Volume 190 Issue 7

Cycling is an affordable, convenient and achievable form of physical activity for all Australians Cycling, the fourth most popular physical recreation in Australia, is increasingly being used as a means of transport. As a form of regular physical activity, it confers substantial health benefits that are accessible to people of all ages.1 The epidemiological evidence is growing that cycling has health-enhancing effects, independent of other leisure-time physical activity. In a large Danish cohort followed up for 15 years, a 39% reduction in all-cause mortality was observed in those who cycled to work, and this was independent of participation in sport and other physical activity.2 Other large population studies have shown the effects of commuting by bicycle on reducing mortality and cardiovascular risk among Finnish women,3 and similar risk reductions for Chinese adults in Shanghai.4 Ecological observations have noted lower rates of obesity in regions with high rates of cycling.5 The article by Sikic and colleagues in this issue of the Journal describes cycling-related injuries in Victoria, and shows a 5-year increase in emergency department presentations, hospital admissions and major trauma among cyclists.6 This increase is of concern, and the authors reasonably call for preventive approaches. For many years, cycling advocates have called for a greater investment in cycling infrastructure, and studies overseas have demonstrated the potential for this investment to reduce injury outcomes. For example, cycling injuries are between eight and 30 times more common in the United States compared with the Netherlands or Germany.7 Similarly, rates of cycling-related deaths are much lower in Western Europe and declined by 60% between 1975 and 2000, compared with a much smaller decline in the US.5,8 Importantly, as Sikic et al acknowledge, their analyses do not adjust for the population denominator.6 More people are cycling now than 5 years ago — there are about a million new bicycles sold in Australia each year, and more people are cycling to work, with the greatest increases occurring in Victoria where the study by Sikic et al was conducted.1 Although there is a positive correlation between numbers of cyclists and injuries, the association is not simply linear. Known as the “safety in numbers” phenomenon, when more people cycle, collectively it becomes safer, and the injury rate per kilometre cycled decreases.9 Sikic et al suggest that people who ride bicycles should be registered,6 but requiring registration for all cyclists would not provide an accurate measure of cycling “exposure”, such as time spent cycling and distance travelled. It would cost more to administer than it would recoup, and it would likely act as a significant deterrent to casual or occasional cycling. In particular, cyclist registration would make it more difficult to encourage populations to shift to trial spontaneous recreational cycling. Research to calculate cycling times and distances as a population denominator for risk assessment should be a priority. In the Victorian data reported,6 most cycling injuries occurred on streets or highways where bicycles share the road with cars. Even though the absolute risk is still low, these injuries are mostly preventable. Making cycling safer requires better infrastructure and facilities for cycling, especially the provision of separated bicycle paths and cycle lanes.1,7 At the same time, driver attitudes and behaviour must be addressed. Strategies include enforcing lower driving speeds, traffic calming, parking restrictions, and community support for a safer road environment. Further, integrating cycling into public transport schedules and systems, including simple measures such as bicycle parking at train stations, would make cycling easier and give cyclists more options for safe commuting. In London, after the introduction of a “congestion tax” restricting car use into the city centre, combined with new bicycle lanes, cycling education and better public transport, many more cycling trips were made, and yet the overall number of cyclists injured actually declined between 2001 and 2004.10 It is generally understood what needs to be done to increase cycling participation levels. Better urban design, such as higher density development, mixing residential and commercial land use, and shorter trip distances, will facilitate more cycling.1 Other strategies to encourage cycling include behaviour change programs such as TravelSmart, Ride to Work, and Ride to School initiatives, public bicycle events to encourage infrequent and novice riders to cycle in a supportive social environment, and bicycle education programs for both children and adults.1 A dominant car culture and concerns about safety are the main reasons people give for not cycling in Australia.11 Mass media marketing campaigns are needed to help legitimise the value of cycling as transport, and advise drivers about relevant cycling road rules. Despite the perceived risks of cycling, the absolute magnitude of the risk is low, and the benefit-to-risk ratio is overwhelmingly positive; for chronic disease prevention, obesity reduction and mental health, the benefits are substantial.12 Cycling provides an affordable, convenient and achievable form of physical activity for all Australians, including children and youth, through to older adults with chronic conditions. As a physical activity, it also meets transport and traffic management needs, and is eco-friendly. Much more needs to be done in Australia to provide an environment that encourages people to cycle safely. This means giving greater funding and community priority to allocating road space for cycling. It also means physicians recommending that suitable patients consider cycling, and supporting efforts to improve the urban environment for cycling.12

Adrian E Bauman PhD, FAFPHM · Chris Rissel PhD

How can we ensure colonoscopy services are available to those who need them most? Bowel (colorectal) cancer is the most common cancer affecting both men and women in Australia, with 13 076 cases diagnosed and 4164 deaths reported in 2005.1 It is the second commonest cause of cancer-related death, behind lung cancer. The incidence of bowel cancer increases exponentially after 50 years of age, with a lifetime risk of about one in 17 among men and one in 26 among women.1 Bowel cancer satisfies most of the World Health Organization criteria for population cancer screening.2 Specifically, it is a common, serious cancer, and its natural history is reasonably well understood. It arises from precursor adenomas, and removal of these prevents cancer development. Importantly, most adenomas and early cancers are asymptomatic. Detection at early stages confers an excellent prognosis, and there are numerous tests for early detection and intervention, with the potential to reduce the incidence, morbidity and mortality of the disease. Cancer screening aims to identify affected individuals who do not suspect they have the disease. This is in contrast to performing diagnostic investigations for symptomatic patients, or targeting individuals with a significant family history of bowel cancer, a history of inflammatory bowel disease, previous adenomatous polyps or previous bowel cancer. However, bowel cancer screening recommendations can be confusing for medical practitioners. Numerous tests of varying performance levels are available, and it is difficult to separate recommendations for the population from those targeted towards individuals. There are also significant differences between the Australian recommendations endorsed by the National Health and Medical Research Council (NHMRC)3 and two recently published American guidelines, from the United States Preventive Services Task Force (USPSTF)4 and from a collaboration of the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer (representing the American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, American College of Gastroenterology and American College of Physicians) and the American College of Radiology.5 Interestingly, these guidelines differ due to differing interpretations of essentially the same evidence. It is important to note that the newer American guidelines are less relevant to the Australian health care environment, and should not usurp the existing NHMRC recommendations in Australia. The NHMRC guidelines strongly recommend screening from the age of 50 years, by performing a faecal occult blood test (FOBT) at least every second year. The strength of this recommendation arises from three large, population-based, prospective randomised controlled trials demonstrating a mortality reduction of 15%–33%.3-5 No other cancer screening strategy is based on such strong evidence. Flexible sigmoidoscopy performed 5-yearly receives an equivocal recommendation, whereas colonoscopy and computed tomographic (CT) colonography are not recommended because of insufficient evidence. In contrast, the American guidelines recommend presenting information to patients, who then choose from the options, including high-sensitivity FOBT, flexible sigmoidoscopy or colonoscopy.4,5 The American recommendations diverge on CT colonography: the USPSTF does not recommend it on the basis of unknown long-term harm,4 while the collaborative joint guidelines endorse 5-yearly examinations.5 Unlike the US, Australia has moved beyond making passive recommendations to become one of a few countries actively implementing a nationwide population-based bowel cancer screening program — the National Bowel Cancer Screening Program (NBCSP) — although, currently, only individuals aged 50, 55 or 65 years are invited to participate (http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/bowel-about). The NBCSP, which uses a high-sensitivity immunochemical FOBT, began in 2006 after a pilot program (2002–2004) found that bowel cancer screening would be acceptable, feasible and cost-effective.6 The age restriction for invitees is part of a phasing-in process designed to enable resources to cope with increased downstream demand, especially for colonoscopy, which is the recommended investigation for participants with a positive FOBT result. About 7.5% of NBCSP participants have a positive FOBT result, and 5% of these are found to have cancer.7 Although the federal government has made no commitment to the NBCSP beyond June 2011, it is inconceivable that the program will simply be terminated, given the strong evidence basis for its function. The problem facing Australian medical practitioners is what to do in the face of the various disparate guidelines. A simple approach is to recommend participation in the NBCSP for all invitees. Increased awareness of bowel cancer will also cause some individuals outside the eligible ages to enquire about screening. In these cases, the NHMRC recommendations are most appropriate: for medical practitioners wishing to encourage opportunistic screening, an immunochemical FOBT can be recommended for patients aged between 50 and 75 years. Patients with positive FOBT results will then require follow-up colonoscopy. However, these recommendations ignore the growing tendency, often driven by patients, for screening with colonoscopy. In the absence of symptoms, about 500 colonoscopies need to be performed on 50–75-year-olds to identify one cancer,7 with an associated one in 1000 risk of serious complications.8 This contrasts with one cancer found for every 20 colonoscopies in the NBCSP.7 Of course, many patients will have premalignant adenomas that would be found with colonoscopy screening, which in turn creates a substantial requirement for long-term surveillance colonoscopies. Yet the vast majority of patients with adenomas will never develop bowel cancer, even without future intervention.9 Finally, the imperfections of colonoscopy are becoming increasingly recognised, reducing the ratio of its potential benefits to high cost.10,11 Thus, “indiscriminate” use of colonoscopy diverts availability of this expensive resource away from those most in need of it, especially in the public health system. As a step towards improving colonoscopy access, the Western Australian Department of Health will introduce a Colonoscopy Services Model of Care, scheduled for implementation over the next 2 years in the public hospital system, that prescribes appropriate use and referral processes. This will be supported by trained clinical staff and computerised referral systems to improve the quality and triaging of referrals in the public sector. Patients will also be informed of the priority level of their case, and the appropriate waiting time. Other states in Australia should strongly consider implementing similar strategies. Bowel cancer is common, serious and largely preventable. Medical practitioners should be encouraged to refer individuals for bowel cancer screening in compliance with the current Australian NHMRC recommendations and the NBCSP. Such practice will ensure that colonoscopy resources are available to those most in need in our community.

