Volume 192 Issue 1

Good-quality data on tobacco sales are vital for evaluating tobacco control interventions The prevalence of smoking in Australia is among the lowest for high-income countries. In 2007, 17.9% of Australians aged 14 years or older were current smokers, compared with 23.6% in 1998. Yet tobacco remains Australia’s leading risk factor for premature death and disability, accounting for 7.8% of the total disease burden,1 nearly twice the combined burden caused by alcohol (2.2%) and illicit drugs (2.0%). Tobacco is still big business in Australia. In 2004, an industry-commissioned report estimated that the retail value of the Australian tobacco market was about $9.3 billion, and tobacco products accounted for 4.7% of retail sales through about 35 000 retail outlets.2 The federal government also derived an estimated $5.6 billion in tobacco excise taxes for the financial year 2008–09.3 Despite the substantial harm that smoking causes, the sale of tobacco products is minimally regulated in Australia. There are few restrictions on where tobacco can be sold — some states (Queensland and Victoria) do not require tobacco sellers to obtain a tobacco retail licence, or even maintain a register of tobacco sellers.4 Governments increasingly demand good evidence that proposed tobacco control policies will work. National and state-based population surveys are the main source of smoking prevalence data, which are needed to determine whether tobacco control policies are having the desired impact. Although the information that these surveys provide is valuable, it has serious limitations. The collection of self-reported smoking status data in population surveys is costly, and is also increasingly hampered by low response rates caused in part by the uptake of unlisted mobile phone use and the proliferation of call screening and answerphones.5 In addition, self-reported smoking data may have become less reliable as smoking has become increasingly stigmatised in Australian society — fewer people, especially those who smoke occasionally, may be willing to disclose that they smoke. Furthermore, tobacco control interventions are likely to have small, but nonetheless important, effects on smoking in whole populations, which are difficult to detect in yearly or less frequent surveys because of statistical power problems. At the same time, ever greater sensitivity is needed to satisfy the requirement for evaluation of effectiveness of tobacco control interventions at the population level. A comprehensive ongoing data series on tobacco sales would facilitate evaluation of tobacco control policies at national, state or regional levels by taking into account variations in the timing of policy implementation. As suggested in the National Preventative Health Taskforce’s final report,6 state and territory governments or the federal government should require Australia’s three major tobacco manufacturers — Philip Morris (Australia), British American Tobacco Australia and Imperial Tobacco — to provide auditable, postcode-identified monthly data on all tobacco products supplied for retail sale. Data on supply of tobacco products are collected by manufacturers on a daily basis as retailers place tobacco orders. The three manufacturers supply almost all cigarettes sold to Australian retailers.7 Several small importers supply “boutique” brands, but these have negligible brand share. Tobacco sales data would be extremely valuable in monitoring trends in tobacco use and in evaluating the effectiveness of current and proposed tobacco control interventions, such as “quit” campaigns, pack warnings, retail display bans and mandatory plain packaging for tobacco products. Because of its geographic isolation, Australia has a relatively small illicit tobacco market compared with most other countries (Euromonitor International estimates that 3.5% of cigarettes consumed in Australia in 2007 were illicit).8 Therefore, retail data are likely to provide a reasonably accurate estimate of total tobacco consumption in Australia and an unbiased benchmark against which household survey data can be evaluated. Data on tobacco products supplied to retailers on a month-by-month basis are not the same as data on the volume of tobacco excised because of the common habit of manufacturers warehousing large amounts of excised tobacco. This was demonstrated in 2006, when pictorial pack warnings were introduced from March. After this time, it was illegal for any company to manufacture tobacco packaging with the old text-only warnings; but old stock was being sold by retailers 6 months later because manufacturers had over-produced the old packaging and warehoused it.9 The tobacco industry is highly effective at mobilising retailers to lobby against tobacco control strategies, so moves to require provision of tobacco sales data will be opposed. There are no good reasons for opposition. These data are already collected by commercial market research companies on behalf of the tobacco industry and are available for purchase; however, researchers have been denied access to this information when they have attempted to purchase it. The tobacco industry should be legally required to provide governments with data on the sales of a commodity which is more addictive and harmful to population health, and much less regulated, than alcohol.

Coral E Gartner PhD · Simon F Chapman PhD · Wayne D Hall PhD · Melanie A Wakefield PhD

Many patients with heart failure do not have reduced left ventricular ejection fraction, and it is not yet clear whether their treatment should be the same as that of patients who do The syndrome of heart failure is one that is familiar to most clinicians. The cardinal symptoms of dyspnoea and fatigue when combined with signs of fluid retention — lung crackles, elevated jugular venous pressure and peripheral oedema — usually lead one to the diagnosis. Indeed, the Framingham criteria for diagnosis of heart failure are based largely on clinical findings that can be elicited at the bedside.1 When combined with what most of us have been taught in medical school, namely, that heart failure is usually caused by the loss of the pumping capacity of the left ventricle (eg, after myocardial infarction or due to cardiomyopathy), clinicians have become familiar with the concept that most cases of heart failure are associated with impaired left ventricular systolic function, shown by a reduction in the left ventricular ejection fraction (LVEF). As if to reinforce this mindset, major trials of new treatments for heart failure have historically focused on the group of patients with reduced LVEF. Applying echocardiography and other diagnostic imaging modalities to patients with heart failure has led to the realisation that many patients, as many as half in some series, do not have a reduced LVEF. Several terms have been used to describe this population, such as “diastolic heart failure’”, “heart failure with normal systolic function” and “heart failure with preserved systolic function”. All three terms are problematic. Diastolic dysfunction is common in patients with impaired LVEF2 and many patients with preserved LVEF have unequivocal evidence of systolic dysfunction.3 My personal preference is for the term “heart failure with preserved ejection fraction” (HFPEF), as it makes no assumptions about the pathophysiology of heart failure in affected patients. Even this descriptor is not without its problems, as different investigators appear to have differing opinions as to what should be considered a “preserved” LVEF. Investigators in different studies have drawn the line between preserved and reduced LVEF at 50%,4 45%,5,6 40%,7 or even 35%.8 Needless to say, this diagnostic confusion does nothing to help clinicians who are trying to care for these patients. Is it important to distinguish HFPEF from heart failure with reduced ejection fraction (HFREF)? Are they simply different ends of a continuous disease spectrum, or do they represent distinct entities with different causes and different natural histories? Given that they present with the same clinical syndrome, should they be treated the same way? These are important questions for which we currently lack answers. Multiple studies that have compared the demographics and natural history of HFPEF and HFREF have now been published,9 including the study by Wong and colleagues in this issue of the Journal.10 A reasonably consistent finding across these studies has been that, compared with patients with HFREF, patients with HFPEF were older, more likely to be female and more likely to have pre-existing hypertension and atrial fibrillation. Conversely, ischaemic heart disease was more common in those with HFREF. Comparison of the survival of patients with HFPEF versus HFREF has produced conflicting data. While some studies have suggested that those with HFPEF have better survival than those with HFREF, others, including Wong et al,10 have shown no difference in survival. A recently published meta-analysis of the natural history of HFPEF compared with HFREF collected data from 17 studies that included 24 501 patients.9 In that analysis, patients with HFPEF had a significantly better survival than those with HFREF, although it is noteworthy that over an average follow-up of 47 months, almost a third of those with HFPEF had died, indicating that the life expectancy of this group of patients is far below that of the healthy age-matched population. The poor survival of patients with HFPEF was also emphasised in the study by Wong et al,10 and in another recent publication from the Framingham investigators.6 An important observation made by Wong and colleagues is that comorbid conditions and psychosocial factors are important determinants of the outcome of patients with HFPEF.10 They found that anaemia, chronic obstructive pulmonary disease, cancer and dementia were all more common in patients with HFPEF compared with those with HFREF.10 A higher rate of comorbid conditions in patients with HFPEF has also been noted by other investigators.6 In addition, patients with HFPEF had fewer social supports, were more likely to live in nursing homes, and were more likely to require readmission to hospital — mainly for management of comorbid conditions rather than for heart failure. The prognosis and quality of life for patients with HFREF has been markedly improved by the implementation of evidence-based treatments including therapy with β-blockers and inhibitors of the renin–angiotensin–aldosterone system. On the other hand, no treatment has been proven to alter the natural history of HFPEF. Treatment remains empirical, and is aimed at controlling associated conditions such as hypertension and symptoms and signs of fluid retention. Thiazide diuretics, a class of drugs that has largely fallen out of favour for treating hypertension and HFREF, may yet prove to be the most effective drug class for preventing HFPEF. In a recent analysis of the very large ALLHAT trial of patients with hypertension and aged over 55 years,4 antihypertensive treatment with chlorthalidone was associated with a lower risk of developing HFPEF when compared with treatment with lisinopril, amlodipine or doxazosin. Therapeutic trials of other drug classes in HFPEF have been limited, and generally disappointing. Angiotensin-receptor blockers have been the most studied class of drugs, and have been shown in two large trials to have no impact on survival.5,7 β-Blockers appear more promising. In a prespecified analysis of the SENIORS study of the vasodilating β-blocker nebivolol in older patients with heart failure,8 the investigators reported similar benefits of nebivolol in patients with either HFPEF or HFREF; however, the definition of HFPEF in that study was an LVEF of greater than 35%. Clearly, more trials are needed. As our population continues to age, we are facing an impending epidemic of HFPEF together with other diseases associated with ageing. More effective blood pressure control of patients with systemic hypertension stands out as the most obvious preventive strategy, but it is clear that hypertension is only one of a number of antecedents to HFPEF. There is an urgent imperative to gain a better understanding of the pathogenesis of HFPEF in order to identify additional preventive and treatment approaches. This will be particularly challenging in a population exposed to multiple comorbid conditions, increasing physical frailty, and social isolation, as highlighted by Wong and colleagues.10 Optimal management of these patients will require a multidisciplinary approach with the general practitioner taking the central role.

