cervical spine (T1-weighted) showing a large syrinx with type I Chiari malformation (arrow).

Partha P Chakraborty MB BS · Dipanjan Bandyopadhyay MD · Sanjay K Mandal MD · Subhasis Roy Chowdhury MB BS · Ramtanu Banerjee MD · Shounak Majumdar MB BS · Rana Bhattacharji MD

Antidoping laws generally exist in order to provide a safe and fair environment for participation in sport. These laws should prevent and protect athletes from subjecting themselves to health risks through the use of unsafe, but performance-enhancing drugs. Because of difficulties in proving intent to cheat, the World Anti-Doping Agency enforces a principle of strict liability for positive test results for banned substances. An area of major controversy with respect to liability is the “sports supplement” industry, which is poorly regulated when compared with prescription drugs yet is a potential source of doping violations. Medical practitioners can be found guilty of anti-doping violations if they traffic banned drugs, prescribe these to athletes or otherwise assist athletes in taking banned substances. Medical practitioners are also now required to complete paperwork (therapeutic use exemption forms) to enable athletes to take banned substances which are required on medical grounds for specific illnesses.

John W Orchard PhD, FACSP, FACSM · Deborah J Healey LLM · Peter A Fricker OAM, MB BS, FACSP · Louise M Burke PhD, APD, FACSM · Susan L White MB BS. FACSP

CorrectionRe: “Doggonit, it’s Christmas”, by Mervyn D Cobcroft and Charles Pembroke-Corgi, in the 5/19 December 2005 issue of the Journal (Med J Aust 2005; 183: 656-658). An acknowledgement for this article was inadvertently omitted. The acknowledgement should have read: Professor Denis Brosnan, University of Queensland, is responsible for coining the term “interposita”. The html version of this article has been corrected.

Mervyn D Cobcroft MB BS, FANZCA · Charles Pembroke-Corgi

A 40-year-old woman presented with sudden onset of a painful neck swelling, fever and dysphagia. Examination revealed a warm, tender lump in her thyroid gland. Five weeks previously, she had had an abdominal hysterectomy with bilateral salpingo-oophorectomy for pelvic inflammatory disease. There was no evidence of leukopenia or diabetes. Computed tomography and x-ray images were consistent with a diagnosis of thyroid abscess (Figure 1 and Figure 2). Anaerobic culture of a fine needle aspiration of pus confirmed the presence of Bacteroides fragilis. After failing twice to resolve the lump by aspiration, and incision and drainage, a left thyroid lobectomy was performed, with a satisfactory outcome. Antibiotics cefotaxime and metronidazole were administered after operation. There are about 400 cases of acute suppurative thyroiditis reported in the medical literature,1 but Bacteroides fragilis as the causative agent has been documented only once before.1 More than two-thirds of the women and half of the men with acute suppurative thyroiditis have pre-existing thyroid disease.2 Acute suppurative thyroiditis may be secondary to bronchial cleft fistula, pyriform sinus fistula, thyroglossal duct, HIV/AIDS, diabetes, or leukaemia.1,2 1: Computed tomography scan showing an abscess in the left lobe of the thyroid and the presence of air (arrow). 2: X-ray of the cervical spine (lateral view) showing soft tissue swelling in the anterior part of the neck and the presence of air (arrow).

Sashidhar Yeluri MBBS, MS · Jayshree P Mehta MB BS, MS · Siddharth Karanth MB BS, MS · Guneesh Dadayal MB BS

