Volume 193 Issue 6

Objective assessment of the health of the population is the key to policy and planning Accurate, timely information about a population’s health, health risks and use of health services and medicines is essential for planning and evaluating health policies and care. Health surveys based on representative probability samples of the population are designed to provide this by collecting data on health behaviours, health determinants such as socioeconomic disadvantage and obesity, prevalence of diseases, need for health care and whether this has been provided, functional capacity, and nutritional status.1 Such surveys can be classified as health interview surveys or health measurement surveys. The former are based on interviews or self-administered questionnaires and rely on a participant’s subjective assessment, while the latter include the addition of anthropometric, physiological and clinical measurements and tests (such as lung volume spirometry) and/or the collection of blood and other biological samples.2 Thus, the health measurement survey generally provides more objective data than the health interview survey; for example, on the prevalence of various diseases and risk factors, where self-reported information is known to be quite inaccurate (sometimes due to the fact that the disease has not yet been diagnosed).1 The recent announcement of a national Australian population health survey program using objective measures3 is therefore a welcome initiative for the community, health practitioners and policymakers alike. National health measurement survey programs have been conducted regularly in other countries for many years. The longest such series is in the United States, where the first national survey was carried out in 1959 — now known as the National Health and Nutrition Examination Survey (NHANES), it celebrated its 50th anniversary in 2009.4-6 European examples include the Finnish surveys from the 1970s, German and Norwegian surveys from the 1980s, and English and Scottish surveys from the 1990s.1 These survey programs have provided their countries with rich and unique national data sources for monitoring important health issues and formulating public health policies. In the US, for example, federal agencies and other public health organisations use data from NHANES to assess nutritional status and its relationship to health promotion and disease prevention.4,5 Survey findings also serve as the basis for national standard physical measurements like height, weight and blood pressure. Health science researchers use information from the survey to develop public health policy, programs and services, and expand the health knowledge of the nation.4 As a result, numerous advances in public health and nutrition have directly benefited US citizens’ health from the use of survey data to: document blood lead levels before and after the removal of lead from gasoline, paint and other household agents; quantify second-hand smoke exposure and evaluate the impact of policies to reduce or eliminate this exposure; identify low levels of folate in the population and the subsequent increase in these levels after folic acid fortification of foods; document the increase in obesity and diabetes in the population, including undiagnosed diabetes; and underpin the 1977 and 2000 paediatric growth charts.6 In Australia, there has been investment in collecting health information and concomitant biomedical and other measures in the past, but those studies, conducted through the 1980s and up to the mid 1990s, are no longer current, leaving significant gaps in our knowledge of the health of the population.7 More recent health measurement survey proposals have not proceeded, or have failed to deliver reliable national disease and risk factor prevalence estimates because of problems with study design, sampling and response rates.7-9 Now, the Australian Bureau of Statistics (ABS) is including a health measurement survey as an ongoing element of its Australian Health Survey program.3 This is certainly good news for health researchers, community planners, health practitioners and policymakers, and for the Australian public as a whole. The new survey program offers opportunities to provide an improved information base for national health policy development, health program planning and health research in ways that have not previously been possible. The Australian Health Survey program will have four components: National Health Survey, an existing household interview survey; National Aboriginal and Torres Strait Islander Health Survey, an existing household interview survey; National Nutrition and Physical Activity Survey, a new household interview survey; and National Health Measures Survey, a new health measurement survey.10 Planning is being undertaken by the Australian Government Department of Health and Ageing, in partnership with the ABS and the National Heart Foundation of Australia. Beginning in 2011, a representative sample of 50 000 Australians will be asked to complete the Australian Health Survey, representing “the most comprehensive health survey ever undertaken by the ABS”.3 Participants will also be asked to provide voluntary blood and urine samples to allow testing for nutritional status and early indicators of disease, such as high blood cholesterol or glucose levels.10 The investment in this national health survey program, with its inclusion of objective measures, will provide a firm foundation for health policy development in the 21st century, with undeniable benefits for individuals and the Australian community as a whole.

Diana M S Hetzel MB BS · John D Glover BEc, BA

The epidemiology of influenza pandemics demands that Aboriginal and Torres Strait Islander people occupy centrestage in future planning The first wave of pandemic (H1N1) 2009 influenza (pH1N1) broke more heavily on Australia’s Aboriginal and Torres Strait Islander populations than on non-Indigenous Australians. The burden of disease in Aboriginal and Torres Strait Islander people was highlighted by the first Australian death associated with pH1N1 infection: a young Aboriginal man from a remote area of Western Australia who died on 19 June 2009 in an Adelaide hospital.1 The differences between the populations are stark, with Aboriginal and Torres Strait Islander people indisputably over-represented in severe pH1N1 disease. In the Top End of the Northern Territory, pH1N1 rates of notification, hospital admission and intensive care unit (ICU) admission were higher for Aboriginal and Torres Strait Islander people than for the non-Indigenous population (3.5 times, 12 times and 5 times, respectively).2 Similar profound differences have been recorded for Aboriginal communities in New South Wales: Aboriginal people hospitalised with pH1N1 were younger than their non-Aboriginal counterparts (median age of 24.5 years compared with 31.7 years), and the age-standardised rate ratios for Aboriginal to non-Aboriginal admissions to hospital, admissions to ICU and death during the 2009 pandemic wave were 3.2, 4.0 and 4.5, respectively.3 Overall, from May to October 2009 in Australia, Aboriginal and Torres Strait Islander Australians, who comprise 2.5% of the population, accounted for 16.0% of hospitalisations with pH1N1 and 9.7% of pH1N1 admissions to an ICU.4 A fivefold increase in risk of death due to pH1N1 was also reported.5 This experience demands a greater focus on the needs of Aboriginal and Torres Strait Islander communities and their prioritisation in future pandemic planning. We should not have been surprised, as history tragically demonstrates disproportionate morbidity and mortality for Aboriginal and Torres Strait Islander people in previous pandemics.6 It is thus exceedingly disappointing to discover no mention of Aboriginal and Torres Strait Islander Australians in the revised National Action Plan for Human Influenza Pandemic (NAP).7 The 2010 NAP fails to identify Aboriginal and Torres Strait Islander people as a high-risk group during the H1N1 2009 pandemic, although it acknowledges other risk groups that have been recognised internationally and in Australia: severe cases occurred in people with underlying chronic conditions such as respiratory diseases, cardiovascular disease, diabetes, autoimmune disorders and obesity. Pregnant women were also at an increased risk of serious disease.7 It is inexplicable that while Aboriginal and Torres Strait Islander people were identified as a priority group for the rollout of the pH1N1 influenza vaccination — a commendable and necessary preventive strategy — they are overlooked in the NAP.8 Although the Australian Health Management Plan for Pandemic Influenza9 states an equity commitment, and a subsequent appendix10 produced during the “Protect” phase of the 2009 pandemic endorsed the need for partnership between all health care providers in case and contact management among the Aboriginal and Torres Strait Islander population, respectful partnership between governments and Aboriginal and Torres Strait Islander communities to identify culturally appropriate and effective prevention and mitigation strategies enjoys no mention. Given that the NAP is the peak plan for guiding preparations for future pandemics, there is a fundamental need for governments to acknowledge and respond effectively to the specific requirements of Aboriginal and Torres Strait Islander people. Prevention and preparedness must include government support of planning in respectful partnership with Aboriginal and Torres Strait Islander communities, health organisations and representative bodies. Mandating this support and partnership at all levels of government will allow a greater understanding of infection risk and identification of cultural, social, economic and health service factors that may contribute to poor health outcomes, and ensure culturally safe and effective prevention and mitigation strategies. A national project, funded by the National Health and Medical Research Council, working with Aboriginal and Torres Strait Islander communities and health services in NSW, Queensland and Western Australia is learning about feasible and culturally appropriate containment strategies.11 A strong theme emerging from this work is the message to government: “Ask us, listen to us, share with us”. The ability of Aboriginal and Torres Strait Islander communities to develop novel practical mitigation measures has been a particular feature of this respectful engagement that has already informed government strategies in NSW.3 The epidemiology of the current and previous influenza pandemics demands that Aboriginal and Torres Strait Islander people occupy centrestage in future planning. Solutions to limit the burden on Aboriginal and Torres Strait Islander populations exist, but respectful partnership is necessary to unearth them. The partnership must not be a token one, but one developed through engagement with communities, and with the flexibility to be localised to meet the specific needs of diverse urban, rural and remote Aboriginal and Torres Strait Islander communities in all states and territories. Health information delivered with a local flavour is a key message from the project. “Ask us, listen to us, share with us” is a strong message that governments must heed if the impact of pandemic influenza on Aboriginal and Torres Strait Islander communities is to be limited.

