Volume 193 Issue 4

On 22 August 2010, the Australian Mitochondrial Disease Foundation will hold its annual Stay in Bed Day to raise awareness of a genetic disorder that robs thousands of Australians of their energy Mutations in mitochondrial DNA (mtDNA) were discovered to cause mitochondrial disease over 20 years ago.1 Initially thought to be a rare group of neurological disorders predominantly affecting children, it is now known that patients with mitochondrial disease can develop a broad range of symptoms (Box) and may present at any age from early in the neonatal period to very late in adulthood. Debilitating or fatal forms of mitochondrial disease are more frequent in children than in adults, but adult patients often have chronic multisystemic manifestations that require symptomatic treatment and regular long-term surveillance to minimise the chance of life-threatening episodes of acute illness. Mitochondrial disease may present a diagnostic challenge to the clinician. Clinical manifestations are variable (see Box), and family histories suggestive of an inherited condition may not be obvious due to the variability in phenotypic expression that characterises this group of disorders. Moreover, the lack of a “gold standard” test for its diagnosis and the fact that mtDNA analysis is not freely available to all Australians (only in Victoria) exacerbate the difficulties in diagnosing affected individuals. Why are mitochondrial disorders highly variable? This is due to a number of factors. First, there are hundreds of mtDNA mutations that cause a variety of different mitochondrial disease syndromes. Notably, most disease-causing mtDNA mutations are heteroplasmic. Heteroplasmy is the co-existence of both normal (wild-type) and abnormal (mutant) mtDNA within the same cell. Because there are multiple mitochondria within any given cell, the proportion of mutant mtDNA may vary between 0 and 100% within any given tissue. Thus, the tissue used for diagnosis becomes critical, with blood not being the most ideal tissue to sample.2 There is substantial evidence to indicate that the higher the heteroplasmic mtDNA mutational load within the tissue or cell, the greater the level of mitochondrial dysfunction.3,4 A minimum number of mutant genomes are required for the expression of disease, a phenomenon referred to as the threshold effect. The threshold effect is a relative concept, because the critical amount of mutation required to impair mitochondrial function will vary depending on the particular mtDNA mutation involved and the relative metabolic requirements of the tissue’s cells at any given time. Although there are occasional exceptions, higher proportions of mutant mtDNA have typically been observed in more severely affected patients.5 Finally, the proportion of mutant mtDNA may change rapidly between parent and daughter cell. This phenomenon, referred to as mitotic segregation, combined with the concept of heteroplasmy, at least partly explains why some family members may be more severely affected than others and how some patients manifest different clinical manifestations at different stages of their lives. Several studies have now found that pathogenic mtDNA mutations occur frequently in the general population. The first true population-based study showed that the most common pathogenic mutation, known as m.3243A→ G (typically associated with MELAS — mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes — syndrome), was found in one in 500 community-based Australians.6 All mutation carriers aged over 50 years had few or minor symptoms, but none had the clinical features of MELAS syndrome. Although age and other risk factors were not accounted for in the analysis, all m.3243A→ G mutation carriers had developed sensorineural hearing loss, a common but non-specific clinical symptom that frequently affects patients with mitochondrial disease. A second study in the United Kingdom confirmed this frequency of the m.3243A→ G mutation, reporting that it was found in one in 700 live births, although no clinical information on mutation carriers was given.7 The authors analysed a total of 10 common mitochondrial point mutations, and found a population prevalence of pathogenic mutation of more than one in 200 live births. Later, two studies investigating the population prevalence of a different point mutation, m.1555A→ G (originally associated with antibiotic-induced hearing loss), independently showed that this mutation was similarly found in one in 500 subjects.8,9 Children with this mtDNA mutation were asymptomatic, but older individuals were more likely to have developed associated symptoms. In addition to determining that mtDNA mutations were prevalent and usually unrecognised in the community,10 these findings raised questions about how and when mutation carriers become symptomatic during their lives. Should we consider mtDNA mutation carriers in the spectrum of mitochondrial disease? Given the lack of data about the factors that contribute to disease penetrance in mutation carriers, this approach could easily be justified. Patients who develop severe disease caused by their pathogenic mtDNA mutation could represent just the “tip of the iceberg”, with the vast majority of mutation carriers remaining only mildly affected. Changes in lifestyle and use of preventive strategies to delay the onset of symptoms (such as tailored exercise programs and avoidance of metabolic and physiological stressors) should be recommended to all mutation carriers in an attempt to reduce the individual’s risk of developing symptoms, although this may be ineffective in those who are destined to develop severe clinical manifestations. Longitudinal clinical studies of mutation carriers are warranted, to determine the natural history of mitochondrial disease and identify risk factors that contribute to developing severe or life-threatening disease versus mild or no symptoms during life. If the prevalence of mtDNA mutations in Australia is at least one in 250, then 90 000 Australians are potentially at risk of developing symptoms of a mitochondrial disorder. To raise community awareness of this genetic disorder, which robs thousands of Australians of their energy, the Australian Mitochondrial Disease Foundation will hold its annual Stay in Bed Day on 22 August 2010 (see http://www.amdf.org.au for details). Clinical manifestations of mitochondrial disease* Organ system Common clinical manifestations Adults Children Brain Stroke-like episodes, seizures, migraine-like headaches Epilepsy, stroke-like episodes Muscle Proximal myopathy Muscle weakness Ears Sensorineural hearing loss Sensorineural hearing loss Eyes Ptosis, external ophthalmoplegia, retinal pigmentary changes, optic atrophy Ptosis, external ophthalmoplegia, retinal pigmentary changes, optic atrophy Heart Cardiac arrhythmia, cardiomyopathy Cardiomyopathy, hypertrophic cardiomyopathy Endocrine Diabetes Diabetes Gastro−intestinal Intestinal pseudo-obstruction, constipation, abdominal bloating, dysphagia Vomiting, failure to thrive Respiratory Respiratory failure, recurrent aspiration, nocturnal hypoventilation Apnoea Renal Renal tubular acidosis Liver Liver failure * If a mitochondrial disease is suspected due to the presence of one or more of these clinical features, a muscle biopsy, genetic testing or referral to a specialised centre for assessment should be considered.