Peter S MacDonald MB BS, FRACP, PhD

Adaptive responses to a poor intrauterine environment may predispose to obesity and its related chronic diseases in a later, nutritionally enriched, environment The global burden of death, disability and loss of human capital as a result of impaired fetal development is huge, and affects both developed and developing countries.1 The Indigenous people of Australia have high rates of low birthweight and chronic non-communicable diseases in adulthood, leading to premature adult mortality, with current life expectancies 17 years less than for other Australians.2 Improvements are occurring in Aboriginal health, but they are overshadowed by the continuing poor health profile of Aboriginal people. The article by Hoy and Nicol in this issue of the Journal is noteworthy in that it highlights the decreases in neonatal and infant mortality in a remote Northern Territory Aboriginal community.3 The relationship between birthweight and natural mortality described in the article by Hoy and Nicol3 adds to the body of work showing the influences of early life events on later health and disease. These reports first appeared over 70 years ago,4 but it was the influential work of Barker and colleagues from the University of Southampton that gave rise to a whole new paradigm. Now the discipline of the developmental origins of health and disease (DOHaD) is a rapidly growing research area in both basic and clinical sciences, which is supported by an international society and a recently launched journal.5 The initial studies showed inverse relationships between surrogates of fetal growth and central distribution of fat, insulin resistance, the metabolic syndrome, type 2 diabetes and ischaemic cardiovascular disease.6 These studies have been replicated worldwide and later research has focused on the mechanisms underlying these associations. Epigenetic changes in response to the early environmental conditions in fetal development and early infancy are the likely mechanisms; with the effects able to be transmitted to succeeding generations.7 In early life, there are critical times when environmental influences have their major effects, mediated through these epigenetic changes that later result in complex physiological mechanisms affecting final health outcomes.8,9 The study by Hoy and Nicol reporting the association of low birthweight with increased mortality in young adult Australian Aboriginal people suggests that the current epidemic of chronic adult diseases seen in this population may be due to improved survival among low birthweight infants.3 A likely mechanism is that the adaptive responses to a poor intrauterine environment that were initially beneficial for fetal survival become detrimental in a later nutritionally enriched (and therefore mismatched) environment.8 While early life events set the risk for chronic disease, it is further exposure to multiple risk factors that translates this increased risk to overt chronic disease. The highest risk occurs when low birthweight is coupled with later obesity.8,10 This concurrence of low birthweight, infant undernutrition and adult obesity occurs in populations like the Australian Aboriginal population, that are undergoing rapid nutritional transition with the change of traditional diets to energy-enriched carbohydrate diets. This change in diet often occurs in conjunction with decreasing physical exercise.11 A key element in any preventive strategy for chronic disease associated with premature adult mortality is the prevention of overweight and obesity. Obesity is not only a major risk factor on its own, but is an amplifier of other risk factors associated with chronic adult disease. The findings of Hoy and Nicol suggest that improvements in birthweight will be mirrored by improvements in adult mortality in the Aboriginal population in the future.3 Interventions to prepare the intrauterine environment for the developing fetus need to begin before conception. Aboriginal low birthweight is associated with the known preventable factors of young maternal age, maternal undernutrition, smoking and alcohol consumption.12 There are recommendations relating to preconception interventions to influence these factors in the United States population, but adaptations for Indigenous populations in general are yet to be determined.13 Future research should be directed towards developing and evaluating culturally specific adaptations of this early care for young Aboriginal women of childbearing age. Debate continues about the optimum growth patterns for children in populations undergoing the nutritional transition. There are clear short-term survival benefits of increasing the speed of growth for low birthweight babies to prevent immediate morbidity and mortality. However, rapid weight gains during some periods of childhood have been shown to predict adult obesity.14 The challenge is to balance the benefits of weight gain in early life with the risk of later chronic adult disease.15 Currently, there is insufficient evidence to recommend the most favourable pattern of infant growth for preventing adult disease.16 Recent reports suggest that nutritional intervention with rapid changes of body mass index before the first 2–3 years of life are not predictive of adult obesity.17,18 However, considerable work is still needed before firm evidence-based recommendations can be made with confidence. In the meantime, staying with the well known benefits of breastfeeding is probably the most prudent course of action.19 Poor fetal growth has immediate and long-term consequences that encompass all aspects of health over the course of an individual’s life. As the DOHaD concept and its mechanisms unfold, it is likely to have significant impacts on the direction of public health activities worldwide.

Susan M Sayers FAAP, FRACP, PhD · Gurmeet R Singh MPHTM, FRACP, PhD

If you are interested in health care reform, late 2009 is a fascinating time to be in the United States. An appointment as Visiting Professor in the Department of Family and Community Medicine at the University of California, San Francisco has provided me the opportunity to observe the debate and try to understand its meaning, with the help of US primary care leaders Kevin Grumbach and Tom Bodenheimer. Health care reform is writ large on the political and personal agendas of Americans. The newspapers are full of reports on the progress of President Obama’s proposals for reform, and debate about what needs to be done is a barbecue stopper at any social gathering. Despite massive spending on health care (US$2.5 trillion per year), many Americans have poor access to services and, at a population level, the system is underperforming. Inability to pay for health care is the most common reason for personal bankruptcy. The cost of insurance to employers is also a major issue, as access to an insurance plan is often linked to employment and some corporations therefore carry a huge cost burden — the US automobile industry, for example, spends more per car on health care than it does on steel.1 A contentious feature of Obama’s plan for reform is the “public option” for insurance. Under this proposal, the government would offer health insurance in competition with private insurers. The idea is that this would improve access and drive down costs. The public option is seen by many in the Republican Party and by some Democrats as government interfering with personal choice and as “un-American”. Quite why is not clear, especially as the public option will only apply to a limited group of people and is far from being a single-payer system, but terms such as “big government” and “liberal” (which, in this context, roughly translates to creeping socialism) are used, and the spectre of government-controlled health care decisions is raised. The mythical “death panels” have been the extreme example of this political scaremongering. There are also powerful interests, such as insurance companies and the pharmaceutical industry, who may stand to lose from substantive reform. The stakes are high and so is the money being spent on lobbying politicians — about US$2 million per day according to the Center for Responsive Politics.2 Despite this, the public option has survived as part of the Bill that has passed through the House of Representatives and, in a different form, is also part of the Bill to be debated in the Senate. Primary care would seem to have a lot to offer a country that is struggling with overwhelming health care costs and relatively poor outcomes. The work of Barbara Starfield (University Distinguished Service Professor at Johns Hopkins University) provides evidence that countries with a health care system built on a strong foundation of primary care have better health outcomes and lower health costs.3 So what are the opportunities for primary care in the reform process? Primary care leaders have been invited to meet with the President’s health care reform team and put forward suggestions to revitalise primary care in the US. Key issues for reform are changes to the amount and nature of primary care payment systems, investment in primary care infrastructure and organisation, and strategies to attract more local medical students into family practice as a career.4 Sound familiar? Readers of Australia’s draft National Primary Health Care Strategy will see many parallels.5 In payment reform, addressing the disparity in income for US family physicians versus other specialties is called for through changes in the payments from insurers and through examination of payment systems for care coordination tasks and electronic consultations. Increased funding of family medicine rehsidency programs and debt relief for family practice graduates are also suggested reforms. There is evidence that government is listening. The health reform Bills before Congress include changes to Medicare payments for family practice and funding for local Primary Care Cooperative Extension Services that would support primary care transformation and modernisation. Roles of the Primary Care Cooperative Extension Services would include fostering local learning communities to facilitate change and providing technical assistance in practice transformation — including adoption of information technology and development of primary care teams with the capacity to provide systematic chronic disease care and organised preventive services. Already, the massive US stimulus Bill includes funding for improvements in health information technology, but the amount of this that will go towards improving electronic health records and communication systems in primary care remains to be seen. There are excellent examples in the US of good integration between primary care and secondary and tertiary services through alignment of incentives, high-quality communication and shared resources. These include Kaiser Permanente and the Geisinger Health System. Australia has a lot to learn from these models in its thinking about the roles of local primary care organisations. However, like nearly everything else in the US, these models are not generalised across the country and it is not clear how to make such models available nationwide. It is likely that by early 2010 it will be clear whether the reform process in the US is underway or has stalled again. The proposed reforms will only be a start and, if passed, will take years to implement. But there is hope, including opportunities for improved primary care.

