Volume 187 Issue 8

New technologies are often widely available to drivers before their safety can be evaluated In recent years, the availability of technological devices that can potentially be used while driving has expanded rapidly. One device that has received particular attention due to concern about driver distraction is the mobile phone. In this issue of the Journal, Taylor et al report on the use of handheld mobile phones by drivers in metropolitan Melbourne (→ Handheld mobile telephone use among Melbourne drivers).1 This observational study, which follows up research conducted by the same investigators in 2002, indicates that drivers continued to use handheld phones 4 years later, despite legislative and enforcement practices that prohibit their use and evidence that such use increases the risk of having a crash. On the other hand, the rate of use has remained steady even though mobile phone ownership has increased. Mobile phones are just one of a number of devices that may distract a driver. These technologies may be driving-related (eg, satellite navigation and intelligent speed adaptation [ISA] systems), or non-driving-related (eg, iPods, personal digital assistants and wireless email). Driving-related technologies seek to enhance drivers’ mobility and/or safety while non-driving related technologies do not. However, if poorly designed or used inappropriately, both types of technologies have the potential to compromise road safety. Aside from distraction, safety issues include: poor understanding of system operation; negative behavioural adaptation (drivers potentially taking more risks because their cars are fitted with additional safety equipment); system misuse; and increased driver workload. Thus, research is required to evaluate the safety implications of any device that can be used while driving. Apart from mobile phones, little is known about the proportion of Australian drivers who use driving-related and non-driving-related technologies and how frequently the technologies are used while driving. One survey conducted in late 2003 found that use of personal organisers and email was very low (0.3%) during a specified driving trip,2 but did not collect information on the availability and use of novel driving-related technologies. How the use of non-driving-related technologies affects driving performance is under investigation. To date, most research has involved the use of driving simulators. Studies have examined the use of mobile phones, stereo equipment and speech-based email systems, and have shown driving impairment.3-5 Epidemiological studies of the risk of crash relating to the use of devices other than mobile phones are currently lacking. Indeed, the rapid change in non-driving-related technologies means that road safety research can lag behind uptake of these devices by the driving public. In relation to driving-related technologies, early research is showing promise in enhancing safety, though much work remains to be done. A large field trial of ISA systems in Sweden involving over 10 000 drivers using about 5000 fitted vehicles demonstrated reductions in the mean speeds travelled.6 In Australia, the Transport Accident Commission (TAC) SafeCar project, which evaluated four driving-related technologies (ISA, following distance warning [FDW], seatbelt reminder [SR], and reverse collision warning) among 15 drivers using specially equipped vehicles, found positive effects for the ISA, FDW and SR systems.7 Recently, a naturalistic driving method has been developed in which drivers are videorecorded during their everyday driving.8 Multiple views are taken, including the driver, console, and the vehicle’s forward, rear and lateral views. The data can then be used to quantify drivers’ exposure to and interaction with technological devices while driving, and to estimate the risk (or benefit) associated with the use of these technologies. In addition to current research, a large naturalistic driving study to evaluate the safety of technological devices used in vehicles should be conducted in Australia. This will provide locally relevant data to inform the design of these technologies. Periodic surveys to monitor trends in the use of technological devices while driving are also indicated. The impact of driver distraction in all its forms (technological and non-technological) is considerable. Australian studies have shown that drivers commonly engage in distracting activities while driving, and that distraction is a contributing factor in 14%–21% of crashes;2,9 these figures are even higher among inexperienced drivers. In response, passenger restrictions and a ban on all mobile phone use (including hands-free) were introduced for novice drivers in New South Wales and Queensland in July 2007 as part of their graduated driver licensing systems. In Victoria, the TAC has recently launched a driver distraction media campaign to raise awareness,10 and a complete ban on mobile phone use while driving for novice drivers will be enacted in July 2008. Considerable gains have been made in the area of road safety in Australia in the past 30 years. If we are to maintain and improve on these gains, then managing the risks and benefits of technologies that can be used while driving will be critical. If certain driving-related devices are found to benefit road safety, then their uptake should be facilitated. Means to achieve this include regulatory requirements to ensure that new vehicles are fitted with the technology, that drivers are educated about the correct use and benefits of the technology, and that the technology is installed in vehicle fleets. Conversely, any technologies found to be unsafe will require measures to limit their use while driving. Car manufacturers and portable device developers will need to consider the potential for design improvements or the use of appropriate warnings.

Suzanne P McEvoy FAFPHM, MAppEpid, PhD

Withdrawal of government funding may force the closure of this invaluable resource General practice remains the cornerstone of Australia’s health services. About 85% of the population sees a general practitioner at least once in any year.1 Last financial year, that amounted to 103 million general practice services, at a cost to Medicare of $4 billion.2 Over the past decade, the Bettering the Evaluation and Care of Health (BEACH) program has provided a unique insight into these clinical encounters between GPs and their patients. BEACH tells us about the patients that GPs see, the problems that are encountered, and the treatment provided. The BEACH program is a continuous national study of general practice activity in Australia. Indeed, it is the only such study in the world. To date, it includes details of 900 000 encounters between GPs and patients. Every year another 100 000 encounters from a random, ever-changing sample of 1000 GPs are added. The strength of the BEACH data lies first in its sheer sample size, and second in that it provides a reliable, continuous measure of changes in general practice since 1998. Since that time, there have been a number of important changes to Medicare and a raft of new programs and initiatives to help GPs better manage their patients. These include financial incentives to boost bulk-billing, reimbursement for services provided by practice nurses, practice and service incentive payments for the management of patients with asthma and diabetes and for the provision of immunisations and cervical cancer screening tests, and new Medicare items to encourage GPs to work with allied health professionals to provide coordinated care for patients with complex and chronic health problems. Other factors have also intervened in the relationship between GPs and their patients. The GP workforce is increasingly older, has a higher proportion of women, and is looking to work fewer hours.3 At the same time there’s a growing shortage of GPs, especially outside metropolitan areas.4 Their patients are also ageing and beset by chronic illnesses such as heart disease, diabetes, arthritis, depression, and chronic obstructive airway disease. Many struggle to afford the out-of-pocket costs associated with their care, which have grown by 50% over the past decade.5 The push is on to get GPs to encourage their patients to exercise more and smoke less, to prescribe fewer diagnostic tests and medications, to talk to their patients for longer, to enquire about their use of alternative and complementary therapies, and to inform them about the use of generic medicines. This pressure is coming from government,6 professional bodies,7 the National Prescribing Service,8 and patients themselves.9 The BEACH data can be mined for information about all these issues and many more. It provides the only independent source of data about doctors’ prescribing practices, including how many prescriptions are for medicines not listed on the Pharmaceutical Benefits Scheme (PBS). The Pharmaceutical Benefits Pricing Authority uses calculations from the BEACH data to estimate the average monthly treatment cost of each PBS-listed medicine and then adjusts the price that the government pays the manufacturer. All this work is done by a small group of workers at the Australian General Practice Statistics and Classification Centre, a collaborating unit of the University of Sydney and the Australian Institute of Health and Welfare. It is done on a miniscule budget, which in the current financial year amounts to just $1.3 million. Now the Centre is under threat of closure because the Australian Government will not commit to ongoing financial support. The government’s contribution is just 23% of the BEACH budget (the remainder comes from a variety of public and private sources), but without the certainty of these funds for the 2008–09 financial year and beyond, the Centre must make the decision in November to close up shop. The amount involved is insignificant in the grand scheme of health expenditure — $300 000 a year — a sum so small that it is not itemised in the Australian Government Department of Health and Ageing budget, but is paid from the departmental expenses budget. Medical groups and academics have expressed concern that policy should be made and evaluated based on appropriate data, but the Department of Health and Ageing has signalled that it is no longer in the business of general practice research.10 Those who care about health policy and its impact understand the consequences if BEACH ceases to exist. Yet this rich and informative history of general practice activity is at risk because the Australian Government, in its short-sightedness, cannot make the 4-year commitment of $1.5 million that will ensure its future. The loss of BEACH will be a national shame.

