Volume 194 Issue 2

Joining university to clinical service, research to practice The model of the academic health science centre (AHSC) arose decades ago in the United States,1 and is now internationally well established, with 17 centres in Canada, eight in Holland, five in the United Kingdom, two in Singapore, but none in Australia. An AHSC is where a leading university joins with a major tertiary health care provider in a tripartite mission of excellence in clinical service, research and education. AHSCs drive a care continuum from innovation, to bedside, to the community, endeavouring to ensure that the latest advances and highest standards reach patients. They are so well established abroad that the debate has moved on to extending AHSCs into systems or networks to embrace primary health care and global responsibilities.2 Curiously, Australia’s National Health and Medical Research Council (NHMRC) makes no mention of AHSCs in its 2010–2012 strategic plan,3 despite its own external review (the Zerhouni Review) advocating creation of at least a few Australian centres of world-class excellence in translational and clinical research.4 Similarly, AHSCs did not attract serious discussion in the report of the Council of Australian Governments (COAG) National Health and Hospitals Network (NHHN) Agreement (April 2010), although the detail at least acknowledges that engagement with university clinical schools and research centres is critical to translating clinical research into practice, ongoing professional development and training the next generation of clinical leaders.5 Strong advocacy for AHSCs to be introduced in Australia has apparently been ignored,6,7 with Brooks warning that our nation is failing to capitalise on global developments in academic medicine.7 So what are the barriers? First, there is a culture clash between federally funded autonomous universities and state-funded hospitals managed as a separate conglomerate in each state and subject to local politics and regional priorities. Indeed, the emphasis in state health departments, it seems, is more on homogeneity than the excellence strived for in academia. This engenders turf wars between universities and hospitals over their diverse missions, priorities, operational frameworks and employment conditions, with process and contracts frustrating attempts to bridge the gap. Cost shifting replaces what should be cost sharing. The second barrier is that the three AHSC pillars — research, education and health care — are overseen by three separate federal government departments and thus three separate ministers. Third, there are additional players in the research sector — the independent medical research institutes — who, although affiliated with universities and tertiary hospitals, have at times eschewed translational links with clinical medicine in favour of basic science. Finally, Australian health care is delivered in a pluralistic mix of private and public funding. Yet none of these issues is unique to Australia or insurmountable, especially when one considers the complexities of the US health care environment where AHSCs began. Cultural cringe may be a further hurdle for AHSC advocates. The NHMRC has foreshadowed the concept of “advanced health care centres”,8 seemingly in response to sensitivities among its political masters about use of the term “academic”. Surely, however, the Australian public are now mature enough to embrace excellence rather than mediocrity in health care, just as they do in sport? In fact, perceived anti-intellectualism is not uniquely Australian, as the case for retaining the term “academic” similarly needed pressing in the UK. Simply put, the best doctors treat patients, do research and train tomorrow’s health care providers. There is now an international association of academic health centres,9 whereas a web search for the “advanced” variant suggests instead a primary and community care focus. The advent, in mid 2011, of Local Hospital Networks, a central plank of the COAG NHHN Agreement,5 offers a pivotal opportunity to introduce AHSCs. Indeed, the simultaneous introduction of Medicare Locals, organisations intended to integrate and coordinate primary care services, provides a serendipitous platform to extend AHSCs into primary care. Ring-fencing hospital leadership from state health bureaucracies will be essential, particularly given the watered-down version that survived COAG. We should not underestimate the challenges of change management, which will require both top-down and bottom-up approaches to unite hospitals and universities, primary care and medical research institutes in a single mission. The choice of governance method is perhaps best determined locally;10,11 an integrated model with a single organisational structure is the ideal, but affiliated models may be more achievable with multiple partners. The NHHN should foster economic support for AHSCs through the 60% federal funding proposed for research and training in public hospitals (100% in primary care),5 and it will be crucial that new monies be spent at the interface of training, service and research. The real challenge will be winning the hearts and minds of federal and state politicians. As in Europe and North America, politicians will need convincing of the economic benefits of linking research to health and embedding research and training as core business in our leading hospitals and primary care networks. Although our international competitiveness in biomedical science is an important pay-off in its own right, the things that swung the argument abroad were improved patient outcomes and cost efficiencies. How many AHSCs does Australia need? With critical mass and existing academic strength as prerequisites, the number will depend on the extent to which AHSCs develop around universities or existing teaching hospitals, or amalgamate to form geographic clusters. Experience in the UK points to competitive national selection being a valid means of testing commitment and the strength of joined-up partnerships. We advocate a similar international review process here, say with four to six AHSCs designated in the first wave. The time is ripe for Australia’s health systems to grasp this opportunity to move from good to great and establish world-class AHSCs in an Australian context.

Nicholas M Fisk PhD, MBA, FRANZCOG · Steven L Wesselingh BM BS, PhD, FRACP · Justin J Beilby MD, MPH, FRACGP · Nicholas J Glasgow MB ChB, MD, FRACGP · Ian B Puddey MB BS, MD, FRACP · Bruce G Robinson MD, MSc, FRACP · James A Angus BSc, PhD, FAA · Peter J Smith MD, FRACP, FRACPA

Effective dementia care depends on early and accurate diagnosis It is predicted that over the next 40 years there will be a fourfold increase in the prevalence of dementia in Australia, as well as considerably more people with milder forms of cognitive impairment.1 To date, despite extensive research, no effective treatment for established dementia is available. As a result, taskforce policymakers conclude that there is insufficient evidence at present to warrant routine screening for dementia syndromes.2,3 However, emerging evidence shows that early non-pharmacological intervention can improve cognitive outcomes for patients with milder forms of cognitive impairment and those at risk of cognitive decline.4 Early diagnosis also enables patients to plan, with their caregivers, for the future, and deal with matters such as enduring power of attorney authorisation, before they lose the capacity to do so. Over two-thirds of people who notice symptoms of cognitive decline consult a physician for evaluation.5 However, up to 90% of mild cases are missed at the initial primary care assessment.6,7 So how can we improve early detection of cognitive impairment, and what evidence base do we have for dementia screening in Australia? A diagnosis of dementia relies on a full mental status assessment, with comprehensive history taking and physical examination. Presently, detailed neuropsychological testing is the gold-standard tool for objectively evaluating the magnitude and pattern of cognitive decline. However, neuropsychological evaluation is costly, time-consuming and not generally available as only specialist psychologists can do it. Consequently, general practitioners and specialist physicians, who evaluate most patients presenting with cognitive complaints, administer brief screening instruments such as the mini-mental state examination (MMSE) to assess cognition. In Australia, the use of such instruments has been propagated by guidelines for prescribing acetylcholinesterase inhibitors. The MMSE has many documented and widely appreciated shortcomings. It lacks diagnostic specificity and is insensitive to patient variables such as extreme levels of education, premorbid ability and poor command of English.8 It has also been criticised for its unsystematic and atheoretical construction, and its poor ability to detect milder forms of cognitive impairment.8,9 The idea that any brief screening tool would have sufficient sensitivity and specificity to diagnose dementia is unrealistic. However, when used as an adjunct to a good clinical history, a more accurate instrument, particularly one that can be serially administered, would potentially increase the reliability of diagnosis. A recent review of screening instruments available for mild cognitive impairment concluded that there are more useful screening tools than the MMSE.10 Some are in use in Australia, including the Addenbrooke’s Cognitive Examination – Revised (ACE-R); the Alzheimer’s Disease Assessment Scale — cognitive subscale (ADAS-cog); and the Montreal Cognitive Assessment battery. In addition, there are other screening instruments specifically validated for use in Australia, such as the General Practitioner assessment of Cognition (GPCog) and Rowland Universal Dementia Assessment Scale (RUDAS). Recently, the ACE-R was validated for use in an Australian population.11 The ACE-R, which incorporates the MMSE, has been shown to have more diagnostic sophistication, with improved sensitivity and specificity values, than the MMSE alone. This is not to say that the ACE-R is without limitations. For instance, it cannot fully assess some aspects of cognitive function (eg, non-verbal skills). Furthermore, the ACE-R takes on average 16 minutes to administer and is therefore unlikely to see much uptake by busy GPs; however, it could be used by nurses working in general practices. As with all screening tools, clinicians using the ACE-R in the primary care setting need to be trained to correctly score and interpret patients’ ACE-R performances. Development of effective dementia treatments depends on earlier and more accurate identification of disease. Cognitive screening tests will continue to evolve, and may in time be replaced with screening for disease-related biomarkers. However, such diagnostic biomarkers have yet to be discovered. With the number of people with dementia growing each year, the lack of adequately validated diagnostic tools is a serious concern. Empirical investigations to further evaluate and validate screening instruments for cognitive impairment are necessary as we strive to develop effective treatments for all forms of this debilitating disorder.

