Volume 188 Issue 4

The psychological downsides, equity of access for women, and patients’ understanding of the limitations of screening need consideration Australian states are currently rolling out colorectal cancer screening as part of the National Bowel Cancer Screening Program. Its success depends on the “physical or psychological harm to those concerned be[ing] less than the chance of benefit”.1 The benefits are clear. Randomised controlled trials show a 16% reduction in colorectal cancer mortality with faecal occult blood testing and colonoscopy of people with a positive faecal occult blood test (FOBT) result.2 In contrast, less attention has been paid to the psychological impact of colorectal cancer screening. Its effective management may also improve screening outcomes. Breast cancer screening studies show that a screening invitation may cause severe anxiety and, in some cases, non-attendance; people who do not attend for one form of screening are more likely not to attend for other screening.3 Screening studies also show that participants can experience severe anxiety irrespective of results.4,5 An audit of suicides found two occurred between notification of recall after mammography and reattending; one suicide note was written on the recall letter, the other mentioned fear of hospitalisation.4 Neither woman had cancer. These findings emphasise the importance of education, rapid outpatient review and, if required, prompt access to colonoscopy to avoid delay in managing a positive FOBT result.5 FOBT-based screening studies report distress among both those with negative and positive results, and breast and colorectal cancer screening studies show that anxieties may continue even after a subsequent negative result.4-6 Among those who screen negative, distress may be sustained, indicating that this is a risk of screening healthy adults. A general-practice-based coronary heart disease screening study found that participants with no detected abnormality had significantly more psychological distress at 3 months than their unscreened counterparts. If not done carefully, screening may distress individuals who have clinically inconsequential disease.7 Women screened for hepatitis C and found to be positive after inadvertently receiving infected anti-D immunoglobulin reported high levels of psychological distress and poorer quality of life compared with their counterparts 22 years later, despite no progression of their disease.8 These studies emphasise the importance of assessing the appropriateness and benefits of screening. For colorectal cancer screening, with direct-to-patient kit provision, the group most vulnerable are patients unlikely to benefit because of other life-threatening comorbidities. Clinicians, particularly general practitioners, have a pivotal role in counselling these patients. The implications for patients of direct-to-patient kits should become clearer as screening progresses and its analysis should improve management further. A relatively unexplored potential contributor to morbidity is lack of choice of colonoscopist.3,9,10 A United States survey of women’s attitudes to colorectal cancer screening found that almost half reported a preference for a female endoscopist. Eighty per cent of these patients were willing to wait more than 30 days for one, and 14% would pay more for one. Seventy-five per cent of women gave embarrassment as the reason for their preference.10 If this is applicable to Australia, strategies are needed to ensure that women (particularly those who are uninsured, who have fewer options) have equity of access. Currently, fewer than 10% of Australian gastroenterologists are female, and the proportion of female gastrointestinal surgeons is even lower. It will be important for the success of colorectal cancer screening to know whether this workforce shortage has a substantial impact on female participation in the program. Informed participation is the ideal. Challenges include ensuring that patients understand the limits of screening for detecting colorectal cancer; in particular, that an FOBT sensitivity of 92% misses eight per cent of cancers.2 Information supplied in the National Bowel Cancer Screening Program kits emphasises the need for patients to seek medical advice irrespective of a screening result to have any symptoms they may have assessed in their own right. It is clearly important that participants are encouraged to develop realistic expectations about screening’s capacity to prevent cancer. An important unintended outcome of screening can be the “certificate of health effect”, a sense of immunity developing as a result of a negative test. Interpreting screening as a panacea against disease can strengthen unhealthy routines and the idea that regular screening rather than healthy lifestyle maintains health. Screened individuals still need to be encouraged to continue to limit red meat and fat intake, stop smoking and increase their physical activity, not only to reduce their subsequent colorectal cancer risk, but also to improve their general health status. As people value benefits and harms differently, more information is needed, not only on the physical and economic impact of colorectal cancer screening, but also on its psychological impact and on strategies to reduce this impact. Triggers to screening such as the perceived ease of use of the FOBT kit, and social acceptability and mechanisms for encouragement, need to be further assessed, as highlighted in the National Bowel Cancer Screening Pilot Program evaluation. As fewer than 10% of Australian gastroenterologists are female, strategies to ensure equity of access for all Australians, both men and women, may need to be emphasised. Now is an appropriate time to undertake further prospective studies into the impact of colorectal cancer screening on the population groups involved to ensure that its benefits continue to outweigh its risks, and that we maximise its benefits and minimise its risks.

Emma L Rosenfeld MB BS · Anne E Duggan BMed, FRACP, PhD

Teleradiology is like a “two-edged sword” that requires careful consideration and balancing, needing uniform standards to guide quality care while ensuring patient safety The rapid and secure transfer of x-ray and diagnostic imaging studies around the world is being facilitated by new technologies, such as picture archiving and communication systems (PACS), high-speed Internet access, and secure virtual private networks. This transfer of images, usually for assessment by a radiologist at a geographically remote site from where the images were obtained, is known as teleradiology.1-4 Domestic and international teleradiology is practised by individuals and imaging practices (private radiology groups and corporate practices), as well as teleradiology groups in Australia. Based on the 2006 Royal Australian and New Zealand College of Radiologists (RANZCR) Workforce Survey,5 about 67% of Australian radiologists use teleradiology in their daily work: 92% within their own state, 22% between states, and 1.7% internationally. The international teleradiology workflow is bidirectional, with Australian imaging studies being reported overseas and overseas imaging studies being reported in Australia. Clinical teleradiology has advantages, but there are also potential problems and pitfalls. However, in teleradiology, as in any use of radiology, the provision of high-quality, appropriate clinical care and accountability must remain of utmost importance, and this principle should guide teleradiology’s further development. In Australia, there is an escalating demand for diagnostic imaging services. The RANZCR anticipates that demand will greatly outstrip current supply in the radiologist workforce for at least the next 5 years. Further, this ever-increasing demand on diagnostic imaging services is accompanied by an increasing complexity of studies and a continued expectation that they will be reported promptly, 24 hours a day, 365 days a year. Given the geography and demographics (including radiology workforce demographics) of Australia, the benefits of using teleradiology are clear. Teleradiology can provide remote interpretation for rural and regional communities; second subspecialist opinion; workload balancing for diagnostic imaging staff; education; research; and clinical/quality audits.6,7 Out-of-hours interpretation, when local radiology services are unavailable, may also be of great benefit to patients if urgent advice is required. Similarly, however, several potential pitfalls are evident. One key pitfall relates to the “distancing” of the radiologist from patients clinically, as well as geographically — a trend that is already increasing with onsite services, and may only intensify with teleradiology. Radiologists have minimal influence over referrals that occur under a capped diagnostic imaging Medicare budget for billed services or in the public hospital sector. Apart from technological considerations, current legislation, reimbursement schedules and workload demands also exacerbate the increasing distancing of radiologists from clinicians and patients. Reporting radiologists may have little or no clinical or contextual patient information or direct communication with the clinician caring for the patient, resulting in image interpretation occurring in isolation, rather than provision of an integrated expert opinion. However, if this pitfall is avoided, specialist radiologists can make a pivotal contribution to clinical decision making and management — clinicoradiological discussions can result in a change of clinical diagnosis in 50% of cases and a change in treatment in 60% of cases discussed.8 Using radiologists and diagnostic imaging wisely could reduce the burden on the entire health system by not only improving diagnosis and management but also by reducing unnecessary and repeated radiation exposure, thus optimising overall patient care. Other potential problems relate to technical and professional considerations. Transfer of images may result in less than optimal image quality, hampering interpretation. If images are sent overseas, it is possible that the reporting radiologist may not be trained to the same standard as radiologists in Australia. We need to acknowledge that when English is not a radiologist’s primary language, there may be increased potential for error. Indemnity may not be guaranteed, and protection for patients may not be available.2-4,6,9,10 Perhaps the most serious concern relates to the potential evolution of medical services, including teleradiology, as commodities instead of community services. The globalisation of health care has never been more evident than in international teleradiology. The emerging globalisation of health care generally1-4,11 and, more specifically, the progressive corporatisation of radiology providers and the prospect of commoditisation of radiology services9,12 are on our doorstep. To contain cost, maximise efficiency and meet shareholders’ expectations, health care providers increasingly use teleradiology to outsource services.3,4,9,12 In some countries, out-of-hours on-call teleradiology has fully matured, and teleradiology companies are turning to daytime and subspecialty segments to further grow their market share.9 Some observers have noted that teleradiology could be treated as a commodity and traded with forward contracts.12 This concept of forward trading of medical services seems to be quite divorced from more traditional philosophies of the practice of medicine, and, at the very least, the public at large and those who pay for these services should be made aware of this trend. From a community perspective, if teleradiology is viewed purely as a technical service, with no consideration given to the quality, appropriateness or relevance of the interpretation service, nor to patient safety; if it is driven purely by cost and workforce pressures, convenience, or desire for market share, then this would be highly undesirable. Even within Australia, it is possible that commercial leveraging may occur, resulting in disruption to local radiologists, the local clinical diagnostic imaging team, and community service provision if cost-cutting and market share are primary motives for the introduction or further development of teleradiology.2,9,13 Thus, where a local clinical radiology service exists, compelling advantages for patient care would need to be identified to justify the additional provision of teleradiology services. However, when teleradiology can facilitate good patient care, this is an excellent outcome of the application of this technology. Teleradiology, both domestic and international, can be considered a “two-edged sword”, requiring careful consideration and balancing. The rapid growth of teleradiology and the globalisation of health care have led to the need for a set of uniform standards to protect consumer rights, define responsibilities, enable inter-jurisdictional recognition, ensure quality and safety, and enable benchmarking.6,13,14 Accordingly, the International Radiology Quality Network (IRQN)13 has developed a set of international clinical teleradiology principles to guide quality care and ensure patient safety. Australian representatives actively contributed to this development, and the RANZCR has adapted the IRQN principles in a position statement applicable to Australia and New Zealand.15 In general, these principles emphasise that the entire focus of international clinical teleradiology (as for radiology in general) must be solidly based on “what is good for the patient”. For example: the correct imaging procedure should be performed; images should be of a high quality and transmitted accordingly; communication must be made between the treating team and the (appropriately credentialled and indemnified) radiologist, providing a high level of clinical information; images must be interpreted in light of the full clinical history and available previous imaging; and the radiologist’s interpretation of the images and medical opinion must be communicated clearly and in a timely manner. The position statement also addresses specific, serious concerns, including security (eg, sites should comply with all nationally specified data protection standards) and ethics (a system should be in place to document electronic “fingerprints” of interpreting radiologists, to prevent “ghosting” of reports). The position statement will be updated regularly, with additional input sourced from the RANZCR Quality Use of Diagnostic Imaging Program teleradiology projects and the RANZCR Standards of Practice and Accreditation Committee, as well as IRQN updates. Any practice or hospital considering the use of domestic or international clinical teleradiology will be well served to be guided by these principles, and must, at all times, maintain a principal focus on high-quality patient care. With time, the regulatory, legal and ethical framework applicable to teleradiology may well flow on to other medical disciplines.