Lesley Russell BSc(Hons), BA, PhD · Stephen R Leeder MB BS, MD, PhD

Objective: To evaluate change in handheld mobile telephone (mobile) use among motor vehicle drivers between 2002 and 2006.Design and setting: Observational study of motor vehicle drivers at three times (10:00–11:00; 14:00–15:00; 17:00–18:00) on three consecutive Tuesdays in October 2006 at 12 highway sites in metropolitan Melbourne.Main outcome measures: Rates of handheld mobile use overall and by the sex and age of drivers, highway site (major metropolitan road, central business district, freeway exit ramp) and time of day.Results: In 2002, 315 of 17 023, and in 2006, 331 of 20 207 drivers were observed using handheld mobiles. This represented a non-significant rate decrease from 18.5 to 16.3 users/1000 drivers (rate difference, 2.1 users/1000 drivers; 95% CI, − 0.6 to 4.8; P = 0.07). Unlike 2002, the rate of handheld mobile use among men in 2006 was significantly higher than for women (rate difference, 3.7 mobiles/1000 drivers; 95% CI, 0.1–7.3; P = 0.03). In both 2002 and 2006, mobile use was most common in the central business district. In 2002, there was significantly more mobile use in the evening, while in 2006, the evening rate was significantly lower than the morning rate (rate difference, 4.3; 95% CI, − 0.1 to 8.7; P = 0.03) and slightly lower than the afternoon rate (rate difference, 3.0; 95% CI, − 1.1 to 7.1; P = 0.08). The effect of age remained unchanged between 2002 and 2006, with older drivers using mobiles least (P < 0.001).Conclusion: The number of drivers at risk from handheld mobile phone use remains almost unchanged. However, a slight reduction in the rate of use overall and variations in use among driver subgroups are apparent. Policing and public awareness campaigns need to further address this preventable risk of injury.

David McD Taylor MD, MPH, FACEM · Catherine E MacBean BA(Hons) · Atandrila Das · Reizal Mohd Rosli

Objective: Design and setting: Analysis of national surveillance system data for 1993–2006.Main outcome measures: Number and population rate of new HIV diagnoses by year, exposure route and demographic characteristics.Results: Between 1993 and 2006, 12 313 new diagnoses of HIV infection were reported in Australia. From 1993 to 1999, the annual number of diagnoses declined by 32% from 1056 to 718, and then increased by 31% from 763 in 2000 to 998 in 2006. Between 2000 and 2006, diagnosis rates significantly increased in Victoria, Queensland, South Australia and Western Australia. The most frequent route of HIV exposure was male-to-male sex, accounting for 70% of diagnoses. Heterosexual contact accounted for 18% of cases, with just over half of these people born in or having a sexual partner from a high-prevalence country. Exposure by injecting drug use remained infrequent.Conclusions: The number of HIV diagnoses has risen in the past 7 years, but not in New South Wales, which has long had the highest rates. The differences in rates between states/territories are likely to be due to divergent trends in sexual risk behaviour in men having male-to-male sex, which remains the predominant route of HIV transmission in Australia. There is a need for effective, innovative and evidence-based programs for HIV prevention, particularly among men having male-to-male sex.

Rebecca J Guy BAppSc, MAppEpid · Ann M McDonald BSc, MPH · Mark J Bartlett RGN, MPH, MAppEpi · Jo C Murray RN, GradDipNursing · Carolien M Giele RN, DipClinEpi, MPH · Therese M Davey DipHealthCounselling, DipClinEpi · Ranil D Appuhamy BSc, MB ChB, MIntPH · Peter Knibbs RN, DipAppSci(Nursing) · David Coleman BSc(Hons), DipAppSci · Margaret E Hellard FRACP, FAPHM, PhD · Andrew E Grulich MB BS, PhD, FAFPHM · John M Kaldor PhD

Objective: To examine whether television news and current affairs coverage of overweight and obesity frames obesity in ways that support or oppose efforts to combat obesity.Design and setting: A content and framing analysis of a structured sample of 50 television news and current affairs items about overweight and obesity broadcast by five free-to-air television channels in New South Wales between 2 May and 31 October 2005.Main outcome measures: Dominant discourses about causes of overweight and obesity; proposed solutions and location of responsibility for the problem; the age-group focus of television items; the relative prominence of stakeholders; and the aspects of obesity which attract news attention.Results: Most television items (72%) framed obesity as a problem of poor nutrition. Obesity was largely seen as the responsibility of individuals (66% of items). Just over half of news items (52%) focused only on adults while 26% focused only on children. Obesity was framed largely as a problem to be solved by individual nutritional changes, exercise and surgical and medical interventions.Conclusions: While individual lifestyle is crucial to controlling weight, the research community now recognises the importance of sociocultural and environmental factors as drivers of the obesity epidemic. However, television news portrays obesity largely as an individual problem with individual solutions centred mostly on nutrition. Media emphasis on personal responsibility and diet may detract attention from the sociopolitical and structural changes needed to tackle overweight and obesity at a population level.

Catriona M F Bonfiglioli BA(Hons), PhD · Ben J Smith BSW(Hons), MPH, PhD · Lesley A King BScPsych(Hons), MPsych · Simon F Chapman BA(Hons), PhD · Simon J Holding BA

Objective: To highlight recent reductions in mortality rates in Australia and identify conditions and population groups with the greatest potential for further reduction in mortality rates.Design: International benchmarking and intranational comparisons of mortality rates were used to identify areas with the greatest potential for improvement.Results: Latest data from Organisation for Economic Cooperation and Development (OECD) countries confirm that, while Japan’s death rates remain the lowest in the world, Australia’s are decreasing rapidly and we now rival Switzerland for second overall ranking. When the contributions of specific conditions are compared, the areas with the greatest potential for reductions are circulatory diseases (especially ischaemic heart disease); suicide; injury and violence; smoking-related conditions; and cancers amenable to prevention/early detection. Intranational comparisons show considerable scope for reduction in inequalities, especially those between Aboriginal and Torres Strait Islander peoples and other Australians, between males and females, and between low and high socioeconomic groups. These conditions and inequalities are highly interrelated, as differentials in health status are often mediated through broader societal inequalities.Conclusions: Australia should aim to become the country with the lowest mortality rate in the world. This could realistically be achieved by benchmarking performance nationally and internationally, applying current knowledge and available interventions, matching policies with funding, and implementing systemic national programs and activities to promote health and prevent “illth”.

Ian T Ring MB BS, MSc(Stats/Epid), FAFPHM · John F O’Brien MHSc

Objective: To describe changes in delivery of preventive services among adults in Aboriginal communities that occurred in association with a systems-oriented intervention.Design, setting and participants: A quality improvement intervention with a 2-year follow-up was undertaken at 12 Aboriginal community health centres in the Northern Territory between January 2002 and December 2005. The study involved 360 well adults aged 16–49 years who had no known diagnosis of chronic disease.Intervention: Two annual cycles of assessment, feedback workshops, action planning, and implementation of system changes. Assessment included a structured review of health service systems and an audit of clinical records.Main outcome measures: Adherence to guideline-scheduled preventive services including taking basic measurements, laboratory investigations, lifestyle counselling and pneumococcal vaccination.Results: Of 12 preventive services measured, delivery of four services showed improvement over the study period: counselling on diet increased from 3% to 8% (P = 0.018); counselling on physical activity from 2% to 8% (P = 0.006); counselling on smoking from 2% to 11% (P = 0.003); and counselling on alcohol from 2% to 10% (P = 0.007). There was no improvement in important measures such as monitoring of waist circumference, blood pressure and blood glucose level, and delivery of pneumococcal vaccination.Conclusion: Our systems-oriented intervention was associated with some improvement in counselling activities, but no significant improvement in delivery of other preventive services. The main reason may be that implementation focused more on chronic illness management than preventive services for generally well adults.

