Volume 188 Issue 9

Training in a variety of skills while caring for patients, without the burden of unnecessary tasks, and with meaningful feedback and supervision and time for reflection and self-care — too much to ask? In this issue of the Journal, Westbrook and colleagues studied the work of interns, residents and registrars across four wards in a Sydney teaching hospital (→ All in a day’s work: an observational study to quantify how and with whom doctors on hospital wards spend their time).1 Their findings are limited by the study’s small sample size, and the fact that each participant was observed, on average, for just under 8 hours, and not during evening or night shifts. Nevertheless, their key findings are pertinent to understanding a day in the life of a doctor-in-training. As a group, interns, residents and registrars spent about a third of their time in “professional communication”, including meetings, requests for consultations and planning care, about another third on direct or indirect (predominantly reviewing results and planning care) patient care, and a surprising 17% of time on “social” activities (defined as all non-work activity or communication, including meal breaks); 7% of time was viewed as being related to education, the same amount as that devoted to medication tasks, including searching for charts. Finally, about 2% of tasks related to administrative activities that were not a part of patient care, and about another 2% of tasks were carried out while not officially on duty.1 The findings are different from those of an unpublished survey in an Auckland hospital, which found that only 15% of employed time was spent doing things for which a medical education was necessary.2 So what should a day in the life of a doctor-in-training look like? The ideal day should be one that consists of training in a mixture of skills while caring for patients, without the burden of unnecessary tasks,3 and with time for reflective education and self-care. Is this ideal “warm and fuzzy” and totally impractical, or is it a realistic goal? Let’s begin by doing away with the conflicting notions that one is either learning or is involved in direct patient care (ie, “service”). The two are not mutually exclusive, provided appropriate supervision and feedback is given by more senior doctors in the medical team; this is the key to integrating clinical service provision by interns, residents and registrars with their “on the job” training. Does this time-honoured “apprenticeship” model still work now that the medical team encompasses as a minimum, not only doctors, but also nurses, and allied health and clerical staff? There is a push for doctors-in-training to be allocated to a ward rather than to a traditional medical team, but the risk in this is that many doctors-in-training may lose the supervision they require. On the other hand, it is clear that supervision and feedback is not always given in the present system. The solution is simple: if consultants want the privilege of doctors-in-training on the team, then they need to support them and help structure their days towards learning. Meaningful performance agreements between consultants and their clinical or hospital managers could resolve this, but such agreements must reflect genuine support and appreciation from hospitals and universities for the consultants providing this supervision.4,5 In this context, the Australian Curriculum Framework for Junior Doctors6 serves as a useful document, not only to guide the learning experiences of doctors-in-training, but also to assess the ability of hospitals to provide adequate resources and support for such experiences. What unnecessary tasks should be removed from the doctor-in-training’s daily activities? Westbrook et al point out that sometimes things that seem most burdensome are those that are frustrating rather than those that take up much time.1 For example, doctors had included writing discharge summaries among a small number of activities that consumed “all our time”, but Westbrook and colleagues found that only about 5% of time was spent on this activity.1 With appropriate feedback, writing discharge summaries can be a valuable learning experience, as doctors must be able to liaise professionally with colleagues throughout their careers. This emphasises the need for meaningful day-to-day feedback about the role and value of individual tasks. We should also acknowledge that the in-hospital consultation process has become unwieldy; it probably occupied a large proportion of the 33% of time spent on “professional communication” reported in Westbrook and colleagues’ study.1 This could be reformed relatively easily by ensuring that all consultations were approved first by the clinician in charge, and by specialist medical teams continuing to practise general medicine for their patients, thereby reducing the number of consultations required. This would do away with reams of paperwork and duplication of tests. A further “clerical” issue that needs to be addressed is the time-honoured process of charting admissions. It is not unusual for interns and residents in emergency departments, and then emergency or specialty registrars and ward interns to write (similar) admission notes, with no added benefit to the patient or doctor. Finally, given the stress of the job of a doctor-in-training and the high rate of psychological and psychiatric morbidity among our junior medical staff,7 it would be a good thing if some time each day were truly spent on activities such as speaking with their own friends and family, which might allow them to debrief and reflect on the stresses that confront them. The early training years should be an exciting time; learning is rapid, and patients actually benefit from what the doctor-in-training does. We need to promote a strong work ethic whereby our patients come first and we work in support of, and are supported by, our colleagues; this will, by necessity, mean work after-hours, but we still need to move away from the view that “the harder I work, the better a doctor I am”.8 The New South Wales Institute of Medical Education and Training believes true progress can be made in improving the quality and value of a doctor-in-training’s day through the establishment of a training and education agreement between the doctor and the hospital. This has already been introduced in some specialty training areas, but needs to be applied very quickly to the junior medical officer workforce so that doctors-in-training can know what daily education and supervision they should expect, and the hospital knows that these doctors agree to participate actively in their learning opportunities and their service provision to patients and their colleagues. Importantly, we need to begin training in more meaningful places, such as the private sector, general practices, and other community settings, to define appropriate educational goals (which can now be guided by the Australian Curriculum Framework for Junior Doctors)6 and provide proper feedback, supervision and caring for our next generation of doctors. There has been progress, but we can do better.

Mark A Brown FRACP, MD · Stephanie Arnold BSc, MB BS

Cervical cancer prevention relies on two different age-specific technologies, and consumers should not be misled about the role of HPV vaccines The introduction of human papillomavirus (HPV) vaccines to clinical practice is the end result of a remarkable distillation of basic science, new technology, epidemiological understanding, clinical research and commercial development. It has brought together stakeholders from a variety of backgrounds to consider these developments, and Australia is now the first country to implement a population-based mass vaccination program against HPV. The Australian HPV vaccination program was commenced after cost-effectiveness of the quadrivalent vaccine was demonstrated,1 anticipating that the expected reduction in the cost of treating HPV-related disease in Australian women would compensate for the cost of the vaccine. This program, an Australian Government initiative,2 appears to have been very successful in terms of coverage, and offers young Australian women the opportunity to be among the first national cohort to be vaccinated against the virus types that cause most cervical cancers and a variety of other HPV-related diseases. The natural history of HPV infection and the consequent risk of developing cervical cancer are well documented. HPV infection, replication and particle maturation occurs in the stratified squamous epithelia of skin and mucous membranes, with virus spread occurring by skin-to-skin contact. Most people encounter genital HPV soon after the onset of sexual activity,3 with the highest risk of contracting the infection in the first 5–10 years after commencing sexual activity. The clinical consequences of infection will vary according to the type of HPV encountered, and most infections resolve spontaneously, presumably relying on the host’s immune system to clear the infection. For whatever reason, some individuals do not clear their infections, and if these infections are caused by some oncogenic or high-risk varieties of HPV, this persistence will lead to activation of oncogenic viral proteins, the loss of cellular control mechanisms and the potential for malignant transformation. Screening programs based on cytology have had significant impacts on the incidence and mortality of cervical cancer by detecting these potential cancer precursors, but HPV vaccines allow the opportunity to enlist the vaccinee’s own immune system to develop neutralising antibodies before exposure, and to primarily prevent the infection. The two currently available vaccines (a quadrivalent vaccine against HPV types 6, 11, 16 and 18, and a bivalent vaccine against types 16 and 18) have both been developed by recombinant genetic technology that allows expression of the major structural protein of HPV, the L1 protein, that spontaneously assembles into virus-like particles (VLPs) which are both type-specific and highly immunogenic. Both available vaccines contain VLPs, but the products differ in the types of HPV L1 proteins included as antigens, substrates used for production, adjuvant properties and in the final formulation. Antibodies raised to the VLPs provide protection against HPV infection, probably by transudation of IgG from serum to local mucosal/epithelial areas, especially at sites of trauma where HPV can otherwise gain access to basal epithelial cells.4 Published efficacy studies suggest subtle but probably insignificant differences between the two vaccines in preventing type-specific HPV infections and disease.5,6 It seems unlikely that cell-mediated immunity is involved as a direct effector mechanism of vaccine protection.7 Clearly, this mode of action highlights that the current vaccines will only be effective if administered before exposure. These vaccines have shown no therapeutic efficacy for pre-existing infections.8 Trials of both commercially available vaccines, while demonstrating very high efficacy (approaching 100%) in HPV-naïve populations, have shown diminished efficacy in populations with high rates of previous exposure.4,5 The results so far have indicated that women already infected with one of HPV types 16 or 18 can be protected against development of cervical intraepithelial neoplasia grade 2/3 or cervical adenocarcinoma in situ associated with the other type by vaccination. Both trials were conducted in young populations (generally in women aged between 16 and 25 years). Preliminary results indicating significant efficacy (greater than 90%) of the quadrivalent vaccine in an older population aged between 24 and 45 years have been presented, and these data form the basis of the vaccine sponsor’s application to regulatory authorities in both Australia and the United States for expansion of their age indication for this formulation.9 Doctors are used to being exposed to marketing from drug companies, and are susceptible to commercial persuasion with competing claims of superiority and product distinction. The quadrivalent vaccine, Gardasil (Merck), is available at no cost to Australian girls and women between the ages of 12 and 26 as part of the National Immunisation Program. The bivalent vaccine, Cervarix (GlaxoSmithKline), has to date not been included in the program, having initially been rejected by the Pharmaceutical Benefits Advisory Committee (PBAC) on the basis of uncertain cost-effectiveness,10 but subsequently recommended for inclusion.11 This recommendation has not yet been endorsed by the Australian Government. The sponsoring company appears to have decided to promote Cervarix specifically to older women,12 despite the absence of efficacy data and the uncertain population benefits in this age group. Indeed, the decision by the Australian Therapeutic Goods Administration (TGA) to register Cervarix for use in this population, in which no efficacy has been shown, is not easily understood. Under the Therapeutic Goods Act 1989 (Cwlth), the TGA is responsible for evaluating the quality, safety and efficacy of medicines.13 The World Health Organization has issued guidelines for the evaluation of HPV vaccines, indicating that studies that use immunogenicity data to bridge efficacy from younger to older women are not appropriate.14 In Australia, these guidelines have not been adhered to, and Cervarix has been licensed for use in women up to 45 years of age, despite lack of demonstrated efficacy in women over 26 years. To suggest that the vaccine will offer patients some theoretical potential benefit if they are prepared to pay for it does not reflect sound evidence-based, equitable health care provision. The promotion and media coverage of HPV vaccines in Australia have been extensive, and with this has come an increased awareness of HPV, its relation to cervical cancer, and the national HPV vaccination program. The promise of a cancer vaccine is alluring to women who perceive a risk of cervical cancer. Principles of consumer protection, however, demand that expectations should not be raised unduly, and that the available vaccine does not promise to deliver beyond its capacity. Excessive promotion in the older age group, when the vaccine is likely to be of substantially reduced efficacy because of either previous exposure or reduced risk of future exposure, potentially diverts attention and compliance with established methods of cervical cancer prevention based on cervical cytology. HPV vaccines are about preventing future infections. Cervical cytology detects cytological abnormalities from previous infections. It is important that the benefits of these two approaches to cervical cancer prevention are not confused, and that all women receive the best and most appropriate combination of two effective technologies.