on behalf of the Aboriginal and Torres Strait Islander Community Influenza Study Group

Circumcision now to prevent heterosexual HIV transmission in 2030 makes sense Australia is rightly proud of its response to HIV. Thanks to superb formulation of public policy in the early days of the epidemic, it is not only a low-prevalence country but an international leader in many aspects of its clinical and public health responses. To maintain this fine record, Australia should change policy so that infant male circumcision rates are boosted in the face of rising heterosexual transmission of HIV. Regular surveillance indicates that HIV in Australia is slowly following the trend in Western Europe and North America toward an increased proportion of transmission occurring through heterosexual contact.1 Although the epidemic in Australia is likely to remain concentrated for some time among men who have sex with men, the proportion of new diagnoses attributable to heterosexual contact has risen from the negligible levels of the epidemic’s early days.1 The World Health Organization, the Joint United Nations Programme on HIV/AIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria have endorsed male circumcision to control HIV attributed to heterosexual contact in hyperendemic areas, stating: “The efficacy of male circumcision in reducing female to male transmission of HIV has been proven beyond reasonable doubt. This is an important landmark in the history of HIV prevention.”2 This raises the question of whether low-prevalence countries such as Australia — with an increasing proportion of HIV cases attributed to heterosexual contact — should consider increasing the rate of infant male circumcision to reduce future HIV infections. The protection conferred to heterosexual males by circumcision is similar in hyperendemic and low-prevalence settings.3-5 In 2008, the Centers for Disease Control and Prevention (CDC) concluded that male circumcision “may also have a role in the prevention of HIV transmission in the United States”.3 The CDC is now formulating a new policy.4 Being a low-prevalence country does not preclude a population-wide approach to HIV prevention. For example, we test pregnant women to prevent cases of vertical HIV transmission. Infant male circumcision would be a comparable, albeit more interventionist, population-wide strategy. A wealth of research has shown that the foreskin is the entry point that allows HIV to infect men during intercourse with an infected female partner.5,6 Soon after the HIV pandemic was first recognised, much lower HIV prevalence was found in areas of sub-Saharan Africa where more than 80% of males had been circumcised than in areas where the circumcision rate was less than 20%.5,6 These findings were then replicated in Asia.7 In Australia, infant male circumcision was once routine, but plummeted in the 1970s. Circumcision of males is now referred to by many as a “surgical vaccine” against a wide variety of infections and adverse medical conditions over the lifetime.5,6,8,9 The public health benefits include protection not just from sexually transmitted HIV, but also from some common sexually transmitted infections and other conditions.4-6 Although it can be performed at any age, the ideal time is infancy, when adverse effects are uncommon.4-6 Considerable evidence, including data from randomised controlled trials, shows that male circumcision has no adverse effects on sexual function, sensitivity or satisfaction.4-6,8 At present, the major obstacle to increasing the rates of infant male circumcision in Australia is an influential Royal Australasian College of Physicians policy, which has been criticised on scientific grounds.10 A draft of a new policy has also been criticised in a detailed petition by 38 academic and clinical experts (including Fellows of the College). Another barrier is the Medicare rebate, which has been reduced steadily in real terms over many years. No state or territory Department of Health except Queensland Health allows elective infant male circumcision to be performed in public hospitals. Despite official discouragement, Medicare statistics show a rise in the rate of infant male circumcision in Australia from 13% in 1998 to 19% in 2009. Boosting the rate in Australia, as a long-term strategy to reduce HIV transmission (in combination with other interventions), is sound public health policy. Male circumcision is one of the most powerful interventions that is currently available in the fight against HIV.8,9 The prospect of the availability of a vaccine over the next 20 years is unlikely. Thus, circumcision now to prevent heterosexual HIV transmission in 2030 makes sense. In addition to preventing HIV transmission, other benefits, high cost-effectiveness11 and risk–benefit balance5,10,11 justify acceptance of male circumcision as a sensible public health measure.3,5,6 It should be viewed as part of a safer sex package. Condom use remains essential, with promotion of condom use plus circumcision of males being analogous to seatbelts plus airbags for reducing the road toll. Australia would also be acting compassionately if it promoted infant male circumcision in the Asia–Pacific region, especially in Papua New Guinea where a generalised HIV epidemic has become well established. A commitment to increasing infant male circumcision should complement earlier commitments to other strategies for prevention of sexually transmitted infections, including condom use. Twenty-nine years after the existence of this epidemic was first announced, it is clear that a new chapter has opened with the recognition that male circumcision substantially reduces female-to-male HIV transmission. Australia would be wise to take advantage of this knowledge.

David A Cooper MD, DSc · Alex D Wodak AM, FRACP, FAChAM, FAFPHM · Brian J Morris PhD, DSc, FAHA

Objective: To determine the cost-effectiveness of routine administration, irrespective of blood pressure (BP), of a fixed-dose combination of perindopril and indapamide to patients with type 2 diabetes mellitus.Design, setting and participants: Prospective cost-effectiveness analysis within the Action in Diabetes and Vascular Disease: Preterax and Diamicron-MR Controlled Evaluation (ADVANCE) trial, an international, multicentre, randomised controlled trial of 11 140 participants with type 2 diabetes randomly allocated to receive perindopril plus indapamide (4 mg–1.25 mg/day) or placebo.Main outcome measures: Health-related quality-of-life measured by the EuroQol-5D, resource utilisation, and cost-effectiveness (cost per death averted at 4.3 years’ average follow-up, and estimated cost per life-year gained, by extrapolation).Results: The mean health-related quality-of-life score of survivors was 0.80 (on a 0–1 scale [death to full health]), with no difference between treatment groups. Active treatment reduced hospital admissions for coronary heart disease and coronary revascularisation by 5%. For the Australian participants, perindopril–indapamide cost A$1368 per patient during the trial period, but reduced total hospitalisation costs by A$410 and other medication costs (mainly other BP-lowering drugs) by A$332. The absolute reduction in all-cause mortality for the active treatment group was 1.1%, giving a cost per life saved of A$49 200. Lifetime extrapolation gave an estimated cost per life-year saved of A$10 040 (discounted at 5% per year).Conclusion: The combination of perindopril and indapamide in patients with type 2 diabetes appears to be cost-effective.Trial registration: United States National Library of Medicine NCT00145925.