David van Gend Queensland Secretary, World Federation of Doctors who Respect Human Life, Mackenzie House Medical Centre, 116 Russell Street, Toowoomba, QLD 4350. vangendATmachousemedical.com.au To the Editor: As politicians prepare to debate the Therapeutic Goods Amendment (Repeal of Ministerial responsibility for approval of RU486) Bill 2005,1 one question is central: why should mifepristone require special approval from the Minister of Health and Ageing, when all other drugs are simply assessed by the Therapeutic Goods Administration (TGA)? The answer is that abortifacients such as mifepristone are unique in that they are the only drugs designed to end a human life, and therefore their use demands a unique level of ethical assessment and accountability, beyond the scope of the TGA. The TGA has the vital but limited role “to ensure the quality, safety and efficacy of medicines”. These criteria are adequate for assessing most medications, but inadequate for a drug designed to extinguish life. The TGA in its approval process does not consider ethical criteria.2 However, without broader ethical considerations, such as what medical conditions might justify the use of mifepristone, or the moral status of the life to be extinguished, no meaningful assessment of an abortifacient can be made. Abortion “on demand” (ie, without medical justification) is readily available in Australia, even where, as Judge Fred McGuire stated in a Queensland case: “There is no legal justification for abortion on demand”.3 Evidence for the predominantly non-medical justification for abortion was documented in a 1995 survey of women seeking termination of pregnancy in New South Wales.4 The most frequently listed contributing factor, given by 60% of the 2249 respondents, was “financial concerns”. Younger women were more likely to cite youth, career, single parenthood and changes to lifestyle, while women aged over 30 were more likely to cite completed family and problems in their relationship with their partner. Because abortion law is under state jurisdiction, the federal government has no stated position on abortion “on demand”. Now that it is being asked to authorise a drug for abortion, the government has the opportunity and responsibility to defend basic standards of law and ethics by limiting mifepristone use to medically essential terminations of pregnancy, excluding abortion for non-medical reasons. The government should establish, in consultation with medical authorities, valid medical indications for mifepristone, including certain cancers, hormonal diseases, and medically essential termination of pregnancy, and approve the drug for those uses. The criteria could be specified using the existing authority prescription mechanism. This would exclude abortions for which there is no medical indication; for this category, the compelling task for government and the profession is to address the underlying social stresses for which abortion is seen as a solution, reconstructing social supports for women distressed by unplanned pregnancy. Certainly, setting ethical parameters for the use of mifepristone will not affect the availability “on demand” of surgical abortion, which operates without effective ethical or legal restraint. Yet, even largely symbolic acts can be important. If it is right ethically and medically to set limits on the use of abortifacients such as mifepristone, these limits should be set. The medical profession should use the debate on mifepristone to reaffirm ethical limits on abortion, upholding our duty of care to both mother and unborn baby. Disappointingly, in the debate so far, leaders of organised medicine have limited discussion of mifepristone to sterile technical matters of safety and efficacy, as if ethical concerns have no bearing on public policy or medical practice.5 Much expert advice would be needed concerning authentic medical grounds for the use of mifepristone, and even then the authority prescription system could still be abused. But at least the attempt will have been made to establish valid medical indications for this gravest of medical acts, and the profession will be seen to distance itself from abortion “on demand”.

David van Gend

Philip L P Morris Psychiatrist, 16 Riverbank Court, Ashmore, QLD 4214. pmorrisATiprimus.com.au To the Editor: In their letter on “GP Psych Opinion”, Wong and Tiller highlighted the poor uptake by general practitioners of a psychiatric consultation service based in a private psychiatric hospital in Melbourne.1 They compared the results of their service to the similar poor uptake by GPs of the public hospital-based psychiatric consultation service in Brisbane.2 One explanation for this disappointing result may be that most psychiatric illness is chronic, and continuity of care and advice from a consistently available psychiatric colleague is of great importance to GPs — over and above having the patient assessed. This does not seem to have been a strong characteristic of the Melbourne service, given that the assessing psychiatrist was a psychiatric trainee registrar, who is usually either rotating between clinical placements as part of training, or waiting to move on to a more senior position. GPs’ referral practices to specialists are based on a multitude of influences, of which availability is only one. Personal contact, quality of service and continuity of assistance are highly relevant. Perhaps if the Melbourne and Brisbane consultation services can push on and attend to these issues, then utilisation by GPs will increase over time — as this is what happens in more conventional private practice referrals.

