Volume 190 Issue 5

Clinical software governance and real-world testing involving users are urgently needed In this issue of the Journal, a study from the National Prescribing Service (NPS) examines the quality of drug interaction alerts generated by nine clinical software systems currently used by general practitioners and pharmacists in Australia for prescribing or dispensing medications (Sweidan et al).1 The findings will come as no surprise to those who have repeatedly expressed concern about the shortcomings of clinical decision support software.2,3 Only half of the six prescribing systems examined by the NPS alerted users to all 20 of the major drug–drug interactions tested, which can occur with commonly used drugs and with the potential to trigger serious adverse reactions. The best of the three dispensing systems detected 19 of these drug interactions. Yet Australian GPs are heavily reliant on such software alerts: 88% of respondents to a recent national survey reported relying on their prescribing software to check for drug–drug interactions.4 Any failure of decision support systems to provide adequate drug safety alerts is thus likely to pose risks to patient safety. The NPS study provides a snapshot of software performance in response to artificially generated test cases. Different test cases may have yielded different results. Further, as valuable as they are, such studies cannot provide data on the cause of these failures or the likelihood that they will ultimately result in medication errors. At a fundamental level, we know that the performance of any decision support system will be determined by the completeness and accuracy of its knowledgebase. A second potential cause of missed alerts is the internal procedures and logic used within a decision support system. For example, even though the MIMS DrugAlert Interactions knowledgebase detects all 20 major drug interactions tested in the NPS study, the four prescribing systems based on this knowledgebase failed to uniformly report all of these alerts.1 Anecdotally, we also know that there is variation in the logic used to determine which drug interactions different manufacturers elect to display, and which are treated as low priority. At present, there is scarce information available to indicate which of these different components of decision support systems is most likely to generate safety problems. As a consequence, it is currently not possible to provide guidance to clinicians, policymakers or system manufacturers on the most appropriate safety practices needed to avoid misadventure. Moving beyond laboratory testing of software, there is a critical need to examine the safety of decision support systems in the hands of typical users. There is growing evidence that busy clinicians routinely disable or override computer advice. “Alert fatigue” is a well known consequence of using systems that generate high rates of non-serious or irrelevant alerts.5 The long-term impact of using such systems and their influence on clinicians’ decision making have yet to be systematically investigated. Indeed, the NPS found that the three prescribing systems that alerted users to all the major, clinically significant drug interactions also generated unhelpful alerts for 30%–55% of the clinically unimportant interactions.1 To reduce alert fatigue, software designers could consider smarter decision support systems that can be trained to meet individual practice requirements (akin to an email spam filter that can be gradually trained to recognise and remove irrelevant messages). For instance, GPs could train their prescribing software to provide alerts only for newly prescribed medications and ignore repeat medications where the clinician has previously noted an alert. This lack of clear evidence about the causation of computer-related failures in decision support systems, either on their own or in the hands of typical users, is likely to hamper international efforts to improve the safety governance of clinical software. Among the efforts seeking to address calls to regulate the safety of decision support systems,6 the United States Certification Commission for Healthcare Information Technology is introducing specific requirements for drug interaction alerts in ambulatory care systems.7 In September 2008, the United Kingdom’s National Health Service, which took a lead role in embedding a safety management approach into its procurement processes, published simple developer guidelines for safety features in prescribing systems.8 Future versions are planned to cover drug–drug interaction checking and other decision support functions not included in the initial specification. The International Organization for Standardization, using a risk-management approach, is developing standards for the construction, implementation and use of clinical software. In contrast, even though it is clear that we do need to move to some form of decision support system accreditation in Australia, safety governance of software does not yet seem to be on the agendas of the National E-Health Transition Authority or the Therapeutic Goods Administration. As we approach 5 years since publication of the first study to measure deficiencies in safety features of clinical software,9 research efforts have not translated into changes in clinical software governance in Australia. There is little local support for this research, and examination of the safety of clinical software has not moved beyond the use of artificial test cases. Yet it is clear that the safety of clinical software is as much a product of the human user as it is of the machine. If we are to move from safe design to safe use of clinical software, we must accelerate our efforts to systematically examine the safety of decision support systems in the hands of users. While no one suggests that clinicians should stop using decision support systems, given their clear benefit to patients, we need to understand the “side effects” or unanticipated consequences of the technology,10 and understand in which situations their use might lead to unacceptable clinical risk.

Farah Magrabi BE, PhD · Enrico W Coiera MB BS, PhD, FACMI

The effects of cannabis use on health and social adjustment are profound Substance misuse by Indigenous people has long been recognised as one of the devastating consequences of contact with Western culture. Misuse of tobacco, alcohol and petrol among Indigenous Australians has received much attention. Cannabis, by contrast, has not been viewed as a major problem. But since the 1990s, it has become apparent that heavy cannabis use is common in some remote Indigenous communities.1 The associated health and social burdens are now being recognised.1,2 Indigenous Australians, whether living in urban or rural settings, are more likely than other Australians to report cannabis use.3 Recent reports suggest that cannabis use is also relatively high among Indigenous populations in New Zealand, Canada and North America.4 Limited data are available on patterns of cannabis use among Indigenous Australians.3 However, a recent 5-year study of adolescents and young adults in three remote communities in Arnhem Land in the Northern Territory has found that not only is cannabis use common in remote Indigenous settings, but its effects on health and social adjustment are profound.4-6 These three communities are close to one another but very isolated, being over 550 kilometres from the nearest city. There is one local Indigenous language, and English is a secondary language. Tobacco use was found to be the norm in these communities, with over 90% of adolescents and young adults smoking.7 Because of restricted access to alcohol, problem drinking was uncommon.7 In contrast, cannabis use was endemic, with over 70% of males and 20% of females being current users.5 Cannabis was typically consumed mixed with tobacco and smoked using a locally fashioned “bucket bong” that gives the user a rapid and intense dose with little smoke lost.5 Regular heavy use (≥ 6 “cones” daily) was found in almost 90% of users.7 This is around twice the consumption of regular cannabis users elsewhere in Australia.1 Furthermore, about 90% of the Indigenous users reported symptoms of cannabis dependence.1 This compares with about 20% of users aged 18 or over in the general Australian population.3 Of even greater concern was a suggestion that, for most Indigenous users, cannabis was not a passing adolescent phase. After 5 years of follow-up, the great majority reported continuing heavy use.4 Cannabis use was linked to substantial health problems and social burdens in these communities, which are already disadvantaged by isolation and poverty.2,5,8 Up to 10% of the communities’ total income and between 31% and 62% of a user’s median weekly income was spent on cannabis.5 Cannabis users were less likely than non-users to participate in education or training5 and more likely to report auditory hallucinations, suicidal ideation,6 symptoms of depression,7 and having been imprisoned.6 Community violence increased when cannabis supplies were scarce.1,2 The effects on traditional life were described by one NT Indigenous mental health clinician in the following way: Too many of my people are chained to [cannabis]. They don’t go out hunting or spend time by the river with their family. They just sit and smoke [cannabis], then look for money to buy more [cannabis] and get into fights when they can’t get any (Muriel Jaragba, personal communication). What accounts for the unusual patterns of cannabis misuse in these remote Indigenous communities? There is little evidence that cannabis is grown locally,9 but much anecdotal evidence that market networks supplied by dealers based in urban or regional centres are extensive and resilient, making cannabis readily available (A R C, unpublished observation). Alcohol restrictions have been effective in reducing problem drinking within communities, but may have had the undesirable consequence of encouraging an increase in cannabis use where it could be easily obtained.5 As with risks for other forms of substance misuse in these communities, the social context is important. Limited employment and education opportunities; crowded, poor-quality housing; community-wide feelings of disempowerment; and grief and loss related to high mortality, morbidity and incarceration rates are all likely risk factors for substance misuse. Cannabis misuse is likely to be both a consequence of this type of social disadvantage and a perpetuating influence. Cannabis misuse in remote Indigenous communities has been overlooked for too long. It is now clear that it is yet another major problem for these already disadvantaged communities, with evidence of cannabis misuse across a broad area of northern Australia.1,2,9 As well as in the NT, concerns about the level of cannabis use have recently been noted in Cape York8 and anecdotally in other parts of remote and regional Australia. Further research is needed to investigate the impact of cannabis use on urban Aboriginal and Torres Strait Islander Australians. Effective responses will not be easy. Controls on supply by state- or territory-based police are one of the few available measures.6 In order to be effective, policymakers and service providers would need to work collaboratively with local communities to tie in local prevention and treatment initiatives with existing supply control initiatives. Such programs would need to use Indigenous language and cultural frameworks, build capacity of local Indigenous professionals, and improve understanding of the harms associated with cannabis misuse.10 Ultimately, tackling the misuse of cannabis and other substances in remote settings will depend on creating opportunities for social development and for continuing education, training and employment of adolescents and young adults.

K S Kylie Lee BMus(Hons) · Katherine M Conigrave FAFPHM, FAChAM, PhD · George C Patton MD, FRANZCP · Alan R Clough PhD

