Volume 184 Issue 6

Recommendations for primary prevention in women need to be different The efficacy of low-dose aspirin for the secondary prevention of cardiovascular disease among men and women is established.1,2 However, the risk-to-benefit ratio for aspirin in primary prevention is much less clear.2,3 The National Heart Foundation has recommended that low-dose aspirin be considered for people without symptoms but at increased (> 1% annual) risk of a coronary heart disease event.4 This recommendation is based on earlier primary prevention trials, with over 55 000 participants, showing a significant 32% reduction in the risk of myocardial infarction, but no significant change in risk of stroke or cardiovascular death.3 However, women comprised only 20% of trial participants, and fewer than 180 of the 2402 cardiovascular events occurred in women.3,5 Until recently, there has been limited direct evidence for the efficacy of aspirin in primary prevention among women. The Women’s Health Study (see Box) not only addressed this important sex issue, but suggested a significant difference in the cardiovascular response to aspirin between women and men.5 In this study, confined to healthy women aged 45 years or older, aspirin prophylaxis did not lower the risk of a first major cardiovascular event (non-fatal myocardial infarction, non-fatal stroke, or death from cardiovascular causes) — the primary endpoint. However, it did significantly reduce the risk of all strokes by 17%, and ischaemic stroke by 24%, without affecting the risk of myocardial infarction or cardiovascular death.5 This differs from previous aggregate data derived from mostly middle-aged men, and confirmed by a recent sex-specific meta-analysis, which showed that aspirin therapy significantly reduced the risk of myocardial infarction but not ischaemic stroke in men.6 Are there any apparent reasons for the seemingly opposite results for stroke and myocardial infarction in men and women? One possibility is that aspirin lowered the risk of stroke in women, but not men, simply because women have a higher risk of stroke than myocardial infarction. For instance, the ratio of incident stroke to myocardial infarction was 1.4 : 1 among women in the placebo group of the Women’s Health Study, compared with 0.4 : 1 among men of a similar age in the placebo group of the Physicians’ Health Study (a randomised, double-blind, placebo-controlled trial examining whether low-dose aspirin [325 mg every second day] decreases cardiovascular mortality and whether b-carotene reduces the incidence of cancer).7 Conversely, the Women’s Health Study may have lacked statistical power with respect to the risk of myocardial infarction. The study enrolled a group of largely healthy women, 85% of whom had a 10-year Framingham coronary risk score of less than 5%. Women also have a lower age-adjusted incidence of coronary heart disease than men; the rate of myocardial infarction among women in the Women’s Health Study was 97.3 per 100 000 person-years, about one-fifth the rate of myocardial infarction among men in the Physicians’ Health Study.7 Women tend to develop heart disease between 10 and 15 years later than men. This may explain why consistent benefits of aspirin on all major cardiovascular endpoints, including myocardial infarction and stroke, were observed only among women aged 65 years or older in the Women’s Health Study.5 This subgroup comprised 10% of the study population, but accounted for nearly a third of all cardiovascular events. In this subgroup, aspirin, compared with placebo, led to 44 fewer myocardial infarctions, strokes, or deaths from cardiovascular causes, but also caused 16 more gastrointestinal haemorrhages requiring transfusion, emphasising again the importance of balancing benefits and risks.5 A recent overview has also suggested that the risk of gastrointestinal and other bleeding with aspirin use may increase with age, and that the true balance of risks and benefits in the healthy aged population has not yet been established by randomised trials.8 The 100 mg alternate-day dose of aspirin used in the Women’s Health Study is lower than doses employed in previous trials. However, this regimen of aspirin was sufficient to reduce the risk of ischaemic stroke, and hence is likely to be an adequate dose for cardiovascular prevention. Nonetheless, sex differences in salicylate metabolism, platelet responses, vascular reactivity, and the nature of atherosclerotic disease may well cause different biological responses between men and women.9-11 This further highlights the need for women to be well represented in cardiovascular trials. What are the clinical implications of the Women’s Health Study? Overall, this study indicates that clinicians should be very cautious about advising women under the age of 65 years to take low-dose aspirin for primary prevention unless their global risk score is high. Even the benefit of aspirin for prevention of stroke in women needs to be carefully weighed against the increased risk of bleeding complications, and the low risk of stroke and other major cardiovascular events among apparently healthy women. To put this into perspective, the absolute risk reduction with aspirin therapy was about two stroke events per 1000 women treated.5 Thus, as with men, any decision about the use of aspirin for primary prevention among women requires an assessment of the net absolute benefit of therapy in an individual, and such a decision should be made only in association with an overall program of lifestyle measures to reduce cardiovascular risk.2 Reflecting these developments, the National Heart Foundation of Australia has recently amended its position statement on aspirin for cardiovascular disease prevention.12 Summary of the Women’s Health Study5 A large randomised placebo-controlled trial of aspirin (100 mg on alternate days) for primary prevention among 38 876 initially healthy women, aged 45 years or older, followed for 10 years for the occurrence of a first major cardiovascular event (myocardial infarction, stroke, or death from cardiovascular causes). The study recruited healthy women, 85% of whom had a 10-year Framingham risk score of less than 5%. The 10-year absolute cardiovascular event rate was low, and among placebo recipients there were more strokes than myocardial infarctions (266 v 193). At the end of the trial, major cardiovascular events (the primary endpoint) occurred in a non-significant 9% fewer aspirin recipients than placebo recipients (2.4% v 2.6%; P = 0.13). With regard to secondary endpoints, there was a significant 17% reduction in the risk of stroke in the aspirin group (1.1% v 1.3% with placebo; P = 0.04), owing to a 24% reduction in risk of ischaemic stroke; the two groups did not differ significantly in their incidence of myocardial infarction or cardiovascular death. Subgroup analyses showed that aspirin significantly lowered the risk of major cardiovascular events, ischaemic stroke, and myocardial infarction among women 65 years of age or older (6.4% v 8.5% with placebo; P = 0.008). The aspirin group had a higher frequency of gastrointestinal bleeding (4.6% v 3.8% with placebo; P < 0.001), and a non-significant increase in risk of haemorrhagic stroke (0.26% v 0.21% with placebo; P = 0.31). Overall, this trial indicates that caution is necessary when advising apparently healthy women to take low-dose aspirin for cardiovascular disease prevention.