Nicholas A Zwar MPH, PhD, FRACGP

Objective: To determine whether heart failure with preserved systolic function (HFPSF) has different natural history from left ventricular systolic dysfunction (LVSD).Design and setting: A retrospective analysis of 10 years of data (for patients admitted between 1 July 1994 and 30 June 2004, and with a study census date of 30 June 2005) routinely collected as part of clinical practice in a large tertiary referral hospital.Main outcome measures: Sociodemographic characteristics, diagnostic features, comorbid conditions, pharmacotherapies, readmission rates and survival.Results: Of the 2961 patients admitted with chronic heart failure, 753 had echocardiograms available for this analysis. Of these, 189 (25%) had normal left ventricular size and systolic function. In comparison to patients with LVSD, those with HFPSF were more often female (62.4% v 38.5%; P = 0.001), had less social support, and were more likely to live in nursing homes (17.9% v 7.6%; P < 0.001), and had a greater prevalence of renal impairment (86.7% v 6.2%; P = 0.004), anaemia (34.3% v 6.3%; P = 0.013) and atrial fibrillation (51.3% v 47.1%; P = 0.008), but significantly less ischaemic heart disease (53.4% v 81.2%; P = 0.001). Patients with HFPSF were less likely to be prescribed an angiotensin-converting enzyme inhibitor (61.9% v 72.5%; P = 0.008); carvedilol was used more frequently in LVSD (1.5% v 8.8%; P < 0.001). Readmission rates were higher in the HFPSF group (median, 2 v 1.5 admissions; P = 0.032), particularly for malignancy (4.2% v 1.8%; P < 0.001) and anaemia (3.9% v 2.3%; P < 0.001). Both groups had the same poor survival rate (P = 0.912).Conclusions: Patients with HFPSF were predominantly older women with less social support and higher readmission rates for associated comorbid illnesses. We therefore propose that reduced survival in HFPSF may relate more to comorbid conditions than suboptimal cardiac management.

Dennis T Wong MB BS(Hons) · Robyn A Clark PhD, FRCNA · Benjamin K Dundon MB BS, FRACP · Andrew Philpott MB BS, FRACP · Payman Molaee MB BS, FRACP · Sepehr Shakib PhD, FRACP

Objectives: To describe associations between birthweight and infant, child and early adult mortality from natural causes in a remote Australian Aboriginal community against a background of rapidly changing mortality due to better health services.Design, participants and setting: Cohort study of 995 people with recorded birthweights who were born between 1956 and 1985 to an Aboriginal mother in a remote Australian Aboriginal community. Participants were followed through to the end of 2006.Main outcome measures: Rates of natural deaths of infants (aged 0 to < 1 year), children (aged 1 to < 15 years) and adults (aged 15 to < 37 years), compared by birth intervals (1956–1965, 1966–1975 and 1976–1985 for infants and children, and 1956–1962 and 1963–1969 for adults) and by birthweight.Results: Birthweights were low, but increased over time. Deaths among infants and children decreased dramatically over time, but deaths among adults did not. Lower birthweights were associated with higher mortality. Adjusted for birth interval, hazard ratios for deaths among infants, children and adults born at weights below their group birthweight medians were 2.30 (95% CI, 1.13–4.70), 1.78 (95% CI, 1.03–3.07) and 3.49 (95% CI, 1.50–8.09), respectively. The associations were significant individually for deaths associated with diarrhoea in infants, with cardiovascular and renal disease in adults, and marginally significant for deaths from pulmonary causes in children and adults.Conclusion: The striking improvements in infant and child survival over time must be applauded. We confirmed a predisposing effect of lower birthweights on deaths in infants and children, and showed, for the first time, an association between lower birthweights and deaths in adults. Together, these factors are probably contributing to the current epidemic of chronic disease in Aboriginal people, an effect that will persist for decades. Similar phenomena are probably operating in developing countries.

Wendy E Hoy FRACP · Jennifer L Nicol BSc(Hons), MSc(Stats)

Objective: To assess the extent to which general practitioners in Australia are engaged in identifying age-related hearing loss and facilitating its management.Design, setting and participants: Cross-sectional analysis of data collected between 1998 and 2000 from the Blue Mountains Hearing Study (BMHS), a representative population-based cohort of people aged ≥ 50 years in two postcode areas west of Sydney. Also analysed were data collected between 2003 and 2008 from random samples of Australian GPs who participated in the Bettering the Evaluation and Care of Health (BEACH) study, a national continuous cross-sectional survey of GP activity.Main outcome measures: Rate of facilitating management and identification of hearing loss in older patients; content of GP–patient encounters with hearing-impaired people; characteristics of participants seeking help from their GP.Results: Of older people in the BMHS with measured (objective) bilateral hearing loss, about a third reported seeking help frovm their GP. BEACH survey data showed that only about 3 per 1000 GP consultations with patients aged ≥ 50 years involved management of age-related hearing loss. For every 100 age-related hearing problems managed, GPs undertook 12 procedural treatments, provided 20 referrals to specialists, and made 29 referrals to allied health professionals.Conclusion: In their routine consultations with patients, GPs have opportunities to identify hearing loss and appropriately refer patients to specialists or allied health professionals. Although GPs are responding to patient presentations for hearing loss, referring around 50% of cases, there appear to be relatively few cases in which hearing loss is identified opportunistically. Levels of identification and management of hearing loss by GPs in Australia are relatively low.

Julie M Schneider BAppSc(Hons), PhD · Bamini Gopinath BTech(Hons), PhD · Catherine M McMahon PhD · Helena C Britt BA, PhD · Christopher M Harrison BPsych(Hons), MSocHlth · Tim Usherwood MD, BS · Stephen R Leeder MD, PhD · Paul Mitchell MD, PhD, FRANZCO

Objective: To compare the clinical effectiveness of single-dose azithromycin treatment with 7 days of amoxycillin treatment among Aboriginal children with acute otitis media (AOM) in rural and remote communities in the Northern Territory. Design, setting and participants: Aboriginal children aged 6 months to 6 years living in 16 rural and remote communities were screened for AOM. Those diagnosed with AOM were randomly allocated to receive either azithromycin (30 mg/kg as a single dose) or amoxycillin (50mg/kg/day in two divided doses for a minimum of 7 days). We used a double-dummy method to ensure blinding. Our study was conducted from 24 March 2003 to 20 July 2005. Main outcome measures: Failure to cure AOM by the end of therapy; nasal carriage of Streptococcus pneumoniae and non-capsular Haemophilus influenzae (NCHi). Results: We followed 306 of 320 children (96%) allocated to the treatment groups. Single-dose azithromycin did not reduce (or increase) the risk of clinical failure (50% failure rate [82/165]) compared with amoxycillin (54% failure rate [83/155]) (risk difference [RD], – 4% [95% CI, – 15% to 7%]; P = 0.504). Compared with amoxycillin, azithromycin significantly reduced the proportion of children with nasal carriage of S. pneumoniae (27% v 63%; RD, – 36% [95% CI, – 47% to – 26%]; P < 0.001) and NCHi (55% v 85%; RD, – 30% [95% CI, – 40% to – 21%]; P < 0.001). Nasal carriage of S. pneumoniae with intermediate or full resistance to penicillin was lower (but not significantly so) in the azithromycin group (10% v 16%), but this group had significantly increased carriage of azithromycin-resistant S. pneumoniae (10% v 3%; RD, 7% [95% CI, 0.1% to 12%]; P = 0.001). Carriage of β-lactamase-producing NCHi was about 5% in both groups. Conclusion: Although azithromycin reduced nasal carriage of S. pneumoniae and NCHi, clinical failure was high in both treatment groups. The possibility of weekly azithromycin treatment in children with persistent AOM should be evaluated. Trial registration: Australian Clinical Trials Registry ACTRN 12609000691246.