Hooi C Ee MB BS, FRACP, PhD · John K Olynyk MB BS, FRACP, MD

Drugs are expensive in the United States. I am writing, of course, about pharmaceutical agents. In 2006, the US spent $900 per capita on pharmaceuticals — a higher per capita amount than anywhere else in the world, and almost double what Australia spends. Individuals and even state funding bodies often buy their drugs in Canada or Mexico. Apparently, good-quality drugs are available in these countries at a fraction of the cost of the same drugs in the US. Nonetheless, US authors continue to boast about the ready availability of pharmaceutical agents in the US compared with the rest of the world. In December 2008, the New York Times ran an article about a British cancer patient denied access to an expensive new medication1 — the story being that, although there were data to show that the drug worked, the cost–benefit analysis did not favour using it. This is similar to the situation in Australia. The Times crowed with typical US hype: “If the Hardys lived in the United States or just about any European country other than Britain, Mr Hardy would most likely get the drug, although he might have to pay part of the cost”. “Absolute nonsense” is not too strong a description for this statement. Firstly, drugs are expensive in the United States (much more expensive than in Australia), and secondly, the patient would have got the drug only if he could pay for it himself, if his insurance authorised it (assuming he had insurance), or if Medicare or Medicaid accepted it. Thus, if he had been living in the US, he may have had to pay a major part of the cost, and indeed, many patients in a similar position would not have had access to the drug in the US. Most New Yorkers are very well educated about pharmaceuticals, much more so than the average educated Australian. Drugs are advertised on television and in other media. Coupons for free drugs are available in magazines. The patient takes the coupon to the doctor, gets a prescription and then mails in the coupon and script. Free drugs then appear. New Yorkers consider themselves to be discriminating, but they often end up with the latest and most expensive drug rather than the best. Australia’s Pharmaceutical Benefits Scheme (PBS) may not be perfect, but many people think it is the best thing about Australian health care. It ensures that essential drugs are available at a reasonable price for all. The US Medicare system supplies drugs for special categories of people (mostly the elderly), but doesn’t work in the same way as the PBS. US Medicare Part D, which pays for drugs, has the notorious “donut hole” — a gap between the initial coverage limit and the “catastrophic coverage” threshold. This is designed so the government can pretend that it provides pharmaceuticals to needy patients. The patient pays the first $290 of his or her drug costs, after which the plan starts to pay its share. This varies from plan to plan, but the insurance often pays 75% of the cost up to $2700. Once the patient and the plan have spent $2700, the patient has to pay all costs up to $4350. After that, the patient pays only a small proportion of the cost of drugs until the end of the year. Thus, between $2700 and $4350, the patient has to pay 100% of the costs out-of-pocket. I took this example from the official “Medicare and You 2009” booklet put out by the centres for Medicare and Medicaid services. Not only is there a significant gap in coverage above $2700, but the patient also pays a premium to be part of the process. So, in spite of the media hype, drugs are certainly not readily available for the average older person with limited means. On top of this, drugs are restricted, as happens in Australia under the PBS. In fact, Australian doctors may be surprised to know that limits to prescribing in the US may be quite egregious. Thus, a physician may be able to prescribe one statin for one insurance company, but may need to prescribe a different statin for another insurance company. This often involves a phone call from the physician to a non-medical bureaucrat working for the insurance company. Authorisation is required for the drug cost to be reimbursed from insurance. The US drug system is an example of the free market in action. Let us hope this type of free market drug system never arrives in Australia. Speaking of arriving in Australia, this postcard was written shortly after my return to these shores. For those who are interested, working in health care in the United States is a very positive, stimulating, fulfilling experience. But in my opinion, the Australian health care system, for all its faults, is much, much better for doctors and patients.

Jeffrey D Zajac MB BS, FRACP, PhD

Objective: To investigate the incidence of bicycling injuries and bicycle injury characteristics in the Victorian population.Design: Review of prospectively collected data.Setting: Bicycling injury data were extracted from four datasets for the period July 2001 to June 2006: (i) emergency department (ED) presentations from the Victorian Emergency Minimum Dataset; (ii) hospital admissions from the Victorian Admitted Episodes Data Set; (iii) major trauma cases from the Victorian State Trauma Registry (VSTR); and (iv) deaths from the National Coroners Information System.Main outcome measures: The profile and incidence of bicycling injuries across the datasets and years.Results: In the 5 years, 25 920 bicycle-related ED presentations were recorded, 10 552 bicyclists were admitted to hospital, 298 bicycling injuries were classified as major trauma (VSTR), and there were 47 bicycling fatalities. From 2001 to 2006, the incidence of bicycle-related ED presentations (incidence rate ratio [IRR] = 1.42; 95% CI, 1.37–1.48), hospital admissions (IRR = 1.16; 95% CI, 1.09–1.23) and major trauma (IRR = 1.76; 95% CI, 1.22–2.55) increased significantly. Most of those injured were males, aged < 35 years, with road-related injuries. Patients classified as having major trauma had a significantly higher incidence of trunk and head/face/neck injuries compared with those presenting to an ED or admitted to hospital.Conclusion: The incidence of serious bicycling injury has risen over recent years, highlighting the need for targeted prevention programs. Accurate data on cycling participation, use of injury prevention strategies, and injury profiles would assist in reducing bicycle-related injury.

Mirjana Sikic MB BS · Antonina A Mikocka-Walus MA(Psych), MA(Int Relations), PhD · Belinda J Gabbe BPhysio(Hons), MAppSc, PhD · Francis T McDermott MD(Monash), FRACS, FACS · Peter A Cameron MB BS, MD, FACEM

Objective: To determine the number of older Western Australians who had a gastrostomy tube (GT) placement from 1994 to 2004, to describe their characteristics, and to examine outcomes after GT placement, including rehospitalisation for complications and survival.Design and data sources: Secondary analysis of hospital (inpatient) data and linked mortality data from the WA Data Linkage System.Main outcome measures: Patient characteristics (age, sex and morbidity profile); numbers of GT closures, replacements and complications within 1 year of GT placement; age- and sex-specific survival outcomes calculated at 7, 30, 60 and 180 days, and 1 and 3 years; and mortality hazard ratios calculated for six conditions of interest, identified using all available diagnosis information on the inpatient record.Results: In Western Australia, 2023 people aged 65 years or older underwent a GT placement for the first time during the period 1994–2004, half of whom had a known history of cerebrovascular disease (50.3%). Rehospitalisation within 1 year for a GT replacement procedure, mechanical complications and incident pneumonitis occurred in 13%, 4% and 9% of patients, respectively. More than half of the patients who underwent a GT placement died within 1 year. Survival outcomes were poorest for patients with motor neurone disease and metastatic cancer.Conclusion: To better understand this complex area of health care, questions regarding decision making — by patients, families, physicians, hospitals and other caring organisations — about GT placement and maintenance need to be addressed.