Paul P Glasziou MB BS, PhD · Philip M Clarke MEc, PhD · Jan Alexander · Mohana Rajmokan MSc · Elaine Beller BSc, MAppStat · Mark Woodward PhD · John Chalmers MD, PhD, FRACP · Neil Poulter MSc, FRCP · Anushka A Patel FRACP, PhD

Objective: To describe the diagnostic pathways experienced by a large, representative group of Australian women with ovarian cancer, and to document the time between first presentation to a medical professional and clinical diagnosis.Design, setting and participants: 1463 women with epithelial ovarian cancer from an Australia-wide population-based study (2002–2005) completed a telephone interview in which they described the events that led to the diagnosis of their cancer.Main outcome measures: Number and type of doctors consulted, investigations performed, referral patterns and the time from first presentation to diagnosis.Results: Of the 1463 women, 145 had their cancer diagnosed incidentally and were excluded from analysis. Most of the remaining 1318 women (1222, 93%) presented first to their general practitioner. As a result of their first medical consultation, 75 women (6%) were given a diagnosis, and 484 (37%) were referred to a gynaecologist, gynaecological oncologist or oncologist for further assessment. Overall, 85% of women visited three or fewer doctors before their cancer was diagnosed; 66% of cancers were diagnosed within 1 month of the initial presentation, and 80% were diagnosed within 3 months. For 12% of women, the diagnostic process took longer than 6 months; this was more likely for women residing in remote Australia, those with lower incomes, and those presenting with abdominal pain or bowel symptoms, or with more than one symptom.Conclusions: Despite anecdotal suggestions to the contrary, most women with ovarian cancer in Australia are investigated and diagnosed promptly. The diagnostic process is more protracted for a minority of women, and the factors we found to be associated with diagnostic delay warrant further investigation.

Susan J Jordan MB BS, FRACGP, PhD · Jane E Francis MA, MPH · Anne E Nelson PhD · Helen M Zorbas MB BS, FASBP · Karen A Luxford BSc(Hons), PhD · Penelope M Webb MA, DPhil

Objective: To evaluate whether systematic asthma care involving a register-recall system, postcard prompts for review, and education for general practitioners and staff in Australian general practice improves the quality of care and health outcomes for adult patients with moderate to severe asthma.Design and setting: Cluster randomised controlled trial in 40 general practices in urban and rural South Australia and New South Wales over the 2 years 2004 and 2005; practices were randomly allocated to the intervention or control group.Participants: 565 adult patients of these randomly allocated practices who had doctor-diagnosed moderate to severe asthma and were taking inhaled corticosteroids.Main outcome measures: Clinical asthma indicators, quality of care, acceptability of the intervention to patients, quality of life, and asthma self-management skills at baseline, 6 months and 12 months.Results: Although 46% of patients in the intervention group practices responded to the postcard prompts, only 32% actually attended for their asthma review. At 12 months, there was a statistically significant difference in provision of written asthma action plans (rate ratio, 1.9; 95% CI, 1.0–3.5; P = 0.04) for intervention group patients compared with control group patients; there was no significant difference in other indicators.Conclusion: We found little objective evidence of improvement in patient management and outcomes resulting from a systematic model of asthma care.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12605000091606

Christine H Holton GDAcc, GDPH, CPA · Justin J Beilby MD, MPH, FRACGP · Mark F Harris MB BS, MD, FRACGP · Clare E Harper BSc(Hons), MMedSci(Human Nutr) · Judith G Proudfoot GradDipSpEd, MA(Psych), PhD · Emmae N Ramsay BSc(Ma · Richard E Ruffin MD, FRACP, AM

Objectives: To examine the determinants of pregnancy within 2 years of a teenager giving birth for the first time (rapid-repeat pregnancy [RRP]) and resumption of sexual intercourse after the birth.Design, setting and participants: Prospective cohort study between June 2004 and September 2006 at the sole tertiary obstetric hospital in Western Australia involving teenagers who gave birth for the first time. Data were collected using questionnaires at recruitment, 6 weeks and 3-monthly intervals for up to 2 years postpartum.Main outcome measures: RRP and time to a return to sexual intercourse after giving birth.Results: Of the 147 participants, 49 (33%) experienced an RRP. Sexual intercourse was independently significantly associated with using an oral contraceptive (odds ratio [OR], 2.83; 95% CI, 1.38–5.82); living with the birth father (OR, 8.43; 95% CI, 5.12–13.86); intending to become pregnant (OR, 3.20; 95% CI, 1.53–6.65); smoking marijuana (OR, 2.60; 95% CI, 1.38–4.79); and using alcohol (OR, 1.93; 95% CI, 1.17–3.20). Use of long-acting contraceptives was associated with reduced odds of RRP (OR, 0.27; 95% CI, 0.12–0.62), while teenagers who used an oral contraceptive had a similar risk of RRP compared with those using barrier methods or no contraception. Other factors predicting RRP were: being sexually active for more than 3 months (OR, 8.96; 95% CI, 1.97–40.74); intending to become pregnant (OR, 2.39; 95% CI, 1.62–4.93); and being an Indigenous Australian (OR, 2.38; 95% CI, 1.38–4.11).Conclusion: There are two options available to health care providers for reducing the rate of RRP: to facilitate teenage mothers’ access to long-acting contraceptives; and to gain clear understanding of their intention with regard to repeat pregnancy and to provide appropriate support.

