Volume 189 Issue 10

Best-practice guidelines mandate a full postmortem examination in these deaths to identify genetic causes and allow potentially life-saving interventions in the victim’s relatives The sudden and unexpected death of an apparently fit, healthy young person has a devastating effect on the family and community. If there is no adequate explanation for the death, the desperate sadness is usually compounded by frustration and fear that another family member may be struck. Yet, there is no uniform process in place in Australia and New Zealand to obtain a proper medical history of the victim, or to examine and investigate the victim’s family. Such a process could provide clues to the diagnosis and also identify previously undiagnosed genetic diseases. The lack of a consistent definition for sudden unexpected death in young people means there are few prevalence data. The best studies of incidence and causes of sudden natural death in 1–40-year-olds have been conducted by two forensic pathology centres in New South Wales.1,2 These suggest an annual incidence of around 20 per million — about 400 deaths per year in Australia. A striking feature was that the postmortem examination identified no specific cause of death in a third. This suggests an arrhythmic death caused by an underlying cardiac channelopathy, such as long-QT syndrome, Brugada syndrome or catecholaminergic polymorphic ventricular tachycardia.3 Clinical and genetic studies have confirmed the presence of these conditions in the Australian and New Zealand populations.4 They are the consequence of inherited dysfunction of cardiac cell channels (for potassium, sodium and calcium), which are involved in generating the cardiac action potential. The mode of death is ventricular tachycardia or fibrillation. The results of the two NSW pathology studies1,2 were surprising, as previous studies on sudden death in young athletes found that the most prominent causes were the structural heart diseases, hypertrophic cardiomyopathy (HCM) and arrhythmogenic right ventricular cardiomyopathy (ARVC). Cardiac channelopathies, HCM and ARVC are all familial, with over 90% of cases inherited in an autosomal dominant fashion, meaning that 50% of first-degree relatives are potentially at risk. There is now good evidence that people with these conditions can benefit from interventions such as β-blockade and cardioverter defibrillators,5 so that identification of affected family members is potentially life-saving. Cardiological and genetic investigation of the relatives of young victims of sudden death can reveal an inherited heart disease in 40% of cases.6,7 To achieve this outcome, there is a need for a coordinated multidisciplinary team approach to the postmortem investigation of sudden deaths, including expert pathology, cardiology, clinical and molecular genetic assessment.8 The TRAGADY (Trans-Tasman Response Against Sudden Death in the Young) initiative was established in 2005, and comprises a group of over 50 highly motivated Australian and New Zealand health professionals, scientists and patient advocates who share the aim of reducing sudden death in the young caused by inherited heart diseases. The group has formulated a mission statement9 and, recognising the inconsistencies in postmortem practice across Australia and New Zealand, its first aim was to create a best-practice guideline for the postmortem investigation of sudden unexpected death in the young. This guideline has now been completed and formally approved by the Royal College of Pathologists of Australasia, and is available on the College website.10 A key message for the general practitioner is that a skilled postmortem examination is imperative after such deaths. There may be pressure from the family to avoid an autopsy, but ascribing such deaths to “heart attack”, for example, when there was some previous chest pain, misses the opportunity to make a proper diagnosis and potentially save the lives of other family members. Similarly, arrhythmic syndromes such as long-QT syndrome have been falsely diagnosed as epilepsy, and the death of any young person with epilepsy should be investigated in detail. Many families have suffered several sudden deaths because of a failure to investigate completely, as described on support group websites, such as that of the Australian Sudden Arrhythmia Death Syndromes Foundation (http://www.sads.org.au). Key points of the TRAGADY best-practice guidelines are summarised in the Box. Key points of best-practice guidelines on postmortem investigation of sudden death of a young person* A full postmortem examination should be completed in all cases of sudden unexpected death in young people (0–40 years). The investigation, ideally led by a pathologist, involves a team approach, including as a minimum: A person designated to liaise with the family; Specialist cardiology involvement with the family when non-cardiac causes are excluded; and Laboratories with molecular genetics, toxicology and metabolic expertise. A detailed antecedent clinical history must be obtained. A detailed and relevant family history must be obtained. Liaison with the family should be established early and be ongoing until a cause of death is ascertained. Skilled macroscopic and microscopic examination of the organs is required, particularly of the heart (especially right ventricular muscle), and the brain. This may require some specimens to be examined by other specialists. Adequate histological material must be obtained for review or, if necessary, referral. Tissue or blood suitable for DNA extraction must be obtained (paraffin-embedded tissue blocks are not suitable). * Devised by TRAGADY (Trans-Tasman Response Against Sudden Death in the Young) and endorsed by the Royal College of Pathologists of Australasia.

Jon R Skinner MD · Johan A Duflou MMed, FRCPA · Christopher Semsarian PhD, FRACP, FCSANZ

Progressive reduction in trauma mortality and morbidity demands both peer-group and state registry evaluations, with ensuing recommendations implemented by a responsive state government trauma committee Between 1992 and 2005, the Consultative Committee on Road Traffic Fatalities in Victoria (CCRTF) conducted several studies evaluating trauma care delivery and management in consecutive victims of road traffic accidents who had received medical treatment but subsequently died.1-4 These studies found that, between 1992 and 1997, combined preventable/potentially preventable (P + PP) death rates* among patients who died after road accidents were unaltered (* respectively, survival prospects with optimal treatment assessed as ≥ 75%, and as 25%–74%).1,5 Similarly, the frequency of errors and deficiencies contributing to death was unchanged. In 1997, recommendations were made to reduce identified problems6 and, in response, the Victorian Government established a Ministerial Task Force on Trauma and Emergency Services to implement a statewide integrated trauma system to expedite early definitive care.7 Previously, while there had been one adult major trauma service (MTS) in Victoria (The Alfred Hospital), most patients were taken to their nearest public hospital, where P + PP death rates were two to three times higher than at the MTS.3 The statewide integrated trauma system, developed in stages from 2000, has a four-tiered structure, with public hospitals assigned to different service levels according to the complexity of care they provide.7 Implementation of the statewide trauma system involved the development of two additional MTSs in Melbourne (a second adult hospital managing a sufficient caseload of seriously injured patients, and a paediatric hospital) and the designation of 11 metropolitan hospitals, 9 regional hospitals and numerous primary injury services in small rural communities. Under the integrated system, major trauma patients are identified at the scene of injury according to specified anatomical, physiological and mechanistic criteria and transported to an MTS, provided that the anticipated transport time from the scene of injury will not exceed 30 minutes.7 Longer times are accepted for patients who are managed and transported by Advanced Trauma Life Support helicopter crews. Otherwise, the patient is triaged to the nearest designated hospital and, after resuscitation, stabilisation and communication with the hospital, transferred to an MTS if appropriate. Early communication with the hospital from the scene of injury facilitates immediate patient reception by a trauma team. The team is comprised of at least one emergency medicine consultant and surgical and anaesthetic registrars, with a consultant general surgeon attending within 20–30 minutes for time-critical patients. Directors of trauma services are accountable for improved management in the hospital through coordination, audit and feedback. The Victorian State Trauma Registry, established in 2001, monitors and reports on progress to the State Trauma Committee, which is responsible to the Minister for Health.8 In a recent study, the CCRTF compared management and outcomes of 245 consecutive road traffic fatality cases before (1997–1998) and 193 consecutive cases after (2002–2004) the implementation of the integrated trauma system.4 The proportion of these trauma patients with TRISS (Trauma and Injury Severity Score)9 survival prospects of ≥ 75% who subsequently died fell from 31% before to 22% after the introduction of the new trauma system. The proportion of major road trauma victims admitted to MTSs increased from 34% to 62%. More patients were attended by Advanced Trauma Life Support road and helicopter paramedics, with increased time spent by paramedics at the scene of injury and increased transport times. The per-patient number of deficiencies and errors contributing to death was significantly reduced overall, particularly in the emergency department. P + PP death rates fell from 36% to 28% (preventable deaths from 5% to 3%, and potentially preventable deaths from 31% to 25%). While P + PP death rates remained markedly lower at MTSs than at other hospitals, P + PP death rates before hospital arrival and within each of the four hospital groups did not significantly change. The overall reduction in P + PP mortality can largely be attributed to increased admissions to MTSs. Recently, the Victorian State Trauma Registry estimated that there was a 37% reduction in the likelihood of death among hospitalised major trauma patients in 2002–2006 compared with 2001–2002.8 This finding, supported by research by Cameron and colleagues reported in this issue of the Journal (→ A statewide system of trauma care in Victoria: effect on patient survival),10 is further evidence of overall improvement following introduction of the new trauma system. In response to the lack of improvement within each hospital group, the CCRTF established an interactive strategy with the trauma services. Based on the most recent CCRTF findings, consensus recommendations to counter ongoing system and clinical deficiencies were developed jointly with each trauma service.11 Persisting deficiencies in the Victorian system include the lack of Trauma Director/Coordinator appointments at many hospitals; failure to ensure compliance with protocols and guidelines; delays in communication and referral; insufficient intensive-care beds; and problems with coordination, audit and feedback.11 In addition, funding for independent peer-group review of trauma mortality has ceased. Panel studies (involving multidisciplinary peer-group evaluation of patient management), trauma registry data and population-based research indicate that mortality and morbidity are reduced following the introduction of integrated trauma systems and that continuing improvements can be achieved.12-15 Statewide trauma systems operate in all jurisdictions in Australia except for Tasmania, the Northern Territory and Western Australia (where one is pending). Independent peer-group review is currently limited to New South Wales, where some fatalities, pre-hospital care and interhospital transfer cases are evaluated. NSW and Queensland have state trauma committees. Key system weaknesses recognised by the state trauma committees of the Royal Australasian College of Surgeons include MTS caseload dilution in NSW following the development of 12 MTSs; lack of consultant staff attendance for the early management of severe trauma and critical decision making in NSW and South Australia; insufficient surgical and intensive-care beds in the Australian Capital Territory; and deficiencies in theatre access and lack of intensive-care beds and funding in Queensland. Although the initiation of statewide trauma systems in Australia has been a major advance, it is still awaited in three jurisdictions. The number of MTSs designated should allow sufficient caseload of severe injury at each MTS.16 Future quality improvement requires identification of ongoing deficiencies so that targeted countermeasures can be introduced and their effectiveness assessed. Identifying such deficiencies depends on continuing analysis of trauma registry data, complemented by independent peer review of preventable mortality to clarify factors contributing to death. Effective oversight by a state trauma committee is mandatory to ensure an adequate response to the findings of the audit process and to implement corrective actions. Meetings between audit personnel and hospital staff would further facilitate quality improvement. The creation of a national trauma council would help to coordinate and develop standardised quality assurance and improvement in trauma care delivery across all Australian states and territories. Finally, quality improvement remains dependent on the commitment of consultant staff to direct all phases of trauma care.