Janine Calver PhD · Kieran A McCaul PhD · Melinda Burmas BCM · Barbara J Horner PhD · Leon Flicker MB BS, PhD, FRACP

We need more inpatient beds and better management of existing beds The inability to admit emergency patients to a ward bed in a timely fashion (access block) is a blight on our hospitals and our community. Access block is the most serious issue confronting emergency departments (EDs), as the safety and quality of emergency care are compromised, as is access to emergency care.1 There is a 20%–30% excess mortality rate every year attributable to access block and ED overcrowding.2 This equates to at least 80 deaths per million population, a figure that is similar to the road toll.2 Australia has been at the forefront of research into this problem, and there is clear evidence that the main cause of access block and ED overcrowding is that there have been major increases in emergency admissions, but almost no increase in the capacity of the system to meet this demand.2-4 The number of available public hospital beds in Australia was reduced from 2.65 beds per 1000 population in the 1998–99 financial year to 2.4 in the 2001–02 financial year; since 2005 it has remained steady at 2.6 beds per 1000 population.2 These bed numbers are below the average for Organisation for Economic Co-operation and Development (OECD) countries of 3.9 acute-care beds per 1000 population.5 In the same period, the number of ED attendances annually has increased from 4.1 million to 6.7 million,6 and case complexity has also increased.2,3 Furthermore, annual increases in demand for emergency care are expected as a result of population growth and an increase in the burden of disease. This increased demand must be planned for to avoid further unnecessary deaths and suffering. To tackle this issue, the Australasian College for Emergency Medicine (ACEM) hosted the Access Block Solutions Summit in September 2008. The summit was opened by Nicola Roxon, the federal Minister for Health and Ageing, who, acknowledging the problem of access block, noted: “ . . . the capacity of our hospitals has not kept up with this demand. This is reflected in overflowing emergency departments . . .”.7 As a result of the summit, two articles highlighting both the problem of access block and potential solutions appear in this issue of the Journal. Richardson and Mountain provide a robust outline of the problem.8 It is worth highlighting that it has been repeatedly proven that general practice patients do not cause access block, ED overcrowding or delays in unloading ambulance patients8 (ambulance ramping; resulting in delayed ambulance response times). The persistence of this myth is detrimental to finding real solutions. More sobering are the results of the September 2008 point prevalence survey of national access block, conducted for the ACEM by the Road Trauma and Emergency Medicine Unit of the Australian National University.9 Caring for patients who are waiting for inpatient beds now represents around 40% of the workload in major hospital EDs, and up to 70% in some.9 Some patients spend days in EDs waiting for an inpatient bed, in particular, those with mental illnesses who are being admitted involuntarily. The survey confirmed that access block is getting worse, and this development is an indictment of our health system. The problem is nationwide, and no government has been effective in providing sustainable solutions. Cameron and colleagues provide a detailed overview of potential solutions.10 Although these are a pragmatic guide to fixing the problem, it will only be when all stakeholders agree that the problem is systemic and hospital-wide that solutions will be able to be implemented. This requires political will from the Australian Government. It was this political will that achieved significant changes to EDs in the United Kingdom. The health system as a whole must own and address this problem, by implementing improvements ranging from effective chronic disease management within the community, to basic inhospital processes such as efficient bed turnaround time. Patient flow must be maintained 24 hours a day, 7 days a week to achieve a hospital bed occupancy of 85% — a level that should be viewed as the most effective way to manage patient flow.11 This nominated spare bed capacity is essential for the effective management of emergency admissions, and to have surge capacity. This approach will enhance patient safety in the ED and throughout the hospital stay. It is essential that the nation’s performance on access block is included in the Council of Australian Governments’ ambitious health reform agenda for implementation from 2009, and is part of the agenda of the National Health and Hospitals Reform Commission. Key performance indicators with agreed nationwide criteria must be developed, implemented and collected at all levels to monitor this problem. At the same time, more research is needed to inform changes to improve the health system. The bottom line is that it’s all about available beds. Access block is best addressed by increasing the capacity of the system, most directly by increasing the number of beds available at all levels of care within hospitals. This means having more inpatient beds and optimising patient flow processes to increase bed availability. Only a small part of the solution to access block resides within EDs.8 While the science of access block is compelling, it is important to remember always that it is associated with a large amount of preventable human suffering. A fundamental precept of Hippocrates is primum non nocere. Access block is harming our patients and harming our health system. It is time to fix the problem. Australians expect and deserve better.

Daniel M Fatovich MB BS, FACEM · Geoff Hughes FRCP, FCEM, FACEM · Sally M McCarthy MB BS, FACEM, MBA

Hospitals cannot manage their emergency patients when there is significant access block. There are solutions that should be implemented but require national leadership to be effective. These solutions include an immediate increase in the number of acute hospital beds, improved coordination and increased community capacity to manage medical patients with complex conditions outside acute public hospitals, improved hospital processes, and better standardisation of treatment within emergency departments. There is little evidence that telephone triage, ambulatory care clinics or disaster management techniques, including ambulance diversion, reduce access block.

Peter A Cameron MB BS, MD, FACEM · Anthony P Joseph MB BS, FACEM · Sally M McCarthy MB BS, MBA, FACEM

Overcrowding occurs when emergency department (ED) function is impeded, primarily by overwhelming of ED staff resources and physical capacity by excessive numbers of patients needing or receiving care. Access block occurs when there is excessive delay in access to appropriate inpatient beds (> 8 hours total time in the ED). Access block for admitted patients is the principal cause of overcrowding, and is mainly the result of a systemic lack of capacity throughout health systems, and not of inappropriate presentations by patients who should have attended a general practitioner. Overcrowding is most strongly associated with excessive numbers of admitted patients being kept in the ED. Excessive numbers of admitted patients in the ED are associated with diminished quality of care and poor patient outcomes. These include (but are not limited to) adverse events, errors, delayed time-critical care, increased morbidity and excess deaths (estimated as at least 1500 per annum in Australia). There is no evidence that telephone advice lines or collocated after-hours GP services assist in reducing ED workloads. Changes to ED structure and function do not address the underlying causes or major adverse effects of overcrowding. They are also rapidly overwhelmed by increasing access block. The causes of overcrowding, and hence the solutions, lie outside the ED. Solutions will mainly be found in managing hospital bedstock and systemic capacity (including the use of step-down and community resources) so that appropriate inpatient beds remain available for acutely sick patients.

Drew B Richardson MB BS(Hons), FACEM, GradCertHE · David Mountain FACEM

Objectives: To measure the prevalence of interventions used to circumvent intensive care access block and to estimate the attributable mortality and additional hospital bed-days associated with them.Design and setting: Retrospective observational study of 11 adult public hospital intensive care units (ICUs) in Melbourne, Victoria, July 2004 – June 2006.Main outcome measures: Prevalence of five interventions in response to access block; attributable fatalities and/or increased length of stay associated with each.Results: 21 896 ICU admissions and 3039 inhospital deaths (13.9%) were screened. All hospitals reported ICU access block. There were 6787 interventions for access block (mean, 9.3/day) — 4070 (18.6% of admissions) instances of after-hours step-down from an ICU to a low-acuity ward; 1115 (5.1%) delays in an emergency department > 8 hours; 895 (4.1%) postponed major surgeries; 487 (2.2%) interhospital transfers; and 220 (1.0%) instances of premature cessation of intensive care. Based on published risk estimates, these interventions may have resulted in 91.1 (95% CI, 34.7–147.2) attributable deaths and 4368 (95% CI, 333–10 050) additional hospital bed-days each year.Conclusions: Intensive care access block is frequent, and measures to circumvent it increase mortality and length of stay. Further study of the health and financial implications of access block are warranted.

Graeme J Duke MD, FJFICM, FANZCA · Michael D Buist MD, FRACP, FJFICM · David Pilcher FRACP FJFICM, MRCP · Carlos D Scheinkestel FRACP, FJFICM, DipDHM · John D Santamaria MD, FRACP, FJFICM · Geoff A Gutteridge FJFICM, FANZCA · Peter J Cranswick FJFICM, FANZCA · David Ernest FRACP, FJFICM, MHlth · Craig French FJFICM, FANZCA · John A Botha MMed, FRACP, FJFICM

Warfarin and heparin are the traditional mainstay anticoagulant therapies for treating thromboembolic disease. These drugs, with a documented history of utility, also have inherent difficulties in usage; in particular, the complicated monitoring and numerous drug–drug interactions of warfarin, and the need for parenteral administration of heparins. New agents have recently emerged that target specific elements of the clotting pathway. Rivaroxaban, which inhibits activated factor X (Xa), is currently in clinical trials and is the most advanced factor Xa inhibitor. The drug offers once-daily oral dosing, with no need for injections, dose titration, or frequent blood tests to monitor the international normalised ratio. It has a rapid onset of action and, although there is no specific antidote, it has a short plasma elimination half-life (about 5–9 hours). Evidence from recently published large-scale phase III clinical trials shows rivaroxaban to be superior to enoxaparin for prophylaxis of venous thromboembolism after major orthopaedic surgery. Studies have shown rivaroxaban to have a sound safety profile, with an incidence of bleeding similar to enoxaparin in phase III clinical trials. Few side effects and drug–drug interactions between rivaroxaban and common medications have been found thus far, although some interactions with potent cytochrome P450 3A4 inhibitors have been observed. It is hoped that rivaroxaban may be used as a first-line anticoagulant for prophylaxis of venous thromboembolic disease in postsurgical patients.