Lizbeth M Kenny MB BS, FRANZCR · Lawrence S Lau MB BS, FRANZCR

The 35th Annual Physician Assistant Conference held in the United States in May 2007 provided an opportunity for Australia to learn from the experience of other countries The 35th Annual Physician Assistant Conference of the American Academy of Physician Assistants (AAPA), held in Philadelphia in May 2007, was attended by almost 8000 delegates, including physician assistants (PAs), students, academics and policymakers. The conference aimed to promote professional development of PAs, develop ideas and provide education. It also featured an international forum focusing on global developments in PA-related activities. We report here on two countries that have recently introduced PAs, to identify opportunities for improving Australia’s transition into implementing the PA role. Physician assistants: a possible solution to workforce shortage in AustraliaPAs are health care professionals licensed to practise medicine under physician supervision.1,2 They were introduced in the United States in the 1960s to alleviate shortage and maldistribution of primary care physicians. The PA role has now spread outside the US, with various levels of development underway around the world (Box).3-10 The role is now internationally recognised as part of a solution to the combined issues of health workforce shortage and increased demand for health care services.11 Several Australian groups, including public and private health providers in Queensland, the University of Queensland (Centre for Military and Veterans’ Health and the Centre for Health Innovation and Solutions) and James Cook University, are addressing medical workforce issues by piloting and advocating a PA-type role as one of many solutions.12,13 The international forum at the AAPA conference provided an opportunity for Australian delegates to learn from the experience of other countries that have undertaken similar projects. Of eight forum presentations focusing on new and emerging roles and experiences, those from Canada (Ontario) and Scotland were related to projects in pilot phases and were considered the most relevant to the Australian situation. The Ontario experienceJoshua Tepper (Assistant Deputy Minister, Health Human Resources Strategy Division, Ministry of Health and Long Term Care, Ontario, Canada) provided an overview of the progress of the introduction of the PA role into Ontario. A broad government initiative known as HealthForceOntario established a bold and aggressive plan to ensure the right number and mix of health care providers in communities across the province, and to establish new and expanded roles in areas of high need. Implementation of this plan included the following key steps: May 2006: Enabling legislation is enacted for the demonstration projects. June 2006: Consultation with all stakeholders, including employers, educators, regulators, health professionals (eg, medical, nursing and allied health staff at Ontario’s hospitals) and other experts (eg, Canadian Forces, University of Manitoba, Canadian Association of Physician Assistants, overseas medical workforce experts). August 2006: Selection of six hospitals willing to employ emergency care teams that include PAs and nurse practitioners (NPs). April 2007: Definition of competencies profiles and scope of practice statements for PAs to practise in Ontario. May 2007: Employment of PAs and NPs to work at the six selected emergency departments. Assessment begins concurrently and includes outcomes of care for specific diagnoses, patient waiting times, access to care, satisfaction with care, and satisfaction with PAs and NPs. The rapidity of this initiative’s progress is attributed to several factors: development of strong partnerships and collaborative relationships; support from other health professions and experts in the field; high acceptance of overseas-trained PAs participating in pilot projects; completion of a PA competencies document; and significant government investment in the PA initiative. Two elements are considered key. First, the PA role was already in place in the Canadian military as well as in the health care system in the province of Manitoba.7 This allowed policymakers to refer to current experiences within the country. Second, a Physician Assistant Implementation Steering Committee was established to collaboratively guide development, implementation and evaluation of all PA projects. The Steering Committee, co-chaired by two doctors and including a broad base of stakeholders (eg, PA experts and educators, and representatives from partner organisations, nursing, community clinics and academia), met monthly to facilitate communication. Six subcommittees and working groups were responsible for research and design of key components of the project, with a focus on: developing Ontario PA competencies; defining PA scope and role definition; determining compensation; establishing educational programs; addressing liability issues; establishing evaluation; launching demonstration projects in clinical settings; recruiting; and developing communications. With its combination of professional expertise, the Steering Committee overcame a number of challenges such as recruiting the required number of PAs, increased workload due to aggressive timelines, and concerns from other professions about the introduction of a new and unregulated profession. HealthForceOntario is committed to several demonstration projects that are introducing PAs to the Ontario health care system through a wide range of clinical settings and using a variety of employment models throughout the province. A combination of 88 hospitals and at least five community health centres have expressed interest in employing a PA, although only 40 PAs are being recruited. Until HealthForceOntario produces enough “home-grown” PAs, Ontario will recruit PAs with formal education from other jurisdictions, such as retired PAs from the Canadian Forces, and PAs from around Canada and the US who are eligible for Canadian PA certification. The Scottish experienceAt the 2006 AAPA conference in San Francisco, Scotland announced a demonstration project and actively recruited PAs for 20 positions. A total of 240 applications were received — 45 PAs were interviewed, 20 were offered contracts, and 12 American PAs arrived in Scotland to work on a 2-year contract. They are deployed in demonstration projects at various sites, in the areas of family medicine and emergency medicine.10 The leaders of the research team, Ricky Bhabutta (a British Army doctor, and Senior Medical Officer, Scottish National Health Service [NHS]) and Patricia O’Connor (National Clinical Coordinator PA Project, Scottish NHS), discussed the first 6 months of their demonstration project, which began in November 2006. One of the main challenges they faced was the logistics required in settling the expatriates into Scottish life and culture. Despite this, the successful aspects of their project included: Preparation for “cultural” differences of the workforce, the Health Department, the community, and the PAs themselves (eg, through media, local open days, leaflets, emails, conferences, teaching sessions, and hospital and regional awareness campaigns). Country induction using a specific relocation company allowed a smooth transition into Scottish life for the PAs. This included introduction to cultural and social aspects of living in Scotland, introduction to the NHS, and adaptation to British medicine and local programs. Central coordination and site selection provided by the Scottish Executive. Partnership with central (NHS) funding for evaluations, the recruitment process and awareness-raising events. Objective and structured behavioural interviews with the PA candidates. The University of the Highlands and Islands was commissioned to compile monthly evaluation reports for all sites. PA development days and opportunities for feedback into the project allowed for open discussions of difficulties with the project staff or supervisors. The PAs working in Scotland also reflected on their experiences and suggested some things they felt could be done differently. They proposed that a site visit would have allowed them to obtain a better set of expectations regarding the relocation and demonstration process. They felt that a lack of clarity of the job description provided a source of confusion and frustration, and that the recruitment period was too short. The lack of definition of the supervisor role also created some initial confusion. The supervisors and project managers added a few other aspects that could have been managed better, such as involving doctors in the recruitment process, establishing the supervisor role, reviewing the team role of the PAs in the context of major changes in the British medical training model, and obtaining positive media involvement. A perceived hurdle for Scotland is that the PA is not a registered profession in the United Kingdom. Consequently, the PAs are working under a delegation and referral clause. Discussions about further developing PAs for Scotland have been centred on the cost, the necessity, and whether it would be more economical to recruit them from England and North America or to start a university-based program in Edinburgh. The assessment team reflected on a number of observations from the first half of the 2-year experience. A needs assessment by a workforce scholar was deemed a necessity, as it provided a solid literature review on various roles and experiences in the US and Canada.10 For instance, it prevented the “name game” that England experienced (eg, “medical care practitioner” instead of “physician assistant”). Furthermore, drawing on American PA consultants, site visits, involving the citizenry of small towns, and attendance of conferences (eg, those of AAPA) were considered beneficial. According to Dr Bhabutta, it is only a matter of time before PAs are dispersed throughout the North Atlantic Treaty Organization (NATO) countries. Lessons learnedThe experience of these two Commonwealth countries gives some indication of how implementing a PA-type role in Australia can be successfully achieved in a timely manner. The outcomes of this important conference showed that strategies likely to ensure success include reviewing the literature and incorporating the following essential elements: an active steering committee composed of a broad base of stakeholders; legal discussion around enabling legislation and the delegation role of doctors in supervising PAs; a recruitment process, conducted by a professional agency, that draws on these lessons; and clearly defined roles for both PAs and supervisors. State of development of physican assistant (PA)-related activities around the world3 State of development Countries Development of civilian PA programs England,* The Netherlands,* Canada,* South Africa, Scotland,* Taiwan PA-like profession in place India, Liberia, Haiti, Malaysia Use of United States-trained PAs in the national health system Canada,* England,* Scotland,* The Netherlands* Hosting workforce development conferences in which PA profession is proposed The Netherlands,* England,* Germany, South Africa, Taiwan, China, Ghana Developing and establishing formal affiliation agreements with US PA programs for PA student rotation Brazil, Estonia, United Kingdom,* Ghana, Thailand, Honduras, Ecuador, China, Papua New Guinea, Costa Rica Seeking information on PA profession Australia,* Ghana, Ireland, Jamaica, New Zealand, South Africa, Wales * Represented at the 35th Annual Physician Assistant Conference.