Carolyn M Sue MB BS, PhD, FRACP

Physicians need to be aware of this newly described complication Every year, thousands of Australians are prescribed bisphosphonates for the treatment of osteoporosis. They are highly effective agents, with numerous large clinical trials demonstrating a significant reduction in the risk of osteoporotic fractures as early as 6 months after commencement of therapy. Bisphosphonates such as risedronate, alendronate, etidronate, pamidronate and zoledronic acid have an excellent safety profile, although gastro-oesophageal irritation or transient flu-like symptoms may occur in patients receiving oral or intravenous bisphosphonates, respectively. Other side effects, such as renal impairment, uveitis and osteonecrosis of the jaw, have been described but are extremely rare. Since 2005, there have been several reports suggesting another potential side effect of long-term bisphosphonate therapy, namely the development of unusual fractures of the subtrochanteric or diaphyseal femur.1-4 Two initial case series described these femur fractures in a total of 12 patients (11 female) receiving current alendronate therapy. The mean age of these patients was 63 years and the mean treatment duration with alendronate was 6 years.2,4 The fracture pattern appeared morphologically distinct from the more common osteoporotic hip fracture and hence, in 2008, the term “atypical femur fracture” was introduced to describe a combination of three highly characteristic features: (i) a transverse or oblique fracture line occurring in (ii) an area of cortical thickening with (iii) a medial unicortical beak5 (Box). A further peculiar feature was the location of these atypical fractures in the subtrochanteric or mid-shaft femur, which is normally considered the strongest part of the femur. In 2007–2008, three retrospective analyses confirmed the predominance of this particular fracture pattern among bisphosphonate users.6-8 The largest of these included a study of 70 patients with non-hip femoral fractures, of whom 25 were receiving alendronate.6 The atypical fracture pattern was strongly associated with alendronate use, with a reported odds ratio of 139 (95% CI, 19–939; P < 0.001). The authors again noted that these fractures were associated with a longer duration of alendronate use (on average 4.4 years longer than patients without atypical fractures) and appeared to affect younger rather than older women. Most recently, a large 5-year retrospective study of non-hip femoral fractures found strong evidence supporting a potential association between oral bisphosphonate use and the occurrence of atypical fractures.9 Of 152 non-hip femoral fractures, 20 were classified as atypical following a detailed review of individual radiographs. Of the 20 patients, 17 had been receiving long-term therapy with either alendronate (n = 15) or risedronate (n = 2). According to this study, oral bisphosphonate use imparted a 37-fold increased risk of atypical versus typical osteoporotic fracture, with the atypical fracture pattern being 96% specific to oral bisphosphonate use.9 Other potential risk factors for developing atypical fractures include prolonged use of glucocorticoids,2,4,9,10 hormone replacement therapy,2 use of selective oestrogen receptor modulators,4 rheumatoid arthritis9,10 and vitamin D deficiency.9 The occurrence of groin or thigh pain, sometimes manifesting months before the acute fracture, has been described by several authors,1,4,7,8 with one group reporting its occurrence in 13 out of 17 (76%) atypical fracture cases.8 The pain is attributed to the development of unilateral stress fractures and should be viewed as an early warning sign in patients receiving bisphosphonate therapy. Several authors have also noted the occurrence of these fractures bilaterally.1-3,8-10 Attempts to elucidate the precise incidence of these fractures or to confirm their association with bisphosphonates on an epidemiological or observational scale have proved elusive. In 2009, a registry-based cross-sectional study of 11 944 patients failed to demonstrate a greater frequency of subtrochanteric or diaphyseal femoral fractures in patients receiving alendronate.11 Similarly, in 2010, a secondary analysis of three large randomised bisphosphonate trials including 14 195 patients concluded that subtrochanteric femoral fractures were very rare and statistically not associated with bisphosphonate use.12 However, these studies, did not assess individual fracture radiographs but, rather, relied on written reports, all of which were created many years before the recognition of the atypical fracture pattern as a distinct entity. Hence, although these studies indicate that subtrochanteric or diaphyseal femur fractures in patients receiving bisphosphonates are very rare, they do not provide definitive information on the potential association between bisphosphonate use and the occurrence of atypical fractures. The subtrochanteric location of these femoral fractures may offer potential insight into their biomechanical evolution. The theory of bisphosphonate-related severe suppression of bone turnover, with the development of a transverse fracture in the area of maximal weight-related stress, is supported by a number of bone biopsy studies2,4,13 but remains controversial due to the lack of clear causal evidence. In conclusion, the evidence supporting an association between bisphosphonate use and atypical fractures remains preliminary, with the failure of large epidemiological and observational studies to substantiate such an association. Certainly, these fractures are rare and their biomechanical evolution remains unclear. With all of this in mind, physicians should remember that bisphosphonates are highly beneficial in the management of osteoporosis and that their anti-fracture effects by far outweigh the risks posed by this rare, potential reaction. However, they should also be aware of the possibility of atypical femur fractures in patients receiving prolonged oral bisphosphonate therapy, and maintain a low threshold for investigating those who report otherwise unexplained thigh or groin pain. Atypical and typical osteoporotic fractures of the femur A: Radiograph demonstrating the characteristic appearance of an atypical femoral fracture: a transverse or oblique (< 30°) fracture line in an area of cortical thickening with a medial unicortical beak. The biomechanical theory of severe suppression of bone turnover with an insufficiency fracture and secondary cortical thickening at the area of maximal weight-related stress has been proposed. The patient had been receiving alendronate for 7 years before the spontaneous development of this fracture. B: Radiograph demonstrating a typical osteoporotic spiral fracture involving the diaphyseal femur.

Christian M Girgis MB BS(Hons) · Markus J Seibel MD, PhD, FRACP

Australia should support international bans on asbestos trade The adverse health effects of asbestos are well known, with all forms of asbestos recognised as human carcinogens, causing malignant mesothelioma, lung, laryngeal and ovarian cancers1 as well as the debilitating non-malignant diffuse lung disease, asbestosis, and pleural plaques. Although use, import and export of asbestos and asbestos-containing materials is banned in Australia and 51 other countries,2 an estimated 125 million people around the world are still exposed to asbestos in their home and work environments.3 Crocidolite (blue asbestos) and amosite (brown asbestos), two forms of asbestos that were heavily used in the past, are no longer in use. Chrysotile (white asbestos) accounts for 95% of the asbestos produced and used globally since 1990. There is no safe level of exposure to asbestos4 and no discernible threshold below which there is no risk of mesothelioma.5 Given the clear dangers, why are workers and their families in many parts of the world still being exposed to asbestos? Exposure comes from two main sources: residual asbestos-containing materials remaining in buildings constructed before the mid-1980s (when asbestos-containing cement sheet was removed from the market); and continuing mining and use of asbestos in some parts of the world. In Australia, the legacy of asbestos remains a problem. In most cases, asbestos is in a non-respirable form, and is not a hazard to human health if undisturbed. However, if damaged, it can become friable and change to a respirable form. The issues central to this global problem are education and research. Education about when asbestos exposure may occur, and how to avoid it, remains important. In this respect, the recent survey by Safe Work Australia6 is reassuring, with most tradespeople reporting awareness of asbestos-related health risks and demonstrating an understanding of how exposures occur. However, there was a general lack of understanding about which materials may contain asbestos, and there are no data on the level of awareness among people doing their own renovations. Asbestos will be with us for decades, so targeted and contextually appropriate education programs for at-risk populations are required. The effects of such programs should be monitored for their impact on risk, mortality and morbidity. As most of the people who will die from asbestos-related cancers in Australia already have asbestos in their lungs, research aimed at preventing or curing these cancers is also vital. Globally, the major problem is with continued mining and use of asbestos, with over 2 million tonnes produced in 2008.7 Developing countries, especially in Asia and Eastern Europe, are mining or importing asbestos for domestic use, and now account for the majority of the world’s exposure to asbestos. Thousands, if not millions, of people are likely to die in these countries as a result of continued asbestos exposure.8 Chrysotile is the only form of asbestos that is being traded in the 21st century; it is mostly used in the manufacture of asbestos cement sheets and pipes. There is a mistaken belief that this form of asbestos is less harmful than other forms, but overwhelming scientific evidence refutes this assertion.9 All forms of asbestos are classed as human carcinogens by the United States Environmental Protection Agency, and cancer is seen in workers who have only been exposed to chrysotile asbestos.9 There is also a mistaken view that chrysotile can be handled safely. Reports from the National Public Health Institute of Quebec show a failure to achieve “controlled use”, even in Quebec. In many developing countries, exposure is uncontrolled, and education of workers is, at best, minimal, and often non-existent. Tobacco smoking is also widespread in Asia, and is synergistic with chrysotile in increasing the risk of lung cancer. International organisations such as the World Health Organization and the International Labour Organization have called for a global ban of all forms of asbestos, with the goal of eliminating asbestos-related diseases.10 The Collegium Ramazzini, an international academic society independent of commercial interests that examines critical issues in occupational and environmental health, has just renewed its call for such a ban. This could, in part, be achieved via the Rotterdam Convention (http://www.pic.int), an international treaty intended to regulate global trade in chemicals that have been banned or severely restricted because of the hazards they pose to human health or the environment. The Convention was enacted in 2004, and 131 nations, including Australia, are current partners. The goal of the Convention is to protect the world’s most vulnerable countries from importing hazardous pesticides or regulated chemicals without prior knowledge or consent. Repeated efforts to include chrysotile asbestos under the Rotterdam Convention have failed, due to opposition from countries which mine and manufacture asbestos, including Canada. The Canadian Medical Association, Canadian Cancer Society and Canadian Public Health Association oppose exporting asbestos to developing countries, yet their government officially condones this activity. We, personally and on behalf of our respective professional affiliations, call for Australia and Australians to strongly support the latest international effort to ban the mining and manufacture of all forms of asbestos; to increase efforts, at home and abroad, in effective education of the dangers of asbestos both in the workplace and in the environment; and urge our legislators to redouble their efforts to rid the world of asbestos-related diseases.