Lucy N Lewis RM, BSc(Health Sciences), MN · Dorota A Doherty BSc(Hons), PhD(Medical Statistics) · Martha Hickey MB ChB, MD, FRANZCOG · S Rachel Skinner MB BS, PhD, FRACP

Objective: To investigate whether interviewer personality, sex or being of the same sex as the interviewee, and training account for variance between interviewers’ ratings in a medical student selection interview.Design, setting and participants: In 2006 and 2007, data were collected from cohorts of each year’s interviewers (by survey) and interviewees (by interview) participating in a multiple mini-interview (MMI) process to select students for an undergraduate medical degree in Australia. MMI scores were analysed and, to account for the nested nature of the data, multilevel modelling was used.Main outcome measures: Interviewer ratings; variance in interviewee scores.Results: In 2006, 153 interviewers (94% response rate) and 268 interviewees (78%) participated in the study. In 2007, 139 interviewers (86%) and 238 interviewees (74%) participated. Interviewers with high levels of agreeableness gave higher interview ratings (correlation coefficient [r] = 0.26 in 2006; r = 0.24 in 2007) and, in 2007, those with high levels of neuroticism gave lower ratings (r = − 0.25). In 2006 but not 2007, female interviewers gave higher overall ratings to male and female interviewees (t = 2.99, P = 0.003 in 2006; t = 2.16, P = 0.03 in 2007) but interviewer and interviewee being of the same sex did not affect ratings in either year. The amount of variance in interviewee scores attributable to differences between interviewers ranged from 3.1% to 24.8%, with the mean variance reducing after skills-based training (20.2% to 7.0%; t = 4.42, P = 0.004).Conclusion: This study indicates that rating leniency is associated with personality and sex of interviewers, but the effect is small. Random allocation of interviewers, similar proportions of male and female interviewers across applicant interview groups, use of the MMI format, and skills-based interviewer training are all likely to reduce the effect of variance between interviewers.

Barbara N Griffin BPsych(Hons), PhD, MAPS · Ian G Wilson MB BS, PhD, FRACGP

Objectives: To evaluate whether the four criteria used by the University of Notre Dame Australia (UNDA) to select medical students are successful in selecting for graduates with the desired outcomes of academic excellence and Catholic “mission fit”.Design, setting and participants: Prospective cohort study of medical students selected for 2008 and 2009 entry to UNDA in Sydney, New South Wales.Main outcome measures: The statistical association between the two academic selection criteria of the Graduate Australian Medical School Admissions Test (GAMSAT) and grade point average (GPA) compared with the outcome of medical school examination performance, and the two mission selection criteria of a portfolio score and interview score compared with the outcome of a positive attitude towards serving underserved communities as measured using the Medical Student Attitudes Toward the Underserved (MSATU) test.Results: A total of 223 students were enrolled. GAMSAT section 3, GPA and the interview scores were significantly positively associated with academic performance (P < 0.05). However, none of the selection variables were significantly associated with a positive attitude towards serving underserved communities, as measured by the MSATU score.Conclusion: None of the four selection tools used were significantly associated with medical students who had a positive attitude towards serving underserved communities.

Julie A Quinlivan MB BS, PhD, FRANZCOG · Lawrence T Lam BSc(Hons), GradDipBiostat, PhD · Siu hong Wan MB ChB, MRCP, FRCP · Rodney W Petersen MB BS, FRANZCOG, MBA

Objective: To assess the attitudes of health care professionals engaged in open disclosure (OD) to the legal risks and protections that surround this activity.Design and participants: National cross-sectional survey of 51 experienced OD practitioners conducted in mid 2009.Main outcome measures: Perceived barriers to OD; awareness of and attitudes towards medicolegal protections; recommendations for reform.Results: The vast majority of participants rated fears about the medicolegal risks (45/51) and inadequate education and training in OD skills (43/51) as major or moderate barriers to OD. A majority (30/51) of participants viewed qualified privilege laws as having limited or no effect on health professionals’ willingness to conduct OD, whereas opinion was divided about the effect of apology laws (state laws protecting expressions of regret from subsequent use in legal proceedings). In four states and territories (Western Australia, South Australia, Tasmania and the Northern Territory), a majority of participants were unaware that their own jurisdiction had apology laws that applied to OD. The most frequent recommendations for legal reform to improve OD were strengthening existing protections (23), improving education and awareness of applicable laws (11), fundamental reform of the medical negligence system (8), and better alignment of the activities of certain legal actors (eg, coroners) with OD practice (6).Conclusions: Concerns about both the medicolegal implications of OD and the skills needed to conduct it effectively are prevalent among health professionals at the leading edge of the OD movement in Australia. The ability of current laws to protect against use of this information in legal proceedings is perceived as inadequate.

David M Studdert LLB, ScD, MPH · Donella Piper LLB, PhD, LLM · Rick Iedema PhD

Consensus recommendations for managing chronic suppurative lung disease (CSLD) and bronchiectasis, based on systematic reviews, were developed for Australian and New Zealand children and adults during a multidisciplinary workshop. The diagnosis of bronchiectasis requires a high-resolution computed tomography scan of the chest. People with symptoms of bronchiectasis, but non-diagnostic scans, have CSLD, which may progress to radiological bronchiectasis. CSLD/bronchiectasis is suspected when chronic wet cough persists beyond 8 weeks. Initial assessment requires specialist expertise. Specialist referral is also required for children who have either two or more episodes of chronic (> 4 weeks) wet cough per year that respond to antibiotics, or chest radiographic abnormalities persisting for at least 6 weeks after appropriate therapy. Intensive treatment seeks to improve symptom control, reduce frequency of acute pulmonary exacerbations, preserve lung function, and maintain a good quality of life. Antibiotic selection for acute infective episodes is based on results of lower airway culture, local antibiotic susceptibility patterns, clinical severity and patient tolerance. Patients whose condition does not respond promptly or adequately to oral antibiotics are hospitalised for more intensive treatments, including intravenous antibiotics. Ongoing treatment requires regular and coordinated primary health care and specialist review, including monitoring for complications and comorbidities. Chest physiotherapy and regular exercise should be encouraged, nutrition optimised, environmental pollutants (including tobacco smoke) avoided, and vaccines administered according to national immunisation schedules. Individualised long-term use of oral or nebulised antibiotics, corticosteroids, bronchodilators and mucoactive agents may provide a benefit, but are not recommended routinely.

Anne B Chang MPHTM, PhD, FRACP · Scott C Bell MB BS, MD, FRACP · Cass A Byrnes MB ChB, MD, FRACP · Keith Grimwood MB ChB, MD, FRACP · Peter W Holmes MB BS, FCCP, FRACP · Paul T King MB BS, FRACP, PhD · John Kolbe MB BS, FRACP · Louis I Landau MB BS, MD, FRACP · Graeme P Maguire MB BS, FRACP, PhD · Malcolm I McDonald MB BS, FRCPA, PhD · David W Reid MB ChB, MRCP, FRACP · Francis C Thien MB BS, MD, FRACP · Paul J Torzillo MB BS, FRACP, FJFICM

From 1967, the Australian Human Pituitary Hormone Program offered treatment for short stature and infertility using human cadaver-acquired pituitary hormones (human growth hormone [hGH] and human pituitary gonadotrophin [hPG]). The program was suspended in 1985 when a growth-hormone recipient in the United States developed Creutzfeldt–Jakob disease (CJD), an incurable and rapidly progressive neurodegenerative disorder. Since this time, recipients have lived with the significant anxiety that they have an elevated risk of developing CJD. Furthermore, additional CJD infection control measures are required when recipients undergo some types of surgery. As it is 20 years since the last Australian pituitary hormone recipient developed CJD, we evaluated the risk for Australian recipients of developing iatrogenic CJD, and compared Australian data with data from New Zealand and selected other countries who had pituitary hormone programs. Our evaluation indicates that pituitary hormone recipients in Australia have the lowest risk of developing iatrogenic CJD, and that Australia is the only country not to have experienced ongoing CJD-related deaths. Thus, we believe that: in the Australian hGH recipient cohort, the risk of developing CJD is sufficiently low for this cohort to no longer require additional infection control measures in the health care setting; and in the Australian hPG recipient cohort, if another 5 years elapses with no further occurrence of CJD in this group, the hPG recipient cohort could also be considered as not requiring additional infection control measures in the health care setting. These recommendations should not be misunderstood as implying that there is no ongoing risk, but that the risk is acceptably low and generally in keeping with guidelines that stratify the risk.