Damin Si PhD · Ross S Bailie MB BS, MD · Michelle Dowden MPH · Lynette O’Donoghue BSc · Christine Connors MB BS, MPH · Gary W Robinson PhD · Joan Cunningham ScD · John R Condon PhD · Tarun S Weeramanthri PhD

Since publication of the Australasian Creatinine Consensus Working Group’s position statement in 2005, most Australasian laboratories now automatically report an estimated glomerular filtration rate (eGFR) (based on the Modification of Diet in Renal Disease [MDRD] formula) with results of serum creatinine tests in adults. Anecdotal evidence suggests that automatic reporting of eGFR helps to identify asymptomatic kidney dysfunction at an earlier stage and to develop rational and appropriate management plans. Changes to the measurement and calibration of serum creatinine assays and issues regarding implementation of eGFR in clinical practice led the Australasian Creatinine Consensus Working Group to reconvene in 2007. The recommendations contained here build on the original 2005 position statement and consolidate the role of eGFR in clinical practice. The Working Group recommends that the eGFR upper reporting limit be extended to 90 mL/min/1.73 m2, with eGFR values above this amount being reported as “> 90 mL/min/1.73 m2”, rather than as a precise figure. The Working Group has concluded that it is currently premature to recommend age-related decision points for eGFR. However, it is appropriate to advise medical practitioners that, in people aged ≥ 70 years, an eGFR in the range 45–59 mL/min/1.73 m2, if stable over time and unaccompanied by other evidence of kidney damage, may be interpreted as consistent with a typical eGFR for this age group and is unlikely to be associated with chronic kidney disease-related complications. Pending publication of validation studies, the Working Group recommends that Australasian laboratories continue to automatically report eGFR in Aboriginal and Torres Strait Islander peoples and other ethnic groups. The Working Group supports the use of eGFR to assist drug dosing decision making in general practice.

on behalf of the Australasian Creatinine Consensus Working Group

Clinical record A 34-year-old woman was diagnosed with grade III infiltrating ductal carcinoma of her left breast, and had a mastectomy. Reconstructive cosmetic surgery was subsequently performed, with placement of a fluid-filled silicone-encased breast implant in the left chest wall. She had previously been well with no known cardiac history. A nuclear medicine gated heart pool scan (GHPS) was performed before planned chemotherapy involving anthracycline. On the GHPS (Figure 1) a radiolucent pericardial halo was apparent, raising concerns for pericardial effusion. The rest of the study was unremarkable, with normal regional wall motion and quantitative ejection fraction of the cardiac ventricles. Comparison with a recent chest x-ray (Figure 2) revealed radiolucency external to the chest wall. Subsequent transthoracic echocardiography (Figure 3) ruled out the presence of pericardial effusion. 1: GHPS left anterior oblique 45° (1A) and anterior (1B) views. Pericardial halo suggestive of pericardial effusion (arrows). 2: Anterior–posterior chest x-ray showing the saline-filled breast implant as a radio-opaque shadow on the left anterior chest wall (arrows). 3: Two-dimensional echocardiogram. 3A: Subcostal views showing pericardial border anteriorly and posteriorly (arrows) without evidence of pericardial effusion. 3B: Subcostal view with the transducer directed anteriorly to image the saline-filled breast implant (arrow). 3C: Anterior chest wall imaging depicting the implant (arrows). Current national surveys estimate that up to 4 million women, or more than 3% of the adult female population in the United States, have breast implants.1 Of clinical importance, more than 35 000 women each year received breast implant surgery for reconstruction after a mastectomy,1 and most of these patients would have one or more gated heart pool scan (GHPS) studies for the assessment of cardiac function before chemotherapy. In Australia, the incidence of breast cancer has been steadily increasing since the early 1980s, and this is now the most common cancer among women. One in eight women will be diagnosed with breast cancer by the age of 85 years, with more than 13 000 new cases in 2006. In part because of improved and more aggressive treatment strategies, survival prospects following diagnosis continue to improve.2 The accompanying rise in the use of adjuvant chemotherapy, including the anthracyclines, has brought about a concomitant increase in the use of GHPS for monitoring drug-induced cardiac toxicity.3 Lessons from practice Gated heart pool scan (GHPS) studies are commonly used for monitoring drug-induced cardiac toxicity in cancer patients. Many female cancer patients will have breast implants, and these can mimic pericardial effusion on GHPS. Clinical input, chest x-ray and, if necessary, other imaging modalities such as two-dimensional echocardiography, computed tomography or magnetic resonance imaging, are prudent for confirmation of pericardial effusion on GHPS. GHPS was among the earliest imaging tools to be used for the diagnosis of pericardial effusion.2-7 In 1958, Rejali and colleagues,4 after observing the disparity in the size of the cardiac silhouette on radionuclide ventriculography and the chest x-rays, reported the clinical efficacy of radionuclide ventriculography in detecting pericardial effusion. Since the mid 1970s, because of its inherently higher spatial resolution, two-dimensional echocardiography has been the technique of choice for diagnosing pericardial disease in general and pericardial effusion in particular.8 Nevertheless, GHPS remains effective for diagnosing moderate to large pericardial effusion. A report in 1987 of 154 patients documented a high degree of sensitivity (100% for large and 55% for moderate to large effusions) and specificity (98%) by GHPS for diagnosing pericardial effusions.7 False-positive results may be due to benign and sinister aetiologies. Although some researchers have reported subepicardial fat as the most common cause of a false-positive finding of pericardial effusion by GHPS,9 others have documented mediastinal tumours, left ventricular hypertrophy or blood clot as some of the pathologies mimicking pericardial effusion on the GHPS.10,11 The high (98%) specificity previously reported used a set of criteria for moderate to large pericardial effusion,7 including the need for clear perceptibility of pericardial halo around all visible cardiac chambers in both the anterior and 45° left anterior oblique views of the GHPS. In the cancer population, however, the test specificity is anticipated to be lower because distortion and loculation of pericardial effusion is not uncommon.12 Test specificity is likely to be further degraded by the increasing number of women worldwide receiving breast implants for both cosmetic and postsurgical reconstruction purposes. Of clinical importance, extracardiac and intrathoracic pathologies, including pericardial effusion, found on GHPS by and large do not impede the interpretation of cardiac function (which is the principal indication for performing the test), and the incidental findings might even provide relevant diagnostic or prognostic information.13,14 Our case highlights, particularly among female cancer patients, the need for vigilance in assessment of GHPS with extracardiac findings suggestive of pericardial effusion, with breast implant posing as a differential diagnosis of potential false-positive findings. The use of clinical input, chest x-ray and, if necessary, other imaging modalities such as two-dimensional echocardiography, computed tomography or magnetic resonance imaging9 is prudent for confirmation of pericardial effusion on GHPS.

