Volume 193 Issue 8

Providing world-class stroke care in Australia Cerebrovascular disease is the third leading cause of disease burden in developed nations, and is predicted to be the fourth ranked disease burden worldwide by 2030 after unipolar depressive disorders, ischaemic heart disease and trauma.1 All of these conditions are characterised by sudden and unpredictable demands requiring an immediately accessible, systemised and multidisciplinary approach to care. The complexities of acute ischaemic stroke in Australia have been addressed by detailed clinical guidelines.2 An emergency care bundle for stroke and transient ischaemic attack has recently been offered by the National Institute of Clinical Studies of the National Health and Medical Research Council.3 When administered to appropriate patients within 3 hours of stroke symptom onset, the benefits of recombinant tissue plasminogen activator (rt-PA) are significant, with treated patients 30% more likely to be in the excellent outcome grade — an absolute increase of 13%4 — and improvements in modified Rankin scores for some other patients with higher modified Rankin scores. The number of patients needed to treat for benefit may be as low as three.5 The associated risk of an intracerebral haematoma causing deterioration is about one in 30.5 The third European Cooperative Acute Stroke Study (ECASS3), a randomised trial of intravenous rt-PA in the 3–4.5 hour window, demonstrated a smaller but statistically significant benefit with no increase in haematoma rate.6 A recent Cochrane review of 26 thrombolysis trials of rt-PA, streptokinase, desmoteplase, urokinase and pro-urokinase, which included 7125 patients, found a significant net benefit in terms of death and dependency.7 The clinical applicability of new therapies may be exaggerated by the Hawthorne effect of clinical trials. The European Safe Implementation of Thrombolysis in Stroke Monitoring Study (SITS-MOST) registry — a mandated requirement of European drug licensing authorities — was established to monitor thrombolysis in day-to-day clinical practice.8 It included centres not experienced with thrombolysis and demonstrated the feasibility and safety of thrombolytic therapy across Europe. The cover of the issue of The Lancet in which the registry outcomes were published declared that rt-PA is “safe and effective in routine clinical use”. The rate of symptomatic intracerebral haemorrhage (ICH), as defined by the National Institute of Neurological Disorders and Stroke (NINDS), was 7.3% in SITS-MOST for both experienced and new thrombolysis centres, with a calculated mortality rate from ICH at 3 months of 1.9%.8 Early deterioration due to ICH in the SITS-MOST registry occurred in 1.7% of cases. In this issue of the Journal, Simpson and colleagues report the Australian contribution to the Safe Implementation of Thrombolysis in Stroke International Stroke Thrombolysis Register (SITS-ISTR),9 reflecting the local experience of treating acute stroke 15 years on from the NINDS trial.4 Participation in the Australian component of the SITS-ISTR was voluntary. Many centres undertaking thrombolysis did not participate, and this may weaken the generalisability of this new data. Nevertheless, over 500 patients were enrolled and outcomes did not differ from those of the larger international database. The important safety data were reassuring, with a symptomatic ICH rate of 8.3% by the definition used in the NINDS randomised controlled trial, and 1.3% by the SITS-MOST definition. The 3-month ICH mortality rate was 2.2%. A British subset of SITS has been reported recently, with outcomes also comparable to those for the rest of Europe.10 In the SITS-MOST registry, new and experienced centres did not differ in terms of their haemorrhagic complication rates.8 While the Australian report by Simpson et al does not detail information regarding the types of centres involved, implementation of thrombolysis in Australia beyond the centres that participated in the thrombolysis trials is already well established. Audits by the National Stroke Foundation have found that 33 hospitals were regularly treating with rt-PA in 2007,11 and that this increased to 50 by 2009.12 New metropolitan and rural centres can adopt thrombolysis with executive support and leadership from medical and nursing “stroke champions”. This nearly always results in the establishment of a stroke unit and the adoption of a local thrombolysis protocol with coordination of the prehospital emergency services. Mentorships with established metropolitan centres are worthwhile in the early stages. Some direct links using telemedicine for the treatment of the first cases have been employed in Victoria (Associate Professor Bernard Yan, Neurologist and Neurointerventionist, Royal Melbourne Hospital, personal communication). Early recognition and intervention for stroke requires a tightly coordinated interdisciplinary approach and rates of intravenous thrombolysis administration can be used as a clinical quality indicator for stroke care.13 Ongoing participation in the SITS-ISTR and the Australian Stroke Clinical Registry is crucial for monitoring the progress of this important therapy. A coordinated system of care for stroke and transient ischaemic attack in Australia has been stalled by the lack of a concerted effort to adopt thrombolysis. Australian registry data provide reassurance that Australian stroke physicians, emergency physicians and systems that support thrombolysis can achieve similar results to those recorded in Europe. We can now move beyond discussing the efficacy and feasibility of implementing this therapy and work toward a more coordinated system of applying the evidence.

