Volume 193 Issue 1

A major change in medical teaching practices is needed to improve patient safety The Lucien Leape Institute, in Boston, USA, was formed in 2007 to provide a strategic vision for improving patient safety, and is composed of national “thought leaders” (http://www.npsf.org/lli/). The Institute has produced a report on the urgent need to reform medical education,1 and states that many believe we are at a transformational moment similar to that which led to the profound changes in medical education following the release of the Flexner report in the United States 100 years ago.2 It is a decade since the release of national reports on patient safety that triggered a wake-up call,3-5 and 15 years since the publication of the Quality in Australian Health Care study.6 However, progress has been much slower than we would have liked. System-based changes, although desirable and necessary, have not done the job of improving patient safety. Although there have been some notable successes and high-profile champions of safety, we are unable to measure progress or to reassure patients that they will receive safe, high-quality care.7,8 It’s time to turn to those who will actually provide the health care to the patients of the future. Health care is characterised by islands of excellence in a sea of mediocrity, and it is into this sea that our new health sciences graduates are launched. By the time of graduation, most will have been exposed to enough facts and figures about health care-associated harm to find them alarming, and most will have sufficient insight into the dysfunctional nature of “the system” to feel apprehensive about their preparedness for the voyage ahead of them.9 The good news is that the actual delivery of health care takes place at the interface between individual health care professionals and patients (and their carers).9 Although this is where the final link in a chain of errors may be forged, it is also where constant vigilance and attention to detail by both individuals and members of multidisciplinary teams can ensure, on a daily basis, that what needs to happen, does in fact happen.10 Much is said about clinical autonomy, and daily interaction is the sphere in which individual medical and nursing clinicians can have a massive impact on “getting it right”.9 But clinical interaction must be from the perspective of the patient, and in line with best practice, not with old habits, new fashions or outdated dictates from an incumbent hierarchy. Structured, evidence-based care plans provide transparency and allow all team members to monitor patient compliance with treatment, and intervene when necessary. James Reason, who has written extensively on error and safety, has exhorted us to celebrate the remarkable capacity of individual team members to continuously turn potential adverse events into “near misses” in high-risk systems.10 Although altruistic, well intentioned young graduates are forced by the system into moulds and practices they may not like, and over which they have little control, the majority will, against considerable odds, manage to provide high-quality, patient-centred care. However, they could and should be better equipped for the formidable tasks they face. Most new graduates are well equipped to deal with the technical aspects of health care, and are well mentored in these by their seniors,1 but transformational change is needed to produce a new generation of clinicians endowed with a proper understanding of what is wrong. They need to be equipped with non-technical skills such as situation awareness, communication techniques, empathy and graded assertiveness,9 and to be imbued with an understanding that real change is urgently needed and must come from them. The 12 recommendations for transformational change made by the Leape report1 are paraphrased here. The first four address the organisational context, recommending that leaders in medical teaching should: place the highest priority on creating learning cultures that emphasise patient safety; launch a broad effort to promote the development and display of the necessary personal attributes, such as professionalism, collaborative behaviour and transparency; provide incentives and resources to support this effort; and place greater emphasis on screening prospective students for the appropriate attributes. The next three recommendations in the report are about strategies for teaching patient safety, recommending that: patient safety be treated as a science; the shaping of the desired skills, attitudes and behaviours becomes an integral part of the core competencies required by accreditation bodies; and patient safety education becomes a life-long process. The final five recommendations deal with strategies to “leverage acceleration of the desired changes” so as to: modify accreditation standards so that these become curricular requirements, with required competencies at graduation; expand program requirements in postgraduate training programs; direct attention to safety-related preparation of graduates entering clinical training; ensure that medical schools are evaluated with respect to their performance in these areas; and establish incentives to achieve these changes. Health sciences students in Australia are now variously exposed to teaching about systems thinking, interprofessional learning, human error, incident reporting and open disclosure. This is a good start, but an evident lack of system-wide progress, and the robust homeostatic mechanisms that tend to maintain the system’s status quo, show that more than this is needed. Patient safety is not just another technical problem to be added to the curriculum. It is a serious, enormously costly, multidimensional problem8 that can only be addressed by transformational change in the attitudes and behaviours of the people who will be in a position to dictate how medicine will be practised1 where it matters: at the interface between them and the patients of the future.9

William B Runciman PhD, FANZCA, FJFICM

PSA testing may lead to overtreatment, but this should not rule out its judicious use as an early predictor of prostate cancer Two recent articles, an opinion piece from Richard Ablin, the discoverer of prostate-specific antigen (PSA) and a self-proclaimed “authority in the field”, published in the New York Times,1 and a subsequent interview with Ablin published in the BMJ,2 contend to inform the public of the “hugely expensive public health disaster” of PSA testing. Yes, PSA testing is not without its flaws, but to malign it in this manner is truly lamentable. Before 1980, there was no diagnostic test for prostate cancer; there was no effective radiation therapy; there was no safe surgery, and the only option for most men with prostate cancer was to have their testes removed — surgical castration. Most men, of course, feel quite attached to their testes, and castration carries myriad physical and psychological side effects. A common emergency department presentation at that time was acute paraplegia due to prostate cancer metastatic lumbar spine cord compression.3 This is a rare presentation in 2010. Since the introduction of PSA testing in the 1980s, we have seen a 25% reduction in mortality from prostate cancer; stage migration means 80% of men now present with localised, either small-volume or advanced, prostate cancer.4 Because the PSA test facilitates early diagnosis, most men with prostate cancer are diagnosed with a lead time of about 9 years before the onset of metastatic disease.5 The contention, however, is that the PSA test is a poor screening tool; and this is reasonable, because we ask far too much of a single blood test. The PSA test will not differentiate between aggressive and indolent prostate cancer. Furthermore, after the onset of benign prostatic hyperplasia (BPH) in men from about 45 years of age, background noise due to BPH reduces the sensitivity of the PSA test at PSA levels below 10 ng/mL, although a PSA level above 10 ng/mL is still very indicative of the presence of prostate cancer. The key problem facing health professionals dealing with prostate cancer can be readily articulated: it is the inability to discriminate between aggressive and indolent prostate cancer. It is acknowledged that, while PSA testing has led to greatly reduced mortality, its widespread use has also led to greatly increased detection of prostate cancers, many of which will not prove to be life-threatening.6 This has led to considerable overtreatment of indolent prostate cancer by surgery and radiation therapy, although increased use of active surveillance has demonstrated that clinicians are being more considered when counselling men about their management options.7 What if we were to use PSA testing in a more judicious and targeted manner so that men could have a single test before the onset of BPH? Swedish researchers have elegantly shown that the effect of benign transition zone-related PSA levels can be eliminated by testing all men at baseline before the development of BPH. In a study of a large cohort of men in Malmö, Sweden, PSA levels in men below the age of 45 years reliably predicted the development of significant prostate cancer up to 25 years later.8 Between 1974 and 1986, 21 000 Swedish men aged under 45 years provided blood samples as part of a cardiovascular study. At the end of 1999, participants who had developed prostate cancer were identified using Swedish Cancer Registry data. PSA level at 45 years of age was found to be a very strong predictor of prostate cancer being diagnosed up to 25 years later, with an area under the receiver operating characteristic curve of 0.76 (signifying high discriminatory ability). PSA levels between 2 and 3 ng/mL (which are often cited as being within the normal range) were associated with a more than 19-fold increased risk of subsequent prostate cancer development. The researchers went on to show that 80% of advanced cancers (stages T3, T4 and metastatic at diagnosis) occurred in men who had had PSA levels above the median when tested at age 44–50 years.9 This study suggests that we could use a single PSA level as a predictor for the long-term risk of prostate cancer in younger men around the age of 45 years. This supports the advice from the Urological Society of Australia and New Zealand and the American Urological Association that men aged 40 years should have the merits of a PSA test discussed with them. Those with a PSA level well below the median for men in their 40s of about 0.6 ng/mL5 (the vast majority at this stage) could be reassured that they are at very low risk of developing prostate cancer and advised to have another test 5 or 10 years later. The nihilistic musings of Ablin do nothing to help inform a rational policy towards the early detection of prostate cancer. Rather than dispense with a test that has contributed significantly to the reduction in mortality from prostate cancer over the past 30 years, and while we wait for better biomarkers in the future, we should instead advocate a more discriminating use of PSA testing.10