Gerard V Wain FRANZCOG, CGO

Reducing the growing burden of food allergy requires a chronic disease management model, clarification of responsibilities, and better communication of both risks and uncertainties Food allergy and anaphylaxis are increasing in the Australian community, particularly in preschool-aged children,1,2 although, paradoxically, mortality occurs almost exclusively in school-aged children and adults.3 Food allergy and anaphylaxis are high-stakes and highly uncertain issues, where the outcome may be the sudden and unpredictable death of a child.4 The concept that a patient is “at risk” inevitably invokes uncertainty. It is possible to prospectively identify those at risk by virtue of having food allergy, but diagnostic tests are not highly predictive of anaphylaxis. The population with food allergy is substantially larger (about 10–20-fold) than the population who will experience anaphylaxis. Patients and their carers therefore live with being at risk, while not knowing exactly what the nature or extent of the risk is. In clarifying what we mean by “anaphylaxis risk”, the conventional wisdom in risk communication literature is to avoid essentially meaningless terms such as “potential risk” or “high risk” and to instead employ techniques that more accurately convey quantitative estimates of risk. This is risk as numbers, or “the probability that an event will occur, eg, that an individual will become ill or die within a stated period of time”.5 Mortality figures for food anaphylaxis in New South Wales show that the numerical risk that a teenager allergic to peanut or tree-nut will die from anaphylaxis in the next year lies between 1 in 10 000 and 1 in 100 000 — in the same order as the chance of an Australian resident being murdered in the next year.6 The risk that a child aged under 5 years will die from food anaphylaxis in the next year lies between 1 in 1 million and 1 in 10 million — the same order as the risk of death from being struck by lightning.6 However, there are problems with this numerical approach to risk assessment: the data to calculate probabilistic risk for anaphylaxis are either unavailable or not generalisable; numerically small risks are difficult to communicate; and death by lightning or violence is not necessarily viewed in the same way as a child dying from eating food. Due to its emotive characteristics, the risk of food anaphylaxis is likely to be appreciated by experiential rather than analytical cognitive processes,7 which are intuitive, automatic, and greatly influenced by associations and affect. Fear of the unpredictable death of a child may outweigh any rational consideration of its numerical likelihood. Care must therefore be taken when discussing anaphylaxis risk with patients and parents, with a key consideration being the need to sensitively communicate uncertainty as much as communicate risk. As food is essential, some exposure to risk is unavoidable. Although food labelling is becoming clearer, there are persistent uncertainties about mislabelling and cross-contamination with allergens, coinciding with broader concerns about food quality and production, and societal expectations that parents and others will provide safe food for children. Accordingly, food allergy is as much a sociocultural as a medical issue, and, for some, the constant obligation to make careful decisions about what to eat or feed their child, together with ongoing uncertainty about the risks, can create an enormous burden. Reducing this burden requires a coordinated and intersectoral response, from consumers, the health care, teaching and childcare professions, the food and pharmaceutical industries, and statutory bodies at both state and federal level. Clarification of responsibilities is required for food labelling and production, care in schools and preschools, anaphylaxis education (involving anaphylaxis recognition and risk minimisation, as well as correct use of EpiPen autoinjectors [CSL Limited, Melbourne, Vic]), and monitoring EpiPen use. It is encouraging that, in recent months, the Victorian Government has announced legislation mandating a school anaphylaxis management standard8 and the Western Australian Government has committed $6.6 million to a program of interventions.9 Nevertheless, as with other “messy” and uncertain problems, pure science and rationality alone are not sufficient.10 In formulating policy, the process of representation, clarification of common aims and interests, and debate over what we mean by “anaphylaxis risk” may be more important for developing a coherent and coordinated framework for action than would identifying an elusive “right” response. At the service provision level, there has been a tendency for medical treatment of an acute emergency to be the focus of food allergy management. Emergency treatment itself brings additional uncertainties — guidelines for EpiPen prescription leave much to individual judgement, and one study found that only 2% of doctors in a major Australian paediatric teaching hospital could correctly demonstrate all steps in EpiPen administration.11 Fortunately, despite the many uncertainties, most food-allergic patients are generally well and the EpiPen is appropriately unused. Nevertheless, it is more appropriate for food allergy, with its unpredictable “exacerbations” or reactions, and its requirement for community management of risks, to adopt a chronic disease management model, centring on self-management, patient and carer education, continuity of care and multidisciplinary services. Such an approach, including ongoing support from dietitians and nurse educators, is likely to reduce the uncertainties of daily management. The need for parent and carer education is evidenced by an Australian survey of EpiPen use, which found that only 29% of parents administered the EpiPen when indicated.12 Parental satisfaction with information provision is also associated with less seeking of second opinions.13 Thus, adequate parent and carer education and follow-up may ease pressure on referral services, which currently have 10–14-month waiting times for hospital paediatric allergy consultations. The uncertainties surrounding food allergy arise from a lack of scientific, epidemiological and personal knowledge, the need to negotiate between different sectors and interests, and ambiguous language and concepts that are difficult to communicate. Different responses are required at interpersonal, service delivery and policy levels. While some uncertainties are irreducible, patients and carers are also experiencing unnecessary uncertainties. What is certain is that food allergy has become a significant concern for public health, paediatric and general medical practice.

Andrew S Kemp MB BS, PhD, FRACP · Wendy Hu MB BS, PhD, FRACGP

Objective: To quantify time doctors in hospital wards spend on specific work tasks, and with health professionals and patients.Design: Observational time and motion study.Setting: 400-bed teaching hospital in Sydney.Participants: 19 doctors (seven registrars, five residents, seven interns) in four wards were observed between 08:30 and 19:00 for a total of 151 hours between July and December 2006.Main outcome measures: Proportions of time in categories of work; proportions of tasks performed with health professionals and patients; proportions of tasks using specific information tools; rates of multitasking and interruptions.Results: The greatest proportions of doctors’ time were in professional communication (33%; 95% CI, 29%–38%); social activities, such as non-work communication and meal breaks (17%; 95% CI, 13%–21%), and indirect care, such as planning care (17%; 95% CI, 15%–19%). Multitasking involved 20% of time, and on average, doctors were interrupted every 21 minutes. Most tasks were completed with another doctor (56%; 95% CI, 55%–57%), while 24% (95% CI, 23%–25%) were undertaken alone and 15% (95% CI, 15%–16%) with a patient. Interns spent more time completing documentation and administrative tasks, and less time in direct care than residents and registrars. The time interns spent documenting (22%) was almost double the time they were engaged in direct patient care.Conclusions: Two-thirds of doctors’ time was consumed by three work categories: professional communication, social activities and indirect care. Doctors on wards are interrupted at considerably lower rates than those in emergency and intensive care units. The results confirm interns’ previously reported dissatisfaction with their level of administrative work and documentation.

Johanna I Westbrook BAppSc, MHA, PhD · Amanda Ampt RN, MHIM · Leanne Kearney RN · Marilyn I Rob MA, CStat, PhD

Objective: To describe the influenza-related morbidity and mortality in healthy children aged under 5 years in South Australia, in order to further understand the potential role of influenza vaccination.Design and setting: We undertook a descriptive analysis of SA hospital separations data and Australian Bureau of Statistics death data for children aged under 5 years admitted to hospital for influenza. All diagnoses related to an influenza admission were examined to determine whether children were at risk of complications from influenza, according to the criteria of the National Health and Medical Research Council.Main outcome measures: Mean influenza admission rates per 100 000 population per year in children aged under 5 years between 1996 and 2006, and the proportion of children admitted to hospital who did not have a secondary diagnosis putting them at higher risk of influenza-related complications.Results: From 1996 to 2006, 649 children aged under 5 years were admitted to hospital for influenza. Mean annual admission rates per 100 000 were highest in children aged under 1 year (151.0), and decreased with age. Aboriginal and Torres Strait Islander children aged under 5 years had a mean admission rate of 161.8 per 100 000. Most children under 5 years (81%) admitted to hospital did not have an underlying illness that would put them at risk of influenza-related morbidity.Conclusion: Healthy children aged under 2 years and Aboriginal and Torres Strait Islander children under 5 years old have high rates of hospital admission, which may have implications for the target group recommendations for influenza immunisation. Currently, vaccination is recommended only for children with specified chronic diseases.

