Volume 191 Issue 4

Supporting trainees more effectively will benefit doctors and patients In this issue of the Journal, Hore and colleagues discuss clinical supervision in postgraduate medical education.1 They identify multiple difficulties and signal the need for adequate training and supervision, and for environments that support such supervision. What is meant by supervision?Previous articles have discussed the concepts of clinical supervision and educational supervision. There are a number of definitions of supervision; a useful one is “the provision of guidance and feedback on matters of personal, professional and educational development in the context of the trainee’s experience and providing safe and appropriate patient care”.2 This definition links provision of care with personal, professional and educational enrichment. It is further underpinned by the notion of provision of guidance and feedback. Supervision can be considered to have at least three discrete functions: educational, supportive, and managerial or administrative. Supervision should be regular, structured and should relate to agreed-upon learning objectives.3 Is supervision of junior doctors important for patient care?There is evidence from the Netherlands and the United States that training in teaching skills results in positive changes in the teaching and supervisory behaviour of medical doctors.4,5 Additionally, when provided effectively, supervision not only improves trainees’ performance, but also improves patient outcomes.4,5 Health authorities are increasingly recognising that support of education and supervision may lead to better health outcomes. Indeed, closer to home, the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals (the Garling inquiry) identified a number of issues in the New South Wales health service;6 for example, Recommendation 30: Benchmarks which adequately measure the extent of the delivery of postgraduate clinical education and training should be included in performance agreements between NSW Health and area health services and statutory corporations.6 Is supervisory input into our doctors’ professional development important?The educational supervisor has been considered the most critical figure in ensuring the effectiveness of postgraduate medical training.7 Appropriate supervision demonstrates evidence of commitment by educational supervisors to trainees. Critical elements of effective supervision include: providing constructive feedback; offering career advice; helping set learning objectives; listening rather than talking; taking into account trainees’ individual needs; and being encouraging. This type of supervision leads to improved professional development among trainees.8 Is the environment within the health system supportive of supervision?Hore and colleagues’ article clearly shows that the Achilles heel of supervision is the environment within Australian hospitals in which supervision is delivered. They argue for the creation of systems, environments and cultures that support high standards of conduct and effective clinical supervision.1 The Royal Australasian College of Physicians, which trains the largest number of trainees in Australian hospitals, has recently developed a new basic training program called the PREP (Physician Readiness for Expert Practice) Program. The core aspect of this program is effective educational supervision provided by consultants to help trainees construct learning goals, reflect on their learning needs, work with their developing medical professionalism, and closely link their learning experience with the curricula objectives for training. This grand design has a fundamental flaw — it requires extensive supervision in the health sector. Currently, the health sector is struggling to provide the human and financial resources required for effective supervision. Given the evidence that effective supervision not only develops the medical professionalism of a trainee, but can also lead to improved safety and better health outcomes for patients, it would seem clear that the provision of adequate supervision for our trainees is a high priority for our health system. Several comments and recommendations in the Garling report support this, such as: It is absolutely clear to me that there is a culture of service delivery in most hospitals that does not value teaching and education and that effort needs to be made to overcome this culture. The current system for education and training, which is largely opportunistic and ad hoc, will only become more difficult to sustain as hospitals become busier, and in the area of medical education, the number of medical graduates increases. (paragraph 10.12) . . . In my view, what is required is the recognition of the importance of the role of clinical teacher in the provision of facilities for and the dedication of time for teaching. (paragraph 10.102)6 There are multiple demands on our health service. Attending the sick does take priority. However, an examination of the literature around how we prepare and train our doctors during their training programs quickly demonstrates that the provision of good supervision to these trainees yields multiple benefits in that they are better equipped for the work they do, and this will be reaped many times over during that individual’s professional life. There is a need to systematically address the issues of good supervision for our trainees, with a particular emphasis on supporting them educationally and professionally.

Kevin D Forsyth MD, PhD, FRACP

Regardless of how obstructive lung disease is labelled, targeting treatment to components of the problem is the best solution Three-quarters of deaths due to asthma in Australia occur among people aged 55 years or older.1,2 Many more deaths and hospitalisations in older people are attributed to chronic obstructive pulmonary disease (COPD).2 Between 1997 and 2003, 318 deaths per year were attributed to asthma and 5581 deaths per year were attributed to COPD among Australians aged 55 and over.2 How can we do better than we are now in dealing with this problem? First, we need to consider whether we are dealing with two separate problems, or one, or several. This is the subject of some controversy. It has been argued for many years that the terms “asthma” and “COPD” are not particularly useful for clinicians in defining a disease or syndrome, particularly in older people.3 However, the terms are entrenched in clinical usage and, in the case of asthma, general usage. Furthermore, separate guidelines have been promulgated for both conditions. People who are labelled as having asthma have diverse clinical characteristics, and some people with other disease labels have clinical characteristics similar to those labelled as having asthma. There are very few features of aetiology, pathology, natural history, or management strategy that are uniquely linked to the diagnostic labels of asthma or COPD. Our view is that we are dealing with a diverse range of disorders that cannot be adequately classified simply as either “asthma” or “COPD”. The real problem we face is obstructive lung disease, whether it carries the label asthma, COPD, emphysema, or chronic bronchitis. Obstructive lung disease exists as a heterogeneous disorder affecting people of all ages. The manifestations of the disease may include episodic breathlessness (with or without cough) and progressively worsening exertional breathlessness and airflow limitation. In some individuals, this may progress to respiratory failure. Avoidance of smoking prevents one form of the disease, reduces the rate of lung function decline, and improves treatment response in more reversible disease. Rigorous attention to occupational hygiene in high-risk workplaces can prevent some cases of the disease. Reducing indoor exposure to smoke and fumes from biomass fuels may also prevent some forms of obstructive lung disease.4 However, no other preventive strategies are supported by available evidence. The range of management strategies that are available may control the disease, but do not cure it. In clinical practice, the various labels for obstructive lung disease tend to be applied in a fairly haphazard manner.5,6 This is not only because it is difficult to distinguish them clinically but also because there appears to be little point in doing so. Clinical management is most often guided by other characteristics. Among all patients with obstructive lung disease, management is targeted at person-centred problems: for example, pulmonary rehabilitation for breathlessness and loss of physical condition;7 bronchodilators for airflow obstruction and hyperinflation; inhaled corticosteroids for airway inflammation; smoking cessation for smokers; and influenza vaccinations for all those who are at risk of exacerbations. There is also increasing recognition of the need to assess and manage systemic problems and relevant comorbidities in older people with obstructive airway disease.8 In addition to addressing patients’ current problems, assessing their future risk is also important, and anticipation of exacerbations and deterioration will facilitate planning and better management. Targeting treatment to components of the problem in this way may overcome the limitations of a diagnosis-centred approach, and accords with multicomponent-based approaches to illness that are effective in older people.9 Such an approach is also well suited to primary care, where patients present with symptoms, activity limitation and concerns about the impact of the disease on their daily life. Having established that we are dealing with a heterogeneous disease entity with a range of clinical problems, and solutions specific to these problems, what are the barriers to making progress with this disorder? There is evidence of generally poor diagnostic evaluation of symptomatic patients; inadequate availability of some effective therapies, particularly in disadvantaged populations1 and those in rural and remote areas; and lack of services for severely disabled (breathless) patients. Simple interventions such as educating patients on correct use of devices, vaccinations, and prompt treatment of infective exacerbations are not universally implemented. Patients with severe, end-stage airways disease often do not receive appropriate referral for oxygen therapy and frequently miss out on appropriate guidance and discussion of end-of-life issues.10 If these are the barriers to better outcomes for patients with obstructive lung disease, how do we overcome them? Diagnosis is the doorway to effective management and hence improved clinical outcomes. However, for some breathless patients, the correct diagnosis is elusive. Cardiac failure, obesity, anaemia and general unfitness, as well as obstructive lung disease, may individually or collectively cause breathlessness in older patients. Spirometry is crucial to the diagnosis of obstructive lung disease and assessment of its severity, and yet few patients who present with breathlessness have an assessment that includes this procedure. For example, only 6% of general practice encounters for asthma among adults include an assessment of lung function.1 The optimal mechanism for improving patients’ access to spirometry is yet to be established.11 Equipping, training and remunerating general practitioners for performing the procedure is one approach that has been tried12 and may prove more effective as practice nurses are deployed more widely. The alternative is to improve accessibility of specialist pulmonary function laboratories. This latter approach has the advantage of high standards of quality control and linking the procedure to expert interpretation. We need translational research studies to identify the most effective strategy for ensuring that all patients with undiagnosed breathlessness or suspected obstructive lung disease have a valid and reliable objective assessment of their lung function. In a substantial proportion of patients with obstructive lung disease, regular use of inhaled corticosteroids has been shown to be effective in improving a diverse range of clinical outcomes. In particular, patients with reversible airflow obstruction, eosinophilic inflammation,13 severe airflow obstruction and frequent exacerbations gain significant benefits from regular inhaled corticosteroid use.14,15 Research at the Australian Centre for Asthma Monitoring has shown that people who purchase inhaled corticosteroids at the concessional Pharmaceutical Benefits Scheme price are dispensed 2.5 times more prescriptions for these medications than those who pay the full (general beneficiary) price.16 While some of this difference may indicate unnecessary or excessive use, it is clear that a scheme that makes drugs from this class available at a reduced price to those who are most likely to benefit from them and cannot currently afford them will result in substantial health gains. Breathlessness is not only a distressing symptom but also a disabling one. People who are disabled due to breathlessness are poorly served in our community. Exercise-based pulmonary rehabilitation is one intervention that has been shown to help people with this problem. Although many tertiary care hospitals have established programs to deliver pulmonary rehabilitation, their location, predominantly in major centres, means that many people who stand to benefit from these programs cannot access them. We need improved transport services to bring severely breathless patients to the services they need. Surely this is more cost-effective than trying to deliver individualised pulmonary rehabilitation in the home. People who are disabled by breathlessness, either temporarily during exacerbations or permanently, are often institutionalised because they cannot maintain their homes or perform self-care tasks unaided. Provision of enhanced home-help and self-care assistance would enable some of these people to fulfil their desire to stay at home and away from hospitals and other care institutions. As National Asthma Week (1–7 September 2009) approaches, it is time to act now to adopt policies promoting a holistic, person-centred and problem-oriented approach to the care of older people with obstructive lung disease, whether it is labelled as asthma or COPD, or not labelled at all.