Should intrusions by political bodies into personal reproductive decisions be an Australian fact of life? Babies are generally very good news for Australian families, and nationally there is acclaim that our previously declining birth rate has been on a clear rise since 2004 (Box).1 In part, this rise has been a result of welcome government intervention, and several articles and letters in this issue of the Journal relate to reproduction and government subsidy.1-7 Lain and colleagues assessed the effect on New South Wales birth rates of the Howard Government’s cash bonus of $3000 for the birth of a child, introduced on 1 July 2004;1 the then Treasurer, Peter Costello, quipped that a third child could be “for the country”. The Baby Bonus was increased to $5000 on 1 July 2008. Between 1997 and 2006, the proportion of first births in NSW (among a declining total number of births) increased steadily until 2004, after which the proportion of second births, and especially of third and subsequent births, began to rise.1 The timing of the turnaround and the strength of any causal link between the bonus and additional births invites further analysis, using data from the National Perinatal Statistics Unit (Box).8 The $3000 bonus payment to about 272 000 women giving birth nationally during 2005, and 282 000 in 2006, cost about $1.7 billion. We know that in these 2 years over 16 000 of the babies were conceived by in-vitro fertilisation (IVF), and that having an IVF baby most likely indicates reproductive intentions independent of the bonus. If the previous birth-rate trend for non-IVF babies had continued in 2005 and 2006, just over 250 000 babies would have been born in each of these years. This means that about 37 000 of the extra babies born in 2005 and 2006 were attributable to the bonus. The Baby Bonus thus represented a government investment of just over $45 000 for each extra baby. Comparing this figure with the total of $295 million paid out in IVF-related Medicare rebates in the same 2-year period for assisted conception of more than 16 000 IVF babies (an average of less than $20 000 for each baby), it is obvious that, as an ongoing government investment, Medicare funding of IVF is more than twice as productive as the bonus. The Rudd Government has now restricted the bonus to the more disadvantaged in the community by means-testing families. Acknowledging the need to “start in the womb” if we are to close the gap in life expectancy between Indigenous and non-Indigenous Australians,2 de Costa and Wenitong compare Australia’s Baby Bonus with a well established endowment scheme for babies in France that operates with some important differences. An extra payment is recommended for women who commence medically supervised antenatal care before 14 weeks’ gestation; and, instead of a lump sum after the birth, payments are made in instalments linked to positive health practices by the new mothers. The authors make a case for changing the way baby bonuses are delivered in Australia to assist all disadvantaged women to have healthy babies with better life prospects.2 IVF practices, meanwhile, have not stood still.3 When Medicare rebates were introduced for IVF services in 1989, a limit of six treatment cycles was set.9 As IVF practices and outcomes improved during the 1990s,10 including better methods for cryostoring excess early embryos for later transfers, the frequency of multiple pregnancies, with their attendant higher medical and social costs, increased disproportionately.3,10 Since 2000, improved pregnancy rates, the withdrawal of the six-cycle limit for Medicare rebates, and the introduction of the Medicare Safety Net (which decreases out-of-pocket expenses) have worked together to facilitate a fast-increasing practice in Australia of transferring just one IVF embryo at a time. This practice, known as elective single embryo transfer, or eSET, is now the benchmark for best practice. Its effect has been a sharp fall in multiple deliveries after IVF, from a peak of over 22% of confinements in 20008 to now single figures, and better pregnancy outcomes, as Wang et al report3. Improved storage techniques for immature sperm and unfertilised eggs are also pushing the frontiers of what’s possible, biologically and socially. Two such developments are reported in this issue of the Journal.4,5 When a young man is found to be terminally ill or dies suddenly, immature sperm can be collected from a testis before or after death, cryostored, and potentially be available for conceiving a child using IVF — but, if the legal constraint advocated by Middleton and Buist prevails, this will be allowed in Victoria and some other states only if the man has given proven written consent, irrespective of other evidence that this was his wish for his family.4 For women facing sterility from radiotherapy or chemotherapy and who are still to form a permanent relationship, the opportunity to store usable unfertilised eggs has also become technically practicable. Using vitrification, an ultra-rapid freezing method, retrieved mature eggs can be cryostored and, if they survive thawing, can resume a fertilisable physiological state. Given the rise in median maternal age at the birth of a first baby in Australia11 and the increasing physiological sterility of women from their mid 30s,12 this technique can also be used by healthy women to provide what Molloy et al refer to as “reproductive insurance”.5 This is not a development that should disrupt community social order. But governments tend to over-react,13 and can incite indignation. One man has written to the Journal in relation to a statutory limit in Victoria of 10 years for the storage of sperm (in his case his own, for his own use, having survived cancer treatment),6 beyond which each application for continued storage must have the individual approval of Victoria’s Infertility Treatment Authority.7 It seems some parliaments in our country would still subscribe to a 1993 report from Canada’s National Reproductive Technologies Commission, which claimed as paramount the need for “peace, order and good government power”13 and which unintentionally paraphrased Aldous Huxley’s “Community, identity, stability”, the world government’s ruling imperative in Brave new world.14 As Victoria’s statutes stand, a woman seeking “reproductive insurance”5 will likewise need, at a statutorily determined period and presumably regularly thereafter, to justify her decision to store her eggs to an appointed group of people of differing personal views, and she will also need their assent should she wish to take her eggs to another jurisdiction. The power of legislation to destroy individuals’ reproductive futures was demonstrated in the United Kingdom on 1 August 1996.15 Many infertile couples, not able to be contacted over a 3-month period, found out after the event that all UK IVF clinics, to avoid prosecution,16 had been forced by the UK’s Human Fertilisation and Embryology Authority to throw out more than 3000 embryos reaching their 5-year statutory storage limit without a properly formulated request for longer storage. Australia, like most countries, has a long history of government intervention in fertility issues. In 1983, it was the first country to adopt national ethical guidelines for the clinical conduct of IVF. For the safe development of IVF practices, it was considered necessary to do research involving human eggs and sperm (with consent of the providers).17 But (to cut a long story short), a conservative political reaction prevented such research in most states other than NSW until the federal parliament’s passage of the Research Involving Human Embryos Act 2002 (Cwlth). This conservative thinking still finds expression today, with the Australian Health Ethics Committee (a principal committee of the otherwise firmly evidence-based National Health and Medical Research Council [NHMRC]) arguing against research involving human embryos by resting on “an enduring ethical tradition of thought and belief” that has limited community support,18,19 at the expense of outcomes-based ethical principles.13,20 States that legislated to regulate IVF practices in the early 1980s, as Victoria did with its Infertility (Medical Procedures) Act 1984, faced what was then considered radical technology with uncertain social consequences, by applying similar, conservative, non-evidence-based principles. So rapidly were perspectives changing, however, that some parts of this Act were not proclaimed, some parts were later repealed, and, despite a 1996 overhaul of the Act, other parts have come into conflict with Commonwealth legislation.21 The Research Involving Human Embryos Act, which has been mirrored by most state legislatures, legalised embryo research across Australia through special and specific licences administered by the NHMRC. The community clearly recognises and supports the contribution that modern IVF practices make to responsible formation of families in Australia,22 but in Victoria a government authority established under the 1984 Act continues to be responsible for individual, personal decisions affecting all families who have or intend to have their sperm, eggs or embryos exposed in labs. In December 2008, the Assisted Reproductive Treatment Bill 2008, the second rewrite of the legislation in 24 years, and intended to broaden access to assisted reproductive technologies, was passed by the Victorian parliament. Cabinet has apparently over-ridden the advice of the state’s Law Reform Commission and imposed a fitness-to-parent code — compulsory police and child-protection checks — before infertile or childless people can attempt to form families with technological help. The Act also provides for a Patient Review Panel appointed by the Health Minister, with a “primary role” in determining applications for IVF and medically assisted conception.23 For couples with the disability of infertility who need medical help to have children, “the bedroom” is, alas, now a nostalgic metaphor for lost privacy. Intrusions by politically appointed committees into people’s lives and their personal reproductive decisions in Victoria and some other states are real and set to increase. With governments at the bedroom door determined to be part of the detail, too often it’s still two steps in and just a rare step out. Annual IVF and non-IVF births in Australia, 1991–2006 IVF = in-vitro fertilisation. Non-IVF births in 2005 and 2006 above the preceding 4 years’ average (dotted line) are potentially attributable to the Baby Bonus. Data source: Australian Institute of Health and Welfare National Perinatal Statistics Unit.

Robert P S Jansen MD, FRACP, FRANZCOG · Sandra K Dill AM, BComm, MLS

Objective: To compare the perinatal outcomes of babies conceived by single embryo transfer (SET) with those conceived by double embryo transfer (DET).Design, setting and participants: A retrospective population-based study of embryo transfer cycles in Australia and New Zealand between 2002 and 2006, using data from the Australia and New Zealand Assisted Reproduction Database.Main outcome measures: Proportion of SET procedures; comparison of SET and DET procedures with respect to multiple births, low birthweight (LBW), preterm birth and fetal death.Results: The proportion of SET procedures has increased from 28.4% in 2002 to 32.0% in 2003, 40.5% in 2004, 48.2% in 2005 and 56.9% in 2006. The multiple birth rate for all babies conceived by SET (4.0%) was 10 times lower than for those conceived by DET (39.1%) (P < 0.01). The average birthweight for all liveborn babies conceived by SET (3290 g) was higher than for those conceived by DET (2934 g) (P < 0.01). The preterm birth rate of all DET-conceived babies (30.3%) was higher than for SET-conceived babies (12.3%) (adjusted odds ratio [AOR], 3.19 [95% CI, 3.01–3.38]). All babies conceived by DET were more likely to be stillborn than those conceived by SET (AOR, 1.49 [95% CI, 1.21–1.82]). Singletons conceived by DET were more likely to be born preterm than singletons conceived by SET (AOR, 1.13 [95% CI, 1.05–1.22]). Liveborn singletons conceived by DET were 15% more likely to have LBW than liveborn singletons conceived by SET (AOR, 1.15 [95% CI, 1.05–1.26]). There was no significant difference in fetal death rate between DET- and SET-conceived singletons.Conclusion: The increase in proportion of SET procedures has resulted in a lower rate of multiple births and in better perinatal outcomes in Australian and New Zealand assisted reproduction programs.

Yueping A Wang MPH · Elizabeth A Sullivan MPH, MMed(SexHlth), FAFPHM · David L Healy FRACOG, CREI, PhD · Deborah A Black BSc, MStat, PhD

Objective: To assess the change in birth rates, both overall and in age, parity, socioeconomic and geographical subgroups of the population, after the introduction of the Baby Bonus payment in Australia on 1 July 2004.Design and setting: Population-based study using New South Wales birth records and Australian Bureau of Statistics population estimates for the period 1 January 1997 – 31 December 2006.Participants: All 853 606 women aged 15–44 years with a pregnancy resulting in a birth at ≥ 20 weeks’ gestation or a baby ≥ 400 g birthweight.Main outcome measure: Change in birth rate in 2005 and 2006 compared with the trend in birth rates before the introduction of the Baby Bonus.Results: The crude annual birth rate showed a downward trend from 1997 to 2004; after 2004 this trend reversed with a sharp increase in 2005 and a further increase in 2006. All age-specific birth rates increased after 2004, with the greatest increase in birth rate, relative to the trend before the Baby Bonus, being seen in teenagers. Rates of first births were not significantly affected by the bonus; however, rates of third or subsequent births increased across all age, socioeconomic and geographical subgroups.Conclusions: In the first 2 years after the introduction of the Baby Bonus, birth rates increased, especially among women having a third or subsequent birth. This could represent an increase in family size and/or a change in the timing of births.