Katina D’Onise MPHTM, FRACGP · Jane C A Raupach MPH, FAFPHM, FRACGP

Objectives: To describe how intern time is spent, and the frequency of activities performed by interns during emergency department (ED) rotations.Design and setting: Prospective observational study of 42 ED interns from three Melbourne city teaching hospitals during 5 months in 2006. Direct observations were made by a single researcher for 390.8 hours, sampling all days of the week and all hours of the day.Main outcome measures: Proportion of time spent on tasks and number of procedures performed or observed by interns.Results: Direct patient-related tasks accounted for 86.6% of total intern time, including 43.9% spent on liaising and documentation, 17.5% obtaining patient histories, 9.3% on physical examinations, 5.6% on procedures, 4.8% ordering or interpreting investigations, 3.0% on handover and 4.9% on other clinical activities. Intern time spent on non-clinical activities included 4.2% on breaks, 3.7% on downtime, 1.7% on education, and 1.3% on teaching others. Adjusted for an 8-week term, the ED intern would take 253 patient histories, consult more senior ED staff on 683 occasions, perform 237 intravenous cannulations/phlebotomies, 39 arterial punctures, 12 wound repairs and apply 16 plasters. They would perform chest compressions under supervision on seven occasions, observe defibrillation twice and intubation once, but may not see a thoracostomy.Conclusions: The ED exposes interns to a broad range of activities. With the anticipated increase in intern numbers, dilution of the emergency medicine experience may occur, and requirements for supervision may increase. Substitution of ED rotations may deprive interns of a valuable learning experience.

Jia Ni Zhu · Tracey J Weiland BBSc(Hons), PhD · David M Taylor MD, MPH, FACEM · Andrew W Dent MPH, FRCS, FACEM

Objective: To report on the sentiments of the Australian health and medical research (HMR) workforce on issues related to employment and funding opportunities.Design, setting and participants: In August 2006, the Australian Society for Medical Research (ASMR) invited all of its members to participate in an online survey. The survey took the form of a structured questionnaire that focused on career aspirations, career development and training opportunities, attitudes toward moving overseas to work, and employment conditions for medical researchers.Main outcome measures: Researchers’ views on career opportunities, funding opportunities, salary and quality of the working environment; impact of these views on retaining a skilled medical research workforce in Australia.Results: Of the 1258 ASMR members, 379 responded (30% response rate). Ninety-six per cent of respondents were currently based in Australia; 70% had a PhD or equivalent; and 58% were women. Most respondents worked at hospital research centres (37%), independent research institutes (28%) or university departments (24%). Sixty-nine per cent had funding from the National Health and Medical Research Council, with the remainder funded by other sources. Over the previous 5 years, 6% of respondents had left active research and 73% had considered leaving. Factors influencing decisions about whether to leave HMR included shortage of funding (91%), lack of career development opportunities (78%) and poor financial rewards (72%). Fifty-seven per cent of respondents were directly supported by grants or fellowships, with only 16% not reliant on grants for their continuing employment; 62% believed that funding had increased over the previous 5 years, yet only 30% perceived an increase in employment opportunities in HMR. Among the respondents, twice as many men as women held postgraduate qualifications and earned ≥ $100 000 a year.Conclusions: Employment insecurity and lack of funding are a cause of considerable anxiety among Australian health and medical researchers. This may have important implications for the recruitment and retention of researchers.

Maria Kavallaris PhD · Sarah J Meachem PhD · Mark D Hulett PhD · Catherine M West · Rachael E Pitt BA(Hons), DEdPsych · Jennifer J Chesters BSocSc(Hons) · Warren S Laffan BAppSc, QPMR · Paul R Boreham BEcon(Hons), PhD · Levon M Khachigian BSc(Hons), PhD

What impact has the NHMRC Road Map had on Aboriginal and Torres Strait Islander health? A review process now underway aims to find out There are significant disparities in health status between Aboriginal and Torres Strait Islander peoples and other Australians across the life cycle, including lower birthweight, higher death rates, lower life expectancy, and a much higher incidence of a range of illnesses that affect social and emotional wellbeing.1 * The Aboriginal and Torres Strait Islander Health and Research Advisory Committee members are: Professor Cindy Shannon (Chair), Professor Ian Anderson, Dr Ngiare Brown, Professor Yvonne Cadet-James, Associate Professor Terry Dunbar, Associate Professor Jacinta Elston, Associate Professor Lisa Jackson-Pulver, Mr Daniel McAullay, Dr Mark Wenitong and Dr Tim Williams. The National Health and Medical Research Council (NHMRC) is Australia’s peak body for supporting health and medical research. It is also responsible for developing health advice for the Australian community, health professionals and government, and advising on ethical behaviour both in health care and in the conduct of health and medical research. The role of the NHMRC in the Australian Government’s strategic framework for improving the health status of Aboriginal and Torres Strait Islander peoples includes: developing culturally appropriate health advice and guidelines; funding research to improve the health and wellbeing of Aboriginal and Torres Strait Islander peoples; providing information on the ethical considerations that arise in research; supporting Aboriginal and Torres Strait Islander peoples in participating in research capacity building; and commissioning health and medical research in priority areas. The Road MapIn 2002, the NHMRC promoted the development of the Aboriginal and Torres Strait Islander Research Agenda Working Group “Road Map” — a strategic framework to identify agreed national research priorities in Aboriginal and Torres Strait Islander health. More than 250 people had direct input into the development of this framework through attendance at four workshops held in Perth, Darwin, Brisbane and Melbourne. Representatives were drawn from all states and territories and included a balance of Aboriginal and Torres Strait Islander and non-Indigenous participants. Additional input was received from 23 organisations through a written submission process. This process of open consultation and discussion highlighted a number of areas where priority research was urgently needed, to complement existing research-driven programs. The resulting Road Map outlines six research themes crucial to achieving substantial health gains for Aboriginal and Torres Strait Islander peoples (Box).2 The overall objective of the Road Map has been: to advise Aboriginal and Torres Strait Islander communities throughout Australia on the achievement and maintenance of the highest practicable standards of individual and public health, and to foster research in the interests of improving those standards.2 Underlying principles of the Road MapThe Road Map was implemented in 2002, advocating research and development underpinned by the following principles: Health is not just the physical wellbeing of the body but a whole-of-life and unending phenomenon; Community involvement is integral to the development, conduct and communication of research; Research must be conducted ethically3-5 and be of practical value to Aboriginal and Torres Strait Islander peoples and their service providers; Communication of research plans, progress and results is essential; It is important to support research, including enhancing the development of skills, knowledge and capacity in the Aboriginal and Torres Strait Islander research workforce; and It is important to identify “positive models” or examples of success. NHMRC-funded researchWithin the framework of the Road Map research themes, the NHMRC has initiated programs that aim to improve the health of Aboriginal or Torres Strait Islander people or build capacity in the Aboriginal and Torres Strait Islander health research sector. These programs currently include: the Indigenous Short-Term Exchange/Study Scheme; the International Collaborative Indigenous Health Research Partnership; Training Scholarships for Indigenous Health Research; and the Aboriginal and Torres Strait Islander Health Research Fellowship. Funding is also allocated to research on the health of Aboriginal or Torres Strait Islander people through project grants and in response to specific needs, including the Capacity Building Grants in Population Health Research initiative and the Healthy Start to Life for Aboriginal and Torres Strait Islander Communities initiative. Based on the research outcomes reported to date, the NHMRC has been able to develop some understanding of the Road Map’s impact by tracking the extent of employment of Aboriginal or Torres Strait Islander people on projects, the numbers and types of publications and presentations that have resulted from research, the effectiveness of research methodologies, and the level and context of researchers’ relationships with communities. Review of the Road MapThe Road Map continues to be part of a strategic research framework that commits the NHMRC to all research relevant to health — biomedical, clinical, public health and health services — and consultation with all levels of government, the health and medical research sector, and the community about priority research areas. During its development in 2002, it was anticipated that the Road Map would be reviewed in 2007. The review is being undertaken by the NHMRC in consultation with its key advisory committee on Indigenous health issues, the Aboriginal and Torres Strait Islander Health and Research Advisory Committee, chaired by Professor Cindy Shannon. Consultation workshops similar to those used to develop the Road Map will be held in Townsville, Sydney, Melbourne, Alice Springs and Perth during May 2008. Participants will be invited to provide information on their use of the Road Map and its perceived impact, and whether or not the research themes are still valid and important. The NHMRC welcomes the participation of individuals and organisations at these workshops and in a written submission process. Details of the workshops and the written submission process can be found at the NHMRC website (http://www.nhmrc.gov.au) or by contacting Cathy Mitchell, Director of Strategic Partnerships, on (02) 6217 9384 or cathy.mitchellATnhmrc.gov.au. The Road Map’s six research themes2 1. Descriptive research which outlines patterns of health risk, disease and death. This information should be used to inform the development of sound preventive, early diagnosis and treatment-based interventions which are likely to result in meaningful health gain for Aboriginal and Torres Strait Islander peoples. 2. A research focus on the factors and processes that promote resilience and wellbeing — in particular, but not exclusively, during the periods of pregnancy, infancy, childhood and adolescence — and form the basis of good health throughout the lifespan. 3. A focus on health services research which describes the optimum means of delivering preventive, diagnostic and treatment-based health services and interventions to Aboriginal and Torres Strait Islander peoples. 4. A focus on the association between health status and health gain and policy and programs that lie outside the direct influence of the health sector. 5. A focus on engaging with research and action in previously under-researched Aboriginal and Torres Strait Islander populations and communities. 6. Development of the nation’s Aboriginal and Torres Strait Islander health research capacity (including training Aboriginal and Torres Strait Islander researchers) and ethical health research practice in relation to Aboriginal and Torres Strait Islander communities.

for the Aboriginal and Torres Strait Islander Health and Research Advisory Committee*

Objective: To examine the risk of tuberculosis (TB) in migrants a decade after their arrival in Australia.Design, setting and patients: Retrospective review of laboratory-confirmed cases of TB in migrants diagnosed between 1990 and 2004 by the state TB reference laboratory in Victoria, analysed by a multivariate model comparing migrants diagnosed 10 or more years after arrival with those diagnosed within 10 years of arrival.Main outcome measures: Time to diagnosis; characteristics of migrants diagnosed with TB, including age, sex, region of birth, site of infection, and drug resistance.Results: A third of migrants (734/1924) were diagnosed with TB 10 or more years after arrival in Australia. This group was more likely to be European-born (adjusted odds ratio [AOR], 3.4; 95% CI, 2.4–5.0) and older than 34 years (35–49 years: AOR, 3.8; 95% CI, 2.0–7.0), reflecting the longer time European migrants have been in Australia. There were two distinct European groups: European Union (EU)/Western and Central/Eastern. The Central/Eastern group were from countries with current high TB rates and, compared with the EU/Western group, were younger (mean age, 50 v 64 years) and more likely to be diagnosed within 10 years of arrival (47% v 14%; P < 0.001).Conclusion: European migrants were more likely to be diagnosed a decade or more after arrival in Australia. Once migrants from the currently high TB incidence areas of Asia and Africa have been in Australia for a similar period of time, their timing of diagnosis may resemble that for migrants from Europe. The current screening policy should be complemented with more sensitive techniques to detect latent TB.

