Volume 191 Issue 7

Mandatory reporting and public sharing of information would likely lead to improved health care practices and save lives Staphylococcus aureus bacteraemia (SAB) is common, and it causes serious morbidity and mortality. In Australia, it is estimated that there are over 6000 episodes per year, most of which are health care-associated.1 SAB is also a major problem internationally, and this problem is compounded by antibiotic resistance. Methicillin-resistant S. aureus (MRSA) infections are common in most countries, and MRSA bacteraemia has reached epidemic proportions in some areas of the United States.2,3 The study by Turnidge and colleagues on behalf of the Australia New Zealand Cooperative on Outcomes in Staphylococcal Sepsis in this issue of the Journal4 highlights again how frequently these infections occur, their association with health care (particularly with intravascular catheters), and the high mortality rate associated with them (over 20% by 30 days). It also illustrates our rapidly growing problem with community MRSA strains, which caused over 6% of all the SABs in the period June 2007 to May 2008, during which Turnidge et al collected data. Currently, we have only very patchy measurements of this problem in Australia in comparison with New Zealand, Denmark and the United Kingdom,2 where all SABs are measured. Despite probably causing more deaths in Australia than occur on our roads, there is very little investigation into the causes and the preventable factors of individual episodes of bacteraemia. Most of these infections are preventable. Numerous interventions (such as compliance with hand hygiene and improved care of intravenous catheters) have been shown to lead to major reductions in rates of bacteraemia.2,5,6 The current National Hand Hygiene Initiative7 should also achieve a significant reduction. The Australian Commission on Safety and Quality in Health Care has noted how significant these infections are, and the importance of surveillance.2 It has also taken this matter to the Australian Health Ministers’ Conference, which then endorsed the reporting of SABs in each jurisdiction and nationally. It is time that all health care facilities started collecting and acting on information about SABs. However, this probably won’t happen effectively unless all SABs (based on pathology laboratory results) are made “reportable”. After mandatory reporting was introduced in the UK, the number of documented cases increased by 50%.2,8 It is important that we do more than just collect these data. We need to ensure that, in each hospital, every case is looked at to try to determine why it occurred. Then health care professionals need to intervene at their own local level to make sure that appropriate policies are adhered to (or, where necessary, changed). Nearly all people with SABs are either in hospital already, or will be admitted. Thus, it should be possible to see them at or near the time of their infection. This will usually mean that either a physician or an infection control practitioner would look at every case to determine whether it was the result of a health care-associated procedure, and also look into other issues, such as the likely cause (eg, intravascular catheter) and outcomes.2 This would then also allow timely feedback to the teams responsible for the patients’ current and previous medical care about potential preventable factors.9 Many episodes of SAB, even though they are health care-associated, have their onset in the community. Thus, all cases of SAB will need to be looked at, and not just those with their onset in hospitals.1,2,9 While this will seem arduous to some, at the Canberra and Austin Hospitals, it takes between 30 and 60 minutes to see each affected patient and review each case.2,9,10 Even our largest hospitals are unlikely to have more than a couple of hundred SAB episodes per year. As these episodes have a mortality of more than 20%, this is not an undue task to expect hospitals to perform. They need to devote resources to doing this, and make it part of the core duties of any infection control team. It is important that the data be analysed, reported and acted on in a timely fashion, and this process must involve those at the hospital executive level. The success and benefits of doing this at a local level are highlighted in the study reported by Dendle and colleagues in this issue of the Journal.10 The study by Turnidge et al shows how data can be analysed and reported efficiently at a national (and international) level, with relatively few extra resources being supplied, through the use of a web-based tool.4 Such a system allows summaries to be sent back to the individual hospitals so that they can look at their own data in a timely fashion. It also allows some external auditing of the data to ensure they are accurate. Importantly, it will allow hospitals of similar types to benchmark themselves nationally. This is important because we already know that hospitals in Perth have much lower rates of health care-acquired MRSA than those in the eastern states,11 and we should learn from them. Most Australian states do not have sufficiently large populations to make many comparisons internally, especially of their largest hospitals, where most cases of SAB occur. By using national comparisons, institutions with higher rates of infections should be able to learn from those that have lower rates of infections. There are always arguments that looking at these data and having them publicly available does not help. However, the experience in the UK suggests otherwise. Amid controversy, SAB rates have been published on the web for many years, and this type of benchmarking, when coupled with funded infection control interventions, has led to a 50% reduction in the number of MRSA bacteraemias.2,8 This has not only resulted in substantial monetary savings, but, more importantly, has saved many hundreds of lives each year. Internationally, we are seeing rising levels of SAB. This is principally the result of complications of health care, and most of these infections are preventable. It is time we measured these life-threatening episodes much more accurately, examined each case, and intervened to stop further cases occurring.

Peter J Collignon FASM, FRCPA, FRACP · Marilyn Cruickshank RN, PhD, FRCNA

There is still no cure, but what advances have been made in managing this disabling condition? In its more aggravated forms diffuse scleroderma is one of the most terrible of all human ills. Like Tithonus [a Greek mythological hero who was granted immortality but not eternal youth] to “wither slowly” and like him to be “beaten down and marred and wasted” until one is literally a mummy, encased in an evershrinking, slowly contracting skin of steel, is a fate not pictured in any tragedy, ancient or modern. Sir William Osler, 18981 Scleroderma encompasses the name of a disease and a clinical sign (thickened skin) that have eluded any unifying mechanism of causation. While we still await a cure, new and significant pharmacological agents are now available that can assist in the symptomatic treatment and disease modification of this condition. The disease is uncommon, with Australian estimates of prevalence per 10 000 population ranging from 0.4–0.9 (Sydney, 1974–1988)2 to 1.47 (South Australia, 1993)3 to 2.4 (Tasmania, 2007).4 Scleroderma is classified into either localised (skin alone) disease or systemic (internal organ involvement ± skin) disease, which is known as systemic sclerosis. The principal subsets of systemic sclerosis are: diffuse cutaneous systemic sclerosis, limited cutaneous systemic sclerosis, systemic sclerosis sine scleroderma (systemic disease with no skin involvement), environmentally induced scleroderma, overlap syndromes and pre-scleroderma. In limited disease, skin thickening is limited to the extremities distal to the elbows and knees, and the face. Diffuse disease, at its maximal extent, affects not only the skin of the distal extremities and face but also the skin over the proximal extremities and trunk. The disease has three pathological features: fibrosis with excessive collagen and other ground substance deposition; vasculopathy involving small and large vessels; and smooth muscle atrophy. In diffuse systemic sclerosis, inflammation and fibrosis predominate, whereas in limited disease, vascular changes predominate. While skin involvement (dermal inflammation and fibrosis) is associated with variable morbidity, it is the systemic manifestations, especially pulmonary and cardiac, and occasionally renal and gastrointestinal, that are responsible for much of the disease-related premature mortality. Therapy is classified as either “disease-modifying” or “symptomatic” and is tailored to the individual’s tolerance and need. Therapeutic decisions are determined by the pattern of organ involvement (vital or non-vital), underlying pathological features, and other comorbidities. General measures such as staying warm, using gloves and skin moisturisers, taking antireflux or bowel motility agents, modifying timing and volume of meals, brushing teeth regularly to prevent caries, using eye drops for sicca symptoms, and avoiding aggravating factors are important first steps in treating and managing the condition. In the early onset of systemic sclerosis, an activated immune system (Box 1) may be important in the pathogenesis of subsequent fibrotic and vascular lesions, so early disease-modifying drug therapy is aimed at suppressing the immune response. Immunosuppressive drugs such as methotrexate, cyclophosphamide and mycophenolate, often in conjunction with judicious use of corticosteroids (there is some controversy surrounding the causal association between high-dose corticosteroids and scleroderma renal crisis), intravenous gammaglobulin, and minocycline, have been used with varying measures of success. The levels of evidence for therapeutic intervention strategies are outlined in Box 2. “Heavier” immunosuppression, with or without haemopoietic stem cell rescue, is contemplated in patients with early inflammatory vital organ involvement of the lung or myocardium.6,7 Two large multicentre Phase III studies — the ASTIS (Autologous Stem cell Transplantation International Scleroderma) Trial in Europe, and the SCOT (Scleroderma: Cyclophosphamide Or Transplantation) study in the United States — to determine the relative efficacy of haemopoietic stem cell transplantation compared with less rigorous immunosuppression are well underway. In Australia, we have performed autologous stem cell transplantation in seven patients with systemic sclerosis who had progressive vital organ involvement and in whom conventional immunosuppression had failed, and noted a dramatic, sustained, long-term remission in four of them that featured marked skin softening, stabilisation of interstitial lung disease and a three- to fourfold fall in antinuclear antibody titre (H J E, personal communication). These findings support the use of autologous stem cell transplantation as a disease-modifying modality. The use of mesenchymal stem cells (MSCs) in the treatment of arthritic disease is novel, and this approach has shown great potential because of the ease of isolation, rapid growth and extensive culture expansion of MSCs suitable for therapeutic use. In diseases such as scleroderma where there is excessive mesenchymal overactivity, MSCs are an ideal candidate cell type for tissue regeneration and repair of damaged structures. Trials of therapeutic uses of MSCs are currently in progress.8 Therapies directed toward modification of established fibrosis have been uniformly disappointing. D-penicillamine, previously the gold standard of scleroderma therapy, has fallen into disrepute after a US multicentre study showed no outcome difference between very low dose and usual dose D-penicillamine therapy.9 However, occasionally patients will exhibit resolution of skin fibrosis with little or no therapeutic intervention. Pulmonary arterial hypertension is a relatively common complication of systemic sclerosis and is caused by pulmonary arterial narrowing and thickening leading to increased pulmonary vascular resistance and arterial pressures (> 25 mmHg). As early diagnosis and treatment can have a profound effect on outcome, it is extremely important to screen patients for this condition. The gold-standard screening procedure is right heart catheterisation. There is level I evidence5 of efficacy of three categories of medications for pulmonary arterial hypertension: endothelin receptor antagonists, prostanoids, and phosphodiesterase inhibitors. These may be used as a single agent or in combination, with combined epoprostenol and sildenafil being more efficacious than combined bosentan and sildenafil. The use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers has been found to favourably modify the outcome of the vascular pathological features of scleroderma renal crisis. Symptomatic therapies for microvascular hyperreactivity, upper and lower gastrointestinal dysmotility, and musculoskeletal symptoms are outlined in Box 2. Promising new approaches include the use of a protein tyrosine kinase inhibitor, imatinib mesylate (Glivec, Novartis), that interferes with the signalling of platelet-derived growth factor and transforming growth factor-β, two pivotal mediators of the fibrotic process of systemic sclerosis. However, no biological agent has shown definitive evidence of efficacy thus far. Overall, despite the obvious absence of a cure, progress is being made in the understanding and management of this chronic and disabling rheumatic condition. 1 Pathophysiology of systemic sclerosis, with possible sites for therapeutic intervention Rational therapy would be designed to (1) prevent endothelial cell damage; (2) alter communication between mononuclear cells; (3) prevent mononuclear cell stimulation of fibroblasts; (4) prevent mast cell degranulation; (5) block fibroblast production or extrusion of procollagen; or (6) increase solubilisation of preformed collagen. Diagram courtesy of Professor Thomas Medsger, University of Pittsburgh. 2 Therapeutic intervention strategies for systemic sclerosis, with levels of evidence* Organ-specific features† Therapy (level of evidence) Cardiovascular (> 95%) (i) Microvascular (> 95%) Raynaud’s syndrome (> 95%) Efficacious: calcium channel blockers (II); topical glyceryl trinitrate (I); prazosin (I); intravenous iloprost (I); losartan (I); endothelin receptor antagonists; phosphodiesterase-5 inhibitors Disappointing: cisaprost; oral iloprost Promising: autologous progenitor cell implantation (II); protein tyrosine kinase ± Rho‑kinase inhibitors Digital ulcers Efficacious: as above; statins (I); bosentan (I); sildenafil (I) (ii) Macrovascular Myocardium (5%) Efficacious: immunosuppressives (III) Pericardium Efficacious: corticosteroids ± immunosuppressives Skin/adnexae (> 95%) Sclerosis Efficacious: cyclosporin (?II); tacrolimus (?II); cyclophosphamide (III) Disappointing: methotrexate (I) Promising: intravenous gammaglobulin (III) Respiratory (40%) Interstitial lung disease‡ Efficacious: cyclophosphamide (II) Promising: azathioprine (remission) (I) Pulmonary arterial hypertension Efficacious: bosentan (I); sildenafil (I); epoprostenol (I); treprostinil (I) Promising: beraprost (II) Aspiration pneumonitis None Gastrointestinal (75%–90%) Upper Efficacious: proton-pump inhibitors; histamine H2-receptor antagonists Lower Efficacious: domperidone (II); erythromycin (II); cisapride (II); octreotide (II) Renal (10%–15%) Hypertensive renal crisis Efficacious: angiotensin-converting enzyme inhibitors (II) * United States Preventive Services Task Force levels of evidence:5 I = at least one randomised controlled trial; II = well designed trial(s) without randomisation, or well designed case–control or cohort studies, or multiple time series with/without intervention; III = opinions of respected experts based on clinical experience; ?II = probably level II, but uncertain. † Percentages represent prevalence among all patients with systemic sclerosis. ‡ Non-specific interstitial pneumonitis, usual interstitial pneumonitis, bibasilar pulmonary fibrosis.

