Volume 193 Issue 5

We need those not directly in the firing line to appreciate the evidence on overcrowding Resolving access block and emergency department (ED) overcrowding is finally front and centre of the political agenda. Governments have heeded calls for action and responded by announcing a national access target to improve timely treatment in Australian EDs. After the target is implemented, “anyone presenting to a public hospital emergency department will be admitted, referred for treatment or discharged within four hours of presentation, where it is clinically appropriate to do so”.1 In the United Kingdom, a similar 4-hour target has been in place since 2004, and, despite a recent policy announcement concerning its abolition from April 2011, timeliness of care and avoidance of delay once a patient is ready to move to a ward “will always remain an important element of any balanced approach to quality”.2 Reducing the number of hospital beds and increasing occupancy above 85% in the name of operational efficiency have clearly had a negative effect, as the demand for hospital beds in Australia exceeds supply.3 The root cause of the problem will remain unless hospital capacity is addressed in an integrated approach at both national and state levels.3 In this issue of the Journal, several articles discuss hospital occupancy. Keegan articulates the evidence for using hospital bed occupancy as an operational quality measure and target.4 As hospital bed occupancy rises above 85%, adverse effects include increased rates of hospital-acquired infections, staff health deterioration and escalating hospital inefficiency. Keegan advocates a shift to using patient outcome measures, rather than current process measures to judge health system function. This evidence presents a counterpoint to a discussion started by Bain and colleagues earlier in the year, which suggested that the 85% target occupancy figure is “a candidate for myth status” and is “both simplistic and likely to lead to flawed policy”.5 Jones points out that occupancy and hospital size are linked, and therefore broadens the debate to include hospital size.6 He explains clearly what we all know intuitively: hospital planners have been delivering hospitals that are too small. When planning new hospitals, future bed requirements would be more realistically estimated by using readily available figures for occupied bed-days and examining trends over time, compared with just using admission numbers and length of stay. This would take into account factors influencing volatility of demand for beds. Trends in occupied bed-days show that English hospitals needed as many beds in 2007 as in 1998, despite a large reduction in available beds. The situation is the same in Australia and Canada, yet there is a pervading belief among planners that increasing efficiencies will account for any shortfalls. Jones discusses factors apart from demography that affect demand, including clinical practice changes, environmental cycles, and the increasing need for end-of-life care. He concludes, “can we please have a true evidence-based debate . . .?”, as patients and clinical staff deserve to benefit from the tools required to deliver effective and efficient health care. It is very pleasing to see the debate continue; the rapid growth in the published literature on access block and ED overcrowding since 2007 demonstrates increased focus on this issue.3 But further than this, we need those not directly in the firing line to appreciate the evidence on access block and ED and hospital overcrowding, so that we see the end of policy setting without attention to relevant system capacity issues. For instance, the Australian Commission on Safety and Quality in Health Care has identified reduction of hospital-acquired infection as a priority;7 however, interventions are focused only at the individual staff and patient level, without mention of the system issue of overcrowding. Similarly, while EDs are the most commonly complained about sites of care in New South Wales, and a third of these complaints relate to access to care,8 the NSW public health system’s incident management system does not include access block and ED overcrowding as reportable incidents. Failure to acknowledge the causes and consequences of high hospital bed occupancy is seen in well publicised health system responses to incidents that have occurred in overcrowded EDs. The solutions proposed in response to these incidents so far have not included fixing the underlying reason for the patient being stuck in the waiting room — lack of hospital capacity.9,10 Transparent performance reporting and new national standards are part of planned health reforms in Australia, but there are problems with the accuracy of current performance data,11 and, as Keegan points out, development of meaningful outcome measures of patient care is required.4 In the meantime, the verdict is in on access block, high bed occupancy and ED overcrowding — they are bad for patients, staff and the system itself. It is time hospital capacity was also on the patient-safety policy agenda.

Sally M McCarthy MB BS, MBA, FACEM

The importance to patient safety of clinician-led mortality auditing needs system-wide recognition In April 2010, the Council of Australian Governments (COAG) agreed on health and hospitals reform, with the establishment of the National Health and Hospitals Network. The aims of the network include “helping patients receive more seamless care across sectors of the health system” and “improving the quality of care” with “high-performance standards”.1 As a key component of the reforms and a funding condition, health facilities will be required to regularly report performance data to the federal government. Data will be based on national performance indicators that are already agreed to by COAG and address “access to services, quality of service delivery, financial responsibility, patient outcomes and/or patient experience”.2 Disappointingly, the COAG reforms appear to neglect clinical patient outcome data that are reported for the purpose of monitoring and improving patient safety, not least of which are mortality data. In Australia, pooled data on anaesthesia-related and surgery-related perioperative mortality are routinely analysed by the Australian and New Zealand College of Anaesthetists Mortality Working Group and the Royal Australasian College of Surgeons’ Australia and New Zealand Audit of Surgical Mortality, respectively.3 The practice of anaesthesia is highly regarded for its patient-safety record, and mortality reporting is considered an important tool in monitoring safety by informing standards of care with respect to equipment, techniques and classification of patients’ fitness.4 This year will see the first national public reports on surgical mortality in Australia, with early reports from Western Australia supporting the argument that clinician participation and leadership in mortality audits produce changes and improvements in patient care. Data from WA show that the proportion of deaths associated with deficiencies of care has fallen, and 73% of participating surgeons have changed their practice in at least one way.5 Clinician-led mortality reporting can contribute meaningfully to health reform but, sadly, there are few other instances of peer review of treatment-associated mortality and centralised public reporting in Australian health systems. Closer examination reveals that even the national anaesthesia dataset is incomplete because several states do not participate in mortality audits.3 Cooper and Gaba, in an appraisal of international anaesthesia-related mortality reporting, explain the limitations of, and possible reluctance to participate in, mortality reporting, which they claim is “plagued by confounding variation in definitions, relatively small sample sizes from selected institutions, and the lack of large population studies”.4 The Special Committee Investigating Deaths Under Anaesthesia (SCIDUA) in New South Wales — the longest-serving committee of its sort in Australia — is an excellent model of clinician-led mortality reporting.6 Appointed by the NSW Minister for Health and administered by the Clinical Excellence Commission (CEC), SCIDUA reviews all deaths occurring within 24 hours of anaesthesia or sedation. Data analyses by SCIDUA, which this year is celebrating its 50th anniversary, have substantially contributed to mortality reporting internationally.3,7,8 The Australia and New Zealand Audit of Surgical Mortality developed from the SCIDUA model via the NSW Special Committee Investigating Deaths Associated With Surgery (established in 1993, the latter is now the Collaborating Hospitals Audit of Surgical Mortality, and it too is administered by the CEC). SCIDUA’s terms of reference provide solutions to several of the limitations described by Cooper and Gaba4 and are useful starting points for other groups establishing mortality registers.6 Important starting points include a clearly defined preoperative period and phrasing of degrees of contribution to death. SCIDUA’s registry includes both expected and unexpected deaths, enabling identification of unanticipated emerging threats to safety, such as those associated with new drugs and procedures. Patients are classified according to their risk of death from comorbidities. This classification allows data about expected and unexpected deaths to be analysed separately, an essential requirement for trend analysis when concomitant increases in patient and surgical complexity could confound mortality rates. All sources of data obtained by SCIDUA are protected by qualified privilege under section 23 of the Health Administration Act 1982 (NSW). Of historical interest, SCIDUA was responsible for this section of the Act, which ensures qualified privilege to peer-review committees across all clinical disciplines within NSW. Recent changes to the NSW Public Health Act 1991 and Public Health (General) Regulation 2002 have led to a modified procedure for reporting deaths occurring within 24 hours of anaesthesia or sedation (now classified as a Category 1 scheduled medical condition). However, the new procedure retains not only mandatory notification of perioperative death but protection by privilege of anaesthetists who voluntarily submit information and analyses. These provisions encourage frank and comprehensive reporting, evidenced by the breadth of information available for analysis.3 Lessons in maintaining patient safety generated through SCIDUA are communicated widely. SCIDUA sends a confidential report outlining its conclusions about the circumstances contributing to death to the notifying anaesthetist. Pooled de-identified data are incorporated into the Australian and New Zealand College of Anaesthetists’ national triennial mortality report.3 The health care community is alerted to perceived safety risks through an annual report provided to the NSW Minister for Health and through periodic reports published in national and international journals.9,10 All deaths in all health facilities should be subject to clinical scrutiny. De-identified and pooled data should be systematically analysed for the purpose of continually monitoring patient safety as therapies change. The models provided by SCIDUA and, more recently, the Australia and New Zealand Audit of Surgical Mortality are there to be applied by all health care providers. Food for thought!