Francis T McDermott MD, FRACS, FRCS(Eng) · Stephen M Cordner FRCPath, FRCPA, DipCrim

The 2008 National Medicines Symposium examined the science, policy and practice of quality use of medicines The concept of quality use of medicines (QUM)1 was developed in Australia in the early 1990s to promote and support judicious, appropriate, safe and effective use of medicines, including prescription, non-prescription and complementary medicines. The QUM strategy is based on a partnership between consumers, health professionals, the medicines industry and government. Many practitioners, individuals and organisations have been working for over a decade to embed the principles of QUM into the Australian health system. These include the National Prescribing Service (NPS; an independent, non-profit organisation funded by the Australian Government Department of Health and Ageing) and the Pharmaceutical Health and Rational Use of Medicines (PHARM) Committee (which promotes, reviews and oversees the implementation of QUM strategy in Australia, and provides expert advice to the Minister for Health and Ageing and the Department of Health and Ageing). The biennial National Medicines Symposium, hosted by NPS and the PHARM Committee, provides an opportunity for all partners to meet together to share insight and experiences. The 2008 Symposium, held in Canberra from 14 to 16 May, brought together 500 delegates representing practitioners in the field, consumers, health professionals, the medicines industry, government and academics. Delegates heard from local and international speakers and saw QUM in action showcased in 118 poster presentations and 14 workshops developed around the theme QUM — the science, policy and practice. This report summarises several of the key plenary addresses that highlighted the challenges facing QUM in the 21st century. Full proceedings are available on request from infoATnps.org.au. Global challenges to quality use of medicinesTwo international speakers identified global challenges for QUM in the 21st century: confronting commoditisation of health, bridging the access gap to medicines, dealing with diversity in people, and meeting the needs of an ageing population. In her presentation, Medicines, consumers and society: trends and challenges, Professor Anita Hardon (Medical Anthropologist, Amsterdam School for Social Science Research, University of Amsterdam, the Netherlands) identified the issues faced in developing and industrialised countries. She said there is a worldwide trend towards people believing that they need both traditional and modern medicines to stay healthy and treat disease. In many developing countries, modern pharmaceuticals and traditional medicines are aggressively promoted, while all over the world regulatory processes fail to control the circulation of alternative or traditional medicines, which consumers are increasingly using to complement pharmaceutical treatment — at relatively high cost. At the same time, access to medicines is stratified: in industrialised countries, vocal patient collectives call for research on and marketing approval of better and newer medicines, with ever-increasing demands on public health resources, while in resource-poor settings, health systems fail to provide people access to essential life-saving drugs. After more than 20 years of conducting empirical research into medicines use in Africa, Asia and Europe, Professor Hardon has concluded that it is critical for science to radically reorient towards consumer needs and experiences with medicines. The colour, taste and shape of medicines, past experiences, perceptions related to the “newness” or cost of medicines, and social and economic factors all need to be taken into account. QUM, she said, must be seen in the social context of people’s lives. An ageing world: implications for quality use of medicines was the theme of Ms Jean Slutsky’s (Director, Center for Outcomes and Evidence, Agency for Healthcare Research and Quality, United States Department of Health and Human Services, Rockville, Md, USA) presentation. The challenge, she said, is to find integrated treatment strategies that meet the needs of an ageing population, especially the needs of patients with multiple comorbidities. The effects of treatment on older people are not always investigated, and current clinical guidelines often do not include recommendations for modifying treatments for older patients with and without multiple comorbidities. Understanding which medicines exacerbate a comorbidity and which treatment objectives are the most important to meet are at the core of designing a pharmaceutical treatment program that is safe, rational and beneficial, said Ms Slutsky. Innovations in drug therapies need to be evaluated to determine which represent added value, offer minimal enhancements over existing choices, fail to reach their potential, or work for some patients but not others. Consumers need to be involved to ensure that their values and preferences guide decisions about drug therapy and enable them to manage their own care. Both speakers emphasised the importance of communicating the risks and benefits of medicines to consumers. Quality use of complementary medicinesHerbal and natural remedies are our new first preference was the topic of the presentation given by Ms Margaret Williamson (Manager of Research and Development, NPS, Sydney, NSW), who is leading research to explore the use of herbal and natural medicines in Australia. In 2006, around 65% of Australians reported using herbal and natural medicines in the previous 12 months,2 an increase of 23% since 2004.3 Australians spent around $1.31 billion on these medicines in 2004.3 Herbal and natural medicines are more likely to be used by women and people who are middle-aged, have post-secondary education, are employed, or have a higher income. People most commonly report using herbal and natural remedies for promoting health and preventing illness. People with chronic or recurrent illnesses also use them to complement conventional therapy or alleviate the adverse effects of conventional treatment, or as an alternative to conventional therapy. Personal beliefs on life and health are strongly connected to people’s use of herbal and natural remedies. These beliefs include the desire to take a holistic approach to maintaining or improving health and wellbeing, wanting to exercise control over one’s own health, and perceptions that these remedies are natural, risk-free and inherently safe. Critical to the quality use of complementary medicines, Williamson said, is: building the evidence base for their safety, efficacy and quality; providing independent, accurate and accessible information for consumers and health professionals; improving “pharmacovigilance”, ensuring that these products are documented in all health records; and improving their regulation to ensure products meet appropriate quality standards. Active communities for quality use of medicinesActive community engagement was the theme of several presentations and posters. In his presentation, Revolution or evolution: how do we activate communities for QUM?, Mr Bill Bowtell (Director, HIV/AIDS Project, Lowy Institute for International Policy, Sydney, NSW) highlighted the lessons learned from the successful Australian approach to preventing HIV/AIDS that could be applied to other health issues, including QUM. This approach, he said, was based on acceptance that: evidence-based science is the basis for action; HIV/AIDS education could bring about sustained change in at-risk behaviours; high-risk groups would educate peers effectively and sustainably; government would not resort to punitive measures, sanction, isolation and quarantine; and government would tell the truth about HIV/AIDS. Communities active in QUM were honoured in the biennial QUM Awards, with two awards made in the “Community” category. Through the Good Medicines Better Health Pilot Project run by the Aboriginal Health Council of South Australia, the National Aboriginal Community Controlled Health Organisation and NPS, Aboriginal health workers are being educated and empowered to speak confidently within their own communities about medicines. The Seniors Quality Use of Medicines National Peer Education Program, developed and delivered in partnership with NPS, the Council on the Ageing (COTA) Partnership and the COTA Alliance, provides seniors with the opportunity to become better informed about medicines and improve their skills in discussing health and medicines issues with health professionals. In conclusionIs QUM an efficient use of health care resources? was the question asked by Professor Rachel Elliott (Lord Trent Professor of Medicines and Health, School of Pharmacy, University of Nottingham, UK). Economic evaluation of QUM initiatives is necessary to ensure appropriate use of health care resources, she said, and must also include the opportunity cost and the cost of inadvertent effects of QUM initiatives, remembering that even evidence-based, well thought-out policy can have unintended consequences. She also reminded delegates of the importance of understanding that, despite assumptions to the contrary, patients do not always take their medicines. Non-adherence to medicines needs to be understood and addressed if QUM initiatives are to be efficient, she said. In her closing address, Ms Barb Shea (Vice-President, Canadian Optimal Medication Prescribing and Utilization Service, Canadian Agency for Drugs and Technologies in Health, Ottawa, Ontario, Canada) congratulated Australia on its leading role on the world QUM stage. The symposium showcased the breadth of QUM projects in Australia and the diversity in the groups involved. Speakers explored the QUM challenges being faced in hospital settings, pharmacy, general practice, residential aged-care facilities and oncology, along with specific medicines issues related to veterans, children, pregnant and breastfeeding women, and people with asthma, diabetes and other chronic conditions. The broad range of delegates in attendance reflected how QUM is integrating across all health sectors and the community, nationally and worldwide.

