Volume 188 Issue 2

The new Australian surgical training program starts in 2008 The Council of the Royal Australasian College of Surgeons (RACS), with the support of the nine specialty boards and related specialist societies, has approved the new Surgical Education and Training (SET) program, to commence in 2008.1 The RACS has responded to drivers of change in medical education, the bottleneck of basic surgical trainees and a wish to move to a competency-based training program. There will be a single point of selection into one of the nine specialties for medical graduates who have completed at least their second postgraduate year. The training program will be 5 to 6 years, the duration depending on the specialty. The years of training will be called SET 1 to SET 6, with the Fellowship examination remaining the final exit assessment. Selection tools for all specialties include three components: a scored curriculum vitae, reports from mentors and referees, and a semistructured objective interview. The first round of selection was successfully completed in August 2007, with 1538 applications from 1000 applicants over the nine specialties. Applicants could nominate more than one specialty. Most reached the interview stage, and 472 offers were made (198 for SET 1 and 274 for SET 2); 80% of the positions were offered to current basic surgical trainees.2 Medical graduates and students can indicate their interest in surgical training by registering with the RACS in PreSET, an unstructured phase leading to selection into SET. Completion of the Australian and New Zealand Surgical Skills Education and Training (ASSET) course during PreSET will be compulsory. This course provides an educational package of required generic surgical skills.3 During the SET years, assessment will be largely formative and competency-based. It will test the RACS’s nine core competencies and will rely heavily on in-training assessment tools such as Mini-CEX (mini clinical examination) and DOPS (direct observation of procedural skills), with a structured performance management process, overseen by supervisors and trainers, who will have completed a prescribed course on assessment and management of trainees (SAT SET).4 A summative assessment involving a multiple-choice examination and an objective structured clinical examination will have to be completed in SET 1 or 2 before a trainee progresses. In addition, by the end of SET 2, trainees will need to have completed the skills courses: Care of the Critically Ill Surgical Patient (CCrISP), Early Management of Severe Trauma (EMST) and Critical Literature Evaluation and Research (CLEAR). Potential trainees contemplating a career in surgery will have to decide at a much earlier stage, usually as undergraduate medical students. To attract the brightest students, academic surgical departments will need to be innovative and raise the profile of surgery in the curriculum, a task that has proved difficult in the past. Some universities have met this challenge by proposing streaming students into programs with specific surgical modules in the later years of the course. Relationships with academic surgeons and universitiesFor the implementation of SET, the College is considering establishing its own university, and is evaluating other models, one of which is to form closer relationships with existing university surgery departments in curriculum development and infrastructure support and administration. Macquarie University has established a Master of Advanced Surgery program in neurosurgery and is negotiating with the RACS and the Neurosurgical Society of Australasia.5 Other ways that academic surgical departments can form closer relationships with the RACS is in the conduct of the courses, such as ASSET and SAT SET, by providing the venue, organisation, instructors and facilitators, with the added advantage of ease of access for trainees, supervisors and trainers in that institution. University surgical departments could consider providing a package for potential trainees from the undergraduate years through PreSET to selection into SET, giving their students an advantage and an almost guaranteed pathway into SET. The core business of academic surgical departments is research. SET provides a catalyst for undergraduates, graduates and trainees considering research projects, graduate diplomas and higher degrees. Because research and publications rate highly in scoring for SET selection, and the new policies and regulations require research as part of SET, clinical and laboratory-based research projects will be keenly sought after, and many will wish to undertake a Bachelor of Medical Science or higher degrees such as a Master of Surgery, Doctor of Medicine or the combined Fellowship (FRACS)–PhD program. Surgical departments in New Zealand have established a Master of Medical Science diploma, with 50% undertaken by dissertation and 50% by publication combined with research forums and surgical research networks.6 Training for academic surgeryThese initiatives by academic departments also provide trainees with the motivation to consider a career in academic surgery. Closer relationships among universities, the RACS and hospitals can also create the potential for young surgeons with an interest in an academic career to have infrastructure support, such as an administrative assistant or receptionist; acceptance into an existing clinical craft-group practice; operating theatre access; and an appropriate academic title. It is not surprising that when the Association of Surgeons of Great Britain and Ireland and the Society of Academic and Research Surgery met in a consensus conference in September 2005, the focus was on surgical training as the greatest opportunity for preparing young surgeons for an academic career.7 The private sector provides another opportunity. The Commonwealth Government has allocated significant funding and has established the Enhanced Medical Education Advisory Committee to explore opportunities for surgical training in the private sector, including surgical departments in private hospitals with university affiliation. SET is ready. Will academic surgeons and universities see this as an opportunity to go forward? Will they develop innovative programs for undergraduates, sponsor RACS courses, provide SET preparation packages, develop attractive research programs, form closer relationships with RACS and hospitals (public and private) to implement SET and serendipitously promote academic surgery as a career?

Bruce P Waxman FRACS, FACS, MRACMA

With three iron chelating agents now available, management options have substantially increased Outcomes in patients with thalassaemia major have been revolutionised over the past 50 years. Without transfusions, death usually occurred in the first decade of life. In the 1950s, transfusions were given to manage the symptoms of anaemia, which resulted in increased survival but significant morbidity. In the 1960s, regular blood transfusions were introduced to maintain relatively high mean haemoglobin levels in order to suppress the production of abnormal red cells in the bone marrow. This permitted good quality of life in childhood, but led to cardiac death from transfusional iron overload at a mean age of 18 years.1 Fortunately, the parenteral iron chelating agent desferrioxamine was also introduced in the 1960s, and its use to control iron load led to improved survival2 and reduced morbidity.3 Nevertheless, the difficult treatment regimen (subcutaneous infusion for 8–12 hours per night, 3–7 nights per week) resulted in poor compliance. Cardiomyopathy remains the most common cause of premature death in patients with thalassaemia,3 even in well chelated patients.4 The recent development of new magnetic resonance imaging (MRI) techniques (T2*) has allowed the assessment of tissue iron levels (albeit indirectly), including myocardial iron levels, and has increased our understanding of iron overload. The use of this methodology has demonstrated that practically all thalassaemia major patients with cardiomyopathy have excess cardiac iron. It has also shown that the conventional surrogate markers — liver iron concentration and/or ferritin levels — are not predictive of cardiac iron levels.5,6 Cardiac iron overload has also been observed in patients who were previously thought to be well chelated.5,6 The licensing, in 1999, of the oral chelating agent deferiprone as a second-line iron chelator was initially embraced as a relief for patients who could not tolerate desferrioxamine or had adverse reactions to it. Recent data demonstrate that deferiprone is more effective than desferrioxamine in removing excess cardiac iron7 and suggest that it may even be more protective of endocrine glands (eg, the pancreas, thyroid and gonads).8 The beneficial effect may be related to the characteristics of deferiprone, which has a low molecular weight, an uncharged molecule and favourable lipophilicity and is largely unbound to plasma proteins, enabling easy entry into all tissues. The use of deferiprone and desferrioxamine in combination has even been demonstrated to reverse established cardiomyopathy.9 The bottom line is survival. For ethical reasons, prospective studies of survival are not feasible, and in any case it would take many years to acquire meaningful results. Data from observational and retrospective studies must therefore be given due consideration. An Italian epidemiological, natural history study of 516 patients demonstrated a higher incidence of cardiac disease and cardiac-related deaths in a group of patients who continued on desferrioxamine (359 patients) than in a group who were switched to deferiprone (157 patients).10 The latter group experienced no de-novo cardiac disease or iron-related deaths. Reports from other centres are also indicating reduction in cardiac deaths over the past few years, which may be attributable to the use of deferiprone.11 Both chelators are needed because the value of desferrioxamine is limited by poor compliance with treatment, and, although deferiprone is well accepted, its use is limited by concerns about potential adverse effects, particularly agranulocytosis. Although the incidence of this complication is low, its potential occurrence necessitates weekly blood counts. Some patients also complain of the relatively large number of tablets that need to be taken in three divided doses daily. The article by Kidson-Gerber and colleagues in this issue of the Journal12 comes from a unit in which patients are offered optimal management with appropriate monitoring and treatment, including prescription of desferrioxamine and deferiprone (→ Management and clinical outcomes of transfusion-dependent thalassaemia major in an Australian tertiary referral clinic). The authors quantified compliance by comparing prescriptions written with the actual amount of drug collected from the hospital pharmacy. This confirmed that, on average, patients took only 50% of the desferrioxamine prescribed, and only 10% took it exactly as prescribed. Their report firstly confirms the relationship between acceptance of chelation therapy and morbidity, making it clear that acceptance and use of chelation therapy is crucial for satisfactory outcomes, and secondly demonstrates increased compliance with oral chelation therapy. Seventeen patients (mainly non-compliant with desferrioxamine therapy) were additionally prescribed deferiprone. Relatively few took the prescribed quantity of desferrioxamine, but most took the deferiprone, sometimes even more than prescribed, indicating “creep” on the part of the patients towards the more acceptable oral therapy. The therapeutic armamentarium has been further expanded by the recent licensing of the oral chelator deferasirox in Australia and a number of other countries. Deferasirox is a soluble tablet that needs to be taken only once daily and therefore has high patient acceptance. At adequate doses, deferasirox is equivalent to desferrioxamine in its ability to reduce liver iron concentration.13 It has produced some adverse effects, particularly a rise in creatinine levels, but overall its safety profile is acceptable. Prospective studies of its ability to remove cardiac iron are in progress. We need to ensure that all patients with thalassaemia major have access to MRI (to assess their myocardial iron load) and the full portfolio of iron chelation options. In developing countries, the treatments available will be strongly influenced by cost. If the newer oral agents can be shown to be at least as effective as desferrioxamine in preventing iron-induced morbidity, the higher cost of deferasirox may be offset by the reduced cost of managing complications secondary to poor tolerance of desferrioxamine treatment. With three chelating agents now available, the options for chelation management are significantly increased. Chelation therapy can now be tailored to individual patients based on the severity and tissue distribution of the patient’s iron load. Intensive chelation regimens, combining deferiprone and desferrioxamine, are now possible, and data on the various potential combinations of the three chelators are expected to be available in the near future. In summary, the management of thalassaemia major has improved significantly with the ability to monitor not only iron load but also the sites of iron loading, and because clinicians now have the choice of three iron chelators. It can be anticipated that mortality and morbidity will be further reduced and that life expectancy will approach the norm — especially for younger patients. However, as shown by Kidson-Gerber and colleagues,12 prognosis will be largely dependent on compliance with iron chelation therapy.