Mark Fitzgerald MB BS, FACEM · Richard P Gerraty MD, FRACP

Carotid artery stenting has a place in managing symptomatic stenosis, but only sometimes Carotid stenosis remains one of the most readily treatable causes of ischaemic stroke. Its treatment has undergone many changes in recent years, with the advent of endovascular techniques seeming to offer great promise of a much less invasive procedure. In the late 1990s, the Australian Association of Neurologists published guidelines for the use of carotid balloon angioplasty alone (ie, without stenting) as a treatment for carotid stenosis, recommending cautious use in the absence of data from randomised controlled trials (RCTs).1 However, advances in vascular stent technology have resulted in a greatly increased use of carotid artery stenting (stenting), often with specialised filter devices deployed distal to the carotid stenosis to catch embolic debris that may arise from catheter or stent manipulation. Recent evidence from RCTs has cast doubt on the safety of widespread use of stenting for the treatment of patients with symptomatic or asymptomatic carotid stenosis. The overall results from these RCTs indicate that carotid endarterectomy (endarterectomy) is still the preferred treatment option for symptomatic carotid stenosis. The results of three major European studies into the treatment of symptomatic stenosis — Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S); Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE); International Carotid Stenting Study (ICSS) — showed that stenting was more hazardous than endarterectomy for the outcomes of stroke and death during the periprocedural period (30 days), and on longer-term follow-up.2-4 Perhaps in contrast, the recent North American Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) demonstrated equivalent (non-significant) rates of stroke, myocardial infarction and death in its stenting and endarterectomy groups in the periprocedural period, and at 4 years.5 However, in CREST there was a significantly reduced rate of stroke and death in the endarterectomy group, but this was offset by an increased risk of myocardial infarction, in part due to the definition of myocardial infarction used, and a greater number of study patients with comorbid ischaemic heart disease.5 Use of cerebral protection devices during stenting was mandated in CREST but not in the European studies. The value of these devices is in question, with evidence indicating that they were no more effective in reducing the clinical risk of stroke than unprotected stenting.6,7 Moreover, data from a magnetic resonance imaging substudy undertaken as part of the ICSS indicated that, compared with endarterectomy, there was a threefold increase in silent brain infarctions in stenting with use of cerebral protection devices (adjusted odds ratio, 3.28 [95% CI, 1.5–7.2]).7 A meta-analysis of 11 RCTs (including EVA-3S, SPACE and ICSS, but not CREST) showed that endarterectomy was superior to stenting in short-term but possibly not longer-term outcomes, a difference largely driven by non-disabling stroke.8 The Australasian guidelines9,10 have now been upgraded following additional published data from CREST5 and a meta-analysis of the three large European trials (EVA-3S, SPACE, ICSS)11 indicating that stenting is at least as safe as endarterectomy in patients under 70 years of age, while it presents a greater risk of stroke for those older than 70 years (Box). The RCTs indicate that there is currently no clear evidence to support either endarterectomy or stenting as a treatment for asymptomatic carotid stenosis. Indeed, current medical therapies have reduced the risk of stroke in asymptomatic stenosis to as low as 0.5% per year.12 Ongoing RCTs continue to address this question (eg, the Asymptomatic Carotid Surgery Trial 2, comparing stenting and endarterectomy in the treatment of asymptomatic carotid stenosis).13 Until recently, in Australia and New Zealand, there were no specific published guidelines for carotid artery stenting. To redress this, an intercollegiate working group was formed — the Carotid Stenting Guidelines Committee — comprising expert representatives of the Royal Australasian College of Physicians, the Royal Australasian College of Surgeons, and the Royal Australian and New Zealand College of Radiologists. Consensus for guideline parameters was reached using the modified Delphi consensus method of iterative consultation. The committee’s guidelines recommend clinical selection criteria for carotid artery stenting, as well as cognitive and technical requirements that clinicians should meet before performing stenting.9,10 The guidelines do not deal with training criteria and procedural accreditation as these are determined by the Conjoint Committee for Recognition of Training in Peripheral Endovascular Therapy of the abovementioned colleges. On current evidence, the guidelines recommend that carotid artery stenting may be considered a treatment option in specific, high-risk patients with symptomatic severe stenosis who are considered unsuitable for endarterectomy (Box).10 It is important to note that these are relative contraindications to endarterectomy as there is no evidence to support stenting in these patients (indeed, they are often excluded from clinical trials). Finally, it is important that all patients being considered for a carotid intervention have preprocedural neuroimaging and independent neurological assessment before and after the procedure. This allows for an audit comparison with the results of RCTs where neurological evaluation of all patients is routine, and serves as a benchmark for best clinical practice. In summary, the evidence from RCTs indicates that, at present, a cautious approach should be taken to recommending carotid artery stenting — festina lente (hasten slowly). Stenting should not be performed in most patients with symptomatic severe carotid stenosis, and there is currently no evidence to support stenting as a treatment for asymptomatic carotid stenosis. Stenting warrants consideration in younger patients (< 70 years of age) and those with symptomatic severe carotid stenosis unsuitable for endarterectomy. These standards should apply in all health care settings, public and private. Advances in endovascular technologies, and evidence from future RCTs and meta-analyses, will guide revisions of the guidelines. Carotid Stenting Guidelines Committee: recommended indications and contraindications for carotid artery stenting (CAS)10 Indications Symptomatic carotid disease in the following conditions may be assessed at high surgical risk for carotid endarterectomy (CEA) by an appropriate clinician experienced in the management of carotid stenosis: post-radiation therapy block dissection of the neck in-situ tracheostomy recurrent stenosis following previous CEA severe cervical spine arthritis surgically inaccessible carotid stenosis (eg, obesity, high carotid bifurcation) contralateral recurrent laryngeal nerve injury contralateral internal carotid artery occlusion Symptomatic severe carotid stenosis* in patients under 70 years of age, where carotid revascularisation is considered appropriate Symptomatic or asymptomatic carotid stenosis where carotid revascularisation is considered appropriate, and the patient is randomised to CAS in a clinical trial Contraindications Absolute Carotid stenosis in a patient with significant contraindications to angiography Carotid stenosis with angiographically visible intraluminal thrombus Carotid occlusion Relative Carotid stenosis associated with an intracranial vascular malformation Contraindications related to vascular anatomy and atherosclerosis (eg, type 2–3 arch; bovine arch; severe aortic arch or ipsilateral common carotid atherosclerosis; severe proximal common carotid artery tortuosity; severe distal internal carotid artery tortuosity (possibly compromising embolic protection devices); sharply angulated internal carotid artery; carotid string sign; circumferential calcification of carotid plaque; loose thrombus associated with carotid plaque) * Severe carotoid stenosis is defined as ≥ 70% using North American Symptomatic Cartoid Endarterectomy Trial criteria.5

on behalf of the Carotid Stenting Guidelines Committee (Australia and New Zealand)

Objective: To report Australian outcomes from the Safe Implementation of Thrombolysis in Stroke International Stroke Thrombolysis Register (SITS-ISTR).Design: Observational study using data collected prospectively from December 2002 to December 2008.Setting: Centres administering thrombolysis for acute stroke in Australia and worldwide.Patients: All patients treated with recombinant tissue plasminogen activator for acute stroke in participating centres, regardless of stroke severity, time of treatment and other clinical factors.Intervention: Thrombolysis for acute stroke, administered according to local protocol.Main outcome measures: Functional outcome as 3-month modified Rankin score (mRS), and frequency of symptomatic intracerebral haemorrhage (ICH).Results: During the study period, a total of 32 countries participated, and confirmed baseline data were available for 581 Australian patients and 20 953 patients in the rest of the world. Australian patients were older (median age, 73 v 69 years; P < 0.001), were less independent before stroke (premorbid mRS of 0–1, 87.5% v 91.2%; P < 0.005), and had more comorbidities and more severe strokes. Comparing the Australian cohort with the rest of the world, the odds ratio of 3-month mRS of 0–2 was 0.98 (95% CI, 0.88–1.08; P = 0.63), the odds ratio of symptomatic ICH was 0.98 (95% CI, 0.83–1.16; P = 0.85 [by the definition used by the National Institute of Neurological Disorders]) and the odds ratio of death was 1.04 (95% CI, 0.91–1.19; P = 0.54). Good outcome in the Australian cohort was predicted by younger age, presence of hyperlipidaemia, lower premorbid mRS, absence of infarct on early brain imaging, less severe stroke, and lower baseline blood glucose level.Conclusion: Clinical outcomes after thrombolysis in Australia were similar to those worldwide.

Marion A Simpson BSc, MB ChB(Hons), MRCP · Helen M Dewey PhD, FRACP, FAFRM(RACP) · Leonid Churilov PhD · Niaz Ahmed MD, PhD · Christopher F Bladin MB BS, MD, FRACP · David Schultz BM BS, FRACP · Romesh Markus MB ChB(Hons), PhD, FRACP · Jonathan W Sturm MB ChB, PhD · Christopher R Levi BMedSci, MB BS, FRACP · David J Blacker MB BS, FRACP · Jim Jannes BM BS, FRACP, PhD · Richard I Lindley MD, FRCP, FRACP · Mark W Parsons PhD, FRACP

Objective: To document diabetes health services use and indices of glycaemic management of young people with type 1 diabetes from the time of their first contact with adult services, for those living in regional areas compared with those using city and state capital services, and compared with clinical guideline targets.Design, setting and subjects: Case note audit of 239 young adults aged 18–28 years with type 1 diabetes accessing five adult diabetes services before 30 June 2008 in three geographical regions of New South Wales: the capital (86), a city (79) and a regional area (74).Main outcome measures: Planned (routine monitoring) and unplanned (hospital admissions and emergency department attendance for hypoglycaemia or hyperglycaemia) service contacts; recorded measures of glycated haemoglobin (HbA1c), body mass index (BMI), and blood pressure (BP).Results: Routine preventive service uptake during the first year of contact with adult services was significantly higher in the capital and city. Fewer regional area patients had records of complications assessment and measurements of HbA1c, BMI and BP across all audited years of contact (HbA1c: 73% v 94% city, 97% capital; P < 0.001). Across all years, regional area patients had the highest proportion of HbA1c values > 8.0% (79% v 62% city, 56% capital) and lowest proportion < 7% (4% v 7%, 22%) (both P < 0.001). Fewer young people made unplanned use of acute services for diabetes crisis management in the capital (24% v 49% city, 50% regional area; P < 0.001). In the regional area, routine review did not occur reliably even annually, with marked attrition of patients from adult services after the first year of contact.Conclusion: Inadequate routine specialist care, poor diabetes self-management and frequent use of acute services for crisis management, particularly in regional areas, suggest service redesign is needed to encourage young people’s engagement.