Peter D Sly MB BS, FRACP, DSc · Robin Chase MB BS, DPH, FAFOEM · John Kolbe MB BS, FRACP · Philip Thompson MB BS, FRACP · Leena Gupta MB BS, MPH, FAFPHM · Mike Daube BA(Hons), HonDSci · Ian Olver MD, FRACP · Deborah Vallance BMedSci, MB BS, MPH

Using shared care to tackle the complexity of optimal patient management Globally, the burden of disease has shifted from acute to chronic illnesses and the management of multiple comorbidities. To address the challenges this creates, integrated care has received growing attention as a means of improving health care delivery and outcomes.1 Integrated care (frequently equated with “disease management” and “shared care”) is defined by the World Health Organization as a concept bringing together inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation and health promotion. Integration is a means to improve services in relation to access, quality, user satisfaction and efficiency.2 For the first time, Australia has a shared care model for the management of a chronic condition — namely, glaucoma — launched under the Pharmaceutical Benefits Scheme (PBS) in January 2008. Under the new PBS guidelines (Box),3 authorised optometrists can co-manage patients with glaucoma in a shared care arrangement with an ophthalmologist. Also, similarly to optometrists in the United Kingdom, Canada, and the United States, authorised optometrists in Australia may now prescribe therapeutic agents for certain eye conditions under the PBS. In January 2008, prescribing rights for topical ophthalmic medications were extended to certified optometrists as a result of a legislative change (National Health Amendment [Pharmaceutical Benefits] Act 2007 [Cwlth]).4 The range of medications that authorised optometrists may prescribe under the PBS includes lubricants and therapeutic agents for treating allergies, infection, inflammation, and glaucoma. Glaucoma is a heterogeneous group of diseases leading to a progressive optic neuropathy. It is the most common cause of preventable blindness in developed countries.5 Commonly, glaucoma is managed with topical hypotensive medications that include prostaglandin analogues, carbonic anhydrase inhibitors, selective α-adrenoceptor agonists and topical β-blockers. Under the shared care model, the patient’s ophthalmologist and optometrist together develop a written management plan that specifies the treatment goals and the roles and responsibilities of the two practitioners, create a review schedule, and communicate clinical information to the patient’s general practitioner to promote an integrated approach. The PBS guidelines also recommend that a pharmacist be involved in providing medicines information, such as advice related to administration and techniques to limit systemic absorption and side effects of ophthalmic medications, as well as potential interactions with concomitant systemic medications for comorbidities.3 Quality integrated care practices require effective communication and coordination among the involved health care providers and with patients. Decision making in relation to medicines for optimal patient management is increasingly complex because of more pharmacotherapeutic options for more conditions, increasing exposure and age at exposure of older patients to a wider range of medications, and rising numbers of affected patients as the population ages. Ophthalmic medications are often overlooked in medical history taking. Almost half the medical records kept by GPs have been reported to have no record of eye drops being used by patients with glaucoma.6 Ophthalmologists, GPs, optometrists and pharmacists need to consider a patient’s comorbidities and concurrent treatments to be able to provide a holistic approach to patient care. Topical ophthalmic medications may have effects on other diseases and their management: topical β-blockers may cause bronchospasm in those with reactive pulmonary disease,7 and their prescription may warrant an additional bronchodilator. Topical ophthalmic medications may interact with systemic medications. Polypharmacy, especially in the older population, may have serious consequences.8 For example, cimetidine, an over-the-counter H2-receptor antagonist for gastrointestinal irritation, may increase the effect of β-blockade when used in conjunction with β-blockers and should be used with caution in patients with underlying cardiac conditions.9 Australia’s new integrated care model promises to increase patient access to eye health care services, particularly in rural areas, and thereby enhance continuity and quality of care in these regions.2 Involvement of optometrists offers the opportunity for increased detection of glaucoma and patient access to subsidised ocular therapeutic agents. However, the processes and clinical outcomes of this new model of care need to be evaluated rigorously to determine its quality, feasibility and durability. Are anticipated improvements being realised? Are there unintended consequences? Important measures will include the rate of medication-related problems among glaucoma patients before and after the introduction of this shared care arrangement; patient adherence to and persistence with therapy; detection of undiagnosed glaucoma (prevalence of which has been reported to be high10); patient satisfaction; rates of visual field deterioration; and intraocular pressure levels. Some of these outcomes, such as medication use outcomes recorded in computerised health care datasets, will be easier to measure than others. Commitments by government and public agencies to rigorous research and funding to allow prospective studies and direct measures of health outcomes would seem a sound investment. This would provide valuable information not only for Australia but also for other countries that develop and implement integrated care models. Guidelines for the shared care of glaucoma patients under Australia’s Pharmaceutical Benefits Scheme (PBS)3 Confirmation of diagnosis and development of a management plan An authorised optometrist who makes a provisional diagnosis of glaucoma is to refer the patient to an ophthalmologist for confirmation of the diagnosis. With the consent of the patient, the optometrist and the ophthalmologist are to develop a management plan together, including the sharing of care between the two practitioners, and the communication of clinical information to the patient’s nominated general practitioner. Patients being considered for anti-glaucoma therapy with a β-blocking agent should be assessed for any potential cardiovascular or respiratory risk by a medical practitioner (eg, the patient’s GP) before initiating therapy. This assessment should be repeated if a change in dose of the β-blocker is proposed. Once a treatment plan is established with the ophthalmologist, the optometrist can prescribe topical medications under the PBS and perform ongoing reviews to monitor the patient. Changes to the management plan are only made following consultation between treating practitioners. A written patient management plan must specify: all the agreed components of treatment, including any pharmacotherapy; target intraocular pressures and actions to be taken if these are not achieved within a specified time frame; an agreed approach to monitoring visual fields and optic disc imaging and actions to be taken following changes in visual fields; triggers for referral for immediate ophthalmological and GP review; likely side effects from agreed treatment and the action to be taken to address these; an agreed schedule for patient review by both practitioners; who is responsible for performing each of the required tests and the required frequency for performing them; an agreed method for timely communication of clinical findings and patient management between the two practitioners and the patient’s nominated GP.