Sharene A Jackson

Objective: To determine whether the statewide system of trauma care introduced in 2000 has resulted in improved survival for all major trauma patients in Victoria.Design, setting and participants: Population-based cohort study using data from the Victorian State Trauma Registry (VSTR), a registry of all hospitalised major trauma patients in Victoria. The study included major trauma patients with an Injury Severity Score > 15 captured by the VSTR between July 2001 and June 2006.Main outcome measure: In-hospital mortality.Results: The number of major trauma cases captured by the registry rose from 1153 in 2001–02 to 1737 in 2005–06. Adjusting for key predictors of mortality, there was a significant overall reduction between 2001–02 and 2005–06 in the risk of death for patients treated in the trauma system (adjusted odds ratio [AOR], 0.62 [95% CI, 0.48–0.80]). The reduced risk of death was also significant when road trauma cases (AOR, 0.56 [95% CI, 0.39–0.80]) and serious head injury cases (AOR, 0.62 [95% CI, 0.46–0.83]) were analysed separately. The proportion of road trauma patients definitively treated at one of the three major trauma service (MTS) hospitals in Victoria rose by 7% over the 5-year period. Direct transfers from the scene of injury to MTS hospitals rose by 8% for all cases and 13% for road trauma cases over the same period.Conclusions: Introduction of a statewide trauma system was associated with a significant reduction in risk-adjusted mortality. Such inclusive systems of trauma care should be regarded as a minimum standard for health jurisdictions.

Peter A Cameron MB BS, FACEM · Belinda J Gabbe PhD · D James Cooper MB BS, MD, FJICM · Tony Walker BParamedStud, GDipEmergHth, MEd · Rodney Judson FRACS · John McNeil MB BS, FRACP, PhD

Objectives: To examine the characteristics of adult patient attendances to emergency departments (EDs) in Perth hospitals by patients’ frequency of attendance.Design, setting and participants: A linked-data population study of adults (aged ≥ 15 years) attending all nine Perth hospital EDs between 1 July 2000 and 31 December 2006.Main outcome measures: Proportion of frequent attenders (FAs; those attending five or more times annually); and demographic characteristics, mode of arrival at the ED, disposition (admission, transfer, discharge or death), urgency and clinical conditions by frequency of attendance.Results: There was a mean of 1.5 attendances per individual per year, resulting in 1 583 924 attendances by 663 309 individuals over the 6.5 years of the study. Most patients (97.6%) attended Perth EDs fewer than five times a year. The more frequently patients attended, the more likely they were to be male, middle-aged and late-middle-aged, have self-referred, have mental and behavioural disorders and alcohol intoxication, to not wait to be assessed, and to arrive by ambulance. The groups of patients attending between 5–9 and 10–19 times per year (97.4% of FAs) had more urgent conditions, more circulatory system disease and higher admission rates than all other patients.Conclusion: Most FAs at Perth EDs present fewer than 20 times a year and have more serious and urgent illness than other patients, more often requiring inpatient services. A very small minority of patients (around 100 patients/year) attends 20 or more times a year, many with mental and behavioural disorders and alcohol intoxication not requiring hospital admission.

George A Jelinek MD, FACEM, DipDHM · Moyez Jiwa MD, MRCGP, FRACGP · Nicholas P Gibson PhD, RN, FRCNA · Ann-Maree Lynch BSc (Hons), PhD

Objective: To measure long-term survival following combined chemotherapy and radiotherapy for inoperable non-small cell lung cancer.Design and setting: Two prospective Phase I/II studies in the multidisciplinary Lung Service of a dedicated cancer hospital in Victoria, commencing in 1996 and 1997–1998.Patients: 33 patients referred for treatment of histologically or cytologically proven inoperable non-small cell lung cancer, who had no evidence of distant metastases, Karnofsky performance status > 70%, weight loss < 10%, and no prior treatment for lung cancer. Patients were followed until death or for a minimum of 9 years.Interventions: Patients in both studies were treated concomitantly with chemotherapy and radiotherapy 60 Gy in 30 fractions over 6 weeks. Chemotherapy in the first study (LURTCE) consisted of cisplatin and etoposide; in the second study (LURTCF), chemotherapy consisted of escalating doses of carboplatin and fluorouracil.Main outcome measure: Overall survival.Results: Six of 33 patients were still alive 9 years after commencement of treatment. Median survival for the whole group was 2.1 years (95% CI, 1.3–3.1 years), with 18% (95% CI, 8%–35%) of patients still alive at 5 years (plateau).Conclusion: Long-term survival can be achieved in some patients with inoperable non-small cell lung cancer treated by radical chemoradiation alone, suggesting the possibility of cure.

Nikki M Plumridge FRANZCR · Michael J Millward MBioethics, FRACP · Danny Rischin MD, FRACP · Michael P MacManus MD, FRCR, FRANZCR · Andrew Wirth FRACP, FRANZCR · Michael Michael FRACP · Kally Yuen MSc, AStat · David L Ball MB BS, MD, FRANZCR

Objective: To measure the prevalence of somatisation (multiple somatic symptoms and hypochondriasis) among Australian general practice attendees, its recognition by general practitioners, and its relationship with symptoms of depression and anxiety.Design, setting and participants: Self-reported questionnaires completed by 10 507 consecutive patients aged ≥18 years attending 340 GPs enrolled in a 6-hour national mental health program of continuing professional development who accepted invitations to participate; audit form completed by GPs for each patient during the period March 2004 to December 2006.Main outcome measures: Somatic symptom severity (measured with the 15-item Patient Health Questionnaire [PHQ-15]); hypochondriasis (measured with the Whiteley Index [Whiteley-7]; depression and anxiety (measured by the Kessler Psychological Distress scale [K10]); prevalence of “somatisers” (defined by medium to severe somatic symptom severity and hypochondriasis); GP recognition of somatisation (determined by their responses on audit forms to questions on whether patient’s complaints were most likely to have a physical or psychological explanation).Results: 18.5% of patients were classified as somatisers and 9.5% as probable cases of depression or anxiety. While 29.6% of somatisers had high anxiety or depression scores, 57.9% of people with anxiety or depression were also somatisers. Sex and age asserted significant but weak effects on psychometric scores. GPs identified somatic complaints as “mostly explained by a psychological disturbance” in 25.1% of somatisers.Conclusions: Somatisation is common in general practice, and more prevalent than depression or anxiety. While a minority of somatisers have significant anxiety and depression, most patients with depression and anxiety have a significant degree of somatisation. Recognition of depression and anxiety can be hindered by a somatic presentation and attribution. On the other hand, managing somatisation does not just involve recognising depression and anxiety, but also dealing with the health anxieties that underpin hypochondriasis.