Peter S Morris MB BS, PhD, FRACP · Gaudencio Gadil MD · Gabrielle B McCallum BNurs, MPH · Cate A Wilson EN, BPsych(Hons) · Heidi C Smith-Vaughan BAppSci, PhD · Paul Torzillo MB BS, FRACP, JFICM · Amanda J Leach BAgSc(Hons), MAgSc, PhD

Objective: To assess the feasibility of using a rapid access neurology clinic to assess and manage patients considered safe to discharge home from the emergency department (ED), yet requiring specialist neurology review.Design, setting and participants: The ED Rapid Access Neurology (ED RAN) clinic was trialled at Royal Prince Alfred Hospital, a major tertiary teaching hospital in Sydney, over a 12-month period (23 March 2008 – 22 March 2009). The service uses a new clinic and referral system to offer suitable patients specialist neurology outpatient review within 5 working days of their discharge from the ED.Main outcome measures: Quality of patient care, patient satisfaction, estimated service impact on the hospital system.Results: During the 12-month trial period, 311 patients were referred to the ED RAN clinic. Of these referrals, 222 patients (71%) attended the clinic, where a number of serious neurological diagnoses were made, and eight patients required admission after specialist review. All patients attending the clinic found the visit helpful. Consultant ED physicians believed that the clinic prevented 83 unnecessary admissions and 188 out-of-hours neurology registrar consultations, and saved an estimated 809 hours of ED bed time.Conclusions: The ED RAN clinic provides a viable model for improving the quality of patient care, with high levels of patient satisfaction. This model of care may allow significant cost savings and help to relieve the major access block in Australian EDs.

Rebekah M Ahmed MB BS(Hons) · Timothy Green MB BS(Hons), FACEM · Gabor M Halmagyi MD, FRACP · Simon J G Lewis MB BCh, FRACP, MD

Objective: To investigate the Australian public’s expectations, concerns and willingness to accept vaccination with the pandemic (H1N1) 2009 influenza vaccine.Design, setting and participants: A computer-assisted telephone interview survey was conducted between 20 August and 11 September 2009 by trained professional interviewers to study issues relating to vaccine uptake and perceived safety. The sample comprised 1155 randomly selected representative adults who had participated in a 2007 national study exploring knowledge and perceptions of pandemic influenza.Main outcome measures: Likely acceptance of pandemic (H1N1) 2009 vaccination, factors associated with acceptance, and respondents’ willingness to share Australian vaccine with neighbouring developing countries.Results: Of 1155 possible participants, 830 (72%) were successfully interviewed. Twenty per cent of the study group (169/830) reported that they had developed influenza-like symptoms during the 2009 pandemic period. Most respondents (645/830, 78%) considered pandemic (H1N1) 2009 to be a mild disease, and 211/830 (25%) regarded themselves as being at increased risk of infection. Willingness to accept pandemic (H1N1) 2009 vaccination was high (556/830, 67%) but was significantly lower than when pandemic vaccination uptake was investigated in 2007 (88%; P < 0.0001). Respondents who had already been vaccinated against seasonal influenza and those who perceived pandemic (H1N1) 2009 to be severe were significantly more willing to accept vaccination. Most respondents (793/822, 96%) were willing to share surplus vaccine with developing countries in our region.Conclusion: Although two-thirds of Australian adults surveyed were willing to accept pandemic (H1N1) 2009 vaccination, and most supported sharing vaccine with developing countries, there is a need for accessible information on vaccine safety for those who are undecided about vaccination.

Keith Eastwood MApplEpid · David N Durrheim MBChB, DrPH, FAFPHM · Alison Jones MD, FRCP · Michelle Butler MSc

Objective: To update evidence-based guidelines for the treatment of proximal femoral fractures published in the Journal in 2003.Data sources: Systematic search of MEDLINE, CINAHL and EMBASE for articles published from October 2001 to June 2008, and the Cochrane Database of Systematic Reviews (most recent issue searched — Issue 2, 2008).Study selection: Randomised controlled trials and meta-analyses of all aspects of acute-care hospital treatment and rehabilitation for proximal femoral fractures among participants aged 50 years or older with proximal femoral fractures not associated with metastatic disease or multiple trauma.Data extraction: All studies were reviewed independently by two assessors, who recorded individual study results, and an assessment of study quality and treatment conclusions was made according to Cochrane Collaboration protocols. If necessary, a third review was performed to reach consensus.Results: 128 new studies were identified and 81 met our inclusion criteria. Recommendations for time to surgery, thromboprophylaxis, anaesthesia, analgesia, prophylactic antibiotics, surgical fixation of fractures, nutritional status, mobilisation and rehabilitation have been updated. Also, recommendations regarding surgical wound closure, management of postoperative delirium, osteoporosis treatment and hip protectors have been added. The guidelines include the current National Health and Medical Research Council grades of recommendations for clinical guidelines.Conclusions: Significant changes in recommendations have been made, particularly in relation to surgery, rehabilitation and tertiary prevention. Hip fracture should be treated according to the most up-to-date evidence to achieve the best possible outcomes and optimal use of limited resources.

Jenson C S Mak MB BS, FRACP, FAFRM(RACP) · Ian D Cameron MB BS, PhD, FAFRM(RACP) · Lyn M March MB BS, PhD, FRACP

Significant problems in health care, such as access block and long waiting lists for elective surgery, have led to calls for keeping hospital occupancy at no more than 85%. It is elementary queueing theory that a finite-capacity system with variable demand cannot sustain both full utilisation and full availability. However, the statement that there is a single level of ideal or safe occupancy suitable for all situations is a simplistic interpretation and application of the underlying science. We argue that specific study and action are necessary to understand and deal with the problems of long waiting lists and access block in any given health care facility.

Christopher A Bain MB BS, MInfoTech, MACS · Peter G Taylor BSc, PhD · Geoff McDonnell FRACP, MEngSci, MIEEE · Andrew Georgiou PhD, FACHI

High-functioning pervasive developmental disorders (PDDs) have only recently been widely recognised; they are diagnosed mainly in children. Key features are impaired social cognition and communication; obsessive interests, routines or activities; and social or occupational dysfunction. There are scant data about the prevalence of high-functioning PDDs in adults, and it is possible that many Australian adults with these conditions are undiagnosed. A specialist multidisciplinary approach is used for both children with PDDs and adults with other neuropsychiatric disabilities, and has the potential to help adults with high-functioning PDDs. Increased awareness and diagnosis of these conditions should not limit career or personal goals of individuals with PDDs but should aid them in finding happy and productive careers and lives.