Joseph Hung MB BS, FRACP, FACC

All stakeholders should contribute to enhancing Australia’s guidelines for ethical research Health and medical research involving human participants in Australia has been subject to guidelines promulgated by the National Health and Medical Research Council (NHMRC) since 1966. Currently, the key documents are the National statement on ethical conduct in research involving humans (1999)1 and the Joint NHMRC/AVCC statement and guidelines on research practice (1997).2 The former, better known as the “National Statement”, is endorsed by a number of peak national bodies, including the Australian Research Council (ARC) and the Australian Vice Chancellors’ Committee (AVCC). The “Joint Statement” is issued under the aegis of the NHMRC and the AVCC. The National Statement encompasses the ethical principles to be followed in proposing research involving humans, and advises institutions on the requirements for establishing human research ethics committees (HRECs). The Joint Statement provides guidance on good research practice, including details related to data collection, authorship and publication, supervision and mentoring and like matters, as well as providing the framework by which institutions should handle allegations of research misconduct. The system of oversight of human research based on these documents has been updated and modified from time to time and has served the nation reasonably well. However, the guidance provided in the documents has not been without its critics, and weaknesses in relation to the National Statement have been identified. These include under-resourcing of overworked HRECs,3 deficiencies in transparency and accountability of HRECs,3 absence of explicit application of the guidelines to the private sector,3 the failure of institutions and their HRECs to accommodate the vast increase in multicentre research4 and the “one size fits all” process of ethical review.5 The provisions of the Joint Statement for handling research misconduct allegations were severely tested and found wanting in a high profile case in 2004;6 furthermore, compared with Scandinavian countries,7 the education of new researchers in research ethics is patchy, especially outside our universities. As health and medical research has expanded in our teaching hospitals, there have been accusations that these institutions have not paid sufficient attention to the important task of research governance.8 In some instances, this has led to HRECs playing research governance roles for which they are neither equipped nor authorised — a development termed “mission creep”.9 The National Statement was extended by agreement to cover human research beyond the health and medical field, such as sociology, criminology and the humanities.1 However, this extension has led to criticisms of “ethics creep”; that is, the ethical review by HRECs of research of very low risk, thereby discouraging and frustrating some researchers and at the same time creating unnecessary work for HRECs.10 NHMRC guidelines are subject to regular review and any review includes obligatory public consultation. In addition, the Commonwealth National Health and Medical Research Council Act 1992 requires that the NHMRC, its principal committees and any working parties must “have regard” to any submissions received. Currently, both the National Statement and the Joint Statement are under active review by separate working parties of the NHMRC, the ARC and the AVCC. The two documents have already had an initial round of public consultation, and second draft revisions incorporating the responses to those consultations are now available for comment.11,12 Both documents contain important new sections. The necessity for institutions which support research to have solid policies and practices of good research governance (Box 1) is emphasised in both documents. For most institutions, this requirement should not have significant cost implications; rather, it will be a matter of more formally identifying and allocating existing responsibilities and reporting lines.8 The draft revised National Statement11 has been significantly modified. Researchers in fields beyond health and medical research should find it more responsive to their specific needs, and institutions should find it a more flexible document to use when deciding the level of independent review required for any research proposal. For health and medical researchers, interest will focus on several areas of new guidance, including risk in research and research with human stem cells, as well as extensively rewritten chapters such as those on data banks, clinical trials, genetics and tissue. Institutions and their HRECs should carefully consider the new final section on “Processes for research governance and ethical review”, which proposes significant alterations to matters including complaints handling, annual compliance reporting and monitoring of research. The draft revised Joint Statement, now to be known as the Australian code for the responsible conduct of research12 makes the roles and responsibilities of institutions and researchers much clearer. It calls for institutions to be much more active in providing education and induction of researchers in the realms of research ethics, research methods and research governance (Box 2). It spells out the conditions under which authorship of research publications is legitimate. It covers general principles for good research practices, data and records management, supervisory responsibilities, publication and dissemination of findings, peer review and conflicts of interest. Importantly, the new “Australian Code” presents a new look at dealing with research misconduct and fraud, including a proposed new framework for institutional responsibilities in handling allegations of research misconduct. This section was not available in the first round of public consultation, but incorporates material discussed at a stakeholder workshop on research misconduct held in Canberra in October 2005. It provides a more encompassing definition of research misconduct and calls for institutions to appoint “advisers on research integrity” as well as a senior “designated person” to take responsibility for the preliminary investigation of research misconduct allegations. For allegations of a serious nature, the inquiry established by an institution must be made up of people independent of the institution and must follow procedural fairness principles. We believe that these two draft documents herald a new era in the governance of research involving humans in Australia. At a time when commercial and other pressures on researchers may be increasing the risk of fraud and misconduct,13 it is crucial that our system for the oversight of research be sufficiently robust to protect participants and maintain community confidence in research. By emphasising the importance of research governance, reasserting the important roles that researchers and institutions have in the system of oversight, insisting on mechanisms for handling allegations of misconduct that are independent, prompt, fair and just, and making the processes of ethical review more responsive to the needs of different fields of research, the revised documents should be welcomed by all stakeholders. It is important that these stakeholders, including researchers, institutional leaders, sponsors of research, potential research participants, federal, state and territory governments and interested members of the community, consider and comment on the two draft documents. Input from as many stakeholders as possible in this second public consultation will enhance the guidelines and bring a greater sense of shared ownership. 1 Research governance Research governance is the framework by which institutions support, monitor and attest to the safety, ethical acceptability and quality of the research they undertake. Standards which underpin effective research governance exist in the domains of ethics and law, science, information protection, health and safety, intellectual property and commercialisation, financial management and public relations. For a more detailed discussion see reference.8 2 Education, training and induction* “To maintain a culture of responsible research conduct, it is important that institutions provide induction, formal training and continuing education for all research staff, including students and research trainees. Training should cover research methods, ethics, principles of confidentiality, data storage and records retention, as well as regulation and governance. Training should also include the institution’s policies and procedures regarding responsible research conduct, all aspects of this code, and the other sources of guidance that are available. Smaller institutions may make joint arrangements for induction and training with other institutions.” * Extracted from reference.12

Warwick P Anderson PhD · Christopher D Cordner PhD · Kerry J Breen MB BS, MD, FRACP

There is much to be gained by reducing children’s intake of soft drinks and little — except excess weight — to be lost Childhood obesity is a major health issue in Australia. In recent months, a number of organisations, including the Australian Medical Association,1 have released statements demanding stronger action on this issue, including a call to restrict access to and marketing of soft drinks to help reduce children’s consumption. However, the soft-drink industry rejects these proposals and argues that their product is being unfairly singled out for action. Further, many parents are confused as to why a drink they often consider to be a harmless treat should be labelled so damaging to their children’s health. In considering the suggested policy changes, it is therefore important to weigh up the information we currently have about the extent of soft-drink consumption, its impact on childhood obesity, and the potential of a reduction in consumption to contribute to improved weight control. The term “soft drink” covers a number of different beverages, but in Australia it is generally used to refer to carbonated beverages, and more specifically sugar-sweetened carbonated beverages. It may be assumed that other sugar-sweetened beverages, such as cordials and sweetened fruit drinks, which are consumed more regularly by young children, would have a similar impact on energy and nutrient intake. However, sugar-sweetened carbonated beverages and electrolyte drinks are usually singled out for specific attention because they are well identified products, which are readily available, marketed aggressively to teenagers, and make the largest overall contribution to the beverage intake of children. While it is widely reported that children consume too much soft drink, lack of continuous nutrition monitoring makes it difficult to provide accurate current data. Information on soft-drink consumption is available from a variety of sources using different dietary assessment methods and thus needs to be interpreted in different ways. However, the various sources of data are reasonably consistent in relation to the quantity of soft drinks consumed. A recent phone survey by Food Standards Australia and New Zealand found that 78% of all 12–17 year olds had consumed soft drink in the previous week,2 while the 1995 National Nutrition Survey found that around half of all teenagers and a surprising 26% of 2–3 year olds had consumed soft drink during the previous 24 hours. Boys tended to consume more soft drink than girls, with boys aged 16–18 years drinking an average of 480 mL each day (or 836 mL per day among those who consumed soft drink), double the consumption of girls of that age (unpublished data from the 1995 National Nutrition Survey recalculated by us to include soft drinks only. Complete data in National Nutrition Survey: foods eaten, Australia, 19953). This was equivalent to 5.5% of the average total energy consumed by 16–18 year olds or 10.8% of the energy intake of the consumers. Apparent consumption data from the Australian Bureau of Statistics, as well as industry data, suggest that the intake of soft drinks in Australia has grown rapidly in the past 30 years from around 47.3 L per person per year in 1969 to 113 L per person (children and adults) in 1999.4 While this is some way below the per capita consumption of 200 L per year in the United States, it does put Australia within the top 10 countries for consumption and represents a market of around $1.6 billion per year.5 There is reasonable evidence that a high intake of soft drinks is associated with a greater risk of weight gain and obesity. A number of US studies show a strong cross-sectional association between soft-drink consumption and excess energy intake in adolescence,6,7 and NZ children who drank soft drinks more than once a day also were found to have a significantly higher mean body mass index (BMI) than children drinking soft drinks less than once a week, even after controlling for other known risk factors for weight gain.8 Longitudinal studies provide stronger evidence of a role for soft drinks in weight gain in children, with a large observational study of 10 000 children showing a consistent relationship between consumption of sugar-added beverages and weight gain over a 2-year period.7 A smaller 19-month study of 548 children aged 11 years found that both initial consumption and increases in intake levels of soft drink were associated with increased BMI and risk of obesity.9 A 10-week feeding trial found that when overweight adults were given a supplement of sucrose, mostly in the form of soft drink, they gained on average 1.6 kg, while a control group fed an artificially sweetened supplement lost 1.0 kg.10 The low satiating properties of energy-rich fluids compared with solids has been proposed as a possible reason for the close association between energy from soft drinks and weight status.11 Only a few studies have examined the effect on weight status of interventions aimed at reducing energy intake from sugar-sweetened soft drinks. These studies support the potential of such action, while leaving many questions unanswered about how best to achieve the desired outcomes. A school-based intervention that encouraged children (7–11 years old) to reduce their intake of “fizzy” drinks was able to achieve within 1 year a significant reduction in overweight and obesity in the intervention group compared with the control group, although the design and statistical analysis of this study have been criticised. The evidence linking soft-drink consumption to weight gain and obesity, while not complete, is consistent and strong enough to support action. Soft drinks are consumed in large amounts by young people in Australia and thus the calls for curbing intake appear to be justified. As soft drinks have been linked to other health concerns such as dental disease and, moreover, provide no valuable nutrition (apart from fluids), there is potentially much to be gained by reducing the intake of these (and other) sugar-sweetened beverages by Australian children and little (except excess weight) to be lost.

Timothy P Gill PhD GradDipDiet · Anna M Rangan PhD, GradDipNutrDiet · Karen L Webb MPH, PhD

Objective: To determine the psychological wellbeing of sole mothers in Australia.Design: Cross-sectional analyses of survey data from The Australian Longitudinal Study on Women’s Health.Participants: 9689 younger women (aged 22–27 years) surveyed in 2000 and 12 338 mid-age women (aged 47–52 years) surveyed in 1998.Main outcome measures: Demographic characteristics and economic status; prevalence of suicidal thoughts, self-harm, and psychoactive medication use; depression (Center for Epidemiologic Studies Depression Scale) and psychological health (the Mental Health Component Score of the Medical Outcome Short Form Health Survey [SF-36]).Results: Among the younger women, sole mothers were more likely than other women to have experienced suicidal thoughts (odds ratio [OR], 2.18; 95% CI, 1.45–3.27) and self-harm (OR, 3.25; 95% CI, 1.97–5.38). Among the younger and mid-age women, sole mothers were the group most likely to have used medication for depression (ORs, 2.75 [95% CI, 1.76–4.30] and 2.29 [95% CI, 1.56–3.37], respectively). They were more than twice as likely to have experienced depression, and had significantly poorer psychological health (P < 0.001). After adjusting for economic status, only depression and psychological health remained significantly associated with sole motherhood, and the strength of these relationships was reduced.Conclusions: Economic status partly accounts for the relatively poorer psychological health of sole mothers. Sole mothers are more likely than other women to experience debilitating psychological health problems.