Lin Perry PhD, MSc, RN · Katharine S Steinbeck MB BS, FRACP, PhD · Janet S Dunbabin BAg(Sc), PhD · Julia M Lowe MB ChB, FRCP, MMedSci

Objective: To assess emergency department (ED) doctors’ knowledge of radiation doses associated with diagnostic imaging and to describe their practice with regard to informing patients of risk.Design, participants and setting: Prospective, questionnaire-based observational study in May 2009 among all 110 doctors in the EDs of a 570-bed teaching hospital and a 200-bed district hospital.Main outcome measures: Percentage knowledge score; and frequency of discussing radiation risk with patients, based on responses to three scenarios rated on a visual analogue scale (VAS), where a score of 100 indicates doctors would always discuss it.Results: 96 doctors (87%) completed the questionnaire. The overall mean knowledge score was 40% (95% CI, 38%–43%). Senior doctors scored somewhat higher than junior doctors, but not significantly (42% v 39%; P = 0.75). Over three-quarters of doctors (78%) underestimated the lifetime risk of fatal cancer attributable to a single computed tomography scan of the abdomen. Most doctors (76%) reported never having had any formal training on risks to patients from radiation exposure. The frequency at which doctors would inform patients of the risk of radiation varied greatly depending on the clinical scenario (mean VAS scores, between 38 and 90).Conclusion: Emergency doctors in our sample had a varied knowledge of the risks from radiation exposure, but overall knowledge was poor. Staff should receive education, and the diagnostic imaging request process may need to include information on radiation doses and risks.

Gerben B Keijzers MB BS, MSc(Epid), FACEM · Charles J Britton MB ChB

Aim: Design, setting and participants: Retrospective observational study of patients who were tested for influenza A after being admitted to hospital through emergency departments of the Sydney South West Area Health Service from 15 June to 30 August 2009.Main outcome measures: The association of factors such as age, diagnosis at admission, hospital and week of admission with rates of testing and detection of influenza A.Results: 17 681 patients were admitted through nine emergency departments; 1344 (7.6%) were tested for influenza A, of whom 356 (26.5%) tested positive for pandemic influenza. Testing rates were highest in 0–4-year-old children, in the peak period of the outbreak, and in patients presenting with a febrile or respiratory illness. Positive influenza test results were common across a range of diagnoses, but occurred most frequently in children aged 10–14 years (64.3%) and in patients with a diagnosis at admission of influenza-like illness (59.1%). Using multivariate logistic regression, patients with a diagnosis at admission of fever or a respiratory illness at admission were most likely to be tested (odds ratios [ORs], 15 [95% CI, 11–21] and 17 [95% CI, 15–19], respectively). These diagnoses were stronger predictors of influenza testing than the peak testing week (Week 4; OR, 7.0 [95% CI, 3.8–13]) or any age group. However, diagnosis at admission and age were significant but weak predictors of a positive test result, and the strongest predictor of a positive test result was the peak epidemic week (Week 3; OR, 120 [95% CI, 27–490]).Conclusion: The strongest predictor of a clinician’s decision to test for influenza was the diagnosis at admission, but the strongest predictor of a positive test was the week of admission. A rational approach to influenza testing for patients who are admitted to hospital for acute care could include active tracking of influenza testing and detection rates, testing patients with a strong indication for antiviral treatment, and admitting only those who test negative to “clean” wards during the peak of an outbreak.

Andrew Jardine PhD, MAE · Stephen J Conaty MB BS, MPH, FAFPHM · Michelle A Cretikos MPH, PhD, FAFPHM · Wei-Yuen Su MB BS · Iain B Gosbell MD, FRACP, FRCPA · Sebastiaan J van Hal MB ChB, FRACP, FRCPA

Pancreatic exocrine insufficiency (PEI) occurs when the amounts of enzymes secreted into the duodenum in response to a meal are insufficient to maintain normal digestive processes. The main clinical consequence of PEI is fat maldigestion and malabsorption, resulting in steatorrhoea. Pancreatic exocrine function is commonly assessed by conducting a 3-day faecal fat test and by measuring levels of faecal elastase-1 and serum trypsinogen. Pancreatic enzyme replacement therapy is the mainstay of treatment for PEI. In adults, the initial recommended dose of pancreatic enzymes is 25 000 units of lipase per meal, titrating up to a maximum of 80 000 units of lipase per meal. In infants and children, the initial recommended dose of pancreatic enzymes is 500 units of lipase per gram of dietary fat; the maximum daily dose should not exceed 10 000 units of lipase per kilogram of bodyweight. Oral pancreatic enzymes should be taken with meals to ensure adequate mixing with the chyme. Adjunct therapy with acid-suppressing agents may be useful in patients who continue to experience symptoms of PEI despite high-dose enzyme therapy. A dietitian experienced in treating PEI should be involved in patient management. Dietary fat restriction is not recommended for patients with PEI. Patients with PEI should be encouraged to consume small, frequent meals and to abstain from alcohol. Medium-chain triglycerides do not provide any clear nutritional advantage over long-chain triglycerides, but can be trialled in patients who fail to gain or to maintain adequate bodyweight in order to increase energy intake.

James Toouli MB BS, FRACS, PhD · Andrew V Biankin MB BS, PhD, FRACS · Mark R Oliver MB BS, MD, FRACP · Callum B Pearce MB ChB, MD, FRACP · Jeremy S Wilson MD, FRACP, FRCP · Nicholas H Wray MND, BAppSc(ExSportSc), APD

The take-home message is not only early intervention but education and teamwork I was due to fly out to the United States the next morning. I was bending down to clean the floor of my car when it happened. First my right hand wouldn’t respond and I fumbled picking up a spoon from the floor, then my right leg wouldn’t support my weight. I tried to call out to my wife but only grunts came out, except of course the f-word when I knew what had happened. I crawled to the front door of the house, my intensivist wife called 000 and the ambulance was there in 3 minutes! The paramedics ignored my pleas to go to the closer private hospital ... “no you’re off to the Stroke Unit at The Alfred” ... and wasted no time — scoop and run. I was in the resuscitation bay of the emergency department (ED) in 20 minutes and, despite it being late on a Friday night, I was assessed, I had my computed tomography (CT) scan to exclude an intracranial haemorrhage, and the intravenous thrombolytic therapy was running within 60 minutes. The next day a repeat CT scan and a magnetic resonance imaging scan confirmed multiple small infarcts in the insula consistent with an embolic stroke. A patent foramen ovale (PFO) showed up on the transoesophageal echocardiogram on Day 3 and the PFO was occluded, percutaneously, on Day 7. I was home the next day and back at work 3 weeks later, with no significant residual deficit. Bending over in the car may have been the trigger, with a Valsalva that opened up the PFO and caused the clot to flip up my left middle cerebral artery (MCA) into the insular cortex. It is pleasing when published data justifies one’s own teaching; it is even more encouraging when it justifies treatment that affects one’s own life and health. Every 10 minutes, up to 20 million neurones will die in a typical infarct in the MCA territory, if not recanalised.1 A recent updated pooled analysis of eight trials using multivariate logistic regression has been used to assess the relationship of onset-to-treatment time with 3-month morbidity, brain haemorrhage and mortality.2 When selected by symptoms and CT findings, the critical time from onset of symptoms to the intravenous infusion of recombinant tissue plasminogen activator (rt-PA) seems to be 3 hours, though that window of opportunity can be increased to 4.5 hours, after which risk may outweigh benefit. After 4.5 hours, the risk, particularly of reduced recovery of brain function, brain haemorrhage and death, increases. However, not all patients benefit. It was shown that about five patients need to be treated within 0–90 minutes of symptom onset, nine patients within 91–180 minutes or 15 patients within 181–270 minutes for one of them to have an excellent outcome attributed to treatment. Clearly rt-PA is not a panacea, and other interventions need to be analysed for the ultimate objective of reperfusion of 100% of patients rather than 40%. Other modalities need to be investigated, particularly the therapeutic combinations of thrombolytics, neuroprotectives and antithrombotics in addition to ultrasound and endovascular mechanical clot manipulation.1 My experience with swift prehospital assessment and efficient ED intervention with intravenous rt-PA, after sustaining an acute ischaemic stroke, with full recovery, emphasises that time is critical.1 However, the take-home message here is not only early intervention but education and teamwork, similar to the model in trauma care — the “golden hour” and a well trained trauma team.3 For stroke management, this means the development of stroke centres, training of prehospital and emergency staff, prioritisation of patients to achieve door-to-needle times of less than 60 minutes and public education programs on acting early with the onset of symptoms.1,4 For me, it may have been luck: stroking out at home and not in the air; having a medico wife who recognised the signs; a paramedic crew trained to scoop and run and to take me to an ED with a stroke unit, not just passing by the end of my street when they got the call; ED staff who wasted no time; a neurology registrar who started the rt-PA immediately, though pointing out to me and my wife the risks of intracranial haemorrhage; and having a well trained team of health professionals in the Stroke Unit. Some cynics might say I got red carpet treatment because I am a professor of surgery. I disagree. I believe it was not just a stroke of luck but that I benefited from the ideal model of care of stroke management that should be available to all Australians.