Zoe Terpening BPsych(Hons), MSc, DClinNeuropsych · John R Hodges MD, FRCP, FMedSci · Nicholas J Cordato MB BS, PhD, FRACP

Coordinated action is necessary to improve the health of all Australian males The fourth Andrology Australia Forum on men’s health was held in Sydney on 4–6 June 2010, with about 70 researchers, policymakers and health professionals in attendance. The forum theme was “Tackling the inequities of men’s health”, and it provided the opportunity to consider one of the six priority areas of the National Male Health Policy — “Health equity between population groups of males”.1 The presentations and discussions highlighted areas for further consideration in policy implementation, while acknowledging the complexity of addressing health inequities through policy initiatives. Male health policyThe Honourable Warren Snowdon, MP (former Minister for Indigenous Health, Rural and Regional Health and Regional Services Delivery), gave a keynote address on the first Australian National Male Health Policy.1 The Minister described the policy process, highlighting his involvement and drawing on his personal experience working with Indigenous communities, which ensured that a broad range of male health issues through the lifespan were included. Dr Noel Richardson (Director, Centre for Men’s Health, Institute of Technology Carlow, Ireland) followed, giving an account of the Irish experience in formulating a national men’s health policy.2 His account provided a direct contrast between the two policy processes. While both policies were underpinned by extensive community consultation, the Irish policy benefited from a strong evidence base commissioned by the government specifically for the policy, whereas the Australian policy was driven by grassroots men’s groups and guided by the limited available empirical research. This led to different guiding principles: Dr Richardson described the Irish policy as drawing on a “gender-mainstreaming” framework, in which gender is acknowledged as a key determinant of health. It also recognises the interaction of masculinities with social and economic factors in influencing men’s health, compared with the approach using broader social determinants in guiding the Australian policy. The Minister acknowledged that coordinated action by the whole workforce was necessary to drive change. He also emphasised the need to embed the policy into government frameworks to withstand possible changes in government priorities. However, the broader structural change through which health inequities could be addressed was not clearly articulated. An important lesson from the Irish experience was the value of the policy itself in facilitating work across government sectors, not just health services, with men’s health now seen as a priority area. Importantly, both speakers acknowledged the impact of recent economic events on the policies, with the Minister highlighting that in such financial circumstances it was important to direct resources to areas that can further policy objectives in the long term. Finally, forum delegates welcomed the Minister’s announcement that a male health policy reference group would be established. This would be to provide expert advice and assistance with the implementation of policy action areas, such as the proposed National Longitudinal Study on Male Health. This announcement partially reflected one of the fundamental lessons learned from the Irish experience: the need for good governance and accountability. However, it did not go as far as the requirement by the Irish government for annual progress reporting. While policy formulation reflected different mechanisms, both acknowledged the need for an evaluation and monitoring strategy to be established from the outset. Research data, evidence and policySeveral speakers highlighted the need for good data to underpin policy development and implementation. Lisa Thompson and Sally Bullock (data analysts, Australian Institute of Health and Welfare) reported data showing the poorer health status of men living in rural and remote areas. In particular, the data showed higher rates of chronic diseases that are partly due to lower socioeconomic status, but other factors remain to be elucidated.3 More focused data and policy analysis for groups with poor health and/or social isolation were called for, using cross-sectional health surveys, data linkage and longitudinal studies. Professor Sally Redman (Chief Executive Officer, The Sax Institute) expanded on the value of longitudinal studies in providing high-quality evidence for policy questions. Using the 45 and Up Study as an example, Professor Redman highlighted how longitudinal studies can be used by researchers and policymakers. “Add-on” studies and data linkage can be used to answer questions arising over time, thus “future proofing” the significant investment necessary to conduct a longitudinal study. Acknowledging the time lag between evidence and policy, Professor Redman called for better ways to provide robust evidence to policymakers. James Smith (Discipline of Public Health, University of Adelaide) underscored this point by showing how evidence (in this case, qualitative evidence) can debunk myths promulgated by opinion rather than empirical research. Mr Smith argued for closing the biomedical–social and qualitative–quantitative research gaps to answer the important questions in men’s health. He coupled this with an emphasis on translating research into policy and practice. Professor Gavin Turrell (Principal Research Fellow, School of Public Health, Queensland University of Technology) discussed the strong association between socioeconomic status and male health. He emphasised the need for a whole-of-government and whole-of-society approach to tackle socioeconomic inequities. In discussing policy implementation, Professor Turrell argued that interventions should be focused on environments as well as individuals, and occur across the lifespan, requiring an alignment of public policy and health policy. Improved monitoring and surveillance systems could address some of the gaps in Australian men’s health data, allowing proper evaluation of interventions designed to address socioeconomic inequities. On a different theme, Associate Professor Doug Lording (Endocrinologist, Cabrini Medical Centre) highlighted emerging areas that require better policy, such as purchasing unsafe or ineffective medications from the internet or other unregulated markets. Improvements in health literacy and health promotion, as well as better regulation, are needed to meet the needs of those who are vulnerable to health practices that could be described as predatory. Specific groups of men at riskUnderstanding the impact of cultural and social contexts on men’s health, highlighted in several presentations, generated lively discussion. Dr Mick Adams (Director, Fineline Consultancy) set some challenges for redressing past (and present) wrongs that have had significant impacts on Indigenous male health. He emphasised the importance of reconstructing male empowerment to improve quality of life, health status and spiritual wellbeing. Referring to the United States Office of Indian Men’s Health, Dr Adams called for similar initiatives from our government to turn policy statements into real action. On the theme of empowerment, Jack Bulman (Chief Executive Officer, Mibbinbah) described the Mibbinbah (“Men’s Place”) model of health promotion. The focus here is on creating safe spaces for Aboriginal and Torres Strait Islander males where they can acquire skills to take back to work with men in local communities. Mibbinbah’s success lies in its capacity to network with local Indigenous organisations and broader community health organisations. Pino Migliorino (Chair, Federation of Ethnic Communities’ Councils of Australia) highlighted the significant health literacy issues for men, particularly older men, from culturally and linguistically diverse (CALD) backgrounds. He emphasised the importance of bringing ethno-specific organisations on board as partners with mainstream services, to address barriers to accessing health services and to aid in understanding health contexts of men from CALD backgrounds. Gordon Gregory (Executive Director, National Rural Health Alliance) stressed that access issues are also crucial for men living in rural and remote areas, irrespective of whether “rural attitudes” such as “valuing independence” still exist. There are some obvious system barriers, such as a lack of general practitioners in rural areas, that require modern solutions, such as greater use of information technologies. Professor Gary Dowsett (Acting Director, Australian Research Centre in Sex, Health and Society, La Trobe University) gave some background on the gay men’s health movement, arguing that gay men have specific health needs that should be kept on the policy agenda. Although comprehensive data are lacking, Professor Dowsett pointed to eating disorders, drug use and mental health disorders as being common in this group, in addition to sexual health issues. While noting the failure of the current policy to adequately acknowledge gay men’s health needs, he called for better data collection tools to answer the most relevant questions about gay men’s health, requiring a rethinking of traditional health data categories. Workforce capacityThere was general agreement that addressing inequities in men’s health requires a multisector focus on workforce capacity. Dr Michael Wright (Research Fellow, Telethon Institute for Child Health Research) spoke about the Aboriginal and Torres Strait Islander male researcher network. Building Indigenous research capacity to better deliver evidence and engage with policymakers will be integral to improving Aboriginal and Torres Strait Islander male health. Dr Mark Wenitong (Senior Medical Officer, Apunipima Cape York Health Council) spoke about increasing both the capacity and the quality of the Indigenous health workforce. He stressed the cultural importance of male health workers and pointed out that there is a current shortage of male nurses, and Aboriginal and allied health workers. Policy levers such as the Aboriginal and Torres Strait Islander Health Workforce Working Group,4 and programs such as the Indigenous health curriculum framework for medical schools5 and the Andrology Australia Aboriginal and Torres Strait Islander Male Health Module need further investment from government. Dr Wenitong argued for improved pathways and structural support to enable Aboriginal and Torres Strait Islander people to progress through health workforce education and training. Peter Strange (Nurse Practitioner, Bendigo Community Health Services) highlighted the current lack of men’s health education in undergraduate and postgraduate nursing and allied health curricula, and Professor Rob McLachlan (Director, Andrology Australia) spoke about the lack of men’s health education in the medical undergraduate curriculum. These deficiencies flow through to a lack of men’s health specialist services and local programs. Audience discussion reflected on the critical need for more focused training across these domains, reinforcing that men’s health could be incorporated as a core education component and/or specific postgraduate training to build defined men’s health career pathways. Men’s health programsDescriptive accounts of programs designed to address male health disparities through better access and support (Box) prompted discussion of the need for program evaluation. Although the workplace is seen as a potentially successful forum for men’s health promotion, for example with high attendances recorded at WorkSafe Victoria’s workplace health checks, evaluations of the effectiveness of such programs can be limited due to privacy and other issues. ConclusionThe forum provided a timely opportunity to reflect on the National Male Health Policy and its specific aim to address health disparities between population subgroups of men. The forum only provided a snapshot of current men’s health initiatives, and it became clear that a number of areas still require policy focus. These areas included the need for explicit linkage, coordination and cooperation across service provision, research, policy and practice. Policy action areas have been defined, but opportunity exists to reflect on the international, national, regional, local and individual experience to bring coordinated action to improve the health of all Australian males. Examples of men’s health promotion program Bringing health into the workplace Rachel Gualano, Acting Director, WorkHealth, WorkSafe Victoria WorkHealth program health checks for diabetes and cardiovascular disease risk factors done in the workplace Building workforce capacity in community health (in men’s health) Peter Strange, Nurse Practitioner (Men’s Health), Bendigo Community Health Services, Victoria Rural men’s health promotion model: community events for men, male-friendly health clinics and workplace programs, such as health assessments for men in sheep saleyards Strengthening networks through peer support Bill McHugh, Past Chair, Support and Advocacy Committee, Prostate Cancer Foundation of Australia; Brisbane Prostate Cancer Support Network, Queensland Network of 99 prostate cancer support groups with three levels of organisation: individual peer support, state chapters, and the National Support and Advocacy Committee

