Volume 189 Issue 1

Policies need more than development — they need implementation, and continuous reform In his historic Gettysburg Address, President Abraham Lincoln described the core of democracy as “government of the people, by the people, for the people.”1 We were reminded of these words when we witnessed the Rudd Labor Government vigorously emulating this ideal during the recent Australia 2020 Summit.2 In April this year, a thousand Australians gathered in the Great Hall of Parliament House in Canberra to debate 10 national challenges. These included the future of the Australian economy; future directions for rural industries and rural communities; strengthening communities, supporting families and social inclusion; options for the future of Indigenous Australia; and a long-term national health strategy.2 In the challenging area of health, key ideas that were advanced included creating a Health Equalities Commission; creating a National Preventive Health Agency; initiatives for making healthy food choices easy in schools and regional areas; and, finally, the creation of a self-sufficient and flexible health workforce.3 In short, the Summit endorsed the expectation of healthy and long life for all Australians, and the equitable means to achieve this. Before the Summit, the Rudd Labor Government had already set in motion other consultative processes, such as the Preventative Health Taskforce to tackle the health challenges of tobacco, alcohol and obesity, and come up with a national preventative health strategy.4 This body was to be joined by the National Health and Hospitals Reform Commission (NHHRC), created to develop a long-term health reform plan for modern Australia.5 Its brief was to produce a blueprint for tackling future challenges in the Australian health system, such as the burden of chronic diseases and the ageing of the population as well as the rising costs of health care, which have been exacerbated by cost shifting and the “blame game”. In the recent federal budget, the Rudd Government included provisions for another national taskforce to address mental health. In this issue of the Journal, Bennett, Chair of the NHHRC, presents an outline of the Commission’s first report,6 Beyond the blame game: accountability and performance for the next Australian Health Care Agreements.7 At the heart of this report lies the need for the federal and state governments to stop playing the pernicious blame game, and the report advances a raft of relevant performance indicators to govern the Australian Health Care Agreement processes. Also in this issue of the Journal, Southby recounts the workings and achievements of the Hospitals and Health Services Commission, established by the Whitlam Labor Government in the 1970s.8 Its success as a harbinger of change lay in its dual responsibility for both comprehensive development and implementation of policy. In addition, its work was underpinned by an extensive analysis of relevant data, accompanied by consultation with all levels of government, professional bodies, universities and non-government organisations. And this highlights a significant danger for the efficacy of the current health taskforce and commissions — they are advisory only. A government can always ignore or merely cherrypick recommendations and, more worryingly, there need be no real political commitment to developing or implementing policy. Recommendations may well end up gathering dust in ministerial offices in Canberra, or being savaged by the leagues of advisors who prowl those offices. Witness the innumerable reports on health reform emanating from the Productivity Commission, the Council of Australian Governments, the Australian Healthcare Reform Alliance, the Australian Healthcare and Hospitals Association, Consumers’ Health Forum of Australia, and so on . . .9 Most seem to fall on deaf political ears. And yet, we continue to tolerate a health care system whose capacity to deliver is faltering in the face of increasing community demand. What Australia desperately needs is a continuous health reform agenda. We need to abandon the episodic and ad-hoc response to public disquiet and discontent, followed by the inevitable political quick fix. To ensure that this becomes a reality, the NHHRC needs to become a body with similar functions and status to those of the Whitlam era’s Hospitals and Health Services Commission, with a brief for wide involvement. Effectively, it needs to be responsible for driving reform, mirroring President Lincoln’s democratic dictum “by the people, for the people”. We also need to keep the government honest and up to the task of reform through an overarching body, perhaps the “Australian Health Council”, which would promote greater accountability of governments in driving reform effectively. The Council would also need to meet regularly in a different location each time, to have its members discuss health issues with Australian communities in open forums. The time has come to stop the reform rhetoric and political gamesmanship and acknowledge that good health is a right for all Australians. Indeed “the health of the people is the highest law”.10 But we can only achieve this most basic of human rights by making a sincere commitment to implementing meaningful reform of the health care systems we now have.

Martin B Van Der Weyden MD, FRACP, FRCPA

Updated guidelines recommend improving access to specialised stroke units and thrombolytic therapy, and the rapid assessment of patients with transient ischaemic attacks for stroke risk Stroke, with its high incidence and serious consequences, is one of the foremost health challenges for Australia and globally. Although stroke rates appear to be decreasing,1 population ageing will intensify the impact of this disease and the need for effective prevention and management strategies.2 Stroke is a complex disease with a range of causes, manifestations, outcomes and treatment approaches, but is too common and costly to be left as the province of a single clinical discipline, neurology. As the therapeutic time window in which to rescue or “protect” the brain from ischaemic damage is extremely short, there is a need for good systems of communication and responsive, expert team care, both in the community and in hospitals, to ensure safe and effective delivery of interventions early after onset and in subsequent phases of acute stroke. Indeed, the single most important therapeutic advance in stroke medicine is arguably the recognition that well coordinated, multidisciplinary care in the form of stroke care units (SCUs) can significantly improve the chances of recovery from stroke. So how can we improve patient access to expert SCU care and therapies that provide the best opportunity for a favourable outcome? A popular approach to improving the quality of health care delivery is the development of clinical guidelines. A good example is the Clinical guidelines for acute stroke management,3 produced by the National Stroke Foundation in 2007. These guidelines update a document published in 2003 and are available from the Foundation’s website (http://www.strokefoundation.com.au). They aim to provide clinicians and patients with all the key information needed to make the best decisions about the benefits and risks of treatment, through the use of systematically developed statements, recommendations and algorithms based on supporting grades of evidence. In addition, the document may provide a degree of medicolegal protection for the treating clinician, and political leverage for developing services both locally and generally. So what can we learn from these stroke guidelines, developed with specific relevance to the local context? The guidelines followed the rigorous standards of development and production set down by the National Health and Medical Research Council (NHMRC) and cover a wide range of clinically relevant topics in a simple, accessible format. The multidisciplinary expert working group that developed the guidelines is to be commended for seeking a wide range of external advice and comment, for incorporating consumer values and preferences in a unique additional grading of the recommendations, and for making sensible judgements for nearly half of the 148 recommendations where high-level randomised evidence was lacking — not surprisingly, mainly in the areas of supportive care and early rehabilitation. A key recommendation emphasised in the updated guidelines is the need for rapid assessment and management by specialists of patients who present not only with established features of an acute stroke but also with a transient ischaemic attack (TIA). TIA has generally been considered more “benign” than stroke and akin to migraine, because of its brevity and reversibility. However, recent studies show that the risk of recurrent stroke early after a TIA is similar to the risk after mild ischaemic stroke: about 10% in the first week and 20% by 3 months.4,5 Thereafter, the annual risks of stroke and myocardial infarction are around 5% and 2%–3%, respectively.6 Given that 30%–40% of patients with ischaemic stroke have had a preceding TIA or minor stroke,7,8 and that evidence is accumulating of the benefits of early interventions such as antiplatelet therapy, blood pressure-lowering therapy and carotid endarterectomy, TIAs provide an important opportunity for stroke prevention.8,9 However, the diagnosis of true stroke-related “focal” TIA is often challenging as it generally relies on patients recalling symptoms from a time when they were possibly impaired. As outlined in the stroke guidelines, a simple measure — the ABCD2 tool (a 7-point score calculated from age, blood pressure, clinical features, duration of symptoms, and diabetes status [Box])10 — can help clinicians, including those in primary care, with patient triage. Those at “high” risk of subsequent stroke have the option of admission to hospital to expedite investigations and management, while those with “low” risk could be followed up quickly in specialist outpatient clinics, where available. Early assessment offers further benefits for patients, through establishing correct diagnoses for TIA-mimics, such as syncope, seizure, anxiety–hyperventilation and vestibular disturbance, allowing specific interventions and avoidance of unnecessary, costly and sometimes risky avenues of management. For all these reasons, and as suggested by Kehdi et al in this issue of the Journal,11 early in-hospital management of patients with TIA may improve outcomes. However, there are major implications for resources and service configuration if rapid expert neurological assessment is to be provided to patients who present to emergency departments with TIA as well as those with stroke. Importantly, the stroke guidelines also included cost-effectiveness analyses of the currently available, clinically proven interventions for prevention and treatment of stroke. Most noteworthy was the finding that substantial economic and health-related benefits could be derived from improved patient access to high-quality stroke services through a modest additional investment of resources. Given that a substantial proportion of the Australian population lives in rural or remote areas, where there are no SCUs or other specialty services, the guidelines recommend the creation of networks linking smaller regional and rural centres to larger centres with SCUs. Furthermore, as the availability of SCUs varies widely even in urban settings, the guidelines recommend that ambulances preferentially transfer patients with suspected stroke to hospitals with SCUs. This recommendation is controversial. Recent audits12 and experience indicate that not all SCUs are resourced appropriately to allow safe and effective use of the thrombolytic agent, recombinant tissue plasminogen activator (rtPA), in carefully selected patients who present within the first few hours after the onset of ischaemic stroke. Given that rtPA is proven to be cost-effective, a reorganisation of services to allow ambulances to route patients directly to “active rtPA SCUs” could allow many more people to benefit from this treatment. How can the recommendations in the stroke guidelines be implemented in the real, service-challenged world, where modifying the behaviour of clinicians and providers is difficult, and clinical settings are often not conducive to change? The transfer of evidence into clinical practice has, to date, been unpredictable and often slow and haphazard for many reasons, including poor knowledge, limited therapeutic expertise, lack of time and, in particular, economic restraints. The use of guidelines can better align clinical management with evidence-based practice, but this is difficult when expertise and services are non-existent or inappropriately resourced. There is limited empirical evidence to support any specific strategy for change over another, but current data suggest that change is possible through comprehensive approaches that target different levels and settings in the health care system.13 The stroke management guidelines are a positive step. Implementation strategies, including the development of policy at the highest, central level, are now needed. A key step would be for the federal government to mandate the recommendation of the National Service Improvement Framework that all people with acute stroke receive SCU or appropriate alternative care around the country.14 Implementation of such policies would provide the best opportunity to improve the outcomes for patients with stroke and the growing population at risk of this devastating illness. ABCD2 tool for assessment of patients with transient ischaemic attack10 A. Age ≥ 60 years = 1 point. B. Blood pressure ≥ 140/90 mmHg = 1 point. C. Clinical features: unilateral weakness = 2 points, speech impairment alone = 1 point. D. Duration > 60 minutes = 2 points, 10–59 minutes = 1 point. D. Diabetes = 1 point. Total. 0–3 = low risk of stroke, 4–7 = high risk of stroke.

