Volume 189 Issue 7

All topical ophthalmic agents should be considered potentially potent systemically Many Australians are prescribed topical ophthalmic medications for chronic conditions such as glaucoma, ocular inflammation, infection and allergy. Despite their overall safety, these agents have the potential to cause significant systemic side effects and to have serious interactions with oral medications. In many cases, these effects may go unreported by the patient or misdiagnosed by the medical community. There is a need for improved prescribing practices in both the ophthalmic and general medical communities, with increased awareness of the full range of therapeutic agents being taken by the patient. With the recent passage of legislation allowing optometrists prescribing rights under the Pharmaceutical Benefits Scheme (PBS) (National Health Amendment [Pharmaceutical Benefits] Act 2007 [Cwlth]), it is timely to remind all health care practitioners of the potential hazards of topical ophthalmic medications. Pharmacokinetics make ocular drug delivery more akin to intravenous than to oral administration.1 Topically administered medications gain access to the highly vascular nasal mucosa and are variably absorbed, avoiding first-pass hepatic metabolism.2,3 One drop of timolol 0.5% solution in each eye approximates a 10 mg oral dose for treating systemic hypertension or angina.2 All topical agents should be considered as potentially potent systemically. A retrospective analysis of de-identified PBS billing data from Medicare Australia revealed that, between 1999 and 2004, 20 000 Australians per year had been exposed to co-supply of topical and systemic β-blockers.4 This combination has been linked with adverse respiratory and cardiovascular events, as well as reduced topical ocular hypotensive efficacy.5 The scale of this as a Quality Use of Medicines issue is larger than was anticipated. Multiple factors may be responsible: an assumption that topical therapy is systemically “homoeopathic”; the fact that many patients may not mention eye drops when asked about their drug history; and the fact that patients may not remember their full list of medications. Topical medications usually constitute first-line therapy for glaucoma. Parasympathomimetics (pilocarpine derivatives) have been in use for 140 years, topical β-blockers for 30 years, and, more recently, carbonic anhydrase inhibitors, α2-agonists and prostaglandin analogues have emerged. While the overall safety of these agents is recognised, there is a potential for serious side effects in a small proportion of people. As well as their own direct effects systemically, topical agents may have significant additive or interactive effects with systemic medications. Topical β-blockers may precipitate or aggravate bronchospasm, congestive heart failure, bradyarrhythmias, sinus arrest, a variety of central nervous system effects and dyslipidaemias.6-8 In this issue of the Journal, Schweitzer and colleagues (page 406)9 describe a case involving two episodes of melancholic depression in a patient who had been prescribed β-blocker antiglaucoma agents. Taking these medications has been rated as the most significant risk factor for falls in glaucoma patients.10 Parasympathomimetics locally provoke brow ache and/or headache, miosis and myopia, and, with systemic absorption, carry the risk of bradycardia, hypotension, bronchospasm,7 gastrointestinal symptoms and urinary frequency. Topical α2-agonists have been associated with central nervous system depression and with profound hypotension in children.11 Topical carbonic anhydrase inhibitors do not seem to produce the metabolic side effects of their oral counterparts, but may be associated with an idiosyncratic bone marrow suppression and sulphonamide allergy.6 To date, topical prostaglandin analogues have not been associated with cardiovascular or respiratory side effects, adding support to their use as first-line antiglaucoma agents.6 However, their use has been associated with headache, flu-like symptoms and myalgias in up to 10% of patients, with case reports of neurological referral and investigation.11,12 Co-prescription of systemic and topical β-blockers can reduce heart rate in patients with glaucoma.5 Simultaneous administration of topical timolol and systemic verapamil has been associated with severe bradycardia.7 Co-administration of topical α2-agonists with oral monoamine oxidase inhibitors carries a risk of hypertensive crisis and is contraindicated.3 Salicylates have been shown to cause accumulation of systemically administered carbonic anhydrase inhibitors; this is also theoretically possible with topical carbonic anhydrase inhibitors.3 Topical steroid drops are key to the management of ocular allergy and inflammatory disease. While they are well tolerated systemically, their ocular side effects are potentially blinding: potentiation of infection, cataract and glaucoma. Commonly perceived as a “safe” alternative, fluorometholone has been associated with all these ocular side effects, albeit less frequently.13 Topical chloramphenicol is commonly prescribed to treat infective conjunctivitis, and is used perioperatively with ocular surgery. Although bacteriostatic rather than bactericidal in action, its broad spectrum of activity and lack of systemic use make it an ideal first-line ocular topical agent. Its potential to induce life-threatening aplastic anaemia remains controversial: the risk has been estimated to be about 1 in 150 000, at worst,14 but it is likely to be much lower.15 Whether the rare occurrence of this condition is by a dose-dependent or a dose-independent (idiosyncratic) mechanism,14,15 prescribers need to be cautious when prescribing for patients with a personal or family history of blood abnormalities. Concern about this risk has been enough to marginalise the use of chloramphenicol in the United States. Additionally, chloramphenicol should only be prescribed when conjunctivitis is likely to be bacterial in origin and for clinically appropriate time periods.16 We believe prescribing practice can be improved with simple steps: (i) take a full drug history, and specifically ask about eye drops; (ii) physicians must remember to ask whether the patient’s optometrist has prescribed any medication, and should be aware of the newer combination preparations (Combigan [Allergan], Cosopt [Merck, Sharp and Dohme], DuoTrav [Alcon], Xalacom [Pfizer]), all of which contain the β-blocker timolol; (iii) ophthalmologists (and now optometrists) should be aware of a patient’s concurrent systemic health and medication status before commencing any topical agents, particularly β-blockers. The eye is not an isolated organ but may be influenced by systemic diseases and therapies. Further, recent publications1,4,8 highlight the converse — topical therapies for the eye may have significant systemic effects and/or interactions with systemic medications. It is important to be alert to possible systemic side effects and interactions between systemic and topical agents and to investigate and modify treatment regimens appropriately. Limit the use of topical steroids, and use them only with adequate supervision. Remind all patients using topical medications to follow the “double DOT” procedure (Don’t Open eyes Technique and Digital Occlusion of the Tear duct), which involves closing the eyes and applying digital pressure over the lacrimal sac for 1–2 minutes after drop administration (Box 1, Box 2). This reduces systemic absorption by two-thirds, thereby significantly widening the safety margin of all agents.17,18 Recent legislative changes across Australia allow practitioners who are not medically trained to prescribe topical medications, although, at present, legislation varies from state to state. These changes underline the importance of general practitioners and physicians recognising the potential systemic effects of these topical ophthalmic medications and being alert to interactions with other medications. Improved communication between all health care practitioners and ophthalmologists will be vital for patient safety. 1 Lacrimal drainage system 2 The “double DOT” procedure* for reducing systemic absorption of topical ophthalmic medications * Don’t Open eyes Technique and Digital Occlusion of the Tear duct.

Ivan Goldberg MB BS, FRANZCO, FRACS · Gregory Moloney MB BS · Peter McCluskey MB BS, FRANZCO

The future viability of general surgery may depend on combining subspecialty elective surgery with full-scope acute practice in both public and private settings Subspecialisation in surgery is an irresistible and irreversible force. It improves standards of patient care1 but tends to be accompanied by an erosion of competence in the broad scope of the major specialty. For example, many major hospitals in Australia have had difficulty retaining subspecialty breast surgeons on the on-call roster because these surgeons feel that their competence to manage the full range of general surgical emergencies has been diminished by their day-to-day practice involving primarily the breast and axilla and rarely the abdomen. Nevertheless, the community needs surgeons willing and able to provide acute surgical care in the major specialties, including general surgery. Is it possible to have a model of care that satisfies both of these apparently divergent scopes of practice? A century ago, there was a single broad field of surgery. During the 20th century, specialties within surgery developed, many of these arising from general surgery, which continues to be the largest specialty. The Royal Australasian College of Surgeons (RACS) currently recognises nine specialty disciplines, by training and examination: general surgery; orthopaedic surgery; otolaryngology, head and neck surgery; plastic and reconstructive surgery; cardiothoracic surgery; neurosurgery; paediatric surgery; urology; and vascular surgery.2 Recognition as a surgical specialty has required definition of a discrete area of knowledge and skills, and a group of practitioners dedicated to the practice, teaching and advancement of the specialty. Subspecialisation within each specialty continues this development, driven by surgeons’ motivation to increase their knowledge and improve patient care. However, it may also have professional and personal benefits for the surgeon, including a more regulated lifestyle and enhanced prestige and remuneration. Examples of subspecialisation within the specialty of general surgery are breast, endocrine, upper gastrointestinal, hepato-pancreatico-biliary, and colorectal surgery. Of particular concern is that general surgery — comprising the largest specialty group of surgeons and those most likely to be required to treat emergencies — is now attracting proportionally fewer applicants for training. In 2007, general surgery offered 51% of available training posts but attracted only 30% of applications.2 Until recently, a third of trainees transferred to another specialty during their training. Although it is hoped that the new Surgical Education and Training (SET) program3 will bring improvements for all surgical specialties, attraction to and retention in general surgery training is likely to be a continuing challenge. Despite the best efforts of the RACS and public hospitals, the number of training positions in general surgery of sufficient quality to meet accreditation standards has increased only gradually from 266 in 2004 to 304 in 2008.2 These factors at the supply end, combined with the fact that 40% of active general surgeons are aged over 60,2 are creating serious workforce pressures. Very few surgeons remain on the on-call roster after age 60. The situation seen in Australia is similar in other developed countries and is particularly concerning in the United States, where Fischer has warned of the impending disappearance of the general surgeon.4 General surgical specialists have been trained to a competent level in the full range of the specialty, including trauma and the acute abdomen. However, as subspecialisation develops, surgeons may become de-skilled in the requirements of emergency surgery. Thirty years ago, general surgeons practised the full range of the specialty, taking pride in the breadth and depth of their knowledge and skills. This has changed significantly. In a 2003 survey,5 the practice patterns of members of General Surgeons Australia were: general surgery with subspecialty, 45% general surgery with more than 90% subspecialty, 23% “general” general surgery, 18% subspecialty only, 14% Nevertheless, 83% felt an obligation to stay on emergency rosters out of duty to the community, trainees and professional colleagues. But for how long will this goodwill continue? Emergency work is demanding, and reliance on a diminishing pool of “general” general surgeons will not be sustainable. Indeed, the future viability of the specialty of general surgery may depend on the development of a model of practice that combines subspecialty elective surgery and full-scope acute practice in both public and private settings. What is required to encourage surgeons to continue to work on emergency rosters? First, we need a review of these rosters. The tradition of ongoing responsibility for the care of patients taken in during an on-call period being maintained by visiting surgeons — who make up most of the workforce and who are in private practice outside the public hospital for most of their working week — should be reconsidered. The Australian Medical Association has promulgated safe-hours principles,6 and these depend, in part, on the acceptance of safe-handover principles.7 The RACS supports both these professional workplace ideals.8 Rosters have been successfully trialled where a consultant-led surgical team is on call exclusively for emergencies, with no scheduled elective duties, for a defined time period such as 24 hours, or longer. At the end of this time, the team completely hands over care of patients with unresolved problems to the next team.9 Second, we need a review of the efficient use of operating theatres for emergency and elective surgery. Lack of access to beds and operating theatres for elective surgery is a continuing source of frustration for patients, surgeons and trainees, and may be solved by separating the services.10 This can be achieved by establishing a separate hospital for elective surgery, at least for surgery of minor or moderate complexity, or by effective quarantining of services within a major hospital complex. Third, surgeons need to maintain competence in emergency surgery relevant to their major surgical specialty. It is possible to identify the requirements of emergency surgery as a defined scope of practice within each of the nine major specialties. This set of knowledge and skills could be formalised in a curriculum for continuing professional development and delivered in an adult learning format, including online modules and hands-on technical skills laboratories. Surgeons would then have the confidence to continue to serve on on-call emergency rosters, thereby acting as mentors and role models for trainee surgeons, while also continuing to practise a subspecialty interest in elective surgical practice. Finally, hospitals should value their surgeons and provide appropriate incentives and conditions of service, including adequate remuneration and tangible support for continuing professional development. This will require cultural and organisational reform, but hospitals could then reasonably expect surgeons to provide emergency services as a condition of their employment. My emphasis here has been on general surgery, where the problems are so obvious. However, service issues also apply to other surgical specialties with developed and developing subspecialisation (notably orthopaedics and otolaryngology) and are also relevant to other medical specialties. Problems particularly occur in the public sector; while provision of acute care in the private sector is also problematic, motivations and incentives in private sector settings appear to be more effective in maintaining services. In rural and remote areas, the provision of elective and emergency services is also threatened by workforce pressures beyond the issue of subspecialisation. The RACS has recently responded to concerns about the increasing difficulties in providing adequate emergency and trauma care by publishing a position statement outlining guidelines for the sustainability of emergency surgery services.10 To continue to provide emergency surgical care to the Australian community, it is apparent that models of coexistence must be found, and that solutions will include effective rostering and practice models, the certainty of availability of facilities for care, and the appropriate valuation of surgeons, as well as ongoing support for the maintenance of professional competence.