Veronica R Collins PhD · Robert I McLachlan MB BS, FRACP, PhD · Carol A Holden PhD

Objective: To determine the impact that mandatory fortification with folic acid of wheat flour used in breadmaking has had on the blood folate levels of an Australian population since it was introduced in September 2009.Design, setting and patients: A retrospective analysis of serum and red blood cell (RBC) folate levels of 20 592 blood samples collected between April 2007 and April 2010 from a wide variety of inpatients and outpatients and analysed in a large public hospital diagnostic pathology laboratory.Main outcome measures: Prevalences of low levels of serum and RBC folate and monthly mean levels before and after introduction of mandatory fortification.Results: Between April 2009 and April 2010, there was a 77% reduction in the prevalence of low serum folate levels (from 9.3% to 2.1%) in all samples tested and an 85% reduction in the prevalence of low RBC folate levels (from 3.4% to 0.5%). In April 2010, the prevalence of low RBC folate levels for females of childbearing age was 0.16% for all samples. There was a 31% increase in mean serum folate level (from 17.7 nmol/L to 23.1 nmol/L; t = 9.3, P < 0.01), and a 22% increase in mean RBC folate level (from 881 nmol/L to 1071 nmol/L). The greatest increment in mean serum folate levels occurred in September 2009, the month that mandatory fortification was introduced, although there was evidence of a gradual change during the preceding months.Conclusion: The introduction of mandatory fortification with folic acid has significantly reduced the prevalence of folate deficiency in Australia, including in women of childbearing age.

Ross D Brown PhD, MBA, FAIMS · Mark R Langshaw BAppSci, GradDipIT · Elaine J Uhr MSc(BiolSc) · John N Gibson PhD, FRACP, FRCPA · Douglas E Joshua DPhil, FRACP, FRCPA

Objective: To determine antibody levels and estimate incidence of infection with pandemic (H1N1) 2009 influenza in children and pregnant women during the 2009 winter in Western Australia.Design, setting and participants: Two cross-sectional serosurveys using stored specimens collected for unrelated pathology testing, from before and after (3 August to 30 November 2009) circulation of the pandemic virus, and before commencement of the pandemic vaccination program. Specimens were from three groups: children aged 1–4 years, older children and teenagers aged 5–19 years, and pregnant women aged 21–45 years. The groups were geographically representative of the WA population.Main outcome measures: Reactivity against pandemic (H1N1) 2009 and seasonal A(H1N1) influenza viruses measured using haemagglutination inhibition (HI) assays.Results: Antibody titres were determined for 648 individuals in the prepandemic period and 736 in the postpandemic period. In the prepandemic period, HI titres ≥ 40 against the pandemic virus were found in 0 (95% CI, 0.0%–1.6%) children aged 1–4 years, 8.3% (95% CI, 5.3%–12.7%) of older children and teenagers, and 4.5% (95% CI, 2.4%–8.3%) of pregnant women. In postpandemic specimens collected from 1 September 2009 (when influenza activity had declined to near-baseline levels), estimated infection rates (subtracting prepandemic levels) were 25.4% (95% CI for difference, 18.6%–33.4%) in 1–4-year-old children, 39.4% (95% CI, 29.8%–48.5%) in older children and teenagers, and 10.2% (95% CI, 4.1%–17.1%) in pregnant women.Conclusions: A quarter of preschool children and about 40% of school-aged children and older teenagers had serological evidence of pandemic influenza infection during winter 2009, indicating high levels of mild or asymptomatic infection. The infection rate in pregnant women was much lower. The high infection rates in children help explain the reduced impact of the pandemic virus during the 2010 winter. Augmented by vaccination, there should be sufficiently high levels of immunity in the Australian population to significantly reduce the impact of the virus in future influenza seasons.

Gary K Dowse MB BS, MSc, FAFPHM · David W Smith BMedSc, MB BS, FRCPA · Heath Kelly MB BS, MPH · Ian Barr PhD · Karen L Laurie BSc(Hons), PhD · Anthony R Jones BSc, MASM · Anthony D Keil MB BS, FRCPA · Paul Effler MD, FAFPHM

Objective: To report the latest conditional survival estimates for patients with cancer in Queensland, Australia.Design, setting and participants: Descriptive study of state-wide population-based data from the Queensland Cancer Registry on patients aged 15–89 years who were diagnosed with invasive cancer between 1982 and 2007.Main outcome measure: Conditional 5-year relative survival for the 13 most common types of invasive cancer, and all cancers combined.Results: The prognosis for patients with cancer generally improves with each additional year that they survive. A significant excess in mortality compared with the general population ceases to occur within 10 years after diagnosis for survivors of stomach, colorectal, cervical and thyroid cancer and melanoma, with these groups having a conditional 5-year relative survival of at least 95% after 10 years. For the remaining cancers we studied (pancreatic, lung, breast, prostate, kidney, and bladder cancer, non-Hodgkin lymphoma, and leukaemia), conditional 5-year relative survival estimates (at 10 years after diagnosis) ranged from 82% to 94%, suggesting that patients in these cohorts continue to have poorer survival compared with the age-matched general population.Conclusions: Estimates of conditional survival have the potential to provide useful information for cancer clinicians, patients and their carers as they are confronted by personal and surveillance-related decisions. This knowledge may be effective in building realistic hope and helping people manage uncertainty about the future. We suggest that measures of conditional survival be incorporated into routine statistical reporting in Australia.

