Volume 187 Issue 9

Can politicians rise to the challenge, or do doctors need to become politicised? As the federal election campaign unfolds, two key questions emerge: how will alternative health care policies of the two major political parties influence voter choice, and how will health care change once the political victors take charge of the Treasury? There is actually no paucity of political and professional opinion as to how health care in Australia should change. The looming election merely triggers a crescendo in the chants of the Greek chorus of health care experts — “we need to change this” or “we must do that” — all part of an incessant stream of advice, mostly devoid of any evidence base, calling for reform of our health care system. Presently, our system is characterised by “fragmented roles, responsibilities and regulatory arrangements . . . inadequate co-ordination between governments, planners, educators and service providers . . . inflexible regulatory practices . . . perverse funding and payments incentives . . . and entrenched custom and practice”.1 There is actually no paucity of political and professional opinion as to how health care in Australia should change Furthermore, the system is beset with such problems as: reduced opportunities for Australians to access health care when and where they need it; downstream effects of a chronic shortage of doctors, nurses and other health professionals and the system’s chronic reliance on overseas imports; a diminished focus on prevention and primary care; insufficient financial support and a wastage of resources inherent in the current federal–state funding structure; lack of political resolve to undertake reform; and the abysmally poor health status of Indigenous Australians. In short, the system is diminishing in its capacity to deliver universal access to equitable and quality care. It is ripe for reform. Some experts advise that there should be structural change rather than continual incremental changes to tackle the major problems,2,3 and observe: Our health leaders lack the will for health reform because they are strongly influenced by the vested interests that abound in health — doctors (particularly specialists), state health bureaucracies, parochial political interests, private health insurance funds, pharmacies and the pharmaceutical companies.2 Missing from all this rhetoric is a clear, prioritised account of the precise challenges facing our health system. Also missing are detailed enunciations of the health policies and plans of the major political parties contesting the election. To demystify the confusion and rhetoric, in this issue of the Journal we have canvassed the views of a group of seasoned and respected health experts who outline their perspectives on the current challenges facing Australia’s health care system (→ Challenges in health and health care for Australia), along with the electioneering health policies of the Liberal Party (→ Good health systems, getting better), the Labor Party (→ Taking leadership — tackling Australia's health challenges), and the Australian Medical Association (→ A mandate to strengthen the health system). Some of our readers may well ask why the MJA is straying into politics. In embarking on this initiative, the Journal is simply returning to a longstanding tradition of the MJA and following the lead of the Journal of the American Medical Association which, during the 2004 United States presidential election, boldly published responses to the question “How would you ensure access to health care for the citizens of the United States?” by presidential hopefuls George W Bush and John Kerry.4,5 But there is a more fundamental reason. In contemplating our apparent foray into politics, we turned to Julian Tudor Hart (the Welsh general practitioner who described “inverse care law” — that the availability of health care varies inversely with the need for it), who recently decried New Labour’s introduction of private providers to serve the United Kingdom’s National Health Service in his book The political economy of health care.6,7 Among other claims, he contends that if political parties are incapable of confronting the challenges of modern health care, then doctors need to become a politicised profession.8 Have we reached that point in Australia? We might know better when the outcome of this federal election is known, whether the newly elected government will have the political will to pursue reform and will step out from the comforting shadow of the blame game.

Martin B Van Der Weyden MD, FRACP, FRCPA

The next Australian Government will confront major challenges in the funding and delivery of health care. These challenges derive from: Changes in demography and disease patterns as the population ages, and the burden of chronic illness grows; Increasing costs of medical advances and the need to ensure that there are comprehensive, efficient and transparent processes for assessing health technologies; Problems with health workforce supply and distribution; Persistent concerns about the quality and safety of health services; Uncertainty about how best to balance public and private sectors in the provision and funding of health services; Recognition that we must invest more in the health of our children; The role of urban planning in creating healthy and sustainable communities; and Understanding that achieving equity in health, especially for Indigenous Australians, requires more than just providing health care services. The search for effective and lasting solutions will require a consultative approach to deciding the nation’s priority health problems and to designing the health system that will best address them; issues of bureaucratic and fiscal responsibility can then follow.

Bruce K Armstrong AM, DPhil, FRACP · James A Gillespie BA, PhD · Stephen R Leeder MD, PhD, FRACP · George L Rubin FRACP, FAFPHM · Lesley M Russell BSc(Hons), BA, PhD

In view of the impending election, we asked representatives from the two major political parties for their policies on health. The Minister for Health and Ageing replies. On any fair judgement, Australia has excellent health systems. Our healthy life expectancy ranks just behind that of Japan, Iceland and Sweden. There has been a 10-year increase in Australians’ life expectancy since 1960, and a 3-year increase since 1996. These results testify to the effectiveness of the individuals and organisations involved in providing health care. Australia does not need radical experiments in health care delivery. We need refinements and improvements that build on our existing strengths. Our greatest strength, of course, is the dedication and professionalism of Australia’s health staff, who can invariably be trusted to act in their patients’ best interests. Australia’s health systems face four key challenges: the affordability of increasingly sophisticated health services; the expansion of the health workforce to meet the needs of an older population; the treatment of chronic disease in the community rather than in hospitals; and the integration of complex services to deliver seamless care to patients. All these challenges have been substantially addressed since 1996, but there is still a great deal to do. In particular, the next round of Health Care Agreements should not be about government but about health services. The real test of health policymakers (and would-be policymakers) is not the intensity of their critique, but the practicality of their specific proposals for change. It is easy to say, for instance, that we must take the pressure off emergency departments, or we must put more stress on prevention rather than cure. It is much harder to specify how these worthy objectives might be achieved. It is important to pledge more money for health programs but also to maintain the strong economy needed to sustain them. Since 1996, the Howard Government has boosted spending on health and ageing from 15% to 22% of the federal budget. In the current financial year, the federal Government alone will spend $52 billion on health and ageing, including $13 billion through the Medicare Benefits Schedule, $9 billion under the Australian Health Care Agreements, $8 billion on aged care, $7 billion through the Pharmaceutical Benefits Scheme and $3 billion on private health insurance rebates. The Government has improved the private sector as an essential complement to a strong Medicare system. Most importantly, the Government has respected the fee-for-service principle because this is the best way to ensure that money is spent on patients rather than bureaucracy. Eleven-year-old governments do not change their spots. People can expect the same values and better services if the Government is returned. AffordabilityThe Howard Government has made health care more affordable through record bulk-billing rates, the new Medicare Safety Net and the Private Health Insurance Rebate. Since 2003, largely thanks to the bulk-billing incentive payments that were part of the Strengthening Medicare program, general practitioner bulk-billing rates have recovered to over 78%. For children under 16 years, people over 65 and people living in rural areas, bulk-billing rates are now at an all-time high. At 73%, the overall bulk-billing rate for GPs and specialists is also at an all-time high, 2 percentage points above the rate in March 1996. Bulk-billing is important and should be widely available, especially for people who see their doctors frequently, but not everyone can expect to be bulk-billed for everything all the time. In 2004, the Government introduced a new Medicare Safety Net for people with high out-of-hospital, out-of-pocket medical costs to rebate 80% of the gap between the Schedule fee and the doctor’s charge. Last year, more than 1.5 million Australians stood to benefit from this safety net, which paid an additional $260 million in Medicare rebates. By contrast, the Labor Party promised to abolish this safety net at the last election and is still making up its mind at this one. The Government has made private health insurance more affordable and more widely available, after private coverage fell from 70% to 35% under the former Labor Government. More than 9 million people (including a million people earning less than $25 000 a year) now have the choice and security that private cover brings. This is a 30% increase since the late 1990s. Although more than 80% of privately covered services have no gap, about 15% of private hospital episodes still involve gaps (averaging nearly $700), for which no informed financial consent was previously obtained. The Government is working with the Australian Medical Association and other professional bodies to ensure that patients are warned in advance about all reasonably foreseeable medical costs, because these “nasty surprises” cause people to drop their private cover. This Government is a reluctant regulator and hopes that it will not be necessary to make obtaining informed financial consent mandatory, but will have to act if rates do not continue to improve. WorkforceThanks to the Howard Government, record numbers of doctors and nurses are in training. Even before the Australian Medical Workforce Advisory Council formally told the Government in November 2002 that there was an across-the-board deficiency in future doctor numbers, the Government had been moving to expand doctor training places. In 2004, there were nearly 1300 medical graduates from Australian universities. In 2012, there will be about 2800 domestic graduates. There have also been large expansions in places for other health professionals (including, most recently, 500 extra places a year for enrolled nurses trained wholly within hospitals). The Government has already committed $60 million for registrar positions outside public hospitals, and will continue to expand private-sector procedural training, as almost 60% of all operations are now done in that sector. The Government has funded nine new medical schools and established 14 rural clinical schools and 11 university departments of rural health. The Government is paying country doctors up to $25 000 a year in special rural retention payments and has boosted the pay and training support offered to rural proceduralists. This has already boosted country doctor numbers by 30% since 1996 (in full-time workload equivalent terms based on Medicare data), but more needs to be done as small country centres are always only a retirement away from a workforce crisis. The Government is working with the states to establish a national system for the registration and accreditation of health professionals. Once registered, doctors (and other health professionals) should be able to work anywhere, and there should be a high, uniform professional standard for everyone practising in Australia. Under the Government’s model, each profession will have its own national registration and accreditation board to set standards and procedures. Each national professional board will be assisted by a national registration and accreditation secretariat. Existing state registration boards will become committees of the national board and will administer the registration process in their state. Each board will be sovereign over its own profession, subject only to the national Health Ministers Council, which will operate by consensus. There will be a national health registration advisory council, but it will have no authority over the individual professions’ boards. The Government will continue to oppose any state’s move to use national registration to push “task substitution”. For instance, the Government supports the use of nurses in general practice as part of a team rather than as independent nurse practitioners. Chronic diseaseWithin a generation, chronic disease (such as heart disease, the complications of diabetes, and cancer) will account for 80% of Australia’s total disease burden. The Government has anticipated this by expanding Medicare to prevent the onset of chronic disease and to treat it in the community before it triggers life-threatening crises requiring admission to hospital. Since 1999, under the Enhanced Primary Care Program, the Government has encouraged GPs to focus on promoting wellness as much as on treating sickness. After a series of refinements, this Program is now working well for patients with chronic disease. In the past financial year, there were nearly 700 000 Medicare-funded GP care plans, nearly 400 000 team care plans, and nearly a million Medicare-funded allied health professional consultations on GP referral. In the first 8 months of operation, there were nearly 300 000 GP mental health care plans and nearly 600 000 Medicare-funded psychologist consultations. As well, in the past financial year, there were more than 250 000 Medicare-funded comprehensive health checks for people aged over 75. The Budget changes to the Medicare dental scheme are likely to be one of the most important recent innovations in health. From 1 November 2007, GPs can refer patients who have team care plans to private dentists for up to $4250 worth of Medicare-funded dental work. This is directed to people with chronic disease and contributing poor oral health, rather than to the 650 000 people estimated to be on state public dental waiting lists. Still, many of the latter are pensioners who are likely to be covered by the new measure, which, like all Medicare programs, will be demand-driven rather than budget-limited. From 1 November, Medicare will fund longer consultant physician items for patients with multiple morbidities. From mid 2008, there will be subsidised lifestyle modification classes available on GP referral for patients at serious risk of developing type 2 diabetes. It is too early to be definitive about the reductions in hospital admissions arising from the use of care plans. Still, general practices involved in the collaborative quality improvement program report significant improvements in patients’ management of blood sugar and other chronic-disease variables. Certainly, more practices are starting to focus on their patients’ long-term health outcomes. As well, GPs are becoming health managers for their patients, coordinating the delivery of a network of Medicare-funded services, rather than simply treating as much as they can themselves. There are still many GPs in solo or small practices delivering excellent care. There are also increasing numbers of primary health care centres involving collocated GPs, practice nurses, visiting specialists, part-time allied health professionals, on-site diagnostic services and a pharmacy. These are largely funded through Medicare on a fee-for-service basis. They represent private health professionals’ intelligent responses to the changing imperatives of health care under the Medicare system. This sensible evolution of services is potentially threatened by government-funded “super clinics” in competition with the private profession. Seamless health care deliveryWhich level of government delivers care is not important as long as it is the right care at the right time. The fact that public hospitals are the responsibility of the state governments, while most other health programs are the responsibility of the federal government, does not matter as long as people receive the appropriate level of care. The existing divisions of governmental responsibility are a function of history rather than logical design. This does not mean that health institutions cannot be made to work well as things stand, or that the theoretical benefits of major structural change justify the costs of upheaval. For its part, the Howard Government is determined to run federal health programs well, effectively manage the interface between federal and state programs, and fund state health services in ways which maximise service delivery. This Government believes in solving problems, not creating more bureaucracies or inquiries to tell people what they already know. The states habitually claim that public hospital problems are really the federal government’s fault. In fact, the triage system means that emergency patients are seen promptly, and general practice-type patients are seen only when there are no more pressing cases. In any event, the Government has restored bulk-billing rates and funded over 140 after-hours GP services since 2004 through higher Medicare rebates and cash grants. Some of these have been collocated with public hospital emergency departments. As well, the Government has boosted the number of operational aged care places, from 145 000 in 1996 to 210 000 now; funded 2000 “step-down” places under the current Health Care Agreement, and introduced a transition care program for 13 000 patients a year who are too sick to go home but no longer need acute hospital services. Public hospital problems are caused more by bad management than by poor funding. Doctors and nurses are the “meat in the sandwich” between penny-pinching managers and the patients affected by their decisions. The states’ “top-down” management structures typically give local managers little real autonomy. Any local revenue is invariably “clawed back” by head office. Critical new spending decisions are invariably referred to committees, and then passed up the line to a director-general or the minister’s office for further procrastination. It is no wonder that many of the best staff seek refuge in the private sector, while their colleagues soldier on out of a sense of duty to patients rather than faith in their superiors. Putting a different bunch of bureaucrats in charge will not be change for the better. The proposal for a Commonwealth-funded, community-controlled public hospital at the Mersey site in Tasmania is about running hospitals better, not swapping a state bureaucracy with a federal one. It is not a precursor to the federal takeover of all public hospitals, but a test case for a better management system that the states should consider adopting. The Mersey will be run by a chief executive officer accountable to a local hospital board, including representation from local hospital staff. Staff will have an incentive to be creative because the hospital will keep any extra revenue. The government’s immediate postelection task will be the renegotiation of the Health Care Agreements. At present, these are block grants to the states. How the states spend the $42 billion the Agreements provide is entirely up to them. All that is required in return is to at least match the growth in Commonwealth funding, report on waiting lists, and guarantee to treat public patients at no charge. A re-elected Government will provide at least as much public hospital funding under future Agreements as it does under the current ones. The Government is considering how the next Agreements might drive better hospital performance and, in the long term, fund services rather than bureaucracies. Certainly, the next Agreements should be about better services to patients rather than turf wars between governments. There are two further matters vital to modern service delivery and fair health systems in Australia. The Government will make Pharmaceutical Benefits Scheme and Medicare data on patients available to these patients online, securely and accessibly, before the end of 2008 as its practical contribution to establishing an integrated electronic health record. The Government will also ensure that there is sustained follow-up treatment for problems identified by Indigenous child health checks in the Northern Territory. Spending on Indigenous health and aged care programs has more than doubled in real terms since 1996, but more needs to be done to give Indigenous patients access to health services comparable to that of the general Australian community. Australians are entitled to have high expectations of their health care systems and to demand much of the governments responsible for them. The latest opinion poll reveals that people are twice as inclined to blame the state governments as the federal government for problems in health care. This might be a good guide as to which side of politics can really be trusted to keep Medicare safe.