Sarah J Abrahamson MB ChB, FAFRM, GradDipClinEpi · Peter G Enticott BAppSci(Hons), PhD · Bruce J Tonge MD, MRCPsyc, FRANZCP

Clinical record A 66-year-old woman was brought to the emergency department at the Alfred Hospital in Melbourne with severe headache and confusion after 2 days of a “flu-like illness”. Her medical history was significant only for rheumatoid arthritis, for which she was prescribed low-dose methotrexate. On initial assessment, she was found to be febrile (38°C) and agitated, and quickly required intubation for decreased consciousness. Full peripheral blood examination showed a total white blood cell count of 35.4 × 109/L (reference range, 4.5–11.5 × 109/L) and acute renal impairment (creatinine concentration, 169 μmol/L, reference range, 45–80 μmol/L). Lumbar puncture performed after intubation showed turbid cerebrospinal fluid (CSF), with 198 × 106/L polymorphs and no lymphocytes seen on microscopy. A Gram stain of her CSF showed gram-positive cocci, which were subsequently confirmed to be Streptococcus pneumoniae. S. pneumoniae was also cultured from blood taken at presentation. Intravenous therapy with vancomycin, benzylpenicillin, ceftriaxone, and dexamethasone was commenced initially, and the patient was transferred to the intensive care unit for ongoing management, including inotropic support. After antibiotic susceptibility testing, benzylpenicillin therapy alone was continued. The patient became afebrile and haemodynamically stable after 48 hours, but her neurological recovery was prolonged. She remained intubated for 10 days after admission, and required a tracheostomy for respiratory weaning. Films from blood taken shortly after admission showed target cells, acanthocytes and Howell–Jolly bodies, raising the possibility of anatomical or functional asplenia. Her family and general practitioner were questioned, but they were unaware of previous splenic surgery, or surgical scars or abdominal trauma, and did not believe that the patient had ever received pneumococcal vaccination or prophylactic antibiotics. After extubation, the patient revealed that an absent spleen was noted many years previously when she had a laparoscopic cholecystectomy, but that she was unaware of any implications or required management of asplenia. After the discovery of her (presumed congenital) asplenia, she was referred to the Victorian Spleen Registry for vaccination, commencement of antibiotic prophylaxis, and ongoing education. During her subsequent hospital stay, it became apparent that the patient had persistent neurological deficits, in particular, unilateral sensorineural hearing loss and difficulty with cognitive tasks and concentration. She spent a total of 19 days in an acute-care hospital and a further 50 days in a rehabilitation centre, and has since returned home with ongoing support from allied health professionals and carers. Overwhelming postsplenectomy infection (OPSI) is a well recognised long-term risk in patients who have undergone splenectomy. In addition, there are patients who are asplenic for other reasons, including congenital asplenia or medical conditions such as coeliac or sickle cell diseases.1 The incidence of OPSI can be reduced by instituting a suite of preventive measures,2 although auditing has shown that adherence to recommendations is poor, both in Australia and elsewhere.3-5 Partly in response to these studies, a number of national and international guidelines have been published, including recent guidelines produced by the Australasian Society for Infectious Diseases.6 In Victoria and elsewhere, there have been more systematic efforts, including the establishment of registries for people who are asplenic. Our case illustrates the risk of OPSI, and, below, we describe how this risk can be minimised. Although an individual’s risk for OPSI is only in the order of one in 500 patients per year, this carries a 50% chance of mortality for those affected,6 and a risk of significant morbidity. The cost to the health system of an individual case of OPSI can be significant, and systematic approaches to prevention are cost-effective.7 Guidelines based on the limited evidence available usually recommend a combination of vaccination and long-term antibiotic prophylaxis, plus the supply of emergency antibiotics and, possibly most importantly, patient and family education about health after, and the possible consequences of, splenectomy.1,6,8 In retrospective studies, adherence to these guidelines appeared to reduce the rate of OPSI by about 50%.2 As was the case in our patient, most cases of OPSI are due to S. pneumoniae.6 Vaccination against this organism is important, as is vaccination against Neisseria meningitidis and Haemophilus influenzae type b, and vaccination with the influenza vaccine (Box 1). Prophylactic long-term antibiotic therapy is also recommended (Box 1), on the basis of a similar level of evidence. Lack of antibiotic prophylaxis is associated with increased risk.2,3 If patients cannot tolerate long-term prophylaxis, an emergency supply of antibiotics and information on when to take these may be an appropriate alternative.6,8 Education is also important in recognising signs of infection and the need for early presentation to medical care. Insufficient medical advice to patients and their treating medical practitioners, and forgetting this advice, have been purported to be responsible for cases of OPSI occurring decades after the original splenectomy.3 Education also includes the need for travel advice, especially to areas where malaria exists, and consideration of antibiotic therapy after animal bites or other trauma. Poor adherence to guidelines has given rise to the suggestion that an active spleen registry may be the best option to ensure adherence to best-practice recommendations.9 There are few previous reports of spleen registries, and those that exist show that registries vary in their methods of operation.10 Lessons from practice Overwhelming postsplenectomy infection occurs in one in 500 patients per year, but the associated mortality rate is 50%. This risk can be reduced by about half with education, vaccination and antibiotics. Systematic approaches to postsplenectomy care are likely to be more efficient than ad-hoc approaches. The Victorian Spleen Registry was established in 2003 with funding from the Victorian Government Department of Human Services for an initial 18-month period. The registry team includes the registry coordinator, infectious disease physicians, clinical haematologists and a clinical immunologist, with additional advice received from surgeons, pharmacists and anatomical pathologists. The registry actively enrols asplenic patients; referral and patient consent are required for inclusion. Patients enrolled on the registry are provided with written information about the management of asplenia, and provided with memory aids such as refrigerator magnets and wallet-sized cards. More than 1000 patients are now enrolled. However, continuing funding for the registry is an ongoing problem. This case and others, like the one illustrated in Box 2, show the severity of even non-fatal OPSI when it occurs, and the real need to minimise the risk to patients by ensuring that they receive regular vaccination, appropriate antibiotic advice and education, as provided in a registry setting. 1 Summary of current recommendations for adult patients who are asplenic Recommendation Frequency Vaccination Pneumococcal conjugate Consider at baseline Meningococcal conjugate C Baseline Haemophilus influenzae type b Baseline Pneumococcal polysaccharide (23 valent) Baseline + 5 year Quadrivalent polysaccharide meningococcal vaccine Baseline + 5 year Influenza Annual Antibiotic prophylaxis Amoxycillin 250 mg orally or Daily, lifelong penicillin 250 mg orally Twice daily, lifelong Roxithromycin 150 mg (if allergic to penicillin) Daily, lifelong Amoxycillin 3 g (if prophylaxis not tolerated) In emergency (eg, febrile illness when unable to access medical care) Enrolment in a spleen registry where one is available 2 Middle-aged woman after overwhelming postsplenectomy infection This patient had not had all the necessary vaccinations; she survived, but required amputation of all four limbs.

Justin T Denholm BMed, MBioethics · Penelope A Jones RN, GradDipEpi · Denis W Spelman MPH, FRACP · Paul U Cameron PhD, FRACP · Ian J Woolley MB BS, FRACP

To the Editor: We describe two liver transplant patients who presented with unexplained dyspnoea and were subsequently found to have unilateral right diaphragmatic palsy, an uncommon complication of orthotopic liver transplantation.1-3 Both transplant recipients were male. One, aged 64 years, had a liver transplant in 2005 for hepatitis C-related chronic liver disease. The other, aged 66 years, had a liver transplant in 2004 for end-stage alcoholic liver cirrhosis. Both patients had presented with exertional dyspnoea several weeks after transplantation. Both were reformed smokers with no prior respiratory symptoms or established respiratory or cardiac condition. Preoperative pulmonary function tests had been essentially normal in both patients (Box 1). Chest x-rays of both patients during the postoperative convalescence period showed unilateral elevation of the right hemidiaphragm compared with the immediate pre-transplant images. (Images for Patient 1 are shown in Box 2.) Fluoroscopic study (the “sniff test”) and a computed tomography scan of the chest confirmed the presence of right hemidiaphragmatic palsy in both patients. Follow-up chest x-rays and pulmonary function tests over 2 years showed no significant improvement. In both patients, the postoperative clinical course over these 2 years was characterised by recurrent hospital admissions with hypoxaemia and intercurrent respiratory tract infections, some requiring supplemental oxygen therapy, non-invasive positive pressure ventilation and invasive ventilation in the intensive care unit. Currently, one of these patients is well, apart from dyspnoea on moderate exertion. The other patient died from a cause unrelated to his diaphragmatic palsy. Unilateral diaphragmatic palsy following liver transplantation is thought to be related to traumatic crush injury to the right phrenic nerve from a clamp placed on the inferior vena cava (IVC) during surgery.1 The proximity of the phrenic nerve to the IVC renders it very vulnerable to this type of injury from side-to-side cross-clamping of the suprahepatic IVC.1,2 In 2008, we modified our technique to avoid cross-clamping of the IVC by performing cavocavostomy, a type of “piggyback” technique that involves “side-biting” (partial clamping) of the retrohepatic IVC away from the diaphragm.4 Unilateral diaphragmatic palsy can reduce exercise tolerance5 and may place additional mechanical stress on ventilation, which could exacerbate hypoxaemia if these patients develop intercurrent pulmonary infections. Reporting on a series of patients with phrenic nerve injury after liver transplantation, McAlister and colleagues1 found right hemidiaphragmatic palsy in 38% of patients after transplantation, but most of the patients recovered their diaphragmatic function within 9 months. In contrast, our patients did not show any signs of recovery for over 2 years, indicating that loss of diaphragmatic function after liver transplantation may be longstanding or permanent. 1 Comparison of pulmonary function tests before and after orthotopic liver transplantation* Patient 1 Patient 2 Pulmonary function test Before transplant After transplant Difference Before transplant After transplant Difference FEV1 (% of predicted) 2.72 L (80%) 1.73 L (51%) – 29% 2.78 L (85%) 1.40 L (47%) – 38% FVC (% of predicted) 3.79 L (87%) 2.41 L (56%) – 31% 3.83 L (92%) 2.17 L (57%) – 35% FEV1/FVC 0.72 0.72 0.73 0.65 TLC (% of predicted) 5.81 L (87%) 4.28 L (62%) – 25% 7.09 L (110%) 5.18 L (86%) – 24% FEV1 = forced expiratory volume in 1 second. FVC = forced vital capacity. TLC = total lung capacity. * Tests were performed while the patients were in a clinically stable condition. 2 Erect chest x-rays before and after orthotopic liver transplantation, Patient 1 A: In 2005, before liver transplant. B: In 2006, 6 months after liver transplant. Note marked elevation of the right hemidiaphragm and presence of bilateral calcified pleural plaques.