Guy B Marks PhD, FRACP · Leanne M Poulos BMedSc(Hons), MPH(Hons) · Christine R Jenkins MD, FRACP · Peter G Gibson MB BS, FRACP

Large-scale randomised controlled trials in Europe and the United States are informing evidence-based clinical advice Population-wide prostate-specific antigen (PSA) screening for prostate cancer is not recommended in Australia, primarily because of the lack of large-scale randomised trial evidence of a beneficial effect on prostate cancer mortality and the known harms of overdiagnosis and unnecessary treatment that may ensue. In spite of this, PSA testing is common; the limited evidence available suggests that more than 50% of Australian men over the age of 50 years have had the test.1,2 In March 2009, the New England Journal of Medicine published the first articles from two large, randomised controlled trials to report on whether screening for PSA reduces the risk of death from prostate cancer.3,4 It was hoped that these long expected — albeit not final — reports from the European Randomized Study of Screening for Prostate Cancer and the prostate cancer component of the US Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (Box) would answer outstanding questions about the efficacy of prostate cancer screening. In the European trial, 162 243 men aged 55–69 years were randomly allocated to receive an invitation to undergo PSA screening about once every 4 years or usual care. After a median of 9 years of follow-up, there were 71% more cases of prostate cancer and a 20% reduction in the risk of death from prostate cancer in those allocated to screening than in those receiving usual care (relative risk [RR], 0.80; 95% CI, 0.65–0.98), but no reduction in overall mortality (RR, 0.99; 95% CI, 0.97–1.02). In the US trial, 76 693 men aged 55–74 years were randomly allocated to receive an annual PSA test for 6 years and an annual digital rectal examination for 4 years, or usual care. After a minimum of 7 years of follow-up, there were 22% more cases of prostate cancer but no reduction in the risk of death from prostate cancer in those randomly allocated to screening compared with usual care (RR, 1.13; 95% CI, 0.75–1.70). The trials have a number of notable differences, including length of follow-up, screening interval, PSA threshold for recommending biopsy, and proportion of the control group screened (Box). Although these differences prevent easy comparison of their results, it is important to note that the relative risks for prostate cancer mortality with screening do not differ significantly between the trials (χ12 = 2.19, P = 0.14), and that the 95% confidence interval about their summary relative risk, estimated using fixed-effects meta-analysis, includes unity (summary RR, 0.86; 95% CI, 0.71–1.03) (Box). These trials have important limitations. First, their combined power is low, so that a moderate beneficial effect of screening cannot be established or excluded without longer follow-up or other trials. Moreover, in the US trial, although 85% of the screening arm had a PSA test, so too did 52% of the control arm. With only a 33% difference in screening between the groups, the power of the study to detect an effect of screening was substantially reduced. Screening in the control arm of the European trial was not reported. Second, the trials are yet to report on other outcomes of PSA screening, including major treatment side effects, which are crucial to deciding whether large-scale screening is appropriate. The risk–benefit equation for PSA screening is complex. The major potential benefit is a reduction in risk of death from prostate cancer. The main risks are physical or psychological complications of screening and detection, overdiagnosis and concomitant treatment side effects, and unwarranted costs. Some elements of these risks were reported in the European trial. Overall, 16.2% of all PSA tests gave positive results and presumably led to biopsy, and 75.9% of these were found to be false-positives.4 The risk of undergoing radical prostatectomy in the screening group was nearly three times that in the control group (277 versus 100 per 10 000 men).5 To prevent one prostate cancer death, 1410 men needed to be screened, and 48 men needed to be treated.4 Although the number needed to screen compares favourably with that for breast6 and colorectal7 cancer, the issues around overdiagnosis are probably greater for prostate cancer. The cost-effectiveness of PSA screening is yet to be established. Even if it were shown to be favourable, the appropriate testing interval, target age range and PSA cut-off levels are not known. Hence, the persisting uncertainty about the effect of PSA testing on mortality is compounded by other outstanding questions. What are the implications of the trial results for men and their doctors? The findings of these studies are finely balanced. Before they were reported, we had no valid randomised trial evidence; now we have evidence, but it is inconclusive and consistent with a modest but uncertain reduction in prostate cancer mortality at 10 years. Both trials can continue to inform us with longer-term follow-up and comprehensive assessment of all treatment outcomes. What is the best advice that we can give now about PSA screening for prostate cancer? Population-wide PSA screening should not be recommended. The findings from these two studies provide important evidence but are not adequate to allow a conclusion either for or against a benefit of screening. In addition, they reveal potentially high levels of overdiagnosis and its consequent costs and harm. For individual men considering PSA screening, the potential risks and benefits should be carefully considered. Information from these trials and other studies, and data on the potential of treatments for localised prostate cancer to affect quality of life should be communicated, stating that uncertainty continues to cloud this issue. Clearly, men with a life expectancy of less than 10 years are particularly unlikely to benefit from screening, but those who wish to be tested after considering the evidence available should be given the test. Clinical practice includes treating patient concerns and worries, so that if a well informed man really wants to know whether he has prostate cancer, proceeding with PSA testing is a reasonable step. GPs play a crucial role in disclosing the uncertainties of PSA testing and in supporting men in their decision making. Research assumes even greater importance when decision making is clouded by uncertainty. There is a clear need for more evidence on all effects of PSA testing. A greater understanding of decision making around PSA testing is also needed,8 as is better information to help men and their doctors address the issue. Whether screening for prostate cancer lowers risk of death from prostate cancer remains uncertain. However, our uncertainty is increasingly based on evidence, which is far preferable to uncertainty based on ignorance. Characteristics of two published randomised controlled trials of the effect of PSA screening on prostate cancer mortality ERSPC (n = 162 243) PLCO (n = 76 693) Trial period 1991–2003 1993–2001 Age range (years) 55–69 55–74 No. of participants (S v C) 72 890 v 89 353 38 343 v 38 350 Average screening interval 4 years 1 year PSA cut-off for biopsy 3 ng/mL* 4 ng/mL Tested with PSA (S v C) 82% v not stated 85% v 52% Prostate cancers (no.) 5990 v 4307 2820 v 2322 Cumulative incidence of prostate cancer (S v C) 8.2% v 4.8% 7.4% v 6.1% RR (95% CI) of incident prostate cancer in S v C 1.71 (1.64–1.78)† 1.22 (1.16-1.29) No. of prostate cancer deaths (S v C) 214 v 326 50 v 44 Prostate cancer death rate (per 10 000 person-years) (S v C) 3.3 v 4.1 2.0 v 1.7 RR of prostate cancer death in S v C (95% CI) 0.80 (0.65–0.98) 1.13 (0.75–1.70) Summary RR of prostate cancer death in S v C (95% CI) 0.86 (0.71–1.03)‡ PSA = prostate-specific antigen. ERSPC = European Randomized Study of Screening for Prostate Cancer. PLCO = prostate cancer component of the US Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial. S = screening group. C = control group. RR = relative risk. * Two centres had slightly different cut-offs, of around 4 ng/mL. † Calculated from data presented in the report of the ERSPC, Table 1, using a Poisson approximation for the variance. ‡ χ2 (heterogeneity) = 2.19, P = 0.14.