Leonie M Watterson MB BS, FANZCA, MClinED · Ross B Holland MB BS, FANZCA, FHKCA · Jan M Davies MSc, MD, FRCPC · Clifford F Hughes AO, MB BS, FRACS

Recent reviews suggest a low risk of allergic reactions to egg-cultured influenza virus vaccines Australian influenza notification and hospitalisation rates are highest in children aged under 5 years,1 the group most commonly affected by egg allergy. While vaccines derived from influenza virus grown in mammalian cell cultures exist, those currently distributed in Australia and New Zealand are grown in hen eggs. The ability to safely vaccinate egg-allergic individuals (particularly in the context of epidemic influenza) will remain an important public health issue, well after concerns surrounding recent non-allergic adverse reactions in young children subside (Australian governments recently suspended seasonal flu vaccination for healthy children aged under 5 years; see http://www.immunise.health.gov.au). Product information and current Australian vaccination guidelines list egg anaphylaxis as an absolute contraindication to influenza vaccination,2 yet recent studies suggest that most egg-allergic individuals can be safely vaccinated. Most reported cases of anaphylaxis in egg-allergic patients after influenza vaccination occurred over 20 years ago, when the amount of egg protein in vaccines was substantially higher. The amount of egg protein (measured as ovalbumin) in vaccines distributed in Australia and New Zealand in recent years has been about 1 μg or less per dose (manufacturer data), which is substantially less than the estimated 130 μg likely to trigger reactions in patients with egg allergy if taken orally.3 Are concerns about vaccinating egg-allergic individuals evidence-based? Recent reviews suggest a very low risk of allergic reactions to influenza vaccination.4 A United States population study reported 11 cases of non-fatal anaphylaxis (none involving egg allergy) after 48 million doses of influenza vaccine had been given.5 Although this suggests there is a low risk of harm from the vaccine, patients with egg allergy were probably excluded from the vaccination program. More useful information is obtained from recent prospective studies. In a US study of 83 egg-allergic patients (27 with anaphylaxis) and 124 controls, positive vaccine skin tests were detected in four allergic patients and one control subject, yet all tolerated split-dose vaccination (a 10% dose followed by the remaining 90% 30 minutes later).6 An Italian study demonstrated a similar safety profile in 44 children with asthma and egg allergy (10 with anaphylaxis).7 In a Canadian study of split-dose H1N1 vaccination of 830 egg-allergic children, nine developed rash (treated with antihistamines) and three developed bronchospasm, but none progressed to anaphylaxis.8 In an expanded vaccination program, the same study reported rash, cough, or throat irritation or constriction in 71 of 3640 patients, but none developed anaphylaxis.8 In Western Australia, after the death from influenza of three otherwise healthy preschoolers in 2007, 165 egg-allergic children aged 6 months to 16 years (48 with anaphylaxis) were vaccinated. One patient developed mild facial urticaria after the first dose, but tolerated the second dose.9 In a recent US study, 164 of 171 patients (aged 6 months to 18 years) with non-anaphylactic egg allergy tolerated split-dose vaccination. Six experienced urticaria or wheeze after the 10% vaccine dose and one experienced flushing and hives after the 90% dose, but none had anaphylaxis.10 British, Canadian, European and US consensus guidelines4,8,11,12 suggest that most patients with egg allergy can safely receive seasonal and H1N1 vaccines if they contain no more than 1 μg/dose of egg ovalbumin. The Australasian Society of Clinical Immunology and Allergy concurs with these views and has released guidelines for vaccination of the potentially egg-allergic patient (http://www.allergy.org.au/content/view/27/8). We acknowledge that these proposals are at variance with Australian immunisation guidelines.2 People presenting for vaccination may be classified into three risk groups: Those considered to be at no additional risk. This includes people with non-egg food allergy, past egg allergy (who can now eat whole egg), and family (not personal) history of egg allergy, as well as those who react to raw egg but can tolerate at least a teaspoon of lightly cooked egg (eg, scrambled or boiled). This group can receive the vaccine as a single dose, followed by the 15-minute observation period recommended in Australian guidelines2 (20 minutes in NZ). Importantly, egg allergy is not a contraindication for the measles–mumps–rubella vaccine, which contains no egg protein. Those with non-anaphylactic allergic reactions to eggs or egg-containing food. Some authorities recommend a 10%–90% split-dose regimen, 30 minutes apart, if no adverse reaction occurs after the first dose; others recommend a single dose. Data from split-dose protocols6-10 have not indicated any significant adverse reactions in this risk group, despite administration of the full dose over 30 minutes. Based on current evidence, we suggest that the vaccine can be safely administered as a single dose with a 30-minute observation period, rather than the standard 15 minutes. Those who have had egg anaphylaxis in the past, and those who have never ingested egg in any form, but have had positive skin or blood test results for egg allergy. As reactivity and severity cannot be assessed in advance, these patients merit consideration as a potentially higher-risk group. The decision to vaccinate should include a risk–benefit evaluation of the vaccination, consultation with an allergy specialist (including initial telephone contact), direct medical supervision of vaccination, and use of a split-dose protocol (10%–90%, 30 minutes apart), with another 30-minute observation period after the final dose. Skin-prick or intradermal allergy testing with the vaccine before administration is not recommended, as results correlate poorly with vaccine tolerance. If the first vaccination is tolerated, the second vaccine dose can be given as a single dose in the same year. Since tolerance one year does not guarantee safety the next (due to yearly fluctuations in egg vaccine content), we recommend that the same process be followed each year. Rare allergic reactions (including reactions to non-egg vaccine ingredients) cannot be totally excluded. Vaccines should always be administered in facilities with health professionals able to recognise and treat anaphylaxis. Adverse events following vaccination should be reported to the Advisory Committee on the Safety of Medicines (Australia) or Medsafe (NZ), documenting the timing of onset, nature and severity of symptoms, likelihood of a relationship with vaccination, and any other relevant health details.

Raymond J Mullins MB BS,PhD, FRACP · Andrew Kemp MB BS, PhD, FRACP · Michael Gold MB ChB, MD, FRACP