Abhishek K Verma BSc(Med), MB BS · Timothy A Brighton MD, FRACP, FRCPA

Chromobacterium violaceum infection is uncommon but potentially fatal, with a clinical picture similar to melioidosis but with different antibiotic sensitivities and treatment. This infection can involve any organ, but we believe this is the first reported case of C. violaceum endocarditis. Clinical recordA 40-year-old woman was admitted to hospital with a 1-week history of general malaise, fever, rigors, lower back pain and headache. She reported swimming in a freshwater lake in Litchfield National Park in the Northern Territory a week previously, during the wet season, at which time she had sustained a graze on her thorax from a tree branch. On admission, the patient’s temperature was 38.5°C, her pulse was 113 beats/min, blood pressure was 105/64 mmHg, respiratory rate was 22 breaths/min, and oxygen saturation was 98% on room air. A small resolving skin lesion was noted on her thorax. She had a grade 2/6 pansystolic apical murmur. Findings from the general examination were otherwise normal. Haematological investigations found her haemoglobin level was 130 g/L (reference range [RR], 110–165 g/L), white blood cell count was 10.2 × 109/L (RR, 3.5–11.0 × 109/L) with neutrophils at 8.96 × 109/L (RR, 2.0–8.0 × 109/L), and C-reactive protein (CRP) level was 300 mg/L (RR, < 2.5 mg/L). Results of liver function tests peaked between Days 17 and 20 at the following levels: alkaline phosphatase, 193 U/L (RR, 42–98 U/L); γ-glutamyltransferase, 101 U/L (RR, < 38 U/L); alanine aminotransferase, 117 U/L (RR, < 34 U/L); and aspartate aminotransferase, 78 U/L (RR, < 31 U/L). Normal results were obtained for urea, creatinine, electrolytes, lumbar puncture, urinalysis and a chest radiograph. Serological tests for Burkholderia pseudomallei, Leptospira spp., rickettsiae, Q fever, hepatitis A, B and C viruses, dengue virus and HIV were negative. T-cell subsets and immunoglobulin levels were normal. Intravenous aciclovir and ceftriaxone were commenced, and a diagnosis of melioidosis was considered. On Day 3, patient temperatures up to 40°C were recorded, and motile gram-negative bacilli were detected in the two initial sets of blood cultures after 28–39 hours of growth. Intravenous gentamicin was added to the patient’s antimicrobial regime. On Day 4, a computed tomography (CT) scan of the abdomen and pelvis showed multiple discrete hypodense lesions measuring up to 1.7 cm throughout the liver, and a bulky spleen (Box 1, A). Deep-purple and black colonies grew on Mueller–Hinton blood agar and antibiotic sensitivity plates. Chromobacterium violaceum, sensitive to ciprofloxacin, meropenem and co-trimoxazole, but resistant to gentamicin, was identified, and confirmed by testing on the VITEK 2 system (bioMérieux, Durham, NC, USA). B. pseudomallei, the causative organism of melioidosis,1 is not usually pigmented. The patient was commenced on intravenous meropenem. Abatement of symptoms was slow, but the patient’s CRP level fell to 17 mg/L on Day 13. A repeat CT scan of the abdomen and pelvis on Day 10 showed generalised reduction in size of the liver abscesses. A transthoracic echocardiogram on Day 11 revealed mild mitral regurgitation. A contrast CT brain scan performed on Day 13 showed no abnormalities. A transoesophageal echocardiogram (TOE) performed on Day 15 demonstrated a small, 8 mm × 1 mm, linear mobile echodensity arising from the left ventricular outflow tract between the commissures of the left and right coronary cusps, consistent with a small vegetation (Box 1, B). An electrocardiogram was normal. The patient was discharged home in Week 5 and continued on home intravenous therapy with meropenem to complete a course of 6 weeks’ intravenous treatment. A 6-week course of oral ciprofloxacin 750 mg twice daily was introduced, starting in Week 6. The patient had a total of 11 weeks of antibiotic treatment. A follow-up abdominal ultrasound during Week 6 showed complete resolution of the liver abscesses. A repeat TOE during Week 11 showed resolution of the aortic valve vegetation after antimicrobial therapy. After 11 weeks, the patient’s white blood cell count and CRP level remained normal and she was clinically well, so antibiotics were ceased. Three months after ceasing antibiotics, the patient remained clinically well and had normal full blood count, CRP level and liver function test results. DiscussionC. violaceum is a gram-negative, facultative anaerobic, non-sporing coccobacillus. It is commonly found in water and soil in tropical and subtropical regions of South-East Asia, South America and northern Australia. Apart from South America, it is endemic in the same regions as B. pseudomallei.1 Human disease is rare, and is most frequent in the wet season. Trauma is often an antecedent event, with abscess formation at the site. Systemic infections can be rapidly progressive, leading to metastatic abscess formation identical to that seen in melioidosis, with past documented mortality rates of 60%.2 We believe endocardial C. violaceum infection has not been reported previously. Immunodeficiency predisposes to the infection, although most patients with C. violaceum infections have no underlying immunodeficiency. B. pseudomallei and C. violaceum are both characteristically resistant to penicillin, ampicillin and first- and second-generation cephalosporins. However, there are some significant differences between the antibiotic sensitivities of the two bacteria. Ceftazidime and meropenem have become the drugs of choice for treating B. pseudomallei infection.3 White and colleagues demonstrated a 50% reduction in mortality from melioidosis using ceftazidime compared with combined chloramphenicol, co-trimoxazole and doxycycline.4 Sookpranee et al demonstrated the benefit of ceftazidime combined with co-trimoxazole compared with combined co-trimoxazole, chloramphenicol and doxycycline.5 Currie recommends ceftazidime, meropenem or imipenem as initial intensive therapy for melioidosis.6 Cheng et al found meropenem and ceftazidime equally effective in 6 years’ experience with 214 patients, although meropenem was preferred in critically ill patients.7 Resistance of B. pseudomallei to amikacin has been documented.8 In contrast to B. pseudomallei, C. violaceum infection is uncommon, with about 150 cases reported in the world literature, compared with over 200 cases of melioidosis documented in one series alone.7 No reports of controlled therapeutic trials have been published. Susceptibility to third-generation cephalosporins and aminoglycosides varies.9 However, there are documented cases of ceftazidime resistance from Australia,10 India11 and Brazil,12 with resulting fatalities. Amikacin in combination with gatifloxacin has been found to be successful for the treatment of puerperal sepsis from C. violaceum.13 Other case reports record cures with co-trimoxazole, quinolones, tetracyclines and chloramphenicol.14 Currently, there are limited published studies confirming the success of meropenem in treating C. violaceum infection.14 In conclusion, physicians should not rely on ceftazidime alone for treating a febrile traveller with suspected melioidosis, until infection with C. violaceum has been ruled out by microbiological cultures. There is a minor role for amikacin as combination therapy for C. violaceum infections (but no role for B. pseudomallei). Co-trimoxazole in combination with other agents may be an alternative if carbapenems are contraindicated. To exclude endocarditis, transoesophageal echocardiography should be considered. A summary of antibiotic recommendations for B. pseudomallei and C. violaceum infections is provided in Box 2. 1 Chromobacterium violaceum infection A: Computed tomography scan of the abdomen showing multiple hepatic abscesses. B: Transoesophageal echocardiogram showing C. violaceum vegetation on aortic valve (cursors). 2 Summary of antibiotic recommendations Bacterium Ceftazidime Amikacin Meropenem Burkholderia pseudomallei Standard therapy Resistant Standard therapy Chromobacterium violaceum Failures and fatalities reported Success in combination Anecdotal success

Ivan W M Lim MB BCh, BAO · Peter J Stride MB BS, FRACP · Robert L Horvath MB BS, FRACP · Christian R Hamilton-Craig MB BS, FRACP · Phi P Chau MB BS

Azithromycin is recommended as the first-line antibiotic for the prophylaxis and treatment of pertussis, a common vaccine-preventable communicable disease. Azithromycin is better tolerated than other macrolide antibiotics. Access to azithromycin is limited, as the product information and the Pharmaceutical Benefits Scheme do not include azithromycin for pertussis. Issues regarding access to azithromycin are highlighted in a case report of pertussis exposure in a tertiary paediatric hospital.