Anthony J Costello MB BS, FRACS · Declan G Murphy MB, FRCS Urol

Vaccine scares are inevitable and we need to plan accordingly Twelve years after The Lancet published the study by Wakefield and colleagues1 that suggested a link between measles–mumps–rubella (MMR) vaccination, inflammatory bowel disease and autism, the journal has fully retracted the article. The retraction followed the findings of the Fitness to Practise Panel of the UK General Medical Council, released 28 January 2010, that certain statements in the article were false — namely, that children were “consecutively referred” and that investigations were “approved” by the local ethics committee.2 Wakefield’s theory had a significant impact on MMR vaccination rates in the United Kingdom. Looking at why Australia was relatively unaffected provides insights into how to better manage vaccine scares in the future. After publication of the article, many readers had written without delay to The Lancet regarding methodological deficiencies of the original research.3 Subsequent studies overwhelmingly supported the safety of MMR vaccination, but the accumulation of this evidence took years to achieve, with considerable opportunity costs, including time and resources spent on investigations which could have been better directed elsewhere.4 In the UK, the MMR vaccination rate fell from 91% in 1997–98 to 80% in 2003–04.5 Notably, there has been no decline in coverage for other vaccines for children in the UK. Despite a recovery in the MMR vaccination rate to 85% by 2008–09,5 there was a large upsurge in measles occurrences in the UK, beginning in 2002.6 In 2009, 1144 laboratory-confirmed measles cases were reported in England and Wales.6 The impact was also felt in the United States, where Wakefield’s theory augmented unsubstantiated fears about thiomersal (a mercury-based preservative) in some vaccines leading to autism. A recent survey found that one in four US parents believed that some vaccines cause autism in healthy children.7 Vaccine scares are typically depicted as conflicts between science and dogma; between the informed and the misinformed.8 The publication of Wakefield et al’s article in The Lancet breached the boundary between the two: here was a well credentialled specialist at a highly regarded teaching hospital whose findings were published in a renowned journal. These signifiers of prestige may have overshadowed the relatively poor quality of the science in the original article. Fortunately, in the years since the article was published, Australia’s MMR vaccine uptake has been relatively stable, as measured by the Australian Childhood Immunisation Register9 (Box). However, there were other consequences of Wakefield et al’s article, including the time and resources needed to address parents’ concerns.11 Some health professionals appeared to accept Wakefield’s theory. A 2006 survey of doctor and nurse vaccination providers in regional New South Wales found that 12% believed there was an association between MMR and autism, with a further 29% being unsure.11 Despite this, Australian MMR coverage remained essentially unaffected. The fact that Australian MMR vaccination rates remained stable may be related to some key differences between Australia and the UK: (i) in Wakefield, the UK had a “home-grown champion” for the MMR–autism theory; (ii) the extensive and sustained coverage of this issue in the UK media continually exposed new cohorts of parents of MMR-eligible children to the theory, while Australian television only sporadically reported the story; (iii) there is bipartisan political support for immunisation in Australia, whereas there was grandstanding by a member of the UK Conservative opposition and a refusal by the nation’s Labour Prime Minister to reveal whether his own son was immunised;12 and (iv) a foundation of mistrust in UK government assurances was perpetuated by public perceptions of the management of the Creutzfeldt–Jakob disease issue.13 The child vaccination program is held in high regard by most Australians, and, for this reason, the media have traditionally sidelined our small but vocal antivaccination lobby. This high level of public confidence has been helped by the structural support originating from the first National Immunisation Strategy in 1993, followed in 1997 by the federal Immunise Australia: Seven Point Plan, including financial incentives for parents and providers to adhere to the national vaccination schedule.14 What can the world learn from the Wakefield experience? First, we should accept vaccine scares as inevitable and plan accordingly. There remains the potential for vaccine safety scares to lead to large-scale opting out of vaccination, exacerbated by dwindling familiarity with the severe effects of vaccine-preventable diseases, and a groundswell of dissent from the antivaccination movement. Second, public communication about vaccine risk, particularly regarding responses to adverse events following vaccination in new vaccine programs, needs to be planned, and should involve multiple stakeholders, as new issues can arise with little warning. This occurred as recently as 23 April 2010, when Australia’s Chief Medical Officer advised a temporary suspension of the 2010 trivalent seasonal influenza vaccine to children 5 years of age and under.15 This suspension followed an increase in febrile convulsions among young child vaccine recipients reported in Western Australia. Third, the current level of trust in vaccine programs that we enjoy in Australia is a precious resource and must be continually fostered with good communication. Such communication is more than a didactic one-way process — it requires an interactive engagement between professionals, the public and the media. Clearly, this will be important and challenging after the recent suspension of the trivalent influenza vaccine, because professional and public concern generated by this suspension could spread to concern about influenza vaccination for other age groups.16 Australian federal, state and territory governments are now developing a new national vaccination strategy. Essential considerations in this strategy will be how the postmarketing surveillance of adverse events following vaccination is to be conducted, and authoritative and timely communication about vaccine safety with professionals and the public. MMR, DTP, OPV, Hib and hepatitis B vaccine coverage for Australian children at 24 months of age, 2000 to 2009*10 MMR = measles–mumps–rubella. DTP = diphtheria–tetanus–pertussis. OPV = oral polio vaccine. Hib = Haemophilus influenzae type b. Hep B = hepatitis B. * Figure updated with 2008–2009 data (Brynley Hull, Epidemiologist, National Centre for Immunisation Research and Surveillance, personal communication).

Julie Leask PhD, MPH, DipAppSci · Robert Booy MD, FRACP, FRCPCH · Peter B McIntyre PhD, FRACP, FAFPHM

A simplified revision of the uniform conflict of interest disclosure form is now available The great variability in the processes that different journals use to ask about and report authors’ potential conflicts of interest creates confusion for authors, readers and the public. To help lessen this confusion, the International Committee of Medical Journal Editors (ICMJE) developed an electronic uniform disclosure form and placed it in the public domain in October 2009. The ICMJE member journals piloted the form, encouraged other journals to use it, and invited feedback. We recognised that the reporting of competing interests is complex and nuanced and sometimes contentious, and thus anticipated modifying the form based on feedback received. We are grateful to the many authors, editors and other interested parties who took the time to comment on the form and its implementation. The issues raised ranged from technical problems about the correct deployment of the form (it requires the user to download version 8.0 or higher of the free Adobe Reader software to function) to concerns about the ethics of inquiring about non-financial associations. The Committee considered these valuable comments and revised the form at our most recent meeting. We made several modifications. The major change in the reporting instrument is the removal of the queries about potential competing interests of authors’ spouses and minor children and about non-financial competing interests. We made this change based on the largely negative feedback that we received about these sections. People who commented about this issue made it clear that there is immense difficulty in defining competing interests beyond those that involve the direct exchange of money from an interested party to an individual author or the author’s institution. Because the Committee continues to believe that there are situations in which indirect or non-financial factors could influence (or appear to influence) the conduct or interpretation of work, we replaced the specific questions with a single open-ended query (new Section 4) that asks, “Are there other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, what you wrote in the submitted work?” This change places the onus on the person completing the form to identify and report appropriate non-financial competing interests. It has the advantage of being less intrusive than the previous queries, while providing a locus where authors can report non-financial relationships that may be perceived as potential conflicts of interest. In response to comments about the clarity of the form, each field in the form now has a numeric designation. We have modified the language in the instructions and in the individual queries. To make the form more useful to non-native English speakers, we are creating a glossary of terms used in the form and will be posting guidelines for translation of the form’s instructions into multiple languages. The translation of this form is particularly challenging because translations must capture the essence of the queries rather than their literal meaning. The glossary and guidelines will be available at the ICMJE website (http://www.icmje.org) in the next few months; translations will be posted on the ICMJE website as they become available. The new form, in English, is currently available on the ICMJE website and the websites of our member journals. Authors who have completed the older version of the form in conjunction with a journal submission need not complete the new form, but the new form will be the standard for new submissions. We welcome continued input from the user community. Comments can be sent via the “Contact ICMJE” link at the ICMJE website. The Committee will consider comments received before 1 May 2011 when we prepare the next iteration of the uniform conflict of interest disclosure form. The complexity, subjectivity and emotionality of conflict disclosure assures that some will consider this vehicle for reporting to be excessively burdensome, while others will think it falls short in one area or another. We cannot, however, let the perfect be the enemy of the good. We hope that the revised ICMJE form will be another step towards simplifying and standardising reporting of conflicts of interest. A more uniform reporting process will alleviate the confusion that prevails when multiple journals use different reporting formats, and will ease the reporting burden on members of the biomedical research community, so they can pursue the research that will improve the care that we deliver to our patients. With these thoughts in mind, we encourage all journals to adopt the new version of the uniform disclosure form.