Tony Abbott MP

In view of the impending election, we asked representatives from the two major political parties for their policies on health. The Shadow Minister for Health replies. Labor recognises that national leadership is needed to drive better health outcomes for the community. Hospitals and health services are struggling to meet demand; our health workforce is overworked and under stress; and many Australians have problems accessing the care they need. Federal Labor has a $2 billion health and hospital reform plan which will kick-start the reform process needed to end the “blame game” between the states and the Commonwealth, to better equip our health system for the needs of the future, and to put preventive health care at the centre of our approach, rather than at the margins. Poor health affects the quality of life of Australians and their families, and can have significant economic effects by reducing their ability to participate in the workforce and through lost productivity and higher costs for business. A constellation of challenges face our health system: Long term trends, such as population ageing, the increasing prevalence of chronic disease, labour costs and shortages, and the escalating cost of new health technologies; Costs and inefficiencies generated by blame and cost shifting between levels of government over funding agreements that concentrate on inputs rather than health outcomes; Health care services that reflect these flawed funding arrangements rather than the needs of patients; and Health care services that fail to intervene early or comprehensively to maximise people’s productivity and workforce participation. Under the Howard Government, our health system is plagued by rising costs and is increasingly unable to cope with the changing health needs of Australian families. Labor believes change is needed to ensure these challenges are tackled, guaranteeing the long-term sustainability of the Australian health system. Australians are sick and tired of politicians passing the buck when it comes to health care and hospitals. To end the blame game, Federal Labor has announced that it will take responsibility for improving Australia’s health and hospital system — easing pressures on families and delivering long-term productivity benefits to the community. To deliver that change, Labor has proposed the single biggest health reform since Federation. Big picture reform: Labor’s National Health and Hospitals Reform PlanA Rudd Labor Government will invest $2 billion in a National Health and Hospitals Reform Plan to kick-start investment in immediate reforms to reduce blame and cost shifting and improve health services for Australians. Labor’s reform funding program will: Invest in hospital and primary care infrastructure that will help drive needed reforms; Provide incentive payments to state and territory governments if they achieve agreed reform milestones based on improved health outcomes, not simply inputs; and Provide more appropriate care options for older Australians. Our aim is to improve health outcomes and reduce the pressure on our hospitals. We will fund projects that: Reduce avoidable hospitalisations and readmissions to hospital; Reduce non-urgent accident and emergency presentations; Decrease waiting times for people who require essential hospital services, such as elective surgery; Provide more appropriate non-acute care for older Australians; and Increase access to medical and specialist services in the community. Within the first 100 days of its election, a Federal Labor Government, through the Council of Australian Governments (COAG), will establish a National Health and Hospitals Reform Commission to develop a long-term health reform plan for the nation. This Commission, headed by an eminent Australian, will, in cooperation with the states and territories, and in consultation with health experts, professionals and consumers, develop stringent performance benchmarks that the states and territories will be required to meet. Pressing issues, ranging from rural health to workforce, will be key parts of the Commission’s work. The Commission’s early work will form the framework for developing the next Australian Health Care Agreements. Our aim is to deliver better health outcomes through negotiation with the states. However, if the states and territories have not begun implementing a national reform plan by the middle of 2009, a Rudd Labor Government will seek a mandate from the Australian people for the Commonwealth to assume full funding responsibility for the nation’s public hospitals. If a Commonwealth takeover of hospital funding was supported by the Australian people, a model would be devised that ensures the future of state, private and community-managed hospitals. There would be provision for regional and local authorities to participate in the management of public hospitals and to ensure responsiveness of local hospitals to community needs. Under Labor’s proposal, no public hospitals would be managed directly from Canberra. The assumption of Commonwealth funding for all public hospitals would require a parallel reduction in Commonwealth outlays to the states and territories at the point of transfer, to ensure there would be no windfall gain of any description to the states and territories. Despite some mischievous suggestions, this will under no circumstances involve an increase to the GST. At the time of writing, three important components of this national strategy have been detailed. GP Super ClinicsAs part of the $2 billion Health and Hospitals Reform Plan, a Rudd Labor Government will invest $220 million in the health system to establish GP Super Clinics in local communities — bolstering frontline health care for Australian families. Labor’s GP Super Clinics plan will help get doctors and other health professionals into areas that need them most, working together to meet the new service delivery challenges of modern medicine. The plan will provide infrastructure funding for general practitioners and other health professionals, including allied health workers, nurses and some specialists, to work together in the one place, providing a greater range of quality services in local communities — and much greater convenience for patients. The clinics will be tailored to the needs of local communities and particularly targeted to rural, regional and outer urban areas where Medicare has not been utilised to its fullest extent because of workforce shortages. Along with incentives to pay for administrative and nursing support, funds can be used to provide teaching rooms and facilities to make the GP Super Clinics attractive to new graduates, trainees and GP registrars — encouraging health workers into regions where there are currently workforce shortages. With 65% of Australia affected by a GP workforce shortage, initiatives that encourage doctors to train and work in underserviced areas are crucial to the long-term sustainability of our health system. By having renovated or purpose-built facilities that allow space for group sessions and a range of staff, the GP Super Clinics will have a particular focus on assisting people to stay well or to better manage existing chronic conditions. Labor’s GP Super Clinics will: Help take the pressure off hospitals; Provide a greater focus for tackling the challenge of chronic disease in local communities; Attract medical graduates and health professionals to areas of need; and Mean much greater convenience for patients. Aged careCurrently, about 2300 older Australians who have been assessed as needing residential aged care are waiting in hospital wards. Some have waited months for a bed in a nursing home. This is tough on families, and also means that much needed hospital beds are not available to Australians of all ages waiting for surgery or medical treatment. A Rudd Labor Government will help older Australians waiting in hospital wards to get an aged care bed or to return home sooner. This will ensure that older Australians get more appropriate care, and that significant pressure is taken off our hospital system. Under Federal Labor’s initiative, $158 million will be invested over the next 5 years to create up to 2000 transition care beds for older Australians who are currently waiting in hospital for an aged care bed and to allow others to return to their home. Federal Labor will also provide $300 million of loans at zero real interest rates to aged care providers to make up to 2500 permanent residential aged care beds available sooner to older Australians. Preventive healthFor the past year, Federal Labor has been arguing to move prevention to the centre, not the margins, of our health system. A Rudd Labor Government will treat preventive health care as a first-order economic challenge, as well as a health issue — because failure to do so will have a long-term negative impact on workforce participation, growth in productivity and the overall health budget. A Rudd Labor Government has committed to: Develop a National Preventative Health Strategy to provide a blueprint for tackling the burden of chronic disease, with an initial focus on obesity, tobacco and excessive consumption of alcohol. The Strategy will be supported by an expert taskforce. Shift the focus from so-called “6-minute medicine” in general practice by beginning a reform process to provide incentives for GPs to practise quality preventive health care, including longer consultations; Broaden the focus of the major health care agreement between the Commonwealth and the states and territories beyond hospital funding by developing a National Preventative Health Care Partnership; and In its first term, commission the Treasury to produce a series of definitive reports on the impact of chronic disease on the Australian economy, and the economic benefits of a greater focus on prevention in health care. A focus on prevention would mean nothing without attention to the health of Australian children. There can be no better investment in Australia’s future. By ensuring that children are able to develop healthy habits early in life, we take a significant step forward in our battle against chronic diseases. We have committed Labor to some major initiatives for children: All children starting school will receive a health and early skills assessment. The Healthy Kids Check will include an assessment of a child’s basic health, such as teeth, hearing, balance and sight. The Australian Early Development Index will be rolled out from 2008. This rigorous checklist, covering five key aspects of children’s development, will assess how Australian children are faring when they reach school age. A Healthy Habits for Life guide will provide practical information to help parents assist their children to develop healthy habits for life. $12.8 million will be provided to establish the Stephanie Alexander Kitchen Garden Program in 190 primary schools across Australia. The program will tackle the rising trend of childhood obesity by giving children hands-on experience in healthy eating: teaching them how to grow, harvest and cook produce, as part of the school curriculum. $1.7 million will fund research that brings together the lessons learned from community obesity prevention projects, analyses the data to determine which projects work, and shares this knowledge with other communities who want to be involved in similar initiatives. $3.5 million will be provided to develop and distribute guidelines on healthy eating and physical activity in early childhood settings. This package forms the start of the comprehensive approach needed to tackle children’s health and the particular issues with childhood obesity. Severe problems in our health systemFor years, Australia has struggled to provide decent health services to our Indigenous and rural communities. Delivery is often hampered by workforce shortages, which have not been planned for, or dealt with consistently, by the Howard Government. These issues, and Labor’s commitments, will be part of Labor’s overall health strategy, but some concerns and commitments are flagged here as an indicator of our concern. Rural healthInvestment under Labor’s $2 billion National Health and Hospitals Reform Plan will prioritise areas where need is greatest, based on indicators that include workforce shortages and poor infrastructure. Those areas will include many rural and remote areas of Australia, as we have noted with our GP Super Clinics plan. The Reform Commission will have the task of developing a long-term rural health strategy. Federal Labor believes it is worth considering in this process whether the next Australian Health Care Agreements should include a rural health service commitment. It is time to consolidate and invest in existing successes, not to continue with more and more pilot programs. Consistent with this approach, Federal Labor will reform the Rural Medical Infrastructure Fund, expanding its eligibility and raising its funding cap to ensure more communities can access this important source of funding. Indigenous healthA Rudd Labor Government has committed to closing the 17-year gap in life expectancy at birth between Indigenous and non-Indigenous people within a generation. Labor will make a $260 million down-payment on this commitment with our investment in Indigenous early childhood health. This initiative will ensure that Indigenous women have access to: Proper antenatal care (including a visit to a midwife or doctor, an ultrasound examination and a general health check); Practical advice on parenting, breastfeeding and nutrition for their babies; Home visit services for new Indigenous mothers and children aged 0–8 years (in conjunction with the states and territories). Dental healthLabor has announced the first instalment of its plan to establish a Commonwealth Dental Health Program and will fund up to one million additional dental consultations and treatments for Australians needing dental care. Federal Labor will invest up to $290 million in a Commonwealth Dental Health Program — one of the first programs scrapped by the Howard Government in 1996. The Howard Government’s Medicare Chronic Disease Management scheme has failed to help the hundreds of thousands languishing on dental waiting lists. Over the past 3 years, it has helped only 7000 people, owing to its complex eligibility and referral criteria. The complexity of the referral process has also overloaded GPs with even more red tape, creating more work for doctors who are already under pressure. As part of Federal Labor’s determination to take national leadership and end the blame game in health, our funding will be available for the states and territories to help clear the backlog at public dental clinics. They will either supplement their existing services or purchase private-sector appointments for the hundreds of thousands stuck on their waiting lists. Our dental plan is a significant investment in making health care more affordable for Australians. We know that rising health costs under the Howard Government are a challenge for many families, and we will work to tackle this situation. Because we realise that many family budgets now rely on them, we support the private health insurance rebates and the Medicare Safety Net. ConclusionFederal Labor has outlined a clear, comprehensive national strategy for health care. A national, coordinated strategy has been lacking from Australia’s health system for far too long. Federal Labor believes that the long-term challenges facing Australia in health must begin to be tackled immediately. That is why Labor has announced policies in key areas of health, including primary care, hospitals, prevention and chronic disease, children’s health, dental health, aged care and Indigenous health. Australia deserves a government willing to re-examine the health system, and to drive the changes that we all know are needed. A Rudd Labor Government will do precisely that, delivering clear solutions, responding to the needs of people across Australia, and establishing a long-term direction for the future of health in Australia.