Peter D Baade PhD · Danny R Youlden BSc · Suzanne K Chambers PhD

The medical and psychosocial needs of children and adolescents differ from those of adults, and this should be reflected in the care they receive in all areas of a health service. Children and adolescents must be accommodated separately to adults to ensure that their unique needs are met and risks of harm are minimised. The Standards for the care of children and adolescents in health services have been developed by a working group of clinicians, health service providers and consumer advocates based on a combination of available research evidence, published best practice guidelines and multidisciplinary expert consensus. Stakeholder input was obtained through invitations to comment, and pilot testing of the Standards was conducted in six metropolitan, regional and rural hospitals. The Standards provide detailed recommendations in the areas of recognising rights; the provision of child-, adolescent- and family-friendly health service facilities; the availability of child- and adolescent-specific equipment; and the importance of appropriately trained staff. To facilitate implementation and allow ongoing performance monitoring, the Standards have been developed for use alongside the Australian Council on Healthcare Standards Evaluation and Quality Improvement Program. The Standards provide a vehicle to ensure patient safety and to facilitate the provision of high-quality care for children and adolescents in Australian health services.

Melissa K Hill BSc(Hons), PhD · Marjorie Pawsey MB BS, DPH · Anne Cutler MEd(Health) · Joanna L Holt BSc, MHP · Sharon R Goldfeld FRACP, FAFPHM, PhD

Four formal rounds of Trans-Pacific Partnership Agreement (TPPA) negotiations took place in 2010. They involved over 200 officials from Australia, the United States, New Zealand, Chile, Singapore, Brunei, Peru, Vietnam and Malaysia. Future negotiations officially are set to include three issues with public health and medicines policy implications for Australia and our region: ways to approach regulatory coherence and transparency; how to benefit multinational and small–medium enterprises; and multilateral investor–state dispute settlement. US-based multinational pharmaceutical companies are lobbying for TPPA provisions like those in the Australia–US Free Trade Agreement, which reduce government cost-effectiveness regulatory control of pharmaceuticals, threatening equitable access to medicines. They also advocate increased TPPA intellectual monopoly privilege protection, which will further limit the development of Australian generic medicine enterprises and restrict patient access to cheap, bioequivalent prescription drugs. Of particular concern is that proposed TPPA multilateral investor–state dispute settlement procedures would allow US corporations (as well as those of other TPPA nations) to obtain damages against Australian governments through international arbitral proceedings if their investments are impeded by Australian public health and environment protection legislation.

Thomas A Faunce BA LLB, BMed, PhD · Ruth Townsend RN, LLM

Publications written by doctors about subjects outside their professional activities are often widely read and may be more enduring than their technical publications. Dr Graeme Robertson, Sir Clive Fitts and Professor Richard Lovell were three doctors from Victoria who wrote with skill and artistry about subjects outside their professional work. Here I discuss these publications and the reasons these doctors came to write them, and offer some reasons for the enduring interest of these publications.

Thomas H Hurley MD, MB BS, FRACP

Electronic referrals and discharge summaries can improve the quality and timeliness of clinical communication. The electronic summary care record (SCR) extends the concept of digital health summaries to create a perpetually updated and centrally stored summary of care, extracting key data from local systems after each encounter. The only major SCR evaluation to date, in England, found that rates of usage were low, and any impact on care was difficult to quantify. The SCR is seen by some as a first step to building a national distributed shared electronic health record (SEHR). However, the SCR may be a problematic diversion, creating a need for centralised databases, while the SEHR can function by sharing locally stored records, letters and discharge summaries. Uncertainty about the quality and provenance of SCR data raises concerns about patient safety, as key data may be absent and old data may persist, partly because of a lack of ownership of the summary. A national e-health strategy should emphasise the true stepping stones to a distributed and shared electronic record, including encouraging the uptake and meaningful use of electronic clinical records, clinical messaging, electronic discharge summaries and letters, and services such as decision support and e-prescribing, all of which have good evidence to support them.

Enrico Coiera MB BS, PhD

Procedures to select medical specialist trainees aim to predict which junior doctors will become the best specialists. A 1998 review of Australian postgraduate selection processes recommended use of the principles of good assessment. Australia has expertise in national procedures used by medical schools to select students for undergraduate and graduate courses, but little experience in national specialist training program selection. A system for selection into postgraduate general practitioner training, based on a national “selection-centre” approach used in the United Kingdom, is being piloted in Australia. Initial evaluation shows the piloted system to be feasible but further evaluation is needed. Any selection-centre approach must be adapted to the Australian health care context and have the confidence of the trainees, the professional colleges, the training providers and the public.

Christopher Roberts FRACGP, MMedSci, PhD · John M Togno MB BS, FRACGP, GradCertHEd