Alison Boyd DipAppSci(Nursing), GradDipGenCoun · Genevieve M J A Klug BSc(Hons), PostGradDipEpiBioStat · Lawrence B Schonberger MD, MPH · Amelia McGlade BSc · Jean-Philippe Brandel MD · Colin L Masters MD · Steven J Collins MD

To the Editor: I would like to correct some inaccuracies in an article by Jelinek and Gawler in the December 2008 issue of the Journal about a survivor of disseminated osteosarcoma.1 The article describes a 58-year-old man who was diagnosed in 1974, at the age of 24 years, with histologically confirmed high-grade osteosarcoma of the right femur. He underwent a full leg amputation in January 1975, but metastases recurred 11 months later, in December 1975. The authors of the article misreported a sequence of medically significant events, altering the patient’s actual history. (The correct chronology and early clinical history of the case have been published elsewhere.2,3) The errors and omissions in the article by Jelinek and Gawler, together with the correct sequence of events and relevant inclusions, are outlined in Box 1. In summary, the major errors in the article were as follows: Timeline errors. The authors stated that the patient first saw Dr Meares in September 1976, after chemotherapy had failed. In fact, the patient consulted Meares as a first-line treatment approach on 12 December 1975, and did not consider chemotherapeutic options until September 1976. The authors also stated that the patient had palliative radiotherapy in September 1976. In fact, the patient had only one course of palliative radiotherapy treatment, in February 1976. Vegan diet. The patient never followed a vegan diet. Date of photographs. The photographs in Figures B and C of the article by Jelinek and Gawler were taken on 7 July 1977 (Box 2), not at the time of first contact with Meares, as implied in the article. An appraisal of the patient’s symptoms, combined with an accurate clinical history, reveals a more plausible scientific hypothesis for his remission than the effects of diet and meditation. Although diet and meditation may be adjuncts to a patient’s wellbeing, it is unlikely in this case that they were curative, and certainly veganism was not a relevant factor. Immunotherapy with BCG vaccine treatments, the timing of symptoms and the patient’s eventual diagnosis of tuberculosis could be associated with his remission, as postulated by his radiation oncologist in 1978.6 There is extensive scientific literature about remission of cancer, including osteosarcoma, associated with febrile conditions.5,8-15 The patient’s sporadic visits to doctors meant that metastases were not diagnosed histologically and much of the information reported on his case is anecdotal. Clearly, in this and other cases, unbiased investigative scientific research needs to be undertaken before reporting anecdotes and extrapolations as if they were fact. Teasing apart the errors in Jelinek and Gawler’s story, now on the public record and almost medical myth, is an enormous task, but one that must be done, because correctly reporting the patient’s clinical timeline is crucial in any discussion about the causes of his remission and the flow-on effect to cancer patients and their treating doctors.16 1 Corrections to errors in the article by Jelinek and Gawler1 Errors and omissions in the article Facts, corrections and inclusions December 1975: widespread bony and pulmonary metastases were diagnosed. December 1975: an isolated metastasis in an inguinal node was diagnosed. The patient undertook the Gerson dietary regimen,4 immunotherapy with BCG vaccine,5 and the Meares intensive meditation program.6 September 1976: “[the patient] underwent three cycles of palliative chemotherapy with vincristine, adriamycin, cyclophosphamide and darcarbazine, as well as brief palliative radiation therapy”. September–October 1976: growth of tumours on the sternum increased, and metastases were detected in the left lung. Coughing and haemoptysis were present.6 Experimental chemotherapy (with adriamycin, vincristine and methotrexate)2 was ceased at 10 weeks after December 1976. No radiation therapy was given at this time. Palliative radiotherapy was administered in February 1976, not September 1976. September 1976: “He elected to discontinue these therapies as his condition deteriorated further.” “The patient then consulted prominent psychiatrist and hypnotherapist Dr Ainslie Meares ...”. December 1975: the patient first consulted Meares. In February 1976, he abandoned the Meares meditation program. The 10-month discrepancy between December 1975 and Jelinek and Gawler’s stated date of September 1976 (actual date, October 1976) alters the patient’s medical timeline, implying that it was only after other treatments had failed that meditation began and played a key role in his recovery. Dates of photographs shown in the article: “When Meares first saw the patient, he had visible bony tumours protruding from his ribs, sternum (Figure B) and iliac crest, and was coughing up blood containing small spicules of bone (Figure C).” The article by Jelinek and Gawler implies that the photographs in their Figures B and C were taken around the time when the patient first contacted Meares. The photograph in Figure B was actually taken on 7 July 1977, 19 months after his first contact with Meares. Tumours were not protruding from the sternum when Meares first saw the patient to begin meditation in December 1975, and there were no visible metastases. The coughing up of blood containing bone spicules (Figure C) began in mid 1977, not in the period between December 1975 and February 1976. Vegan diet: “[the patient] adhered faithfully to a vegan diet”. The patient never followed a vegan diet. Veganism involves exclusion of all animal products. The Gerson regimen4 includes dairy foods and calf liver juices. For the following 22 years, the patient’s diet included seafood, dairy products and eggs. First appearance of tuberculosis: “Presumably related to immunosuppression from chemotherapy, he developed pulmonary tuberculosis in June 1978, and was treated for this condition for 12 months.” In 1978, an oncologist diagnosed advanced tuberculosis (TB) dating back to early 1976. (Previous x-rays were examined, showing evidence that TB had been present and undiagnosed for at least 2 years. The patient had very advanced TB by June 1978.6) The suspected cause was BCG vaccine treatments administered in December 1975, possibly exacerbated by chemotherapy and associated immunosuppression in late 1976. 2 Original photographs of patient’s chest taken on 7 July 1977 I am in possession of these original photographs (left), which were dated 7 July 1977 (date enlarged in inset). A copy of page 227 from the original edition of You can conquer cancer7 also confirms the accurate date of the photographs as 7 July 1977 (date enlarged in inset)