Asha C Bowen BA, MB BS, DCH · Mark J Ferson MD, FRACP, FAFPHM · Linda V Graudins BPharm, DHP, FSHPA · Pamela Palasanthiran MB BS, FRACP, MD

A 56-year-old man with a history of rheumatoid arthritis presented with a 2-day history of worsening pain in his left foot. Treatment with high-dose steroids was of no benefit, hence a diagnosis of septic arthritis was considered. However, the patient’s condition deteriorated despite empirical antibiotic therapy. Following persistent investigation, the cause was identified as a fastidious Legionella longbeachae infection, and appropriate antibiotic therapy led to complete resolution of the sepsis. This emphasises the importance of considering infections with atypical organisms in patients on immunosuppressive therapy. Clinical recordIn July 2008, a 56-year-old retired man presented with a 2-day history of worsening pain in his left foot. His medical history included seropositive active rheumatoid arthritis (RA), type 2 diabetes mellitus with microvascular complications, and idiopathic dilated cardiomyopathy managed with an implantable cardioverter-defibrillator and permanent pacemaker (left ventricular ejection fraction: 12% in 2006, 42% in 2008). His RA had been difficult to control — intermittent flares, usually involving his feet, were managed with high-dose steroids. Before presentation, the patient was taking weekly oral methotrexate (20 mg) and daily prednisolone (7.5 mg). Leflunomide, hydroxychloroquine and sulfasalazine therapy had failed to control his RA in the past and were withdrawn because of adverse reactions. Treatment with rituximab, an anti-CD20 monoclonal antibody, in September 2007 (two 1000 mg infusions, administered 2 weeks apart) had also failed to control his RA, and tumour necrosis factor-α (TNF-α) inhibitors were contraindicated owing to his cardiac disease.1 On examination, the patient had diffuse swelling with tenderness over the small joints of his left foot and ankle, with minimal erythema. He was not constitutionally unwell; however, his C-reactive protein (CRP) level was 64 mg/L (reference range [RR], 0–10 mg/L), and he was anaemic (haemoglobin level, 86 g/L [RR, 130–175 g/L]) and leukopenic (white cell count, 2.0 × 109/L [RR, 4.0–11.0 × 109/L]; neutrophil count, 1.6 × 109/L [RR, 1.5–7.5 × 109/L]). A provisional diagnosis of RA flare was made, the patient was admitted to a private hospital, and high-dose oral prednisolone therapy (50 mg/day) was begun. Over the next 2 days, there was no improvement in the patient’s left foot swelling and pain, and his haemoglobin and CRP levels worsened further (haemoglobin level, 77 g/L; CRP level, 102 mg/L). However, he remained afebrile. He was transfused with three units of packed red cells. A whole body bone scan was performed to test for underlying infection, and it revealed intense tracer uptake in the region of the fourth and fifth tarsometatarsal joints of the patient’s left foot (Box). He subsequently developed fever, chills, tachycardia and painful swelling in his left wrist. In view of the worsening clinical features and the increasing CRP level, an alternative diagnosis of septic arthritis or osteomyelitis was strongly suspected, rather than a flare of RA. Blood cultures were ordered, and intravenous flucloxacillin therapy was begun; methotrexate was withdrawn, and the dose of prednisolone was reduced to 25 mg daily. A computed tomography scan of the patient’s left foot showed only soft tissue swelling, with no cortical destruction, fracture or collection. The patient was then transferred to our institution as his treating physician was to go on leave. On examination, he was febrile, had synovitis of his left wrist, and had marked swelling and erythema of his left foot, extending to the ankle. A Gram stain of an aspirate from his left wrist, collected on admission to our hospital, revealed occasional gram-negative bacilli. Further blood cultures were ordered and flucloxacillin was substituted with meropenem. The next day, meropenem was changed to cefepime for better coverage of possible Pseudomonas infection, pending blood culture results. The cellulitis of the patient’s left foot did not resolve during the next 2 days, and possible septic arthritis developed in the right fourth finger (distal interphalangeal joint). Despite ongoing antibiotic therapy, the patient’s condition deteriorated. He became neutropenic (neutrophil count, 0.3 × 109/L), and the swelling of his left foot extended to the knee. His haemoglobin level dropped to 82 g/L, and he required transfusion of two additional units of red cells. He had daily temperature spikes, but blood and synovial fluid cultures were still showing no growth at 4 days after the initial aspirate and blood samples were taken. To identify the apparently fastidious bacterium noted in the initial wrist aspirate, synovial fluid from the left wrist was plated onto various selective media. Colonies grew on buffered charcoal yeast extract medium, and a Legionella species was suspected. Azithromycin and moxifloxacin were added to the treatment regimen 5 days after the patient was transferred to our institution, and cefepime was withdrawn. The neutropenia was treated with subcutaneous injections of granulocyte colony-stimulating factor. The patient’s condition improved dramatically during the next few days; complete resolution of cellulitis and joint swellings occurred with ongoing appropriate antibiotic therapy. Polymerase chain reaction analysis confirmed that the isolated bacterium was a Legionella species, which was subsequently shown by 16S ribosomal RNA gene sequencing to be Legionella longbeachae. Extensive review of environmental risk factors did not reveal a recent source of exposure to this organism, and there had been no precedent pneumonia. He was discharged home and prescribed a 6-week course of oral azithromycin and moxifloxacin. On follow-up at 6 weeks, his CRP level and white cell count had normalised, with complete resolution of symptoms. DiscussionThis case shows how challenging it can be to differentiate between flare and infection in patients with RA who present with worsening local symptoms. Adding to the diagnostic challenge in this case was the involvement of a particularly fastidious organism. To our knowledge, this is the only reported case to date of septic arthritis with L. longbeachae without preceding pulmonary infection in a patient with RA, although two cases of septic arthritis with Legionella pneumophila in immunocompromised patients without lung involvement have been reported.2,3 Extrapulmonary infections by Legionella species are rare and are generally thought to arise from haematogenous spread after pulmonary infection. L. longbeachae is responsible for about 4% of cases of community-acquired legionellosis worldwide, and about 30% of cases in Australia and New Zealand.4 It is commonly found in soils and potting mixes, and occasionally in water.5 However, our patient was not a gardener, and we could not identify any other recent source of exposure to L. longbeachae. Patients with RA have an increased risk of infection because of the disease itself and immunosuppressive therapy.6 Therefore, a differential diagnosis of underlying infection with typical and atypical organisms should be considered when patients with RA present with disease flares that do not respond to appropriate escalation of immunosuppressive therapy. Several factors complicated the management of this patient’s condition. In particular, his RA was difficult to control; he also could not be administered TNF-α inhibitors (owing to his underlying moderate-to-severe heart failure) as per current expert consensus recommendations.1 Abatacept (a selective blocker of T-cell co-stimulation) is being considered as a future treatment option in this patient. He also had anaemia of chronic disease secondary to the active RA, for which erythropoietin therapy was begun after discharge; he did not require further blood transfusions over the 6 months after discharge. In addition, he was leukopenic; this was likely to be secondary to the sepsis because, although he had previously been treated with rituximab, his lymphocyte count was normal 1 month before presentation and at follow-up. Our patient presented with an apparently simple flare of RA that developed into life-threatening sepsis with neutropenia. This case illustrates the need for a high index of suspicion of infection with unusual organisms when symptoms suggestive of active arthritis in such patients do not respond to standard treatment. Delayed regional bone scans of a patient with persistent pain and swelling of the left foot Intense tracer uptake is visible in the left foot — in the fourth and fifth tarsometatarsal joints, with flare extending along the shaft of the fourth metatarsal. A: Posterior view of both feet. B: Anterior view of both feet. C: Left lateral view of left foot. D: Right lateral view of left foot.

Manish Dugar MB BS · Wayne A Rankin PhD · Emily Rowe MB BS · Malcolm D Smith PhD, FRACP

To the Editor: We read with interest the recent editorial by Van Der Weyden on the issue of doctor displacement.1 We agree completely that a transparent and evidence-based approach to health care roles is essential. In proposing a pilot program of physician assistants (PAs) in South Australia to examine the potential of “physician extenders”, we broadly used the model applied to the introduction of new therapies in medicine, including new drugs: Evidence of an unmet need; Evidence of safety and efficacy in another setting; A monitored pilot/trial in practice; Re-evaluation after a defined period with a defined process; and An emphasis on any ongoing utilisation being a consistent and national process. This last point is noted in the Australian and New Zealand College of Anaesthetists’ submission to the National Health and Hospitals Reform Commission.2 We emphasised the need for any proposed future clinical role for PAs to be defined, followed by identification of the required knowledge base, training and education requirements, and certification. Not all new health care roles have followed such a pathway, and this provides potential challenges for ensuring quality, safety, consistency and “trademark definition” (widespread understanding of the role). In the case of PAs, it was evident at a recent International Forum for Physician Assistant Education in the United States that the definition of the term “physician assistant” varies greatly internationally, potentially confusing future debate on this topic in Australia. Hence, to develop a robust Australian model, any proposals for ongoing use and training of PAs would have to be discussed at a national level.