David M Clarke PhD, FRACGP, FRANZCP · Leon Piterman MMed, FRACGP, FRCP · Claire J Byrne BSc(Behav)(Hons) · David W Austin PhD

Objectives: To ascertain changes in: women’s knowledge of the role of folic acid in the prevention of neural tube defects (NTDs); intake of folic acid among pregnant women; and prevalence of NTDs in South Australia.Design, setting and participants: Computer-assisted telephone interviews of South Australian households from 1994 to 2007 over a period encompassing a statewide folate promotion campaign (1994–1995), continuing folate promotion, as well as the introduction of voluntary folate fortification of foods (1996); ascertainment of the total prevalence of NTDs from births and terminations of pregnancy from 1966 to 2007.Main outcome measures: Changes in women’s knowledge of the role of folic acid in the prevention of NTDs; changes in the prevalence of NTDs.Results: From 1994 to 2006 and 2007, knowledge about the role of folic acid increased from 25% to 77% (P < 0.001) and knowledge that folic acid needs to be taken in the periconceptional period increased from 12% to 39% (P < 0.001). The proportion of pregnant women who increased their periconceptional intake of folate rose from 61% in 1998 to 81% in 2006 and 2007 (P < 0.001), with significant increases in the consumption of fortified cereals (from 15% to 29%) and folic acid tablets (from 37% to 64%). The total prevalence of NTDs fell from 2.06 per 1000 births in 1986–1990 to 1.23 per 1000 births in 2002–2007 (relative risk, 0.60; 95% CI, 0.48–0.74; P < 0.001).Conclusions: Folate promotion and voluntary fortification of certain foods with folic acid were associated with increased awareness of the role of periconceptional folic acid, increased folate consumption and a reduction in the prevalence of NTDs in South Australia by 40% (95% CI, 26%–52%).

Annabelle C Chan DPH, DCCH, FAFPHM · Phillipa van Essen BHSc, MPH · Heather Scott · Eric A Haan BMedSc, MB BS(Hons), FRACP · Leonie Sage RN, RM · Joan Scott RN, RM · Tiffany K Gill MAppSc, CertHealthEc, PostGradDipHlthSc · Anh-Minh T Nguyen BSc(Hons)

Objective: To describe the prevalence of neural tube defects (NTDs) in Victoria, and to evaluate women’s knowledge and awareness of the importance of folate after the introduction of voluntary food fortification.Design and setting: Descriptive study, set in Victoria, Australia, based on routinely collected data from the Victorian Birth Defects Register (VBDR) for 1998–2006, and responses by women aged 18–50 years to five questions relating to folate on the 2005 and 2006 Victorian Population Health Surveys (2314 and 2488 women, respectively). Main outcome measures: Prevalence of NTDs, and extent of women’s knowledge of the importance of folate in NTD prevention, comparing the period before and since voluntary food fortification and a folate awareness campaign.Results: The total prevalence of pregnancies affected by NTDs declined from approximately 17 to 14 per 10 000 births from 1997 to 1999 (coinciding with the period when voluntary food fortification was introduced, and a 1-year folate awareness campaign was held). It has since remained static. Over the 9-year study period, the termination of pregnancy rate was 79%, resulting in three NTD-affected babies per 10 000 livebirths. Compared with women aged 30–34 years (the reference group), those aged 20–24 years had the greatest likelihood of having a baby with an NTD (adjusted odds ratio, 1.70; 95% CI, 1.33–2.18; P < 0.001). Women aged 18–24 years had the lowest rate of folate supplement use (15.9% in 2006), while women aged 30–34 years had the highest rate (30.3% in 2006).Conclusions: There has been no further reduction in prevalence of NTDs in Victoria since 1999, and this prevalence remains well above that achievable through adequate folate intake. Accurate knowledge of folate consumption, population-based NTD prevalence data and folate awareness data are essential in monitoring the effectiveness of the mandatory fortification program to be implemented in Australia in the next 2 years.

Louise du Plessis BSc(Hons), MB ChB, FRACP · Rod W Hunt BM BS, MMed, PhD · Ashley S Fletcher BSc, MEpi · Merilyn M Riley BApplSc, GradDipEpi, Biostat · Jane L Halliday BSc, PhD

Objective: To identify current prescribing and administration practices in relation to intravenous potassium chloride (IV KCl).Design and setting: A prospective multicentre assessment of IV KCl prescribing and administration at six public hospitals (three large metropolitan hospitals, a smaller metropolitan specialty hospital, and two rural hospitals) in Victoria between August and December 2006. Data were collected for either a 4-week period or for 200 IV KCl orders, whichever occurred first, in clinical areas where concentrated KCl ampoules were available.Main outcome measures: Number and type of IV KCl prescriptions and dose administrations; method of preparation and administration of each dose.Results: A total of 888 prescriptions and 1088 administrations were assessed across the six hospitals. There were 69 different types of orders for IV KCl, varying in either concentration or volume. KCl ampoules were used in 59% of all administrations of IV KCl. In instances where the prescription matched an available premixed IV KCl infusion, the premix was used on 89% of occasions.Conclusions: There is significant variability in the prescribing and administration of IV KCl in these Victorian hospitals. New formulations of premixed IV KCl infusions may enable the removal of ampoules from patient care areas. The medical profession can play a major role in driving the adoption of consistent practice and supporting and leading this important safety initiative.

Melita A Van de Vreede BPharm, MHSM, GradDipHospPharm · Sally G Wilson BPharm, PhD, GradDipHospPharm · Michael J Dooley BPharm, GradDipHospPharm

Chronic neonatal lung disease (CNLD) is defined as a supplemental oxygen requirement beyond 36 weeks’ postmenstrual age, with more severely affected infants requiring oxygen beyond a full-term-equivalent age. Low-flow supplemental oxygen facilitates discharge from hospital of infants with CNLD who develop hypoxia in air. There is a lack of data on the most appropriate minimum mean target oxygen saturation (Spo2) level. Reflecting a variety of clinical practices and infant comorbidities (frequency of oxygen desaturation, presence of pulmonary hypertension, retinopathy of prematurity, and adequacy of growth), the minimum mean target range for Spo2 during overnight oximetry should be 93%–95%. The effect of supplemental oxygen on carbon dioxide retention should be considered before deciding on an oxygen flow. Most infants with CNLD are not ready for discharge until their supplemental oxygen requirement is ≤ 0.5 litres per minute delivered through a nasal cannula. The safety of short-term disconnection from supplemental oxygen should be assessed before discharge. Assessment of oxygenation during sleep with continuous overnight oximetry or polysomnography is recommended when weaning infants from supplemental oxygen. Discontinuation of oxygen therapy is based on clinical assessments and documentation of adequate oxygenation in room air. There is limited objective evidence on which to base recommendations.

Dominic A Fitzgerald MB BS, PhD, FRACP · R John H Massie MB BS, PhD, FRACP · Gillian M Nixon MB ChB, MD, FRACP · Adam Jaffe MD, FRCPCH, FRACP · Andrew Wilson MB BS, PhD, FRACP · Louis I Landau MD, FRACP · Jacob Twiss MB ChB, FRACP · Greg Smith MB ChB, FRACP · Claire Wainwright MB BS, MD, FRACP · Margaret Harris MB ChB, FRACP

Since its election, the Rudd Labor Government has created 10 new advisory bodies in the health portfolio, in addition to the 100 or more that were already established. An expansive and devolved advisory system could improve the health policy-making process, but only if it is integrated into the processes of government. We outline eight simple and practical measures that, if implemented, would make Australia’s health advisory system more transparent and effective. Past experience shows that the most important factor governing the impact of health policy advisory bodies is political leadership.