H S Subhash · John W C Chen · Libby John · Jeffery J Bowden · Dimitar Sajkov · Peter Frith

To the Editor: There has been considerable debate about whether selective serotonin reuptake inhibitors (SSRIs) can induce suicidal thoughts and behaviour. Using data from the 2007 National Survey of Mental Health and Wellbeing (NSMHWB),1,2 we examined the relationship between SSRI use and suicidality. The NSMHWB was a nationally representative household survey of 8841 individuals aged 16–85 years. Respondents were interviewed face-to-face and they provided information to assess whether they met International Classification of Diseases (10th revision) criteria for a lifetime affective disorder, and had symptoms in the previous year; had experienced suicidality in the previous year; and had used SSRIs (and/or other psychotropic medications) in the previous fortnight (and, if so, whether they had been taking them for < 1, 1–2, 3–5 or > 5 months). We restricted our analyses to the 555 individuals with symptoms of an affective disorder in the previous year, and examined their suicidality over that year. In our first analysis, we compared those who had used SSRIs in the previous 2 weeks and had been taking them for any duration (n = 109) with those who had not used SSRIs in the previous 2 weeks (n = 446 [respondents in this group were not asked whether they had taken SSRIs at any other time]). Secondly, we compared the subgroup who had been taking SSRIs for more than 5 months (n = 80) with the same non-user group we used in the first analysis. In both analyses, SSRI users were no more likely than non-users to have seriously thought about suicide, made a suicide plan or made a suicide attempt (Box). These findings are consistent with two recent systematic reviews of studies of SSRI use and attempted or completed suicide.3,4 Our study results add to their findings because we considered a fuller range of suicidal thoughts and behaviour. Although the reviews concurred with our findings with respect to adults, they found some evidence for SSRI use increasing the risk of suicidality among children and adolescents. The NSMHWB had limitations, including a potential for recall and misclassification bias, and its inability to account for all possible confounders. Importantly, its cross-sectional nature precluded determining whether an individual’s SSRI use preceded or followed his or her suicidality. By restricting our second analysis to SSRI users who had used SSRIs for more than 5 months, we increased the likelihood that SSRI use occurred first, but we could not determine this conclusively. This would have been a problem had we found an association, because we could not infer the direction of causality. However, with no association demonstrated causality becomes a moot point. Our findings support the contention that SSRI use in adults with affective disorders is not associated with suicide risk. Nonetheless, clinical judgement is required in prescribing SSRIs. Suicidality in the previous year among SSRI users and non-users All users* (n = 109) Non-users† (n = 446) χ2 P Long-term users‡ (n = 80) Non-users† (n = 446) χ2 P Seriously thought about suicide 23% 15% 3.20 0.27 20% 15% 0.83 0.58 Planned suicide 9% 5% 1.76 0.31 4% 5% 0.45 0.41 Attempted suicide 8% 3% 5.23 0.10 2% 3% 0.52 0.52 SSRI = selective serotonin reuptake inhibitor. * SSRI use in previous 2 weeks and for any duration. † No SSRI use in previous 2 weeks (use at other times unknown). ‡ SSRI use in previous 2 weeks and for > 5 months.

Jane E Pirkis · Philip M Burgess · Amy K Johnston · Harvey A Whiteford

To the Editor: On behalf of the Australian Medical Council (AMC), I would like to comment on a recent article1 and two letters2,3 in the Journal about the content of the AMC’s Good medical practice: a code of conduct for doctors in Australia (“the Code”)4 and the consultation process used to support its development. The AMC developed the Code on behalf of state and territory medical boards. It was endorsed by the AMC directors and will be recommended to the new Medical Board of Australia, due to be established later this year. The Code was strengthened by a robust consultation process (supported financially by the Australian Government Department of Health and Ageing) and has been supported by members of the medical profession and the community.5,6 Myers2 seems unaware of the make-up of the AMC, which includes nominees of its many stakeholders (including medical boards). He also seems to be unaware that medical boards in Australia (including the Medical Practitioners Board of Victoria) have already issued codes of professional conduct and that the new national Code brings together and builds on the key elements of these existing codes. The core roles of the AMC are the assessment of international medical graduates on behalf of state and territory medical boards and the accreditation of Australian medical schools and medical colleges. It is not the role of the AMC to “evaluate . . . laws and regulations” or to “address the issue of the accountability of regulatory bodies”, as suggested by Myers. Komesaroff and Kerridge1 and Myers2 appear to believe that a code of professional conduct can be legally binding. Although disciplinary tribunals may use the Code as a guide in their task of assessing allegations of unprofessional conduct, the most important role of the Code is to guide doctors about professionally acceptable conduct. Such conduct is based on many elements, but must especially encompass conduct that is consistent with both professional and legal standards developed by the profession and by parliaments, respectively. It would be neither feasible nor useful to develop a code to guide doctors in meeting those standards in their daily work, without reference to the law and to ethical and professional standards. The Code is not designed to enforce particular kinds of outcomes, but does have an educational focus, and we believe it will contribute to informing and enriching practice. Perhaps Komesaroff, Kerridge and Myers would do well to familiarise themselves with the codes of conduct already in place around Australia and to recognise that they have been used for many years by medical boards to assess complaints about doctors’ conduct. The final code is available online.4 It will be interesting to observe how it is used in the years ahead.