Ian R Gough MD, FRACS

Objective: To assess the quality of Australian clinical guidelines for chronic diseases and their relevance to older people with multiple comorbid conditions. Design: Selection and assessment of national clinical guidelines for chronic conditions listed as National Health Priority Areas: cardiovascular health, diabetes mellitus, mental health, asthma, arthritis and musculoskeletal conditions, and cancer. Main outcome measures: Standardised mean scores obtained with the Appraisal of Guidelines Research and Evaluation (AGREE) instrument (criteria grouped into six domains: scope and purpose; stakeholder involvement; rigour of development; clarity and presentation; applicability; and editorial independence). Relevance of guidelines for older people with multiple comorbid conditions. Results: 17 guidelines were included in the study. Guidelines approved by the National Health and Medical Research Council (NHMRC) scored significantly better than those not approved by the NHMRC in all domains except for editorial independence and clarity and presentation. The mean quality of guidelines not approved by the NHMRC was below 50% in all domains except clarity and presentation. Half of the guidelines addressed treatment for older patients or for patients with one comorbid condition, but only one addressed treatment for older patients with multiple comorbid conditions. Conclusions: Professional societies and charities should be encouraged and supported to develop clinical guidelines in compliance with NHMRC requirements. Future guidelines should place more emphasis on the management of older people with multiple comorbid conditions.

Agnes I Vitry PhD · Ying Zhang MB BS, PhD

Objective: To determine whether Helicobacter pylori eradication is an effective treatment for Australian patients with chronic immune thrombocytopenic purpura (ITP).Design, setting and patients: Retrospective analysis of clinical records of a consecutive series of ITP patients referred to a gastrointestinal surgeon in a tertiary referral hospital for laparoscopic splenectomy between August 2005 and November 2007.Main outcome measures: Platelet response (measured at least 3-monthly) following successful H. pylori eradication therapy (confirmed by urea breath test 4 weeks later).Results: Of 16 patients, seven were H. pylori-negative and underwent laparoscopic splenectomy. Nine were H. pylori-positive and successfully underwent H. pylori eradication therapy; five of the nine had an initial platelet response. Four patients had platelet counts > 100 × 109/L (reference range, 140–450 × 109/L) and were off all immunosuppression at 9 months; three had a sustained response beyond 12 months. One patient had an initial response at 3 months (15 × 109/L to 208 × 109/L), but relapsed 4 months after H. pylori eradication and underwent splenectomy with platelet count recovery. The remaining four patients showed no platelet response and subsequently underwent splenectomy.Conclusion: Larger prospective studies are needed to fully ascertain the role of H. pylori in Australian patients with ITP. However, H. pylori eradication is simple and safe. H. pylori screening and eradication should be considered before immunosuppression or splenectomy.

Vanaja Sivapathasingam BSc(Med), MB BS(Hons) · Michael P Harvey PhD, FRACP, FRCPA · Robert B Wilson BSc, MB BS(Hons), FRACS

Objective: To review television and print media coverage of the campaign to regulate solaria that was initiated by Clare Oliver before her death from melanoma in late 2007, and to investigate how the media constructed the aetiology of her disease.Design and setting: Frame analysis of all direct and attributed statements about the causes of, and responsibility for, Oliver’s melanoma, and about the legacy of her campaign, in reportage on five free-to-air Sydney television stations and in Australian capital city newspapers, 21 August 2007 to 20 February 2008.Results: 26 television and 83 print media reports were identified, containing 279 statements on Oliver: 146 (52%) dealt with the responsibility of >solaria or their need for regulation, 23 (8%) were on issues of self-responsibility, and 110 (40%) were on her legacy. Oliver stated she had visited solaria 10 times, but had spent years acquiring a tan outdoors. However, less than one in 10 statements about the aetiology of her melanoma referred to her outdoor tanning history, with most explaining the cause as solarium ultraviolet radiation. Oliver’s campaign was credited with precipitating rapid regulation of solaria in Australia. However, the new regulations will not prevent a person of her age or skin type visiting solaria and fall well short of the ban she hoped for.Conclusion: Unlike sun exposure, solaria are an entirely tractable factor contributing to melanoma. Failure to ban solaria has been a disappointment in a high-profile window of opportunity to change public health law.

Ross MacKenzie MA · Michelle Imison MIPH · Simon Chapman PhD · Simon Holding BA

Leading international health organisations are concerned about high use of artificial tanning services and the associated risk of skin cancer. Similar concerns exist about the growing Australian solarium industry. Pre-teens appear to be ignoring sun safety messages in their desire to tan and use solaria. A significantly elevated risk of melanoma exists among people exposed to artificial ultraviolet radiation; the risk is higher for those younger than 35 years at first solarium use. For all users, the risk of squamous cell carcinoma is more than doubled compared with non-users. We estimated the numbers of new melanoma cases and melanoma-related deaths attributable to solarium use by younger people in the five most populous Australian states and indirectly quantified potential costs to the health system that could be saved by effective regulation of the solarium industry. Annually, 281 new melanoma cases, 43 melanoma-related deaths and 2572 new cases of squamous cell carcinoma were estimated to be attributable to solarium use. The annual cost to the health system — predominantly Medicare Australia — for these avoidable skin cancer cases and deaths is about $3 million. By successfully enforcing solarium regulations that ban use by people younger than 18 years or with fair skin, favourable health and cost benefits could be expected.

Louisa G Gordon MPH, PhD · Nicholas G Hirst BComm, BEc · Peter H F Gies PhD · Adèle C Green MB BS, PhD

Objective: To describe the quality of postoperative documentation of vital signs and of medical and nursing review and to identify the patient and hospital factors associated with incomplete documentation.Design, setting and participants: Retrospective audit of medical records of 211 adult patients following major surgery in five Australian hospitals, August 2003 – July 2005.Main outcome measures: Proportion of patients with complete documentation of medical review (each day) and nursing review and vital signs (heart rate, blood pressure, respiratory rate, temperature and oxygen saturation) (each nursing shift), and the proportion of available opportunities for medical and nursing review where documentation was incomplete. Univariate and multivariate odds ratios for the association between incomplete documentation and hospital and patient factors.Results: During the first 3 postoperative ward days, 17% of medical records had complete documentation of vital signs and medical and nursing review. During the first 7 postoperative ward days, nursing review was undocumented for 5.6% of available shifts and medical review for 14.9% of available days. Respiratory rate was the most commonly undocumented observation (15.4% undocumented). Certain hospitals were significantly associated with incomplete documentation. Vital signs were more commonly undocumented in patients without epidural or patient-controlled (PC) analgesia, during evening nursing shifts, and during successive postoperative ward days. Nursing review was more commonly undocumented in the evening and for patients without epidural or PC analgesia. Medical review was more commonly undocumented on weekends.Conclusion: Hospital and patient factors are associated with incomplete documentation of clinical review and vital signs after major surgery.