Identifying the emerging threats for which we must be vigilant In 1922, infectious diseases accounted for 15% of all deaths in Australia, but this rate declined dramatically to 1% by 2007 due to a combination of antibiotics, vaccination and public health measures. Yet infectious diseases continue to feature prominently in Australia. The Australian Institute of Health and Welfare has just released its biennial publication on the health of the nation, Australia’s health 2010 — a statistical and informed commentary that examines a variety of health issues dominating the national landscape.1 Here, I summarise the report’s chapter on infectious diseases to paint a picture of where we are today and the challenges we may well face in our future. Among vaccine-preventable diseases, invasive meningococcal disease remains one of the most feared. However, notification data continue to show a pleasing trend of decreasing cases annually.1 Much of this decline can presumably be attributed to the introduction of the meningococcal C conjugate vaccination program in 2003.2 Not surprisingly, cases of the B strain, for which there is no vaccine, dominate the notifications, although numbers have been stable and certainly haven’t increased. Similarly, rates of invasive pneumococcal disease remain steady and well below those seen before the introduction of universal infant vaccination in 2005.1 Concerns continue that there will be a surge of invasive pneumococcal disease due to non-vaccine serotypes — so-called serotype replacement — following introduction of the conjugate vaccination program that will offset any reductions from the program; however, this has not yet happened. Pertussis notifications reached unprecedented levels in 2008 and 2009, with a particularly large increase in the proportion of cases in 0–4-year-olds — the group most vulnerable to severe disease from pertussis.1 Yet it is likely that this increase in notifications can at least partly be explained by increased testing and easier access to better tests, such as polymerase chain reaction (PCR). The world experienced its first influenza pandemic in 41 years with the outbreak of pandemic (H1N1) 2009 influenza (popularly known as “swine flu”). There were over 45 000 laboratory-confirmed notifications of influenza in Australia in 2009, eclipsing those of previous years — by comparison, in 2007, the other severe influenza year in recent times, there were 10 445 notifications. However, there was undoubtedly more testing conducted in 2009. The figure shown in the Box elegantly demonstrates how the swine flu virus behaved like a typical pandemic strain, predominantly affecting adolescents and young adults, while the 2008 “standard” seasonal strain mainly targeted people at the extremes of age.1 Although pandemic influenza has had the highest profile in recent times, chlamydia, with over 62 000 notifications, was the most highly notified infection in Australia in 2009 and remains an important issue among the sexually active. However, as with pertussis and influenza, increased testing has almost certainly contributed to the large number of infections seen recently.1 From 2000 to 2009, there was a decline in rates of newly diagnosed hepatitis B and C infections. Particularly among adolescents and young adults, this decline may be due to factors such as a reduction in injecting drug use and a vaccination program for adolescents against hepatitis B infection. Despite this, however, chronic hepatitis B and C infections are looming as long-term challenges for Australia.1 One model predicts that the 2008 figure of 187 000 people living in Australia with chronic hepatitis B infection could markedly increase to 276 000 cases in 2017 if current practices and resources remain unchanged. This would be associated with a large increase in hepatitis B-related deaths, including those from hepatocellular cancer.3 It is estimated that 212 000 people were living with chronic hepatitis C infection in Australia in 2008, and these people are at risk of similar chronic sequelae as those with chronic hepatitis B infection.4 Challenges include increasing awareness of the diseases and improving access to treatment for affected people, many of whom are from marginalised groups (eg, non-English speaking migrants, Indigenous Australians and injecting drug users). The federal government has responded to these challenges by releasing its first national hepatitis B strategy and third national hepatitis C strategy.4,5 A dengue outbreak featured prominently in northern Queensland between November 2008 and June 2009. Around 1000 cases occurred during this 8-month period, matching the total for the preceding 9 years. The outbreak was characterised by all four strains of dengue circulating, including a virulent DENV-3 strain that had a shorter incubation period within both mosquitoes and humans.1 Hendra virus infection remains unique to Queensland, where outbreaks continue to occur, causing much angst among the public and communicable disease services alike. In 2008 and 2009, Hendra virus, which is transmitted to humans from infected horses, caused the deaths of two veterinary workers.1 There are two emerging infections of concern in Australia. First, hypervirulent Clostridium difficile (also known as PCR ribotype 027 or NAP1) infection has become well established in the health care systems of many northern hemisphere nations in recent years, with high case-fatality and bowel-resection rates. Although a milder form of the infection has been well established here for years, Australia had remained free of this particular hypervirulent strain until our first imported case was detected in Western Australia in 2009.6 This was followed in May 2010 by an outbreak among patients in a Melbourne hospital,7 raising concerns that it may become established in Victoria before spreading elsewhere. Second, the appearance of multiresistant gram-negative organisms such as Escherichia coli in returning travellers, especially those arriving from Asia, is of concern. Although colonisation with these organisms in the bowel is asymptomatic, the problem arises when they cause symptomatic illness, typically in the urinary tract. Few antibiotics are available to treat such infections, and they are often expensive (eg, carbapenems) or dangerous (eg, potential nephrotoxicity and ototoxicity from amikacin). One study found that, while 8% of travellers were colonised with multiresistant E. coli before leaving Australia, almost 50% were colonised on their return.1,8 (It appears that Customs officials may have to worry about more than concealed drugs in travellers’ bowels on their return to Australia!) The health inequities experienced by Australia’s Indigenous peoples are well recognised and apply to many infectious diseases. One example is acute rheumatic fever and rheumatic heart disease. Indigenous people in the Northern Territory have one of the highest rates in the world of these conditions and are around 20 times more likely to die from rheumatic heart disease than non-Indigenous Australians.9 Despite the advances in combating acute and chronic infectious diseases over the past century, both continue to present challenges to our health system, especially for certain Indigenous populations. Multiresistant gram-negative bacterial infections acquired from overseas and hypervirulent C. difficile infection are emerging threats in Australia for which we must be vigilant. This is in addition to infections caused by the already established multi-resistant nosocomial pathogens such as vancomycin-resistant enterococci. The need to isolate affected patients and use expensive antibiotics to treat them only further burdens the hospital system. A mandatory reporting system for certain hospital-acquired infections could be one way to address this. Although childhood immunisation programs have generally been successful, we need to be watchful for resurgent infections, such as pertussis, where immunity from childhood vaccination has waned. Finally, as last year’s swine flu outbreak demonstrated, a pandemic has the potential to consume considerable resources and generate widespread concern. While the 2009 influenza outbreak has passed, the potential for further pandemics and the need to prepare for them persist. Avian influenza, which continues to cause human infections overseas, immediately comes to mind in this regard. Age distribution of influenza notifications in a pandemic year (2009) versus a standard seasonal year (2008)* * Reproduced from Australia’s health 2010 with permission of the Australian Institute of Health and Welfare.1

Sanjaya N Senanayake FRACP, MAppEpid, MB BS

Objective: The aim of this study was to characterise rates of late mortality and second cancers in an Australian cohort of childhood cancer survivors and compare these to rates observed in the New South Wales population.Design, setting and participants: Records for 896 childhood cancer survivors treated at the Sydney Children’s Hospital between 1972 and 1999 were linked to the National Death Index and NSW Central Cancer Registry to identify deaths and notifications of second cancers. Survivors were defined as those alive for at least 5 years after diagnosis and were followed until death or 31 December 2004, whichever occurred first.Main outcome measures: Standardised mortality ratios (SMRs) and standardised incidence ratios (SIRs) were used as measures of relative risk. A Cox proportional hazard model was used to quantify the influence of demographic and disease-related characteristics on the risk of death and second cancers.Results: The SMR and SIR were 7.46 and 4.98 times higher, respectively, among cancer survivors relative to the NSW population. Relative mortality was highest in survivors of soft-tissue sarcoma (SMR, 18.95 [95% CI, 6.88–40.81]) and central nervous system (CNS) malignancies (SMR, 16.78 [95% CI, 7.62–31.64]). The leading causes of death included recurrence of the primary childhood cancer (55%) and second cancers (12%), as well as treatment-related complications (17%) The most frequently observed second cancers were bone and thyroid cancers, melanoma, and CNS malignancies, and second cancers were most common among survivors of leukaemia, soft-tissue sarcoma and Hodgkin’s lymphoma.Conclusions: Compared with the general population, survivors of childhood cancer in Australia are at increased risk of late mortality and second cancers. These findings highlight a continuing need to assess health issues faced by childhood cancer survivors and develop strategies to minimise the adverse outcomes associated with treatment for childhood cancer.

Carmen L Wilson BSc(Hons), PhD · Richard J Cohn MB BCh, FRACP · Karen A Johnston RN, MN · Lesley J Ashton MPH, PhD

Objective: To investigate the potential contribution of international medical students at Australian universities to the Australian medical workforce.Design, setting and participants: A prospective survey in 2006–2007 of 619 international medical students in their final 2 years of undergraduate- and graduate-entry medical courses across eight Australian universities, followed by a 2009 survey of 88 international medical graduates of the University of Melbourne (most of whom were respondents of the earlier survey), assessing the correlation between students’ intended place of internship and their actual place of internship.Main outcome measures: The survey respondents’ preferred internship location; the proportion of respondents who intended to remain in practice in Australia long term; and correlation between respondents’ intended internship locations and actual placements in their first postgraduate year.Results: Of the 619 international medical students surveyed in 2006, 358 (58%) responded. Most planned to undertake Australian internships and seek permanent-resident status, although a third were undecided about their long-term plans. Nationality was a highly significant variable. Most preferred city rather than regional or rural training locations and expressed interest in migrating to Australia. The 2009 survey of the University of Melbourne’s 2008 medical graduates showed a high correlation between students’ plans in their last two years of study and outcomes in their first postgraduate year, with 73% accepting Victorian internships for 2009.Conclusion: International medical students studying at Australian universities represent a substantial and highly acceptable medical workforce resource for Australia. Their requirement for internships needs to be considered in, and should influence, infrastructure planning.