Laurent A Frossard PhD · Genevieve Liebich · Roderick S Hooker PhD · Peter M Brooks PhD · Lynn Robinson MD

The Oxford Health Alliance is willing to work with organisations, public or private, whose business goals are aligned with promotion of health and human capital Some years ago, one of us (S P) left his job as a specialist physician in the Danish National Health Service to take up a position in the pharmaceutical industry, with the Danish diabetes care company, Novo Nordisk. He spent the next 15 years fielding the questions of worried people who wanted to know if he missed working as a (real, honest) doctor. Today, he heads the Oxford Health Alliance, a non-profit global collaboration for health — started with an industry grant from the same company. The Alliance is trying to find solutions to the huge problems arising from lifestyle disorders such as diabetes, cardiovascular diseases and chronic lung diseases.1 The Alliance includes not only academia, government and non-government organisations, but the private sector, including some global corporations. In some people’s minds, this makes it inherently untrustworthy. We find ourselves fielding another question: “Can you work with industry to improve the public’s health without sacrificing your professional and organisational ethics and integrity?” Surprisingly, the most vocal critics of any involvement of for-profit organisations in efforts to advance public health come from opposing camps. On one side are purist academics and certain non-government organisations, and on the other, some business people and fundamentalist economists.2 One obvious problem is conflict of interest arising from extensive alliances between scientists and academic institutions and the private sector.3 Another valid criticism is that the pursuit of self-interest comes at the expense of objectivity, demonstrated by studies that have found a significant relationship between industry-funded research and results that favour industry.4 The politically based critics of alliances with industry automatically assume that industry is motivated by the desire for improved public relations, the co-option of opinion leaders in the scientific community, or leverage to forestall legislative and regulatory efforts that may prove unfriendly to business. When companies are driven by the need to make profits for their owners and investors, corporate objectives are seen by many as inherently incompatible with initiatives to improve the health of the general public.5 In the business world, it is not uncommon to hear phrases such as “the business of business is business”, or that the only true responsibility is to the shareholders and any deviation from this is bad business. But, in the light of global warming and the magnitude of the social and health burden associated with contemporary lifestyles, these truisms do not hold up. We are not advocating naivety. After all, tobacco use has been fought for 50 years and still it increases in many countries, despite the World Health Organization’s Framework Convention on Tobacco Control and the irrefutable evidence that underpins it. The tobacco war has left almost everyone in the public health professions with the feeling that you cannot trust industry. At the same time, the powerful pharmaceutical industry has gradually lost much of its credibility by concentrating more on making money than finding new and better drugs. The pharmaceutical industry has also been repeatedly, and in many cases deservedly, criticised for suppressing unfavourable research results.5 However, while we unreservedly subscribe to the notion that “two wrongs don’t make a right”, we cannot quite come to terms with the different standards often applied to the self- interest of government and the self-interest of corporations. For example, there is considerable anecdotal evidence that government departments have declined to publish commissioned reports, or parts thereof, for fear of attracting criticism if they or the incumbent government fail to act on the content. What this tells us is that whenever two or more parties interact, regardless of whether the interaction is public–private or public–public, there will always be potential for interference and tensions between the self-interests of the parties concerned. Such conflicts are part of life, so the lesson is not to refrain from working together, but to put safeguards in place to control the dominance of the party whose interests may have detrimental consequences and, in the case of industry, to engage early and transparently to find solutions that produce mutual benefit. In the long term, business can only grow and thrive in societies that function well, and faltering economies, damaged human capital and global warming will also heat boardrooms. All businesses function within the legal frames defined by the societies in which they operate and will not survive in the long run if they do not. In an ideal world, business could be regulated in ways that are closely aligned with the goals of the democratic societies in which they function. But regulation is often too little, too late, and we do not always know precisely what will fix the problems we create. Furthermore, governments are far better at using regulation to punish bad corporate practice than at creating incentives for companies to compete on their contribution to improving health and the environment. However, the recent leadership of the climate change debate, adopted by many corporations previously opposed to change, is one example of how change is possible when the balance between punishment and incentives is shifted. The collaboration between the World Wide Fund for Nature and the large construction company Lafarge is an example of integrating sustainability into the company vision.6 The Forest Stewardship Council is an example of a successful worldwide collaboration for sustainable forestry among loggers, foresters, and environmentalists.7 Today, we see some early adopters — these are corporations that are adjusting their product portfolios and corporate social responsibility policies to contribute to solving big societal issues. For example, Novo Nordisk has for many years reported on its environmental impact. The company works to reduce harm through corporate programs and a foundation to support better access to health in the least developed nations.8 Some companies are redefining what it means to be a good business and playing important roles in finding solutions to the problems of health and environment, for a variety of reasons — social responsibility, or to grow and protect their future as well as their current business interests.9 Capitalism has many forms, and the Scandinavian model seems to show that a collaborative public–commercial approach can work if people want it to, and even in a way that creates happiness for the population, as evidenced by the consistently high rating of the Scandinavian countries on world happiness rankings.10 And, as well understood by Gro Harlem Brundtland when she called on relevant industries to collaborate on the global diet and physical activity strategy shortly before retiring as Director-General of WHO, markets can be shaped to promote better lifestyles if we can find the right levers.11 We will never know how successful Brundtland may have been in this had she remained at WHO, but we do know that the dialogue between WHO and industry has continued. A synergistic approach will take time, and we have little history of sustained interaction to guide us. We must therefore seek ground where profitability and public health coincide and challenge practices that place profits and public health in conflict. Market forces, applied appropriately, could be a powerful means of advancing health. Having no interaction with industry means missing the opportunities for using the unique skills and resources of all parties. Yet interaction, particularly when money changes hands, must not undermine public confidence or the common good, or distort what all progress must be based on — sound evidence from rigorously objective research and evaluation. So the answer to our question about working with industry and business is that we cannot afford not to. They make our world go around: their products, services and advertising shape our lives and construct our futures, and their capacity to employ people far outstrips that of governments. Health and the physical environment cannot be changed without them. We must put aside ideological trench wars and make a genuine and concerted effort to find ways of working together for health that satisfy and uphold transparency, accountability and community ethics. This will require experimentation and the will and innovation of public authorities to find appropriate and accountable ways of working with all stakeholders, including the food, agriculture, building and other industries. There will be mistakes, possibly even blunders, but if we are to achieve lasting, positive change, this must be tried and tested. The Oxford Health Alliance illustrates a new way of working with industry, that is, bringing public and private interests to the same debate at the same table. It intentionally works with industry and, in its short life, has been instrumental in taking the chronic disease prevention agenda out of the health silo and into the broader environment in which the agents of chronic disease are generated. The Alliance is conscious of the potential pitfalls associated with industry partnerships. It guards against these by: (1) making public its methods1 and the names of its collaborators and funders (see http://www.oxha.org); (2) having and following transparent guidelines for working with industry; and (3) prohibiting the use of its name in association with specific products. The Alliance will not work with the tobacco industry and has been a strong supporter of the Framework Convention on Tobacco Control. It is willing to work with any legally constituted, credible entity that wishes to align its business goals with promoting health and human capital, whether public or private, and which is willing to work within the Alliance’s philosophy and framework for transparency.

Stig Pramming MD · Ruth Colagiuri BEd, GradCertHlthPolMgnt

Objectives: To explore awareness of the causes of kidney disease and recollection of kidney function testing in a cohort of Australian adults.Design, setting and participants: An interviewer-administered cross-sectional survey, conducted from October to December 2004 as a nested study within the 5-year follow-up phase of the Australian Diabetes, Obesity and Lifestyle Study (AusDiab); 852 subjects who attended a testing site in New South Wales were interviewed.Main outcome measures: Responses to the questions “What sort of things do you think may lead to a person developing kidney disease?” and “Has a doctor or health care worker ever tested your kidney function, outside of the AusDiab study?”Results: Respondents most commonly believed that kidney disease was caused by alcohol misuse or poor diet, with few identifying diabetes or high blood pressure. Awareness of risk factors was no greater in respondents identified as having chronic kidney disease (CKD). A third of respondents with CKD recalled having undergone a test of kidney function within the previous 2 years, while another third replied they had never had their kidney function tested. Of participants with previously diagnosed diabetes or treated hypertension, 54.1% and 32.0%, respectively, reported having their kidney function tested within the previous 2 years.Conclusions: Knowledge of risk factors for kidney disease and recall of kidney function testing were both limited, even among subgroups of the cohort who were at greatest risk of CKD. Prevention efforts may benefit from public and patient education to improve recognition of risk factors for CKD.

Sarah L White MPH · Kevan R Polkinghorne FRACP, MClinEpi · Alan Cass FRACP, PhD · Jonathan Shaw FRACP, MD · Robert C Atkins FRACP, DSc · Steven J Chadban FRACP, PhD

Objective: To determine the population incidence and clinical features of Escherichia coli bacteraemia in Canberra, Australia.Design, setting and participants: Canberra (including the nearby local government areas of Queanbeyan and Yarrowlumla) has a geographically isolated population of about 366 000 people. Its six hospitals also provide tertiary medical services for the surrounding region. Confining our analysis (by residential postcodes) to Canberra residents only, we used microbiology laboratory records and population statistics to calculate the population incidence of E. coli bacteraemia from January 2000 to December 2004. Clinical data were also collected prospectively on episodes occurring within three of the hospitals.Main outcome measures: Population incidence of E. coli bacteraemia; place of acquisition of infection; focus of infection within body; recovery, new morbidity or death at 7 days.Results: During the 5-year period, 515 episodes of E. coli bacteraemia occurred in Canberra residents, an incidence of 28 per 100 000 population per year. The highest rate was in men aged ≥ 80 years (463 per 100 000). Overall, E. coli bacteraemia occurred in equal numbers in males and females, but incidence was higher in males aged < 1 year and ≥ 60 years. Most episodes occurred in people aged ≥ 60 years (316/511 [62%]) and most were community-associated (347/511 [68%]). Half the infections (257/511) had a genitourinary focus and 28% (141/511) a gastrointestinal focus. The 7-day case-fatality rate was 5%. Prostate biopsies and urinary catheters were notable preventable foci of health care-associated bacteraemia. Resistance of isolates to gentamicin (2.1%), ciprofloxacin (1.8%) and cefotaxime (0.4%) was low.Conclusions: E. coli is the most common cause of bacteraemia in Canberra, and incidence increases with age. Most cases have a community onset, but many episodes are related to health care procedures. Ongoing surveillance is important for identifying risk factors that may be modified to reduce disease.

Karina J Kennedy MB BS · Jan L Roberts RN · Peter J Collignon MB BS, FRACP, FRCPA

Objective: To examine trends in preoperative clinical characteristics, risk profiles and postoperative outcomes of patients undergoing isolated coronary artery bypass graft (CABG) surgery in Victoria.Design, setting and patients: A prospective analysis of 9372 patients undergoing isolated CABG surgery between 1 July 2001 and 30 June 2006 in six Victorian public hospitals, using the Australasian Society of Cardiac and Thoracic Surgeons database.Main outcome measures: Trends in patient baseline characteristics and risk factors, postoperative morbidity and 30-day mortality rate.Results: Over the 5 years, the mean age of patients undergoing isolated CABG surgery increased, from 65.4 years in 2001–02 to 66.0 years in 2005–06 (P < 0.001). There was also an increase in the proportion of patients with hypertension (70.2% to 75.8%; P < 0.001), respiratory disease (83.2% to 89.5%; P < 0.001) and left main coronary artery disease (22.1% to 26.1%; P = 0.03), while the number of patients undergoing repeat CABG surgery decreased (4.4% to 2.6%; P = 0.002). The overall 30-day mortality rate remained unchanged (2.2% to 1.8%; P = 0.983). Rates of other major postoperative complications showed no significant change over the study period.Conclusion: Rates of 30-day mortality and postoperative morbidity after CABG surgery have remained steady, despite the surgical population being older. Short-term outcomes after CABG surgery in Victoria remain among the most favourable reported in any population undergoing this surgery.