Michelle E McPherson BSc/BA, MPH, MAppEpi · Heath Kelly MB BS, MPH, FAFPHM · Mahomed S Patel MB BCh, FRACP, FAFPHM · David Leslie MB BS, FRCPA

Haematopoietic stem cell transplantation (HSCT) is an accepted curative therapy for many malignant and non-malignant conditions affecting children and adults. Where possible, stem cells for HSCT are provided by human leukocyte antigen (HLA)-matched, related donors. Only 30% of patients have a suitable matched donor; for other patients, donors are sought from bone marrow registries or public umbilical cord blood (UCB) banks. While public UCB banks have been established to support transplant programs in Australia and internationally, parents also have the option of storing their child’s UCB in a private commercial UCB bank for personal or family use. In contrast with public UCB banks, there is little social or medical justification for private UCB banking, as it provides no benefit to the community and little benefit to parents (other than reassurance and amelioration of regret), due to the very low likelihood of requiring autologous UCB later in life. Should UCB prove to be beneficial for tissue repair or replacement in the management of degenerative disorders, such as diabetes and Parkinson’s disease, then a stronger case may be made in support of commercial banking of UCB for personal use. This may have a major impact on public UCB programs.

Gabrielle N Samuel PhD · Ian H Kerridge MPhil, FRACP, FRCPA · Tracey A O’Brien FRACP, BMed, MHL

Streptococcus suis is known to cause sporadic infections in people who have occupational exposure to pigs and pig meat. A large outbreak occurred in China in 2005, where there was 62% mortality among those who developed toxic shock syndrome. Despite S. suis being common in pigs, this is the first published report of a human case of S. suis toxic shock syndrome in Australia. Clinical recordIn April 2007, a 41-year-old man developed sudden-onset lower abdominal pain and rigors. Fevers, headache, diarrhoea, vomiting and dizziness developed and continued throughout the day. In the evening, he presented to the emergency department of a suburban non-teaching hospital in Melbourne. He had no pre-existing illness and had worked for 5 months as a pet-food processor, handling carcasses of sheep, cattle and pigs. He had a temperature of 38.8°C and his blood pressure was 84/40 mmHg. Investigations revealed acute renal failure and slightly raised serum bilirubin levels (Box). He was presumed to have infective gastroenteritis and was given intravenous fluid replacement. Septic shock was suspected when the patient’s blood pressure failed to normalise after intravenous administration of 6 L physiological saline over 12 hours and he developed neutrophilia and disseminated intravascular coagulation (Box). The presence of multiple cuts on his hands and severe tooth decay led to suspicion of staphylococcal or streptococcal sepsis. He was given vancomycin and flucloxacillin and was transferred to the intensive care unit of a teaching hospital for inotropic support. Subsequently, culture of seven of eight blood samples taken in the first 36 hours grew α-haemolytic streptococci (on horse-blood agar). Given the patient’s poor dentition, the antibiotic therapy was changed to high-dose benzylpenicillin with gentamicin to treat possible endocarditis. API 20 Strep identification system (bioMérieux, Lyon, France) gave the profile 4641473, corresponding to Streptococcus suis II (99.9%; bioscore, 0.99). Phenotypically, the isolate was very similar to Streptococcus parasanguinis, a human viridans streptococcus that is not in the API 20 Strep database. Our isolate was confirmed as S. suis by 16S rRNA (ribosomal RNA) sequencing. A 519-base-pair fragment of the 16S rRNA gene was amplified using universal primers (unpublished sequences). The primer-binding positions corresponded to positions 21–42 and 565–583 of the Escherichia coli numbering system.1 A BLAST search on the GenBank database matched several S. suis sequences exactly (519/519 bases; 100%) and partially matched many other S. suis sequences, including type strains. The next closest match was Streptococcus bovis (≤ 94% sequence homology). On Day 7, liver function tests gave abnormal results (Box). Results of a liver ultrasound examination and a transoesophageal echocardiogram were normal. The patient received intravenous benzylpenicillin and gentamicin for 2 weeks, followed by oral amoxycillin for 1 week. The patient made a full recovery, with liver function returning to normal; he subsequently changed employment. Public health responseWe notified the Victorian Government Department of Human Services, which planned to respond if additional cases of S. suis toxic shock syndrome occurred. We also referred the case to workplace occupational health and safety investigators because of a concern that an inadequate supply of gloves and other personal protective equipment had limited their use in the workplace. A worksite visit found no evidence to substantiate these concerns. Further, there were no concerns about plant and personal hygiene, washing facilities and staff training in the most recent quarterly audit report. We are not aware of any increase in S. suis disease in the Australian pig industry around the time our patient presented. In Victoria between 2002 and 2006, most streptococcal isolates submitted to the three main veterinary laboratories were not identified to species level. Therefore, although there were at least 33 confirmed S. suis isolates from pig specimens in Victoria during this period, the true burden is unknown (Brenda McCormack, Diagnostic Laboratory Manager, Pig Health Research Unit, Victorian Government Department of Primary Industries; Mary Dep, Scientist, Atwood Veterinary Diagnostic Services; and Dr Mark Williamson, Veterinary Pathologist, Gribbles Pathology, personal communications). Around the time our patient presented, Australia’s National Animal Health Information System recorded only four cases of S. suis, in piglets in Queensland.2 DiscussionS. suis is a common pathogen in pigs, and in the developed world has been recognised as a cause of sporadic disease in humans who have occupational exposure to pigs and pig meat products.3 S. suis infection in humans recently received considerable attention following a large outbreak in China in 2005, where there were 215 cases, with 62% mortality among those who developed toxic shock syndrome.4 Sepsis originating from the skin is common in meat workers due to the frequent skin lacerations they sustain, with Streptococcus pyogenes and Staphylococcus aureus often isolated.5 Other causes of sepsis in those working with pig meat products include salmonella, campylobacter, yersinia, leptospira and brucella.6 In humans, S. suis may cause toxic shock syndrome, meningitis, arthritis, endocarditis and pneumonia.3,7 Toxic shock syndrome has a distinct presentation, as seen in our patient. The predominant features are fevers, hypotension, disseminated intravascular coagulation (often with subcutaneous haemorrhage), diarrhoea, vomiting, acute renal failure, abdominal pain and liver dysfunction.3 S. suis infection occurs after contact with infected pigs or pork via wounds or inhalation.3,7 However, symptomatic or severe infection after exposure appears to be uncommon. In Australia and other high-income countries, pigs are frequently colonised with S. suis, and the seroprevalence in pig farmers and meat workers may be as high as 21%.7,8 Measures to prevent S. suis infection in meat workers include covering skin lesions; wearing gloves; avoiding eating, drinking and smoking in work areas; and frequent hand washing.6 Measures are often less stringent in domestic slaughter of pigs, which facilitated the 2005 Chinese outbreak.4 Prohibiting domestic slaughter of pigs and assisting farmers with hygienic handling of dead or sick pigs were the major interventions used to control the Chinese outbreak.4 To our knowledge, our patient is the first human case of S. suis toxic shock syndrome in Australia. Since submission of this manuscript there have been at least three unpublished recent human cases of S. suis infection in other parts of Australia, reported in February 2008 via Ozbug, an email discussion group of the Australasian Society for Infectious Diseases. Phenotypically, S. suis resembles the viridans streptococcal species Streptococcus sanguinis, S. parasanguinis and Streptococcus gordonii, and therefore may be misidentified.9 This case demonstrates the importance of correct identification to species level, which established the occupational source of infection and prevented it being attributed to poor dental hygiene. This has implications for compensation, occupational health and safety, and public health. In conclusion, it is important to consider S. suis infection in individuals with occupational exposure to pigs, as mortality may be high without timely treatment. It is also important to inform the microbiology laboratory of exposure to pigs in cases of streptococcal sepsis and meningitis to avoid misidentification. Haematological and biochemical features of a patient with Streptococcus suis toxic shock syndrome Day after onset Reference range 0 1 7 33 Haematological analysis Haemoglobin (g/L) 124 113 115 142 130–170 White cell count (× 109/L) 4.4 24.6 21.1 10.4 4.0–11.0 Neutrophil count (× 109/L) 4.2 22.7* 13.5 5.5 2.0–8.0 Platelet count (× 109/L) 182 103 259 238 140–400 INR — 2.0 1.0 0.8–1.3 APTT (s) — 37 22 24–35 Fibrinogen (g/L) — 2.8 2.8 2.0–5.0 Biochemical analysis Sodium (mmol/L) 140 141 138 135 – 145 Potassium (mmol/L) 3.2 3.6 4.8 3.5 – 5.5 Creatinine (μmol/L) 120 120 90 50 – 110 Urea (mmol/L) 7.9 6.9 4.7 2.5 – 8.3 Albumin (g/L) 42 28 34 41 35 – 50 Alkaline phosphatase (U/L) 90 72 157 98 < 120 γ-Glutamyltransferase (U/L) — 37 113 58 < 50 Alanine aminotransferase (U/L) 17 29 86 21 < 55 Aspartate aminotransferase (U/L) — 38 59 17 < 50 Bilirubin (μmol/L) 46 38 16 15 < 19 Total protein (g/L) 63 49 65 75 60 – 82 C-reactive protein (mg/L) — 173 13 < 2 < 8 INR = international normalised ratio. APTT = activated partial thromboplastin time. * Included band forms 18.0 × 109/L. Bold indicates abnormal results.