Helen J Englert MB BS, PhD, FRACP · Nicholas Manolios MB BS, PhD, FRACP

Time to debate the recommendations of the National Health and Hospitals Reform Commission is slipping away When the history of the Rudd Labor Government is written, undoubtedly a chapter will be devoted to its penchant for summits, inquiries and reports. Health has not escaped this inquisitorial focus. There have been, among others, inquiries and reports regarding preventive health,1 primary care,2 and health care delivery in general.3 The latter was the remit of the National Health and Hospitals Reform Commission (NHHRC), and its final report, A healthier future for all Australians, was released in June this year.3 If the NHHRC’s 123 recommendations are enacted, they have the capacity to change Australian health care in a manner reminiscent of the establishment of Medibank. Despite the report’s length (292 pages) and its prolific list of recommendations, common themes emerge: shared responsibility for care; increased responsibility by the federal government for existing and new health services; consolidation and integration of services, with an emphasis on non-institutional care; shifting care towards being more patient- and person-responsive than provider-convenient; better intrasectoral communication through the use of information technology; extracting greater efficiencies from hospitals; relating remuneration to outcomes and performance targets; and, finally, fundamental changes in the provision of health insurance. In short, if implemented, the report will mean a time of uncertainty, inherent in change. Despite this, the report has not yet been widely debated within the profession. In this issue of the Journal, we commence a series of articles (National health reform: it’s time for a decision, A healthier future for all Australians: an overview of the final report of the National Health and Hospitals Reform Commission and Final report of the National Health and Hospitals Reform Commission: will we get the health care governance reform we need?) exploring the social, health and professional impact of the recommendations of A healthier future for all Australians. Prime Minister Rudd is currently engaged in a whirlwind “getting to know you” tour of selected Australian hospitals, before the federal government’s response to the report is further massaged by the Council of Australian Governments into a united policy and a possible implementation plan. If the profession seeks to influence these outcomes, now is the time to present our views and recommendations. If we do not accept this challenge, change will be imposed from on high and may well be uncomfortable or even intolerable! Although it is important to “talk the talk”, this should not excessively delay “walking the walk”.

Martin B Van Der Weyden MD, FRACP, FRCPA

Objective: To document the types of, and mortality from, Staphylococcus aureus bacteraemia in Australia and New Zealand, and determine factors associated with mortality.Design and setting: Prospective observational study in 27 independent or hospital pathology laboratories in Australia (24) and New Zealand (3), employing a web-based database to prospectively record demographic features, selected risk factors, principal antibiotic treatment and mortality data on all patients with positive blood cultures for S. aureus from June 2007 to May 2008.Main outcome measure: 30-day all-cause mortality.Results: 1994 episodes of S. aureus bacteraemia were identified, and complete 30-day follow-up data were available for 1865. Most episodes had their onset in the community (60.8%; 95% CI, 58.7%–63.0%). Methicillin-resistant S. aureus (MRSA) caused 450 episodes (24.1%; 95% CI, 22.2%–25.9%), and 123 of these (27.3%) had a susceptibility profile consistent with community-associated MRSA. All-cause mortality at 30 days was 20.6% (95% CI, 18.8%–22.5%). On univariate analysis, increased mortality was significantly associated with older age, European ethnicity, MRSA infection, infections not originating from a medical device, sepsis syndrome, pneumonia/empyema, and treatment with a glycopeptide or other non-β-lactam antibiotic. On multivariable analysis, independent predictors of mortality were age, sepsis syndrome, pneumonia/empyema, device-associated infection with a secondary focus, left-sided endocarditis, and treatment with a glycopeptide such as vancomycin, but not MRSA infection.Conclusions: S. aureus bacteraemia is a common infection in both the community and hospitals in Australia and New Zealand, and is associated with appreciable mortality. Invasive MRSA infection may be more life-threatening, partly because of the inferior efficacy of the standard treatment, vancomycin. National web-based surveillance of S. aureus bacteraemia and its outcomes is not only important but also easily achievable.

John D Turnidge FRACP, FRCPA, MASM · Despina Kotsanas BSc(Hons), MClinEpi · Wendy Munckhof FRACP, FRCPA, PhD · Sally Roberts MB ChB, FRACP, FRCPA · Catherine M Bennett BSc(Hons), MAppEpid, PhD · Graeme R Nimmo MPH, FRCPA, FASM · Geoffrey W Coombs BApplSci(Med Sci), PostGradDipMedSci · Ronan J Murray MRCPI, FRACP, FRCPA · Benjamin Howden MB BS, FRACP, FRCPA · Paul D R Johnson MB BS, PhD, FRACP · Kate Dowling BSc, GradDip(AppStats) · on behalf of the Australia New Zealand Cooperative on Outcomes in Staphylococcal Sepsis

Objective: To determine whether the availability of patients’ own medications (POM) in emergency departments (EDs) results in decreased prescribing errors of patients’ usual medications on admission.Design, participants and setting: Observational study of patients presenting by ambulance to the ED of Austin Hospital, a Melbourne metropolitan teaching hospital, between 13 and 31 March 2006. Patients were enrolled if they were brought to the ED by ambulance, aged 18 years or older, taking four or more regular medications, admitted to hospital, and not referred to a pharmacist before the admission medication chart was written. ED pharmacists determined patients’ regular medications and details of medications brought in by ambulance. Admission medication charts were assessed and discrepancies were recorded as prescribing errors if a change was made after a pharmacist discussed the discrepancy with the prescriber.Main outcome measures: Percentage of medications correctly prescribed when POM were brought in to the ED compared with when they were not; the nature and frequency of prescribing errors on admission.Results: 100 patients were enrolled; they were taking 4–17 regular medications (mean, 8.0; SD, 3.7). Among the 428 POM that were brought to the ED, 56 errors occurred (13.1%); and among the 372 regular medications taken by patients for whom POM were not brought in, 95 errors occurred (25.5%) (difference in percentages, 12.4%; 95% CI, 6.7%–18.0%; P < 0.001). The most prevalent prescribing errors were omissions (40.4%), and most errors (72.8%) were classified as of “moderate” clinical significance.Conclusions: When POM were brought to the ED by paramedics, significantly fewer errors occurred on admission medication charts. An intervention program to encourage paramedics to bring POM to the ED is indicated.

Esther W Chan BPharm(Hons), MClinPharm · Simone E Taylor PharmD, GCCRM · Jennifer L Marriott BPharm, PhD, GCHE · Bill Barger AssDipHthSci, MICACert

Objective: To examine the initial impact of the National Bowel Cancer Screening Program (NBCSP), which was launched in May 2006 and offers faecal occult blood testing to Australians aged 55 or 65 years.Design and setting: Review of data on colorectal cancer (CRC) cases diagnosed between May 2006 and June 2008 from a prospective database used at 19 Australian hospitals, linked and analysed by BioGrid Australia.Main outcome measures: Number of CRC cases detected through the NBCSP or symptomatic presentation, and differences by sex, stage at diagnosis, tumour location and level of socioeconomic disadvantage.Results: 1628 cases of CRC were identified; 1268 had information on the patients’ test status as part of the NBCSP, and 40 of these (3.2%) were recorded as being detected by the NBCSP. Of 75 CRC cases in patients aged 55 or 65 at diagnosis, 22 were NBCSP-detected. Overall, there was no difference in NBCSP-detected cases by sex. The distribution of tumour locations was similar between NBCSP-detected cases and symptomatic cases, but NBCSP-detected cancers were diagnosed at an earlier stage than symptomatic cancers (stage I, 40% v 14%; stage IV, 3% v 15%, respectively). Of patients diagnosed through the NBCSP, 63% were from areas of least socioeconomic disadvantage (deciles 8–10) and 18% were from the most disadvantaged areas (deciles 1–4) (P = 0.0375).Conclusion: Initiation of the Australian NBCSP has had a measurable impact on CRC stage at diagnosis, and an improvement in survival would be anticipated. The lower uptake among people from disadvantaged areas is of concern.