Forbes McGain FANZCA, FJFICM · Michelle A Cretikos MB BS, PhD, MPH · Daryl Jones FRACP, FJFICM · Susan Van Dyk RN · Michael D Buist FRACP, FJFICM, MD · Helen Opdam FRACP, FJFICM · Vincent Pellegrino FRACP, FJFICM · Megan S Robertson FRACP, FANZCA, FJFICM · Rinaldo Bellomo MD, FRACP, FJFICM

Vested interests are the main obstacles to reform, and the voice of the community is the main force for change Implementation of health care reform is difficult because serious redesign of health care runs immediately into the power of vested interests. I personally witnessed this at the birth of Medicare in the 1970s, when I was Head of the Department of the Prime Minister and Cabinet. Government archives, both federal and state, are full of health reform proposals that have never been effectively implemented because of the power of these vested interests (see the article by Leeder and Lewis in this series1). The exercise of power in health is reflected in many ways: in the vested interests of bodies like the Australian Medical Association, Medicines Australia and the private health insurance companies, whose lobbying activities make union power look feeble in comparison; in the way the public debate is invariably between the health minister and vested interest groups, while the community is excluded; in the inertia of health bureaucracies that are inward-looking and very beholden to vested interests; in the way some ministers, particularly state ministers, are easily dominated by their departments because of the complexity of the health portfolio; in the way the system is always under pressure and in crisis mode because ministers will never publicly admit that we cannot have all that we want in health care, making planning for long-term change difficult; in the very hospital-centric nature of our health care, which has come about because many vested interests are congregated around hospitals; and in the way states’ rights get in the way of the community’s rights. Lack of political will to contest vested interests is the major cause of failed reform. Australia is not unique — just ask Hillary Clinton, and witness the debacle in American health care today. In light of the way power is exercised in the health sector, what can be done in implementation? The federal Health Minister should stand back from day-to-day crisis management and focus on longer-term redesign of health services, including strategies for improving population health and developing a whole-of-government approach that embraces the social determinants of health. The main cause of poor health is poverty. The Minister should, wherever possible, be prepared to devolve and delegate greater responsibility and decision making to professional and independent organisations (eg, Medicare, the Pharmaceutical Benefits Advisory Committee) and people, and let them explain and defend what they are doing on behalf of the Minister. The Minister should avoid the media loop in which vested interests try to dominate with their own agendas. The Minister should have a clear role in government in all decisions affecting health, such as housing, jobs, transport and education. She is the Minister for Health, and not only for health services. The Australian Government Department of Health and Ageing should be reshaped as a priority to enhance its economic expertise and ensure that it focuses on the community’s interests. Programs should be output-focused rather than input-focused (as they are now, around inputs of hospitals, pharmaceuticals and medical services). The Department is not presently equipped to be the administrative driver of reform. The government should elicit from the Australian community the principles that should drive health reform and thereby establish a constitution or covenant for health care (see my earlier article in this series on principles,2 and another by Mooney on community consultation3). A small, external, professional and independent Australian Health Commission should be established to monitor and advise the Minister on the implementation of its health principles and its health plan following decisions made in response to the National Health and Hospitals Reform Commission report and the national Preventative Health Taskforce. The Australian Health Commission should report to Parliament twice a year. An important role of this Commission would be public education to challenge the views of vested interests and, hopefully, to persuade the community about the case for reform. A supportive community will make political decisions easier, and the case for health reform must be won in the community. A joint federal–state Health Commission should be established in any state where the federal and state governments can agree. The Commission would jointly fund and plan the delivery of health services in that state. Implementation would be relatively easy if there were the political will.4 The federal government should: wind back the $6 billion per annum taxpayer subsidy to private health insurance companies and pay the money directly to public and private hospitals; expand the role of Treasury, Finance and the Prime Minister and Cabinet in the health reform process. They can bring greater rigour, an “outsider’s view” and a whole-of-government approach; cease providing money without reform. For example, the increased funding of state hospitals should be conditional on significant governance and workforce reforms; make primary care the priority area for implementation and funding, with the rollout of 200 multidisciplinary primary health care clinics across Australia;5 involve clinicians, but not organisations of clinicians, in the reform process; and urgently support the recruitment and training of good health managers. The major issue in implementing health reform is political will to break the political paralysis that is cultivated by vested interests. Other issues are much easier to resolve. Good health policy and good health politics require the Australian Government to skilfully and resolutely reduce the power of vested interests in favour of community interests.

John Menadue AO, BEc

Consensus recommendations for managing bronchiectasis in Indigenous children and adults living in rural and remote regions were developed during a multidisciplinary workshop and were based on available systematic reviews. Successful diagnosis, management and prevention of bronchiectasis in Indigenous Australians requires access to comprehensive health care services, as well as improved housing, education and employment and reduced poverty levels. Diagnosis of bronchiectasis requires a chest high-resolution computed tomography scan. Children who have bronchiectasis symptoms but non-diagnostic scans are described as having chronic suppurative lung disease (CSLD), rather than bronchiectasis. Untreated CSLD may progress to bronchiectasis. Chronic wet cough (> 4 weeks) or recurrent wet cough (> 2 episodes/year) are important but often under-reported symptoms. Bronchiectasis is suspected when chronic cough is excessively prolonged (> 12 weeks) or if a chest radiographic abnormality persists despite appropriate therapy. Intensive treatment aims to improve symptom control and quality of life while preserving lung function and reducing acute exacerbation frequency. Antibiotics should be prescribed for acute infective episodes according to culture results of respiratory secretions, local susceptibility patterns and clinical severity. Patients not responding promptly to oral antibiotics should be hospitalised for more intensive treatment. Ongoing care requires regular primary health care and specialist review, including monitoring for complications and comorbidities. Corticosteroids, bronchodilators and mucoactive agents may be used in individual cases, but routine use is not recommended. Physiotherapy and exercise should be encouraged, nutrition optimised, environmental pollutants (including tobacco smoke) avoided, and immunisations maintained.

Anne B Chang MPHTM, PhD, FRACP · Keith Grimwood MB ChB, FRACP, MD · Graeme Maguire MB BS, FRACP · Paul T King MB BS, FRACP, PhD · Peter S Morris MB BS, FRACP, PhD · Paul J Torzillo MB BS, FRACP

Objective: To present a descriptive overview of the quality and recommendations of clinical practice guidelines (CPGs) on diagnosis or management of osteoarthritis (OA) of the hip and/or knee.Data sources: CPGs were identified from several research databases (MEDLINE, EMBASE and The Cochrane Library) and guideline-specific databases from 1966 to August 2005.Guideline retrieval: Thirty-four relevant CPGs were identified.Data extraction: Recommendations were extracted from CPGs and categorised into: assessment and diagnosis, pharmacological management, nonpharmacological management, complementary/alternative therapy, or surgery. The quality of the CPGs were assessed by two appraisers using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument.Data synthesis: Most recommendations for aspects of diagnosis and treatment of OA of the hip and/or knee were consistent among the CPGs included in this study. However, quality varied considerably, with few CPGs being “strongly recommended” according to the AGREE quality appraisal instrument.Conclusions: Given the number of CPGs available relevant to OA, and the consistency of recommendations within them, and considering the time and resources required for CPG development, future efforts to guide management of OA of the hip and/or knee may be better directed towards adapting existing CPGs to the local context, implementing practices known to be effective, and facilitating research to answer important questions where there is little evidence.

Marie L Misso BSc(Hons), PhD · Veronica J Pitt BSc(Hons), PhD · Kay M Jones BSW, MT · Hayley N Barnes BBiomedSc(Hons) · Leon Piterman MMed, MEdSt, FRACGP · Sally E Green GradDip(MT), BAppSc(Physio), PhD