Guy L Ludbrook · Guy J Maddern

To the Editor: The Journal’s Editor is a man of words and we love him for it, but, as Lord Tennyson said: “For words, like Nature, half reveal and half conceal the Soul within” (In memoriam A. H. H., 1850). So what does his Christmas issue editorial1 really reveal about our man of words? He has unfortunately biased the debate about physician assistants and other alternative health care providers with his editorial’s very title: “Doctor displacement”. Doctors will not be displaced — liberated, perhaps, to concentrate on things that interest them, where their advanced skills can be best used and where they can make the most impact. This is not (nor should it be) about maintaining the status quo. The debate should be about how to provide health care to patients and the community, ensuring that they can get appropriate advice from well trained professionals when and where they require it. Most health services are now provided by teams — no longer is it ethical to promote the idea of an autonomous practitioner, be it nurse or doctor. The great strength of the physician assistant is that it is a “delegated model”, dependent on the doctor and not, as the editorial suggests, able to practise independently. Physician assistants will never be able to practise independently; they will always have to practise under supervision and within the scope of practice of their supervisor. Nowhere in Van Der Weyden’s editorial is the issue of preventive health, as an important physician assistant or other health professional role, raised, nor the fact that health professionals might use teleconsulting to link across disciplines and geographical areas. These are aspects that could change workforce requirements dramatically. Australia currently spends a minor fraction (less than 5%) of its $90 billion health budget on trying to prevent illness.2 We must use our health dollars more wisely and effectively. Also absent from the editorial is mention of the current global shortage of 4.5 million health workers. On this point, the MJA should look to the Lancet to see how it has consistently run a global agenda on health services and workforce, pointing out our responsibilities to low- and middle-income countries.3 The world is divided into those with and those without effective health care. Opinions on proposed changes to health care split into those who say “why?” and those who say “why not?” Editor, you have always appeared to us to be in the latter group. Please don’t disappoint us now by becoming a nay-sayer. We want to see this Journal promoting a health system that is patient-focused and health professional-friendly, and not one that just maintains the status quo.

Peter M Brooks · Charles A Mitchell

In reply: I appreciate the comments of Brooks and Mitchell on the importance of words to editors — they are, after all, their tools of trade. Indeed, this is no more so than in the titles of editorials, wherein their succinctness must not only encapsulate the tone and theme of the text but, having captured the readers’ attention, induce them to read on. It seems, however, that the title of my recent editorial “Doctor displacement: a political agenda or a health care imperative?”1 has caused disquiet and prompted the accusation of “bias”. And the offending word? “Displacement”. The Concise Oxford Dictionary defines the verb “displace” as: “shift from its accustomed place”, “remove from office” and “take the place of; oust”. Given the substance of the editorial, it was my intention that all these connotations were relevant in the context of this many-layered debate. In essence, the editorial focused on the urgent need for the profession to address, or at least debate, the increased instances of “task transfer” or “role substitution” occasioned by the escalating numbers of nurse practitioners and physician assistants. Despite Brooks and Mitchell proffering the conventional justification of this recent phenomenon as being “teamwork”, history tells us that this may well be academic double-speak. One precedent was the protracted tussle some 300 years ago between organised medicine and apothecaries, who were to eventually evolve into the progenitors of general practitioners.2 More recently, there have been well documented instances of physician assistants establishing independent practices in the United States.3 One could say that the very title of my editorial seems to have mesmerised Brooks and Mitchell, who have fixated on its seeming bias, ignoring the editorial’s subsequent exploration of current workforce issues in the delivery of quality health care and the urgent plea for the profession to have an evidence-driven debate. On the other hand, it is easy to appreciate their sensitivity to the phrase “doctor displacement”, given their ongoing commitment to the University of Queensland’s postgraduate physician assistant training program.

Martin B Van Der Weyden

To the Editor: Isoniazid is used extensively for the treatment of active and latent tuberculosis (TB). It is generally well tolerated by children, and hypersensitivity reactions resulting in skin rash and requiring cessation of treatment are rarely reported in this age group.1,2 We report a case of isoniazid hypersensitivity in a 21-month-old boy potentially exposed to TB in a childcare setting. He was one of over 80 children screened after contact with a childcare worker who showed a positive smear result. His initial tuberculin skin test (TST) was negative and, in line with New South Wales guidelines,3 he was commenced on isoniazid 150 mg daily (10mg/kg/day) while awaiting a repeat TST. After 3 days of treatment, he developed a small number of round vesicular lesions on his tongue. They were associated with mild discomfort but his appetite was not affected. There were three small maculopapular lesions on his legs and back that reportedly looked like mosquito bites before blistering. The child remained afebrile and was systemically well. The family general practitioner considered that this presentation was possibly an allergic reaction and isoniazid was discontinued. Population health staff were consulted, and the risks and benefits of further isoniazid treatment were discussed with paediatric TB specialists. It was recommended that, after the rash had resolved, isoniazid be reintroduced at half the dosage and with close supervision. Two days after isoniazid 75 mg daily was recommenced, the rash recurred. The child’s mother described lesions appearing as “burns all over his tongue” and reported further sores around his lips and six welt-like lesions on his legs. Isoniazid was immediately discontinued, the skin lesions resolved within 5 days and no further antituberculous therapy was administered. His repeat TST 12 weeks after the initial test was negative and he remains well. No other potential triggers for a hypersensitivity reaction were identified. In particular, no other medications were administered during this period or for the week before commencing isoniazid. According to his mother, the child had experienced a similar reaction within 1 hour of a single dose of ibuprofen when he was 8 months old. Several tongue blisters were accompanied by a generalised fine maculopapular rash lasting several days. We concluded that the child most likely had a hypersensitivity reaction to isoniazid that required discontinuation of treatment. We reported this to the Therapeutic Goods Administration, which advised that it had received seven other reports since 1991 of suspected hypersensitivity, but none were for children under 10 years of age.

Tony D Merritt · Peter D Massey

To the Editor: Accidental asphyxia in very young children is an ongoing problem caused by hazardous sleeping environments and toddlers’ inability to understand dangers or to physically extricate themselves once entrapped. Two common problems involve children becoming wedged between mattresses and cot sides or walls, and hanging from clothing caught on projections inside cots.1 Autopsy in such cases requires careful death scene evaluation to prevent confusion with sudden infant death syndrome and to identify any evidence of inflicted injury, if present. National legislation requiring both new and second-hand cots to meet Australian safety standards has reduced the numbers of unsafe cots on the market. I report a case of another continuing, albeit less common, circumstance that is also resulting in lethal outcomes for toddlers — about one child dies every 1–2 years in Australia in this manner.2 A healthy 13-month-old boy was placed in his cot next to a window with blinds from which a cord was hanging. A loop of the cord measuring about 10 cm was hanging inside the cot. When checked later, the boy was found unresponsive, hanging from the cord. Resuscitation attempts were to no avail. At autopsy, a parchmented ligature mark was present around the neck, with facial and conjunctival petechiae. There were no other injuries or significant illnesses present. Death was therefore attributed to accidental hanging. (Further information on this case is available in the Finding of Inquest.3) Prevention of such tragic fatalities requires ongoing public awareness campaigns, using pamphlets such as the Australian Government’s blind and curtain cords safety alert brochure,2 to advise parents and child carers to keep cots and furniture that can be climbed on away from windows that have curtain or blind cords, to use cleats and cord wind-ups to keep cords at least 1.6 m above the floor, to cut loops, and to keep cords that must be looped under tension with tie-down devices. A safety tassel is also available that clips the two ends of a cord together but that easily separates when put under pressure.4 In addition, national legislation similar to that currently enacted in New South Wales and other states would provide uniform guidelines for managing these devices that would include warning labels and written safety information for parents.4

Roger W Byard

To the Editor: There is danger of a perception developing that, to ensure patient confidentiality, quality assurance (QA) activities in health care should be regarded as research. The Australian Law Reform Commission (ALRC) has delivered proposals for the review of the federal Privacy Act 1988 (Cwlth) that may lead to all but the most basic monitoring of health care activities being characterised as research.1 Recommendation 65–3 emphasises that “research” should include “the compilation or analysis of statistics” and the ALRC also stated that “some funding, management, planning, monitoring, improvement and evaluation activities also may be characterised as research”. This drives the possibility for policy interpretation of QA activities into the realm of research necessitating ethics approval and/or informed consent, rather than retaining the current level of exemption. Australian governments are crying out for increased transparency to improve safety, but labelling QA activities as formal research could seriously compromise and retard patient safety efforts. A key to enabling optimal patient safety is the implementation of evidence by practitioners competent in judgement, skill and knowledge within an environment characterised by leadership and adequate resources (for example, through morbidity and mortality meetings and clinical audits).2 Implementing clinical monitoring (eg, antibiotic use, so essential to optimal outcomes and to minimising antibiotic resistance) requires audit of patients’ files. Improvement in current practices requires scientific, planned, data-driven study with ongoing review, which includes elements that could easily be characterised as research. If these activities and resultant quality improvement efforts are now regarded as research, their progress may be impeded. It should be considered unethical not to act on established evidence. It would be dangerous to label as research surveillance and QA activities that are designed to ensure implementation of such evidence, even if they fall within the broad definition of research. Patient privacy and confidentiality must be managed within a transparent regulatory framework without impeding safety mechanisms with research frameworks that would inevitably lead to delays and increased costs, as well as seriously discouraging staff from implementing them. These effects are well documented overseas where the enactment of similar privacy rules relating to the use of patient information has resulted in detrimental unintended consequences.3,4 Work undertaken to discover new and better evidence needs to be regarded as research, not work to ensure that established evidence-based practice is properly implemented. Herein lies the difference. Although the National Health and Medical Research Council (NHMRC) provides advisory guidelines,5,6 the proposed privacy (health information) regulations to be developed by the Office of the Privacy Commissioner1 will provide the legal basis for the use of health information. The public benefit of QA activities with appropriate privacy management and regulation that avoids designation as research requires strenuous championing during development of the regulations to ensure continued improvement in patient safety.