Sumitra S Ananda MB BS, FRACP · Stephen J McLaughlin MB BS, FRACS, FRCS · Frank Chen MB BS, FRACS · Ian P Hayes MB BS, FRACS, FRCS · Andrew A Hunter MB BS, FRACS · Iain J Skinner MB BS, FRACS · Malcolm C A Steel MB BS, FRACS · Ian T Jones MB BS, FRACS, FRCS · Ian A Hastie MB BS, FRACS · Nicholas A Rieger MB BS, FRACS · Susan Shedda MB BS, FRACS, MPH · Daniel J Compston BHIthInfoManagement · Peter Gibbs MB BS, FRACP, MD

A national system financed and governed by the Australian Government would open up access to the widest range of health services After 18 months of summits, taskforces, and work by the National Health and Hospitals Reform Commission (NHHRC),1 it is still unclear whether Australia’s health system stands on the threshold of major change. Despite Prime Minister Kevin Rudd’s bold statements during the 2007 election campaign, we do not know the real shape, scope or timetable for health reform. Why the delay? First, the government was elected without a detailed health reform plan. Second, substantive change requires a national leadership group with the confidence and technical expertise to confront the vested professional, business and political interests that will resist change. Importantly, the general public and most clinicians still support the view that the national government should take overall responsibility and lead the reform agenda. Inevitably, the Rudd Government has faced a choice between two contrasting paths. The first is to “talk tough, but do little”. This path characterises Australians as enjoying both excellent health and access to one of the world’s best health care systems. Consequently, new initiatives are limited in scope and largely reactive to the “crises” of the day. To date, the new government’s big actions — financial commitments to the 2009–2014 Australian Health Care Agreements, new hospital-based infrastructure, and reduction of surgical waiting lists — have continued down this conservative road. The alternative is the “road less travelled”. This alternative characterises the current system as chronically stressed and dysfunctional, and is well summarised by the NHHRC.1,2 It recognises daily failures in clinical care and systemic neglect of Indigenous health, mental health, dental care and aged care. Most importantly, it states that our current “hospital-centric” system will not cope with the coming tsunami of chronic disease. This alternative path demands new operating principles that prioritise equity of access, reduce out-of-pocket costs, promote consumer-responsiveness, value collaborative and out-of-hospital care, incorporate new technologies, and build systems to support clinical and system-level accountability. Although the conceptual basis for this approach was established internationally,3,4 it is rarely implemented. If this is the season for radical reform, what should the Australian Government do in the next 6 months? Most importantly, it must decide swiftly on a preferred model for finance and governance. In February 2009, the NHHRC set out three options.2 The conservative option (Option A) is that the federal government assumes financial responsibility for all out-of-hospital care. Sadly, this would leave public hospital funding to the states alone. Even if Option A were combined with partial federal funding of state hospitals,1 we would still retain many of the worst features of our current divided system. Instead, a bold move to a national system that reduces the service gaps is urgently required. The government could adopt the NHHRC’s Option B (regional health authorities) and Option C (national social insurance).2 A public financing system that originates in one level of government, supplemented by private health insurance, would start to open up access for all Australians to the widest range of health services. Unfortunately, in its final report, the NHHRC repackaged and watered down its three original options into two: building a “Healthy Australia Accord”; and then, possible development of “Medicare Select”.1 These are nice names but serve to obscure the real political choices and delay the implementation of change. I believe new national financing arrangements are also the best way to support regional health providers. That is, only a nationally coordinated system can work effectively to reduce health inequities and utilise all clinicians fully. The additional goals of reducing out-of-pocket expenses and containing overall national health expenditure (currently below 10% of gross domestic product1) can be built into a national framework. As in other countries such as the Netherlands, this financing option may work best if implemented by more than one national insurer.5 Its viability may well depend on revising the current level of taxation support for private health insurance. Any new financing options must be linked with active development of a vibrant new breed of health service providers. Although these providers must deliver high-quality, evidence-based clinical care, they also need to develop collaborative care packages for those with complex or chronic needs. Here, Australia needs to learn from overseas experience.3,4,6 Real innovation and the development of consumer-responsive care rely on the existence of genuine competition between providers. Our rigid state-based systems offer no real choice to the users or alternative options for those who require services that the states cannot provide. A government committed to reform of the health system must move away from sole reliance on both federal and state bureaucracies. An independent implementation authority with sufficient resources and legislative power, and a timetable for delivery has a greater chance of achieving real change. Within such an authority, there is the need to embed strong clinical leadership alongside the requisite management and health system expertise.3,4 Together, these actions would start to drag our 19th century hospital-centric system into a 21st century framework that could deliver dynamic and responsive health care. These actions do not require another round of hollow consultations, a national plebiscite or another election campaign. They require political decisions.

Ian B Hickie MD, FRANZCP

After extensive community and health industry consultation, the final report of the National Health and Hospitals Reform Commission, A healthier future for all Australians, was presented to the Australian Government on 30 June 2009. The reform agenda aims to tackle major access and equity issues that affect health outcomes for people now; redesign our health system so that it is better positioned to respond to emerging challenges; and create an agile, responsive and self-improving health system for long-term sustainability. The 123 recommendations are grouped in four themes: Taking responsibility: supporting greater individual and collective action to build good health and wellbeing. Connecting care: delivering comprehensive care for people over their lifetime, by strengthening primary health care, reshaping hospitals, improving subacute care, and opening up greater consumer choice and competition in aged care services. Facing inequities: taking action to tackle the causes and impact of health inequities, focusing on Aboriginal and Torres Strait Islander people, people in rural and remote areas, and access to mental health and dental services. Driving quality performance: having leadership and systems to achieve the best use of people, resources and knowledge, including “one health system” with national leadership and local delivery, revised funding arrangements, and changes to health workforce education, training and practice.

Christine C Bennett MB BS, FRACP, MPaed

The National Health and Hospitals Reform Commission (NHHRC) has recommended that Australia develop a “single health system”, governed by the federal government. Steps to achieving this include: a “Healthy Australia Accord” to agree on the reform framework; the progressive takeover of funding of public hospitals by the federal government; and the possible implementation of a consumer-choice health funding model, called “Medicare Select”. These proposals face significant implementation issues, and the final solution needs to deal with both financial and political sustainability. If the federal and state governments cannot agree on a reform plan, the Prime Minister may need to go to the electorate for a mandate, which may be shaped by other economic issues such as tax reform and intergenerational challenges.

Johannes U Stoelwinder MD, FRACMA, FACHSE

Objective: To evaluate the practicality and effectiveness of a new program that made health care-associated Staphylococcus aureus bacteraemia (SAB) a quality indicator at Austin Health.Design and setting: Roll-out of the program over 9 months and review over 27 months from January 2006. Every episode of SAB at Austin Health was promptly reviewed, and classified as community- or health care-associated and as inpatient- or non-inpatient-related. Feedback was provided to treating clinicians for every SAB episode considered potentially preventable, and education-based interventions were introduced where appropriate.Main outcome measure: Episodes of SAB associated with health care at Austin Health per 1000 separations (hospital discharges) per month.Results: We identified 131 episodes of health care-associated SAB, of which 90 (68.7%) were caused by methicillin-susceptible S. aureus, 96 (73.3%) occurred in inpatients, and 65 (49.6%) were associated with a vascular access device. The health care-associated SAB rate was 1.1 per 1000 separations in the first 9 months, and fell by 55% to 0.51 per 1000 separations in the subsequent 18 months. We estimated that there were 80 fewer SAB episodes (95% CI, 20–140) than expected had the initial rate remained unchanged, a notional saving of $1.75 million to Austin Health over 27 months. About 16 hours per month of clinical nurse consultant time was required to maintain the program, representing a 0.1 equivalent full-time position, or a cost of $7000–$9000 per year.Conclusion: Introducing a structured program to investigate all health care-associated SABs, rather than only infections with methicillin-resistant S. aureus, revealed a large under-recognised burden of potentially preventable infections. The program was simple and low-cost, and the rate of health care-associated SAB has fallen significantly since its introduction.

Claire Dendle MB BS, FRACP · Rhea D Martin RN, MPH · Donna R Cameron RN, BAppSci · Elizabeth A Grabsch BSc, MPH · Barrie C Mayall FRACP, FRCPA · M Lindsay Grayson FRACP, FAFPHM · Paul D R Johnson FRACP, PhD

The Australian Government will provide $275 million over 4 years to general practice infrastructure across Australia with the rollout of 31 General Practice Super Clinics. One of the core objectives of these Super Clinics is to support medical education. Several studies have demonstrated that the major barriers to teaching in general practice are time, space and money. We argue that General Practice Super Clinics can provide a responsive, flexible work culture; and improved payment and targeted resources to support the need for increased teaching capacity, and to attract and retain workforce for general practice and primary care.

Alistair W Vickery MB BS, FRACGP · Jennifer Dodd PhD, BASocSci(Hons) · Jon D Emery MB BCh, FRACGP, DPhil