Bruce P Waxman FRACS, FACS, MRACMA

Whether pilots with insulin-dependent diabetes should be allowed to fly has long been a controversial issue. Hypoglycaemia remains a significant threat to flight safety, and a barrier for pilots with insulin-dependent diabetes to overcome. Some countries allow recreational pilots to fly while treated with insulin under strict conditions. Recent changes in aeromedical certification in Australia will give pilots with diabetes more freedom to exercise the privileges of their licence, while adopting mechanisms to ensure the safety of air navigation.

David J P Fitzgerald MB BS(Hons), DipAvMed, FAFOEM(RACP) · Pooshan D Navathe MB BS, FAFOEM(RACP), PhD · A Michael Drane MB BS, MAvMed, FRNZCGP

The recent review of taxation in Australia — the Henry tax review — has recommended that the federal government increase the taxes already levied on tobacco and alcohol. Tobacco and alcohol taxes are put forward as the best way of reducing the social harms caused by the use and misuse of these substances. Junk foods have the same pattern of misuse and the same social costs as tobacco and alcohol. The Henry tax review rejects the idea of taxing fatty foods, and to date the government has not implemented a tax on junk food. We propose that a tax on junk food be implemented as a tool to reduce consumption and address the obesity epidemic.

Molly E Bond BBiotech(Hons), DipLang · Michael J Williams BA(Hons), LLB(Hons) · Brad Crammond MA(Hons), LLM · Bebe Loff LLB, MA, PhD

Health systems are increasingly recognised to be complex adaptive systems (CASs), functionally characterised by their continuing and dynamic adaptation in response to core system drivers, or attractors. The core driver for our health system (and for the health reform strategies intended to achieve it) should clearly be the improvement of people’s health — the personal experience of health, regardless of organic abnormalities; we contend that a patient-centred health system requires flexible localised decision making and resource use. The prevailing trend is to use disease protocols, financial management strategies and centralised control of siloed programs to manage our health system. This strategy is suggested to be fatally flawed, as: people’s health and health experience as core system drivers are inevitably pre-empted by centralised and standardised strategies; the context specificity of personal experience and the capacity of local systems are overlooked; and in line with CAS patterns and characteristics, these strategies will lead to “unintended” consequences on all parts of the system. In Australia, there is still the time and opportunity for health system redesign that truly places people and their health at the core of the system.

Joachim P Sturmberg MFM, PhD, FRACGP · Diana M O’Halloran FRACGP, MHPEd, FAICD · Carmel M Martin PhD, FRACGP, FAFPHM

Cimicifuga racemosa, better known as black cohosh, has been widely used in Western cultures as a herbal treatment for relieving symptoms of menopause. It has previously been linked to cases of liver toxicity. We report a case of reversible complete heart block in a woman who had recently begun taking a herbal supplement containing black cohosh. We review the known side effect profile of black cohosh and its relationship to our case. Clinical recordIn April 2009, a 59-year-old woman presented to a hospital emergency department after experiencing three episodes of syncope. She had never experienced cardiac ischaemic symptoms and there was no identifiable precipitant for a vasovagal event. She had no history of thyroid disease, hypertension, hyperlipidaemia or diabetes. Her personal and family medical histories were unremarkable, and she was a lifelong non-smoker and non-drinker. She had no recent febrile illness. She took no regular medications, but 2 weeks earlier had commenced taking one tablet daily of Remifemin (Schaper & Brümmer, Salzgitter, Germany; distributed by SciNat Australia, Gold Coast, Qld), a herbal preparation for the alleviation of menopausal symptoms. While undergoing cardiac monitoring in the emergency department, the patient experienced a further episode of syncope. Telemetry (Box 1, A) and an electrocardiogram (ECG) (Box 1, B) demonstrated complete heart block. An atropine bolus was administered and an isoprenaline infusion commenced. The initial ECG performed after commencement of isoprenaline demonstrated 2:1 heart block. The patient’s serum electrolyte levels were normal. Further symptomatic complete heart block occurred while the patient was receiving the isoprenaline infusion (10 μg/min). A temporary pacing wire was placed, with reliable capture at a rate of 60 beats/min, an output of 0.5 V and reliable sensing at greater than 10 mV. Remifemin was ceased. Measures of thyroid function and serial serum cardiac troponin I levels were within normal ranges. Echocardiography demonstrated a structurally and functionally normal heart. The patient required intermittent pacing for heart block throughout the next 2 days, after which pacing was no longer required, and she was successfully discharged on Day 5 with normal sinus rhythm. She underwent 24-hour ECG Holter monitoring 1 week after discharge, which confirmed no further episodes of heart block. She did not recommence Remifemin treatment and, 12 months later, reported no further episodes of syncope. DiscussionThe only listed active ingredient of Remifemin is isopropanolic Cimicifuga racemosa root extract, also known as Actaea racemosa and most commonly known as black cohosh (BC). Remifemin contains the most thoroughly researched formulation of BC.1 BC was traditionally used by Native Americans of Canada and the eastern United States to treat malaria, impaired kidney function, sore throat, rheumatism, menstrual irregularities, and pain during childbirth.2 Recently, there has been interest in its use in the treatment of menopausal symptoms. A recent systematic review identified over 72 studies of BC,3 but only 13 of these were clinical studies involving BC-only preparations published since an earlier review in 2003.4 Findings regarding adverse events were consistent with those of another earlier review, which had found that in more than 2800 patients, the rate of adverse events was about 5.4%, and over 97% of events were minor.3 Most adverse events identified by the more recent review were gastrointestinal symptoms and musculoskeletal and connective tissue disorders.3 Three recently published reviews have examined hepatotoxicity3,5,6 — the most commonly reported serious adverse event associated with BC. They described seven, 42 and 31 cases of hepatotoxicity, respectively, but all three concluded that, in general, data supporting definite causality are lacking. The US Pharmacopeia Dietary Supplements Information Expert Committee, the European Medicines Agency, and the Australian Therapeutic Goods Administration (TGA) recommend that preparations containing BC should carry a warning of possible hepatotoxicity.5-7 Other serious adverse events reported include anaphylaxis, cutaneous vasculitis and myotoxicity.8-10 Studies of BC for mutagenicity, teratogenicity and carcinogenicity have produced negative findings.11 A search of MEDLINE identified no reports of bradycardia due to BC in the literature. However, a Google internet search using the terms “black cohosh” and “heart rate” yielded numerous natural therapy websites describing “slow heart rate” as a side effect of BC. Slow heart rate is also described as a side effect of BC in the Micromedex AltMedDex System database (version 5.1; Thomson Reuters [Healthcare] Inc, Denver, Colo, USA). We notified the TGA of this adverse event. The TGA has received 33 previous reports of suspected adverse events involving BC; none have involved bradycardia or syncope, and one involved hypotension (Rob Crowdy, Adverse Drug Reactions System Database Manager, TGA, personal communication, 3 June 2010). The mechanism by which BC exerts its effects is uncertain. The rhizome of BC contains a number of biologically active constituents, including the triterpene glycosides actein, 27-deoxyactein and cimicifugoside, as well as long-chain fatty acids, resins, caffeic acids, isoferulic acids, phytosterin, fukinolic acid, salicylic acid, sugars and tannins.12 To date, over 50 compounds derived from BC have been described.13 Serotonergic effects not due to serotonin selective reuptake inhibition have been demonstrated with BC preparations.14,15 BC exhibits competitive binding to the 5-HT1A, 5-HT1D and 5-HT7 receptors14-16 and is a partial agonist at serotonin receptors.17 This is noteworthy, as studies show that activation of 5-HT1A receptors in the hypothalamus inhibit hypothalamus-mediated increases in heart rate and blood pressure.18,19 One study investigating the vasoactive effects of BC demonstrated that BC-derived cimicifugic acids inhibit noradrenaline-mediated contraction in rat aortas by inhibition of calcium influx.20 In their 1993 review,4 Borelli and colleagues described a 1935 study in which four glycosidic fractions obtained from the rhizome of BC were administered to dogs; the fraction insoluble in water was found to induce strong arterial hypotension, a decrease in cardiac contraction, and bradycardia to the point of death. Based on the published pharmacology of the components of BC, it is difficult to provide a clear explanation as to how it mediates complete heart block. It is noteworthy that bradycardia is a widely listed side effect of BC in non-academic literature and that profound bradycardia has been documented in animal studies following administration of its extracts.4 Applying the Naranjo algorithm to this case shows that BC was probably responsible for the presentation of our patient (Box 2).21 Given the severity of the adverse reaction and the 2-week delay until its onset, reintroduction of BC while appropriately monitoring the patient to strengthen the argument for causality is not feasible. Although BC is potentially useful in the treatment of menopausal symptoms, it has not been subjected to the extensive postmarketing surveillance that conventional pharmacological agents receive and has potential for numerous adverse effects. It should be considered as a potential cause of unexplained signs or symptoms of cardiac conduction disturbance. 1 Patient’s telemetry and electrocardiogram (ECG) traces Cardiac monitoring telemetry trace (A) and ECG (B) showing complete heart block. 2 Application of the Naranjo algorithm21 to this case Criteria (score applied) Score 1. Are there previous conclusive reports on this reaction? Yes (+1) No (0) Do not know or not done (0) 0 2. Did the adverse event appear after the suspected drug was given? Yes (+2) No (- 1) Do not know or not done (0) 2 3. Did the adverse reaction improve when the drug was discontinued or a specific antagonist was given? Yes (+1) No (0) Do not know or not done (0) 1 4. Did the adverse reaction appear when the drug was readministered? Yes (+2) No (- 2) Do not know or not done (0) 0 5. Are there alternative causes that could have caused the reaction? Yes (- 1) No (+2) Do not know or not done (0) 2 6. Did the reaction reappear when a placebo was given? Yes (- 1) No (+1) Do not know or not done (0) 0 7. Was the drug detected in any body fluid in toxic concentrations? Yes (+1) No (0) Do not know or not done (0) 0 8. Was the reaction more severe when the dose was increased, or less severe when the dose was decreased? Yes (+1) No (0) Do not know or not done (0) 0 9. Did the patient have a similar reaction to the same or similar drugs in any previous exposure? Yes (+1) No (0) Do not know or not done (0) 0 10. Was the adverse event confirmed by any objective evidence? Yes (+1) No (0) Do not know or not done (0) 1 Total score* 6 * ≥ 9 = definite adverse drug reaction (ADR); 5–8 = probable ADR; 1–4 = possible ADR; 0 = doubtful ADR.