Vasili Berdoukas OAM, MB BS, FRACP · Bernadette Modell PhD, MB BChir, FRCP

After a decade of closures, a flexible approach is needed About one in three Australian women give birth outside metropolitan areas. Historically, most of these women have been cared for by general practitioner obstetricians and midwives in local hospitals. However, in recent years it has been difficult to recruit and retain midwives and doctors with the necessary skills to adequately staff many rural maternity units providing traditional models of care. Whenever any essential component of obstetric, anaesthetic, paediatric or midwife infrastructure has become unavailable, maternity units have been closed, and women in the area are required to travel to the nearest maternity centre instead. It is estimated that more than 130 Australian rural maternity units have closed since 1995.1 In this issue of the Journal, a description by Scherman and colleagues (→ The first year of a midwifery-led model of care in Far North Queensland) of the first year’s experience at Mareeba District Hospital’s midwifery-led maternity unit provides some interesting and valuable insights into the role of low-intervention birth units for low-risk women in rural areas.2 Women planning to give birth at Mareeba were screened for risk factors, and low-risk women were selected for maternity care provided by a midwife. Medical back-up was provided through regular case conferences with an obstetrician at the nearby Cairns Base Hospital, who also visited Mareeba once a month, and on-site back-up from local GPs, who were able to perform caesarean section delivery if necessary. Intrapartum transfer was rarely used and largely confined to primiparous women. The authors reported no significant preventable morbidity or mortality in mothers or their babies, and their findings would appear to support the feasibility of this model of care, especially for multiparous women — although they acknowledge that the number of births so far is too low to support any conclusions regarding safety. Intervention rates were significantly below state averages. In 2004, 207 women gave birth at Mareeba District Hospital under the previous model of care,3 and in the 12 months of this study (2005–2006), 147 low-risk women (plus 11 high-risk women) did so under the care of a midwife. Had the maternity unit been closed, these women would have had to travel over 60 km to Cairns Base Hospital for delivery, as did the 45 women who required transfer during pregnancy for pre-existing or emergent risk factors. Interestingly, the powerful sway of maternity care politics is evident. What other clinical discipline would employ three full-time and nine part-time staff in a dedicated unit with medical back-up to treat 203 patients a year, with an alternative facility 60 km away that ultimately treated almost a quarter of them anyway? The study by Scherman and colleagues raises several other significant issues. The low use of epidural anaesthesia (1%) — which required transfer to Cairns when requested — surely reflects the lack of access at Mareeba, rather than true patient preference. Although facilities for some caesarean deliveries are in place at Mareeba, it is not always possible to perform an emergency caesarean section on site. Recorded transfer times for unplanned deliveries at Cairns Base Hospital were 80–145 minutes, with transfer required either for epidural request or first-stage failure to progress. There is little evidence upon which to base recommendations for the optimum time interval between decision to transfer and emergency delivery, and perhaps transfer would be completed more urgently in a situation where delay could compromise the mother or baby, but most clinicians would agree that a shorter interval than those reported is desirable. A related issue is whether or not staff (both medical and midwifery) providing obstetric care at such units should also spend some time working in a higher-level unit, to maintain their skills in management of relatively rare complications. For example, the treatment of catastrophic life-threatening obstetric haemorrhage is rarely required — but will outcomes be optimal in units where this complication might only be seen by staff once every 5 or 6 years? A Cochrane review of outcomes at birth centres and medical-led units found a statistically significant higher perinatal mortality rate (relative risk, 2.38) in birth units staffed by midwives who did not also work in medically supervised hospital units.4 The search for models of maternity care best suited to women in rural areas will continue to challenge health service planners. A paradox haunts them: the more remote a maternity service is from a referral centre, the higher the perceived community value in keeping it open, but also the higher the risk in operating a low-intervention unit that can provide care for most low-risk women but which ultimately relies on emergency transfer of women with unexpected complications. It is noteworthy that 70% of women who develop pregnancy complications are classified as low risk on initial assessment.5 It seems likely that continuing provision of maternity services in rural areas will depend on optimum use of the local workforce and health facility infrastructure. Individual regional areas will need to come up with arrangements based on consultation with the local community and health workforce. This will require a flexible approach and should recognise that transfer of women may sometimes be required, because of temporary unavailability of a core of necessary staff. It is unlikely that a “one size fits all” approach will deliver solutions to all areas at all times. The key will be cooperation and consultation with the local medical and midwifery workforce, open disclosure to women of what services can and can’t be provided locally, and facilitation of transfer of pregnant women to referral centres if they so choose. Since the MJA’s acceptance of the review of the Mareeba Maternity Unit, reports of an intrapartum, apparently avoidable stillbirth have been published in the press. The incident is being investigated by the Health Quality Complaints Commission following an internal review.

Andrew F Pesce MB BS, FRANZCOG

Objective: To evaluate the management, clinical outcomes and adherence to chelation therapy in adult transfusion-dependent patients with thalassaemia major.Design, setting and participants: We reviewed all transfusion-dependent adults with thalassaemia major (n = 44) attending the Haematology Department at the Prince of Wales Hospital, Sydney, in 2005. Data were collected retrospectively (2000–2005) and prospectively (2005) for cross-sectional clinical audit from clinical reviews, patient questionnaires, pharmacy dispensing records and routine laboratory investigations.Main outcome measures: Iron overload and its complications; complications of transfusion; adherence to subcutaneous and oral chelation therapy (expressed as a percentage based on the ratio of the amount dispensed to the prescribed dose).Results: The prevalence of diabetes mellitus was 18%; hypothyroidism, 16%; hypogonadism, 32%; cardiomyopathy, 9%; and osteopenia/osteoporosis, 83%. Serological evidence of exposure to hepatitis C and hepatitis B was present in 41% and 14% of patients, respectively, and 23% of patients had active hepatitis C infection. Predictors of complications included increasing number of years of transfusion, increasing age, coprescription of desferrioxamine and deferiprone, and poor adherence to desferrioxamine treatment. There was a wide range of adherence to therapy with desferrioxamine (0–100% of prescribed dose; mean, 46%; median, 49%) and deferiprone (29%–214% of prescribed dose; mean, 117%; median 112.5%).Conclusion: The health outcomes in our patients were similar to or better than those of patients in other cohorts, but, despite the availability of effective chelating agents, our patients had marked iron overload and a high incidence of complications.

Giselle L Kidson-Gerber MB BS, BSc · Sally Francis DipAppSc(Nursing) · Robert Lindeman FRACP, FRCPA, PhD

Objective: To determine whether asking general practitioners to offer chlamydia screening at the same time as Pap screening increases chlamydia screening rates.Design: A pragmatic cluster randomised controlled trial.Participants and setting: Doctors from 31 general practices in the Australian Capital Territory performing more than 15 Pap smear screens per year, and all women aged 16–39 years attending those practitioners between 1 November 2004 and 31 October 2005.Intervention: Doctors in the intervention practices were asked to routinely offer combined chlamydia and Pap screening to eligible women; doctors in the control practices were asked to implement screening guidelines based on a risk assessment of the individual patient (ie, usual practice).Main outcome measure: Chlamydia screening rate per visit.Results: There were 26 876 visits by eligible women during the study period: 16 082 to intervention practices and 10 794 to control practices. Chlamydia screening occurred during 6.9% (95% CI, 6.5%–7.3%) of visits to intervention practices and 4.5% (95% CI, 4.1%–4.9%) of visits to control practices. After controlling for clustering and potential confounders, there were twofold greater odds of chlamydia screening occurring during a visit by an eligible woman to an intervention practice than to a control practice (adjusted odds ratio, 2.1 [95% CI, 1.3–3.4]).Conclusion: Combining chlamydia and Pap screening increases the rate of chlamydia screening in general practice. Implementing this approach would require little additional infrastructure support in settings where a cervical screening program already exists.