Craig S Anderson FRACP, PhD

Cervical cancer screening needs to take into account a partially vaccinated population and new technologies A national, well funded and organised program of screening using the conventional Pap smear has significantly reduced the incidence of and mortality from cervical cancer in Australia.1 While the program has been in place, there has been a great increase in knowledge of the pathogenesis of cervical cancer, with certain oncogenic subtypes of human papillomavirus (HPV) shown to be a necessary cause for development of this disease.2 In addition, a national program of vaccination against two of the 15 oncogenic viruses began in April 2007, and tests to detect HPV are now available. Furthermore, research showing that new technologies for screening cervical samples are superior to conventional cytology has also been published.3,4 How is the cervical screening program responding to the presence of a partially vaccinated population and these newly available tests? When the Pharmaceutical Benefits Advisory Committee assessed the value of funding HPV vaccination, it noted that the current cumulative lifetime risk of cervical cancer in Australia’s screened population is 0.78% — a substantial reduction from the estimated 2.4% risk in an unscreened population, reflecting the success of the screening program. With continued screening, this risk was predicted to further decrease to 0.38% following vaccination of 12-year-old girls, 0.43% for 14-year-old girls and 0.59% for 26-year-old women.5 The Committee further commented that there would be cost savings if vaccination were to completely replace cervical screening, but the cervical cancer lifetime risk would increase to 1.173%.5 The recommendation therefore is that screening must continue after vaccination. The screening interval and screening test for vaccinated women should be different to those for unvaccinated women and should be determined by population-based research over the next 5–10 years, as the vaccinated cohort reaches maturity. A national HPV vaccination register is being established, which will be critical for determining the appropriate screening regimen. HPV testing is already recommended and funded as a “test of cure” for follow-up of high-grade cervical disease after treatment. The Digene HPV test is used in Australia and detects any one of 13 high-risk HPV subtypes but does not identify the specific subtypes. Although some individual HPV subtyping assays are available, these are expensive and not widely used, and no serological tests for HPV are available in routine practice. Use of the HPV test is therefore limited but, given its importance, should its use be expanded for screening and management of cervical disease? There has been much discussion overseas about replacing cervical cytology tests with HPV testing for primary screening.6 Currently, there is no justification for this as HPV testing is highly sensitive but not specific. It has a limited role in women under the age of 30 years, as large studies have shown that about 25% of women in this age group test positive for the oncogenic viruses.7 The great majority of these women clear the virus naturally, usually via a cell-mediated immune response or, less often, through an antibody response. Such infected women may not show any sign of disease. It is when the virus persists that women are at greater risk of both high-grade cervical intraepithelial disease and invasive cancer. HPV testing is also not recommended before vaccination8 in women who request it but are already sexually active as the decision to proceed with vaccination will not be altered by the results of the test. HPV testing may have a greater role in the management of indeterminate abnormalities detected by cervical cytology tests. Data from large United States studies are fairly compelling in assigning a true risk of significant disease based on cervical cytology and HPV testing. The latter is more accurate than colposcopy in determining the significance of low-grade squamous intraepithelial lesions detected by cervical cytology. So-called “reflex” HPV testing in women with these findings is recommended in the US.9 Another major question for cervical cancer screening in the short term is whether image-guided liquid-based cytology samples should be used as the preferred screening test. The use of liquid-based cytology in this country has long been controversial.10 However, there is now good evidence that one of the techniques — the ThinPrep Imaging System (Hologic, Marlborough, Mass, USA) — is superior to conventional cytology.4 This technique decreases the number of unsatisfactory samples and detects more true abnormalities. There are also substantial laboratory efficiencies when using this technology, which could potentially overcome the chronic shortage of trained scientists. The increased sensitivity might allow the screening interval to be lengthened. This technique also provides a sample for HPV and other microbiological testing, and is ideal for a vaccinated population in which the number of screen-detected abnormalities will decrease. Although Australia has an enviable record in the control of cervical cancer, new knowledge and associated technologies should be incorporated into screening and management of cervical disease, as they offer real benefits. Both HPV testing and ThinPrep imaging are more expensive than conventional cytology, but they could be cost-effective if used appropriately in conjunction with a comprehensive review of the cervical screening program.

Annabelle Farnsworth FRCPA, FIAC, DipCytopath(RCPA)

Determining risk is the first step in deciding on appropriate management Osteoporosis, most simply and elegantly defined as “too little bone in the bone”, is generally the result of progressive bone loss which, for all practical purposes, starts at menopause in women and at about the age of 50 years in men. Because women have a lower bone organ density than men and then lose bone more rapidly,1 and also because women live longer, osteoporotic fractures, particularly at the hip, affect more women than men in Western countries — there are 20 000 hip fractures per year in Australia, with women outnumbering men by a ratio of two to one. The immediate cost of osteoporosis in Australia has been estimated at nearly $2 billion per year, with a further $5–6 billion in indirect costs.2 Doctors are in a difficult position when it comes to managing osteoporosis and preventing fractures. As with most disorders, they need to know the risk of an event such as fracture before reaching a treatment decision. They know that bone mineral density (BMD), measured by dual energy x-ray absorptiometry (DXA), is a major determinant of fracture risk, and they may have read that the risk goes up by a factor of 1.5–2 for every standard deviation fall in BMD3 (which is actually incorrect, as shown below), but they have no means of converting this information into absolute numbers. This is partly because of long-standing confusion between odds and risk, exemplified by the fact that the relative risks quoted in the literature3 are generally odds ratios or hazard ratios. The difference between odds and risk, well understood by professional statisticians, is not well understood by most clinicians. If 30 women out of 100 develop a fracture over a given period, the fracture risk is 30/100 or 0.30, but the fracture odds are 30/70 or 0.43 — a very different figure. At low levels of risk, say below 0.10, the difference between odds and risk is very small (one in 10 is close to one to nine) and can legitimately be ignored. However, as the risk increases, or the period over which it is calculated is extended, odds rise in a multiplicative fashion with fall in BMD, but risk does not. Odds have no upper limit, whereas risk can never rise above unity or rise by a multiplicative factor. A recent article sought to dispel this confusion by explaining the difference between fracture odds and fracture risk by reference to published data.4 A follow-up article,5 based on a prospective study carried out in Perth,6 contained a graph representing true fracture risk as a function of age and BMD in women without prevalent fracture. For those who would like to calculate the 6-year risk, the formula is: Odds = 0.025 × 1.08age > 55 × 1.49 –ve T-score Risk is then derived from odds as: odds/(1 + odds) We now wish to make this graph more readily available to doctors in Australia by reproducing it (Box). In women with any symptomatic prevalent fracture after the age of 50 years, 5 years should be added to the patient’s age because, in the above study, the effect of prevalent fracture on fracture risk was equivalent to a 5-year increase in age.5 (This, incidentally, shows the fallacy of using fracture as a substitute for densitometry in the diagnosis of osteoporosis, as is increasingly happening in Australia). Moreover, as men and women experience fractures at about the same BMD,7 it is probably safe to use the same graph to calculate approximate fracture risk in men by adding one to the T-score. Needless to say, it is for the individual clinician, in consultation with the patient, to decide the level of risk at which any particular intervention is called for. An arguable policy is to use calcium supplementation (with vitamin D if indicated) to prevent bone loss in patients at low risk, and to reserve more expensive remedies for patients at high risk in whom osteoporosis is already established, especially as the pivotal studies for these remedies have been performed in patients with T-scores of − 2 or lower. We are aware that our fracture risks are somewhat higher than those derived from the Garvan Institute algorithm8 which are in turn higher than those from the World Health Organization algorithm,9 but the former appears to underestimate the effect of age, and the latter has already been criticised as being too low.10 Only time will show which model is nearest the truth. Six-year fracture risk in women aged over 50 years without prevalent fractures