Samantha J Lain BComm, BHlthSci(Hons), MPH · Jane B Ford BA(Hons), PhD · Camille H Raynes-Greenow BA, MPH, PhD · Ruth M Hadfield BSc, DPhil(Oxon), GCBiostat · Judy M Simpson BSc, PhD · Jonathan M Morris MB ChB, FRANZCOG, PhD · Christine L Roberts MB BS, MPH, DrPH

Closing the gap in life expectancy between Indigenous and non-Indigenous Australians needs to start in the womb. Rates of perinatal mortality, preterm birth and low birthweight are two to three times greater among the babies of Indigenous women than among those of non-Indigenous women; low birthweight predisposes infants to greater risks of chronic illness in later life. Indigenous women in Australia tend to present for antenatal care later in pregnancy than do non-Indigenous women. There are many barriers for Indigenous women seeking to access antenatal care — geographical, social, cultural, financial and in some cases a lack of service provision. Many of these problems are being addressed within the public health system and by Indigenous community-controlled health services. However, more needs to be done. While antenatal care cannot solve all medical and social problems, commencing such care as early as possible in pregnancy has the potential to improve maternal health and hence pregnancy outcomes. Changes in the way the government Baby Bonus is paid to new mothers could act as an incentive not only to service providers but also to women themselves to initiate antenatal care in the first trimester of pregnancy. Such a system has been well established for many years in France. Any changes to the Baby Bonus scheme should provide incentives and not be punitive in nature.

Caroline M de Costa FRANZCOG, FRCOG, MPH · Mark Wenitong BMed

An unexpected consequence of the increase in the use of fertility treatment is that emergency department and intensive care doctors are receiving requests from wives (actual or de facto) of dying or recently deceased men for sperm removal. Legislation in all states and territories regulates removal of sperm from a dying man and, provided that lawful consent is obtained, a doctor can harvest sperm. In several states, including Victoria, harvested sperm cannot be used in a fertilisation procedure without the man’s consent, and debate surrounds the issue of consent and how it can be proved. Recent Victorian Law Reform Commission recommendations attempt to streamline the law to make a man’s consent the cornerstone of decision making for both harvesting and subsequent use of sperm.

Sarah L Middleton BA/LLB(Hons), PhD · Michael D Buist FRACP, FJFICM, PostGradCertHlthEcon

Cryopreservation of unfertilised oocytes for later use in initiating pregnancy is now a viable technology, with acceptable pregnancy rates (over 20% per thaw cycle). Oocyte cryopreservation used as a form of insurance against “social” (age-related) infertility can improve the lifetime chance of pregnancy in women who defer pregnancy into their late 30s or early 40s. We report two pregnancies using oocytes that were frozen for social rather than medical reasons, as part of a larger series of nine pregnancies using cryopreserved oocytes. Use of oocytes harvested and frozen from women aged under 35 years may more than double the chance of pregnancy for a 41-year-old woman. The disadvantages of oocyte freezing for social infertility reasons include cost, the usual risks associated with in-vitro fertilisation, and the lack of a guarantee of eventual pregnancy.

David Molloy MB BS, FRANZCOG · Barbara A Hall MB BS, FRANZCOG · Marianne Ilbery MB BS, FRANZCOG · Jacqui Irving BSc(Hons), MSc · Keith L Harrison BSc, MSc

To the Editor: Before starting chemotherapy, many young men with cancer arrange to have their sperm stored to allow them the chance to father a child later. However, hundreds of these Australian cancer survivors have been informed that their stored sperm samples were to be destroyed by government order. The Victorian Infertility Treatment Act 1995 mandates that stored sperm must be destroyed after 10 years.1 In contravention of the Universal Declaration of Human Rights and even the preamble to the Infertility Treatment Act itself, it would seem that the main action of Infertility Treatment Authority (ITA) policy is to stop genetically unfit people from reproducing. Because some cancer and leukaemia survivors will have germline mutations that caused their disease, the 10-year storage cut-off is a tool for eugenics. Although eugenics policies of the 1930s and 1940s have been rescinded and are looked back upon with disapproval by many ethicists and civil libertarians, none have spoken out against the current Act. Australian civil rights groups speak out about forced sterilisation in other countries; why have none looked at the government actions in our own country? When I appealed to the ITA 7 years ago for an extension of storage time, I found the response I received to be arrogant and insensitive. The ITA representative implied that the legislation exists merely to deal with samples that people have forgotten about. When one has to pay several hundred dollars every year to continue storing sperm, I expect most people would stop paying if they didn’t want the sperm stored any longer. It is a physical, emotional and financial ordeal to survive leukaemia or cancer in youth and young adulthood. Many young men who survive choose not to have a family immediately after initial treatment because they don’t know their chances of survival. In my own case, this was highlighted by the circumstances of a friend who had a bone marrow transplant several years earlier and chose to have a child by in-vitro fertilisation. Unfortunately, he died from an unexpected complication of his treatment soon after his baby was born. Unable to get life insurance after leukaemia treatment, many individuals choose to wait until they are more financially secure (leukaemia or cancer will quickly throw a young person into debt) before starting a family. Being a doctor, I am prepared to fight such authoritarian directives, but many other men, now cured of their disease, would simply have given up their hope of having a family after receiving this draconian news. Forced sterilisation is unacceptable in this country, and this legislation must be amended. In reply: The Victorian Government develops policy around matters concerned with the storage of gametes and embryos and determines the length of storage time for sperm, eggs or embryos via specific clauses within legislation (the Infertility Treatment Act 19951). It is the role of the Infertility Treatment Authority (ITA) to administer the Infertility Treatment Act. Section 51 of this Act provides that gametes must not remain in storage for more than 10 years, unless the ITA has given its approval for a longer period. The ITA approves storage extensions on application from men or women who have stored gametes before undergoing chemotherapy for cancer. The ITA is sympathetic to people requiring a longer storage time for medical reasons and makes every attempt to discuss any issues arising with storage. People who have stored gametes for their own use have, to date, been granted an extension. The intent of the legislation is not to restrict people undergoing chemotherapy from having children, but to provide a timeframe for review of storage of gametes by the owners. If the owners of gametes or embryos have not kept their contact details up-to-date with the place where their reproductive material is stored, then the gametes or embryos can be removed from storage once they reach the statutory time limit, rather than being kept indefinitely. The current Act will be replaced by the Assisted Reproductive Treatment Act 2008, passed by the Victorian Parliament in December last year. The requirement for gaining approval for extension of storage will not change; however, applications for extension of storage beyond 10 years will now be made to a new Patient Review Panel. The ITA would be more than happy to provide further information about how the application process works, and the Chief Executive Officer, Louise Johnson, can be contacted on (03) 8601 5250 or ita@ita.org.au.

Jock Findlay

Objective: To investigate the quality of drug interaction decision support in selected prescribing and dispensing software systems, and to compare this information with that found in a range of reference sources.Design and setting: A comparative study, conducted between June 2006 and February 2007, of the support provided for making decisions about 20 major and 20 minor drug interactions in six prescribing and three dispensing software systems used in primary care in Australia. Five electronic reference sources were evaluated for comparison.Main outcome measures: Sensitivity, specificity and quality of information; for major interactions: whether information on clinical effects, timeframe and pharmacological mechanism was included, whether management advice was helpful, and succinctness.Results: Six of the nine software systems had a sensitivity rate ≥ 90%, detecting most of the major interactions. Only 3/9 systems had a specificity rate of ≥ 80%, with other systems providing inappropriate or unhelpful alerts for many minor interactions. Only 2/9 systems provided adequate information about clinical effects for more than half the major drug interactions, and 1/9 provided useful management advice for more than half of these. The reference sources had high sensitivity and in general provided more comprehensive clinical information than the software systems.Conclusions: Drug interaction decision support in commonly used prescribing and dispensing software has significant shortcomings.

Michelle Sweidan BPharm, MPH · James F Reeve BPharm, PhD · Jo-anne E Brien BPharm, BS(Pharm), PharmD · Pradeep Jayasuriya MB BS, MHlthServMan · Jennifer H Martin MA, FRACP, PhD · Graeme M Vernon BPharm, FSHP

Supraventricular tachycardia (SVT) is a common cardiac rhythm disturbance; it usually presents with recurrent episodes of tachycardia, which often increase in frequency and severity with time. Although SVT is usually not life-threatening, many patients suffer recurrent symptoms that have a major impact on their quality of life. The uncertain and sporadic nature of episodes of tachycardia can cause considerable anxiety — many patients curtail their lifestyle as a result, and many prefer curative treatment. SVT often terminates before presentation, and episodes may be erroneously attributed to anxiety. Sudden-onset, rapid, regular palpitations characterise SVT and, in most patients, a diagnosis can be made with a high degree of certainty from patient history alone. Repeated attempts at electrocardiographic documentation of the arrhythmia may be unnecessary. Treatment of SVT may not be necessary when the episodes are infrequent and self-terminating, and produce minimal symptoms. When episodes of tachycardia occur frequently, are prolonged or are associated with symptoms that affect quality of life, catheter ablation is the first choice of treatment; it is a low-risk procedure with a high success rate. Long-term preventive pharmacotherapy is an alternative approach in some patients.