Jeffrey M Drazen MD · Peter W de Leeuw MD, PhD · Christine Laine MD, MPH · Cynthia Mulrow MD, MSc · Catherine D DeAngelis MD, MPH · Frank A Frizelle MB ChB · Fiona Godlee MB BChir, BSc · Charlotte Haug MD, PhD, MSc · Paul C Hébert MS, MHSc · Astrid James MB · Sheldon Kotzin MLS · Ana Marusic MD, PhD · Humberto Reyes MD · Jacob Rosenberg MD, DSc · Peush Sahni MS, PhD · Martin B Van Der Weyden MD · Getu Zhaori MD

Objective: To investigate community attitudes to abortion, including views on whether doctors should face sanctions for performing late abortion in a range of clinical and social situations.Design, setting and participants: An anonymous online survey of 1050 Australians aged 18 years or older (stratified by sex, age and location) using contextualised questions, conducted between 28 and 31 July 2008.Main outcome measures: Attitudes to abortion, particularly after 24 weeks’ gestation.Results: Our study showed a high level of support for access to early abortion; 87% of respondents indicated that abortion should be lawful in the first trimester (61% unconditionally and 26% depending on the circumstances). In most of the clinical and social circumstances described in our survey, a majority of respondents indicated that doctors should not face professional sanctions for performing abortion after 24 weeks’ gestation.Conclusions: Our data show that a majority of Australians support laws which enable women to access abortion services after 24 weeks’ gestation, and that support varies depending on circumstances. Simple yes/no polls may give a misleading picture of public opinion.

Lachlan J de Crespigny MD BS, FROCG, COGU · Dominic J Wilkinson MB BS, MBioeth, FRACP · Thomas Douglas BMedSc, MB ChB, BA(Hons) · Mark Textor BEc · Julian Savulescu MB BS, BMedSci, PhD

Objective: To determine the opinions and current practice of obstetricians and gynaecologists and trainees in the specialty with regard to induced abortion.Design, setting and participants: A voluntary, anonymous survey of Australian Fellows and specialist trainees of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists was conducted between 23 June and 31 July 2009 using an email invitation to proceed to an online questionnaire.Main outcome measures: Attitudes to abortion; self-reported usual practice of induced abortion.Results: Of 1498 Fellows and trainees invited to complete the questionnaire, 740 (49%) did so. Of these respondents, 632 (85%) stated that they did not hold religious or conscientious views that would make them totally opposed to abortion; 463 of these (73%) reported performing abortion as part of their personal practice, with 204 (44%) doing so only for severe fetal abnormality or serious maternal medical conditions. 108 respondents reported holding views that made them totally opposed to abortion — 60 (56%) opposed it in any situation at all and 48 (44%) opposed it with limited exceptions. Of those opposed, 34 (32%) added comment that they perform abortion for severe fetal abnormality or serious maternal medical conditions, and a further 17 (16%) commented that they refer women requesting abortion in these circumstances to colleagues. Of the respondents not opposed to abortion, 89% supported the availability of induced abortion within the public health system, and half felt that national availability of mifepristone would modify their practice of induced abortion.Conclusions: There was broad support among responding specialist obstetricians and gynaecologists and trainees for the availability of induced abortion in Australia. This study highlights the difficulties of accurately reporting a wide range of views on a contentious issue.

Caroline M de Costa PhD, FRANZCOG, FRCOG · Darren B Russell FRACGP, DipVen, FAChSHM · Michael Carrette MB BCh, FRANZCOG

Objectives: To establish the rate of clinically significant weight change after 12 months in patients who have had a primary total hip arthroplasty (THA); to identify patient characteristics that predicted weight loss or gain; and to compare clinical and functional outcomes between obese and non-obese patients.Design, setting and participants: Prospective study of 471 patients who underwent THA between 2006 and 2007 at St Vincent’s Hospital, Melbourne, a university-affiliated tertiary referral centre. Patients were classified as non-obese, obese and morbidly obese, and were assessed using the Harris Hip Score (HHS) and 12-item Short Form Health Survey (SF-12).Main outcome measures: Incidence of weight loss or gain 12 months after surgery; preoperative patient variables predictive of weight change; functional and quality-of-life outcomes and rate of adverse events at 12 months; differences in outcomes between obese and non-obese patients.Results: 194 patients (41%) were obese or morbidly obese. At 12-month follow-up, 18 obese or morbidly obese patients (9%) had lost ≥ 5% of their preoperative weight and 118 patients (25%) had gained ≥ 5% of their preoperative weight. No preoperative predictor of weight loss was identified, but weight gain was associated with lower preoperative SF-12 mental health scores (odds ratio [OR], 0.98 [95% CI, 0.96–0.99]; P = 0.04). There were no significant differences between obesity groups in improvement in HHS or SF-12 physical health scores. Improvement in SF-12 mental health scores was greater in obese (+ 3.6 [SD, 12.2]) and morbidly obese (+ 3.7 [SD, 9.4]) patients than in non-obese patients (– 0.1 [SD, 11.7]) (P = 0.01). Compared with non-obese patients, the odds of a postoperative complication were significantly greater in obese patients (OR, 1.81 [95% CI, 1.05–3.11]) and morbidly obese patients (OR, 5.77 [95% CI, 2.10-15.86]).Conclusion: Clinically significant weight loss in obese patients after THA is uncommon. Obese and morbidly obese patients experience comparable reduction in pain and improvement in function after THA, but the risk of complications in the first 12 months after surgery is significantly greater than the risk in non-obese patients.

Michelle M Dowsey RN, BAppSc, PhD · Danny Liew MB BS(Hons), FRACP, PhD · James D Stoney MB BS, FRACS, FAOrthA · Peter F M Choong MD, FRACS, FAOrthA

Objective: To model the effect of excluding payment for eight hospital-acquired conditions (HACs) on hospital payments in Victoria, Australia.Design, setting and participants: Retrospective ecological study using the Victorian Admitted Episodes Dataset. The analysis involved all acute inpatient admissions to Victorian public and private hospitals between 1 July 2007 and 30 June 2008.Interventions: Each admission record includes up to 40 diagnosis and procedure codes from which payments are calculated. The model deleted diagnosis codes for eight HACs from all records, then recalculated payments to estimate the impact of a policy of non-payment for HACs.Main outcome measure: The effect on hospital payments of excluding diagnosis codes for eight HACs.Results: 2 047 133 cases with total estimated payments of $4902 million were identified; 994 cases (0.05%) had one or more diagnoses meeting the code definition for a definable HAC, representing total payments of $24.1 million. In-hospital falls and pressure ulcers were the most commonly coded HACs. Applying a model that excluded HAC diagnosis codes changed the diagnosis-related group for 134 cases (13.5%), thereby generating a $448 630 reduction in payments.Conclusions: Introducing a non-payment for HACs policy similar to that introduced by Medicare in the United States would have little direct financial impact in the Australian context, although additional savings would accrue if HAC rates were reduced. Such a policy could add further incentive to current initiatives aimed at reducing HACs.

Peter D McNair BN, MPH, MHS · Terri J Jackson PhD · Daniel J Borovnicar PhD

Mifepristone is a safe, effective and relatively cheap drug that plays an important role in women’s health care and is widely used for early medical abortion in many countries. The Therapeutic Goods Administration (TGA) can authorise mifepristone to be imported into and marketed in Australia. To date, no pharmaceutical company has applied to register mifepristone in Australia. The TGA can also permit medical practitioners to prescribe medicine that is not approved for marketing in Australia under the Authorised Prescribers scheme. The number of approvals for mifepristone has gradually increased, in spite of a complicated and protracted application process. Approval under the Authorised Prescribers scheme requires medical practitioners to comply with state or territory legislation. Abortion laws in Australia vary between jurisdictions, and in some states the law is unclear and confusing. The decriminalisation of abortion in all Australian jurisdictions would protect medical practitioners from criminal liability, promote the health interests of Australian women, and discourage the illegal importation of abortifacients that are being used without quality controls or medical supervision. The Victorian Abortion Law Reform Act 2008 is one legislative model for this.

Kerry A Petersen LLB, LLM, PhD

The Australian Health Technology Assessment Review has the potential to have a major effect on the availability of new medical technology and the listing of associated medical procedures on the Medicare Benefits Schedule. Despite this, only about 15% of submissions to the Review came from “medical associations”. Pharmaceutical and medical technologies are inherently different, and there are a number of difficulties associated with evaluating medical technology using the same process and evidence levels as those used for pharmaceuticals. The current sequential and lengthy processing of new medical technology and procedures is delaying access to beneficial medical technology and could be substantially reduced. There is currently no effective funding process for medical technology classified as capital equipment or consumables and disposables. This has created a perverse incentive in favour of using funded implantable prostheses based on access to funding rather than superior clinical effectiveness. The existing horizon scanning process could be better used to not only identify all potentially cost-effective new and emerging medical technology and procedures as early as possible, but also to identify gaps in the evidence.

