Volume 189 Issue 3

What is a reasonable approach to management of women with pelvic pain? Pelvic pain in women is as common as the common cold, it seems. Certainly that is the impression one is left with after reading the article by Pitts et al on the prevalence and correlates of pelvic pain in Australian women. Pitts and colleagues found that 72% of women experienced dysmenorrhoea and only one in four women did not report any kind of pelvic pain.1 A systematic review of international studies reported a similar prevalence of dysmenorrhoea and pelvic pain.2 Is the experience of pelvic pain, particularly dysmenorrhoea, just a normal part of life? If this is the case, then we need to ask how clinicians should most appropriately respond to the many women presenting for assistance with chronic pelvic pain. What proportion of women with pelvic pain will have underlying pathology? Most studies of women with dysmenorrhoea suggest that endometriosis is present in 30%–40% of cases.3 But the pain felt by women during menstruation may be no less severe than the pain experienced by women with pathology. Period pain can lead to lost days from school or the workplace and may have a considerable impact on daily living. Which women with pelvic pain should be referred for further investigation with laparoscopy? Common sense suggests that women who warrant further investigation are those for whom empirical approaches (such as suppression of the menstrual cycle) have failed and those who have symptoms at the severe end of the spectrum. The guidelines of the Royal College of Obstetrics and Gynaecology in the United Kingdom and the consensus statement of the American College of Obstetrics and Gynecology support the use of an empirical approach before laparoscopy.4-6 Such an approach has been justified on the basis of the risks of the procedure and the possibility that pain will not be relieved even if surgery is undertaken, and that ongoing medical therapy will be necessary.7 Additionally, there would be the potential for harm if even 20% of adolescents with dysmenorrhoea were to undergo laparoscopy. A laparoscopy is an invasive procedure that may have unexpected consequences: performing extensive biopsies or peritoneal stripping could potentially lead to adhesion formation and impaired fertility. Further considerations concern patients and doctors alike. Women have stated that they find diagnostic laparoscopy reassuring because is either confirms or rules out endometriosis.8 Surveys of women with established endometriosis have reported delays of up to 12 years between the onset of pain symptoms and the surgical diagnosis of endometriosis.9 Some women are frustrated about these delays, and there have been calls for such delays to be avoided through greater education of health professionals, changes in guidelines and increased access to diagnostic laparoscopic services.7,10 The assumption underlying these women’s frustration is the possibility that when they first experienced pain they already had pathology that was not diagnosed. However, there is no evidence for this, as there are few longitudinal studies of pelvic pain and it is not possible to perform laparoscopy on all women with pelvic pain symptoms. Then there is the concern that the delay in diagnosis of endometriosis may have an impact on future fertility. But it is possible that the experience of pain as an adolescent is unrelated to a later diagnosis of endometriosis. So, on the one hand, clinicians are increasingly being asked to investigate women with pelvic pain, yet, on the other hand, the likelihood of pathology is less than 50%, especially in the adolescent age group. Furthermore, treatment of dysmenorrhoea can be initiated without a firm diagnosis. Decision making is thus a trade-off between missing a pathological condition and overinvestigation. In the light of current evidence, what is a reasonable management approach to women who present with pelvic pain? In adolescents with dysmenorrhoea, the first-line strategy should be to prescribe non-steroidal anti-inflammatory drugs (NSAIDs) with the oral contraceptive pill. Both of these have been found to reduce the experience of pain and reduce days of absenteeism.11,12 Avoiding menstruation by skipping the non-hormonal pills and allowing bleeding only 3–4 times a year is another useful strategy, although some women will experience breakthrough bleeding. Reassurance should be given that the experience of dysmenorrhoea is normal and that serious pathology such as advanced endometriosis is unlikely to arise during the adolescent years. Women who fail to respond to first-line approaches may need to consult a gynaecologist for consideration of a laparoscopy. For women in their 30s and 40s with pelvic pain, doctors should be aware of the increasing likelihood of underlying pathology. New or worsening symptoms can initially be managed with simple strategies such as the use of NSAIDs and oral contraceptives, but women who fail to respond to these should be referred to a gynaecologist earlier rather than later, especially if they wish to conceive in the future. Finally, there is a small group of women with chronic pelvic pain who have had repeated surgery and may suffer from a form of neuropathic pain. Such patients generally require the help of a multidisciplinary team that should include gynaecologists, psychologists, pain specialists and physiotherapists.

Cynthia M Farquhar MB ChB, MD, FRANZCOG

Removing the protection of confidentiality will not help raise standards of care Governments confronting serious adverse health care events feel obliged to be seen to be doing something. They often set up an inquiry or, less commonly but peremptorily, amend legislation, attempting to avoid repetition of the events. The Davies Inquiry, “with particular reference to Dr Jayant Patel.”, was Queensland’s response to adverse incidents in that state.1 By contrast, New South Wales responded to adverse incidents relating to Dr Graeme Reeves2 by amending the Medical Practice Act 1992 (NSW) in the Medical Practice Amendment Act 2008 (NSW), obliging practitioners to notify the NSW Medical Board of “disruptive” or “wayward” colleagues (see Box). The amendments, welcomed by the Board, allow for generally speedier suspension or deregistration of professionally incompetent doctors. These actions can, however, still be delayed by doctors appealing to the Medical Tribunal (customarily, two medical practitioners in the same field of practice as the respondent, a lay person, and a District Court judge as chairman) or the Supreme Court (which has, on legal grounds, stayed the Board’s suspensions of two subsequently deregistered doctors), and by the inclusion of lay persons in these inquiries. In NSW, unlike in other Australian states, the Health Care Complaints Commission, not the Board, investigates and prosecutes breaches of the Act, and the Medical Tribunal, not the Board, strikes off and re-registers doctors. The Board’s jurisdiction covers registration, impairment, performance, and disciplinary breaches that would not warrant de-registration. The amendments to the Medical Practice Act allow the Tribunal to take into account, in a re-registration application, complaints received subsequent to deregistration. Further, the proceedings of the Medical Board’s professional standards committees (PSCs) will no longer be confidential, will be chaired by a legal practitioner, and their findings made public. The mandatory notification included in the amended Act overcomes some of the problems facing whistleblowers who, traditionally, are encouraged to voice their concerns locally — at their hospital or Area Board.5 Already, in many jurisdictions, doctors must report colleagues with health problems that could affect their practice of medicine. Mandatory reporting in the areas of professional standards and competence, however, is a first for Australia. Such reporting is mandated in seven of the United States of America (Arizona, Delaware, Montana, Nebraska, New Jersey, Oregon and Texas). The NSW Board’s much publicised standards of professional care expect doctors to make such notifications6 in accordance with section 86E of the Act: persons may notify the Board of “any matter that the person thinks indicates that the professional performance of a registered medical practitioner is unsatisfactory”. Failure to report concerns has led to serious consequences: the United Kingdom General Medical Council set a precedent when it found a senior anaesthetist guilty of serious professional misconduct for failing to pursue complaints that a locum was endangering patients.7 In 2005, it punished two doctors who had not reported their concerns about a patient of Harold Shipman,8 found guilty of murdering 15 patients and implicated in the deaths of many more. Despite longstanding obligations to report “impaired” colleagues, we know that there is a continuing reluctance among doctors to do so. Will they be any more forthcoming in reporting “incompetent” colleagues? Unless harm to patients is qualified to refer to serious, perhaps life-threatening, harm, as in New Jersey (“conduct which would present an imminent danger to an individual patient or to the public health, safety or welfare”9), the way could now be open for cross-complaints where “turf wars” exist between branches of the profession. Some plastic and reconstructive Fellows of the Royal Australasian College of Surgeons are dismayed by the work of “cosmetic physicians” who lack surgical training; and orthopaedic and neurosurgeons might dispute one another’s spinal surgery techniques. These areas of practice are bedevilled by patients’ complaints. With the amendments now effective, the effects of the “law of unintended consequences” (inevitable unanticipated consequences of the actions of people, and particularly of governments10) remain to be seen. How will the NSW Medical Board, Medical Tribunal and Supreme Court define a flagrant departure from accepted standards? Proof that a doctor ought reasonably to have believed that a colleague warranted being reported will, no doubt, trigger much legal disputation. Over the past two decades, the NSW Medical Board has moved away from seeing all breaches of standards as requiring punishment. Part 5 of the Medical Practice Act enables the Board to help doctors in difficulty continue in practice, with appropriate treatment and monitoring (provided they are no threat to the public). Under Part 5A, the Board has a well established system of performance appraisal. Both procedures are based on confidentiality. A balance needs to be struck between the public interest of raising standards through frank discussion (in confidence) among professional peers, and satisfying individual patients’ or relatives’ desire to know the facts of individual mistakes. Just as the confidentiality of meetings on maternal and perinatal mortality and morbidity and on anaesthetic deaths has led to improvements in standards, so too has the confidentiality of meetings of PSCs. From its inception in 1987, the PSC was understood, and accepted by the NSW Government, as a professional assessment of standards. Cabinet agreed to the trade-off of confidentiality to encourage respondents to be frank and truthful, thus assisting PSCs to improve standards. Respondents are, therefore, not legally represented at these professional hearings. By contrast, serious breaches go to the Medical Tribunal, where respondents have legal representation before a judge, with a right of appeal on points of law to the Supreme Court. Now that PSC findings are no longer confidential, respondents are faced with representing themselves in potentially career-damaging proceedings with publicly available findings. This might make them decline to appear, instead entrusting the defence of their reputation to a barrister before the Medical Tribunal. Such a change, from a discussion with colleagues about techniques or therapies, aimed at improving standards, to a courtroom with a barrister, trying to prove no wrongdoing, is inconsistent with raising standards of care. Are these proposals then simply another example of a government wishing to be seen to be doing something, or are the benefits likely to outweigh the disadvantages? In view of the established policies of the Medical Board, breaches of which are already sufficient to attract disciplinary action, the only gain would seem to be directing whistleblowers to the Board instead of to their local hospital or Area Board.11 This could avoid the futility experienced by nurse Toni Hoffman, in informing her hospital superiors of her concerns about Dr Patel.12 Regrettably, as agreed by complainants’ advocate Terry Stern,13 the abolition of the confidentiality of PSC hearings will hinder the Medical Board’s attempts to improve medical standards. The looming uncertainty, of course, is how these issues will be handled if, when and how the Council of Australian Governments’ proposals for national registration of health care professionals14 are implemented. Reportable misconduct under the Medical Practice Amendment Act 2008 (NSW) (Section 71A) NSW doctors must report if they reasonably believe or ought reasonably to believe that a colleague has: engaged in sexual misconduct in the practice of medicine; practised while intoxicated by drugs or alcohol; or flagrantly departed from accepted standards of professional practice or competence, risking harm to patients.