Francis J Bowden FRACP, FAChSHM, MD · Marian J Currie RN, RM, PhD · Helen Toyne MB BS, DipRACOG · Clare McGuiness MB BS, PhD · Lynette L Lim MSc, PhD · James R Butler MPolEcon, PhD · Nicholas J Glasgow MB ChB

Objective: To determine if low-ankle-pressure graduated-compression tights (GCTs) reduce flight-induced ankle oedema and subjectively rated travel symptoms of leg pain, discomfort and swelling, and improve energy levels, ability to concentrate, alertness, and post-flight sleep.Design, setting and participants: Open, randomised crossover trial comparing the effects of GCTs (5 mmHg at ankle, 17–20 mmHg at calf and falling to 10 mmHg above knee and 4 mmHg at buttocks) among 50 adults on flights of 5 hours’ or more duration between 1 May and 8 October 2006; 47 volunteers (pilots and passengers) completed the trial.Main outcome measures: Differences in right ankle circumference before and after flight with GCTs and without GCTs; travel symptoms rated on visual analogue scales.Results: Low-ankle-pressure GCTs decreased ankle swelling (mean difference, − 0.19 cm; 95% CI, − 0.33 to − 0.65 cm; P = 0.012). Participants reported their legs felt better (mean, 1.6; P < 0.001; 95% CI, 1.0 to 2.1), warmer (mean, − 1.1; P < 0.001; 95% CI, − 1.6 to − 0.6), and they had a better night’s sleep (mean, 1.2; P < 0.001; 95% CI, 0.8 to 1.7) after the flight when they wore GCTs. Shifts in rating-scale probability distributions showed improvements in the ratings of pain (60%; P < 0.001), leg discomfort (50%; P = 0.001), leg swelling (45%; P = 0.006), energy levels (18%; P = 0.016), alertness levels (13%; P = 0.031), and concentration (12%; P = 0.023) when wearing GCTs.Conclusions: Low-ankle-pressure GCTs reduce flight-induced ankle oedema and subjectively rated travel symptoms of leg pain, discomfort and swelling, and improve energy levels, ability to concentrate, alertness, and post-flight sleep.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12606000150549.

Melissa J Hagan BSc, MEdSt · Stephen M Lambert RN, MAppSc

Objective: To describe a midwifery-led model of care in Far North Queensland and the outcomes obtained in its first year of operation.Design, setting and participants: Prospective analysis of data for all women who were booked for antenatal care with the midwifery-led unit at Mareeba District Hospital (MDH) and who gave birth during its first year of operation, from 27 June 2005 to 30 June 2006.Main outcome measures: Number of women giving birth at MDH; antenatal, intrapartum and postpartum transfers to a higher-level referral centre (Cairns Base Hospital [CBH]); and labour and delivery outcomes.Results: Of the 203 women who were booked for antenatal care at MDH and gave birth in the 12-month period, 170 were categorised as low risk and suitable to give birth at MDH. Of these, 147 (86%) did give birth at MDH, while 17 women (10%) had their care transferred antenatally to CBH, and six (4%) were transferred intrapartum. Of the 33 women categorised as high risk, 22 (67%) gave birth at CBH as planned, seven (21%) had elective caesarean sections performed by a general practitioner at MDH, and four (12%) presented to MDH in labour and gave birth there with no complications. Of the 158 women who gave birth at MDH, 146 (92%) had a spontaneous vertex delivery.Conclusion: Outcomes for the first year of operation of the midwifery-led model of care are consistent with a viable maternity unit, with delivery outcomes and transfer rates that compare favourably with other similar units in Australia.

Samantha Scherman MB BS, FRANZCOG · Jan Smith RM · Megan Davidson RM

Objective: To identify and analyse factors underlying intern prescribing errors to inform development of specific medication-safety interventions.Design: A prospective qualitative study that involved face-to-face interviews and human-factor analysis.Setting: A tertiary referral teaching hospital, Brisbane, Queensland, February–June, 2004.Participants: Fourteen intern prescribers involved in 21 errors.Method: A structured questionnaire was used to identify factors causing the errors. Transcripts were analysed on the basis of human-error theory to identify underlying themes.Main outcome measures: Factors underlying prescribing errors.Results: Errors were multifactorial, with a median of 4 (range, 2–5) different types of performance-influencing factors per error. Lack of drug knowledge was not the single causative factor in any incident. The factors in new-prescribing errors included team, individual, patient and task factors. Factors associated with errors in represcribing were environment, task and number of weeks into the term. Defences against error, such as other clinicians and guidelines, were porous, and supervision was inadequate or not tailored to the patient, task, intern or environment. Factors were underpinned by an underlying culture in which prescribing is seen as a repetitive low-risk chore.Conclusion: To reduce the risk of prescribing errors, a range of strategies addressing patient, task, individual, team and environment factors must be introduced.

Ian D Coombes BPharm(Hons), MSc · Danielle A Stowasser BPharm, PhD · Judith A Coombes BPharm, MSc · Charles Mitchell MB BS, FRACP

Objective: To compare the national inpatient medication chart (NIMC) with the chart previously used at Royal Perth Hospital (RPH) in Western Australia, and with charts used at 13 other hospitals across Australia; and to audit NIMC performance in practice and to assess its design characteristics.Design: Audit of patient prescribing documents extended to include a comparison with aggregated pilot study data and the previous RPH chart. Assessment of design features by inspection, based on their likely effect on medication safety.Setting: A tertiary public hospital.Main outcome measures: Compliance with the requirements of chart fields, measured as the percentage of correct entries according to predetermined criteria as required by the WA Office of Safety and Quality in Health Care.Results: Average compliance was 56% (95% CI, 43%–67%). Differences in compliance after introduction of the NIMC were variable and only one was classified as “major”. The number of charts required per admission increased from 3.1 for the previous RPH chart to 6.3 for the NIMC, and chart replacement was required after 2.9 days for the NIMC compared with 5.5 days for the previous RPH chart. Of seven advantages of the NIMC claimed by the WA Director General of Health in a letter to doctors, five (71%) were not confirmed in practice. Ten notable design features of the NIMC with a potential adverse influence on medication safety were identified.Conclusions: The NIMC contains adverse design features and is inferior to the medication chart previously in use at RPH. The purported advantages of introducing a national standard chart were not experienced at RPH.

J Alasdair Millar PhD, FRACP, FRCP · Robyn C Silla BN · Glenda E Lee BN, PGDipClinN(CritCare) · Ann Berwick BPharm, PGDipPharm

Abortion law reform focuses on early abortion. Women wanting to have a family who have a fetal abnormality detected later in pregnancy are neglected in the debate and harmed by the consequences of current legal uncertainty. Unclear abortion laws compromise: the quality of prenatal testing; management when an abnormality is found; and patient care, through obstetricians’ fears of legal repercussions. Women carrying a fetus with an abnormality are being denied abortion, even when the abnormality is so severe that non-treatment would be an option if the baby were born. Many women are likely to refuse to consider motherhood if they are denied appropriate prenatal testing and access to abortion if serious abnormalities are detected. Current abortion laws result in discriminatory and inconsistent practices, where access to prenatal testing and termination of pregnancy depends on location, the values of the treating doctor or hospital ethics committee, and a woman’s personal resources. Legal certainty is needed to reduce the suffering of couples wanting to have a family.

Lachlan J de Crespigny MD, BS, FRANZCOG · Julian Savulescu MB BS, BMedSci, PhD

Legislation has the potential to reduce chronic disease, but political will and leadership are essential If the law required restaurants to tell you the total calories and the grams of saturated fat, trans fat, carbohydrates and salt in the food you order, would it make a difference to your food choices? The California legislature thought so. In September 2007, it passed a law requiring food facilities with 15 or more outlets to prominently display nutritional information for all fixed-menu food items, together with the statement: “Recommended limits for a 2000 calorie daily diet are 20 grams of saturated fat and 2300 milligrams of sodium”.1 The Bill was hotly contested by the food industry and subsequently vetoed by Governor Schwarzenegger.2 New York City, meanwhile, recently reintroduced its own restaurant labelling law, which requires calorie information to be displayed in a typeface as large as the price.3 Although governments are increasingly using legislation in innovative ways to support the prevention of chronic disease, the law’s role remains controversial. The food, tobacco and alcohol industries have lucrative markets to protect, and there is a pervasive assumption that the solution to galloping rates of obesity, diabetes and other lifestyle diseases lies in individuals exercising greater self-control. But preaching self-control will not work if healthy choices are constantly being undermined by other, more powerful influences. While the law is not a complete answer, it can help to create supportive environments for changing the average behaviour of populations. Successful tobacco control programs illustrate this point. Success has not come by merely insisting that smokers exercise more willpower. Nor have laws been drafted with the aim of persecuting smokers or seeking to micromanage their lives. Instead, tobacco control laws have taken a population focus: addressing the price of tobacco through taxation and regulating businesses through laws that dictate smoke-free environments, point-of-sale controls, advertising restrictions and warning labels. This has resulted in conditions that discourage people from starting smoking and better support of individual attempts to quit (eg, the Quitline). The law and behavioural risk factorsLaws can influence the behavioural risk factors for chronic disease at three distinct levels: First, by better supporting interventions led by health care providers. Although Medicare now covers a range of allied health services aimed at improving care for chronic diseases,4 the challenge remains to design incentives for preventing such diseases in primary care,5 building on Lifescripts (tools for general practitioners to use when providing lifestyle advice to patients)6 and the new Medicare item for a health check for chronic disease risk factors at age 45 years (Medicare Benefits Schedule item 717).7 Laws can seek to change behaviour directly. In the United States, federal regulations permit health insurance premium discounts for people who control their weight and other lifestyle risks.8-11 In Australia, this approach would have the risk of creating disincentives to private health coverage and increasing the burden on Medicare. Laws can influence risk factors by addressing the social, economic and environmental influences on lifestyle choices (Box 1).12,13 While this is where we see the best opportunities for the law, the combined weight of multiple legal interventions will be needed if our aim is to slowly reverse broad population trends. Information policiesInformation is a powerful tool for fighting chronic disease. Laws can mandate the provision of information to consumers and, more controversially, can restrict advertising to consumers. Consumers have difficulty understanding the significance of nutrition information. Despite this, we still lack nationally agreed and standardised criteria for a front-of-pack, readily understandable labelling scheme to flag products that are high in saturated fat, salt and sugar. The United Kingdom’s “traffic-light” labelling system uses visual signposts (red, amber and green) to flag these levels in food (Box 2).14 This approach is simple to use, in real time, in supermarket aisles. Food labels can also support healthy choices by showing the amount of fat, sugar and salt as a proportion of the daily recommended intake for a normal adult. In takeaway food outlets, appropriate labelling might alert customers that the “large meal deal” delivers 52% and 77%, respectively, of the average daily energy intake for men and women.15 A “child protection” model is evident in the UK, where the Office for Communications has banned the advertising and promotion of foods with high levels of salt, sugar and fat in television programs likely to appeal to children. Some states in the US are using the law to improve the nutritional quality of food sold in schools. Any serious attempt at regulation in this area must also confront the increasing complexity of food advertising, encompassing television, the Internet, mobile phones and print media.16 The built environmentWhile improvements in the built environment could facilitate and encourage physical activity, the legal processes for making these changes are not well understood.17-19 Many aspects of the built environment are shaped by zoning and planning policies and laws, and all levels of government have a role to play. The possibilities go well beyond using the law to create mixed-use neighbourhoods that encourage walking and cycling and that are well integrated with public transport. For example, in the US, zoning laws have been used to “thin out” the density of fast food outlets. Economic policiesThe workplace is an important setting for interventions to reduce lifestyle risks. In the US, employer-funded health insurance coverage, which includes chronic disease prevention, is seen as central to reducing rising care costs.20 There are proposals before Congress to deepen this trend by partial tax relief for companies offering prevention programs that meet specified criteria.21 While Australian employers do not have the same responsibility for employees’ health insurance, the opportunity remains for Australian companies to improve productivity and reduce absenteeism by investing in workplace health promotion and disease prevention programs.22 Tax relief for companies that invest in employee wellbeing could encourage this. Other economic policies include taxing unhealthy foods to raise revenue for health promotion initiatives or to create price disincentives for overconsumption of these foods. How can this come about?Successfully addressing the broader influences on lifestyle will require policies that engage with the food production system, address public health nutrition, the built environment, transport and urban development, key settings such as schools and the workplace, and issues like food advertising and taxation. No health department, state or federal, is currently mandated to begin doing this. Successful coordination of policies across multiple sectors requires governance structures that can rise above the boundaries and entrenched cultures of existing bureaucracies and agencies, and a clear legal mandate to get things done. The central choice is between politically owned structures with cabinet-level leadership and independent-of-government agencies with clear powers and cross-sectoral reach. Either could work, but the point is that current structures are failing.23,24 Australia has a brand new federal government with a clear mandate for policy change. Will it maintain the reactive model of its predecessors — directing all its resources to disease treatment by the health care sector — or opt for a more preventive approach that engages with the socioeconomic and environmental determinants of health and illness? Most importantly, will it grasp the nettle and establish a national overarching structure — with adequate funding, support and leadership from the highest levels — to make effective intersectoral and interagency action a reality? Or will we be left, yet again, with only the rhetoric? 1 How the law can improve the health of populations10,11 The law can influence behavioural risk factors for chronic disease through: health infrastructure and governance: improving the quality and implementation of public health policies and programs through agencies that have a clear mandate to follow the evidence and to engage with stakeholders across all sectors; shaping the information environment and creating “information assets”; taxing, spending, making grants, subsidising and creating economic incentives; designing and altering the physical and built environment; economic policies addressing the socioeconomic gradient: confronting and addressing health inequalities; and command and control regulation: directly regulating persons, professionals, businesses and other organisations. 2 Traffic-light food labelling14 This traffic-light label shows the shopper, at a glance, that the labelled food is high in fat (> 20%), particularly saturated fat (> 5%), but low in sugar (< 5%) and moderate in salt (0.3–1.5%).