B E Christopher Nordin MD, PhD, FRACP · Richard L Prince MD, ChB, FRACP · Graeme R R Tucker BSc

Objective: To compare outcomes at 28 days and 1 year between patients admitted to hospital and those discharged after presenting to the emergency department (ED) with transient ischaemic attack (TIA).Design and setting: All TIA presentations to EDs in a large metropolitan and rural region of Sydney and its surroundings, New South Wales, between 2001 and 2005 were extracted from state health department databases and followed up over 1 year. Admission and discharge data and subsequent TIA or stroke presentations were identified.Main outcome measures: TIA recurrence or stroke.Results: Of 2535 presentations to an ED with TIA during the 5-year period, 1816 patients were admitted to hospital (71.6%) and 719 were discharged from the ED (28.4%). At 28 days, the discharged group had significantly higher rates of recurrence than the admitted group for all events (TIA or stroke) (5.3% v 2.3%, P < 0.001), stroke (2.1% v 0.7%, P = 0.002), and recurrent TIA (3.2% v 1.6%, P = 0.01). During the 29–365-day follow-up period, there was no significant difference between the discharged and admitted groups for all events (4.2% v 5.1%; P = 0.37), stroke (1.3% v 2.5%; P = 0.06) or recurrent TIA (2.9% v 2.6%; P = 0.65).Conclusion: Patients with an ED diagnosis of TIA may benefit from admission to hospital through a reduced risk of early stroke.

Elias E Kehdi MB BS, MOptom · Dennis J Cordato FRACP, PhD · Peter R Thomas PhD · Roy G Beran FRACP, MD · Cecilia Cappelen-Smith FRACP, PhD · Neil C Griffith FRACP · Ibrahim Y Hanna FRACP · Alan J McDougall FRACP, PhD · John M Worthington FRACP, BSc · Suzanne J Hodgkinson FRACP, PhD

Objective: To investigate a reported increase in tinea capitis in an English-language school to determine if it was an outbreak and whether control measures were warranted.Design: Cross-sectional study.Setting and population: Primary school children enrolled at an English-language school in an outer suburb of Melbourne were screened for tinea capitis in November 2005 by clinical examination, collection of scalp, skin or nail specimens where clinically indicated, and scalp brushing.Main outcome measures: Clinical diagnosis of tinea capitis confirmed by microscopy and culture.Results: Parental consent was obtained for 180 children (98%), of whom 153 (85%) were screened. Dermatophytes were isolated from 21% (32/153) of the children screened, comprising 23 infected children (cases) and 9 carriers. Three dermatophyte species were identified: Trichophyton soudanense, Trichophyton violaceum and Microsporum audouinii. Cases and carriers were significantly different to non-cases by ethnicity (P = 0.010): a higher proportion came from Africa, notably Sudan, and Arabic countries.Conclusions: Although our result may reflect what is expected in these migrant groups, tinea capitis caused by these three dermatophyte species is rare in Australian school children. Tinea capitis may continue to be a problem in these groups on account of continuing migration.

Michelle E McPherson BSc/BA, MPH, MAppEpid · Alan J Woodgyer BSc(Hons) · Kleete Simpson BSci(Med), MB BS(Hons), MPH · Alvin H Chong MB BS

Objective: To quantify an anecdotally apparent increase in motorcycle-related injuries in children and adolescents across Victoria.Design, setting and participants: Retrospective analysis of paediatric motorcycle injuries (1 July 2000 – 30 June 2004) from a statewide emergency department (ED) database (Victorian Emergency Minimum Dataset [VEMD]) and the Trauma Registry database at the Royal Children’s Hospital (RCH), Melbourne.Main outcome measures: Trends in paediatric motorcycle-related injuries over time; patient demographics, circumstances of accidents (on or off road), and injury characteristics, including severity markers.Results: The VEMD recorded 3163 patients aged ≤ 16 years presenting to EDs with motorcycle injuries during the study period; population-based rates of these injuries increased by an average of 9.6% per year (95% CI, 6.2%–13.1%; P < 0.005). In the same period, there was a total of 167 motorcycle-related admissions to the RCH, increasing annually in line with statewide ED presentations. About a quarter of paediatric motorcycle accidents occurred in children aged under 10 years (VEMD, 22%; RCH, 27%) and most occurred off road (VEMD,89%; RCH, 71%). At the RCH, median length of stay was 3 days (interquartile range [IQR], 1–7 days) and the median Injury Severity Score was 9 (IQR, 4–10); 41% of patients required an operation, 13% were admitted to an intensive care unit, and two died.Conclusion: In Victoria, the incidence of motorcycle-related injuries is increasing in children and adolescents. Most of these injuries occur off road, outside of any legislative framework. There is an urgent need for coordinated legislative changes and educational efforts to decrease motorcycle injuries in children.

Catherine A Bevan MB BS, MRCPCH · Franz E Babl MD, MPH, FRACP · Penny Bolt MB BS, FRACP · Lisa N Sharwood RN, MPH

Objectives: To use community pharmacy medication records to identify patients whose asthma may not be well managed and then implement and evaluate a multidisciplinary educational intervention to improve asthma management.Design, setting and participants: We used a multisite controlled study design. Forty-two pharmacies throughout Tasmania ran a software application that “data-mined” medication records, generating a list of patients who had received three or more canisters of inhaled short-acting β2-agonists in the preceding 6 months. The patients identified were allocated to an intervention or control group. Pre-intervention data were collected for the period May to November 2006 and post-intervention data for the period December 2006 to May 2007.Intervention: Intervention patients were contacted by the community pharmacist via mail, and were sent educational material and a letter encouraging them to see their general practitioner for an asthma management review. Pharmacists were blinded to the control patients’ identities until the end of the post-intervention period.Main outcome measure: Dispensing ratio of preventer medication (inhaled corticosteroids [ICSs]) to reliever medication (inhaled short-acting β2-agonists).Results: Thirty-five pharmacies completed the study, providing 702 intervention and 849 control patients. The intervention resulted in a threefold increase in the preventer-to-reliever ratio in the intervention group compared with the control group (P < 0.01) and a higher proportion of patients in the intervention group using ICS therapy than in the control group (P < 0.01).Conclusions: Community pharmacy medication records can be effectively used to identify patients with suboptimal asthma management, who can then be referred to their GP for review. The intervention should be trialled on a national scale to determine the effects on clinical, social, emotional and economic outcomes for people in the Australian community, with a longer follow-up to determine sustainability of the improvements noted.