Anthony P Morton · Susan E Smith · Peter R Croll · R Michael Whitby

To the Editor: In the 3 November 2008 issue of the Journal, Millar recommends against routine thromboprophylaxis in medical patients.1 The evidence base for clinical decision making regarding thromboprophylaxis in medical patients remains limited. Although its overall benefit may be low, the absolute benefit to the community is significant. As up to 40% of cases of venous thromboembolism (VTE) occur in patients recently hospitalised for medical illness,2-3 there is a significant burden of disease that justifies prophylaxis in patients at high risk of VTE. The challenge is to identify medical patients at greatest risk of VTE, and to provide appropriate pharmacological prophylaxis, but to avoid using prophylaxis in patients at lower risk of VTE. Millar states that aspirin is as effective as heparin, with reference to the Pulmonary Embolism Prevention (PEP) trial.4 However, the PEP trial compared aspirin with placebo, and many participants also received heparin — it did not compare aspirin with heparin. Participants were undergoing surgery for hip fracture, and none were medical patients. A reduction in the endpoint of fatal pulmonary embolus (PE) is difficult to demonstrate in trials where imaging is used to detect disease at an early stage. This prompts treatment of asymptomatic deep vein thrombosis and modifies the natural history, leading to low reported PE rates. Rather than recommend for or against routine thromboprophylaxis in medical patients, we advise that patients should have a VTE risk assessment and that appropriate prophylaxis should be given according to evidence-based guidelines such as those of the American College of Chest Physicians5 and the International Consensus Statement6 (which we have attempted to summarise and condense into a practical, pocket-sized booklet7).

John P Fletcher · Donald MacLellan · Harry Gibbs · Geoff Matthews

To the Editor: “What is the health service for?”1 In essence, this is a question of definition and ownership. What is the definition of quality health care and who decides how it is defined? Who are the recipients of health services, the funders, those who stand to lose or benefit from the way in which health care is delivered? The answer is citizens. When we define quality, we are making a value judgement; we are saying what it is about health care that we consider important and worthy of achieving. In a democratic society, we expect that the values of citizens will be reflected in the definition of health care quality. The United States Institute of Medicine initiative, “Crossing the quality chasm”, emphasises “patient-centered(ness)” and care “customized according to patient needs and values” as system attributes for delivering quality health care to individuals.2 Yet, a broader perspective is suggested in the following statement on the objectives of health care systems from the World Health Organization: The objective of good health itself is really twofold: the best attainable average level — goodness — and the smallest feasible differences among individuals and groups — fairness. Goodness means a health system responding well to what people expect of it; fairness means it responds equally well to everyone, without discrimination.3 Implicit in both definitions is knowing what people expect, need and want from their health service. What do Australians expect, need and want from their health service at an individual, local and national level? How can we engage citizens effectively to answer these questions? We need a process of informed public consultation, a process that is constructive, efficient and representative, to guide the vision and values that form the basis of our health system. Menadue highlights the Canadian Romanow-led Royal Commission as an example of community engagement.1 A similar initiative underlies the United Kingdom’s “Our NHS [National Health Service] our future”, where a process involving consumer consultation has been employed at all levels of health care reform and in the development of an “NHS Constitution”.4 Mooney suggests “citizens’ juries” and a “National Citizens’ Summit”.5 Whatever our Australian national solution, as key stakeholders in the health system, as its patients and its health workforce, citizens need to be given a genuine opportunity to influence and contribute to the future direction of Australian health care.

Amanda E James

To the Editor: Wills and Coory emphasise maternal smoking as a risk factor for preterm birth and low birthweight, with exaggerated effects apparent in Indigenous women.1 They suggest that governments have a responsibility to ensure that interventions are offered to help women quit. Unfortunately, there are adverse effects of smoking cessation that mitigate the gains of cessation and introduce a caveat to that otherwise laudable motive. It has been shown that young women who cease smoking almost always gain significant weight.2 The fall in smoking rates in women over the past 20 years appears to have been in inverse proportion to the rise in rates of obesity in pregnancy, suggesting a possible relationship. The adverse maternal and fetal effects of overweight and obesity in pregnancy have been confirmed in numerous studies,3-5 and equal or exceed those of smoking. Typical odds ratios (ORs) from the literature3-6 are shown below. Maternal overweight (body mass index [BMI], 25–30 kg/m2) and obesity (BMI, > 30 kg/m2) are associated with significant increases in pre-eclampsia (OR for overweight, 1.8; OR for obese, 3.0), gestational diabetes (1.8; 3.2), macrosomia (1.6; 2.4), shoulder dystocia (2.9 for obese), obstructed labour, caesarean delivery (1.5; 2.0), postpartum haemorrhage (1.2; 1.5), wound infection (1.3; 2.2), venous thromboembolism (1.3; 2.8) and maternal death. Further, overweight and obesity are also associated with increased rates of infertility, fetal abnormality (OR, 1.3–3.5), miscarriage (1.2–3.0), stillbirth (1.5; 2.0), admission to neonatal intensive care (1.2; 1.4) and neonatal death (1.6–2.7 for obese). In addition, the adverse effects of excessive weight gain during pregnancy are very similar to those detailed above.7 The long-term effects on the offspring of women who were obese in pregnancy (increased rates of obesity, diabetes and components of the metabolic syndrome) are well documented,8 and at least equal in severity to the consequences for the children of smokers. What then should we do? Should we condone smoking during pregnancy? No one would agree. Ideally, women should never start smoking, or they should give up without gaining weight, but these are elusive aims. At the very least, the conscientious practitioner must provide weight-control counselling, referral to a dietitian and an exercise program lest the gains of smoking cessation be overwhelmed by the losses accompanying excess maternal weight gain, overweight and obesity in pregnancy.

Barry N J Walters

Therapeutic guidelines. Toxicology and wilderness. Emergency Medicine Expert Group. Melbourne: Therapeutic Guidelines, 2008 (xxii + 311 pp). ISBN 978 0 9804764 0 8. Poisoning is a common presentation to Australian emergency departments and a common cause of death in those under 40, yet there is a real paucity of Australasian toxicology texts. Toxicology and wilderness, a new release in the Therapeutic Guidelines series, is a subset of topics prepared by the Emergency Medicine expert writing group for the electronic eTG complete. Toxicology and wilderness sensibly starts with in-depth information on the many aspects of resuscitation. There is a good overview on the approach to the poisoned patient, with a great nomogram to help assess the risk of torsades from a prolonged QT. The majority of the book is based on the toxicology of individual agents. It approaches each agent in a structured manner, detailing the indicators for toxicity, clinical presentation, key investigations and treatment. It has much helpful and sensible advice. The authors seem to advocate routine activated charcoal for most poisonings that present within 1 hour, which I would disagree with. The discussion on antidotes is understandably brief, although I was curious to read in detail about dicobalt edetate for the treatment of cyanide poisoning, and not the currently recommended and far safer hydroxocobalamin. I felt that there were sections where better emphasis on the potential for severity of the poisoning or management issues could have occurred. The book ends with a well written section on envenoming, then the unusual bedfellow of wilderness medicine. I think the strength of this book lies in the ready access of the electronic format for hospital practitioners. I found the information a good starting point but, due to the restrictions of the structure of this series, a little light in some areas. As to whether it sits on your bookshelf — you need to browse through to see if it fits a need.