Peter C Arnold BSc, MB, BA

VTE prophylaxis is effective and safe, but grossly underused in Australian hospitals In this issue of the Journal, Ho and colleagues report their findings from a Perth community-based study of venous thromboembolism (VTE).1 They found an incidence of VTE, which includes deep vein thrombosis and pulmonary embolism, of 0.83 (95% CI, 0.69–0.97) per 1000 population per year. This figure is consistent with hospital discharge data from the Australian Institute of Health and Welfare, which predict an estimated 14 716 VTE cases in 20082 or an incidence of 0.74 per 1000. This incidence comes with high costs to Australian society in terms of deaths, morbidity and health care expenditure. VTE is a major cause of hospital deaths — Australian Institute of Health and Welfare data indicate that 7% of all deaths in Australian hospitals are due to VTE,2 and autopsy studies suggest the percentage may be as high as 10%.3 Thus, VTE causes more deaths than any common cancer (breast, lung, prostate or bowel) and is 40 times more deadly than HIV/AIDS in Australia. VTE also causes significant long-term morbidity from post-thrombotic syndrome (chronic leg swelling, pain and skin ulcers) and pulmonary hypertension. A report by Access Economics estimated that the cost to Australia of treating VTE is currently $1.72 billion annually (0.15% of gross domestic product).2 This estimate includes costs attributable to direct health system expenditure ($148 million), productivity loss ($1.38 billion) and efficiency loss ($162 million). If costs relating to premature mortality are included, then VTE represents the most costly disease burden among the 16 diseases (including cancer, dementia, osteoporosis, cardiovascular disease and schizophrenia) that have been studied and ranked by Access Economics in recent years. The key to saving lives, improving patient outcomes and reducing the huge financial cost to individuals and the nation lies in prevention of this disease. Evidence-based findings from well designed studies have clearly shown that prevention is possible.4,5 With a modest outlay, VTE incidence can be significantly reduced, effectively and safely, using anticoagulants such as unfractionated or low-molecular-weight heparins, or, particularly if a risk of bleeding exists, by mechanical means (compression stockings and intermittent calf compression). However, current data suggest that VTE prophylaxis is grossly underused in hospitals in Australia and overseas.6 The ENDORSE study (which enrolled over 68 000 medical and surgical patients in 32 countries, including Australia) showed that 51.8% of hospital inpatients were at risk of VTE, but only 58.5% of at-risk surgical patients and 39.5% of at-risk medical patients received VTE prophylaxis.6 This is consistent with the findings of a prospective audit carried out by the National Health and Medical Research Council (NHMRC) National Institute of Clinical Studies in Australian hospitals in 2005–2006 (Dr Sue Phillips, Director, Research Implementation Program, National Institute of Clinical Studies, NHMRC, Melbourne, personal communication). These studies show that many at-risk hospital patients in Australia and overseas, especially medical inpatients, are left unprotected against VTE. Adoption of clinical guidelines by hospitals can lead to increased levels of appropriate prescribing of VTE prophylaxis.7 However, the risk of thromboembolic events continues after hospital discharge, and far less research has been conducted into the use of VTE prophylaxis in the community. There is an increasing trend for at-risk medical patients (eg, patients with chronic lung disease or cardiac failure) to be managed in the community, especially through hospital-in-the-home and early discharge programs.8 With increasingly short hospital stays for both surgical and medical patients, it is important that community-based doctors are aware of the importance of VTE risk assessment and the continuation or commencement of VTE prophylaxis for their patients. The Australia & New Zealand Working Party on the Management and Prevention of Venous Thromboembolism has been convened to formulate a national strategy to promote the optimal use of VTE prophylaxis. Initiatives of the Working Party will include: Developing simple, user-friendly VTE prevention guidelines that will assist doctors to identify and treat at-risk patients. The fourth edition of the Working Party’s VTE prevention guidelines — based on the recommendations of the American College of Chest Physicians4 and the International Union of Angiology,5 but adapted to local conditions (see http://stgcs.med.unsw.edu.au/stgcsweb.nsf/page/TBD) — has recently been published.9 Promoting hospital and community education programs to create awareness of the VTE prevention guidelines and enhance understanding of VTE risk assessment. Researching and developing recommendations for reminder systems, including computer alerts10 or interventions by a VTE nurse or pharmacist, with the intention of reminding doctors to prescribe appropriate VTE prophylaxis. Establishing VTE centres of excellence that will act to promote optimal VTE patient care. Lobbying federal and state governments to initiate health policies that will lead to increased use of VTE prophylaxis in Australian hospitals, including designating VTE prophylaxis rate as a hospital performance indicator. This is particularly relevant now, while the federal government is working with state governments to reduce surgical waiting lists. If patients undergoing surgery do not receive appropriate VTE prophylaxis, this could lead to increases in adverse outcomes of VTE and fatal pulmonary embolism. Hosting a national VTE summit to generate new ideas for improving VTE prevention. VTE is a significant health issue internationally and in Australia. It is a common cause of hospital deaths and a considerable financial burden on governments and individuals. Doctors, nurses, health administrators and governments should work together to ensure all surgical and medically ill patients in hospital have their VTE and bleeding risk assessed, and to maximise appropriate use of VTE prophylaxis. Achieving this will improve patient outcomes, save lives and reduce health costs.

Beng H Chong MB BS, FRACP, PhD · Jeffrey Braithwaite MBA, PhD, FCHSE · Mark F Harris MB BS, FRACGP · John P Fletcher MD, MS, FRACS

GPs can play a crucial role in screening for problem gambling Problem gambling is a significant mental health problem in Australia. Estimates of the prevalence of serious gambling problems in Australia range from 1% to 2% of the general adult population, with higher rates in specific groups.1 An estimated 2.5%–5% of the Australian adult population display at-risk gambling behaviour (according to standard diagnostic criteria).1 The prevalence of problem gambling exceeds that of stroke and coronary heart disease, and is comparable with the estimated prevalence of type 2 diabetes in Australia.2 Further, problem gambling has been shown to be strongly comorbid with other health and mental health problems with high burdens of disease.3 A large-scale study in the United States found that 73% of pathological gamblers (as defined by the Diagnostic and statistical manual of mental disorders,4 fourth edition [DSM-IV]) had an alcohol use disorder, 38% had a drug use disorder, 60% had nicotine dependence, 50% had a mood disorder, 41% had an anxiety disorder, and 61% had a personality disorder.5 A recent Australian study found that, compared with non-gamblers, problem gamblers had a relative risk of 18.8 of having a severe mood disorder, and were over four times more likely to have hazardous alcohol use.6 The causal nexus between depression, excessive alcohol use and problem gambling is not known, but the associations are very strong. Thus, problem gambling is a significant clinical problem with high prevalence that is strongly associated with other high-burden health problems; it therefore warrants attention in primary care practice. In 1999, the Australian Medical Association released its pioneering position statement, Health effects of problem gambling.7 The statement noted that medical practitioners need to be aware of “the adverse impacts of problem gambling” and its comorbidities. It recommended that practitioners include gambling as part of lifestyle risk assessment. Despite this recommendation, many Australian general practitioners are not screening for gambling problems in their patients.8 This may be because they lack the requisite knowledge and tools to deal effectively with problem gambling when it is identified.8 How can this be remedied? Internationally, various medical associations have devised policy statements and toolkits to guide medical practitioners in the treatment of problem gamblers and their families. In 2007, the British Medical Association released protocols for the treatment of gambling addiction within the United Kingdom’s National Health Service.9 These protocols advise that practitioners develop an awareness of problem gambling, its prevalence within key population groups and its comorbidities, and recommend education and training for GPs. The American Medical Association has endorsed policies on problem gambling, emphasising the importance of patient education about the risks of gambling, and has published a patient information sheet in the Journal of the American Medical Association.10 Some jurisdictions in the US have released clinical protocols to help health professionals screen for and treat problem gambling. Essentially, there is international agreement that GPs routinely encounter problem gamblers and that an effective response is required. However, what should this response be? The first step must be effective screening. But how should patients be screened, and who should be screened? The most popular diagnostic tools for problem gambling are the Canadian Problem Gambling Index,11 the DSM-IV criteria for pathological gambling,4 and the South Oaks Gambling Screen.12 However, these tools are too time consuming for routine use in primary care practice. Recently, we developed a one-item screening test for use in primary care practice with beyondblue and Victorian Government funding. We have found that answers to the question “Have you ever had an issue with your gambling?” closely predict answers to the full Canadian Problem Gambling Index tool.6 We wish to extend the screen to include family members of problem gamblers, as they also experience serious difficulties as a result of their family member’s gambling.13 As for who should be screened for problem gambling, we recommend screening patients with anxiety and depressive symptoms or high drug or alcohol use, because of the high rates of comorbidity of these conditions. Those who screen positive to the question “Have you ever had an issue with your gambling?” should be referred for further assessment and treatment by appropriately trained specialist practitioners in problem gambling. There is a developing body of research on treatment for problem gambling.14 The major therapies include counselling, cognitive behaviour therapy and drug treatments. At present, there is limited evidence from randomised controlled trials for their effectiveness. It is recommended that problem gambling interventions be delivered by specialists. Family members may also require treatment for psychological problems because of the impact of their family member’s gambling. Most gambling treatment services accommodate both gamblers and their family members. All Australian jurisdictions have networks of publicly funded practitioners who specialise in the treatment of problem gambling, and a wide range of psychologists and psychiatrists provide treatment in mental health and private practices. However, GPs are well placed to detect and initiate treatment for this debilitating psychological problem.

Shane A Thomas PhD · Leon Piterman MMed(Primary Care), MEdSt, FRACGP · Alun C Jackson PhD

Objective: To identify the prevalence and correlates of three types of pelvic pain (dysmenorrhoea, dyspareunia, and other chronic pelvic pain [CPP]) in a nationally representative sample of Australian women.Design and setting: The CPP survey was part of a broader national study of health and relationships. Computer-assisted telephone interviews were administered to a random sample of 8656 Australian households; 4366 women aged between 16 and 64 years were interviewed in 2004 and 2005. Eighteen of the more than 200 potential survey questions related to pelvic pain.Main outcome measures: Self-reports of dysmenorrhoea, dyspareunia, and any other CPP not associated with sexual intercourse or menstruation.Results: Data on 1983 women aged 16–49 years who were still menstruating and sexually active were analysed. Prevalences were 71.7% for dysmenorrhoea, 14.1% for dyspareunia and 21.5% for other CPP; 23.3% of women reported no pelvic pain of any kind. Severe pain was reported by 15.0% (95% CI, 13.0%–17.1%) of women with dysmenorrhoea, 7.8% (95% CI, 5.0%–11.9%) of women with dyspareunia and 20.0% (95% CI, 16.1%–24.6%) of women with other CPP. Just over a third (34.2%) of women who reported any pain had sought advice from a health professional. Women reporting CPP were also likely to report other health conditions, most notably depression and anxiety. There were clear associations between CPP and sexual difficulties, pregnancy and pregnancy outcomes.Conclusions: Rates of pelvic pain in Australian women are high. General practitioners need to be ready to discuss these issues with patients, particularly in relation to underlying anxiety and depression.