Lesley M Russell BSc(Hons), BA, PhD · Anne-marie Boxall BApplSc(Physiotherapy), MPH(Hons), PhD · Stephen R Leeder MB, PhD, FRACP

In April 2008, the Australian Government established the National Preventative Health Taskforce to develop a National Preventative Health Strategy by June 2009. The Strategy will provide a blueprint for tackling the burden of chronic disease currently caused by obesity, tobacco and excessive consumption of alcohol. The Taskforce has produced a discussion paper, Australia: the healthiest country by 2020. It presents a wide range of options, some of them contentious, to achieve this ambitious target.

A Rob Moodie MB BS, FAFPHM, MPH

A 62-year-old woman presented with left frontotemporal pain, scalp tenderness and raised levels of inflammatory markers. Temporal arteritis was considered likely, and symptoms resolved with prednisone therapy. This delayed diagnostic bone biopsy until a soft tissue abscess formed, and Pott's puffy tumour associated with Prevotella osteomyelitis of the frontal bone was diagnosed. This case highlights the value of early histopathological examination, and is a reminder of a condition seen frequently in the pre-antibiotic era. Clinical recordA 62-year-old woman was referred with a 6-month history of spontaneous left frontotemporal scalp pain. Initially, the pain was associated with a soft swelling over the scalp and resolved within 6 weeks. It recurred 4 months later, without associated swelling, localised to the left frontal region and became progressively more severe, disturbing the patient’s sleep. She remained systemically well and had no history of fever, sinusitis, dental infection or diabetes mellitus. Investigation by the patient’s general practitioner revealed raised erythrocyte sedimentation rate (130 mm/h; reference range [RR], < 20 mm/h), C-reactive protein (66 mg/L; RR, < 3 mg/L) and alkaline phosphatase (121 U/L; RR, 25–100 U/L). There was no paraprotein in the serum or urine. A plain radiograph revealed apparent osteolysis (Box, A) and a bone scan revealed intense uptake of technetium-99m-methylenediphosphonate in the skull (Box, B). A computed tomography (CT) scan confirmed diffuse lucency in the left frontal bone, without evidence of underlying sinusitis. These radiological and scintigraphic features suggested osteoporosis circumscripta cranii (the lytic phase of Paget’s disease of the skull), although the raised inflammatory markers were inconsistent with this diagnosis. A specialist opinion was sought. At review, the patient was afebrile and results of physical examination were normal except for marked tenderness over the left temporal region, raising the possibility of giant cell arteritis. Urgent temporal artery biopsy was arranged while the patient began oral prednisone therapy (80 mg per day). Her condition improved dramatically — the pain was alleviated and levels of inflammatory markers decreased — but no histological evidence of vasculitis in the temporal artery was found. A presumptive diagnosis of biopsy-negative giant cell arteritis was made, and oral corticosteroid therapy was continued with a tapering regimen. Prophylactic trimethoprim–sulfamethoxazole (320 mg/1600 mg twice per week) was administered to prevent Pneumocystis infection; concurrently, bisphosphonate therapy was begun (40 mg alendronate per day) for suspected osteoporosis circumscripta cranii. The occurrence of two separate pathological processes was considered improbable, and a skull biopsy for definitive diagnosis was discussed with the patient. However, she was reluctant to undergo further invasive testing because of the rapid symptomatic improvement. She was monitored clinically and biochemically at regular intervals while the prednisone dose was reduced over the following 6 months. Throughout this period, she remained pain-free and systemically well, with normal levels of inflammatory markers. Six months after initiation of corticosteroid therapy, while the patient was taking 10 mg of prednisone per day, she developed a tender fluctuant swelling over the left frontal region of the scalp. The swelling enlarged rapidly, and a CT scan revealed a 6 × 11 × 4.5 cm collection overlying the left frontal bone (Box, C). Neurosurgical consultation and exploration of the swelling were arranged. During exploratory surgery, copious malodorous pus was drained and a biopsy sample of the underlying skull, which appeared discoloured, was taken. A pure growth of Prevotella sp., an anaerobic gram-negative rod-shaped bacterium, was isolated on culture of the pus. The organism was identified as either Prevotella melaninogenica or Prevotella oralis. Histopathological examination of the biopsy sample revealed infiltration of the marrow spaces by neutrophils (Box, D), and the presence of plasma cells with admixed fibrosis (Box, E), consistent with concurrent acute and chronic osteomyelitis. The diagnosis was revised to Prevotella osteomyelitis of the frontal bone with associated soft tissue abscess (Pott’s puffy tumour). Prednisone and alendronate were withdrawn, and the patient was treated with intravenous antibiotics for 6 weeks. As the organism was penicillin-resistant, clindamycin (600 mg four times per day) was administered for 2 weeks, and this was followed by ertapenem (1 g per day) as outpatient therapy. The intravenous antibiotics were combined with oral metronidazole (400 mg three times per day) and were followed by treatment with oral clindamycin (300 mg four times per day) for another 6 weeks. The patient’s condition responded rapidly to medical management and she remained clinically well with normal levels of inflammatory markers at 12-month follow-up. A subsequent CT scan of the calvaria showed resolution of the lytic changes without bony sequestrum. DiscussionAnaerobic organisms predominate in head and neck infections, occurring in a mixed growth in more than 90% of dental, oral and neck space infections.1 Clinically relevant anaerobes include the gram-negative rods Bacteroides, Prevotella, Porphyromonas, Fusobacterium and Bilophila, and gram-positive rods (eg, Clostridium, Actinomyces and Propionibacterium) and cocci (eg, Peptostreptococcus).1 Despite frequently being found in mixed bacterial populations, Prevotella sp. was isolated as a pure growth in our patient. Although trimethoprim–sulfamethoxazole therapy (used as Pneumocystis prophylaxis in our patient) is generally thought to lack useful activity against anaerobes,1 it may have suppressed the infection. Osteomyelitis of the skull is uncommon; recognised clinical syndromes include frontal bone osteomyelitis secondary to frontal sinusitis, and skull base osteomyelitis associated with malignant otitis externa. Skull osteomyelitis may also result from direct inoculation during surgery or occur in association with retrograde septic thrombophlebitis.2 Haematogenous seeding of bacteria in the skull is rare. Although our patient had no clinically or radiographically recognised sinusitis or history of dental instrumentation or infection, it is likely that the organism originated in the oral cavity or frontal sinus. The duration of the history suggests that chronic osteomyelitis may have accounted for our patient’s initial symptoms, but, if present, Paget’s disease of the skull may have predisposed to bacterial seeding. Paget’s disease is a reported risk factor for osteomyelitis of the jaw.2 Pott’s puffy tumour is a complication of frontal osteomyelitis that was first described by Sir Percival Pott in 1760.3 It appears as a circumscribed swelling on the forehead, representing a subperiosteal abscess that forms when infection breaks through the frontal bone.2 Epidural abscess, subdural empyema, brain abscess and cortical vein thromboses have been described in association with Pott’s puffy tumour. It was predominantly seen in children and adolescents before the widespread availability of antibiotics.2,4 In our patient, the administration of corticosteroids masked the underlying anaerobic infection until dose tapering permitted an abscess to form. Our patient illustrates a diagnostic challenge. It seemed unlikely that two unrelated diagnoses would account for a single presentation, but the prompt clinical response to corticosteroids led to a delay in diagnostic bone biopsy. The final diagnosis of frontal bone osteomyelitis with subperiosteal abscess is a reminder of a condition seen commonly in the pre-antibiotic era. Radiography and computed tomography (CT) scans, and bone biopsy specimens, of a patient with Pott’s puffy tumour associated with Prevotella osteomyelitis of the frontal bone A: Plain radiograph of the skull before corticosteroid therapy, showing patchy osteolytic areas in the frontal cranium. B: Delayed skull spot views on a bone scan before corticosteroid therapy, showing accumulation of technetium-99m-methylenediphosphonate. C: CT scan of brain (using intravenous iopamidol contrast medium) after 6 months of corticosteroid therapy showing a large collection over the left frontal bone. D: Bone biopsy specimen taken after 6 months of corticosteroid therapy, showing infiltration of the bone marrow spaces by neutrophils and scattered osteoclastic giant cells adjacent to the bony trabeculae, indicating active inflammation (haematoxylin and eosin stain; original magnification, × 400). E: Bone biopsy specimen taken after 6 months of corticosteroid therapy, showing plasma cells with admixed fibrosis, indicating chronic inflammation (haematoxylin and eosin stain; original magnification, × 400).