Philip L P Morris

Dorothy L Robinson Senior Statistician, Armidale Air Quality Group, Building W46, University of New England, Armidale, NSW 2351. drobinsoATmendel.une.edu.au To the Editor: There should be no contradiction in recommending that people enjoy recreational exercise when air pollution is low but nonetheless walk/cycle for transport.1 I cycle home after 5 pm, when pollution increases to health-hazardous levels (Box), but it is astounding to see people out jogging in such unhealthy air. Cycling for transport is undoubtedly better than driving. Despite dangers from pollution and busy roads, commuter-cyclists have 40% lower mortality than drivers.2 Nonetheless, cycling in diesel fumes at concentrations typically present on busy roads causes significant damage to blood vessels,3 and should be avoided if there is a choice. This concept is no harder to understand than the concept that moderate intake of mono- and polyunsaturated fats is beneficial but excessive saturated fat intake is bad. Regrettably, this distinction was once considered so complicated that people were told simply to reduce all fat consumption. Until people understand the hazards of air pollution, controls will remain inadequate. In Sydney, Melbourne, Brisbane and Perth, air pollution causes an estimated 1611 premature deaths every year, with more than 3000 estimated for Australia as a whole. The most serious health problems relate to fine particles (PM2.5), emitted predominantly by diesel-powered vehicles and woodheaters.4 Winter measurements in Liverpool, Sydney, follow a similar temporal distribution to those in Armidale, in regional New South Wales (Box), suggesting that both regional and metropolitan residents should jog at lunchtime in winter, rather than after work. A recent review estimated that health costs of PM2.5 emissions in urban Australia range from $100 to $300 per kilogram of particles. A typical woodheater (emitting 20 kg of these particles every winter) therefore generates $2000–$6000 in health costs — considerably more than switching to non-polluting heating.4 Older (pre-1990) diesel cars and utilities emit about 0.75 g PM2.5 particles per kilometre (13.8 kg per 20 000 km), generating estimated annual health costs of $1380–$4140. This exceeds the cost of converting to liquid petroleum gas or retrofitting a particle trap/oxidation catalyst. When PM2.5 pollution was reduced in Dublin by banning non-smokeless coal in 1990, there were 2154 fewer deaths in the first 6 years of the ban than the previous 6 years (15.5% fewer respiratory and 10.3% fewer cardiovascular deaths/year).1 Euro II emission limits for new diesel-powered vehicles became mandatory in 1996/97 in Europe (and in 2002/03 in Australia). Simple, cost-effective measures for reducing the major sources of urban PM2.5 pollution — including converting or retrofitting diesel-powered vehicles that exceed Euro II limits, phasing out woodheaters and strongly discouraging stubble-burning in areas where it increases smoke pollution in rural towns1 — would significantly reduce pollution-related illness. It would also allow cyclists, pedestrians and joggers to exercise whenever desired, with fewer worries about air quality. Hourly concentrations of fine particle pollution (PM2.5 measured by nephelometer scattering coefficient) in Armidale (regional NSW) and Liverpool (Sydney) on the first occasion (11 June 1997) that Sydney residents were asked to reduce pollution by not using woodheaters. (Data sources: Sydney, NSW EPA; East Armidale, Armidale Air Quality Group, with assistance from CSIRO Department of Atmospheric Resources.)