David P Smith BA, MPH, PhD · Emily Banks MB BS(Hons), PhD, FAFPHM · Mark S Clements BSc(Hons), PhD · Robert A Gardiner MD, FRCS, FRACS · Bruce K Armstrong MB BS(Hons), DPhil, FAFPHM

Objective: To provide an estimate of the morbidity and mortality resulting from abdominal overweight and obesity in the Australian population.Design and setting: Prospective, national, population-based study (the Australian Diabetes, Obesity and Lifestyle [AusDiab] study).Participants: 6072 men and women aged ≥ 25 years at study entry between May 1999 and December 2000, and aged ≤ 75 years, not pregnant and for whom there were waist circumference data at the follow-up survey between June 2004 and December 2005.Main outcome measures: Incident health outcomes (type 2 diabetes, hypertension, dyslipidaemia, the metabolic syndrome and cardiovascular diseases) at 5 years and mortality at 8 years. Comparison of outcome measures between those classified as abdominally overweight or obese and those with a normal waist circumference at baseline, and across quintiles of waist circumference, and (for mortality only) waist-to-hip ratio.Results: Abdominal obesity was associated with odds ratios of between 2 and 5 for incident type 2 diabetes, dyslipidaemia, hypertension and the metabolic syndrome. The risk of myocardial infarction among obese participants was similarly increased in men (hazard ratio [HR], 2.75; 95% CI, 1.08–7.03), but not women (HR, 1.43; 95% CI, 0.37–5.50). Abdominal obesity-related population attributable fractions for these outcomes ranged from 13% to 47%, and were highest for type 2 diabetes. No significant associations were observed between all-cause mortality and increasing quintiles of abdominal obesity.Conclusions: Our findings confirm that abdominal obesity confers a considerably heightened risk for type 2 diabetes, the metabolic syndrome (as well as its components) and cardiovascular disease, and they provide important information that enables a more precise estimate of the burden of disease attributable to obesity in Australia.

Adrian J Cameron MPH · David W Dunstan PhD · Neville Owen PhD · Paul Z Zimmet MD, PhD · Elizabeth L M Barr MPH · Andrew M Tonkin MD · Dianna J Magliano PhD · Shirley G Murray GradDipPractMan · Timothy A Welborn PhD · Jonathan E Shaw MD

Objective: To investigate the frequency, goals and outcomes of second-opinion consultations at the Sydney Cancer Centre.Design, setting and participants: A questionnaire-based study of patients who registered to see a medical oncologist at the Sydney Cancer Centre between January 2006 and January 2008 and who were seeking a second opinion.Main outcome measures: Proportion and demographic characteristics of patients who had previously seen a medical oncologist and who stated they were seeking a second opinion.Results: 123 of 1892 new patients (6.5%) stated that they were seeking a second opinion, of whom 22 declined study participation, were excluded from study participation or had been referred specifically for enrolment in a particular clinical trial. Of the remaining 101 patients, 77 completed a questionnaire; 59 were women and 26 had a university degree. Reasons for seeking second opinions included: to obtain information related to treatment (54 patients), for reassurance about diagnosis or treatment (47), and dissatisfaction with the information given by the first medical oncologist (24). Sixty-four patients reported that they received new information at the second-opinion consultation, with 45 identifying discussion of treatment options and 34 identifying discussion of future or prognosis. Fifty-one patients reported how the second-opinion consultation differed from the first, identifying it as longer (24), and indicating that the oncologist answered concerns (26). Most patients were aware of multidisciplinary teams and treatment guidelines, but fewer had read guidelines.Conclusions: Patients seeking a second opinion from a medical oncologist are typically more educated, younger and female, probably due to preferences for more detailed information. The most common reasons for seeking a second opinion were to obtain additional information or reassurance about recommended management.

Martin H N Tattersall MD, MSc, FRACP · Rachel F Dear MB BS, FRACP · Jesse Jansen MA, PhD · Heather L Shepherd PhD · Rhonda J Devine RN · Lisa G Horvath MB, FRACP, PhD · Michael J Boyer MB, FRACP, PhD

A 71-year-old man who presented to hospital with chest pain and a history of cardiovascular disease was repeatedly hospitalised over the course of a month for care that included multiple investigations, intensive care, transfer to and from a metropolitan hospital, discharge, and readmissions for collapse, hemiparesis, and vision change. The medical team excluded underlying disease related to his initial chest pain and subsequent neurological symptoms. A search for (undisclosed) prior hospitalisations revealed multiple previous admissions and invasive investigations at hospitals across Australia, resulting in a diagnosis of Munchausen syndrome. Assuming that, despite interventions, patients with Munchausen syndrome or somatoform disorders often continue to seek care at other hospitals, we discuss the implications of this patient’s behaviour for the health care system, society, and the risk to his own health. In our view, this case highlights conflicts between privacy legislation and doctors’ mandates to protect the patient from harm, as well as their duty to attend to the financial viability of health services by communicating with other potential health care providers. The health care system and similar patients may benefit from efforts to educate doctors about this spectrum of disorders and from considering the implementation of a highly confidential, structured notification system.

Dawn E DeWitt MD, FACP, FRACP · Stephanie A Ward MB BS · Sandeep Prabhu MB BS(Hons), LLB(Hons) · Bruce Warton MB BS, GradDipHealth

Patients who present repeatedly for care with medically unexplained symptoms raise challenges for the health system. One proposed strategy for dealing with such patients is the introduction of electronic medical records (EMRs) to identify these patients and thus limit the demands on resources their management involves. This measure may ultimately be appropriate but fails to consider equally critical core issues in psychiatric ethics. Identifying patients as “somatisers” invites a problematic relaxation of clinical vigilance, increasing the likelihood that an actual life-threatening medical problem will not be identified. Management of such patients requires regular, structured therapeutic contact with a skilled mental health clinician, that is independent of the patient’s distress level. Psychiatric problems and medical problems are frequently seen as two distinct, unrelated categories. This is a false dichotomy, as mental health and physical health are interdependent. Given patient privacy considerations, EMRs would be unlikely to reveal the kind of sensitive mental health information needed for the identification and management of somatising patients in busy health systems. Cost-effective interventions for somatising patients’ problematic behaviour, such as structured clinical intervention, antidepressant medication and cognitive behaviour therapy, are available at a fraction of the cost of EMR systems. Citing cost savings as a justification for violating the privacy of mental health patients compounds the manifest injustice these patients already face in the health system.

Michael D Robertson MB BS(Hons), FRANZCP · Ian H Kerridge MPhil, FRACP, FRCPA

Clinical supervision is a vital part of postgraduate medical education. Without it, trainees may not learn effectively from their experiences; this may lead to acceptance by registrars and junior doctors of lower standards of care. Currently, supervision is provided by consultants to registrars and junior doctors, and by registrars to junior doctors. Evidence suggests that the clinical supervision provided to postgraduate doctors is inadequate. Registrars and juniors doctors have the right to expect supervision in the workplace. Impediments to the provision of clinical supervision include competing demands of hospital service provision on trainees and supervisors, lack of clarity of job descriptions, private versus public commitments of supervisors and lack of interest. Supervisors should be trained in the process of supervision and provided with the time and resources to conduct it. Those being supervised should be provided with clear expectations of the process. We need to create and develop systems, environments and cultures that support high standards of conduct and effective clinical supervision. These systems must ensure the right to supervision, feedback, support, decent working conditions and respect for both trainees and their supervisors.

Craig T Hore MB BS, FACEM, FJFICM · William Lancashire MB BS, FRACGP, CCFP · Robert G Fassett MB BS, PhD, FRACP

We believe that a lack of adequate alcohol measures research is partly responsible for the failure of the Australian Government to pass legislation to equalise the excise applied to straight spirits and premixed spirits (“alcopops”). Current measures only assess total alcohol consumption rather than patterns of consumption, and do not adequately identify alcohol-related harm at a population level. Possible solutions include making further efforts to develop applied community-level measures and responding to the repeated calls for national collection and analysis of alcohol sales data. With the Australian Government able to retain the alcopops excise raised to date, there is a unique opportunity for greater collaboration between researchers and government to ensure high-quality and publicly relevant research is funded and conducted to address the current lack of adequate measures research. Measures research is a priority, as this is the basis for increasing the accuracy of data with which more cost-effective public policy and initiatives can be formulated and evaluated. The challenge is for researchers and the Australian Government to align their expertise to ensure revenue from public taxes engenders measurable public health benefit.