Adrian R Tramontana MB BS · Maryza Graham MB BS · Vincent Sinickas PhD, FRACP, FRCPA · Narin Bak MPH, FRACP

To the Editor: In his article “Teaching Tamil Tigers”,1 Whitehall gives the grossly false impression that the Sinhalese majority and Tamil minority are fighting with each other in Sri Lanka. It is not a conflict between Tamil and Sinhalese communities, but a terrorist issue. The terrorist organisation that calls itself the Liberation Tigers of Tamil Eelam (LTTE) is fighting the elected government of Sri Lanka in an attempt to carve out a separate monoethnic state in areas in the north and east of Sri Lanka. The LTTE’s terrorist approach is denounced by most of the democracies of the world. The LTTE claim that the Tamils in Sri Lanka are discriminated against by the majority Sinhalese. This claim is contradicted by the fact that the 54% of Tamils who live in the southern part of Sri Lanka live in harmony with the Sinhala and Muslim communities. In the south, Tamil businessmen perform better than their Sinhala counterparts in Colombo; Tamil students continue their university studies undisturbed; and the Tamil language is treated as one of the official languages, on a par with the Sinhalese language. These are facts publicly available for all. Whitehall claimed that “the conduct and cost of the conflict is obscured by suppression of the press on the government side and lack of access of the press to the other” — an unfounded statement that is deliberately crafted to tarnish the image of the Sri Lankan Government. Perhaps Whitehall is unaware of the numerous newspapers and other publications available in Sri Lanka that openly criticise the government and its conduct, and of the many international journalists and press organisations that report on the current situation in Sri Lanka on a daily basis to the rest of the world without any hindrance. Whitehall referred to Kilinochchi as the administrative centre of the “Tamil” land. He appears ignorant of the fact that there are no separate lands for Sinhalese, Tamil and Muslim communities on the island. There is only one territory in Sri Lanka, and that territory belongs to all its people. Whitehall describes the poor conditions at Kilinochchi Hospital. Kilinochchi was predominantly controlled by the LTTE terrorists, against whom the government forces are fighting to liberate the civilians. The LTTE requisitions whatever provisions are sent to the region by the government and utilises them for their cadres. Unfortunately, the outside world seems unaware of this situation. Perhaps Whitehall’s opinion would be different if he was aware that the LTTE has been proscribed in the United States, the United Kingdom, Canada, the European Union and India because of its atrocities against innocent civilians, politicians and moderate Tamils who disagree with the LTTE philosophy, and because of the assassinations of the former Indian Prime Minister Rajiv Gandhi and the former Sri Lankan President Ranasinghe Premadasa. The former Foreign Minister of Sri Lanka, Lakshman Kadirgamar, an ethnic Tamil, was also assassinated by the LTTE. Terrorism should be condemned wherever and whenever it manifests. The Sri Lankan Government is democratically elected and reserves the right to protect its citizens and the sovereignty and integrity of the state against a terrorist organisation. While using military forces to eliminate terrorism on its soil, the government of Sri Lanka is continuing its efforts to find a lasting solution to the conflict.

Asoka Girihagama

To the Editor: The Sri Lanka College of Paediatricians views with great concern the publication of Whitehall’s article “Teaching Tamil Tigers”1 in the Journal. Whitehall’s article ignores the ground situation and the actual realities in the Northern Province of Sri Lanka. Furthermore, it represents a biased and misleading point of view. It focuses on creating sympathy for the Liberation Tigers of Tamil Eelam (LTTE), without giving any credit whatsoever to the good work done by the Sri Lankan Government in protecting civilians, preserving democracy and maintaining health services and civil administration in the north in the face of enormous obstacles placed by the LTTE, a terrorist organisation. Whitehall was not registered with the Sri Lanka Medical Council during his stay in the country, and thus the alleged “services” he claims to have provided constitute an illegal act under the laws of the Democratic Socialist Republic of Sri Lanka. In view of this, his purported honest and sincere intention of being of service as a doctor in the Northern Province is of dubious value. Another cause for concern is the fact that Whitehall provided training to members of the medical wing of the LTTE. The government provides training to medical students at the University of Jaffna in the Northern Province according to the established norms and procedures for undergraduate medical education, as stipulated by the University Grants Commission and Sri Lanka’s Postgraduate Institute of Medicine. Thus, there was no necessity for Whitehall to teach medicine to LTTE cadres, who would, in any case, be inadequately educated and patently incompetent at performing responsible medical duties. There are fully trained doctors currently serving in the Northern Province, including those from the Sinhalese and Muslim ethnic groups. The Sri Lankan Government provides free medical services (including all infrastructure facilities, personnel, drugs and vaccines) to all citizens of Sri Lanka, including those in the Northern Province, irrespective of race, caste or religion. Thus, there is no truth in Whitehall’s claim that the government does nothing for the Northern Province. In spite of severe problems, mainly caused by the LTTE, it makes every effort to ensure that essential medical supplies reach the LTTE-controlled northern part of Sri Lanka, which includes the hospitals at Kilinochchi and Mullaitivu. The costs of medicines, consumables, meals, capital expenditure, maintenance, and salaries of all hospital staff are borne by the government of Sri Lanka. Free immunisation programs are also provided by the government. All these facts show that the government is genuinely concerned about people in the Northern Province and does its utmost to help them. It is pertinent to ask whether any country in the enlightened world, including Australia, would allow a foreigner who blatantly abuses the laws of the country to work and teach in that country. Would any civilised country allow people who are not properly registered with the relevant medical council to practise and to teach paediatrics to terrorists in that country? It is also disappointing that a medical journal of a country committed to eradicating terrorism from the world has deemed it fit to publish an article of this nature. Whitehall admits that he has written the said piece at the behest of the LTTE. This is obviously another publicity stunt by the LTTE to try to rebuild their deteriorating image internationally. In our opinion, by associating with a terrorist organisation that has been banned in many areas of the globe, Whitehall has blatantly violated the hallowed fundamentals of the Hippocratic Oath.

Sri Lanka College of Paediatricians

In reply: I assure the Deputy High Commissioner of Sri Lanka and the Sri Lanka College of Paediatricians that I did look at “the actual realities” during 6 months of visiting hospitals and participating in tsunami relief in the south of Sri Lanka and teaching paediatrics in the Tamil north. I did see another side of the story that I felt needed telling, though not “at the behest of the LTTE [Liberation Tigers of Tamil Eelam]”. I observed a great disparity between the health facilities in the north and south of the country, and witnessed the stunting and wasting of Tamil women and children. I did go through a government-approved channel, using lawful means. I was employed by an international organisation that handled my visit and redirected me, after arrival, to teach in the north. Before that, I had never knowingly met a Tamil Tiger. If my organisation did not register me with the Medical Council, it would not have been unusual in that post-tsunami period, when many organisations brought doctors from a range of countries into Sri Lanka. I do not wish to name my organisation for fear of endangering its workers. Seventeen members of the French-based organisation Action Against Hunger have been murdered and, according to the Sri Lanka Monitoring Mission, “the Security Forces of Sri Lanka are widely and consistently deemed to be responsible”.1 I abhor terrorism as much as most, but the question for Sri Lanka is: “Who is terrorising whom?” The use of terrorism by the LTTE is well publicised. Its use by the state is not, yet its aerial bombing has killed civilians, destroyed facilities and emptied villages, according to church sources.2 Over 250 000 people have been displaced, and “a deliberate policy of extrajudicial killings and abductions of Tamils” has resulted in hundreds of deaths and the disappearance of over 1000 people since early 2006.3 The dead include 23 aid or church workers and 68 children.4 Tamils fear that the underlying intention is genocide. It is hard for me to believe that the government is “protecting [Tamil] civilians” and doing its “utmost to help them”. Has the Sri Lanka College of Paediatricians protested the suffering of Tamil children? Contrary to the Deputy High Commissioner’s assurances of freedom of the press in Sri Lanka, seven media workers have recently been killed,5 and in 2007 the country earned 156th place in a Worldwide Press Freedom Index, just above Somalia.6 The statement of the College of Paediatricians that there was “no necessity . . . to teach medicine to LTTE cadres, who would, in any case, be inadequately educated and patently incompetent at performing responsible medical duties” is ignorant of “the actual realities”. These practitioners began medical studies in 1992 based on the curriculum of the University of Jaffna. Since then, theory has been complemented with long periods of clinical responsibilities — from staffing field and civilian hospitals during warfare and peacetime to dealing with cholera and malaria outbreaks, the chronic problem of tuberculosis, the acute needs of tsunami victims and the constant needs of sick children. They function as medical officers of the Department of Health of the de-facto government of the vast north-east region, historically inhabited by the Tamil race, whose needs exceed the capacity of the relatively few government doctors who, I acknowledge, do a great job with limited resources. They wanted to learn more paediatrics. Should they have been left “inadequately educated”? For me, that would have constituted medical malpractice. Regarding the Hippocratic Oath, I assure the College of Paediatricians that I stayed in Kilinochchi “for the benefit of the sick, remaining free of all intentional injustice”, but I must confess that things I saw and heard in the course of the treatment I have not kept to myself, believing silence to be more “shameful”.