Scott C McKenzie MB BS, BSc, FRACP · Atifur Rahman FRACP

To the Editor: Nelson and colleagues1 referred to the limited community data from the Melbourne Medical Deputising Service (MMDS) that was analysed by Carville et al.2 MMDS consultations also represent general practice consultations, although the majority of MMDS consultations occur after hours. We can now provide an update on MMDS consultations from January 1998 to June 2010, stratified by age. De-identified data were extracted from the MMDS database for diagnoses that included the terms “chicken pox” or “varicella” and “shingles” or “zoster”, and patient age. Using the total consultations as the denominator, we calculated the crude and age-specific rates of varicella (chickenpox) and herpes zoster (HZ [shingles]) per 1000 consultations by week, and present the results here by year. These updated data support the conclusions reached by both groups of researchers that there has been a decrease in varicella cases and a rise in HZ cases in Australian general practice consultations since the introduction of a varicella vaccine in 2000. We had previously shown a decrease in hospitalisations and MMDS consultations for varicella and an uncertain effect on HZ up to 2007 after the introduction of varicella vaccine.2 The overall rate of varicella-related MMDS consultations continued to decline from 2007 to 2010, with an annual average rate of 3.3/1000 consultations in 2000 decreasing to 1.5/1000 consultations in 2007 (P < 0.001, 2000–2007) and to 1.0/1000 consultations for the first half of 2010 (P = 0.043, 2007–2010). Decreasing rates of varicella-related consultation were seen in all age groups, although an apparent increase in the consultation rate for children aged less than 5 years in 2010 might be explained by a summer peak in varicella infection and incomplete annual data (Box 1).3 The trend in HZ-related MMDS consultations showed an increase in the annual average rate from 1.7/1000 consultations in 2000 to 2.7/1000 consultations in 2007 (P < 0.001, 2000–2007) and to 3.4/1000 consultations for the first half of 2010 (P = 0.020, 2007–2010). There was a substantial increase in the HZ-related consultation rates for people aged 70–79 years and 80+ years (Box 2). Our updated data support the recommendation for adding vaccination against HZ to the vaccine schedule for older Australians,1 although the optimal age at which this should occur remains to be determined. 1 Varicella (chickenpox)-related consultation rates, by age group, 1998 to June 2010* * Data from the Melbourne Medical Deputising Service database. 2 Herpes zoster (HZ [shingles])-related consultation rates, by age group, 1998 to June 2010* * Data from the Melbourne Medical Deputising Service database.

Kristina A Grant · Kylie S Carville · Heath A Kelly

To the Editor: The article in the Journal by Leach and colleagues highlights workforce shortages in the Australian health care sectors.1 The authors identify 12 clinical professions for which data from the 2006 Australian Bureau of Statistics census show poor retention rates, and warn of the implications for the Australian population of these future shortfalls in the health workforce. However, in our opinion, the imminent workforce shortage in the pathology sector (rather than that in the higher profile specialties) is likely to represent the vulnerable point of first failure of the health care system in Australia. Pathology and diagnostic laboratory medicine are major areas in the health system, with about 70% of medical decisions being based on laboratory test results.2 About 13% of Australia’s federal health budget is allocated to pathology testing, and a similar percentage is allocated from state health budgets. Within pathology laboratories, medical scientists form the single largest professional group, although they are usually unrecognised and overlooked in workforce surveys, as is the case in the article by Leach and colleagues. Medical scientists face these same problems of poor retention within the health workforce, leading to the risk of future shortfalls in laboratory capacity and an inability to provide adequate diagnostic support for the medical system. The potential laboratory capacity shortfall has been accelerated by government policies leading to reduced funding for pathology, and the consequent failure to invest in workforce recruitment, training and development. Such an approach may deliver short-term savings, but is leading to an unsustainable environment due to the lack of an appropriately qualified and trained workforce.3 This problem is not restricted to Australia, but highlights the need for a sustainable and long-term approach to ensuring access to relevant health resources for all Australians.