Bonnie J Bereznicki BPharm(Hons) · Gregory M Peterson BPharm(Hons), PhD, MBA · Shane L Jackson BPharm(Hons), PhD · E Haydn Walters DM, FRCP, FRACP · Kimbra D Fitzmaurice BPharm · Peter R Gee BPharm(Hons)

Objective: To investigate the association between socioeconomic status (SES) and outcomes for seriously ill patients.Design and setting: A retrospective cohort study based on data from an intensive care unit clinical database linked with data from the Western Australian hospital morbidity and mortality databases over a 16-year period (1987–2002).Main outcome measures: In-hospital and long-term mortality.Results: Data on 15 619 seriously ill patients were analysed. The in-hospital mortality rate for all seriously ill patients was 14.8%, and the incidence of death after critical illness was 7.4 per 100 person-years (4.8 per 100 person-years after hospital discharge). Patients from the most socioeconomically disadvantaged areas were more likely to be younger, to be Indigenous, to live in a remote area, to be admitted non-electively, and to have more severe acute disease and comorbidities. SES was not significantly associated with in-hospital mortality, but long-term mortality was significantly higher in patients from the lowest SES group than in those from the highest SES group, after adjusting for age, ethnicity, comorbidities, severity of acute illness, and geographical accessibility to essential services (hazard ratio for death in lowest SES group v highest SES group was 1.21 [95% CI, 1.04–1.41]; P = 0.014). The attributable incidence of death after hospital discharge between patients from the lowest and highest SES groups was 1.0 per 100 person-years (95% CI, 0.3–1.6 per 100 person-years).Conclusion: Lower SES was associated with worse long-term survival after critical illness over and above the background effects of age, acuity of acute illness, comorbidities, Indigenous status and geographical access to essential services.

Kwok M Ho MPH, FRCP, FJFICM · Geoffrey J Dobb FRCA, FANZCA, FJFICM · Matthew Knuiman PhD · Judith Finn PhD · Steven A Webb MPH, PhD, FJFICM

The federal government announced the establishment of the National Health and Hospitals Reform Commission (NHHRC) in February 2008 to advise on future directions of health care delivery in Australia. In late April, the NHHRC issued its first report, Beyond the blame game, giving its views on key issues for the proper function of the Australian Health Care Agreements. In this report, the NHHRC has proposed 44 benchmarks to be met by both federal and state governments, where performance should have clear consequences for the accountable party.

Christine C Bennett MB BS, FRACP, MPaed

Health was a prominent policy issue in the 1972 Australian federal government elections, and the policy of the new Labor Government at that time emphasised the regional approach to health service delivery, including community-based services and preventive health programs, in close cooperation with the states. The Hospitals and Health Services Commission Act 1973 (Cwlth) was passed in December 1973 and members of the new Commission were appointed in April 1974. The Commission had broad-ranging functions and powers that had major influences on national health policy development in Australia. Major accomplishments of the Commission included the Community Health Program, which incorporated: the Hospitals Development Program, health services planning and research, a review of the School of Public Health and Tropical Medicine at the University of Sydney, diagnostic services, rehabilitation, Aboriginal health, rural health, health transport, nursing personnel, health careers and occupational health, many of which were long-neglected areas of public health. The National Health and Hospitals Reform Commission established by the Rudd Labor Government in February, 2008, while welcome, is an investigative body, whereas the Hospitals and Health Services Commission was responsible for both health policy development and implementation.

Richard F Southby PhD, FCHSE, FFPH

Objective: To identify patient safety measurement tools in use in Australian public hospitals and to determine barriers to their use.Design: Structured survey, conducted between 4 March and 19 May 2005, designed to identify tools, and to assess current use of, levels of satisfaction with, and barriers to use of tools for measuring the domains and subdomains of: organisational capacity to provide safe health care; patient safety incidents; and clinical performance.Participants and setting: Hospital executives, managers and clinicians from a nationwide random sample of Australian public hospitals stratified by state and hospital peer grouping.Main outcome measures: Tools used by hospitals within the three domains and their subdomains; patient safety tools and processes identified by individuals at these hospitals; satisfaction with the tools; and barriers to their use. Results: Eighty-two of 167 invited hospitals (49%) responded. The survey ascertained a comprehensive list of patient safety measurement tools that are in current use for measuring all patient safety domains. Overall, there was a focus on use of processes rather than quantitative measurement tools. Approximately half the 182 individual respondents from participating hospitals reported satisfaction with existing tools. The main reported barriers were lack of integrated supportive systems, resource constraints and inadequate access to robust measurement tools validated in the Australian context. Measurement of organisational capacity was reported by 50 (61%), of patient safety incidents by 81 (99%) and of clinical performance by 81 (99%).Conclusion: Australian public hospitals are measuring the safety of their health care, with some variation in measurement of patient safety domains and their subdomains. Improved access to robust tools may support future standardisation of measurement for improvement.

Caroline A Brand BA, MPH, FRACP · Joanne Tropea BPhysio, MPH · Joseph E Ibrahim PhD, FRACP · Shaymaa O Elkadi BA, GradDipAppPsych · Christopher A Bain MB BS, MInfoTech, MACS(Prov) · David I Ben-Tovim PhD, MRCPsych, FRANZCP · Tracey K Bucknall BN, GradDipAdvNurs, PhD · Peter B Greenberg MD, PhD, FRACP · Allan D Spigelman MD, FRACS, FRCS

The recent national conference of the Australian Medical Association in Hobart was the venue for several awards involving the Journal and its editors MJA/Wyeth Prize 2007 Karen Manley (third from left), recipient of the MJA/Wyeth Prize, with (left to right) Dr Michael Lee, Medical Director of Wyeth Australia, Dr Martin Van Der Weyden, Editor of the Medical Journal of Australia and Dr Rosanna Capolingua, President of the AMA. The Journal’s Content Review Committee awarded the 2007 MJA/Wyeth Prize to Karen Manley and colleagues, Margaret Fraenkel, Barrie Mayall and David Power, from Austin Health, Melbourne, Victoria, for their research article, Probiotic treatment of vancomycin-resistant enterococci: a randomised controlled trial, published in the 7 May 2007 issue of the Journal (MJA 2007; 186: 454-457). Vancomycin-resistant enterococci (VRE) often colonise the gastrointestinal tract of hospital patients, particularly those attending renal services. In a double-blind, randomised placebo-controlled trial, Manley and her colleagues demonstrated that a daily dose of commercial yoghurt containing the probiotic Lactobacillus GG strain was effective in eliminating VRE from the bowel. Dr Michael Lee, Medical Director of Wyeth Australia, presented the award. The MJA thanks Wyeth Australia for its continuing commitment to promoting excellence in Australian clinical research through the prestigious MJA/Wyeth Prize. Dr Ross Ingram Memorial Essay Prize Mr Barry Fewquandie (far right), recipient of the Dr Ross Ingram Memorial Essay Prize, with (left to right) Ms Karen Johnson, Ms Tania Ingram, Dr Van Der Weyden, Ms Julie Neville, Dr Ruth Armstrong and Dr Capolingua. This year’s recipient of the Dr Ross Ingram Memorial Essay Prize was Barry Fewquandie, Coordinator of an Indigenous cardiac rehabilitation program in Cairns. His winning essay, The heart of the matter is, that it’s a matter of the heart was published in the 19 May 2008 issue of the Journal (MJA 2008; 188: 580-582). It describes Fewquandie’s personal journey of recovery after acute coronary syndrome, his work in cardiac rehabilitation and his passion for improving the cardiovascular health of Indigenous Australians. In presenting the prize, MJA editorial staff were joined by three members of the late Dr Ross Ingram’s family. AMA President’s Award Dr Capolingua and Dr Van Der Weyden. Dr Martin Van Der Weyden, MJA Editor since 1995 and Chief Executive Officer of the Australasian Medical Publishing Company since 1996, was formally recognised for his “services to the Medical Journal of Australia, the medical profession and the AMA” with the 2008 AMA President’s Award. This award is given to an individual who has made an outstanding contribution towards fostering the objectives of the AMA in pursuit of a better health system for Australia. In presenting the award, AMA President, Dr Rosanna Capolingua said Dr Van Der Weyden has “enjoyed a distinguished, 30-year career in medical practice, teaching and medical administration and ensured the continuing reputation of the Medical Journal of Australia as Australia’s premier peer-reviewed medical journal. He has also managed to raise the profile of medical science and the profession by making the Journal more relevant to general audiences by publishing thematic coverage of medical issues”.