Dorothy L Robinson

Katina Kardamanidis,* Bruce Armstrong† * Research Fellow, Injury Prevention and Trauma Care, The George Institute for International Health, PO Box M201, Camperdown, NSW 2050; † Head, School of Public Health, University of Sydney, NSW. kkardATdoh.health.nsw.gov.au To the Editor: Not all asylum seekers in Australia are confined to detention centres. Those who arrive with a valid visa live in the community. If they apply for refugee status within 45 days of arrival, they are entitled to work and to Medicare while their refugee claims are processed;1 if they apply too late, they are denied these benefits. In New South Wales in 2003 about 1500 men, women and children were in this situation, which may last from 3 months to 3 years. Asylum seekers who appeal a refusal of their application, or are released from mandatory detention with an application outstanding, are in the same situation.2 Some are eligible for the federally funded Red Cross Asylum Seeker Assistance Scheme, but, for most, access to health care is jeopardised because they are unable to pay full fees for medical services.3,4 We asked health professionals working with asylum seekers about the costs of asylum seekers’ difficulties in accessing health care. Their responses, with illustrative quotes, are divided into “tangible costs” and “intangible costs” (Box). Some individuals and institutions sympathetic to the plight of asylum seekers give their professional time or donate money to pay for health care, but are not able to address the full range of health care needs. Obtaining access to secondary care, particularly admission to hospital, is very difficult. There is no uniform approach to charges, either between hospitals or within any one hospital on different occasions. The approach seems to depend on the decision-maker present. Such difficulties in accessing care may lead to uncomplicated health problems developing into chronic and more serious ones. The attempt to save costs is likely to lead to higher costs in the future. The effect on asylum seekers is increased physical, psychological and social disadvantage and diminished opportunities for a healthy life. Health professionals are faced with the dilemma of turning these people away, or aiding them without financial compensation. In either case, they cannot provide the necessary standard of care. Although many Australians are conscious of the hardship of these people, the society as a whole seems unaware of it or of the impact that its unfairness may have on the social fabric of their communities. If all Medicare-ineligible asylum seekers in NSW were to have the same access to health services as other Australians, we estimate that the total annual cost would be about $3.4 million.5 This is about 0.015% of the total annual recurrent health expenditure in NSW in 2000–01.6 This economic cost, some if not most of which will be spent regardless, does not justify the disadvantage created by the Australian Government’s immigration rules. We suggest that state governments consider giving this small group of asylum seekers free access to public hospital services. Costs of asylum seekers’ difficulties accessing health care and who bears the costs: responses of health professionals working with asylum seekers Theme Illustrative quote Tangible costs Insufficient voluntary aid to address all health needs “We have one patient . . . with a urinary infection, and it was decided that . . . he needed a TURP [transurethral resection of the prostate], and then they realised he didn’t have any funds and they discharged him . . .” Inconsistent attitudes of hospitals “There’s quite a difference between different hospitals. For example, the X hospital at Y is very tough. . . . much tougher than the hospital here, on refugees. . . . They are different Area Health Services . . . it may not even be the Area Health Service directors, but the hospital manager’s idea that these people should pay.” More costs in the long term “I have a lot of patients with diabetes and high blood pressure . . . Now if their diabetes or their blood pressure or their cholesterol is not managed properly, then they get heart disease or strokes. So, I have a patient who has had a stroke . . . high blood pressure and so on . . . if he had [had] better access to health care, would he have had the stroke? . . . So [now], the government has had to pay . . . it doesn’t make any sense really.” Intangible costs To the asylum seeker (recounted by a health professional) “If you say to someone, I really think you need to have this test, but, if I refer you, you have to pay a lot of money, so I’m not going to refer you, how does that make you feel? It makes you feel worried and powerless.” To health professionals “. . . if someone came in complaining about it [diarrhoea, losing weight], you would do a whole lot of checks, and with that particular lady . . . we were able to negotiate to get a couple of tests done free, and the family and she paid a certain amount of money to get some others [done] . . . if the person had Medicare, you’d take it that step further and do extra just to be 101% sure. So, there is that real ethical dilemma . . .” To the Australian society “. . . if people actually knew on a face-to-face level . . . what it meant to deny a newborn baby the right to health care, [or] . . . turn away someone who is extremely depressed . . . [Would they] actually be able to say ‘No, they don’t [have a right to health care]’.”

Katina Kardamanidis · Bruce Armstrong

To the Editor: British authors Wilson and Parker in their editorial on hospital in the home1 acknowledge the outdated Cochrane review of 20012 in relation to costs of hospital in the home. More recent research in New South Wales provides compelling evidence of cost saving in excess of 50% when community costs are compared with inpatient costs for certain diagnosis related groups.3,4 Patient selection for these services is based on safety, functional ability, carer support, and consent. The treatment regimens are based on evidence and governed by strict quality assurance. These elements form the foundations of successful acute and post-acute care programs. Amendments to the National Health Act 1953 (Cwlth) in 2001 endorsed the provision of acute care in places other than hospital beds.5 The Macarthur Health Service in south-western Sydney received Commonwealth acute outreach accreditation in 2004 and currently supplies at least 13% of total bed-days in the specialties of medicine, surgery and paediatrics. An added benefit is a system that allows people to choose a private outreach service instead of a hospital bed and have expenses covered by their health fund, which pays a bed-day rate for this care in the community. Patient quality of care, choice and satisfaction have been the drivers for hospital in the home. Demonstrated savings for ambulatory sensitive diagnoses and the opportunity for revenue from private patients should be appealing to hospital administrators in an environment of chronic bed shortages. Editor’s note: The Cochrane review was updated after Wilson and Parker submitted their editorial: Shepperd S, Iliffe S. Hospital at home versus in-patient hospital care. Cochrane Database Syst Rev 2005; (3): CD000356. Available at: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000356/frame.html (accessed Dec 2005).

