Volume 194 Issue 5

The MJA bids a fond farewell to its Editor of 16 years When Martin B Van Der Weyden, 11th Editor of the Medical Journal of Australia, retired a few weeks ago, it was the end of a remarkable chapter in the Journal’s history. Sixteen years earlier, in his first message as Editor to the Journal’s readership,1 Martin had promised to oversee the MJA’s return to relevance for the medical profession and the abolition of its sometime reputation as the “Blue Comic”. He achieved this, and more, taking the Journal to a new level, not just for readers but among its international peers. Martin rose from humble beginnings, as the third of seven children of postwar Dutch immigrants, to become a prodigious researcher and a leader in his specialty of haematology, before taking on the editorship of the Journal, one of the most influential positions in Australian medicine. As Editor, Martin raised the profile of the MJA locally and internationally to make it one of the key drivers of change in Australian medical practice. He significantly improved the academic calibre of the MJA’s content; broadened its reach, relevance and readership; and presided over the biggest change in the Journal’s 97-year history with the embrace of electronic publishing. Martin’s intelligence and diligence took him from a migrant camp at Bathurst when he was 8 years old and a “good Catholic school” in Wollongong, where his family settled (near the steelworks, the employment mecca for migrant workers), to win a bursary at age 12 to attend Holy Cross College in Ryde as a boarder, and then a Commonwealth scholarship to study medicine at the University of Sydney. He graduated MB BS in 1966 and spent his early postgraduate years at Sydney Hospital, supported as a medical registrar by a Penfold family scholarship. Martin trained in clinical medicine and pathology, obtaining Membership of the Royal Australasian College of Physicians (RACP) in 1969 (and Fellowship of the RACP in 1974), and moved to the Alfred Hospital and Monash University in Melbourne to take up a position as Research Fellow in Clinical Haematology with the late Professor Barry Firkin (a position made possible by a scholarship from the Alfred Hospital Research Fund). In 1972, Martin was awarded a Merck Sharp & Dohme International Fellowship in Clinical Pharmacology to work with Professor Bill Kelley in the Division of Rheumatic and Genetic Diseases at the Duke University Medical Center in Durham, North Carolina. While at Duke, a further scholarship from the United States National Science Foundation allowed him to contribute to major work in the delineation of the effect of adenosine deaminase deficiency in patients with severe combined immunodeficiency. He quickly gained a reputation at Duke for his prodigious output and quirkiness. Many remember him as the “mad” Aussie who wandered into a ward one snowy morning, totally oblivious to the fact that he was on fire! Lost in thought, he had plunged his briar pipe into his overcoat pocket while it was still smouldering. Despite offers of positions at the US National Institutes of Health and at US medical schools, Martin returned to Australia in 1975 on yet another scholarship, as a National Health and Medical Research Fellow at the Alfred Hospital and Monash University. Having been supported by scholarships for most of his life, Martin finally got his first full-time paid job in 1977, when he became a Senior Lecturer in Medicine at Monash University. He graduated MD from Monash in 1978, and became a Fellow of the Royal College of Pathologists of Australasia in 1980. His clinical and research interests encompassed aspects of haematology, immunology, marrow transplantation, and haematological oncology. In 1981, Martin was awarded the RACP’s prestigious Eric Susman Prize for research into purine and pyrimidine enzyme activities in haematological malignancies. He was appointed Professor of Haematology at Monash University in 1985 and Director of the Department of Haematology at the Alfred Hospital. From 1985 to 1987, Martin served as President of the Haematology Society of Australia and New Zealand, presiding over the International Convention of Haematologists held at the Sydney Opera House. In 1989, he became Chairman of the Division of Investigative Medicine, and then Chief of Investigative Medicine Services to the Alfred group of hospitals in 1993. During this time he squeezed in a voluntary position as Haematology Subeditor for the Australian and New Zealand Journal of Medicine and a short, intensive stint at Harvard Business School in 1994. Working as an administrator during the time of the frenetic dismantling of the Victorian hospital system, Martin’s priorities were always the preservation of first-rate patient care and the provision of quality academic and clinical medical education. In time, the strictures of economic rationalism on medical services were to prove demoralising for the profession as a whole. When the frustrations of seemingly soulless restructuring became overbearing, Martin looked for a new challenge, and found it in the Journal. Though sad to leave Melbourne, his children were overjoyed that he no longer paced the front garden in the dead of night, shrouded in a smoky haze from his much loved Dutch cigarillos. Thus, in 1995, Martin, his wife Merle, and their three children moved back to Sydney. Martin’s medical, scientific, research and administration experience, and his familiarity with the research communities in Melbourne and Sydney, placed him well for taking on the mantle of Editor of Australia’s leading peer-reviewed general medical journal. He quickly stamped his mark on the Journal and earned the respect of the medical community, by following the