Anthony Shakeshaft PhD · Christopher M Doran PhD · Joshua Byrnes BEcon

The best available evidence for making decisions about prostate-specific antigen (PSA) screening comes from two recent randomised trials, the larger and more robust of which showed that PSA screening reduced the risk of death from prostate cancer, but that the absolute benefit was small, and the chance of prostate cancer being diagnosed and treated (even if biologically unimportant) was increased by a much larger amount. The important question is whether the small reduction in numbers of deaths outweighs the harms inherent in the diagnosis and treatment of many additional cancers. Men considering screening should understand both its possible benefit and its possible harms, and that the harms are more immediate than any benefit. The challenge for future research is to find a test that reliably detects prostate cancers that are curable if they are treated early and life-threatening if they are not.

Alexandra L Barratt MB BS, MPH, PhD · Martin R Stockler MB BS, MSc(ClinEpi), FRACP

The case that established the lawfulness of terminating pregnancy to preserve women’s health Aleck W Bourne (4 Jun 1886 – 27 Dec 1974) “I . . . decided to bring forward a test case, in which there would be no real danger to life . . . but in which one might strongly suspect great danger to health. I was also concerned to establish in the eyes of the Law that mental health was just as important as physical health, and in certain cases perhaps even more so.”4 Europe, July 1938: Hitler and his Nuremberg rallies are gaining strength; invasion of Czechoslovakia seems imminent; German concentration camps are under construction; and Chamberlain is seeking appeasement. Meanwhile, in London, the Old Bailey criminal court is staging an unusual trial. In the dock of the austere Edwardian building stands Mr Aleck Bourne, FRCS, FRCOG, Consultant Gynaecologist to London’s St Mary’s Hospital, charged under the Offences Against the Person Act 1861 with unlawfully using an instrument to procure an abortion.1 Following the introduction of the harsh measures of the 1861 Act, prosecutions for abortion had been relatively common.2 However, in virtually all cases the defendants were women with little or no medical training, who performed abortions for small fees — so-called backstreet abortionists.3 At any one time, around 50 women convicted of the crime were incarcerated for up to 14 years in London’s Holloway Prison. Motivation was not necessarily purely financial. One woman said, “I knew it was against the law but I didn’t think it was wrong. Women have to help each other”.2 Bourne, an eminent medical practitioner, was different, though he shared some of the altruistic motivation, performing the procedure with no thought of a fee. On 14 June 1938, he openly carried out an abortion in St Mary’s. The 1861 Act stated that “therapeutic” abortion was legal — justified if the woman’s life was in danger — but the definition of “therapeutic” was unclear. Very familiar with the disastrous consequences of unsafe abortion for many women, Bourne had previously performed, without publicity, a small number of “therapeutic” abortions he believed to be justified on strong medical grounds. He now felt an urgent need to test the law in court, and was prepared to risk conviction to do so.4 Bourne’s 1975 obituary in the British Medical Journal described him as “a man of great compassion and understanding”.5 In May 1938, he was asked to see a girl of 14 years who had been raped by five officers of the Royal Horse Guards at their London barracks. They had enticed her there promising to show her a horse with a green tail — she was clearly an inexperienced child. Following the rape, the girl and her parents had first sought treatment at St Thomas’s Hospital. It soon became evident that the girl was pregnant, and abortion was requested. The response of the consultant at St Thomas’s was that, as the rapists were officers and therefore apparently gentlemen, “she might be carrying a future Prime Minister of England”, and anyway, “girls always lead men on”. He refused the request.1 At St Mary’s, Bourne had no such class illusions. He carefully considered the case, noting that the girl was “not mentally defective and not of the prostitute type”.1 Bourne concluded that, although a plea of danger to her life could not be substantiated, termination of the pregnancy was justified because of the risks to her physical and mental health. He could not, he later told the Court, “draw a line between danger to life and danger to health; if one waited for danger to life the woman would be past assistance”.1 He performed a surgical curettage, then deliberately informed the police.1 Justice Macnaghten presided over the case. Bourne’s defence lawyers called several of his colleagues, who testified that there were significant risks of both physical and psychological damage if the pregnancy had continued. Macnaghten took the view that, if there was “unlawful” abortion, there should also be situations in which abortion was “lawful”. He extended the meaning of “the life of the woman” to include her health, and in his directions to the jury said that “if the doctor is of [the] opinion on reasonable grounds . . . that the probable consequences . . . will be to make the woman a physical and mental wreck, the jury are quite entitled to take the view that the doctor . . . is operating for the purpose of preserving the life of the mother”.2 Bourne was acquitted, and his actions were widely applauded by the medical profession. The Lancet commented that, although the acquittal “left the legal position . . . only a little less obscure than before . . . [c]ompulsory pregnancy for the victims of criminal assaults . . . is an idea abhorrent to civilised Society”.6 Bourne was commended for “an example of disinterested conduct in consonance with the highest traditions of the profession”.6 A week later, Bourne himself wrote to the Lancet: “The Attorney General admitted that abortion is legally recognised when life is in danger. Now we know it is also admitted when there is serious danger to health . . . the majority of the profession would feel they are on safer ground if the precedent just established were incorporated in a new Act, passed in days when much more knowledge of medicine, surgery and psychology is available than was the case in 1861”.4 In the same issue, another writer called for “the law [to be] amended in an open and straightforward way to meet the demands of justice and humanity”.7 However, it would be 30 years before such changes came to pass. In that time, R v Bourne (1939), while not providing complete legal clarity for practitioners, nevertheless acted as a definite precedent — in Australia and the United States as well as in Britain — allowing doctors to undertake therapeutic abortions when they honestly believed the woman’s health was at risk if the pregnancy continued. The Bourne case was significant in the 1969 landmark ruling of Justice Menhennitt in the prosecution of Dr Ken Davidson for procuring abortions in Victoria.8 Menhennitt believed that Macnaghten had used the principle of “necessity” in composing his judgment, meaning that an act which would usually be a crime can be excused if it was done to avoid otherwise inevitable and undesirable consequences. Menhennitt ruled that abortion would be unlawful if the person performing the abortion did not honestly believe on reasonable grounds that the abortion was necessary to preserve the woman from serious danger to her life or her physical or mental health, or if the person did not honestly believe that in the circumstances the abortion was in proportion to the danger to be averted.9 Menhennitt’s directions to the jury were favourable to Dr Davidson, who was acquitted. The Menhennitt ruling became the basis on which abortion was safely and openly offered to women in Victoria from 1969 onwards, and subsequently the basis for the 1975 Levine and 1986 McGuire judgments, which similarly made abortion more accessible to women in New South Wales and Queensland, respectively.9 Nevertheless, it is worth noting that abortion remains in criminal legislation in NSW and Queensland, and was only removed from the Victorian Crimes Act 1958 in late 2008. In England, the decision in R v Bourne made little immediate difference to most women seeking abortion, whatever their reasons — economic, social or medical. Backstreet abortion was as common as ever, with a high mortality for women, although those who could afford it could obtain a safer surgical procedure from a discreet private clinic. This was the subject of the film Vera Drake (2004) in which Vera, an English factory worker who, in the early 1950s, provided abortions at no charge for poor women in their own homes, went to prison, whereas the doctor running a lucrative private abortion practice faced no such penalty.10 During the 1960s, there was increasing pressure from the new women’s liberation movement and other groups for changes to abortion law in Britain. There was also concern among some politicians about the huge discrepancy between the law and the practice of abortion, and this led Liberal MP David Steel to introduce a bill to decriminalise abortion that resulted in the The Abortion Act 1967 (UK). This Act, with some modifications since, allows induced abortion when continuing the pregnancy poses a greater risk to the life or physical or mental health of the woman, or her existing family or children, than if abortion is carried out. This legislation obviously built on the principles underlying the ruling in the Bourne case.11 Interestingly, Bourne himself did not support the introduction of the 1967 Act. He had written in 1938 that: “I would not have it believed that I have worked for a loose interpretation of the law”,4 and after 1967 he campaigned for the Society for the Protection of the Unborn Child, believing the new legislation to be too liberal. As noted in his obituary, “he never lacked the courage to express in public views which he held with great conviction and sincerity”.5 He made many contributions to the wider sphere of his discipline, including the struggle to have the importance of psychological factors recognised in gynaecological disorders. A keen yachtsman who often invited his junior staff to join him on board, he retired, reluctantly, from both active medical practice and sailing in 1964, at the age of 77 years. The place of R v Bourne in the history of the decriminalisation of abortion in the English-speaking world should not be forgotten. The British Medical Journal noted: “Bourne rightly deserves great credit for his determined and courageous action . . . based as it was on a deep sense of responsibility and compassionate understanding”.5