Christine Y Lu BPharm, MSc, PhD · Vicky H Lu MB BS, MPH · Ivan Goldberg MB BS, FRANZCO, FRACS · Richard O Day MD, FRACP

Objectives: To describe the characteristics, management and outcomes of patients with major trauma who were taking warfarin; explore the use of rapid anticoagulation reversal; and assess the effect of reversal on outcomes.Design and setting: Retrospective cohort analysis of prospective data extracted from the trauma registries and patient charts of the two adult trauma referral hospitals with neurosurgical units in Western Australia, 2000 to 2005. Inclusion criteria were: major trauma (injury severity score > 15); first international normalised ratio (INR) after injury > 1.4; and documented (in registry or chart) warfarin use.Results: Eighty patients were identified. Their mean age was 76.8 years. Forty-six were men; 34 were transferred from another hospital; 28 died; and the functional outcomes of 58 were worse at discharge from hospital than before injury. Intracranial haemorrhage (ICH) occurred in 62, of whom 25 died; the difference in mortality between those with ICH and those without ICH was insignificant. Warfarin reversal started 17.4 hours (mean) after injury and the documented period between injury and completion of reversal was 54.2 hours (mean). Multiple logistic regression models, controlling for age, sex, on-scene Glasgow Coma Scale (GCS), initial INR and progressive ICH, showed no independent survival benefit for rapid reversal. Factors associated with mortality were age (22% increase per year [95% CI, 17%–34%]) and progressive ICH on computed tomography scan (24 of the 36 patients with progressive ICH died v one of the 26 patients with stable ICH died). Every point increase in on-scene GCS > 8 increased survival likelihood by 215% (95% CI, 119%–388%).Conclusions: Patients with major trauma taking warfarin at the time of injury have high mortality rates, poor functional outcomes and long delays to initiation and completion of anticoagulation reversal. Rapid, appropriate warfarin reversal was rarely performed and was not independently associated with survival. Age, low on-scene GCS and progressive ICH were strongly associated with mortality, but presenting INR, ICH v no ICH, and sex were not.

David Mountain MB BS, FACEM · Vera Sistenich MB BS, FACEM · Ian G Jacobs BAppSc, PhD, RN

Objectives: To assess whether a collaborative interdepartmental pathway involving emergency department (ED) physicians activating the cardiac catheterisation laboratory (CCL) with immediate patient transfer to the CCL reduces door-to-balloon (DTB) times for patients with suspected ST-elevation myocardial infarction (STEMI).Design, setting and participants: A quasi-experimental before-and-after observational study using a prospective database, supplemented by chart review, of consecutive patients transferred from the ED to the CCL for suspected STEMI, from January 2007 to October 2009, at Sir Charles Gairdner Hospital, an adult tertiary-care hospital, Western Australia.Main outcomes measures: Median DTB time and proportion of patients with DTB time of < 90 minutes. Secondary outcomes, based on analysis of predefined subgroups, included door-to-activation time, activation-to-balloon time and false-positive activations of the CCL.Results: Two hundred and thirty-four patients underwent emergency coronary angiography for suspected STEMI, with 188 (80%) undergoing percutaneous coronary intervention (118 before and 70 after implementation of the new pathway). Following implementation of the new pathway, median DTB time reduced from 97 to 77 minutes (P < 0.001), median door-to-activation time from 28 to 15 minutes (P = 0.002) and median activation-to-balloon time from 66 to 53 minutes (P < 0.001). The proportion of patients with recommended DTB time of < 90 minutes increased from 41% to 77% (P < 0.001) with no change in false positive CCL activation rates (12% v 11%; P = 0.38).Conclusion: ED physician activation of CCL with immediate patient transfer is associated with highly significant improvements in DTB time without increased false positive rates.

Alexander B Willson MB BS(Hons), MPH, FRACP · David Mountain MB BS, FACEM · Joanne M Jeffers MB BS · Cheryl G Blanton MSc · Brendan M McQuillan MB BS, PhD, FRACP · Joseph Hung MB BS, FRACP, FCSANZ · Michael H Muhlmann MB BS, FRACP · Michael C Nguyen MB BS, FRACP

Objective: To document trends in subject demographics, anthropometry and sleep disorder severity over 21 years of diagnostic sleep studies.Design, participants and setting: A retrospective observational study of consecutive subjects undergoing initial diagnostic polysomnography for investigation of possible sleep disorders in a university-affiliated tertiary public metropolitan hospital in the Hunter New England region of New South Wales between 1987 and 2007.Main outcome measures: Body weight, body mass index (BMI) and severity of sleep-related breathing disorders (apnoea-hypopnoea index [AHI]).Results: Between 1987 and 2007, 14 648 new diagnostic sleep studies were performed. The median age of subjects (51 years; interquartile range, 41–61 years) did not change over time and the proportion of women increased from 20% to 39%. Median body weight increased from 89 kg to 99 kg for men (11%) and from 73 kg to 85 kg for women (16%), equating to a yearly increase in median BMI of 0.15 kg/m2 for men and 0.14 kg/m2 for women. The proportion of subjects who were morbidly obese (BMI ≥ 40) increased from 3% in 1987 to 16% in 2007. Median AHI progressively increased from 1992–1995 to 2004–2007 (from 6.5 events/h to 14.3 events/h; P < 0.001), indicating increasing disease severity. Over the same period, for every unit increase in BMI, AHI increased by 5.5 events/h for men and by 2.8 events/h for women. About 80% of the observed variance in AHI over this period was attributable to variance in BMI.Conclusion: There is a continuing trend towards increasing body weight and BMI in people undergoing diagnostic sleep studies. Our data do not support the hypothesis that increased accessibility to diagnostic services and increased awareness of sleep disorders are resulting in a decline in disease severity. These findings are consistent with the premise that worsening severity in sleep-disordered breathing is primarily attributable to increasing obesity.

Jeffrey J Pretto DHlthSc, BAppSc, CRFS · Stephen G Gyulay GradDipClinEpid · Michael J Hensley MB BS, PhD, FRACP

Objectives: To examine 5-year survival from haematological malignancies in children, adolescents and young adults in Australia and determine if there has been any improvement in survival for the older age groups compared with children (the age-related “survival gap”).Design, setting and participants: Population-based study of all Australian children (aged 0–14 years), adolescents (15–19 years) and young adults (20–29 years) diagnosed with acute lymphoblastic leukaemia (ALL), acute myeloid leukaemia (AML), Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) between 1982 and 2004, with follow-up to 2006.Main outcome measures: 5-year survival from ALL, AML, HL and NHL analysed for four periods of diagnosis (1982–1989, 1990–1994, 1995–1999 and 2000–2004).Results: During 1982–2004, 13 015 people aged ≤ 29 years were diagnosed with primary leukaemia or lymphoma in Australia. For those with ALL, 5-year survival for adolescents improved from 40% (1982–1989) to 74% (2000–2004); the improvement for young adults was smaller (31% to 47%), and both these groups still had lower survival than children, whose 5-year survival improved from 74% to 88%. There was a larger narrowing of the gap for AML: for cases diagnosed in 2000–2004, 5-year survival was similar for young adults (63%), adolescents (74%) and children (69%). For lymphoma cases diagnosed in 2000–2004, 5-year survival in all age groups was greater than 95% for HL and greater than 81% for NHL, although children fared better than adolescents and young adults.Conclusions: These Australian population-based data confirm an improvement in survival from haematological malignancies across all three age groups, but an age-related survival gap remains for adolescents and young adults compared with children, especially for young adults with ALL. Greater participation of adolescents and young adults in clinical trials and more detailed data collection are needed to provide evidence about optimal treatment regimens in these age groups.