John S Whitehall

Comment: The article by Whitehall1 provoked a barrage of 15 emails to the Medical Journal of Australia that either criticised the Journal for publishing such an article or questioned Whitehall’s agenda and some details of the article. In short, it was suggested that the article was nothing but a propaganda tool for Tamil terrorists or a blatant attempt to romanticise “the terrorists”. Others were perturbed that the MJA saw fit to publish such a confronting article. However, these criticisms were balanced by another 40 emails congratulating the Journal for having the courage to expose what is occurring in Sri Lanka. The Journal strongly stands by its decision to publish Whitehall’s article, as it gives an Australian insight into the turmoil and suffering affecting people caught up in an internal conflict that is foreign to our stable and largely harmonious society.

Martin B Van Der Weyden

To the Editor: Calcium and vitamin D play a central role in preventing osteoporosis and fractures,1 so a recent study published in the BMJ claiming that calcium supplements increased the risk of heart attacks and strokes in postmenopausal women2 naturally received widespread media attention — so much so that many patients are already stopping calcium treatment. The study, based on a previously published randomised controlled trial of calcium supplementation in 1471 healthy women,3 showed that self- or family-reported heart attack, stroke or sudden death was significantly more common in those taking calcium than in the placebo group (P = 0.008). This conflicted with the findings of a much larger study.4 Further, the difference became non-significant when the analysis was corrected for covariables (P = 0.08), or when the analysis was repeated using data on cardiovascular events obtained from medical records (P = 0.08). Yet, it still gained a place in a leading medical journal. The small excess of cardiovascular events in the women taking calcium could be due to chance and needs to be tested further; one way of doing this is to examine available data for evidence of mortality in patients taking calcium. We have done this. In the 29 randomised trials in a recent meta-analysis of the effect of calcium and vitamin D in fracture risk,1 five trials comprising 12 609 subjects provided crude mortality data.5-9 When these mortality data were pooled using a random effects model, there was no evidence that calcium supplementation increased mortality (Box). We find it hard to believe that calcium can have a significant adverse effect on cardiovascular disease without increasing mortality. Our reservations about this study are further strengthened by the weak theoretical basis of the case against calcium. Metastatic calcification in renal failure, which the authors quote as an analogy,2 is due to the high serum calcium–phosphorus (CaxP) product levels caused by hyperphosphataemia, which may be aggravated by calcium supplementation. In women without this condition, this degree of oversaturation cannot be reached by the 5% rise in plasma calcium10 resulting from the recommended dose of calcium citrate used for supplementation. Moreover, coronary blockage is not due to calcification of atheromatous vessels, which is a dystrophic calcification secondary to tissue damage, but rather to ruptured atheromatous plaques and the thrombi which form upon them. Thus, it is premature to conclude that calcium supplementation should not be given to older women. Effect of calcium supplementation on mortality, data pooled by a random effects model

Benjamin M P Tang · Christopher Nordin

To the Editor: Primary cerebral vasculitis (PCV) is a potentially fatal disease. Early diagnosis and therapy are vital. We describe a case where confounding factors delayed diagnosis. A 42-year-old woman presented with headache, nausea, vomiting, malaise and binocular blindness for 3 days. Two weeks previously, she had presented to the emergency department with headache and vomiting, but investigations, including computed tomography (CT) of the brain and lumbar puncture, gave normal results. She had a history of depression, was a smoker (20 pack-year history), and used cannabis regularly and alcohol occasionally, but denied other recreational drug use. Her mood appeared depressed. Vital signs and findings from a general examination were normal. Eye movements were full, direct and indirect pupillary reflexes were intact, and optic fundi were normal. Results of a CT angiogram were reported as normal by a consultant radiologist. Results of blood tests, including inflammatory markers, and a repeat lumbar puncture, were unremarkable. A toxicology screen was not performed. Depression with conversion disorder was diagnosed, and admission with analgesia was advised. A neurologist’s review on Day 2 did not detect organic disease. The mental health team diagnosed severe depression and prescribed antidepressants. On Day 4, the patient’s condition deteriorated and she become non-communicative with signs of right hemiplegia. An electroencephalogram showed polyrhythmic generalised slow waves consistent with encephalopathy. She was transferred to a tertiary centre where magnetic resonance imaging (MRI) and CT angiography of the brain showed multiple bilateral infarcts (Figure, A) with beaded arteries, the classic appearance of vasculitis. She was given high-dose prednisolone and cyclophosphamide. Investigations were negative for causes of secondary vasculitis. Her condition continued to deteriorate and she died 8 days after admission. Autopsy was refused. Subsequent review of the second CT scan detected irregular cerebral vessels (Figure, B). PCV is an uncommon disorder of the central nervous system, with unknown aetiology and no specific characteristic features, affecting small cerebral arteries but not extracranial vessels. Symptoms and signs vary but include headache, encephalopathy, seizures, personality change, weakness, and altered level of consciousness, as well as superimposed focal cranial neuropathy or hemiplegia. Recognition is difficult, but differentiation from reversible cerebral vasoconstriction syndrome is important.1,2 Brain biopsy is seen as the “gold standard” for diagnosing PCV. CT angiography may show diffuse or localised changes, with vessel beading, aneurysms, and luminal narrowing. MRI may show areas of white and grey matter infarction, or haemorrhage. MRI is more sensitive than CT, but less sensitive than CT angiography. Up to 100% of biopsy-positive cases appear abnormal on MRI. Suspected cases require careful clinical appraisal and either CT angiography or MRI, probably followed by an image-guided brain biopsy.3 Initial reported cases of PCV had a poor prognosis; most patients died within a few weeks.2 Immunosuppressive therapy with glucocorticoids and cyclophosphamide (as used in secondary severe vasculitis) may be beneficial, although there are no clinical trials.4 A future therapeutic alternative may be infliximab, which has been used successfully for one patient with cerebral vasculitis secondary to Behçet’s disease who had known elevated levels of tumour necrosis factor α.5 Despite increasing awareness and advances in angiography, PCV remains an uncommon diagnostic and therapeutic problem which should be considered in cases of severe, non-febrile neurological illness with stroke-like features. A: Magnetic resonance image showing multiple bilateral infarcts. B: Computed tomography angiogram showing irregular cerebral vessels (“beading”, arrows).

Sanjaya S Herath · Dayna B Law · Peter J O Stride · Vernon J Heazlewood · Luke S Gaffney

To the Editor: We report the case of a 71-year-old woman who presented with a 3-week history of lethargy, subacute confusion and drowsiness. She was known to have a seizure disorder for which she had been taking lamotrigine 100 mg and sodium valproate 500 mg twice a day for 2 years. On examination, the woman was disoriented with regard to person and time, and had constructional apraxia and asterixis. The rest of the physical examination was unremarkable. A full blood count, electrolyte levels, coagulation parameters, arterial blood gas measurements and hepatitis serology were normal. Tests for immunological markers of autoimmune liver disease were negative. Liver function tests showed longstanding raised levels of alkaline phosphatase (158 U/L [reference range (RR), 30–110 U/L]) and γ-glutamyl transferase (434 U/L [RR, < 40 U/L]). Serum drug levels were sodium valproate 51.0 mg/L (therapeutic range, 50–100 mg/L) and lamotrigine 9.5 mg/L (therapeutic range, 3–14 mg/L). The venous blood ammonia level was 109 μmol/L (RR, < 50 μmol/L). A liver ultrasound scan was normal. Computed tomography of the brain showed microvascular changes and an old cortical infarct. An electroencephalogram (EEG) showed diffuse slowing, with a predominance of rhythmical theta activity and some delta activity, suggestive of encephalopathy. As hyperammonaemic encephalopathy secondary to sodium valproate therapy (VHE) was considered a possible diagnosis, sodium valproate treatment was discontinued. The patient’s confusion resolved completely and the asterixis disappeared within a week. At the same time, her blood ammonia level fell to 19 μmol/L and her EEG normalised. Eight months after discontinuing sodium valproate treatment, the woman was still asymptomatic. A subsequent percutaneous liver biopsy, to investigate her persistently abnormal liver function, showed features consistent with primary biliary cirrhosis. Sodium valproate is used not only for management of epileptic disorders but also for migraine prophylaxis and treatment of several psychiatric conditions. Although a generally well tolerated drug, it has a few well known side effects, including hyperammonaemia and, rarely, VHE.1-3 The possible pathophysiology of VHE has been described elsewhere.2 Gerstner et al reported on a series of 19 patients with VHE between 1994 and 2003.4 Review of the literature suggests that VHE is under-recognised, leading to considerable delay in the diagnosis of this potentially reversible condition.3,5 In our patient, it is reasonable to presume that sodium valproate precipitated the encephalopathy on a background of evolving unrecognised liver disease. The marked improvement in her clinical manifestations after discontinuation of valproate further supports this presumption. We have drawn attention to this case to highlight that VHE should be considered in patients presenting with confusion. Prompt measurement of the ammonia level and cessation of valproate treatment should be considered if clinically appropriate. Patients with previously unrecognised liver disease may be at particular risk. Acknowledgement: We thank Professor Peter Roberts-Thomson, Director of the Department of Immunology at Flinders Medical Centre, for his expert opinion and advice.