Deborah Loxton PhD, BPsych(Hons) · Rosemary Mooney BA(Hons) · Anne F Young PhD, AStat

Objective: To describe the management of and outcomes in a population-based cohort of patients with newly diagnosed glioma.Design, setting and patients: Retrospective cohort study of patients with glioma newly diagnosed over the period 1998–2000 in Victoria. Patients were identified from the population-based Victorian Cancer Registry (VCR). Doctors involved in managing the patients were surveyed by a questionnaire sent out in 2003. The cohort was followed until the end of 2004 to obtain at least 4 years’ follow-up data on all patients.Main outcome measures: Reported treatment, referral patterns and survival rates.Results: Over the study period, 992 cases of glioma were identified; 828 completed surveys on eligible patients were obtained (response rate, 93%); 473 patients (57%) had glioblastoma multiforme (GBM); 105 patients (13%) diagnosed with “glioma” had had no histological confirmation. Complete macroscopic resection was performed in 209 patients (25%); 612 patients (74%) were referred for radiotherapy and 326 (54%) for chemotherapy; 39 (5%) were enrolled on a clinical trial. Median survival was 9.2 months for all patients and 7.4 months for patients with GBM.Conclusions: This is the largest reported glioma management survey in the world to date. Much of the patient demographics and approach to treatment were as expected and represent a reasonable “standard of care”. However, there are some areas for improvement, including the absence of histological diagnosis in some patients, lack of multidisciplinary care, low clinical trial enrolment and poor use of ancillary services.

Mark A Rosenthal MB BS, FRACP, PhD · Katharine J Drummond MB BS, FRACS · Michael Dally MB BS, FRANZCR · Michael Murphy MB BS, FRACS, MD · Lawrence Cher MB BS, FRACP · David Ashley MB BS, FRACP, PhD · Vicky Thursfield BSc, GradDipAppl Stats · Graham G Giles MSc, PhD

Objective: To assess maternal concern about overweight in Australian preschool-aged children and factors predicting maternal concern about children’s current and future weight status.Design: Cross-sectional survey of child’s body mass index and parent questionnaire. Setting: Participants: A community-based cohort of 324 4-year-old children and their parents.Main outcome measures: Mothers’ reports of concern about the child’s current and future weight status, and perceptions of the child’s weight, diet and activity relative to their peers were compared with the child’s measured weight status, and parent and child characteristics.Results: The prevalence of overweight or obesity was 19%, but only 5% of mothers indicated concern about their child being currently overweight, while 16% worried their child would become overweight. Over 70% of mothers of overweight children saw them as being of similar weight to their peers. Most mothers saw their children as being equally or more active than other children and having a diet at least as healthy as their peers. Overweight daughters were more likely to elicit maternal concern about current weight than overweight sons (relative risk, 4.6; 95% CI, 1.1–19.8). Mothers were more likely to worry about their child’s potential for future overweight if they or the child’s father were overweight.Conclusions: Despite mounting public concern about childhood obesity in Australia, most mothers surveyed were not concerned about their child’s weight, and many mothers did not perceive their overweight children as different from their peers. This may have implications for interventions that rely on acknowledgement of child overweight as a first step to change.

Michele W-C Campbell FRACP · Joanne Williams PhD · Anne Hampton BSc, PGradDipPsych · Melissa Wake FRACP, MD

Objective: To describe the implementation of a nurse-led preoperative cataract assessment and postoperative care clinic and to assess the safety, efficacy and outcomes.Design, setting and participants: A prospective study involving 185 public patients (221 eyes) referred to the Department of Ophthalmology at Flinders Medical Centre for cataract surgery. The study was conducted between February 2003 and August 2004.Interventions: Patients were assessed in the nurse-led preoperative assessment clinic. Those deemed suitable for cataract surgery were also assessed by an ophthalmologist and underwent cataract surgery if appropriate. The nurse managed postoperative care.Main outcome measures: Concordance between nurse practitioner and ophthalmologist assessments; waiting times for first clinic appointment and surgery; visual acuity and degree of visual disability; patient satisfaction.Results: 114 patients (61.6%) were assigned to see the ophthalmologist for cataract surgery. Median waiting times fell from 115 days (range, 23–268 days) to 21 days (range, 9–43 days) for initial clinic appointment, and from 44 days (range, 5–148 days) to 29 days (range, 14–154 days) for surgery. All 114 patients were listed for cataract surgery, and surgery had been performed on 121 eyes by the end of the study. After surgery, visual acuity improved by a mean of 0.45 logMAR (logarithm of the minimal angle of resolution) (SD, 0.24; range, 0.08–1.32). All patients had improved visual ability and high levels of satisfaction. Three quality assurance evaluations demonstrated full concordance between nurse and ophthalmologist assessments.Conclusions: Implementing a nurse-led cataract assessment clinic improved access to care for public patients with cataracts. The safety and efficacy of the program and its excellent visual and patient-centred outcomes commend its adaptation and implementation to other ophthalmology departments.

Bradley J Kirkwood MA · Konrad Pesudovs PhD · Paul Latimer FRCOphth · Douglas J Coster FRANZCO, AO

Objective: To report on strategies for, and outcomes of, evaluation of knowledge (publications), health and wealth (commercial) gains from medical research funded by the Australian Government through the National Health and Medical Research Council (NHMRC).Design and methods: End-of-grant reports submitted by researchers within 6 months of completion of NHMRC funded project grants which terminated in 2003 were used to capture self-reported publication number, health and wealth gains. Self-reported gains were also examined in retrospective surveys of grants completed in 1992 and 1997 and awards primarily supporting people (“people awards”) held between 1992 and 2002.Results: The response rate for the 1992 sample was too low for meaningful analysis. The mean number of publications per grant in the basic biomedical, clinical and health services research areas was very similar in 1997 and 2003. The publication output for population health was somewhat higher in the 2003 than in the 1997 analysis. For grants completed in 1997, 24% (31/131) affected clinical practice; 14% (18/131) public health practice; 9% (12/131) health policy; and 41% (54/131) had commercial potential with 20% (26/131) resulting in patents. Most respondents (89%) agreed that NHMRC people awards improved their career prospects. Interpretation is limited by the relatively low response rates (50% or less).Conclusions: A mechanism has been developed for ongoing assessment of NHMRC funded research. This process will improve accountability to the community and to government, and refine current funding mechanisms to most efficiently deliver health and economic returns for Australia.

for the National Health and Medical Research Council Evaluations and Outcomes Working Committee

Rheumatoid arthritis is associated with an increase in cardiovascular mortality and morbidity; this increase is independent of traditional cardiovascular risk factors. Effective treatment of rheumatoid arthritis with disease-modifying antirheumatic drugs appears to reduce cardiovascular mortality. The optimal approach to prevention of cardiovascular disease in rheumatoid arthritis is evolving, but will include a combination of: cardiovascular risk factor screening and management; effective and sustained control of joint and systemic inflammation; and a high index of suspicion for silent cardiac disease.

Sharon Van Doornum FRACP, GradDipClinEpi, MD · Garry L R Jennings MD, FRCP, FRACP, FAHA · Ian P Wicks

A 90-year-old woman was admitted with acute vomiting for the previous 24 hours and acute, diffuse, intense abdominal pain. Her medical history included atrial fibrillation and hysterectomy. Clinical examination revealed a generally distended, tender, tympanic and silent abdomen. Blood pressure was 98/54 mmHg; her pulse was irregular at 67 beats per minute. A plain x-ray of the abdomen revealed bowel distension without air–fluid levels. A computed tomography scan of the abdomen showed the presence of gas in the portal venous system (Box 1) and the intestinal wall (Box 2). At laparotomy, 142 cm of necrotic ileum was removed. The postoperative course was uneventful, and the patient was discharged 1 month later. The precise mechanism for formation of gas in the portal venous system is uncertain.1 The primary factors that favour this development are intestinal wall alterations, bowel distension and intra-abdominal sepsis.1 In many cases, two or three of these circumstances may coexist. In 15% of cases, the cause of air in the portal venous system remains unknown.1 Several conditions, such as perforated ulcer, interventional procedures, trauma, and infectious or inflammatory abdominal diseases, but most commonly intestinal ischaemia (as in our patient), can cause alterations of the gastric and bowel wall, permitting the passage of intraluminal gas into the portal venous system.1-3 Gas from the intestinal lumen passes through the intestinal wall and travels via the small mesenteric veins and the superior or inferior mesenteric vein to the portal venous system. Further, the presence of gas simultaneously in the portal venous system and intestinal wall seems to be specific to intestinal ischemia.4 Because hypotension was moderate and usual in our patient, we believe that the intestinal ischaemia was secondary to embolic disease related to atrial fibrillation. This case also demonstrates that portal venous system gas formation does not necessarily imply a worse prognosis and that surgery may be beneficial in the presence of this sign.1,5 Abdominal computed tomography scan with contrast showing air in the portal venous system (1) and intestinal wall (2).