Lyndal J Tacon MB BS · Jonathon F Parkinson MB BS · Bernard J Hudson FRACP, FRCPA · Janice M Brewer MB BS, FRCPA · Nicholas S Little MB BS, FRACS · Roderick J Clifton-Bligh FRACP, PhD

A 50-year-old man presented with cough, wheeze, intermittent haemoptysis and progressive dyspnoea. He had no relevant past history. On examination, he was hypoxic but haemodynamically stable. Results of routine blood tests, including full blood count, urea and electrolyte levels, and erythrocyte sedimentation rate, were within normal ranges. Pulmonary function tests confirmed severe airway obstruction and diffusion impairment. A chest x-ray revealed multifocal areas of nodularity and consolidation in both lungs (Figure, A). A computed tomography scan showed thickening and calcification of the bronchial walls with multiple cavities and nodules throughout both lungs (Figure, B). A virtual bronchoscopy revealed irregular narrowing of the right main bronchus (Figure, C; arrows), and a bronchial biopsy confirmed pulmonary amyloidosis (light-chain type). Pulmonary amyloidosis occurs in three forms: tracheobronchial (the most common, which is limited to central airways and which this case exemplifies), diffuse and adenopathy-associated.1 Nearly all cases are of the light-chain type.2 Treatment is difficult and controversial; repeated bronchoscopic resection is conventional,3 but the role of external beam radiotherapy in tracheobronchial amyloidosis has also been described.4

Kshitij Mankad · Michael J Darby

Albert (“Bert”) Bencsik was born on 15 October 1931, the only child of Hungarian immigrants recently arrived in Australia. The family lived in Rose Bay, and Bert attended Woollahra primary school and Sydney Technical High School, where he was a prefect. After graduating from the University of Sydney in 1956, Bert did his residency at the Mater Misericordiae Hospital, Crows Nest. In 1960, he travelled as a ship’s surgeon to the United Kingdom, where he worked in Portsmouth, London and Edinburgh and became a Fellow of the Royal College of Surgeons of Edinburgh in 1964. Returning to Sydney after completing his Fellowship, he worked as a Surgical Registrar at St George Hospital from 1964 until 1966. During this time, he was a founding member of the Resident Medical Officers Association and an Honorary Medical Officer for the Australian Racing Drivers Club. In 1967, Bert joined the Australian orthopaedic training scheme, and in 1970 commenced private orthopaedic practice in Chatswood and Kogarah, and later also in Canterbury and Bankstown. He was an Honorary Medical Officer, subsequently Visiting Medical Officer, at St George and Canterbury hospitals. He developed a special interest in hand surgery and was secretary of the New South Wales Hand Surgery Association. Together with Bill Cumming, almost 40 years ago, he founded the St George Hospital hand clinic, which gradually developed into a first-class trauma unit. He was strongly involved in the St George Hospital Orthopaedic Skills Laboratory, which was the first and largest fully equipped such facility in the world. Positions Bert held included honorary convenor of the Papua New Guinea orthopaedic registrar training program, examiner for the Australian Orthopaedic Association Board of Studies, and founding honorary secretary of the Med-Law Association of NSW. Bert was a careful, unhurried, caring clinician whose demeanour instilled great confidence in his patients. After retiring from elective surgery in 1997, he continued to consult, particularly in medicolegal matters. In his leisure time, Bert was an avid gardener who designed and cultivated a beautiful garden at his home, “Ysabel”, in Hunters Hill. He was a lover and connoisseur of fine wines and food, and delighted in attending meetings of the Tipplers Wine Club, of which he was a founding member. He also had more than 70 letters, on a wide range of subjects, published in the Sydney Morning Herald from 1964 to 2007. Bert died on 26 June 2008 of acute renal failure and prostate carcinoma. He is survived by his children Michael, Susan, Catherine and Nicholas, and seven grandchildren, to whom he was devoted.

William J Barnett

Becoming a doctor. Surviving and thriving in the early postgraduate years. Jo Burnand, editor. Sydney: Churchill Livingstone, 2007 (xii + 216 pp). ISBN 978 0 729 53758 2. This compact all-Australasian volume is written by experts in their field who are both knowledgeable and passionate about junior doctor education in Australia. The topics covered are all those that later-year medical students and early-year postgraduate doctors need information about when planning their initial career movements (such as transition from student to intern/junior hospital doctor, career planning and organising, what to do when things go wrong, and having a family or a life). The book is not as appealing to the expected audience as it could have been. It is written by doctors and other experts who have not been new medical graduates any time recently; they write from authority rather than from the recent graduate’s perspective of survival. Although the chapters are all very relevant, they are written in a uniformly dense style with few tables and charts and no cartoons — there isn’t an instant visual appeal to Gen Y readers. The appendices are useful, especially the Junior Doctors Curriculum Framework, but this material (along with much of the material on orientation and how the health service works) is available on health service and hospital websites, which are possibly less likely than printed material to become out of date. I see this as a useful reference book for medical education officers and supervisors of training, particularly those new to their positions. It is valuable for ideas on orientation programs, education sessions and assistance when confronted by junior doctors exhibiting stress at work. It should also be a staple in medical school and hospital libraries for students and junior doctors to consult in their spare moments.

Eleanor M Flynn

General anatomy. Principles and applications. Norman Eizenberg, Christopher Briggs, Craig Adams, Gerard Ahern. Sydney: McGraw-Hill, 2007 (ii + 258 pp + CD-ROM). ISBN 978 0 07 013414 0. At first glance, I was nonplussed. Yet this is much more than a simple anatomy text. Compared with classical texts, it’s light at only 700 g (Martini’s latest Human anatomy weighs 3.2 kg). It is spiral-bound so that it opens flat anywhere. And it’s no intellectual lightweight. Written by a group associated with the Department of Anatomy and Cell Biology at the University of Melbourne, General anatomy is aimed at students in the health professions, and is clearly amenable to both problem-based and traditional discipline-based courses. My immediate impression was that it looked more like cartoon anatomy than the “real thing”, and some of my anatomist colleagues were dismissive. However, when I showed it to a medical student the immediate response was, “Where can I get it? This is just what I’ve been looking for!” The more I explored, the better I liked it. The “cartoon” diagrams are actually excellent snapshots of key concepts and processes that integrate anatomy and function in an imaginative, logical and effective manner. The text comes supplemented with a prize-winning audiovisual CD, “an@tomedia”, and is linked to a good website (http://www.anatomedia.com). My heart sank when I started the CD on a Mac as it defaults to the Classic operating system, which of course is not supported on the latest generation of computers. However, it booted happily in OS 10.5. I can’t advocate this as a stand-alone anatomy text: the coverage is too superficial. As a back-up learning resource, however, it’s superb. The index is rather sketchy, but the book is laid out so logically that it’s easy to find what you are looking for, and there’s a lot of medical information there. I’ll definitely keep this: my student friend can buy her own!

James M Cummins

Incorrect drug dose: In the Clinical Update “Avoiding common problems associated with intravenous fluid therapy”, in the 3 November 2008 issue of the Journal (Med J Aust 2008; 189: 509-513), an incorrect drug dose was printed. On page 512, at the base of the first column, the intravenous dose of desmopressin to control urinary free water loss in central diabetes insipidus was given as 2–4g. It should have been 2–4µg. Both the HTML and PDF versions of the article have been corrected.