Ross Pinkerton MD, FRACP · Rachael-Anne Wills BAppSc(Hons) · Michael D Coory FAFPHM, PhD · Christopher J Fraser MB BS, FRACP, MPH

Objective: To describe changes in the incidence of hospitalised injury for New South Wales residents involved in non-traffic crashes for the period 1 July 1998 to 30 June 2007.Design, setting and participants: This study identified 37 480 NSW residents admitted to hospitals for injuries resulting from non-traffic crashes from the NSW Admitted Patients Data Collection during the study period. Injury rates were calculated by applying 2001 census-derived estimates of NSW population figures as the denominator, and directly adjusting to the age distribution of the 2001 Australian population. The significance of trends in rates was assessed by the per cent change annualised estimator.Main outcome measures: Age-standardised rates of hospitalisation for injuries, and trends by inpatient demographics, travel mode and severity of injuries.Results: The annual rate of hospitalisation for injury showed a significant increase of 0.7% per annum (95% CI, 0.2% to 1.2%) for NSW residents involved in non-traffic crashes over 10 years. Annual hospitalisation rates for serious injuries increased by 2.2% (95% CI, 0.9% to 3.6%). The hospitalised injury rate for motorcyclists and pedal cyclists increased significantly by 3.3% per annum (95% CI, 2.4% to 4.2%) and 3.7% (95% CI, 2.6% to 4.9%), respectively, but the rate declined significantly for car occupants and pedestrians by – 8.3% per annum (95% CI, – 9.5% to – 7.0%) and – 2.2% (95% CI, – 4.2% to – 0.2%) respectively.Conclusions: The rate of hospitalisation for injury from non-traffic crashes increased significantly over time for NSW residents from 1998–99 to 2007–08, especially for serious injuries and injuries to motorcyclists and pedal cyclists. These findings call for continuing and specific effort to prevent road non-traffic injuries.

Shanley Chong PhD, MAppStat, BA(Stats) · Wei Du PhD, MPH, MB BS · Julie Hatfield PhD

Increasing numbers of patients are presenting for unscheduled medical admission to hospitals worldwide, prompting clinical redesign of “front-door” emergency medical services. In the United Kingdom, there has been considerable investment in the establishment of acute medical units (AMUs) and the training of acute medicine physicians. Some centres in Australia have established similar medical assessment units. While these initiatives have undoubtedly met with some success, the evidence base for their overall benefit remains elusive. We describe key aspects of the recent establishment of acute medical services in Britain and discuss the relevance of these experiences to Australia. Successful models of care in acute medicine have often been shared with other centres. The adaptation of existing models of care to meet local demands is superior to simply adopting an existing model. Once the desired clinical functionality of a service is determined, informed decisions can be made on staffing requirements, skill mix, and the structure of any new clinical unit. The functionality of the acute medical service, rather than simply the physicality of an AMU, should drive service design.

Paul F Jenkins MA, MB, FRCP · Lorna L Barton MB BS, MRCP · Gregor B S McNeill MB ChB, MRCP

Academic teaching hospitals and their networks can best serve patients and other stakeholders by achieving critical mass and scope of clinical services, teaching and research. Successful hospital reconfigurations are associated with a convincing case and majority clinician buy-in. The inscrutable political decision to relocate services away from a major teaching hospital campus and into a merged Queensland Children’s Hospital was determined without broad stakeholder consultation or a transparent and accountable business case. This compromised process poses a significant and enduring risk to patient care and Queensland’s paediatric, perinatal, adolescent and obstetric academic teaching hospital services. As the proposed major stakeholder in Australia’s public hospitals and medical workforce training, the federal government should review this decision using an effective methodology incorporating relevant criteria. National guidelines are needed to ensure best practice in the future planning and auditing of major health care projects. The medical profession is responsible for ensuring that health care policy complies with reliable evidence and good practice.

Christopher K Davis MB ChB, MBA, FRACP · Harry Smith MB BS, MD, FRCPA

Prompt myocardial reperfusion, particularly if achieved within 2 hours of the onset of symptoms, improves outcomes in patients with ST-elevation myocardial infarction (STEMI). Recent data suggest that ambulance-administered prehospital thrombolysis, if given within 2 hours of the onset of STEMI, produces superior outcomes to primary percutaneous coronary intervention (PCI); if given within 4 hours, the outcomes are similar. For optimal results after thrombolysis, patients require angiography (and PCI where appropriate) within 24 hours of the event. These developments have major implications for the practice of cardiology and for the organisation of health services in Australia.

Richard W Harper MB BS, FRACP, FACC · Jeffrey Lefkovits MB BS, FRACP, FCSANZ

When a patient presents to hospital after a suicide attempt and appears to refuse treatment, clinicians should first assess if he or she should be treated under mental health legislation, regardless of competence to refuse treatment. When it is not possible or is inappropriate to treat under mental health legislation, the person’s competence to refuse treatment should be assessed. If the patient is definitely competent, his or her decision to refuse treatment should probably be honoured. If an incompetent patient carries a document refusing treatment, clinicians must determine the validity of that document as an advance care directive — including whether or not the patient was competent at the time it was written. The law around the right to refuse treatment after a suicide attempt remains unclear and, if uncertain of what to do, clinicians should provide urgently required life-saving treatment and simultaneously seek an urgent court order to clarify how they should proceed. In all but extraordinary circumstances, a patient who refuses treatment after a suicide attempt can and should be given life-saving treatment, under either mental health legislation or the common law concept of necessity.

Christopher J Ryan MB BS, FRANZCP · Sascha Callaghan BEc(SocSci), LLB(Hons)

To the Editor: The prophylactic use of inferior vena cava filters (IVCFs) in trauma patients for whom anticoagulation is contraindicated has markedly increased over the past few years. Their need for caval filtration is usually only transient, and once the risk of venous thromboembolism is deemed to be minimal, it would seem appropriate that IVCFs be retrieved. However, a large number of IVCFs remain in situ, due to either failure of retrieval or lack of follow-up. We observed a case that touches on both of these two major problems associated with IVCF retrieval. A 34-year-old man received a prophylactic IVCF after he had sustained severe pelvic fractures, several undisplaced spinal fractures and a splenic laceration in a motorbike accident. He was deemed to be at high risk of venous thromboembolism, and immediate prophylactic anticoagulation was contraindicated because of his pelvic and splenic injuries. The scheduled IVCF retrieval, 8 weeks after insertion, failed due to technical difficulties. A large clot between the struts of the IVCF (Figure) meant further withdrawal attempts were deemed too dangerous. The patient was informed that he had two options: if the filter remained in situ, he would possibly need lifelong oral anticoagulation; or the IVCF could be surgically removed. Soon after this, the patient was discharged with instructions to continue oral anticoagulation. About 5 months later, at a follow-up consultation with the orthopaedic surgeon about his injuries, the patient expressed his concern about the IVCF and especially about the anticoagulation. He was taking it for no other indication than the IVCF. The radiologist who had inserted the IVCF was contacted, and subsequently removed it without any complications. In the case described here, an initial retrieval attempt was thwarted by filter tilt and a large clot burden. After discharge, the patient was lost to follow-up with respect to the IVCF. Fortunately, this was addressed by one of the specialists involved in management of the patient’s other problems. Without this intervention, the patient may have ended up with the filter permanently in situ, with its attendant risks, and an unwarranted lifetime of anticoagulation. When filters have a significant clot burden, anticoagulation can help dissolve this to the point at which retrieval can be effected safely.1 This case highlights the need for appropriate follow-up after IVCF insertion. Various studies have outlined different follow-up strategies, some using a protocol drawn up in a multidisciplinary team setting,2 others designating a key person (usually the clinician who inserted the filter) to undertake this task.3,4 Both strategies have been shown to reduce the number of patients lost to follow-up. The clot, occluding nearly the whole lumen of the inferior vena cava (IVC), is seen as a radiolucent area between the IVC filter struts as the contrast agent passes by.