Susanne P O’Malley BA, MEc, DipTeach

Objective: To use data from an evaluation of the Flinders University Parallel Rural Community Curriculum (PRCC) to inform four immediate challenges facing medical education in Australia as medical student numbers increase.Design, setting and participants: Thematic analysis of data obtained from focus groups with medical students undertaking the PRCC, a year-long undergraduate clinical curriculum based in rural general practice; and individual interviews with key faculty members, clinicians, health service managers and community representatives from 13 rural general practices and one urban tertiary teaching hospital in South Australia. Data were collected in 2006 and re-analysed for this study in January 2009.Main outcome measures: Participants’ views grouped around the themes of the four identified challenges: how to expand the venues for clinical training without compromising the quality of clinical education; how to encourage graduates to practise in under-served rural, remote and outer metropolitan regions; how to engage in a sustainable way with teaching in the private sector; and how to reverse the current decline in altruism and humanism in medical students during medical school.Results: Participants’ views supported the PRCC approach as a solution to the challenges facing Australian medical education. The enabling capacity of the PRCC’s longitudinal integrated approach to clinical attachments was revealed as a key factor that was common to each of the four themes.Conclusions: The continuity provided by longitudinal integrated clinical attachments enables an expansion of clinical training sites, including into primary care and the private sector. This approach to clinical training also enables students to develop the skills and personal qualities required to practise in areas of need.

Ian D Couper BA, MB BCh, MFamMed · Paul S Worley MB BS, PhD, FACRRM

Bowel cancer kills over 4000 Australians each year. From the late 1980s to October 2005, research evidence guided the development of bowel cancer screening policy proposals, but political, financial and institutional constraints restricted implementation options. Since 2006, the Australian Government has provided a limited bowel cancer screening program, based on what the government deems it can afford, rather than on evidence of what is required to implement a successful population-based screening program. Even a partial program can be implemented in an evidence-based way, and failure to do so threatens to undermine the potential public health gains of a national bowel cancer screening program. To realise the expected public health gains from a national bowel cancer screening program, bowel cancer screening policy should return to its evidence-based beginnings, starting with an analysis of Australian age-specific cost-effectiveness data.

Kathy L Flitcroft BBSc, MA(Govt), GradCertHealthPolicy · Glenn P Salkeld GDipHealthEconomics, MPH, PhD · James A Gillespie PhD · Lyndal J Trevena MB BS(Hons), MPhilPH, PhD · Les M Irwig MB BCh, PhD, FFPHM

Laboratory-confirmed influenza is a nationally notifiable disease in Australia. According to notification data, Queensland has experienced more severe influenza seasons than other states and territories. However, this method ignores available denominator data: the number of laboratory tests performed. We propose that negative results of laboratory tests for influenza should be made notifiable, alongside laboratory-confirmed disease, and used to calculate the proportion of positive test results in real-time. Using data from the public health pathology services of three Australian states — Queensland Health laboratories, the Victorian Infectious Diseases Reference Laboratory and Western Australia’s PathWest — for 2004 to 2008, we show that incorporating laboratory-negative test data into national surveillance data would add to and improve our understanding of influenza epidemiology.

Stephen B Lambert MB BS, MAppEpid, PhD · Cassandra E Faux MSc(ClinMicro) · Kristina A Grant BSc · Simon H Williams BSc(Hons) · Cheryl Bletchly BSc(Hons), GradCertHlthMgt, PhD · Michael G Catton MB BS, FRCPA · David W Smith MB BS, FRCPA, FACTM · Heath A Kelly MB BS, MPH

Neuroendocrine tumours (NETs) are increasing in both incidence and prevalence and, as a group, are more prevalent than either gastric, pancreatic, oesophageal or hepatobiliary adenocarcinomas, or any two of these cancers combined. Clinical awareness of the protean and intermittent symptoms of NETs (eg, sweating, flushing, diarrhoea, and bronchospasm) is critical for timely diagnosis; however, the classical carcinoid syndrome is relatively uncommon. The most useful diagnostic test for gastrointestinal NETs is measurement of plasma chromogranin A (CgA) levels. Disease extent is assessed by both anatomical imaging, and nuclear imaging with radiolabelled somatostatin analogues. Pathological evaluation comprises tumour–node–metastasis classification, a minimum pathological dataset, CgA and synaptophysin immunostaining, as well as mitotic count or Ki-67 index (a marker of cell proliferation) to define grading. Resection of the primary lesion and as much metastatic disease as possible increases the efficacy of medical therapy. Other management strategies include hepatic embolisation and peptide receptor radionuclide therapy. Patients with tumours expressing somatostatin receptors should be treated with somatostatin analogues. Depending on the tumour grade, other effective agents include cytotoxics, tyrosine kinase inhibitors, and antiangiogenics. The overarching requirement for best management of patients with NETs is to ensure that they have ready access to experienced multidisciplinary clinician groups located within centres of appropriate subspecialty expertise.

Irvin M Modlin MD, PhD, DSc · Steven F Moss MB BS, MD, MRCP · Kjell Oberg MD, PhD · Robert Padbury MB BS, PhD, FRACS · Rodney J Hicks MB BS, MD, FRACP · Bjorn I Gustafsson MD, PhD · Nicholas A Wright MD, PhD · Mark Kidd PhD

Clinical record A previously well 4-month-old girl presented to an Australian Capital Territory hospital emergency department in August 2009 with a 2-day history of fever, vomiting and bloody diarrhoea with rectal prolapse. On arrival, she was alert, active and afebrile but had profuse diarrhoea and tachycardia. She was admitted, and stool cultures were requested. Intussusception was considered unlikely, and oral rehydration via a nasogastric tube was commenced. Over the following 48 hours, diarrhoea persisted, with some vomiting and low-grade fevers. Stool culture showed Salmonella species. After 4 days, the child was afebrile, had good oral intake and was discharged from hospital, although diarrhoea continued. No other family members were ill. Salmonellosis is a notifiable infection in all Australian states and territories, and interviews are sought with all affected patients in the ACT to locate sources of infection. Following receipt of the laboratory notification, an environmental health officer interviewed the mother of the infant. Exclusive breastfeeding meant that food-related illness was unlikely. The infant’s siblings were reported to handle kangaroo excreta and to examine the infant for new teeth. This was nominated as a possible source and mode of transmission. The household pet cat and dog were healthy. No other environmental exposures, including recent travel, were nominated. Subsequently, serotyping characterised the salmonella as Salmonella enterica serotype Rubislaw (S. Rubislaw), the first recorded instance of infection with this serotype in the ACT. S. Rubislaw has been isolated from various non-human sources in Australia: native animals and birds, feral goats, kangaroos and water supplies from the northern regions of Australia, and also captive snakes and lizards, including bearded dragons in South Australia in 2008 and New South Wales in 2009 (National Enteric Pathogens Surveillance Scheme [NEPSS], September 2009, unpublished data). The infant’s mother was re-interviewed and revealed that the family kept a 4-year-old pet eastern bearded dragon (Pogona barbata) (Figure). The mother reported that she cared for the lizard, fed it and cleaned its terrarium. The reptile was not permitted to roam the house but was removed from the terrarium on occasion to be held by the mother. There was no report of direct contact between the infant and lizard, and only rare contact with other children. The family was advised about the high Salmonella carriage in reptiles and the risk to young children. Environmental samples were collected from the terrarium (lizard faeces, drinking water, bark, swabs of the terrarium environment) and the household vacuum cleaner filter. S. Rubislaw was isolated from all these environmental samples. After being advised of these results, the family of the infant felt an unacceptable risk remained and the lizard was euthanased. Salmonellosis is frequently classified as a foodborne disease because contaminated food, mainly of animal origin, is the predominant mode of transmission.1 In the United States, “exotic pets” such as reptiles have become popular and reptile-associated salmonellosis has emerged as a public health problem.2-5 In Australia, although accurate figures on pet reptile ownership and reptile-associated disease are difficult to obtain, the risk to human health must be considered. International evidence suggests reptile-associated Salmonella infections are more likely to be associated with invasive disease, more commonly lead to hospitalisation and more frequently involve infants and younger children than do other Salmonella infections.4 The particular susceptibility of children to disease transmission from reptiles kept in the family home may be due to greater exposure to the contaminated reptile and greater host vulnerability.5 Much of the available evidence regarding risk in children comes from case–control studies conducted in the US.2,5 There have also been numerous reports of sporadic cases of invasive disease and hospitalisation of children and infants with salmonellosis linked to reptiles.3 A fatal case of S. Rubislaw meningitis in a 3-week-old baby was linked to a pet water dragon in England.6 It has been estimated that 90% of reptiles are colonised with Salmonella, which is shed intermittently in their faeces.7 Such high rates of colonisation suggest Salmonella are commensal organisms of the gastrointestinal tracts of these animals.4 There are over 2500 Salmonella serotypes, with most (including S. Rubislaw) belonging to S. enterica subspecies I.8 Serotypes of S. enterica subspecies I cause most Salmonella infections in humans and other warm-blooded animals. By contrast, over half of the S. enterica serotypes reported from reptiles in Australia belong to subspecies IIIa, IIIb and IV, which are rare in humans (NEPSS, unpublished data). Salmonella carried by reptiles can be transmitted either through handling a reptile, or indirectly by contact with an object contaminated by a reptile or its faeces.5 The droppings of free-roaming reptiles may result in widespread contamination of the home environment. The hands of younger children are readily contaminated, while infants may be indirectly infected via their parents or siblings. Ultimately, bacteria are transferred to the mouth and ingested. Hand washing may not eliminate the risk of infection. As the entire surface of a reptile may be contaminated, so may be the clothes and skin (beyond the hands) of the handler.9 Between nine and 19 human cases of S. Rubislaw were reported annually in Australia from 2000 to 2009 (NEPSS, unpublished data), predominantly from the northern tropical regions. Two-thirds of patients were aged less than 5 years (and most often less than 1 year), suggesting the importance of contact with environmental sources. We suspect the Australian public may not be familiar with reptile-associated salmonellosis. In the US, public health authorities have advocated the prohibition of the sale or gifting of reptiles without written point-of-sale education being provided by pet-store owners.3 Australian states and territories vary in their regulation of reptile ownership. NSW pet stores are not permitted to buy or sell reptiles or even to have them on their premises, whereas commercial reptile dealing occurs in Victoria, SA, the Northern Territory and ACT.10 In the ACT, eastern bearded dragons are classified as Category A reptiles (licence exempt), under the Nature Conservation Act 1980, and can be kept by individuals without prior experience in keeping such animals. Within the ACT there is no compulsion for pet stores, breeders or reptile keepers to inform prospective reptile owners or members of the public of possible risks to human health associated with reptile ownership or contact. We recommend that owners and prospective owners of reptiles be better informed of the risks to human health, particularly the threat to children. Lessons from practice Some Salmonella serotypes that occupy specific environmental niches infect humans through environmental sources rather than foods. Clinicians managing a young child with salmonellosis should ask parents or guardians about contact with household pets, including lizards, snakes, turtles and fish. Investigating individual cases of unusual infections can shed light on novel and evolving public health risks. Reptile-associated salmonellosis may become a more significant issue for medical practitioners and public health authorities in Australia. Parents and guardians should be advised about the risks (including invasive salmonellosis) that pet reptiles may pose to infants and young children.