Ruth M Armstrong · Bronwyn Gaut

A 64-year-old man presented with abdominal distension and nausea, following 5 days of colicky abdominal pain and constipation. He had been taking antihypertensive and anti-asthma medication for 15 years. Clinically, generalised abdominal tenderness and guarding were present. A chest x-ray revealed hepatodiaphragmatic interposition of the large bowel (Chilaiditi sign). Abdominal computed tomography confirmed the presence of bowel loops anterior to the liver (Figures, arrows) and grossly dilated large bowel with no evidence of pneumoperitoneum. Biochemical analysis revealed hyponatraemia and hypokalaemia. No evidence of mechanical bowel obstruction was found during surgery. The final diagnosis was acute colonic pseudo-obstruction (Ogilvie syndrome) with Chilaiditi syndrome. To our knowledge, this is the first report of a patient with both these rare, and possibly correlated, syndromes.

Shobhit Mathur · Om J Lakhani · Virsing P Hathila · Dipesh D Duttaroy · Anis S Vohra · Himesh R Chauhan

Objective: To examine trends in invasive pneumococcal disease (IPD) in Indigenous people in north Queensland following the introduction of the 7-valent pneumococcal conjugate vaccine (7vPCV).Design: Trends in IPD were compared over three 3-year periods: before the introduction of 7vPCV for Indigenous children (1999–2001), and two consecutive periods after its introduction (2002–2004 and 2005–2007).Main outcome measures: Incidences of IPD in Indigenous children and adults in 1999–2001 and 2005–2007; trends in IPD caused by 7vPCV and non-7vPCV serotypes; and trends in indirect protective effects and emergence of non-7vPCV serotype IPD.Results: From 1999–2001 to 2005–2007, there was a 60% decline in IPD, with the virtual elimination of 7vPCV serotype IPD in young (< 5 years) Indigenous children. There is no evidence yet of an increase in non-7vPCV serotype IPD in these children. Although the annual incidence of IPD in Indigenous adults remained virtually unchanged, there was a 75% decline in 7vPCV serotype IPD in these adults (χ2trend = 11.65, P < 0.001). However, the incidence of IPD caused by non-7vPCV serotypes more than tripled in adults (χ2trend = 7.58, P = 0.006). Serotype 1 IPD has been prominent over the 9 years, but there is no evidence of a recent increase in serotype 19A IPD.Conclusions: Vaccinating Indigenous children with 7vPCV has protected Indigenous adults in north Queensland through an indirect “herd immunity” effect. However, this benefit has been offset by a recent increase in non-7vPCV IPD in Indigenous adults. Newer pneumococcal conjugate vaccines could prevent, both directly and indirectly, a considerable amount of the persisting IPD in Indigenous people in the region.

Jeffrey N Hanna MPH, FAFPHM · Jan L Humphreys · Denise M Murphy DipMedTech

Suburban shaman: tales from medicine’s frontline. Cecil Helman. London: Hammersmith Press, 2006 (197 pp). ISBN 978 1905 140 084. This short book is one of those which, once started, is difficult to put down. Helman’s storytelling is supreme as he recounts his experiences as a medical student in apartheid South Africa, and his journey to London to rid himself of the shackles of medicine and seek solace in anthropology and poetry. But of necessity, he became a general practitioner in suburban London, and herein lies the strength of his story — his insights into his experiences from medical and anthropological viewpoints, with a fair sprinkling of self-analysis. Suburban shaman has 24 short chapters and is divided into three parts: Helman’s formative experiences as a medical student in Cape Town, South Africa and his search for a specialty to which he could devote his life; his life as a GP in suburban London; and his views on the art of medicine. All are flavoured by a strong anthropological perspective. Throughout the book he reflects on traditional healers who capitalise on their patients’ inherent strengths — physical, psychological, social or spiritual — to heal themselves, and argues that conventional medicine has a lot to gain from using these attributes to promote healing and holistic practices. He decries the current pre-eminence of “technomedicine”, with its preoccupation with parts of the human body rather than the whole. He asserts that specialists and “technocrats” have little time for family doctors and their broad, unfocused areas of knowledge, archaic listening skills, collections of medical tales and quaint aphorisms. He reminds us of the strength of the placebo effect in medical practice, and how little this differs from the intent of shamans and other traditional healers. Many of Helman’s themes are not new, but the strengths of his book are how he explores these themes, particularly the placebo effect, and how he relates these to everyday practice in clear prose. Suburban shaman is a must-read book for most doctors and should be compulsory reading for all medical students. I recommend it highly.

Martin B Van Der Weyden

Girl stuff. Your full-on guide to the teen years. Kaz Cooke. Melbourne: Penguin, 2007 (554 pp). ISBN 978 0 670 02887 0. Kaz Cooke seems to have explored every nook and cranny in a teenage girl’s mind in this colourful, accessible tome. Divided into four parts: body, head, heart and “info to go,” she covers a vast range of issues from puberty, friends, and stress, to money matters and job hunting. Girl stuff understands where adolescents are coming from — useful for those of us working with them! The minutiae of pubertal development (vaginal secretions, nipple colour, tampon traumas ...) may never come to our attention in the consulting room, but can cause hours of angst for many a young woman. How to negotiate relationships is more important to the sexually experimenting adolescent than the risk of invisible sexually transmissible infections. Cooke learned about the concerns of teenage girls via a web-based survey that received over 4000 responses, and hundreds of these quotes appear throughout. The more medical issues (puberty, acne, eating disorders, and depression, just to name a few) have been well researched, and there is an impressive list of adolescent health experts among the acknowledgements. The book is heavily sprinkled with Kaz Cooke’s delightful humour as well as her great cartoon illustrations. I would have liked more integration of cross-cultural issues. In the otherwise excellent chapter on families, there is no mention of the cultural differences that shape families. An overt statement about how beliefs about sex and gender may be culturally determined and that not everyone will be part of the dominant culture would be preferable to the passing reference to how religion and culture influence people’s beliefs about sex. Adolescent substages progress rapidly, and by the time most adolescent girls are faced with sexual decision making, they may have worked out puberty. Conversely, the chapters on sex and drugs may not seem appropriate for a very young adolescent preoccupied with buying her first bra. It has been handy having three adolescent girls at home, one in each substage, to test this out. The book is so full of common sense and practical information including statements such as “don’t read this chapter if you’re not ready”, that I had no qualms myself. I wish it had been around when I was a teenager.

Melissa S L Kang

To the Editor: Although there are data on the population needs for residential aged-care facilities (RACFs)1 and models of engagement by general practitioners once someone is resident in a facility,2-4 there are ongoing administrative barriers for people trying to secure a place in an RACF. The aim of requesting data before admission is to provide continuity and quality of care, but the burden of paperwork currently falling on family members and GPs is of concern. We initiated an audit when it became apparent that local acute public and private hospital inpatient units had a policy of insisting that once an inpatient was eligible for RACF residency, he or she was required to be placed on waiting lists for 8–10 different RACFs. As part of a broader project to coordinate better care at times of transition, all RACFs in southern Adelaide (feeder population 400 000) were approached to provide us with the forms that need to be completed before someone can be placed on their waiting list. All 22 facilities in southern Adelaide provided a copy of the application pack that they normally give to a family member. A median of 4.5 forms had to be completed before a person could be placed on a waiting list (range, 0–13). The most frequently requested forms were an Aged Care Assessment Team form (17 facilities), an application form (15 facilities), a medical history form (12 facilities), and an assets declaration (9 facilities). One RACF required direct debit payment forms to be filled out before considering an application, and another required documentary evidence of funeral arrangements. By contrast, four RACFs required no forms at all. GPs were responsible for the medical history form. This form was unique to each RACF, with the result that similar data had to be provided multiple times in different formats. GPs were also potentially required to witness several other forms for each different application. There is an inherent challenge in balancing the need to run a financially viable RACF and provide best care from the moment a resident arrives with minimising the paperwork that frail spouses or busy family members are often expected to generate or replicate for many facilities simultaneously. These forms, most of which will never be used, create a burden on family members at an already stressful time. An agreed national industry standard for an Aged Care Assessment Team form, an assets form and a medical history form (to be filled out once by a GP) would ease stress at arguably one of the more difficult transitions any person and his or her family can face.