Clinical record A 66-year-old man with a history of ischaemic heart disease, hypertension and hypercholesterolaemia presented to a rural centre with a 2-week history of malaise, jaundice, right upper quadrant pain and daily rigors. Liver function tests revealed a raised bilirubin level (100 μmol/L; reference range [RR], 1–20 μmol/L) and abnormal levels of liver enzymes (alkaline phosphatase, 357 U/L [RR, 40–135 U/L]; γ-glutamyltransferase [GGT], 687 U/L [RR, 15–73 U/L]; alanine aminotransferase, 344 U/L [RR, 21–72 U/L]; aspartate aminotransferase, 216 U/L [RR, 17–59 U/L]). Results of serology tests for hepatitis B and C were negative. Full blood examination revealed a normal level of total white blood cells and mild thrombocytopenia (platelet count, 124 × 109/L [RR, 150–400 × 109/L]). Results of a computed tomography scan of the abdomen and pelvis were unremarkable. A presumptive diagnosis of acute cholangitis was made, and intravenous ceftriaxone (1 g daily) and metronidazole (500 mg every 8 h) therapy was initiated. The patient had undergone a percutaneous coronary intervention with bare-metal stent placement about 2 months earlier, and had been prescribed clopidogrel (an antiplatelet agent; 75 mg daily) at this time. His other regular medications included aspirin, irbesartan–hydrochlorothiazide, simvastatin and omeprazole. Clopidogrel was ceased on the day of admission to the rural centre because of concern about increased bleeding risk if potential urgent endoscopic or surgical intervention was required. After 24 hours, the patient’s condition had improved markedly, and he was discharged 7 days after admission. Clopidogrel was restarted on the day of discharge from the rural centre. His symptoms returned within 24 hours of discharge, upon which he presented to our tertiary institution. The patient was tachycardic (pulse rate, 114 beats/min), hypotensive (blood pressure, 90/60 mmHg), febrile (temperature, 39.6°C) and jaundiced. The remainder of his physical examination was unremarkable. Results of liver function tests at this time were markedly abnormal (Figure, A). His serum creatinine level was elevated (167 μmol/L; RR, 60–120 μmol/L). His international normalised ratio was 1.3 (RR, 0.8–1.2), with an activated partial thromboplastin time of 35 s (RR, 26–40 s). Abdominal ultrasound and magnetic resonance cholangiopancreatography showed no evidence of gallstones, biliary tree dilatation or choledocholithiasis. He was prescribed intravenous ceftriaxone (1 g daily), ampicillin (1 g every 6 h) and metronidazole (500 mg every 8 h). Clopidogrel was ceased on the day of admission, pending surgical review. His symptoms abated and liver function improved over the next 3 days. Clopidogrel was recommenced on Day 4 of admission. On Day 5 he had a fever of 40°C with rigors, and his liver function deteriorated significantly (Figure, A). Clopidogrel was withheld again in anticipation of surgery, and his antibiotic therapy was changed to intravenous ticarcillin–clavulanate (3 g/0.1 g every 6 h). His condition gradually improved over the next 5 days. Clopidogrel was restarted on Day 10. His condition deteriorated again within 24 hours, with a fever to 39.0°C and rise in GGT to 2205 U/L. His antibiotic therapy was changed to intravenous meropenem (500 mg every 8 h) and endoscopic retrograde cholangiopancreatography (ERCP) was scheduled, prior to which clopidogrel was ceased on Day 11. He suffered ongoing rigors between Days 10 and 17. On Day 17, ERCP revealed a normal intrahepatic and extrahepatic biliary tree. His symptoms and liver function abnormalities persisted; on Day 25, a transjugular liver biopsy revealed scattered poorly formed granulomas within the portal tracts and the hepatic lobules (Figure, B). The granulomas did not involve the interlobular bile ducts. Neutrophils were seen in the bile ductule epithelium, in keeping with acute cholangiolitis (Figure, C). The liver histopathology was initially thought to be consistent with primary biliary cirrhosis, a diagnosis that did not correlate with the clinical presentation. A review of the patient’s medication chart revealed that he had received clopidogrel intermittently since Day 10, despite the treating medical team’s request that it be ceased. Given this new information, the liver histopathology was reviewed and clopidogrel-induced granulomatous hepatitis was diagnosed. Clopidogrel was ceased permanently and he was discharged. At follow-up about 2 months later, his liver function had completely normalised and his symptoms had not recurred. Liver function test results throughout the patient’s tertiary hospital admission (arrows indicate prescribed and documented clopidogrel administration). Section of transjugular liver biopsy specimen (Picro-Mallory trichrome stain, magnification x 100) showing granuloma formation (arrow). Section of transjugular liver biopsy specimen (haematoxylin–eosin stain, magnification x 400) showing neutrophils (arrow) surrounding small bile ducts in the portal tract. The more common adverse effects of clopidogrel include gastrointestinal disturbance, rash and bleeding.1 However, several cases of clopidogrel-induced hepatic injury have been described. In Australia, 15 cases of hepatic injury associated with clopidogrel have been reported to the Adverse Drug Reactions Advisory Committee since the year 2000. Given the widespread use of clopidogrel, this adverse effect appears to be rare. The liver function test derangement associated with clopidogrel use has included hepatocellular2 and mixed hepatocellular and cholestatic3-6 patterns. In our patient, the diagnosis of clopidogrel-induced granulomatous hepatitis was accompanied by the clinical features of the systemic inflammatory response syndrome. The direct temporal relationship between the administration of clopidogrel and the development of symptoms, signs and liver function test abnormalities on three separate occasions during his admission was highly suggestive of causality. In addition, clinical improvement was noted each time clopidogrel was ceased. To our knowledge, this is the second time that the histopathology within the liver of a patient with clopidogrel-induced hepatic injury has been documented; the first was reported in 2006.6 The relatively mild hepatocyte death in contrast to the marked cholangiolitis correlated with the pattern of liver function test derangement. The presence of poorly formed granulomas within the patient’s hepatic lobules was highly suggestive of a drug-related aetiology. The other main differential diagnoses of granulomas in the liver (sarcoidosis, tuberculosis and primary biliary cirrhosis) have different histological characteristics, and are inconsistent with our patient’s clinical presentation. It appears from the emerging number of case reports that clopidogrel-induced systemic inflammatory response syndrome and hepatic injury is a real clinical entity that may be more common than previously suspected. This case demonstrates the importance of considering the possibility of an adverse drug reaction in the differential diagnosis. It also illustrates the potential difficulty and delay in diagnosis that can be encountered when the symptoms and signs of an adverse drug reaction mimic other, more common clinical entities (in this case, cholangitis). Given the increasing evidence for the effectiveness of clopidogrel in a wide variety of cardiovascular disease states, it is important that clinicians are aware of the possibility of this serious adverse effect.

Piers A Blombery BSc(Biomed), MB BS(Hons) · Prudence A Russell MB BS(Hons), FRCPA · John R Daffy MB BS, FRACP

Objective: To describe a prolonged outbreak of mumps in the Kimberley region of Western Australia in 2007–2008.Design: Descriptive analysis of all mumps cases notified to the WA Notifiable Infectious Diseases Database for the period 1 July 2007 to 30 June 2008.Main outcome measures: Notified cases of mumps by patients’ place of residence, age, Indigenous or non-Indigenous ethnicity, vaccination status and method of diagnosis.Results: 84% (153/183) of mumps notifications in WA over the study period occurred in the Kimberley region or were directly linked to Kimberley cases. Median age of patients was 18 years (range, 2–63 years), and 54% of patients were aged less than 20 years. Almost all (92%) were Australian Aboriginal people; 67% (102/153) had received at least one dose of mumps vaccine, and 52% had received two doses. The highest notification rate (1816 cases per 100 000 population) was in the Aboriginal 15–19-years age group, and 92% of these patients had received at least one dose of mumps vaccine. Almost all outbreak cases (94%) were laboratory confirmed. Genotyping was performed on 20 mumps virus isolates: all were genotype J.Conclusion: A prolonged outbreak of mumps occurred in a well defined, highly vaccinated, predominantly young Aboriginal population in the remote Kimberley region of WA. This outbreak raises questions about the effectiveness and scheduling of the current vaccine (which is genotype A-derived), especially for Aboriginal people. Surveillance of circulating mumps virus genotypes and neutralisation studies will help in evaluating the protection provided by the current vaccine against genotypically different strains.

Revle D Bangor-Jones MB BCh, MRCGP, MPH · Gary K Dowse BMedSc(Hons), MSc, FAFPHM · Carolien M Giele BSc(Hons), MPH, GradDipClinEpi · Paul G van Buynder MB BS, MPH, FAFPHM · Meredith M Hodge MB BS, MPHTM, FRACP · Mary M Whitty RN, RM, ChildHlthCert