Caroline Medi BMed, FRACP · Jonathan M Kalman MB BS, PhD, FRACP · Saul B Freedman MB BS, PhD, FRACP

A previously well 2-year-old girl presented with acute respiratory distress. After multiple investigations she was diagnosed with spontaneous chylothorax, attributed to strenuous vomiting. To our knowledge, this is the second reported case of spontaneous chylothorax occurring after the neonatal period. (MJA 2009; 190: 262-264) Clinical recordA 2-year-old child presented to her local hospital with acute respiratory distress and a 2-day history of forceful vomiting and diarrhoea. She was afebrile, with no history of cough, coryza, trauma to the chest or spine, weight loss, or lethargy. She was born at term with no perinatal complications, and was growing along the 25th percentile for weight and height. She was not dysmorphic. On examination, the patient’s temperature was 36.8°C, heart rate was 154 beats/min, respiratory rate was 67 breaths/min, and blood pressure was 96/68 mmHg. Her chest was dull to percussion, with poor air entry over the right hemithorax. The remainder of the physical examination was unremarkable. A chest x-ray (Box, A) revealed opacification of the right hemithorax with mediastinal shift to the left. An intercostal catheter (ICC) drained 900 mL of pink-stained milky fluid. Intravenous flucloxacillin and gentamicin therapy were begun for presumed empyema. She was transferred to a tertiary paediatric hospital. On arrival, the patient’s condition was stable, and she had good air entry on the right side of her chest. Pleural fluid loss from the ICC was occurring at 12 mL/kg/h. Pleural fluid analysis revealed a total cell count of 2630 × 106 cells/L with more than 80% lymphocytes, and a triglyceride level of 23.7 mmol/L (reference range [RR], <1.2 mmol/L). Spontaneous chylothorax was diagnosed. Computed tomography of the chest excluded a mediastinal mass. Tests were negative for tumour markers, including α-fetoprotein, β-human chorionic gonadotropin and urinary biogenic amines. A Mantoux test returned a non-reactive result (diameter, 0 mm). Radionuclide lymphoscintigraphy (Box, B) confirmed normal lymphatic anatomy, but also detected rapid drainage of lymph into the right side of the chest. The patient was initially managed with restriction of fat intake and a medium-chain triglyceride (MCT) diet. A 5-day culture of pleural fluid taken at Day 1 showed no growth, and antibiotics were withdrawn. The chyle loss decreased to 5 mL/kg/h after 1 week on the diet. An octreotide infusion at 5 μg/kg/h was added, and pleural fluid loss dropped to 2.5 mL/kg/h within 5 days. Blood tests on Day 8 showed a reduced immunoglobulin G level (1.2 g/L; RR, 3.2–13.4 g/L) and reduced lymphocyte count (0.51 × 109 cells/L; RR, 3.0–9.5 × 109 cells/L). Sulfamethoxazole/trimethoprim therapy was begun as prophylaxis against Pneumocystis jiroveci infection. The patient’s weight dropped from 12.1 kg before admission to 10.5 kg by Day 9. Because of continuing significant chyle loss, malnutrition and the risk of infection, surgery was performed on Day 19. Using video-assisted thoracoscopic surgery (VATS), chyle leaking above the level of the right diaphragm was detected. The region of leakage was oversewn with no attempt to isolate or ligate the thoracic duct. After surgery, there was minimal fluid loss through the ICC, and the ICC was removed 72 hours later. There was no fluid re-accumulation thereafter. A normal diet was re-introduced, and the patient was discharged home 4 days after surgery. DiscussionThis unusual case of chylothorax in a 2-year-old child had none of the previously recognised causes of chylothorax and was attributed to strenuous vomiting. To our knowledge, this is the second reported case of spontaneous chylothorax occurring after the neonatal period. Chylothorax is an uncommon cause of pleural effusion in children. Damage to the thoracic duct causes the pleural space to accumulate chyle — lymphatic fluid enriched with fat (chylomicrons) absorbed by the intestinal cells and transported into the circulation via the thoracic duct.1,2 It is well recognised in newborns as a congenital condition, or secondary to birth trauma. In childhood, it generally occurs after cardiac surgery. Other causes include neck surgery, scoliosis surgery, congenital malformations of the pulmonary or thoracic lymphatic system, and dysmorphic syndromes (Turner, Noonan and Down syndromes).2,3 Chylothorax can occur following blunt trauma to the chest, subclavian vein thrombosis or thoracic duct infiltration. Our patient had no previously recognised causes of chylothorax. Multiple investigations were undertaken to identify a cause such as malformation, infiltration or injury to the thoracic duct. On review of the medical literature (MEDLINE search, 1956–2008), one reported case of spontaneous chylothorax in a child was identified.4 Straining of the thoracic duct due to strenuous vomiting was suggested to have caused the rupture, which we consider to be the likely explanation in our case. Despite appropriate medical management, the high rate of chyle leak necessitated surgical repair. The VATS approach is worth considering early in cases of spontaneous chylothorax when the chyle leak cannot be controlled with maximal medical therapy. The diagnosis of chylothorax was straightforward in our patient. The fluid appeared milky, and the triglyceride level was extremely elevated, as was the lymphocyte count.1 The cause of the chylothorax was more difficult to ascertain. Knowledge of the anatomy of the thoracic lymphatic system is helpful in determining the site of disruption of the thoracic duct associated with right, left or bilateral chylothorax. Rupture of the thoracic duct between the diaphragm and the fifth thoracic vertebra results in accumulation of chyle in the right pleural space. In adults, lymphography has been used to define the anatomy, but is not practical in children due to difficulty cannulating lymphatics; for this reason, we used radionuclide lymphoscintigraphy instead. This showed leakage of chyle above the diaphragm on the right side. Disruption of the thoracic duct at this point was confirmed by thoracoscopy. As both our patient and the previously reported patient4 had right-sided chylothorax, the thoracic duct might be most susceptible to injury from forceful diaphragmatic contraction as it traverses the diaphragm. Hence, forceful vomiting is the most likely explanation in our patient. The management of chylothorax is the same regardless of cause, although no treatments have been subjected to a randomised controlled trial. The initial step is aspiration of pleural fluid for diagnosis. The basic principle of chylothorax management is to reduce the chyle flow in the thoracic duct while waiting for spontaneous healing. This is usually managed by a low-fat and MCT diet or, occasionally, enteric rest with total parenteral nutrition. Spontaneous healing can take weeks. MCT oil consists of triglycerides with saturated fatty acids that are 8–12 carbons in length; these are absorbed directly into the portal venous system, bypassing lymphatic drainage.5 A report on 51 children with chylothorax, aged 0–16 years (median age, 1.7 years), showed that most developed chylothorax secondary to cardiothoracic surgery (46/51), one did so after chest trauma, and four had congenital lymphatic malformation. Complete resolution of the chylothorax was achieved with a 4-week, low-fat and MCT diet in 80% of patients. Patients with congenital chylothorax or chylothorax secondary to obstruction were at higher risk of failure of medical treatment and proceeded to surgical repair.1 Octreotide, a somatostatin analogue, has recently been advocated for use in children with chylothorax that does not respond to conventional therapy.6,7 Somatostatin has a wide range of inhibitory effects on gastrointestinal and endocrine function. Its mechanism of action in treating chylothorax is unclear, but a possibility is reduction of splanchnic vascular tone, eventually leading to a decreased flow of chyle through the thoracic duct.8,9 Nevertheless, the efficacy of octreotide has not been demonstrated in a controlled trial. Although there is no clear dosage regimen, we used a continuous infusion as this was reported most often in the literature.10-13 Reduction in rate of chyle flow within 24–48 hours of treatment initiation has been reported, and the treatment appears to be safe.8,9,14 Some cases of chylothorax cannot be controlled by medical therapy, and surgery is required. There are numerous surgical approaches, including thoracic duct ligation and pleurodesis (surgical or chemical). VATS has been suggested recently, which is much less invasive than an open approach,15 and provides a superior view of the thoracic duct as it enters the thorax. In the previous report of spontaneous chylothorax in a child, ligation of the thoracic duct by VATS was also successful.4 There is no consensus on the timing of surgery, but most authors advocate 3–4 weeks of medical therapy beforehand.1,2,16 In our patient, surgery was undertaken earlier than this as spontaneous healing was considered very unlikely. Earlier surgery could reduce hospitalisation, malnutrition and risk of infection. Surgical correction is definitive and does not lead to lymph stasis because of the rich network of collateral lymphatic vessels. Chylothorax is an unusual cause of pleural effusion in children after the neonatal period and without a history of cardiothoracic surgery. Determining the cause can be challenging, thus knowledge of the thoracic duct anatomy and use of radionuclide lymphoscintigraphy can be helpful. Initial treatment involves drainage and measures to diminish chyle flow. Early surgical treatment is appropriate when medical therapy fails, and, if possible, VATS should be considered. Images used to diagnose a 2-year-old patient with spontaneous chylothorax A: On presentation, a chest x-ray showed complete opacification of the right hemithorax with mediastinal shift to the left. B: One week after admission, a lymphoscintigraphy scan showed rapid leakage of lymphatic fluid into the right hemithorax (arrowhead), suggesting significant rupture of the thoracic duct.

Manuel E Soto-Martinez MD · Vanessa Clifford MB BS, BA(Hons), BMedSc · Tom Clarnette MB BS, MD, FRACS(PaedS) · Sarath Ranganathan MB, MRCP, PhD · R John Massie MB BS, PhD FRACP

Dengue transmission in Australia is currently restricted to Queensland, where the vector mosquito Aedes aegypti is established. Locally acquired infections have been reported only from urban areas in the north-east of the state, where the vector is most abundant. Considerable attention has been drawn to the potential impact of climate change on dengue distribution within Australia, with projections for substantial rises in incidence and distribution associated with increasing temperatures. However, historical data show that much of Australia has previously sustained both the vector mosquito and dengue viruses. Although current vector distribution is restricted to Queensland, the area inhabited by A. aegypti is larger than the disease-transmission areas, and is not restricted by temperature (or vector-control programs); thus, it is unlikely that rising temperatures alone will bring increased vector or virus distribution. Factors likely to be important to dengue and vector distribution in the future include increased dengue activity in Asian and Pacific nations that would raise rates of virus importation by travellers, importation of vectors via international ports to regions without A. aegypti, higher rates of domestic collection and storage of water that would provide habitat in urban areas, and growing human populations in northern Australia. Past and recent successful control initiatives in Australia lend support to the idea that well resourced and functioning surveillance programs, and effective public health intervention capabilities, are essential to counter threats from dengue and other mosquito-borne diseases. Models projecting future activity of dengue (or other vector-borne disease) with climate change should carefully consider the local historical and contemporary data on the ecology and distribution of the vector and local virus transmission.

Richard C Russell MSc, PhD, FACTM · Bart J Currie FRACP · Michael D Lindsay PhD · John S Mackenzie PhD · Scott A Ritchie PhD · Peter I Whelan BSc

Health systems can be improved appreciably by making them more efficient and accountable, and enhancing the quality of care, without necessarily requiring additional resources. Australia, like other nations, cannot escape making difficult health care choices in the context of resource scarcity, and the challenge of delivering quality care, informed by best available evidence, to an ageing population with multiple comorbidities. An opportunity exists for a cost-saving or cost-neutral agenda of reallocation of resources within the existing health budget, through reducing the use of existing health care interventions that offer little or no benefit relative to the cost of their public subsidy. This would allow reallocation of funding towards interventions that are more cost-effective, maximising health gain. Criteria based on those developed for health technology assessment (HTA) might facilitate the systematic and transparent identification of existing, potentially ineffective practices on which to prioritise candidates for assessment as to their cost-effectiveness. The process could be jointly funded by all relevant stakeholders but centrally administered, with HTA groups resourced to undertake identification and assessment and to liaise with clinicians, consumers and funding stakeholders.