Dominik Baschera · Jonathan K Sebunya · René Zellweger

To the Editor: We welcome the thoughtful analysis from Elkin and Studdert on international students missing out on internship places.1 Given the impending shortage of available internships in Australia, this is of considerable interest to the over 500 international students who graduate each year. Sydney Medical School (University of Sydney) should be commended for explicitly discouraging international students’ expectations of internship.2 Sadly, this is an isolated example. We agree with the authors that universities have an ethical obligation to ensure this information is adequately conveyed to current and prospective international students. Education policymakers and medical school administrators should be forthcoming with vital information on the future of training for international students in Australia. The Australian Medical Students’ Association is currently developing a comprehensive information booklet, which we will distribute to prospective international students. Among other details, this will clearly outline the issue. However, the issues raised by Elkin and Studdert are not confined to international students. The authors observe that the recent health ministers’ communiqué only guaranteed internship to students in Commonwealth-supported places.3 This not only excludes international students, but also local fee-paying students at private universities and those in state-funded places. The authors argue that international students have no legitimate expectation that they will be provided with an intern place on graduation, given the “clear” statements from the federal government. However, there has been no similar guidance for local private university or state-funded students. Do these students have a legitimate expectation of internship? One could argue that state-funded students do, given the funding bodies are the same ones that will also provide their internships. While Australian permanent residents and citizens currently have first or second priority for internships, depending on their state of study and the state to which they are applying, it seems that in the future these students may miss out in favour of Commonwealth-supported students covered by the health ministers’ guarantee. Elkin and Studdert concluded that Australian courts would be unlikely to find that international students hold a legitimate expectation of internship. It is less certain whether this conclusion might apply to state-funded students or Australian permanent residents and citizens at private universities. At a minimum, these applicants too deserve “full and frank information” about their internship prospects.

Christopher X J Wong · Samuel J Whitehouse · Thomas D Crowhurst · Ross L Roberts-Thomson

To the Editor: Blecher correctly asserts that alarm is not the appropriate reaction to the potential dangers of computed tomography (CT) scans.1 Such alarm risks discouraging patients from having the CT scans they need. Appropriate CT scans are good; inappropriate ones are bad. Blecher is also correct in stating that the linear, no-threshold (no dose is entirely safe however small) model of radiation risk is theoretical.2 However, the advice of all international regulatory radiation protection authorities is to assume that the model is correct. To do so is prudent, even if overly conservative. And while these authorities hold this position, it would be professionally irresponsible to ignore it. Notwithstanding the Health Physics Society statement that the risk of ionising radiation below 100 mSv is negligible,3 the risk is thought to be cumulative. Furthermore, a single CT scan of the chest, abdomen and pelvis may expose a patient to 30 mSv or more, and the risk in children and young adults is considered to be 2–3 times greater than the average.4 The atomic bomb data are based on radiation dose levels as low as 5 mSv,5 with the cohort exposed to doses between 5 and 20 mSv showing an 85% chance that the risk is worse than we think and a 15% chance that it is better than we think. Although not statistically significant at the 95% confidence level, these figures indicate that great care is needed. The dimensions of the risks of low-dose radiation are contentious, but are we willing to ignore the danger of accepting Blecher’s argument? It is a Pascal’s wager. Providing we do not spook patients from having necessary scans (and this requires better communication with patients), our possibly over-cautious approach should result in more appropriate use of diagnostic imaging. The benefits go beyond those of limiting unnecessary radiation. Blecher finds it ironic that concerns about the dangers of CT are rising as radiation doses are falling. Doses may be falling, although that depends on where the baseline is drawn. When multidetector CT scanning was introduced, doses rose,6 but if, since then, doses have been falling, there is nothing ironic about this. Doses are falling because of the concern. Whether a patient undergoes an imaging procedure should be subject to the process of justification mandated in the Australian Radiation Protection and Nuclear Safety Agency code of practice.7 If the potential benefit outweighs the risk, the procedure is justified and the examination should proceed, but optimised to ensure that the lowest possible dose of radiation is used to provide diagnostic images — the ALARA principle (As Low As Reasonably Achievable). In summary: If a CT scan is clinically justified, then it should be performed and we should certainly avoid alarming our patients. If a scan is not justified, it should not be performed. We should adhere to the ALARA principle. Whenever appropriate, a non-ionising alternative to CT scans should be considered, particularly for children and young patients.

Richard M Mendelson · Richard A Fox · Nicholas H de Klerk

To the Editor: Seizures can be precipitated by treatment with praziquantel in patients with underlying neurocysticercosis, but this is rare and has not previously been described in Australia. We describe the case of a patient who developed seizures after antischistosomal therapy. An asymptomatic 23-year-old Burmese man underwent migrant health screening by his local doctor a month after arriving in Australia. His schistosomal serological results were positive (titre, 1:32) and he received three doses of 600 mg praziquantel. Three days later, he experienced several generalised tonic–clonic seizures in short succession, each lasting a few minutes. A magnetic resonance imaging (MRI) scan revealed three ring-enhancing lesions less than 1 cm in diameter, suggestive of neurocysticercosis. He was treated with phenytoin and also received dexamethasone for 1 month. A repeat MRI scan 6 months later showed significant reduction in the size of the lesions, to less than 3 mm. Phenytoin therapy was ceased after 3 months, with no seizures at last review (6 months). In view of the temporal association between the treatment and the seizures in this previously asymptomatic patient, we believe the seizures were precipitated by the praziquantel therapy. Cysticercosis, which is endemic across the developing world, is caused by the helminth Taenia solium. Clinical disease, including neurocysticercosis, is often asymptomatic. Symptomatic neurocysticercosis often presents as seizures, especially as the cysts degenerate, and is the commonest cause of acquired, late-onset epilepsy in the developing world.1 The benefit of treatment remains controversial, especially when there are only a few cysts.1-3 Praziquantel and albendazole therapy accelerate cyst degeneration, and subsequent inflammation may precipitate seizures, which are sometimes pre-emptively managed with corticosteroids.1 There is conflicting evidence on the benefit of treatment for long-term seizure frequency.2,3 Although screening for some parasitic infections in refugees in Australia is recommended,4 this does not include cysticercosis. Serological tests for T. solium cannot differentiate between active and past infections, have limited sensitivity, are not widely available in Australia, and cannot differentiate between neurocysticercosis and cysticercal disease elsewhere.5 The only reliable method for diagnosis is neuroimaging, which is impractical for mass screening. Nevertheless, we advocate a high degree of suspicion for neurocysticercosis in migrants from Taenia-endemic areas. Geographical origin alone is insensitive for identifying an at-risk population. A history of seizures, or the presence of subcutaneous nodules, should prompt investigation with serological testing and subsequent neuroimaging before consideration of treatment. In such symptomatic patients, this will allow the need for anthelmintic therapy to be assessed, along with consideration of adjunctive corticosteroid therapy.