Marian K Pitts BA(Hons), PhD, MAPS · Jason A Ferris BPsych(Hons), MBiostat, GStat · Anthony M A Smith BSc(Hons), PhD · Julia M Shelley BA(Hons), MPH, PhD · Juliet Richters BA, MPH, PhD

Objective: To determine the incidence of venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), in a well defined urban community broadly representative of the Australian population in terms of age, sex and ethnic distribution.Design, setting and participants: A prospective, community-based study conducted over a 13-month period from 1 October 2003 to 31 October 2004. People in a population of 151 923 permanent residents of north-eastern metropolitan Perth, Western Australia, who developed VTE during the study period were identified prospectively and retrospectively through multiple overlapping sources.Main outcome measure: Number of cases of symptomatic, objectively verified DVT and PE.Results: 137 patients had 140 VTE events (87 DVT and 53 PE). The crude annual incidence per 1000 residents was 0.83 (95% CI, 0.69–0.97) for VTE, 0.52 (95% CI, 0.41–0.63) for DVT, and 0.31 (95% CI, 0.22–0.40) for PE. The annual incidence per 1000 residents after age adjustment to the World Health Organization World Standard Population was 0.57 (95% CI, 0.47–0.67) for VTE, 0.35 (95% CI, 0.26–0.44) for DVT, and 0.21 (95% CI, 0.14–0.28) for PE.Conclusion: If the crude annual incidence of VTE in this area of metropolitan Perth is externally valid, then VTE affects about 17 000 Australians annually. Future studies of trends in VTE incidence will be needed to measure the effectiveness of VTE prevention strategies.

Wai Khoon Ho FRACP, FRCPA · Graeme J Hankey MD, FRACP · John W Eikelboom FRACP, FRCPA

Objectives: To explore general practitioners’ perceptions of their preparedness for an influenza pandemic, the changes they would make to their practice, and the ethical justifications for their planned actions.Design and setting: A qualitative study was performed among South Australian GPs between March and October 2007. A semi-structured interview was carried out with each participant in his or her practice, and the interviews were audio-recorded, transcribed and analysed thematically.Participants: 10 GPs were recruited: five from a metropolitan Division and five from a rural Division of General Practice.Results: Some participants felt they would not be able to cope with an influenza pandemic, while others felt it would simply mean an increase in their workloads. Most respondents considered creating separate waiting rooms, moving the reception desk outside of the practice and delaying all non-urgent consultations in order to deal with a pandemic more effectively. Respondents mentioned the conflict between their various roles and responsibilities as a primary source of tension when thinking about the way they would organise their work in the event of a pandemic. A number of GPs said they would not practise in the event of a pandemic, as they felt their responsibility to their families outweighed that to their patients.Conclusions: Professional codes of ethics should include guidance about the scope of the duty to treat during infectious disease outbreaks. The community has to uphold the value of reciprocity, and ensure that GPs and their families are provided with support during a pandemic and are given the opportunity to be actively involved in pandemic preparedness planning.

Olga Anikeeva BHlthSci(Hons) · Annette J Braunack-Mayer PhD, BMedSci(Hons) · Jackie M Street PhD, BSc(Hons), GradDipPrimaryHealthCare

Objective: To analyse the uptake of interventions known to reduce the risk of perinatal HIV transmission among Australian women with HIV infection (who knew their HIV status before delivery), and identify predictors of uptake.Design: Retrospective analysis of perinatal HIV surveillance data in Australia.Patients: Women reported as having HIV infection and having given birth to a child (1982–2005) were identified through three mechanisms: an informal network of clinicians (1982–1993); an active surveillance program through paediatricians (since 1993); and state health department reports of children born to women newly diagnosed with HIV (since 1995).Main outcome measures: Uptake of interventions — avoidance of breastfeeding (after 1985), use of zidovudine during pregnancy (after 1994), and elective caesarean section (after 1999). Factors associated with uptake of these interventions were identified by univariate and multivariate analyses.Results: 367 live births were reported in 291 women with HIV infection. Among the subgroup diagnosed with HIV infection before delivery, 4/255 (1.6%) elected to breastfeed (post 1985), 44/185 (24%) did not receive zidovudine (after 1994), and 41/118 (35%) did not have an elective caesarean section (after 1999). In multivariate analysis, there were significant differences in uptake of zidovudine and elective caesarean section according to year of birth and state in which the birth took place.Conclusion: In Australia between 1982 and 2005, uptake of interventions to reduce mother-to-child transmission of HIV was high. There were significant differences associated with use of zidovudine and mode of delivery according to location of delivery and year of birth.

Michelle L Giles MB BS, FRACP · Ann M McDonald BSc, MPH · Elizabeth J Elliott MD, FRCP, FRCPCH · John B Ziegler MD, FRACP · Margaret E Hellard FRACP, FAPHM, PhD · Sharon R Lewin MB BS, FRACP, PhD · John M Kaldor PhD

Objectives: To test the hypothesis that television news coverage of different cancers reflects their incidence and burden, and to examine the journalistic approaches used in reporting cancer.Design and setting: Content analysis of all news, current affairs and infotainment reports on cancer broadcast on five free-to-air television channels in Sydney, New South Wales, 2 May 2005 – 6 January 2008.Main outcome measures: Number of items on specific cancers, relationship with burden of that cancer (disability-adjusted life-years [DALYs]), and category of “story lead” used for the item.Results: Cancer was the fifth most reported health issue, with 1319 items; 25 different cancers received news coverage. The most reported cancers were breast cancer (42.5% of all items on specific cancers), melanoma (11.9%) and cervical cancer (11.6%). Some cancers were significantly over-reported in relation to their DALYs (eg, cervical cancer was over-reported by a factor of 10.2 compared with the number of reports predicted on the basis of DALYs) while others were under-reported, including colorectal, lung and pancreatic cancers. The most common story leads used in cancer reports were treatment (32% of items) and celebrities with cancer (21%), particularly breast cancer.Conclusions: The current predominance of reports on breast and cervical cancer and on young women with cancer may be distorting public and political perceptions of the burden of cancer. The success of advocates in raising the news profile of breast cancer may hold lessons for agencies wishing to improve the newsworthiness of other cancers.

Ross MacKenzie MA · Simon Chapman PhD · Natalie Johnson MIPH · Kevin McGeechan MBiostat · Simon Holding BA

Objective: To evaluate the feasibility, reliability and acceptability of the mini clinical evaluation exercise (mini-CEX) for performance assessment among international medical graduates (IMGs).Design, setting and participants: Observational study of 209 patient encounters involving 28 IMGs and 35 examiners at three metropolitan teaching hospitals in New South Wales, Victoria and Queensland, September–December 2006.Main outcome measures: The reliability of the mini-CEX was estimated using generalisability (G) analysis, and its acceptability was evaluated by a written survey of the examiners and IMGs.Results: The G coefficient for eight encounters was 0.88, suggesting that the reliability of the mini-CEX was 0.90 for 10 encounters. Almost half of the IMGs (7/16) and most examiners (14/18) were satisfied with the mini-CEX as a learning tool. Most of the IMGs and examiners enjoyed the immediate feedback, which is a strong component of the tool.Conclusion: The mini-CEX is a reliable tool for performance assessment of IMGs, and is acceptable to and well received by both learners and supervisors.

Balakrishnan R Nair FRACP, FRCP · Heather G Alexander PhD · Barry P McGrath MD, FRACP · Mulavana S Parvathy FRACGP · Eve C Kilsby BA(Psych) · Johannes Wenzel MD, FACEM · Ian B Frank BA(Hons) · George S Pachev PhD · Gordon G Page PhD

Musculoskeletal conditions are a major contributor to the burden of disease globally and their impact is predicted to increase. Consistent with findings in other countries, the current standard of musculoskeletal education in Australian medical schools is inadequate to meet today’s musculoskeletal care requirements. A national multidisciplinary approach unifying the key musculoskeletal clinical and basic science disciplines has been adopted to provide clear, evidence-based education guidelines that are specifically aimed at priority musculoskeletal conditions; a direct link is therefore established between community health care needs and education at a national level. This “top-down” approach provides the potential for a far more effective and efficient delivery of musculoskeletal education by allowing the identification of the key basic knowledge and skills required to achieve core competencies and by providing appropriate direction for students. The Australian Core Competencies in Musculoskeletal Basic and Clinical Science are being developed for medical schools to incorporate into their curricula, with the ultimate aim of improving the standard of health care for Australians with musculoskeletal conditions.

Mellick J Chehade PhD, MB BS, FRACS(Ortho) · Aleksander Bachorski BE(Hons), GradDip(MW

Objective: To investigate the effect of duration of clinical training placements in the Northern Territory on rate of return of medical students for an internship in the NT.Design, setting and participants: Retrospective analysis of medical school and hospital data on all medical students who completed a placement with the Northern Territory Clinical School (NTCS) between 1998 and 2007.Main outcome measures: Logistic regression analysis of weeks spent training in the NT against the binary category of return or non-return for an internship in the NT; number of weeks of placement in the NT required for one returning intern for training models with different placement duration and timing.Results: 683 students completed an NTCS placement: short-term Year 4 placements only, 538 (duration, 1–19 weeks, 534; and ≥ 20 weeks, 4); Year 3 40-week placements only, 16; and both Year 3 and Year 4 placements,129 (Year 4 duration, 1–19 weeks, 82; and ≥ 20 weeks, 47). For each student who returned for an NT internship, 122 weeks of placement were required. Placement length was a significant predictor of an NT internship (P < 0.05; odds ratio, 1.08; 95% CI, 1.07–1.09). The most efficient training models (fewest weeks per returning intern) were longer placements (≥ 20 weeks) in Year 4, both for students who also undertook a 40-week Year 3 placement and those who did not (90 and 47 weeks of training per intern, respectively). Students who spent only brief periods in the NT in Year 4 were less likely to return for an internship (P < 0.05).Conclusions: The rate of return increased with the total length of time spent training in the NT. Short-term Year 4 placements offered the least return for the total number of weeks of placement provided.