Nicola Roxon MP

The President of the AMA describes the key issues for health This is an exceptional election. Many Australians have memories only of a federal Liberal Government in power, and a health system based on Medicare and public hospitals, with a greater balance and contribution from the private sector in the past few years. The issue for the Australian Medical Association (AMA) is: what will this federal election outcome deliver for the health of Australians? We believe that our health system provides for the community to a degree, but at the same time needs rejuvenation. The AMA wants to ensure that the health system is capable of serving the Australian community properly into the next decade and beyond. The system needs to incorporate clinician-driven ideas, fresh thinking, and more strategically targeted and audited funding and resources. The AMA has put forward its blueprint for reform in the Key health issues for the 2007 federal election document.1 This is not an all-encompassing plan, but highlights the pillars of health that must be reinforced if we are to continue to provide high quality and affordable health services in an equitable way to all Australians — and to ensure that we cover any gaps and improve areas of concern. A few months ago, health was missing from the political table. Neither of the major parties was raising the bids in the great pre-election health policy debate. However, as Election Day draws nearer, health policy continues to rise on the ladder of vote-changing election priorities. Health policy may well decide this election. The signs are there. And some of these indicate a change in thinking. The Government played a trump card with its Indigenous health and child abuse intervention in the Northern Territory, but it is still too early to judge the success of this action. The Mersey Hospital takeover in Tasmania has delivered mixed results for the Government. Is it a one-off to win a marginal seat, or is it a test case for things to come? Perhaps the Coalition is betting that all health politics are local, affecting individuals at the coalface. Meanwhile, the Opposition is running hard with preventive care, its $2 billion National Health and Hospitals Reform Plan, and GP Super Clinics. Questions remain in regard to all these initiatives. Both sides are determined to win the hearts, minds and health votes of the Australian people. The AMA is interested in what will be delivered in terms of real service for Australians. While Labor still promotes itself as the party that brought you Medicare, which is popular with voters, the party has been out of power for 11 years. In that time, the Coalition has established impressive credentials in health policy, especially since 2004. The Medicare Safety Net, the private health insurance rebate and lifetime health cover, additional rebates for bulk-billing children and health care card holders, and “for and on behalf of” items for practice nurses and allied health providers have all added value to the health system and enhanced the ability of medical practitioners to deliver quality health care. Labor has now embraced these changes. While Australia has a good health system by world standards, there is more to do. The AMA does not support “big bang” reform to set the health system up for the next decade. We need to identify and build on the positives. Each year, the system delivers a large number of high-quality health services for a relatively modest overall cost (about 10% of gross domestic product, middle-ranking among OECD countries2). Australians enjoy good health outcomes. For example, the World Health Organization, in its World health report 2000, ranked Australia second in the world for disability-adjusted life expectancy.3 There is value for money in the system: each year, Australians access some 260 million medical services through Medicare (more again in public hospitals), while one in three Australians accesses in-hospital care. The medical workforce works hard to render 100 million general practitioner consultations each year, performing a gatekeeper role that seeks to achieve appropriate early intervention while avoiding wasteful overuse of investigative, specialist consulting and hospital services. There is always room for improvement, particularly in meeting the health challenges of an ageing population. The strengths of the Australian health system include: A well trained, highly professional health workforce; Good quality health infrastructure; Complementary public and private health providers; and A productive health research sector. The weaknesses of the Australian health system largely arise because the nation has not invested enough in the health of the nation. Australia has failed to: Adequately meet the overall current demand for health care; Train enough health professionals to meet the rising expectations and increasing needs of an ageing population; Significantly improve the very poor health status of Aboriginal and Torres Strait Islander peoples; Find ways to deliver adequate health care to people living in rural and remote areas; and Properly educate and inform the community on health promotion and health prevention. Now is the time to invest — and invest substantially and strategically — in the future health of our nation and our people. The AMA’s Key health issues document articulates where the investment needs to be made.1 Indigenous healthAboriginal and Torres Strait Islander peoples have the poorest health of any group living in Australia. Indigenous standardised mortality ratios are more than three times the expected rate, and death rates in the 25–54-years age group are five to eight times those seen in non-Indigenous Australians. Indigenous infant mortality rates are three times higher than for non-Indigenous infants. The 17-year gap in life expectancy between Aboriginal and Torres Strait Islander Australians and the rest of the Australian population must be closed. It is not acceptable in 2007 for any Australian to have a 1920s’ life expectancy. The AMA calls for an additional $460 million per year in targeted resources, particularly for primary care, to be delivered in consultation with Indigenous communities and Indigenous health professionals. Public hospitalsOur public hospitals are dangerously underfunded and under-resourced. Waiting times are long. Emergency departments are overwhelmed and under unsustainable pressure. Doctors are working long hours. Morale is low and at crisis level. Patients want access to good-quality public hospital services in a timely manner. Generally, emergency services fall short of reasonable expectations. Public hospitals should not operate for extended periods at more than 85% bed occupancy. Some public hospitals in Australia are operating at 120% occupancy. Patients are treated in corridors. Patients want to be treated in appropriate settings and to be assured of the safety of the system. All contenders for the election need to take the public into their confidence and, before the election, explain their solutions to the current woes of the public hospital system. The federal government must increase its current funding effort by 8%–9% per annum over the life of the next Australian Health Care Agreement, and commit to a joint federal–state “fix” and regular public audit of the system. Medical workforceIn response to increasingly serious workforce shortages, the Australian Government has embarked on the most significant expansion of medical student places that Australia has ever seen, and announced further measures to increase nursing intakes. Between 2006 and 2012, the number of graduates from medical schools will double. This presents Australia with a unique opportunity to reduce its heavy reliance on overseas-trained doctors. By 2013, around 3400 intern places per year will be required (current numbers are less than half that, at 1622). Similar increases in vocational training places will also be needed. This is a huge challenge for governments, hospitals and medical colleges. A critical issue will be the expansion of training places without compromising the high standards that have underpinned the high quality of the Australian medical workforce. In particular, if doctors are not given enough experience in dealing with a wide range of medical conditions, then the quality of their training will suffer, and the high quality of patient care will be compromised. Workforce substitution (using lesser trained professionals) is not the solution. When Australians are sick or injured, they want to see a doctor. The federal government must provide additional funding and work with the AMA to establish a system for GP training, prevocational training in general practice, specialist training, and training in expanded clinical and rural settings. The states and territories should be locked into cooperating with these arrangements through the Australian Health Care Agreements. Aged careDemand for aged care services is growing rapidly. We are seeing accelerated growth in numbers in the older age group (those aged 65 years and over) and even faster growth in the very old (those aged 85 and over). The AMA expects there will be an increasing preference by users for care in the community, where possible (and for as long as possible), and an increasing need to provide quality dementia care in all settings. A shortage of adequately skilled staff, disincentives for GPs to provide services in both residential and community aged care settings, and difficulty accessing medical specialists continue to affect the quality of care provided to older people. The federal government must lift funding across the board for aged care, and provide additional incentives for GPs to provide services in residential aged care facilities. This will involve better consulting rooms and equipment in these facilities, with access to computers for patient records and prescribing. Health promotion and preventionThe Australian health system has had an emphasis on curative services. To meet patient hopes and expectations, Australia must become more effective in health promotion and prevention. The responsibility for this falls widely on governments to invest in public health education and reinforcement of lifestyle improvements. Then individuals, GPs and allied health professionals can support and sustain healthy lifestyles and preventive medical interventions to have an impact into the future. Individual choices are very important in this area. But so too are the social and environmental factors that affect how people live and work, such as education, income, housing and employment. The key health promotion and prevention challenges include smoking; alcohol and drug misuse; immunisation; obesity; nutrition and exercise; and lifestyle diseases such as diabetes. Government has a leadership role in each of these areas. The AMA calls on the federal government to give GPs greater incentives to spend more time with their patients on health promotion and prevention. Rural healthRural and remote Australia is undergoing great change. Some rural communities are growing rapidly through “sea change” population movements, putting considerable pressure on health and community services. Other communities are struggling to survive a prolonged, drought-accentuated decline. Rural and remote areas deserve, but have not enjoyed, a “fair go” when it comes to access to health care. The lack of access to quality facilities, services and doctors is a key barrier to improving the health and wellbeing of rural communities. Health care in rural areas depends on a strong primary health care workforce and a viable public hospital system. Country patients miss out if they do not have both. Further, without access to quality public hospital facilities, doctors cannot maintain their procedural skill levels, and the opportunity to train new doctors in rural areas is greatly diminished, leaving many communities with no doctors or too few doctors. The AMA wants the government to link rural health to its recent generous drought-relief programs. Whenever funding is allocated to keep people on the land and working in regional communities, to produce food and resources for the nation and for export, a similar priority should be given to providing the medical workforce and equipment needed to keep the rural population healthy and able to work and support their families. The Rural Medical Infrastructure Fund, Patient Assisted Travel Scheme, Medical Specialist Outreach Assistance Program, Rural Retention Program and telemedicine programs need a substantial boost in funding and resources. The federal government must take a leadership role in providing rural and regional Australia with properly resourced doctors in adequate numbers to serve local communities. Preserving the independence of the medical professionOne of the hardest messages to get into the heads of politicians of all persuasions is that the health system cannot succeed without a well trained, independent medical workforce. Patients want to see doctors, and have a right to do so. Too much effort is being put into second-best or third-best options when attempting to solve medical workforce problems. The reality is that doctors cannot be replaced or substituted with lesser trained people. We need better utilisation of the health workforce through a carefully managed team approach, in which the doctor is always the coordinator of care and the clinical leader. Despite patient and community suspicion and concern about doctor substitution, some governments persist with proposals that will ultimately lead to poorer quality patient care. The Council of Australian Governments (COAG) has been pushing one of these perilous barrows for some time, in the form of its plan for a single national system of registration and accreditation for all nine health professions. The federal government has realised the risks in compromising the quality of the health workforce in this plan and is on the brink of rejecting the states-led initiative, but the election has taken the momentum out of this action. The COAG plan must be scrapped postelection, whoever wins. There has been mutual recognition of registration of medical practitioners between the jurisdictions for many years. The AMA supported previous attempts by the jurisdictions to harmonise standards to allow portability of registration across borders with a minimum of red tape. The last attempt to achieve portability for medical registration in 2003–2004 failed because not all the states and territories would agree on harmonising legislation. The new COAG model threatens the safety and quality of medical care in Australia, opening the door to government control — for political expediency — of the accreditation of all medical courses and undergraduate and specialist training. These roles should remain independent of government, and the Australian Medical Council must be retained. The quality of Australian doctors is a pillar of our health system. ConclusionThe AMA wants a government that is prepared to invest in health while times are wealthy, to tide us across the times ahead — with changing population demographics, increasing expectations, increasing ability to investigate and treat deformity and disease, and a sheer increase in population and chronic disease. This requires dollars, clinicians in the driver’s seat, and accountability at the community level. The AMA has some runs on the board, but the quest is eternal. Our responsibility to our patients and the doctors who serve them does not just peak pre-election; it is a constant work that extends beyond election cycles.

Rosanna Capolingua

Provision of incorrect information or incorrect data interpretation does not serve anyone well In this issue of the Journal, MacKenzie and colleagues present data to show that, over an 18-month period, media reports about prostate cancer were dominated by statements emphasising Australian men’s risk of prostate cancer, encouraging screening for early detection, and providing reassurance about side effects for treatments that emphasise emerging technologies (→ "The news is [not] all good": misrepresentations and inaccuracies in Australian news media reports on prostate cancer screening).1 In particular, they draw attention to rhetoric that unequivocally supports screening, which would seem to be irresponsible, given the lack of definitive data to show that population-based screening will reduce mortality. Although this is a fair comment to make, the enthusiasm with which the media has responded to the call to promote screening should not take anyone by surprise. Prostate cancer is the most common internal male malignancy in Australia and the second most common cause of cancer deaths in men.2 In 2003, there were 13 526 new cases of prostate cancer and 2837 deaths. By contrast, in that same year, 11 788 women were diagnosed with breast cancer and 2710 died of this disease. Although the biology of these cancers may differ, from the lay public point of view it is a “line ball” call. Little wonder then that, in the face of seeming inaction by government, consumer advocacy groups and some clinicians find a willing media to enter into a discourse that promotes action. In the context of a disease with a high community and individual burden, uncertainty about effective management plans and with no clearly articulated national public health strategy in place, advocacy such as this may be inevitable. A particular characteristic of this debate has been the polarisation of views for and against screening to the point where, at times, constructive debate has been constrained. However, it is important to differentiate between prostate-specific antigen (PSA) screening, with indiscriminate testing of all men (between prescribed ages), and testing after informed consent, as recommended by peak Australian cancer control and health agencies.3-6 Apart from the fact that PSA is not a test for prostate cancer and has no threshold level providing a high sensitivity and specificity, but rather has a continuum of prostate cancer risk at all values,7 a raised PSA level often commits men to the invasive procedure of transrectal ultrasound (TRUS) guided biopsies. Most men presenting for TRUS biopsies have serum PSA levels of 4–10 ng/mL and do not have prostate cancer detected with extended numbers of biopsy cores. If the diagnostic process were non-invasive and treatments with curative intent were not associated with significant unwanted effects, few would quibble about whether it is appropriate to be tested. Although estimates vary, there is no doubt that many men having treatment with curative intent are unlikely to benefit in terms of survival.8-10 Problematically though, such men are at risk of physical and psychosocial adverse effects from treatment that will affect both them and their partners.11,12 As a consequence, there is increasing support for stratifying patients, with an active surveillance protocol advocated for men identified as having low-risk prostate cancer.13 One expert advocates an intense monitoring protocol to identify the minority of low-risk patients (about 30%) with unappreciated aggressive disease for whom definitive therapy should be considered.13 However, this strategy can be undertaken only after biopsy diagnosis. There is no doubt that timely intervention does save lives. However, at the outset, men need to be fully informed of the possible adverse effects of potentially curative treatments and then consider whether, in the event of an abnormal PSA result and subsequent prostate cancer diagnosis, they would wish to proceed to treatment. Only then should they have a PSA test. Nomograms indicating cardiovascular life expectancy accurately may have a role in the future to allow a more tailored approach to overall management, including whether to proceed with prostate cancer testing. MacKenzie et al call for health authorities to commission and promote decision aids to assist men in making an informed decision about PSA testing for the early detection of cancer.1 Such decision aids already exist in a wide range of formats and have been shown to improve men’s understanding and knowledge about prostate cancer and to reduce decision-related conflict, although they have little effect on actual testing behaviour.14 The current need is not to develop more decision aids, but to translate shared and informed decision making about prostate cancer testing into primary care, the place where the decision to test is enacted.15 Barriers to translation include time constraints in busy general practices, general practitioner concerns about medicolegal risks, and GPs’ own knowledge and attitudes to prostate cancer testing. To address these barriers, a consortium, led by The Cancer Council Queensland and including The Cancer Council Australia, Australian Prostate Cancer Collaboration, Urological Society of Australia and New Zealand, and the National Cancer Control Initiative, developed an educational program and decision-aid showcard to support shared decision making about the early detection of prostate cancer in primary care.15 With funding from Andrology Australia, these materials are now available online, and uptake from general practice has been steady, with positive review by users.6 Importantly, the Prostate Cancer Foundation of Australia, as the leading prostate cancer consumer group in Australia, has been included in this initiative. This has been an important step in moving towards a constructive dialogue about this contentious issue. Whatever strategies emerge in terms of diagnosis and treatment in the future, provision of incorrect information, incorrect data interpretation or adverse consequences of the editing process itself do not serve anyone well, least of all patients and their relatives. Moreover, the task of supporting informed patient decision making is made more difficult when having to address misconceptions that may be derived from such reports. Articles such as that by MacKenzie et al highlight the need for media spokespeople to ensure that public discussion of prostate cancer is directed towards a realistic representation of the current status and limitations in relation to PSA testing and prostate cancer management in this country.