I am an Aboriginal Kuku Yalanjii and Birri Gubba man. My Yalanjii people are from north of Mareeba, near Cairns, and my Birri Gubba connection is in Proserpine, right next to the beautiful Whitsunday Islands. My family grew up in Inala, on the outskirts of Brisbane, where we have lived for over 25 years. I come from a family of eight children. My mother is from Woorabinda and my father is from Proserpine and they are both Aboriginal. I have always heard about Aboriginal and Torres Strait Islander men having heart attacks at a young age and in higher proportions than non-Indigenous men. I have lost a number of uncles from heart disease, through not eating right, hereditary factors, high alcohol consumption and lack of exercise. In terms of my own health, I thought I was fine because I was always physically active, playing rugby league and touch football and being very involved in the community. I would never have believed it possible that at 34 years of age I could suffer a heart attack. I am sharing this story with other Aboriginal and Torres Strait Islander people around Australia in the hope that it will make some kind of impact on their lives. My story demonstrates how working in the Aboriginal and Torres Strait Islander community can have both a positive and a negative impact on yourself, your family and your community. I started working in the Inala Indigenous Health Service in 2001 as a research assistant and then moved to the role of community health worker. Before this, I’d had no experience in the areas of health or education. The main experience I’d had in community work was as a youth worker with the Queensland Department of Family, Youth and Community Care and as a teacher aide at the Glenala State High School. I’d also had experience as a volunteer coach of a Junior Rugby League side at Inala that has a high proportion of young Aboriginal and Torres Strait Islander people, parents and families involved. Working in the service gave me valuable experience under the guidance of our Aboriginal doctor Noel Hayman and Aboriginal nurse manager Nola White. Together, they gave me the confidence to undertake a Bachelor of Applied Health Science in Indigenous Primary Health Care at the University of Queensland in Brisbane. It took me 5 years to complete the course, while simultaneously juggling commitments to my family, community and employer. All I ever wanted to do was give back to the community that I grew up in, and working at the Inala Indigenous Health Service has given me that opportunity. In the 8 years I have worked at the Health Service, I have been involved in all areas of Indigenous health, including hearing health; drugs and alcohol; health status research; mental health; nutrition; counselling; transport; Indigenous leadership; youth issues; youth and adults incarceration; and health promotion. A major role I shared with my mentor Matilda Bani (Indigenous Service Officer with Centrelink) was coordination of the Inala Aboriginal and Torres Strait Islander Interagency Forum. This forum, which has been going for over 12 years, promotes information-sharing between departments and other agencies working with the Inala Aboriginal and Torres Strait Islander community. Shared Responsibility Agreement: making a differencePerhaps one of the biggest achievements in my life (besides having children) was being involved in establishing a Shared Responsibility Agreement (SRA) between my community and the federal government in 2006 (Box 1). The central aim of the SRA was to improve the health and wellbeing of Aboriginal and Torres Strait Islander men in our community via their engagement in rugby league. Rugby league has been an institution within our community, particularly among Aboriginal and Islander boys and men. For 5 years prior to the SRA, there was no opportunity for men in Inala to play rugby league, due to a lack of activities and sporting programs for Aboriginal and Torres Strait Islander men, and few Aboriginal and Torres Strait Islander men were likely to go outside the community to play rugby league. Without football in the community, few men played sport, and this contributed to many problems such as boredom, poor health, low self-esteem, and high intake of drugs and alcohol — all of which can lead to incarceration. Through conversations with the federal government, I developed a proposal to get a group of respected Aboriginal and Torres Strait Islander men to look at ways of getting our brothers involved in sport, employment and healthy living for themselves and their families. The federal government agreed to fund two open rugby league sides at Inala, on the condition that men in the community participated in health, employment, education and mentoring opportunities within the community. My role as the Community Health Worker was to encourage Aboriginal and Torres Strait Islander men to come to the Inala Indigenous Health Service for adult health assessments, and to participate in other health promotion activities such as the Inala Indigenous Health Calendar (Box 2) and workshops on nutrition and physical activity. The men were also enlisted to participate in mentoring activities, such as coaching, refereeing, volunteering with junior teams, participating in local training and employment initiatives (if they were unemployed), promoting healthy lifestyles, and demonstrating positive behaviour on the sporting field and in the community. Through this process, many local men also participated in training that saw them become qualified referees, coaches and first aid officers. Since being involved with the SRA in Inala, I have seen some great success stories. Seeing other young Aboriginal and Torres Strait Islander men putting their hand up to be involved in rugby league as coaches, referees, first aid officers and volunteers at the club has really built the self-confidence of men in our community. The pressures of community work, family and volunteering: my healthDuring this time, I was so passionate about my work that I forgot who I was. I was doing this as part of my role as Community Health Worker, but was also a volunteer. I was so busy taking care of everyone else that I forgot to take care of myself. I was at the club nearly 7 days a week with the junior and senior teams, feeling constantly stressed, spending a lot of time away from my family, and not taking time out for myself. Because I was always on the go, I was not eating healthily. I just wanted the SRA to succeed and be sustainable, so that Inala Aboriginal and Torres Strait Islander men could be strong, self-reliant, and able to source other avenues such as sponsorship and fundraising. I was also a rugby league player at the time, so I was heavily involved in the game, both on and off the field. Rugby league has always been my passion and, although I would go to games to help with strapping and make sure everything was taken care of, I would often jump on the field and play if the team were short of players. It was towards the end of the 2008 season that I put on the jersey for Inala, like so many times before. But during this particular game, I started experiencing dizziness, came off the field and collapsed. Although I didn’t know it at the time, I had just had a heart attack. Fortunately, the coach of the team (one of my closest friends and a participant in a first aid course delivered under the SRA) and the registered first aid officer kept me alive until an ambulance arrived. It was only their quick actions that saved my life. All I remember is drinking a sports drink and then waking up in the ambulance. When I asked the ambulance officer if I had been knocked out on the field, he told me I’d had a cardiac arrest and said that, if it wasn’t for the coach and first aid officer, I wouldn’t be alive. Since then, I have had three operations on my heart and am now fitted with a defibrillator in my chest in case a similar episode happens again. At 34 years of age, I am very lucky to be alive, and to this day I feel enormous gratitude to the coach and first aid officer to whom I owe my life. There is an irony in the fact that the very thing that caused so much stress in my life was also the very thing that led to my life being saved. My illness also made a big impact on the Inala Aboriginal and Torres Strait Islander community in the south of Brisbane. There has been an increase in the number of people attending the Inala Indigenous Health Service, and the number of health checks has doubled. Many Aboriginal and Torres Strait Islander people aged 35 years and over are now attending the health service. I’m glad that some good has come out of my heart attack, not only for me and my family, but also for the community as a whole. It has changed my life dramatically — I thought I was OK, and then all of a sudden my whole life was turned upside down. Lessons I have learntAfter having all the operations and undergoing mainstream cardiac rehabilitation at a hospital in Brisbane, I started to get my confidence up with doing exercise such as walking and playing tennis and doing things around the house with my family. Back at work a month after having surgery, I am slowly easing my way back into work, eating more healthily, and getting lectures from family and community members about taking it easy in the community. I am doing OK now and just taking life one day at a time. I am grateful to everyone for their support — my family, my work colleagues and my community. There is much good that is happening, and Inala is continuing to grow and develop into a really great community. After all the operations and cardiac rehabilitation, I decided to get married to my lovely partner of many years. I put the pain behind me to set up a new chapter in the lives of me and my family. At times I don’t think about the heart attack, I just think every day what I can do to get my kids out of the house and do something active. My family is my life, my community is my strength, and my work keeps me active. I share my story with people who are reluctant to go for a heart operation and encourage them to have it done so they will be able to live longer and see their children and grandchildren grow up. Today I am enrolled in a Master of Philosophy by research at the University of Queensland, while working as a research fellow with the Inala Indigenous Health Service and at the George Institute for International Health in Sydney. This will broaden my role in my line of work and will enhance my capacity to be a good role model and mentor for my community. I feel very passionate about working in Indigenous health, especially in the field of heart disease, kidney disease and diabetes, with the support of the Inala Indigenous Health Service and the George Institute’s Kanyini program. Rugby league is continuing to thrive in Inala with the keen involvement of other Aboriginal and Torres Strait Islander men in the community. They have been playing the game for 3 years now without any funding assistance from the federal government. They won a grand final in 2007, were runners-up in 2008 (Box 3), and are very actively involved in community events and the junior club. I am slowly working my way back into the community, having learnt some valuable lessons from this journey — in particular, the need to balance my family commitments, work and volunteering. I have taken a big step back from being involved in the community in a voluntary capacity. Inala is going forward in a very positive way, and members of the next generation are putting up their hand to give back to the community that has supported them. 1 Some of the people involved in our Shared Responsibility Agreement Left to right: John Brady, Tricia Button (State Manager, Indigenous Coordination Centre), Mal Brough (former Minister for Families, Community Services and Indigenous Affairs), Robert Duncan (Junior Club President). 2 Health messages from the Inala Indigenous Health Calendar 3 Inala rugby league team members and young supporters

John P Brady BAppHlthSc

To the Editor: The Therapeutic Goods Association (TGA) has informed Australian eye banks that nucleic acid testing (NAT) of donor sera will be required in addition to routine serological tests for hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV. NAT can detect viral genome in the window period between infection and the appearance of antigen or antibody, and is to commence in Australia as soon as possible. However, we believe the benefit of NAT would be small and the cost considerable. Importantly, it would be likely to have an adverse effect on the availability of donor corneas for transplantation. HBV, HCV or HIV have not been transmitted from seronegative donors by means of corneal transplantation. In the mid 1980s, HBV was almost certainly transmitted by corneal tissue to two recipients in the United States who developed acute hepatitis B; HBV surface antigen was detected subsequently in the donor sera.1 The transmission of HCV or HIV has not been reported despite corneal transplantation from infected donors.2,3 The American Red Cross instigated HCV/HIV (but not HBV) NAT for blood donors in 1999, and the US Food and Drug Administration mandated HCV/HIV NAT for eye donors in 2007. So, how many window-period eye donors could be identified by NAT? It has been estimated that 7.2 per 100 000 American tissue donors are in this period for HBV, HCV or HIV.4 With NAT, the number reduced to 1.8 per 100 000 (most assays, including NAT, have sensitivity limitations). Let us assume that the prevalences of HBV and HCV are the same in Australia and the US, the prevalence of HIV in Australia is half that of the US, and that prescreening by medical and social history is equally effective in both countries. At 700 corneal donors (1200 grafts) per year in Australia, one window-period donor would be expected every 23 years, falling to one every 93 years with NAT. Thus, one window-period donor would be detected by NAT every 30 years at an estimated cost of $9 million ($50 per donor averaged up for out-of-hours testing and kit wastage) plus any charges for specimen transport. If only HCV/HIV NAT is performed, such a donor would be detected every 52 years. What is the actual risk of infection? Assuming 25 000 corneal donors (43 000 grafts) per year in the US, the figures4 suggest that eyes were collected from one window-period donor every 7 months between 1990 (when a serological test for HCV became available) and 2007, but no infections have been reported. Perhaps there was no virus in the corneal tissue; even among donors who are seropositive for HBV, HCV or HIV, few have detectable viral genome in the cornea.5,6 It is not known whether these viruses can invade the cornea before the appearance of antibody, but the risk that infection will occur in recipients of corneas from HCV/HIV-seronegative, NAT-positive donors appears to be very small indeed. The TGA’s decision may have been based on factors other than this type of analysis. We believe the decision should be reconsidered.

Paul R Badenoch · Douglas J Coster

To the Editor: Compared with the Australian population, all-cause mortality rates among prisoners are four times greater among men, and eight times greater among women.1 Fatal drug overdoses and suicides comprise the overwhelming majority of deaths in post-release cohorts;2 hence, a large proportion of post-release deaths are preventable. However, the information necessary to determine appropriate public health responses to the issue of post-release mortality is largely absent, because there is no routine nationwide collection of numbers of prison separation episodes as there is, for example, for prison receptions.3 We aimed to estimate the number of inmate separation episodes occurring in Australia for the financial year 2007–08, using benchmark data obtained from public documents on the websites of each state and territory government department responsible for prisons. For each state and territory, we attempted to obtain the total number of inmates (ie, sentenced and on remand) released from prison for the financial year 2007–08. This figure was available for Victoria (5356), South Australia (4177) and the Northern Territory (2857). For New South Wales, data could only be obtained for separations of sentenced prisoners (7645). Hence, data on separations of either total or sentenced inmates were available for jurisdictions covering 62% of the national prison population. To adjust for separations of prisoners on remand in NSW, we assumed that separations of sentenced prisoners comprised 40% of all separations, reflecting the ratios of sentenced to total separations in other jurisdictions. Hence, the total number of separations in NSW was estimated to be 19 113. A multiplier of 1.6 (1/0.62) was applied to the sum of separations from Victoria, SA, the NT and the adjusted figure for NSW separations, in order to estimate separations for the national prison population. This produced an estimate of 50 405 prison separations nationally for 2007–08. Each of these separations is associated with a significant increase in risk of death. We have made an estimate of the number of prison separations in Australia for 2007–08, but believe that a more appropriate and precise method for obtaining this information would be to include separations for the total number of prisoners and for sentenced prisoners as items in routine data collection systems such as the Australia Bureau of Statistics Prisoners in Australia collection. This would enable better through-care service planning and provision of life-saving pre-release and post-release health services, such as prison-based opioid substitution treatment4 and overdose prevention and treatment interventions such as distribution of naloxone.5