Cameron R M Moffatt BBusHealthAdmin, MPH, MAppEpid · Antony R Lafferty MB ChB, FRACP · Sara Khan MB BS · Radomir Krsteski BApplSc, DipApplSc · Mary Valcanis BSc, MPH, MASM · Joan Powling BAgrSc · Mark Veitch MB BS, MAppEpid, FAFPHM

To the Editor: Infections caused by multiresistant gram-negative organisms are difficult to treat. Carbapenems are often used as a last resort but even these are under threat with the emergence of acquired metallo-b-lactamases worldwide, including Australia,1,2 India, China and Europe. We report the first case of a Providencia rettgeri producing the blaNDM-1 (New Delhi metallo-b-lactamase) type of metallo-b-lactamase in Australia. A man from Canberra, aged in his mid 50s, had elective plastic surgery in India in September 2009. This was complicated by a hypoxic brain injury, after which the patient spent 4 weeks in an intensive care unit. He was subsequently transferred to Canberra for ongoing hospital care. A urinary catheter specimen collected on admission in November 2009 showed a heavy growth of multidrug-resistant P. rettgeri and Pseudomonas aeruginosa. The P. rettgeri was resistant to all b-lactam antibiotics, including meropenem, as well as to all aminoglycosides, ciprofloxacin, tigecycline and colistin. The P. aeruginosa was resistant to all antipseudomonal antibiotics except for colistin (tigecycline was not tested as it has low or no antipseudomonal action). The patient was not given antibiotic therapy but the indwelling urinary catheter was changed and contact precautions were put in place. Both organisms were sent for molecular testing, which showed that the P. rettgeri had 100% homology with blaNDM-1.3 The patient cleared the organisms after 2 months, and since then has received ongoing inpatient care in the rehabilitation unit. The first NDM-1 type of metallo-β-lactamase was found in Klebsiella pneumoniae isolated from a Swedish patient who had recent medical contact in India.3 Data from the United Kingdom’s Antibiotic Resistance Monitoring and Reference Laboratory suggest that isolates with the NDM-1 enzyme have recently been repeatedly imported to the UK from the Indian subcontinent. There may now be circulation of these resistant isolates in the UK because some infected patients have no identifiable overseas links. Hospitals have been urged to be vigilant for multiresistant gram-negative bacteria in patients with recent hospital contact in the Indian subcontinent as well as the Eastern Mediterranean.4 Identification of an Enterobacteriaceae organism carrying blaNDM-1 is very concerning. No antibiotic may be available to treat patients who develop serious infection with such organisms, and there is the added concern regarding cross-infection in health care facilities. The plasmid carrying blaNDM-1 also contains genes that confer resistance to several other antibiotics.3 It appears likely that, in the near future, the NDM-1 enzyme will become a very successful metallo-b-lactamase globally. Patients infected with multiresistant gram-negative bacteria have entered the “post-antibiotic era”.

Geethanie A T P Fernando · Peter J Collignon · Jan M Bell

To the Editor: The arrival of national registration of health professionals on 1 July 2010, and consequential amendments to state and territory legislation, overcomes registration and recognition complexities currently facing Australian medical practitioners who wish to practise in multiple jurisdictions. However, national registration stops short of removing current inconsistencies among state and territory laws in various areas of medicine — including those that regulate prescription of Schedule 8 (S8) medicines. Despite recognition of S8 restrictions in every part of the country, medical practitioners potentially need to have a working knowledge of up to eight separate sets of controlled substances laws when prescribing S8 medicines. Imagine a general practitioner providing a morphine prescription with repeats to a couple caravanning around Australia for 3 months. That prescription may need to comply with the laws of each jurisdiction as to what details need to be included on the prescription form. Getting it wrong could result in significant delay and inconvenience for the holidaymakers if the pharmacist refused to dispense the prescription because it didn’t comply with local laws. For example, in South Australia a prescription for a drug of dependence must not be dispensed by a pharmacist if the patient’s date of birth is not included on the prescription form1 — yet there is no similar requirement in New South Wales, Tasmania, Victoria or the Australian Capital Territory.2-5 Conceivably, through unawareness or habit, a prescriber in one of the latter jurisdictions might omit a patient’s date of birth from a relevant prescription form, leading to problems for the patient when travelling in other states. Granted, such a situation could be corrected with a few phone calls or faxes, but in a busy practice, who has time to be repeating tasks? National regulation of health practice (achievable through referral of powers or harmonising state and territory laws) — in this case, the prescription of S8 medicines — would logically complement national registration and help maximise anticipated benefits after 1 July 2010.

Colin M Brown

To the Editor: We report the case of a 19-year-old female veterinary student who presented with a 2-week history of a rapidly growing mass on the lateral side of the deltoid area of her left arm. On examination, the mass was soft, freely movable, slightly warm and non-tender. There was no regional lymphadenopathy. The patient was afebrile, with no signs of systemic illness. Ultrasound showed a 3.2 × 2.3 × 1 cm, low-echogenic, lobulated lesion in the subcutaneous fat, with surrounding increased echogenicity suggestive of inflammation. Magnetic resonance imaging showed a poorly defined lesion throughout the deep and superficial fascia, with infiltration into the underlying deltoid muscle (Box 1). A provisional diagnosis of sarcoma was made, but an ultrasound-guided core biopsy sample showed non-necrotising epithelioid granulomas (Box 2). Two weeks after presentation, the patient noticed a smaller raised lump, about 1 cm in diameter, on the volar aspect of her left forearm. Four months before presentation, following negative results of both Q fever serological testing and a Q fever skin test administered on the volar aspect of her left forearm (at the site of the smaller lump), the patient had received a Q-VAX (CSL, Melbourne, Vic) vaccination in the left deltoid (at the site corresponding to the larger mass). Three months after this, and about 3 weeks before the deltoid mass first appeared, the patient received a Fluvax (CSL, Melbourne, Vic) influenza vaccination at the same left-deltoid site as the Q fever vaccination. This raises the possibility that the influenza vaccination may have been associated with the subsequent Q fever granuloma reaction. Q fever, a disease caused by the zoonotic rickettsial organism Coxiella burnetii, is an occupational hazard for many Australians in animal-related professions. The disease is characterised by an acute, self-limiting febrile illness, with pneumonia and hepatitis being infrequent complications. In 2001, an Australian national Q fever vaccination program was initiated, which led to a 50% decline in the incidence of Q fever.1 Side effects are normally rare and minor; during 2001–2004, only 86 adverse reactions were reported from about 49 000 vaccinations.2 Development of non-necrotising granulomas following Q fever vaccination is uncommon, with only six cases previously described.3-5 To explore the possibility of a causal association between influenza vaccination, Q fever vaccination, and development of a granuloma, we traced four of these six patients with Q fever granuloma by contacting the authors of the previous reports. One patient had been vaccinated against influenza 2 months before the time of Q fever vaccination, and another had influenza vaccination afterwards (as in our case). Of the five cases (including our case) for which clinical history was available, three had a temporal association between influenza vaccination and Q fever vaccination, followed by the development of the non-necrotising granuloma. The indurated lesion at the separate Q fever skin-test site on the volar forearm, found in two other patients5 as well as ours, supports the notion of a systemic immune reaction rather than simply a local reaction at the vaccination site. The Naranjo score in this case was 7, indicating a “probable” adverse drug reaction. Although the granuloma was self-limited in all known cases, this case shows that there is significant risk of misdiagnosis on clinical grounds. It seems prudent to be aware of the possible association between these two vaccinations. Magnetic resonance images of lesion Axial (top) and coronal T1-weighted fat-saturated post-contrast (bottom) images demonstrate a poorly defined enhancing lesion (red arrows) in the subcutaneous fat, which superficially infiltrates and extends in a plaque-like manner in relation to the underlying deltoid muscle (white arrows). 2 Ultrasound-guided core biopsy sample of lesion The core biopsy of fibroadipose tissue shows numerous well formed non-necrotising epithelioid granulomas (arrows). The granulomas are composed of epithelioid histiocytes and a few multinucleated giant cells, surrounded by numerous lymphocytes (a mixture of B and T cells, with a greater proportion of T cells). (Original magnification × 100; haematoxylin–eosin stain.)