Tony Badrick · Leslie Burnett · Peter E Graham · Peter P Vervaart

To the Editor: We read with interest the article by Seed and colleagues1 about the collection and distribution of blood from two donors diagnosed with Plasmodium vivax malaria following travel to Papua New Guinea (PNG). Although the potentially infectious blood components were recalled before transfusion, this case underscores the complexity of managing the risk of transfusion-transmitted malaria (TTM). Three points in particular are worth noting. First, the donors were asymptomatically harbouring infection at donation following routine foreign travel. (Between 1963 and 1999 in the United States, only one donor was implicated in TTM following routine travel, compared with more than 30 donors with lengthy residence in Sub-Saharan Africa.2) Second, both donors acquired malaria despite observing Australian guidelines for chemoprophylaxis. Finally, both were non-reactive on the enzyme immunoassay (EIA) used to screen their donations (Malaria EIA, NewLabs, Newmarket, United Kingdom) after intervals of 4 and 13 months between return from PNG and their donations. Interestingly, chemoprophylaxis for these donors was both the cause and a potential solution for the “near-miss” event. The primary prophylactic regimens used were sufficient to modify the primary infection such that antibody response to the blood-stage antigens, on which the EIA is based, occurred only after relapse months later. Had the donors taken primaquine following their travel, the parasitaemia triggered by the hepatic hypnozoite forms that characterize P. vivax infections might well have been prevented. Although primaquine is not universally recommended for terminal prophylaxis, it is consensually recommended for terminal prophylaxis for travellers who have had “intense” or “significant” exposure to P. vivax or Plasmodium ovale, such as PNG would offer.3 Seed and colleagues suggest the need for an exception to blood service management practices for donors who have recently visited a geographic area with distinct epidemiological risk for malaria. Noting the disproportionate risk associated with travel to PNG, they suggest excluding donors with a history of recent visits to PNG from routine testing for malaria (and excluding their donations from fresh component production for an appropriate period). In the United States, regulators are similarly considering carving out an exception for travellers to Mexico,4 a low-risk country where the areas associated with most (approximately 75%) malaria deferrals report near-zero malaria risk (our unpublished data). US data suggest that more than 45 000 donors will be recovered annually if the Mexican state of Quintana Roo is exempted from the deferral requirements, and regulators are weighing this benefit against the exquisitely low added risk. The outcome of this deliberation is pending, but the fact that risk gradients within a given risk category are prompting consideration of differentiated management in two countries is notable.

Bryan R Spencer · Louis M Katz

To the Editor: Children have been seen as a key priority group for pandemic (H1N1) 2009 influenza (“swine flu”) vaccination. In Australia and New Zealand, children aged 0–4 years had the highest population rate of intensive care unit admissions for swine flu.1 From 3 December 2009, the Australian Government provided free H1N1-specific influenza vaccine for all Australians aged 6 months and older. However, it was not known how parents and other caregivers would respond to the offer of vaccination. We sought to determine caregivers’ intentions regarding whether their child would receive the pandemic vaccine. The study was approved by the human research ethics committee of the Children’s Hospital at Westmead and was conducted in November and December 2009, immediately before, and alongside, the commencement of the pandemic vaccination program for children. A paper-based questionnaire (with an alternative web-based option) was sent to caregivers of children aged 6 months to 5 years who were attending 16 long-day-care centres across metropolitan Sydney. It included questions about attitudes, behaviour, intentions and beliefs regarding swine flu, seasonal influenza and vaccines. We analysed responses using SPSS, version 17 (SPSS Inc, Chicago, Ill, USA) and conducted univariate analysis (as factors had high collinearity) to search for factors associated with caregivers’ intention for their child to receive the pandemic vaccine. The response rate was 44% (431/972). Most respondents had families of two children (47%) or one child (41%); 90% were mothers; and 48% had a postgraduate education. Caregivers were asked to report in relation to their eldest child attending the day-care centre (mean age, 38 months). Three children (out of 427 responses; 0.7%) had already received the pandemic vaccine; 23% of caregivers (92/400) said they would have their child vaccinated; 54% (217/400) were unsure; and 22% (87/400) would not. Intentions regarding seasonal influenza vaccination were similar. Factors associated with caregivers’ intention to have their child vaccinated with pandemic vaccine are shown in the Box. Those with the strongest associations included caregivers’ intention to have their child vaccinated against seasonal influenza in 2010 and belief that seasonal influenza vaccine is completely safe or only a slight risk. Factors not significantly associated with respondents’ intention to have their child vaccinated with the pandemic vaccine were the respondent’s age group, sex, education level, language spoken at home, and number of children in the household. The study indicated that at the commencement of the Australian pandemic influenza vaccination program for children, there was significant uncertainty among this sample of relatively highly educated respondents. The proportion of respondents intending to have their children vaccinated was far lower than recent Australian estimates (6% of children aged 4 years and under).2 Our findings suggest that, despite the acknowledged severity of pandemic influenza, respondents’ concerns about vaccine safety were influencing their intentions. Indeed, the program commenced in a context of public debate about the response to the influenza pandemic and the vaccination program, including concerns about the safety of using multi-dose vials for vaccine delivery.3,4 Among respondents intending for their child to have the pandemic vaccine, the association with the child having had a previous influenza vaccination suggests that, having once taken up vaccination, respondents were more likely to intend to do so again. More recent events in Australia leading to suspension of use of all three 2010 seasonal influenza vaccines for children under 5 years of age are likely to further increase safety concerns.5 While two vaccines have since been reinstated, these events present a significant challenge for future influenza vaccination programs. Providers are likely to have an important role in communicating recommendations and addressing caregivers’ concerns. Factors associated with caregivers’ intentions for their child to receive the pandemic (H1N1) 2009 influenza vaccine Survey responses Intention “yes” (n = 92) Number OR (95% CI) Would you have your child vaccinated against seasonal flu in 2010? (n = 396) No 8 1.00 Unsure 33 2.29* (1.11–5.15) Yes 51 17.49* (7.55–40.50) How safe do you think the seasonal flu vaccine is for children aged 1 to 5 years? (n = 396) Moderate/high risk 7 1.00 Don’t know 19 2.04 (0.82–5.07) Completely safe/slight risk 66 6.64* (3.00–15.22) How safe do you think the seasonal flu vaccine is for babies aged 6 to 11 months? (n = 395) Moderate/high risk 21 1.00 Don’t know 36 1.35 (0.75–2.44) Completely safe/slight risk 35 4.32* (2.27–8.22) Did your child receive seasonal flu vaccination in 2009? (n = 394) No 77 1.00 Yes 15 3.48* (1.65–7.36) How concerned do you feel about your child catching the flu? (n = 396) Not at all/ a little/ moderately 31 1.00 Very/extremely 61 2.46* (1.46–4.17) Does your child have any medical conditions requiring ongoing visits to a health care professional? (n = 396) No 76 1.00 Yes 16 2.00† (1.03–3.87) The flu vaccine can give you the flu. (n = 396) Agree 24 1.00 Don’t know 23 1.18 (0.62–2.23) Disagree 45 1.82† (1.04–3.20) OR = odds ratio. * P ≤ 0.01. † P ≤ 0.05.

Julie Leask · Maria Yui Kwan Chow · Catherine King · Robert Booy

To the Editor: The World Health Organization Surgical Safety Checklist (Checklist) has recently been editorialised by Merry and Barraclough.1 We are all keen to see perioperative mortality and morbidity reduced to a minimum, and one cannot disagree with the intent of the Checklist, which was tested in a pilot study2 involving almost 8000 patients in eight hospitals (in disparate developed and developing countries). The study showed a reduction in the death rate associated with surgery from 1.5% to 0.8% (or 15 per 1000 down to eight per 1000). Impressive indeed! My concerns are firstly with process. One hospital in Brisbane has already introduced the Checklist without the constructive engagement of those at the clinical coalface, contrary to what proponents of the Checklist advocate, and it is being used in a way which distracts personnel during the induction of anaesthesia. To those familiar with accident analysis, this is a good example of poor process implementation by a hospital administration and its managers. Secondly, I am concerned by the use of the study of Haynes and colleagues2 to underwrite the Checklist. Results of the study would be more meaningful if the reduction rates in mortality in the hospitals in the developed countries (Canada, United States, United Kingdom and New Zealand) were separated from those in the developing countries. Or would this have shown the developed countries’ reduction rate to be statistically non-significant? Are we to believe that use of the Checklist could save seven lives per 1000 procedures in Australia, or 15 000 to 21 000 lives across the three million procedures undertaken here annually? Total figures for perioperative mortality across all procedures in all operative categories remain a matter for conjecture. However, in looking at the high-risk group of cardiac surgical operations in Victorian public hospitals,3 we can see a published mortality rate of 10 per 1000 for coronary artery bypass or isolated valve surgery, only a little higher than that seen after the introduction of the Checklist across a broad surgical population. We should be careful to see that spin does not become embedded within medicine, even where it is associated with what is probably a good idea.