Kristy A Martire · Sarah Larney

To the Editor: Pet abuse is considered another form of family abuse, and is a powerful marker for other forms of violence happening in the home. Women and children living with violence, isolated by their abuser, often form intense bonds with their pets. Perpetrators will use animal cruelty as a means to intimidate and control their partners and children.1,2 Women will put themselves at increased risk due to concern for their pets.1-5 RSPCA New South Wales acknowledges the link between domestic violence and cruelty to animals. In 2004, it initiated the Safe Beds for Pets program, which provides emergency accommodation for pets of women and children seeking refuge from domestic violence (http://www.rspcansw.org.au/programs/safe_beds_for_pets). The Central Coast, NSW, arm of this program conducted an anonymous, self-administered survey to identify the prevalence of perpetrator violence against the family pet and its effect on decision making by women. The survey was offered to local women who owned a pet, were aged 18 years or over, were experiencing domestic violence and had attended the Central Coast Domestic Violence Court Advocacy Service, and was conducted between August and November 2007. Of 187 women, 92 owned a pet, 85 of whom completed the survey. Almost 75% (63/85) owned at least one dog, 45% (38/85) owned at least one cat and 22% (19/85) owned at least one bird. We found that 27% (22/82) of partners had threatened to hurt or kill a pet, and 23% (18/80) had done so. These data are at the low end of findings of other studies, which found that 40%–53% of partners threatened to hurt or kill a pet, and 26%–57% had done so.3 Out of concern for their pets, 27% (22/83) of women in our study delayed leaving home (compared with 33% in another study3), and 27% (23/85) returned to their partner. Women also delayed calling the police (17%, 14/84) and refused to lay charges (11%, 9/83) out of concern for their pets. Women whose partners had threatened or killed a pet were more likely to delay leaving, return home, delay calling police, or refuse to lay charges than women whose partners had not (Box). The study’s main weakness was that it was restricted to current pet ownership, thus excluding women who may have recently rehomed or abandoned their pets, or whose pets may have already been killed.3 Clinicians do not necessarily ask clients about the role of pets in their health. If the issue is not raised, women often feel reluctant to speak up.4,5 We encourage clinicians to: ask patients experiencing domestic violence whether they have pets, whether their pets are at risk of abuse, and whether they need help to keep their pets safe; and talk with human and animal service providers about opportunities for cross-service programs, such as Safe Beds for Pets. We support the development of a nationwide strategy allowing the simultaneous relocation of a woman, her children, and pets from a violent home.3 Relative risk (95% CI) of women’s decisions if their abusive partners threatened or hurt their pets Partner’s action Delayed leaving Returned home Delayed calling police Refused to lay charges Threatened to hurt 3.00 (1.54–5.83) 3.78 (1.95–7.30) 34.29 (4.74–247.97) 9.00 (1.97–41.07) Threatened to kill 2.41 (1.23–4.71) 3.64 (1.91–6.94) 5.58 (2.21–14.09) 4.12 (1.28–13.32) Threatened to hurt or kill 2.81 (1.44–5.50) 3.55 (1.82–6.89) 32.18 (4.44–233.18) 8.43 (1.84–38.57) Actually hurt 1.93 (0.92–4.07) 2.12 (1.04–4.30) 7.63 (2.66–21.88) 6.78 (1.88–24.43) Actually killed 1.35 (0.26–7.01) 4.59 (3.01–6.99) 5.78 (2.57–12.97) 6.33 (1.82–22.00) Actually hurt or killed 1.93 (0.92–4.07) 2.12 (1.04–4.30) 7.63 (2.66–21.88) 6.78 (1.88–24.43)

Cheryl Travers · Andrew Dixon · Karen Thorne · Kaye Spicer

To the Editor: Training of adequate numbers of surgeons and other medical specialists has, until recently, been a sleeper issue.1‑3 Trainees are intimately involved in public hospital patient care, but it is generally assumed that private patients are off limits for training. To our knowledge, the perceptions of patients in a private hospital setting have not been formally explored before. We present the results of a survey of attitudes of private hospital patients towards trainee involvement in their care. At a major private hospital in Melbourne, 82 consecutive inpatients undergoing elective general surgery over a 6-week period in 2005 were invited by us to respond to a survey (given prior to surgery and collected prior to discharge). Ethics approval was obtained. Sixty-eight survey forms (83%) were returned by the 82 patients. The median age of respondents was 56 years (range, 18–78 years), and 35 (51%) were men. The most important reasons given for having private health insurance were choice of surgeon (68% of respondents), quality of medical facilities (28%) and shorter waiting-list time (4%). Availability of trainees in the hospital to (a) communicate with the surgeon, (b) manage emergencies, and (c) perform minor procedures were all ranked as very to highly important, as was the ongoing education of trainees. When asked how comfortable they felt with trainees being involved in their care, 88% of patients said they supported having a trainee assist the consultant surgeon with surgery. Providing the trainee was under direct supervision of the surgeon, patients supported allowing a trainee to perform part of the surgery (75% of respondents), most of the surgery (50%), or the entire operation (41%). No significant differences in attitudes attributable to patients’ age or sex were found (Mann–Whitney U test). Within the limits of our small survey structure and incomplete response rate, our results show that most patients support the concept of having a trainee involved in ward care. There was polarised opinion on how much of the operation could be performed by the trainee, and this may vary for different subspecialties. Currently, junior medical staff work in many private hospitals, gaining valuable experience in perioperative care and exposure to a range of surgery. These jobs would be ideal for junior Royal Australasian College of Surgeons (RACS) trainees at Surgical Education and Training Level 1 or 2. However, individual surgeons may be concerned about the potential for increased complications4,5 and longer operating times, with a reduced number of cases and earnings per list. Discussion of medicolegal issues, remuneration and accreditation of posts would need to take place between hospitals, government and the RACS. It is clear that increasing demand for surgical training necessitates the consideration of an accredited role for the advanced surgical trainee in the private health care system.

Lih-Ming Wong · Lisa P Wun · Julie Shaw · Dominic Vellar

To the Editor: Roe and McDermott recently noted that the health benefits of swimming pools demonstrated by Silva and colleagues1 may be more modest than reported.2 Our initial observations from a remote South Australian Aboriginal community support this observation, but there are also many difficulties with study implementation that may introduce biases. A swimming pool was constructed during 2007 as a result of a community-led initiative. With ethics approval, trachoma screening was performed before the pool opening (November 2007) and 6 and 18 months after the pool was opened. Rates of middle ear infections, skin infections and antibiotic prescriptions among children aged 1–15 years were assessed using a retrospective analysis of clinic records between May 2007 and April 2009. A questionnaire regarding the benefits of and barriers to swimming pool use in the community was administered to key persons, such as community health workers and school teachers in April 2009. We aimed to examine every child in the community aged 1–10 years; 45/56 (80%), 46/62 (74%) and 59/64 (92%) children were examined at each of the three visits. The proportion of children with follicular trachomatous inflammation remained low and unchanged at the three time points (7%, 7% and 8%). The clinic records of 166 children showed a trend of increasing rates of infection and antibiotic prescriptions for the period. With hypoendemic rates of trachoma and possible confounding factors, including a small sample size, population mobility, reporting bias and a high turnover of health personnel, we were unable to demonstrate health benefits of pool usage. Our findings highlight the importance of avoiding complacency once a single intervention, such as a swimming pool, has been put in place. Long-term maintenance and supervision are needed to ensure efficacy of a pool. Aspects such as housing, sanitation, nutrition, education and substance misuse should also be high priorities when trying to address health conditions for which low socioeconomic conditions are major risks.3,4 Although we found no specific health benefits of having a pool, interviewees reported that the pool benefited the community in other ways, including providing an opportunity for exercise and recreational activity for otherwise unoccupied children, and creating an incentive to attend school, owing to a “no school, no pool” policy. The pool is a “public good”2 that cannot be denied based on lack of health benefits. Ongoing investigation is planned to monitor the effects of the pool in this community, and it may be too early to draw final conclusions concerning the health benefits of swimming pool use.

Anu A Mathew · Collin J McDonnell · Jill Benson · Hugh R Taylor

To the Editor: Li and colleagues analysed avoidable hospitalisation rates for Aboriginal and non-Aboriginal people in the Northern Territory, examined trends over time, and assessed “the implications for future primary care interventions”.1 Their study results confirmed that Aboriginal Australians in the NT experience significantly higher rates of avoidable hospitalisations than non-Aboriginal people. They also report a widening gap between avoidable hospitalisation rates of Aboriginal and non-Aboriginal people during the study period, 1998–99 to 2005–06. Avoidable hospitalisation rates are used nationally and internationally as an indicator of primary health care effectiveness and accessibility. However, debate continues about which conditions to include as “avoidable”, and the potential for errors in allocating and coding the primary diagnosis. Furthermore, serious methodological issues remain regarding the use of avoidable hospitalisation rates as an indicator of primary health care effectiveness and accessibility. The outcome measure “avoidable hospitalisation” is affected by more than just primary health care. This is acknowledged by Li et al,1 who identify other factors that affect hospitalisation, including disease prevalence and severity, and geographical remoteness.2 If these factors are not controlled for, it is not possible to attribute differences in hospital admissions to differences in quality of primary care. This would only be possible if Indigenous and non-Indigenous populations were similar in health status and residential location (and other important respects). Aboriginal people in the NT experience far higher rates of diabetes than non-Aboriginal Australians and the age of onset is far younger. For example, there is a 10% prevalence of diabetes in Aboriginal people aged 25–34 years residing in remote areas of the NT. This is 19.5 times the rate of diabetes in a sample of the Australian population of the same age (which will be close to the non-Indigenous rate in the NT), using data from the AusDiab study.3 This young Aboriginal population is also 18 times more likely to have multiple chronic conditions than the AusDiab group of the same age.3 Hospitalisation rates of a population with this health profile should be high, particularly if the primary care system is performing well. Even though Li and colleagues recognise the complexity of measuring primary health care effectiveness and access,1 they still attribute higher rates of avoidable hospitalisations to Aboriginal people’s lack of access to effective primary care. This simply cannot be deduced from their analysis, as it fails to adjust for the high and increasing incidence, prevalence and severity of chronic diseases in the NT Aboriginal population compared with the non-Aboriginal population. This type of misinterpretation of data is serious, given the potential policy implications. We agree that the research question is important, but it warrants a sophisticated analysis that properly adjusts for the most important confounders.

Odette R Gibson · Leonie Segal

In reply: The national and international use of avoidable hospitalisations as an indicator of accessibility and overall effectiveness of primary care1 has included reporting differences in hospital admissions for different ethnic populations and across different geographical regions to highlight inequities in access to primary care. Avoidable hospitalisation rates are also routinely reported for the Aboriginal and Torres Strait Islander population.2 Currently, there is no “gold standard”, but compared with other indicators, such as self-reported data from population surveys, avoidable hospitalisation rates are regarded as an objective and robust measure of primary care.3 Despite the established use, there are well recognised limitations in the interpretation of avoidable hospitalisations, which are outlined in our article,4 and also raised in the letter by Gibson and Segal. What our article highlights, using well identified data sources, is the difference in avoidable hospitalisation rates between the Northern Territory Aboriginal and non-Aboriginal populations, as well as the very different trends. There are expectations that current reforms in the delivery of primary care for Aboriginal Australians can be directly monitored by improvements in avoidable hospitalisation rates. Our results highlight the need for caution in interpreting changes in these rates, and the substantial risks associated with unrealistic performance benchmarks.