principles of good communication: clarity, brevity, simplicity and humanity. Martin boosted the quality of the Journal’s articles by increasing the number of editorials and encouraging authors to confront controversial topics; introducing a higher academic standard for research articles in particular (and thus significantly increasing the manuscript rejection rate); and expanding the reach of the Journal to cover health policy and reform, workforce issues, medical politics and medical education. Because many Australian researchers choose to submit their best work to higher profile US or British journals, the MJA suffers from “small country syndrome” in terms of international rankings, but Martin made significant inroads to address this. In 1993, before Martin took over, the MJA languished at 30th (out of about 100) in the ranking of general medical journals; in 2008, it reached an all-time high of 18th, with an impact factor of 3.32. Martin is a clear thinker: decisive, with strong opinions and astute judgement. He is a diligent observer of all things medical, is politically savvy, and is a forthright speaker and writer who abhors “bullshit” and has never toadied to political correctness. At times he would play the classic Editor, making a frenzied string of phone calls to his impressive collection of friends and experts to get to the bottom of a story or current event. But he has never published anything that did not meet his own rigorous academic standards, understanding the value of the MJA’s reputation as an unbiased, accurate source of information. He has a wicked sense of humour and an enduring enthusiasm to challenge people to think outside the square. The same qualities that made Martin an excellent Editor also make him a sought-after speaker and a highly valued guest at meetings and conferences, where he can be relied on to stir up debate, ask the difficult questions and offer insightful and constructive criticism. A year into the job as Editor, Martin also took on the demanding role of Chief Executive Officer (CEO) of AMPCo (the Australasian Medical Publishing Company, which publishes the Journal and the Medical Directory of Australia and manages Australia’s largest commercial medical database). He continued in the dual positions of Editor and CEO for 14 years. He is also a member of the International Committee of Medical Journal Editors, which sets the standards for biomedical publishing, and has recently served as a Director of the Executive Board of the World Association of Medical Editors. Under Martin’s leadership, the Journal was an early adopter of electronic publishing, including an innovative trial of interactive, electronic peer review. By 2001, all Journal content was freely available on the web, remaining free until 2009 when, against his better judgement, some articles became accessible to subscribers only. Technical capacity was always a limiting factor but, last year, the Journal finally launched MJA InSight, an online newsletter for doctors. His own background and self-confessed political left-leaning tendencies made Martin open to some of the more marginalised elements of Australian society, providing those working in prison and refugee health, drugs and alcohol, sexual health, mental health and Indigenous health with a much needed mainstream outlet for their research and commentary (but only if they met the Journal’s high academic standards). Two annual theme issues, one on Indigenous health and another on general practice, were established, and remain of great importance to the target contributors and readers. As Martin matured into the job, he became the heart, soul and, indeed, the face of the Journal. His fortnightly column, “From the Editor’s desk”, was frequently on the MJA’s top 10 website hits list from its inception in 2004 — a tribute to his reputation as an astute observer with a long-range view of Australian health care. Dr Martin Van Der Weyden with portrait by (Dr) Ann Theresa Gregory. Those of us who worked with Martin understand how he was able to achieve so much. Even in his spare time, his mind was never far from the Journal. He would often turn up on a Monday morning, brandishing a book he had just read on medical history or health policy, or an editorial he had written over the weekend. He had a knack for appearing erratic, distracted or even perverse, and then coming up with the exact solution required for the problem at hand. On an initial meeting, he liked to shock with a blunt statement or seeming non sequitur, before revealing his incisive intellect and, ultimately, a humane and surprisingly soft inner core. When congratulated for his work at the Journal, he maintained that his genius had been in assembling a competent team: there was method in his madness — to get the best out of people. In his rare spare time, Martin listens to Bach, Beethoven and Haydn, and is a voracious reader of crime fiction and books of medical miscellany with a philosophical bias. His wife Merle remains a huge source of inspiration and moderation, as does his Catholic faith and his involvement in his local parish. When asked how he would like his tenure at the Journal to be remembered, Martin is typically offbeat. His success may be measured in many ways: the rise of the Journal’s impact factor and standing in the international ranking of journals; an increase in high-quality submissions; a robust presence in the media and in health policy machinations; the respect of medicopolitical, Indigenous and other leaders; and the unswerving loyalty of those who worked for him. Yet, 16 years after he penned that first editorial, he was most proud of one outstanding achievement. Nobody, anywhere, was referring to the MJA as the Blue Comic.