Ali Mofredj MD · Harry Toledano MD · Richard Boutboul MD

As shared responsibility agreements between Indigenous communities and the Australian Government become more prevalent, where their goal is health improvement we need to consider whether the rewards and obligatory behaviours are acceptable, whether communities have real freedom of choice, whether the arrangements can be implemented and evaluated, and whether they will improve health. The Howard Government’s New arrangements in Indigenous Affairs have seen 76 shared responsibility agreements (SRAs) signed between leaders of 64 Indigenous communities and the Australian Government.1 The first SRA publicised, in December 2004, entailed community leaders in Mulan in the East Kimberly ensuring that children were given showers daily in return for funding for a new petrol bowser and health programs. The main rationale for the agreement presented in the media was improving child health, particularly reducing the incidence of trachoma.2 The near-silence of health commentators on this issue was, thankfully, broken last year by Collard and colleagues in this Journal.3 These authors questioned the morality of the government in placing conditions on the provision of basic rights to Indigenous communities. However, behind both the government’s enthusiasm and Collard et al’s criticism lie enduring public health dilemmas. Below, I present five questions that may help readers consider these issues as they relate to the Mulan SRA in particular, and to incentives and obligations in general. But first, we need a working definition. In the context of health, let us say that “mutual obligation” means obligating people to adopt healthy behaviours in return for a reward. While the Mulan agreement incorporated a number of obligations and rewards (see Box), here I focus on the obligation of parents and children to maintain hygienic behaviours and the reward of a petrol bowser. The key questions presented here refer only to obligations placed on communities, rather than on governments. Furthermore, for the purposes of this discussion, it is assumed that community members are in a position to fulfil the obligations (for example, they have access to a functioning water supply). Is the reward acceptable?For many, this question hinges on the distinction between a right and a privilege. Is it the right of a small, isolated community to be provided with a petrol bowser by the government, or is it a privilege? Most would agree that it is unfair to offer something as a reward if it is a human or civil right, such as the provision of health care. If it is a privilege, however, it may be considered acceptable to use it as an incentive. This distinction is highlighted by “no school, no pool” programs (in which children who do not attend school may not use the community pool), which share features with mutual obligation arrangements, and also use improved child health as their rationale.4 There has been no prominent criticism of the government providing swimming pools to remote communities conditionally, perhaps because swimming pools are seen as a privilege, not a right. In making these judgements, the special status of Indigenous peoples must be taken into account. Their historical status as Australia’s first peoples, their current position of extreme social disadvantage, and their cultural distinctiveness all mean that the government has special responsibilities towards them.5 For instance, if it is shown that swimming pools hold long-term benefits for child health, it may be argued that they should be provided to remote communities as part of their right to health-promoting infrastructure. Is the obligatory behaviour acceptable?Is it acceptable to ask parents to ensure their children are clean? Some people would consider it an intrusion into the family unit, an affront to personal autonomy, or dangerously close to the paternalism of the assimilation era. Others would argue that the grave situation of child health means that we should explore any approach that can improve it, including addressing basic health behaviours such as hygiene. The issue of who is obliging the behaviour is clearly important. If it can be shown that the community itself wants to dictate the behaviour of community members, there may be less basis for concern. For instance, when community councils enact alcohol restrictions, obliging people not to drink, they are celebrated by many as effective public health interventions.6 Is it acceptable that people adopt the behaviour in order to obtain the reward?Public health science has long wrestled with the problem of changing behaviour, including whether and when education, incentives or compulsion are the best strategies.7 Economic incentives and disincentives for healthy behaviour are generally acceptable in some forms, such as taxes on tobacco and alcohol, and health insurance rebates for spending on healthy activities such as gym membership and yoga classes. The question is whether it is acceptable for people to adopt healthy behaviours in order to obtain the reward (a petrol bowser or saving money), or whether sustainable behaviour change must stem from genuine belief in the related health benefits. This question is partly one of effectiveness: some argue that once a behaviour is adopted it becomes habitual, regardless of why the behaviour was adopted, while others question this reasoning.8 But the question is also one of ethics: is the reward an inappropriate inducement, despite the “healthiness” of the obligation? This relates to the issue of autonomy I now turn to. Do communities freely choose to participate?This is the key issue for Collard and colleagues,3 and others for whom community autonomy and self-determination are central concerns. They suggest that the Mulan community was not “well placed to judge whether the benefit they will get from a petrol bowser will be worth the ‘price’ they have agreed to pay”,3 implying an element of exploitation or coercion in the government’s approach. The proponents of the agreements, however, argue they enhance community autonomy by allowing the community to deal directly with government, rather than through intermediaries in multiple bureaucracies.9 Some would consider that the substantial power difference between a small, isolated Aboriginal community and the Australian Government means that a community can never freely participate, even if community representatives truly believe they are making an autonomous choice. Others think that to dismiss the choices communities make as “false” is paternalistic.10 Can the arrangement be implemented?It is concerning that there are no formal evaluative mechanisms built into SRAs, as there are numerous questions surrounding the implementation of these agreements. How would the cleanliness of children be assessed? Would the government take the bowser away if people stopped showering their children? If one family in the community didn’t comply, would they be barred from using the bowser? These are but a few of the immediate questions that would need to be addressed in the implementation of the Mulan SRA — questions that remain unanswered. Will it improve health?The public health literature indicates that incentives and obligations that promote healthy behaviours have a role in improving health.7 The lack of attention to the implementation and evaluation of these agreements on the government’s part suggests that they, at least, are not taking the potential health benefits seriously. A more serious approach to the potential health benefits of SRAs would employ public health expertise and an evidence-based approach. For instance, face-washing programs need to be integrated with screening and treatment programs and environmental health programs to have maximum impact on trachoma rates.11 It is also difficult to judge how genuinely Indigenous communities themselves are engaging with the health-related obligations of SRAs. A pessimistic view might be that, to access much-needed resources, communities are agreeing to obligations they have no intention or ability to meet. This may have the inadvertent effect of focusing the public health gaze on individual behaviours and distracting us from necessary structural change. An optimistic view would welcome the opportunity for community leaders to voice their concerns about health and adopt novel health promotion approaches, in a similar vein to alcohol restrictions and “no school, no pool” policies. There may also be potential to use the agreements to hold the government accountable for the provision of basic infrastructure and services necessary for good health. The political reality of SRAs is complex and fraught. However, the current focus on incentives and obligations provides an opportunity to reflect on the variety of methods available for practising public health, and the factors that may affect the application of SRAs in Indigenous contexts. Draft agreement between the government and the residents of Mulan Government The federal government will contribute $172 000 for the installation of fuel bowsers at Mulan. The Government of Western Australia will undertake to “monitor and review” the adequacy of health services in an area where trachoma rates are “arguably the worst in the world”. Mulan Aboriginal Community The residents will: Ensure children shower daily and wash their faces twice a day; Ensure rubbish bins are at every house and are emptied twice weekly through the local work-for-the-dole scheme; Undertake household pest control four times a year; and Act to prevent petrol sniffing. Families and individuals will also make sure children attend school, crêche and the health clinic; and they will keep their homes clean and pay rents (to ensure the local council can afford pest control and repairs like plumbing). Source: Collard, et al. Med J Aust 2005; 182: 502.3

Emma Kowal MB BS, BA(Hons)