Adam G Elshaug BSc(Hons), MPH, PhD · John R Moss MSocSci, FCHSE, FPHAA · Peter Littlejohns MD, FFPH, FRCP · Jonathan Karnon BA(Hons), MSc, PhD · Tracy L Merlin BA(Hons), MPH · Janet E Hiller MPH, PhD, FPHAA

General practitioners are often the first point of contact for patients with oral white lesions, which represent a wide spectrum of diagnoses of varying seriousness. Some clinical features are classical and others overlap between different diagnoses; they should be correlated with patient history, and sometimes other investigations, for diagnosis. Leukoplakia is a clinical term, and is a diagnosis of exclusion with no histopathological connotation. It has been redefined to describe a predominantly white lesion with premalignant potential. Patients with lesions that are potentially malignant should be referred to an oral medicine specialist or oral maxillofacial surgeon for systematic management.

Kai H Lee MB BS, FRACDS, FRACD(OMS) · Ajith D Polonowita BDS, MDSc

Clinical record A: Tattooed area of right arm, showing erythema, papules and nodules. B: Histopathology of skin biopsy from forearm, showing a poorly formed granuloma (arrow) (periodic acid–Schiff stain; original magnification, × 200). A 32-year-old Maori man presented with a 2-week history of worsening erythema, oedema and pain in parts of the recently acquired Maori tribal-style tattoos on his right arm and right lower leg. He developed a skin reaction, predominantly over the right cubital fossa, right thigh and calf. The reaction was unusual for such tattooing. Over a 2-month period he had had serial extensive tattooing to his thigh and arm at a Sydney parlour. The tattoos were all by the same artist, using the same pattern and ink colour. The patient was systemically well and had not experienced any fever. There was no history of immunocompromise and he was not taking any regular medication. When the lesions had first appeared, some 3 weeks after the tattoos had been done, he had presented to his general practitioner, who had treated him empirically with cephalexin, doxycycline and topical hydrocortisone 1%. When there was no improvement, he was referred for a dermatological opinion. On examination, the patient was exquisitely sensitive to light touch in the tattooed areas of the right cubital fossa, right upper thigh and calf. Erythema, oedema and violaceous nodules were present, but there was no ulceration or abscess formation and there were no palpable cords. Pulses were detectable, and there was no associated lymphadenopathy or nodular lymphangitis (Figure A). A skin biopsy from the forearm was sent for histopathology and culture (including deep fungi and mycobacteria). Histopathological examination showed an inflammatory infiltrate, most marked in the upper dermis, and poorly formed granulomas (Figure B). Mycobacterium chelonae was grown from the specimen cultures and was identified by both high-performance liquid chromatography and line probe assay at the reference laboratory at Westmead Hospital. Susceptibility testing by the agar disk diffusion technique (used to test rapidly growing mycobacteria such as M. chelonae and M. fortuitum1) showed susceptibility to clarithromycin; intermediate susceptibility to moxifloxacin, tobramycin and azithromycin; and complete resistance to all other agents, including minocycline, rifampicin, cotrimoxazole, imipenem, ciprofloxacin, cefoxitin and amikacin. Given the clinical context, our patient was assessed for associated comorbidities predisposing to an atypical mycobacterial infection. Serology testing for HIV, hepatitis B and hepatitis C was negative; blood sugar levels were normal; and a chest x-ray proved unremarkable. Because of the extensive skin surface area involved (about 10% of the body surface area), surgical excision was inappropriate and systemic antimicrobial therapy was warranted. As the organism was resistant to most antimicrobials, dual therapy with clarithromycin 500 mg twice daily and moxifloxacin 400 mg daily was commenced. The clarithromycin dose was increased to 1 g twice daily over a 4-week period. Antimicrobial therapy was continued for 4 months, resulting in significant clinical improvement. On clinical review, there was some residual nodularity and scarring but no evidence of recurrence of the infection. A repeat skin biopsy demonstrated no mycobacterial growth. Inspection of the tattoo parlour sourced the M. chelonae to a tattoo ink bottle that had been mixed using an industrial bolt that was left in situ. The same ink bottle had been used on multiple clients over a 2-month period. We are aware of three other clients who had similar reactions, including the index patient’s father. The tattoo parlour was referred on to the public health authorities. Fearing retribution, the patient did not wish to provide sufficient details to the public health unit for further investigation. Mycobacterium chelonae is a rapidly growing, non-tuberculous mycobacterium, classified as one of the Runyon group IV mycobacteria. A ubiquitous saprophyte in the environment, it has been found in soil, water, sewage and dust particles.2,3 In humans, the organism is an uncommon cause of localised cutaneous lesions (eg, associated with surgical wounds or acupuncture) and also disseminated disease.4,5 Often the source is contamination from colonised tap water, although there have been reports of contaminated tissue-marking agents used in surgery.6,7 M. chelonae infections most commonly occur in immunosuppressed patients, such as transplant patients, in whom disease can be progressive and disseminated. In this context, there should be a high index of suspicion for M. chelonae infection.8 Tattooing carries with it several medical risks, including transmission of infectious disease due to organisms such as hepatitis B virus, HIV, Treponema pallidum, papillomavirus, and typical or atypical mycobacteria.9,10 There have been case reports of cutaneous M. tuberculosis infection following inoculation by tattooing,11 but, to our knowledge, M. chelonae infection associated with tattooing has not been previously reported. In purely cutaneous disease, M. chelonae is introduced by trauma to the skin.12 The organism can also cause various clinical syndromes, including isolated lymphadenitis, osteomyelitis, joint infections, ocular disease and pulmonary disease. Lesions characteristically commence as red-to-violaceous subcutaneous nodules that may be painful and sometimes progress to cellulitis, abscesses or ulcers. Regional lymphadenopathy may be present,3 but constitutional symptoms are typically absent.7 Disseminated disease, usually originating from primary skin and soft tissue lesions, occurs almost exclusively in immunocompromised patients, such as those having solid organ transplants.13,14 Interestingly, in the case described here, the infection was only cutaneous and the patient was otherwise well. However, the case highlights the need to consider the possibility of systemic disease. Although there are no set guidelines for M. chelonae work-up, management of our patient warranted investigation for infectious diseases cotransmitted with tattooing as well as a chest x-ray to rule out pulmonary involvement.15 Treatment for M. chelonae infection is challenging, as the organism is resistant or only partially susceptible to many antibiotics. Based on sensitivities, and to avoid the emergence of resistance, dual treatment with clarithromycin and another antibiotic is recommended. Resistance to monotherapy with clarithromycin has been reported.8 Therapy often needs to be continued for several months, which can be difficult in terms of patient compliance.12 Because of the extensive skin surface area involved in this case, surgical excision of the affected skin was not appropriate. However, surgery may be a management option in cases in which there is abscess formation or in which drug therapy is difficult. Removal of any foreign bodies, such as iatrogenically introduced devices (eg, catheters, breast implants) is essential for management.15 Although cutaneous mycobacterial infections are uncommon, a high degree of suspicion is warranted when investigating skin lesions that do not respond to standard antimicrobial therapy. When assessing a patient with a tattoo reaction, M. chelonae infection should be considered in the differential diagnosis. Lessons from practice Mycobacterium chelonae is a ubiquitous microorganism and an uncommon cause of infection in humans. Most infections have been reported in immunocompromised patients. There should be a high index of suspicion for atypical pathogens in patients with skin lesions that do not respond to standard antimicrobial therapy. Investigations should include a diagnostic skin biopsy (in formalin) sent for histopathology and a fresh specimen sent for microscopy, culture and sensitivity testing. Sensitivity testing is essential to determine the most appropriate antimicrobial therapy. Although there is a high standard of public health regulation of tattoo parlours in Australia, cases such as these highlight the need to consider atypical pathogens as well as more common pathogens (eg, hepatitis C virus) in patients with suspected tattoo infections.

Veronica A Preda MB BS, BSc(Hons) · Michael Maley MB BS, FRACP, FRCPA · John R Sullivan MB BS(Hons), FACD

To the Editor: Between 1997 and 2006, suicide rates fell in all mainland Australian states and territories.1 Despite a rise in the small-population jurisdictions of Tasmania (1997–2006)1 and an earlier rise in the Northern Territory (1981–2002),2 the overall unadjusted national suicide rate has fallen steadily, from 14.7 per 100 000 in 1997 to 9.06 per 100 000 in 2006, the year for which the most recent statistics are available. Trends in suicide occurrence are usually examined with reference to suicide rates. However, because there has been population growth in all parts of Australia, examination of the actual number of suicide deaths in each region is also useful to ascertain whether the demographic changes accompanying population growth can alter unadjusted suicide rates. Annual suicide mortality statistics by state and territory from 1975 to 20061,3,4 show that the number of suicides peaked in every mainland state in 1997 or 1998. Since then, the number of suicides has fallen in New South Wales by 46.5%, in Victoria by 33.5% and in Queensland by 36.4% (Box). There has been larger variation in the number of suicides over time in NSW than in other states. Suicides in NSW rose from under 600 per year (approximately 11 per 100 000 population) in the early 1980s to a peak of 935 suicides in 1997 (14.9 per 100 000) and then fell to 504 suicides (7.4 per 100 000) in 2006. Data available to 2002 indicate that the decline in suicides occurred in almost every NSW health service area and was mainly due to a reduction in the number of suicide deaths in males, including young males.5 By 2006, NSW had the lowest suicide rate in Australia of 7.69 per 100 000 compared with 9.73 per 100 000 for other states and territories. The reasons for the steeper rise and subsequent fall in suicide in NSW compared with other states are unclear, but warrant further investigation with a combined clinical and epidemiological approach. The decline in suicide in NSW coincided with a change to the Mental Health Act 1990 in 1997 that broadened criteria for involuntary care and allowed more people to be treated. However, this factor alone would not explain the extent of the decrease nor the continued decline over a decade. It is possible that programs to prevent suicide or measures to improve access to psychiatric care in NSW have been more successful than those in other parts of Australia. Annual number of suicides in Australian states and territories, 1975–2006* * Data are from the Australian Bureau of Statistics.1,3,4