Aine G Greene · Bernadette Kenny · David C Currow

To the Editor: In the January issue of the Journal, Harvey et al raised some serious concerns about the listing system for complementary medicines.1 In particular, they suggest scrapping the listing system (AUST L) and requiring complementary medicine (CM) products to be evaluated by the Therapeutic Goods Administration (TGA) for efficacy. Scrapping the system would be a significant setback for natural medicines, which have an important role to play in the health system. Such a move would be likely to remove products from the market, while the problem outlined by Harvey et al is more about the claims made for products rather than the products themselves. Certain CM products play a valuable role in many chronic diseases, in situations where existing synthetic products are often lacking. The regulatory system should encourage evidence-based CM products, and appropriate sanctions and enforcement should downgrade the claims made on products that don’t have a specific evidence base. CMs, especially herbal medicines, are complex products with numerous biologically active components. This means that the evidence is specific to the product and cannot be extrapolated. This fact has two important consequences for practitioners and the health system as a whole: the “generic” concept of synthetic pharmaceuticals (eg, interchangeability of paracetamol-containing products) is invalid for CM, meaning that a prescription for “St John’s wort” for example is not reliable, as St John’s wort is not one substance; and meta-analyses and systematic reviews of a “substance” (eg, a herb, or glucosamine) are easily misinterpreted because the products made from that “substance” are so different, any conclusions drawn can only be applied to the particular products that have been trialled.2 While the health system fails to discriminate between products that have specific trial evidence and those that do not, practising evidence-based complementary medicine will remain difficult. Encouraging evidence-based use of CM products, including supporting specifically clinically proven products, will lead to further research and better integration of CM into our health system for the benefit of the Australian public.

Nigel A Pollard

To the Editor: I am writing in response to the recent article by Harvey and colleagues about complementary medicines in Australia.1 Rottapharm is the developer and manufacturer of DONA glucosamine, a patented form of glucosamine. DONA is a registered medicine in 54 countries, in many on the equivalent of the Pharmaceutical Benefits Scheme. DONA is the leading glucosamine product in the world measured by specific trial evidence, sales and registration approvals. The fundamental issue is that different products that contain glucosamine and other complementary medicine (CM) products should be considered to be distinct products. Standards of active ingredients and methods of manufacture of finished products are substantially different between companies. Specific clinical trial evidence for glucosamine is essential because of: formulation differences (DONA glucosamine is a patented formulation of crystalline glucosamine sulfate, which is not comparable with glucosamine hydrochloride or other glucosamine sulfate formulations); bioavailability of glucosamine sulfate (unlike all other formulations on the Australian market, DONA has proven plasma concentrations and synovial fluid levels consistent with a clinical effect at a dosage of 1500 mg once a day, and is the only glucosamine product available with proven human bioavailability and pharmacokinetics);2 and results of specific clinical trials (studies of non-DONA glucosamine products [unknown formulations] have had mixed results while DONA has shown consistent efficacy across all trials, and has been assigned level 1A evidence by the European League Against Rheumatism).2-6 Not requiring sponsors to have evidence to support claims made about their products encourages low quality. For example, the market-leading glucosamine products in Australia have not been subject to independent peer review to establish whether they are effective. As the claims allowed on such products are identical to the claims allowed on DONA, there is no incentive for the industry to source the “real thing” or conduct their own clinical trials. In the interests of their patients, we believe that health professionals have a right to be able to identify specific products that have been clinically proven. Use of CMs that is not evidence-based is likely to lead to failure to realise significant health benefits of CM for the Australian public.

Antonino Santoro

To the Editor: The article by Harvey et al raises important concerns about the complementary medicine (CM) industry, particularly with respect to inappropriate marketing and advertising by some sponsors.1 The role of the Therapeutic Goods Administration (TGA) in setting standards and regulation of CMs should not be taken lightly. Australia has one of the highest quality standards for CMs internationally. Many CM products in Australia are assessed by expert authorities within the Office of Complementary Medicines and the Complementary Medicines Evaluation Committee of the TGA for safety and (where appropriate) efficacy relating to claims made for products.2 This is not fully appreciated by the authors. While many CMs may lack high-quality research to validate efficacy, this does not necessarily mean they are not clinically effective. Many clinicians and consumers find CMs to be of clinical value in improving health status. By suggesting that “the listing system should be scrapped, and CAMs [complementary and alternative medicines] . . . be assessed for efficacy and delisted if evidence is lacking” would be to deny consumers choice of treatment and potential health benefits, and lead to a “black market” or buying products from overseas which may not compare in quality. The authors fail to acknowledge that much of the drive for CM sales is actually coming from consumers through their choice of health care treatment.3 Consumers have the right to trial CMs. It is our role to ascertain safety issues and encourage clinical trials where they are lacking. For thousands of years, populations have relied on some CMs for health benefits, not having the advantage of any trials, but relying solely on traditional use. If the risk of harm to human health from the use of a CM outweighs any proven or unproven efficacy, consideration should be given to delisting the product or restricting its use. More research is required to assess safety data and efficacy for CMs. Australia has come a long way in regulating CMs. To say the “listing system should be scrapped” does not appreciate the tremendous efforts and gains made by the TGA compared with international efforts to enforce good manufacturing practice and various methods to better safeguard consumers. The authors do raise a valid point in saying that sponsors should provide “key evidence supporting each indication of the ARTG [Australian Register of Therapeutic Goods] . . . [which] should be publicly available on the Internet”. This may be useful for consumers and health practitioners, but requires appropriate funding to be viable. Furthermore, codes of conduct and complaints procedures for CMs, such as through the Complaints Resolution Panel, need to be strengthened, particularly with respect to breaches in the advertising code.4 To date, the Parliamentary Secretary has asked the TGA for advice on the proposals put forward by Harvey and colleagues.1,5 The government will consider its response to these proposals in the context of taking forward legislative changes that were deferred in anticipation of the establishment of an Australian New Zealand Therapeutic Products Agency (TGA advice, 28 May 2008).

Vicki Kotsirilos

To the Editor: Harvey et al1 have a right to be concerned about the parlous state of regulation in the billion-dollar complementary medicine (CM) industry. They are not alone, with various leaders from CM doctor groups and other leaders also expressing concern.2,3 Predictably, those in the CM industry itself are denying any problems exist, and just repeat their mantra that their products are safe and effective.3 As business people, the leaders of the CM industry must be pleased with the unchallenged run they have had over the past 20 years (except for one challenge with the Pan Pharmaceuticals debacle4). Consider one company (Mannatech) whose multilevel marketed products are promoted by their associates (natural drug representatives) as useful for arthritis, diabetes, dementia, attention deficit hyperactivity disorder, Parkinson’s disease, asthma, cancer and various other chronic diseases. The associates promoted claims that a product, Ambrotose, would assist with the above conditions using literature that did not carry the company logo, and used the company literature for non-specific claims and testimonials, thus absolving the company of responsibility. The Therapeutic Goods Administration is helpless in such a situation, and it was only when a medical practitioner started selling Mannatech products, including Ambrotose, from his surgery that the state medical board took an interest.5 However, the medical board has no jurisdiction over the company, and when the doctor was deregistered, he would have been able to keep marketing the product for the company. Mannatech launched Ambrotose in Australia, quoting the benefits of their product from a trial conducted and published in the Journal of the American Nutraceutical Association by American immunologist Dr See and colleagues.6 Eighteen months later, the published trial was the subject of much controversy.7 There was little if any effect on the company from this, in stark contrast with what one would expect in the pharmaceutical industry. Yes, Harvey and colleagues are just starting to scratch the surface of controversies that are decades old in this unregulated industry. For the good of the public and for the good of the CM industry, there needs to be a watchdog, similar to Medicines Australia, to regulate CM.