Grace O Gawler

In reply: In conjunction with the patient’s memory, and teasing out details, where available, from medical records and investigations of over 30 years ago, we sought to piece together our follow-up story of a remarkable recovery from cancer as accurately as possible.1 We did not attempt to reproduce the original case report in the Journal,2 but rather were highlighting the long-term issues that can be associated with such recoveries. We thank Ms Gawler for attempting to clarify the original timelines. However, based on the medical records and published data, as well as checking further with the patient himself, it seems her letter does little more than muddy the waters in this case. Ms Gawler claims the patient abandoned the Meares meditation program in February 1976. This is factually incorrect and misleading. The patient continued to use Meares’ methods to meditate for 3 hours daily until he recovered, and has meditated at least 1 hour daily since then. The timelines quoted around the photographs in Figures B and C in our original article1 were based on information from Meares’ 1978 article.2 He was somewhat inaccurate, as is Ms Gawler, who claims the photos were taken in July 1977. This is incorrect. Figure B was photographed in July 1976 as chemotherapy was commenced. Figure C was photographed in 2008 and documents bony spicules coughed up during the first half of 1977, collected and retained by the patient. Regarding the use of BCG vaccine treatments, the patient reports that none of the three tuberculosis (TB) specialists whom he consulted gave credence to Ms Gawler’s suggestion that the onset of TB was related to the BCG vaccine. Ms Gawler further postulates that the remission could be linked to a febrile condition associated with TB. The patient did have severe night sweats (which may or may not have been accompanied by fever) over a period of 2–3 weeks in February and March 1976, at a time when he almost certainly had not yet contracted TB, and after which the metastases continued to grow rapidly. After this time, the patient never reported fevers that would make sense of this claim. Ms Gawler claims that the patient’s metastases were not diagnosed histologically and that much of the reported evidence is anecdotal. This is misleading and would surely surprise the involved surgeon, oncologist and other physicians, who used the best available medical evidence at the time and cooperated in the preparation of our original article. The case is documented with a thorough medical history, the patient’s surgeon and other specialists were consulted regularly, and accurate records were retained. Full details confirming the report are available in the patient’s biography.3 The metastases were thoroughly investigated and confirmed by the Peter MacCallum Cancer Centre in Melbourne and regularly tracked via x-ray. The original lesion seen on x-ray was diagnostic for osteosarcoma and the diagnosis was confirmed histologically by biopsy, and again after amputation. The case history is certainly complex and compelling. The message is clear: unexpected recovery from disseminated cancer remains a possibility, and is likely to be influenced by lifestyle factors.

George A Jelinek · Ruth H Gawler

To the Editor: The Between the Flags project of the Clinical Excellence Commission (CEC) is designed to establish a “safety net” in all New South Wales public hospitals, to enable early identification and management of deteriorating hospital inpatients.1 A paediatric advisory group within of the program is currently developing five age-group-specific paediatric observation charts to account for the changes in normal physiological parameters that occur with age in children, and these have been distributed for comment before finalisation. Each chart has specific physiological calling criteria defining when a clinical review or rapid response is required from medical staff (Box). If one or more criteria fall in the “red” zone, the patient requires an immediate, rapid response; if criteria fall in the “yellow” zone, the patient needs a clinical review within 30 minutes. A paucity of data on what represents an abnormal parameter for each age group has also led to a lack of clear triage guidelines for emergency department nurses. For example, the paediatric physiological discriminators of the Australasian Triage Scale include terms such as “mild tachycardia” as a guide for allocating patients to triage Category 3 and “moderate tachycardia” for Category 2.2 We trialled the CEC paediatric inpatient calling criteria to determine whether they could also be used for emergency department triage purposes. We carried out a retrospective review of patients presenting to triage at the emergency department of the Children’s Hospital at Westmead between 1 and 14 March 2010. We assumed that patients who met the CEC’s yellow criteria should be allocated to triage Category 3 (“urgent: review within 30 minutes”) and those who met the CEC’s red criteria should be allocated to at least triage Category 2 (“emergency: review within 10 minutes”). Patient outcomes were classified as “admitted”, “discharged” or “did not wait”. From 1968 presentations, 1885 patients had observations at triage available for review. The numbers of patients in each triage category were: Category 1 (5); 2 (41); 3 (403); 4 (422); and 5 (1014). Only 10 of the 46 patients in Category 1 and 2 would have been flagged by the CEC parameters as needing a rapid response (ie, review within 10 minutes), and none of the three patients admitted to the paediatric intensive care unit would have been identified by the CEC parameters. Of the 403 patients in Category 3 (needing review within 30 minutes), 32 would have been uptriaged to Category 2 by the CEC criteria. Twelve of these 32 patients were in fact discharged home, indicating that the CEC criteria are unsuitable for triage purposes. Of the 1436 patients in Category 4 and 5, 30 would have been uptriaged to Category 2 according to the CEC parameters and, of these, only three were admitted. A further 271 patients would have been uptriaged to Category 3 (181 of these were discharged and 54 did not wait). Of particular note is that 151 of the 271 patients met the yellow criteria because of low respiratory rates that were flagged by the charts but were normal for the patient. At present, the physiological parameters defined in the new CEC paediatric inpatient observation charts are not suitable as a triage tool in the paediatric emergency department, do not replace an experienced triage nurse, and are a poor predictor of disposition. CEC calling criteria* and physiological parameters for children, by age group Calling criteria, by age group Call Physiological parameter < 30 days 1–12 months 1–4 years 5–11 years ≥ 12 years Red† Heart rate (beats/min) Above 180 190 170 160 150 Below 80 80 70 60 40 Respiratory rate (breaths/min) Above 100 65 60 50 40 Below 20 15 15 10 5 Systolic blood pressure (mmHg) Above — — — — — Below 60 50 70 70 80 Oxygen saturation (%) Below 85 85 85 85 85 Temperature (°C) Above 38 — — — — Yellow‡ Heart rate (beats/min) Above 160 170 150 140 130 Below 90 100 80 70 50 Respiratory rate (breaths/min) Above 60 50 50 35 30 Below — 30 20 15 10 Systolic blood pressure (mmHg) Above — 120 120 130 160 Below 70 80 80 80 90 Oxygen saturation (%) Below 95 90 90 90 90 Temperature (°C) Above 37.5 — — — — CEC = Clinical Excellence Commission. * Calling criteria as of March 2010 at the time of this study (the CEC has subsequently revised some of these criteria). Only one “flag” was required to meet a calling criterion. Other calling criteria such as pain, work of breathing and level of consciousness were not measured in our study but will also generate a call. Where no values are present, there are no calling criteria for the parameter. † Red call requires immediate, rapid response. ‡ Yellow call requires review within 30 minutes.