Deborah Burnett · Leslie Burnett

To the Editor: When I looked at the cover of the 5 April issue of the MJA, I feared finding another article focused on discrediting the prostate-specific antigen (PSA) test. Instead, I congratulate the authors, and the Journal, for presenting one of the rare balanced articles on this topic.1 Denham and colleagues called for an end to taking sides in the debate over PSA testing, and focused instead on helpful guidance. The problem is not whether PSA helps us find prostate cancer, but that we lack clinical tools for deciding which patients would benefit from aggressive treatment. However, the authors point out that there are two important tools that can help with this decision: low free to total PSA ratios, and rapid PSA doubling time (< 3 years).1 The PSA test is now one of the most sensitive, precise and highly standardised immunoassays in the clinical laboratory. The difficulty does not lie with the measurement but with its application. The Royal College of Pathologists of Australasia, together with the Urological Society of Australia and New Zealand, recently produced a monograph that discussed the appropriate use of the PSA test.2 It emphasised using age-related cut-offs for PSA levels, the free to total PSA ratio, and the calculation of PSA doubling time as modern tools to achieve optimal benefit from the test. The Australian Medicare Benefits Schedule (MBS) was changed in May 2009 (following a suggestion from the Urological Society of Australia and New Zealand) to improve utilisation of free to total PSA ratios. The Box indicates the per capita request rates of PSA testing (MBS item number 66655) and free to total PSA ratios (MBS item number 66659) from May 2009 to February 2010. Consistent with Denham et al’s observation that there are regional differences in the attitudes to prostate cancer,1 there is a twofold variation in PSA requesting and a sevenfold difference in free to total PSA ratio requesting across the Australian states. Furthermore, the relationship between the two tests is, if anything, inverse, suggesting that increased use of PSA testing is less commonly followed up by modern tools such as free to total PSA ratio. As a chemical pathologist, the appropriate clinical use of the PSA test has been a career-long concern of mine.3 Even though the discoverer of PSA has labelled the test a public health disaster,4 recent “case–controlled” studies using PSA in an outdated approach (without free to total PSA ratios or doubling times) have shown a marginal benefit for screening.5,6 The indiscriminate use of PSA testing can be helpful to some but disastrous for others. Modern PSA tools may significantly improve management beyond these marginal effects. As always, the value of medical investigations lies in how intelligently we use them. Average per capita request rates of PSA testing* and free to total PSA ratio,† May 2009 – February 2010 PSA = prostate-specific antigen. ACT = Australian Capital Territory. NSW = New South Wales. NT = Northern Territory. Qld = Queensland. SA = South Australia. Tas = Tasmania. Vic = Victoria. WA = Western Australia. * Medicare Benefits Schedule (MBS) item number 66655. † MBS item number 66659.

Kenneth A Sikaris

To the Editor: Many of the arguments put forward by Bain and colleagues about modelling hospital occupancy1 are true in an academic sense. We agree that many acute care models use simplified inputs and outputs, without accounting for rapid daily fluctuations in occupancy. Occupancy definitions are often misleading and subject to gaming. We agree with the work by Bain, Taylor and others that highlights as a problem “the inability to move patients from the [emergency department] to a ward” and that hospitals should “engage procedures to free inpatient beds well in advance” of access block occurring.2 The capacity of a hospital must have flexibility to deal with demand fluctuations.1 However, we do not agree that the “85% occupancy” figure for optimal efficiency is a candidate for myth status. This threshold is used in various systems around the world. Efficiency is a well recognised concept in queuing theory and depends on setting the utilisation (occupancy) rate at a level where the costs of “underutilised” resources (beds, staff not fully used, etc) are shown to acceptably match the “costs” from delayed care (mortality, morbidity, economic, political, prolonged stay, etc). In particular, quoted occupancy figures often look better than reality because of unopened, unusable beds or data manipulation to improve reported occupancy. The more complex and variable the inputs into a system with multiple competing queues (such as hospitals, where acute admissions may be > 70% of the workload), the greater the need for additional capacity to avoid deferred service. Major acute care hospitals show dramatic daily fluctuations in bed use, with changes between low and high occupancy rates in the order of 15%–20%.3 As inputs and variation increase, the likelihood of marked performance deterioration increases exponentially. Real life (or “clinical modelling”) shows that reported occupancies around or above 85% routinely lead to loss of access to care. No benefits of emergency department or hospital overcrowding have been reported in the medical literature, only harm.4 Relying on developing complex mathematical models before accepting that we are already beyond the acceptable “efficient” occupancy of our current health systems is not a realistic way forward, when patients are dying due to the lack of available appropriate beds.4 Garling, in the overview of his report referred to by Bain and colleagues, states “my recommendations should make more beds available and reduce access block”, but that even with more efficient bed usage “the addition of 350 beds each year” will be required.5 Action is required now and shouldn’t be delayed or subverted by searching for perfect mathematical models. Our hospitals have demonstrably inadequate capacity, resulting in overcrowding with devastating effects. As we have repeatedly stated, it’s all about available beds.

David Mountain · Daniel Fatovich · Sally McCarthy

To the Editor: In her editorial, Christiansen states that the 2010 edition of Therapeutic guidelines: antibiotic (version 14) is very likely to recommend 24 hours of antibiotic prophylaxis for cardiac surgery,1 rather than the present regimen, which recommends that patients having routine cardiac surgery be given a large dose of cephazolin at induction, with a second dose if the operation is prolonged for more than 3 hours, and no doses after surgery.2 The only evidence presented in support of this proposed change is a single randomised controlled trial that purported to show a higher rate of surgical site infections after a single dose of cephazolin, than after a prolonged, multidose regimen.3 The study was flawed, for two reasons. First, cephazolin was not given until 20–30 minutes after induction of anaesthesia, which is likely to have been too late, because, as Christiansen points out, β-lactams should be given 30–60 minutes before incision.1 Second, the trial was analysed on a per-protocol, rather than an intention-to-treat basis, and 189 of the 1027 participants (18%) were excluded, so the findings may be seriously biased.4 Three other trials have compared one or two doses of a cephalosporin with multiple doses of the same antibiotic in patients having cardiac surgery; none found that multiple doses were superior, although all three were small studies with faults in their design.5-7 In 1998, McDonald and colleagues published a detailed review of single versus multiple doses of antimicrobial prophylaxis for major surgery. The analysis was in response to a suggestion by Christiansen and others that single-dose antibiotic prophylaxis may be inadequate for patients undergoing vascular surgery.8 McDonald and colleagues pointed out that the recommendation for single-dose surgical prophylaxis in Therapeutic guidelines: antibiotic (version 13),2 is based on microbiological first principles, published studies reporting efficacy, convenience of administration, reduced antibiotic resistance and toxicity, and relatively low cost. Their careful analysis of 28 randomised trials, in which the same antimicrobial was used in each arm, showed no advantage from the administration of multiple doses; the odds ratio for infection was 1.06 (95% CI, 0.89–1.25). There is no microbiological reason to suppose that the crucial interaction between contaminating bacteria and the prophylactic antibiotic in the heart is any different from that in the lung, biliary tree, uterus, bowel, prostate or bone.8 In the absence of such evidence, there is no sound reason to change the current, long-standing Therapeutic guidelines: antibiotic2 recommendation.