Diem T Dinh PhD · Geraldine A Lee BSc, RGN, PGDE · Baki Billah PhD, MAS · Julian A Smith FRACS · Gilbert C Shardey FRACS · Christopher M Reid DipEd, MSc, PhD

Objective: To evaluate the use of clinical practice guidelines for the management of acute coronary syndromes published by the National Heart Foundation (NHF) of Australia and the Cardiac Society of Australia and New Zealand (CSANZ) in patients presenting with chest pain.Design: Cross-sectional study of consecutive patients admitted with chest pain.Setting: Prospective case note review was undertaken in 2380 patients admitted to 27 hospitals across five states in Australia between January 2003 and August 2005. Patients were divided into two groups: those who presented to centres with angiography and percutaneous intervention facilities (n = 1260) and those treated at centres without these facilities (n = 1120).Main outcome measures: The proportion of patients whose care met quality of care standards for diagnostic and risk-stratification procedures and management according to NHF/CSANZ treatment guidelines.Results: Significant delays were identified in performing electrocardiography, administering thrombolysis, transferring high-risk patients to tertiary centres, and performing revascularisation. Medical therapy was underused, especially glycoprotein IIb/IIIa antagonists in patients with high-risk acute coronary syndromes. Patients treated at centres without interventional facilities were less likely to receive guidelines-based medical therapy and referral for coronary angiography (20.11%) than patients treated at centres with interventional facilities (66.43%; P < 0.001).Conclusion: There are deficits in the implementation and adherence to evidence-based guidelines for managing chest pain in hospitals across Australia, and significant differences between hospitals with and without interventional facilities.

Darren L Walters MB BS, MPhil, FRACP · Constantine N Aroney MD, FRACP · Derek P Chew MPH, FRACP · Linden Bungey BSc, MSc · Steven G Coverdale MB BS, FRACP · Roger Allan MB BS, FRACP · David Brieger MB BS, FRACP

Objective: To study persistence and adherence with the use of common antihypertensive (AHT) medications.Design, setting and participants: Longitudinal assessment of Pharmaceutical Benefit Scheme claim records covering the period January 2004 to December 2006. We analysed a 10% random sample of all Australian long-term health concession card holders who had been commenced on an angiotensin II receptor antagonist (A2RA), an angiotensin-converting enzyme inhibitor (ACEI) and/or a calcium channel blocker (CCB), but for whom no AHT medication had been dispensed in the previous 6 months.Main outcome measures: Proportion of patients failing to fill a second prescription; median persistence time with medication (ie, non-cessation of therapy); persistence with medication over 33 months; median medication possession ratio (MPR, defined as the proportion of prescribed medication actually consumed by patients persisting with treatment).Results: The database yielded information relating to 48 690 patients prescribed AHT medication. Nineteen per cent of patients failed to collect a second prescription. The median persistence time was 20 months. The data were little different from the population average with respect to A2RAs or ACEIs, but persistence was 57% poorer with respect to CCBs (log-rank P < 0.001) (28% of patients prescribed CCBs failed to collect a second prescription; median persistence time, 7 months). There were differences in persistence between individual drugs in the respective classes, the best outcomes being with candesartan and telmisartan (A2RAs; 10%–20% better), perindopril (ACEI; 25% better) and lercanidipine (CCB; 25% better). Median MPRs were generally around 100%, indicating that most patients who collected prescriptions also showed good adherence to treatment regimens.Conclusion: There is an ongoing problem of poor persistence with commonly used AHT medications. This may represent a diminished opportunity for cardiovascular disease prevention.

Leon A Simons MD, FRACP · Michael Ortiz BPharm, PhD · Gordon Calcino BA, GradDipMedStats

Objective: To determine the prevalence, staffing, methods, timing and allocation of bereavement programs in Australian palliative care services.Design: Questionnaire-based postal survey.Setting and participants: The questionnaire was mailed in January 2007 to all 324 palliative care centres identified from the Australian Palliative care national directory 2004.Results: 236 of the 324 centres responded (73%), and 95% of these undertook bereavement follow-up, with similar prevalence in metropolitan and regional areas. Staff from a range of disciplines were involved in coordinating and delivering these services, with nurses taking on these roles in most regional centres. Common types of bereavement follow-up included individual sessions and visits, telephone contact, letters, anniversary cards and memorial services. Most centres (74%) approached the bereaved within 2 weeks of the death, and 83% of centres offered bereavement support to families or “significant others” of all patients who died under their care. Some form of risk assessment for complicated grief was performed by 69% of participating centres.Conclusion: Bereavement care is an integral part of Australian palliative care services. Given the multidisciplinary staffing demonstrated, it is important that those coordinating and delivering these programs are adequately trained and supported. There is a need for further research to guide the development of bereavement support practice.

Mark A Mather BMed · Phillip D Good FRACP · John D Cavenagh FRCA, FAChPM, MMedSci(Epidemiology) · Peter J Ravenscroft MD, FRACP, FAChPM

Objective: To determine which industries and occupational groups are associated with employment of older workers with chronic work-limiting health conditions in Australia.Design and participants: Analysis of data from the 2005 National Health Survey for 4228 workers aged 45–64 years.Main outcome measures: Rate of employment by industry and occupation of older workers with specific chronic conditions.Results: Compared with the reference industry of property and business services, workers in the retail trade industry were found to be more likely to suffer from musculoskeletal conditions (relative risk ratio [RRR], 1.56; 95% CI, 1.04–2.36), while those in health and community services had higher rates of cardiovascular disease (RRR, 2.17; 95% CI, 1.11–4.24). Compared with the reference occupation group of professionals, managers and administrators were less likely to suffer neoplasms (RRR, 0.25; 95% CI, 0.07–0.97). Similar rates of chronic disease were seen across other occupations.Conclusion: Increasing rates of chronic health conditions are unlikely to have an even impact across the workforce, as the rate of employment of older workers with these conditions varies between industries.

Deborah J Schofield PhD, BSpPath, GradDipComp · Susan L Fletcher BAppSc(Psych), PGDipPsych · Arul Earnest BSocSc, MSc · Megan E Passey BMed(Hons), MPH, MSc · Rupendra N Shrestha BSc, MSc(Statistics)

As part of the 3E program, we conducted a systematic literature review and gathered consensus from 23 practising Australian rheumatologists to develop guidelines for early identification of ankylosing spondylitis and specialist referral. In three rounds of break-out sessions followed by discussion and voting, the specialist panel addressed three questions related to diagnosis of ankylosing spondylitis: In individuals with back pain, what are the early clinical features that suggest ankylosing spondylitis? How useful is imaging in identifying early ankylosing spondylitis? Based on which clinical features should a general practitioner refer a patient to a rheumatologist for further evaluation? The panel agreed on six recommendations related to the three questions: 1a. Early clinical features to suggest ankylosing spondylitis include inflammatory back pain and age at symptom onset < 45 years. 1b. The absence of symptomatic response to an appropriate course of non-steroidal anti-inflammatory drugs makes the diagnosis of ankylosing spondylitis less likely. 1c. Raised inflammatory markers are supportive, but their absence does not rule out the diagnosis of ankylosing spondylitis. 2a. Despite low sensitivity to detect changes of early ankylosing spondylitis, plain radiographs of the pelvis and spine are appropriate initial imaging techniques. 2b. Magnetic resonance imaging is a useful imaging modality for detecting early changes of ankylosing spondylitis. 3. Individuals with inflammatory back pain should be referred to a rheumatologist for further evaluation. Effective dissemination and implementation of these recommendations are important to standardise the approach to early diagnosis of ankylosing spondylitis.

Tracey Kain MB ChB, MPH · Jane Zochling MB BS, FRACP · Andrew Taylor MB BS, FRACP · Nicholas Manolios MB BS, FRACP · Malcolm D Smith MB BS, FRACP · Mark D Reed MB BS · Matthew A Brown MB BS, MD, FRACP · Lionel Schachna MB BS, FRACP, PhD

Human papillomaviruses (HPVs) are the major cause of cervical cancer. Cervical cancer mortality has been reduced in Australia because of effective screening programs, but there are still about 800 new cases and 300 deaths per year. Worldwide, mortality and morbidity are high. Australia was the first country to introduce fully funded immunisation with a quadrivalent HPV vaccine for girls aged 12 and 13 in schools. A 2-year catch-up program covers all women to the age of 26 years. Age stratification of HPV prevalence showed the highest rates in women under 25 years of age, a decrease in women from 30 years of age and a second smaller peak in those over 45 years. Recently, a bivalent HPV vaccine has been licensed for use in women aged up to 45 years. Older women have robust immune responses to the bivalent HPV vaccine, and so should derive benefit from the vaccine if exposed to HPV type 16 or 18 in the future. It is likely that this vaccine will need to be purchased by women in the older age group (27–45 years).

S Rachel Skinner MB BS, PhD, FRACP · Suzanne M Garland MD, FRANZCOG, FRCPA · Margaret A Stanley OBE, FMedSci · Marian Pitts PhD · Michael A Quinn MRCP(UK), FRCOG, FRANZCOG

Qualitative research most commonly involves the systematic collection, ordering, description and interpretation of textual data generated from talk, observation or documentation. A report of qualitative research should address the following criteria: Clarification and justification; Procedural rigour; Representativeness; Interpretative rigour; Reflexivity and evaluative rigour; and Transferability. Because of the limitations on article length for the Medical Journal of Australia, authors should focus on only a couple of aspects of the research, rather than trying to present a simplified description of multiple aspects.

Simon C Kitto PhD · Janice Chesters PhD · Carol Grbich PhD

The first aim of a medical registration scheme should be to protect patients. Medical registration boards currently offer variable information to the public on doctors’ registration status. Current reform proposals for a national registration scheme should include free public access to professional profiles of registered medical practitioners. Practitioner profiles should include: practitioner’s full name and practice address; type of qualifications; year first registered, and duration and type of registration; any conditions on registration and practice; any disciplinary action taken; and participation in continuing professional education.