Bronwyn Gaut MB BS, DCH, DA · Ruth M Armstrong BMed · Ann T Gregory MB BS, GradDipPopHealth · Peter C Arnold BSc, MB BCh, BA

In the absence of conclusive evidence, the winner is the mask that has the confidence of clinicians Australian infection control strategies for pandemic influenza are influenced by world authorities — the Centers for Disease Control and Prevention (CDC) and the World Health Organization. WHO guidelines1 take into account the lack of health resources in many communities, and focus on affordability as well as reductions in infection risk. CDC guidelines2 presuppose a well resourced health sector and are aimed at achieving zero risk. The different approaches of the two organisations are manifest in their conflicting recommendations for the type of face mask to use in routine care of patients with influenza: CDC recommends the N95 respirator (equivalent to the P2 mask used in Australia), while WHO recommends the cheaper surgical mask. By giving the world free access to their guidelines, the organisations have saved countries the cost of guideline development. Yet, the gain in risk reduction with the adoption of the CDC’s recommendation is unknown and may not be cost-effective. Conversely, those who opt for the WHO guideline might not appreciate that health care workers (HCWs) in well resourced settings are unlikely to accept a strategy if they perceive it to be significantly riskier than the more costly alternative. The important question is whether either guideline is based on the best evidence and relates the potential risk reduction to the cost involved. A potted history of CDC’s change in preference from surgical to P2 masks may help those seeking well informed policies about the use of masks for routine patient care. The history of the use of masks by HCWs has been classified into three eras: development and testing (1905–1920); “awareness of the importance of masks” (1920–1940); and the “unimportance of masks secondary to antibiotics” (1940 and beyond).3 We nominate a fourth era, “over-importance of masks” (1990s to the present), which was set in motion by changes to CDC guidelines.4 The CDC’s decision to recommend P2 masks instead of surgical masks for routine care of patients with tuberculosis (TB) was prompted by an unusual outbreak of multidrug-resistant TB in HCWs.5 The CDC made the change despite acknowledging that (1) P2 masks were manufactured to filter industrial, non-pathogenic aerosols and tested to filter out 95% of 0.3 μm sodium chloride particles, not airborne or droplet-sized bioaerosols; (2) some surgical masks were also capable of filtering out 95% of 0.3 μm sodium chloride particles; and (3) the protective efficiency of P2 masks against specific pathogens was unknown. The revised recommendation instigated a widespread non-evidential assumption of a link between wearing masks and preventing aerosolised transmission of pathogens based on particle size: that is, it was assumed that P2 masks prevent disease transmission by airborne particles (≤ 5 μm in size), and surgical masks prevent transmission by droplet particles (> 5 μm in size).4 With neither laboratory nor in vivo efficiency data to compare mask types, why were P2 masks advocated to protect HCWs against TB? The answer lies in the principles of evidence-based medicine. Despite its deceptive moniker, evidence-based medicine values not only research evidence, but costs and the “needs and values” of stakeholders, including clinicians. CDC leaders moved from surgical masks to P2 masks to solve the “problem of merging scientific and theoretical data into a sound infection control approach for the protection of HCWs against tuberculosis”.6 The problem was not resolved on evidential grounds because the evidence was simply not there. Rather, the solution prioritised the needs and values of clinicians concerned that the surgical mask permits transmission of multidrug-resistant TB because it allows a gap between the face and mask. As a consequence, this revision bred a legacy that associates mask type with particle size rather than with HCWs’ needs and values.6 Confronted with a similar debate about influenza transmission, the Australian Department of Health and Ageing commissioned us to review the protectiveness of masks,7 antiviral prophylaxis and vaccination, and to develop evidence-based infection control algorithms8 for the protection of HCWs during a pandemic. Development of the algorithms was informed by the following considerations. Proper use of a mask is more protective than not using a mask, but research findings show that neither the P2 nor surgical mask type is statistically superior. This concurs with findings from a review9 as well as results of a randomised control trial showing