Stephen F Wilson · Nicholas Collins

Allen C Cheng,* Andrew J Hughes,* Julian B Stella,† Eugene Athan* * Infectious Diseases Physician, Hospital in the Home Programme, Department of Infectious Diseases, † Emergency Department Physician, Geelong Hospital, Geelong, VIC 3220. allencATmenzies.edu.au To the Editor: We note with interest the studies published in the Journal by Richards et al and Ong et al.1,2 The authors conclude that treating pneumonia and pulmonary emboli in an ambulatory setting is safe for selected patients. However, this represents a large change in the conditions traditionally treated on this basis, from conditions that are associated with a very low mortality (such as cellulitis) to a subgroup of patients with potentially serious infections that are identified as being of low risk. We feel that safety is of prime importance in hospital-in-the-home programs because of limited or delayed access to acute medical care, and that both studies were underpowered to define this endpoint. Both studies incorrectly quote previous work that suggests that the groups they have identified have mortality rates of up to 5% (for pulmonary emboli) and up to 9.2% (for mild to moderate pneumonia). Published data suggest that the mortality of mild pneumonia (with CURB-65 scores ≤ 2) is in the range 1.7%–3%,3,4 and that mortality from treated sub-massive pulmonary emboli is in the range 1.0%–1.3% within the first week.5 These rates, although seemingly small, are still much higher than that associated with the treatment of soft tissue infections on ambulatory care programs. Recurrent pulmonary embolus, in particular, may be sudden and unexpected. Although admission to hospital may not necessarily prevent these deaths, the additional trauma of a death at home, particularly soon after transfer to ambulatory care, may carry a higher significance in the minds of patients, their families and the public than a death in hospital. We acknowledge that benefits for patients in ambulatory treatment programs need to be balanced against potential adverse outcomes. However, if these conditions are to be treated where access to medical attention may be delayed, it is imperative that informed consent be obtained from patients (including an awareness of the possibility of death), a mechanism be available for patients to summon urgent attention at any time, and patients and health care providers be aware that readmission to the hospital may be necessary in the event of clinical deterioration.

Allen C Cheng · Andrew J Hughes · Julian B Stella · Eugene Athan

Dee A Mangin (née Richards),* Les J Toop,† Michael J Epton,‡ Graham R B McGeoch,§ G Ian Town,¶ Simon M H Wynn-Thomas,** Robin D Dawson,†† Michael C Hlavac,‡‡ Anja M Werno,§§ Paul D Abernethy¶¶ * Senior Lecturer, † Head, †† Research Fellow, Department of Public Health and General Practice, ‡ Senior Lecturer, ¶ Dean, ‡‡ Research Fellow, Department of Medicine, Christchurch School of Medicine and Health Services, Otago University, PO Box 4345, Christchurch, New Zealand; § Director, Community Care, ** Medical Director, Extended Care @ Home, ¶¶ Manager, Health Services, Pegasus Health Independent Practitioners Association, Christchurch, NZ; §§ Community Patholgist, Canterbury Health Laboratories, Christchurch, NZ. derelie.manginATchmeds.ac.nz In reply: Thank you for the opportunity to reply to the letter from Cheng et al. The mortality figures we cited are correct.1 The cited article by Lim et al supports our statement that “Patients with a CURB-65 score of 0–2 have a low mortality (0.7%–9.2%)” (Table 4 shows mortality for CURB-65 score 0 is 0.7% and for score 2 is 9.2%).2 The 3% figure in the abstract is a summary measure obscuring the difference across the CURB 0–2 range — important information for anyone considering community management of community-acquired pneumonia where, we agree, safety is paramount. The rate of 1.7% cited by Cheng et al is for a modified CURB-65 score, which adds a further point, and thus is for the equivalent of CURB-65 scores of < 1.3 Cheng et al correctly observe our study was not powered to detect mortality differences. As explained in our discussion, mortality was not a primary outcome measure. With low mortality, large numbers are required to detect a statistically significant difference — the base rate of 3% in the validation study would require 10 602 patients in a randomised controlled trial to detect a 33% relative (1% absolute) increase in mortality. The study did provide for informed consent (including the possibility of readmission) and the ability to summon urgent attention. Careful patient selection, routine twice-daily nurse and daily doctor visits, along with a highly trained nurse available by telephone 24 hours a day who can dispatch a doctor or nurse immediately, provides a structure that should match hospital care. Careful patient monitoring will detect failure to respond as expected. It is important to treat in hospital those who will benefit, but not feasible to admit all with potential mortality risk (nor is there evidence of benefit). Hospitalisation also has risks. With this tool for predicting accurately who will suffer worse outcomes, it could be argued there has to be good evidence that better outcomes will result from continuing inpatient treatment of mild to moderate community-acquired pneumonia. These wider issues are worthy of debate. There is an assumption by some professionals and consumers that hospital-sanctioned death is more acceptable, that everything possible has been done, and that community-based death implies unsatisfactory management. As a counterpoint to this, there is a clear patient preference for treatment in the home where possible. Avian influenza may, of course, drastically redefine our expectations about locus of care and of death.