Roger S Magnusson BA/LLB(Hons), PhD, GDipManDev · Ruth Colagiuri BEd, GradCertHlthPolMgnt

Chlamydia screening programs overseas have failed to reduce chlamydia prevalence despite screening 20%–30% of young sexually active women. The Australian federal government announced in 2005 that it would provide $12.5 million for chlamydia control. Policymakers must look to chlamydia screening programs in other countries to learn from their experience. Australia has an excellent primary health care system and a strong track record in establishing highly successful public health programs. This experience places it in a strong position to design and implement an innovative chlamydia screening program to reduce chlamydia prevalence.

Jane S Hocking MPH, MHthSc(PHP), PhD · Jennifer Walker BAppSc, MPH · David Regan BSc(Hons), PhD · Marcus Y Chen MRCP, FAChSHM, PhD · Christopher K Fairley PhD, FAFPHM, FACSHP

Three types of infant formula (soy, extensively hydrolysed and amino acid) may be appropriate for treating cows milk protein allergy. Selection of a formula depends on the allergy syndrome to be treated. Extensively hydrolysed formula is recommended as first choice for infants under 6 months of age for treating immediate cows milk allergy (non-anaphylactic), food protein-induced enterocolitis syndrome, atopic eczema, gastrointestinal symptoms and food protein-induced proctocolitis. Soy formula is recommended as first choice for infants over 6 months of age with immediate food reactions, and for those with gastrointestinal symptoms or atopic dermatitis in the absence of failure to thrive. Amino acid formula is recommended as first choice in anaphylaxis and eosinophilic oesophagitis. If treatment with the initial formula is not successful, use of an alternative formula is recommended.

Andrew S Kemp PhD, FRACP · David J Hill FRACP · Katrina J Allen FRACP, PhD · Kym Anderson FRACP · Geoffrey P Davidson FRACP · Andrew S Day MD, FRACP · Ralph G Heine MB ChB · Jane E Peake FRACP, DTM · Susan L Prescott BMedSc, PhD, FRACP · Albert W Shugg DCH, FRACGP, FRACP · John K Sinn MMed(ClinEpi), FRACP

Our aim was to disseminate research results about the very high rates of cannabis use in three remote Aboriginal communities in Arnhem Land, Northern Territory, to the study populations. To achieve this we translated prevalence estimates, using local concepts of life stages, numbers and quantities. The reaction of the local community to results presented in this way was characterised by the phrase used when understanding something for the first time: Wa! Ningeningma arakba akina da! (“Oh! Now I know, that’s it!”). To successfully disseminate research findings in these communities, it is critical to undertake comprehensive community liaison, to find common conceptual understandings and to build the skills of local Indigenous researchers.

K S Kylie Lee BMus(Hons) · Muriel J Jaragba Cert III(Mental Health) · Alan R Clough PhD · Katherine M Conigrave FAChAM, FAFPHM, PhD

Learning to consult. Rodger Charlton, editor. Oxford: Radcliffe Publishing, 2007 (xiii + 282 pp). ISBN 978 1 85775 852 8. Consulting is something that every doctor does. For most, it is performed without reflection and for many with only the patient (or a relative) observing. This is a pity because consulting has a rich theoretical framework, and every skill should be practised and refined to ensure it achieves the best outcomes for patients. It should also be an activity, when done well, which provides us with some intrinsic satisfaction. This book is edited and written by general practitioners but it is aimed at all students, trainees and medical educators, both undergraduate and postgraduate. The authors have extensive clinical and teaching experience, and while all are from the United Kingdom the lessons are universal. While the book does focus on consulting skills, particularly communication, it also touches upon the themes of partnership and understanding that are central to a modern comprehension of the consultation process. The summaries and practical points throughout the book are well written and useful. The chapter on consultation models, incorporating biomedical and psychosocial approaches, was particularly helpful and enabled me to better understand my own evolution and interrelationships. The book also incorporates chapters on the physical examination, aids to learning, and prescribing for common conditions. This is a little ambitious as there are many more comprehensive textbooks available covering these areas, yet it doesn’t detract from the overall aim of the book to provide the reader with tools to develop or improve their consultation style. Finally, the referencing, although not extensive, was more than adequate for an educational text. Overall, this textbook provides a good starting point for medical students to learn about consulting skills and could be used as a text or revision aid for postgraduate trainees, particularly in general practice. It also offers experienced doctors a chance to consider their own consulting style and perhaps incrementally improve a fundamental part of their clinical practice.