Suzanne K Steginga PhD · Robert (aka Frank) A Gardiner MD, FRCS, FRACS

Regulation of tobacco products and their emissions is long, long overdue The modern cigarette is an unmitigated public health disaster, more so than tobacco used in any other form. Together with other types of tobacco product, cigarettes are responsible for several million global deaths annually and expected to cause about 10 million annually by 2030.1 Modern cigarettes are uniquely efficient nicotine delivery devices because of sophisticated technology that controls such elements as pH and droplet size, and consequently provides rapid absorption and a rapid nicotine “fix” while using less tobacco, but many more additives, than its Second World War predecessor.2 Australia is at the forefront of the battle to control diseases caused by tobacco through the use of regulation of marketing and vigorous antismoking campaigns. The result is that “only” about a fifth of Australians smoke, and index diseases such as lung cancer and heart disease are declining in prevalence. There is, however, a strong social-class factor evident among continuing smokers, with the less educated and less well remunerated being over-represented in this population.3 Given Australia’s exemplary role in the regulation of cigarette marketing, it is bizarre that no regulations at all are applied to the product or its emissions. In this respect Australia is no different to most other countries as, apart from meaningless restrictions on tar, nicotine and carbon monoxide in Europe, no country worldwide has established control over cigarette emissions. A potential exception may be the United States, which currently has a bill before Congress that would empower the Food and Drug Administration to regulate cigarette emissions. The World Health Organization is moving to change this with its publication, The scientific basis of tobacco product regulation.4 This technical report sets out a practical rationale for regulating tobacco smoke, and makes specific recommendations for setting upper limits for two of the best understood carcinogens, the tobacco-specific nitrosamines, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) and N-nitrosonornicotine, with the indication of more proposals to follow, plus discussions of design features that contribute to toxicity and marketability, such as candy flavourings, and recommendations for future research. Consumer products of virtually all types are regulated. Controls apply to almost every marketed product, from the proportion of rat droppings permitted in wheat, to the amount of fat allowed in sausages, and even to the amount of mint allowed in nicotine replacement therapy. With this background, it seems astonishing that the federal Minister responsible for drug and alcohol policy recently rejected claims that a new tobacco product (a “heatbar” which heats but does not burn tobacco) should be subject to regulation and said there were no plans to even investigate the product.5 This product is unlikely to be any worse than other tobacco products. It may even be an improvement, but we won’t know if it is not to be investigated. There seems to be a general view that all cigarettes are dangerous, which is true, but also that they are all virtually the same. Not true. Nitrosamines, for example, are potent carcinogens whose level can readily be reduced, almost to the point of elimination, by the manufacturers, but this would increase production costs and the tobacco industry is moving very slowly, in most places not at all, to reduce them. A global analysis of the Philip Morris brand, Marlboro, in 1996 showed a ninefold variation in the amount of NNK per cigarette.6 This would be unremarkable if it was merely a flavouring agent. However, it is a carcinogen and such unnecessary variation should not be allowed. Most industries would move in this direction voluntarily, but the tobacco industry long ago gave up trying to make cigarettes “safer”.7 Instead, their research has focused on ways to make nicotine better absorbed, and for cigarettes to be more flavoursome as well as less harsh.8 The need to regulate the constituents of cigarette smoke is not trivial. With one in five Australians still smoking, and with even higher proportions among the blue-collar end of the social spectrum, the tobacco-associated death rate will remain unnecessarily high. It is high time to regulate to reduce those major toxins and carcinogens that can be reduced, as this is one way to help continuing and addicted smokers. The WHO has led the way and will continue to recommend practical changes. Countries as sophisticated as Australia should be able to move ahead of other less developed countries and, in the case of a new and untested product, could be expected to do so as a matter of urgency. The Australian Government should recognise the WHO recommendations and set in train a process of tobacco regulation — one that is flexible and can be updated as the WHO continues to develop its regulatory program. This would be consistent with the approach taken to both pharmaceuticals and other consumer products, and is very long overdue. Now that the WHO has set out a practical approach, the federal government has few excuses for further delay.

Nigel J Gray FRACP

The absence of information on immunisation after the age of 7 years leaves a public health void The Australian Government currently funds the Australian Childhood Immunisation Register, including financial incentives for vaccine providers and parents, to update and record vaccinations given to children up to 7 years of age.1 The register provides information enabling appropriate updating of vaccination status for young Australian children. It also provides invaluable data on immunisation coverage, allowing ongoing evaluation, at a population level, of implementation, impact on disease, and vaccine safety for current childhood vaccination programs. However, this information is not available for vaccines administered after 7 years of age, the number of which is steadily increasing with the availability and funding of new vaccines as part of the National Immunisation Program. In 2007, a separate register was developed for human papillomavirus vaccine. But, in the absence of a register for other vaccines administered after age 7, providers, clinical researchers and assessors of program implementation must rely on self-reported vaccination status or on locating vaccination records. In some other countries there are alternatives for accessing data on vaccination status at a population level (eg, the records of health maintenance organisations providing private health cover for sub-populations in the United States,2 or population-based linked databases such as a government-run initiative in Catalonia, Spain3), but none exist at present in Australia. In 2006, the Australian Government Department of Health and Ageing announced a scoping exercise to examine the need for a “whole-of-life” immunisation register.4 It is illuminating to consider some key points informing this important debate relating to vaccination of elderly Australians. These have included the potential impact of relying on self-report to vaccinate elderly Australians, as well as improvements in program evaluation and opportunistic vaccination that might occur with the introduction of an expanded immunisation register. Influenza vaccine and 23-valent pneumococcal polysaccharide vaccine (23vPPV) have been funded in Australia for people aged ≥ 65 years since 1998 and 2005, respectively. They have proven benefit against confirmed influenza and invasive pneumococcal disease in this age group. Yet current assessment of coverage achieved by the program is limited to annual telephone surveys based on self-reported data from about 1000 people from each jurisdiction, and excludes residents from institutions such as aged-care facilities.5 Adverse events are reported via passive surveillance to the Therapeutic Goods Administration. Such an approach is likely to provide much poorer population estimates than accessing an effective register for the entire population. In addition, providers vaccinating individuals must continue to rely on self-report or location of vaccination records, and there is no facility for evaluating program implementation in other recommended at-risk groups such as Indigenous adults. The most recent of two Australian studies examining the validity of self-reported 23vPPV and/or influenza vaccination status in elderly people, which included almost 3000 Victorians, confirmed that self-report is problematic.6 Compared with provider-confirmed dates of influenza vaccination in the previous year, self-report had low specificity (56%) and over-estimated true coverage by 10% (86% versus 76%) — estimates that fall within the range provided by earlier studies.7-10 Estimates for validity of self-reported 23vPPV status in the previous 5 years (76%–85%)7 are also consistent with these earlier studies. Further improvements in vaccination coverage for elderly Australians with 23vPPV and influenza vaccine are warranted, given recent population coverage estimates of 71%–79% (influenza vaccine)5,7,11 and 51%–53% (23vPPV).5,7,11 A study of opportunistic vaccination among 4772 elderly hospital inpatients11 revealed a zero in-hospital opportunistic vaccination rate, despite virtually all unvaccinated subjects having had multiple visits (an average of 12) to vaccine providers in the community or the same hospital in the year before admission. Furthermore, only 2% of the inpatients had had their 23vPPV or influenza vaccination status recorded during admission — an omission previously cited as the single most important factor impeding opportunistic vaccination.12 Providers clearly have competing priorities and are failing to fully implement vaccination policy. Given the difficulties inherent in relying on self-reported vaccination status or written records, a register would greatly improve ascertainment of vaccination status among elderly people and potentially contribute to delivery of more vaccinations. Influenza vaccine and 23vPPV for the elderly are just two examples. It is highly likely that a national vaccination register would also improve the delivery and assessment of other vaccines received after age 7. An expanded register with the facility to include current and new National Immunisation Program vaccines beyond the 0–7-year age group could improve vaccination status and prevent over-vaccination. It would also allow evaluation of programs and monitoring of adverse events, and would be a valuable addition to any future national data linkage system that included health care records and drug prescription data, for which Australia has the potential to be a world leader.13 How Australia chooses to record vaccination status for all of its citizens will require careful consideration of costs and will no doubt be examined by the current scoping exercise. Assessment of the issue should include the potential human costs of incomplete vaccination and suboptimal monitoring of adverse events related to vaccination.

Susan A Skull FAFPHM, FRACP, MAppEpid · Terence M Nolan FAFPHM, FRACP, PhD

Financial motivation can encourage greater sports injury prevention efforts A landmark study published recently in the BMJ has shown that the rate of catastrophic spinal injury in rugby union in New Zealand has halved.1 For the period 2001–2005, the rate was 1.3 spinal injuries per 100 000 players per year, compared with 2.7 per 100 000 players per year in the period 1996–2000, which was typical of the previous 25 years.1 This drop coincided with the introduction of “RugbySmart” (http://www.rugbysmart.co.nz), a 10-point annual injury prevention program that was made compulsory from 2001 for all coaches and referees in New Zealand.1,2 While the observational study does not claim that the drop in catastrophic spinal injuries can be unequivocally attributed to RugbySmart, an accompanying editorial in the BMJ stated: “The beauty of the RugbySmart programme is that it can do no harm, and according to the results of this study may do great good”.3 What is the current state of play with respect to catastrophic spinal injuries in rugby in Australia? Although comparisons of spinal injury rates between New Zealand and Australia are difficult,1 recently published rates in Australia are substantially higher (between 3.24 and 6.85 injuries per 100 000 players per year). New Zealand is in a much better position to accurately determine incidence rates because compensation for all injuries (both sporting and from other causes) is available through a universal, government-funded scheme operated by the Accident Compensation Corporation (ACC).6 From 2005, the Australian Rugby Union (ARU) instituted a similar (but less extensive) program called “SmartRugby” for its referees and coaches. Tests of its effectiveness have not been reported, but it should be noted that the ARU does not have nearly the same financial motivation as the ACC to make it successful. In New Zealand, the ACC compensates for all catastrophic spinal injuries with lifetime medical care and annual replacement of 80% of wages, which can be up to NZ$14 million per case.2 In Australia in 2005, the maximum compensation paid to a rugby player rendered quadriplegic was A$300 000, accurately described by Carmody et al as “grossly inadequate”.4 This is particularly so when compared with a median payout of A$7.6 million for quadriplegia in recent negligence cases in Australia.7 Orchard and Finch argued in 2002 that, from a public health viewpoint, New Zealand’s system of maintaining a government body that monitors, compensates and seeks to prevent sports injuries is superior to Australia’s lack of any comparable system.6 Noakes and Draper suggested that New Zealand’s drop in spinal injuries “would not have been possible if the New Zealand government did not provide a national insurance policy that also covers sports injuries”.3 The ACC can also claim other successes in preventing sports injuries that we have not yet achieved in Australia. Mouthguard use in rugby in New Zealand has increased from 67% to 93%, reducing rugby-related dental claims to the ACC by 43%.8 A similar analogy can be used — in Australia there is no organised body paying dental claims, so there is no strong financial motivation to encourage increased mouthguard usage. The ACC is already in the position where it is evaluating New Zealand’s national sports injury prevention programs (in many sports) for cost-effectiveness, in terms of reducing injuries and claim payments.9 By comparison, in Australia there is generally no monitoring of sports injury rates, let alone well coordinated national sports injury prevention programs in place. If a national body was created in Australia to take on this role, even if it was not fully funded out of general revenue like the ACC, at the very least it could insist that federal government funding for sports be tied to minimum standards of monitoring injury rates and instituting injury prevention programs. Reducing work-related and traffic accidents have been listed as two of the top 10 public health achievements of the 20th century.10 These achievements would not have been possible without major bodies having responsibility for monitoring injury rates and instituting preventive measures. New Zealand is already showing that this model works equally well for sports injuries, so why should it not be applied in Australia? A new federal government body would cost money to establish and maintain, but the New Zealand experience suggests that subsequent savings may soon cover the costs of establishment and operation.2 In conclusion, the following matters deserve our urgent attention in Australia: The creation of a federal government body either primarily responsible for monitoring and preventing sports injuries or, at the very least, delegating these responsibilities to sporting bodies in a coordinated fashion. This body should compensate for injury, either (1) totally, as is the case in New Zealand; or (2) partially, in conjunction with sporting bodies, private insurers, public hospitals and Medicare. The minimum compensation for complete quadriplegia occurring in sport in Australia should be increased at least tenfold, both (1) to bring compensation for sporting quadriplegia more into line with compensation for quadriplegia arising from other causes; and (2) to give compensating and sporting bodies a much stronger financial motivation for prevention, as is the case in New Zealand.