An article in the 20 September issue of the Journal that suggested circumcision of infant boys could be considered a "surgical vaccine" against future sexually transmitted HIV has attracted strong criticism from many of our readers (MJA 2011; 194: 97-101) To the Editor: In a recent editorial, Cooper and colleagues recommend increasing infant circumcision to combat increasing rates of heterosexual transmission of HIV infection, and contend that the major obstacle to increasing male circumcision in Australia is a Royal Australasian College of Physicians (RACP) policy.1 In September, after a literature review and analysis, the RACP released a revised policy on infant male circumcision, concluding that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand.2 While evidence of HIV prevention by circumcision is strong in high-prevalence settings with predominantly heterosexual transmission,3 this is not so in low-prevalence environments where homosexual transmission is more important.4 Evidence of the protective effect of circumcision against other sexually transmitted infections in Australia is limited.5 Cooper et al’s comparison of circumcision with vaccines is misleading. Protection against HIV by circumcision is predominantly for males, and the risk for females may increase.6 There is minimal protection against homosexual acquisition of HIV.4 The RACP acknowledges the strong and differing opinions on this topic, ranging from the strong pro-circumcision views of Cooper et al to the equally strong diametrically opposed views of the Royal Dutch Medical Association, which believes that (for reasons of ethics and medical risks) legal prohibition of infant circumcision is warranted.7 The RACP recognises the important role of parents in decision making, and recommends that parents contemplating circumcision of their newborn sons be carefully apprised of the risks and benefits. If they elect to proceed with circumcision, the procedure should be undertaken in a safe child-friendly environment, with appropriate analgesia, and by an appropriately trained, competent practitioner who is capable of dealing with complications. We believe that this approach safeguards the social and community interests of children, and offers protection from unnecessary surgical risks.2 The RACP does not accept that its policy on circumcision of infant males represents an obstacle to effective public health policy — it believes that, at present, the evidence does not allow a recommendation for widespread infant male circumcision and that Cooper et al have misrepresented this evidence. In the interests of children, and of public health more generally, it is important that this evidence be kept under review and decisions that could lead to increased morbidity and mortality of children only be made when it is clear that the benefits very clearly outweigh any risks. To the Editor: In their recent editorial, Cooper and colleagues propose newborn circumcision as primary prevention for heterosexual HIV transmission in Australia.1 However, they cite no evidence for its effectiveness as a primary prevention measure, and their editorial references few high-quality studies, offering instead opinions from like-minded individuals. Experience in the United States suggests that circumcision is unlikely to be effective in preventing heterosexual HIV transmission. While having a high infant circumcision rate for the past 60 years, the US has had one of the highest rates of heterosexually transmitted HIV infection among developed nations. African Americans have the highest rates of both circumcision2 and heterosexually transmitted HIV infection.3 Circumcision removes the most sensitive tissue of the penis4 and serious complications include death (about 0.9 deaths per 10 000 circumcisions).5 If two-thirds of Australian newborn boys were circumcised at birth, around nine would die every year from complications. Cooper et al sidestep the ethical issues raised by non-therapeutic circumcision. Infants and children lack the legal capacity to grant consent but have human rights. The High Court of Australia holds that parents may grant consent only when surgery to the genital organs is therapeutic,6 which does not include neonatal circumcision. Without valid consent, circumcision constitutes legal battery. It is far preferable legally and ethically for circumcision decisions to be deferred until the child is competent to make a fully informed decision for himself. Cooper et al state that infant circumcision is cost-effective, but the cost analysis that they reference does not directly assess cost-effectiveness.7 In fact, the data suggest that infant circumcision costs more than it saves. Another cost analysis showed that a circumcision program would be five times more costly in preventing HIV than providing free condoms, and that condoms are 95 times more effective than circumcision.8 In summary, newborn circumcision for primary prevention of HIV remains unsupported by evidence of efficacy or cost-effectiveness, introduces potentially serious risks, and raises complex ethical and medicolegal issues. New 2010 Royal Australasian College of Physicians guidelines9 continue to not recommend circumcision, despite pressure from a well funded, international, pro-circumcision lobby group.10 Instead of adopting a circumcision experiment that has failed in the US, Australia should take its lead from the Royal Dutch Medical Association and condemn non-therapeutic circumcision in boys.11 To the Editor: We refer to a recent editorial in which Cooper and colleagues made a case for boosting infant male circumcision in Australia to reduce female-to-male HIV transmission.1 The case is strong for hyperendemic countries, such as those in sub-Saharan Africa, given the evidence for circumcision reducing the prevalence of HIV when infections are primarily from heterosexual contact.2 However, the epidemiology of the HIV epidemic in Australia paints a radically different picture from these countries. Most striking is that men who have sex with men (MSM) still comprise the largest group — around 83% — of people living with HIV.3 Prevalence of HIV among men and women who report a history of heterosexual contact only remains at less than 0.5%4 while MSM continue to have the majority of new infections.4 In short, efforts to reduce Australia’s HIV epidemic still require a primary focus on MSM. With this in mind, a recent meta-analysis of 18 international studies and a combined pool of 53 567 MSM5 showed only a small, statistically non-significant trend toward a protective benefit from circumcision with regard to HIV and other sexually transmitted infections. Hypothesised benefits are limited to the insertive partner; however, circumcised MSM who engaged primarily in insertive anal intercourse (IAI) were not significantly less likely to be HIV-positive than other MSM. The sexual repertoire of many MSM suggests that interventions designed specifically to protect those who engage in IAI are unlikely to be successful at a population level. Data from a national survey of 856 homosexual men, conducted recently by the Australian Research Centre in Sex, Health and Society, show that only 9% of those who had anal intercourse in the past 12 months reported taking an exclusively insertive role. Of the remainder, 8% were exclusively receptive and 83% were versatile, adopting each role at least once over the preceding 12 months. Uncircumcised men who engaged exclusively in IAI were just as likely to be HIV-negative as their circumcised counterparts (P = 0.90). As infant male circumcision programs are rolled out in some hyperendemic countries, we encourage policymakers to tread carefully when considering such a move in Australia. Boosting education campaigns that promote HIV awareness and safer sex may prove to be more cost-effective and successful than large-scale infant male circumcision programs which seem likely to offer, at most, a marginal benefit to the extremely small proportion of the Australian male population who are exclusively insertive partners in homosexual anal intercourse. To the Editor: In their recent editorial, Cooper and colleagues argue for a shift in Australian policy to boost neonatal male circumcision levels, in an effort to prevent future heterosexual acquisition of HIV.1 There is very strong evidence for a protective effect of male circumcision against HIV acquisition in high-prevalence settings, where heterosexual intercourse is the most common mode of transmission and access to antiretroviral therapy is poor. However, Australia is a low-prevalence setting with an HIV epidemic that largely affects the homosexual population and excellent access to condoms and antiretroviral therapy. There have been very few studies on the protective effect of male circumcision in settings similar to Australia, and those that have been reported have produced variable results.2 The publications cited by Cooper et al do not strongly support the notion that male circumcision confers similar protection in both high- and low-prevalence settings — the conclusions are based on expert opinion or other inconclusive, low-quality evidence.2-4 There are also other issues to consider when discussing a population-based intervention strategy for a low-prevalence disease. Given that rates of male circumcision in Australia are currently low,1 compliance could be an issue, as parents may be unwilling to accept a surgical procedure for their newborns on the basis of predictions about future HIV protection. Is circumcision cost-effective compared with other modalities used to prevent or treat heterosexually transmitted HIV? Cost-effectiveness studies have been carried out in the United States, where health care costs are likely to be significantly different to those in Australia. The Centers for Disease Control and Prevention consultation report cited by the authors acknowledges that the available cost and cost-effectiveness research on male circumcision is subject to a variety of “methodologic limitations and data insufficiencies”.2 Further, the case needs to be made that neonatal male circumcision is a more cost-effective option in preventing heterosexual HIV transmission than the current response — targeted education campaigns, antiretroviral therapy, and medical advice regarding safe sex practices. In conclusion, the jury is still out with regard to the role of male circumcision in HIV prevention in Australia on two counts: efficacy and cost-effectiveness. To justify a shift in policy towards actively encouraging routine neonatal circumcision at a national level, we should have access to high-quality, relevant data. Until such information is available, the environment doesn’t exist for parents or policymakers to make a truly informed decision about this issue. To the Editor: In a recent editorial, Cooper and colleagues asserted that infant male circumcision reduces heterosexual (female-to-male) transmission of HIV.1 However, they failed to acknowledge the serious methodological flaws of the three African randomised controlled trials (RCTs) on which the claim is based, including early termination and loss of participants to follow-up. These RCTs reported on circumcision of adults in Africa and, therefore, are not relevant to children in Australia. In a major oversight, the editorial did not cite contradictory RCT evidence