James P Bradley

In reply: Thank you for the opportunity to respond to Bradley’s letter. We agree that constructive engagement of clinicians is essential in adoption of the World Health Organization Surgical Safety Checklist (the Checklist) — that point is clearly made in our editorial.1 Bradley’s anecdotal comment about use of the Checklist causing distraction during the induction of anaesthesia is difficult to evaluate in the absence of more detail. Surely any competent anaesthetist committed to patient safety could liaise with other team members to find an acceptable time to fulfil the entirely reasonable expectation of ensuring that relevant safety checks have been done? Furthermore, the study of Haynes and colleagues2 provides considerable reassurance about the possibility of unintended harm from use of the Checklist. Justification for the Checklist does not depend on the above-mentioned study alone: the Checklist was developed by an extensive process of literature review and consultation. It reflects expert consensus, and its endorsement by the Australian and New Zealand College of Anaesthetists, the Royal Australasian College of Surgeons and many other organisations adds to this consensus. There is no suggestion that the Checklist will save any particular number of lives in any given country — rather, its use is likely to reduce the number of patients harmed during surgery, and this is surely worthwhile.

Alan F Merry · Bruce H Barraclough

To the Editor: The editorial by Runciman in the Journal was cogent and timely.1 The Garling report on acute care services in New South Wales public hospitals highlights areas where critical changes need to be made in order to improve patient safety.2 It is widely recognised that junior doctors play a vital role at the coalface in many key areas, including assessment and escalation of care for deteriorating patients and the handover of patient care, both in hospital between shifts and also from hospital to the community. In NSW, these processes are currently receiving much needed attention in order to ensure patient safety within hospital settings. As Runciman so rightly identifies, junior doctors also play a critical role in “transformational” cultural change. In public hospitals such as my own, it has been fascinating to observe the small ways in which a junior doctor can influence senior clinicians in fields such as compliance with hand hygiene protocols, and in querying transfusion requests which do not conform to National Health and Medical Research Council clinical guidelines. We need to continue to mentor junior doctors so their messages about change and improvement are well delivered and well received. With the move of junior doctor pre-vocational training into community settings (the Prevocational General Practice Placements Program) there are increasing opportunities for change on a larger scale. In the future, patients will not be the only agents who move from community to hospital settings and back again. Junior doctors will be employed across both settings and will be an important vector for change and improvement. We will also need to encourage supervision by senior doctors who engage with and understand the health system, not just the hospital system. Providing junior doctors with appropriate tools to drive change (eg, training in graded assertiveness and situational awareness), encouraging them to view their role in health system improvement at the whole-of-community level, and providing leadership across the system, give us every reason to believe that Runciman’s vision of transformational change is possible, and indeed likely.

Joanna R Sutherland

To the Editor: I read, with encouragement and hope, Runciman’s timely editorial concerning the pressing need for patient safety education to become an integral part of medical undergraduate curricula.1 I also support his plea for patient safety to now be treated as a full-blooded science. His description of medicine as “islands of excellence in a sea of mediocrity” is both apt and perhaps still somewhat generous. In many health care ranks (in common with the rest of the human race) there continues to be a reluctance at the personal level to admit the natural and ever-present human tendency to err.2 Consequently, opportunities continue to be lost to learn from analysis of these mistakes by reporting their mechanisms honestly in detail, either anonymously or openly in a trusting work environment. Sadly, the ongoing barriers of a blame culture (often accompanied by outcome bias), misplaced ego and lack of understanding of such fundamental issues as error cascades and latent errors work against these simple and powerful safety improvement steps. The preoccupation of sections of our medicolegal system with blaming and shaming usually innocent health care individuals for system failures is also a barrier to such reporting. While Runciman suggests a gradual awakening of appreciation of such system faults, lip service still abounds and basic human error concepts continue to be uncomprehended or overlooked, even by some of the more senior and influential members of our profession. This works against the education of junior doctors. As Runciman urges, the only way to deal with this now is to give the young, fertile medical undergraduate minds the opportunity to grasp these fundamental concepts at the beginning of their clinical lives. It is their patients who will benefit as well as their own peace of mind and, importantly, their own humility, throughout their years ahead. The repeated objection that undergraduate curricula are already overloaded is not acceptable. The science of patient safety is no longer an optional or minor subject for medicine. It should be woven intimately throughout the undergraduate curriculum.

John A H Williamson

To the Editor: The pace of improvement in the safety and quality of health care has been disappointing. However, the recent enthusiasm for medical education providing a new solution is troubling.1,2 The safety and quality movement has been regrettably dismissive of the need for creation of evidence.3 Indeed, it now seems that the focus on “dramatic” errors has been a distraction from the major volume of harm due to the poor care of patients with chronic disease.4 There is substantial literature on the development of professionalism, which attests to the difficulty of teaching medical students non-technical skills (or of selecting students with “appropriate” attitudes). There are three major reasons for this difficulty. The first is the problem of defining the desirable standard — whether of safety or professionalism.5,6 The second is the so called “hidden curriculum” — the ubiquity of error, unsafe practice and unprofessional behaviour that students are exposed to in clinical environments. Third, many of the safety and quality issues and skills just do not seem relevant to the students, despite the care that has been taken in the development of safety and quality curricula. To provide “experience that is arranged to be both motivating in the moment and consequential for capabilities in the long run”7 will require a new and more pragmatic approach to education. We need to select safety and quality issues that all doctors can influence by exercise of their personal knowledge and skills. This is the stuff of medical education. Errors in clinical reasoning8 form an excellent teaching topic, but many safety problems are simply too hard for medical students (neither do we expect medical students to learn the details of intensive care or casemix funding). Provision of appropriate experiential learning requires links to the people who understand and manage governance and safety in the clinical workplace. Rather than a stand-alone communication syllabus, the medical students in Queensland, for example, should receive the same teaching about clinical handover as the junior (and senior) medical staff of Queensland Health. Handover is then perceived as a highly relevant skill. If competencies in safety for medical stu-dents are to be required they must be linked to both fuller competencies for graduate training and the introduction of safer workplace practices. Without these parallel and more important activities, the proposed reform in medical education is likely to be disappointing in its impact.

Christine M Jorm

Des McGarry was born on 16 May 1931 in Concord, Sydney, at the peak of the Depression. He was educated by the Christian Brothers and Redemptorist Fathers, and initially trained to be a teaching brother and priest. In 1950, deciding he wasn’t suited to the religious life, he set his sights on medicine, but first had to save enough money to finance his studies. He worked as a jackeroo, a labourer and a penciller for a bookmaker, then joined the Royal Australian Navy (RAN) as a medical undergraduate at the University of Sydney. After graduation in 1960, Des spent a year at the Mater Hospital in Brisbane before returning to Sydney to complete 4 years as a Medical Officer for the RAN. In 1965, Des and his wife Marie moved to Longreach in central Queensland. Des and I set up practice together. We had met as interns and conceived a plan to provide a first-class, city-type practice to a remote rural region — and in the mid 60s, there were few places in Queensland more remote than Longreach. It was exciting and satisfying delivering good medical care to the region. Des proved in every way to be the complete general practitioner. Skilful at procedures, astute in the diagnosis and management of illness, caring and understanding, his gentleness, his air of quiet authority and common sense engendered in his patients a trust and confidence. He was a genuine all-rounder who also brought a great sense of humour to his work. He was awarded a Fellowship of the Royal Australian College of General Practitioners in 1974. In 1976, Des left to set up practice in Brisbane with Terry Bennett. Des tutored junior medical officers at the Royal Brisbane Hospital, and was a foundation member of the Medico-Morals Committee advising Catholic hospitals in Queensland. He was a long-time member of the Australian Medical Association. Des was easily likeable and enjoyed company, a beer, and good cigars. He loved sport, especially boxing, surfing and rugby league. He was also a serious thinker, and enjoyed reading and deep conversations. His life experience fitted him well for the role of GP, but beneath that charm and worldliness lay a much deeper emotion — a deep spirituality and love of God. He died on 7 September 2009 from metastatic cancer of the lung, leaving behind his wife Marie and their four children Patrick, Joanne, John and Paul.