Anna McDonnel Smedts PhD · Michael P Lowe MD, FRACP

Ideas abound, but robust evidence from health care services research is still scarce In 2000, 3 years after the election of the Labour Government in Britain, the then Prime Minister, Tony Blair, launched an ambitious reform program for the National Health Service (NHS), which would make it “the healthcare system the world most envies.” The reform was underpinned by the largest ever investment in the NHS, with spending increasing from £23.7 billion in the 2000–01 financial year to £90.2 billion in 2007–08.1 The reform package included not only more medical school places and increased rewards for consultants, but also more specialist registrars, general practitioners and GP trainees. There was also to be a quantum leap in the numbers of nurses and other health care professionals, along with widening of their practising opportunities through task transfer. The Blair NHS plan signalled 7000 more beds in hospitals and 100 new hospitals over 10 years, along with a commitment to modernising general practice premises and opening 500 new one-stop primary care centres.1 It was promised that, by 2005, the maximum waiting time for outpatient appointments would be 3 months; for inpatient admissions, 6 months; and waiting lists for hospital appointments and admissions would be replaced by a booking system, designed to give patients a choice of a convenient time within a guaranteed maximum waiting time. In short, there were to be more doctors, nurses and other health professionals, more hospitals beds as well as improved patient access to GPs and specialists.1 So, what were the outcomes of this radical and incisive reform of a health system? The answers are in the report by the NHS Audit Commission, issued in June this year. The overall verdict was that the NHS system reform has improved management of the health service but needs more time to deliver significant benefits for patients.2 In Australia, there is an expectation that the newly elected Rudd Labor Government might emulate the Blair health reform agenda. But since its election last November, beyond a $423 million commitment to general practice super clinics,3 what we have witnessed is a cavalcade of commissions and taskforces, such as the National Health and Hospitals Reform Commission, the National Preventative Health Taskforce and the National Primary Health Care Strategy. Cynics may well say that the Rudd Government is affected by decision-paralysis, while others might say that it is in the process of gathering evidence to underpin its policies and reforms. In a recent speech, Prime Minister Rudd noted that: “A third element of the Government’s agenda for the public service is to ensure a robust, evidence-based policy making process. Policy design and policy evaluation should be driven by analysis of all the available options, and not by ideology.”4 Furthermore, Sally Redman, Chief Executive Officer of the Sax Institute, a health policy think-tank in Sydney, believes: “Policymakers need timely information that is locally relevant, of high quality and dependable.” (personal communication). But they also need ideas. In this issue of the Journal, we commence a series of articles written by leading proponents of health care reform in Australia, and coordinated by the Series Editor Gavin Mooney, Director of the Social and Public Health Economics Research Group (SPHERe) at Curtin University of Technology in Western Australia (→ The people principle in Australian health care5; → What is the health service for?6). There can be no doubt that Australian health care does indeed need reform, and that there are many ideas upon which to draw. But what is missing from the mix is robust evidence. The National Health and Medical Research Council (NHMRC) is the major powerhouse for health care research in this country. It should be of concern that, in 2000, only $1.7 million was spent on health services research, and this had risen to a mere $23.7 million by 2007.7 Indeed, the funding for new grants for health services research has, on average, scored around less than 3% of total commitments.7 Furthermore, over the same period, successive governments have allocated infrastructure support to a bevy of Australian biomedical research institutes, while fledgling Australian health policy research institutes continue to be poor cousins. This relative poverty in health services research was highlighted in the 2004 Investment review of health and medical research (by the Grant Committee).8 It recommended the development of strategies to improve the impact of research influencing policy and practice, through a dedicated process, NHMRC staffing, an advisory committee and appropriate investment.8 Now, some 4 years later, the NHMRC has announced a package of $108 million over 2 years to support: research — preferably though collaboration between researchers and those responsible for the design and delivery of health services; centres of excellence — undertaking policy research from which a national institute of health research may well emerge; and a program for capacity-building grants for health services research — each of $2.5 million over 5 years (Warwick Anderson, Chief Executive Officer, NHMRC, personal communication). These initiatives are to be welcomed, but there is one missing element — a comprehensive research agenda to guide the gathering of evidence pertinent to health care reform. As the Prime Minister has stressed, health policy formulation and its inherent health care reform should be driven by relevant evidence. The Rudd Government may well consider yet another taskforce that brings together key stakeholders to identify those areas in health care that currently need robust evidence to support future reform. Ideally, establishing this agenda might be an item for consideration at the next Australian Health Care Agreements meeting. After all, health care systems are the responsibilities of all our governments — federal, state and territory. Given the recent highly publicised recommendations to expunge the “blame game” from the Australian Health Care Agreements,9 it could be the seminal test case.

Martin B Van Der Weyden MD, FRACP, FRCPA

We need a set of precise principles to underpin and drive health policy in Australia Key propositions The federal government should outline the principles to inform the work of the National Health and Hospitals Reform Commission and others advising on or implementing national health policy. The federal government should establish an independent and professional “Romanow-type” commission2 to engage widely with the Australian community on the design principles for health care in Australia. That commission should have an ongoing role to consult with the community and report publicly to the government on whether its health programs are consistent with the agreed principles, and on the effectiveness of health departments and health units in implementing these principles. It is hard to find any coherent set of principles that guide health policy in Australia. So much is ad hoc, short term, and seemingly born out of political compromise, designed to placate vested interests. Some services are provided free, while others, like dental, receive little government support. Some services are covered by tax-funded insurance through Medicare, but at the same time there are large incentives for, mainly those on high incomes, to opt out of sharing and into private health insurance. Politicians talk of “universalism” and a “commitment to Medicare” while encouraging the development of a two-tier hospital system. Governments, particularly coalition governments, speak vaguely about the importance of markets, but there are few areas of health care in which there is market competition. Labor politicians sing the praises of bulk-billing while supporting high copayments for pharmaceuticals and maintaining the Medicare safety net, which mainly advantages the wealthy.1 Overall, it would appear that the health debate in Australia focuses on managerialism without first establishing the values that should underpin and drive a national health service. Fragmentation, inefficiency and waste are important issues, but do we want a well managed and efficient system that lacks guiding values? Our values are a statement about who we are and what is important in being an Australian. Our values and our national identity are inseparable. Values such as fairness and equal opportunity are widely shared, but for practical purposes, we need to translate these broad values into more precise principles that guide the development of policy and programs. I believe that there are some key principles, listed below, that should guide health policy design. Having a universal single-payer system accessible to all. Poor and rich should have access to the same high-quality health care services. That does not require subsidising inefficient private health insurance companies — a single payer like Medicare would fund both public and private providers. Further, a universal system does not also imply a “free” system. Promoting private and public health care delivery to ensure efficiency and effectiveness, particularly in hospital services. Designing services around patients’ needs, and not the historic interests of health care providers. Fairness through universal taxpayer funding. Giving priority to disease prevention and keeping people healthy. Actively involving the community in setting priorities (eg, Indigenous health and mental health). Achieving technical efficiency so that we obtain the maximum benefit from our limited health care dollars. Subsidiarity, whereby health care is delivered by the most local health unit (eg, primary care) subject to national policies, national funding and national standards.1 This is not to say that we should be unsympathetic to governments that have to make pragmatic decisions on the basis of perceived or actual public concerns and the self-interest of health care providers. Governments can only build on what we have at the moment. But in health, as in so many areas, we need some clear principles that provide guidance and discipline in the development of health care. I suspect that there is widespread agreement, particularly on the principles of universality and equity, but, in a democracy, the only acceptable way to establish and assert principles is serious and continuing community engagement. Political leadership is important in articulating and shaping principles, but, in the end, it is the community’s values and principles that matter. In Canada a decade ago, the federal government established a Royal Commission to conduct a dialogue with citizens, and to make recommendations to the government on an ideal health care service for Canadians. In Renewing the foundations (of Canadian health), the Commissioner, Roy Romanow, proposed a Canadian Health Covenant that expresses Canadians’ collective vision for health care and that outlines the responsibilities and entitlements of individual citizens, health providers and governments in regard to the system. We need consensus on why the system exists, what it is intended to achieve and how its component parts should fit together. This is vital to restoring the public’s confidence in the system.2 In referring to “consensus on why the system exists, [and] what it is intended to achieve”, Romanow was, in effect, saying that Canadians needed to agree on the principles that should guide the design of the Canadian health care system. His report underlined the wide support among Canadians for the principle of universality. In this series of articles on health care reform, Mooney outlines how community engagement can be effective.3 We must avoid the tokenism which so often is a feature of community consultation or engagement. The Australian Government has not spelled out why the Australian health care system exists and what it is intended to achieve. Principles must come before managerialism.

John Menadue AO, BEc

As we are dealing with the people’s health, the people’s voice needs to drive the principles underpinning our health care system Key propositions In seeking to establish the principles to underpin the Australian health care system, the people to ask are informed citizens, and this is best done through citizens’ juries. Evidence to date suggests that, compared with the existing implicit principles, citizens are much more supportive of equity of access and of public health and preventive medicine. A consultative process to establish a health service “constitution” should be set up with 20 citizens’ juries across the country, each with 15 randomly selected members (“20.15”), to be followed by a “National Citizens’ Summit”. In the wake of Menadue’s call for setting principles to underpin our health care system,1 one key principle that members of “citizens’ juries” advocate is that the appropriate group to set the principles are citizens! Health services are first and foremost social institutions — that is, not just there for the people, but to be based on the values of the people. I have facilitated a number of these citizens’ juries.3 They are a form of deliberative democracy.4 They bring together randomly selected citizens; and it is crucial that they are randomly selected, not hand-picked or self-selected. It is emphasised to the members of these juries that they are there as citizens, not consumers, and if the focus is, say, the Western Australian health service, that they are there as citizens of Western Australia, and not just of their home towns of Bunbury or Broome. They are given good information by experts whom they can quiz about health, health care services and resource availability. They are then asked to deliberate on what sorts of principles they want to guide their health services. It seems difficult to argue against this idea of “the people” setting these principles. The issues involved are not technical ones. These principles might include value for money (efficiency); equity (and how this is defined and how important it is); transparency in decision making; prevention and its relative importance compared with treatment; and so on.3 Interestingly, in my experience, the people on these juries just love to act as citizens! They act responsibly and with pride in the role. Two things are clear on the basis of the results of six juries in which I have been a facilitator.3 First, the citizens’ values and the relative weights they attach to them are broadly consistent across different juries. They want better access to services, especially a reduction of the barriers caused by a lack of awareness of where and how to get services; improved equity, particularly for Aboriginal people; and more emphasis on public health and prevention. Second, if built on the principles arising from these six juries, the health care service would be rather different. For example, the citizens place less weight on hospital care and more on equity than the health service does currently. Care needs to be exercised when choosing the issues about which citizens’ values are elicited. Citizens appear to feel comfortable when they are asked to consider principles and broad priorities. They argue that anything more detailed or at a more operational level is better left to others. For the nation as a whole, I propose that there be 20 juries, each with 15 members (“20.15”), each covering a metropolitan, rural or remote geographical area and ensuring a good mix of these. Having just 15 members allows “a conversation” to be conducted within each jury, which is the ideal. These juries might be followed by a “National Citizens’ Summit” (NCS) at which one representative from each jury would present his or her jury’s findings; the NCS would then seek to achieve a consensus at a national level. Metropolitan, rural and remote juries may not be able to agree, but that is to be expected — what people in these different areas want from their health services is quite likely to be different. The other advantage of establishing these principles — or a “constitution” (as I, along with my colleague, health economist Virginia Wiseman, have called these5) — is that this provides a base, indeed an incentive, to establish a more rational and systematic priority-setting system.6 Sadly, one of the most serious methodological failings of the Australian health service is the lack of such a system. This needs to be put to rights and to be based on what Australian health economist Stephen Jan has called long-term “credible commitment”.7 What is needed in setting these values and the subsequent priorities is to ensure that whoever sets them has a genuine long-term credible interest in wanting the system as a whole to function well. Citizens are the only stakeholders who fit this description. There may be opposition to citizens’ juries. The former Health Minister, Tony Abbott, opposed citizens’ juries, believing, wrongly, that they would take power away from politicians and government.8 When I called for a citizens’ jury to look at the funding of aged care, the then President of the Western Australian branch of the Australian Medical Association was quoted as saying: “I don’t think a focus group [sic] debating it is the way you make big decisions.”9 However, these juries are not intended to be decision-making bodies; their role is to set the constitution. The idea will, however, have to be sold to those suspicious of using the lay public’s values in this way. The approach has been adopted in other countries, most notably Canada10 and the United Kingdom.4 Menadue has argued that we badly need principles to guide our health care system.1 I endorse that view. Ethically and politically there is no group that is better placed to do this than the (informed) citizens whose health is at stake. Citizens’ juries provide a tried and tested way to elicit these values. Let’s get on with them — and soon!