Middle lobe syndrome — recurrent atelectasis and/or bronchiectasis involving the right middle lobe and/or lingula — has, up to now, not been reported as the pulmonary manifestation of primary Sjögren’s syndrome. We describe a patient in whom lymphocytic bronchiolitis in the atelectatic lobes was proved histologically from two separate transbronchial biopsies. The atelectasis responded well to glucocorticoid treatment, suggesting that the peribronchiolar lymphocytic infiltrates may have played an important role in the development of middle lobe syndrome in this patient. Clinical record A 53-year-old woman was admitted to our hospital in 2003 with symptoms, for the past 3 days, of shortness of breath, cough, and blood-tinged sputum. Primary Sjögren’s syndrome had been diagnosed in 2002, based on the presence of xerostomia, keratoconjunctivitis sicca, anti-Ro/La antibody, and rheumatoid factor, as well as a positive Schirmer’s test and the results of sialoscintigraphy. The patient had no prior history of smoking, fever, rhinitis or pharyngitis. Physical examination was unremarkable, except for a rapid respiratory rate (20 breaths/min) and coarse crackles heard during the early inspiratory phase in the middle lung field. A complete blood count, C-reactive protein levels, erythrocyte sedimentation rate, and the results of serum biochemistry were all within normal limits. A chest x-ray revealed a vague opacity in the right lower lung that obliterated the cardiac border in the posteroanterior view, and a wedge-shaped density in the cardiac area in the lateral projection (Box, A). Sputum studies for bacteria, mycobacteria and fungi, and serological tests for Mycoplasma pneumoniae and Legionella pneumophila all gave negative results. A computed tomography (CT) scan of the chest showed inhomogeneous opacities, as well as dilated airways crowded in the medial segment of the right middle lobe and inferior segment of the lingula, without mediastinal lymphadenopathy (Box, B). A fibrobronchoscopic examination to verify central bronchial patency showed no intraluminal obstruction in the affected bronchi. Cultures of the lavaged bronchial fluid were negative for tuberculosis and other microorganisms, and no malignant cells were found in aspirated specimens. A transbronchial biopsy from the atelectatic middle lobe revealed lymphocytic bronchiolitis with a moderate degree of mononuclear cell infiltration, predominantly by lymphocytes, in the terminal bronchiolar walls and adjacent interstitial areas, and no granuloma formation (Box, C). A diagnosis of middle lobe syndrome secondary to Sjögren’s syndrome was made and the patient was initially treated with methylprednisolone (125 mg/day for 4 days), followed by prednisolone (20 mg/day). The glucocorticoid dose was tapered off as the atelectatic lesions resolved. A repeat CT scan performed 1 year later showed that the atelectatic lesions had almost completely disappeared with this treatment (Box, D). Subsequently, the prednisolone dose was ceased. In 2005, atelectasis developed once again in the lingula. Malignancy and infection were excluded after extensive studies, including cytological examination, virus isolation, and bacterial and mycobacterial cultures from the endobronchial aspirates. Pulmonary tissue, obtained from the atelectatic lingula by biopsy, again showed evidence of lymphocytic bronchiolitis. With the use of medium-dose prednisolone (20 mg daily), the atelectasis gradually resolved. At the time of writing, there has been no further relapse in this patient. DiscussionMiddle lobe syndrome is a disorder of recurrent or fixed atelectasis involving the right middle lobe and/or lingula.1-3 It can result from either extraluminal or intraluminal bronchial obstruction, but also may develop in the presence of a patent lobar bronchus without identifiable obstruction.1-3 Inflammatory processes and defects in the bronchial anatomy and collateral ventilation have been designated as the non-obstructive causes of middle lobe syndrome.1-3 Middle lobe syndrome is commonly associated with many underlying lung conditions, such as neoplasms, asthma, broncholithiasis, microbial infections, granulomatous disorders, mucous plugging, or foreign body aspiration.1,2 It has, up to now, not been reported in patients with primary Sjögren’s syndrome, although similar radiological findings have been described in a patient with systemic lupus erythematosus with suspected secondary Sjögren’s syndrome.4 Primary Sjögren’s syndrome is a chronic inflammatory autoimmune disease characterised by lymphocytic infiltrations in the involved organs. This disorder predominantly affects the salivary and lacrimal glands, but can also involve internal organs resulting in many extraglandular complications.5 A wide spectrum of pulmonary manifestations has been described, including xerotrachea, obstructive airway disease, interstitial lung disease, and lymphoproliferative disease.6 With pulmonary involvement in primary Sjögren’s syndrome, the inflammation can be focal and predominantly cellular, with lymphocytes infiltrating the small airway walls.7,8 Local bronchial or bronchiolar lymphocyte infiltrates and inflammatory cell products may lead to impairment of tracheobronchial mucociliary clearance.8,9 In our patient, lymphocytic infiltrations in the terminal bronchioles were found in the atelectasis of the right middle lobe and lingula. The atelectatic and bronchiectatic lesions seen on the chest CT scan resolved after immunosuppressive drug treatment. Lymphocytic bronchiolitis with underlying bronchiectasis has also been described in patients with non-obstructive middle lobe syndrome. Our findings suggest that the peribronchiolar lymphocytic infiltrates may have been involved in the pathogenesis of the middle lobe syndrome in our patient. Lymphocytic bronchiolitis is common in primary Sjögren’s syndrome, but pulmonary atelectasis, as in our patient, is fairly rare.6,10,11 Therefore, mechanisms other than impaired mucociliary function and lymphocytic bronchiolitis may also have contributed to the development of this disorder. The right middle lobe bronchus is at higher risk of obstruction from inflammatory processes, as it has a relatively narrow diameter and an angular attachment to the intermediate bronchus. Compared with other areas of the lung, the middle lobe and lingula have a large ratio of pleural to non-pleural surface because of the presence of deep fissures, which are effective barriers to the collateral ventilation.,3 These anatomical features may thus predispose to the formation and persistence of atelectasis. Immunosuppressive drugs, either azathioprine alone or in combination with prednisolone, are effective in treating the pulmonary complications of primary Sjögren’s syndrome.7 In our patient, the lymphocytic bronchiolitis-associated atelectasis resolved after prednisolone therapy, but relapsed when the drug was ceased. Therefore, we think that immunosuppressive drugs, such as glucocorticoids, should be considered in this unusual pulmonary complication of primary Sjögren’s syndrome. Tapering of the dose must be gradual to avoid disease recurrence, and a long follow-up period is necessary. Box A A: Lateral chest radiograph showing a wedge-shaped dense area (arrows) with the apex pointing to the hilum. Box B B: Computed tomography scan of the lung showing atelectasis and bronchiectasis in the medial segment of the right middle lobe (arrow) and the inferior segment of the lingula (arrowhead). No pulmonary fibrosis or space-occupying lesion was observed elsewhere. Box C C: Lung tissue from a transbronchial biopsy revealing lymphocytic infiltrations in the terminal bronchiole (arrow) and adjacent interstitial area (arrowhead) (haematoxylin?eosin stain, original magnification, × 100). Box D D: Computed tomography (CT) scan performed 1 year after the first CT scan, showing almost complete resolution of the atelectatic lesions (arrow and arrowheads).

Horng-An Chen MD · Shinn-Liang Lai MD · Wei-Kang Kwang MD · Juhn-Cherng Liu MD · Chun-Hsiung Chen MD · De-Feng Huang MD

Sports participation among children is declining. Sport and physical activity are important in childhood for optimising bone mass and reducing obesity and insulin resistance. Physical activity reduces cardiovascular risk factors in adults, and can improve survival in patients with cardiac failure. Musculoskeletal injury is the most common complication of sports participation in adults — not cardiac events. Some of the decline in function which occurs with ageing can be positively affected by regular physical activity.

Carolyn R Broderick MB BS, FACSP, GDSSc · Gregory J Winter FACSP, FRACGP, MSpMed · Roger M Allan FRACP, FCSANZ, FACC

Noel McK Bennett Infectious Diseases Physician, Victorian Department of Human Services, 14A Marquis Street, Ashburton, VIC 3147. bennettnATbigpond.net.au To the Editor: In a recent issue of the Journal, Chew et al described a woman from Vietnam with skin nodules that, on histological examination, showed lobular panniculitis with granulomatous inflammation.1 No mycobacteria were visible and a polymerase chain reaction test for Mycobacterium tuberculosis was negative. Two months after starting quadruple antituberculous therapy (including rifampicin), her lesions had resolved. Erythema induratum (ostensibly due to hypersensitivity to M. tuberculosis) was diagnosed, despite the absence of evidence of tuberculosis. Other possible diagnoses were considered, but leprosy was not mentioned. In regions of Australia where leprosy is not endemic, the disease is frequently overlooked.2 Birrell3 described a man from Malta with recurring skin lumps. Biopsy showed panniculitis with giant cells, and the man was initially misdiagnosed as having “Weber–Christian syndrome” or “relapsing febrile non-suppurative nodular panniculitis”. Soon after, another Maltese patient presented similarly. This time, leprosy was suggested, and a biopsy revealed the presence of Mycobacterium leprae.4 Re-examination of slides from the first case showed similar organisms, confirming leprosy.5 The patients described by Chew et al and Birrell had migrated from countries in which leprosy was endemic, and biopsies revealed granulomatous panniculitis. Weber–Christian syndrome and erythema induratum are rare, ill-defined conditions with confused aetiologies, and both lack a specific diagnostic test. Therefore, cases of leprosy can be easily misdiagnosed as one of these conditions. That the biopsy in this patient did not show visible M. leprae is against a diagnosis of leprosy. But in my experience, even in lepromatous (multibacillary) disease, occasionally a skin smear of a lesion or (more rarely) a biopsy specimen may fail to reveal bacilli. Of course, this would be likely if the patient had received specific treatment for leprosy previously. Respectfully, I suggest that Chew et al should attempt to exclude lepromatous leprosy in their patient by looking for possible missed stigmata of leprosy, enquiring whether she has ever been treated for leprosy, asking whether any close acquaintances have had the infection or a chronic skin condition, and following up the patient in the long term.

Noel McK Bennett

James B Muir Dermatologist, Southeast Dermatology, 1202 Creek Road, Carina Heights, QLD 4152. arnoldmuirAToptusnet.com.au To the Editor: One of the Journal’s recent Lessons from Practice illustrates common errors in the approach to dermatological conditions.1 As in all areas of medicine, an accurate diagnosis is crucial to the management of any skin disease. This is especially so if a medical practitioner institutes treatments, such as oral steroids, that have considerable potential for causing morbidity. The lessons I would draw from the case of erythema induratum described are as follows. If you suspect an unusual presentation of a common condition, perform investigations to confirm your suspicions. Although erythema nodosum classically occurs on the anterior lower leg, lesions above the knee may occasionally be seen. To make a diagnosis, investigations need to be appropriate. The battery of blood tests ordered in the case described would not have shed light on the pathological process occurring in the skin. There is a reluctance among the general medical community to perform skin biopsies. These procedures cause little morbidity, have a high diagnostic yield, and should be within the skill set of any medical graduate. Concern over causing a scar is often cited as a reason for not doing a biopsy. But, in my experience, patients are rarely worried about such a prospect. Missing the diagnosis is surely of much greater concern. Taking a simple biopsy, including fat, at the initial presentation would have saved the patient in question a lot of trouble and risk. If there is no response to your treatment, it may well be that the initial diagnosis was incorrect. For example, it is common to see “steroid-resistant eczema” that is actually intraepidermal carcinoma. Erythema nodosum will usually show at least some response to non-steroidal anti-inflammatory treatment. Lack of response to a treatment that usually works should lead to a re-evaluation of the diagnosis. Systemic steroids should not be used for a dermatological condition without a firm diagnosis. Firstly, they can suppress many of the clinical and histological changes that allow a diagnosis to be made. Appropriate investigations need to be done before starting steroids. Secondly, a drug like prednisolone may well make matters worse, especially if, as here, there is an infectious aetiology. Patients from areas in which tuberculosis is endemic should have this condition excluded before being given systemic steroids. A lack of obvious exposure to or symptoms of tuberculosis is not unusual in patients from such areas who are subsequently shown to harbour this infection. The authors state that, as erythema induratum can resolve with corticosteroid treatment, this can lead to an erroneous diagnosis of erythema nodosum. Using response to treatment as a quasi-diagnostic test is dangerous indeed. Steroids will cause many conditions associated with significant inflammation to improve or even appear to resolve. But this does not mean that there is no infectious or malignant aetiology.