Kiran Swaraj MB BS, FRACP · Hosen Kiat MBBS, FRACP · Michael Lin MB BS, FRACP · Peter Lin MB BS, FRACP · Ivan Ho-Shon MB BS, FRACP · Sithoeun Sam BSc · John Chu MB BS, FRACP

A 16-year-old boy presented with rapidly progressive ascending paralysis 1 hour after eating raw salmon. Seafood poisoning was initially considered. Although salmon is not a common cause of toxic seafood poisoning, cases have been reported in the Pacific region. The patient rapidly developed acute left heart and respiratory failure, and investigations revealed a rare tracking intramedullary haematoma of the spinal cord. Structural abnormalities of the central nervous system may present with acute paralysis and spinal shock, mimicking toxicological syndromes. Clinical recordA 16-year-old boy presented to the emergency department with severe epigastric pain, headache and ascending lower limb weakness 1 hour after eating raw salmon. The weakness ascended rapidly over the next hour to involve the upper limbs. In hospital, he was alert, but was soft-voiced and in obvious respiratory distress. He had tachycardia (heart rate, 110 beats per min), hypertension (blood pressure, 205/128 mmHg), tachypnoea (22 breaths per min) and oxygen saturation of 89% (using a non-rebreathing oxygen mask). Although his sensation and mental state appeared normal, he had profound quadriparesis. Pupils were 3 mm in diameter, equal and sluggishly reactive to light. Because of a rapid deterioration in his respiratory status, the patient was intubated, ventilated, and sedated with a propofol infusion before a more complete neurological examination could be completed. The patient’s medical history included thalassaemia minor and a short viral illness 2 weeks previously. He denied using any regular medications or substance misuse. Initial chest radiography revealed clear lung fields, but, 10 minutes after intubation, pinkish frothy sputum was noted from the endotracheal tube, and there were widespread crackles. An urgent echocardiogram showed severe global hypokinesis with a left ventricular ejection fraction estimated as less than 30%. Laboratory tests revealed neutrophilia, but all other results of a full blood count, serum electrolyte concentrations, renal function, liver function tests and coagulation screen were normal. Serum creatine kinase and creatine kinase-MB concentrations were raised, and peaked the following day at 2716 U/L (reference range [RR], 30–135 U/L) and 10 μg/L (RR, < 0.7 μg/L), respectively, suggesting myocardial injury. An electrocardiogram showed sinus rhythm with voltage criteria for left ventricular hypertrophy, but no acute ischaemic changes. Provisional diagnosis at this stage was a neurological or toxicological aetiology. The fact that the patient’s mother also ate the salmon without becoming unwell counted against seafood poisoning but did not exclude it (eg, in puffer-fish poisoning, a specific part of the fish is most poisonous). To exclude a cervical lesion, magnetic resonance imaging (MRI) of the spine and brain was performed urgently, with the intention of proceeding to nerve conduction studies if MRI results were normal. The MRI showed an extensive intramedullary haemorrhage within the spinal cord, originating at the T7/T8 vertebral level, and extending from the conus caudally to the cervicomedullary junction rostrally (Box 1). The patient was managed supportively in the intensive care unit, with complete resolution of pulmonary oedema and normalisation of cardiac function by Day 3. A spinal angiogram confirmed the presence of an arteriovenous malformation arising from the anterior spinal cord at the T9 vertebral level. The malformation was excised the following week, and histopathological examination of the resection specimen confirmed the radiological diagnosis (Box 2). After 6 months of intensive rehabilitation, the patient had restored power in one arm, but remained paralysed below the T9 cord level. DiscussionInitially, this case represented a diagnostic challenge, with acute onset, rapidly progressive ascending paralysis associated with left ventricular failure, and a history of seafood ingestion. MRI gave the correct diagnosis, obviating the need for peripheral neurophysiological investigations. Useful clues to the diagnosis of myelopathy, such as sphincter dysfunction and the level of sensory loss, were difficult to assess because of the patient’s sudden cardiorespiratory deterioration. The initial differential diagnosis is summarised in Box 3. Toxicological considerationsPoisoning from ingested seafood is a global and increasing problem that should be considered in the emergency department. Seafood associated with medically important poisoning include puffer fish (fugu), ciguateric fish, several types of shellfish and mussels, as well as fish from the Scombridae family (eg, mackerel and tuna). Salmon is not known as a major cause of seafood toxin poisoning, although scombroid and ciguatera have been described after salmon ingestion.1-3 Tetrodotoxin from fugu fish causes a rapid descending paralysis and cardiovascular collapse in severe cases.4 Paralysis is uncommon in ciguatera, which is caused by a toxin produced by marine dinoflagellates.5 Paralytic shellfish poisoning is clinically similar to tetrodotoxin poisoning and typically causes a descending paralysis. Autonomic disturbance can also be a feature of marine neurotoxin poisoning. Other toxins that can cause paralysis include botulinum, diphtheria and tick paralysis toxin, but these have slower onset of action and produce prodromal symptoms. Organophosphate poisoning is also worth considering: paralysis and copious bronchial secretions consistent with cholinergic toxicity are seen. Neurological considerationsThe hyperacute onset of our patient’s symptoms suggested an acute inflammatory demyelinating polyneuropathy, especially in view of the preceding infective illness. Even so, the presentation and progression of the weakness were unusually rapid. Similarly, autoimmune neuromuscular junction disorders, such as myasthenia gravis and Lambert–Eaton myasthenic syndrome, run a more subacute, relapsing course. Periodic paralysis can cause sudden weakness, but there is often a history of recurrent attacks. Toxic and inflammatory myopathies and neuropathic heavy metal poisoning have a more chronic and progressive course. The cause in our patient was an intradural intramedullary arteriovenous malformation, the most common form of spinal cord vascular lesion in childhood and adolescence.6 These lesions can haemorrhage and cause catastrophic autonomic dysregulation accompanied by spinal shock. Complications include neurogenic pulmonary oedema, with the sympathetic storm contributing to transient myocardial impairment via direct neurogenic and humoral mechanisms. ConclusionThis patient illustrates an uncommon scenario of rapidly progressive flaccid paralysis presenting to the emergency department. Emergency physicians need to consider a broad neurological and toxicological differential diagnosis in the patient with flaccid paralysis. Structural abnormalities of the central nervous system may present with acute paralysis and spinal shock, mimicking toxicological syndromes. 1 Magnetic resonance image of the cervical spinal cord A sagittal T2-weighted image showed a high signal (arrow) within the cervical cord caused by blood breakdown products (intracellular methaemoglobin). 2 Lesion excised from the spinal cord Histopathological examination of the resection specimen showed abnormally clustered vessels of venous (V) and arterial (A) type intermingled with spinal nerve bundles (N). This vascular configuration is typical of an arteriovenous malformation. (Haematoxylin and eosin stain; original magnification, × 40.) 3 Toxicological and neurological causes of acute paralysis Ascending paralysis Toxicological: tick paralysis (Ixodes spp.) Neurological (peripheral): acute inflammatory demyelinating polyradiculoneuropathy (Guillain–Barré syndrome) Descending paralysis Toxicological: puffer-fish (tetrodotoxin) poisoning, paralytic shellfish poisoning, snake bite, botulism, diphtheria Neurological (peripheral): myasthenia gravis Other Toxicological: ciguatera, neurotoxic shellfish poisoning, organophosphate poisoning Neurological (peripheral): myopathies (including myositis and periodic paralysis), acute poliomyelitis and toxic neuropathies

Naren Gunja FACEM · Robert P Dowsett FACEM · Karl Ng MRCP, FRACP

To the Editor: The recent editorial by Ring and Wenitong1 about interventions to prevent child abuse in the Northern Territory highlights the importance of treating the causes as well as the symptoms. This is true not only for children in remote Aboriginal communities, but for all children across Australia. Child abuse and neglect is not a “new” national emergency. In 1966, Bialestock2 wrote in the Journal: This situation should be considered as a national emergency as lethal to the lives of potential Australians as is a war. Immediate allocations of revenue to prevent this situation should be made if the[se children] . . . are to be allowed to grow into adults able to live in dignity and to work to contribute to our economy. We must not sentence these children to a lifelong need for State support. There are no reliable prevalence data, but Australian Institute of Health and Welfare data indicate that there were 266 745 notifications of suspected child abuse and neglect in Australia last year, double the number 6 years ago. About one in five of these notifications were “substantiated”. Over 25 000 children are in state care at any one time, an 82% increase in the past decade.3 Our child protection systems are at risk of imploding under the strain. These systems are also potentially dangerous, with high levels of multiple placements contributing to the very high prevalence of mental health problems among children in care.4 The contributory factors are well known. Children with disabilities, chronic health problems, difficult temperaments and externalising behaviours, families where there is domestic violence and parental mental health or substance misuse, and communities characterised by poverty, unemployment, higher residential mobility, and a low adult to child ratio are at much greater risk. We must close the gap between what we know and what we do. A public health approach is needed to reduce the risk factors, using population-based measures of child abuse and neglect, and tapping the potential of universal health, welfare and education services as platforms for primary and secondary prevention. In relation to health services, the adequate provision of universal maternal and child health services, including sustained nurse home-visiting programs, is vital. General practitioners and mental health and drug treatment services using child-sensitive and family-centred approaches also have a major role to play. These interventions have also been shown to improve overall outcomes for children in education, health, and social and economic participation. Hence, economists have suggested that they are the most cost-effective intervention for a nation.5 Now is the time to ask whether governments are really serious about preventing child abuse and neglect.