Les J Toop · Michael J Epton · Graham R B McGeoch · G Ian Town · Simon M H Wynn-Thomas · Robin D Dawson · Michael C Hlavac · Anja M Werno · Paul D Abernethy

Bin Soo Ong,* Margaret A Karr,† Daniel K Y Chan,‡ Anthony Frankel,§ Qing Shen¶ * Director, Department of Ambulatory Care, † Research Manager, ‡ Director, ¶ Research Assistant, Department of Aged Care and Rehabilitation, § Respiratory Physician, Bankstown-Lidcombe Hospital, Locked Mail Bag 1600, Bankstown, NSW 2200. bin.ongATswahs.nsw.gov.au In reply: We acknowledge the concerns of Cheng and colleagues regarding the safety of patients with pulmonary embolism (PE) treated in an ambulatory care setting. Caution is important as this is a relatively new area of treatment in ambulatory care compared with the management of deep venous thrombosis. The main objective of our study was to describe our experience in the management of PE in ambulatory care; it was not a randomised controlled study to conclusively define safety as such. As stated in our paper, there have been reports of the management of PE in the ambulatory care setting.1,2 We now know that more than 90% of patients with sub-massive PE will have a good response to treatment. The challenge is to accurately define this group. The mortality rate we quoted of less than 5% was derived from a review article on prognosis of patients with PE.3 This article quoted three studies on sub-massive PE, one of which was referenced by Cheng and colleagues in their letter.4 We note also that the specific study that was referenced4 included patients with cyanosis and shock; these patients would have been excluded by our selection criteria. We do not advocate management of all patients with sub-massive PE in the ambulatory care setting. It is also important to be conservative initially in the selection of these patients. There have been various studies examining prognostic indicators for PE, which we have referenced in our paper. There is evidence now that, for patients with specific prognostic indicators, the risk of death and adverse outcomes is significant and such patients should always be admitted. The practice of managing patients with sub-massive PE should only occur in ambulatory care units which are appropriately resourced, have strict admission criteria and well defined protocols and specialist medical input, consistent with the recommendation of the British Thoracic Society.5 In the meantime, further studies are required before this becomes standard practice in ambulatory care or hospital-in-the-home units.

Bin Soo Ong · Margaret A Karr · Daniel K Y Chan · Anthony Frankel · Qing Shen

Stephen F Wilson,* Peter McGeorge† * Program Director, Population Health, Sacred Heart Rehabilitation Centre, † Director of Mental Health Service, St Vincent's Hospital, Darlinghurst, NSW 2010. stwilsonATstvincents.com.au To the Editor: Corbett’s recent proposal to create a “Ministry for the Public’s Health” has merit. However, this Ministry may not achieve its intended purpose in relation to disadvantaged people, chronic and complex health care, or the mental health problems confronting acute services in today’s urban communities. The current situation may be the result of long neglect of population health. However, a new Ministry runs the risk of becoming yet another compartment within an existing non-integrated health care system. The efficiencies of an integrated service for acute health care of older people are well known.2 This integration requires a reinvestment in community care and changes in roles and relationships of health workers. There is currently a gap between services maintained by state funding for acute care in and around hospitals, and services which are federally funded for the community sector via general practice, preventive and maintenance services. The gap created between these two workforces results in suboptimal “management” of chronic and complex disease and mental health, and care of disadvantaged groups. The lack of a strong focus on management drives patients to rely on the acute health care system, particularly emergency departments. This situation is aggravated by the poor coordination with general practice, non-government organisations and community services. The current challenge is to develop a health environment which simultaneously addresses the present and future needs for prevention, management and response. Another approach is to construct a health “sandwich”, with a foundation layer of population health, a “filling” of illness management services, and a top layer of acute response and hospital services. A model guided by the mission of St Vincent’s Hospital, and implemented in 2005, has created a partnership for emergency department, community health, aged care, rehabilitation and palliative care within an administrative division called Population Health. A Psychiatric Emergency Care Centre within the emergency department has established a shared approach to acute patient care along with the mental health services. In the future, a patient entering the emergency department for an acute response to physical, mental or combined illness should also be “consuming” a health program of management and disease prevention, which is lacking in current health service provision. This healthy sandwich may prove easier to digest than the dry biscuits of policy.