James B Muir

Gary Y Chew,* Christopher Henderson,† John W Quin‡ * Registrar, ‡ Director of Clinical Immunology, Department of Immunology, Liverpool Hospital, Bigge Park Centre, PO Box 103, Liverpool, NSW 2170; † Anatomical Pathologist, South Western Sydney Area Health Service, Liverpool, NSW. john.quinATswsahs.nsw.gov.au In reply: We thank Bennett and Muir for their pertinent comments. Our patient did not have any history or clinical evidence of lepromatous leprosy. The skin biopsy did not reveal any dermal granulomatous involvement, and there were definitely no organisms seen on an auramine stain of the biopsy specimen. Subcutaneous involvement in leprosy is uncommon except in erythema nodosum leprosum or as a neurotropic phenomenon. When present, it tends to be a neutrophil-rich hypersensitivity necrotising vasculitis — no features of which were seen in this case. Neither the woman’s partner nor child had a chronic skin condition or clinical history of leprosy or tuberculosis. Furthermore, the patient has been followed up for 12 months, with no recurrence of the rash. We agree with Muir that an accurate diagnosis is crucial to managing any skin disease and that there were many lessons to be gathered from this case apart from the five points we listed. It is our usual practice not to begin definitive treatment until we have examined a skin biopsy of any suspicious lesion and made a diagnosis. As this patient was very concerned about getting a scar, we did not perform a skin biopsy initially, but informed her that we may need to do so if the condition did not respond to treatment. We agree that patients from areas where tuberculosis is endemic should have tuberculosis excluded before instituting systemic steroid treatment. In this case, the patient was given a chest x-ray by the appropriate authorities before her migration to Australia. She has not returned to Vietnam since then. Furthermore, the patient had failed a trial of a non-steroidal anti-inflammatory drug and found the lesions cosmetically distressing. Consequently corticosteroids were instituted.

Gary Y Chew · Christopher Henderson · John W Quin

Mu Li,* Kay V Waite,† Gary Ma,‡ Creswell J Eastman§ * Senior Lecturer, School of Public Health, University of Sydney, Sydney, NSW 2006; † Technical Officer, ‡ Principal Scientist, § Director, Australian Centre for Control of Iodine Deficiency Disorders, ICPMR, Westmead Hospital, Sydney. muliAThealth.usyd.edu.au To the Editor: Iodine is essential for production of thyroid hormone. The recommended daily intake is 100 μg for children, 150 μg for adults and 250 μg for pregnant and lactating women.1 Sporadic surveys of population iodine intake in Sydney, New South Wales, between 1985 and 1992 showed median levels of urinary iodine excretion (UIE) > 200 μg/L, indicating iodine sufficiency.2 However, a recent national study demonstrated mild iodine deficiency (median UIE < 100 μg/L) in New South Wales and Victoria, borderline levels in South Australia and adequate intake in Queensland and Western Australia.3 The major sources of dietary iodine are dairy milk and dairy products, seafood and iodised salt. In Australia, few people purchase iodised salt, and, except in Tasmania, the food industry does not use iodised salt in the production and preparation of food.4 For decades, milk contaminated with iodine residues from sanitising solutions (iodophors) used in the dairy industry has probably been the largest source of iodine in the Australian diet. We undertook a survey of the iodine content of milk samples from supermarkets around metropolitan Sydney in 2001 and 2004. In each year, iodine levels were measured in 13 samples, comprising a range of milk types (including whole, full cream, lite and skim) and brands (including Dairy Farmers, Devondale, Farmdale, Farmland, Perfection, Pura and Woolworths). Iodine concentrations were highly variable. Median concentrations were 140 μg/L in 2001 (range, 60–220 μg/L) and 195 μg/L in 2004 (range, 66–412 μg/L). Iodine concentrations varied between samples of the same brand and type by up to 100 μg/L. Many samples contained less than 200 μg/L (10/13 in 2001 and 7/13 in 2004). A 1975 survey of iodine concentration in milk conducted by the Australian Consumers’ Association found mean concentrations of 593.5 μg/L and 583 μg/L in NSW and Victoria, respectively.5 Because of concerns about iodine toxicity, Food Standards Australia and New Zealand specified an iodine limit of 500 μg/L in the Food Standards Code 1982. The replacement of iodophors by other sanitisers in the dairy industry appears to be the reason for the decrease in iodine content of Sydney milk. The perception that milk is a rich source of iodine is no longer true. A cup (250 mL) of milk a day would provide at most 50–60 μg iodine, approximating a third of the daily requirement for an adult. We suggest that the reduced amount of iodine in milk is likely to be one of the explanations for the re-emergence of iodine deficiency in Sydney and perhaps elsewhere in Australia. Despite these changes, dairy milk remains an important source of dietary iodine. The iodine content in milk should be monitored.

Mu Li · Kay V Waite · Gary Ma · Creswell J Eastman

Carol Breeze,* Caroline M de Costa,† Mark Jagusch‡ * Senior Registrar, † Professor, Department of Obstetrics and Gynaecology, James Cook University School of Medicine; ‡ Director of Pathology, Cairns Base Hospital, PO Box 902, Cairns QLD 4870. caroline.decostaATjcu.edu.au To the Editor: The incidence of cervical cancer in Far North Queensland (FNQ) is 10 times the national average and the mortality rate five times greater.1,2 Of the Australian states, Queensland has the lowest average rate of regular cervical screening (57% of eligible women), and in some FNQ communities rates of less than 40% have been reported. Cairns Base Hospital (CBH) provides all public colposcopy services in Cairns and throughout Cape York for a population that is largely rural, remote and transient. In 2004, through the outpatients department of CBH, 12 new cases of invasive cancer were diagnosed (with additional advanced cases admitted directly to the surgical services). None of these women had undergone cervical screening in the previous 4 years. We conducted a three-part study at CBH: a 3-month retrospective study (Feb–Apr 2004) and a 3-month prospective study (Oct–Dec 2004) comparing cytological reports with histological results, and a further study (Oct–Dec 2004) of women who were referred for colposcopy but failed to attend. In the retrospective study, of 43 new patients with a cytology report of low-grade epithelial abnormality (LGEA) who had histology performed, 19 (44%) had a histological diagnosis of a high-grade epithelial abnormality (HGEA). (“Low-grade cytology” was defined in the 1994 National Health and Medical Research Council [NHMRC] guidelines3 as two consecutive “atypical” smears or one smear reported as cervical intraepithelial neoplasia [CIN 1], with or without the presence of human papilloma virus. CIN 2 or CIN 3 were defined as “high-grade” abnormalities.) In the prospective study, of 40 women with a cytology report of LGEA, 13 (33%) had HGEA on histopathology. Although our numbers were small, the incidence of histologically confirmed HGEA in patients presenting with LGEA on cytology appeared to be higher than the 24.5% reported by the Queensland Pap Smear Registry in 2000 for Queensland as a whole.4 Our colposcopy attendance study showed that, of 341 women referred for colposcopy over a 3-month period, 106 (31%) failed to attend scheduled appointments. Non-attenders included 27 Indigenous women, 10 women living only transiently in the area and 40 women living in remote areas. Thirty per cent of newly referred women and 32% of follow-up patients failed to attend, despite prolonged efforts by doctors, nurses and social workers to persuade them to do so (Box). (These proportions are substantially higher than those reported in clinics in large urban centres.5) Under previous NHMRC guidelines, women with reports of CIN 1 were immediately referred for colposcopy.3 However, under the recently adopted guidelines, such women are required to have at least one further smear 12 months later and demonstrate ongoing abnormality before referral.6 This policy assumes a stable, informed, compliant population with well motivated patients able to return for long-term follow-up. It also requires a reliable, non-labour-intensive system to track down non-attenders. In the FNQ region, with limited health care personnel, a population scattered over a huge area and patients often non-compliant (for many reasons, including social, financial, geographic and educational factors), we feel that the latest NHMRC policy is likely to be counterproductive, with the women most at risk possibly slipping through the net. We believe that in FNQ, and possibly in other rural areas where the incidence of cervical cancer is high, it may be appropriate to adapt the new national guidelines and continue with policies for managing LGEA that are more akin to the former guidelines. Breakdown of patients who failed to attend for colposcopy, by last-recorded cytology/histopathology results LGEA or less Possible HGEA HGEA Total number of non-attenders Newly referred patients (n = 157) 27 3 17 47 (30%) Follow-up patients (n = 184) 44 0 15 59 (32%) HGEA = high-grade epithelial abnormality. LGEA = low-grade epithelial abnormality.