Judith M Healy BA, MSW, PhD · Costanza L Maffi BSc(Hons), MSc, GradDipIT · Paul Dugdale MPH, PhD, FAFPHM

A 59-year-old man presented with persistent abdominal discomfort 12 months after splenectomy for thrombocytopenia to ameliorate progressive myelofibrosis. Physical examination revealed bilateral loin masses. Computed tomography of the abdomen identified perinephric cuffing by soft tissue nodular masses in the perinephric fat (Figure A). Core needle biopsy of the right perinephric fat revealed haematopoietic cells (Figure B). Extramedullary haematopoiesis is not uncommon when intramedullary haematopoiesis is impaired.1-3 Common sites include the liver and spleen. It is unusual for extramedullary haematopoiesis to involve the perinephric fat. The role of splenectomy in accelerating the development of extramedullary haematopoiesis in uncommon sites has become increasingly apparent.1

Philip Y-I Choi

Transition care is a new program to Australia that is designed to facilitate transitions of frail older people between the hospital and aged care systems. This program is designed to deliver potentially important improvements to the Australian health care system — but will it deliver? The current evidence base regarding the efficacy of this type of program is mixed, and there is little evidence to indicate improved patient outcomes. An average transition care episode is expensive (about $11 000). Therefore, careful consideration of the relative cost-effectiveness compared with other interface programs such as inpatient subacute services is essential. Transition care services should be established within the context of overall regional plans for aged care, incorporating hospital acute and subacute inpatient services, and long-term community and residential care programs.

Len C Gray PhD, FRACP · Catherine M Travers PhD · Helen P Bartlett PhD, MSc, BA · Maria Crotty PhD, FAFRM(RACP) · Ian D Cameron MB BS, PhD, FAFRM(RACP)

Three patients with Australian parasitic myositis caused by the muspiceoid nematode Haycocknema perplexum are described. Treatment with albendazole led to a slow and incomplete recovery, but treatment with steroids caused life-threatening deterioration. Clinical recordsPatient 1A 23-year-old woman presented to Cairns Base Hospital with a history of 2 years of insidiously progressive weakness, including 1 year of difficulty swallowing. She weighed 42 kg, having lost 18 kg in recent years. There had been no myalgia. The patient had grown up in Queensland and was living in Innisfail, but had travelled around Australia in the 3 previous years, visiting Western Australia, New South Wales and Victoria. Although not acutely unwell or febrile, the patient was thin, with limb weakness and proximal and distal wasting. The facial muscles were wasted and weak, but palatal and ocular movements were normal. She was unable to stand from sitting without using her arms and had bilateral foot drop, but toe extension was preserved (Box 1). Reflexes were absent at the ankles and depressed elsewhere. Sensation appeared intact. Haematological testing showed eosinophilia (1.1 × 109/L; reference range [RR], < 0.4 ×109/L), which was found to have been known since 1998. It had been assumed to be due to intestinal parasites, a common problem in North Qld, but results of subsequent serology testing for Strongyloides were negative, as were stool samples. The serum creatine kinase (CK) level was high (1370 U/L; RR, <160 U/L), and there was mild derangement of liver transaminases (alanine aminotransferase, 60 U/L; RR, < 40 U/L); aspartate aminotransferase, 52 U/L; RR, < 35 U/L). Levels of inflammatory markers were also high (erythrocyte sedimentation rate, 50 mm/h; RR 0–20 mm/h; C-reactive protein, 37 mg/L; RR, < 5 mg/L). Electromyography showed low-amplitude polyphasic potentials, consistent with myopathy, and nerve conduction studies showed a mild coexistent sensory neuropathy. A biopsy of the quadriceps showed the muscle to be pale, flaccid and atrophic. On examination of paraffin sections, the muscle appeared highly abnormal; several muscle fibres contained sarcoplasmic nematode parasites characterised by a simple cephalic end and a sharply tapered caudal end. Unlike other nematodes that cause myositis, these parasites were not encysted. There was patchy interstitial and perivascular inflammation, predominantly with lymphocytes, and numerous necrotic fibres showing florid myophagia (Box 2). The parasite stained red with Gomori’s trichrome and positive with ATPase and cytochrome oxidase. Electron microscopy showed scattered sarcoplasmic parasites. Gravid female parasites were characterised by a thin cuticle, a central triradiated oesophageal lumen, and ova (Box 3). The parasite was identified as the nematode Haycocknema perplexum.1 The patient was treated with albendazole 400 mg twice daily for 8 weeks. Percutaneous endoscopic gastrostomy provided nutritional support initially. Steroids were not used at any stage of treatment. After 2 weeks, CK had fallen to 235 U/L and C-reactive protein to 1.1 mg/L. After 2 months, the patient remained diffusely weak, with ongoing dysphagia, but was able to stand from sitting. Two months after she had completed treatment, the patient’s CK began to rise, without eosinophilia. A second biopsy, of the deltoid muscle, did not show any live parasites, but showed numerous lysosomal structures, consistent with resorption of dead parasites. Significant replacement of muscle with collagenous connective tissue was noted. Twelve months after treatment, the patient had significant ongoing muscle weakness and persistently high CK levels (about 300 U/L), but normal eosinophil counts. Patient 2A 61-year-old man was admitted to a Townsville hospital for investigation of a 3-year history of slowly progressive dysphagia and dysarthria, and 1 year of limb weakness. Concurrent medical problems included diabetes mellitus, renal impairment and biliary duct ectasia. Six months before presentation, hypercalcaemia had been noted and briefly treated with oral prednisone for presumed sarcoidosis, although serum angiotensin-converting enzyme levels were normal. The patient had grown up in Tasmania, but had moved to Mackay in North Qld more than 20 years earlier, and had not travelled outside the region since. On examination, he was unwell and cachectic, with bilateral facial and palatal weakness, diffuse limb weakness and wasting and depressed reflexes, but normal sensation. On the basis of elevated CK (1263 U/L) and inflammatory markers, high-dose oral prednisone was commenced for presumed polymyositis, pending muscle biopsy results. In retrospect, peripheral eosinophilia was known to have been present for at least 2 years. After the patient had received steroids, the eosinophil count normalised. Within days, he deteriorated, requiring admission to intensive care for ventilatory support. After the muscle biopsy results showed parasitic myositis, steroids were gradually withdrawn and albendazole was commenced. The muscle function stabilised, but a biopsy 4 weeks later showed live H. perplexum nematodes. Further biopsy after 9 weeks of treatment showed no live nematodes. The intensive care stay was complicated by dependence on ventilation, sepsis, pneumonia, renal and hepatic failure and encephalopathy. Seven months later he was discharged to a regional hospital for convalescence but died from complications of sepsis and renal failure. Patient 3A 61-year-old man from Mackay, Qld, was admitted to Townsville Hospital with a 2-year history of hand cramping, progressive diffuse weakness eventually causing difficulty climbing stairs, and 1 year of dysphagia. He had lived in North Qld all his life, and had never travelled to Victoria or Tasmania. He had never consumed the meat of native animals or other “bush tucker”. He was diffusely thin and weak, with bilateral incomplete foot drop and depressed reflexes, but intact facial strength and normal ocular movements. The serum CK level was 1230 U/L and, in retrospect, had been 1000 U/L 2 years earlier, but had not been investigated. Alanine aminotransferase was 69 U/L (RR, < 45 U/L); aspartate aminotransferase, 67 U/L (RR < 40 U/L); and peripheral blood eosinophils, 1.36 × 109/L (RR, < 0.4 3 109/L). Review of earlier investigations confirmed persistent eosinophilia over the prior 42 months, at least. Muscle biopsy confirmed H. perplexum. He received 8 weeks’ oral treatment with albendazole. Steroids were not given. Four months later there was some improvement in limb strength and swallowing, although his CK level remained high. DiscussionAlthough H. perplexum myopathy has previously been reported, in two people from Tasmania,1,2 the patients we report had spent most or all of the past few years in tropical northern Australia. We contacted the physicans caring for the earlier patients, who confirmed that they, too, had been exposed to tropical Australia (Box 4). One had travelled extensively in Cape York, Far North Qld, and Kakadu National Park, Northern Territory, 5 years before diagnosis. Around that time, he developed a non-specific illness with raised liver transaminase levels, and liver biopsy showed mild reactive hepatitis with eosinophils. The other was a botanist who had visited the Northern Territory, Tasmania, Europe, Kenya and Indonesia on fieldwork before developing muscle weakness. Clinical features common to H. perplexum myositis patients were the insidious onset of diffuse limb weakness and dysphagia. The documentation of persistent eosinophilia up to 7 years before diagnosis suggests that infection may be subclinical for years. Consistent clinical signs have been diffuse limb wasting and weakness, including bilateral foot drop. Uniform abnormalities included an elevated serum CK, blood eosinophilia and mild elevations of liver transaminases. Although muscle biopsy is required to confirm diagnosis, in one reported case the initial biopsy did not reveal parasites, but a second biopsy after steroid treatment showed H. perplexum. H. perplexum is a minute nematode measuring about 350 m by 20 m. The parasite appears to be able to complete its life cycle within human muscle, as adult nematodes are found within the sarcoplasm of muscle cells, while larvae are found both inside and outside myofibres.3 Electron microscopy shows the characteristic features of H. perplexum: a cuticularised triradiated oesophagus–intestine terminating in dark refringent granules (trophosomes).1 The outer cuticle is thin and has exterior corrugations. The male is shorter and narrower than the female, with the testes occupying 50%–60% of its body. The gravid female has paired uteri where 12 to 24 ova develop into larvae. Auto-reinfection is thought to occur when third-stage larvae escape by bursting through the female nematode’s body, a phenomenon known as endotokia matricida. The resulting damaged myofibres incite an intense inflammatory reaction resulting in myophagia. H. perplexum was first described in the late 1990s, having been identified as the cause of a case of human myositis.2 The parasite is a member of the Robertdollfusidae family of Muspiceoidea nematodes. Distinct species of Muspiceoidea nematodes have been found in the tissues of various Australian vertebrates,4 including mice,3 bats,5 kangaroos and wallabies,6 and koalas.7 In animals, there is some evidence for cutaneous penetration as the mechanism of infection.3 The mechanism by which humans acquire H. perplexum is unknown. Other parasitic myopathies such as trichinosis and cysticercosis are acquired through consumption of poorly cooked meats. Intestinal parasites, including Strongyloides, may be acquired via direct cutaneous penetration, such as when walking barefoot, a common practice in tropical Australia. Mosquitoes, which are very common in tropical Australia during the wet season, could also be a vector for infection. Treatment with albendazole improved muscle strength in all three cases of H. perplexum myopathy, although recovery was slow and incomplete. A biopsy after 4 weeks of treatment showed live nematodes. After 9 weeks of treatment, no live nematodes were seen on biopsy, correlating with a reduction in CK levels and peripheral eosinophilia. Therefore, treatment for at least 8 weeks is suggested to prevent auto-reinfection. Treatment solely with albendazole, without concomitant steroid use, was not associated with adverse reactions from nematode death. Furthermore, steroid therapy resulted in deteriorating muscle function and delayed diagnosis by falsely normalising blood eosinophilia. 1 A 23-year-old woman with progressive muscle weakness (Patient 1) The patient had diffuse wasting of major lower limb muscle groups, including the quadriceps. The white arrow shows wasting of the tibialis anterior muscle, which caused foot drop. The black arrow shows the well preserved digitorum brevis muscle, accounting for preserved toe extension. 2 Micrographs of skeletal muscle (Patient 1) A: Transverse section of quadriceps muscle fibres (M) shows a nematode, Haycocknema perplexum (HP), in cytoplasm, surrounded by interstitial chronic inflammatory cells (INF) (haematoxylin and eosin stain; original magnification, × 400). B: Longitudinal section shows parasitic nematode lying within the muscle fibre (toluidine blue stain; original magnification, × 1000). 3 Electron micrographs of Haycocknema perplexum nematode A: Cross-section through nematode in skeletal muscle (M), showing cuticle (Cu) and oesophagus (O) (original magnification, × 2500). B: Enlargement shows cuticularised triradiated lumen of the oesophagus (original magnification, × 20 000). 4 Clinical and laboratory features of myopathy caused by Haycocknema perplexum Patient Place and year of diagnosis Prior travel Duration of symptoms (years) Dysphagia CK level (U/L)* Eosinophil count (× 109/L)† Outcome 1 North Qld, 2005 Extensive 2 ++ 1370 1.1 Weak, CK ~ 300 U/L 2 North Qld, 2004 None in 20 years 3 ++ 1263 High Weak, died 3 North Qld, 2006 Nil 2 + 1230 1.36 Weak, CK ~ 250 U/L Previously reported cases2 A Tasmania, 1996 Extensive, including Far North Qld 1.5 ++ 1586 2.0 Weak, CK ~ 280 U/L B Tasmania, 1994 Extensive, including northern Australia 5 + 2168 0.8 Good recovery CK = creatine kinase. Qld = Queensland.+ = mild–moderate. ++ = moderate–severe. * Reference range (RR), < 160 U/L. † RR, < 0.4 3 109/L.