non-inferiority of surgical masks.10 The effectiveness of antiviral prophylaxis against future strains cannot be tested. However, antiviral prophylaxis is effective against seasonal influenza when administered in the first 48 hours of illness and if the drug-resistance of the virus is low.11 Given the efficacy of seasonal vaccines, a novel pandemic vaccine may provide a similar level of protection. Implementing the recommendation that HCWs wear P2 masks for routine patient care in a pandemic has several difficulties, including cost and fit-testing. The need for fit-testing was added to both CDC and WHO infection control guidelines1,2 after occupational-acquisition of the severe acute respiratory syndrome (SARS) by HCWs. However, there is no evidence that fit-testing affords higher levels of protection than a comfortably fitting mask. During our study of stakeholders’ needs and values, local clinicians unanimously disputed the recommendation for the use of surgical masks for routine care despite the recommendation being only one part of our multi-tool infection control strategy, which included antiviral prophylaxis, vaccination and a face shield for eye protection.8 The clinicians told us that they were taught, when training in the management of SARS, that P2 masks give superior protection. Nearly a century ago, the recommendation for use of the gauze mask came with a warning that it should not provide the wearer with an “unwarranted feeling of security”, but should be considered as one part of an infection control process.12 Research evidence7 suggests that a surgical mask plus face shield, rather than a P2 mask, is sufficient protection against pandemic influenza, but will this measure serve as sufficient protection for a health care system that needs healthy HCWs to manage a pandemic-sized caseload? Conventional evidence-based principles give equal importance to research evidence, economic cost, and needs and values of stakeholders. When research is inconclusive, principles should be prioritised. WHO guidelines1 prioritise research evidence within the limitations of resources of different socioeconomic settings; CDC guidelines2 prioritise the needs and values of clinicians within the limitations of research evidence. The new infection control algorithms8 compensate for weak research evidence — they remove the “over-importance” given to masks by prioritising needs and values of HCWs, while presenting masks as just one component of an infection control strategy. Without seminal research evidence of influenza being transmitted exclusively by airborne transmission, and in the absence of studies testing for superior protection of P2 masks, it would be prudent for health care executives to view providing P2 masks to HCWs, not as an additional cost, but as an additional investment in the continuity of health service provision — and in the full knowledge that, on today’s evidence, P2 masks provide a level of protection equivalent to that of surgical masks.

Mary-Louise McLaws DipTropPubHlth, MPH, PhD · Jan Gralton BSc(Hons)

New ablative techniques can eradicate dysplastic Barrett oesophagus more effectively, but require longer-term follow-up to strengthen their evidence base Barrett oesophagus is a precursor lesion that can progress to oesophageal adenocarcinoma. Barrett oesophagus affects about 1% of the population and is believed to be due to chronic gastro-oesophageal reflux disease.1 Patients with Barrett oesophagus have a 30–40-fold relative risk of developing oesophageal adenocarcinoma, which usually occurs via progression through low-grade dysplasia (LGD) to high-grade dysplasia (HGD).2 Management of patients with non-dysplastic Barrett oesophagus comprises surveillance endoscopy and biopsies every 2–3 years, along with acid suppression. The traditional approach for treating LGD has been intensified endoscopic surveillance. A new trend has evolved in the management of patients with HGD and intramucosal cancer. Oesophagectomy has been standard treatment for these patients because of studies showing that cancer is discovered in about 40% of oesophagectomy specimens after a preoperative diagnosis of HGD.3 Oesophagectomy in high-volume centres now carries a mortality rate of around 1%; however, morbidity rates can be up to 30%.4 Recently, improved capacity to identify early cancers with modern endoscopes and advances in endoscopic resection and ablation techniques have resulted in excellent outcomes for individuals with HGD and intramucosal cancer treated with endoscopy alone. Staging dysplastic Barrett oesophagus requires meticulous endoscopic assessment, using the newest generation of high-definition endoscopes to identify nodules and subtle mucosal abnormalities that can harbour