Saliya S Hewagama · Jonathan D Darby · Harsha Sheorey · John R Daffy

To the Editor: “Student medical journals” are a very broad church, encompassing everything from pseudo-magazines to rigorously peer-reviewed publications. In April this year, a national journal of the latter variety was launched here in Australia: the Australian Medical Student Journal (AMSJ).1 The AMSJ accepts research, review and opinion articles from students of medicine or health sciences at Australian universities. The journal’s volunteer staff comprises only medical students, and peer-review is by academics associated with Australian medical schools, or clinicians at Australian teaching hospitals. The inaugural issue could hardly have been more national in its focus, with students from 14 Australian medical schools, covering every state, being represented among the authors. The issue was recently distributed free of charge to thousands of medical students around Australia in both print and electronic formats. After the success of the inaugural issue, we plan to begin biannual production from 2011, continuing in both formats. The AMSJ operates as a not-for-profit student organisation, and printing and other costs are provided for by sponsors, including the Australian Medical Association, Australian General Practice Training, and the Royal Australasian College of Physicians. While it is unique in a number of facets, the AMSJ is not the first publication of its kind. The Australian Medical Students’ Association magazine Panacea began life in 1968 as a journal, albeit not peer-reviewed.2 Several individual Australian medical schools have had their own academic publications for varying periods, such as the Sydney University Medical Journal, which was first published around 1905.3 More recently, our counterparts across the Tasman were well ahead of us, with the New Zealand Medical Student Journal releasing its first issue in 2004.4 Further afield, some of the better known student journals are the McGill Journal of Medicine (MJM) in Canada and the Student BMJ in the United Kingdom. Most student journals fall roughly into one of two categories: those whose focus is primarily instruction and entertainment, with shorter educational or blog-style articles (often written by non-students) having appeal to time-constrained students (eg, Student BMJ); and those that publish academically rigorous student work, perhaps at the expense of reader interest (eg, MJM). The AMSJ has a number of aims (Box), although central to our mission is to transcend this artificial tension and attract student-authored articles that are both thoroughly interesting and academically substantial. The rationale is that anything short of a proper peer-reviewed journal is patronising towards students, but, on the other hand, articles that are not appropriately pitched cause disenchantment. Medical students have played key roles in the history of medicine: notable discoveries made or shared in by medical students include heparin, insulin, the sinoatrial node, the pancreatobiliary sphincter, ether anaesthesia, islets of Langerhans, and spermatozoa.6 We hope that the AMSJ can continue to promote and foster this tradition of student achievement. Aims of the Australian Medical Student Journal5 To provide a medium for Australian medical students to publish their work and share ideas with their peers. To provide a suitable forum for students to make the transition between assignment writing and producing publishable academic work. To inform students about medical topics and issues not typically addressed in core curricula. To facilitate discussion of current issues relevant to medical students. To allow Australian medical schools to showcase the research aspects of their programs. To provide a further incentive for students to produce high-quality work in their studies. To foster the next generation of Australian medical researchers and physician–scientists. To provide an avenue for students interested in a career in medical editing or publishing to pursue this interest as a student staff member.

Matt D Schiller

Hoffenberg. Physician and humanitarian. L Ross Humphreys. London: Royal College of Physicians, 2010 (xi + 174 pp). ISBN 9781860163661. “Hoffenberg” probably means little to most Australian doctors other than those fortunate Queenslanders who met him during his short tenure as Professor of Medical Ethics from 1993 to 1995. It means a lot, however, to expatriate South African-trained doctors, to Fellows of the Royal College of Physicians, London, and to Queenslander Ross Humphreys. Humphreys has written an eminently readable biography of one of those stars of the South African medical firmament who, after leaving the country during the apartheid era, distinguished themselves in their field in Britain. Unlike most of the other expatriate doctors in this group, Hoffenberg was, literally, exiled. Nevertheless, Sir Raymond (Bill) Hoffenberg shone among his fellow ex-South African FRCPs, Fellows of the Royal Society, Knights of the Realm and Nobel prize-winners. Humphreys, in explaining Hoffenberg’s forced departure from South Africa, provides an excellent introduction to apartheid. He details Hoffenberg’s progress, from his appointment at Birmingham University to his time as President of the Royal College of Physicians and President of Wolfson College, University of Oxford. He describes Hoffenberg’s interest and research in a wide range of diseases, and in teaching and mentoring colleagues, as well as his initiation of medical audit and his overwhelming concern with medical ethics. Hoffenberg never lost his emotional attachment to South Africa, as evidenced by his continued assistance to other “refugees” from the system and, when apartheid ended, his strong support for medical research and education in that country. His connection with Australia commenced when he came to Brisbane to join his sons. This little book will appeal to anyone with an interest in South Africa, in British medical history from the late 1960s to the early 1990s, and in medical education, research, clinical audit or ethics. My only criticism is of the proofreading. My friend and colleague is not Patricia but Priscilla Kincaid-Smith; sloppy grammar and punctuation require a double-take of some sentences, and I was saddened to see the need for “Apostrophe Man”.*

Peter C Arnold

Inside chronic pain. An intimate and critical account . Lous Heshusius. New York: Cornell University Press, 2009 (xvii + 167 pp). ISBN 978 0 8014 4796 9. The lessons contained in this concise, personal narrative of an articulate patient crippled by chronic pain present a number of challenges to all who read it. There is a brief, scholarly foreword by David Morris, Professor of English at the University of Virginia, that sets the scene — conceptually, all chronic illness must be constructed at the crossroads of biology and culture. And there is an excellent coda by Scott Fishman, Professor of Anesthesiology and Pain Medicine at the University of California, Davis, which emphasises that the story you’ve just read is not unique. We have to ask ourselves, how can we consistently access all the options to put it together for these patients? How often do we even say, “I will go through this journey with you, and be your consultant”? More often than we care to admit, we neglect the social, spiritual and cultural dimensions of our patients’ experience in favour of a medical model of disease. The patients bear the largest burden on the journey towards recovery. How does one competently advocate for oneself when emotion and dysfunctional cognitions unduly influence the processes? Support systems are needed to negotiate a maze of clinicians, contradictory information and advice, and adversarial bureaucracies, yet time has to be spent alone in the present — not in the past or future — practising individualised coping strategies. This book will make you annoyed and frustrated — with the writer, her health care professionals, yourself, and with the system. Perhaps, you may also reflect on your management of chronic pain, and open new communication channels with your patients and your colleagues. Even undergraduates can learn from this little book, but I think it would be best read and digested by experienced clinicians. The only real downside is its North American setting. However, I can assure readers it all happens here too.

Robert D Helme

A primer of clinical psychiatry. David Castle, Darryl Bassett. Sydney: Churchill Livingstone, 2010 (xv + 311 pp). ISBN 9780729539036. Clinical Psychiatry is a rich and often challenging discipline. Clearly and concisely describing, in book form, the myriad presentations, tools of assessment and methods of treatment is no easy task. Yet Professor David Castle from Melbourne and Darryl Bassett from Perth, assisted by fellow Australian psychiatrists in some of the chapters, have achieved this with their “primer”. Medical students, in particular, and students of other health disciplines as well, will find this book very useful, but it will also appeal to general practitioners wanting a quick refresher or ready resource. As one might expect, the book covers the psychiatric interview, common investigations, major syndromes, biological and psychological treatments, and issues pertaining to special patient groups (eg, child and adolescent, old age, forensic, “dual disability”). A problem frequently encountered with introductory texts of this type is that, in attempting to provide a broad overview in limited space, they become “remote”, are reduced to checklists, fail to convey the essence of a field, and lack soul. Such criticisms cannot be levelled reasonably at Castle and Bassett’s book. For instance, the numerous case examples, advocacy for a hierarchical classification, and boxes and tables of practical information (such as “A safe restraint method” in the chapter on psychiatric emergencies) infuse the text with relevance and life. The book is not without quirks. For example, the only appendix, “Objective Structured Clinical Examinations (OSCEs) in psychiatry” sits oddly, if confirming the book’s utility for students. And the reason for including substance-use disorders among “special patient groups” rather than “psychiatric syndromes” is elusive, given the prevalence of such disorders. Finally, the authors eschew discussion of the ethical dimension of psychiatric practice, which I think is necessary even in the briefest and most basic of primers. Despite these limitations, this is an excellent text, bound to enhance the psychiatric knowledge and skills of the reader and, thus, render psychiatry less daunting.