Stephen F Wilson · Peter McGeorge

Avian flu: drug resistance Drug-resistant avian influenza A (H5N1) viral infection is no longer just a theoretical prediction — it is a reality, with the recent report of a case of resistance to oseltamivir (Tamiflu).1 A 13-year-old Vietnamese girl died 7 days after being admitted and treated for influenza A (H5N1) virus infection, despite receiving early, therapeutic doses of oseltamivir. She deteriorated from Day 4 after admission, suggesting that drug resistance developed during treatment. The case report authors said that new treatment strategies such as using higher doses and longer durations of antiviral therapy or combination therapy may deserve further evaluation. An accompanying editorial said that, in light of this frightening report, improper use of personal stockpiles of oseltamivir, which may promote resistance, should be strongly discouraged.2 1. N Engl J Med 2005; 353: 2667-2672 2. N Engl J Med 2005; 353: 2633-2636 Out of this world Australian researchers continue to boldly go where no others have gone before. Lacking any guidance from previous researchers, Lim and colleagues from Melbourne’s Burnet Institute set out to answer the age-old question, “Where have all the bloody teaspoons gone?”. They conducted regular weekly or fortnightly counts of 70 discreetly numbered teaspoons of differing quality that had been distributed among the institute’s tearooms. After 5 months, four out of five teaspoons had disappeared, with the quality of spoon having had no effect on rate of loss. The Burnetians calculated the half-life of the teaspoons to be 81 days — ie, half had disappeared permanently by that time. As for where the spoons went, no definitive answer could be reached but it was speculated, among other possibilities, that the teaspoons had escaped to a spoonoid planet to live their equivalent of the good life. BMJ 2005; 331: 1498-1500 Concerning green tea A case of reversible hepatotoxicity associated with taking a Chinese green tea (Camellia sinensis) extract has been reported in the US. The 37-year-old woman had been using a weight-loss supplement with C. sinensis as the major ingredient. On two separate occasions a year apart, hepatotoxicity occurred within months of starting the supplement and resolved on cessation. The author of the report believes that large amounts or concentrated preparations of C. sinensis are dangerous and should be avoided. Ann Intern Med 2006; 144: 68-71 Don’t panic, try exercise Aerobic exercise may have an acute anti-panic activity, according to German researchers. A small group of 15 healthy subjects without panic disorder received a panic attack-inducing intravenous injection of cholecystokinin tetrapeptide after experiencing 30 minutes of either quiet rest or exercise on a treadmill. Panic attacks occurred in 12 subjects after rest but in only six subjects after exercise. If this anti-panic effect of exercise can be confirmed in patients with panic disorder, acute exercise may offer another treatment option for this disorder. Am J Psychiatry 2005; 162: 2376-2378 Google Medicine? A Canadian biomedical librarian has advised the Internet search engine Google’s founders to build a specific medical portal. Giustini says that such a portal — “call it Google Medicine” — might well be the badly needed, all-purpose interface that medicine needs to help us access the best available evidence. He envisages Google Medicine as a superior tool to the currently available Google Scholar (scholar.google.com), which indexes more peer-reviewed research than Google but still requires sifting for currency and quality. Like PubMed and Google, Google Scholar is free on the web. BMJ 2005; 331: 1487-1488 Sleep apnoea, snoring and the didgeridoo Playing a didgeridoo could be an effective treatment for patients with moderate obstructive sleep apnoea syndrome (OSAS), say Swiss researchers. They had embarked on a small proof of concept, randomised controlled study after a didgeridoo instructor reported, anecdotally, some beneficial effects. Daytime sleepiness and other measures were assessed in 25 non-obese adults with moderate OSAS randomised to either receive didgeridoo lessons and daily practice or to be on a waiting list for lessons. After 4 months, the researchers found reduced daytime sleepiness, reduced snoring and an improved apnoea-hypopnoea index in the didgeridoo group compared with the control group. Training of upper airways muscles may be responsible for the effects detected. Participants in the didgeridoo group used a standardised acrylic plastic didgeridoo — apparently these are easier for beginners to learn on than conventional wooden ones. BMJ Online, 23 Dec 2005 Dr Ann Gregory, MJA

Ann Gregory