Matthew M Large · Olav B Nielssen · Steven M Lackersteen

To the Editor: We evaluated follow-up by SMS (short message service) text messaging of contacts of a patient with meningococcal disease. An 18-year-old woman from south-western Sydney was diagnosed with invasive meningococcal disease in July 2008 after presenting to hospital with a rash that appeared after a 2-day prodromal illness. The Sydney South West Public Health Unit identified the patient’s household and similar contacts, and arranged for these individuals to be treated with clearance antibiotics. The patient had visited a bar with friends 3 days before symptom onset. The extent of contact with people in this social network did not warrant treating them with clearance antibiotics. However, it was appropriate to warn them about meningococcal disease as recommended by national guidelines.1 A list of mobile phone numbers of 14 people who visited the bar with the patient was compiled by one of her friends. A text message was sent 2 days after the patient’s diagnosis to everyone on the list via a broadcast messaging service: Message from public health. A friend of yours has meningococcal disease. Watch out for symptoms. Please read the fact sheet at http://www.health.nsw.gov.au/factsheets/infectious/meningococcal.html or call 9515 9420. The message sender appeared as “SMS4U”. Two weeks later, one of us (J E C) made up to three attempts to telephone each of the contacts, explaining that this was a follow-up about a text message they may have received from the Public Health Unit. Contacts were asked whether or not they remembered receiving the message, had viewed the website, and found the information helpful. Twelve were contacted (six men, six women; age range, 18–24 years); all remembered receiving the message, nine looked at the website, and 11 found the message helpful. All were happy to receive the information this way. Some knew of their friend’s illness through other social contacts. This is the first time we have used SMS to communicate information to social contacts of a patient with meningococcal disease. To our knowledge, this is the first reported use of SMS for this purpose, although email and the Internet have been used previously.2 SMS communication appeared highly acceptable to these young people and provided useful information, but it may be less useful in other age groups. SMS has been used successfully in other health contexts — appointment and vaccination reminders3,4 and diabetes education.5 It enables delivery of a concise, timely and consistent message that can easily be broadcast to large groups. There are potential pitfalls: limited information can be conveyed; there is uncertainty regarding whether the message is received (the broadcast service we used provided a “successful send” receipt but not a “message opened” receipt); those without mobile phones cannot be contacted; those without Internet access cannot access web-based resources; and some recipients may not understand the message. The authority of a message from SMS4U (the only available option) was also of concern. We did not exploit the capability of forwarding an SMS message and, by doing so, “snowballing” the information. This could be valuable for alerting large contact networks. Our study was small, and we recommend further evaluation of SMS communication in larger groups.

Johanne E Cochrane · Chris Lowbridge · Patrick Maywood · Stephen J Conaty

To the Editor: We concur with Aratchige and colleagues that mumps in young adults is a “forgotten” disease,1 and believe that mumps control in Australia has suffered from both the successes and failures of our measles elimination program. Among residents of Sydney’s eastern and southern suburbs, 100 cases of mumps were notified in the second half of 2007. Sixty-three per cent of those who contracted the disease were aged 20–29 years, and 65% were male. This compares with an average of 13.6 cases (range, 4–32 cases) notified per annum from 1999 to 2006. During the second half of 2007, one institution managed three cases of severe orchitis in men aged 25–29 years whose diagnosis was confirmed by a positive mumps IgM test. In all three, initial fever and transient parotitis were followed after 7–10 days by severe testicular pain and swelling. Fever and testicular pain continued for a further 1–2 weeks, precluding their return to work. None had been vaccinated. Although mumps vaccine was introduced in Australia in 1980, mumps control has not been an explicit priority compared with measles.2 It seems that public health authorities in industrialised countries have assumed that measles control efforts based on two doses of the measles–mumps–rubella (MMR) vaccine would lead to simultaneous mumps control. While doubt has been cast over the effectiveness of this approach and raised the possibility of a three-dose schedule,3 we agree with the view of Schmid and colleagues that public health authorities should focus on adequate vaccination coverage and adherence to the recommended two-dose MMR vaccination scheme.4 The Australian birth cohort reported by Aratchige et al to have a dip in mumps immunity was the cohort born in the years 1978–1982.1 This group may have avoided natural measles (as well as mumps), missed the Measles Control Campaign in 1998 (which targeted primary-school children with MMR vaccine), and was subject to an ineffective national effort in 2001 to target young adults with MMR vaccine.2 At the time of the 2007 mumps outbreak, this cohort was aged 25–29 years and was the hardest hit. Concerted action to raise the level of two-dose coverage among young adults is urgently needed. Novel strategies exist for targeting this highly communication-aware age group through convergent Internet and mobile phone technologies. Social network sites such as MySpace and Facebook are heavily used by young people, and the proportion of mobile phones with Internet access is increasing. Sporting clubs and major entertainment events are another avenue to be considered with respect to both their physical and virtual locations (eg, posters at the clubs or events, advertisements on their websites). A comprehensive guide has recently been produced for Internet-based prevention of sexually transmitted diseases.5 It is well and truly time to adapt such methods to the promotion of MMR vaccination.

Mark J Ferson · Pam Konecny

To the Editor: The University of Sydney recently established a Chair of Radiology and appointed Professor Ming Wang as the first full Professor of Radiology in New South Wales. This long overdue appointment resulted from a bequest of Arthur Parker-Hughes, after whom the Chair is named. Likewise, it was largely through the generosity of Edgar John Rouse that the first university department of radiology in Australia was established at the University of Melbourne in 1965; I was appointed Foundation Professor. Considering the role of radiology in modern medicine, it is remarkable that to date in Australia, establishing Chairs of Radiology depends largely on private sponsorship. Soon after Roentgen’s discovery of x-rays in 1895, Scandinavian countries promoted the triad of medicine, surgery, and roentgenology, as it was then designated, as the basis of clinical management. Radiology departments were nurtured in their universities, and were leaders in research. European medical schools followed suit, and since about 1960, university radiology departments in the United States have been at the forefront of research. In Australia, university clinical departments developed relatively late, and, when they did, the Australian Universities Commission recognised the need to provide space and basic staffing for these new departments to achieve the desired academic standard.1 In recent decades, development of new university radiology departments has languished. Established in 1975, the radiology department at Flinders University closed in 2002. The radiology department at the University of Queensland began in 1977. Currently, medical schools rely on busy radiologists employed by teaching hospitals for academic input, and provide them with various adjunct titles. The range of diagnostic imaging modalities and interventional radiological procedures continues to expand, providing significant research opportunities. Medical science students should understand what is available, the benefits and limitations, inherent risks, and should appreciate the economic burden on the community from inappropriate use. Also, radiology provides an excellent means of teaching basic medical subjects, such as anatomy and pathology. Considering the importance of radiology in the health system, and how its academic status is recognised by leading overseas universities, surely it is reasonable that each medical school in Australia should include a department of radiology, or, at least, a full Professor of Radiology, financed primarily from within the university.

William S C Hare

To the Editor: The author of “High levels of confusion for cholesterol awareness campaigns”1 identifies my comment as the source of her perplexity. My remark, which Hall quotes in relation to the “Test the Nation” campaign, was actually given in response to a question about the Pfizer-sponsored “National Cholesterol Awareness Campaign”, which ran simultaneously. It seemed too inconsequential to request correction of the relevant newspaper article,2 because public health guidelines differ in regard to the target population for lipid testing. My comment reflected conservative Australian guidelines.3 It is well known that other sources recommend more widespread testing of adults.4 Hall’s confusion was a rhetorical device to justify her discussion of “condition branding” and to “explore the motivations” of the campaigns. Hall’s article attacks two programs that promote diet and lifestyle management of cardiovascular risk. It also criticises pharmacological treatment, thus eliminating all available options to address this important problem. The article undermines the tenuous availability in Australia of plant sterol-containing products, such as yoghurt, but provides no alternative strategies. It fails to take responsibility for its potential negative impact on the implementation of nutritional and other life-saving interventions. It is disconcerting that such a negative article has emanated from a so-called Centre for Health Initiatives. The cholesterol awareness campaigns are likened to “an unnecessary focus on an unimportant health problem” and disparagingly compared with a program devoted to public awareness of fungal nail infections. Understandably, the latter led to professional irritation and frustration. By contrast, the formal involvement of the Royal Australian College of General Practitioners in the Test the Nation–National Cholesterol Education Program of Australia (NCEPA) represents an effort to ensure that the initiative was justified, that the content was relevant, and that the logistics were attuned to primary care practice. The participation of professional organisations reinforced the quality, relevance and independence of the information provided. The dietary advice that was distributed by the NCEPA was widely acclaimed. Dyslipidaemia accounts for 49% of the attributable risk of coronary heart disease.4 Full implementation of risk factor guidelines could massively reduce cardiovascular disease,5 but public and professional adherence to guidelines is suboptimal.6 Chen and colleagues report that, in addition to those with diabetes or coronary heart disease, over 700 000 Australians are at high risk,7 but most Australians are unaware of the consequences. It seems extraordinary that anyone with a professed interest in public health could be so opposed to public education about risk factor management. Consequently, Hall’s article itself generates further confusion. The health sector is in the process of responding to calls for greater independence from commercial interests. Both cholesterol programs illustrate the implementation of many of the suggested changes. Unfortunately, Hall’s article suggests an open-ended list of demands that will be impossible to satisfy. Calls for further change need to be more constructive and clearly enunciate realistic proposals, supported by evidence that the net impact on Australian health care has been (or will be) beneficial. The article implies restrictions that would be impractical in other sectors. Standards for the interaction between industry and the health sector should be an example to emulate, rather than a soft target that loses step with normal practice.

David R Sullivan

In reply: My article1 was submitted for debate when two separate, industry-sponsored cholesterol awareness campaigns were simultaneously targeting the Australian public. There is potential for public confusion following exposure to concurrent campaigns with differing sponsors, creative techniques, and messages such as “Test the Nation”. My article did not diminish the importance of cholesterol screening (nor of the prevention of or treatment for hyperlipidaemia), and indeed it reiterated the National Heart Foundation guidelines. Its intent was to raise debate about industry-sponsored disease awareness campaigns, as there is growing concern in Australia about “disease mongering”2 and the evidence that this is occurring in the cholesterol market in the United States.3 I agree with Sullivan that the Australian public needs education about asymptomatic risk factors, including hypertension and hyperlipidaemia. Ideally, this would include clear information and non-emotive marketing techniques to convey who is most at risk, as well as transparent disclosure of sponsor interests.4 Contrary to Sullivan’s charge, I believe there are many opportunities for quality health education and behaviour change programs, several of which the Centre for Health Initiatives is currently undertaking.5 The intent of my article was to generate critical analysis of industry-sponsored campaigns in order to improve their public health benefit.