Caroline M de Costa FRANZCOG, FRCOG, MPH

West Nile virus is an arbovirus that has caused large outbreaks of febrile illness, meningitis and encephalitis in Europe, North America and the Middle East. We describe the first laboratory-confirmed human case of West Nile virus infection in Australia, in a 58-year-old tourist who was almost certainly infected in Israel. The case is a reminder of the need to consider exotic pathogens in travellers and of the risk of introducing new pathogens into Australia. Clinical recordA 58-year-old man presented to the emergency department of our hospital with chills, malaise, myalgia and epigastric pain. He was a tourist from Israel who had arrived in Australia with his family 3 days previously to visit relatives. The family flew directly from Tel Aviv to Melbourne, with a brief transit stop in Hong Kong airport. The patient reported a 5-day history of low-grade fevers, malaise, headache and epigastric discomfort, which started before he left Israel. He was previously well with no significant past medical history. He resided on a large cooperative farm in the southern district of Israel but worked in administration, with minimal contact with farm animals. He was not taking any regular medications, consumed alcohol infrequently and was a non-smoker. On examination, he had a temperature of 37.8°C and a diffuse erythematous macular rash. He was diagnosed with “viral illness”, treated symptomatically and discharged from the emergency department. On Day 7 of the illness, the patient re-presented to the emergency department increasingly unwell. Symptoms now included rigors, headache, dizziness and ear pain. On examination, he had a fever (temperature, 39.6°C), but no neck stiffness, photophobia or focal neurological deficit. After investigation and stabilisation in the emergency department, he was transferred to a ward for ongoing investigation by the infectious diseases team. Supportive care was instituted. Over the next 24 hours, the patient’s condition deteriorated with ongoing fevers and the onset of mild delirium and ataxia. A presumptive diagnosis of encephalitis was made, and diagnostic investigations were undertaken. Acyclovir was commenced empirically for herpes simplex encephalitis until this diagnosis was excluded. The patient’s fever began to resolve by Day 10 of the illness, and he was discharged after 18 days in hospital with mild ataxia. At outpatient review 2 weeks after discharge, he had persisting lethargy and mild ataxia. He returned to Israel with his family, where he underwent outpatient rehabilitation. InvestigationsExtensive investigations were undertaken to diagnose the aetiology of the encephalitis. Cerebrospinal fluid (CSF) sampled on Day 10 of the illness showed leukocytosis (polymorphs, 2 × 106/L; lymphocytes, 75 × 106/L; unidentified cells 12 × 106/L; and erythrocytes, 90 × 106/L), raised protein level (0.84 g/L; reference range [RR], 0.15–0.4 g/L), but a glucose level in the reference range (3.7 mmol/L; RR, 2.5–4.5 mmol/L). However, culture and polymerase chain reaction (PCR) tests for common viral and mycobacterial pathogens gave negative results. Serological testing of acute and convalescent blood samples for common viral and bacterial causes of encephalitis showed no acute infection. Appearance of the brain on magnetic resonance imaging (MRI) was unremarkable. Diagnosis of West Nile virusPaired sera from Day 9 and Day 31 of the illness were tested in parallel in a flavivirus group-reactive enzyme-linked immunosorbent assay (ELISA) for IgG and IgM. This showed a fourfold rise in IgG titre, and IgM seroconversion. The sera were then tested against a panel of flaviviruses for total antibody (by neutralisation) and for IgG and IgM (by immunofluorescence). The strongest reaction by immunofluorescence was against the New York 99 strain of West Nile virus (WNV; Box 1); seroconversion to this virus was confirmed by neutralisation (“gold standard”) tests (Box 2). A stored CSF sample tested positive for IgM against WNV by immunofluorescence. Flavivirus RNA was not detected in CSF or serum by PCR testing. DiscussionThis is the first report of a laboratory-confirmed human importation of WNV infection in Australia. The only previously diagnosed case of acute WNV infection in Australia was in a horse imported for the breeding season, which acquired the infection overseas but became symptomatic on arrival (unpublished data, Arbovirus Emerging Diseases Unit, CIDMLS, Westmead Hospital, Sydney, NSW). WNV transmission has not been recorded in Australia. WNV is a single-stranded RNA flavivirus that was first isolated in 1937 from a patient with fever in the West Nile District of Uganda.1 The virus exists in a bird–mosquito–bird cycle, with wild birds as the amplifying host and reservoir.2 It has been isolated from 43 species of mosquito, mostly bird-feeding members of the Culex genus. Humans and other mammals are incidental hosts, when bitten by infected mosquitoes. Since first described, WNV has spread widely, with an associated dramatic increase in disease severity.3,4 It is found in Africa, Europe and the Middle East, with large outbreaks identified during the past decade in Romania, North America and Israel.5-7 About 80% of patients with WNV infection are asymptomatic. The incubation period for symptomatic disease is 2–14 days. “West Nile fever” is a non-specific febrile illness that includes headache, myalgia, and occasional gastrointestinal symptoms and usually resolves spontaneously in less than a week.8 Acute neurological illness is uncommon, occurring in fewer than 1% of infections, and can present with meningitis, encephalitis or a poliomyelitis-like acute flaccid paralysis.9 Our patient was almost certainly infected in Israel, where WNV is endemic, with episodic outbreaks reported since the 1950s, most recently in 2000.7 Israel is the likely origin of the WNV strain now circulating widely in North America.6 In Australia, WNV is not routinely considered in locally acquired encephalitis but was investigated in our patient because of the country where he acquired the illness. Close communication was needed with the testing laboratory to convey a more detailed history and clinical description than is usual on a standard request form. The most frequent arboviral cause of encephalitis in Australia is Murray Valley encephalitis virus, which is endemic in northern Western Australia, the Northern Territory and northern Queensland, and has epidemic activity in southern Australia.10 Less common arboviral causes of locally acquired encephalitis include Japanese encephalitis virus and Kunjin virus.11 The latter shares 80% of its genome with WNV and has been classified as a subtype of WNV.12 It is endemic in northern tropical regions of Australia,13 and the usual presentation is as a febrile illness; it is a rare cause of encephalitis.11 There have been no reports of locally acquired flavivirus in Melbourne, Victoria, where our patient resided while in Australia. Infection with WNV was diagnosed retrospectively in our patient based on serological testing of acute and convalescent sera. WNV IgM concentration was then measured in a stored CSF sample. The initial low-positive serological results for flavivirus group IgG suggested the patient had previously been infected with another member of the flavivirus family. The fourfold rise in IgG titre and new detection of IgM antibodies to WNV indicated this presentation was a new infection. The strongest reaction was to the New York 99 strain of WNV, which is closely related to strains isolated in Israel. Reactions to the Sarafend strain of WNV and the closely related Kunjin virus were significantly weaker. Negative PCR results are common in WNV infection because of the low-level transient viraemia of WNV.8 Similarly, only about 30% of patients have abnormal MRI findings.8 Our patient’s presentation illustrates the common clinical features of encephalitis. Fever, headache, personality change or delirium and altered conscious state are typical, and focal neurological deficits and seizures may also occur.14 The onset can be gradual. In this case, encephalitis was diagnosed on Day 9 of the illness. Initially, headache and dizziness were attributed to systemic infection until further neurological symptoms became apparent. The CSF findings were also typical of encephalitis, with an elevated white cell count and protein concentration, and glucose concentration in the reference range.14 The likelihood of WNV causing encephalitis rather than an isolated febrile illness or meningitis increases with advanced age.9 From a public health perspective, this case raises the question of whether WNV could be introduced into Australia. Culex mosquitoes are distributed widely throughout the country, and recent research has confirmed that Australian Culex mosquitoes can be infected with, and transmit, the North American strain of WNV.15 However, because of the similarity between WNV and Kunjin virus, antibodies to the latter in vertebrate hosts may limit the infectivity and establishment of WNV in the Australian environment, depending on the geographic distribution of Kunjin virus.16 The type of animal harbouring, and thus importing, WNV is also important. Some research shows humans are likely to be “dead end hosts”, with a level of viraemia that is too low to transmit to an uninfected mosquito.17 This suggests the risk of secondary cases from our patient was very low. The inadvertent or illegal importation of infected mosquitoes or birds would pose a far greater risk of introducing WNV into Australia. This is the first human case of laboratory-confirmed WNV infection recorded in Australia. It highlights the importance of considering the geographic origin of illness in travellers and is a reminder of the various arboviral causes of encephalitis. It is also a reminder of the possibility of international travellers, human or otherwise, introducing new infective agents. Fortunately, spread of the virus beyond the index patient was unlikely in this case. We urge vigilance regarding the possible introduction of new pathogens to the Australian environment. Any concern should be reported promptly to the relevant state or territory authorities. 1 West Nile virus Transmission electron micrograph of the West Nile virus (from another case). (Original image, Cynthia Goldsmith, Centers for Disease Control and Prevention, Atlanta, Ga, USA.) 2 Antibody titres against a range of flaviviruses* in the patient’s acute (Day 9) and convalescent (Day 31) sera Antibody assay Day 9 Day 31 Enzyme-linked immunosorbent assay Flavivirus group IgG 100 400 IgM < 100 800 Immunofluorescence test West Nile virus (New York 99) IgG < 10 640 IgM < 10 40 West Nile virus (Sarafend) IgG < 10 20 IgM < 10 < 10 Kunjin virus IgG < 10 20 IgM < 10 < 10 Murray Valley encephalitis virus IgG < 10 < 10 IgM < 10 < 10 Neutralisation test West Nile virus (New York 99) < 10 2560 West Nile virus (Sarafend) < 10 40 Kunjin virus < 10 80 * Sera were tested against representatives of a range of West Nile virus groups: New York 99 (Lineage 1, Clade 1a); Kunjin (Lineage 1, Clade 1b), and Sarafend (Lineage 2).