Gavin H Mooney MA

Two children with advanced lung disease underwent successful cadaveric bilateral lobar lung transplantation, using lungs “cut down” from deceased adult donors — the first reported use of the technique in Australia. This approach, while it cannot address the lack of donor organs, may enable us to redress any size bias limiting paediatric lung transplantation. Clinical recordsPatient 1A previously healthy 9-year-old girl presented in early 2007 with an upper respiratory tract infection that progressed over 10 days to respiratory failure, requiring intubation and ventilation with high inspiratory pressures. Subsequent tracheal aspirates were positive for Mycoplasma (by polymerase chain reaction), with consistent serological results (antibody titres, 1 : 640). Computed tomography of the chest demonstrated widespread bronchiectasis (Box 1, A). Although she was extubated 6 weeks after initial presentation, she remained in hypercapnic respiratory failure (Pco2, 80 mmHg), requiring continuous oxygen supplementation (5 L/min) and bilevel non-invasive positive-pressure ventilation (BiPAP). She was listed for lung transplantation in May 2007, but, given the severity of her lung disease and in the absence of appropriately matched donor organs, the transplant team gave early consideration to cadaveric bilateral lobar transplantation using an adult “oversized” donor. This was performed in August 2007. Patient 2A 13-year-old girl with cystic fibrosis was referred for consideration of lung transplantation. She had been diagnosed with cystic fibrosis at birth (Δ508 homozygous, without liver, sinus or diabetic sequelae), and over the preceding 2 years developed progressive bronchiectasis (Box 1, B), necessitating supplemental oxygen and initiation of nocturnal BiPAP. She was initially listed for either lung transplantation or heart–lung transplantation; however, after 9 months of progressive respiratory failure (Pco2 increased to 46 mmHg; forced expiratory flow in 1 second [FEV1], 16%; forced vital capacity [FVC], 28% predicted), the transplant team considered cadaveric bilateral lobar transplantation, which was performed in September 2007. Surgical procedure and clinical courseBoth children underwent cadaveric bilateral lobar transplantation as described by Starnes and colleagues1 for living-related lung transplantation. Briefly, the donor right lower lobe was resected, and the right upper and middle lobes were implanted, the anastomosis being performed at the right main bronchus. On the left, the inferior pulmonary vein, interlobar artery distal to its lingular branch, and bronchus were transected, and the lower lobe removed. Size mismatch was compensated for by seating the donor bronchus inside the recipient bronchus, while pulmonary vessel mismatch was taken up in the suture lines. Neither patient required cardiopulmonary bypass, and resected lobes were not used further. Following surgery, both children were established on an internationally standardised immunosuppression regime, comprising prednisolone, tacrolimus and mycophenolate mofetil.2 Both patients made a good postoperative recovery, with short intensive care unit stays. Patient 1 required a longer inpatient stay for treatment of pneumonia. Neither patient developed allograft rejection, and lung function gradually improved (Box 2). Both patients were discharged to their respective tertiary hospitals for continuing follow-up. Both patients were well and without complication at follow-up 10 and 9 months postoperatively, respectively. DiscussionTo our knowledge, these are the first reported cases of cadaveric bilateral lobar transplantation in Australia. They demonstrate its efficacy as a means of reducing waiting-list mortality for paediatric lung transplantation recipients. Lung transplantation is now an established treatment for patients with severe end-stage lung or pulmonary vascular disease. Despite attempts to increase organ donation worldwide, the number of patients requiring lung transplantation far exceeds the availability of donor lungs. In Australia, this is of particular concern for children awaiting appropriate size-matched donor organs.3 Review of the Australian and New Zealand Organ Donation Registry between 2002 and 2006 revealed that very few lungs are retrieved from paediatric donors younger than 14 years (26/497 lung donors).4 The number of children with severe lung disease warranting consideration of lung transplantation, both globally and in Australia, is, fortunately, very small. The most recent data from the International Society for Heart and Lung Transplantation show that only 65 paediatric lung transplantations were performed worldwide in 2005.2 However, of concern is that waiting-list mortality is greater for children than for adults — a worrying trend as fewer paediatric lung transplantations have been performed per annum, while adult lung transplantation numbers have increased.5 In Australia during 2006, 181 donor lungs were offered for lung transplantation, with only seven paediatric donors contributing, all of whom were aged 6–14 years (Ross Pettersson, Australian and New Zealand Cardiothoracic Organ Transplant Registry and Heart Transplant Data Manager, St Vincent’s Hospital, Sydney, NSW, personal communication). Despite an active policy of utilising “extended” donor organs (eg, from older donors or donors with previous cancer, smoking or aspiration history) wherever possible, only 30%–50% of available lungs are actually suitable for transplantation,6 further diminishing the number of available donor lungs, which is low by international standards.7 In the absence of appropriately size-matched organs, children from our institution have died while on the waiting list (2/9 listed in 2000–2007); after reviewing the 2007 donor referrals, it became apparent that the children described here would most likely have died while waiting. Minimising paediatric waiting-list mortality requires consideration of non-traditional donor sources, such as live donors, who have been used in small numbers in the United States and Japan.8 The technique involves a bilateral lobar transplantation, typically taking one lobe from each of two larger, usually related, adult donors. Outcomes for living-donor bilateral lobar transplantation are similar to cadaveric lung transplantation, but there are significant ethical and technical issues with such an approach, and a potential 300% mortality rate. The number of these procedures being performed is declining.5 To our knowledge, no centre presently offers this service in Australia. In adults, cadaveric lungs have been cut down to facilitate lung transplantation where size mismatch between donor and recipient could prevent transplant.9 Typically, this involves non-anatomical “lung shaving” or anatomical lobar resection. Rarely is this a bilateral extensive procedure, given the potential complications, including persistent air leaks, airway stenoses and stump dehiscence. Lobar transplantation is not specific to lung transplantation and has become common practice in liver transplantation; lessons may be learned from these experiences.10 Paediatric lobar transplantation has not been widely performed outside of the living-related scenario, but despite the additional surgical complexity, outcomes have proven comparable to cadaveric lung transplantation.8,9 Starnes and colleagues’ work suggests our two patients can be expected to ultimately achieve near-normal lung function,11 and their total lung capacity will increase as they grow.12 Cutting down cadaveric adult donor lungs for use in paediatric recipients raises ethical and practical issues about removing donor lungs from an already insufficient adult pool. Should lungs that might “perfectly” match an adult be cut down for a paediatric patient? Is a child more deserving than an adult? Our approach to reducing waiting-list mortality is to perform transplantation on recipients with the most severe lung disease at the first opportunity, and both these children satisfied that criterion. In conclusion, our cases illustrate the difficulty experienced by many centres in acquiring an adequate number of donor lungs to service the needs of the paediatric lung transplantation waiting list. Using cut-down adult donor lungs had a good outcome in both our patients. Such an approach is likely to expand the donor pool available for children needing lung transplantation, thereby reducing the high waiting-list mortality experienced by this age group. 1 Computed tomography scans of the two patients’ lungs before transplantation A: Patient 1 had cysts and lung destruction after Mycoplasma infection (arrows). B: Patient 2 had severe cystic fibrosis-related bronchiectasis (arrows). 2 Clinical course after cadaveric bilateral lobar transplantation in two children Patient ICU days Hospital days Respiratory infection in first 3 months Biopsy (ISHLT grade) 30 days 90 days 180 days FEV1 (% pred) FVC (% pred) FEV1 (% pred) FVC (% pred) FEV1 (% pred) FVC (% pred) 1 2 27 Pseudomonas, Staphylococcus A0 0.89 (40%) 0.90 (37%) 1.02 (46%) 1.33 (54%) 1.26 (55%) 1.81 (78%) 2 2 11 Staphylococcus A0 1.12 (72%) 1.27 (71%) 1.17 (75%) 1.45 (81%) 1.11 (63%) 1.66 (94%) ICU = intensive care unit. ISHLT = International Society for Heart and Lung Transplantation. FEV1 = forced expiratory flow in 1 second. pred = predicted. FVC = forced vital capacity.