Andrew K Hilton · Vincent A Pellegrino · Carlos D Scheinkestel

To the Editor: Impacts of alcohol consumption on health and wellbeing in remote Indigenous communities are well documented. In response, governments have applied supply and demand reduction programs, including the “Meeting Challenges, Making Choices” program, which has lowered the rate of serious injury. Although a pattern of heavy, episodic drinking has been documented, the nature of physical dependence in relation to acute alcohol withdrawal syndrome is uncertain. We report the results of sudden, temporary removal of alcohol in a small Indigenous community. In a remote Queensland Indigenous community (population, 1021) with one licensed premises, patterns of extreme drinking (30 standard drinks per session) are commonly seen around paydays. In 2008, the Queensland Government withdrew the sole liquor trading licence with 72 hours’ notice because of a breach of licensing laws. The licence was subsequently renewed after several months. During this time, there was no significant access to alternative (illegal) sources of alcohol within the community, as the prohibition against bringing alcohol into the community (initiated in 2003) was strictly enforced by police. Health services in this community comprised a primary health care centre (PHCC) with Queensland Health resident nursing staff, Royal Flying Doctor Service medical staff on weekdays (the principal doctor was S A M), and visiting specialists provided by both organisations, including a psychiatrist (E H). When the closure was being arranged, Queensland Government authorities requested that these health providers establish a process to treat any patients who developed acute alcohol withdrawal syndrome; this was monitored by S A M. Four weeks after the sudden cessation of alcohol availability, PHCC staff did not notice any outmigration of regular drinkers, and no patients presented with acute alcohol withdrawal syndrome. These findings are consistent with the anecdotal experience of E H, who has not encountered any cases of withdrawal delirium in this community over the past 16 years. By contrast, in recent years E H has observed several cases of withdrawal symptoms from cannabis use in this community, as seen previously in remote Northern Territory Indigenous communities.5 Our results suggest that people can develop physiological or psychological tolerance for heavy episodic drinking, which may be a function of adaptation to the intermittent nature of financial resources. This finding removes a potential health-related impediment preventing governments from considering sudden cessation of legal alcohol supply in these or similar environments.

Stephen A Margolis · Valmae A Ypinazar · Alan R Clough · Ernest Hunter

To the Editor: Urinary stones are very common, with a cumulative lifetime incidence of 5%–15% and a recurrence rate of about 50%.1 Many new treatment techniques have been developed, but availability, particularly in public hospitals, is variable. The Greater Metropolitan Clinical Taskforce2 assessed patterns of treatment in patients requiring urological consultation who presented to the emergency departments (EDs) of 12 New South Wales public teaching hospitals in major centres that had a specialty urology registrar. Between February and September 2007, the urology registrar or specialist completed a survey on consecutive patients presenting with urolithiasis who agreed to participate. The survey contained questions on patient demographics, the position and size of the stone, and the preferred treatment option. One of us (J W H M) conducted a telephone interview with each patient to obtain details of treatment, and follow-up interviews at 3-monthly intervals (until treatment was completed or the study ended) to determine the outcome. Ninety-two patients entered the study: 64 men (mean age, 50.4 years) and 26 women (mean age, 47.8 years) (sex was not reported for two patients). Thirty-seven patients were subsequently treated in the public system, and the remainder in the private system, either using private health insurance or at their own expense. The preferred treatment option of the treating medical officer, usually the urology registrar, was nominated: non-operative (spontaneous stone expulsion) with or without calcium-channel blockers, 13 patients (received by 6); rigid ureteroscopy with grasper or lithoclast, 21 patients (18); rigid ureteroscopy with laser, 4 patients (4); flexible ureteroscopy with laser, 17 patients (2); percutaneous nephrolithotomy, 3 patients (3); extracorporeal shock wave lithotripsy, 6 patients (2); or “other”, 28 patients — of whom stent was specified in 24 (23). The preferred treatment option was not used for 34% of patients because it was not available at the hospital. The mean duration of treatment (defined as the period between initial ED presentation and final treatment episode) for patients with pelvi-ureteric or upper ureteric stones requiring more than one treatment episode is shown in the Box. Thirty-nine patients had stents inserted in the ED, of whom four did not reach definitive management by the end of the study. Of the remaining 35, 20 were public patients and 15 were private patients. Fourteen had stents in situ for more than 3 months and required a change of stent before initiation of definitive treatment to avoid encrustation; 12 of these patients had treatment in the public system. Despite the relatively small number of participants in this study, its findings on access to timely treatment for public patients should not be ignored. Management of kidney stones was heavily influenced by insurance status. Ureteric stents are intended to be temporary, but patients treated in the public system who had a stent inserted at initial presentation had a 60% (12/20) chance of still having it 3 months later, thus requiring a change of stent before definitive intervention — an unnecessary procedure that increases hospital re-admissions. Patients would be treated more efficiently and effectively with more timely access to appropriate resources. This is an unacceptable burden of morbidity for patients. Urgent action is required to improve the current state of care for public patients with kidney stones in NSW. Duration of treatment of public and private patients with a pelvi-ureteric junction or upper ureteric stone who required more than one treatment episode* Public patients (n = 18) Private patients (n = 18) Mean duration of treatment in weeks (95% CI) 18.3 (12.9–23.7) 6.2 (3.0–9.4) Range (weeks) 3.0–49.5 0.6–25 Difference in weeks (95% CI) 12.1 (5.5–18.7) P < 0.001 * Up to four treatment episodes.

Finlay Macneil · James W H Macneil · Kylie L Fraser · Andrew J Brooks

To the Editor: The Australian Transport Council should be commended for approving the National Transport Commission’s revised road rules for the safety of children in motor vehicles.1 A key requirement is that children aged 4–7 years are to be restrained in an approved forward-facing child restraint or booster seat. It is expected that such changes, once enacted by states and territory governments, will result in fewer children being injured and killed. In a letter in the 4 August issue of the Journal, Zurynski and colleagues argued that these changes will bring Australian rules closer to — but nevertheless fall short of — overseas jurisdictions, where children up to 12 years of age or 145 cm in height must be restrained in booster seats.2 Notably, a wider selection of booster seats is available in these jurisdictions, including seats suitable for children weighing up to 36 kg. In contrast, the Australian/New Zealand Child Restraint Standard (AS/NZ 1754) stipulates that an “approved booster seat” is one that has a maximum design weight threshold of 26 kg.3 Mandatory consumer information notes that booster seats are “to be used only with lap-sash seatbelt or with a seatbelt and child harness for a child weighing from 14–26 kg”, and that they are not to be used if the child’s eye level is above the top of the booster back, or above the top of the car seat back or headrest when restrained in the booster seat.3 The matter of children exceeding the maximum weight threshold of 26 kg while failing to meet the transition height to adult seatbelts is far from trivial. Previous research published in the Journal found that about 50% of 7-year-olds whose height fell between 100 cm (the upper recommended height for child car seats) and 145 cm (the recommended seatbelt transition height) exceeded 26 kg, with only 27% having an age- and sex-adjusted body mass index > 25 kg/m2.4 Consequently, due to the current range of approved booster seats available in Australia, children may be placed at some unquantified risk in the event of a crash, as optimal protection above this weight threshold cannot be guaranteed. Further compounding this scenario is that pursuant to r266 of the Australian Road Rules, if a child “cannot safely be restrained as required . . . because of his or her height or weight”, the use of a seatbelt may be deemed acceptable.1 To avoid this scenario, it is essential that booster seats with a higher maximum weight threshold be made available in Australia as soon as practicable.

Michael P Fitzharris · Diana M Bowman

To the Editor: Despite expert recommendation, Australian states have yet to enact legislation requiring use of child restraints beyond the age of 12 months. Our analysis of police crash records and linked hospital separation data for the period July 2000 to June 2001 in New South Wales found that a large proportion of children who were hospitalised following motor vehicle accidents were reported by police as having used adult (standard) seatbelts at the time of injury (Box). It is of particular concern that over 80% of 5–8-year-olds in this cohort were using standard seatbelts rather than child restraints (eg, booster seats). This pattern of premature “graduation” to seatbelts has also been reported in general populations of child motor vehicle passengers both overseas1 and in Australia,2 and also in presentations of child motor vehicle passengers after a crash to a NSW hospital’s emergency department.3 Child restraints are specifically designed to provide crash protection for children’s anthropometrical dimensions. Standard seatbelts are not designed to accommodate children, so they are unlikely to achieve the good fit to rigid body parts required for safety. Consequently, use of standard seatbelts by young children allows more head excursion during a crash, thereby negating their primary goal of protecting against central nervous system injury, and potentially causing Chance fractures and abdominal injuries.4 Our results provide further evidence that such seatbelt use may not protect, or may even cause injuries, during a crash. Child road trauma is largely preventable or controllable with the use of appropriate child restraints, including booster seats. A cost–benefit analysis showed that the use of booster seats produced a benefit–cost ratio for road trauma prevention of 9.4 (US$1854/US$197).5 To prevent child road trauma in Australia, all child motor vehicle passengers should use appropriate child restraints. Australian child road safety stakeholders recommend that child motor vehicle passengers use appropriate restraint systems according to their height, weight and age when travelling on road. Our findings provide further justification for proposed legislative changes that would require the compulsory use of appropriate child restraints for child motor vehicle passengers. Child restraint use among children (0–8 years) hospitalised for injury after a motor vehicle accident, compared with that of the general population, New South Wales Hospitalised children* General population† Restraint use 0–4 years 5–8 years Total 0–4 years 5–8 years Total Child restraint 9 (22%) 0 9 (10%) 295 (94%) 70 (31%) 365 (68%) Adult seatbelt 11 (27%) 42 (82%) 53 (58%) 12 (4%) 153 (67%) 165 (31%) Unknown/ no restraint 21 (51%) 9 (18%) 30 (33%) 6 (2%) 4 (2%) 10 (2%) Total 41 (100%) 51 (100%) 92 (100%) 313 (100%) 227 (100%) 540 (100%) * Linked hospital and police data from July 2000 – June 2001 were accessed from the NSW Injury Risk Management Research Centre. Case selection is based on corresponding codes in the International Classification of Diseases, 10th revision, Australian modification, 2nd edition. † Based on a telephone survey conducted in NSW during 2005–2006.