Danika V Hall

To the Editor: The recent article by Penington, highlighting the apparent neglect by Australian hospitals of actively participating in research over the past two decades,1 is both timely and concerning. During this time, many of our hospitals have seen themselves increasingly as clinical service providers, with teaching and research perceived as additional costs rather than contributions to their status, to the quality of patient care and to clinical and scientific discovery. My point is not simply to add weight to Penington’s eloquent historical, contemporary and strategic analysis of the nexus between hospitals and universities, but to explore areas that he touched on that need more detailed examination. I refer to the potential link between hospitals and community-based primary care. As Penington points out, “health care is increasingly provided outside hospitals”, yet this vital link between hospitals and primary care is often defunct, particularly when it comes to general practice. When Penington refers to hospitals working with “general practice networks” to meet the demands of an ageing population and chronic disease, we need to ask: which hospitals and which networks? In Melbourne, we have health networks that include groups of hospitals with extended primary care and community facilities and responsibilities. Driven by casemix funding, the hospitals or health networks have a vested interest in primary care to ensure short patient stays. However, not all states are the same and not all hospitals have similar links with the community. The other issue of concern is that general practice networks are often politicised and factionalised. Divisions of General Practice do not speak with a single voice, and their state-based organisations and national body do not always represent the views of regional Divisions. Added to the mix of 120 Divisions, we have 22 regional general practice training providers, the colleges (Royal Australian College of General Practitioners, Australian College of Rural and Remote Medicine), the Rural Doctors Association, the Australian Association for Academic General Practice, the Australian Medical Association, etc. Integration of the research, teaching and training activities of general practice or primary health care with hospital networks can only be achieved at a regional level. We need to think globally, but act regionally. This calls for the formation of new regional consortia including universities, health networks (hospitals), Divisions and regional training providers (responsible for general practice registrar training) to work together on national clinical and health service research agendas in large and well defined geographic regions. If the National Health and Hospitals Reform Commission is to take its role seriously, it will need to move beyond the confines of traditional hospital settings and explore opportunities in the community.

Leon Piterman

To the Editor: Penington identifies the appointment of a National Health and Hospitals Reform Commission (NHHRC) and the suspension of 5-year Australian Health Care Agreements as a “once in a generation” opportunity to rediscover university teaching hospitals for Australia.1 He identifies changes to health funding in Australia since 1975, the growth of “cost shifting” between federal and state governments, and reduced funding for university functions in hospitals as important contributors to the decline of university teaching hospitals in Australia.1 We agree with this analysis, but propose that the privatisation of many outpatient clinics as a result of cost shifting has had a disastrous effect on the clinical training of medical students, residents and registrars. Moreover, the reduced funding of university functions in hospitals has been replaced in “teaching” and community hospitals by industry funding, and the perception that industry has “bought” patients for their “research” agenda by providing data management services through per capita payments and gifts or perks for clinicians. The infrastructure sustaining clinical research should not be so reliant on industry. Funding from the federal government (in partnership with state governments) is needed to nurture independent research in university teaching hospitals. Penington highlights the fact that the key element of the university teaching hospital model was leadership of all units by academic clinicians with questioning minds. Since 1975, we believe leadership of units in “teaching” hospitals has changed such that very few are now led by academic clinicians. We recently experienced a lack of interest by medical specialists in supporting clinical research that had been approved and funded by the National Health and Medical Research Council (NHMRC). The project will evaluate doctor–patient communication about treatment options in oncology, including clinical trials. Participating doctors were required to post letters of invitation to patients and audio-record one consultation per patient recruited (20 per doctor). Specialists in all major teaching hospitals in New South Wales and Victoria were contacted; 17 of 41 specialists contacted in NSW (41%) and 15 of 52 contacted in Victoria (29%) have agreed to participate. The most common reasons doctors gave for not participating was that they were too busy or that there was no reward for participation. It is notable that no specialist from two major teaching hospitals — one in Sydney (3 contacted) and one in Melbourne (6 contacted) — agreed to participate. A concerning theme is that the motivation to participate in trials is driven by financial incentives rather than the importance of the question being addressed or interest in supporting novel investigator-initiated clinical research. A starting point for improving the quantum and calibre of “independent” clinical research in university teaching hospitals would be to support clinical research infrastructure by providing per capita payments for recruited patients — a model used by industry. Rebuilding independent research capacity in university hospitals will improve the standard of research in this country, and foster clinical research training. We believe reviving the university teaching hospital model in Australia is an important task for the NHHRC.

Rachel F Dear · Martin H N Tattersall

To the Editor: A causal connection between alcoholic mothers and developmental delays and physical abnormalities in their babies was identified in the 1970s and termed fetal alcohol syndrome (FAS). Other less extreme but still disabling effects fall under the umbrella term of fetal alcohol spectrum disorder (FASD).1 Some studies have found higher prevalences of FAS among indigenous children in several countries, including Australia.2-4 However, none are as high as those cited in a webcast video program produced by the Rural Health Education Foundation and accredited by (and examinable for professional development points awarded by) the Royal Australian College of General Practitioners, Australian College of Rural and Remote Medicine, Pharmaceutical Society of Australia, Royal College of Nursing Australia, and the Australian Physiotherapy Association.5 In this program, an Indigenous Australian health worker states that 540 out of 614 children aged under 12 in an (unnamed) Indigenous community are “already showing signs of primary and secondary disabilities associated with FAS and FASD”.5 These findings are not sourced and therefore not verifiable. We believe that unsubstantiated claims such as this can fuel racism against Indigenous children. Research conducted within a Queensland Aboriginal community school found that teachers were using information such as that provided in the video program to explain students’ poor school performances, when no formal diagnoses of FASD had been made for the children.6 It is racially discriminatory to impute a lifelong and incurable disability to Indigenous children when no teratogenic condition has been diagnosed. The prevalence of FAS and FASD has not been comprehensively established in Indigenous or non-Indigenous communities in Australia. There are other reasons why Indigenous students might not be succeeding in school, such as hearing impairments, being taught in Standard English (which is not their first language), or being assessed with culturally and linguistically biased school and IQ tests.6,7 Stigmatising them as intellectually impaired can lead to low self-esteem, behavioural problems, and absences from school. These outcomes have been noted here and overseas,7 yet some educationalists persist in blaming prenatal factors (including “bad genes”) rather than addressing the more difficult issues of systemic racism in the educational setting. In light of the federal government’s campaign to protect Indigenous children and to encourage their educational potential, as well as its general attack on binge drinking, it is essential to fund programs that address FAS and FASD in both Indigenous and non-Indigenous communities. Further, all governments need to support the dissemination of clear and substantiated information on this preventable cause of intellectual impairment.

Loretta R de Plevitz · Judith S Gould · Terrina M Smith

In reply: The Rural Health Education Foundation is sorry that a statement on its live-to-air, interactive program was interpreted as being racist. We can see how this has occurred and have added an addendum to the program’s website description to avoid any future misinterpretation of what the presenter was intending to communicate.1 The research on fetal alcohol spectrum disorder (FASD) quoted in the Foundation’s program by an Australian Aboriginal health worker is currently unpublished, and was undertaken in 2000 during a fieldwork placement as a requirement for a Master of Applied Epidemiology (Indigenous Health).2 This research identified that 540 out of 614 children aged under 12 in an (unnamed) Indigenous community had prenatal exposure to alcohol that exceeded the National Health and Medical Research Council (NHMRC) recommendations on alcohol consumption during pregnancy,3 and were subsequently at risk of primary and secondary disabilities associated with fetal alcohol syndrome (FAS) and FASD. During the program’s live discussion, the panel member incorrectly stated that the research cohort was already showing signs of primary and secondary disability related to FAS and FASD. Two individual projects within the Masters research contributed to the findings. The first, examining the risks of maternal alcohol use for child physical and psychological development, involved retrospective, longitudinal analysis of a data subset from an existing study over a 5-year period of 8556 women who received antenatal care, with subsequent follow-up of the mothers and their children when the children were 5 years old. The second was a descriptive study involving all women in the (unnamed) Indigenous community who gave birth within a 5-year period immediately before the research. Medical record audit and focus groups (talking circles) were conducted. This research is currently being expanded in the context of PhD studies, and the candidate intends to submit the new findings for publication in the near future. The video program content was developed in consultation with a group of health professionals with expertise in the area of Australian Indigenous health and FASD. At all times, the Rural Health Education Foundation seeks to provide positive examples of “what works” in its location-based filmed case studies. The Foundation and its representatives in no way meant to infer racism or discriminate against this (or any other) group of Indigenous Australians.

Brian D Bowring · Amanda Little

To the Editor: The randomised controlled trial recently reported by Blashki and colleagues does not support their hypothesis.1 The drop-out rates in both arms of the trial were very high — only 62% of general practitioners in the intervention group and 54% in the control group completed the trial. One cannot have any confidence in their conclusion that a short training course can improve GP skills in the provision of cognitive behavioural strategies (CBS). For example, what if the 38% of GPs in the intervention group who dropped out actually deteriorated in their CBS skills and therefore declined to be videotaped? Furthermore, only 56 of 1021 GPs in Victoria were willing to enrol in the trial. The authors concluded that their findings could only be applied to GPs who have a special interest in mental health. Perhaps the low participation rate indicates another more relevant idea — that GPs have had enough of “training models” being imposed on their lives. A recent systematic review has confirmed the low impact that educational training programs have on GPs for the management of mental health problems.2

Marjan Kljakovic

In reply: Our words in conclusion to our article were carefully chosen as: “Competency in CBS [cognitive behavioural strategies] in highly motivated GPs [general practitioners] can be improved by a brief training intervention”1 (italics added) — not that all such interventions will lead to improvements for all GPs, but that well designed and conducted training for selected GPs can do so. Research so far leaves open the possibility of large enough effect sizes for GP mental health training to be relevant to policy.2 The review cited by Kljakovic was limited in scope and noted the poor quality of studies included.3 A drop-out bias in our study, as proposed, seems most unlikely to us. Rather than being imposed, this training model was developed with GPs, by GPs and for GPs, and so might achieve better results than previous interventions studied. Funding for GP participation such as that more commonly available in drug studies might have increased participation. It is true that a great deal of training has been offered to GPs, and we hold that our study shows that such training can lead to GPs significantly improving their skills in this area. GP training should be considered within multifaceted interventions to improve primary mental health care.4

Grant A Blashki · Leon Piterman · Graham N Meadows · David M Clarke · Vasuki Prabaharan · Jane M Gunn · Fiona K Judd

To the Editor: Sondergaard is essentially correct in his criticism of the Australian and New Zealand College of Anaesthetists (ANZCA).1 And ANZCA president Leona Wilson’s obfuscatory response to the criticism provided me with little reassurance.2 We all know that our health care system is “highly complex” and involves multiple jurisdictions, but these points have no relevance in determining whether Sondergaard is adequately trained and competent to work in Australia as a specialist. To decide that someone with his history and qualifications cannot give anaesthesia unsupervised is patently nonsensical, as is the insistence that experienced overseas specialists must take the College’s final exams. All of us who were Fellows of the ANZCA precursor, the Faculty of Anaesthetists of the Royal Australasian College of Surgeons, were granted automatic Fellowship of the ANZCA on its formation in 1992, as were some senior practitioners who had never sat the Faculty exams. The College can, it seems, arbitrarily waive the exam requirement for some, and it regularly awards Honorary Fellowships to distinguished overseas visitors. However, these doctors are not the competent working clinicians with overseas qualifications who would, if they could, take up vacant positions in rural areas, such as Katoomba just outside Sydney. Here, in October last year, a woman in labour was turned away from a hospital for want of an anaesthetist and gave birth in an ambulance by the roadside. I worked as a specialist anaesthetist in Sweden for nearly 2 years and can verify that Scandinavia produces competent anaesthetists. The attitude of the ANZCA to overseas-trained specialists seems elitist and denies the Australian people access to the services of competent people who happen to have learned this essential specialty elsewhere.