Mark Little

Travel medicine. 2nd ed. Jay S Keystone, Phyllis E Kozarsky, David O Freedman, et al, editors. Philadelphia: Mosby, 2008 (xiii + 611 pp). ISBN 978 0 323 03453 1. This is a great book and worth the $215 asking price. It is a comprehensive tome for clinicians new to travel medicine, as well as having much to offer those with more advanced knowledge. It would be a useful tool for those studying for the International Society of Travel Medicine Certificate of Knowledge Examination. The book is well written, with up-to-date and practical discussions. The list of authors is a “who’s who” of the luminaries of travel medicine, each writing about their area of expertise. It is well laid-out and easy to read, with good use of colour, flow charts, tables, figures and photos. Boxes highlighting key points at the start of each chapter are a useful aid for the time-poor. The book comes with a searchable CD-ROM, although the book’s index and table of contents are so good that the CD-ROM seems almost superfluous. The scope of the discipline is well covered — from different travellers (eg, expatriate workers, people with disabilities, older people, pregnant women, and children) to different diseases (including extensive discussion of traveller’s diarrhoea) and health precautions (eg, vaccines, malaria medication, water purification); from pretravel to post-travel, different types of trips (eg, cruises, international adoption, medical tourism), along with psychological and environmental aspects of travel health care. A small component of the information is only relevant to readers in the United States, such as details about insurance companies and paying for visits. American spelling is used. There are a few minor omissions (such as the option of Quantiferon screening for tuberculosis). This does not detract from the excellence of the book. At 640 pages, it takes a bit of reading but the reader is well rewarded.

Deborah J Mills

Fred Schwarz, an Australian medical doctor-turned-political activist, died on 24 January 2009 in Camden, New South Wales. The fourth of 11 children, Fred was born in Brisbane on 15 January 1913. After graduating with a science degree in 1933, he worked as a school teacher, then returned to university to study arts and medicine. While a medical student at the University of Queensland, he continued to work as a teacher at night, and also preached to the Christian Revelers, a body he founded to emphasise the joy of Christian service. As a new graduate in 1944, Fred led an approach to the Queensland Industrial Court, seeking better conditions for first-year medical graduates in public hospitals. The case was ably presented by him and “Mickey” Whyte, later Professor H M Whyte of the John Curtin School of Medical Research, Canberra. The Court awarded residents an increase in salary from £200 to £350 a year and a limit to their hours of work. Although this industrial action seemed scandalous to older doctors at the time, it is clear that every graduate of an Australian medical school since then owes a debt of gratitude to Fred. Fred moved to Sydney in 1946 to take over a medical practice in North Strathfield. The practice grew to become one of the busiest in Sydney’s western suburbs. As an extension of his strong Christian beliefs, Fred developed a deep concern about the atheistic values and ambitions of the communist states. In 1955, he closed his medical practice and moved to the United States to work full-time for the Christian Anti-Communism Crusade, an organisation he had established in Iowa in 1953 (at the request of evangelist Billy Graham) to spread information about the nature, aims and methods of communism. He conducted lectures, seminars and debates, and wrote a book, You can trust a communist (to be a communist), which sold over a million copies. He also published regular newsletters and conducted week-long anti-communism schools. He opposed communism not for political or economic reasons, but because of its attitude to God and man. Another of his books, Beating the unbeatable foe, is both an autobiography and the story of his crusade. Of special interest is a letter to him and his wife from Ronald Reagan, who said, “Fred, you’re to be commended for your tireless dedication in trying to ensure the protection of freedom and human rights”. In 1996, Fred returned to Sydney, moving a few years later to Camden. He died of cerebrovascular disease at the age of 96 years. Consistent with his contrarian wit, he attributed his longevity to his complete lack of exercise, his high-stress lifestyle and his high-fat, high-salt, high-sugar diet. He is survived by his wife Lillian and children John (a general practitioner), Rosemary (a psychiatrist) and David (an airline pilot).

Derek H Meyers

A 77-year-old man with no significant medical history presented to the orthopaedic clinic of a metropolitan hospital with longstanding left mechanical knee pain. Examination and x-ray revealed features consistent with degenerative arthritis (Figure, A), and he subsequently underwent total knee arthroplasty. During surgery, a bluish-black pigmentation of the bone and the cartilage of the knee joint was noted (Figure, B). The patient’s surgery and recovery were uneventful. It was later discovered that he had a previously undiagnosed rare metabolic disorder, alkaptonuria, which affects one in 250 000 to 1 000 000 people worldwide.1 Alkaptonuria was one of the first inborn errors of metabolism to be described, in 1908.2 It is caused by mutations in the homogentisate 1,2-dioxygenase (HGD) gene, which results in a deficiency of HGD, which catabolises homogentisic acid (HGA). This leads to accumulation and deposition of HGA in cartilaginous tissues, causing a bluish-black discolouration (ochronosis).3 Ochronosis is generally asymptomatic, but ochronotic arthropathy due to deposition of pigments in the joints is common.3 The patient also had the characteristic ochronotic discolouration in the sclera (Figure, C), ear cartilage, fingernails and buccal mucosa, but did not report dark urine. The gene defect was not further investigated because of his age and excellent premorbid health status.

See-Seong Chang · Eugene T Ek · Vicki Pliatsios

Adolescence and obesity Overweight and obese adolescents and those who smoke are at greater risk of adult premature mortality, according to the results of a large, long-term Swedish study. In the 38-year study of almost 46 000 Swedish men from late adolescence onward, researchers analysed the effects of underweight, overweight, obesity, and smoking status on mortality. Incidence of premature death was lowest in normal-weight men and highest in obese men. Extremely underweight (BMI <17) participants also had a significantly increased risk of premature death. Risk gradually increased with the number of cigarettes smoked daily, and being obese was as hazardous as smoking more than 10 cigarettes a day. Despite these trends, there appeared to be no significant synergistic effects between BMI and smoking status, although the combination of heavy smoking and obesity was associated with a large increase in the risk of premature death. BMJ 2009; 338: b496 Allergy epidemic Peanut allergy is common and its incidence is increasing in Australia and around the world. Action in research and public health is required to understand and control this alarming epidemic, say Australian researchers. A retrospective study of over 700 patients with peanut allergy in the Australian Capital Territory showed that most allergies (90%) developed by the age of 72 months, and peanut allergy increased 2.5-fold between 1995 and 2007. Age of onset and severity of allergic reactions have not changed over time, suggesting that the observed increase is not an artefact of early presentation of milder cases. Later age of the first reaction to peanut was associated with an increased severity of reaction, including anaphylaxis, leading the authors to suggest that delayed introduction might actually increase the risk of more serious reactions. They conclude that longer follow-up of data is required to support this hypothesis, but that peanut allergy needs to be considered a public health issue, particularly in the face of the increasing incidence of this potentially life-long problem. J Allergy Clin Immunol Online; 12 Feb 2009 Guidance on guidelines The number of clinical practice guidelines published in recent years has been increasing, and such publications are often considered the pinnacle of appropriate care, prompting US researchers to analyse the evolution of recommendations and the levels of evidence on which guidelines are based. Using the joint cardiovascular practice guidelines of the American College of Cardiology and the American Heart Association between 1984 and 2008, the authors found that the number of recommendations increased by 48%, and that a minority of recommendations were based on level of evidence A, with most based on level of evidence C or expert opinion. They conclude that the process of developing guidelines needs to be improved, and that clinicians should be cautious when using recommendations supported by a tenuous evidence base. JAMA 2009; 301: 831-841 Fat, protein, carbs? The debate about the relative merits of weight-loss diets based on varying proportions of nutrients continues to rage in the popular media. Despite this interest, there is conflicting evidence in the scientific literature on the benefits of high-carbohydrate, low-fat and high-protein diets and, in particular, on their long-term effects on weight loss. In an attempt to shed light on the issue, US researchers designed a 2-year randomised controlled trial to compare the effects on bodyweight of various energy-reduced combinations of macronutrients. Over 800 overweight adults were randomly assigned to one of four diets. Two diets were low-fat and two high-fat; two were average-protein and two high-protein. Carbohydrates were added to the diets, ranging from 35% to 65% of energy intake, to allow a dose-response test, and group and individual instructional sessions were offered to all participants. At 2 years, the average weight loss was 4 kg and there was no significant difference between any of the groups in terms of weight loss, satiety, and hunger. Attendance at sessions was strongly associated with weight loss. The authors conclude that any calorie-restricted diet taught with persistence, and preferably tailored to individual preferences, can succeed. N Engl J Med 2009; 360: 859-873 Suicide and depression Suicidality appears to be distinguishable from depression and can be viewed as a separate construct, though the two are substantially correlated, say Australian researchers. In a community-based study of over 7000 people who completed depression and suicidality scales, researchers found that people can experience suicidal thoughts and behaviours independent of depression. The findings were stable across different ages and sexes. The authors suggest that suicidality should be conceptualised as a separate syndrome from depression, and that this should be reflected in disease classifications such as DSM and ICD. Aust N Z J Psychiatry 2009; 43: 208-215

Tanya Grassi

Med J Aust 2009; 190 (7 Suppl).