Nigel P Stocks

Mediastinal lymphadenopathy in a patient with previously treated T-cell acute lymphoblastic leukaemia is a diagnostic problem. The differential diagnosis in an adult is sarcoidosis, metastases, lymphoma or, rarely, tuberculosis. Mediastinal lymph node involvement is uncommon in tuberculosis. In view of its relative rarity but good prognosis, it is important to distinguish tuberculous mediastinal lymphadenitis in adults from other causes of mediastinal masses. Clinical recordAn 11-year-old boy presented in September 1995 with bilateral cervical lymph node enlargement for 2 months and fever for 10 days. There was no significant medical or family history. On examination, he had generalised lymphadenopathy. Systemic examination was normal. He had a high white blood cell count (60 × 109/L) and a low platelet count. The diagnosis on bone marrow aspiration was T-cell acute lymphoblastic leukaemia. He was treated with the MCP-841 protocol as induction therapy,1 after which his bone marrow was reported to be in complete remission. He then underwent consolidation chemotherapy and prophylactic cranial radiotherapy and subsequently received six cycles of maintenance chemotherapy, which were completed by December 1997. He was lost to follow-up. He presented again in January 2006 with hoarseness of 2 months’ duration. His complete blood count was normal. The erythrocyte sedimentation rate was 40 mm/h (reference range, 0–10 mm/h). His chest x-ray appeared normal. The Hopkins test (indirect laryngoscopy) showed a fixed left vocal cord. A subsequent computed tomography (CT) scan of the chest showed lymph nodes in the left para-aortic and aortopulmonary windows (Box 1). CT-guided fine-needle aspiration cytology was reported as inconclusive. Fluorodeoxyglucose F18 positron emission tomography (PET) scan of the whole body showed active disease foci in lymph nodes in the aortopulmonary window and left axillary regions (Box 2). A bone marrow aspirate appeared normal, and bone marrow biopsy showed mildly hypocellular normal marrow. Video-assisted thoracoscopic surgical biopsy of the aortopulmonary lymph node showed histiocytic collections forming epithelioid granulomas with foreign-body and Langhans giant cells suggestive of necrotising granulomatous inflammation typical of tuberculosis (Box 3A and Box 3B). Stains for acid-fast bacilli and fungi were negative. Biopsy cultures for mycobacteria and fungi were negative. A Mantoux test was negative. In April 2006, the patient was started on antituberculosis treatment with the standard four-drug regimen consisting of rifampicin, pyrazinamide, ethambutol and isoniazid. After 2 months of treatment, he was symptom-free and was started on a two-drug regimen of isoniazid and rifampicin for 7 months. DiscussionIsolated mediastinal lymphadenopathy can be a challenge for the best of clinicians, more so when the patient has a history that might influence the diagnosis. In mediastinal lymphadenopathy, the differential diagnosis has to include both benign and malignant causes, because the therapeutic implications and prognosis of both are broad. Childhood lymphoblastic leukaemia is usually assumed to have been permanently eradicated in patients in long-term remission,but occasionally can recur after many years.2 In post-treatment relapses, or even very late relapses (5 to 20 years after diagnosis) in children, the tumour cells are clonally related to the leukaemic cells at diagnosis (shown by immunoglobulin heavy-chain locus or T-cell receptor gene sequencing), and are considered, therefore, to represent a slow re-emergence or escape of the initial cells.3 In a retrospective study of 2169 patients, the cumulative incidence of secondary neoplasm was 4.17% (SE, 0.46%) at 15 years and increased substantially after 20 years, reaching 10.85% (SE, 1.27%) at 30 years.4 In our case, the disease-free interval was 9 years. A diagnosis of relapse was initially suspected, but the peripheral smear and bone marrow results were normal. As the CT-guided fine-needle aspiration cytology, done to clinch the diagnosis of relapse, had inconclusive results, a PET scan was planned to avoid an invasive procedure. PET is more efficacious than CT in differentiating benign from malignant focal lesions. However, fluorodeoxyglucose is not a cancer-specific agent, and false-positive findings have been reported. Infectious diseases (mycobacterial, fungal and bacterial), sarcoidosis, radiation pneumonitis and postoperative surgical conditions are reflected by intense uptake of fluorodeoxyglucose on PET scan.5 The results of bone marrow aspiration to rule out relapse were normal. Hence, it was decided to go ahead with a video-assisted thoracoscopic surgical biopsy of the active focus in the aortopulmonary window, which led finally to the diagnosis of tuberculosis. Although mediastinal lymphadenopathy is not a common manifestation of tuberculosis in an adult, the possibility should be considered in the differential diagnosis.6 In a study of 1161 patients admitted to hospital for tuberculosis, the incidence of lymph node tuberculosis without pulmonary involvement was reported to be about 5.1% (60 patients). Of these, 1.3% (16) had isolated mediastinal lymphadenopathy.7 Mediastinal lymphadenopathy may occur as a complication of pulmonary tuberculosis or as a primary disease without pulmonary involvement. Tuberculous adenitis of the mediastinum manifests itself as dysphagia, stridor, acute respiratory distress, chest pain or perforation of the oesophagus or tracheobronchial tree.8 Paralysis of the recurrent laryngeal nerve caused by mediastinal lymphadenopathy due to tuberculosis is an extremely rare condition. We have come across just two published cases.9,10 Awareness of the occurrence of mediastinal tuberculous lymphadenopathy could lead to early diagnosis by bronchoscopy or thoracoscopy and early implementation of antitubercular chemotherapy. This would help to reduce the significant morbidity associated with mediastinal complications. In our case, the diagnostic dilemma was compounded by the fact that the patient had previously been treated for T-cell acute lymphoblastic leukaemia. 1 Computed tomography scan of the thorax Contrast-enhanced image shows soft tissue density in the region of the aortopulmonary window corresponding with uptake of fluorodeoxyglucose F18. 2 Positron emission tomography (PET) scan Fluorodeoxyglucose F18 PET scan showing uptake in the aortopulmonary lymph nodes. 3 Biopsy specimen of aortopulmonary lymph node A: Histological view of a biopsy specimen showing a Langhans giant cell (arrow) and epithelioid histiocytes (magnification × 20). B: View of the same specimen, showing central caseation necrosis (arrow) surrounded by palisading epithelioid histiocytes. Haematoxylin and eosin stain, magnification × 40.

Narayan Karanth MD DM · Kumar P Prabhash MD DM · Pranjali N Karanth MB BS · Tanuja Shet MD · Shripad D Banavali MD · Purvish M Parikh MD, PhD

To the Editor: The Mandometer treatment for patients with eating disorders (Box 1), developed at the Karolinska Institute in Stockholm, was brought to the attention of the public and the profession in Australia through Norman Swan’s Health Report in 2003.1 Since then, 40 patients from Australia have received treatment using this method, 29 of whom were treated in Stockholm, seven in Melbourne and four in San Diego. In a randomised controlled trial, Mandometer treatment brought 75% of patients into remission in an average 14 months, with a relapse rate of about 10% during 5 years of follow-up.2 There are seven criteria for remission, including normal eating behaviour, normal body mass index (BMI) and physical parameters, and remission of psychiatric symptoms. Patients must have returned to school or work, be comfortable with their body weight, and have avoided binge eating and vomiting for at least 3 months. Patients fulfilling five of these criteria are considered in partial remission. Of the 40 (39 female) patients reported here, 27 patients (68%) were diagnosed according to criteria of the Diagnostic and statistical manual of mental disorders, 4th edition, with anorexia nervosa, seven (17%) with bulimia nervosa, and six (15%) with an eating disorder not otherwise specified. The median age of patients was 18.7 years (range, 10.7–39.3 years). On admission, they had been ill for a median period of 5 years (range, 1–25 years) and they had had up to 20 previous unsuccessful episodes of treatment (median, 3 episodes). Fourteen patients (35%) fulfilling five remission criteria have returned to Australia for follow-up, but have not yet returned to school or work. Eight patients (20%) are in full remission, 11 (28%) are in treatment, and seven (17%) withdrew from treatment before completion, some after only a few days. All patients who are treated in Stockholm and San Diego are followed up in Melbourne, and outpatient treatment is also offered at the Melbourne clinic. Of the 27 patients with anorexia, 16 have entered full or partial remission, with marked improvement in all parameters (Box 2). Six achieved remission and 10 partial remission in 220 (range, 129–257) and 220 (range, 168–570) days, respectively. The five anorexic patients who dropped out of the treatment had low BMI (11.3, 13.5, 13.8, 14.6 and 15.7 kg/m2), had been ill for 4, 5, 8, 14 and 25 years, and had had up to nine previous episodes of treatment. This report concerns severely ill Australian patients who had previously undergone many episodes of care. These preliminary results are encouraging, given the known resistence of these disorders to treatment.4,5 Although the outcomes reported here appear to be better, comparison with other methods used in Australia should be made in a randomised controlled trial. The Melbourne Mandometer Clinic is willing to participate in such a trial. 1 Mandometer treatment has four interventions 1. The patient re-learns how to eat using Mandometer, a computerised procedure that provides feedback during meals (Figure). In about 5–6 months, anorexic patients are able to eat a normal meal and perceive a normal level of satiety after practising eating gradually larger meals. Bulimic patients are similarly trained, but they are able to eat normal amounts of food from the beginning of treatment. After using Mandometer, patients are trained to eat socially. 2. Patients rest in warm rooms after each meal. Warmth has an anxiolytic effect and prevents compensatory hyperactivity and vomiting after the meal. 3. Physical hyperactivity is prevented by use of wheelchairs and warming jackets between meals. 4. Patients are trained to re-learn social skills. Manuals describing the details of treatment are used at all clinics. The patient can adapt her or his eating rate to a linear curve displayed on the monitor (A), because she or he sees her or his own eating rate emerging (B). At regular intervals, the patient rates her or his feeling of fullness on a scale that appears on the monitor (C) and adapts her or his ratings to an s-shaped curve (D). The axes have no numerical values during training. 2 Body mass index (BMI) and obsession, anxiety and depression scores in six Australian anorexic patients treated to remission and in 10 anorexic patients treated to partial remission Psychiatric symptoms were evaluated by the Comprehensive Psychopathological Rating Scale.3 Values are medians and ranges. There were no significant differences between the groups.