Patients who notice a red eye or other acute ophthalmic symptoms often present first to their general practitioner, optometrist or local hospital emergency department. Although the most common acute eye diseases in primary practice are the usually benign conditions of viral, bacterial and allergic conjunctivitis, rarer but more serious causes of red eye such as iritis, keratitis and acute glaucoma can lead to permanent loss of vision. The primary health care provider’s initial diagnosis and management can be critical to the patient’s ophthalmic outcome. In one United Kingdom study of 55 patients in which an ophthalmologist had diagnosed a red-eye disorder, only nine had been correctly diagnosed by the referring practitioner.1 To our knowledge, no study of the accuracy of diagnosis of eye conditions by primary health care providers in Australia has yet been published. We audited the hospital records of 1062 new patients presenting to the eye emergency services of the ophthalmology departments of the two major Brisbane hospitals, and analysed the accuracy of the diagnosis and implications of the initial care provided to these patients by their local doctor or optometrist. Lessons from practice Patients with acute eye problems presenting to primary health care providers are often misdiagnosed or mismanaged. Topical antibiotic therapy is overprescribed for acute eye conditions. Particular attention should be paid to sentinel warning symptoms — in particular the presence of one or more of pain, photophobia or blurred vision — as these symptoms almost always indicate serious acute eye disease rather than conjunctivitis. If a patient with a red eye reports pain, photophobia or blurred vision he or she should be given no treatment and referred immediately. Methods Patient records from consecutive presentations to eye emergency services of ophthalmology departments at two hospitals — Princess Alexandra Hospital (PAH) from 18 April to 25 October 2006 and the Royal Brisbane and Women’s Hospital (RBWH) from 1 July to 30 September 2006 — were collected and reviewed. Approval for the project was obtained from the Director of Surgery, Head of Ophthalmology and Ethics Committee of each hospital. Inclusion criteria were initial presentation to a primary health care provider (PHCP) — defined as a GP, optometrist or hospital emergency department doctor — and subsequent referral or patient self-presentation to an eye emergency service for the same complaint. The diagnosis in the ophthalmology department was compared with that by the PHCP, and the accuracy of diagnosis was determined. A preventable adverse outcome was deemed to have occurred if the patient had eye pain, loss of vision, or had been given inappropriate medication that could have been avoided with appropriate initial management or prompt referral. A further subjective assessment of the severity of the adverse outcome was then made. ResultsData were collected for 1062 patients during the designated periods at the two hospitals: 614 (57.8%) from PAH and 448 (42.2%) from RBWH. The referring PHCP was a GP in 50.4%, hospital emergency department doctor in 38.9%, and an optometrist in 10.7% of cases. The 10 most common reasons that PHCPs referred patients to ophthalmology departments are shown in Box 1. Accuracy of primary health care practitoners’ diagnosesA correct initial diagnosis (ie, matching the final ophthalmology department diagnosis) was given for 192 (35.9%) of the 535 patients referred by GPs, 173 (41.9%) of the 413 patients referred by emergency department doctors and 55 (48.2%) of the 114 patients referred by optometrists. Implications of initial inappropriate care by primary health care providersPreventable adverse outcomes: In 123 of the 1062 patients (11.6%), there was an adverse outcome resulting from misdiagnosis or mismanagement by the PHCP. Adverse outcomes in these 123 patients were mild in 63 (51%), moderate in 49 (40%) and severe in 11 (9%). Conditions that were misdiagnosed and subsequently associated with a severe adverse patient outcome are shown in Box 2. In most cases (74%), adverse outcomes were associated with misdiagnosis by PHCPs; in the remainder (26%), there had been a correct initial diagnosis, but subsequent incorrect treatment, or a significant delay in referral. In the 123 patients with preventable adverse outcomes resulting from misdiagnosis or mismanagement, the PHCP was a GP in 78%, an emergency department doctor in 17% and an optometrist in 5% of cases. The 11 most severe preventable adverse outcomes are described in Box 3. Topical antibiotic therapy: Of the total of 1062 patients, 199 (18.7%) had been prescribed topical antibiotic therapy at their initial consultation with their PHCP. Of the 535 patients referred by GPs, 108 (20.2%) had been prescribed antibiotic eye drops before referral. In 54% of these 108 patients, the therapy was judged inappropriate or unnecessary on ophthalmic review, and was ceased. Iritis: There were 59 patients with iritis (acute anterior uveitis), representing 5.6% of the total 1062 patients. Less than a third of patients with iritis (16 of 59; 27%) were diagnosed correctly by the PHCP. Eleven of the 59 patients with iritis (19%) were initially misdiagnosed as having conjunctivitis and treated with topical antibiotic therapy by their GP. Fourteen patients were given no diagnosis and no therapy. Seven patients had their condition misdiagnosed as red eye and were given no therapy. Iritis was misdiagnosed as glaucoma in three patients, hyphaema in two patients, keratitis in two patients, cataract in two patients, and as macular oedema and pain in one patient. The average time to referral or self-presentation to an eye emergency service for patients with iritis was 2.4 days (range, 0–16 days). DiscussionPatients with acute eye problems presenting to PHCPs, especially GPs, are often misdiagnosed or mismanaged. In most cases, this does the patient no harm — for example, misdiagnosing viral conjunctivitis as bacterial conjunctivitis and inappropriately prescribing antibiotic eye drops is unlikely to cause complications, and the patient will spontaneously recover from the infection. However, in some acute eye conditions, the prescription of topical antibiotics can be very harmful indeed — not through any ill effects of the drug, but through the subsequent delay in referral. In the case of serious acute eye conditions like severe iritis or acute glaucoma, a delay of even a few days can result in permanent loss of vision or even blindness. Examples of potentially serious eye diseases that may present to PHCPs are shown in Box 4. In our survey, of 11 patients identified as having had a preventable, severe adverse outcome, 10 had initially presented to their PHCP with a unilateral red eye. All 10 were incorrectly diagnosed as having conjunctivitis and all had been inappropriately prescribed chloramphenicol eye drops as treatment. All had reported ocular pain, photophobia or blurred vision to their PHCP at the initial consultation. The 11th patient had retinal detachment. There is a perception among many ophthalmologists that many GPs “call every red eye conjunctivitis” and that topical antibiotics are overprescribed for acute eye problems. In our review, in more than 50% of cases in which topical antibiotic therapy had been commenced by the PHCP, it was immediately ceased at the first ophthalmology review as being unnecessary or inappropriate. In addition to contributing to a serious delay in patient referral, topical antibiotic use can occasionally cause serious local and rarely systemic complications2 (eg, agranulocytosis from chloramphenicol). There may also be concerns that using antibiotics unnecessarily contributes to increasing antibiotic resistance of organisms.3 How can the situation be improved? A major problem is the lack of equipment, expertise and time available to a GP in a busy practice facing a new patient with an acute eye problem. Many eye conditions (including iritis and acute glaucoma) cannot be diagnosed without a slit lamp microscope and a means of measuring intraocular pressure — equipment that is rarely available to GPs. In addition, many GPs have had little ophthalmological training, and have limited time to spend with each patient. To address these problems, it is suggested that GPs pay careful attention to the symptoms reported by patients with eye complaints, given the difficulty of accurately evaluating their signs. Particular attention should be paid to sentinel warning symptoms — in particular the presence of one or more of pain, photophobia or blurred vision — as these symptoms almost always indicate serious acute eye disease rather than conjunctivitis.4 Patients reporting one or more of these symptoms should be given no treatment, and referred to an ophthalmologist urgently. It should also be recognised by GPs that although unilateral viral conjunctivitis is common, a single red eye should be viewed with more suspicion than bilateral red eyes, which are more likely due to conjunctivitis. 1 The 10 most common reasons that primary health care providers referred patients to ophthalmology department emergency services 2 Conditions originally misdiagnosed by primary health care providers, leading to adverse events for patients 3 Severe adverse outcomes in 11 patients as a result of misdiagnosis or mismanagement by primary health care providers* Patient Age and sex Ophthalmology department diagnosis PHCP diagnosis PHCP treatment Delay in referral Preventable adverse outcome 1 79 M Acute anterior uveitis Red eye Chloramphenicol eye drops 8 days Severe permanent vision loss and severe pain 2 55 F Acute anterior uveitis Conjunctivitis Chloramphenicol eye drops 7 days Moderate permanent vision loss and severe pain 3 77 M Acute anterior uveitis Red eye Chloramphenicol eye drops 10 days Severe pain 4 38 M Acute anterior uveitis Red eye Chloramphenicol eye drops 15 days† Severe pain 5 55 F Acute anterior uveitis Conjunctivitis Chloramphenicol eye drops 9 days Severe pain 6 26 F Bacterial keratitis Conjunctivitis Chloramphenicol eye drops 2 days Severe pain 7 95 F Herpes zoster ophthalmicus Red eye Chloramphenicol eye drops 3 days Mild permanent vision loss, severe pain, delay in commencing antiviral treatment 8 56 M Herpes zoster ophthalmicus Red eye Chloramphenicol eye drops 14 days Severe pain, delay in commencing antiviral treatment 9 77 M Neovascular glaucoma Herpes zoster ophthalmicus Chloramphenicol eye drops 7 days Severe pain 10 26 F Glaucoma and diabetic retinopathy Conjunctivitis Chloramphenicol eye drops 5 days Severe pain 11 29 M Retinal detachment No diagnosis Nil 7 days† Severe permanent vision loss M = male. F = female. PHCP = primary health care provider. * The PHCP was a general practitioner for all patients except Patient 10, who saw a hospital emergency department doctor. † Self-presented. 4 Examples of “red eye” diseases that may present to a primary health care provider

Michael O Statham MB BS(Hons), BAppSci(Optom)(Hons) · Anamika Sharma MB BS(Hons), BMedSci(Hons) · Anthony R Pane MB BS(Hons), MMedSc, FRANZCO

Clinical record A man in his 70s was prescribed DuoTrav eye drops (Alcon Inc; combined prostaglandin analogue [travoprost] and β-blocker [timolol]) for worsening glaucoma. (He had previously been treated with latanoprost.) Within 2–3 days, he felt depressed and described “a black cloud descending over [him]”. His symptoms included tiredness, poor concentration, sleep disturbance, and loss of libido and appetite. Normally fit and active, with a zest for life and a good sense of humour, he struggled to get up in the mornings and lost interest in socialising. His general practitioner prescribed venlafaxine (75 mg, then 150 mg) for the depression. Subsequently, DuoTrav therapy was stopped and a combination of travoprost, brimonidine tartrate and brinzolamide started. A month later, his sleep and appetite were considerably improved and he rated himself as 70% better. Eleven years previously, he had suffered an episode of major depression with melancholic features after his initial diagnosis of glaucoma, for which he was prescribed the β-blocker betaxolol.1 At that time, his symptoms had been worse and of longer standing, requiring hospitalisation and electroconvulsive therapy (ECT). He had recovered slowly, while continuing to experience lethargy and a heavy head. Only several months later, when the episode of depression was linked to the initiation of betaxolol and the β-blocker was stopped, did he fully recover. Within 48 hours of ceasing betaxolol therapy, he felt more energetic, alert and alive. The patient had been treated once before with ECT when he experienced his first depressive episode, at the age of 50 years, associated with severe work-related stress. Both subsequent episodes of depression were seemingly unrelated to stressors or life events. The most common medical treatments for glaucoma in Australia are prostaglandin analogues. However, β-blockers still comprise a substantial proportion of all prescriptions, either alone or in combination. Despite their topical administration, β-blockers are absorbed from the eye through the conjunctival epithelium, lacrimal channels, nasal mucosa and gastrointestinal tract into the systemic circulation. Although only small amounts are absorbed, concentrations may be sufficient to cause systemic β-adrenergic receptor-mediated effects, including slowing of heart rate, lowering of blood pressure and non-response to bronchodilators. Central effects such as depression have also been reported. Lessons from practice Ophthalmic β-blockers are absorbed systemically and may cause central side effects. Depression is an occasional adverse effect of β-blockers, including those used for glaucoma. Ophthalmic β-blockers should be avoided in patients who have a history of clinical depression. When depression evolves soon after commencing β-blocker treatment, serious consideration should be given to changing the medication, as the β-blocker may be the causative agent. The literature investigating a causal relationship between β-blockers and depression is controversial. An evidence-based review concluded that depression was an uncommon side effect of treatment with β-blockers and usually occurred only in the presence of a pre-existing condition.2 Randomised controlled studies of β-blockers in cardiovascular disease found the incidence of depressive symptoms was similar in β-blocker- and placebo-treated groups.3 However, a review of 24 case reports4 showed a temporal relationship between the use of β-blockers and depression in more than half the cases. If there is a close temporal relationship between the commencement of a new treatment and the development of symptoms, the symptoms are considered likely to have been caused by the medication. In the initial case that we reported on this patient,1 depressive symptoms began within days after the diagnosis of glaucoma and commencement of betaxolol treatment. The patient’s symptoms only fully remitted when the drug was stopped, providing further evidence of a causative relationship. The case we report here describes recurrence of depression after the introduction of another β-blocker, timolol, and again cessation of symptoms when treatment was stopped. The recurrence of the syndrome following a re-challenge further strengthens the argument for a causal relationship. (The travoprost component of the medication was unlikely to have been the cause of the depression.) It is possible that the onset of the disorder occurred coincidentally with the introduction of the medication (though such an event is unlikely to have occurred twice) or was caused by the underlying illness for which the new medication was prescribed. In the only study we could find of ophthalmological patients with depression with and without glaucoma, no association was shown between depression and glaucoma.5 Glaucoma is mostly a disease of older people, a group prone to developing depressive illness. Depression is often dismissed in older people as a normal reaction to ageing, loss or chronic illness. However, it is treatable, with a very good prognosis. Older patients are frequently taking multiple medicines and may develop depressive symptoms as a side effect. The purpose of this case presentation is to emphasise that even a drug that is administered topically, such as antiglaucoma eye drops, is absorbed systemically and can potentially cause adverse effects elsewhere, including centrally. There are credible theoretical reasons why β-blockers may cause depression: the number of β1 receptors is increased in the brains of suicide victims and chronically stressed animals, and antidepressants cause down-regulation of β1 receptors. The fact that only a few patients develop depression after taking β-blockers may be due to genetic differences. It is possible that poor metabolisers of the enzyme cytochrome P450 2D6 will be exposed to higher systemic concentrations of β-blockers than those who are normal or fast metabolisers.6,7 To our knowledge, there have been no studies of depression in relation to β-adrenergic receptor gene polymorphisms, although associations have been found between these polymorphisms and haemodynamic effects after administration of betaxolol and timolol.8 Variability between individuals in the time course, affinity and extent of receptor occupation may also be relevant. Vuori and Kaila9 found substantial β1 and β2 blockade in plasma for up to 12 hours after administration of topical timolol. Thus, 12-hour dosage intervals could lead to substantial systemic blockade and could explain the reported systemic side effects. Our report adds to the evidence that depression is an occasional adverse consequence of treatment with β-blockers, including topical antiglaucoma agents. Development of depression is a serious consequence. Discontinuation of a β-blocker may relieve symptoms, but specific antidepressant treatment may also be needed. As there are alternative antiglaucoma medications, it is prudent not to prescribe β-blockers for patients who have a history of depressive illness. If depression develops after commencement of a β-blocker antiglaucoma agent, an alternative medication should be substituted if possible.