Fenton M O’Leary · Jennifer I Major

To the Editor: Chen and colleagues1 published a risk assessment tool for type 2 diabetes (AUSDRISK) based on the Australian Diabetes, Obesity and Lifestyle Study (AusDiab).2 We tested AUSDRISK’s performance in an independent cohort of 1494 women enrolled in the Geelong Osteoporosis Study (1994–1997; 77% participation),3 comprising an age-stratified sample of women randomly selected from the Barwon Statistical Division and followed prospectively over a decade.4 In 2004–2008, of 1015 surviving study participants aged 25 years or older at enrolment, 800 (79%) returned for follow-up assessment. We excluded 261 women who did not have a fasting plasma glucose (FPG) test result at both baseline and follow-up assessments, and 33 with baseline diabetes. The remaining 506 women formed the cohort on which the AUSDRISK tool was tested. Diabetes was defined by one or more of three criteria: FPG level ≥ 7.0 mmol/L, treatment with insulin or oral hypoglycaemic agents, or self-report. Demographics, ethnicity and lifestyle factors were documented by questionnaire. Participants were described as “active” if they described their mobility as “moves, walks and works energetically, and participates in vigorous activity”; otherwise, they were considered “inactive”. As our baseline questionnaire did not document a history of high glucose levels, we performed two analyses: one assuming no participants had this history, and a second identifying participants with baseline impaired fasting glycaemia (FPG level, 6.1–6.9 mmol/L). The study was approved by the Human Research Ethics Committee, Barwon Health. Using the final AUSDRISK model,1 we allocated points for baseline characteristics according to sex, age, ethnic background, parental history of diabetes, history of high blood glucose (FPG level, ≥ 6.1 mmol/L), use of antihypertensive medications, current smoker status, physical inactivity, and waist circumference. The predictive power of AUSDRISK was determined using the area under the receiver operating characteristic curve (AROC). Using a total AUSDRISK score ≥ 12 as the criterion for prediction of diabetes, we evaluated the performance of AUSDRISK by calculating its sensitivity, specificity and positive predictive value (PPV) in our cohort. Ninety-eight participants had an AUSDRISK score ≥ 12 (or 106 if those with impaired fasting glycaemia were scored for a history of high blood glucose). Statistical analyses were performed using Stata software, version 9 (StataCorp, College Station, Tex, USA). Twenty-eight participants (5.6%) developed incident diabetes during the period of follow-up (13 with FPG ≥ 7.0 mmol/L, 14 receiving treatment with insulin or hypoglycaemic agents, and seven self-reporting the condition). If we assumed that none of the participants had a history of high blood glucose levels, the AROC for AUSDRISK in the Geelong cohort (0.78 [95% CI, 0.72–0.85]) was comparable with that in the AusDiab cohort (0.78 [95% CI, 0.76–0.81]).1 In our study, the sensitivity of the AUSDRISK tool was 50.0% (95% CI, 30.6%–69.4%), specificity was 82.4% (95% CI, 78.7%–85.7%) and PPV was 14.3% (95% CI, 8.0%–22.8%). Recognising baseline impaired fasting glycaemia increased AUSDRISK’s predictive power (AROC, 0.81 [95% CI, 0.74–0.88]; sensitivity, 60.7% [95% CI, 40.6%–78.5%]; specificity, 81.4% [95% CI, 77.6%–84.8%]; and PPV, 16.0% [95% CI, 9.6%–24.4%]). Study limitations were that we only evaluated women, we did not collect data on a history of high blood glucose levels, diabetes was diagnosed in the absence of an oral glucose tolerance test, and criteria for inactivity differed from those used in the AusDiab study. Our population was older than that of the AusDiab study and would probably have had a higher prevalence of diabetes, influencing our PPV result. Not surprisingly, including individuals with impaired fasting glycaemia increased the point estimates for AROC, sensitivity and PPV. In conclusion, our data independently demonstrate the limited predictive value of AUSDRISK for women over a 10-year period.

Julie A Pasco · Mark A Kotowicz · Margaret J Henry · Geoffrey C Nicholson

To the Editor: Evidence is beginning to accumulate on the effectiveness of the low-density lipoprotein (LDL) cholesterol-lowering medicine ezetimibe. While there are no completed trials investigating ezetimibe’s effect on clinically important end points, two recent trials investigating its effect on carotid intima media thickness (CIMT) have both reported disappointing results.1,2 After each of these trials, the Journal has published editorials by Hamilton-Craig, who offers reassurance about ezetimibe and encourages ongoing prescription of this drug to patients who have elevated LDL levels despite maximum-tolerated statin therapy.3,4 Such a sanguine opinion seems at odds with the negative trial evidence, and therefore worthy of debate. Briefly, the ENHANCE (Ezetimibe and Simvastatin in Hypercholesterolemia Enhances Atherosclerosis Regression) trial, which compared ezetimibe plus simvastatin with simvastatin treatment alone in 720 patients with familial hypercholesterolaemia, found no significant difference (and a trend in the direction of harm) with respect to the primary end point of CIMT.1 The ARBITER 6-HALTS (Arterial Biology for the Investigation of the Treatment Effects of Reducing Cholesterol 6 — HDL and LDL Treatment Strategies in Atherosclerosis) trial compared ezetimibe with extended-release niacin in statin-treated patients with coronary heart disease.2 Among 315 patients with available results, the group taking niacin showed a statistically significant reduction in CIMT, but the group taking ezetimibe showed no such reduction. Of concern, increased cumulative exposure to ezetimibe was associated with progression of CIMT (P = 0.05). Although far from definitive, the results of these two trials offer no reassurance of benefit from ezetimibe and, in my view, may portend harm. It may seem counterintuitive that ezetimibe, which significantly lowers LDL cholesterol levels,1,2 could be ineffective or harmful. However, the history of medicine is replete with examples of interventions that improve numerical disease measures without benefit to patients. One recent example was torcetrapib, which, despite increasing high-density lipoprotein cholesterol and reducing LDL cholesterol levels in a promising manner, was found to cause serious adverse events, including death.5 I agree with Hamilton-Craig that we require trials measuring major cardiovascular events to really understand the effects of ezetimibe. Where we disagree is how to manage our patients during the period of uncertainty until publication of the results of these trials. While he argues for continued prescribing of ezetimibe, I suggest we should explicitly share our uncertainty about the safety and efficacy of this drug with our patients by discussing the existing research. Some patients will, like Hamilton-Craig, place their faith in the cholesterol hypothesis and be reassured by an assumption of cardiovascular protection as their LDL falls. Others will choose to wait until we have more robust evidence that ezetimibe is safe and effective. I would wait.

Brett D Montgomery

In reply: I agree with Montgomery that cardiovascular disease (CVD) outcomes are required to determine the role of ezetimibe. The Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) trial (in which patients with aortic stenosis were treated for 52.2 months with statin plus ezetimibe or statin plus placebo) showed a 4.7% reduction in ischaemic CVD events in the ezetimibe group (P = 0.02; number needed to treat, 23), driven by a reduced need for coronary artery bypass grafting.1 In contrast to previous trials showing regression of atherosclerosis in response to statin therapy, baseline carotid intima media thickness (CIMT) levels in the ENHANCE (Ezetimibe and Simvastatin in Hypercholesterolemia Enhances Atherosclerosis Regression) trial were normal, due to previous statin therapy. This is likely to account for the lack of change in CIMT with ezetimibe treatment in the ENHANCE trial.2 As no placebo group was included, neither lack of benefit nor harm from ezetimibe therapy can be inferred.2 Data from animal studies have shown atherosclerosis regression after ezetimibe treatment through multiple mechanisms.3-5 Prospective randomised controlled trials with statins, resins or surgery have independently shown an approximate 1% reduction in CVD per 1% reduction in low-density lipoprotein cholesterol (LDL-C) level. Evidence for the benefits of lowering LDL-C is among the most robust in medicine. Pending the outcomes of IMPROVE-IT (the Improved Reduction of Outcomes: Vytorin Efficacy International Trial, a multicentre study of ezetimibe plus simvastatin versus simvastatin treatment of patients with acute coronary syndrome [http://clinicaltrials.gov/ct2/show/NCT00202878]), or clinical outcome data confirming those of the ARBITER 6-HALTS (Arterial Biology for the Investigation of the Treatment Effects of Reducing Cholesterol 6 — HDL and LDL Treatment Strategies in Atherosclerosis) trial,6 it seems reasonable to continue to use ezetimibe to lower LDL-C levels in patients who are not achieving LDL-C targets despite statin therapy or who are intolerant to statins. Extended-release nicotinic acid (Niaspan [Abbott Laboratories, Chicago, Ill, USA]) may be an appropriate alternative to statins as second-line therapy, and should be made available under the Pharmaceutical Benefits Scheme for treating patients with dyslipidaemia. (Niaspan has approval from the Therapeutic Goods Administration for marketing in Australia, but is not being imported into Australia at this stage.)