Frank Shann

In reply: Professor Shann raises three issues regarding the recommendation for 24 hours’ prophylaxis for cardiac surgery. First, he states that the trial1 on which this recommendation was made was flawed, because “cephazolin was not given until 20–30 minutes after induction of anaesthesia, which is likely to have been too late”. The trial included patients having coronary artery surgery and/or cardiac valve replacement, and, for these procedures, the time between induction of anaesthesia and surgical incision is about 60–75 minutes, as patients require the placement of intravenous lines and preparation for coronary artery bypass surgery. Antibiotic administration is recommended 30–60 minutes before incision, thus, administration 30 minutes after induction provides optimal serum concentrations at incision, in patients undergoing cardiac surgery. Second, the per-protocol analysis is perhaps less than ideal, but the demographics, clinical characteristics and operative data were comparable for the patients included in the analysis. Third, as stated by Professor Shann, the three earlier studies2-4 were either very small or flawed in design. The McDonald systematic review5 included 28 studies, only two of which were on cardiac surgery, both being the earlier flawed studies2,3 quoted above. The Therapeutic guidelines: antibiotic review process involves a rigorous, evidence-based assessment with input from experts in the field. The medical community of Australia can have every confidence that the recommendations made are current and evidence-based.

Keryn J Christiansen

To the Editor: I agree with the claim by Richardson that “the overlap between [primary care and emergency department (ED)] services is not as important as many have claimed” and that “‘primary care patients’ and ‘ED [Australasian Triage Scale] category 4 and 5’ patients are not interchangeable”.1 A review of the literature — especially from New Zealand — would show there are considerable differences between patients who attend the two types of services. For example, a comparison of patients with asthma attending either a Wellington after-hours medical centre or an ED service located only 800 metres away2 found that the after-hours medical centre was more likely to see younger patients who live further from the service, are given repeat medications, and are referred back to their general practitioner. In contrast, the ED patients were less likely to be referred by a GP and more likely to be admitted to hospital with asthma than patients attending the after-hours centre. Thus, the two services differed in terms of their clinical policies (repeat prescribing and referral) and patients’ demographic characteristics (age, place of residence). I applaud Richardson for highlighting the powerful effects of hospital policies on the behaviour of people outside hospital walls by saying, “it is not the so-called primary care patients who are blocking ambulances from offloading — it is the ‘access block’ patients waiting for beds on the inpatient wards who are inappropriately occupying ED space and staff time”. This claim has nothing to do with the kind of patients who attend primary care services, but more to do with the influence of management policies arising from within hospitals on patient flow from primary care. It confirms research in New Zealand demonstrating how hospital policies (on advertising their services) can have powerful contradictory effects on attendance at EDs. In some cases, people have been subjected to hospitals advertising the clear message that people should attend the ED when they should be seen in primary care instead; and in other cases, people are dissuaded from attending the ED when they are subjected to advertisements about the poor choices people make to attend a hospital. In each case, it is the hospital policy that determines the direction of flow, not the patients in primary care.3-5

Marjan Kljakovic

To the Editor: A recent commentary from the Editor of the Journal1 raises the health-funding dilemma facing current and future Australian governments. All stakeholders in the health industry need to dispassionately scrutinise the role of current models in perpetuating inefficient or socially discriminatory patterns of care. Health care economics is indivisible from the tendency of the broader economy to sustain growth or create disparities, and comparative analysis of systemic economic policies informs the divergent evolution of health systems. The United States, epitomising the free market paradigm, combines a high gross national product with a high poverty rate and significantly unequal income distribution.2 Per capita health care expenditure and its annual rate of increase are comparatively high.3 This is juxtaposed with one of the highest infant mortality rates in the developed world,3 as well as significant racially related variations in health indices. The Scandinavian societies, particularly Sweden, epitomise the benefits of a social welfare model that maintains low unemployment, relatively low income disparity, and advanced technology, while maintaining a healthy private sector.2 The Swedish health care system, which maintains best practice health indices, is characterised by administrative devolution, combined taxation and insurance-based funding, high equity of access, guaranteed maximum primary-care waiting times, and annually capped out-of-pocket expenses.4 Although it had one of the highest per capita health expenditures in the 1980s, its annual rate of increase is one of the lowest in the OECD.3 Since 1975, Australian economic and social policy has increasingly shifted towards a free-market orientated system, comparable with that of the US and United Kingdom rather than the more mixed economies of most European countries or the social welfare economies of Scandinavia. In this context, Medicare is an anomalous relic, which, because of inadequate funding, has struggled to contain patients’ out-of-pocket expenses and maintain equity. The most successful health care systems have a relatively small private sector, limited fee-for-service provisions, and smaller income disparities between health care workers. In contrast, Australia’s hybrid model has a significant private/entrepreneurial component based on a fee-for-service structure that is driven by market forces rather than needs analysis. As Medicare increasingly withers due to neglect, out-of-pocket expenses will continue to rise and health equity will diminish, but sections of private medicine, fuelled by demand from the more affluent, will continue to thrive. As we confront the unpalatable likelihood that the market-driven private sector is a major cause of increasing per capita expenditure, we shall have to justify the viability and equity of the dominant fee-for-service model.

Jeremy W Butler

To the Editor: Observing jugular venous pressure (JVP) is central to cardiovascular examination. Lewis, in 1930,1 was the first to report the use of the external jugular vein as a manometer for recording pressure in the right atrium. Unfortunately, some textbooks on clinical examination and many clinical teachers incorrectly state that the external jugular is unreliable for measuring JVP and that only the internal jugular should be used. The problem with this is that the internal jugular vein is located deep within the neck, where it is covered by the sternomastoid muscle and is therefore not usually visible. Lewis used the sternal angle as a reference point, presuming that it lay 5 cm above the centre of the right atrium in all positions of the patient between lying and sitting. A recent study using computed tomography to examine 160 patients noted that the median vertical distance between the sternal angle and the mid right atrium was 5.4 cm, thus confirming that Lewis’s estimate of the sternal angle in relation to the right atrium was correct (bearing in mind that adults are taller than they were in the 1920s).2 The mean right atrial pressure is the mean of the peak and trough of the external jugular wave above the sternal angle expressed in cm H2O. Over the past few decades, several studies have confirmed that the original findings of Lewis were correct: there is no significant difference in JVP whether it is measured using the internal or external jugular vein, and the external jugular pulse accurately reflects directly measured right atrial pressure.3 In a study of 52 patients with chronic congestive heart failure who had right heart catheterisation, elevation of the JVP showed 57% sensitivity for a raised pulmonary capillary wedge pressure (≥ 18 mmHg) and 93% specificity for non-elevation of JVP, corresponding with a capillary wedge pressure of ≤ 18 mmHg. If elevated JVP was inducible as well, sensitivity increased to 81% and specificity dropped to 80%, with a predicted accuracy of 81%.4 Generations of frustrated medical students and doctors who have stared intently at their patients’ necks awaiting that elusive flicker of the internal jugular pulse have been overlooking an accurate source of clinical information — namely the pulse in the external jugular vein. Lewis was right 80 years ago: measuring the external JVP is a valuable clinical tool and should be practised frequently.

David M Colquhoun · Glenn Jenkins

To the Editor: It seems that the perceived value of invasive therapy for different acute coronary syndromes varies according to how one chooses and values the various trials.1-3 The differing opinions may have been enriched had they not only considered short-term cardiovascular outcome but also weighed quantitatively — in absolute terms — the purported benefits (or lack thereof) of invasive therapy against the immediate complications and the long-term risks and burden of the combined aspirin and clopidogrel antiplatelet therapy usually necessary after stent placement. It may be that with all this information, patients also have a range of opinions regarding benefits and risks.4 It is difficult to deny that cardiologists in general and the industry sponsors of academic cardiology have an enormous vested interest in complicated, expensive therapies. It does not necessarily follow that the current guidelines and their defenders are unduly biased, but nevertheless the conflict of interest should be confronted and addressed, not taken personally, defensively and indignantly.2 Ideally, the guidelines would both be genuine and seen to be so. For conservative physicians, there is also a conflict of interest of sorts in that a conservative interpretation of the literature supports their practice. Forge’s suggestions regarding this issue should be taken more seriously.1 This problem of vested interest is, however, not confined to cardiology. Recently, while highlighting vested interest in mammography, Quanstrum and Hayward broadened their scope and suggested that “independent panels of generalists . . . [be] responsible for objectively synthesizing the medical evidence around a given question or process of care”.5