cancer. Biopsy samples are taken from visible abnormalities, and four-quadrant biopsy samples are taken from every 1 cm of Barrett oesophagus. New endoscopic technologies, such as narrow band imaging and confocal endomicroscopy, appear to aid identification of dysplastic areas and may reduce the need for random biopsies. Endoscopic mucosal resection is a technique to remove 10–15 mm areas of mucosa, to the depth of the submucosa. Larger areas, or the entire Barrett oesophagus up to 3–5 cm in length, can be completely removed by this method with several contiguous resections. Endoscopic mucosal resection of focal mucosal abnormalities is essential to identify and remove early cancers and to determine the depth of invasion. If dysplasia or cancer is confined to the mucosal layer, the chance of spread to perioesophageal lymph nodes is less than 5%. On the other hand, if cancer extends into the submucosal layer, the chance of lymph node involvement is about 30% and oesophagectomy is therefore indicated.5,6 In expert hands, focal endoscopic mucosal resection achieved complete removal of HGD and intramucosal cancer in 96% of 231 patients.7 However, metachronous lesions occurred in 22% of patients at mean follow-up of 61 months; incomplete removal of the residual Barrett oesophagus was the main risk factor for recurrence. This highlights the importance of removal of the entire Barrett segment.7 To address this issue, a few European centres have advocated stepwise complete resection of short segments of Barrett oesophagus. In a recent multicentre study, complete eradication of all neoplasia was achieved in 98% of patients (165/169) after median follow-up of 32 months.8 Endoscopic mucosal resection has a 1% risk of serious complications, such as major bleeding or perforation. Symptomatic stenosis requiring dilatation develops in up to 50% of patients following stepwise complete resection.9 Endoscopic ablation therapies rely on the fact that squamous mucosa will replace the ablated Barrett oesophagus in a non-acid environment. Older endoscopic therapies include argon plasma coagulation, photodynamic therapy and multipolar electrocoagulation. These techniques are limited by variable mucosal ablation and “buried Barrett” under squamous mucosa. The HALO radiofrequency ablation system (Barrx Medical, Sunnyvale, Calif, USA) consists of two devices for delivering radiofrequency energy to the Barrett oesophagus. The HALO360 device is a balloon that is inflated in the oesophagus to deliver a 3 cm circumferential burn, which can be repeated to treat long segments. The HALO90 is a flat device attached to the tip of the endoscope to ablate smaller areas of Barrett oesophagus. Energy delivery is automated, leading to a more predictable and uniform ablation, enhancing safety and efficacy compared with other ablative therapies. A randomised controlled trial of HALO radiofrequency ablation compared with a sham procedure has shown much higher rates of complete remission after 12 months in individuals with HGD (81%) and LGD (91%) compared with the control groups.10 The 2–3-year follow-up of patients who remained in the study has confirmed durability of response, with 95% of patients who achieved complete remission of Barrett oesophagus at 12 months remaining so at 2 years. Furthermore, 85% of those who failed to eradicate Barrett oesophagus at 12 months achieved complete eradication at 2 years with a mean of 1.2 further focal ablation sessions. Longer-term follow-up beyond 5 years is required to address maintenance of remission and reduction in cancer progression.10 The principle of combination therapy is to remove visible mucosal abnormalities that may harbour invasive cancer with endoscopic mucosal resection, then to ablate the remaining Barrett oesophagus with HALO radiofrequency ablation. Using this approach, 22 of 23 patients with early cancer or HGD achieved complete remission of Barrett oesophagus, with no neoplasia recurrence after 22 months.11 Endoscopic therapy with HALO radiofrequency ablation and/or endoscopic mucosal resection has now emerged as a credible alternative to surgical oesophagectomy and should be considered as a valid alternative to surgery for patients with HGD and intramucosal cancer. Our institution favours the combination endoscopic approach. The optimal management of patients with dysplastic Barrett oesophagus requires meticulous assessment and an individualised approach. Patients who undergo endoscopic therapy will need to be informed, motivated and compliant, as careful endoscopic surveillance after eradication is required to ensure that any recurrence is detected and treated early. Therefore, endoscopic therapy is best performed at tertiary centres with expertise in this evolving area.