Garry Walter

Evidence-based practice. Across the health professions. Tammy Hoffman, Sally Bennett, Chris Del Mar, editors. Sydney: Churchill Livingstone, 2009 (xiv + 349 pp). ISBN 9780729539029. Putting evidence into practice is a challenge for all health professionals; not just knowing the evidence, but being able to interpret it and put it into practice in the face of a range of barriers and constraints. The editors of this book are specialists in evidenced-based practice and have led classes in the subject for students from a range of health professions. Tammy Hoffman and Sally Bennett are both lecturers at University of Queensland’s School of Health and Rehabilitation Sciences, while Chris Del Mar is Professor of Primary Care Research at Bond University and a Coordinating Editor of the international Cochrane Collaboration. Contributors include experts from Australia and overseas, who provide a wealth of examples on how evidence-based clinical decisions are made by different health professionals. The book takes the reader from formulating the question to finding and evaluating the evidence required to answer it. This is not for the faint-hearted — the various chapters describe in detail how to appraise the validity (and bias) of intervention trials and how to interpret the significance of their findings. It may be pretty heavy going for many clinicians. However, the book then goes on to work through examples encountered by different health professionals in a wide variety of real-life clinical settings. For example, the questions about the efficacy of interventions range from cognitive behavioural interventions by practice nurses to adjuvant temozolomide with radiation therapy for glioblastoma. Most of the chapters focus on appraising individual studies. This is a good way to illustrate the use of appraisal skills and avoids the risk of providing simplistic answers to clinical questions. However, much of routine practice may be more appropriately informed by systematic reviews of the literature (such as Cochrane reviews) and systematically developed evidence-based guidelines. These are covered in Chapters 12 and 13, but without the in-depth case study analysis used in the earlier chapters. This is a little disappointing. Despite these reservations, I found this to be a surprisingly readable and thorough introduction to the appraisal of evidence for multidisciplinary clinical practice.

Mark F Harris

Incorrect statement of risk: In “Factors associated with psychiatric morbidity and hazardous alcohol use in Australian doctors” in the 2 August 2010 issue of the Journal (Med J Aust 2010; 193: 161-166), there was an error in the last paragraph of the Results section (page 163). The wording of the last sentence of the paragraph should be: “Doctors were at less risk of hazardous alcohol use if they: trained overseas rather than in Australia (OR, 0.56 [95% CI, 0.39–0.81); worked more than 60 hours a week compared with less than 40 hours a week (OR, 0.67 [95% CI, 0.45–0.99]); and had not taken a holiday in more than a year (OR, 0.63 [95% CI, 0.43–0.93]).”

Louise M Nash · Michele G Daly · Patrick J Kelly · Elizabeth H van Ekert · Garry Walter · Merrilyn Walton · Simon M Willcock · Chris C Tennant

Safe sex and little blue pills Doctors who prescribe drugs for erectile dysfunction should also routinely offer counselling on safe sex, even to older men, advise the authors of a recent US study. In an analysis of health insurance claims for approximately 34 000 men aged over 40 years prescribed drugs for erectile dysfunction, the risk of sexually transmitted disease (STD) was increased threefold compared with controls. This was mainly driven by HIV infection, and also chlamydia. To see if the observed effect could be explained by changes in sexual activity or behaviour after starting the drug, they also assessed STD rates in the preceding year. They found no significant change, with high rates among the users during both time periods, suggesting that the observed increase in STDs was more likely to be due to the types of patients using the erectile dysfunction drugs than a direct effect of the drug’s availability. Ann Intern Med 2010; 153: 1-7 Reporting impaired colleagues A survey of 1891 American doctors has shown that about a third of those who were aware of an impaired colleague in their workplace did not inform authorities, despite reporting requirements by professional bodies. Publication of these findings coincides with the new Medical Board of Australia’s policy for mandatory reporting of “notifiable conduct” by health professionals. Failure to report was most often due to a belief that someone else was taking care of the problem (19%), that it was not their responsibility (10%), or that nothing would happen as a result (15%); only 12% cited fear of retribution as a reason for not reporting a colleague. Reporting was least likely to occur in smaller practices compared with large clinics or hospitals. The study authors suggest that professional self-regulation can be further improved, possibly by improving doctors’ confidence in the system and providing appropriate education. JAMA 2010; 304: 187-193 doi:10.1001/jama.2010.921 Time of birth and neonatal death Babies born out of office hours may be at slightly increased risk of neonatal death, according to a study of over one million singleton births in Scotland. The estimated risk of neonatal death for babies born out of office hours was 5.6/10 000 compared with 4.2/10 000 for babies born during office hours. Of the 539 deaths, about half were ascribed to intrapartum anoxia (odds ratio for death due to anoxia was 1.7 [95% CI, 1.2-2.3] for after-hours deliveries), and this association remained even after excluding elective caesareans from the analysis. The authors say that these findings may be explained by a number of factors, including variations in staffing at certain times of day and the immediate availability of senior clinicians, and access to clinical facilities such as obstetric operating theatres. BMJ 2010; 341: c3498. doi:10.1136/bmj.c3498 Methadone users still inject While opiate substitution treatments such as methadone can increase survival of injecting drug users, this comes at a price — it also appears to reduce their chances of achieving long-term abstinence. A 27-year follow-up study of 655 injecting drug users living in an impoverished suburb of Edinburgh has shown that those treated with opiate substitution for more than 5 years had a median duration of injecting of 20 years, which was four times that of those who did not have such treatment. However, those who did not take methadone were approximately four times more likely to die within 25 years of first injecting, and the effect on survival remained after adjustment for confounders such as HIV infection, history of drug overdose or incarceration. The impact of treatment became more apparent the longer it was used, with more than 5 years of treatment conferring the most substantial impact. BMJ 2010; 341: c3172 doi:10.1136/bmj.c3172 Killer heatwaves Stimulated by increasing concern about climate change, European researchers have studied the impact of severe heatwaves on mortality over 15 years. They found that longer heatwaves were associated with a 1.5 to threefold rise in mortality each day compared with shorter ones and that death was most likely to be due to respiratory, rather than cardiovascular, causes. Older women appeared to be the most vulnerable. The study included the heatwave of 2003, the hottest ever recorded in Europe, with temperatures 20%-30% higher than usual. During this time the relative increase in mortality for residents of Paris was 20 times higher than expected, and five times higher for London and Barcelona.1 According to the authors, the variable impact of the 2003 heatwave within European cities could not be explained by differences in maximal temperature alone — with factors such as individual adaptability and pre-existing health systems and housing conditions also playing a role.1,2 Additional risk factors such as living alone and not having access to transport have been identified in a review article published in another medical journal.3 1. Environmental Health 2010, 9:37 doi:10.1186/1476-069X-9-37 2. Environmental Health 2010, 9:38 doi:10.1186/1476-069X-9-38 3. CMAJ 2010; 182: 1053-1060 doi 10.1503/cmaj.081050

Alison Williams

Med J Aust 2010; 193 (4 Suppl).