Ron Basuroy MRCP · Robert Pennisi FRACGP · Thomas Robertson FRCPA · Robert Norton FRCPA, MRCP · John Stokes FJFICM · Jon Reimers FRACP · John Archer FRACP, PhD

An article published in April last year has prompted debate about the interpretation of time series analyses. (MJA 2007; 186: 408-411) To the Editor: Our comments and question relate to the interesting article by Wilson et al on asthma and chronic obstructive pulmonary disease (COPD) in Australia.1 The statistics on mortality trends for these diseases were complex, but the gist of the matter seems to relate to averaged trends for COPD and asthma over a 10-year period. However, the rigorous statistics missed (or the article did not comment on) what seemed from the figures to be a single step in opposite directions for COPD and asthma mortality in about 1997 — most marked in a downward direction for asthma from 1997 to 1998 and an upward direction for COPD in females from 1996 to 1997. (Box 3 and Box 4 from the original article by Wilson et al are reproduced here for ease of referral.) To us, the data seem, for the most part, to suggest sets of two horizontal lines linked by a sudden, presumably artefactual, discrete change for both conditions at around the same time. Do the complex statistical trend analyses miss an essential feature? Was there, for example, a change to International classification of diseases coding for airway disease specifically around 1997? 3 Deaths from chronic obstructive pulmonary disease (COPD) in Australia, 1993 to 2003, by sex (reproduced from original article by Wilson et al1) 4 Deaths from asthma in Australia, 1993 to 2003, by sex (reproduced from original article by Wilson et al1) In reply: In response to Walters and Wood-Baker, we point out that changes to the International classification of diseases, 10th revision (ICD-10) coding for mortality occurred in January 1997 and changes to morbidity coding occurred later.2 The General Record of Incidence of Mortality books identify “comparability factors” (CFs) for comparing the closeness of agreement between ICD-9 and ICD-10 codes. The CFs for asthma and chronic obstructive pulmonary disease (COPD) are 0.75 and 0.93, respectively. CFs close to 1.0 indicate little difference between the manual ICD-9 and automated ICD-10 coding. In the article by us that Walters and Wood-Baker refer to,3 there would seem to be a dislocation for asthma between 1997 and 1998 — not between 1996 and 1997, when the ICD coding changed. For COPD there was little or no change in trends for men and women over time, and coding made little difference to comparability before and after 1997. It is, therefore, difficult for us to accept an “artefactual” discrete change for both conditions at essentially the same time. Our conclusion from the data is that, over the observed period, there was a downward trend in deaths from asthma in both men and women. Deaths from COPD in men showed a similar downward trend, but the trend for COPD deaths in women showed no change. Given that COPD imposes a much greater burden on women than asthma, we think the most important question to ask is why this is so and what needs to be done about it — which was the main thrust of our article. Comment: Attributing cause in the context of sparse data is fraught with difficulty. I invite readers to consider what the four graphs depicted here (Box) have in common with Wilson and colleagues’ description of deaths from asthma in Australia.1 Surprising as it may seem, the graphs all describe similar phenomena — temporal changes in outcome (eg, incidence, mortality), which may or may not be related to an identified change in circumstance at a particular point in time — albeit in different contexts: breast cancer incidence (A),2 paracetamol poisonings (B),3 police shootings (C),4 and health care expenditure (D).5 The data in all of these graphs arise from uncontrolled time series. The vertical lines in the graphs mark an “interruption” in the time series — a point at which a nominated change occurred. The common question in such studies is simple (and expressed eloquently by Walters and Wood-Baker6): did the interruption result in a change? The answer, I’m afraid, will be unpalatable to some: we don’t know for sure. No amount of statistical analysis will make up for lack of data or the presence of extraneous effects threatening internal validity (eg, events that co-occur with the intervention and that account for the observed changes). In such cases, statements attributing causality are, at best, speculative. While speculations may lead to testable hypotheses, those that can not be tested remain conjectural and must be viewed in this manner. “Interrupted” time series* * Vertical lines mark an interruption in the time series. A: Incidence rate of breast cancer in Australian women aged 50–69 years with nominal start of population-based screening mammography. B: Age-standardised mortality rate for poisoning involving paracetamol in England and Wales with nominal start of legislation restricting availability of drug. C: Rate of police shootings in Philadelphia, Pa, USA, with nominal change in statutory law. D: Per capita expenditure for inpatient care in Taiwan with nominal peak of severe acute respiratory syndrome period.

E Haydn Walters · Richard Wood-Baker · David H Wilson · Graeme Tucker · Robert J Adams · Elmer V Villanueva

To the Editor: I am concerned that the Journal supplement “Early intervention in youth mental health”, published on 1 October 2007, may contravene the MJA policy on sponsored supplements. Item 9 of that policy (http://www.mja.com.au/public/information/instruc.html#Supplements) states: The supplement’s articles should not favour drugs/interventions/views/products of the supporting body to the detriment of other drugs/interventions/views/products. While many of the articles in this supplement are clearly scientific papers, a minority read more as advertorials and promote the interests of two of the supplement’s sponsors.1-3 The ORYGEN–headspace approach to adolescent mental health differs from the approach of other expert organisations, including the Faculty of Child and Adolescent Psychiatry of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and the Australian Infant, Child, Adolescent and Family Mental Health Association.4 Both these organisations support ORYGEN and headspace in seeking to enhance mental health services and transition to adult services for adolescents, but not in the proposed “specialist youth-specific (12–25 years) mental health services providing comprehensive assessment, treatment and social and vocational recovery services”2 (Dr Phill Brock, Chair, Faculty of Child and Adolescent Psychiatry, RANZCP, personal communication). This arrangement does not fit with the way in which other service providers (education, juvenile justice, medicine) are organised, or with the legislative framework that protects the rights, welfare and safety of children (0–17 years of age). Children are not young adults, and child and adolescent mental health service models differ significantly from the traditional focus of adult mental illness. Most teenagers require a family-centred, developmentally appropriate, contextually sensitive, multimodal and systemic model that is less well developed in adult mental health services, including ORYGEN. In spite of claims to the contrary in the supplement, these different approaches are in competition for resources. ORYGEN and headspace have a product to sell (to government and to the medical and lay community). The publication of this supplement has provided them with a platform without presenting an alternate view.

Jon N Jureidini

In reply: Dr Jureidini’s response to the “Early intervention in youth mental health” supplement is puzzling and idiosyncratic. He asserts some kind of impropriety on our behalf or that of the MJA — an assertion we strongly reject. All articles were peer reviewed by experts in the field, including the editorial,1 which is obviously and explicitly the authors’ point of view and therefore open to debate, which we welcome. Other articles Jureidini characterises as “advertorial” are genuine descriptions of new models of care.2,3 Far from selling a product, we are advancing legitimate clinical and scientific arguments, and describing active reforms in mental health. Our “interests” are the pursuit of better mental health care and outcomes for young Australians, pure and simple. No evidence is provided for the assertion that the models described are in competition for resources. headspace has been fully funded with a completely new allocation of federal resources, with no funding redirected from other programs to support it. Furthermore, the youth mental health reform model was selected by the Australian Government through a nationally competitive tender process, in which anyone with a different approach was free to put it forward; indeed, several other submissions were considered and rejected. Similarly, no resources have been diverted to create the ORYGEN model; it is simply a successful restructure of existing resources that is demonstrably better accepted and more effective. Evidence shows that young people and their families find services structured in this way much more user-friendly, and levels of access, engagement and retention are substantially increased over traditional models. One of us (P M) is a member of the Faculty of Child and Adolescent Psychiatry of the Royal Australian and New Zealand College of Psychiatrists (RANZCP), and neither we nor headspace are aware of any official position of the RANZCP that is inconsistent with or unsupportive of the headspace development. Most of the 30 new headspace services across the nation are being established in partnership with local child and adolescent psychiatrists and public mental health services. While many psychiatrists are supportive of and working within the headspace and ORYGEN models, a small subset have expressed a fear that strengthening the focus on adolescents and young adults will somehow disadvantage children. Where is the evidence to support this fear? We are wholly supportive of further investment and improvement in mental health services for children. Unnecessary division on this issue will hamper all progress and is against the interests of patients and families. We strongly agree that there is clearly unmet need in the 0–12-years age group, as well as a further need for preventive interventions beyond the clinical service system, which may in time reduce the surge of incident cases of adult-type disorders. We call on Dr Jureidini to put his efforts into increasing resources and developing innovative service models to improve the mental health of both children and young people, rather than engaging in sterile arguments over professional territory and distribution of existing resources that will benefit no-one.