Carol Breeze · Caroline M de Costa · Mark Jagusch

Simon R Brice,* Marie V Pirotta† * Honorary Research Fellow, † Senior Lecturer, Department of General Practice, University of Melbourne, 200 Berkeley Street, Carlton, VIC 3053. chiro_6AThotmail.com To the Editor: During a recent year-long Primary Health Care Research, Evaluation and Development (PHCRED) research fellowship, we encountered all the usual barriers to undertaking good research (funding, time, etc). While privacy legislation has been reported to adversely affect research,1,2 we were unprepared for the time and cost of dealing with the Health Insurance Commission (HIC — now “Medicare Australia”). Our research involved mailing a survey to Victorian general practitioners. For approved research, the HIC supplies a valuable service in providing representative datasets of randomly selected GPs. This was once a quick and relatively inexpensive process — a boon when conducting research with limited funding. Being the first within our department to use this service since the new privacy laws were introduced, we struck unexpected administrative and financial barriers. To maintain anonymity of potential respondents, research materials (ie, surveys and plain language statements) must be mailed by the HIC. So, all items must first be forwarded to the HIC, from where they are remailed to respondents. This process raises a number of hurdles: materials need to be approved (and altered if required) by the “Privacy” department at the HIC, despite prior approval from a duly constituted university ethics committee; there is a limit of two reminder mail-outs (usual protocols for maximising response rates require up to four mail-outs, and inadequate response rates may render research findings unrepresentative and therefore useless); and each mail-out is sent with the same HIC covering letter. Additional requirements lead to an increase in costs — sending envelopes, surveys and plain language statements in bulk to Canberra (numerous times), printing HIC covering letters, and charges for “preparing business rules, extraction specifications, project manage processes to completion . . .”. The list goes on. We were also charged for extraction of the same dataset again for mailing the reminder letter, as more than 2 weeks had elapsed since the original data extraction. Finally, there is the added time. We estimated this to be around 4 weeks, which is detrimental in a limited fellowship position. While the people we dealt with at the HIC were helpful and professional, the time and expense were almost overwhelming. We respect the need to protect the privacy of research participants. However, the “side effects” of applying the new privacy laws are having an adverse impact on primary health care research. Let this be a friendly warning to all those about to set off down the research path — excessive red tape is no longer the exclusive domain of practitioners.

Simon R Brice · Marie V Pirotta

Kari A J Jarvinen,* Bradley J McCall,† Clare B Nourse,‡ Joe G McCormack,§ Martyn H Tilse¶ * Senior Public Health Registrar, † Public Health Medical Officer, Communicable Disease Control, Brisbane Southside Public Health Unit, 39 Kessels Road, Coopers Plains, QLD 4108; ‡ Paediatric Infectious Diseases Physician, § Director of Infectious Diseases, ¶ Director of Microbiology, Mater Health Services, South Brisbane, QLD. kari_jarvinenAThealth.qld.gov.au To the Editor: Pertussis continues to be a significant public health problem in Australia. Children aged under 1 year are most at risk from severe, life-threatening complications from the disease.1 Traditionally, erythromycin has been the drug of choice for treatment of cases and prophylaxis in selected contacts. However, its use in neonates is known to carry a risk of infantile hypertrophic pyloric stenosis.1,2 Its propensity to cause QT prolongation and ventricular arrhythmias is also well described.2,3 Both azithromycin and clarithromycin have been recently recommended as suitable alternatives for management of pertussis.2,4 The US Centres for Disease Control now regard azithromycin as the agent of choice for neonates less than 1 month of age.1 There is evidence suggesting azithromycin has less pro-arrhythmic potential than erythromycin or clarithromycin.5,6 Azithromycin does not interact significantly with the hepatic cytochrome P450 system and has less potential for significant drug interactions than other macrolide antibiotics.3,5,6 Azithromycin and clarithromycin also require less frequent administration (1–2 doses per day) and shorter treatment regimens (5–7 days) than erythromycin. In Australia, roxithromycin is the most widely prescribed macrolide antibiotic. However, there are no clinical studies on its effectiveness in pertussis, and in-vitro sensitivity studies suggest it may be inferior to erythromycin. Thus, roxithromycin cannot be recommended in pertussis.4 Updated versions of Australian antibiotic guidelines to be released later this year will recommend azithromycin for pertussis treatment and prophylaxis. However, access to azithromycin for this purpose in Australia is currently limited by the restrictions placed on prescribing through the Pharmaceutical Benefits Scheme (PBS). Azithromycin is currently approved for Chlamydia trachomatis urethritis, cervicitis and trachoma. Pertussis is an approved indication only for the use of 500 mg tablets under the Repatriation PBS. This restriction has important implications for the effective and safe management of pertussis in Australia. Widespread use of newer macrolides in the community is not advisable because of the propensity of macrolides to induce antibiotic resistance, and their greater cost. However, for pertussis infection, Australians need to be able to access agents such as azithromycin. PBS restrictions for this indication need to be revised, for both tablet and liquid formulations.

Kari A J Jarvinen · Bradley J McCall · Clare B Nourse · Joe G McCormack · Martyn H Tilse

Michael Guy Duke Psychiatrist, Family Counselling Service, Victorian Aboriginal Health Service, 279 High Street, Northcote, VIC 3070. mmgdukeATbigpond.net.au To the Editor: Rey seems to me to have struck upon the ideal solution for the 20% of Australians who suffer from the various mental illnesses.1 Daniel Defoe (The shortest way with dissenters) would doubtless have approved. There is ample European precedent in the idea of a “ship of fools”. The solution, as Rey says, is to ship everyone diagnosed with a mental illness to a Pacific island. This would solve many problems at a stroke. The population of Australia would be reduced by 20% (and this would be continually improved as more cases develop), thus freeing resources for proper healthy Australians. Thoroughly screened (for mental illnesses) refugees and asylum seekers would easily enter the depleted urban centres. General practices would have a reduction of more than 40% of patients, as we all know this is roughly the percentage of people presenting with primarily mental health problems. No more crisis with general practitioner numbers. Hospitals would have a similar reduction of cases. No more shortages of hospital beds. Single vehicle traffic fatalities would surely reduce, if alcohol and other drug-dependent people were to be included under the umbrella of one of the mental illnesses. I envisage a whole fleet of Tampas flowing back and forth to the Pacific nations, ferrying more than 4 million psychiatric emigrants to their proper places in the world.

Michael Guy Duke

Andrew J A Holland,* Frank I Ross,† Patricia Manglick,‡ Fiona E Fahy,§ Daniel T Cass¶ * Associate Professor of Paediatric Surgery and Urology, † Clinical Nurse Consultant, ‡ Scientific Officer, § Clinical Nurse Consultant, ¶ William Dunlop Professor of Paediatric Surgery and Director of Trauma, Department of Academic Surgery, The Children's Hospital at Westmead, University of Sydney, Locked Bay 4001, Westmead, NSW 2145. andrewh3ATchw.edu.au To the Editor: Several studies from Australasia and North America have identified that in up to 24% of children with pedestrian motor vehicle injuries (MVIs) the event occurred in a driveway.1-4 Earlier work from our centre in Sydney and others in Auckland, New Zealand, highlighted prevention as the most effective method for reducing the morbidity and mortality associated with this unique mechanism of injury.2,3,5 With ethics committee approval, we prospectively reviewed injury circumstances in children under 16 years of age presenting with a driveway MVI to our institution over a 3-year period between June 2002 and May 2005. Of 36 children injured in 35 separate driveway MVIs, 26 caregivers agreed to an interview and scene visit. Fifteen patients (58%) were male, with a mean age of 48 months. The majority of events occurred in western and south-western Sydney — a paediatric population centre — in the afternoon (18; 69%) and on a weekday (19; 73%), with a trend for greater frequency at the beginning and end of the working week. In all but two cases, the injury occurred at the child’s home, which was owned by the parents in 13 cases (50%; with a mean occupation period, 47 months) and rented in 10 (38%; mean occupation period, 22 months). The majority of homes (22; 85%) had no separation between the dwelling, external play areas and the driveway. Even when a separation was present, this had been circumvented. Sedans were the most common vehicle involved (18; 69%), with the remainder four-wheel drives (4WDs) or light commercial vehicles, and 22 (85%) were reversing. The vehicle was driven by an adult known to the child in 21 cases, but in four the vehicle was inadvertently set in motion by another child. Box 1 reports parental perception of contributing factors and Box 2 lists injuries sustained, with 23 (89%) children receiving injuries severe enough to warrant hospital admission. There were no deaths. This review indicates that driveway MVIs persist as a common and potentially fatal problem for children in New South Wales, with at least one child injured every month.2 Following our previous study published in 2000, and findings of the NSW Child Death Review Team, campaigns by the Motor Accidents Authority of NSW and others have focused on driveway safety, particularly for young children. This review suggests that further intervention is needed to reduce the frequency of these injuries, either through enhanced application of present strategies or the development of more effective, novel approaches. 1 Parental perception of factors contributing to their child sustaining pedestrian motor vehicle injuries in the driveway Lack of supervision 15 Child playing in parked car 5 Children’s behaviour around cars 5 Negligent driving 2 Excessive speed 2 Hand brake not applied 1 Front house door left open 1 Hurrying when leaving home 1 2 Injuries identified in children sustaining pedestrian motor vehicle injuries in the driveway Head and neck Skull fracture 1 Intracranial haematoma 1 Concussion 2 Retropharyngeal haematoma 1 Torso Hepatic contusion 1 Adrenal haematoma 1 Haemopneumothorax 1 Multiple rib fractures 1 Pelvic fracture 1 Major soft tissue injury 1 Limb Fractures 2 Burns Full thickness 4 Partial thickness 3 Major soft tissue injury 1 Minor soft tissue injury 17