Dominic T Keating MD, MRCPI · Glen P Westall FRACP, PhD · Silvana F Marasco MS, FRACS · Jacquie H Burton DipAppSci(Nursing), BN, GradDipPaed · Mark R Buckland MB BS, FANZCA · Colin F Robertson MSc(Epi), MD, FRACP · Trevor J Williams MB BS, FRACP, MD · Gregory I Snell MB BS, FRACP, MD

To the Editor: A 26-year-old woman presented with 24 hours of severe constant epigastric pain and vomiting. She had no history of similar pains, alcohol consumption or gallstones. Four days before presentation she had received her first dose of human papillomavirus (HPV) vaccine. Two days after vaccination she developed a fever and self-limiting rash of 3 days’ duration. Examination revealed marked epigastric tenderness and temperature of 40°C. Other physical parameters were within normal limits. Biochemical investigations showed normal liver function, moderate leukocytosis, a serum amylase level of 1900 U/L (reference range [RR], 23–85 U/L) and lipase level of 3400 U/L (RR, 0–160 U/L). An upper abdominal ultrasonography showed a non-dilated biliary tree and no evidence of gallstones. Computed tomography showed an oedematous pancreas with peripancreatic fat stranding and arterial enhancement of the pancreatic parenchyma, consistent with pancreatitis without necrosis (Box). Other investigations showed normal serum levels of calcium, triglycerides and parathyroid hormone. Serological tests were negative for acute infection with coxsackie A9, coxsackie B1–6, echo, mumps, herpes simplex, hepatitis and varicella zoster viruses. The patient was diagnosed with pancreatitis and treated conservatively with intravenous fluids and analgesia. Pain, symptoms and biochemical abnormalities settled after 10 days. She was discharged and remains well. Magnetic resonance cholangiopancreatography performed after discharge showed no pancreatic parenchymal or ductal abnormality. Acute pancreatitis is common, with an incidence of 5.4–80 per 100 000.1 Gallstones and alcohol use account for 70%–85% of cases; other causes include drugs, viral infections, tumours, hyperlipidaemia, hypercalcaemia, trauma, iatrogenic injury and pancreatic ductal anomalies. The cause is unidentified in up to 10% of cases.1,2 Viral pancreatitis is well recognised, with cytomegalovirus and mumps, coxsackie, hepatitis, herpes simplex, and varicella viruses all known causes.3 Vaccines have been implicated, with pancreatitis associated with measles–mumps–rubella and hepatitis A and B vaccines.4,5 To date, there has been no report linking HPV vaccination with pancreatitis. The pathophysiology linking vaccination with pancreatitis is unclear. It has been postulated that viral replication in immunodeficient hosts receiving live attenuated viral vaccines can cause pancreatitis. Alternatively, “molecular mimicry” could stimulate production of auto-antibodies, which react with host antigens and cause autoimmunity.5 The HPV vaccine is a quadrivalent, recombinant, non-infectious formulation, eliminating viral replication as a mechanism of pancreatitis. Therefore, an autoimmune mechanism is possible. Extensive clinical testing has demonstrated the safety of HPV vaccine in the general population. In our patient, intensive history taking and investigation failed to identify another cause for pancreatitis, and the close temporal relation of the HPV vaccination, the development of a prodromal illness, and fever without evidence of sepsis led us to postulate that pancreatitis was secondary to vaccination. A coincidental illness causing pancreatitis cannot be ruled out, but neither can HPV vaccination be excluded as a potential cause. We therefore suggest that pancreatitis be considered in cases of abdominal pain following HPV vaccination and if proven, notified to the Adverse Drug Reactions Advisory Committee. Computed tomography scan of the abdomen in a patient with pancreatitis Portal venous computed tomography images showing oedematous enlargement of the pancreas, with surrounding fat stranding and ascites. The pancreas (arrows) appears fully enhanced with contrast, suggesting there was no necrosis. A: Pancreatic head. B: Pancreatic body and tail.

Amitabha Das · David Chang · Andrew V Biankin · Neil D Merrett

To the Editor: Australian consensus guidelines for selecting formulas for infants with cows milk protein allergy (CMPA) have recently been published.1 We reviewed formula choices and outcomes for 51 children with immediate allergic reactions to cows milk protein who were referred to one of us (S S M) in a tertiary specialist clinic over a 2-year period before the guidelines were published. The formula was selected by the referring specialist medical practitioner in 44 cases (and by S S M in the other seven). Of the 51 children (mean age at initial reaction to cows milk protein, 7.8 months), 42 had skin and/or gastrointestinal features, and nine had an anaphylactic reaction with respiratory and/or cardiac features. Forty-six children had a positive skin prick test to cows milk protein, and one had a positive radioallergosorbent test. Four children with immediate (< 30 min) reactions of generalised erythema and/or angioedema (3) or vomiting (1), but a negative skin prick test, were also included. Soy was the most common formula used, followed by extensively hydrolysed formula (EHF) (Box). Three of eight children commenced on EHF had allergic reactions, with urticaria and angioedema, and one child also had a transient (60 s) cough. Three children were given partially hydrolysed formula (PHF), with one experiencing an immediate cutaneous reaction. These observations suggest that, in clinical practice, soy is frequently a satisfactory first choice for children with CMPA, as suggested in the guidelines.1 Some children with CMPA will also react to EHF, providing a rationale for choosing amino acid-based formula as a first-line treatment prior to allergy evaluation in children with anaphylaxis to cows milk protein. As about 5% of infants with CMPA also react to EHF,2 some allergists advocate the introduction of EHF under medical supervision in either all children with immediate CMPA3 or only those who have had severe life-threatening reactions.4 Although PHF is tolerated by a significant proportion of children (70%) with immediate CMPA,3 it is not recommended for the treatment of CMPA1 due to its high content of potentially allergenic cows milk protein. The fact that three children with CMPA were given PHF suggests there is confusion in the prescribing community, and that the availability of the new guidelines may help in achieving a more appropriate choice of formula. Feeding choice for 51 children referred with cows milk protein allergy Type of feeding selected No. of children Mean age at initial reaction to cows milk (months) No. who reacted to selected feeding Soy 29 9.5* 0 Extensively hydrolysed formula (EHF) 8 5.3 3 Amino acid-based formula (AAF) 6 4.2 0 Partially hydrolysed formula (PHF) 3 6.0 1 Breastfeeding 5 6.0 0 * P < 0.05 for soy versus PHF, EHF, AAF or continuing to breastfeed (t test).

Sam S Mehr · Andrew S Kemp

To the Editor: A 37-year-old man was referred to our emergency department with an acute 7 cm abscess of the buttock. The abscess was incised, and the patient was prescribed oral β-lactam antibiotics and discharged. After 48 hours, culture of samples from the abscess showed methicillin-resistant Staphylococcus aureus with a community-acquired antibiotic resistance pattern (CA-MRSA). The isolate was resistant to β-lactam antibiotics, but sensitive to trimethoprim, gentamicin, and tetracycline. Unusually for an Australian CA-MRSA strain,1 the isolate was also resistant to erythromycin and ciprofloxacin. On reviewing the patient’s history, it was noted that he was a previously well United States resident who had visited Australia and New Zealand as part of the support team for an international rock band. Further testing was undertaken, and the isolate tested positive for genes coding for the Panton–Valentine leukocidin toxin, associated with staphylococcal virulence (eg, recurrent furunculosis, abscess formation, and necrotising pneumonia).2 Pulsed-field gel electrophoresis (performed by the Gram-Positive Bacteria Typing and Research Unit, Department of Microbiology and Infectious Diseases, Royal Perth Hospital, WA) confirmed the isolate as the ST8-MRSA-IV strain, also known as USA300. Most CA-MRSA strains remain susceptible to a majority of non-β-lactam antibiotics, including clindamycin, trimethoprim–sulfamethoxazole, tetracyclines and fluoroquinolones. This helps distinguish CA-MRSA isolates from the typically multiresistant hospital strains, and facilitates oral outpatient therapy. USA300 is the dominant strain causing CA-MRSA infections in the US.3 Among 422 patients with soft-tissue infections presenting to 11 US emergency departments in 2004, 59% of cases were caused by CA-MRSA, of which 99% were USA300. Recent reports indicate that multiresistance is emerging within this strain, with acquisition of resistance to erythromycin, clindamycin, mupirocin and fluoroquinolones. An increasing association of USA300 infections with buttock and perineal infections is also reported, as well as potential sexual transmission, particularly among men who have sex with men. Our case highlights the ease of international spread of microorganisms. Arguably, a “one-night stand” tour could be an ideal vehicle for microbial dissemination. CA-MRSA was not considered in the patient’s initial assessment, and the patient was discharged with oral β-lactam antibiotics and no planned follow-up. Moreover, the isolate may not have been identified as the “epidemic” USA300 strain without more involved tests. A recent study documented a rising incidence of USA300 isolates in Western Australia between 2003 and 2007. Of 61 patient isolates, 35 were diagnosed in 2007 (Pearson J, Coombs G, Christiansen K, et al. USA300 MRSA identified in the Australian community [abstract PP3.2]. Abstract presented at the Australian Society for Antimicrobials 9th Annual Scientific Meeting; 2008; Feb 21–23; Sydney). Our case suggests we should be more alert to CA-MRSA infection presenting with furunculosis and soft tissue infections, not only in Indigenous communities and young people, but also in international travellers and patients whose infections fail to respond to usual therapy. It also reinforces the value of incision and drainage. As β-lactam susceptibility is no longer assured, such specimens should routinely undergo culture and susceptibility testing.

Thomas Gottlieb · Wei-Yuen Su · John Merlino · Elaine Y-L Cheong

To the Editor: We report significant sinus bradycardia in a patient presenting with an acute coronary syndrome shortly after beginning bupropion therapy to assist with smoking cessation. A 53-year-old man was attended by paramedics for typical ischaemic chest pain. He had sinus bradycardia (45 beats/min) and hypotension (blood pressure, 85/60 mmHg), and was found to have a serum troponin I concentration of 1.2 μg/L, but no diagnostic electrocardiographic changes. He was admitted to our hospital with an acute coronary syndrome. He reported his medications at the time of admission as including metoprolol 50 mg twice daily (for hypertension) and paroxetine 20 mg daily (for depression). The patient was given multiple doses of intravenous atropine (total, 1.2 mg) and adrenalin (total, 2 mg). After an adrenalin infusion was begun, he developed ventricular tachycardia (170 beats/min), but his cardiac rhythm spontaneously returned to sinus bradycardia. Two days after admission, two coronary stents were successfully deployed in a critically stenosed right coronary artery. Bradycardia (45–50 beats/min) persisted. The following day, it was discovered that 3 weeks previously, the patient’s general practitioner had prescribed bupropion 150 mg twice daily to assist with smoking cessation, which he had been taking up until the day of admission. Bradycardia continued until hospital discharge. One month after discharge, he was in sinus rhythm (60 beats/min) and was clinically well. Bupropion is a selective noradrenalin, dopamine and serotonin reuptake inhibitor. The mechanism by which it enhances the ability of patients to abstain from smoking is unknown.1 Bupropion inhibits the activity of the cytochrome P450 2D6 isoenzyme, which metabolises metoprolol.2 Concurrent use of bupropion and metoprolol can increase serum metoprolol levels, and clinically significant bradycardia has been reported.3 Further, paroxetine, a selective serotonin reuptake inhibitor (SSRI), is a potent cytochrome P450 2D6 inhibitor, which would have further increased serum metoprolol levels. Bradycardia associated with metoprolol and paroxetine dual therapy has been described.5 Additionally, there is the potential for serotonin syndrome to develop in a patient administered multiple SSRIs. In our patient, the administration of bupropion and paroxetine could have potentially led to serotonin syndrome.6 Our patient’s pharmacological profile was complex, with potential adverse pharmacodynamic effects. The most likely precipitant of the patient’s bradycardia was his acute coronary syndrome, although bupropion may have contributed. The case highlights the potential for significant drug interactions when new drug therapies are initiated. Bupropion and metoprolol (and other drugs metabolised by the cytochrome P450 2D6 isoenzyme pathway) should be co-administered with caution. The importance of common pathways of drug metabolism should be recognised to avoid potential adverse events, particularly when multiple medications are used.