Benjamin A Rogers MB BS · Linda Hueston MSc · Irani Ratnam MB BS, FRACP

To the Editor: Following the letter by Kitson et al, about a patient with asymptomatic ocular syphilis,1 we describe another unusual presentation of syphilis, with perioptic neuritis that mimicked papilloedema. A 28-year-old man presented with blurry central vision of his right eye on waking. He had had flu-like symptoms 2 days before presentation. There were no symptoms suggestive of meningitis, no raised intracranial pressure and no obvious ocular infection or inflammation. He had been diagnosed with type 2 diabetes mellitus at age 15 years, and had no known microvascular complications. His only medication was metformin. His visual acuity was 6/12 in the right eye and 6/6 in the left. The right eye had an enlarged blind spot with a small paracentral scotoma, with a central relative scotoma to red. The visual field in the left eye was normal. There was no relative afferent pupillary defect, and the anterior chambers were normal. Fundoscopy confirmed bilateral swelling of the optic discs (Box). Computed tomography and magnetic resonance imaging of the brain excluded space-occupying lesions and demyelination. Examination of the cerebrospinal fluid (CSF) showed: normal opening pressure; a white cell count of 66 × 109/L (reference range, 4–11 × 109/L), 100% lymphocytes; a protein concentration of 1.12 g/L (reference range, 0.15–0.45 g/L); a glucose concentration of 8.9 mmol/L (reference range, 2.7–4.4 mmol/L); and no bacterial growth. Findings of a baseline blood analysis were normal, but with an elevated glycated haemoglobin (HbA1c) level of 10.5% (reference range, < 6%), indicating poorly controlled diabetes. We thus initially considered diabetic papillopathy and non-arteritic ischaemic optic neuropathy, but the patient subsequently (about a week later, after most other investigations gave negative results) reported having had unprotected sexual intercourse with different men about 5 months previously. He recalled having a transient palmar maculopapular rash 2 months before presentation. Neurosyphilis was then confirmed with a strongly positive result on an absorbed fluorescent treponemal antibody (FTA-ABS) test in CSF. Results of serological tests for syphilis were positive (reactive [3+] on a Treponema pallidum particle agglutination test and a markedly elevated titre on a rapid plasma reagin test [1:128]), but results of tests for HIV and hepatitis were negative. Contact tracing was initiated. After 21 days of treatment with intravenous penicillin, the vision in his right eye was completely restored. At 9-month follow-up, the bilateral swelling in his optic discs had resolved, and there was a tenfold decline in the rapid plasma reagin test titre (1:8). This case illustrates syphilitic perioptic neuritis with optic disc swelling that is indistinguishable from papilloedema. Perioptic neuritis describes inflammatory involvement of the optic nerve sheath without inflammation of the nerve itself. The affected eye often has normal visual acuity with no visual field defect except for an enlarged blind spot.2,3 The prevalence of infectious syphilis has been rising in recent years, especially in Victoria and New South Wales, predominantly among men who have sex with men.4,5 Endemic syphilis should also be considered in patients with HIV co-infection and Indigenous patients, particularly those in the remote communities of Western Australia. Physicians should be vigilant in looking for neurosyphilis in any sexually active individual with unexplained eye or neurological signs. The swollen optic discs of a patient with syphilitic perioptic neuritis

Grace S H Low · Robert H Edis

To the Editor: We report a case of a 13-year-old girl with cystic fibrosis (CF) and chronic Pseudomonas aeruginosa lung infection who developed an unusual infection that was challenging to manage. At a regular review, and with no obvious change in clinical respiratory status, the patient’s forced expiratory volume in 1 second (FEV1) was 70% of the predicted value — a drop from her usual 90%. A subsequent 3-week admission, including treatment with standard antipseudomonal antibiotics, physiotherapy and addition of nebulised dornase alfa, did not significantly improve her lung function. She was discharged home on a trial of azithromycin. One month later, she had a non-productive cough, and a bronchoalveolar lavage specimen showed no growth on culture. Four months later, the patient presented with increased non-productive cough and sudden further deterioration in FEV1 to 52% of the predicted value. She was admitted and given standard intravenous antipseudomonal antibiotics. Culture of a repeat bronchoalveolar lavage specimen grew Mycobacterium abscessus, sensitive to clarithromycin, imipenem and amikacin; hence, the patient was given intravenous imipenem and amikacin for 3 weeks. During this period, high-resolution computed tomography (CT) of the patient’s chest showed mucus plugging, marked diffuse parenchymal involvement with typical “tree-in-bud” appearance and, surprisingly, given her poor lung function, only moderate bronchiectasis (Box). Two years earlier, results of a chest CT scan were normal. The patient was discharged home on long-term nebulised amikacin, oral ciprofloxacin and oral clarithromycin. Her lung function gradually improved after discharge and, 6 months later, her FEV1 was 69% of the predicted value and a sputum culture produced no growth. CF is a risk factor for non-tuberculous mycobacterial (NTM) lung disease, which is notoriously difficult to eradicate. A recent multicentre prospective study in the United States estimated that, in patients with CF who are older than 10 years, the prevalence of non-tuberculous mycobacterium was around 13%. The most common species were M. avium complex (72%) and M. abscessus (16%).1 Another study suggested that M. abscessus was more common in paediatric patients.2 Clinical signs and symptoms of NTM infections are usually difficult to distinguish from those of chronic respiratory infections that occur during the advanced stages of CF. High-resolution CT often reveals features of parenchymal involvement, as demonstrated in our patient. No guidelines exist for treating NTM infections in the CF population. However, for M. abscessus infection, oral clarithromycin in combination with intravenous amikacin and either cefoxitin or imipenem for 2–4 months has been recommended, with sputum surveillance for at least 12 months after a negative culture result.3 Suppressive maintenance therapy with clarithromycin, intermittent intravenous antibiotics and aerosolised amikacin have all been reported, but not confirmed by controlled studies. Surgical resection may be curative in localised disease. As the life expectancy of patients with CF improves, the prevalence of NTM infections is likely to increase. The American Thoracic Society recommends that all patients with CF who are on macrolide therapy should be screened annually for atypical mycobacteria.3 Atypical mycobacteria should always be borne in mind when treating patients with CF and an unexplained decline in lung function. Computed tomography scan showing diffuse parenchymal involvement, mucus plugging and moderate bronchiectasis in a girl with cystic fibrosis and non-tuberculous mycobacterial lung disease