Lesleyanne Hawthorne PhD, MA, BA(Hons) · Jan Hamilton MA, BA, GradDip Multicultural Education

Objectives: To determine the prevalence of occult brain abnormalities in magnetic resonance imaging of active amphetamine users.Design, setting and participants: Prospective convenience study in a tertiary hospital emergency department (ED). Patients presenting to the ED for an amphetamine-related reason were eligible for inclusion. We collected demographic data, drug use data, and performed a mini-mental state examination (MMSE).Main outcome measures: The proportion of patients with an abnormality on their MRI scan.Results: Of 38 patients enrolled, 30 had MRI scans. Nineteen were male and their mean age was 26.7 ± 5.4 years (range 19–41 years). The mean age of first amphetamine use was 18 years (range 13–26 years). Sixteen patients used crystal methamphetamine (mean amount 2.5 g/week), nine used amphetamine (“speed”) (mean amount 2.9 g/week), and 23 used ecstasy (mean amount 2.3 tablets/week). Marijuana was smoked by 26 (mean amount 5.9 g/week), and 28 drank alcohol (mean amount 207 g/week). The median MMSE score was 27/30 (interquartile range, 26–29). Abnormalities on brain MRI scans were identified in six patients, most commonly an unidentified bright object (n = 4).Conclusion: In this pilot study of brain MRI of young people attending the ED with an amphetamine-related presentation, one in five had an occult brain lesion. While the significance of this is uncertain, it is congruent with evidence that amphetamines cause brain injury.

Daniel M Fatovich MB BS, FACEM · David L McCoubrie MB BS, FACEM · Swithin J Song MB BS, FRANZCR · David M Rosen MB BS, FRACP, PhD · Nick D Lawn MB ChB, FRACP · Frank F Daly MB BS, FACEM

Objective: Design, setting and participants: Descriptive study of alcohol consumption in the NT population, based on sales data and self-report surveys, and alcohol-attributable deaths and hospitalisations among people in the NT in the 2004–05 and 2005–06 financial years using population alcohol-attributable fractions specific to the NT.Main outcome measures: Per capita consumption of pure alcohol, self-reported level of consumption, and age-standardised rates of death and hospitalisation attributable to alcohol.Results: Apparent per capita consumption of pure alcohol for both Aboriginal and non-Aboriginal populations in the NT has been about 14 litres or more per year for many years, about 50% higher than for Australia as a whole. We estimated that there were 120 and 119 alcohol-attributable deaths in the NT in 2004–05 and 2005–06, respectively, at corresponding age-standardised rates of 7.2 and 7.8 per 10 000 adult population. Alcohol-attributable deaths occur in the NT at about 3.5 times the rate they do in Australia generally; rates in non-Aboriginal people were about double the national rate, while they were 9–10 times higher in Aboriginal people. There were 2319 and 2544 alcohol-attributable hospitalisations in the NT in 2004–05 and 2005–06, respectively, at corresponding rates of 146.6 and 157.7 per 10 000 population (more than twice the national rate).Conclusion: In recent years, alcohol consumption and consequent alcohol-attributable deaths and hospitalisations for both Aboriginal and non-Aboriginal people in the NT have occurred at levels far higher than elsewhere in Australia.

Steven J Skov MB BS, FAFPHM, MPH · Tanya N Chikritzhs BA(Hons), PostGradDip(Epi · Shu Q Li BM, BN, MPH · Sabine Pircher BNutrDiet, MPH · Steven Whetton BEc(Hons), MSc(Economics)

Health professionals worry that information about adverse events conveyed to patients in open disclosure (OD) may be used against them in medicolegal proceedings. Whether and how strongly state and federal laws in Australia protect against such uses is unclear. Our analysis concludes that existing laws do not prohibit the sharing of most types of information on adverse events with patients. However, none of these laws was enacted with OD in mind and, in general, the protections they provide are quite weak. If policymakers want OD to become a routine part of medical practice, law reform may be needed in the form of stronger protections directed specifically at the contents of OD communications.

David M Studdert LLB, ScD, MPH · Mark W Richardson LLB, MSc

Objective: To investigate the specific factors that graduates perceive to influence their success in obtaining primary training in a chosen field.Design, setting and participants: The New South Wales Medical Registration Board provided data on doctors who were registered to practise between 1995 and 2006. A brief, paper-based survey was sent to a random selection of 2000 doctors. Main outcome measures: Doctors’ self-reported perceptions on the impact of demographic details, specialty training applied for, university training and other factors on opportunities for further training after medical school.Results: Of the 375/1915 doctors (19.6%) who responded, most had completed a 6-year undergraduate degree from the University of Sydney, University of NSW or University of Newcastle, and most were at registrar level. Of 242/321 doctors (76%) who had applied for a training position, 240 (99%) had been accepted. The support of a mentor was considered the most positive influence on meeting long-term career goals (255/318 [80%]). Learning how to communicate with patients was valued as the most helpful aspect of medical school (270/318 [85%]).Conclusion: The personal attributes of graduates were considered more influential in achieving career goals and accessing further training than perceived features of a medical program. This suggests that more emphasis and research should be devoted to selecting the most appropriate candidates, rather than restructuring medical curricula to meet a presumed need for more content knowledge before graduation.

Sarah J Hyde BA(Psych)(Hons) · Pippa L Craig BSc, MHPEd, PhD · Ann J Sefton AO, MB BS, PhD, DSc · Greg L Ryan RN, MA, PhD · Stephanie J Arnold MB BS, BSc(Hons) · Vasi Naganathan MB BS, FRACP, PhD

Objective: To assess the outcomes of appendicectomy in an acute care surgery (ACS) model compared with a traditional on-call (Trad) model.Design: Retrospective historical control study comparing appendicectomy outcomes in the Trad period (April 2004 to March 2005) with outcomes in the ACS period (April 2006 to March 2007).Setting: The Prince of Wales Public Hospital, a metropolitan tertiary referral centre in Sydney.Patients: All adult patients undergoing appendicectomy during 1-year periods before and after the introduction of the ACS model.Intervention: The introduction of an ACS model for managing all emergency general surgical presentations.Main outcome measure: Complication rate.Results: A total of 402 appendicectomies were performed, 176 during the Trad period and 226 during the ACS period. There was no perioperative mortality. The complication rate was lower in the ACS period than the Trad period (9.3% v 17.0%; P = 0.02). After the intervention, there was no significant change in the time from presentation to arrival in theatre or in length of stay, but the proportion of operations performed at night (24:00–08:00) was reduced from 26.1% to 15.0% (P = 0.006). The proportion of negative appendicectomies was reduced from 22.7% to 17.3%, but the change was not statistically significant (P = 0.08). There was no difference in perforation rate before and after the intervention (13.6% v 13.3%; P = 0.86).Conclusion: The ACS model provides a safe surgical environment for patients and is associated with a reduced complication rate. Under the ACS model, there was an increase in the number of patients treated conservatively overnight, but this did not lead to an overall increase in perforation rate or length of stay.