John W Orchard MD, PhD, FACSP · Stephen R Leeder PhD, FRACP, FAFPHM · Gary E Moorhead BA(Hons), MEd · Jessica J Coates LLB(Hons), BEc · Peter D Brukner MB BS, FACSP

Objective: To list and critically review recent inaccurate statements made by advocates of prostate cancer screening in Australian news media.Design: Accuracy audit of all news on prostate cancer broadcast on Sydney footprint free-to-air television stations between 2 May 2005 and 18 December 2006 (42 items), and published in print media from 6 February 2003 to 31 December 2006 in Australian capital cities (388 items). These contained 436 direct or attributed statements.Results: Of the 436 statements analysed, 44 (10%) were factually inaccurate or made claims not supported by the scientific literature or most cancer control agencies. Misleading statements about prostate screening and its sequelae were found in five categories: mortality from prostate cancer; expert agency support for screening; the efficacy of screening in preventing death from prostate cancer and the importance of early detection; the accuracy of the prostate-specific antigen test; and prevalence and severity of adverse effects from treatment.Conclusions: Despite near universal lack of support for prostate cancer screening of asymptomatic men by leading international and Australian cancer control agencies, Australians are exposed to an unbalanced stream of encouragement to seek testing. This coverage includes inaccurate information which ignores scientific evidence and the general lack of expert agency support.

Ross MacKenzie MA · Simon Chapman PhD · Alexandra Barratt PhD · Simon Holding BA

Objective: To describe tumour characteristics and clinical management of melanomas newly diagnosed in 1996 and in 2000 — before and after publication of the clinical practice Guidelines for the management of cutaneous melanoma by the Australian Cancer Network (1997), and their endorsement by the National Health and Medical Research Council (NHMRC) and republication (1999).Design and setting: Survey of clinicians involved in the management of patients with melanoma sampled from the Victorian Cancer Registry. The Registry is notified of all cases of cancer diagnosed by pathology laboratories and hospitals in both the public and private health sectors in the state of Victoria.Patients: People with a cutaneous melanoma newly diagnosed in 1996 and 2000. All invasive melanomas > 1.50 mm in thickness were included, and for each year random samples were selected of 100 each of invasive melanomas 0.76–1.50 mm in thickness, invasive melanomas ≤ 0.75 mm, and in-situ melanomas, plus 50 melanomas of unknown thickness.Main outcome measures: Biopsy method, adequacy of pathology reporting, adequacy of definitive excision (compared with margins recommended by the Guidelines), and follow-up procedures.Results: The use of partial biopsies increased between 1996 and 2000. Recommended margins of definitive excision were used in only 33.6% of cases. Margins were smaller than recommended for 36% of in-situ melanomas, risking recurrence of primary melanoma. Documented follow-up examinations for subsequent primary skin malignancy were uncommon (6%).Conclusions: Many aspects of the management of primary cutaneous melanoma appear not to meet the recommendations of the published Guidelines. Further studies to explore the reasons for failure to meet the Guideline recommendations are needed.

John W Kelly MD, FACD · Michael A Henderson MD, FRACS · Vicky J Thursfield BSc, GradDip(Applied Stats) · John Slavin FRCPA · Jill Ainslie FRANZCR · Graham G Giles PhD

Objective: To analyse changes in the incidence of injuries requiring hospitalisation for child passengers in motor vehicle crashes.Design, setting and participants: Population-based study of children (aged 0 –15 years) residing in New South Wales and admitted to hospital for injuries resulting from a traffic crash in the period 1 July 1998 – 30 June 2005, identified from the NSW Inpatient Statistics Collection.Main outcome measures: Age-standardised rates of hospitalisation for injuries, and trends by inpatient demographics, severity of injuries, and injury sites and types.Results: 2297 children were hospitalised for injuries sustained in a motor vehicle crash over the study period. The overall hospitalisation rate for injuries was relatively constant, with a non-significant decline of − 0.4% (95% CI, − 3.1% to 2.3%). The rate of hospitalisation for serious injuries also declined non-significantly (− 5.5% [95% CI, −11.8% to 1.1%]). Only hospitalisation rates for traumatic brain injuries declined significantly (−11.1% [95% CI, −19.0% to − 2.8%]) over the study period.Conclusion: The rate of hospitalisation for injuries to NSW-resident child motor vehicle passengers due to traffic crashes has not significantly decreased. High hospitalisation rates and the subsequent burden to the community and public health system make further injury prevention efforts for child motor vehicle passengers a priority.

Wei Du MPH · Caroline F Finch PhD · Andrew Hayen PhD · Julie Hatfield PhD

Straightforward, unambiguous terminology can reduce the risk of labelling patients inappropriately Whenever the definition of a diagnostic term is changed, a Pandora’s box of potential confusion is opened. Are all clinicians and research investigators using the same criteria? If a patient has been given a diagnostic label, does it refer to the old or the new definition? Barrett’s oesophagus has changed its definition more than once over the past five decades and is a prime example of how changing definitions causes confusion for clinicians and investigators alike.1,2 A solution to this problem lies in avoiding the potentially confusing term “Barrett’s oesophagus” altogether. Moreover, this is possible by using existing terminology without the need for any new definitions. Historical perspectiveBarrett’s oesophagus takes its name from Norman Barrett, who published on the subject in 1950.1,2 He observed that, in some individuals, the oesophagus is lined by glandular rather than squamous mucosa, and he assumed, like some earlier investigators, that a congenitally short oesophagus had drawn the stomach into the thorax. However, within a few years studies had shown that this columnar-lined tubular structure was not stomach, but true oesophagus characterised by submucosal glands and muscularis propria typical of the oesophagus. Furthermore, it often had islands of squamous epithelium. Since it was assumed that the presence of gastric mucosa in the distal oesophagus might be a normal occurrence, early investigators into the phenomenon wished to avoid false positive diagnoses by excluding anyone who might have putatively normal glandular mucosa at the distal end of the oesophagus, and thus ensure that only patients who really did have metaplastic glandular mucosa were included in their studies. They therefore set arbitrary criteria for the length of columnar lining in the tubular oesophagus required for a diagnosis of Barrett’s oesophagus; some investigators stipulated 3 cm, others 2 cm.1 During the 1960s, clinicians adopted these inclusion criteria as literal definitions of Barrett’s oesophagus, and considered glandular mucosa in the distal 3 cm or 2 cm of the oesophagus to be normal. However, there is very little evidence that gastric mucosa normally extends proximal to the anatomical gastro-oesophageal junction, and some researchers believe that any such extension is abnormal (ie, columnar metaplasia).2,3 These early studies established that glandular metaplasia of the distal oesophagus is caused by reflux, and that the normal mucosa is replaced by a mosaic of glandular epithelium of various types: cardiac, intestinal, and/or gastric fundic with parietal cells.2,4-7 The general term “columnar metaplasia” is appropriate for all three types. However, in the 1980s it became clear that the risk of developing adenocarcinoma was particularly associated with the intestinal type of epithelium.8 As a result, researchers whose major focus was the oncogenic potential of the condition defined Barrett’s oesophagus as the presence anywhere in the oesophagus of intestinal metaplasia (IM), as shown by the presence of goblet cells in histological sections.1 Clinicians again followed the cue of the researchers, and the definition changed once more so that Barrett’s oesophagus became synonymous with oesophageal IM. This concept has been refined, and the definition promulgated by a number of international consensus conferences is that Barrett’s oesophagus is diagnosed when columnar epithelium containing goblet cells is found in a biopsy from mucosa having the endoscopic features of Barrett’s oesophagus.4,7,9-11 Current usage of “Barrett’s oesophagus”Despite this definition, the requirement for goblet cells has not been applied consistently. Some pathologists continue to use the term Barrett’s oesophagus for any glandular mucosa in the true oesophagus, whether it be of fundic, cardiac, or intestinal type. This position seems to have been more common in the United Kingdom, and recent guidelines issued by the British Society of Gastroenterology explicitly state that IM is not necessary for the diagnosis.12,13 The rationale is that sampling errors at endoscopy may miss foci of IM, but that essentially all patients, at least those with long-segment disease, will show IM at some time if enough biopsies are taken.13 However, there is evidence that this assumption may be erroneous: in a large population-based study in Northern Ireland, patients with columnar metaplasia of the oesophagus had an increased risk of developing adenocarcinoma only if IM was found; furthermore, there was 93% concordance between IM status on the first biopsy and any subsequent biopsy.14,15 These results suggest that some patients simply do not exhibit IM in their columnar-lined oesophagus, and that biopsies are able to divide patients into well stratified risk groups based on this fact. Consistent with this conclusion are the observations of others that even multiple biopsies, especially in short-segment disease, sometimes contain no goblet cells.16 It is unfortunate, to say the least, that doctors in different parts of the world should be using completely different diagnostic criteria. The potential for miscommunication between clinicians and researchers is obvious. The problem of oesophagus versus stomachA significant practical diagnostic problem arises if Barrett’s oesophagus is defined by the presence of IM, because the diagnosis is only correct if the biopsy specimen showing IM comes from the oesophagus (ie, mucosa that was previously squamous) and not from the stomach. This distinction is important because, despite the methodological problems that plague studies in this area, there is evidence that IM of the proximal stomach is different clinically and pathologically from IM in the oesophagus. Therefore, “Barrett’s oesophagus” should be avoided if the specimen might have come from the stomach, because the diagnostic label could imply the wrong disease process. In particular, compared with IM in the gastric cardia, IM in the oesophagus is more likely to be associated with reflux and more likely to become dysplastic.17 On the other hand, patients with IM of the gastric cardia are more likely to have Helicobacter pylori gastritis. Some immunohistochemical markers have been found to show a difference between gastric and oesophageal IM, including DAS-1 and CDX2,18-20 and differences in expression of the cytokeratins CK7 and CK20 have been described by some researchers (although not all).21,22 Unfortunately, despite these and other differences between IM in the oesophagus and IM in the stomach, no histological technique has yet been shown to reliably distinguish IM in the two sites in clinical material.4,13,18 There is one exception: if the pathologist observes a feature specific for the oesophagus (eg, a submucosal gland or its duct), then origin from the oesophagus can be definitively stated. However, this is only likely if jumbo forceps are used, and even then it only occurs in some cases.10 In general, the only way in which the pathologist can tell where the biopsy came from is by the endoscopist providing the information. Hence the problem — clinicians do not always give accurate information on the request form regarding the site of the biopsy. Pathologists may try to get around this problem by making statements such as: “The biopsy appearances would be consistent with Barrett’s oesophagus if the biopsy came from the true oesophagus”. Consequently, there is a risk that patients will be inappropriately labelled with the diagnosis of Barrett’s oesophagus through miscommunication. There is a controversy regarding the cardiac mucosa that touches on this discussion. Some researchers have suggested that cardiac mucosa (ie, mucosa composed of glands without oxyntic cells at the gastro-oesophageal junction) is always abnormal, and represents a change due to reflux.2,3 According to this hypothesis, only oxyntic mucosa is normal in the proximal stomach, only squamous mucosa is normal in the oesophagus, and what most people call cardiac mucosa is actually a pathological change (“reflux carditis”). A consequence of this is that finding cardiac mucosa in a biopsy would automatically imply that the specimen came from the oesophagus, not the stomach.2,3 However, the idea that there is no such thing as normal cardiac mucosa is a minority opinion and is not supported by the conclusions of studies showing that the gastric cardia in individuals defined as normal is usually lined by pure mucous glands or a mixture of mucous and oxyntic glands for up to 4 mm.23-25 The solutionA solution to these problems of inconsistency and confusion is to stop using the term “Barrett’s oesophagus” altogether, and instead use alternative terms that are less ambiguous. A biopsy from the oesophagus showing IM could be diagnosed as “columnar metaplasia with intestinal metaplasia”, while one without IM could be labelled “columnar metaplasia without intestinal metaplasia”. This terminology is based on well established usage and does not depend on subscribing to a particular definition of Barrett’s oesophagus; it avoids the problem of variable definitions, and the risk factor of IM is clearly and unambiguously stated. In any case, avoiding the term Barrett’s oesophagus should be routine if the biopsy site is unclear, because it implies a risk of neoplasia that would be incorrect if the biopsy came from the stomach. A diagnosis such as “glandular mucosa with intestinal metaplasia” combined with a statement in the pathology report about the uncertainty of the exact site of the biopsy would eliminate the potential misunderstanding that could arise if the word Barrett’s appeared. One could argue that a general term to describe the various morphological changes in the vicinity of the gastro-oesophageal junction remains useful. However, using “Barrett’s oesophagus” in this way is inappropriate because it now has precise definitions — even though these definitions have significant regional differences. One could also suggest that appropriate education is all that is required to allow Barrett’s oesophagus to be diagnosed correctly. Nevertheless, we still need to know which definition is being used before we can understand what a colleague means by Barrett’s oesophagus. It would be much simpler just to say what we mean using straightforward words. Others have suggested this solution before (including Norman Barrett himself),1 yet it does not seem to have been widely adopted. Although it might take a long time to eliminate a term as entrenched as Barrett’s oesophagus, the medical community has successfully negotiated changes in diagnostic terminology many times before. In this case, no new definitions would be required — simply the application of expressions we already understand.