Fiona J Stanley · Dorothy A Scott · Melissa O’Donnell

To the Editor: I congratulate the Journal for publishing the article by Smith and Baird on the radiographer’s role in radiological reporting.1 It demonstrates the Journal’s objectivity by providing an opportunity to examine a health service model that, if carefully implemented and evaluated, may enhance outcomes in diagnostic imaging within a clinically useful timeframe. It is quite understandable that the Royal Australian and New Zealand College of Radiologists (RANZCR) would move quickly to defend its professional jurisdiction. However, in their editorial published in the same issue of the Journal,2 Kenny and Andrews, representing the RANZCR, seem to have overlooked the contribution of the Smith and Baird article to the development of new models of health care delivery. Further, their defence ignores the reality that, in the Queensland public hospital system, for example, diagnostic imaging is conducted in 108 centres but radiologists are only present at eight of those centres. The past three decades have seen rapid technological change, resulting in an array of diagnostic and interventional imaging modalities and providing a challenge to 21st century radiologists. However, plain radiographic images were being interpreted by non-radiologists for two or more decades before the medical specialty evolved.3 Alerting rural general practitioners and junior medical officers in emergency departments to abnormal features on plain films is a work practice that radiographers have always performed. Image interpretation in plain radiography is a skill they are exposed to every day of their working lives. Formal postgraduate training would develop that skill and formalise the practice. The nurse practitioner model developed because of identifiable health care service deficiencies, particularly in vulnerable, underserved communities.4 Similar service gaps exist in diagnostic imaging. The maldistribution of radiologists in Australia will never change, for economic and lifestyle reasons. There will never be a radiologist to supervise, advise, report findings and communicate results of plain radiographs at 3 am in a provincial hospital — nor in a metropolitan emergency department, for that matter. The radiographer will be there, however. It is time that due recognition be given to radiographers and enhanced training provided. The RANZCR, as the responsible body of medical professionals, owes it to the communities that they are unable to serve.

Wayne J Nuss

To the Editor: On the basis of the recent traumas experienced by the United Kingdom in rolling out its Modernising Medical Careers program, you warn the Royal Colleges to “resist political pressure to solve medical manpower problems created by governments”.1 Kenny and Andrew,2 representing the Royal Australian and New Zealand College of Radiologists (RANZCR), clearly link the need to cope with increasing demand for diagnostic imaging with the drive to allow non-medical staff to develop roles previously reserved for the medically qualified — and they oppose much of this. Meanwhile, Smith and Baird3 argue cogently — and supported by evidence, rather than conjecture — that there is a place for allied health professionals with appropriate training and education to take on some of the more traditional medical roles. Each group could be arguing from a position of self-interest. The representatives of the RANZCR (surprisingly) do not mention reimbursement of radiologists,2 while university teachers advocate a wider role for their institutions.3 The arguments are further mired by the assumption that role development or delegation is and should only be driven by unmet service demand. That need not be. Smith and Baird,3 in describing many of the UK developments, correctly assume that service demand is a driver, but that is not always the case. In diagnostic and therapeutic radiography in many parts of the UK, such as Scotland, the process of role development is seen as a natural progression in training and work practice that allows individuals to develop the skills they are capable of using. This is not merely a process reserved for areas of understaffing. In fact, medical staff have extra roles — in training, mentoring and supervising. They are also able to free up time for more demanding medical work. Notably, resistance to such change (of which I see very little in therapeutic radiography) is not confined to medical staff: major opposition is often expressed by radiographers and their managers. Thus, the process of role development of all clinical staff requires close cooperation between all professional and educational bodies. That is a proper role for a medical college — rather than that of a trade group protecting its patch or resisting change. Personally, I find it highly enjoyable to practise with experienced, motivated nursing and allied health colleagues who have been trained to perform these enhanced tasks.

Alan Rodger

To the Editor: The views of Mendelson and Murray1 regarding inappropriate use of diagnostic imaging and how it might be reduced are timely and important. Unless governments, doctors, the medical imaging industry and consumers acknowledge the significant barriers to Mendelson and Murray’s proposed changes, the number of inappropriate tests will grow. The authors argue that radiologists need to be more active in vetting requests. This is often hindered by the lack of relevant clinical information from referrers about the indications for tests. Broadhurst et al2 found that 34% of unselected Australian requests for shoulder ultrasound contained “no tangible information to assist the radiological examination”. Surveys of doctors in the United Kingdom found that their knowledge of the radiation delivered by various imaging tests, relative to that of a chest x-ray, was poor.3 This lack of knowledge makes it difficult, if not impossible, for doctors to inform patients about the risks and benefits of an imaging test. The Quality Use of Diagnostic Imaging (QUDI) Program of the Royal Australian and New Zealand College of Radiologists was set up in 2004 to develop a knowledge base of evidence-based best practice in radiology. To date, it has commissioned over 25 quality-related projects in areas such as development of information for consumers, best practice standards for radiology requests, and audit–feedback analysis of radiation dosage in paediatric computed tomography. The QUDI Program and the National Institute of Clinical Studies have sponsored fellowships in evidence implementation, training radiologists in the art and science of supporting clinicians’ use of evidence-based, appropriate diagnostic imaging. The results of QUDI projects are used in strategies to improve the use of radiology. The Australian Medical Association is advocating that general practitioners have access to magnetic resonance imaging, arguing that it would reduce costs and radiation exposure.4 However, this does not address the issue of appropriate consultative referral, and has the potential to simply add to the burgeoning diagnostic imaging budget rather than directly benefiting patients. A multifaceted approach to change is required, involving the referrer, the consumer and the entire radiology industry. This must be based on best-practice, patient-focused use of radiology. Radi-ologists are central to providing advice on the most appropriate imaging procedures and reducing the burden of inappropriate imaging. This is likely to require changes to practice and to legislation.

Lizbeth M Kenny · Stacy K Goergen · Catherine J Mandel

To the Editor: The authors of the editorial “Towards the appropriate use of diagnostic imaging”1 canvass possible strategies to improve the appropriateness of requests for diagnostic imaging. One strategy that research suggests may be effective is feedback provided by the providers of diagnostic services.2,3 Discussion of the feedback could, and should, be supported by federal government funding, perhaps via Divisions of General Practice, and should attract continuing professional development points for the general practitioners involved.