Richard A Smallwood

To the Editor: Complementary and alternative medicine (CAM)1 has become increasingly popular, with Australians spending an estimated $1.8 billion on CAM per year.2 We conducted a prospective study to determine the prevalence and patterns of CAM use among Australian patients with osteoporosis and to identify demographic, socioeconomic and disease-specific features that predict its use. A recent Canadian study of 360 patients with osteoporosis showed that 57% used CAM; CAM users tended to be younger than non-users and better educated, but with a lower quality-of-life score for mental health.3 To our knowledge, there have been no similar studies carried out in Australia. We surveyed 202 randomly selected patients of a Sydney tertiary hospital osteoporosis clinic over a 10-month period (March to December 2007). The clinic sees a wide spectrum of people, from healthy postmenopausal women to patients with multiple comorbidities. At their routine clinic visits, participants completed a prospective questionnaire based on previous CAM therapy surveys.3,4 They were asked about use of CAM, reasons for use, cost, perceived benefits, household income, medical insurance status and educational background. Ethics approval for the survey was obtained from the hospital’s ethics review board. The mean age of participants was 68.5 years (SD, 10.9 years); 80% were women; and 56% were born overseas. We analysed responses using firstly a fairly broad “standard” definition of CAM (including all therapies listed in the Box), and then a more stringent definition that excluded hypnosis, multivitamin therapy, tai chi and yoga. CAM use was reported by 104 patients (51%) and 62 patients (31%) based on the standard and stringent definitions, respectively. Comparative popularity of the CAM therapies used by the surveyed patients is shown in the Box. Common reasons for CAM usage were its holistic approach (53%) and the perception that conventional therapy was providing inadequate pain control (29%). Seventy-three per cent of respondents did not consult a physician before starting CAM, and 23% stated that their treating specialists were unaware of their CAM use. Eighty-eight per cent paid for their therapies out of pocket and the mean cost per patient per month was $21. (Given that 2.2 million Australians have an osteoporosis-related condition5 and 51% of these patients use CAM, the estimated annual expenditure on CAM therapies by patients with osteoporosis is $696 million.) CAM users were more likely than non-CAM users to be university-educated (26% v 14%; P = 0.05); to be born in Asia (20% v 13%; P = 0.03); to have a lower lumbar spine bone mineral density T score (mean, − 2.35 SD v − 2.20 SD; P = 0.05); and to make more frequent clinic visits (mean T score, 1.8 v 1.5 visits /12 months; P = 0.03). More than half the respondents (57%) were unable to differentiate between the terms “osteoporosis” and “osteoarthritis”, especially those from a non-English-speaking background (64% compared with 46% of patients from English-speaking backgrounds; P = 0.02) and CAM non-users (57% compared with 41% of CAM users; P = 0.01). The proportion of patients using CAM in our study was comparable to the proportion in a similar Canadian cohort (51% v 57%).3 Patients who resort to CAM for pain relief may be suffering residual fracture pain or coexisting conditions, such as osteoarthritis; patients unable to differentiate between osteoporosis and osteoarthritis may be seeking relief from pain caused by the latter. Given the low rate of patient disclosure of CAM use to physicians in our study and the reasonable chance of interaction between CAM and conventional therapies (17%),3 physicians would be prudent to regularly and clearly discuss concurrent CAM use with patients (using interpreters when necessary) to avoid potentially harmful drug interactions and side effects. At the same time, physicians could recommend appropriate balance-training therapies,6 such as tai chi, which has been shown to improve bone health and prevent falls.7 Proportion of osteoporosis clinic patients who reported using various complementary and alternative medicine (CAM) therapies (n = 104) Therapy No. (%) of patients* Multivitamins 25 (24%) Fish oil 24 (23%) Acupuncture 20 (19%) Tai chi 15 (14%) Glucosamine 14 (13%) Yoga 13 (13%) Chiropractic/osteopathy 12 (12%) Naturopathy 6 (6%) Herbal therapy 5 (5%) Chinese medicine 3 (3%) Aromatherapy 2 (2%) Massage therapy 2 (2%) Homeopathy 1 (1%) Hypnosis 1 (1%) Minerals 1 (1%) Laser therapy 1 (1%) Any CAM (standard definition) † 104 (51%)‡ Any CAM (stringent definition) † 62 (31%)‡ * Percentages total > 100% because patients used multiple therapies. † The standard definition of CAM includes all therapies listed here; the stringent definition excludes hypnosis, multivitamin therapy, tai chi and yoga. ‡ These are percentages of the total sample (N = 202).

Jenson C S Mak · Steven Faux

To the Editor: Robertson and Kerridge1 criticised our article “Patient privacy versus protecting the patient and the health system from harm”2 based on an interpretation that we were advocating notification for all patients with somatisation disorders, but our recommendation for a confidential notification system pertained specifically to factitious disorder. We agree that “ignoring or failing to integrate mental health care in future health planning is to invite a higher burden of morbidity, mortality and cost”.1 Indeed, we do not wish to “[constrain] the patient’s interaction with the health system”, but rather believe that a more complete, accurate and easily available patient history would allow doctors to optimise such patients’ care within the system. Clinically appropriate resource allocation would substitute appropriate psychiatric/psychological and primary care for more costly and inappropriate (potentially harmful) emergency and procedural care, such as numerous cardiac catheterisations. The case described in our article illustrates well the higher burden of morbidity and cost that the patient, and the system, had to endure because of the failure of multiple health providers across a range of acute settings to diagnose and treat the patient’s primary illness.2 Avoidance of truthful disclosure on the part of the patient contributes to this diagnostic failure. An electronic medical record (EMR) notification in this kind of case would allow any given doctor to overcome the otherwise almost insurmountable barriers to collating such a patient’s history, and thus to be aware of, to balance and to manage the factitious disorder diagnosis — a notoriously difficult task.3 Robertson and Kerridge argue there is a lack of evidence for “costly” EMR systems. However, it has been found that “Hospitals with automated notes and records [have] fewer complications, lower mortality rates, and lower costs”.4 A truly private portable EMR should help all patients obtain more appropriate and cost-effective care, by reducing duplication of costly investigations and doctors’ time spent chasing records. Conversely, patients might reasonably abhor a privacy system that inadvertently results in duplicate computed tomography scans — the prior records being “private” and unavailable — when radiation exposure increases the risk of cancer.5 We would be the first to acknowledge the risk of “stigmatisation” and agree with safeguards to mitigate potential consequences, as mentioned in our article.2 However, in the case of this patient and others in a similar situation, we still believe that he, the doctors struggling to provide appropriate care, and the system deserve better, which certainly won’t happen with the status quo.

Dawn E DeWitt · Ravi Bhat · Stephanie Ward

To the Editor: ANZAME (the Australian and New Zealand Association for Medical Education) shares two significant concerns about medical education in Australia that were raised in articles published recently in the Journal.1,2 The first concern is the status of health professional education (HPE) research in Australia. In 2007, the ANZAME Committee of Management investigated the profile of HPE research with the National Health and Medical Research Council (NHMRC) and the Australian Research Council (ARC); both noted they would accept grant applications for such research. At that time, the ARC indicated that they did not have any HPE research expertise among their reviewers. A number of nominations, which included ANZAME members, were made, and the comments of Roberts and Conn1 suggest this has been successful. HPE research was further assisted by an Australian Bureau of Statistics “Field of Research” classification. Professor Brian Jolly was instrumental in achieving this classification code. Fortunately, the code occurs in the education section, as ARC guidelines state they will not fund medical or dental research. At each annual ANZAME conference, educational research is discussed and presented. While Roberts and Conn are correct in stating that other local conferences on education have arisen in recent years,1 this year’s ANZAME conference was the largest ever, and showcased a wide range of research, both completed and in progress. ANZAME also promotes research through seeding grants, by providing particular supports to students who undertake educational research, and by publishing educational research articles in the Association’s journal, Focus on Health Professional Education. The second concern is the need for significant increases in the number of health professional educators to meet the needs of increasing numbers of students and young professionals. Such educators are invariably swamped by the aspects of their work related to program delivery and service requirements, at the expense of research activity. Brooks’ proposal to establish academic centres2 may go some way to overcoming this. However, we need to develop the HPE expertise that will enable new and innovative educational programs to be developed, implemented and evaluated. How are we going to recruit and train HPE academics for these roles? Earlier this year, ANZAME put out a draft position statement to highlight some of the issues and to indicate our support for promoting academic pathways.3 Workshops at the recent ANZAME conference further refined a set of recommendations. It will take vision, time, commitment, and a real increase in funding to ensure we have the trained personnel in place to achieve the required outcomes. HPE in Australia and New Zealand has matured — it now needs support for ongoing research and careful workforce planning to ensure the high quality of health professional educators is maintained.

on behalf of the ANZAME Committee of Management

To the Editor: My compliments on the issue of the Journal on the survival of general practice (20 July 2009). But something was missing — a patient’s perspective. I hear from fellow Sydneysiders that they cannot find a general practitioner offering continuity of care. They tell me that: All recommended GPs have “closed books”. They can’t get an appointment on the day and have to wait until a few days later, unless it’s a “real emergency”. At big, “commercial” practices, they seldom see the same GP again — and must tell their story each time. Their GP (preferably female) is there some weekdays only. They can’t find a GP who does home visits. Neither “their” GP, nor any of the others in the practice, is available after hours — they must ring an emergency doctor with no access to their records. GPs want them out quickly with a prescription or referral. GPs say that, although it’s a simple procedure, it’s better done by a specialist. GPs want to start a “care plan”, even if there’s nothing much wrong. They’re not happy with attention from the nurse — they want to see the doctor. And so it goes. Back in 2006, the Australian Consumers Association, together with advice on choosing a GP, commented: The relationship you have with your doctor can be one of the most crucial in your life ... A positive ongoing relationship with your GP is extremely valuable, making it all the more important to choose the right one.1 Shouldn’t the MJA open its pages — on an issue which matters so much to them — to patients, to air their concerns? As it would be anecdotal, we would need evidence. A recent article in the BMJ surveyed British attempts at harnessing the views of patients.2 The authors’ opening comments were: “There is now a widespread realisation that patients’ views are not optional but essential to achieving high quality care.” Similarly, Australian patients’ expectations about weight management in general practice were discussed in the Journal in 2006.3 Is general practice’s survival not about adapting to meet patients’ requirements for high quality of service? In special issues devoted to the adaptation of general practice to future change, should not bodies like the Australian Consumers Association and some of the patient support groups, such as Arthritis Australia, be asked to contribute? Perhaps the MJA’s discussion is missing the wood for the trees?