Norman J Carr MB BS

Why all patients with a pituitary mass need to be seen by an endocrinologist For the average general practitioner, pituitary disorders are relatively uncommon. However, post-mortem and magnetic resonance imaging (MRI) studies show that about 10% of the population may harbour a pituitary mass, although most are small, non-functioning microadenomas.1 Pituitary adenomas are the commonest intracranial neoplasm, making up about 10%–15% of such lesions.2 In most large series, prolactinomas are the most prevalent subtype, at between 40% and 50%; non-functioning adenomas account for about 30%, with other functioning adenomas (secreting growth hormone, causing acromegaly; secreting adrenocorticotropic hormone, causing Cushing’s disease; or secreting glycoprotein hormones, such as intact follicle-stimulating hormone, luteinising hormone and thyroid-stimulating hormone) making up the remainder.3 We would like to put forward the view that the endocrinologist should be the key practitioner in a multidisciplinary approach to pituitary masses. Within the Australian health system, most patients in whom a pituitary mass is discovered are referred directly to a neurosurgeon. Many non-endocrinologists making such referrals do not realise the critical importance of the neurosurgeon’s specific pituitary surgical experience in patient outcome. Initial assessment of a patient with pituitary disease includes differential diagnosis, making decisions regarding necessity for surgical intervention, and medical management, including correction of any underlying hypopituitarism or hormone excess. On occasion, an endocrinologist may detect subtle variations in a patient’s presentation that can significantly alter management. Therefore, we encourage practitioners to refer patients initially to an established multidisciplinary pituitary team using a shared management approach — a team in which an endocrinologist works in conjunction with a pituitary neurosurgeon. Other relevant health professionals may include a neuroradiologist, ophthalmologist and radiation oncologist. Such teamwork can ensure optimal benefits for patients at all stages of management. With respect to functioning adenomas, most prolactinomas do not require surgery, even when a significant visual field defect is present. Mild increases in serum prolactin levels can be seen with some non-functioning pituitary lesions because of the interruption of dopamine delivery down the pituitary stalk. A level elevated more than 10-fold has traditionally been diagnostic of prolactinoma, for which the initial management should, in most circumstances, be with dopamine agonists.4 More recent evidence indicates that, for about 99% of histologically confirmed non-functioning adenomas, the serum prolactin level can be up to 2000 mIU/L; the authors of that article recommended a trial of dopamine agonist in patients with a macroadenoma and serum prolactin levels of more than 2000 mIU/L.5 There are tumours that secrete enough adrenocorticotropic hormone or growth hormone to produce only subtle clinical features of Cushing’s syndrome or acromegaly, respectively. Because the perioperative management of a patient with Cushing’s disease and acromegaly differs from the management of a patient with a non-functioning mass, it is important to detect these cases of subclinical pituitary hypersecretion before surgery, so the correct functional diagnosis is made from the outset.6 This also gives the endocrinologist the opportunity to use medical therapies such as somatostatin receptor analogues in the pre- or postoperative setting where appropriate. Patients with hypopituitarism benefit from hormone replacement.7 Although giant, vision-threatening tumours do occur, most cases do not generally require emergency surgical intervention, so there is time, in consultation with the neurosurgeon, for adequate assessment and stabilisation of the patient’s hormone state before surgery. Patients with clear hypopituitarism should begin taking maintenance doses of glucocorticoid and thyroxine before surgery. Sex steroid replacement can be delayed until after postoperative assessment. Successful resection of a macroadenoma may result in reversal of the hypopituitarism.8 Appropriately timed postoperative pituitary function testing and correct interpretation of the results is required for optimal outcome. Not all pituitary or suprasellar masses are pituitary adenomas. Sometimes characteristics on MRI can distinguish between the other various causes.9 The presence of diabetes insipidus is a strong clue that the mass is not a pituitary adenoma.7 Inflammatory (eg, Langerhans’ cell histiocytosis and lymphocytic hypophysitis) and other neoplastic lesions (eg, craniopharyngioma and germinoma) are commonly associated with diabetes insipidus, whereas it is very rare for an uncomplicated pituitary adenoma to present in this way. Preoperative recognition of non-adenomatous lesions may alter management. For example, lymphocytic hypophysitis often responds to high doses of glucocorticoids, even when a large mass with visual field compromise exists;10 Langerhans’ cell histiocytosis responds well to low-dose radiotherapy;11 and germinomas, which may be associated with increased serum or cerebrospinal fluid β-human chorionic gonadotropin levels, are best treated with a combination of chemotherapy and radiotherapy.12 With a collaborative, multidisciplinary approach to patient care, the endocrinologist can evaluate the likely differential diagnosis, in conjunction with the pituitary neurosurgeon and neuroradiologist, relevant investigations can then be performed, and a collective decision can made on the most appropriate management for each particular patient. Trans-sphenoidal pituitary surgery is a highly specialised procedure, and it is clear from published data that the experience and skill of the neurosurgeon is of paramount importance in determining outcome, particularly for secretory lesions. A review from the United States showed that higher surgical volume is associated with significantly reduced mortality, fewer complications and a reduced length of hospital stay.13 The best results were achieved by units where more than 25 patients were operated on per year.13 It has been estimated in the United Kingdom that only one pituitary neurosurgeon is needed for each five million of population.14 In a country such as Australia, it would seem pragmatic to have a small number of specialised neurosurgeons who do virtually all the pituitary surgery. However, such a scenario seems a long way off and would be fraught with political, personal and inter-hospital rivalries. Nevertheless, informal management networks can be forged by altering referral patterns. In Birmingham, UK, the cure rate for acromegaly almost doubled when the endocrinologists sent all their patients to one neurosurgeon, compared with when eight neurosurgeons in the city were performing pituitary surgery.15 This is another key reason why we believe referrals for patients with pituitary masses would be best directed to an established multidisciplinary team involving, as two key members, an endocrinologist with primary responsibility for pre- and postoperative assessment, and an experienced pituitary neurosurgeon. Pituitary masses are the commonest intracranial neoplasm. The initial point of referral should be an endocrinologist within an established multidisciplinary team. We are aware that a number of teaching hospitals in the major Australian cities have developed considerable expertise in the multidisciplinary management of pituitary lesions. In our opinion, this approach provides a high standard of care and contributes to the ongoing training experience of endocrinology and neurosurgery registrars. We believe patients who wish to be cared for in the private sector would also benefit from being managed jointly by an endocrinologist and a specialised pituitary neurosurgeon, if not by a full multidisciplinary team.

Warrick J Inder MB ChB, MD, FRACP · Frank P Alford MB BS, MD, FRACP

Autoimmune hepatitis is a rare but increasingly recognised serious complication of treatment with the tumour necrosis factor-α (TNF-α) blocking agent, infliximab. This report adds to the small but growing number of articles describing this significant adverse effect. Baseline liver function should be routinely tested in all patients receiving anti-TNF-α agents, and periodic monitoring for the development of hepatitis is important. Clinical recordA 56-year-old woman was referred with a 15-year history of ankylosing spondylitis, with clinical features of inflammatory back pain, fused sacroiliac joints, spondylosis and a positive test result for human leukocyte antigen (HLA)-B27. She was an ex-smoker and non-drinker, and was taking no regular medication. She had taken non-steroidal anti-inflammatory agents initially, but tolerated them poorly. Leflunomide therapy was trialled for 9 months in 2004, then ceased because of a poor clinical response; this therapy had no adverse effects (including hepatic complications) in this patient. Infliximab (infusion dose, 5 mg/kg) was introduced in 2005. Baseline findings included normal liver function test (LFT) results, and a negative anti-nuclear antibody (ANA) test result. During infliximab therapy, routine blood tests (including LFTs) were performed every 3 months. A minor elevation in transaminase level was noted within 3 months of commencing infliximab therapy. After a total of six infusions, infliximab therapy was ceased because the patient developed epigastric discomfort, jaundice and pale stools, and her LFT results showed gradual deterioration, with a mixed hepatitic/cholestatic picture. Results of her blood tests at cessation of infliximab therapy are shown in Box 1. Computed tomography of the abdomen showed diffusely non-homogeneous liver texture consistent with chronic liver disease, with no intra- or extrahepatic duct dilatation. A past cholecystectomy was also evident. A liver biopsy showed marked inflammatory infiltrate, particularly around the portal tract, with neutrophils, lymphoid, and plasma cells, bridging necrosis and piecemeal necrosis consistent with autoimmune chronic active hepatitis (Box 2). Prednisone therapy was commenced and, after 3 months, the patient’s clinical condition had improved with the only persisting liver function abnormality being an elevated γ-glutamyl transferase level (162 U/L; normal, 5–30 U/L). At this time the patient tested positive for ANA (titre, 1/160, homogeneous pattern); mildly positive for double-stranded DNA antibody (anti-dsDNA; titre, 5.7 IU/mL); and positive for smooth muscle antibody (titre, 1/2560). An attempt to introduce azathioprine therapy was unsuccessful because the patient developed a drug fever. DiscussionTumour necrosis factor-α blocking agents (anti-TNF-α agents) are used for treating conditions such as Crohn’s disease, ankylosing spondylitis, rheumatoid arthritis, and psoriatic arthritis. Commercially available anti-TNF-α agents include etanercept, infliximab, and adalimumab. Both infliximab and etanercept have been evaluated in double-blind placebo-controlled studies for the treatment of Crohn’s disease, rheumatoid arthritis, and ankylosing spondylitis. Minor side effects of treatment with anti-TNF-α agents are common, and include upper respiratory tract infections, rash, myalgias, asthenia, sinusitis, flushing, fever and headache.1 More serious side effects include the reactivation of latent Mycobacterium tuberculosis; reactivation of hepatitis B in chronic carriers; infusion reactions (related to induction of anti-chimeric antibodies against infliximab); severe neutropenia and thrombocytopenia; demyelinating disorders; autoimmune antibody formation; and hepatotoxicity. Minor abnormalities in LFT results are relatively common with the use of anti-TNF-α agents.1 Severe hepatic reactions are much less common. These may include jaundice, hepatitis and cholestasis, autoimmune hepatitis, and acute liver failure. It is noteworthy that a number of cases of liver failure resulting in liver transplantation or death have now been reported.2,3 According to the manufacturer of infliximab, at least 35 patients were reported to have had severe hepatic adverse events in the postmarketing period up to 2004.4 Autoimmune hepatitis (AIH) is a rare but nonetheless increasingly recognised complication of treatment with infliximab. Ten cases of AIH had been reported to the manufacturer of infliximab up to 2003, eight of which were considered either possibly or probably related to infliximab (H B, personal correspondence). However, events had been submitted voluntarily and thus may be under-reported. This report is important in highlighting a case of the de-novo development of autoantibodies and onset of AIH related to the use of infliximab in a patient not receiving concurrent confounding immunosuppressive therapy such as methotrexate. It adds to the small but increasing number of published cases of these adverse effects. Most cases published to date describe reversibility of the hepatitis and resolution of LFT abnormalities with immunosuppressive therapy. Box 3 shows a comparison of our case and several other published cases of postulated infliximab-related AIH, including a case of acute liver failure which led to liver transplantation.2 Neither that patient2 nor our patient received concurrent immunosuppressive therapy during treatment with infliximab. Autoimmune manifestations may possibly be more significant when infliximab is used alone, or in higher doses. This is often the situation with spondyloarthropathy or psoriasis, where additional immunosuppression may not necessarily be part of the protocol. This differs from the treatment of, for example, rheumatoid arthritis, for which patients often also take methotrexate. One published report describes the development of autoantibodies and liver inflammation following infliximab therapy in two women treated with infliximab for rheumatoid arthritis.2 Liver disease occurred 8 and 17 months, respectively, after infliximab therapy was initiated, and there was de-novo development of ANA in both patients. In the first and most striking case, a 39-year-old woman eventually required liver transplantation after a 45-day admission with hepatic failure and cirrhosis. She had previously been taking leflunomide (20 mg/day for 3 months) with no significant response. Before infliximab therapy, her LFT results were normal, and she tested negative for ANA. At last report, post-transplant, she was well on immunosuppressive therapy including cyclosporin and corticosteroids. In the second case, a 54-year-old woman with rheumatoid arthritis developed acute hepatitis after infliximab treatment. A complete recovery (based on symptoms and LFT results) was noted 1 month later, after treatment with prednisolone (0.5 mg/kg/day) and azathioprine (50 mg/day). Two major types of AIH have been described: type 1 classic AIH, as seen in our patient (related to ANA and/or smooth muscle antibody seropositivity; and type 2 (related to liver/kidney microsomal antibody seropositivity). The histological hallmark of AIH is interface hepatitis, characterised by mononuclear cells, lymphocytes, plasma cells and macrophages infiltrating the portal tract.7 The primary pathogenetic mechanism of AIH is thought to be a loss of tolerance against the patient’s own liver.8 This predominantly periportal hepatitis is thought to be initiated by CD4+ T cells, which recognise self-antigen. Hepatocytes in patients with AIH are postulated to aberrantly express HLA class II molecules on their surface, a process normally involved in the presentation of antigen to CD4+ T cells and other inflammatory cells. Autoimmune disease results from the resultant inflammatory cell activation, with subsequent hepatocyte destruction (cell-mediated autoimmunity).7,8 AIH may also involve the unmodulated production of autoantibodies directed against the hepatocyte membrane (antibody-dependent autoimmunity). This includes elevated immunoglobulin G levels, seen in up to 80% of patients with AIH.7 A genetic predisposition is also thought to be important, with the HLA DR3 and DR4 alleles being associated with the development of type 1 AIH.8 Infliximab is thought to contribute to development of AIH in predisposed patients by triggering development of autoantibodies. These include ANA and anti-dsDNA.9 One possible explanation for this is that TNF-α blockade interferes with the normal cytotoxic T lymphocyte suppression of auto (self)-reactive B cell production. Another is that anti-TNF-α agents interfere with the induced cell death of CD8 T cells, leading to an accentuated lymphocyte presence.9 Studies in patients with rheumatoid arthritis support infliximab-related autoantibody development,9,10 showing elevations in both ANA and anti-dsDNA titres after infliximab therapy. The occurrence of AIH, and other serious, though uncommon adverse drug reactions, may become more evident with increased use of anti-TNF-α agents. Monitoring of liver function is not routine for patients being treated with anti-TNF-α agents (or those receiving other disease modifying agents, such as methotrexate and leflunomide). Routine blood tests, including LFTs, should be considered for all patients receiving anti-TNF-α agents. 1 Results of blood tests at cessation of infliximab therapy Parameter Patient Reference range Electrolytes, renal function Normal Normal Bilirubin 97 pmol/L 2–21 pmol/L Albumin 25 g/L 35–53 g/L Alkaline phosphatase 521 U/L 30–115 U/L γ-Glutamyl transferase 614 U/L 5–30 U/L Alanine aminotransferase 621 U/L 7–33 U/L Aspartate aminotransferase 821 U/L 10–45 U/L Prothrombin time 13 s 11–17 s Anti-nuclear antibody titre 1/640 < 1/40 Anti-nuclear antibody pattern Homogeneous No pattern or speckled Anti-dsDNA titre 5.7 IU/mL 0–5 IU/mL Anti-smooth muscle antibody titre 1/2560 Negative Anti-mitochondrial antibodies Negative Negative Anti-liver/kidney antibodies Negative Negative Viral hepatitis serum tests Negative Negative Iron studies Normal Normal Caeruloplasmin Normal Normal Anti-dsDNA = double-stranded DNA antibody. 2 Thin sections of the core liver biopsy sample A: × 50 view, showing inflammation around portal tracts with architectural distortion. B: × 200 view, showing lymphocytes, plasma cells, neutrophils and occasional eosinophils, piecemeal necrosi and focal apoptotic cells. 3 Comparison of our case with other published cases of postulated infliximab-related autoimmune hepatitis Patient Sex Age (years) Disease Infliximab infusions Methotrexate use ANA titre Anti-dsDNA development Steroid response Reversible condition Dose (mg/kg) No. Concurrent Past Pre- infliximab Post- infliximab A2 F 39 RA 3 6 No No 0 1/640 Yes No No† B2 F 54 RA 3 12 Yes Yes 0 1/160 nd Yes Yes C5 F 36 RA 3 3 No Yes 1/20 1/640 Yes Yes Yes D6 F 53 PsA 3 8 Yes Yes 1/80 1/160 Yes Yes Yes E* F 56 AS 5 6 No No 0 1/640 Yes Yes Yes * Our patient. † Requiring liver transplantation. ANA = anti-nuclear antibodies. Anti-dsDNA = double-stranded DNA antibody. AS = ankylosing spondylitis. nd = not done. PsA = psoriatic arthritis. RA = rheumatoid arthritis.