that male circumcision increases heterosexual (male-to-female) HIV transmission by 61.4%.2 Therefore increased male-to-female transmission of HIV would negate any reduction in female-to-male HIV transmission. Common law recognises the right of bodily integrity.3 International human rights law enshrines the right to security of the person.3 The High Court of Australia opines that parents may grant surrogate consent only when a surgical intervention is therapeutic.3 As male circumcision amputates healthy, functional, protective, erogenous tissue,3 imposing male circumcision on unconsenting minors violates these rights. It has been strongly argued that non-therapeutic infant circumcision is tantamount to criminal assault.3 Unlike America, which has a high incidence of male circumcision and a high prevalence of HIV infection (0.6%),4 in the Australian context there is a low incidence of male circumcision among men aged under 35 years combined with a very low prevalence of HIV (0.1%).4,5 HIV infection in Australia occurs mostly among homosexual men.6 It has been reported that any prophylactic value of male circumcision in preventing homosexual transmission of HIV is not statistically significant,7 so male circumcision would be of little value in reducing future Australian HIV infection rates. Despite calling for increased non-therapeutic infant male circumcision, Cooper et al unequivocally stated “Condom use remains essential”. Since this is the case, what is the purpose of inflicting lifelong bodily and psychosexual harm8 on defenceless children, contrary to ethical or moral principles? Furthermore, circumcision of unconsenting minors may amount to criminal assault.3 To the Editor: Cooper and colleagues propose circumcision of male infants in Australia as a strategy for reducing the incidence of heterosexually transmitted HIV infection.1 They base this suggestion on evidence, from three clinical trials in Africa, that circumcision of adult men can reduce the risk of men acquiring HIV during unprotected sexual intercourse with an infected female partner. The proposal must be rejected because it is irrelevant to the Australian situation and departs from the principles of evidence-based medicine. The proposal is irrelevant because it targets infants, who are not at risk of infection by sexual contact and will not be at risk until they become sexually active in 16–20 years time, by which time treatment and prevention options, and the virus itself, may have altered beyond recognition. Evidence-based medicine requires that recommendations for treatment or prophylaxis follow logically and directly from the evidence. In this case, there is a radical disconnect between the evidence and the recommendation. Even assuming the African evidence is reliable and applicable (and ignoring the many critiques),2,3 the logical prescription arising from these data is that sexually active adult men who have regular intercourse with numerous different female partners and who do not always use condoms should consider circumcision for themselves as a means of lowering their risk of infection. This is not what Cooper et al propose. What they prescribe is that parents be advised to circumcise their boys in infancy as a precaution against a risk they will not face until they are adults, and against a disease that is very rare among heterosexually active adult men in Australia. Even if circumcised, they would still have to use a condom to be sure of avoiding infection, as the risk reduction promised by the African data is only partial — between 38 and 66 per cent.4 We have no data at all on what the risk reduction in Australia might be. If it is still necessary to wear a condom there seems little point in getting circumcised. As others point out,5 moreover, the African trials on which Cooper et al rely involved sexually active adult men, not infants, and there is no hard evidence that neonatal circumcision has any protective effect against acquiring HIV. Arguments concerning other possible, non-HIV-related benefits of circumcision (all contested in the literature and rejected in the policy statement on circumcision recently issued by the Royal Australasian College of Physicians6) are irrelevant to HIV infection itself. In sum, the prescription offered has so little connection with the evidence on which it relies that it cannot be taken seriously. To the Editor: I write in response to the editorial by Cooper and colleagues, which advocates an increase in male infant circumcision as an anti-HIV strategy.1 The authors claim that male circumcision is effectively a surgical vaccine for preventing female-to-male HIV transmission and, while the authors do present evidence in favour of this, they fail to canvass the serious and inevitable long-term adverse effects of the procedure. Far from being an inconsequential snip, male circumcision is a highly mutilating operation which seriously impairs penile function. Glibly quoting four articles which “prove” that circumcised and uncircumcised males are equally satisfied sexually, the authors totally ignore a large and expanding body of evidence to the contrary,2-4 and indeed growing popular movements against circumcision and for restoration of the foreskin. Circumcision typically removes nearly half the skin of the penis3 — including its most sensitive areas — and, by exposing the glans to the elements, induces keratinisation of its formerly moist mucosal surface — making it rougher, dryer and less sensitive. It also destroys the “sliding” or “rolling” action of the shaft in the skin tube and most certainly impairs both male and female sexual satisfaction.4,5 It is totally inappropriate to suggest that circumcision is akin to vaccination: needle vaccination generally confers high-level immunity to the majority of its recipients with few, if any, long-term sequelae. In contrast, circumcision confers moderate immunity at best, and does so at the cost of mutilating and de-functioning every penis so treated. I strongly urge my colleagues who still believe that male circumcision is a trivial operation to type “foreskin restoration” into a search engine and see what they find. Finally, I implore us all to refrain from removing body parts from our unconsenting children without immediate and direct surgical need. To the Editor: I read with interest the editorial by Cooper and colleagues in which the authors argue for infant male circumcision as a population-wide strategy to reduce HIV transmission.1 Circumcision is an irreversible body-altering procedure and, therefore, as far as possible, individuals should participate in the decision of whether or not to be circumcised. Male circumcision in infancy removes an individual’s ability to participate in the decision-making process. Further, the protective benefits of infant circumcision with regard to reduction of HIV transmission are not conferred until an individual becomes sexually active and is capable of understanding the risks and benefits. Deferment of circumcision to a later age would allow individuals to fully appreciate the magnitude of the procedure and participate in the decision-making process, and it would not necessarily negate the protective benefits. This should be considered by anyone who advocates infant male circumcision as a strategy to reduce HIV transmission. In reply: In our editorial we, just as other academic experts in various countries,1-4 likened infant male circumcision to a “surgical vaccine”. Both vaccination and male circumcision effectively, safely and inexpensively afford lifelong protection against a wide array of adverse, sometimes fatal, medical conditions. Both are most effective if provided early in life. Both are criticised vigorously and relentlessly by opponents. There is now an impressive and growing number of high-quality research publications attesting to the wide-ranging benefits of male circumcision.2,4 The letters to the Journal in response to our editorial rely largely on opinions, and often cite superseded and spurious references. Forbes ignores the high prevalence in Australia of sexually transmitted infections (STIs), which male circumcision protects against, including oncogenic human papillomaviruses. Moreover, male circumcision provides similar protection against heterosexual HIV infections in men in low-prevalence settings as those in high-prevalence settings.1-5 In the United States, infant male circumcision is cost-saving for HIV prevention.6 In claiming that male circumcision increases HIV risk to women, Forbes, Boyle and Hill cite an outlier study, ignoring a meta-analysis and new data which show that male circumcision reduces the risk of male-to-female transmission.7,8 There is no reason to expect that male circumcision would protect a man who engages in receptive anal intercourse, the primary mode of HIV transmission in Australia and the US. Australian data show, however, greater than 90% protection against HIV and syphilis in the smaller proportion of homosexual men who are insertive only.9 While there are few Australian studies of other STIs and male circumcision in heterosexual people, research in the US and elsewhere, including randomised controlled trials (RCTs), shows strong protection.2,4 Paix argues that circumcision is a “highly mutilating operation which seriously impairs penile function”, while Travis and colleagues assert that circumcision “removes the most sensitive part of the penis”. However, there is now strong research evidence, including RCTs, showing not only no loss of function, satisfaction, sensitivity or sensation,2 but, in one large RCT, that sexual experience is enhanced by male circumcision.10 In rejecting male circumcision for HIV prevention, Travis et al and Boyle and Hill present arguments against circumcision repudiated previously by 48 international academic experts.11 Moreover, in response to Darby, it is well established that condoms are often not in place during sex, whereas male circumcision always is. Also, population-level condom use does not correlate with reduced HIV transmission.12 Parents have a duty to help prevent renal damage, physical, inflammatory and hygiene problems, STIs and cancers in their sons and their sons’ future sexual partners. They can do this by arranging for their son to be circumcised. The level of risk and severity of such adverse medical conditions in Australia is sufficiently high to support infant male circumcision. Not to do so may have legal ramifications.13 Chin argues that male circumcision should be delayed until the boy can make up his own mind. He fails to recognise that, as for vaccination, infancy is by far the safest, quickest, cheapest and most convenient time for male circumcision; when performed in infancy, circumcision confers immediate benefits with very limited short- and long-term risks.1-4 While our warning of a future HIV epidemic in Australia unless infant male circumcision is increased is based on a rise in the proportion of new infections attributable to heterosexual sex (from 841 in 2000–2004 [20% of total diagnoses] to 1185 [23%] in 2005–2008),14 there are currently epidemics of other STIs, many of which could have been prevented by male circumcision. The very low risk and considerable benefits of male circumcision attest to the wisdom of performing the procedure in infancy to maximise individual and public health gains.