Wei Du · Caroline F Finch · Lynne E Bilston

To the Editor: Samuel and colleagues’ article on the ethics of umbilical cord blood (UCB) banking1 reflects much of the misinformation and bias that bedevil this debate. They argue against storage of autologous stem cells from UCB for a variety of contradictory, paternalistic or ideologically driven reasons. The indication for autologous UCB storage is in anticipation of developments in regenerative medicine, an exciting field that holds great promise; it is not in anticipation of transplantation for malignancy, which is unlikely to occur. Samuel et al acknowledge these points, yet base their criticism of autologous storage on the latter indication. Next, they state that autologous stem cells can be easily harvested at any time in life. Perhaps, for use in transplantation; but cells obtained later in life are likely to be of little use in regenerative medicine. Capacity for in-vitro manipulation declines with age. Third, they argue that the two alternatives of public and private UCB storage are mutually incompatible — “public good or private benefit” (my emphasis). Australia’s three public banks are close to achieving the desired number of cords (about 20 000) needed for transplantation medicine in the non-Indigenous population.2 There is no shortage, and certainly no shortage of potential donors. Why argue against autologous storage as if there is? Fourth, the authors disapprove of the for-profit motive in private-sector medicine. That may be their ideological position, but it is paternalistic to impose that view on the rest of us. Can parents not make up their own minds on the value of autologous storage? At $2000 upfront and $150 a year, storage is not so expensive that “only a small proportion of the population are able to afford [it]”. I remind readers of media reports that the Australian Government’s Baby Bonus (now $5000) was often used to purchase luxury items such as flat-screen televisions rather than being spent on the baby’s needs.3 The authors are correct in one respect: some (but not all) private UCB banks have been deliberately deceptive and misleading in their marketing, and, in so doing, have been predatory and exploitative. However, it does not then follow that parents cannot access sound and sober health advice in the marketplace. The public versus private UCB storage debate does have an ethical dimension, but not this one. This debate is really just a turf war.

David E Roberts

In reply: Roberts asserts that we are biased, paternalistic and driven by an ideological objection to private umbilical cord blood (UCB) storage. While this is impressive rhetoric, it bears little resemblance to the points made in our article.1 Contrary to Roberts’ assertion, we do not object to private UCB storage. Our primary concern is that marketing campaigns make misleading or grandiose claims about the possible application of privately stored UCB in cancer care and regenerative medicine. For, although stem cell research does have great promise, it remains clinically unproven in the management of degenerative conditions. Offering hope of cure or amelioration of illness based on scientific speculation is enormously problematic, especially when directed at vulnerable parents concerned about their unborn child. While some private UCB banks take great care to avoid deliberate deception, many do not.2,3 We agree that parents should be able to decide for themselves how and if to store their child’s UCB, but they need accurate information to do so. Finally, Roberts asserts that there is no shortage of public UCB units or donors. In reality, there is a vast shortage of UCB units available to ethnic minority and Indigenous patients.4 North Caucasian donation also needs to be maintained, particularly as the impact of double-cord transplantation becomes apparent.4

Gabrielle N Samuel · Ian H Kerridge · Tracey A O’Brien

To the Editor: I have read every issue of the Journal since graduating in 1953. In my opinion, one of the best articles I’ve seen is Dawn DeWitt’s story, “I went to work with a ‘cold’ ...”.1 Dr DeWitt’s dilemma mirrors that of the average doctor precisely. Her “solution” gives us a good dose of commonsense that we seldom hear. In my time as a general practitioner, I have given thousands of doses of influenza vaccine; but I have never had the flu or pneumonia shot myself (nor has my wife — a registered nurse). I took 2 weeks off duty in 1971 with a “cold”, when I simply flaked out on the floor. A corneal transplant and transurethral resection of the prostate were done while “on vacation”. Luckily, I no longer have the dilemma of whether or not to go to work when I am sicker than my patients, but I will have the flu shot this week anyway. Thanks Dawn.

John F Knight AM

Bullying behaviour Children who are bullied are at greater risk of developing psychosomatic and social adjustment problems than uninvolved children, according to the results of an Italian study. The cross-sectional study of 565 primary school children assessed responses to questionnaires measuring bullying, victimisation and psychosomatic complaints. Children were classified as “bullies”, “bully victims”, or “victims of bullying”. Teachers supplied ratings of each child on a strengths and difficulties scale. Victims and bully victims had a higher risk of conduct symptoms and hyperactivity, with victims also reporting more symptoms with peers. All groups of children involved in bullying had a higher risk of psychosomatic symptoms, but interestingly, bullies manifested the fewest adjustment problems. The author concludes that health assessments of paediatric patients should include evaluation of peer victimisation. J Paed Child Health 2008; 44: 492-497 Flu fighters Immunising pregnant women against influenza may result in significant health benefits for both the women and their infants, according to a study carried out by US and Bangladeshi researchers. A total of 340 pregnant mothers were randomly assigned to two groups, receiving either an influenza vaccine or a pneumococcal vaccine (the control group). Mothers were followed up weekly until 24 weeks after birth, and sick infants were tested for influenza antigens. Fewer cases of confirmed influenza were seen in the infants of mothers immunised against influenza, with the vaccine reducing proven influenza by 63% in infants up to 6 months of age. The immunised mothers also showed a significant reduction in the rate of febrile respiratory illness. The researchers comment that vaccination of pregnant women against influenza may prove beneficial, particularly in areas with limited financial resources. N Engl J Med 2008; 359: 1555-1564 Vitamin B and Alzheimer’s A regime of high-dose vitamin B supplementation does not appear to slow the decline of cognitive function in patients with Alzheimer’s disease (AD), say US neuroscientists. Working with the previously observed association between high homocysteine levels and AD, researchers set out to find whether the homocysteine-lowering properties of vitamin B could be translated into a beneficial effect on people with mild to moderate AD. The trial involved 340 participants who were randomly assigned to two groups; one of which received high-dose vitamin B supplements and the other a placebo. The main outcome measure was change in the cognitive domain of the Alzheimer’s Disease Assessment Scale. Despite the effectiveness of vitamin supplementation in reducing homocysteine levels overall, no difference in the cognitive score was observed between the groups. Adverse events involving depression were more common in the active treatment group, a result which the authors found surprising, and which they felt warranted further investigation. JAMA 2008; 300: 1774-1783 AAA in women Clinically relevant events such as repair and rupture of abdominal aortic aneurysm have been studied in a large prospective observational cohort study of postmenopausal women.1 In an analysis of potential risk factors for abdominal aortic aneurysm events, over 161 000 postmenopausal women were followed up for a mean of 7.8 years. Events were strongly associated with smoking and age in particular, but also with height, hypertension and coronary and peripheral vascular disease. A negative association was noted with diabetes, a finding also shown in men in previous studies. There was also an apparent negative association with hormone replacement therapy, a finding that the authors suggest needs further consideration. An accompanying editorial suggests that the results of this large study are significant, as although abdominal aortic aneurysm is less common in women, mortality after repair is greater, and the prognosis is worse in women.2 1 BMJ 2008; 337: a1724 2 BMJ 2008; 337: a1894

Tanya Grassi

Med J Aust 2008; 189 (10 Suppl).