Abdullah A Yousef · Adam Jaffé

To the Editor: Since colonial times, alcohol has been central to Australia’s political, cultural and social fabric.1 In the past year, concern about alcohol misuse has re-emerged as a dominant feature in the political landscape. We analysed the New South Wales emergency department (ED) data collection, on the NSW Department of Health’s HOIST (Health Outcomes and Information Statistical Toolkit) database, to describe the epidemiology of ED attendances due to acute alcohol problems. Data from 43 hospitals that contributed reasonably complete diagnosis information since 2000 were used. Attendances were selected using codes for alcohol intoxication, alcohol dependence/withdrawal, or drug or alcohol blood test from the ninth and 10th revisions of the International classification of diseases (ICD-9 and ICD-10) or from the Systematized Nomenclature of Medicine — Clinical Terms (SNOMED-CT). Population rates by age, sex and year were calculated. To assess the association between alcohol-related ED presentations and large public social events, time series of 24-hour counts ending at midday were used (because most presentations for acute alcohol problems occur at night).2 Between 2005 and 2008, the rate of ED presentations for acute alcohol problems rose sharply from around 110 to almost 150 per 100 000 population (Box 1). Between 2000 and 2008, the highest rates of ED attendance involved 18–24-year-olds of both sexes, and 25–64-year-old men. The largest increase was among 18–24-year-olds. Notably, in that age group, the rate in women converged with that of men at 228 per 100 000 in 2004 and was then higher until it re-converged in 2008 at around 390 per 100 000. In all years, the rate of presentation in 10–17-year-olds was slightly higher for females than for males (Box 2). Among children aged less than 10 years, the rate was under four per 100 000 in all years. Many peaks in ED attendance coincided with large public gatherings, including New Year’s Eve celebrations and the closing of the 2000 Sydney Olympic Games. In 2007 and 2008 especially, the Sydney Gay and Lesbian Mardi Gras was associated with marked increases (Box 3), which may reflect underlying increases in alcohol use in the younger age groups that might be attracted to this now mainstream event. Because the coverage of the ED data collection was limited, these figures underestimate the true incidence. Nevertheless, most urban and larger rural hospitals were included. We were unable to include the far greater number of ED presentations in which alcohol use was a factor, but not the primary reason for presentation.3 The trends and rates we observed were similar to those found in a recent Victorian study of young people.4 The small decline in overall rate from 2000 to 2002 (Box 1) is consistent with declining per-capita consumption of beer and spirits, while the subsequent increase in young people, which flattened out in 2008, is similar to the trend in consumption of ready-to-drink alcoholic beverages over the same period.5 Studies of the types of beverages used before ED presentation are urgently required to assess whether this is a causal association. Analysis of routine ED databases can provide a timely insight into the social and epidemiological context of high-risk drinking. The rise in alcohol-related presentation among teenagers and young adults bodes poorly for subsequent long-term alcohol use disorders and other risk behaviours and their consequences.6 The correlation between peaks in ED presentations and large-scale social events suggests that the development of cultural norms may have a strong influence on individuals’ behavioural choices. 1 Number and rate of presentations to 43 emergency departments for acute alcohol problems, New South Wales, 2000–2008 Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 Number 6400 6215 6203 6762 6826 7652 9112 10119 10382 Rate per 100 000 population* 98.7 94.5 93.6 101.3 101.7 113.2 133.7 147.1 149.4 * Rates are an underestimate because not all NSW emergency departments are included. 2 Population rate of presentations to 43 emergency departments for acute alcohol problems,* by year, sex and age,† New South Wales, 2000–2008 * Rates are an underestimate because not all NSW emergency departments are included. † Values not shown for people aged < 10 years because all values were below 4/100 000 population. 3 Daily counts* of presentations to 43 emergency departments for acute alcohol problems, New South Wales, 2000–2008 * Counts are aggregated over 24-hour periods, ending at midday.

David J Muscatello · Sarah V Thackway · Daniel A Belshaw · David McGrath

To the Editor: Recycling water from sewage into drinking water was recently discussed in the Journal.1 Although this is technically feasible, we need to be very wary. Such recycling is associated with very high ongoing monetary and energy costs, but, most importantly from a health perspective, is a “very high-risk”2 proposal that reverses 150 years of good public health policy of striving to keep sewage out of our drinking water supplies. When we need to recycle water from highly contaminated sources, it is much safer to do so for industrial purposes using separated pipelines (as is done in Singapore and Brisbane). The most extensive scientific review on this issue concluded that putting it into drinking water should be a “last resort”, that should be adopted only if other measures — including other water sources, nonpotable reuse, and water conservation — have been evaluated and rejected as technically or economically infeasible.3 Sewage contains very high concentrations of pathogens and drugs. Viruses (the most difficult pathogens to remove) can occur in concentrations higher than 106 per litre — orders of magnitude higher than in even the most polluted rivers. The technical and human performance needed to remove viruses safely will have to be proportionately higher than current practice — difficult to achieve, as we already have skills shortages. We would also need to ensure that the system will work all the time. Reverse osmosis (RO) is the most effective way to remove viruses and drugs from sewage, and should remove virtually all viruses and drugs. Surprisingly, few in-use data are available to check this. RO membranes seem to leak. One study found that RO only removed 92% of antibiotics.4 Recent safety reviews, including an Australian review5 (based on the previous study3), showed viruses were still detected post-treatment at three of seven sites on some occasions. The calculated virus removal ranged from 87% to > 99.995%, which equates to a “log reduction” of 1 to 5. However, to produce safe drinking water from sewage, we need a consistent 9.5-log reduction for enteroviruses.2 Even Giardia was not always removed. This less than optimal performance was when the system was not known to be malfunctioning; lowered performance might occur as often as 5 days a year.6 Current surrogate testing (eg, organic carbon) can only detect a membrane leak (or bypass) of at least 1%, which is well short of meeting the 9.5-log reduction we need for virus removal and reasonable safety.2 We need real-time tests to show that there is adequate virus removal, rather than none at all or only becoming aware of a problem after processed but contaminated water is already in our reservoirs.

Peter J Collignon

In reply: We agree that augmentation of drinking water sources with recycled sewage goes against the traditional policy of separating the two, and that many factors including cost and energy use need consideration in securing future water supplies. Our editorial1 was not written to promote potable recycling, which ultimately is a political and societal decision, but rather to point out that the carefully considered Australian guidelines for water recycling2 have been developed to ensure that, if this form of recycling is contemplated, it is done in a manner that safeguards public health. Main messages in the recycling guidelines include the importance of risk assessment for each individual scheme; avoidance of complete reliance on any single technical step (including reverse osmosis) for removal of contaminants, via a “multiple barrier” approach; adequate operational and water quality verification monitoring; and optimising training and skills management within water treatment facilities. Importantly, credits given for “log removal” for each treatment step are based on verifiable on-line performance, not theoretical values.2 These practical messages are also fundamental to the way we manage our conventional drinking water supplies.3 Consequently, discussions about recycling help reinforce the importance of continual assessment of water management, regardless of the source, and help ensure we do not become complacent.

Karin S Leder · Joanne E O’Toole · Martha I Sinclair

To the Editor: The recent withdrawal of faulty faecal occult blood testing (FOBT) kits by the government highlights the flaws in the National Bowel Cancer Screening Program (NBCSP), with 475 000 kits needing to be replaced. In their recent editorial,1 Ee and Olynyk attempted to persuade us that the NBCSP, which has now temporarily suspended the issuing of new invitations to participate, is both rational and appropriate for an affluent country such as Australia. The facts about bowel cancer mortality are not disputed — it is second only to lung cancer, equating to about 12 Australian deaths per day from a potentially preventable cancer. There are only two serious contenders for bowel cancer screening: FOBT and colonoscopy. Annual FOBT has the potential to reduce mortality by 15% (realistic) to 33% (optimistic).2 Colonoscopy is both diagnostic and preventive, with a predicted reduction in mortality of 76% (realistic) to 90% (optimistic).3 Recent United States guidelines advocate colonoscopy at 10-yearly intervals as the test of choice.3 Cost and potential mortality are two major issues raised by proponents of FOBT versus colonoscopy. However, Australian data using all costs, including infrastructure, colonoscopy, surgery, pathology, anaesthesia, chemotherapy and disinfection, have shown that 10-yearly colonoscopy is of equal cost–benefit to annual FOBT.4 A recent publication from Germany highlights some important facts.5 In a study of 269 144 colonoscopies, the completion rate (ie, reaching the caecum) was high, at 97.3%. The perforation rate was low (0.02%), as was the incidence of bleeding (0.16%), though this was predictably greater in those requiring polypectomy (0.8%). There were no deaths attributable to perforation or bleeding. Colonoscopy is therefore a rational option for screening, with the potential for prevention — a feature not shared by FOBT. The NBCSP’s letter of invitation and FOBT kit are sent only to individuals aged 50, 55 and 65 years. It ignores other age groups and gives no educational advice about alternative strategies such as colonoscopy. Ee and Olynyk1 clearly believe that centrally organised government screening programs are to be preferred, and they disapprove of colonoscopy screening “driven by patients”. Recent case series show colonoscopy to be safe and to have a higher completion rate than older series.5 Current initiatives in Australian colonoscopy training programs should improve safety and completion rates further. For those with no active interest in their health, centralised, directive programs are likely to be the most effective. For the informed, however, discussion about lifestyle changes, screening programs and healthy dietary alternatives should be their right.