Isaac Schweitzer DPM, FRANZCP, MD · Kay Maguire BSc(Hons), MSc, PhD · Chee H Ng MMed, FRANZCP, MD

A 21-year-old, otherwise well man presented with a 3-month history of bilateral deteriorating vision. His visual acuity was 6/60 on the left and 6/12 on the right. Fundus examination revealed bilateral papilloedema, with optic discs grossly swollen and bulging forward (Figure: A, left eye; B, right eye). There were bilateral haemorrhages of the retinal nerve fibre layer surrounding the disc, and macular folds (Figure, arrows). An urgent computed tomography scan revealed a 5.8 cm × 5.3 cm mass in the inferior right frontal lobe, with cystic and necrotic components. The patient was referred for urgent surgical debulking. Histopathological examination of the mass confirmed that it was a high-grade anaplastic astrocytoma.

Vivek B Pandya · Neil S Sharma · Peter Khong · John Males

Palliative care. A patient-centered approach. Geoffrey Mitchell. Oxford: Radcliffe Pubishing, 2008 (xiv + 168 pp). ISBN 978 1 85775 737 2. Next time you visit the trade display at a palliative care conference, you will find a plethora of books on the subject, covering just about every conceivable aspect of this expanding field: “textbook”, “handbook”, “practical guide”, “core skills and competencies”, “pearls”, “practices”, “guidelines”, “emergencies” etc. Geoffrey Mitchell, professor of palliative care at the University of Queensland and well known in Australian palliative care circles, has found another angle that definitely needed covering: “a patient-centered approach” (a fundamental philosophical concept underpinning good quality palliative medicine practice but, surprisingly, not always well covered by the standard texts). This small, easy-to-read book is the latest monograph in a UK-based series on patient-centred medicine (which is “transforming the clinical method”, according to the series editor) as it applies to various specialties. The book is clearly aimed at general practitioners but is also relevant to specialists in the field, especially the middle chapters that cover various dimensions of the interaction between the terminally ill patient, their illness and the environment. These chapters cover such topics as “the illness experience”, “understanding the whole person” and “enhancing the patient–clinician relationship”. On the other hand, chapters on the pathophysiology of symptoms and their management are definitely written for the GP readership. A particular strength of the book is its in-depth coverage of how the patient-centred approach applies to children. The book will also help specialists better understand the perspective of their colleagues in general practice, who provide the majority of palliative care. In dedicating the book to his family, the author says he has been truly blessed. Dying patients whose GPs adopt a patient-centred approach to palliative care will also be blessed.

Paul A Glare

Journeys with the black dog. Inspirational stories of bringing depression to heel. Tessa Wigney, Kerrie Eyers, Gordon Parker, editors. Sydney: Allen & Unwin, 2007 (x + 280 pp). ISBN 978 1 74175 264 9. This is an inspirational book, useful to people who experience chronic depression. It holds the stories of over 600 people who entered a writing competition, challenged to write about their mood disorder — the black dog. Divided into logical sections, the text moves the reader from the experience of depression through to stories of healing and recovery. Innovatively, friends and family are also included in one section of the book, providing their insights into the difficulties people experience when they have a loved one with depression. I was pleased to see the “Staying on course” section, about adjuncts to medical treatment. My experience as a general practitioner and depression researcher is that many people find these things ofs equal, if not more, benefit than medication, particularly for those with moderate depression. Themes of having someone to talk to and really being listened to are prominent throughout the book. The tips for maintaining wellbeing at the end of the book are great and revolve around having a passion in life, being kind to oneself, living in the moment and savouring happiness when it does occur. The only limitation of the book is that it is weighted to the moderate to severe end of the spectrum of mood disorders, with many of the contributors having bipolar and long-term severe depression. Many of them are on medication and have been hospitalised. I would recommend Journeys with the black dog to my patients and to all people who live with or are touched by the black dog — it will provide inspiration to endure, survive and hopefully even thrive.

Kelsey L Hegarty

Trachoma: a blinding scourge from the bronze age to the twenty-first century. Hugh R Taylor. Melbourne: Haddington Press, 2008 (282 pp). ISBN 978 09757695 9 1. Why would a substantial scholarly work devoted solely to trachoma be published in Australia? For two good reasons: firstly, trachoma, a disease of poverty and poor countries, is still found in Australia. Secondly, it is written by a world renowned trachoma expert, the University of Melbourne’s Professor Hugh Taylor. Taylor’s passion is evident in this comprehensive review of trachoma from antiquity to the present, a scientific work of great detail and scope. Copies and extracts of documents, photographs and images, both from the author’s own collection and from sometimes obscure sources, support the text. Many of the photos were taken by Professor Taylor during his extensive field studies in Africa, Mexico and Australia, as well as in his laboratory studies. To this extent, the book provides a record of Taylor’s many years in the field and in the laboratory, his work ranging from vaccine development to simple, practical but effective means of eliminating trachoma in children at risk. Taylor draws our attention to the fact that the establishment in the 19th century of many now-famous ophthalmic hospitals was due to the trachoma epidemic in Europe, and even in Australia. He describes how improved living conditions in Europe and much of Australia at the beginning of the 20th century led to the almost total disappearance of trachoma. There is a clear exposition of why trachoma still exists in some remote areas of Australia, offering evidence of control measures and, importantly, evidence for advocacy to policymakers so that they may make evidence-based decisions on the subject. This book is an invaluable reference work for medical researchers, providing an in-depth knowledge of the subject. For public health planners, sections on the prevalence and natural history of the disease, with proven interventions detailed, will be invaluable. Students will find that this work covers much of what they need to know about a disease all but eliminated, yet which still persists in pockets of disadvantaged areas around the world.

Jill E Keeffe

Born on 8 March 1921 in Melbourne, Ken was educated at St Thomas’ Grammar School and Scotch College and studied medicine at the University of Melbourne, graduating in 1943. In 1947, after gaining a Diploma of Ophthalmology, Ken was appointed Resident Medical Superintendent at the Eye and Ear Hospital in Melbourne. With his appointment, a new era opened for the old Hospital. These were the days when a group of three — the Medical Superintendent, Matron and Manager — ran a public hospital. They were responsible to a semi-autonomous board of management and worked on a shoestring budget. The commander-in-chief was usually the Medical Superintendent, occasionally the Matron, but never the Manager. Ken was very much in charge, and no function of the Hospital was too remote to escape his attention. A small man, dressed informally (sometimes even in overalls), with prominent eyebrows and a penetrating gaze, he was the first contact every new resident doctor had with the Hospital. He was clearly a man of enormous energy and organising ability, dedicated to the revival of the old Hospital and looking for people to help him do it. Ken was a man of few words who loathed pretence and humbug. In the early days, he made it his business to work in the clinics of the Hospital — both the Eye Clinic and the Ear, Nose and Throat Clinic — in order to see proceedings at first hand and to assess the calibre of doctors-in-training. In the inevitable committee work, he did not always side with the majority view, but his formidable intellect, combined with the most thorough preparation, usually ensured that his view prevailed. Over about 20 years, the Hospital was rebuilt and thoroughly modernised, thanks to generous bequests from Peter Howson, Smorgans and others. But Ken’s real obsession was education — postgraduate and undergraduate, medical and nursing. He was pivotal in the establishment of the chairs of Ophthalmology and Otolaryngology at the University of Melbourne, and set up the William Gibson lectures for undergraduates on Saturday mornings, starring Dr John Colvin. Meanwhile, in cooperation with the general hospitals, the steady work of training specialists in both disciplines for fellowships of the Royal Colleges went on. Special clinics, such as those for glaucoma; retinal detachment; orbit, plastic and lacrimal; deafness investigation; and the bionic ear, sprang up and greatly enlivened proceedings. He helped found the Royal Australian College of Ophthalmologists in 1969 and became its President in 1981–82. Ken retired to the Victorian seaside town of Inverloch in 1990 and immersed himself in local affairs and computer activities until his death on 24 May 2008 from mesenteric artery thrombosis. His wife Betty survives him, together with his two sons David and Robert, who are also in the medical profession.

John R Thomson

Re: “Does practice make perfect? The effect of coaching and retesting on selection tests used for admission to an Australian medical school”, by Barbara Griffin, David W Harding, Ian G Wilson and Neville D Yeomans, in the 1 September 2008 issue of the Journal (Med J Aust 2008; 189: 270-273). In the Results section, under “Prevalence of coaching”, the words “were more likely to be male (57.6% v 44.4%; χ2 = 4.88; P = 0.03)” should read “were more likely to be male (57.6% v 42.4%; χ2 = 4.88; P = 0.03)”.

Barbara Griffin · David W Harding · Ian G Wilson · Neville D Yeomans

To the Editor: Trachoma, caused by the bacterium Chlamydia trachomatis, is the leading cause of infectious blindness worldwide.1 In Australia, the burden of disease falls almost exclusively on the Aboriginal population.2 However, there has been little consistent data collection on the prevalence of trachoma in recent years in Australia.3,4 Furthermore, despite Australian Government recommendations for biennial screening of people aged 40–54 years and annual screening of people aged ≥ 55 years in areas where trachoma is or has been endemic,5 very little screening of older people for trachomatous trichiasis has been conducted.2,4 We report on the first large-scale population study in 30 years of the current prevalence of active and cicatricial trachoma in the Northern Territory Aboriginal population. We conducted a standardised clinical screening study of five Aboriginal communities in the Katherine Region of the NT over a 5-week period in 2007. A representative sampling frame of those believed to be currently living in each community was constructed using the medical clinic patient list, the council housing list and the local knowledge of Aboriginal Health Workers seconded from the clinics to assist with the project. All people in each community were invited to undergo a clinical eye examination for trachoma. The parameters of the World Health Organization simplified grading scheme6 were used to determine prevalence of the five signs of trachoma: tarsal conjunctival follicles, intense inflammation, tarsal scarring, trichiasis and corneal opacity. A total of 1316 people (85.2% of the total estimated population), including 415 children aged under 10 years, were screened for trachoma. Across the five communities, active trachoma (assessed as the presence of either follicles or inflammation in one or both eyes) was at an endemic level (> 10%). The prevalences of active trachoma, scarring and trichiasis in different age groups are summarised in the Box. The overall rate of active trachoma in children under 10 years of age was 19.8% (95% CI, 16.0%–23.9%) (n = 82), and two communities had hyperendemic prevalence of trachoma (> 20%) in this age group. The youngest child observed with active trachoma was just over 1 year old. The prevalence of scarring in people aged 20 years and over was 32% (95% CI, 28.3%–35.9%) (n = 193). The youngest person identified with scarring was 7 years old. Six people (2.3% of all people aged 40 years and over) were identified with trichiasis requiring urgent ophthalmological attention. Across the population, this placed the prevalence of unoperated trichiasis at more than four times the acceptable threshold set by the WHO. A seventh person had had trichiasis surgery. That trachoma is still hyperendemic in Aboriginal communities more than 30 years after the National Trachoma and Eye Health Program first identified the extent of trachoma is unconscionable. Urgent and sustained public health and clinical interventions are required, with greater commitment from politicians and health policymakers, if Australia is to join the ranks of other developed nations in eradicating endemic trachoma. The guidelines for trachoma control developed by the Communicable Diseases Network Australia5 need to be resourced appropriately and implemented. Prevalence of active trachoma, scarring and trichiasis in five Aboriginal communities in the Northern Territory in 2007, by age group* TFI = active trachoma (follicles [TF] and/or inflammation [TI]). TS = trachomatous scarring. TT = trachomatous trichiasis. * Vertical bars indicate 95% CIs.