David A Forbes · John W Travis · Sarah J Buckley · Paul Mason · Ken McGrath · Robert S Van Howe · George Williams · Anthony N Lyons · Marian Pitts · Anthony Smith · Jeffrey Grierson · Niall Conroy · Gregory J Boyle · George Hill · Robert J L Darby · Bruce R Paix · Jeremy J Chin · David A Cooper · Alex D Wodak · Brian J Morris

To the Editor: Trachoma control guidelines from the World Health Organization1 and Communicable Diseases Network Australia (CDNA)2 recommend the “SAFE” strategy that includes surgery for trichiasis, antibiotic treatment, facial cleanliness and environmental improvement. Lack of access to antibiotics in isolated areas should not be a major contributor to the persistence of trachoma in Australia because special Pharmaceutical Benefits Scheme arrangements (SPBSA) under section 100 of the National Health Act 1953 for the supply of medicines to remote-area Indigenous health services should enable a ready availability of azithromycin. The 1999–00 to 2001–02 evaluation of the SPBSA suggested that the program had led to major increases in the supply of medicines in remote areas, but that the supply of azithromycin did not change as a result of the introduction of the program.3 We assessed the relationship between reported azithromycin treatment of people with trachoma, their household contacts, and community members; levels of treatment recommended by WHO and CDNA guidelines; and the total number of courses of azithromycin available through the SPBSA. The National Trachoma Surveillance and Reporting Unit (NTSRU) provided 2008 data on treatment with azithromycin and trachoma prevalence in the Northern Territory, South Australia and Western Australia (refer to the report for limitations of the data).4 Data for 2007–08 on the supply of azithromycin to health services under SPBSA were obtained from Medicare Australia. The WHO guidelines recommend treatment of an entire community if the prevalence of active trachoma among children is above 10%.1,5 The CDNA guidelines2 recommend that contacts (> 6 months of age) of infected children within a household be treated. Our estimate of trachoma treatment according to CDNA guidelines is based on multiplying the number of infected children (from the NTSRU data) by the average number of members in remote Indigenous households.5 The impact of shared and multiple residence on estimates of household contacts could not be taken into account. The Box shows the numbers of azithromycin courses available through the SPBSA to remote-area Aboriginal and Torres Strait Islander health services in the three states. In the NT, the reported number of courses given (3069) fell well below the level recommended by both WHO (by 34%) and CDNA (by 41%) guidelines. In SA, reported courses of azithromycin given (7) fell well below the 45 suggested by the CDNA guidelines. The prevalence of trachoma did not exceed 10% in any SA community, so no treatment was required under WHO guidelines. In WA, the reported number of courses given (2917) also fell below recommended levels, although the deficit (WHO, 35%; CDNA, 81%) varied substantially depending on which guidelines were used. Reported treatment with azithromycin was below levels recommended by the CDNA and the WHO despite health services having sufficient courses available to them to mostly meet these targets. All aspects of the SAFE strategy are important in the eradication of trachoma. However, improving the supply and distribution of azithromycin should be relatively easy to implement, fund and monitor. Azithromycin courses* available, 2007–08;† courses given, 2008;‡ and WHO- and CDNA-recommended courses,§ in three Australian states with remote-area Indigenous health services WHO = World Health Organization. CDNA = Communicable Diseases Network Australia. * Azithromycin courses are given to those with active trachoma, their household contacts, and community members. † Under special Pharmaceutical Benefits Scheme arrangements and reported by Medicare Australia. ‡ Reported by the National Trachoma Surveillance and Reporting Unit (NTSRU). § Based on NTSRU data and using community population estimates.

Margaret Kelaher · Angeline S Ferdinand · Hugh R Taylor

To the Editor: Girgis and Seibel1 are to be congratulated as endocrinologists for raising the important issue of bisphosphonate therapy and femoral fractures. This is a relatively new phenomenon that even a couple of years ago, although already documented, did not seem to be on many endocrinologists’ radar. However, I question the authors’ statement that such fractures are rare. In my small outpost of the orthopaedic world (Northeast Health Wangaratta), three cases have been seen in 12 months. All patients characteristically had a spontaneous non-traumatic fracture, a short oblique or transverse fracture in the subtrochanteric area, and had been on alendronate for more than 5 years. If a journeyman orthopaedic surgeon is seeing a cluster of cases, I suggest that these fractures are not rare. On the other hand, a review of our audit figures in Wangaratta in north-eastern Victoria (where we have a stable rural population of about 17 000) provides an interesting statistic. Over 15 years (1993–2008), Northeast Health Wangaratta admissions for fractured neck of femur fell steadily from 74 to 35 a year. This trend continues. We should not throw out the baby with the bathwater — osteoporosis treatment is likely partly responsible. Also, a deeper level of community aged care support and much better comorbidity management may have helped to reduce falls. The real question is whether all patients who have been on alendronate (or any bisphosphonate) for 5 years need to have a mandatory holiday from the drug. In line with Wolff’s law (bone will adapt to loads under which it is placed), the precursor femoral stress lesions will heal by remodelling, as long as bisphosphonate therapy is suspended. I suggest that the suspension should be for 2 years, which is the time required for full fracture remodelling. I agree with Girgis and Seibel that these drugs have been effective in reducing fracture incidence; however, their long-term use needs further study.

Michael P Falkenberg

In reply: We thank Falkenberg for his comments in reference to our article in the Journal.1 Two recent large-scale population-based studies have suggested that subtrochanteric femur fractures are rare both in the general population and among bisphosphonate users.2,3 While personal experience may often suggest otherwise, a cluster of atypical fractures cannot be used as an indicator of true incidence in the absence of data on the frequency of bisphosphonate use in a particular population. It is certainly safe to say that atypical fractures occur much less frequently than osteoporotic hip fractures. In a 5-year retrospective analysis of femur fractures at our centre, osteoporotic hip fractures outnumbered atypical fractures by a factor of greater than 60.4 Given the body of high-quality evidence on the antifracture efficacy of bisphosphonates, we agree that discarding an effective class of drugs because of a presumed association with an uncommon fracture pattern would be like throwing out the baby with the bathwater. Should we routinely advise patients to take a drug holiday after, say, 5 years of bisphosphonate therapy? There is no good evidence for that either. Although bisphosphonates bind to bone for extended periods, severely suppressed bone turnover or signs of mechanical failure (microcracks) are rarely, if at all, seen in patients chronically treated with bisphosphonates. Similarly, the few bone biopsy studies in patients with atypical fractures do not uniformly support the hypothesis of severely suppressed bone turnover as a cause of these fractures.5,6 Instead of being based on the theoretical assumption of an uncertain risk, the decision for a drug holiday should be made on a case-by-case basis, guided by factors such as the patient’s on-drug fracture history, the presence of other relevant risk factors for osteoporosis, and changes in bone density and bone turnover. Many questions remain unanswered regarding atypical femoral fractures and their biomechanical evolution. Until further research is conducted, the fear of the unknown, namely the impact of bisphosphonates on bone remodelling and microfracture accumulation, should not replace strong evidence in support of their antifracture efficacy.