Gerard Ozorio MB BS · Bruce McGarity MB BS, FRACP · Haesung Bak MB BS, FRACP · Andrew S Jordan MB BS, BSci(Med) · Henry Lau MB BS, FRCPA, FACTM · Cathy Marshall MB BS

A 44-year-old man with a history of childhood brain injury presented with dysarthria, confusion, reduced oral intake and reduced mobility after a week of heatwave conditions. He had severe hypernatraemia and raised serum creatine kinase levels, consistent with rhabdomyolysis. In most previous case reports linking hypernatraemia and rhabdomyolysis, other factors have potentially contributed. From the available evidence, severe hypernatraemia alone appears sufficient to induce muscle injury. Clinical recordA 44-year-old man presented to a rural hospital with a 48-hour history of reduced mobility, dysarthria, confusion and reduced oral intake. He had sustained a traumatic brain injury at the age of 6 years and had intellectual impairment, mild right hemiplegia and post-traumatic epilepsy, but had not experienced a seizure for many years. Ambient temperatures were anecdotally reported to be up to 48°C during the week before presentation. The patient was cared for by his brother, who confirmed there had been no recent seizures, exertion, significant falls or prolonged recumbency. His only regular medication was rabeprazole. At presentation, he was dehydrated, febrile (temperature, 38°C), anuric and hypotensive, with a blood pressure of 90/50 mmHg. Initial blood biochemical tests showed the following levels: serum sodium, > 180 mmol/L (reference range [RR], 135–145 mmol/L); serum potassium, 4.3 mmol/L (RR, 3.2–4.5 mmol/L); bicarbonate, 13 mmol/L (RR, 22–33 mmol/L); haemoglobin, 204 g/L (RR, 135–180 g/L); and serum creatinine, 455 μmol/L (RR, 70–120 μmol/L). Creatine kinase (CK) concentration was 13 000 U/L (RR, < 200 U/L), while troponin I was minimally elevated, with a peak value of 0.8 μg/L (RR, < 0.2 μg/L), consistent with rhabdomyolysis. Laboratory technical difficulties precluded a urinary myoglobin assay. A snake venom assay was negative, and the patient’s coagulation profile was normal. On clinical examination, there was no evidence of trauma or compartment syndrome. Initial treatment comprised fluid resuscitation (with a total of 5 L intravenous fluid) and empirical intravenous antibiotics. The patient was transferred to a tertiary hospital intensive care unit, where he received further fluid replacement, electrolyte correction and renal replacement therapy. A single brief generalised tonic–clonic seizure several hours after his arrival was treated with phenytoin. The CK concentration peaked at 31 200 U/L. Renal function recovered to baseline over 6 weeks, and the man was ultimately discharged home from the hospital’s rehabilitation unit, having returned to his premorbid functional state. DiscussionThe patient developed severe dehydration and hypernatraemia as a result of increased insensible losses and inadequate fluid intake during a week of extreme weather conditions, despite having unrestricted access to water. Whether he had a degree of hypothalamic hypodipsia as a result of acquired brain injury is uncertain. A careful history and physical examination did not suggest a single obvious cause for his rhabdomyolysis. Core temperature was not sufficiently elevated to favour heat stroke as a diagnosis. The CK concentration was already raised before the seizure, which was not prolonged. A review of the literature identified hypernatraemia as a potential contributor. Rhabdomyolysis is a clinical and laboratory syndrome characterised by muscle necrosis and release of intracellular muscle constituents into the circulation. It ranges in severity from asymptomatic elevation of CK concentration to severe life-threatening cases associated with extreme rise in CK concentration, myoglobinuria and acute renal failure. The most common causes include muscle compression or trauma, hyperexertional states (such as prolonged seizure or extreme exercise), metabolic and inflammatory myopathies, heat stroke, and drug- or toxin-related muscle injury.1 Severe electrolyte derangements, including hyponatraemia, hypokalaemia and hypophosphataemia, are also described, with the proposed mechanism being cell membrane disruption as a result of deranged sodium–potassium–ATPase pump function.2 Multiple case reports and series have linked hypernatraemia and rhabdomyolysis.3-5 Most cases have been in the setting of hyperosmolar states, such as those associated with diabetes mellitus. In many cases, other factors have potentially contributed to the development of rhabdomyolysis, including recumbency resulting from altered levels of consciousness or seizures. Evidence for a direct causal link between hypernatraemia and rhabdomyolysis is provided by three reported cases of central diabetes insipidus resulting in severe hypernatraemia and rhabdomyolysis in the absence of other potential causes.6-8 In all cases, the serum sodium concentration was greater than 180 mmol/L. In 1992, Abramovici and colleagues, reporting a case series of 18 patients with hypernatraemia, showed a significant linear correlation between serum sodium concentration and serum CK level. They were then able to induce rhabdomyolysis in laboratory rats by rendering them severely hypernatraemic after fasting and intraperitoneal injection of hypertonic saline. Pre- and post-injection biochemical analyses confirmed that only serum sodium concentration and CK concentration were altered significantly.9 In summary, rhabdomyolysis can be induced by a range of insults, and is often multifactorial. From the available evidence, severe hypernatraemia alone appears sufficient to induce muscle injury, and should be considered as a potential cause.

Jason P Denman BAppSc, MB BS(Hons)

Basic health care is often out of reach for millions of Australians still living in poverty Poverty and ill health are frequent companions. This is relatively easy to establish in poor societies where the living standards of people are so low that the problems of ill health “can be laid fairly directly at the door of poverty”.1 However, the evidence linking low income to poor health is also accumulating in wealthy nations, including Australia.2 This is literally a matter of life and death. In Australia in 2001, a boy born in one of our most disadvantaged regions could expect to live 3.6 years less than a boy born in an area of least disadvantage, while a girl could expect to live 2.4 years less.2 The gap in average life expectancy between Indigenous and non-Indigenous men is 18 years.2 This situation is compounded by the fact that basic health services are often beyond the reach of the poorest Australians, especially when major out-of-pocket costs apply. For example, the Australian Council of Social Service (ACOSS) estimates that 40% of Australian adults do not have access to a comprehensive oral health check or a course of basic dental treatment every 2 years. There are more than 500 000 people on waiting lists for public dental care.3 A recent Senate Committee report argued that the “link between health and socioeconomic status has been clearly shown in studies both in Australia and overseas” and recommended that providing people in poverty with broad access to health care services is an essential component of the fight against poverty.4 The importance of these issues has been obscured by disagreement over how to measure poverty. However, although measurement problems are universal, this has not stopped other countries, with active government support and involvement, from measuring poverty, seeking new and better indicators, and setting poverty reduction targets. For this to happen in Australia, we need to reignite a public conversation about the role of poverty reduction in the pursuit of social justice more generally. The focus needs to move beyond the achievement of higher average incomes to look at how that increased prosperity is (and should be) distributed, including to those below the poverty line. It seems that poverty has fallen off the agenda in Australia through fear that acknowledging it exists will result in pressure to do something about it, and will raise questions about the wisdom of policies that pay inadequate attention to distributional issues. This calls for a better understanding of the extent of poverty in Australia and who it affects. A report recently published by Australia Fair (http://www.australiafair.org.au),5 an alliance of organisations promoting action to improve fairness in Australia, contained a range of international comparisons of wellbeing and attracted wide media coverage. The report featured new research from the Social Policy Research Centre (SPRC) at the University of New South Wales, which indicates that the war on poverty has by no means been won; almost two million Australians live in households with income below the most austere poverty line commonly used in international poverty research.6 The proportion of Australians living below this poverty line has also risen sharply over the past decade or so — a period of strong growth in the economy and employment. The lowest poverty line used in the SPRC study, which is also used by the Organisation for Economic Co-operation and Development (OECD), was set at 50 per cent of the median disposable income of all Australian households, after adjusting for differences in household size and composition. Many countries use poverty lines set higher (at 60 per cent of median income), but none use a relative benchmark set at a lower percentage of median income, so it is hard to argue that the line is too high. In the 2003–04 financial year, the 50 per cent of median income poverty line was equivalent to $249 per week for a single adult, $373 for a couple, and $522 for a couple with two children. These incomes are required to meet all household needs: food, housing, clothing, transportation, schooling, household bills, and so on. Poverty lines are widely used in Australia and overseas as indicators of the risk of financial hardship. Although low incomes tell only part of the story of deprivation and social exclusion, it is an important part. Research underway at SPRC, in collaboration with ACOSS, Mission Australia, the Brotherhood of St Laurence, and Anglicare, indicates that people living below poverty lines have a significantly greater risk of missing out on the “essentials of life”, such as access to medical treatment, warm clothes, and a substantial meal at least once a day,7 and of experiencing exclusion from effective participation in the labour market, community services and social networks. Using the 50 per cent of median income measure, the SPRC study indicates that in 2004, 1.935 million people, or 9.9% of all Australians, including 365 000 children, were living below the poverty line. If the higher (60 per cent of median income) poverty line is used, the number of people in poverty increases sharply to 3.859 million, or 19.8% of the population. Using this measure, 786 000 children — a fifth of all Australian children — were living in households below the poverty line. Consistent with previous poverty studies, the new estimates show that the risk of poverty is much higher among certain groups. For example, the Australians living below the 50 per cent of median income poverty line include: 40.2% of all unemployed people; 39.0% of single adults over 65 years of age; 31.5% of all people whose income derives mainly from social security; 22.8% of single adults of workforce age; and 11.4% of sole-parent families. Examining trends in poverty over time using the two poverty lines, the SPRC research found that poverty in Australia increased significantly over the decade to 2004: from 7.6% to 9.9%, using the 50 per cent of median income poverty line; and from 17.1% to 19.8%, using the 60 per cent of median income poverty line. It is notable that, in proportionate terms, the increase in poverty is significantly greater using the lower poverty line: an increase of 32% compared with less than 16%. Thus, the lower poverty line makes the situation appear better at the end of the period, but shows less improvement during the period. Australian and international research indicates that the correlates of poverty include unemployment and joblessness, the adequacy of income support, and the incidence of low pay. Strong employment growth over the past decade should have made it possible to stop poverty from rising in Australia, but it has not reduced it (at least by 2004). The concentration of joblessness within disadvantaged families and communities, and slower growth in income support payments and low pay compared with average incomes are factors behind the increase in poverty during this period. To convert strong economic growth into reductions in poverty, a determined effort is needed to improve the skills and capacities of jobless people and increase income support and wages of the most vulnerable. These are among the reasons why the British Government has succeeded in reducing poverty among children over the past decade.8 But economic growth by itself will not automatically reduce poverty, although it does generate the resources required to tackle the problem. Combating the cycle of poverty and putting an end to deprivation and social exclusion also requires taking a broader view of living standards than simply income alone; investment in low-cost housing; early child education and care; and sustained, whole-of-government strategies to renew the most deeply disadvantaged communities. Achieving improved health outcomes becomes more difficult when poverty is high — and rising — because inadequate resources lead to deprivation and low subjective wellbeing, both of which have adverse health effects. It is for this reason that the health care sector should be concerned about Australia’s lack of progress in addressing poverty. Tackling poverty will improve social justice and lay the foundation for our future health and prosperity.