Terry D Bolin · Melvyn G Korman · Alistair E Cowen

How to succeed at medical school. An essential guide to learning. Dason Evans, Jo Brown. Chichester: Wiley-Blackwell, 2009 (ix + 179 pp). ISBN 978 1 4051 5139 9. The authors of this guide both come from St George’s, University of London, where they work in the Centre for Medicine and Healthcare Education. They have long track records in medical and health science education and as examiners and are well placed to co-author a book such as this. The book endeavours to equip a student to perform well at a British medical school. The curriculum that the hoped-for readers face would be quite familiar to Australian students and faculty, encompassing the spectrum of courses found here. I don’t believe there is another book quite like it. There are similar books from North America, but they are less relevant to this country and tend to concentrate on how to get into medical school and get the residency of your choice, rather than the bit in the middle — the subject matter of this book. Much of this information would be available in the form of student guides and the like in most Australian medical schools, begging the question: will students see the price for a consolidated source of advice as a good investment? This book is, however, a rich and compact source of advice. A medical teacher of many years, I found myself in agreement with virtually the whole book. The background to knowledge and learning are sound. That there is a lot to grasp in medicine, requiring something more than pre-exam cramming, the value of working in teams, the necessity of continuous practice to ensure that clinical skills are like riding a bike — these are all concepts of value to students. Information about the different sorts of examinations and assessments is spot on. The book is easy to read. It is well set out and has good revision points in the form of reflective questions at the end of each chapter. Both teachers and students would benefit from it, although if the publishers seriously want it to sell in Australia they should replace references to the GMC (General Medical Council), and the like, with appropriate Australian ones.

Paul A Gatenby

Younger onset dementia. A practical guide. John R Hodges, Carol Gregory, Colleen McKinnon, et al. Sydney: Alzheimer’s Australia, 2009 (38 pp). Alzheimer’s Australia has been producing the Quality Dementia Care series of useful fact sheets and booklets for people with dementia and their carers but, until recently, had neglected the area of dementia with early onset. This booklet, together with a few others released during the past couple of years, helps rectify the situation. John Hodges, one of the world’s leading authorities on younger onset dementia, gathered a competent group of collaborators to produce this document, which can be freely downloaded from: http://www.alzheimers.org.au/content.cfm?infopageid=5484. The booklet is divided into five sections covering key features of the clinical presentation of younger people with dementia, practical approaches to manage cognitive deficits and behavioural disturbances, issues that are of relevance to carers, preparing for the future (including legal issues), and further resources. The document has a smart layout that will make it easy for readers to find the information they are after; and although information has been maintained at a basic level (basic, but up to date), carers will certainly appreciate the helpful hints on issues related to management, services and how to access other relevant resources. If you work with people with dementia, I would encourage you to keep a few copies of this booklet at hand in your office. I certainly will.

Osvaldo P Almeida

Dick Smidlin was born in Sydney on 15 March 1932. He was educated at “Shore” (Sydney Church of England Grammar School) and the University of Sydney, graduating in medicine in 1956. His father was a dermatologist and his mother a gynaecologist. His grandfather Frank Smidlin, an electrician at Sydney Hospital, took the first x-ray in Sydney in 1896. Dick was a Resident Medical Officer at Sydney Hospital, the Royal Alexandra Hospital for Children and the Royal Hospital for Women. He went to England in 1960, where he worked as a Surgical Registrar at West Hertfordshire Hospital and at St John’s Hospital and West Middlesex Hospital in London. Returning to Australia after 5 years, he did further training in anaesthesia at Sydney Hospital and became a specialist anaesthetist. He was a Visiting Medical Officer at the Rachel Forster Hospital for many years. In 1966, Dick spent 3 months working as a Flying Doctor with the Bush Church Aid Society in Ceduna, South Australia, and in 2008 he wrote a book called Flying doctor praying about his experiences with the service. He also visited Antarctica as a ship’s surgeon in the 1990s. Dick had many interests, including farming, travel, military history and sailing. He owned a 10 000 acre cattle property called “Wicketty Wees” at Putty, north-west of Sydney. As a foundation member of the Second Anzac Medical Society, he made many overseas trips to places such as Gallipoli and Europe to pursue his interest in military medicine and military history. From his youngest years, Dick shared his father’s love of sailing. He was a member of the Middle Harbour Yacht Club for more than 60 years, and sailed with the Sydney Amateur Sailing Club and the Cruising Yacht Club. He had numerous boats — the last one, named “Trim” after Matthew Flinders’ cat, having a black cat outlined on the mainsail. He was an excellent skipper and won many races. Dick visited France most years. He had a barge called “Wilma” moored in Paris, and would spend up to 2 months each year exploring the canals of France and entertaining friends on board. Dick died on 6 October 2008 of lung cancer. He is survived by his sister Anne and wife Jeanette, from whom he was divorced in the 1960s. He was buried at Waverley Cemetery in a position that has a wonderful view of the ocean.

James B Roche

Capsule vs colonoscope Having an endoscopy may soon be as simple as swallowing a specially designed capsule consisting of a tiny endoscope with a video camera at both ends. In an effort to assess the specificity and sensitivity of the method, capsule endoscopy has been compared with traditional optical colonoscopy in a multicentre, prospective trial. All 328 participants in the study had known or suspected colonic disease, and each underwent both capsule endoscopy and optical colonoscopy, which was considered the standard for comparison. The sensitivity of the capsule for detecting polyps that were 6 mm in size or greater was 64% and for advanced adenoma, 73%. The sensitivity of the method was higher in patients with better colon cleanliness after colonic preparation. The authors conclude that, although capsule endoscopy allows visualisation of the colonic mucosa without sedation or sufflation, its sensitivity is still low compared with optical colonoscopy. N Engl J Med 2009; 361: 264-270 The burden of liver cancer Patients with chronic liver disease should be screened regularly for hepatocellular carcinoma, as the results of delayed diagnosis are devastating, according to New Zealand expert Edward Gane. In a discussion of the controversy surrounding screening for liver cancer, the author calls for an optimal screening interval of 6 months, using serum alpha fetoprotein measurement and abdominal ultrasound. Patients at greatest risk — those with cirrhosis and chronic hepatitis B infection — could then be diagnosed at an early stage, when treatment still has a chance of cure. An accompanying review by Warner and colleagues discusses the use of antiviral drugs for hepatitis B aimed at preventing the development of hepatocellular carcinoma, and outlines the emergence of drug resistance in the hepatitis B virus that has the potential to accelerate progression of liver disease to cancer. Cancer Forum 2009; 33: July 2009 Online Ovarian cancer and HRT Enquiry into the relationship between postmenopausal hormone therapy and ovarian cancer continues, with a Danish study aimed at assessing the risks of different formulations of hormone therapies. In a nationwide, prospective cohort study spanning 10 years and including almost 1 million women aged 50–75 years, prescribing data and information from cancer and pathology registries were analysed. Results showed an increased risk of ovarian cancer even with short durations of hormone use (0–4 years) and no significant difference in risk with route of administration and dose, or between oestrogen alone and combined therapy. In practical terms, the absolute risk of 0.12 per 1000 years would have resulted in about 140 extra cases of ovarian cancer in Denmark over the mean follow-up of 8 years. This accounts for 5% of the total ovarian cancers detected in the study. The authors comment that although the figure seems low, ovarian cancer remains highly fatal, and that the risk should be considered when prescribing hormone therapy. JAMA 2009; 302: 298-305 Mammography — the risk of overdiagnosis Overdiagnosis, the detection of abnormalities that will not cause symptoms or death in a person’s lifetime, remains the bane of screening programs. According to the authors of a systematic review of breast cancer incidence, mammography screening may also be prone to the problems of overdiagnosis and the potentially damaging overtreatment that follows.1 Incidence data covering at least 7 years before and after mammography screening had been fully implemented were analysed — including the results of studies from the United Kingdom, Canada, Australia, Sweden and Norway. The results showed that, in populations offered organised breast cancer screening, overdiagnosis was 52% when carcinoma in situ was included and 35% for invasive breast cancer only. This translates as the overdiagnosis of one in three breast cancers. The observation remained stable when the researchers took into account an assumption of the increasing background incidence of breast cancer in these populations. An accompanying editorial states that “the question is no longer whether overdiagnosis occurs, but how often it occurs”.2 The author comments that women need to be informed of the trade-off between the number of deaths from breast cancer and those overdiagnosed and calls for more research, not only into women’s choices based on this information, but into refining estimates of overdiagnosis and minimising its occurrence. 1. BMJ 2009; 339: b2587 2. BMJ 2009; 339: b1425

Tanya Grassi