Robert C Gandy MB ChB, MRCS · Phillip G Truskett MB BS, FRACS · Shing W Wong MB BS, MS, FRACS · Sanchia Smith MB BS · Michael H Bennett MB BS, MD, FANZCA · Andrew D Parasyn MB BS, FRACS

Objectives: To determine which laboratory tests are first associated with severe envenoming after a snakebite, when (ie, how long after the bite) the test results become abnormal, and whether this can determine a safe observation period after suspected snakebite.Design, patients and setting: Prospective cohort study of 478 patients with suspected or confirmed snakebite recruited to the Australian Snakebite Project from January 2002 to April 2009, who had at least three sets of laboratory test results and at least 12 hours of observation in hospital after the bite. Severe envenoming was defined as venom-induced consumption coagulopathy (VICC), myotoxicity, neurotoxicity or thrombotic microangiopathy.Main outcome measures: International normalised ratio (INR), activated partial thromboplastin time (aPTT), creatine kinase (CK) level, and neurological examination.Results: There were 240 patients with severe envenoming, 75 with minor envenoming and 163 non-envenomed patients. Of 206 patients with VICC, 178 had an INR > 1.2 (abnormal) on admission, and the remaining 28 had an INR > 1.2 within 12 hours of the bite. Of 33 patients with myotoxicity, a combination of CK > 250 U/L and an abnormal aPTT identified all but two cases by 12 hours; one of these two was identified within 12 hours by leukocytosis. Nine cases of isolated neurotoxicity had a median time of onset after the bite of 4 hours (range, 35 min – 12 h). The combination of serial INR, aPTT and CK tests and repeated neurological examination identified 213 of 222 severe envenoming cases (96%) by 6 hours and 238 of 240 (99%) by 12 hours.Conclusion: Laboratory parameters (INR, aPTT and CK) and neurological reassessments identified nearly all severe envenoming cases within 12 hours of the bite, even in this conservative analysis that assumed normal test results if the test was not done.

Graham Ireland MB BS · Simon G A Brown FACEM, PhD · Nicholas A Buckley BMed, FRACP, MD · Jeff Stormer RN · Bart J Currie MB BS, FRACP · Julian White MB BS, MD · David Spain MB BS, FACEM · Geoffrey K Isbister BSc, FACEM, MD

Timely access to safe hospital care remains a major concern. Target bed-occupancy rates have been proposed as a measure of the ability of a hospital to function safely and effectively. High bed-occupancy rates have been shown to be associated with greater risks of hospital-associated infection and access block and to have a negative impact on staff health. Clinical observational data have suggested that bed occupancies above 85% could adversely affect safe, effective hospital function. Using this figure, at least initially, would be of value in the planning and operational management of public hospital beds in Australia. There is an urgent need to develop meaningful outcome measures of patient care that could replace the process measures currently in use.

Andrew D Keegan MB BS, FRACP, PhD

Objective: To investigate morbidity related to misuse of over-the-counter (OTC) codeine–ibuprofen analgesics.Design and setting: Prospective case series collected from Victorian hospital-based addiction medicine specialists between May 2005 and December 2008.Main outcome measures: Morbidity associated with codeine–ibuprofen misuse.Results: Twenty-seven patients with serious morbidity were included, mainly with gastrointestinal haemorrhage and opioid dependence. The patients were taking mean daily doses of 435–602 mg of codeine phosphate and 6800–9400 mg ibuprofen. Most patients had no previous history of substance use disorder. The main treatment was opioid substitution treatment with buprenorphine–naloxone or methadone.Conclusions: Although codeine can be considered a relatively weak opioid analgesic, it is nevertheless addictive, and the significant morbidity and specific patient characteristics associated with overuse of codeine–ibuprofen analgesics support further awareness, investigation and monitoring of OTC codeine–ibuprofen analgesic use.

Matthew Y Frei MB BS, FAChAM · Suzanne Nielsen BPharm, PhD, MPS · Malcolm D H Dobbin PhD, MB BS, FAFPHM · Claire L Tobin RN, MPH

Current methods used to calculate the required size of hospitals are underestimating the true capacity needed for operational efficiency. Trends in occupied bed-days (rather than admissions and length of stay) give better estimates of future bed requirements. Hospital occupancy rates depend on volatility in demand, not efficiency. Larger bed pools and hospitals can operate at higher average occupancy. Cost efficiency should be focusing on staffing based on the patients in the beds and not on the available beds. Hospitals require supporting climatalogical forecasts to allow for seasonal and other climate-related changes in admissions, if flexible staff deployment is to become a reality.

Rodney P Jones BSc(Hons), PhD, ACMA

There is considerable public, political and professional debate about the need for additional hospital beds in Australia. However, there is no clarity in regard to the definition, meaning and significance of hospital bed counts. Relative to population, there has been a total decline in bed availability in Australia over the past 15 years of 14.6% (22.9% for public hospital beds). This decline is partly offset by reductions in length of stay and changes to models of care; however, the net effect is increased bed occupancy which has in turn resulted in system-wide congestion. Future bed capability needs to be better planned to meet growing demands while at the same time continuing trends for more efficient use. Future planning should be based in part on weighted bed capability matched to need.

Andrew Wilson MB BS(Hons), PhD · Gerard J FitzGerald MD, FACEM, FRACMA · Susan Mahon BN, MBA, AFCHSE

Clinical record In 2008, an 88-year-old woman with a background of well controlled systemic hypertension and high myopia presented to an emergency department with a 5-day history of left periorbital swelling, erythema and mild discomfort, without visual loss. She was seen in the ophthalmology clinic on the same day. Her visual acuity was 6/12 in each eye. She was afebrile, with left upper and lower lid erythema, oedema closing the palpebral fissure, and conjunctival and scleral injection. Slit-lamp biomicroscopy revealed normal anterior chambers; clear, well centred intraocular lens implants from previous uncomplicated cataract surgery; and posterior staphylomata (an incidental finding of bulging of the globe seen in some highly myopic patients). A computed tomography (CT) scan revealed left periorbital soft tissue thickening, with stranding confined to the preseptal area (Figure A). Radiologically, the patient appeared to have periorbital cellulitis, although clinical examination, being more sensitive to ocular signs, revealed postorbital septal spread of infection as evidenced by scleral injection (not expected to be seen on a CT scan), leading to the diagnosis of orbital cellulitis. Intravenous antibiotics were administered for 3 days, with moderate resolution of the periorbital swelling, although the scleral injection remained. Three days after discharge on oral antibiotics, the patient re-presented to the emergency department with recurrence of left periorbital swelling, erythema and discomfort. After administration of intravenous antibiotics for five days, her lid oedema and erythema resolved, but conjunctival and scleral injection persisted. Investigations during this second admission revealed raised erythrocyte sedimentation rate (ESR) and C reactive protein (CRP) level, with a normal blood leucocyte count. Soon after her second discharge, the patient presented again with persisting and worsening erythema of the left eye, with no associated lid swelling or erythema. A clinical diagnosis of non-necrotising anterior scleritis was made (Figure B), and it was thought that conjunctival lymphoma should be excluded. B-scan ultrasonography revealed fluid in Tenon’s capsule and scleral thickening, consistent with anterior and posterior scleritis (Figure B), and investigations again revealed a raised ESR and CRP level. Screening for tuberculosis (TB) (Mantoux test and chest x-ray), antinuclear antibodies, extractable nuclear antigen antibodies, rheumatoid factor, syphilis, and angiotensin-converting enzyme (an indicator of sarcoidosis) were negative. Screening for Wegener’s granulomatosis with perinuclear antineutrophil cytoplasmic antibodies was positive, but attempted confirmation by screening for antiproteinase 3 antibodies and antimyeloperoxidase antibodies was negative. Magnetic resonance imaging revealed marked high T2 signalling and enhancement of the left sclera, extraocular muscle insertions and distal optic nerve (Figure C). A scleroconjunctival biopsy was performed to exclude conjunctival lymphoma or other uncommon diagnoses, such as tuberculosis and fungal infection. The biopsy revealed a dense inflammatory infiltrate consisting of B and T lymphocytes, plasma cells and occasional neutrophils, with no granulomatous inflammation. Flow cytometry; immunohistochemistry; bacterial, fungal and mycobacterial staining and culture; and TB polymerase chain reaction tests were all negative. Haematological consultation excluded systemic or central nervous system lymphoma. A short course of oral prednisolone (1 mg/kg/day for 14 days) resulted in complete resolution of the patient’s signs and symptoms, and she remained well at 6-week follow-up. A: Sagittal computed tomography scan showing left periorbital soft tissue thickening and posterior staphyloma. B: Superior scleral injection and B-scan ultrasound showing fluid in Tenon’s capsule and scleral thickening, consistent with anterior and posterior scleritis. C: Magnetic resonance images showing high T2 signalling and enhancement of the left sclera, extraocular muscle insertions, and distal optic nerve. To our knowledge, this is only the second reported case of posterior scleritis mimicking orbital cellulitis. We believe that a diagnosis of posterior scleritis should always be considered when patients with presumed periorbital or orbital cellulitis do not respond appropriately to intravenous antibiotic treatment. In the previous report of posterior scleritis mimicking orbital cellulitis, the authors hypothesised that inflammation had spread anteriorly, involving the upper lid structures, causing lid swelling and simulating cellulitis.1 Orbital cellulitis has an incidence of 5.8 per 100 000 population in people aged 65 years or older.2 Posterior scleritis is much less common. McCluskey and colleagues3 published a single-centre case series of patients with posterior scleritis seen at Moorfields Eye Hospital in London that shed much light on the nature of the disease. Between 1974 and 1996, only 137 patients were diagnosed with posterior scleritis. Interestingly, in this series, only 31% of patients had visual loss, little more than half (56%) had pain, and 17% had no physical signs of posterior scleritis on examination. Anterior scleritis at or after presentation occurred in 60% of patients, with 36% having combined anterior and posterior scleritis on presentation. Only 28% had an associated systemic disease, and no patient had necrotising posterior scleritis. Our patient had no pain, no visual loss, and no physical sign of posterior scleritis on clinical examination. Her initial examination appeared to be consistent with the diagnosis of orbital cellulitis. With respect to diagnostic criteria, there were many signs in her clinical presentation that are shared by orbital cellulitis and posterior scleritis. Features that favoured the eventual diagnosis of posterior scleritis were the presence of physical and radiological signs in the absence of an appropriate response to intravenous antibiotic treatment, and a positive response to oral prednisolone treatment. Patients presenting with signs of periorbital or orbital cellulitis should always be treated with intravenous antibiotics immediately, pending the results of any radiological investigation. However, when a systemically well patient with no radiological or clinical evidence of an orbital abscess requiring surgical drainage does not respond positively to intravenous antibiotic treatment, ophthalmologists should suspect non-infective aetiology. Lessons from practice Periorbital cellulitis can spread posteriorly into the orbit, cavernous sinus and brain, and is therefore potentially lethal. Intravenous antibiotic treatment for probable cellulitis should be started immediately, without waiting for the results of diagnostic radiological investigations. When a systemically well patient with no radiological or clinical evidence of an orbital abscess requiring surgical drainage does not respond positively to intravenous antibiotic treatment, ophthalmologists should suspect non-infective aetiology. Any patient with periorbital or orbital cellulitis should be assessed by an ophthalmologist.