Peter Saunders · Peter Davidson BSocWk

Globalisation has brought with it many advances in health, but also a new range of challenges. There is a need to move from “nation-focused” (international) public health to global public health — and the terminology we use here matters. Global public health leadership requires that respect be shown to evidence, especially that about the changing nature of disease worldwide. The Australian medical and research communities have a significant opportunity to provide global public health leadership.

Stephen R Leeder FRACP, FFAPHM, FFPHM, AO · Susan U Raymond PhD · Henry M Greenberg MD

Over the past decade, student participation in international health has moved beyond individual elective terms in developing countries to collective responses led by student international health organisations. There are now at least 10 such organisations, with more than 500 medical students participating at a local or national level each year. Student international health organisations can deliver short- and long-term benefits to developing countries, while equipping students with skills such as leadership, teamwork and cultural sensitivity. Activities include delivery of medical equipment, fundraising, educating university communities, and acting as advocates for social justice. We believe Australian medical schools must formally incorporate international health into their curricula, drawing upon the experiences of schools in Europe and North America.

Gregory J Fox BSc(Med), MB BS(Hons) · James E Thompson · Victor C Bourke · Gregory Moloney BSc(Med), MB BS(Hons)

To the Editor: The Australian Pharmaceutical Benefits Scheme records 35 657 prescriptions (for either one or two devices) for EpiPen autoinjectors (CSL Limited, Melbourne, VIC), the self-injectable form of adrenaline, in 2006. This is a 650% increase on the 4758 prescriptions for EpiPens in 1998. The increase is much greater than the increase in the rate of food allergy. It is not enough to merely prescribe an EpiPen. It is vital that carers (of children), patients and prescribers understand its use. A previous South Australian study of children who had been prescribed an EpiPen at an allergy clinic found that, in 71% of severe reactions, the parents failed to use the device appropriately. Another study found that only two of 100 doctors in a major Australian paediatric teaching hospital could correctly demonstrate EpiPen use. In 2006, we surveyed EpiPen use by 120 parents of children attending the allergy clinic at the Children’s Hospital at Westmead. Children with egg allergy who were aged under 5 years when seen in 2003 were selected. Seventy per cent (84/120) of the children were prescribed an EpiPen. Half of the children had additional food allergies. Of those prescribed an EpiPen, 69% always carried it, 13% often carried it, 13% sometimes carried it and 5% never carried it. Ten per cent of parents had ever used the device, and 86% stated they were confident that they knew how and when to use it. Despite this, almost 40% stated they had concerns about using the EpiPen in an emergency. These included doubting their ability to correctly administer the EpiPen, whether they would have enough time and would inject correctly, concerns they may hurt their child, concern for the child in the event they needed it, doubt about the effectiveness of the EpiPen, and concern about appropriate timing. In the United Kingdom, 69% of parents were found to have problems using the EpiPen.4 Where, when and how to use the EpiPen was recently identified as one of 12 core parental information needs in our clinic.5 The findings that, even for parents of children attending a specialist allergy clinic where education strategies for EpiPen use are in place, 30% did not always carry the EpiPen, and 40% had concerns about its use in an emergency situation highlight the facts that just providing the device is an inadequate measure and that education and reinforcement, both in EpiPen use and in avoiding relevant allergens, are critical.

Clare W Allen · Dianne E Campbell · Andrew S Kemp

To the Editor: A 5-year-old girl with known peanut allergy presented with an acute allergic reaction after ingesting “nut-free” butter containing sunflower seeds (85%), sugar, emulsifier and antioxidant. The label on this product stated that it was processed in a peanut-free facility, and that each batch was tested for traces of nuts and peanut protein. The child had a history of atopic eczema, asthma, allergic rhinitis and egg allergy. At age 17 months, after eating a small amount of Thai satay containing peanut, coconut and chicken, she developed generalised urticaria, vomiting and marked angioedema. Skin prick tests at the time showed a negative reaction to sunflower seed (Box). The patient continued to avoid all nuts and egg. At the age of 5 years, within minutes of first eating a few mouthfuls of sunflower seed butter on toast, she developed generalised urticaria and angioedema of the lips. (The toast was made from the bread she usually ate, both before and after the reaction.) Skin prick tests at this time showed a strong positive reaction to sunflower seed (Box). She was thus diagnosed with generalised allergic reaction secondary to sunflower seed ingestion. Allergic reactions to sunflower seed are rare, with fewer than 30 published cases.1 Here, we report a child with peanut allergy who developed an allergic reaction after eating “nut-free” sunflower seed butter. The marketing by online and specialty shops of sunflower seed butter as a safe alternative to peanut butter for those with peanut allergy raises concerns, because allergic reactions can still occur, possibly through the development of new sensitisation. Our patient may have been sensitised through eating foods containing sunflower seeds, such as muesli bars and breads. There was no evidence of sensitisation through inhalation — for example, of seeds in bird feeds — although this has been reported.2 Another potential cause of allergic reaction is a previously unknown co-allergy to sunflower seed. This co-allergy was reported by 9.5% of patients with peanut allergy in one study.3 Yet patients with peanut allergy are often not tested for sunflower seed allergy because of its rarity. The promotion of sunflower seed butter as a safe alternative for those with peanut allergy raises concerns. As medical practitioners, we should carefully consider the safety of sunflower seed butter in individuals with peanut allergy. Skin prick test results,* by patient age Weal diameter (mm) Test extract 18 months 5 years Histamine (10 mg/mL) 3 8 Glycerosaline Negative Negative Dermatophagoides pteronyssimus 4 10 Cat Not done 13 Dog dander 4 Negative Egg white 6 15 Egg yolk Not done 10 Peanut 6 21 Almond Not done 6 Hazelnut Not done Negative Cashew Not done Negative Coconut 2 6 Sunflower seed Negative 16 * Skin prick tests were performed with a Microlance lancet using HollisterStier allergen extracts (HollisterStier Laboratories, Spokane, Wash, USA). Weal size was expressed as the average of two diameters. Average diameter ≥ 3 mm (with negative glycerosaline control) was considered positive.

Denise C Hsu · Constance H Katelaris

To the Editor: I refer to the recent letter by De Costa and Calcutt1 about diagnosis and management of possible Down syndrome pregnancies in remote areas of Queensland, and more specifically the lack of abortion facilities and cost of travel to larger centres for this service. Nowhere in the letter was impartial counselling mentioned. The following anecdote may be anathema to an academic journal, but I think it is relevant. Thirty years ago I took my 7-year-old son, who has Down syndrome, to a hospital cricket match. He had enormous fun trying to play cricket, as kids do. Watching was a young doctor whose wife fell pregnant not long after. The tests of those days suggested that the child might have Down syndrome. With memories of our son, they decided to go ahead with the pregnancy. As it happened, the child did not have trisomy 21. Children with Down syndrome, given a normal family life and lots of stimulation and love, may be able to achieve normal school levels and even work outside sheltered workshops. And they give lots in return. At a World Down Syndrome Conference in Sydney some years ago, adults with Down syndrome took part in the presentations, and notably present were a number of babies with Down syndrome whose mothers seemed quite happy with their lot. I am not against free choice, but people making that choice should be fully informed of the positive side of having a child with Down syndrome.

Kevin B Orr

To the Editor: Coory and colleagues revealed a disturbing attitude to children with Down syndrome in their recent report in the Journal on trends in Down syndrome birth rates in Queensland.1 The authors inform us that, of the 70 children with Down syndrome who would have been born without a particular form of “antenatal care” (selective termination), 21 were aborted, but another 22 could (and, by implication, should) have been aborted, had the recommended “antenatal care” by private obstetricians been replicated across the whole of Queensland. The United Nations Committee on the Rights of the Child has condemned selective termination as discrimination against children and “a serious violation of their rights, affecting their survival”.2 The Committee’s recent General comment on the rights of children with disabilities affirmed that these children have a right to positive antenatal care.3 The concluding comment of Coory et al that “When the costs of screening are offset against the life-time costs of caring for a person with Down syndrome, screening is less costly . . .” is deeply disturbing. Surely a person with Down syndrome is entitled to the same recognition of inherent dignity and worth as are all other members of the human family. The authors acknowledge that their view may be regarded by some as “distasteful”, but offer the defence that they are merely advocating that “. . . all expectant parents should be provided with the same information and have the same access to services so that they all have the same choices”. But termination is not a value-free choice. By suggesting that the best outcome of screening is a reduction in the births of children with Down syndrome by cutting these children’s lives short, the authors make a moral judgement that steps outside medicine and contravenes universal human values. The human rights of children have been recognised by the international community since the 1924 Geneva declaration of the rights of the child4 and continuously re-affirmed to the present day. It is frightening to see how much progress we have still to make when authors such as Coory and colleagues can argue that reducing the births of children with Down syndrome by the practice of selective termination is a positive thing.

Mary C Joseph

In reply: The aim of our article was to assess trends in Down syndrome births by rurality and type of antenatal care provider.1 Whether to have prenatal screening is a decision for expectant parents. It has been argued that the availability of screening for Down syndrome means that expectant parents are confronted with unprecedented ethical dilemmas and responsibilities.2 However, the available evidence shows that expectant parents do not take decisions about Down syndrome screening lightly and, in particular, do not take the implications of a positive result lightly.3 We cited three analyses of the cost-effectiveness of Down syndrome screening, but could have cited several more, all of which use essentially the same methods. Our calculation of the absolute number of Down syndrome births (the number which might have occurred if screening rates had been lower) was a statistical analysis and carries no intrinsic ethical judgement. Others may choose to apply their own moral evaluation to it. Our only intention was to report the data as clearly as possible. Several expert groups, including the Royal Australian and New Zealand College of Obstetricians and Gynaecologists,4 recommend a population-based approach to Down syndrome screening. An important aspect of such population-based screening is to provide equal access for all expectant parents, regardless of where they live or who provides their antenatal care. Another is to provide clear information so that expectant parents can make their own well informed decisions.

Michael D Coory

Pituitary problems Hypothalamopituitary dysfunction following traumatic brain injury (TBI) or aneurysmal subarachnoid haemorrhage (SAH) may be more common than previously thought, according to the authors of a recent systematic review. Researchers collected data from 19 studies including over 1000 patients and found the prevalence of hypopituitarism in TBI patients to be 27.5% in the chronic phase. Patients who suffered an aneurysmal SAH showed a prevalence of pituitary dysfunction of 47%. The authors comment that deficiencies of pituitary hormones such as growth hormone, the sex steroids, corticosteroids and thyroid hormone result in clinical consequences that may be difficult to diagnose and significantly contribute to morbidity in these patients. JAMA 2007; 298: 1429-1438 Broken-hearted The link between stress and cardiovascular disease has been further elucidated by a review of epidemiological studies on the subject. In an attempt to gather evidence for the association between stress and acute and chronic cardiovascular disease, researchers reviewed the literature and possible mechanisms mediating the response to psychological and physical stress. It appears that psychological stress elicits changes in the sympathetic-parasympathetic balance and the tone of the hypothalamic-pituitary-adrenal axis. The cardiovascular system may be acutely affected by triggering of arrhythmia, or the precipitation of myocardial ischaemia via impaired endothelium-mediated vasodilation at the microvascular level. Chronic stressors appear to be associated with cardiovascular disease through acceleration of atherosclerosis. The authors comment that there is clear evidence of genetic variation between individuals of this effect, and that there is great potential for therapeutic intervention. Lancet 2007; 370: 1089-1100 Xeno-oestrogens Serum xeno-oestrogenic activity may be measured and potentially used as a biomarker of occupational exposure to pesticides, according to Danish researchers. Using current reports of pesticides with oestrogen-like properties as a basis for their investigations, the authors analysed serum samples from pregnant and non-pregnant female greenhouse workers for xeno-oestrogenic activity. Workers were categorised as having low, medium or high exposure, depending on working conditions and level of contact with the relevant pesticides. After adjustment for confounders, xeno-oestrogenic activity appeared to be positively associated with the level of pesticide exposure in both groups of women. The response in serum of pregnant women was higher than in non-pregnant women, irrespective of the level of pesticide exposure. The researchers comment that the variability in activity of the biomarker within the groups made it less useful as a measure of exposure on an individual level. Occup Environ Med 2007; 64: 708-714 Cholesterol all in the family Screening children and their parents for familial hypercholesterolaemia simultaneously could be very useful in preventing the serious consequences of this disorder, British researchers have found. A meta-analysis was performed of available data on total and low-density lipoprotein cholesterol levels in people with and without familial hypercholesterolaemia. Data were analysed for detection rates according to age groups ranging between birth and over 60 years. Detection rates were best between the ages of 1 and 9 years, when serum cholesterol concentrations discriminated best between those with and without hypercholesterolaemia. Subsequent serum cholesterol measurement in the affected child’s parents is estimated to detect about 96% of parents with the condition. BMJ 2007; 335: 599 The Pill and cancer — the facts? Use of the oral contraceptive pill does not appear to be associated with an overall increased risk of cancer, and may have a net positive population effect, according to a large UK cohort study. Using data from the Royal College of General Practitioners’ oral contraception study, researchers analysed almost 340 000 woman-years of observation for never-users of oral contraceptives and 744 000 woman-years for ever-users. Women who had used oral contraceptives had statistically lower rates of cancers of the bowel, uterine body, ovaries, and main gynaecological malignancies combined. Small, statistically non-significant increases were found in the risk of lung, cervix and central nervous system cancers. No difference was found between the groups for breast cancer. In both groups, rates of any cancer increased with smoking and age. There was no evidence of an increased risk of cancer overall in users of oral contraceptives in this British cohort. Potential confounders were adjusted for in the analysis, and made little difference to the observed rates of cancer. The researchers point out that the strengths of the study include the very large number of woman-years of observation (over one million) and the length of the study, allowing most cancers to be “caught” as the subjects became postmenopausal. They comment, however, that the results may not be applicable to oral contraceptive users today, as currently available preparations may have different associated risks. BMJ 2007; 335: 651

Tanya Grassi