H S Subhash · Robert J Heddle · David W Schultz · John Ring · Campbell H Thompson

To the Editor: The timely article by Healy and colleagues1 should provoke debate within the profession. The authors’ decision to not consider “the relative merits of national versus regional registration boards” should not stifle discussion in the Journal. In particular, Australian doctors and the public should be aware that the medical board system to which we are accustomed is not operational in most countries. In much of the English-speaking world, boards comprise mainly doctors and have considerable independence from government; medical boards in non-English-speaking countries are generally part of the health bureaucracy.2 The fundamental danger of having a Council of Australian Governments-inspired national registration “body” lies in the potential for a switch from the “English” system of self-regulation under common law to the “European” model of bureaucratic rule under administrative law. Public and professional suspicion of self-regulation lay behind the 1987 amendments to the Medical Practitioners Act 1938 (NSW), which removed the power of deregistration from the New South Wales Medical Board, handing it instead to the Medical Tribunal chaired by a District Court Judge. This move avoided both the “Scylla” of public distrust of the profession and the “Charybdis” of criticism, such as have afflicted the boards in Victoria and elsewhere, where boards retained that power. No less important problems with a national board lie in the assessment of local problems and surveillance of doctors whose registration is conditional. This is already difficult in the larger states, such as Queensland, NSW and Western Australia. The continued failure of the centralised Health Insurance Commission to prevent and prosecute the abuse of Medicare by doctors, despite repeated ineffectual changes to the legislation,3 does not encourage optimism that a national medical board could effectively manage impaired doctors or those performing below standard. Having served on Commonwealth working parties on both mutual recognition of medical qualifications and Medicare “overservicing” and “inappropriate practice”, I would opt for an independent, publicly accessible national database containing a “uniform set of items that are allowable under existing privacy legislation”.1 The elements of such a database are already operational in the safe hands of the Australian Medical Council (AMC). It should not be too difficult, and certainly less cumbersome, for state and territory governments and medical boards to agree on that uniform set, on the foundations already laid by the AMC, and to continue the AMC’s ownership of the database.

Peter C Arnold

In reply: Arnold makes some interesting points about the balance of state and professional involvement in medical registration arrangements. Wherever the balance is struck, politicians, bureaucrats and medical professionals all derive their power in some measure from the public whom they serve. Our point is that variations in registration information and public access to multiple registers make it difficult for members of the public to access and use the information, especially given the mobility of the medical workforce between jurisdictions. A public national medical register should be seen as a practical measure to improve public accountability, rather than as a battleground between the profession and the bureaucrats. We did not express a view in our article1 on how national access to medical registration details should be arranged. As Arnold suggests, the Australian Medical Council is one candidate for maintaining a national database. It is well placed to publicly call on the existing state medical registration boards to cooperate speedily to make national access a reality, pending the negotiations underway regarding a national medical board.

Judith M Healy · Paul Dugdale

To the Editor: With the World Health Organization’s annual World No Tobacco Day to be held on 31 May, it is timely to encourage all patients who smoke to reconsider their actions. During my registrar training in the 1970s, I developed a simple and effective method of helping smokers consider some consequences of their tobacco habit. I offer this in the hope that others may find it useful too, as a more meaningful exercise than the concept of “pack-years”.1-3 First, enquire when the patient began to smoke regularly. I call this the “tobacco-arche” (analogous to menarche and coitarche). Next, determine how many years the patient has smoked regularly, remembering to subtract any years he or she may have suspended the habit. Then, have the patient estimate overall daily usage, relying, if possible, on prompting from an accompanying person to determine a realistic rather than idealised figure. Finally, multiply the number of years by the daily usage and by the number of days in a year. A reasonable approximation is to multiply by 400 rather than the more cumbersome 365.25. For example: a 65-year-old person who has smoked 20 cigarettes per day since his or her mid teens (ie, for 50 years) yields 20 × 50 × 400 = 400 000 — approaching half a million cigarettes lifelong. In my three decades of experience as a general physician, I have noted that an accumulated intake of a quarter of a million cigarettes usually results in at least some cough, breathlessness and end-expiratory wheeze on forced expiration, and decreased exercise tolerance; half a million cigarettes generally causes chronic smoker’s bronchitis, with or without some degree of emphysema, and other harmful effects on the body; while three-quarters of a million cigarettes makes cancer a distinct possibility.4 A further inducement for patients to confront the effects of their harmful habit is to calculate the amount of their lifetime tobacco intake in terms of the dollar cost. In the case of cigarettes, 500 000 at 60 cents each yields the impressive figure of $300 000. This usually comes as a sobering revelation to the smoker and their “significant others”. The above method can thus contribute to the desirable effect of reducing or eliminating tobacco consumption, with flow-on benefits to patients’ health, finances, and personal and occupational relationships.

C Ross Philpot

To the Editor: In his article on medical specialist education and training in Australia, Phelan1 raises two major issues: financial and educational. On the financial front, Phelan asks about the advantages and disadvantages of the new funding model for specialist (pre-Fellowship) training. One of the advantages of the model is that it makes the funding process more explicit. We believe that all who benefit from this educational exercise — trainees, supervisors, private hospitals and society — should contribute financially in some way. On the educational front, Phelan is disappointed that we did not provide evidence that university education will enhance the educational experience of trainees. However, undertaking educational studies that meet the standards required of reductionist experiments has proven to be difficult, and we have to make do with a more ecological approach. We have no doubt that our Macquarie University scholars will derive lasting benefit from working in an environment in which learning is one of the primary goals of their existence, rather than an add-on, after-hours, activity. Learning arises not from watching, but from doing. Modern concepts of neurobiology and learning suggest that learning results in structural changes in the brain, and these will be enhanced for the learner by full participation in all processes of care. We shall ensure that learning is maximised by an appropriate balance between scholars’ clinical experience and the educational opportunities that their clinical experience will provide. The Canadian contracting model, which Phelan mentions, is not dissimilar to the arrangement that will flow from the Memorandum of Understanding between Macquarie University and the Royal Australasian College of Surgeons and the Neurosurgical Society of Australasia, in that College trainees will substitute experience at Macquarie University for time spent in public hospitals in the College’s Surgical Education and Training Program. In Australia, we do not share the Canadians’ advantage of having only two postgraduate colleges. Given the current fragmented state of postgraduate medical education in Australia, we believe that it is better to experiment with and to evaluate new models than slavishly to copy what appears to work in a different setting. One of the flavours of the decade is competition, and we believe that competing models should be set up and should be rigorously evaluated from both educational and financial viewpoints. If history shows that the Macquarie lighthouse has illuminated the way to improved health for the Australian people, we shall be well satisfied.

Rufus M Clarke · Michael K Morgan

To the Editor: I recently received written advice from the Australian Safety and Compensation Council (a division of the Department of Employment and Workplace Relations) that the records of the Australian Mesothelioma Surveillance Program (AMSP) have been lost. As some of your readers would be aware, the AMSP, which ran between 1980 and 1985, was one of the most comprehensive medical surveys of mesothelioma undertaken anywhere in the world.1 The records of the program contain full occupational and environmental histories of about 1000 mesothelioma cases reported in the early 1980s. The program has played a significant role in helping to understand the epidemiology of mesothelioma in Australia. The level of detail of data in the AMSP has not been repeated by the Australian Mesothelioma Register, which succeeded the AMSP in 1985. This less detailed reporting scheme is the current basis for mesothelioma reporting to cancer registries in the country. I am a geologist with an interest in medical geology currently studying to obtain a doctorate on naturally occurring asbestos and mesothelioma risk in Australia. I had hoped to use the detailed environmental and occupational data of the AMSP to help determine the possible influence of naturally occurring asbestos on mesothelioma in Australia, in particular in the eastern states and South Australia, but without the records this is no longer possible. Data from the Australian Mesothelioma Register are not sufficiently detailed for this purpose. My intention in writing this letter is not to embarrass staff from the Australian Safety and Compensation Council, who have done their best to find the records and have been supportive of the project, but to create awareness of the loss, in the hope that the publicity may jog someone’s memory and result in the records being located. The potential permanent loss of these records would be a great loss to mesothelioma research in Australia and raises questions about the federal government’s policies surrounding long-term storage and archiving of nationally significant scientific research datasets that may be of benefit to future researchers.

Marc Hendrickx

Comment: The Australian Mesothelioma Surveillance Program (AMSP) operated between 1980 and 1985 and was maintained by the Commonwealth School of Public Health and Tropical Medicine at the University of Sydney. These files were transferred to the National Occupational Health and Safety Commission (NOHSC) on its establishment in 1985. The NOHSC was relocated from Sydney to Canberra in 2001, and AMSP records went into storage at that time. In February 2005, the NOHSC was succeeded by the Australian Safety and Compensation Council. We attempted to locate the records over several months in 2007. This involved manually searching through all files and boxes held by our contracted storage company marked as relating to either the AMSP or the Australian Mesothelioma Register. In addition, we had a staff member of the storage facility manually search the warehouse for these records in case they were in unmarked boxes or filing cabinets. In November 2007, having been unable to locate the records, we informed Mr Hendrickx that we would be unable to assist him with access to the AMSP records for his doctoral studies. It is certainly not our policy to discard records such as these and we were disappointed when they could not be easily located. We regret the potential loss of these important records to the research community and are still attempting to locate them.