John Court · Cecilia E K Bergh · Per Södersten

To the Editor: Senna is widely used in laxatives, but the results of its misuse are not inconsequential. We describe a 36-year-old woman admitted with hypercalcaemia and renal failure. She had a 6-year history of anorexia nervosa and ingestion of 50–100 senna tablets daily for weight loss. Examination revealed clubbing of the fingers and toes, a body mass index (BMI) of 17.7 kg/m2 and postural hypotension. Laboratory findings on admission are shown in Box 1. Results of autoimmune studies and protein electrophoresis, and the serum angiotensin-converting enzyme level were normal. Parathyroid hormone-related peptide was absent. She had a bland urinary sediment, trace proteinuria (150 mg/24 h; reference range, < 150 mg/24 h) and a urine pH of 5.0 (physiological range, 4.5–8.0). Computed tomography scans did not detect malignancy or infection, but showed bilateral medullary renal calcifications. Renal biopsy confirmed extensive nephrocalcinosis and the absence of primary glomerular disease. A skeletal survey showed prominent periosteal reaction and new bone formation at the ends of long bones (Box 2, A). A bone scan revealed increased tracer uptake in a pattern consistent with hypertrophic osteoarthropathy (HOA; Box 2, B). Interestingly, bone mineral density (BMD) scans showed increased lumbar and femoral T scores (1.2 and 1.3, respectively). Four years later, the renal failure, clubbing and HOA persisted despite a reduction in senna intake. Low urine volume is a prerequisite for urolithiasis, but hypercalcaemia is the key requirement for nephrocalcinosis.3 The suppressed parathyroid hormone level and elevated serum calcium level excludes primary hyperparathyroidism and made familial hypocalciuric hypercalcaemia unlikely. The serum and urine biochemistry was inconsistent with thiazide diuretic use or renal tubular acidosis. Hence, exogenous calcium is the likely cause of hypercalcaemia. Each of the senna (calcium sennosides) tablets the patient ingested contained 12.5 mg of calcium. Chronic ingestion, in addition to dehydration (with low calcium excretion) and a low BMI may contribute to a vicious circle of calcium phosphate retention, renal failure and nephrocalcinosis. Indeed, hydration increased her calcium excretion to 6.23 mmol/day and normalised her serum calcium and phosphate levels after a week. The association between finger clubbing and senna misuse, and the reversibility of finger clubbing, were reported in 1975.4 Several reports have followed, but only one noted concurrent HOA on plain x-rays.5 We believe that our report is the first to show the extent and distribution of HOA related to this disorder. It remains unknown whether HOA is reversible with abstinence from senna. Patients with anorexia are also more likely to have a low BMD, and the increased BMD scores seen in our patient might be the result of metastatic calcification or periosteal new bone formation. Neither could be conclusively proven. The development of nephrocalcinosis in anorexic patients is more common than is generally appreciated. Clubbing and HOA are useful clues to senna misuse, and BMD measurements should be interpreted with caution in this setting. 1 Biochemical parameters on admission before treatment Parameter Patient value Reference range Serum concentrations of: Sodium (mmol/L) 139 135–145 Potassium (mmol/L) 3.2 3.5–5.0 Magnesium (mmol/L) 0.74 0.80–1.50 Chloride (mmol/L) 102 95–107 Bicarbonate (mmol/L) 24 21–30 Urea (mmol/L) 8.6 2.5–7.8 Creatinine (μmol/L) 166 40–120 Albumin (g/L) 28 35–45 Corrected calcium (mmol/L) 2.93 2.20–2.60 Ionised calcium — pH adjusted (mmol/L) 1.51 1.14–1.29 Phosphate (mmol/L) 2.58 0.80–1.20 25-hyroxyvitamin D (nmol/L) 23 55–108 Parathyroid hormone (pmol/L) 1.0 1.1–7.7 Rates of: Creatinine clearance (mL/min) 20 90–150 Urine sodium excretion (mmol/day) 28 40–100 Urine potassium excretion (mmol/day) 29 50–140 Urine calcium excretion (mmol/day) 1.56 2.0–7.5 2 Ankle x-ray and full bone scan

Andy K H Lim · David H Hooke · Peter G Kerr

To the Editor: The editorial by Woollard and Newman1 discussing the best management of stable coronary artery disease is welcome and timely, but we believe their conclusions undervalue the benefits of optimal medical therapy. The authors correctly point out that the early trials comparing surgery with medical treatment did not include aspirin, β-blockers or lipid-lowering drugs in the medical treatment group. Clearly, the benefits of these treatments have been so dramatic as to make these original trials irrelevant to current practice. After reviewing trials comparing percutaneous coronary intervention (PCI) with coronary artery bypass graft (CABG) surgery and discussing their limitations, the authors conclude that: The best interpretation of currently available data is that, for patients with severe coronary artery disease, the more invasive procedure with a longer recovery time (CABG) has a better long-term clinical outcome and is more cost-effective than the less invasive fast-recovery procedure (PCI). We believe this conclusion is only appropriate for those patients in whom an adequate trial of medical therapy has failed to achieve sufficient relief of anginal symptoms. Based on current evidence, including that from the MASS II2 (comparing medical therapy with both CABG and PCI), COURAGE3 (comparing PCI with medical therapy) and AVERT4 (comparing intensive lipid-lowering therapy using atorvastatin with PCI) trials, we conclude the following about the management of stable coronary artery disease: Irrespective of whether patients under-go CABG or PCI (or neither), aggressive medical therapy combined with appropriate lifestyle measures is the means by which patients are protected from major adverse cardiovascular events. There is no evidence that either PCI or surgical treatment is superior to the current best medical treatment in preventing death or myocardial infarction. Patients with stable angina should be informed accordingly and be reassured that their symptoms are likely to abate or resolve with optimal medical treatment over a period of time. Intervention should be reserved for patients in whom an adequate trial of medical treatment has failed to relieve symptoms or in whom medication is poorly tolerated, and possibly for patients in whom satisfactory anti-atherosclerosis treatment targets cannot be achieved. Performing PCI and CABG in patients with stable angina consumes a significant portion of the Medicare budget. We believe many patients with absent or relatively minor symptoms consent to these procedures in the mistaken belief that their lives will be prolonged. Application of evidence-based guidelines would significantly reduce the number of interventions currently performed and make much needed resources available for prevention strategies and for selected patients with acute coronary syndromes in whom this expensive treatment has proven benefit. Lastly, we strongly support the implication by Woollard and Newman that patients should “undertake consultation with other providers” regarding treatment options — including medical therapy.

Richard W Harper · Esther M Briganti · Brett H R Forge

In reply: We agree with Harper and colleagues that for most patients with stable coronary artery disease, prevention of death or other cardiac events is best achieved with medical treatment. Many patients and even some doctors are so impressed by the restoration of coronary blood flow achieved with angioplasty that they incorrectly assume it will provide a prognostic benefit. However, we do not agree that intervention should be reserved for patients in whom medical treatment has failed. It is unlikely that a trial comparing current medical treatment with coronary artery bypass graft (CABG) surgery for severe left main coronary disease will ever be performed, and current evidence favours CABG at least in this group. In addition, many patients with angina prefer a mechanical intervention to long-term antianginal medications, and why should they be denied that choice?

Keith V Woollard · Mark A J Newman

To the Editor: In Australia, the rising cost of the Pharmaceutical Benefits Scheme (a comprehensive system for subsidising prescription medicines for the whole population) has led to the Australian Government instituting a number of cost-saving strategies. One of these strategies is to encourage the use of generic medicines. However, generic prescribing is a contentious issue among Australian prescribers. The debate has centred on issues related to bioequivalence, quality and safety.1,2 Further, previous studies have shown that changing existing prescribing behaviour is difficult.3,4 To avoid the difficulty of having to change existing prescribing behaviour, education about the benefits of generic prescribing should be aimed at medical students, who are the prescribers of the future.5 To explore and evaluate senior (final-year) medical students’ perceptions of and knowledge about generic medicines and generic prescribing, we undertook a nationwide, web-based survey of senior medical students in Australian universities from 18 June to 18 September 2004. Of 1497 senior medical students in 10 universities throughout Australia, 400 (26.7%) responded to the survey. The first part of the questionnaire required students to select the correct bioequivalence limits allowed by the Therapeutic Goods Administration when comparing a generic medicine with a brand-name medicine. We compared responses to detect differences according to sex, graduate (students with a Bachelor or higher degree on entry to medical school) versus non-graduate status, and between the 10 universities using Fisher’s exact test. For the first question, six options were given, with the correct answer being 80%–125%. Most respondents (64%) did not answer the question, and only three (0.8%) answered it correctly. Responses to other individual questions in the web survey are shown in the Box. Seventy-one per cent of respondents (287) thought that they needed more information on how bioequivalence tests are conducted. More than 90% of respondents did not believe that generic medicines registered in Australia are equal in terms of quality and efficacy to their brand-name counterparts. A similar proportion of respondents thought that generic medicines would cause more side effects than brand-name medicines. Eighty-seven per cent highlighted pharmacists as one of the most important health care professionals to advise them on generic medicines. Almost 92% of respondents agreed that their future prescribing habits would be likely to be influenced by their senior colleagues and medical consultants. More than 60% believed that their respective university did not adequately cover the topic of cost-effective prescribing in their medical curriculum. Our survey clearly shows that medical students in Australia need to be better taught about issues relating to generic medicines and generic prescribing. Modifying existing curricula to include education about generic medicines will be a critical strategy towards promoting rational use of generic medicines by medical practitioners. Responses to questions assessing knowledge and perceptions of senior medical students in Australia about generic medicines and bioequivalence Responses P (Fisher’s exact test) Survey question/statement Strongly agree Agree Neutral Disagree Strongly disagree Sex Graduate status* University† All generic products of a particular medicine that are rated as “generic equivalents” are: therapeutically equivalent to the innovator brand product 66 (16.5%) 276 (69.0%) 18 (4.5%) 36 (9.0%) 4 (1.0%) 0.692 0.094 0.096 therapeutically equivalent to each other 4 (1.0%) 49 (12.3%) 23 (5.8%) 263 (65.8%) 61 (15.3%) 0.846 0.998 0.107 I have not been introduced to the issues of bioequivalence for generic drugs during my medical education 120 (30.0%) 153 (38.3%) 47 (11.8%) 69 (17.3%) 11 (2.8%) 0.703 0.893 0.010 I need more information on how bioequivalence tests are conducted for generic medicines 73 (18.3%) 214 (53.5%) 74 (18.5%) 34 (8.5%) 5 (1.3%) 0.036 0.572 0.195 A generic medicine is bioequivalent to a brand-name medicine 79 (19.8%) 270 (67.5%) 18 (4.5%) 30 (7.5%) 3 (0.8%) 0.574 0.943 0.827 A generic medicine must be in the same dosage form (eg, tablet, capsule) as the brand-name medicine 27 (6.8%) 106 (26.5%) 52 (13.0%) 196 (49.0%) 19 (4.8%) 0.751 0.677 0.152 A generic medicine must contain the same dose as the brand-name medicine 47 (11.8%) 171 (42.8%) 44 (11.0%) 126 (31.5%) 12 (3.0%) 0.919 0.905 0.048 Generic medicines are of inferior quality to brand-name drugs 148 (37.0%) 226 (56.5%) 20 (5.0%) 5 (1.3%) 1 (0.3%) 0.006 0.944 0.054 Generic medicines are less effective than brand-name medicines 151 (37.8%) 228 (57.0%) 19 (4.8%) 1 (0.3%) 1 (0.3%) 0.029 0.124 0.010 Generic medicines produce more side effects than brand-name medicines 148 (37.0%) 222 (55.5%) 26 (6.5%) 3 (0.8%) 1 (0.3%) 0.052 0.619 0.023 Generic medicines are less expensive than brand-name medicines 165 (41.3%) 215 (53.8%) 9 (2.3%) 9 (2.3%) 2 (0.5%) 0.190 0.154 0.072 Brand-name medicines are required to meet higher safety standards than generic medicines 112 (28.0%) 219 (54.8%) 42 (10.5%) 22 (5.5%) 5 (1.3%) 0.747 0.843 0.162 * Comparing graduate (those with a Bachelor or higher degree on entry to medical school) with non-graduate students. † Differences between the 10 universities represented.