Jacqueline Landau · Andrew E Ajani

To the Editor: I challenge the assertion made by Donohoo (Managing Editor of MIMS [the Monthly Index of Medical Specialities]) that “MIMS is held . . . in high regard” and that the “vast majority of MIMS subscribers recognise that the quality information provided by MIMS is essential in their daily encounters with their patients”.1 In fact, the most common MIMS annual to be seen around hospitals, in nursing homes and in doctors’ surgeries is an out-of-date one. Furthermore, as a general practitioner, when I do use MIMS, it is because it is packaged with our desktop software, rather than by choice or active decision. I have online access to the Australian medicines handbook (http://www.amh.net.au/), and various other references. I have no need to refer to MIMS, and I tire of the understandable bias MIMS has always had for proprietary prescribing.

Lilon G Bandler

To the Editor: Walters recently suggested that Australia should implement population control strategies as part of an approach to reduce global warming.1 As a father of four, I found his assertion that my decision to father more than two children is “arrogant” to be offensive. Walters’ arguments are, at best, poorly reasoned. As a “citizen of this world”, he clearly rejects the rights of other citizens to live on an equal footing and follow their religious, cultural or social beliefs if those beliefs oppose contraception. I would argue this is contrary to law.2,3 His mathematical calculations ignore all costs required to achieve his objective, such as those associated with “contraceptives, intrauterine devices, diaphragms, condoms and sterilisation procedures”. Further, he fails to consider costs associated with the supporting bureaucracies required to effect his policy, including material amendments to the Australian taxation system. Rather, and in my opinion strangely, he advocates issuing carbon credits for the additional consumption of contraceptive products. According to Walters, people should be judged by their anticipated rather than actual emissions. A logical extension would be to punish those who exceed a predetermined mean acceptable level of emissions. No doubt, meeting the medical and ancillary needs of many sick, older and disabled people often generates excess emissions. Perhaps we should adopt some of the practices used in China and India, including abandonment and neglect of disabled children and older people.4,5 How would we deter and punish those who cannot pay? Walters addresses the issue of overpopulation by comparing Australia to India and China. This is notwithstanding that Australia has one of the lowest population growth rates in the world6 and, with its ageing population and labour shortages,7,8 has significantly different population and social concerns to these countries. There are no grounds to support the comparison made. Environmental issues are among the greatest challenges facing society. As a father, I am deeply concerned for the world my children will inherit. We must deploy our limited resources efficiently and effectively to maximise their impact. To demand social controls in the manner Walters suggests, within a society heavily burdened with laws and struggling to meet labour and health system demands, would defeat this objective. Reading Walters’ views, which I consider fundamentally flawed, in a publication such as the Journal imparts to them a validity I believe is unjustified. I do not consider that Walters’ social engineering policies could benefit anyone in Australia, while his “moral” concerns are ill conceived.

Cathal A Smith

In reply: I thank Smith for the opportunity to clarify some scientific points. The science behind climate change is undeniable and was reviewed in February this year. Moreover, “there is a greater than 90 per cent probability that the warming observed since the 1950s is due to human activities”. Therefore, attempts to prevent environmental calamity will not succeed with boundless population growth. In this sense, the more people there are, the worse it is for our earth. In particular, no nation should encourage population growth. I do not argue for compulsory sterilisation. I do argue that we recognise the cost of every extra human being to our overburdened earth. Smith labelled my note of caution about limitless procreation as “offensive”. I believe such disparagement is founded on personal and cultural beliefs, not on science, which informs and guides medicine. There is only one atmosphere. Australians occupy this planet with no more rights than others do. Racism is anathema to us. If others must observe population restraint, then so must we. Contrary to Smith’s assertion, I plead that all should be able to “live on an equal footing”. Is this not the laudable basis of law? I share his concern for the world that his “children will inherit”; my concern embraces the children of others as well.

Barry N J Walters

To the Editor: We read Pham and colleagues’ recent article1 with interest, as evidence mounts against the use of probiotics in critically ill patients. Although a plausible and attractive theory, probiotics in the patient with acute illness now appear ineffective, if not positively harmful. A recent randomised trial of probiotics in 298 patients with severe acute pancreatitis showed a non-significant rise in infective complications,2 in keeping with results of previous studies of critically ill patients.3,4 Disturbingly, mortality in the probiotic group was more than double that in the placebo group (P < 0.01). Bowel ischaemia was a prominent feature of deaths in the probiotic group (eight patients), but was not associated with any deaths in the placebo group (P < 0.004). It may be that non-occlusive mesenteric ischaemia in critical illness is exacerbated by the added bacterial load itself, or through a pro-inflammatory response by gut epithelial cells. While probiotics may be a benign and beneficial adjunct to enteral feeding in certain clinical situations, there is persuasive evidence that probiotic therapy is associated with increased infective complications in critically ill patients and significant mortality in patients with severe acute pancreatitis. Until there is evidence to the contrary, we believe probiotics should not be administered to patients with severe acute illness.

Shimonti Chatterjee · John Fraser

To the Editor: Pham and colleagues commented on the effects of probiotics; however, not much is known about the impact of probiotics on weight gain and obesity. It is known that a predominance of certain bacteria, such as Lactobacillus, in the bowel can promote weight gain. Many of these bacteria are found in probiotic products. The human intestinal microbiota is predominantly colonised by the Firmicutes and Bacteroidetes phyla of bacteria. Lactobacillus and Bifidobacterium, found in a number of probiotic products, belong to the Firmicutes phylum. A study has shown that obese people carry a higher proportion of bacteria from the Firmicutes phylum and that there is a statistically significant decrease in the proportion of Firmicutes bacteria as they lose weight.3 A similar pattern of Firmicutes predominance has been found in obese mice. Furthermore, the microbiota of the obese mice were more likely than those of lean mice to break down otherwise indigestible polysaccharides from the diet.4 In other words, a higher proportion of Firmicutes bacteria was associated with increased and more efficient caloric uptake from food. These data did not necessarily imply causation, so the investigators performed another experiment. They transferred intestinal microbiota from obese and lean donor mice to germ-free mice, and found that the mice who received microbiota from the obese donors had a significant increase in body fat after 2 weeks compared with the recipients from the lean donors.4 It is therefore likely that the bacteria often found in probiotics can cause weight gain. Obesity in children and adults is a major health problem in developed nations. Given the increasing use of probiotic products in such countries, large studies should be performed to characterise the association between probiotics and obesity. Such studies may not find any association or may find that there is only a dose-related risk. If there is an association, probiotics may still prove useful in certain circumstances (eg, for weight gain in children failing to thrive).

Sanjaya N Senanayake

In reply: The comments by Chatterjee and Fraser regarding the danger of administering probiotics to patients with acute severe illnesses are important additions to the debate on the risks and benefits of probiotic administration. We also thank Senanayake for his interesting comments on the possible role of probiotics in weight gain. The recently published multicentre trial1 describing unexpected adverse events associated with probiotics in acutely unwell patients with severe pancreatitis is one example of an adverse outcome following probiotic administration. The use of probiotics in patients with severe comorbidities and in those who are immunocompromised is also contraindicated. There are reported cases of Lactobacillus GG sepsis in premature babies with short gut syndrome,2 and Saccharomyces boulardii fungaemia has been described in immunocompromised patients.3 It is interesting to note that two systematic reviews have assessed the efficacy of probiotics in prevention of necrotising enterocolitis in premature (< 33 weeks’ gestation) and very low birthweight (< 1500 g) infants.4,5 Both reviews concluded that probiotics may decrease the incidence of necrotising enterocolitis in preterm infants, and that severe adverse events were not associated with probiotics in these unwell and immunodeficient patients. However, there were insufficient data to comment definitively on the short-term or long-term safety of probiotics in these infants; this will require assessment in future large trials. The increased scrutiny of probiotics resulting from the publication of the adverse outcomes in adults with severe acute pancreatitis1 may, by necessity, slow the commencement and progression of these larger trials in infants in the neonatal intensive care setting.

Mimi Pham · Daniel A Lemberg · Andrew S Day

To the Editor: On 25 January 2008, the Australian Transport Council approved the National Transport Commission’s seventh amendment to the Australian Road Rules. This amendment provides for the mandatory use of forward-facing child restraints for children aged 6 months to 4 years, and the use of Australian Standards-approved booster seats for children aged 4–7 years and weighing up to 26 kg. It also recommends that children aged less than 7 years should not travel in the front passenger seat. These changes are welcome. They bring Australian rules on child restraints and seating position closer to (but still not on par with) restraint laws already implemented in the United Kingdom and other countries in the European Union, where booster seats are mandatory for all children aged under 12 years or less than 145 cm tall. Implementation of the amendment poses several challenges. A small proportion of children will exceed the 26 kg weight limit for booster seats by their seventh birthday; however, there is no evidence that these seats are not safe for slightly heavier children. In addition, the Australian Standard (AS 1754) is currently being revised and is likely to move towards recommending restraint selection based on seated height rather than weight, as well as developing new standards for booster seats for older children. Height is the most important determinant of adequate seatbelt fit, and children need to be about 145 cm tall before the lap portion of an adult seatbelt sits correctly over the iliac crests rather than on the soft abdomen. Community education campaigns will be pivotal in successfully implementing these new road rules. As misuse of restraints is high, education campaigns must emphasise correct use of recommended restraints.-4 Furthermore, the new recommendations may contribute to financial hardship, particularly for low-income families with several children under the age of 7 years. Subsidies or loan schemes may be required to assist such families. Fitting three restraints across the rear seat of small cars may also be difficult. Adequate enforcement will be required to maximise compliance. Research studies and injury surveillance will play an important part in maximising the effectiveness of these rule changes. Finally, the seventh amendment to the Australian Road Rules does not constitute law, and legislative changes will need to be enacted by each state and territory before these changes become law. We hope that the state and territory governments will take swift action to enact these laws, to prevent injuries and deaths in Australian children due to motor vehicle crashes.