Michael Rossiter-Thornton BMedSc(Hons), MB BS(Hons) · Lia Rossiter-Thornton BMedSc, MB BS(Hons) · Raf Ghabrial MB BS, FRANZCO · Domit A Azar MB BS(Hons), MPH(Hons), FRANZCO

To the Editor: National best practice guidelines recognise that accurate data on the health of Indigenous Australians are crucial to improving health service delivery.1 The draft revision of the RACGP Standards for general practices acknowledges the need for improvement and requires that a practice demonstrates how it routinely records, in active patient health records, self-identified Aboriginal and Torres Strait Islander status.2 This is a commendable improvement but should be further strengthened, requiring that Indigenous status be recorded for at least 90% of active patients, the level required for a history of allergies. Improved record keeping in general practice has resulted in the potential to improve Indigenous identification among patients notified with a communicable disease. This enables the documentation of health disadvantage, and allows evaluation of measures aimed at closing the gap in health outcomes between Indigenous and non-Indigenous people. Demographic data in the NSW notifiable diseases database (NDD) were audited for all 258 Hunter New England (HNE) Salmonella infection notifications in 2007 by interviewing patients and their referring general practitioners. Interviews were completed for 83% of patients. Indigenous status was poorly recorded. The NDD listed three patients with salmonellosis as Aboriginal, but showed an unknown status for 87%. Among patients who had attended a GP during their illness (66%), practice records listed two as Aboriginal, but Indigenous status was unknown for 70%. Most GPs (95%) reported using electronic medical records, and 89% completed pathology requests with practice software. Many GPs (60%) requested information on how to appropriately ask about a patient’s Indigenous status. Interviews with patients who had been notified as having had salmonellosis identified 13 as Aboriginal, and no resistance to identification was encountered. The crude salmonellosis notification rates per 100 000 population were 42.2 (95% CI, 19.3–65.1) for Aboriginal HNE residents and 25.5 (95% CI, 21.7–28.6) for non-Aboriginal HNE residents which, while not statistically significant for this small sample, suggests a differential salmonellosis burden, consistent with studies elsewhere.3 The true burden of disease was likely to have been substantially higher, as many infections are not notified.4 The differential burden may also be an underestimate if Aboriginal HNE residents were less likely to be notified than non-Aboriginal residents due to, for example, reduced access to health services. The widespread availability of electronic practice software for generating pathology requests provides a new opportunity to substantially improve Indigenous identification in communicable disease notifications.3 Indigenous status should be routinely recorded by GPs and automatically included on their pathology request forms and subsequent laboratory notifications. There is now a need for a coordinated national approach to ensure consistent inclusion of Indigenous status on all laboratory notification data.

Anthony D Merritt · April R Roberts-Witteveen · David N Durrheim

To the Editor: I refer to the article by Gallego and colleagues in the 19 April 2010 issue of the Journal,1 which stated that (as at the time of writing, in July 2009) Australia had no formal policies for iodine supplementation in pregnant and lactating women. In January 2010, the National Health and Medical Research Council (NHMRC) released a public statement, Iodine supplementation for pregnant and breastfeeding women.2 The NHMRC recommends that women who are pregnant, breastfeeding or considering pregnancy take an iodine supplement of 150 μg each day; and women with pre-existing thyroid conditions should seek advice from their medical practitioner before taking a supplement. The public statement also provides information on the increased need for iodine during pre-pregnancy, pregnancy and breastfeeding, the risks of not having enough iodine and the types of supplement that should and should not be used. The statement was developed in consultation with an expert reference group and was based on a review of recent international scientific literature for the efficacy of iodine supplementation in increasing iodine levels in pregnant and breastfeeding women to levels that mitigate the risks associated with iodine deficiency.3 The public statement and supporting literature review can be found on the NHMRC website.2,3

Warwick P Anderson

To the Editor: We disagree with the opinion expressed by Gallego and colleagues that Australian “women planning a pregnancy and pregnant and lactating women should be advised to take an iodine supplement”,1 and offer two reasons to support our view. First, the data suggesting mild iodine deficiency in Australian women were collected from opportunistic samples of women not representative of the population at large and were obtained before the introduction of mandatory iodine fortification of bread in October 2009. We believe that recommending iodine supplementation in pregnancy without evaluating the effect of mandatory iodine fortification on iodine intake and status of pregnant women in Australia is premature.2 This is supported by a recent report, developed by the Dietitians Association of Australia on behalf of the National Health and Medical Research Council (NHMRC).3 The report clearly shows that the recommended iodine intake for pregnant women (recommended dietary allowance, 220 μg/day) is achievable from foods alone, together with iodine fortification of bread. Second, there are no randomised controlled trials (RCTs) that have examined the effect of iodine supplementation of pregnant women from regions of mild iodine deficiency (as in Australia) on neurodevelopment of the offspring or any other clinical outcomes. Gallego et al state that “iodine-containing supplements consistently benefit the iodine and thyroid status of both mother and newborn”, citing a review of iodine supplementation of pregnant women from populations with mild-to-moderate iodine deficiency.4 In fact, none of the six RCTs included in that review showed a clear effect of supplementation on maternal and newborn thyroid hormone concentrations, which suggests that the maternal thyroid is able to adapt to meet the increased thyroid hormone requirements of pregnancy in areas of mild-to-moderate iodine deficiency.5 Furthermore, Gallego et al cite no evidence to support their statement “Even subclinical hypothyroidism in the mother, occurring as a consequence of iodine deficiency, can cause irreversible brain damage in the fetus . . .”. In our view, major public health recommendations advising routine iodine supplementation for women planning a pregnancy, as well as pregnant and lactating women, should await the results of current RCTs6-8 examining the effect of maternal iodine supplementation on longer-term maternal health and neurodevelopmental outcome of children in regions with mild-to-moderate iodine deficiency, including Australia and New Zealand.