Shu Q Li · Natalie J Gray · Steve L Guthridge · Sabine L M Pircher

To the Editor: Duckett rightly points out that community knowledge and expectations of the delivery of medical services have increased in recent years, and that the “baby boomers” of today will not accept the hospitals of yesteryear.1 He claims that the Australian health system has responded to technological change, but not to sociological change. Although the introduction of new medical technologies — a process largely driven by clinicians — has helped ensure that Australians still have access to quality health care, the same claim can not be made for the other kinds of technologies necessary to support delivery and review of good-quality care; notably, health information technology lags lamentably behind other sectors. In addition, we have not been “adept in responding to technological change”, because we have not figured out how we are to pay for it. The sociological changes that Duckett is concerned with are well recognised by many working in the public health sector. He states that macro- and provider-level reforms set the context for the interaction between the patient and clinician. He seems inclined to view this interaction as the final frontier — resistant to change and responsible for what he characterises as an ongoing lack of responsiveness in hospitals and health facilities. However, his outdated and stereotypical characterisation of doctors working in the public health sector must call into question his knowledge of what actually goes on in modern health care settings, in addition to pointing to a tendency to underestimate the difficulties of working in these austere and pressured environments. The conversation that privileged baby boomers actually need to have is one that forms part of a public debate about how much health care costs and how we should be thinking about rationing its delivery, or else paying more for it, as Queensland Health has perhaps finally learned. It is disappointing that, despite Duckett’s long years of experience in the public health sector, he fails to address the real implications of the changes, both technological and sociological, to which he alludes in his opening paragraph — how exactly are we going to manage the ever-increasing demand for increasingly expensive treatments by an ageing population?

Heather J Cleland

To the Editor: The next challenge for medicine in Australia, in Duckett’s opinion, will be the need to provide for the “very different expectations . . . and a greater sense of entitlement” of baby boomers, as they reach old age and have more need for health services, in and out of hospital.1 They will not meekly wait for care — but how will waiting lists for appointments and elective surgery be abolished? They will not accept “cattle class” in outpatient departments — but who will pay for the replacement of wooden benches with easy chairs? They will not accept whatever is on offer — but who will provide what is not on offer at a time of need? They will expect frank discussion of choices, risks and outcomes — but which cardiac surgeon or registrar will have the time to go into the 40 different possible complications of coronary artery bypass, an operation with usually excellent results? And if nurse practitioners or podiatrists become leaders of the medical team, will they be professionally and legally responsible when outcomes are unsatisfactory or disastrous? People with visions of the ideal medical service should keep in mind a basic principle, expressed by Enoch Powell 42 years ago.2 Even in prosperous times, limited resources (trained staff, facilities and money) will never meet unlimited demands. Duckett’s baby boomers may have expectations, but they must be measured against reality. With the unceasing growth of knowledge, technology and pharmacology, medicine is not about to become cheaper.

Derek H Meyers

In reply: Notwithstanding the differences in tone, Cleland and Meyers make the same substantive point: that a challenge I ignored in my short piece was the costs of meeting the different expectations of baby boomers. Regardless of the changed expectations I discussed in my article, health costs over the next few decades are predicted to increase from just over 9% of gross domestic product to over 12%.1 Economists recognise that societies appear willing to devote more spending to health care as they get wealthier, perhaps to avoid confronting the difficult choices involved in some rationing decisions.2 But should we immediately jump to the conclusion that more rationing is inevitable? What other choices are there? First, we — policymakers and clinicians alike — need to address the waste and inefficiency inherent in the current system;3 and, second, change the health system so that it is better suited to respond to changing needs4 and potentially “bend the trend” of health cost projections. Third, we need to recognise that rationing — or, to use a less emotive term, priority setting — is already part of our health system. Australia leads the world in terms of formal processes before listing new drugs on the Pharmaceutical Benefits Scheme or items on the Medicare Benefits Schedule, but here too, improvements are needed. Clinicians are already involved in rationing choices, but different clinicians appear to have different thresholds of when (and what) treatment should be recommended. These differences may be cultural,5 and addressing these unexplained variations in practice patterns remains a policy work in progress. Thus, we in the health system have a lot of work to do in putting our house in order so that any rationing debate can occur knowing that alternative strategies have already been pursued.

Stephen J Duckett

To the Editor: Italiano and colleagues described a 49-year-old woman with prolonged vaccine viraemia, associated with hepatitis, streptococcal toxic shock syndrome and poststreptococcal reactive arthritis following routine varicella vaccination.1 The woman, initially seronegative for varicella zoster virus (VZV), was stated to be immunocompetent, possibly because she was previously well and produced varicella IgG following vaccination. It is not clear whether other aspects of her immune status were investigated. Although VZV IgG was detected after vaccination, indicating appropriate adaptive immune activation, this does not necessarily exclude a defect in the innate immune system. Natural killer (NK) cells, which comprise 10%–15% of total lymphocytes, are part of the innate immune system and play an important role in the suppression of VZV replication via direct cell killing and production of γ-interferon.2,3 A smaller population of lymphocytes, known as NKT cells, which express both NK cell surface markers and T-cell receptors, also appear be important in controlling VZV infection in humans.2 The role of these cells in the immune response to varicella vaccine is unclear. In children, NK cell cytotoxicity increased after wild-type VZV infection but not after vaccine administration.4 However, disseminated life-threatening VZV infection was observed after varicella vaccination in a child with NKT cell deficiency.2 Primary isolated deficiencies and functional defects in NK function have been reported in children and adolescents with severe, life-threatening wild-type VZV infection.5 Some of these patients were previously well and came to medical attention only after VZV exposure. It is not clear how many had prior varicella vaccination, but at least one patient had previously received VZV vaccine with no adverse consequences and developed disseminated disease only with the wild-type virus. Acquired defects in NK immunity have also been reported. Severe transient depressions of NK and CD8 cell numbers and NK cell function have been documented in children at the time of severe VZV infection, with return of immune competence following convalescence.3 This phenomenon may be due to initial CD8 and NK cell exhaustion or redistribution of these cells from the circulation into inflamed peripheral tissue under the influence of chemokines.3 It has been suggested that an NK cell defect should be considered in unexplained severe herpesvirus infections.5 It would therefore be of interest to determine NK cell number and function and NKT cell number in the patient reported by Italiano and colleagues.

Sam S Mehr · Andrew S Kemp

To the Editor: The introduction of non-invasive prenatal testing will revolutionise the practice of prenatal diagnosis. One of the many potential applications of non-invasive prenatal diagnosis (NIPD) is to determine fetal RHD status in pregnant Rhesus (Rh) D-negative women, and the feasibility of such testing was aptly demonstrated by Hyland and colleagues1 and commented on by Cole and Savoia.2 It is clear that once the technical problems of indeterminate results and gene variants are resolved, NIPD for RHD status will have improved clinical utility over current invasive testing, thus reducing the need for invasive procedures and prophylactic treatment of all RhD-negative women. The assay developed by Hyland et al can also be used to determine fetal sex, indicating a potential additional use in women at risk of carrying a fetus with a sex-linked disorder, so as to halve the number of chorionic villus sampling (CVS) tests being performed. However, it is worth noting that the number of CVS tests currently performed for this indication is extremely small. In Victoria, the complete population-based dataset on prenatal diagnosis for 2007 shows that there were only eight invasive tests for sex-linked disorders.3 The most significant impact of NIPD technology will be for pregnant women who request prenatal testing for Down syndrome. If NIPD testing for Down syndrome becomes available, it is anticipated that current testing based on chromosome analysis (karyotyping) of a sample obtained by CVS or amniocentesis will become redundant. However, replacing karyotyping — a genome-wide test — with a targeted NIPD test for Down syndrome will mean that many of the other chromosome abnormalities currently detected by CVS or amniocentesis will no longer be detected.4 We do not know whether this is important to women or not. Before implementing any NIPD test, we suggest that each application needs a separate investigation, including a careful comparison of clinical utility between current tests and the proposed replacement technology.

Marleen R Susman · David J Amor · Jane L Halliday

To the Editor: The authors of the recent MJA article “Making cars and making health care: a critical review”1 have misunderstood the importance of process design in a service as complex as health care delivery. They state that the Toyota “lean thinking” model has been “accepted somewhat uncritically” in health.1 In fact, the opposite is true. Work practices and roles in conservative institutions such as public hospitals have changed minimally over many years. Cutting-edge medical technology is delivered within an archaic work practice model that fosters inefficiency, frustration and unnecessary expense. Inefficient work practices give skilled clinicians less time with their patients — not more. Like Winch and Henderson, let’s take an example from the surgical field. Years ago, when public hospital beds were relatively accessible, many patients were admitted for “work-up” and spent days in their pyjamas in hospital before planned surgery. The application of the “just in time” principle has led to the huge turnaround to day-of-surgery and day-only admissions — freeing up beds and saving enormous cost as well as many unproductive days for patients. This is only one small example. Lean thinking is just one model for improving the way in which complex processes are coordinated.2 Far from being “highly stylised and simplistic”, lean thinking is about removing redundant steps and reducing duplication, waiting times and errors. It’s about investing in the talent and skill of trained staff, by maximising the value they add to whatever process they are working on and minimising the extraneous tasks they have to do.3 Managed properly, this can result in faster and better care delivered by happier staff, with more time to “cure and comfort”.1

Susan Ieraci

In reply: Our article highlighted issues with the uncritical adoption of car-making processes into health care planning — specifically, the regulation and splintering of the human element of a care pathway. While day-of-surgery admission speeds patients through the system, the capacity for error remains and relates to our original arguments. For example, one assumption commonly made is that the patient or carer has the literacy level to understand the presurgical procedures, such as fasting, taking particular preparations or completing health history forms. Yet the Australian Bureau of Statistics reported in 2003 that 37% of the population met only the minimum literacy standard (Level 3) required to function in a complex society such as ours in Australia.1 Forty-six per cent fell below this benchmark. For health literacy specifically, 35% of the population met only Level 3 standard, with about 60% falling below this standard. This indicates that some of the work we have happily “outsourced” to the patient may be poorly understood and cause problems further down the line. It also highlights another key difference between cars and people: baseline control of the beginning raw material is difficult to achieve.

Sarah Winch · Amanda J Henderson

To the Editor: Eslick and Eslick believe that the television program The Simpsons causes children to smoke.1 What they gloss over is that in this show, only “losers” smoke. The characters Patty and Selma are old, ugly, mean-tempered, sexually frustrated sisters working in deadening jobs at the motor vehicle licensing office. They don’t just smoke, they chain-smoke — a well established television trope for sleaze and disease — and then they cough, hack, and wheeze. Krusty the Clown, if the name doesn’t tell you already, is a beaten-up, ageing, balding guy. He’s nasty, neurotic, and estranged from his father for abandoning his orthodox Jewish roots for the sinful life of television. Mrs Krabappel, the schoolteacher, is old, divorced, ugly, hates her job, hates her life, and hates children. It may be that children watch The Simpsons. I don’t know, and Eslick and Eslick cite no data that show they do. The questions, though, are: Do children understand what a loser is? Do they emulate losers, or shun them? Eslick and Eslick cite studies showing that any portrayal of smoking causes children to smoke.1 If this is so, why bother to differentiate between “neutral”, “positive” and “negative” portrayals of smoking? And what, precisely, do these labels mean? If, as they say, the “most notable characters” who smoke are these four loser characters, it is strange that they have coded most smoking instances as neutral rather than negative. Even if the authors have a valid labelling system, and even if neutral portrayals cause children to smoke, the question then becomes: is this effect greater than any countervailing effects, such as, perhaps, that of discouraging adults (and adults who are parents) from smoking, or that of creating a broad cultural association between smoking, social failure, and sickness? The logic of the argument put by Eslick and Eslick is that smoking should not be depicted at all in television programs that children watch. Given that children see people smoking in real life, and presumably look around them for some guidance as to whether they should do it too, it seems to me that it is actually commendable to tell them that only losers smoke. Strong evidence and argument that this approach does more harm than good would be very valuable.