Mohamed Azmi Ahmad Hassali · Kay Stewart · David C M Kong

To the Editor: In a recent article, Youl and colleagues provided information about the ability of doctors to accurately diagnose skin lesions that they excise or biopsy.1 We wish to offer some comments about their comparison between general practitioners and skin cancer clinic doctors. First, in the study by Youl et al the behaviour of GPs and patients in mainstream practice was different from that of doctors and patients in skin cancer clinics, as indicated by the comparative frequency of whole body skin examinations performed (GPs, 30.4%; skin cancer clinic doctors, 73.2%).1 The study did not indicate the circumstances under which each decision to excise took place. Did patients become aware of a new or changing skin lesion and bring it to the attention of the doctor, or did the diagnosis result from a whole body skin check that might have revealed an earlier, previously unnoticed and more subtle lesion? It may be useful to separate basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) into histological subtypes, as early superficial BCC and intraepidermal SCC may be more difficult to diagnose than other subtypes.2 Second, the casemix of non-melanotic skin cancers in the two groups of doctors was quite different, with a BCC : SCC ratio of 1.1 : 1 for GPs and 2.1 : 1 for skin cancer clinic doctors. The difference in casemix was reflected in a study of our own3 in which we described the histology of 1247 lesions excised by doctors, including 76 lesions removed by one doctor in a designated skin cancer clinic. In an unpublished sub-analysis, we divided the results into two settings for comparison (Box). Like Youl et al, we found that the casemix of non-melanotic skin cancers was significantly different for the two groups of doctors (P < 0.001), but in our study the BCC : SCC ratio was much higher for skin cancer clinic doctors (4 : 1) than for GPs (0.6 : 1). We believe this most likely reflects an increased pick-up of BCC in skin cancer clinics, owing to the higher frequency of full body skin examinations and the consequent detection of lesions of which the patient is unaware. Third, the reported sensitivity and specificity in the study by Youl et al refers only to excised lesions. There is no information given about the lesions that practitioners decided not to excise. The sensitivity and specificity of skin examinations can only be determined if all relevant skin lesions are assessed, thereby giving an accurate representation of the number of true- and false-negative diagnoses. However, this would require multiple excisions, which would be clinically unacceptable. An important limitation of the study is that it does not assess or compare how many skin cancers each group of doctors missed. In conclusion, although the study by Youl et al provides comprehensive information about diagnostic accuracy, we do not feel — based on the information available — that a meaningful comparison between the two groups of doctors can be made. Comparison of lesion excisions in skin cancer clinic and general practice settings Mean patient age (years) Proportion of excised lesions that were malignant* BCC : SCC ratio Number needed to treat† Skin cancer clinic 56.5 76% (58/76) 4 : 1 (44/11) 4.7 (14/3) General practice 56.9 45% (512/1145)‡ 0.6 : 1 (190/305) 9.0 (154/17) BCC = basal cell carcinoma. SCC = squamous cell carcinoma. * BCC, SCC or melanoma. † Benign or dysplastic naevi excised per melanoma. ‡ There were 26 cases in which histology results were missing. All were in the general practice setting.

Clare Heal · Beverly Raasch

To the Editor: Youl and colleagues are to be commended for their research into the performance of special-interest skin cancer clinicians.1 However, the conclusion that the performance of general practitioners and skin cancer doctors in the diagnosis of skin cancer is similar is highly questionable. To truly compare the two groups and their diagnostic accuracy, it must be established that the participants were representative of the groups they are supposed to represent. The fact that the participating GPs were largely self-selected, perhaps on the basis of their personal interest in the subject, was a potential flaw that the authors acknowledge. Further, an examination of diagnostic accuracy should also take into account whether the lesions found were of similar type, size and stage. There was no determination of any qualitative differences (eg, in size or thickness) between the tumours seen and diagnosed by the two groups. When a patient presents, specifically, with a large, tender, hyperkeratotic squamous cell carcinoma (SCC), there is no real test of diagnostic skills. On the other hand, detecting a small early posterior-thigh melanoma or a superficial BCC on a whole body examination is a challenge. Overall, one would expect at least two to three BCCs to be diagnosed for each SCC found2 — however, in the study by Youl et al, GPs found a similar proportion of each type of lesion, suggesting that perhaps a large number of BCCs were not being detected at all in the GP group. The lower incidence of whole body examinations in the GP group suggests that a higher proportion of asymptomatic lesions may have been missed by the GP group and thus not included in their sensitivity/specificity data. This possibility could have been examined by noting the site of lesions found: identification and diagnosis of lesions in areas covered by clothing or footwear may be more likely on whole body examination. Although Youl et al reported that the diagnostic sensitivity for melanoma among skin cancer clinic doctors was twice that of GPs, a re-examination of the data with all of the above in mind may well reveal that skin cancer clinic practitioners are performing even better than suggested. That being said, the number of melanomas found per week by the skin cancer group (0.25 melanomas/doctor/week) in the study by Youl et al is much lower than in our own dedicated primary care skin cancer clinic (1.47 melanomas/doctor/week, based on audit data gathered between February and September 2007). Good medical care relies on accurate diagnosis and appropriate treatment, and the earlier the diagnosis is made, the less costly and less invasive the treatment and the greater likelihood of a cure. Surely we should all be working together — skin cancer clinic practitioners and GPs, alike — towards achieving optimum outcomes for our patients. To that end, a wider range of higher education in skin cancer medicine is being encouraged by the University of Queensland’s Master of Medicine program3 and the Skin Cancer College of Australia’s fellowship program,4 and bodies such as the Skin Cancer Society of Australia and the Royal Australian College of General Practitioners have been working together to introduce an accreditation process for those practising primary care skin cancer medicine.5,6

Jeffrey Keir

In reply: We thank Heal and Raasch, and Keir for their comments and suggestions. First, as acknowledged in our article, it is possible that general practitioners with an interest in skin cancer may have been over-represented in our sample. It is also the case that the comparison between GPs and skin cancer clinic doctors may have been affected by characteristics of patients attending each type of practice. Patients attending skin cancer clinics are self-selected (often worried about a specific skin lesion), while for those attending GPs in mainstream practice, skin lesions are more likely mentioned during a consultation for something else.1 Case selection, which helps increase diagnostic ability by Bayesian principles (improving pretest probability of malignant lesions), may thus be more likely for skin cancer clinic doctors than GPs.2 Our study represented a broad cross-section of skin cancer clinics, and the number of melanomas excised per doctor per week ranged from 0 to 1.7. The ratio of basal cell carcinomas to squamous cell carcinomas excised ranged from 0.1 to 6.0 for mainstream GPs and 0.8 to 8.0 for skin cancer clinic doctors. Whether clinical and histological features of skin lesions or the type of skin examination undertaken influence diagnostic accuracy was beyond the scope of our initial study. This question will be the subject of future analyses. It has been suggested that a limitation of our study was that it did not assess or compare the number of skin cancers each group missed. However, as specifically stated in our article, the aim of our study was to examine diagnostic accuracy of excised or biopsied lesions. To examine the sensitivity and specificity of all lesions (excised and non-excised) and of screening examinations would require a different study design. We disagree that meaningful comparisons between the two groups cannot be made from the data collected in our study. Our prospective study included over 11 000 skin excisions or biopsies from a large group of mainstream GPs and from doctors working in a variety of skin cancer clinics. One of the most important outcome measures of our study was the degree of accuracy of skin cancer diagnoses within the primary care setting. We have demonstrated that primary care practitioners, whether mainstream GPs or skin cancer clinic doctors, diagnose skin cancer with similar, high levels of accuracy. This is a reassuring result, particularly in a country with the world’s highest incidence of skin cancer.