Katrina Roper · Claude-Edouard C Michel · Paul M Kelly · Hugh R Taylor

To the Editor: The oculocardiac reflex is a potentially life-threatening phenomenon requiring prompt recognition and management. It is defined as a 20% or greater reduction in heart rate and/or the presence of arrhythmias during stimulation of the orbital contents.1 It is most commonly encountered in the context of paediatric squint surgery. We report its occurrence in a young healthy adult man after a traumatic facial injury. While being transported to hospital by ambulance, he had intermittent bradycardia, with a heart rate as low as 38 beats/min, and was administered a 1 g dose of intravenous atropine. His medical and ocular histories were unremarkable, and he had no history of unexplained syncope. In the emergency department, his heart rate remained low (40 beats/min) and his blood pressure was 122/52 mmHg. There was diffuse periorbital lid swelling and bony tenderness along the inferolateral orbital margin. He had restricted upgaze of his left eye; during this manoeuvre, his heart rate dropped to 20 beats/min and he developed hypotension, with a blood pressure of 92/48 mmHg. He was given three intravenous 500 μg boluses of atropine to improve his haemodynamic condition. An electrocardiogram showed sinus bradycardia, and subsequent recordings showed intermittent Mobitz II second-degree atrioventricular block. A computed tomography scan of the left orbit showed a moderately displaced fracture of the orbital floor involving the maxillary bone, with entrapment of orbital fat and the inferior rectus muscle (Box). Given the presence of the oculocardiac reflex with haemodynamic compromise, the fracture was immediately repaired surgically. Postoperatively, the patient’s blood pressure was 134/90 mmHg and his heart rate was 86 beats/min, with normal sinus rhythm. He recovered full eye movement, and no further oculocardiac reflex was recorded. He remained well 1 year after discharge. The oculocardiac reflex was first described by Aschner as a slowing of the radial pulse when pressure was applied to the eye.2 It is a rare but recognised occurrence among young healthy adults with orbital fractures. Clinical manifestations of the reflex may include bradycardia, hypotension, nausea, vomiting and syncope.3 The reflex is acknowledged as an important indication for immediate surgical repair of the orbit.4 In addition to reducing morbidity from the reflex, urgent repair is beneficial as it releases incarcerated soft tissue, leading to a more favourable outcome with less likelihood of squint.5 Cardiac decompensation due to traumatic facial injuries should alert clinicians to the possibility of the oculocardiac reflex and the need for urgent surgical intervention. Computed tomography scans of the patient’s left orbit Sagittal (A) and coronal (B) computed tomography scans showing left orbital floor fracture with entrapment of the inferior rectus muscle (arrows).

Vivek B Pandya · R Max Conway · Richard Conway

To the Editor: Microbial keratitis associated with soft contact lens wear is a well recognised, not uncommon, clinical entity and a preventable cause of ocular morbidity.1,2 A 31-year-old woman who occasionally wore soft contact lenses presented to a general practitioner with a 2-day history of bilateral red eye associated with ocular discomfort, photophobia and purulent discharge. She was diagnosed with bilateral conjunctivitis, commenced on chloramphenicol drops and told to return in 5 days. Her symptoms initially improved, but then worsened. Seven days after symptom onset, she presented to hospital for assessment. History revealed that she had worn soft monthly disposable contact lenses twice in the previous month to correct her mild myopia. On examination, the patient’s visual acuity was equivalent to being legally “blind”, being hand movement in the right eye and light perception in the left. On inspection, both eyes appeared grossly abnormal. The right eye had a large central corneal abscess and the left eye had a complete corneal abscess with 360° peripheral corneal thinning (Box, A) — a significant risk for globe perforation. The conjunctiva was markedly injected bilaterally. Corneal scrapes, the contact lenses and the case containing turbid solution were sent for urgent gram stains and microbiological culture. The patient was admitted to hospital and received intensive topical treatment with gentamicin 0.9%, cephalothin 5% and tobramycin ointment. The corneal scrapes revealed Pseudomonas aeruginosa as the causative organism. The patient showed slow improvement with antibiotic therapy. Although the infection cleared, the residual corneal scarring resulted in permanent loss of corneal clarity and hence vision. Four months after treatment was commenced, the patient’s visual acuity had improved to 6/24 in the right eye and 6/36 in the left (Box, B). An Australian review of outcomes after keratitis found that 52% of patients had a final visual acuity of worse than 6/12, the legal visual acuity for driving.3 In this patient, despite saving both eyes and the improvement in her vision, she still has significant functional impairment, being unable to work as a teacher or drive. Corneal transplantation is now her only option for potentially regaining the loss in her functional vision, with a minimum expected recovery time of 2 years. GPs have a difficult job distinguishing between red eye requiring immediate referral and red eye that is not vision-threatening. All contact lens wearers who present with red eye need to be examined for yellow/white corneal infiltrates and, if present, or if the patient cannot be assessed adequately, immediate referral is mandatory. P. aeruginosa is the most common pathogen and one of the most aggressive organisms isolated in contact lens-related microbial keratitis.4 As it is invariably resistant to the bacteriostatic chloramphenicol, the appropriate empirical treatment is either fluoroquinolones or cephalosporins, which ideally should be commenced after corneal scrapes have been performed.5 Left eye at presentation and after 4 months of treatment A: At presentation, there was marked conjunctival injection, 100% epithelial defect (stained with fluorescein [green]) and severe circumferential peripheral corneal thinning (arrow). B: Four months after presentation, there was dense central scarring and peripheral corneal neovascularisation (arrow). Vivek B Pandya, Ophthalmology Resident1Alessandra Martins, Ophthalmology Registrar1,2Shanel Sharma, Ophthalmologist1,21 Department of Ophthalmology, Sydney Eye Hospital, Sydney, NSW. 2 Department of Ophthalmology, Royal Prince Alfred Hospital, Sydney. shanelATunsw.edu.au Green M, Apel A, Stapleton F. A longitudinal study of trends in keratitis in Australia. Cornea 2008; 27: 33-39. <PubMed> Keay L, Edwards K, Naduvilath T, et al. Microbial keratitis predisposing factors and morbidity. Ophthalmology 2006; 113: 109-116. <PubMed> Green MD, Apel AJ, Naduvilath T, Stapleton FJ. Clinical outcomes of keratitis. Clin Experiment Ophthalmol 2007; 35: 421-426. <PubMed> Stapleton F, Keay L, Sanfilippo PG, et al. Relationship between climate, disease severity, and causative organism for contact lens-associated microbial keratitis in Australia. Am J Ophthalmol 2007; 144: 690-698. <PubMed> Constantinou M, Daniell M, Snibson GR, et al. Clinical efficacy of moxifloxacin in the treatment of bacterial keratitis: a randomized clinical trial. Ophthalmology 2007; 114: 1622-1629. <PubMed> (Received 17 Mar 2008, accepted 28 Jul 2008) ©The Medical Journal of Australia 2008 www.mja.com.au PRINT ISSN: 0025-729X ONLINE ISSN: 1326-5377

Vivek B Pandya · Alessandra Martins · Shanel Sharma

To the Editor: A 37-year-old man infected with HIV through exposure to men who have sex with men (MSM) presented with a 6-week history of intermittent fevers, patchy alopecia and a widespread brown/grey macular rash involving his face, trunk, abdomen and all limbs, with scaling of the face, palms and soles. He had no symptoms of meningism or visual disturbance, and had a chronic mild intermittent headache with no recent change in frequency or intensity. His most recent CD4 cell count was 70 cells/μL and his HIV viral load was > 100 000 copies/mL. On admission, a serological test for syphilis was reactive and showed a rapid plasma reagin (RPR) titre of 1 : 64 and a positive enzyme immunoassay for antibody (EIA-Ab), whereas at the onset of the rash 6 weeks previously, a serological test for syphilis was negative. A punch biopsy of the skin lesions showed a perivascular infiltrate with lichenoid inflammation consistent with secondary syphilis. An ophthalmological review showed a bilateral anterior uveitis. Examination of cerebrospinal fluid (CSF) showed a white cell count of 1 × 106/L (100% lymphocytes), a normal glucose level, a mildly elevated protein level of 0.45 g/L and a weakly positive result for a fluorescent treponemal antibody absorbed (FTA-ABS) test. CSF RPR, EIA-Ab and Treponema pallidum particle agglutination (TPPA) test results were all non-reactive. The patient was diagnosed with asymptomatic ocular and neurosyphilis, and treated with intravenous benzylpenicillin (1.8 g 4-hourly for 15 days) and prednisolone eye drops (four times daily for 14 days). The rash faded and the anterior uveitis subsided in the first week of treatment. There is currently a syphilis epidemic among MSM in Victoria, with the number of syphilis notifications increasing 25-fold between 2000 and 2006.1 A strong association between HIV infection and infectious syphilis has been demonstrated in recent years, including in Victoria.2 HIV-infected MSM with early syphilis have a 1.7% risk of having symptomatic early neurosyphilis3 and a 13% risk of having symptomatic ocular syphilis regardless of CD4 cell count.4 There is no pathognomonic finding in ocular syphilis, and the disease may manifest as uveitis, retinitis, optic neuritis, perineuritis, retinal detachment and papillitis. It is recommended that all patients with ocular syphilis undergo CSF examination and be managed as if they had neurosyphilis.5 Current guidelines also recommend CSF examination in HIV-infected patients who have late-latent syphilis, syphilis of unknown duration, any neurological signs or symptoms, or suspected treatment failure.6 The finding of asymptomatic ocular syphilis in our patient suggests there should be a low threshold for eye examination in HIV-infected people with early syphilis, even in the absence of any ocular symptoms, as the diagnosis of ocular syphilis dramatically alters the management of these patients.