Oliver R Frank

In reply: We thank Kenny and colleagues for their comments and congratulate the members of the Quality Use of Diagnostic Imaging (QUDI) Program of the Royal Australian and New Zealand College of Radiologists on their continuing efforts. We are also grateful to Frank for his constructive suggestion. We entirely agree that a multifaceted approach is needed to improve the appropriateness of referral for diagnostic imaging. We believe that the majority of general practitioners are willing to be educated and guided with regard to their referring practices. However, to do so they require up-to-date guidelines that are easily accessible in electronic form, based on evidence and consensus, practicable and able to be integrated into their everyday desktop applications,1 much like pharmaceutical guidelines are currently. The QUDI Program has chosen to focus on producing guidelines on selected topics, while we, with our “Diagnostic Imaging Pathways”,2 have chosen to work towards a more comprehensive clinical decision support and educational application. Of course, the two approaches are entirely complementary. It also behoves radiologists, at an individual level, to interact with their referrers, to vet requests (ensuring that requests are appropriate and contain adequate clinical information, as emphasised by Kenny and colleagues) and act as the consultants they were trained to be. Sometimes this may be to their short-term economic detriment. However, one hopes that such short-term disadvantage would be countered in the longer term by greater professional satisfaction and a better relationship with referrers, who are likely to remain loyal to those radiologists on whom they can rely for advice and education in addition to trustworthy image interpretation.

Richard M Mendelson · Conor P J Murray

To the Editor: Austin et al1 bring to our attention findings from the report on maternal deaths in Australia in which 26 suicides were reported, making it one of the leading causes of indirect maternal deaths in the perinatal period — a finding consistent with the Confidential Enquiries into Maternal Deaths report from the United Kingdom.2 These reports raise the issue of the importance and risk of maternal mental illness in the perinatal period. While this high rate of suicide is unacceptable, it needs to seen in context: this is a rare event overall, representing a standardised mortality ratio of 1.14 per 100 000 women. This is considerably lower than the suicide rate for women in general, which ranges from 3.6 per 100 000 in the 15–19-year age group to 6.4 per 100 000 in the 25–29-year age group.2,3 This comparison verifies the observation made by Appleby that suicide rates are low during the perinatal period.4 Austin et al recommend that psychosocial screening, in conjunction with ongoing mental health monitoring and clear referral pathways, should be made available to women in a maternity setting as part of the solution to preventing the “relatively high” rate of early maternal suicide. But to date, antenatal screening programs have proven costly to implement, can produce large numbers of false positives, are often poorly accepted by antenatal care providers (as they add to the administrative burden), and do not result in greater uptake of services by at-risk women.5 Remarkably, 40% of the suicides reported by Austin et al occurred in the first trimester, predominantly before women had attended an antenatal clinic and before any psychosocial screening. A number of the suicide cases were already under the care of mental health services, and screening may not have prevented the tragic outcomes. We believe the answer to this problem is for appropriately resourced, accessible and publicly funded specialised perinatal psychiatric services to be put in place (including dedicated mother and baby units) so that high-risk women can be appropriately treated. In providing such services, we would need to develop appropriate strategies to engage mothers who need support from psychiatric services. This concurs with the National Institute for Health and Clinical Excellence perinatal mental illness guidelines,6 which advocate for the identification of pertinent risk factors (such as personal and familial mental health history) and assessment of current distress (through targeted interviewing). Screening is recommended to monitor outcomes but not to dictate clinical decision making.

Phillip M Boyce · Jodi Barton

In reply: Boyce and Barton raise a number of points. Firstly, with respect to their critique of the 2006 beyondblue postnatal depression report,1 there are, to date, no studies assessing the cost of antenatal screening programs. Furthermore, while false positives are a feature of all screening programs, that, in itself, is not a deterrent to using antenatal screening if the rate of false positives is considered acceptable. While midwives have concerns about undertaking routine psychosocial assessment, uptake of such a program can be done through adequate training and support of staff, as now demonstrated in a number of sites around Australia.2 With respect to the inadequate uptake of services by “high-risk” women, these are generally poor in the psychiatric clinic setting3 and would not be expected to be different perinatally. Secondly, the authors report that “a number of the suicide cases were already under the care of mental health services, and screening may not have prevented the tragic outcomes”. This overlooks one of the key attributes of routine psychosocial assessment in the primary health care setting — that it encourages communication and monitoring across the primary (eg, midwifery) and mental health sectors. Thus, while some women may be lost to psychiatric follow-up during pregnancy, most will attend antenatal appointments, thus providing their health care network with an opportunity for ongoing psychosocial review. Thirdly, while we agree with Boyce and Barton that “targeted interviewing” (as described in the UK National Institute for Health and Clinical Excellence guidelines) is important, “psychosocial assessment”, as undertaken in some Australian maternity settings, aims to assess the broad number of psychosocial risk factors that may contribute to the mental health outcomes of a woman and her infant. This point has been identified as a key issue in the 2007 beyondblue national action plan for perinatal mental health briefing document.4

Marie-Paule Austin

To the Editor: I compliment Dunbar and colleagues on their analysis of the systematic problems underlying whistleblowing “scandals” at four Australian hospitals.1 I disagree totally, however, with their major conclusion. I refer to their endorsing the recommendation from the President of the General Medical Council of the United Kingdom that “... if there’s a risk to patients ... we expect people to pipe up, but pipe up locally”. Attempting to put this recommendation into practice is itself the root cause of the problem. The many and varied obstacles to locally notifying one’s concerns about a colleague’s performance are almost insurmountable; any permutation or combination might apply in a particular location. On the part of the whistleblower, obstacles might include fear of their confidence being breached, being suspected of professional envy or of being a troublemaker, a concern for job security or about failure to be promoted, a reluctance to rock the boat in their own working environment, or fear of being victimised at work. On the part of the chief executive officer or equivalent local person to whom the report is made, obstacles might include their potential affront at a slight on their responsibility for overall management or for having appointed the person to whom the notification refers, personal friendships and even family relationships (especially in smaller centres), reluctance to have to inquire into a senior staff member’s work, or financial implications (as in the case of Bundaberg Hospital1). I suggest that, instead of trying to overcome such awkward and off-putting obstacles locally, performance concerns should be taken directly to a statutory body with responsibility for overall standards of health care and with absolutely no “conflicts of interest” in specific local situations. In New South Wales, at least, and specifically in relation to doctors, Section 86E of the Medical Practice Act 1992 provides that persons may notify the medical board of professional performance matters, namely “any matter that the person thinks indicates that the professional performance of a registered medical practitioner is unsatisfactory”. This avenue avoids all the pitfalls involved in attempting to resolve the matter locally, affords the potential whistleblower a recognised means of having their concerns given serious consideration, and reassures the whistleblower that the matter is in the hands of a responsible body with statutory authority and with tried and tested methods of dispassionately assessing the situation. The whistleblower would then have no need to “go public”, with the devastating results so well described by the authors.

Peter C Arnold

In reply: Dr Arnold raises the difficulties involved in bringing poorly performing colleagues to notice and proposes that reporting doctors to a medical board is the best option. There are difficulties in relying solely on medical boards. First, doctors have a very high threshold for referral to a medical board, so poor performance may not be reported. Even serious cases of poor performance can go unreported for many years.1 Second, there are many cases of remediable poor performance2 that require a different approach. In the United Kingdom, local procedures are managed by medical directors as part of their contract. The Good Medical Practice guidelines issued by the General Medical Council make it clear that all doctors have a responsibility to report poorly performing colleagues.3 If the medical director then fails to act, the hospital’s insurance could be invalidated and the medical director would appear before the General Medical Council. A number of Australian jurisdictions, including the Australian Capital Territory, New South Wales and Queensland,4,5 have made substantial progress in developing local procedures that offer the best opportunity for remediation of doctors where possible, and for discipline by the medical board where not. With these procedures, we can assure patients of safety while maintaining as many doctors as possible in the workforce.