Patrick D McGorry · Anthony F Jorm · Rosemary Purcell · Ian B Hickie

In reply: I welcome Dr Jureidini’s criticisms regarding the publication of the MJA supplement “Early intervention in youth mental health”.1 Dr Jureidini has two major concerns. First, a number of articles in the supplement are deemed to unilaterally advocate concepts arising from the ORYGEN–headspace program, with the suggestion that this exclusivity contravenes the MJA policy for publishing sponsored supplements. Second, he claims that the general framework of the ORYGEN–headspace program does not have the endorsement of professional bodies such as the Faculty of Child and Adolescent Psychiatry of the Royal Australian and New Zealand College of Psychiatrists (RANZCP). Eminent mental health experts reviewed the articles in the supplement and, interestingly, not one of these authorities raised the RANZCP’s misgivings. This could mean that propagation of the Faculty’s concerns in the psychiatry fraternity may be selective, or that the rationale for its position has not convinced psychiatrists at large. Dr Jureidini’s other concern — that the supplement favoured the ORYGEN–headspace approach at the expense of other interventions, views or products — reflects the very essence of supplements. The fundamental purpose of publishing research or commentaries is to enter information into the publishing–evidence–integration cycle, wherein the dissemination of evidence or ideas is intended to promote change by influencing other researchers, health care professionals, the public and, ultimately, policymakers. Indeed, the ORYGEN–headspace program must have influenced policymakers, as the federal government recently announced grants totalling $19 million to support the national roll-out of the headspace program, especially in rural communities.2 Even if the publication of the MJA supplement played little or no part in this political endorsement, I am content that it has, at least, fostered debate and may well play a part in improving mental health services for young Australians.

Martin B Van Der Weyden

To the Editor: Little is known about the epidemiology of respiratory syncytial virus (RSV) in arid, desert regions generally, and in central Australia in particular. We performed a 5-year retrospective study from 2000 to 2004, inclusive, of children aged less than 2 years who were admitted to Alice Springs Hospital and identified as having RSV infection. RSV was detected using direct immunofluorescence (Light Diagnostics SimulFluor; Millipore, Billerica, Mass, USA) on nasopharyngeal secretions. The test has a reported sensitivity of 92%.1 We extracted demographic data from case notes and obtained population data from the Northern Territory Department of Health2 and the Australian Bureau of Statistics.3 From case notes over the 5 years, we identified 173 eligible children with RSV infection. The annual incidence rate was 21.4 per 1000 children under 2 years old. The rate in Aboriginal children was 30.9 per 1000, and the rate in non-Aboriginal children 11.6 per 1000 (P < 0.0001). The monthly distribution of cases is shown in the Box. Cases occurred throughout the year, and in every month, but there was a peak in admissions from March to August, which covers the Australian winter. Because Alice Springs Hospital is the only large hospital in the region, and almost all children needing hospital admission for RSV infection will be admitted there, our incidence rates of hospitalisation for RSV infection closely approximate population rates. However, we may have under-estimated the incidence because we only included children in hospital with proven infection, so we may have missed children who were not tested, or whose immunofluorescence test results were falsely negative. There may have been selection bias regarding admissions. Nevertheless, we found that Aboriginal children were more likely than non-Aboriginal children to be hospitalised with RSV infection, a finding in keeping with the known high incidence of pneumonia and bronchiectasis in Aboriginal children.4,5 While the incidence of RSV infection peaked in winter in central Australia, infections occurred throughout the year, and the winter predominance was less marked than is the case in temperate Australia.6 These data provide valuable information about RSV infection in an arid, desert region and can inform decisions about active or passive immunisation against RSV infection in central Australia. Monthly distribution of admissions to Alice Springs Hospital of children aged less than 2 years with respiratory syncytial virus, 2000–2004* * Inclusive.

Apakasimaka Dede · David Isaacs · Paul J Torzillo · John Wakerman · Rob Roseby · Rose Fahy · George Clothier · Andrew White · Paula Kitto

To the Editor: We report the serendipitous finding of non-Hodgkin’s lymphoma in a patient with adrenal Cushing’s syndrome. A 62-year-old previously well man (body mass index, 22 kg/m2) was referred to our institution with newly diagnosed type 2 diabetes, hypertension and dyslipidaemia. Clinical findings included oral thrush, bilateral severe pitting lower limb oedema, lower limb proximal myopathy, kyphosis, and increased abdominal girth (waist circumference, 92 cm), raising suspicion of Cushing’s syndrome (Box 1). Biochemical assessment revealed normal electrolytes, an unsuppressed early morning cortisol (following 1 mg dexamethasone), urinary free cortisol 6475 nmol/day (reference range, 0 – 250 nmol/day), and undetectable adrenocorticotropic hormone levels. Twenty-four-hour urinary catecholamine was normal. His testosterone level was 3.2 nmol/L, and dehydroepiandrosterone sulfate level was normal. Abdominal computed tomography showed a right adrenal mass that measured 3.1 × 2.8 × 3.4 cm (density, 36 Hounsfield units). Thoracic spine x-rays revealed wedge compression fractures at T-10 and T-11. Bone densitometry showed T-scores of − 3.3 at L2 – 4 and − 2.3 at the right femoral neck. Total body fat (18.5 kg; 33%) was higher than the recommended range for age and sex (13%–25%). The patient had a laparoscopic right adrenalectomy. Surgical excision was complete. Post-operatively, blood glucose and blood pressure returned to normal. Histopathology revealed an adrenal cortical tumour with atypical features, including a preponderance of eosinophilic cells, small numbers of clear cells, prominent nuclear pleomorphism, large nucleoli and occasional mitoses (Box 2A). However, the proliferation fraction (Ki67) was low and there was no necrosis. There was no large vessel invasion, although a single area of small vessel invasion was present (Box 2B). Unexpectedly, the adipose tissue adjacent to the adrenal gland was infiltrated by a diffuse large B-cell non-Hodgkin’s lymphoma (Box 2B). This was confirmed by positive CD20 immunohistochemistry. Bone marrow biopsy was normal. [18F]Fluorodeoxyglucose positron emission tomography (FDG-PET) scan showed increased uptake in the right adrenal bed only. The patient was treated with six courses of CHOP chemotherapy (cyclophosphamide, doxorubicin, vincristine and prednisolone) in combination with rituximab. A repeat FDG-PET scan 1 month after chemotherapy was clear. We speculate that lymphoma progression was suppressed by the coexistent steroid-producing adrenal tumour. The decision to treat the non-Hodgkin’s lymphoma was, in part, based on reports of progression of haematological disease following treatment of Cushing’s syndrome.1,2 Although histopathological examination of the tumour revealed some features suggestive of adrenocortical carcinoma, the distinction between adenoma and carcinoma can be difficult. In patients with recurrent or metastatic adrenocortical carcinoma, partial response has been reported using a combination of cylophosphamide, vincristine, cisplatin and teniposide.3 Two of these agents were used to treat our patient’s lymphoma. 1 Patient appearance at presentation, with obvious kyphosis and abdominal swelling 2 Immunohistochemistry A: Right adrenal tumour composed of enlarged pleomorphic cells with prominent nucleoli. B: Adrenal cortex (on right) with tumour showing focal vascular invasion (centre), plus adjacent non-Hodgkin’s lymphoma (on left).

Lai Y Wong · John Moore · Debbie Hill · Phil Brenner · Warick Delprado · Jennifer Turner · Joanne Taylor · Lesley Campbell · Jerry R Greenfield

To the Editor: We agree wholeheartedly with Skull and Nolan’s call for a lifetime immunisation register to enhance monitoring of coverage, provide a clinical support service and provide data for program evaluation.1 An expanded register could also provide information on the vaccine coverage for childhood diseases that may increasingly affect adults (such as varicella and measles), for immigrants who may receive childhood vaccines after childhood, and for occupational groups (eg, influenza vaccine for health care workers). However, we note some policy implications that need to be addressed before such an expanded register could be implemented. In August 2007, at a La Trobe University seminar on human papillomavirus vaccination, the 180 participants (mainly students and staff of La Trobe University) were asked to fill out a survey that included a question about the acceptability of a lifetime vaccination register. Of the 154 who responded, 8.5% were not in favour of such a register and another 8.5% declined to answer that question (unpublished data). This suggests that there may be significant barriers to the implementation of a lifetime register. Principal among the concerns cited were the implications for privacy, which were also noted by consumer groups.2 As with the existing Australian Childhood Immunisation Register, people will need to be aware of what data are being collected (including policies for data retention), their choice to opt out, and a clearly defined purpose in gathering the data (in particular, that the data will not be used in a punitive manner). People will also need to be assured that there are unambiguous policies governing access to the register and penalties associated with breaches of confidentiality. These concerns have led to the suggestion that a private health record should be developed instead,2 but such a record would be unlikely to be adopted widely and could not be used for monitoring or program evaluation. Development of an expanded register could also present potentially significant logistical problems. We would suggest a staged approach, beginning with expanding the current childhood register to include adolescents of school age and elderly people. Incentives to improve vaccine coverage in these groups could be modelled on the current General Practice Immunisation Incentives Scheme, which provides service incentive payments, outcomes-based payments and immunisation infrastructure funding. Many Indigenous Australians are currently covered through Aboriginal-controlled community health organisations. With the consent of those organisations, data could be absorbed into a national register. Later stages of implementation might see the inclusion of special groups (such as post-splenectomy patients and immigrants) and people receiving occupation-related and travel-related vaccines. The register could eventually be expanded to encompass the full Australian population. The current redevelopment scoping study for the Australian Childhood Immunisation Register3 is due for completion in 2008. We support enhancing the current central register, but clearly defined policies to protect privacy are required to address public concerns.

Allen C Cheng · Carmel M Hobbs · Priscilla M Robinson

In reply: We welcome additional dialogue on the important issue of developing a whole-of-life immunisation register in Australia. As with introduction of any register, logistics and concerns about privacy must be carefully considered, and a stepwise approach may well be appropriate. However, it is important to note that a non-acceptance rate of 8.5% derived from a small and potentially non-representative survey of seminar attendees does not necessarily represent a significant barrier to implementation of such a register.