Ian R Hamilton-Craig

CorrectionAcknowledgements omitted: In “A multimodal intervention to improve fragility fracture management in patients presenting to emergency departments” in the 2 August 2010 issue of the Journal (Med J Aust 2010; 193: 149-153), the acknowledgements were omitted. The following text should be inserted before “Competing interests”: Acknowledgements: We wish to thank the following for their contribution to our project: the National Health and Medical Research Council’s National Institute of Clinical Studies and Australian Department of Veterans’ Affairs Fellowship Program; the North Metropolitan Area Health Service, Perth (Sir Charles Gairdner Hospital, Osborne Park Hospital and area rehabilitation and aged care staff); and physicians and general practitioners involved in developing the consensus guidelines. The html and pdf versions of this article have been corrected.

Charles A Inderjeeth · Denise A Glennon · Kate E Poland · Katherine V Ingram · Richard L Prince · Victoria R Van · C D’Arcy J Holman

Enhancing patient care. A practical guide to improving quality and safety in hospitals. Alan Wolff, Sally Taylor. Sydney: MJA Books, 2009 (234 pp). ISBN 9780977578665. Wimmera Hospital, in Horsham, western Victoria, has a well deserved reputation for promoting quality and safety. Here, Alan Wolff, Wimmera’s medical director, and Sally Taylor, its clinical risk manager, outline the steps they followed in developing a rigorous quality management process at the hospital. This is indeed, as claimed, a practical guide and is recommended for all those interested in clinical governance. The Wimmera model appropriately distinguishes between safety and quality, and outlines steps to promote quality and assure safety. In terms of how the book might have been strengthened, I think a chapter outlining what a board safety and quality committee might do would have been useful. Further, the book has its provenance in a regional hospital and there is a question in my mind about whether all the elements of the Wimmera model are scalable. The book also de-emphasises the role of routine data for tracking safety in hospitals. Although hospitals can track their own trends over time using routine data, this sort of monitoring is much more powerful when it involves comparison with other like facilities. The model’s approach to management of adverse events focuses too much on the visible, the “event”, and tends to de-emphasise the myriad small things (eg, the incidence of pneumonia) which might together contribute to a poorer experience of hospitalisation. The book could also have been strengthened by incorporating guidance on how to structure investigations, when they are called for. The Queensland approach “pyramid model” of looking at data, casemix, resources, processes of care and professional issues is a valuable one.1 The book rightly identifies the health professional involved in an adverse event as the “second victim”. The medical director might also be seen as the “third victim”. The role of the medical director is a hard one, especially in a small hospital. It means holding to account local colleagues, often people with whom one has worked for many years. It is an isolated role and one deserving of more support. The authors are to be commended for making this hard journey an easier one.

Stephen J Duckett

Let’s get together Like the open-source software community, an open-science community for rare diseases is needed, say US experts. Forrest and colleagues say that although any one such condition may be rare, about 6% to 8% of people will have a rare disease at some point during life. No single institution, and in many cases no single country, has sufficient numbers of patients to conduct generalisable clinical and translational research on any of these diseases. Thus, the call for a global open-science community with the infrastructure to provide, among other things, a forum for exchange of experiences and knowledge. Wouldn’t it be great if, each time a new registry for a rare disease is developed, we didn’t have to start from scratch? Lancet Online 2 August 2010 Spiderwatch Did you know that New Zealand has over 1100 named species of spiders, approximately 95% of which are unique to the Land of the Long White Cloud? Luckily for New Zealanders, very few of these spiders pose a threat to human health. Nevertheless, there is growing interest in properly identifying any spiders confirmed as having bitten a person in New Zealand. Derraik and colleagues have reported the first account of a bite by the New Zealand native spider Trite planiceps — the patient survived (easily), the spider did not. Less formally known as the black headed jumping spider, this spider is commonly encountered around homes and generally considered to be rather docile. N Z Med J 2010; 123: 112-118 Who oversees artists? In 2008, police raided a Sydney art gallery just before the opening of an exhibition of photographs by noted Australian artist and photographer Bill Henson. Photographs depicting naked children were seized, although later released, and Henson was not prosecuted. The event promoted, at the time, vigorous debate about censorship, and now, an editorial by Isaacs and Isaacs. They say we have a duty to protect children from exploitation and — drawing an analogy with research involving children — ask whether the children photographed were able to give truly informed consent. According to Isaacs and Isaacs, Australian states and territories have varying legislation concerning children in art, including whether it is illegal for artists to work with naked children. They say that the Australia Council for the Arts is developing protocols for artists working with children, and that it is commendable that artists develop a code of conduct which reconciles artistic freedom with the needs and rights of children. J Paediatr Child Health 2010; 46: 369-371 An “author pays” BMJ? With the aim of ensuring the sustainability of open-access publication of research and in the spirit of experimentation, the BMJ is introducing an “author pays” model for research. In announcing this step, Godlee and Groves noted that most other open-access journals already levy fees to cover the costs of peer review, journal production, and online hosting and archiving. A publication fee of £2500 will now apply for each research article accepted by the BMJ — but only when the funder of the research has pledged to pay for open-access publication. The fee will be requested only after a study is accepted for publication; and the seeking and processing of fees will not delay editing or publication, they say. Reassuringly, all submitted research will continue to be judged entirely on its importance, originality, quality and relevance, and not on the author’s (or authors’) ability to pay. BMJ 2010; 341: c4494 Tai chi benefits fibromyalgia Tai chi may be a useful therapy in the multi-disciplinary treatment of fibromyalgia, say US researchers. Wang and colleagues conducted a single-blind randomised trial of classic Yang-style tai chi compared with a control intervention (wellness education and stretching) in 66 patients with fibromyalgia.1 After a 12-week intervention, the tai chi group benefited from significant symptomatic improvement, with improvements maintained at 24 weeks. The tai chi group received instruction from a tai chi master with more than 20 years of teaching experience. In a linked editorial, Yeh and colleagues suggested that even if it is too early for doctors to take out a prescription pad and write “tai chi”, it is now reasonable, given the potential efficacy and lack of adverse effects, to support patients’ interest in exploring these types of exercises.2 1. N Engl J Med 2010; 363: 743-754 2. N Engl J Med 2010; 363: 783-784

Ann T Gregory