James A Dunbar · Prasuna Reddy · Bill Beresford · Wayne P Ramsey · Reginald S A Lord

To the Editor: The recent editorial by Penington and Mitchell1 unreservedly supports the Victorian Government’s legislation allowing “therapeutic cloning” by somatic cell nuclear transfer (SCNT) — generating an embryo by transferring an adult somatic cell nucleus (skin, muscle, etc) from an individual into a donated ovum from which the nucleus has been removed. State and federal support for therapeutic cloning has clearly been dependent upon belief in the therapeutic benefits to be obtained — a belief that the editorial does nothing to dispel. Since the licensing system for embryo research (Research Involving Human Embryos Act 2002 [Cwlth]) was introduced, there have been no discoveries in animal or human embryonic stem (ES) cell research that support an urgent need for therapeutic cloning. This includes references 3–8 in Penington and Mitchell’s editorial, all of which fall far short of providing proof of concept of efficacy of ES cells in treatment. A number of major problems need to be resolved before any remotely credible scientific case could be made for the need for therapeutic cloning. These include achieving prolonged, effective, safe therapy in an animal model of disease, and safe transplantation of ES cells in animals, without any tumour formation — a problem that occurs commonly,2,3 not on the “rare occasions” claimed in the editorial. We need to understand how stable the fully differentiated phenotype is when ES cells are used to generate specialised cells. This can be explored in animal ES cells, but also in human ES cells that do not need to be prepared by therapeutic cloning. If stability is indeed shown, these cells must die eventually — how will they then be replaced? Will this require a compromise of using less “mature” cells and incurring an even greater risk of tumour formation? If cells derived by SCNT are to be used to find “new approaches to ... hitherto unyielding diseases”, proof of this concept could readily be provided by studying animal examples. Crucially though, that will require resolution in animal studies of the effect of SCNT on genetic controls and epigenetic effects in the derived ES cells. These are all scientific requirements. Proceeding to therapeutic cloning provides no scientific advance without them — and of course it should be noted that no one anywhere in the world has ever made human ES cells by SCNT. Penington and Mitchell’s editorial provides a limited view of these matters. It acknowledges the long lead times required if there is ever to be success in ES cell therapies, but does not advance even a single compelling argument in support of SCNT now.

T John Martin

To the Editor: I read with interest the editorial by Penington and Mitchell1 in which they briefly discussed the recent legislative developments with regard to human embryonic stem cells. As a medical student, I delight at the complexity and passion that surround the stem cell debate. How is a student to proceed through this ethical minefield? At the Australian National University, we are taught that international human rights are likely to become more important in professional regulation than classical medical ethics born of the Hippocratic Oath.2 The International Covenant on Civil and Political Rights (ICCPR)3 and the Universal Declaration of Human Rights (UDHR)4 are currently used as the cornerstone for building ethical arguments and controversial legislation. However, problems with these international human rights documents include their relevance and applicability to the 21st century. The medical and technological advances made since they were introduced are mind-numbing; I doubt that stem cell research was a consideration when they were drafted. Both Article 6 of the ICCPR and Article 3 of the UDHR state that every human being has the right to life. An individual’s ethical principles must shape his or her interpretation of this statement. Moreover, ethical argument should not be confused with religious views. Australian society and its belief systems are more than ever moving further away from religion, and medical ethics should incorporate the views of the community at large. An example of religion and international human rights opposing society’s position is the termination of pregnancy. In Australian medicine there is an ethical obligation to uphold a woman’s right to autonomy and wellbeing, while the exact wording of the ICCPR and UDHR is ignored to achieve a currently socially acceptable outcome. We are seeing a similar rationale with stem cell research, in that there is an ethical responsibility to “the greater good”, regardless of the requirements of the UDHR and ICCPR. I am a strong supporter of both stem cell research and a woman’s right to choose. I am simply suggesting that we stop looking to international human rights covenants to be the cornerstone of legislation or to answer ethical dilemmas. I just don’t think current international human rights documentation incorporates all the ethical considerations required of modern medicine. A new alternative is just what the medical student ordered.

Jeffrey J Flaherty

To the Editor: A recent editorial in the Journal suggested that blood could be sent overseas for genetic testing for maturity onset diabetes of the young (MODY).1 We are pleased to be able to point out that genetic testing, including clinical and laboratory support with full gene sequencing for both MODY1 and MODY3 and for neonatal diabetes (mutations in SUR1 and Kir6.2), is available in Australia. Testing for MODY2 and for a number of other disorders of the pituitary–adrenal and pituitary–gonadal axis in children is also available. We are happy to receive specimens and referrals from clinicians who would prefer to use an Australian clinical laboratory accredited by the National Association of Testing Authorities. More information is available via: http://www.mater.org.au/Home/Services/Pathology.aspx.

Mark F Harris · Ivan N McGown · David M Cowley

To the Editor: A recent MJA Supplement discusses prognostic and end-of-life communication for health professionals on the basis of a systematic literature review and an expert advisory panel.1 It is usually the case that malignant disease is diagnosed after biopsy, and this is usually undertaken by a surgeon. In a consecutive series of 100 patients presenting with a lesion in a bone with no past history of malignancy, the lesion was the presenting feature of systemic malignancy in 44 of those patients.2 Hence, it is usually the surgeon’s role to advise the patient (and caregivers) that the patient has a terminal disease and, in some cases, the prognosis can only be measured in weeks. It will be obvious that this can be a significant shock to all, particularly when there was no prior indication that malignancy was a possibility. I note that not one of the 35 experts was a surgeon. I also note that surgery as palliation is given virtually no role other than a brief mention in Box 11, despite the well documented role of surgery.3 It has been my experience that the most common question asked by patients with the diagnosis of a terminal malignancy is about the role of surgery; the question “Why can’t you just cut it out?” is a universal feature. This has not been addressed. It is my sincere hope that further expert advisory panels addressing this area become truly multidisciplinary and include perhaps the most relevant discipline — surgery.

Mark T Clayer

In reply: We agree that the content area of these guidelines is very relevant for surgeons, as for all health professionals involved in the care of adult patients with advanced life-limiting illnesses and their caregivers. Surgical representation on our expert panel would have been very useful. We agree that surgery has an important role in terms of palliative treatment options that may be available for certain clinical circumstances. The issue of how to respond to the question “Why can’t you just cut it out?” is an important one. We believe that the principles outlined in these guidelines would be relevant when responding to this question, but would welcome specific suggestions from Clayer and other surgeons about how they respond to such patients. We would hope to include these suggestions along with other input from surgeons in any future update of these guidelines.

Josephine M Clayton · Karen M Hancock · Phyllis N Butow · Martin H N Tattersall · David C Currow

To the Editor: In their recent Snapshot, Sharma and colleagues reported an interesting case of a woman presenting with prolonged fever and inflammation of external ears, nose, and throat.1 On the basis of negative antineutrophil cytoplasmic antibodies (ANCAs), a diagnosis of relapsing polychondritis was made and the possibility of Wegener’s granulomatosis “ruled out”. Corticosteroid and azathioprine were given to the patient accordingly. However, patients with Wegener’s granulomatosis can present with limited otolaryngological symptoms with or without positive ANCAs.2,3 As a rule, ANCAs are present in 90% of patients with the generalised form of the disease, but in only 60% of those with the limited form.4 Conversely, some cases of relapsing polychondritis can have a positive test result for ANCAs.4 A case has been reported of a Wegener’s granulomatosis patient with otolaryngological manifestations that led to an initial diagnosis of relapsing polychondritis, but who subsequently developed pulmonary and renal involvement.3 While a routine biopsy to exclude Wegener’s granulomatosis in patients with inflammatory otolaryngological symptoms may not be practical, with a limited period of follow-up, a diagnosis of relapsing polychondritis should be made cautiously and only provisionally. This is true even in cases such as the patient described by Sharma and colleagues with 6 months of illness and 7 months of follow-up, as pulmonary and/or renal manifestations could take years to follow. We believe that negative ANCAs should never be used to rule out Wegener’s granulomatosis, especially in its limited form.