Susan A Skull · Terrence M Nolan

To the Editor: I congratulate Haslam on his excellent overview of the role of empathy in medicine.1 He rightly reminds us that empathy is not vague or ill defined; rather, its presence improves clinical outcomes, and it can be both learned and lost. I would go further and argue that empathy is not an optional extra but a clinical competence essential for sound medical practice, no matter what our specialty. All clinical practice requires a doctor–patient relationship, the core skill of which is empathy. I wish to draw readers’ attention to a time-honoured but, in Australia, somewhat neglected educational activity where empathy is the major focus — that of Balint groups. In London in the 1950s, Hungarian-born psychiatrist Michael Balint and his wife Enid developed a unique method for studying the doctor–patient relationship.2 A Balint group is an experiential, small-group educational activity in which practising clinicians meet regularly to discuss their own doctor–patient interactions. The focus is on the emotional content of the doctor–patient relationship; the group’s primary task is to describe and empathise with both the doctor’s and the patient’s experience. Participants’ learning, therefore, is based on real-life situations they have encountered in their practices. A rationale for this kind of training is that all doctors tend to have habitual responses to certain clinical situations. Although these responses can be strengths which doctors bring to the care of some patients, they can also limit their capacity to help other patients. In certain situations, limits to doctors’ capacities for empathy may be unhelpful or even harmful to patients. A growing body of research suggests Balint-group training increases: practitioner sensitivity to hidden patient cues;3 the proportion of the consultation spent listening to the patient;4 practitioners’ experience of wellbeing during the consultation;3,5 practitioners’ sense of control in their work situation;5 and practitioners’ work satisfaction.6 At the same time it decreases: practitioner burnout;3,5 and unnecessary prescriptions,3 referrals5 and tests.5,6 In many countries today, Balint-group training is used in undergraduate and postgraduate education, most often in general practice training, but also in psychiatry, paediatrics, obstetrics and gynaecology, and internal medicine. At an international level, the vibrancy and energy of Balint-group work is reflected in the 26-year-old International Balint Federation (http://www.balintinternational.com). The Balint Society of Australia (http://www.balintaustralia.org), formed in 2005, joined the Federation in 2007.

Marion Lustig

To the Editor: I note the concern expressed by Byard and Matthews about the safety of three-wheel strollers.1 Surely a safer method of control would be for the brake to be on at all times other than when the stroller is in use? This could be done by having a lever that had to be held in position by the user in order to move the stroller. Should not this be required in the safety standard?

Charles Bridges-Webb

Roman Rossleigh, a caring physician, committed family man and community-minded citizen, died of multiorgan failure on 14 September 2007 after a long battle with chronic illness. Roman was born on 13 October 1919 in Kraków, Poland. His mother, a dermatologist, treated venereal diseases in women, and his father, a cardiologist, trained under Karel Wenckebach. When the Nazis invaded Poland, Roman was tortured, resulting in bilateral brachial plexus palsies and a left hemiparesis, which worsened over the years. He was incarcerated in Plaszów and then Mauthausen concentration camps and liberated on 5 May 1945 — a day he celebrated in later years as his “re-birthday”. He became a fourth generation physician after World War II, completing his medical degree in Lódz in 1946. He met his future wife Christine in the same year, fell madly in love, and married her after they had known each other for only 3 days. Their marriage lasted 61 years. Roman migrated to Australia in 1947, studied medicine again at the University of Sydney, and became registered as a medical practitioner in 1952. He was proud to have been able to maintain his medical registration until the end of his life. In 1974, he was awarded Fellowship of the Royal Australian College of General Practitioners, and several years ago was recognised for his 50-year membership of the Australian Medical Association. Practising in Newtown, Sydney, Roman had many migrant patients, owing to his reputation as a good doctor and his ability to speak seven languages. He was a member of the New South Wales Association for Mental Health and was on the committee for migrant mental health. He was a strong advocate for the establishment of an interpreter service, which is now widely used throughout the NSW health system. He opposed the use of children as interpreters for their parents because of the often sensitive nature of the problems discussed and the potential for mental harm to the children. Roman was actively involved in the affairs of the Polish community in Australia, for which he was recognised by the Polish Government with the award of several medals, including the Knight Cross of the Order of Merit of the Republic of Poland (an award analogous to the Order of Australia). He was a Freemason, a strong supporter of many charities and a lover of books, history, music, travel and ball sports — in particular, football (soccer) and cricket. Roman is survived by Christine, his daughter Monica, a nuclear medicine physician, and son Martin, a school teacher.

Monica A Rossleigh

How not to be a doctor and other essays. John Launer. Oxford: Royal Society of Medicine Press, 2007 (112 pp). ISBN 978 1 85315 752 3. What lucky people, the subscribers to QJM, which, like the BMJ, prefers its initials to its full name! (In this case, it is apt — QJM is no longer the Quarterly Journal of Medicine, but now appears monthly.) Those lucky readers, looking forward each month to a Launer column, probably include a few Australians. This slim hardback, containing 50 of Launer’s illuminating short columns, published in QJM this century, is not the usual collection of medical anecdotes. These are insightful comments on how patients and doctors think, how hospitals and health systems work (or do not work), and different approaches to health, illness, living, communicating and dying in different cultures. Launer’s thoughtfulness is reminiscent of that of Booker Prize winner, fellow Briton John Berger (author of A fortunate man: the story of a country doctor. London: Penguin, 1967). Launer’s simple yet elegant writing sets an example for many a doctor–writer. But I have two quibbles with the publisher. At this price, the Royal Society could have afforded an indexer. When someone writes as well as this, readers want to return to his thoughts. Without an index, who can remember what was in which of the 50 essays? And why no date of first appearance in QJM? “Context is everything” say the sages; and “the times” are the essence of the context. It was a pity that the review copy arrived too late to be recommended for the Christmas stocking of every doctor you know. But if a doctor friend has a birthday soon, is a little over $1 per essay too expensive?

Peter C Arnold

Foundations of clinical psychiatry. 3rd ed. Sidney Bloch, Bruce S Singh, editors. Melbourne: Melbourne University Press, 2007 (xii + 642 pp). ISBN 978 0 522 85320 9. A good textbook of psychiatry is hard to find. Not only does such a book have to be well written, but its editors need to think carefully about what information is of relevance and vital to today’s trainee. Mindful of these issues, the editors of the latest edition of Foundations of clinical psychiatry have worked to bring the material up to date and have broadened the text, adding a chapter on intellectual and developmental disability. At the same time, they have retained the previous edition’s clinical focus and kept the book to a realistic length. The text is divided into four sections. The first presents a unifying biopsychosocial approach that trainees need to adopt when dealing with psychiatric patients. Important interviewing, synthesising and framework skills for formulating psychological problems are discussed. The second section deals with the range of basic psychiatric disorders such as trauma, anxiety, mood disorders and schizophrenia, while the third concerns special clinical areas such as children, older people, Indigenous peoples, and suicide. The final section deals with mental health service provision, including biological and psychological treatments. Importantly, Bloch and Singh recognise the calls that both science and the science of understanding people make on clinical practice by including a chapter on understanding and explaining psychiatric illness. To the best of my knowledge, this is unique in psychiatric textbooks and the key to successfully traversing a complex field. So much so that I would recommend all students read this chapter both at the beginning and again at the end of their training, to assist them in making sense of what they have learned. The second edition of Foundations was good; the third, however, is better. It is a readable, comprehensive textbook of psychiatry that easily meets its key task of educating medical students and interested health professionals.

Christopher J Pollock

Meningococcal vaccine A novel tetravalent meningococcal vaccine appears to be safe and effective in infants, according to the results of a British and Canadian randomised controlled trial. The meningococcal vaccine currently used in the United States to immunise adolescents (serogroup ACWY) is poorly immunogenic in infants — the group with the highest rates of disease. The researchers administered the tetravalent conjugated meningococcal vaccine (MenACWY) to 225 UK and 196 Canadian infants and compared results with a monovalent vaccine. Outcome measures were safety, reactogenicity and human complement serum bactericidal activity — a measure of vaccine effectiveness. MenACWY was well tolerated and immunogenic for the tested serogroups. A booster at 12 months was found to address the problem of waning titres by this age. Despite limitations associated with the small size of the study, the authors conclude the new vaccine extends immune protection in infants and appears to be safe. JAMA 2008; 299: 173-184 Free falling Multifactorial programs aimed at preventing falls in older people appear to have limited effectiveness, say UK researchers. A systematic review and meta-analysis of 19 randomised controlled trials assessed studies that evaluated interventions to prevent falls. Interventions were based in emergency departments, primary care or the community. Analyses showed little evidence to support the effectiveness of interventions to prevent falls in older people in these settings. A subgroup analysis suggested that interventions actively providing treatments aimed at reducing risk factors may be more effective than those providing knowledge and referral alone. BMJ 2008; 336: 130-133 Publication bias and antidepressant trials Selective publication of clinical trials has come under fire from a group of US researchers and clinicians. Reviews from the US Food and Drug Administration (FDA) for studies of 12 antidepressant agents were obtained and matched with published studies via a systematic literature review. From a total of 74 FDA-registered studies, 31% were not published, accounting for 3449 participants. The authors claim to have detected a bias in publication, with a slant towards studies with positive outcomes. With reference only to the published literature, it would appear that 94% of trials were positive, but analysis of the FDA data showed 51% were actually positive. Although unable to determine how the bias arose (from failure to submit manuscripts, journal editorial decisions, or as a result of peer review), the authors comment that selective reporting of clinical trials may have negative consequences for patients, researchers and clinicians. N Engl J Med 2008; 358: 252-260 Steroids for stiffness Modified-release prednisone appears to provide a clinically useful reduction in morning stiffness in patients with rheumatoid arthritis compared with standard preparations of the glucocorticoid. In a multicentre, randomised double-blind trial, 288 patients were randomly assigned to either a morning dose of immediate-release or a bed-time dose of modified-release prednisone, which is released after a 4-hour delay. The change in duration of morning stiffness of the joints was significantly higher with modified-release prednisone, indicating a greater improvement in the patients with rheumatoid arthritis treated with this formulation. There was no apparent difference in the safety profile of the treatments. The authors comment that this form of glucocorticoid takes advantage of the altered circadian rhythms in patients with rheumatoid arthritis, improving the benefit-risk ratio of glucocorticoid therapy. Lancet 2008; 371: 205-214 MRSA in USA Multidrug-resistant, community-associated, methicillin-resistant Staphylococcus aureus (MRSA) appears to be an emerging infection in men who have sex with men, a US study has shown. The incidence, spatial clustering, and risk factors for infections with the MRSA clone USA300 were studied in a population-based survey and cross-sectional study based in San Francisco and Boston. Male-male sex was an independent risk factor for infection, which manifested mainly as infection of the buttocks, genitals, or perineum. The authors speculate that infection with USA300 MRSA might be sexually transmitted, and comment that more research is needed to determine how spread of the infection may be controlled. Ann Intern Med 2008; Jan 14 [Epub ahead of print]

Tanya Grassi