Philippa H Youl · Peter D Baade · Monika Janda · Christopher B Del Mar · David C Whiteman · Joanne F Aitken

To the Editor: Dabadghao and colleagues have drawn attention to the high prevalence of diabetes mellitus and impaired glucose tolerance (IGT) among Australian women with polycystic ovary syndrome (PCOS).1 Quite rightly, both in this article and in the accompanying editorial by Teede and Stuckey,2 the authors have stressed the need to test women with PCOS for diabetes, and that long-term follow-up and lifestyle modification are important. However, it is important to note that many of these women were attending a reproductive endocrinology clinic for treatment of infertility. Therefore, two other points need to be highlighted. First, the high prevalence of glucose intolerance among this group is of immediate concern, as type 2 diabetes can pose a considerable risk to a pregnancy.3 The dangers include miscarriage, fetal malformation and perinatal mortality. Data from New Zealand indicate that perinatal mortality in pregnancies of women with type 2 diabetes was about triple that in pregnancies of women without diabetes; and, in women with type 2 diabetes which was not detected until after pregnancy was achieved, perinatal mortality was 4.5 times that of women without diabetes.4 Screening for diabetes therefore provides an opportunity to ensure that women with glucose intolerance are adequately prepared for pregnancy, thereby minimising the risks. Important measures include high-dose folate therapy and tight glycaemic control, in accordance with guidelines previously published in the Journal.5 Second, the risk of adverse pregnancy outcomes related to the women’s obesity (mean body mass index, 35.1 kg/m2) is also of concern. Therefore, stringent efforts should be made to take the opportunity presented to normalise the weight of women with PCOS before conception.6 The data presented by Dabadghao and colleagues also provide insights into the most appropriate means of screening for diabetes in this high-risk population. They have shown that screening by fasting glucose level alone will miss a third of cases of diabetes. Furthermore, at least 81% of IGT will also be missed! Glucose tolerance testing is therefore far superior to fasting glucose level for the detection of diabetes and IGT. This is a critical point, given the potential ramifications of undetected diabetes. Given these findings, we urge clinicians to routinely perform a glucose tolerance test for women with PCOS attending for fertility treatment, so that all cases of abnormal glucose tolerance are detected, and appropriately managed, before and after conception. It would be a tragedy for a woman to achieve a pregnancy through in-vitro fertilisation, only to develop complications from undiagnosed diabetes.

N Wah Cheung · Jeremy J N Oats

To the Editor: Drug-eluting coronary stents (DES) were approved for use in Australia in 2002, after they were found to be effective in limiting the incidence of restenosis.1 However, their cost is three to four times that of traditional bare-metal stents, and most Australian states restricted their use in the public health system. In 2006, we reported in the Journal that DES were used in 45% of patients undergoing percutaneous coronary intervention (PCI) in Victorian public hospitals, and that they were largely reserved for patients with risk factors for restenosis, such as diabetes, small vessels, and complex lesions.2 However, in the private health system, DES can be claimed as prostheses from insurance funds, so their use is not limited by financial constraints. In early 2007, multiple reports from around the world noted a small but significant increase in late stent thrombosis occurring 1–4 years after implantation of DES.3,4 This caused concern, as stent thrombosis has a mortality rate approaching 50%. It is now recommended that all patients with DES maintain aspirin and clopidogrel therapy for at least a year, although the appropriate duration of this treatment remains unknown.5 Further, long-term dual antiplatelet therapy is associated with an increased risk of bleeding and is problematic for patients requiring surgery.4,5 We examined the use of DES from February 2006 to June 2007 in 674 patients undergoing PCI by 10 operators in a Victorian private hospital. Monthly use dropped dramatically, from a peak of 91% of patients in July 2006 to 34% in June 2007 (Box). In 118 PCIs performed between March and May 2007, DES were used more often in: diabetic than non-diabetic patients (67% v 47%; P = 0.05); small (≤ 2.5 mm) vessels compared with large vessels (74% v 53%; P = 0.04); and long lesions (> 20 mm stent length) compared with shorter lesions (62% v 52%; P = not significant). This mirrors the pattern previously seen only in patients treated in the public health system.2 Given the issue of late stent thrombosis and the need for prolonged dual antiplatelet therapy, reserving DES for patients who are at high risk of restenosis in both the public and private health systems seems very appropriate. Utilisation is likely to change again with a better understanding of the long-term safety of DES, but a cautious approach should be maintained. Drug-eluting stent (DES) use per month (February 2006 – June 2007) in patients in a Victorian private hospital

Suzanne M McLean · David J Clark

To the Editor: After the recent New South Wales parliamentary inquiry into Royal North Shore Hospital, one might ask whether the deliberations will deliver real change to the hospital system. An article in the Lancet draws attention to some adverse outcomes in London hospitals.1 One such case is reported from the evidence and conclusions of the Islington Coroners’ Court into the death of a man as a result of his outpatient management. The report states: The jurors have . . . taken into consideration the large number of patients attending Guy’s Hospital as casual patients, [and] are of the opinion that the skilled supervision is insufficient, and should be increased; but they . . . believe the deceased received all the care and attention which the present arrangement of the hospital affords. The report goes on to discuss the effect of the excessive numbers of patients each house surgeon is expected to manage daily. The writer is of the mind that “the reported cases are now so frequent that something will have to be done”. As for immediate solutions, the report suggests: The officers of hospitals will have to be a little more careful. The committees and governors of hospitals must not impose impracticable quantities of work on one man’s shoulders; they must take steps either to diminish the amount of casual out-patient work, or they must increase the number of competent and qualified persons. The article concludes that “there is another party in these questions who is not entirely free of blame — viz., the public”. The writer supports the public’s right to “express indignation at defective diagnosis and accommodation in hospitals” but implores the public to be more liberal with hospital funding. The conclusions are straight to the point: The committees of hospitals cannot multiply beds and qualified house-surgeons without funds, any more than one can make bricks without straw. And if the maimed and the diseased are not to be denied skilled advice and accommodation at hospitals, or are not to be passed from one hospital to another, the public must be far more liberal in its support of hospitals than it has been. This report was published in the Lancet on 20 August 1881. Has nothing changed?! The public has now relinquished its responsibility for running public hospitals to the state. I hope more permanent solutions to the problem will follow the recent inquiry! As the writer suggested in 1881, “something will have to be done”.

Catherine E Storey

Good fats fight diabetes Dietary intake of omega-3 fatty acids appears to be associated with a reduced risk of pancreatic islet autoimmunity (IA) in children who have an increased genetic susceptibility for type 1 diabetes. In a US longitudinal observational study, 1770 children at risk of developing diabetes were followed to a mean age of 6.2 years. Autoantibodies against islet components were measured, and dietary intake of polyunsaturated fatty acids from the age of 1 year was assessed. Omega-3 fatty acid intake seemed to be associated with a decreased risk of IA. The association was independent of caloric intake. A smaller case–cohort study also showed that a high level of omega-3 fats in erythrocyte membranes was inversely associated with the risk of IA. The authors conclude that their results are highly suggestive of the benefit of such fatty acids, and that dietary supplementation could become an important part of early intervention to prevent the development of type 1 diabetes. JAMA 2007; 298: 1420-1428 Chlamydia diagnostic tool passes the test A rapid point-of-care test for Chlamydia trachomatis using vaginal swab specimens has potential to be an effective diagnostic and screening tool for Chlamydia infection in women. In a UK study, 1349 women were assessed using the immunoassay-based test, which provides a same-day result. Findings from self-collected vaginal swab specimens and clinician-collected specimens were compared. Results were also compared with those from a traditional polymerase chain reaction diagnostic tool. The rapid test was found to correlate well with the other test in terms of sensitivity, specificity, and positive predictive value. There appeared to be no significant difference between self-collected and physician-collected swabs. The high acceptability and convenience of the test, conclude the researchers, make it a useful alternative to current forms of diagnosis. BMJ 2007; 335: 1190-1194 Overweight kids at risk A higher body mass index (BMI) in childhood is associated with a greater risk of coronary heart disease (CHD) in adulthood, according to Danish researchers. The study followed a cohort of over 250 000 adults with available records of weight and height from their childhood. Information about CHD events was gathered and correlated. Among boys, the risk of a CHD event in adulthood increased significantly with rising BMI between the age of 7 and 13 years. A similar but lower risk was found in girls. The authors comment that, despite some limitations, the large size and population-based nature of the study give it sufficient power to make the results significant. The findings are of particular concern given the current “epidemic” of obesity among children. N Engl J Med 2007; 357: 2329-2337 Nose knows best If you are wondering about the best treatment for your patients with acute sinusitis, you might like to consider no treatment at all, say British researchers. In the face of high antibiotic prescribing rates and controversy surrounding management options, the group conducted a double- blind, randomised, placebo-controlled trial of 240 adults with acute non-recurrent sinusitis. Patients were placed into four groups receiving combinations of amoxicillin, a nasal steroid (budesonide) and placebo forms of both treatments. The main outcome measures were the proportion clinically cured at 10 days and duration and severity of symptoms. Neither the antibiotic nor the nasal steroid appeared to be effective as a treatment for acute non-recurrent sinusitis in the general practice setting. The only qualifying situation was in the milder cases, where the nasal steroid had an apparent positive effect on outcome. JAMA 2007; 298: 2487-2496 The cost of human life What price to save a life? Not a great deal it seems, according to an international study on the cost and prevention of chronic diseases. Almost 14 million deaths world-wide could be prevented over a period of 10 years by reducing dietary salt intake and controlling tobacco usage, say researchers who analysed modifiable risk factors for common chronic diseases and estimated the cost of interventions. Eighty per cent of the burden of chronic disease is felt in a small number of low- and middle-income countries. Using the results of meta-analyses on the long-term health effects of reduction of salt intake, the researchers modelled the effect of a 15% reduction in salt consumption on blood pressure on populations in these countries. They also estimated the benefits of the reduction in tobacco usage that would result from implementation of the interventions from the World Health Organization Framework Convention on Tobacco Control. Collaborators in the study estimated that most deaths prevented by these measures would be from cardiovascular disease, respiratory disease, and cancer. And the cost of implementing the two interventions and averting 13.8 million deaths? Less than US$0.40 per person per year in low-middle-income countries. The authors conclude that the numbers of deaths potentially prevented, although large, still account for only a small percentage of the burden of mortality resulting from chronic disease. Lancet, online 5 Dec 2007 Dr Tanya Grassi, MJA

Ann Gregory