Shao J Zhou · Sheila A Skeaff · Philip Ryan · Maria Makrides

In reply: While Zhou and colleagues disagree with our viewpoint that Australian “women planning a pregnancy and pregnant and lactating women should be advised to take an iodine supplement”,1 we note that they suggest any such recommendation should await the results of their planned randomised controlled trial (RCT) examining the effects of maternal iodine supplementation on maternal health and neurodevelopmental outcome of the offspring. They neglect to mention that the National Health and Medical Research Council (NHMRC) issued a public statement in January this year, with supporting evidence attached, stating that: “The NHMRC recommends that all women who are pregnant, breastfeeding or considering pregnancy take an iodine supplement of 150 μg each day”.2 Similar recommendations, based upon available scientific evidence, have been issued by the World Health Organization, International Council for Control of Iodine Deficiency Disorders, American Thyroid Association and American Endocrine Society. We agree that there is a paucity of RCT evidence examining the effect of iodine supplementation of pregnant women living in mildly iodine-deficient areas, and this is regrettable. Given the overwhelming animal and human evidence that maternal iodine deficiency causes brain damage in the offspring of deficient mothers, we consider there are major ethical issues in conducting such trials where pregnant women would be deprived of iodine and their babies put at risk of brain damage. Zhou and colleagues imply that mild-to-moderate iodine deficiency is not widely prevalent in Australia. This statement ignores the evidence from several clinical studies of pregnant women in New South Wales, Victoria and Tasmania, all showing that mild-to-moderate iodine deficiency is widespread in the majority of the Australian population. Analysis of the data in some of these studies shows between 20% and 40% of women tested are moderately to severely iodine deficient.3 Furthermore, food modelling studies by Food Standards Australia New Zealand (FSANZ) predict between 45% and 75% of Australian women will continue to be iodine deficient after the mandatory use of iodised salt in bread that commenced in October 2009.4 Finally, we disagree with their assertion that the recommended iodine intake for pregnant women can be achieved by the majority of women from foods alone, together with iodine fortification of bread. A trial of bread fortification in Tasmania showed this was not achievable.5 If this were achievable, it is questionable why Zhou and colleagues would even consider conducting an RCT of maternal iodine supplementation in pregnant women in Australia and NZ.

Gisselle Gallego · Stephen Goodall · Creswell J Eastman

In reply: I thank Mountain and colleagues from the Australasian College for Emergency Medicine for their letter.1 Despite their interpretation of our article,2 I think we share many points of agreement. Having worked extensively as a clinician, I agree that patient harm is occurring because of insufficient capacity to treat, and that patients will benefit from more capacity to treat. I also agree that this is an important issue and that approaches to dealing with it should not be subverted. Most importantly, I would also agree that the number of available hospital beds is critical — the unanswered questions are about how many beds, and where they should be provided. I also thank the authors for their acknowledgement that “clinical modelling” is a fundamental driver for their position. Our industry would do well to take its direction in the use of queuing theory from internationally recognised experts in the area, rather than from within the ranks of my fellow doctors. In response to Mountain et al’s call for an 85% bed-occupancy limit as a solution, my call is for more detail about the practicalities of how we would implement this limit, which could start with the provision of clear answers to the following questions: How would compliance with the 85% occupancy limit be monitored? What are the practical measures that bed managers, nurse unit managers, executives and others could use to ensure that compliance occurs? If patient throughput in acute inpatient areas increased, what downstream effects could we expect? How would the application of resources in fixing “access block” compare with the application of the same resources in fixing “exit block”? (And an obvious sub-question: what is the relationship between the two phenomena?) Has a consensus been reached with all specialist groups as to which clinical units in hospitals should have access to extra beds when they become available? Or is it intended that an 85% limit would be applied across the board, irrespective of the differences between patient care needs, lengths of stay, rates of arrival and staffing mixes in different wards? How and when would the effectiveness of such an initiative be assessed? Perhaps another occupancy figure would appear even more efficacious through the lessons learned. I believe these are reasonable questions that ought to be answered by anyone calling for this change. I repeat my group’s call for more, and more informed, investment in health system capacity given this huge problem and the solution being proffered.

Christopher A Bain

To the Editor: In his letter1 regarding Heeley et al’s article on cardiovascular risk perception and evidence–practice gaps in Australian general practice,2 Radford quotes, “no [automated blood pressure-measuring machines] were accurate enough to ... replac[e] a manual sphygmomanometer”. The citation dates from 1973, when oscillometric blood pressure monitors such as the Omron HEM-907 — distributed by the High Blood Pressure Research Council of Australia (HBPRCA) with support from the Servier Foundation — did not exist. In defence of digital blood pressure devices, a cluster randomised controlled trial conducted in Australian general practice has demonstrated their superiority compared with existing manual devices.3

Mark R Nelson

To the Editor: The recent MJA supplement provides an excellent summary of internet interventions for a range of psychiatric conditions, including anxiety, depression and substance misuse.1 However, in highlighting the positive uses of the internet, it is important to remember other aspects of online engagement that can have a negative impact on patients’ mental health. It is useful to ask patients specifically about their internet activities, as they will not necessarily volunteer this information. For example, people can spend a large amount of time accessing pornography online. Negative effects of this may include the impact on existing real-world relationships, the cost, and the risks associated with participation in illegal activities. Some patients may go further, arranging to meet people they have encountered on the internet in person, which entails a risk of physical or sexual assault. The internet provides an opportunity for discreet gambling and, as with other forms of gambling, the effects can be destructive. Excessive participation in online games such as World of Warcraft, to the extent that people spend virtually all their waking hours engrossed in playing games, can also be a problem. Bullying and socially destructive behaviour occurring on widely used social networking sites such as Facebook can cause considerable distress to the victim. Such sites can be used to deliver unwelcome information (eg, ending a relationship by changing one’s Facebook status to “single” and “de-friending” the partner). Privacy can also be an issue, and Facebook provides much information to potential stalkers if users fail to adequately protect their data. Some medical practitioners have allowed patients to become their “friends” on Facebook, which can involve inappropriate access to the doctor’s personal life and a risk of blurring professional boundaries.2 Finally, the internet is increasingly being incorporated into delusions expressed by people with psychotic disorders.3 For example, patients with schizophrenia may have paranoid beliefs that derogatory material about them is being distributed via the internet. Enquiring about patients’ internet activities is therefore a useful addition to the standard mental health assessment.

Cherrie A Galletly

Blood on my hands: a surgeon at war. Craig Jurisevic. Melbourne: Wild Dingo Press, 2010 (328 pp). ISBN 9780980757002. This Autobiography is set in Kosovo 1999, in the weeks before North Atlantic Treaty Organization bombing finally forced Serbia to make peace and stop its ethnic cleansing of Kosovars. The author, Craig Jurisevic, a cardiothoracic surgeon from Adelaide, served with the International Medical Corps in Albania. There he kept a journal which, a decade later, he revisited, with the help of writer Robert Hillman, to write this book that describes what he saw and how he felt. As the chapters unfold, it is unnerving to see how the author’s sense of responsibility escalates, not only towards the wounded soldiers and civilians on whom he operates but also to those exposed on the front line without medical support. Jurisevic (his mother’s Slovenian surname) becomes disgusted, angered and eventually consumed by the injustice — the evil of ethnic cleansing and the brutality of its perpetrators, the Serbian militia. It is not only the dreadful injuries that move him, but also the way in which they are inflicted and the manner in which people are executed. He is unable to act the part of a detached foreign doctor, nor tolerate the Albanians who exploit and extort the sick and injured Kosovars — local mafia barons who enrich themselves on the suffering. During the final weeks of the war, Jurisevic serves on the front-line, operates in a cave, and is forced to defend himself against Serbian attacks. This is an extremely well written book, but not one that is just to be enjoyed — it is brutal and honest; shocking but authentic. There is no other like it, and small wonder that it is being adapted for the big screen. Its readership will be much wider than the medical market and it is likely to become a bestseller. The worst comment I can make about its content is that it is all true.