James F Wilkinson

Pediatric respiratory medicine. 2nd ed. Lynn M Taussig, Louis I Landau, editors. Philadelphia: Mosby, 2008 (xxiii + 1118 pp). ISBN 978 0323 04048 8. If you are looking for an up-to-date encyclopaedia of paediatric chest disease, then this is it. As expected, this second edition is a substantial improvement over the first. Most of the 75 chapters are short and user friendly. The text is broken up with numerous coloured diagrams, figures, tables, x-ray images and boxed sections highlighting key points, teaching points, pitfalls and controversies. For those who want teaching resources, all images can be captured with ease directly into Powerpoint presentations via electronic access. This edition is slightly less hefty than the previous edition, largely because the references are not included in the book — however, they are accessible electronically, with direct links to MEDLINE abstracts. Most chapters are very heavily referenced (eg, Chapter 3 has over 300 references) and remarkably up to date for a multi-author textbook, including a few references from as late as 2007. Since the editors are from Western Australia and the United States, it is understandable that the majority of the expert authors are also from WA and the US. Nevertheless, all are clearly national and international authorities on their specific topics. Because there are over 130 separate authors, the style and format vary considerably. It is disappointing to see some very user “unfriendly” chapters. For example, in Chapter 35 (bacterial pneumonia) there are over 30 pages of continuous, dense text with only occasional subheadings, and illustrated with a total of only four small x-ray images. To check both content and ease of access, I tested for several of my pet topics — including “plastic bronchitis” and “genetic surfactant deficiency mimicking interstitial lung disease”. Both were readily found, comprehensively covered, and with key references included. At $190.00, the book represents outstanding value for money, given the quality of the content, the outstanding diagrams and figures, and the huge number of electronic references.

Craig M Mellis

Fight your dark shadow: managing depression with cognitive behaviour therapy. Therrie Rosenvald, Tian P S Oei. Brisbane: Depressionmanaged.com, 2007 (136 pp). ISBN 978 0 646 47032 0. Cognitive behaviour therapy (CBT) has been demonstrated to be a highly effective treatment for depression, both as a stand-alone treatment for mild cases, and in combination with medication for moderate and severe cases. Fight your dark shadow provides a basic introduction to the fundamental components of CBT, using clear, simple language and brightly coloured illustrations to convey its message. There are several CBT-based self-help books currently on the market, but Fight your dark shadow is unique. Firstly, it was co-written by professional and patient, resulting in accurate and relevant information presented in a very colloquial style. Secondly, it is brief, with introductory information only. Many self-help books contain case studies, questionnaires and worksheets that, while undoubtedly adding value for those who use them, may overwhelm and deter those looking for a very simple introduction. Fight your dark shadow would be useful for friends and family of sufferers as well as those experiencing depression directly. Co-author Tian Oei is a professor of clinical psychology at the University of Queensland, and the director of the CBT unit of Toowong Private Hospital. Professor Oei has published widely in the area of CBT, and this text reflects his expertise. As well as an introduction to CBT, the book provides information about diagnosis, depressive symptoms and medication. While there is emphasis on the cognitive component of CBT (identifying and challenging unhelpful beliefs), and some mention of behavioural strategies towards the end of the book, it would be enhanced by an earlier chapter addressing the importance of behavioural activation. Overall, this is a good resource, particularly for patients who are considering engaging in CBT for the first time.

Sarah Perini

Alan Ferrier was born in Lismore, New South Wales, on 23 July 1954. As a child he suffered from severe asthma, and on medical advice his family moved to Sydney for a better climate. He attended Knox Grammar School, where he achieved distinction academically and at cricket. After graduating from the University of Sydney in 1978, Alan undertook specialist training in obstetrics and gynaecology at the Royal North Shore Hospital in Sydney. From 1986, he spent several years in North America training in gynaecological oncology at institutions such as the Memorial Sloan–Kettering Cancer Center in New York and the University of Toronto in Canada. Returning to Sydney in 1991, Alan was appointed Senior Lecturer in Obstetrics and Gynaecology at the University of Sydney. He was largely responsible for establishing the gynaecological oncology service for the Northern Metropolitan Region of Sydney. Alan soon earned a reputation as a cancer surgeon of exceptional ability. Despite an extraordinarily heavy surgical workload, he continued to enjoy practising obstetrics, which he felt brought a happy balance to his professional life. He mastered new laparoscopic techniques and was one of the first surgeons in Australia to apply them in oncology. He became an expert at radical trachelectomy with laparoscopic lymphadenectomy. Many of his specialist colleagues benefited from his advice and help with difficult cases. This assistance was given without hesitation and was often life-saving. Alan loved to teach and shared his knowledge and techniques generously. He had numerous research articles, book chapters and other publications to his credit and was involved in a broad range of research projects at the time of his death. He was an examiner for many years, a convenor of several postgraduate courses, and a member of various committees, including Chairman of the NSW Committee of the Royal Australian College of Obstetricians and Gynaecologists. Alan was absolutely devoted to his family. He strove to achieve excellence in all that he did personally and professionally. He was renowned for his urbane demeanour and sartorial elegance. Because of his asthma, he was also committed to keeping fit. Despite this, he died in his sleep of a cardiac arrhythmia on 23 December 2007, aged 53 years. Alan is farewelled as one who honoured his family and practised medicine with enormous skill and compassion. He is survived by his wife Sarah and daughters Katherine and Charlotte.

Robert M Ford · Keith G Hartman · Jonathan R Stretch

Joyless on the job Interpersonal conflict at work can be bad for your health, according to researchers in the Netherlands. In a study of over 10 000 men, researchers analysed the effects of conflict with either co-workers or supervisors over a 2-year period. The results showed that conflict with co-workers was a significant risk factor for prolonged fatigue, poor general health, external occupational mobility (ie, changing employers), and an elevated need for recovery from work. Supervisor conflict appeared to be a risk factor for similar problems, with the addition of internal occupational mobility — a job change within the company. The researchers controlled for demographic factors, long-term illness, and other workplace stressors. They comment that one limitation of the study is that it included only men, and suggest that the effect on women, who are more emotionally responsive, may be even more serious. Occup Environ Med 2009; 66: 16-22 Genes and heart disease A gene linked to the development of cardiomyopathy and subsequent heart failure is carried by millions worldwide, particularly in the Indian subcontinent. A group of Indian and international researchers have focused on cMyBP-C (cardiac myosin binding protein C), a constituent of the thick filaments of the cardiac sarcomere. Through the development of abnormal cardiac muscle fibres, individuals with the genetic defect suffer from late-onset symptoms of dilated or hypertrophic cardiomyopathies, and eventually cardiac failure. In a case-control study of 800 people with the genetic defect and 699 controls, researchers were able to pinpoint the 25-base-pair deletion in MYBPC3, a common variant of the genetic defect in South Asians, as significantly associated with the risk of heart failure. They comment that genotyping may be used for the identification of people at risk of the disease. Nat Genet 2009; 41: 187-191 Metastases linked to inflammation The defining ability of malignant tumours to metastasise appears to be related to their surrounding inflammatory environment, say international cancer researchers studying features of metastatic carcinomas. The process of metastasis depends upon both the properties of cancer cells and their environment. According to researchers, the inflammatory microenvironment of malignant tumour cells is partially in response to molecular pathways involving macrophage-activating factors secreted by metastatic carcinomas. Macrophages produce cytokines, growth factors, and matrix-degrading enzymes, which assist metastasis. The authors, who studied a human lung cancer cell line, identified a factor, versican, which appeared to induce macrophage cytokine production. Versican is a protein of the extra-cellular matrix, which the researchers comment is often upregulated in many human lung cancers. Nature 2009; 457: 102-106 CT angiography — a viable alternative? Computed tomography angiography (CTA) is becoming increasingly attractive as an alternative imaging modality for patients with lower extremity peripheral arterial disease. The accuracy of this method compared with digital subtraction angiography (DSA) was the subject of a recent systematic review and meta-analysis of 20 studies including over 900 participants. Most patients included in the studies suffered from intermittent claudication. The overall sensitivity of CTA for detection of greater than 50% stenosis or occlusion was 95%, and specificity was 96%. The authors discuss the limitations of the analysis in detail, listing problems with the quality of the available studies, the small sample sizes, possible overestimation of sensitivity due to how stenosis was measured, and potential publication bias as possible confounders. Nonetheless, they conclude that, compared with intra-arterial DSA, computed tomography angiography is a reliable modality in patients with predominantly intermittent claudication. JAMA 2009; 301: 415-424 Dying for a tan New, self-administered “tanning drugs” are now available without regulation over the Internet. Melanotan I and II are analogues of α-melanocyte stimulating hormone. Dermatologists and a pathologist in the United Kingdom have noted rapidly changing moles in patients using the drugs, raising further concerns about the safety of these compounds. In a letter to the Editor, the doctors describe rapid hyperpigmentation and growth of moles in two women self-administering the drugs. Despite concurrent use of sunbeds by both patients, the authors comment that the clinical picture may be confused by rapid changes in pigmented lesions in people using these unregulated drugs. BMJ 2009; 338: b277

Tanya Grassi