C Scott Masters

In reply: We agree with Kotsirilos that the current listing process of the Therapeutic Goods Administration (TGA) provides some protection for consumers by ensuring that complementary medicines (CMs) are manufactured in accordance with good manufacturing practice. The TGA claims that about 25% of new listings are assessed in detail each year for compliance with requirements, including that sponsors must hold evidence to support promotional claims made.1 However, we understand that the TGA does not assess this evidence for quality, and that literature searches are not performed to see if more recent evidence2 contradicts that submitted by the sponsor.3 In addition, sponsors can make a conservative claim at the time of listing but then make very different claims in promotional campaigns. An under-resourced, laboriously slow and largely impotent complaint system provides little disincentive to such unethical (but profitable) behaviour. While the Medicines Australia code of conduct (for prescription medicines) still has room for improvement, we agree with Masters that it currently provides more effective sanctions for breaches (eg, fines up to $200 000) than the options currently available to the TGA. Medicines Australia also proactively monitors compliance with the code of conduct and provides useful annual reports.4 Regardless, claims for CM that cannot be substantiated by appropriate evidence are better dealt with at the time of a marketing application rather than many months after advertisements have been published and when consumers have long been misled. We also recommended that therapeutic equivalence of the product in question should also be assessed at this time; a point reiterated by Santoro and Pollard. We support the right of consumers to choose from a variety of therapeutic modalities offered in the market place. However, good decision making requires evidence-based information about risks and benefits, regardless of whether the medicine in question requires a prescription, can be obtained over the counter or is a CM. Even if the risks of CMs are relatively low, the financial and opportunity cost for consumers can be significant. A pragmatic compromise to delisting CMs that lack evidence of effectiveness would be an opt-in system, funded by an additional fee, that would independently evaluate the effectiveness of specific CM products. A product with reasonable evidence of effectiveness could be awarded a symbol similar to the the National Heart Foundation “red tick”. Implementing this measure, together with the disclaimer and other recommendations we made in our article,5 would assist consumer choice and provide a market advantage for the sponsors of evidence-based, ethically promoted CMs. These proposals have received support from health professional and consumer organisations as well as sections of the CM industry. They have been put to the Parliamentary Secretary who assists the Minister for Health and Ageing.3

Ken J Harvey · Viola S Korczak · Loretta J Marron · David B Newgreen

To the Editor: The recent article by de Crespigny and Savulescu1 is nominally about the medical care of pregnant women, but its ramifications extend more widely into power relations, law and ethics, and matters of life and death. The article is entirely adult-centred: its authors never hint that a doctor who is treating a pregnant woman has not one but two patients. There is never the faintest suggestion that the fetus is a separate human being with his or her own medical interests. The “research” reported is a survey of 20 obstetricians, who all agree with the authors on abortion for fetal abnormality. Unsurprisingly, most said they would prefer fewer constraints on such abortions. Which abnormalities are grounds for termination? The authors never say, although terminations are performed in Victoria for conditions as readily treatable as cleft lip.2 The authors cite an estimate that where Down syndrome is identified in Victoria, 95% of pregnancies are terminated. Yet people with Down syndrome do not appear to find their lives intolerable: is the misery we want to put Down syndrome children out of their misery, or their parents’? The authors insist that in Victoria, “uncertain laws compromise good prenatal care”. The prenatal care they seem to have in mind can hardly be called care of the child: can it be called care of the mother? In one of the cases cited, a woman at Melbourne’s Royal Women’s Hospital was threatening suicide unless her pregnancy was terminated after a diagnosis of dwarfism at 31 weeks.1 Instead of providing her with urgent psychiatric care (had they never encountered a suicidal patient before?), the doctors terminated her pregnancy. If she had demanded the amputation of her left arm, would they have called in the surgeons? The surgical mutilation of an adult patient would not have been considered for a moment, but the surgical killing of a fetal patient was an available and practised routine. This woman was already not well, and the “prenatal care” she received put her further at risk. This case illustrates how true prenatal care is compromised, not by the few remaining legal limits on child destruction and abortion, but by their ready availability. Readers of the literature on post-abortion syndrome will have encountered many other illustrations of what should be obvious: that you are not likely to help a woman by destroying her child. Experienced and attentive general practitioners and psychiatrists will be able to give their own examples. Doctors need to pay close attention to the short paragraph on conscientious objection.1 The authors declare that “a doctor’s conscience should not be allowed to interfere with medical care” and that if “some individuals or institutions have moral objections ... those objections cannot compromise patient care”. If that does not mean that the authors want to exclude anyone who disagrees with them about what constitutes “medical care” from medical practice, what does it mean? There could hardly be a plainer threat to doctors’ personal professional judgement.

Edward D Watt

To the Editor: Superficially, de Crespigny and Savulescu make a compelling case for clarifying late-term abortion law.1 However, at a deeper level, it is disappointing that alternative points of view were not discussed in their article. The only solution offered in the case of a potentially imperfect child is to abort the pregnancy and try again. Unfortunately, this ignores several important issues. First, the consequences of abortion for the mother, both physical and psychological, are neglected.2 Our experience, as general practitioners, is that late-term abortions only lead to heartache and regret, even depression and anxiety, as the mother tries to deal with what has happened to her. Every time she sees either a “normal” or an “abnormal” child, her loss is re-lived. A patient of one of us (S B G) has developed Asherman syndrome as a result of a late-term abortion; she is now infertile. Second, without a definition of “child”, any discussion regarding abortion law is, at best, futile; at worst, it is emotionally charged and reliant on anecdotes. If a fetus is defined as a child, then that child has a right to live, whatever the disability. If not, then any disability up to the defined age could potentially justify “abortion” (ie, destruction). Third, the references given to support the assertion that women might “refuse to consider motherhood” without genetic testing described women who carry germline monogenic abnormalities (eg, thalassaemias, Huntington genotypes). These women would be eligible for earlier antenatal screening, such as pre-implantation genetic diagnosis, amniocentesis and chorionic villus sampling — all of which are available well before the current legal time frames in question. Fourth, de Crespigny and Savulescu’s premise for allowing late-term abortion is that there is a life-threatening fetal abnormality and the mother wishes to have children. However, a consequence of liberalising the law for the benefit of these women would be that women with non-life-threatening fetal abnormalities, and also those who simply did not want a child, could also access late-term abortion more easily. This is obviously a major concern. Finally, use of the term “child destruction” in the law is important when considering these situations. A helpful definition of the purpose of the law is to prevent injustice.3 As seen by the ability for women to access “legal” abortion before 20 weeks’ gestation, any law that protects children needs to stand. The pregnant woman clearly has a voice; unfortunately, the unborn child does not have the same ability to state his or her case before an ethics committee.

Simon B Gerber · John T Wenham

In reply: Watt seems to wish to return to the days of no prenatal testing; we believe today’s women reject this paternalistic view. However, Watt is correct in saying our article is “adult-centred” — it is not self-evident that the fetus is a patient, nor is this view consistent with those of most liberal legal jurisdictions. It has been found that 81% of Australians,1 including a majority in all major Australian religious groups,2 agree with a woman’s right to choose an abortion. Only 4% of Australians consider abortion wrong.3 We echo Amnesty International’s call for abortion to be decriminalised globally.4 Abortion laws should no longer discriminate against pregnant women with fetal abnormalities. Contrary to Watt’s claims, it is well documented that an experienced psychiatrist was central in managing the pregnant woman who had an abortion at 32 weeks at the Royal Women’s Hospital. In addition, we do not believe abortion has been demonstrated to cause psychiatric “post-abortion syndrome”,5,6 nor that abortion is analogous to amputating a healthy limb. We do not challenge doctors’ personal judgements. All individuals must be free to make their own value judgements for their own lives, including doctors. However, doctors have a duty to inform patients of all appropriate treatments. When a patient requests abortion and the doctor has a moral objection to providing it, the doctor must refer the patient to another practitioner.5 Contrary to Gerber and Wenham’s claims, we did not suggest that “to abort the pregnancy and try again” is the only option for fetal abnormality. Abortion — or continuing the pregnancy — must be the woman’s decision. One of us (L J d C) has 30 years’ experience of prenatal testing, including treating many women after terminations for fetal abnormality. Such women are sad about the diagnosis and outcome, extremely worried during subsequent pregnancies, and regret having had to make an awful decision. However, none have said that they made the wrong decision. Regarding Gerber and Wenham’s comments about the definition of “child”, our position is that (before birth) the fetus does not have the rights of a child.7 The data we cited show that prenatal testing for Huntington disease “allows” at-risk women, who might otherwise choose not to conceive, to have children. Personal experience (of L J d C) shows that women with a past history of other serious fetal disorders are no different. We did not suggest that late abortion should be available only in cases of life-threatening fetal abnormality. Indeed, our article clearly related to “pregnant women with fetal abnormalities” (not necessarily life-threatening). The claim that women would request late abortion simply because they don’t want a child demeans women’s integrity. We need clear abortion laws so that pregnant women and their doctors can know when abortion is lawful. Developing clear laws necessitates removing the crime of child destruction.8