Thomas J Murphy

Herbert Gibson, well known in Victoria for his dedicated work on HIV/AIDS, bloodborne viruses, and drugs and alcohol, died suddenly on 5 June 2010 at the age of 64. Born on 19 August 1945 in Bendigo, Victoria, Herbert studied medicine at Monash University, graduating in 1970. He did his residency at Bendigo Base Hospital and the Lakeside Psychiatric Hospital, Ballarat. In 1973, he helped found the Middle Park Clinic in Melbourne, where he was at the centre of medical care and studies to combat HIV/AIDS. His work included lecturing on sexually transmitted diseases and bloodborne viruses for Monash University, the Victorian Health Promotion Commission, the Royal Australian College of General Practitioners and the Alfred Hospital, where he was also Honorary Clinical Assistant at the Special Microbiology Unit (HIV/AIDS). In addition, he undertook honorary palliative care work for a number of Melbourne’s medical facilities. In 1994, Herbert moved back to his home town of Bendigo to care for his elderly mother. He became Senior Psychiatric Medical Officer with the Bendigo Health Care Group, and also worked for the Rural Health General Practice division of Monash University in Bendigo. He was an Outreach Rural Mental Health visiting consultant and Crisis Assessment Team clinician throughout the extensive Loddon/Campaspe region of Victoria. The stress of long hours and distance travel eventually took its toll, and family-inherited bipolar disorder and diabetes began to wear him down. In 2007, he retired from practice and moved to Sydney, where his health greatly improved. Apart from his dedication to medical care for the underprivileged and marginalised, Herbert’s passions in life were reading European history and tracking down rare stamps for his collection, especially stamps of Imperial Russia and the early Soviet Union. He also enjoyed painting with watercolours and relaxing with his music collection of Wagner, Mozart and Shostakovich. A suspected minor stroke/brain haemorrhage in 2010 saw him admitted to St Vincent’s Hospital, Sydney. He was transferred to the nearby Sacred Heart Hospice, where he died within a few days. A month later, a celebration of Herbert’s life was held in Melbourne, where some 70 former patients, staff, colleagues and friends gathered to remember a convivial, compassionate medic, a brilliant diagnostician and generous associate who enjoyed both solitude and good company.

Edward Underwood

CorrectionIncorrect year: In “Interviewer bias in medical student selection” in the 20 September 2010 issue of the Journal (Med J Aust 2010; 193: 343-346), there was an error in the third-column subheading of Box 2 (page 345). The subheading should read “2007 mean score (SD)”. 2 Mean scores for multiple mini-interview (MMI) interviewer ratings of interviewees and for interviewer personality traits, and relationships (correlation coefficients) between these values Correlation coefficient* 2006 mean score (SD) 2007 mean score (SD) MMI score Agreeableness Extraversion Neuroticism Conscientiousness Openness MMI score 10.95 (1.29) 10.50 (1.19) — 0.24‡ 0.19 − 0.25‡ − 0.06 0.00 Agreeableness 4.23 (0.56) 4.11 (0.65) 0.26† — 0.28† − 0.22‡ 0.12 0.32† Extraversion 3.24 (0.79) 3.29 (0.69) − 0.06 0.24† — − 0.30† − 0.06 0.26† Neuroticism 2.30 (0.66) 2.42 (0.71) − 0.08 − 0.17‡ − 0.16 — − 0.06 0.04 Conscientiousness 3.85 (0.68) 3.84 (0.72) 0.09 0.11 − 0.08 − 0.19‡ — − 0.02 Openness 3.30 (0.52) 3.18 (0.65) − 0.01 0.12 0.19‡ 0.01 − 0.11 — * Correlation coefficients for 2006 data on lower diagonal (darker shading) and for 2007 data on upper diagonal (lighter shading). † P < 0.005. ‡ P <0.05.

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

Cast or splint? A recent randomised controlled trial in children has shown that using a removable splint may be just as effective as a cast in treating minimally angulated fractures of the distal radius, and is preferred by patients and parents. Ninety-six children aged between 5 and 12 years were randomly assigned to either a cast, or a prefabricated splint which could be removed only for bathing or hygiene reasons. At six weeks, there were no significant differences between the groups in physical function, degree of angulation, pain, or side effects such as irritation and discomfort. In terms of patient and parent preference, use of the splint was superior to the cast — among the splint group, 12% of children and 5% of parents indicated that they would have preferred a cast; while among the cast group, 68% of children and 60% of parents would have preferred a splint. CMAJ 2010. doi:10.1503/cmaj.100119 A walk in the park “Green” exercise (physical exercise undertaken in natural environments) can lift mood and self-esteem, and this may be achieved in as little as 5 minutes a day, suggest UK researchers. The multistudy analysis pooled data from 1252 participants and showed that green exercise was associated with significant improvements in mood and self-esteem — and that these effects were evident in participants with and without a history of mental illness. While all green environments, including “urban green”, countryside and woodlands, were beneficial, the strongest effect was seen with waterside habitats. The authors conclude that access to natural places should be considered by planners and architects, that green exercise could also be considered as a therapeutic tool, and “that the environment provides an important health service”. Environmental Science and Technology 2010; 44: 3947-3955. doi 10.1021/es903183r Lifting the stigma Depressed medical students report beliefs endorsing stigma associated with this illness more often than their non-depressed peers, and such beliefs represent a considerable barrier to seeking treatment, according to a recent survey.1 Just over half of students who self-reported symptoms of moderate to severe depression believed that that their fellow medical students would respect them less, and 83% had concerns that faculty members would question whether they could handle responsibilities. Depressed students felt more strongly that telling a counsellor would be risky, and less than half indicated that they would seek treatment for depression, while 87% of their peers reported that they would seek treatment if they had depression. On the positive side, belief in stigma associated with depression decreased significantly as students progressed through medical school. The author of a linked editorial suggested that this may be due to “the iterative experiences of medical training [which] may inspire more accurate and empathic understanding of the illness experience, whether in a patient or a colleague”.2 1 JAMA 2010; 304: 1181-1190 doi:10.1001/jama.2010.1300 2 JAMA 2010; 304: 1231-1233 doi:10.1001/jama.2010.1347 Flu vaccination and first heart attack Results of a recent UK study reinforce current recommendations for annual influenza vaccination in patients with medical risk factors, and suggest that there may be additional benefits in preventing myocardial infarction in those without established cardiovascular disease. The case-control study enrolling 16 012 patients aged over 40 years with a first myocardial infarction found that flu vaccination was associated with a 19% reduction in myocardial infarction. While vaccination early in the flu season (before mid November in the northern hemisphere) conferred the most benefit (adjusted OR, 0.79), vaccination after this time was still advantageous (adjusted OR, 0.88). Although pneumococcal vaccination was also included in the analysis, it was not associated with a reduced risk of myocardial infarction (OR 0.96, 95% CI 0.91-1.02). CMAJ 2010. doi.10.1503/cmaj.091891 Blame it on the weather Stroke incidence has been shown to vary according to geographical location (such as the “stroke belt” in south-eastern USA); however, a recent Japanese study suggests that, in women, this variation may be explained solely by the weather. The cohort study involving 12 communities identified a total of 450 stroke events over about 10 years of follow-up. On multivariate analysis, the association between stroke and low average temperatures and high annual rainfall was independent of conventional risk factors for stroke, as well as geographic and demographic factors. The authors hypothesise that this could be due to increases in coagulation factors in cold temperatures, and the gender difference explained by oestrogen-mediated increases in vascular reactivity. Rural and Remote Health 2010 online:1493 .

Alison Williams

Med J Aust 2010; 193 (8 Suppl).