Peter C Arnold

Joffre Bartholomew Cowle was born in Sydney on 28 June 1931. He was educated at Waverley College and the University of Sydney, graduating in medicine in 1956. While still an undergraduate, Joffre had spent 2 years in the university’s Department of Pharmacology under Professor Roland Thorp studying the mode of action of cardiac glycosides. Their research, showing that cortisone increased the rate of polymerisation of skeletal actin but had no effect on cardiac actin, was published in the journal Nature,1 and Joffre was awarded a Bachelor of Science in Medicine with first class honours. After a 2-year residency at the Mater Misericordiae Hospital in Sydney (1956–1957), Joffre spent some time at the Peter MacCallum Cancer Centre in Melbourne and also worked as a Flying Doctor. In 1959, newly married to Colette, a casualty nurse, he went to the United Kingdom, where he worked at the Glasgow Eye Infirmary and later at the Cambridge Regional Hospital. From 1960 to 1961, he held the position of Assistant Professor of Pharmacology at the University of Ottawa in Canada, where he was involved in the pharmacology teaching program for medical students. He obtained a Diploma in Ophthalmology in 1961. Returning to Australia in 1962, Joffre worked at Hornsby District Hospital and the Medical Eye Service of New South Wales, specialising in glaucoma, and then at the Department of Ophthalmology and Eye Health of the University of Sydney. He also did experimental and clinical ophthalmology work in conjunction with the Department of Veterinary Medicine. While working in clinical practice, he continued to do research, and was involved in developing neutral pilocarpine eye drops. Joffre held a number of prestigious positions and awards. He was a Foundation Fellow of the Royal Australian College of Ophthalmologists, established in 1970. In 1980, he set up and became Director of the Research Establishment of Engineering; Biology and Medical Sciences in Sydney. In 1989, he was made a member of the Instituto Barraquer in Barcelona, Spain, a world renowned ophthalmological centre. He was also a Knight of the Military and Hospitaller Order of St Lazarus of Jerusalem and became President of the NSW Commandery. One of Joffre’s great loves was music. He played the Hawaiian steel guitar and built his own recording studio. With his wife and seven children, who played numerous instruments, he performed on radio and television. Although suffering from diabetes, Joffre continued to do research until his death from a heart attack on 21 May 2009. He is survived by Colette, his six sons (who work in various fields of engineering) and his daughter (a musician).

James B Roche

Medical toxicology of natural substances. Foods, fungi, medicinal herbs, plants, and venomous animals. Donald G Barceloux. New York: Wiley, 2008 (xxi + 1157 pp). ISBN 978 0 471 72761 3. Books on clinical toxicology are usually either pocket-sized manuals offering quick and easy reference to doctors treating acutely poisoned patients, or enormous tomes of information, much of it not directly relevant to the clinician and often out of touch with current management. Barceloux’s Medical toxicology of natural substances breaks out of that mould. This book is the first of a series of four major textbooks replacing Ellenhorn’s Medical toxicology, reflecting the rapid growth in clinical toxicology and its evidence base over the past decade. Planned further volumes cover recreational, occupational, and pharmaceutical poisoning. The text’s layout is consistent throughout, with historical facts providing an interesting backdrop to more detailed analytical and toxicokinetic data, before clinical and management issues are discussed. A Californian emergency physician, Barceloux is clearly very comfortable with acute management; his recommendations are current and evidence-based, and the book could easily be used to guide acute management despite its size and impressive detail. Textbooks published in the United States are often reluctant to consider other parts of the world — in contrast, Barceloux provides a detailed region-by-region examination where necessary. Of minor irritation, secondary rather than primary references are cited. As well, the publisher hasn’t supported the outstanding content with comparable publication quality. A decent cover and coloured illustrations throughout, rather than just a few pages in the middle, would have improved the overall package. Nevertheless, from lepidopterism to latrodectism, syndromes caused by the squirting cucumber to licorice, cholera to platypus envenoming, this wonderful book covers an enormous subject with attention to detail and direct clinical relevance in a style that is surprisingly easy to read. The remaining volumes will be eagerly awaited by clinical toxicologists everywhere.

George A Jelinek

Incorrect author name: In the letter “Invasive pneumococcal disease in Western Australia: emergence of serotype 19A” in the 2 February 2009 issue of the Journal (Med J Aust 2009; 190: 166), there was an error in one of the author's names. The name “Keil D Anthony” should have been “Anthony D Keil’.

Carolien M Giele · Anthony D Keil · Deborah Lehmann · Paul G Van Buynder

Killing headaches It’s well known that oxygen will feed a fire; it’s less well known that oxygen can curtail an attack of cluster headache. Once nicknamed “suicide headache” because of its severity, cluster headache is characteristically experienced as recurrent attacks of unilateral excruciating pain usually in the eye, periorbital region and temple, with associated cranial autonomic symptoms.1,2 Untreated attacks typically last for 15 to 180 minutes. A randomised, double-blind, placebo-controlled crossover study in 109 patients with cluster headache in the UK has confirmed that, compared with placebo, treatment with inhaled high-flow oxygen at symptom onset is more likely to result in patients being pain-free within 15 minutes.2 The more usual treatment for cluster headache is a triptan, administered by injection. The researchers said that a head-to-head comparison between a triptan and oxygen is both warranted and feasible. 1. JAMA 2009; 302: 2502 2. JAMA 2009; 302: 2451-2457 In a different vein For much of his adult life, King Henry VIII was plagued by a “sorre legge” due to chronic, often infected, ulcers. In an essay, British authors say Henry’s infamous vile temper — he was reportedly responsible for more deaths than any English monarch before or since — was undoubtedly influenced by his clinical situation. They canvassed various potential diagnoses, including syphilis and untreated compound fracture, settling on classical venous ulceration. Apparently, Henry himself was keenly interested in medicine: apart from founding the Royal College of Physicians in 1518 and forming the Company of Barber-Surgeons in 1540, he also personally prepared salves and ointments for the treatment of his friends and, later, for himself. J R Soc Med 2009; 102: 513-517 The right dose(s) A man who weighs 90 kg and is 1.9 m tall and a woman who weighs 56 kg and is 1.5 m tall would both receive the same dosage of antibiotic, according to current treatment guidelines. However, in our current era of increasing antimicrobial drug resistance, this one-size-fits-all strategy for prescribing antimicrobial agents to adults is now outdated, say Greek authors. In a Viewpoint in the Lancet, they opined that the use of the highest acceptable antibiotic dose is a means to prevent the emergence and selection of resistant pathogens during therapy. Further, achieving appropriately high serum concentrations could be important to overcome relative antimicrobial drug resistance. Individual patient-tailored dosing of antimicrobial agents could help to reduce drug-dependent drug toxicity. Apart from body size, body composition can also affect drug pharmacokinetics. For example, the renal clearance of some antibiotics can increase in obesity. Not surprisingly, the authors say more studies are needed. Lancet 2009; 28 Oct [Epub ahead of print] Appendicitis and air pollution Air pollution may trigger some cases of appendicitis, suggest Canadian researchers. They demonstrated an association between short-term exposure to air pollution and appendicitis in a case-crossover study of over 5000 adults admitted to hospital with appendicitis. The effect of air pollution was greatest in the summer months, when individuals were most likely to be outside. The researchers say that, if their findings are substantiated, this association may explain the trends in incidence of appendicitis in industrialised nations: incidence increased dramatically in the 19th century and the early part of the 20th century; then, without explanation, it decreased in the middle and latter part of the 20th century, coinciding with legislation to improve air quality. The mechanisms by which air pollution may increase the risk of appendicitis are unknown. One possibility is that exposure to air pollutants may impair gastrointestinal immunity, increasing the risk of bacterial invasion and resulting in appendicitis. CMAJ 2009; 181: 591-597 Dr Ann Gregory, MJA

Ann Gregory