Christian M Girgis · Markus J Seibel

To the Editor: Point prevalence studies have been used for many years as markers of antimicrobial consumption,1,2 but they have suffered from a lack of standardisation with regard to the populations studied and the data collected. These deficiencies make it difficult to generalise the data outside the study populations. In recent years, the European Surveillance of Antimicrobial Consumption (ESAC) has sought to overcome these weaknesses by implementing a web-based point prevalence survey in 20 European countries using standardised definitions for site of infection, indication and quality indicators, such as whether the indication for prescription is documented in the case notes.3 As Australian studies of this type have not been published, we undertook a pilot study to assess whether this point prevalence tool is feasible and useful in an Australian setting. All surgical inpatients (excluding intensive care patients) in Sydney’s Royal North Shore Hospital (a 541-bed tertiary referral hospital) at 8 am on a single day in December 2009 were included. Current prescriptions for antimicrobials were captured from the medication prescription charts, and data on duration of therapy, dose and route of administration were collected for that point in time to give a “snapshot” of prescribing on that day. We reviewed patients’ medical records to establish site of infection, indication for treatment, and whether the reason for the antimicrobial was documented. ESAC codes for site of infection and indication were used. Of 178 patients, 95 (53%) had been prescribed 140 antimicrobials (ESAC mean, 30% of patients; range, 19%–59%).3 Cephazolin was the most commonly prescribed antimicrobial (32/140; 23%), and 115 antimicrobials (82%) were administered intravenously. Intra-abdominal sepsis (31/140; 22%) and cellulitis or wound infection (21/140; 15%) were the most common anatomical sites requiring treatment. Of the 140 prescriptions, 48 (34%) were for community-acquired infections, 29 (21%) were for postoperative infections, and 35 (25%) were for surgical prophylaxis. Of the 35 prescriptions for surgical prophylaxis, 14 (40%) were administered for more than 1 day (ESAC, 57%).3 The reason for initiation of the antimicrobial was documented in the patient’s medical notes for 95 of 140 prescriptions (68%) (ESAC, 64%).3 Use of the ESAC methodology allowed us to benchmark our results against published international reports. However, it gave no information on the appropriateness of the prescriptions or whether they adhered to antimicrobial guidelines. The ESAC point prevalence tool is easily applicable to the Australian health care system and provides useful information on antimicrobial consumption and quality indicators at an institutional level. Addition of questions regarding appropriateness of prescribing could be incorporated to give further relevant information.4 Use of the same methodology in other Australian centres would enable comparison across institutions and, potentially, national and international collaboration.

Jennifer A Kieran · Rosaleen G O’Doherty · Bernard J Hudson

EpiphanyRex and John, both Australian neurosurgeons, were attending a conference in Oxford. That high summer day on the deck of the Head of the River relaxed by his ploughman’s lunch and ale Rex looked into the cloudless sky saw several far-off small black dots: maybe Canada geese, if not maybe, he smiled, a replay of the Battle of Britain. Hard to be certain ... But the dots stood still. Rex set down his glass stunned by rapid-fire thoughts of probabilities. “I think”, he said quietly to John “I have secondaries in my brain”. Ten years ago Rex had a melanoma on his back. There were questions then. “One never knows”, his surgeon said. “Are you sure they’re not floaters?” Rex closed each eye in turn. “Positive.” he said. “Migraine aura?” “Never before.” Rex knew the drill. For a decade he had savoured each day freed it from bureaucracy and strife. Fancy him, a wise man from the east receiving this epiphany in Oxford — Oxford, home of Tolkien and other master weavers of fantasy — this clear, prosaic sentence! How ironic that its execution would be inside his head! “I think that we should finish lunch”, Rex said slowly. John touched his arm. Both turned again to their cheese, meat and bread, emptied their glasses and left with the calm they assumed as they emerged from theatre weary with effort, seeking relatives in the waiting room desperate for news of a miracle to confess that it was not within their powers to remove all their loved one’s tumour though they’d tried for hours.

Stephen R Leeder MD, PhD, FRACP

CorrectionsIncorrect criterion for timely reperfusion in figure legend: In “Reperfusion therapy in the acute management of ST-segment-elevation myocardial infarction in Australia: findings from the ACACIA Registry” in the 1 November 2010 issue of the Journal (Med J Aust 2010; 193: 496-501), there was an error in Box 2 (page 498) in the legend of the second (“Door-to-balloon time”) graph. The criterion for timely reperfusion given as 30 min should have been 90 min. The html and pdf versions of this article were corrected on 30 Nov 2010.

Luan T Huynh · Jamie M Rankin · Phil Tideman · David B Brieger · Matthew Erickson · Andrew J Markwick · Carolyn Astley · David J Kelaher · Derek P B Chew

Incorrect author details: Incorrect author details: In “A multilevel analysis of three randomised controlled trials of the Australian Medical Sheepskin in the prevention of sacral pressure ulcers” in the 6/20 December 2010 issue of the Journal (Med J Aust 2010; 193: 638-641), Damien Jolley’s qualifications and affiliation were incorrectly given. His qualifications should be shown as MSc(Epidemiol), MSc, AStat and his affiliation as the School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC. The html and pdf versions of this article were corrected on 10 January, 2011.

Patriek J Mistiaen · Damien J Jolley · Sunita McGowan · Mark B Hickey · Peter Spreeuwenberg · Anneke L Francke

CorrectionIncorrect statement of risk: In “Factors associated with psychiatric morbidity and hazardous alcohol use in Australian doctors” in the 2 August 2010 issue of the Journal (Med J Aust 2010; 193: 161-166), there was an error in the first paragraph on page 163. The sentence regarding solo practitioners should read: “Solo practitioners had a lower risk of psychiatric morbidity than non-solo practitioners (OR, 0.78 [95% CI, 0.61–0.99]).” The html and pdf versions of this article were corrected on 10 November 2010.

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

Sex and the older man In the not-so-distant past, sex was regarded as not only inappropriate but also immoral once we were aged beyond our reproductive years. Australian researchers have now reported that a substantial proportion of older men may have unmet sexual needs. Hyde and colleagues studied the prevalence of sexual activity and associated factors in more than 3274 community-dwelling men from Perth, Western Australia, who were aged 75 to 95 years old. One in two of these elderly men considered sex to be important but only one in three reported being sexually active. The researchers said that addressing risk factors, such as depression, diabetes and medication use may improve sexual activity but will not benefit partnerless men. Further multidisciplinary research was needed to explore how older men can achieve sexual fulfilment when they are widowed, or when their partners are incapable of or uninterested in sex. Ann Intern Med 2010; 153: 693-702 Mythbusters According to Danish urban folklore, it is possible to become drunk by submerging one’s feet in alcoholic beverages. However, according to three Danish doctors, who tested the validity of this myth, it doesn’t hold water. They submerged their clean, skin disease-free feet in a washing-up bowl containing the contents of three 700 mL bottles of vodka. Their plasma ethanol levels remained below the detection limit of 2.2 mmol/L (10 mg/100 mL) throughout the 3-hour experiment. With this myth busted, what’s next? Did you know that claims exist of urine becoming red when feet are submerged in beetroot juice ... ? BMJ 2010; 341: c6812 Phantom vibrations It is nearly 500 years since French surgeon Ambroise Paré described phantom limb syndrome in soldiers who felt pain in their amputated limbs. Now, US researchers have reported phantom vibration syndrome in doctors. They surveyed about 170 staff by questionnaire, finding that two-thirds had experienced “phantom vibrations” — the sensory hallucination sometimes experienced by people carrying pagers or cell phones when the device is not vibrating. Phantom vibrations were equally common with pagers and cell phones. Most experienced the phantom vibrations either weekly or monthly but some experienced them on a daily basis. Some even felt the device vibrating when they were not in contact with it. BMJ 2010; 341: c6914 Only the lonely “Doctor”, she asks, “can you give me a cure for loneliness?” The Lancet’s Wakley Prize for the best essay on a clinical topic of public health importance goes to ... Dr Ishani Kar-Purkayastha. In her final year of specialist training as an Academic Clinical Review Fellow in Public Health in the UK, Kar-Purkayastha wrote about an elderly widow who did not want to leave hospital in the days before Christmas, and of her own feelings about this patient. “... she’s not clinically depressed. It’s just that she has been left behind by a world that no longer revolves around her, not even the littlest bit of it.” Lancet Online, 16 Dec 2010 About redheads Traditionally, surgeons and anaesthetists have regarded red-haired patients with some trepidation as, apparently, redheads have a reputation for excessive bleeding, a reduced pain threshold and an anecdotal increased tendency to develop hernias. UK researchers reviewed the literature to seek out evidence about the clinical effects of having red hair, finding that people with red hair may have an increased requirement for anaesthesia but that they had no greater operative risk than the rest of the population. They said the genetic basis of red hair was identified in 1997 in association with the melanocortin-1 receptor (MC1R) located on chromosome 16. Two copies of a recessive gene on chromosome 16 changes the MC1R protein leading to the red hair phenotype. Overall, 80% of redheads have the MC1R gene variant. BMJ 2010; 341: c6931

Ann T Gregory