Stephen P Fitzgerald

Greg Mundy was born on 16 June 1942 in Melbourne. Over his career in Australia and the United States, Greg touched the lives of many Australian and US medical graduates. Greg graduated from the University of Melbourne in 1966 and moved with his wife, Helen, to take up a residency at the Royal Hobart Hospital. He immediately stood out as someone destined for leadership in academic medicine. He pursued a doctorate in multiple myeloma under the guidance of Albert Baikie, Professor of Medicine at the University of Tasmania. This probably set the scene for Greg’s continuing interest in the area of bone biology and cancer. After completing his physician training in Hobart, he moved to the US in 1971. Initially, he worked in clinical pharmacology at the University of Rochester, New York, before collaborating with Larry Raisz at the University of Connecticut, Farmington. This laid the foundation for his subsequent career as an international leader in bone biology. In 1980, Greg took up the Chair of the Department of Endocrinology at the University of Texas Health Science Center in San Antonio, establishing a reputation in the top 2% of National Institutes of Health (NIH) awardees. In 2006, Greg was appointed Director of the Center for Bone Biology at Vanderbilt University, Nashville, as John A Oates Chair in Translational Medicine and Professor of Medicine, Pharmacology, Orthopedics and Cancer Biology. He won many prestigious awards from the American Society for Bone and Mineral Research, was President of that Society and of the International Bone and Mineral Society, and also served on several other NIH committees. Greg established OsteoScreen, a successful biotechnology company, in partnership with the University of Texas. He trained more than 150 PhD students from around the world, published over 540 articles, authored 34 patents and developed many international collaborations. Greg was a giant of a man physically and intellectually, but he was a gentle giant. He maintained close ties to Australia and an interest in cricket and football, being an avid Essendon supporter to the end. Despite his extraordinarily frenetic professional life, Greg lived very much for his family — Helen and his children, Gavin, Ben and Jennifer. He died at home on 25 February 2010 after a long fight with a cerebral tumour.

Peter M Brooks · Michael G Loughhead · Allan J McLean

A 66-year-old woman on peritoneal dialysis for end-stage renal disease secondary to diabetic nephropathy was admitted on Christmas Day with suspected osteomyelitis of her left third toe. During admission, she complained of constipation and mild abdominal pain. There were no focal abdominal findings on examination. Of note, she was prescribed 750 mg three times daily of the rare metal lanthanum carbonate hydrate for hyperphosphataemia of renal failure. An abdominal x-ray was taken after the second dose of the day (Figure). Lanthanum has been shown to be radio-opaque on x-ray1,2 and computed tomography,3 and this is briefly mentioned in the full product information. The radiology report in this case suggested alternative diagnoses of residual contrast from a barium study, sclerosing peritonitis, tuberculosis or lead ingestion, none of which were consistent with the clinical history. The use of lanthanum as a phosphate binder is likely to increase since it was listed on the Pharmaceutical Benefits Schedule in 2009. Awareness of its radio-opaque features will prevent unnecessary investigations.

Yohan Chacko · Carolyn J Clark

Riwayat. Sanjay Patole, Ajay Rane, producers. Horizon Films, 2010. http://www.riwayatmovie.com. It’s not often that the Journal publishes film reviews. It’s not often, however, that two busy Australian clinicians get together to produce a full-length Bollywood extravaganza, complete with swooning love scenes and beautifully crafted song sequences. While the essential ingredients of love, death, family feuding and a happy ending are all present, Riwayat is no ordinary Bollywood set piece. Instead, Indian-born Townsville urogynaecologist Ajay Rane and Perth neonatologist Sanjay Patole have taken on the serious medical and social topic of “the missing millions” of Indian women — those female infants who, over the past few decades, were conceived and sometimes born but either aborted or killed at birth simply because they were female. “Riwayat” means “tradition” in Hindi — and, traditionally, many female infants in India have been killed at birth, mainly in poor communities. More recently, ultrasound has been misused, by those who can afford it, to detect female fetuses for the purpose of abortion. The film is in Hindi, with English subtitles, and will be screened in India as well as overseas. Riwayat is the story of three generations of the upper-class Desai family, whose two sons and their wives are expected to follow the dictates of its autocratic patriarch. This has already led to two abortions and the consequent psychological distress of the elder son’s wife. (Conveniently, the Desais include a private hospital and ultrasound facility in their substantial property portfolio.) The wife of the younger son, who had a love match rather than the traditional arranged marriage, is made of sterner stuff. Having also conceived a female child, she leaves the family home when ordered to abort and returns to the village where she has been working for a non-government organisation (NGO) — an opportunity for the filmmakers to display the beautiful Indian countryside, take a few digs at the doubtful benefits of NGOs to poverty-stricken Indian citizens, and demonstrate the weight of traditional customs at village level. Her Portia-like intervention in the court case of a villager who kills his daughter at birth is designed to show Hindi-speaking viewers the urgent need to cast off this dreadful aspect of their “tradition”, disastrous for those girls and women denied life, but also for society as a whole. Riwayat is both an enjoyable romp and an important piece of social commentary. Hopefully, it will be widely shown in Australia.

Caroline M De Costa

Vision and falls For older people with presbyopia, changing glasses for different activities can prevent falls. Although multifocal glasses are helpful for activities that require changes in focal length, they impair depth perception and have been shown to increase the risk of tripping and falling. Sydney researchers performed a randomised trial over 13 months among elderly regular wearers of multifocal glasses, in which the intervention group swapped to using single lens distance glasses for activities outside their own home such as walking, going up and down stairs and covering uneven ground. They found only a modest 8% reduction in falls in the intervention group overall, but a much larger (40%) reduction in a subgroup who usually engaged in regular outdoor activities. However, for those who did not normally take part in outdoor activities, the change in glasses significantly increased their risk of an outdoor fall. The authors of a linked editorial cautioned that any changes to glasses in the elderly involve careful instruction, and should be introduced gradually so that the person is not overwhelmed. BMJ 2010; 340: c2265. doi:10.1136/bmj.c2265BMJ 2010; 340: c2456 .doi:10.1136/bmj.c2456 Flu and flying In 2009, nine members of a school group travelling in the rear section of a Boeing 747 had flu-like symptoms during the long-haul flight, and pandemic (H1N1) 2009 influenza infection was confirmed on reaching their destination. What was the risk of spreading infection to other passengers? At 3.5% for passengers within two rows of the school group and 1.9% for the passengers in the entire rear section of the plane, the risk was lower than expected, according to an investigation by public health officials. The spread of infection was confined to those seated within two rows of the infected school group. Rigorous follow-up of those seated in the rear of the aircraft located 93% of passengers, but found that only three passengers subsequently developed confirmed infection within 3 days of exposure. The low transmissibility of H1N1 influenza suggests that focusing on passengers seated near infected passengers may be a more appropriate use of resources than following up all passengers on a flight. BMJ 2010; 340: c2424. doi:10.1136/bmj:c2424 Benefits of happiness Having a positive affect — experiencing pleasurable emotions such as joy, enthusiasm, contentment and excitement — may prevent coronary heart disease (CHD), says a report from the Canadian Nova Scotia Health Survey. The researchers claim this is the first prospective study to show an independent relationship between positive affect and coronary heart disease. The study assessed the positive affect of 1739 healthy adults on a five-point scale ranging from “none” to “extreme”. Positive affect was associated with a hazard ratio for CHD of 0.78 (95% CI, 0.63-0.96; P = 0.02) per point on the scale, after controlling for other cardiovascular risk factors. The researchers suggest that physiological mechanisms, such as reduced heart rate and sympathetic activity, may confer protection from heart disease, although a direct cause and effect relationship is yet to be proven. Eur Heart J 2010; 31: 1065-1070 doi:10.1093/eurheartj/ehp603 Breastfeeding and fever Fever is one of the most common adverse effects after infant immunisations — can it be reduced by breastfeeding? Mothers attending an immunisation clinic in Naples, Italy, were asked to record their baby’s temperature for 3 days after the infant received a routine hexavalent combination vaccine. Of 460 infants, fever (≥38°C) was reported in 25% of exclusively breastfed infants, 31% of those partially breastfed and 53% of infants who were not breastfed at all. The relative risk for fever among exclusively and partially breastfed infants was 0.46 (95% CI, 0.33–0.66) and 0.58 (95% CI, 0.44–0.77), respectively, and the protective effect remained even after adjustment for potential confounders. Different immune responses in breastfed infants and the presence of anti-inflammatory agents in breastmilk may explain this observation, according to the authors. Pediatrics 2010; 17 May. doi:10.1542/peds.2009-1911 Neighbourhood design and obesity Choice of neighbourhood can help adolescents avoid obesity, with opportunities for physical activity such as sport and provision of safe walking and cycling paths to and from community venues playing an important role. In a large national cross-sectional study conducted in the US, researchers correlated the prevalence of obesity among 13–16-year-olds with their physical activity, type of sports venues available and their perceived personal safety within the neighbourhood. Perception of safety was the strongest predictor of physical activity. Interestingly, there was no association between the presence of parks and sports fields and increased physical activity; the authors suggest that park users are primarily children and adults, and these settings may be less important for older youths. Such information should guide future developments to create more active neighbourhoods. J Adolesc Health 2010 doi:10.1016 j.jadohealth.2010.03.017

Alison Williams