Lachlan J de Crespigny · Julian Savulescu

To the Editor: We believe that Tang and Nordin1 misunderstood the findings of our recent study of calcium supplementation.2 We disagree with their claim that the increase in the number of women with self- or family-reported myocardial infarction, stroke or sudden death became non-significant after adjustment for covariables. They correctly noted that the increased number of women experiencing the composite endpoint of cardiovascular events (after adjudication of events and inclusion of unreported events from hospital records) was not statistically significant. However, the increased event rate for this composite endpoint with calcium was statistically significant (rate ratio, 1.43; 95% CI, 1.01–2.04; P = 0.043). Thus, in our study, the number of women needed to treat with calcium for 5 years to cause one cardiovascular event was 29, and the corresponding number to prevent one fracture was 50.2 Tang and Nordin then meta-analysed data from five studies of calcium and vitamin D supplementation to conclude that calcium supplementation does not increase mortality.1 We disagree. For one of the studies, they classified a subgroup of participants who received annual vitamin D but no calcium supplements as having received “calcium supplementation”.3 Further, for the RECORD (Randomised Evaluation of Calcium Or vitamin D) study, they compared the number of deaths between people receiving and not receiving vitamin D (16.5% v 17.4%) rather than between those receiving and not receiving calcium (17.7% v 16.2%).4 The trend for increased deaths with calcium supplementation in RECORD was greater when analysis was restricted to those treated with calcium monotherapy (18.5%) and placebo (16.3%). As our study was of calcium monotherapy, the results of Tang and Nordin’s meta-analysis are of questionable relevance to our findings. In addition, ours was a 5-year study, and the differences in vascular events between the groups only emerged after 2 years.2 Only one study in Tang and Nordin’s meta-analysis had an average follow-up duration of more than 25 months.4 Further, there is evidence from other studies of trends towards vascular events occurring more frequently in people who take calcium monotherapy.2,5,6 In three out of four studies that reported mortality, there were trends towards increased death rates in people receiving calcium.2,4-6 As we concluded,2 these data are not definitive, but flag cardiac health as an area of concern in relation to calcium use. Finally, we did not suggest that calcium supplementation should not be given to older women. However, in view of the evidence that any fracture risk reduction with calcium is small (< 10%),7,8 and the suggestions that calcium supplementation might increase the risk of hip fractures9-11 and vascular events, it seems reasonable and timely to reassess the role of calcium supplementation.

Mark J Bolland · Andrew B Grey · Ian R Reid

In reply: In Table 5 of Bolland and colleagues’ study, the P value after allowing for covariables was 0.08,1 which is not significant. This was without including smoking, which would undoubtedly have reduced the significance further as there were more smokers in the calcium group. Based on Bolland and colleagues’ suggestion, we reanalysed the data by removing the group receiving vitamin D but no calcium supplements in the NoNOF (Nottingham Neck of Femur) study,2 and using data for those treated with calcium monotherapy (18.5%) compared to placebo (16.3%) in the RECORD (Randomised Evaluation of Calcium Or vitamin D) study.3 The reanalysis still failed to show any evidence of an increase in mortality (relative risk, 1.05; 95% CI, 0.88–1.26; P = 0.56).

Benjamin M P Tang · B E Christopher Nordin

To the Editor: My attention was drawn to the Snapshot of an apical lung hernia published in the Journal last year.1 Persons with emphysematous hypertrophic lungs are often found to have clinically discernible supraclavicular swellings (Box). The finding of these swellings is a surprisingly common sign that is little remarked upon in clinical descriptions. These swellings are the bullous expansions of the apices of the lungs. Supraclavicular swelling in patients with emphysematous hypertrophic lungs A woman (A) and a man (B) with visible supraclavicular swellings.

George R Crowe

Re: “Bystander basic life support: an important link in the chain of survival for children suffering a drowning or near-drowning episode”, by Jeanette Marchant, Nicholas G Cheng, Lawrence T Lam, Fiona E Fahy, S V Sounndapound, Danny T Cass and Gary J Browne, in the 21 April 2008 issue of the Journal (Med J Aust 2008; 188: 484-485). The fifth author’s name was spelled incorrectly. The correct spelling of the author’s name is S V Soundappan. The web version of this article was corrected on 2 June 2008.

Jeanette Marchant · Nicholas G Cheng · Lawrence T Lam · Fiona E Fahy · S V Soundappan · Danny T Cass · Gary J Browne

Re: “Misleading advertising of PI-based drug information?”, the letter by Jim R Stockigt, in the printed version of the 2 June 2008 issue of the Journal (Med J Aust 2008; 188: 679-680). Professor Stockigt’s affiliations were incorrect and incomplete, and should have read: Further, it should be noted that the question mark in the title was added at the Editor’s discretion.

Jim R Stockigt

Not so tiny tots Evidence suggests that the prevalence of overweight and obesity has been increasing among children in the United States. A recent US study looking at trends in body mass index (BMI) in children and adolescents aged 2-19 years has shown some interesting and controversial results.1 Height and weight measurements were obtained from over 8000 children and adolescents over the period 2003-2006. These data were compared with those for 1999-2003. Overall, 11.3% of the participants were at or above the 97th percentile of growth for age charts created in 2000 by the Centers for Disease Control and Prevention. About 16% were at or above the 95th percentile, and 32% were at or above the 85th. Surprisingly, the prevalence of high BMI for age showed no significant changes between 2003-2004 and 2005-2006, and there were no significant trends detected between 1999 and 2006. An accompanying editorial2 comments on the usefulness of BMI as a measure of childhood obesity, and discusses the validity of cut-off points and BMI percentiles in the definition of childhood overweight and obesity. The authors of the editorial also question how well BMI-for-age percentiles predict the risk for obesity-related disease. 1 JAMA 2008; 299: 2401-2405 2 JAMA 2008; 299: 2442-2443 Silicone saga The use of injected silicone products as cosmetic fillers has again come under fire after an investigation by the US Centers for Disease Control and Prevention (CDC). In a series of case reports, the CDC document three cases of acute renal failure linked to injections of silicone oil for cosmetic purposes. All cases were linked to non-registered untrained practitioners, and doubt exists as to the actual content of the injections. With medical tourism on the rise, particularly in the field of cosmetic medicine, Australian doctors may need to become aware of such complications. MMWR Morb Mortal Wkly Rep 2008; 57: 453-456 Quitting is contagious Social networks appear to be an important aspect of an individual’s ability to stop smoking, according to a large, longitudinal report based on the US Framingham Heart Study. Researchers evaluated a network of over 12000 people who underwent assessment of social connections and smoking behaviour for a period of 32 years. Results show that smokers and non-smokers tend to exist in discernible clusters based on social groupings, and that social cohorts appear to quit in concert within these clusters rather than randomly. Not only did smoking cessation by a social contact decrease a person’s chances of smoking, but the closeness of the tie determined the level of chance. Thus a spouse quitting led to a 67% decrease in a person’s chances of smoking, while a co-worker ceasing smoking resulted in a 34% reduction. In an interesting twist, smokers were observed to gradually move towards the periphery of the social network. The researchers conclude that smoking behaviour seems to spread through social ties, and that connected clusters of people stop smoking in concert, making the findings a potentially valuable tool for use in future public health interventions. N Engl J Med 2008; 358: 2249-2258 Systematically more complex The use of existing systematic reviews to create more complex reviews is the subject of a recent interesting and useful update.1 Used increasingly in the development of clinical practice guidelines and as an adjunct to health policy planning, complex systematic reviews tend to evaluate a number of clinical questions, interventions or tests. The ensuing intricacy of the review process calls for a standard method of conducting such analyses. The authors list a series of methodological steps for conducting complex reviews, which include locating existing reviews, assessing relevancy and quality, incorporating studies, and reporting results. An accompanying editorial2 applauds the discussion and encourages further work in this area, and in turn quotes super sleuth Sherlock Holmes in A Study in Scarlet: “Like all other arts, the science of deduction and analysis is one which can only be acquired by long and patient study... let the inquirer begin by mastering the more elementary problems”. 1 Ann Intern Med 2008; 148: 776-782 2 Ann Intern Med 2008; 148: 786-788 SpIrituality in medicine The subtle difference between healing and curing patients with critical illness is the focus of a commentary aimed at encouraging research into the effect of introducing spirituality into medical care. Introducing the concept that healing can occur even when the prognosis for cure is bleak, the author suggests the use of facilitators from a team comprised of physicians, nurses, social workers, and chaplains. These facilitators would act to help the family and patient find meaning in and make sense of their experience. Tackling the reasons why research into the role of spirituality in physical health is often criticised, the author proposes a framework for future investigation, suggesting possible experimental designs that might make such research more acceptable to the mainstream. JAMA 2008; 299: 2440-2441 Dr Tanya Grassi, MJA

Tanya Grassi