David A K Watters

WWyeth Australia has been a valued partner with the Medical Journal of Australia since 1995 in recognising and rewarding the best of original research published each year in the Journal. The 2009 MJA/Wyeth Award was presented at the Australian Medical Association (AMA) National Conference in Sydney on 28 May 2010. The Journal’s Content Review Committee has awarded the prize for 2009 to Tanya Bubner and her colleagues from the University of Adelaide and Flinders University for their research paper, “Effectiveness of point-of-care testing for therapeutic control of chronic conditions: results from the PoCT in General Practice Trial”, published in the 1 June 2009 issue of the Journal. Point-of-care testing (PoCT) provides the treating general practitioner with immediate test results and has the potential to improve monitoring of chronic conditions, therapeutic control and clinical efficiency, and to enhance clinical decision making within the time frame of the consultation. PoCT not only provides an alternative method of pathology testing, but also allows a different style of patient management compared with traditional pathology laboratory testing. Demand for PoCT in general practice is increasing; however, there is little evidence about its benefits, particularly these related to clinical outcomes. Bubner and colleagues assessed the safety, clinical effectiveness and cost-effectiveness of and satisfaction with PoCT in general practice. In a large, multicentre, cluster randomised controlled trial, they found that PoCT was equivalent to pathology laboratory testing for a variety of pathology tests in chronic diseases. The researchers found that for the proportion of patients with results in the target range, PoCT was equivalent to pathology laboratory testing for measuring glycated haemoglobin, urine albumin, albumin–creatinine ratio, total cholesterol and triglyceride levels, but not for high-density lipoprotein cholesterol level and international normalised ratio. The research by Bubner and colleagues provides important evidence for the introduction of PoCT into general practice. The award was presented by Ms Yvonne Bowyer, Deputy Managing Director, Wyeth Australia; I thank her on behalf of the AMA and the Australasian Medical Publishing Company, the publisher of the MJA, for Wyeth’s continuing commitment to promoting excellence in Australian clinical research through the prestigious MJA/Wyeth Award. Martin Van Der Weyden, Jane Harrison, Ruth Armstrong, Justin Beilby, Yvonne Bowyer, Tanya Bubner, Andrew Pesce

When consummate Aboriginal and Torres Strait Islander storyteller Jane Harrison took the stand to receive the 2010 Dr Ross Ingram Memorial Essay Prize in late May, it was an opportunity to reflect on the growing involvement of Aboriginal and Torres Strait Islander people with the MJA — as authors, contributors and reviewers — since the competition’s inception 5 years ago. Jane’s winning essay, Healing our communities, healing ourselves, in which she explores the particular challenges faced by Aboriginal and Torres Strait Islander people who work to improve Indigenous health while facing difficulties in their own lives, was published in the 17 May 2010 issue of the Journal. Jane is a descendant of the Muruwari people of New South Wales, from the area around Bourke and Brewarrina. Currently the Aboriginal Child Rearing Stories Project Officer at the Secretariat of National Aboriginal and Islander Child Care, she spent 6 years researching and writing the award-winning play, Stolen, which has brought the stories of Australia’s stolen generations to thousands of people in Australia and overseas since its release in 1998. Her other work includes the play, Rainbow’s end, and an episode of the popular SBS series, The circuit. In receiving her prize, Jane challenged those present to take their interest in Indigenous health and welfare beyond abstract gestures and endeavours to the personal level, by having real conversations and forging real relationships with Aboriginal people. Entries for next year’s Dr Ross Ingram Memorial Essay Competition are currently open. For full details see http://www.mja.com.au/public/information/RossIngramCompetition.html. Martin Van Der Weyden, Jane Harrison, Ruth Armstrong, Justin Beilby, Yvonne Bowyer, Tanya Bubner, Andrew Pesce

Mind the gap Tongue piercings are becoming more common, but they can cause damage to adjacent teeth and gums. Dentists in Buffalo, NY, report a case of a young woman who developed a large gap between her upper front teeth seven years after having the tip of her tongue pierced — apparently the result of the metal stud being constantly pushed against her teeth. The patient required orthodontic work with a fixed brace for an extensive period of time to close the gap. J Clin Orthod 2010; 44: 426-428 Love and longevity Although the link between quality of social relationships and health has been recognised for several decades, the impact on survival may be much greater than previously thought. A meta-analysis of 148 studies (including more than 300 000 participants followed over a mean of 7.5 years) showed improved survival among those with stronger social relationships (OR, 1.5; 95% CI, 1.42-1.59). Moreover, perceived “loneliness” conferred a risk of mortality comparable with smoking 15 cigarettes a day and drinking excessively. Socialisation was assessed in several ways, including marital status, number of networks and other measures of the quality of relationships. Although all were predictive of reduced mortality, the effect was more evident where relationships were characterised by greater perceived support and social integration, indicating that the quality rather than the quantity of relationships may be most important. PLoS Medicine 2010; 7: e10000316 Pregnant pause Some doctors recommend that women delay becoming pregnant after miscarrying, but results of a recent study indicate that those who conceive again within 6 months are actually less likely to miscarry a second time.1 The Scottish study analysed data for about 31 000 women and found that those who conceived again within 6 months of miscarriage had one-third the risk of having a subsequent miscarriage and half the risk of ectopic pregnancy or termination, compared with those who waited 6-12 months. The shorter time interval was also associated with a reduced likelihood of caesarean section, preterm delivery, and having an infant with low birth weight. Although it is unclear why the shorter interpregnancy interval seemed to improve outcomes, one theory is that women who conceive soon after miscarriage have a tendency towards increased fertility and have better pregnancy outcomes anyway.2 1. BMJ 2010; 341: c3967. doi:10.1136/bmj.c3967 2. BMJ 2010; 341: c4181. doi:10.1136/bmj.c4181 Vitamin D and Parkinson disease Results of a large Finnish study suggest that vitamin D may protect against development of Parkinson disease.1 The study, which claimed to be the first longitudinal study to prospectively investigate this relationship, found that participants with vitamin D levels in the highest quartile had a relative risk of Parkinson disease of 0.33 (95% CI, 0.14-0.78) compared with those in the lowest quartile. This association remained even after adjusting for potential confounders such as body mass index, physical activity and month of blood draw. Interestingly, the study population lived in a country with limited sunlight exposure (vitamin D levels were reported to be 50% of the suggested optimal level) — consistent with observations of some epidemiological studies that there is a latitudinal north-south gradient for Parkinson disease, similar to that seen in multiple sclerosis.2 1. Arch Neurol 2010; 67: 808-811 2. Arch Neurol 2010; 67: 795-797 Lucky shorts According to German researchers, the impact of superstitious beliefs and rituals among sports players such as wearing “lucky shorts” should not be underestimated. Their series of experiments showed that using a good-luck-related superstition (such as a lucky charm) resulted in a consistent improvement in both motor and cognitive performance. In one experiment, volunteers were asked to bring a lucky charm with them, which the researchers subsequently took away to photograph — however, only half of them had it returned before starting a memory test. Those who kept it performed significantly better, and this was reported to be owing to increased confidence in their abilities. Similarly, “crossing your fingers” improved manual dexterity, and being given a lucky golf ball improved putting prowess. Psychol Sci 2010; 21: 1014-1020 doi: 10.1177/0956797610372631

Alison Williams

Med J Aust 2010; 193 (5 Suppl).