Matthew T Kitson · Michelle K Yong · Jennifer F Hoy

To the Editor: Snowboarding is increasing in popularity, but Australian snowboarders have been shown to have 2.4 times as many fractures as skiers, with 35% of upper limb injuries being fractures.1 The most common site of injury is the wrist, accounting for 21.6% of all snowboarding injuries.2 It has been suggested that the use of wrist guards could reduce the risk of injury, particularly as snowboarding injuries tend to be impactive rather than torsional.3,4 However, concern has been raised that use of wrist guards will redistribute the impact of the force to more proximal areas of the arm, causing elbow injuries.5 We conducted a case–control study at the Mount Buller Medical Centre, Victoria, during the 2004 and 2005 ski seasons to assess: the association between wrist guard use and wrist fracture in snowboarders in Australia; and the association between wrist guard use and the severity of wrist and elbow injury. Cases were defined as any snowboarder seen at the clinic with a fractured wrist (n = 119). Controls (n = 375) were snowboarders — identified by their boots — who attended the clinic, either as companions to case participants or other patients, or as patients presenting for a reason other than wrist fracture. Study participants completed a questionnaire about wrist guard use and snow-sport behaviour. The site and severity of fractures were recorded by clinic staff. Logistic regression was used to determine adjusted odds ratios for risk factors against the main outcome measure of wrist fracture and injury in snowboarders with and without wrist guards. Characteristics strongly associated with wrist fracture were being of school age (odds ratio [OR], 2.37; P < 0.001) and being a novice at snowboarding (OR, 3.41; P < 0.001) (Box). After adjustment for all significant variables — sex, age, days of snowboarding and snowboarder ability — the odds of having worn wrist guards were lower in snowboarders with a wrist fracture (cases) than in those without such a fracture, but the difference did not reach significance (adjusted OR, 0.58; 95% CI, 0.32–1.04; P = 0.07). Full analysis of all factors considered is available from the authors. Among the sample of 494 snowboarders, 15 had elbow injuries, comprising: five with soft tissue injuries (4/86 wearing wrist guards v 1/391 not wearing wrist guards; adjusted OR, 17.6; 95% CI, 1.93–160.2; P = 0.01); and 10 with elbow fractures or dislocations (3/86 wearing wrist guards v 77/391 not wearing wrist guards; adjusted OR, 1.84; 95% CI, 0.46–7.30; P = 0.39). The association between wrist guard use and increased soft tissue elbow injuries, but not elbow fractures and dislocations, supports the value of wearing wrist guards to reduce overall injury severity. Despite a lack of overall statistical significance, the clinical context and consistency in direction of the findings suggest that snowboarders who wear wrist guards in Australian snow conditions could benefit from a reduction in wrist fracture injury of approximately 42%. This is consistent with reports from other countries that show a protective effect of wrist guards of 52% to 87%, with the greatest benefit in novice snowboarders.4 We suggest that wrist guard use should be strongly recommended for novices, and should be mandatory for school-aged snowboarders. Local schools in the Mansfield district, near Mt Buller, have adopted a policy of “no wrist guard = no snowboard”, and we hope that other schools visiting Mt Buller, and indeed other ski resorts in Australia, will follow this lead. Characteristics associated with wrist fracture among snowboarders Characteristic Cases (n = 119) Controls (n = 375) Odds ratio (95% CI) P for difference Wearing wrist guards today No 100 (84%) 299 (80%) 1.00* Yes 18 (15%) 75 (20%) 0.72 (0.41–1.26) 0.25 Missing data 1 (0.8%) 1 (0.3%) Age (years) 0–19 72 (61%) 149 (40%) 2.37 (1.55–3.63) < 0.001 > 19 46 (39%) 226 (60%) 1.00* Missing data 1 (0.8%) Ability of snowboarder Novice 60 (50%) 112 (30%) 3.41 (1.79–6.49) < 0.001 Intermediate 43 (36%) 173 (46%) 1.58 (0.82–3.04) 0.17 Advanced 14 (12%) 89 (24%) 1.00* Missing data 2 (2%) 1 (0.3%) * Reference category.

Graham M Slaney · Judith C Finn · Angus Cook · Philip Weinstein

To the Editor: Streptococcus suis is an emerging zoonosis in humans and a common pathogen in Australian pigs.1 However, only two cases of human infection have previously been reported in Australia.2,3 We recently treated two Australian piggery workers, from the same town in New South Wales, for S. suis endocarditis. The first patient, a previously healthy 46-year-old woman, presented in October 2006 with a 3-month history of fatigue, anorexia, night sweats and weight loss of 20 kg. Her job involved hands-on work at a piggery. She was afebrile, with blood pressure of 145/50 mmHg, bilateral clubbing, splenomegaly, and a long diastolic murmur without evidence of heart failure. Transthoracic echocardiography confirmed severe aortic regurgitation associated with a vegetation. Blood cultures grew S. suis. The patient was treated with benzylpenicillin (1.8 g, 4-hourly for 6 weeks) and gentamicin (60 mg, 8-hourly for 2 weeks). Severity of aortic regurgitation necessitated aortic valve replacement. The second patient, a 58-year-old man, presented in January 2008 with headache, fever (38.7°C), neck stiffness and confusion. He had been unwell for 1 month with fevers, sweating, fatigue and weight loss of 6 kg. His job involved transporting pigs from local piggeries, including the one at which the first patient worked, to an abattoir, and involved direct contact with pigs. On admission, he was treated with ceftriaxone (2 g) and benzylpenicillin (2.4 g). Cerebrospinal fluid (CSF) examination showed leukocytosis (10 300 × 106/L; reference range, < 5 × 106/L) with 95% polymorphs. Scanty gram-positive cocci were visible, but there was no growth on culture of the CSF. Blood cultures grew S. suis. Transthoracic echocardiography revealed an aortic valve vegetation with trivial regurgitation. The patient was then treated with benzylpenicillin (1.8 g, 4-hourly for 4 weeks) and gentamicin (80 mg, 8-hourly for 2 weeks), and made a full recovery. Both cases were investigated by the NSW Department of Health, including assessment of workplace practices, staff education and rates of porcine infection at the piggeries and abattoir at which the patients had worked, but no significant factors for infection were identified. Since the first reported human infection with S. suis in Denmark in 1968,4 more than 400 cases have been reported, including an outbreak in China in 2005 that affected 215 people.5 The most common manifestations are meningitis (affecting 72.5% of patients) and bacteraemia (24.2%); endocarditis is relatively uncommon (1.1%).5 In a series of 16 cases of S. suis endocarditis, the mean period between onset of symptoms and diagnosis was 23 days, and seven patients required valve replacement.6 Similarly, our patients had subacute presentations: severe aortic regurgitation and secondary meningitis. In Australia, it is likely that there have been other S. suis infections in humans that have gone unrecognised because of mild presentations, difficulties with laboratory diagnosis, and empirical treatment of unrecognised infection. While it is unlikely that S. suis is a common zoonosis in Australia, these cases show that it is an occupational hazard in Australian piggeries, with potential public health, animal health and medicolegal implications.

Karina J Kennedy · Assad A Jadeer · Chong W Ong · Sanjaya N Senanayake · Peter J Collignon

To the Editor: The study by Nichols and colleagues1 and the associated editorial by Hughes2 struck a chord of familiarity for me, as patient safety issues are currently high on the political agenda in the United Kingdom. An estimated 850 000 incidents of harm or near harm affect National Health Service (NHS) hospital patients in the UK each year.3 In April 2004, the Health Foundation (an independent charity that aims to improve the quality of UK health care), together with the Institute for Healthcare Improvement, launched the Safer Patients Initiative (SPI). The four hospitals initially chosen to participate conducted hospital-wide programs to radically improve patient safety, with the aim of reducing adverse events by 50% by October 2006. In November 2006, Phase 2 was launched, adding 20 more sites.3 These hospitals meet regularly to report on progress and exchange ideas. Discrete projects focus on medicines reconciliation, ward-based care, critical care, and perioperative care. The overall aim of the SPI is to improve the patient safety culture within each organisation. Specific targets for all participating hospitals include a 15% reduction in mortality of in-hospital patients; 300 days between central line bloodstream infections in critical care units; 80% of blood sugar levels in diabetic patients falling within their target treatment range; a 30% reduction in cardiac arrest calls; and 50% reductions in methicillin-resistant Staphylococcus aureus bloodstream infections, harm from anticoagulation, and surgical site infections. In my intensive care unit, hand hygiene compliance among medical staff has been regularly audited and has improved from a range of 20%–90% per day to 60%–100%. This compares favourably with a recent Australian hand hygiene initiative.4 When practice improvements are shown in one location, the project team takes on the responsibility of spreading these across the hospital. Initial scepticism from senior clinicians and nurses in my hospital has generally been replaced by cooperation and, in many cases, ideas for other ways to improve delivery of safer clinical care. Large multisite evidence-based trials in intensive care units in the United States showed that, with focused effort on sterile technique and catheter care and by rectifying lapses in standard procedures, a reduction of 66% in catheter-related bloodstream infections was possible.5 The SPI is trying to replicate results such as these within a relatively short period. My intensive care unit has now gone 190 days without a line-related bacteraemia; previously, we had infections almost every month. The SPI Phase 2 completion date is November 2008, with full national reporting due at that time. It is intended that practice improvements will then be spread across the NHS. The experience in my hospital has been that sharing experiences both within the hospital and externally has led to tangible progress in this area.

Peter J Shirley

To the Editor: The recent article on the review of the University of Sydney Medical Program (USydMP)1 by Goulston and Oates included a lengthy list of “changes made or planned in accordance with key recommendations”.2 Regrettably, and to the despair of many, the most needed change will not take place. It is reported in the review that the average age of future USydMP graduates will be 29–30 years, as it has been for the past decade.1 From 2008, those who aspire to be surgeons will competitively enter the new Surgical Education and Training (SET) program of the Royal Australasian College of Surgeons (RACS) after completing “at least their second postgraduate year”.3 The SET program is for 5–6 years, depending on the specialty. Most trainees subsequently take a subspecialty fellowship for 1–2 years, either in Australia or overseas, by which time our hapless graduates will be 40 years old. A woman may have to have leave of absence for a pregnancy. A postgraduate degree is now a prerequisite for an academic career and this involves an additional 2–3 years of full-time research. Finally, it takes in the order of 5 years to establish a referral specialist practice in most branches of medicine. In the review document, Goulston and Oates nihilistically state “There is no opportunity for streaming within the USydMP”.1 There is no mention of undergraduate education in Australia, let alone the streaming of such education, in the article from the RACS outlining the SET program.4 However, strangely enough, it is noted therein: “North American students must make their long-term career choice in the final year of their medical school and are streamed accordingly”. One wonders if there is any purposeful communication between the RACS and our universities. There certainly should be. It is imperative in this day and age that undergraduate and postgraduate medical education be considered as a continuum so that we can begin to rid ourselves of the absurdly long and manifestly inefficient process outlined above. The historian and journalist Paul Johnson put his astute finger on the problem in writing a column about universities generally: “. . . a visitor from another planet, unfamiliar with the history of the institution, would think it odd that our ablest boys and girls, at a time when their mental and physical powers are at their highest, are withdrawn from the service of society and kept in comparative idleness . . .”5 One can but conclude that, at least for future surgeons, the wrong people are at the helm at the RACS and at the University of Sydney’s Faculty of Medicine.