Weekitt Kittisupamongkol · Wanla Kulwichit

To the Editor: Scott and colleagues have shown that Australia is no different to the rest of the world in applying evidence-based treatment predominantly to patients at lower risk.1 They suggest that therapy may be withheld from high-risk patients because of over-estimation of the risk of treatment, under-estimation of the actual absolute risk of non-treatment, and consideration of cost-effectiveness and social inequalities. I suggest that their data support the concept that the patient at highest risk who misses out on evidence-based treatment may in fact be being managed with kindness and wisdom. Such a patient is old, has comorbidities, can be frail, and may be taking 10 pills or more per day, so questions of optimal prognostic therapy must be balanced against quality-of-life factors. There is abundant evidence that patients at highest risk do not receive the maximum amount of therapy. I suspect the kindness and wisdom factor is underestimated in clinical decision making. What we need now is some good qualitative data — market research — to help explain this phenomenon before we intensify the evidence-based mantra.

V Michael Jelinek

In reply: Jelinek rightly draws attention to the need, when caring for patients with acute coronary syndromes, to distinguish disease-related risk from age-related risk arising from frailty, comorbidity, physical disability, cognitive impairment, depression, social isolation, age–treatment interactions, and quality of life. All these factors affect treatment goals in older patients and may, as we conceded, justify withholding certain treatments in individual cases. However, even after accounting for “wise compassion”, under-treatment is still likely because: our treatment eligibility criteria excluded patients with advanced comorbidity or who declined treatment; population-based studies of risk–benefit trade-offs argue for more intense treatment use in patients ≥ 75 years,1,2 in whom absolute risk reductions exceed those in younger patients by as much as 10%;3 and all four key treatments at discharge (aspirin, β-blocker, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, and statins) can be administered as once-daily, single tablet formulations, which are usually well tolerated. Given that a third of patients presenting with acute coronary syndromes are aged 75 years or older, for whom 30-day risk of death or myocardial infarction exceeds 20% and who account for 60% of all deaths related to myocardial infarction,4 we recommend, similar to expert bodies,4,5 judicious (not mantra-driven) use of evidence-based treatments in all eligible older patients.

Ian A Scott

To the Editor: We refer to the study reported by Correa-Velez and colleagues, which found lower hospital utilisation rates among patients from refugee-source countries compared with the Australian-born population in Victoria.1 As noted by the authors, there is a dearth of evidence on the use of health services by refugees. Their 6-year investigation stands as a singular study of its kind in Australia, and we recognise its potential to inform policy on refugee health care. However, we argue that the authors’ conclusion that “the Refugee and Humanitarian Program does not currently place a burden on the Australian hospital system” cannot be drawn from the data collected in the study. Refugee groups have health needs related to histories of torture and trauma, and associated somatic symptoms.2 Furthermore, refugees have often been exposed to diseases that are infrequently encountered in the general Australian population. Considerable time is required to train health professionals to diagnose and treat such complex clinical presentations. In addition, adequately servicing the special needs of this patient group requires the provision of appropriately qualified interpreters. When an interpreter is required during a clinical consultation, additional time is often needed to gain clarity. Interpreters can also be difficult to source, which places added time and resource pressures on health care administrative staff and budgets. Correa-Velez et al do refer to the “multiple barriers that prevent refugees from adequately accessing health care services”. Further research is required to comprehensively assess the reasons why, given the complexity of their health care needs, refugees are not accessing the hospital system at the same rate as other Australians. The authors suggest that reasons for an increase in service utilisation by refugees in recent years may include an increased level of familiarity with services, or poorer health status of recently arrived refugees. Previous reports have indicated that refugees tend not to utilise health care services where fundamental issues of access, such as language barriers and lack of education about the availability of health care services, have not been addressed.2,3 Since Correa-Velez and colleagues’ data were collected, several states, including Victoria, have developed primary health care programs for refugees, with varying degrees of success. As the Queensland Government considers a new statewide model for refugee health,4 it is essential to ensure adequate resources are allocated for refugee and staff education programs and interpreting services.

Joy L Mendel · Claire E Brolan

A toothsome tale Oral health does appear to have an association with mortality patterns, although the exact relationship is difficult to determine due to the presence of confounding factors such as smoking. Using data from the large, ongoing Glasgow Alumni Cohort study, researchers set out to investigate whether oral health in young adults is independently associated with cardiovascular disease later in life. Over 15 000 participants were followed for up to 57 years. Those with nine or more missing teeth at baseline had a significantly increased risk of cardiovascular disease mortality compared with those with fewer than five missing teeth, after adjusting for potential confounders. The association was not linear, suggesting the relationship is complex and affected by many variables. The authors comment that, as pathological pathways between oral health and systemic disease remain unclear, prospective studies are needed to unravel this complex relationship. Heart 2007; 93: 1098-1103 Weight loss — longer life Weight loss after bariatric surgery may reduce mortality in previously obese people, according to a Swedish study. The prospective, controlled study involved over 4000 obese subjects, almost half of whom underwent bariatric surgery. Surgical procedures included gastric bypass, banding, and vertical-banded gastroplasty. The remaining individuals received non-standardised, conventional treatment. Weight losses in all surgical groups remained significant and stable (up to 27%) after 15 years. The non-surgical group showed weight changes of only ± 2% over the observation period. The hazard ratio for overall mortality for the surgery group was 0.76 as compared with the control group. Myocardial infarction and cancer were the most common causes of death. A drawback of the study is the lack of randomisation in the trial, but the authors comment that this may be difficult to achieve due to the risk of selection bias. N Engl J Med 2007; 357: 741-752 Diabetes and heart failure —between a rock and a hard place How to treat diabetic patients who also have heart failure is an important clinical question and one that is fraught with difficulty. A Canadian systematic review and meta-analysis of controlled studies has revealed that metformin appears to be the only anti-diabetic agent not associated with harm in patients with both conditions. Thiazoli-dinediones were associated with a reduced all-cause mortality, but an increase in hospital admissions for heart failure. The results from the two studies addressing sulfonylureas were contradictory, reflecting the controversy surrounding use of this class of drugs in diabetic patients with comorbid cardio-vascular disease. The authors comment that the presence of bias may have affected the results of the included studies and call for further randomised controlled trials analysing the use of metformin or thiazolidinedione in patients with heart failure and diabetes. BMJ Online, 30 August 2007 Unravelling the MS mystery A central nervous system (CNS) protein with anti-apoptotic and neuroprotective functions may be a key player in the autoimmune assault on myelin that underlies the pathogenesis of multiple sclerosis (MS). The heat shock protein αβ-crystallin (CRYAB) is the major target of CD4+ T cells in the MS brain. Using mouse models, researchers have shown that the autoimmune attack on CRYAB, rather than causing damage directly, worsens tissue injury by abolishing the protein’s role in impeding the inflammatory process. CRYAB also has a function as an inhibitor of glial apoptosis, or programmed cell death. When subjected to experimental autoimmune encephalitis, mice that lacked the CRYAB gene showed worse disease with more severe CNS inflammation and damage than their wild-type counterparts. In addition, antibody to the protein can be found in the cerebrospinal fluid of patients with MS. The implications for treatment of MS are promising, with CRYAB a possible protective agent if administered early in the disease process. Nature 2007; 448: 474-483 Meningococcus targets bonny babies Morbidity and mortality associated with meningococcal disease appear to be linked to nutritional status in a surprising way, according to Argentinean researchers. Anecdotally, physicians have noted that lethal invasive meningococcaemia is extremely rare in malnourished children. A prospective, observational study of 127 children aged 1 month to 4 years with invasive menin-gococcal infection was performed, with severity of disease and survival as clinical endpoints. Anthropometrical parameters were recorded prospectively for each child. Patients who died, had amputations, or required reparative surgery were considered to have severe disease. When anthro-pometrical data were compared, children who had a higher weight for age and height for age were significantly more likely to have severe meningococcal infection. The authors comment that malnutrition may confer a protective status through modulation of inflammatory mediators in poorly nourished children. Arch Dis Child 2007; 92: 790-794

Tanya Grassi