Julie Hill

The medical community lost one of its most passionate, innovative and hardworking members with the recent death of Ralph Reader. He changed the way Australians thought about cardiovascular disease, raising awareness of risk factors and promoting policies to counter the disease. He also championed cardiovascular research, being one of the key drivers of National Health and Medical Research Council (NHMRC) policies and decisions during the 1960s and 1970s. Ralph was born in Brisbane in 1918, but grew up in Sydney, where he attended Fort Street Boys’ High School and the University of Sydney. After graduating in medicine in 1940, he became a Resident Medical Officer at Royal Prince Alfred Hospital (RPAH) before joining the navy and serving as a surgeon until the end of World War II. In 1941, he married Hazel Scanlon, to whom he remained married until her death in 1994. After the War, Ralph conducted research into renal disease at the University of Sydney. In 1948, the grant of a Nuffield Medical Fellowship took him to Oxford, UK, where he completed a PhD. On his return to Australia, he set up a private practice, worked as an Honorary Medical Officer at RPAH and lectured at the University of Sydney. His research led to kidney transplants at RPAH, where he established the first nephrology unit. In 1961, Ralph was appointed inaugural Medical Director of the National Heart Foundation (NHF), and was its Director and Chief Executive until 1980. It was during this period that he played a key role in the establishment of the triple-0 emergency telephone line. Over two decades, Ralph became the face of the NHF, devoting his time and energy to public education and professional practice, as well as developing the Foundation’s research program. He was also very active in the NHMRC. Between 1966 and 1975, he was a member of several of its committees and subcommittees, including the Medical Research Advisory Committee, the Standing Postgraduate Scholarship Committee and the Medical Statistics (Standing) Committee. In 1968, Ralph was the first to report a plateau then a fall in the number of deaths related to heart attacks, heart failure and stroke. Australia was the first country to reverse the upward trend. (At its peak, cardiovascular disease was the cause of two in three Australian deaths.) He also helped to develop policies for reducing cholesterol levels and oversaw the establishment of coronary care units in hospitals across Australia. He discovered the effectiveness of prescribing antihypertensive drugs for patients with mild hypertension and conducted the groundbreaking Australian National Blood Pressure Study. Ralph was made a Companion of the Order of St Michael and St George in 1976 and was awarded an honorary doctorate by the University of Sydney in 2006. Ralph died in Canberra on 13 January 2008. He is survived by his children Brian, Carolyn and Jeremy.

Warwick P Anderson · John S Horvath · Phil Mayne

Social marketing. Why should the devil have all the best tunes? Gerard Hastings. Oxford: Butterworth-Heinemann, 2007 (xvii + 367 pp). ISBN 978 0 7506 83500. Not so long ago, it seemed businesses couldn’t swap their products for our money fast enough before disappearing. Now we can’t even have a haircut without surrendering our name, address, phone number and date of birth. Welcome to relationship marketing. Today’s companies really do care about our satisfaction because customer satisfaction underpins repeat business, explains Gerard Hastings in Social marketing. Why should the devil have all the best tunes? Hastings, the United Kingdom’s first professor of social marketing, argues that public health needs to expand the use of these successful marketing strategies to make health promotion more powerful. By examining commercial practices and dissecting case studies of public health interventions, he demonstrates how health promotion is moving beyond fear campaigns and short-term interventions to building relationships with people and providing practical, ongoing assistance to encourage risk reduction and healthier living. Hastings clearly and succinctly explains the theories underlying social marketing: stages of change, social cognitive theory and exchange theory. He argues that social marketing requires strategic analysis of the problem, of the competing forces and of the target population to underpin solutions that work. Hastings and his colleagues at the University of Stirling, Scotland, recently demonstrated the power of analysing a problem by systematically reviewing the impact of junk food advertising and finding there are adverse effects on children’s food preferences, purchases and consumption. Understanding competing forces is crucial, he argues, because one of the reasons we have binge-drinkers, smokers and people who eat and drink unhealthily is that companies have been better at marketing than have health professionals. Hastings’ well structured and clearly written book equips readers with a valuable tool of public health that can be used to counteract the “hazard merchants”, who market death and disease through products (such as tobacco), and to promote healthier living.

Catriona M F Bonfiglioli

A 25-year-old woman presented with progressively worsening shortness of breath, which was attributed to cardiac tamponade caused by pericardial effusion. Urgent pericardiocentesis revealed haemorrhagic fluid, which continued to accumulate after the procedure. A repeat echocardiogram after pericardiocentesis showed dilatation of the right ventricle and severe pulmonary hypertension. Subsequent computed tomography revealed a massive pulmonary embolism in the right lung (Figure) and multiple small emboli in the left lung, while cytological examination of pericardial and pleural fluid showed adenocarcinomatous cells from a primary lung cancer. Pericardial effusion and pulmonary embolism usually present in isolation. Their coexistence in this patient — presumably related to the underlying neoplasm — may paradoxically have saved her life, as the raised right ventricular pressure created by the pulmonary emboli delayed the onset of cardiac tamponade.1 Her condition improved initially with chemotherapy and anticoagulation, but she died a year later due to progression of the lung cancer. PE = pulmonary embolism. PCE = pericardial effusion. PLE = pleural effusion.

Namal Wijesinghe · Cherian Sebastian · Hugh McAlister

A 79-year-old woman presented with a 3-month history of rapid growth of multiple long, thin, non-pigmented hairs, distributed diffusely over the entire body, preferentially on the face and trunk (Figure, A). After extensive investigations, two neoplasms were detected — a breast mucinous carcinoma and a metastatic endometrial carcinoma (Figure, B) — establishing the diagnosis of paraneoplastic hypertrichosis lanuginosa acquisita. Acquired hypertrichosis is strongly associated with underlying neoplasm (mainly lung and colorectal cancer).1,2 Therefore, detailed and extensive investigations are mandatory to detect the associated malignancy and to allow early and specific therapy. B: Pelvic magneticresonance imagingrevealed anendometrial tumour(arrow) and multipleenlarged lymph nodes (asterisks)

Marta Ferran · Montserrat Gilaberte · Josep E Herrero-Gonzalez · Lara Pijuan · Ramon M Pujol

Probiotics in pancreatitis Probiotics should probably not be used in patients with predicted severe acute pancreatitis, according to the results of a randomised, double-blind, placebo-controlled trial.1 Within 72 hours of symptom onset, 298 people with predicted severe acute pancreatitis were randomly assigned to receive an enterically administered probiotic preparation or a placebo for 28 days. Although there was no significant difference in the rate of infectious complications between the two groups, nine patients in the probiotic group developed bowel ischaemia (compared with none in the control group) and 24 died (compared with nine in the control group). These results appear to be at odds with the published literature, which has not shown an increase in mortality with the use of probiotics. The authors speculate that the bowel ischaemia may have been a side effect of increased bacterial load, leading to inflammation and a reduction in capillary blood flow. An accompanying commentary2 advises caution in the interpretation of the results, pointing out that the selection process may have been skewed, with more people in the probiotic group having organ failures at the time of randomisation. The possibility of contamination of the probiotic mixture or interaction with the enteric feeding formula is raised as a possible confounder. The authors of the commentary also discuss the thorny question of safety in clinical therapeutic trials, and contemplate whether earlier cessation of the trial may have saved some patients. 1 Lancet 2008; 371: 651-659 2 Lancet 2008; 371: 634-635 Thank you for not smoking We know that smoking and exercise have opposite effects on coronary risk factors, but can smoking negate the advantage conferred by regular exercise on the prevention of coronary heart disease? A large Japanese study involving over 76 000 people appears to have found a worrying answer. Among non-smokers, people who participated in sports for 5 hours or more a week had a 50%-80% lower age-adjusted risk of mortality from coronary heart disease compared with those who exercised 1-2 hours a week. For smokers, no association was found between exercise and reduced risk. Adjustment for known cardiovascular risk factors did not appear to alter these associations. The authors comment that although the study had some limitations, including a lack of data on the history of dyslipidaemia, there is strong evidence that smoking may reduce the beneficial effects of sports participation for the reduction of coronary heart disease. Heart 2008; 94: 471-475 Why not vaccinate? The vaccination rate for the combined measles-mumps-rubella vaccine (MMR) declined worldwide after reports of a possible association with autism and bowel disease in 1998. A UK study has explored factors associated with the uptake of MMR, which reached a low in that country of 79% in 2003. In a cohort study of over 14 000 children born between 2000 and 2002, immunisation status with MMR or a single antigen vaccine at 3 years of age was recorded. Overall, 88.6% of children were immunised with MMR and 5.2% with a single antigen vaccine. Children were more likely to be unimmunised if they lived in a household with other children or a lone parent, or if their mother was under 20 or over 34 years of age at the time of the child’s birth, more highly educated, or not employed. Nearly three-quarters of parents who did not immunise made a “conscious decision” not to do so. The authors comment that social differentials appear to play an important part in vaccine uptake, and these factors could be used to target interventions aimed at increasing uptake. BMJ Online, 28 February 2008 Apgar may equal intelligence Infants with a low Apgar score (< 7) at birth appear more likely to have low intelligence quotients (IQ) in their late teens, according to a large study of Swedish children. Data on the Apgar scores at birth were gathered for over 170 000 male infants born between 1973 and 1976 and correlated with educational achievement and IQ in the teenage years. Infants with a brief (< 5 minutes) or prolonged (> 5 minutes) low Apgar score were more likely to have a low IQ at age 18. Additionally, there was an increased risk of a low IQ the longer it took for the infant to achieve a normal Apgar score. The authors suggest that mild perinatal hypoxia may be sufficient to cause neuronal damage and affect cognition, supporting the concept of a “continuum of reproductive risk”. Arch Dis Child Fetal Neonatal Ed 2008; 93: F115-F120 Penalties and panic in a pandemic As the risk of pandemics looms in the wake of the severe acute respiratory syndrome (SARS) epidemic and with the rise of avian influenza, renewed discussion has arisen in medical communities around the obligations of health care professionals (HCPs) to work during a pandemic. A recent commentary by health and law policy experts calls for a rational approach to the conundrum, advocating that HCPs who refuse to work during a pandemic should not be penalised by loss of licence or jailing. The authors argue that penalties for HCPs who refuse to work in a pandemic should be limited to those dealt out in a non-pandemic situation where a HCP refuses to treat a patient with an infectious disease. They conclude that instead of relying on punitive measures, incentives to become involved in such situations should be implemented, including hazard pay for those who volunteer to work. JAMA 2008; 299: 1471-1473

Tanya Grassi