Andrew J A Holland · Frank I Ross · Patricia Manglick · Fiona E Fahy · Daniel T Cass

Neville R Blomeley President, Sports Doctors Australia, and Medical Director, Optima Sports Medicine, 6/66 Station Road, Indooroopilly, QLD 4068. drnbauscareindATbigpond.com Comment: I would like to draw readers’ attention to a very enthusiastic and active group of sports medicine practitioners that was not mentioned in the editorial by Orchard and Brukner,1 which introduced the Sports Medicine Practice Essentials series. Sports Doctors Australia comprises general practitioners and others from areas such as orthopaedics, rehabilitation, accident and emergency, and sports dentistry. Virtually all fellows of Sports Doctors Australia (SDrA) have obtained a postgraduate degree in sports medicine from an Australian university (most commonly a masters degree from the University of New South Wales). We are committed to delivering excellent care in all areas of sports medicine to the general public as well as to elite athletes. Because of our wider background in general medicine, we are in an ideal position to provide overall care to teams and individual athletes. Many of our fellows are, or have been, very successful team doctors for national teams. A number of fellows are active in clinical research and have academic appointments with university medical schools. Our main aim is not to obtain specialist status (as it is for members of the Australasian College of Sports Physicians), but to provide excellence in sports medicine care for athletes at all levels, and to provide sports medicine education to other doctors, medical students and the general public.

Neville R Blomeley

Garry J Walter Professor of Child and Adolescent Psychiatry, Coral Tree Family Service, University of Sydney, PO Box 142, North Ryde, NSW 1670. gwalterATmail.usyd.edu.au To the Editor: I read with interest Brooks’ letter on the value of professorial titles.1 It is not only in academic circles that the subject sometimes arouses passions. A short while ago, my wife had reason to speak sternly to our two young children. Losing the plot, my daughter replied, “What would you know, mum? You’re not a professor.” At that moment in this household, as I found myself slinking towards my study, the status of a professorial title — at least in my wife’s eyes — amounted to very little.

Garry J Walter

Christina V T Ng Specialist and Lecturer — Medical Oncology, Department of Medicine, University Malaya Medical Centre, Jalan Universiti, Lembah Pantai, Kuala Lumpur, 59100, Malaysia. christinavtngAThotmail.com To the Editor: I would like to clarify several issues pertaining to the case report published in the 7 February 2005 issue of the Journal.1 The patient reported was under the care of Dr Craig Underhill and Dr Kerrie Clarke, who are medical oncologists at Albury Base Hospital, Albury, New South Wales. Their contribution to the reporting of this rare and interesting case must be acknowledged. I regret any misconceptions arising from this article, and I would like to thank Dr Underhill and Dr Clarke for their support and professionalism.

Christina V T Ng

The beginner’s guide to winning the Nobel Prize. A life in science. Peter Doherty. Melbourne: Melbourne University Publishing, 2005 (304 pp). ISBN 0 522 85120 7. Nobel laureates are particularly prone to publishing their memoirs and sharing their wisdom. Examples include James Watson’s The double helix: a personal account of the discovery of the structure of DNA and Macfarlane Burnet’s Changing patterns: an atypical autobiography. The latest addition to this passing parade is Peter Doherty’s The beginner’s guide to winning the Nobel Prize. The title stimulated me, but it may deter other readers. Doherty and Rolf Zinkernagel won the Nobel Prize in Physiology or Medicine in 1996. The book has many themes: selected autobiographical details; forays into the history of the science of medicine; the story of the progress of immunology in the 20th century and the many Nobel Prizes gained along the way; the immunological research that won Doherty and Zinkernagel the Nobel Prize; the human aspects of the modern research enterprise and its culture; and the people and areas of research that are contenders for future Nobel Prizes. More accessible topics are Doherty’s views on science and religion, politics and the media, and the importance for a nation’s economy of supporting the research enterprise. All these topics are embellished with Doherty’s wisdom and wit. The book’s encyclopaedic coverage is both its strength and its weakness. Its continuity is broken at times by poorly placed and unnecessary diversions. Despite this, I persisted, in pursuit of the advice promised in the book’s title. Ultimately, the answer was revealed, but you will have to read the book yourself for the revelation. It is difficult to know to whom to recommend the book. It could be for anyone, from the curious citizen to the young scientist wanting to become street-smart for his or her journey to Stockholm and the Nobel Prize. Martin B Van Der WeydenEditor, The Medical Journal of Australia

Martin B Van Der Weyden

Looking at saw palmetto Saw palmetto, a widely used herbal preparation, may be no more effective than placebo in reducing the symptoms of benign prostatic hyperplasia (BPH), according to a US study. Bent and colleagues conducted a year-long, randomised controlled double-blind study in 225 men, aged over 49 years of age, with moderate-to-severe symptoms of BPH, comparing the effects of a saw palmetto extract (160 mg twice a day) with placebo. Both placebo and saw palmetto led to a similar small, clinically insignificant reduction in lower urinary tract symptoms. The researchers could not address the possibility of whether the level of active ingredient in the extract used was insufficient in this study as this ingredient, if it exists, has not been identified. N Engl J Med 2006; 354: 557-566 Keeping track of diabetes According to New York City’s Health Commissioner, Thomas Frieden, diabetes is the only major health problem in the US that is getting worse, and getting worse rapidly. About 9% of New York adults have been diagnosed with diabetes; in the South Bronx the figure is even higher — 18%. However, it is not known how many have poorly controlled diabetes or who cares for them. Frieden has previously said that the city’s local public health infrastructure had not kept pace with the transition in common causes of death over the last century from communicable to non-communicable diseases. Now, in an effort to “get a better handle” on the situation, the Big Apple has introduced novel, mandatory electronic reporting of glycosylated haemoglobin values by laboratories to the city’s Department of Health and Mental Hygiene. The test results and other identifying information will be confidential. The department hopes to use this registry data to implement and evaluate a pilot intervention program in the South Bronx. N Engl J Med 2006; 354: 545-548 Bugged mobile phones Health care workers’ mobile phones could pose an infection risk, say UK researchers. Brady and colleagues swabbed more than 100 mobile phones carried by doctors and nursing staff at one district general hospital. On culture, most of the phones demonstrated bacterial contamination, with swabs from about one in five phones growing three or more different species. Of concern, swabs from 15 of the phones sampled grew bacteria known to cause nosocomial infection, including methicillin-resistant Staphylococcus aureus. The researchers say that the potential of mobile phones to spread infection is an important argument to consider when debating whether restrictions on mobile phone use in hospitals should be relaxed. J Hosp Infect 2006; 62: 123-125 Chronic work stress linked to the metabolic syndrome Do you have job strain — that is, does your job have high demands, with little that can be controlled, and no support? If so, you may be at increased risk of developing the metabolic syndrome. UK researchers measured work stress on four separate occasions over 14 years in more than 10 000 London-based civil servants. They also determined who had developed metabolic syndrome by the end of follow-up, and found a dose-response relationship existed between work stress and the risk of metabolic syndrome. Civil servants with chronic work stress (ie, three or more exposures to work stress) were more than twice as likely to have developed the metabolic syndrome than those without work stress. BMJ Online First, 14 Feb 2006 Moving movies Emotions evoked by watching a movie can affect endothelial function, say US researchers. Impaired endothelial function may contribute to an increased risk of coronary heart disease. The researchers asked 20 healthy adult volunteers to watch at least part of a 15-30 minute segment of two movies, one designed to induce mental stress (eg, the opening scene of Saving Private Ryan) and the other to induce laughter (eg, There’s something about Mary). Subjects were instructed to watch each movie segment until they felt they had been affected by viewing it. The researchers found that the subjects’ average brachial artery flow mediated endothelial dependent vasodilatation (FMD) was increased 22% by laughter and reduced 35% by mental stress. The overall difference in brachial artery FMD between the mental stress and laughter phases exceeded 50%. The mechanism responsible for this effect is not, as yet, known. Heart 2006; 92: 261-262 Lupus: a salvage solution Patients with severe systemic lupus erythematosus that is refractory to all drug treatments may benefit from a salvage regimen which involves autologous haemopoietic stem cell transplantation (HSCT) in addition to immunosuppressive agents. US authors reported a series of 50 such patients with organ- or life-threatening visceral involvement who were treated with cyclophosphamide, anti-thymocyte globulin and autologous HSCT. Disease-free survival at 5 years was 50%; the longest continuous duration of remission has been 7.5 years. The stem cell infusion shortens the duration of cyclophosphamide-induced neutropenia and thus decreases the risk of infection. JAMA 2006; 295: 527-535

Ann Gregory