Thomas K F Taylor

In reply: Taylor raises several issues that the Royal Australasian College of Surgeons (RACS) has carefully considered. The new Surgical Education and Training (SET) program commenced this year.1 The acronym SET could equally mean Shorter Efficient Training. In the previous program, 2–5 years of basic surgical training was followed by 4–6 years of advanced training, resulting in surgeons entering specialist practice an average of 10 years after graduating with their medical degrees. We responded to societal and regulatory factors, including the older age of medical (compared with other) graduates, sex, work–life balance, safe-hours requirements, workforce pressures and competition from other specialties. Our new system aims to streamline training by early selection directly into one of nine surgical specialties and completion of training by Postgraduate Year 7 or 8 in most cases. It is not only shorter, but more comprehensive than previously. It is much more than an apprenticeship, where training occurs by random clinical exposure. We are covering defined curriculum objectives for every trainee by offering training in metropolitan and regional hospitals, synthetic laboratories and the private sector. We are moving away from reliance on the number of years of training and numbers of operations as measures of experience. We are focusing on the development of a range of surgical competencies encompassing professionalism, communication, collaboration, clinical decision making, scholarship, leadership and health advocacy, as well as essential medical and technical expertise. These competencies are regularly monitored by performance assessment throughout training. At the completion of training and the RACS fellowship examination, a surgeon is competent to commence practice as a specialist. Additional formal training experience is optional. Of course, the RACS promotes the concept of lifelong learning. The RACS and universities are communicating. Common concerns are the compromised state of basic science education and the limited exposure of medical students to a range of surgical specialties. The College has had discussions with many universities and health authorities about the possibility of “streaming” in the later years of medical school and in Postgraduate Years 1 and 2. It is worth noting that the University of Sydney has plans for the final 2 years of its course to be integrated, with increased emphasis on critical care and surgery.2

Ian R Gough

In reply: We are in sympathy with Taylor’s concerns about the length of medical training and point out that a more careful reading of our review of the University of Sydney Medical Program1 contained the following comments (on page 203): Discussion with the Royal Australasian College of Physicians canvassed the possibility that students might master some educational modules during their medical degree which would be credited by the College. This could well apply to other Colleges. Such a process would be more easily achieved if the Colleges moved to an overall “point system” i.e. students (especially in nonclinical areas such as Ethics, Quality and Safety etc) could study postgraduate modules pari passu with the USydMP, gaining some points towards their chosen college specialty qualification. This is followed by three recommendations on page 204: Students with an early interest in a specialty could gain some speciality experience or credit towards their specialty by either working towards an MPhil and by making use of the electives, options and Honours research project. The future situation with regard to medical training in some of the specialties is fluid eg, the Royal Australasian College of Surgeons is introducing a method of streaming for surgical training (SET) and IMET [Institute of Medical Education and Training] is looking at criteria for competency in the residency years. In view of this the Dean should explore further opportunities for streaming when the options for future specialty training become clearer. Early streaming should be re-examined by Faculty when the curriculum and educational changes being considered by some of the Colleges become clearer.

Kerry J Goulston · R Kim Oates

To the Editor: During the recent international cricket series between Australia and India, we were alarmed by the sight of our Australian cricketers prominently badged with the logo of the fast food giant KFC. Australia is experiencing an epidemic of overweight and obesity, a problem that is especially affecting children, adolescents and young adults.1 This epidemic is worsening as a direct result of unhealthy eating habits and low levels of physical activity. Obesity is associated with chronic and costly diseases that lead to premature death and ill health. These include diabetes, cardiovascular disease, respiratory problems, sleep apnoea, certain cancers, mental illness and osteoarthritis, which can begin in adolescence.1 Cricket in Australia enjoys considerable popularity and a strong national following. Our cricketers are national sporting heroes who enjoy widespread support and respect throughout the community, particularly among younger members of the community, who aspire to emulate them. Against this background, we are increasingly concerned and disappointed that Cricket Australia has a sponsorship agreement with, and consequently promotes, KFC — going as far as publicly declaring the company the “official fast food restaurant of Cricket Australia”.2 This advertising uses the standing of cricket and its players to endorse and promote unhealthy eating habits, one of the major root causes of obesity in Australia. KFC products have caloric and fat contents well above the national dietary guidelines, which recommend < 30% energy from total fat and < 10% energy from saturated fat.3 For example, a standard serve of original-recipe chicken contains about 58% total fat and 24% saturated fat.3 Furthermore, we have shown that even one common KFC meal per week can adversely affect recommended healthy diets.4 It is ironic and regrettable that Cricket Australia, while having done so much for the sport, encourages the promotion of unhealthy, high-fat, high-calorie KFC products that negate the benefit of increased physical activity associated with playing cricket. With the explosion of obesity-related illness, we need champions to encourage health-promoting behaviours, particularly healthy eating and increased physical activity. The enthusiastic encouragement of unhealthy and undesirable eating habits should have no place in sporting sponsorship. Not so long ago, similar sentiments were being expressed about tobacco sponsorship of sport, which fortunately has been eradicated. Cricket Australia should consider its responsibilities to Australia’s children and youth and review its sponsorship by KFC. This would benefit the health of the community and demonstrate leadership and social responsibility by Cricket Australia and Australia’s elite cricketers.

Stephen Colagiuri · Ian D Caterson

In reply: Cricket Australia (CA) actively supports physical activity, healthy eating and healthy lifestyles and continues to invest considerable effort in encouraging Australians to play cricket, in everything from formal, organised competitions to social games in the backyard, in parks and schoolyards and at the beach. In a time of declining community physical activity, we are heartened to see that active participation in cricket is growing strongly, and note that female cricket is the fastest growing female sport in Australia. As a community-based, not-for-profit organisation, we are heavily dependent on the support of all of our sponsors, including KFC, to be able to implement the activities we undertake. These range from community-based programs that get kids running around outside to programs in schools, clubs and Indigenous communities, and further activity needed to develop and put elite international cricketers onto the field. In relation to KFC, we believe in a little of everything and everything in moderation. Setting aside the truly elite athletes, the formula that is going to work best for most cricketers and cricket fans is reasonable, not extreme, training and physical activity, together with a balanced diet, not one that features total abstinence from high-energy foods. Our view on alcohol is the same. Our CA advertising featuring Merv Hughes encourages fans to enjoy a beer, but not at the rate of one per over. The overall issue is about balance. Consumer research — commercially confidential, so it can’t be referenced here — shows that KFC consumption in Australia is an occasional treat, not a dietary staple. More broadly, CA is comfortable that Australian cricket’s collective activity has a net positive impact in encouraging healthy and active lifestyles.

Peter Young

Alexander alleviates pain Low back pain is common, can be difficult to treat and causes significant morbidity, particularly when it becomes chronic. The Alexander technique aims to develop skills that help people avoid poor habits which affect postural tone and neuromuscular coordination. Promisingly, the technique appears to be effective in treating patients with low back pain, according to the results of a UK randomised controlled trial. A total of 579 patients with chronic recurrent low back pain were randomly assigned to groups receiving either normal care, massage, or six or 24 Alexander technique lessons from registered teachers. After the lessons, half of each intervention group received a prescription for exercise by a doctor, with behavioural counselling from a nurse. The outcome measure was based on a score measuring impairment by pain. Either six or 24 lessons in the Alexander technique and prescription of exercise remained effective at 1 year, but massage did not show long-term benefit. The authors suggest that the technique may limit muscle spasm, strengthen postural muscles, and improve coordination and flexibility, thus leading to a reduction in back pain. BMJ 2008; 337: a884 Free radicals and food intake Another piece of the puzzle of weight gain and appetite control may have been found by Chinese and US researchers who have studied the phenomenom in mice. The gut-derived hormone ghrelin, which promotes food intake, affects the brain by regulating neuronal activity in the hypothalamus. A previously poorly understood intracellular mechanism has been revealed to be dependent on protein-uncoupling in the mitochondria of certain hypothalamic neurons, driven by the burning of fat and the production of free radicals, which are used in the uncoupling process. This in turn triggers ghrelin-induced food intake. The authors speculate that free radical-induced damage to surrounding vulnerable neurons over time may be associated with age-related onset of obesity. Nature 2008; 454: 846-851 Facial transplantation — the follow-up The recipient of a partial facial allotransplant in China 2 years ago has survived and the graft has proved to be successful long term, according to a follow-up and review of the procedure. The 30-year-old man suffered severe facial injuries after being attacked by a bear in the remote Yunnan province. The wound was initially repaired by a forearm pedicle flap, which was only partially successful. The subsequent partial face transplant consisted of anastamosis of the right mandibular artery, facial nerve and facial vein; and whole repair of the nose, upper lip, parotid gland, front wall of the maxillary sinus, infraorbital wall, and zygoma. Immunomodulatory therapy included tacrolimus, corticosteroids and monoclonal antibody. Despite three episodes of acute rejection, controlled by methylprednisolone and tacrolimus, the authors note that the graft is now functioning well and that the patient is in the process of re-integration into society. They comment that the success of this pro-cedure holds promise for the management of serious facial disfigurement. Lancet 2008; 372: 631-638 Diverticular diversions Do you advise your patients with diverticular disease to avoid eating nuts, corn, popcorn, and seeds in order to reduce the risk of complications? You may no longer need to do so, according to the results of a large, long-term US study involving over 47 000 men. The participants, who were free of diverticulosis at baseline, were followed for 18 years and completed regular surveys collecting medical and dietary information. The researchers found no association between corn, nut or popcorn consumption and the risk of diverticulosis or diverticular complications. Interestingly, nut and popcorn consumption appeared to be inversely associated with the risk of diverticulitis, independent of other known risk factors. The authors comment that they adjusted for total fibre intake and took into account the normal eating habits of the subjects, strengthening the validity of the results. JAMA 2008; 300: 907-914 Cosmetic neurology? Improving learning, memory and attention skills well beyond the normal range is a seductive proposition, and one which may soon become a reality, according to the proponents of neurocognitive enhancement, or “cosmetic neurology”. A discussion of the potential ethical minefield resulting from the use of these techniques forms the basis of a recent review article proposing protection for those who do not wish to take part in such enhancements. Neurocognitive enhancement may lead to the treatment of healthy individuals with brain-enhancing drugs, with the aim of improving performance in attention, learning and memory. The potential exists for employees who choose not to engage in such enhancements to suffer discrimination from employers and insurers. Apart from the complex ethical issues, the author comments that legislation and policy need to keep pace with science, just as they have been forced to in the field of genetics. J Med Ethics 2008; 34: 616-618 Dr Tanya Grassi, MJA

Tanya Grassi