Yvonne A Zurynski · Lynne Bilston · Elizabeth J Elliott

To the Editor: Court, Bergh and Södersten raise the issue of why and how some therapies with prima facie evidence for their efficacy have a significant take-up by medical practitioners, while others are allowed to languish, sometimes for decades.1 It is 6 years since Bergh and colleagues conducted their Swedish trial on eating disorders, with significant encouraging results.2 Again they report — albeit this time with a non-randomised but local sample — above-average outcomes.1 Again, the fact that their patients had had previous treatments that failed renders the results compelling. We have to ask why no one has found the time, money or inclination to attempt to reproduce their findings or examine which elements of their intervention are successful. It would be ironic if the answer is that medical researchers are afraid of the unusual. While Australian medical research and public health ignore this mandometer treatment, some private health funds have been prepared to contribute up to $60 000 per patient for it, suggesting that they view it as better value for money than alternative therapies.

Phillip Gray

To the Editor: More than 2000 graduates of South African medical schools have migrated to Australia since 1948. Unlike many immigrants from Europe before and after World War II, all were fluent in English and most were able to start practising almost immediately. In chronicling this unique migration and its contribution to Australian health care, I am trying to contact, by email, as many as possible of the 1800 South African doctors now practising here, as well as surviving spouses or children of the 100 or so who have died since arrival. As a 1961 graduate of the University of the Witwatersrand in Johannesburg, I have a particular personal interest in this migration. Assisted by a sociologist and a statistician, I have prepared an email questionnaire. Responses will be de-identified before analysis. I would be grateful if graduates of South African medical schools would contact me by email.

Peter C Arnold

At the time of his death in Georgetown, in Queensland’s Channel Country, Cyril Swaine had enjoyed a successful medical career of over 50 years, spent within and outside Australia, remaining active and moving with the times in a profession that was undergoing unimagined expansion and specialisation. Cyril was born on 1 November 1919 in the Adelaide Hills, the eldest of six children, into times that were frequently hard. He was mentored at an early age by a local general practitioner, Carl Jungfer, a later icon for Australian general practice. On graduating in medicine at the University of Adelaide, Cyril entered the wartime Royal Australian Air Force, serving in Malaya and rising to the rank of Squadron Leader. In 1947, he joined the Repatriation Department in Adelaide, gaining expertise in the management and treatment of tuberculosis. After 9 years in the Repatriation Department, Cyril spent a year working as a Senior Medical Officer at the then-active Woomera Rocket Range, followed by 14 years in general practice at Woodville in Adelaide. The next 13 years were spent in Indonesia and Papua New Guinea working for a mining company, where his practice included occupational and industrial medicine and was enlivened by obstetrics and emergency surgery. In 1983, he returned with his family to Cairns in Queensland with plans to semi-retire. But for a person of his great intellect and altruistic spirit, this proved difficult, and his practice actually expanded to include younger partners and a second site. He became active in Rotary and was elected to the executive of the Cairns Division of General Practice. In 1999, Cyril sustained two accidents that finally forced him to retire. Cyril relocated to Georgetown, where his wife Pam took up a position as Director of Nursing at the hospital. Cyril died there on 14 August 2007 from ischaemic heart disease. His requiem mass in Georgetown was notable for the attendance of many colleagues who had been flown into the relatively remote town courtesy of the Royal Flying Doctor Service. It was suitable recognition for a man who was described during his eulogy as displaying tremendous integrity, loyalty and honesty, and who epitomised the Christian ethic in his professional and personal life. He is survived by his wife Pam and children Marie, Stephanie, Brook and Justin. A son David predeceased him.

Peter P Thomas

Medico-legal radiology. William S C Hare. Sydney: Churchill Livingstone, 2007 (ix + 201 pp). ISBN 978 0 7295 3831 2. Emeritus Professor W S C (Bill) Hare had a long and distinguished career in clinical radiology, including a term as President of the Royal Australian and New Zealand College of Radiologists and Chair of Radiology at the University of Melbourne and the Royal Melbourne Hospital. In retirement, he has continued an active medicolegal practice as well as his writing. This latest book draws on both his personal experience and an extensive review of the extant literature. The first chapter, “Lawmakers and legal processes”, is as succinct a summary of the structure and practice of the law as I have seen. The second chapter, “Radiologists and the law”, examines how both statute and civil law can impinge on doctors in general and radiologists in particular, and the roles doctors can take in legal proceedings (ie, as defendant or as expert witness). The third chapter deals briefly with no-fault and fault-based systems of compensation for iatrogenic injuries, and looks at why patients sue, who they sue, the results of litigation and the impact of the cost of litigation on medical indemnity insurance premiums. Chapter four is a brief primer on how to interpret diagnostic images — a seven-page summary that would make valuable reading for any student or recent graduate, or indeed any doctor who needs to make sense of such images. The fifth chapter, on writing reports, is pure gold. When a defence organisation runs an expert witness seminar, attendees are desperate to learn how to manage themselves in court. But most will write dozens of reports for every time they actually go to court, and the quality of their report will have a great influence on whether they need to be called at all. Doctors generally write poor reports, because few seek instruction on how to write good ones. For radiologists, Professor Hare has now, in just nine pages, written the definitive primer. The remaining 10 chapters deal systematically with the major areas of medicolegal concern in radiology and conclude with a chapter on necroradiology (the title Hare adopts for radiological examination of the dead). Each chapter deals separately with litigation arising from diagnosis and litigation related to procedures. Each chapter ends with a series of dot-pointed “suggestions” which radiology registrars would be well advised to commit to memory! This is a relatively short, well written book. While written in an Australian context, the “suggestions” have application to any radiologist anywhere in the world.

Paul Nisselle

Re: “Patterns and incidence of γ-hydroxybutyrate (GHB)-related ambulance attendances in Melbourne, Victoria”, by Paul M Dietze, Stefan Cvetkovski, Monica J Barrat and Susan Clemens, in the 16 June 2008 issue of the Journal (Med J Aust 2008; 188: 709-711). The third author’s name was spelled incorrectly. The correct spelling is Monica J Barratt.

Paul M Dietze · Stefan Cvetkovski · Monica J Barratt · Susan Clemens

Re: “The increasing problem of motorcycle injuries in children and adolescents”, by Catherine A Bevan, Franz E Babl, Penny Bolt and Lisa N Sharwood, in the 7 July 2008 issue of the Journal (Med J Aust 2008; 189: 17-20). The authors’ affiliations were incomplete and are reproduced correctly below.

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

ECPR — an arresting finding Extracorporeal life support appears to have a benefit in terms of survival over conventional cardiopulmonary resuscitation (CPR) in patients who suffer an inhospital witnessed cardiac arrest. In a 3-year prospective observational study based in Taiwan, outcomes for patients with cardiac arrest of cardiac origin who underwent CPR for longer than 10 minutes were analysed: one group received conventional CPR, and the other underwent CPR and extracorporeal life support via a circuit including a centrifugal pump and oxygenator. There was a significant difference in survival between the two groups, with those patients undergoing extracorporeal CPR having a better survival rate to discharge and a superior 1-year survival compared with those who received conventional CPR. The authors comment that although the observed difference may be in part due to selection bias, they attempted to minimise this possibility through their statistical analysis. Lancet 2008; 4 Jul [Epub ahead of print] Diabetes and deafness Hearing impairment is common in people with diabetes, and diabetes appears to be an independent risk factor for hearing loss, according to the results of a large US study. Over 5000 adults underwent audiometric testing and completed a demographic and health questionnaire. A random sample also received testing for fasting plasma glucose levels to identify further cases of diabetes. In a multivariate analysis, people with diabetes had significantly increased odds of hearing impairment at all levels of severity. The prevalence of low or midfrequency hearing impairment was estimated to be 28% among adults with diabetes, compared with a reported 17% in the US population overall. Researchers suggest that several biological mechanisms may explain the association, including pathogenic changes to microvasculature and sensory nerves. Ann Intern Med 2008; 149: 1-10 Nature and nurture An international group of medical researchers has suggested that environmental factors acting during development influence the subsequent susceptibility of an individual to disease, and should be accorded greater importance in models of disease causation. In a review paper discussing mechanisms of disease, the authors outline epidemiological and clinical factors supporting this view, including observations that smaller size at birth and in infancy is associated with an increased risk of coronary heart disease, diabetes, and osteoporosis. In a fascinating twist on the nature-nurture debate, the developmental-origins hypothesis proposes the induction of an adaptive response in the fetus or infant to signals from the mother about her health or physical state. Responses made by the fetus, including hormone production, metabolic changes, and sensitivity of target tissues to hormones, could result in changes in developing organs, resulting in permanently altered physiological and metabolic homoeostatic set points. Through maternally mediated environmental modulation, the expression of genes transmitted from mother to child may be subject to alteration. The influence of this developmental plasticity, defined as “the ability of an organism to develop in various ways, depending on the particular environment or setting”, is supported by animal and human studies showing how physical, dietary or hormonal challenges from conception to infancy can result in permanent changes to function in the offspring. N Engl J Med 2008; 359: 61-73 Reducing the “ouch” factor Use of a topical vapocoolant spray containing pentafluoropropane and tetrafluoroethane appears to be useful in reducing pain and anxiety in children undergoing intravenous cannulation, say Canadian researchers. In a double-blind randomised controlled trial involving 80 hospitalised children aged 6-12 years, half received the vapocoolant spray and half a placebo prior to cannulation. Children rated their pain using a colour visual analogue scale. A modest but significant reduction in the perception of pain was noted with the vapocoolant spray, and cannulation on the first attempt was more successful using the spray than with a placebo. Side effects to the spray included rare allergic reactions and skin changes secondary to hypothermia if the spray time exceeded 10 seconds. The authors comment that the topical vapocoolant is simple to use and the results are immediate, making it ideal for the emergency situation. CMAJ 2008; 179: 31-36 A pain in the back Low back pain is a common problem in primary care and affects millions of people on a daily basis, with significant economic and personal costs. Australian researchers have performed a cohort study of over 900 patients presenting with acute low back pain to primary care practitioners. Outcome measures of the study included recovery in terms of ability to return to work, and patients’ perception of function and pain resolution. After baseline assessment, follow-up occurred at 6 weeks, 3 months and 12 months. The authors found that contrary to clinical practice guidelines, disability and pain took significantly longer than expected to resolve, with only 72% of participants having completely recovered at 12 months. Factors associated with a longer time to recovery included higher pain intensity, older age, feelings of depression, and a longer duration of pain before consultation. BMJ 2008; 337: a171

Tanya Grassi