Nicholas Jefferson-Lenskyj

To the Editor: The article by Eslick and Eslick1 caught my attention, as the sophisticated parodying of the tobacco industry on The Simpsons has been a much discussed topic among my tobacco-control colleagues. In the introduction to the article, the authors ask if the smoking and tobacco industry portrayals in this program are “just satire, or does the repetitive nature of characters smoking on The Simpsons have an influence on young children watching?” The study design employed cannot answer this question. I was surprised then that the authors concluded that the portrayals of smoking on The Simpsons negatively influence young children. The study results indicate that positive portrayals of smoking on the show are, in fact, extremely rare. It could equally be the case that the more numerous negative portrayals of smoking on this popular and subversive comedy reach young viewers in a way no government-sanctioned health promotion campaign can. Health education messages presented through social satire may not be politically correct, but this does not mean they are ineffective in communicating antismoking sentiments.2 The two most prominent smokers in The Simpsons, Patty and Selma Bouvier, are not characters that any teenager would aspire to be like — disgruntled, middle-aged sisters who live together, work in depressing jobs at the local Department of Motor Vehicles, Selma constantly bemoaning her lack of a husband and fantasising about 1980s heart-throb MacGyver, and Patty best known for her utter joylessness and cynicism. Surely these grim stereotypes would cause most young people to turn away from smoking, and not towards it? Tobacco-control policies themselves were recently lampooned in The Simpsons, with the Simpson family opening a pub in Ireland that illegally allowed patrons to smoke. Much mayhem ensues, and the Simpsons are eventually deported back to the United States for breaking the Irish antismoking laws.3 I am delighted that tobacco control has such universal momentum that it can be parodied on a pop-culture phenomenon like The Simpsons.

Becky Freeman

To the Editor: I read with interest the recent case report by Lim and colleagues on Chromobacterium violaceum endocarditis.1 References to the article do not include a report of a similar case published 20 years ago, also in the MJA.2 Perhaps reference searches can be enhanced — otherwise, identifying such similar cases falls to recollected experience (I was the initial treating doctor in the 1988 case) or an improbably capacious memory in the author or reader. What saved the patient in February 19882 were two new antibiotics that were not generally available at the time but were held at Royal Brisbane Hospital — imipenem and ciprofloxacin. Imipenem is a β-lactam antibiotic of the carbapenem subgroup, derived from Streptomyces cattleya, that was developed in 1985.3 Imipenem and other carbapenems including meropenem, as used to treat the patient in the article by Lim et al,1 are now available in Australia but restricted to intravenous use in hospitals. The oral antibiotic ciprofloxacin became generally available with a Pharmaceutical Benefits Scheme authority benefit soon after the 1988 case. I recall a discussion at that time with the late Dr Richard Kemp (then Director of Infectious Diseases at Royal Brisbane Hospital), who told me that C. violaceum infection in humans had been described in the world medical literature only about 10 times, and there had been no eventual survivors. From a general practitioner’s perspective, there was a lesson to be learned from the case: take the time to swab an abscess. The one in question was unusual — volcanic in appearance, indurated and not productive of pus on incision.

Richard N Pearson

Everybody thinks that if everybody used common sense, the problems in health care would go away — but common sense isn’t that common, and health care is more complex than it seems. However, MJA Books’ latest publication provides a simple, clear guide to effective clinical risk management. So said Professor Bruce Barraclough, President of the International Society for Quality in Health Care, at the official launch of Enhancing patient care: a practical guide to improving quality and safety in hospitals, authored by Alan Wolff and Sally Taylor. The Hon Daniel Andrews, Victorian Minister for Health, officially launched the book on 31 August 2009 at the Victorian Department of Human Services. The book summarises extensive, confusing literature and shows results that can reasonably be expected to be achieved. It provides a logical, simple and effective model, along with summaries and checklists to help put the model in place; and outlines what does and does not work in the real world. Associate Professor Alan Wolff is Director of Medical Services for the Wimmera Health Care Group. He credits the success of the Group’s risk management program (on which the book is based) to five factors: the hospital’s intermediate size; its dedicated, long-serving staff; commitment from those at the top of the organisation; an innovative, flexible and cooperative hospital culture that does not “blame and shame”; and using simple improvement strategies. “We open high-risk medical records on a daily basis, run checklist programs, and have the clinical risk management team located in the wards, not as a separate function”, he said. Mr Andrews praised the book’s authors for taking their own successful project and providing it for others to use. “We can never eliminate errors, but we can have a shared commitment to learn from each error. This is a roadmap of a framework to always make sure health care is about care”, he said. Enhancing patient care is published by MJA Books and is available from the MJA BookShop at <http://shop.mja.com.au> Above Left to right: Sally Taylor, Associate Professor Alan Wolff, the Hon Daniel Andrews and Professor Bruce Barraclough. Below Left to right: Sally Taylor, Alan Wolff and Rivqa Berger.

Rivqa Berger

The wisdom of whores. Bureaucrats, brothels, and the business of AIDS. Elizabeth Pisani. Sydney: Granta, 2008 (xvii + 372 pp). ISBN 978 1 84708 024 0. Given the provocative cover, I approached this book with reservations. And irritatingly, the author scatters the terms “AIDS mafia” and “AIDS industry” throughout the book. She never defines the terms, but she would probably class me as a member of both! Yet after two careful readings, I am totally disarmed. While I disagree on some points, Elizabeth Pisani tells the truth about AIDS clearly and unequivocally. Only global warming is more topical than HIV/AIDS. Any thinking person, lay or professional, must have serious questions. Why is the epidemic in sub-Saharan Africa so different from everywhere else? Why has the long-awaited Grim Reaper scenario (spreading throughout the general community) never eventuated? Why, with a virus which is “not actually all that infectious” but which has nonetheless caused 70 million infections world-wide, are we no nearer to controlling the epidemic? Pisani answers these questions with devastating clarity. She is eminently qualified to do so, with a PhD in epidemiology and more than 10 years’ field experience. She retains, too, the sharpness and ruthlessness of the investigative journalist she once was. There are ribald stories and humour here, but throughout runs a barely repressed strain of anger. Bucket-loads of money are being wasted, good science is often ignored, truth has been replaced by lies and, as the author reminds us, prevention “programs based on lies don’t work”. There is a softer side to this author. She is a friend of harlots and sinners. It is people considered the dregs of society who are most at risk. She says, “Getting HIV prevention services for people who needed them most has begun to seem like a debt I owe”. By her forthright analysis and outline of what needs to be done, she has gone some way towards paying her debt.

David L Bradford

X-Ray exposure Imaging procedures are common and their use is increasing, leading to concerns about the safety for patients of exposure to low-dose ionising radiation. In a US study, over 900 000 adults were identified and utilisation data used to estimate the cumulative effective doses of radiation from imaging procedures. Doses were defined as low, medium or high, and data were used to calculate population-based rates of exposure. Procedures such as nuclear and computed tomography imaging contributed significantly to the total effective dose, despite being less common than plain radiographic procedures. Cumulative effective doses of radiation were higher in women and increased with age. The authors conclude that adults in the US are being exposed to substantial doses of ionising radiation and suggest health strategies are needed to address the safe use of these procedures. N Engl J Med 2009; 361: 849-857 Compensation and causation Assessing compensation claims in cases of occupational injury is usually the task of occupational medicine specialists, but other health care providers may become involved in the process. According to the NZ authors of a recent review of the subject, a lack of common understanding between legal and medical practitioners is at the heart of the issue. They suggest that considering causation as a sequential event involving first general and then specific causation is a useful approach and one that is familiar to medical professionals. A discussion of the judicial meaning of balance of probabilities and the understanding of the scientific meaning of relative risk concludes a useful review for doctors who find themselves involved in medical compensation proceedings. Intern Med J 2009; 39: 506-511 Fibre and IBS — a soluble problem Soluble fibre in the form of psyllium appears to benefit patients with irritable bowel syndrome, but insoluble fibre does not seem to be helpful, according to the results of a randomised controlled trial. In a general practice setting, 275 patients aged 18-65 years with irritable bowel syndrome were placed in three groups treated daily for 12 weeks with 10 g of psyllium, 10 g of bran, or a placebo. All participants completed a validated symptom severity score for irritable bowel syndrome. Patients taking psyllium had the best response, with a significant reduction in symptom severity. Early dropouts were most common in the bran group, mainly because of worsening symptoms of irritable bowel syndrome. The authors conclude that soluble fibre is a useful adjuvant in the management of irritable bowel syndrome, but that bran should be used with caution, and may in fact worsen symptoms. BMJ 2009; 339: b3154 Sex differences in heart mortality The question of sex differences in mortality following acute coronary syndromes (ACS) has been addressed in a study pooling data from 11 independent international trials. Over 130 000 patients were included, all of whom had suffered either myocardial infarction or unstable angina. The main outcome measure in the study was 30-day mortality following ACS. After multivariable adjustment, mortality was not significantly different between women and men overall, but certain interactions were noted depending on the type of ACS experienced. Among patients with ST-segment elevation myocardial infarction (STEMI), mortality was higher among women, but for non-STEMI and unstable angina, mortality was lower among women. When the researchers corrected for the severity of coronary vascular disease (which tends to be worse in men), they found that the differences in mortality became insignificant. JAMA 2009; 302: 874-882 Afghanistan — a legacy of violence A study assessing the mental health of young people in Afghanistan has revealed that mental health problems and exposure to traumatic events continue to be problematic. Using a sample of over 1000 children aged 11-16 years and their caregivers and teachers, researchers conducted interviews and assessed participants for possible psychiatric disorders and social functioning. They also evaluated the mental health of caregivers and examined exposure to traumatic events, with a focus on finding significant risk factors for mental health problems and psychological distress. Results show that Afghan children experience a range of disturbing traumatic events that affect their psychological health, not all associated directly with war. In particular, those related to physical and social stresses within the family can have significant impact. The authors conclude that exposure to multiple traumatic events and poor caregiver mental health are strong predictors of poor mental health in young people living in Afghanistan. Lancet 2009; 21 Aug [Epub ahead of print]

Tanya Grassi