Chatura S Jayasekera MB BS(Hons), FRACP · Finlay A Macrae MD, FRACP, FRCP · Paul V Desmond MB BS, FRACP · Andrew C F Taylor MB BS, FRACP, MD

Early detection and prevention of kidney disease reduces the risk of cardiovascular disease. This official World Kidney Day 2011 editorial is being published concurrently in many medical journals around the world. Protect your kidneys, save your heart 10 March 2011 will mark the celebration of the sixth World Kidney Day, an annual event jointly sponsored by the International Society of Nephrology and the International Federation of Kidney Foundations. Since its inception in 2006, World Kidney Day has grown dramatically to become the most widely celebrated event associated with kidney disease in the world and the most successful effort to raise awareness among both the general public and government health officials about the dangers of kidney disease, especially chronic kidney disease. In 2011, World Kidney Day will call attention to the large, and often unappreciated, role played by kidney dysfunction in increasing premature cardiovascular disease, the most common cause of morbidity and mortality worldwide. Can a focus on early detection and prevention of kidney disease really improve long-term cardiovascular health? We hope to convey the message that increased attention to the kidneys can indeed improve long-term health outcomes by reducing both kidney and cardiovascular disease. This should therefore be a central component of any global health strategy intended to reduce the enormous and growing burden of chronic non-communicable diseases. Cardiovascular disease (CVD) is the most common of the chronic non-communicable diseases that affect global mortality. About 30% of all deaths worldwide and 10% of all healthy life lost to disease are accounted for by CVD alone.1 Although there has been some decline in mortality from CVD in developed countries, no such decline has been reported in developing countries, ethnic and socially disadvantaged minority populations, or in people with accompanying chronic kidney disease (CKD).2,3 The presence of CKD significantly increases the risk of a cardiovascular event in patients with diabetes or hypertension.4,5 However, less well appreciated is that CKD alone is a strong risk factor for CVD, independent of diabetes, hypertension or any other conventional CVD risk factor.6,7 This is especially true when an increase in proteinuria, a major target of any CKD screening program, is present.6-9 The 20–30-fold increase in CVD in patients with end-stage renal disease (ESRD) has long been recognised. However, the association between lesser degrees of renal functional impairment and increased risk of CVD was definitively demonstrated only in 2004, when a community-based study of over 1000 individuals reported an independent and graded association between glomerular filtration rate (GFR) and risk of death, cardiovascular events and hospitalisations.6 Is this dramatic increase in CVD risk associated with CKD really due to CKD or does it just reflect the coexistent diabetes or hypertension present in a majority of these patients? The independent effect of CKD alone has now been well documented in many studies.7 The risk of cardiac death is increased by 46% in people with a GFR of 30–60 mL/min (stage 3 CKD) independent of traditional cardiovascular risk factors including diabetes and hypertension.10 The increased risk of cardiovascular events and mortality in people aged over 55 years with CKD alone is equivalent to, or even higher than, that seen in patients with diabetes or previous myocardial infarctions.11 Both general6,12 and high-risk populations13,14 exhibit an increased risk of CVD with CKD. This increased risk of CVD is not confined to the elderly — in volunteers with an average age of 45 years, the risk of myocardial infarction, stroke and all-cause mortality doubled in those with CKD.14 Proteinuria and cardiovascular riskIn considering the value of recommending screening for CKD along with screening for conventional CVD risk factors in selected individuals, data showing that the risk of CVD is better correlated with proteinuria (albuminuria) than with GFR alone are particularly relevant because proteinuria is virtually always a marker of kidney disease and is not a conventional CVD risk factor.6,8,9,15 Proteinuria has been shown to be a predictor of later CVD. The Prevention of Renal and Vascular Endstage Disease study showed a direct linear relationship between albuminuria and risk of cardiovascular death in the general population, even at levels of albumin excretion generally considered to be within the “normal” range (15–29 mg/day). The risk was increased more than sixfold when albumin excretion exceeded 300 mg/day.8 Recent data from the US National Health and Nutrition Examination Survey database as well as from Japan document an independent effect of albuminuria on risk of both CVD and all-cause mortality at any GFR.15,16 In patients with congestive heart failure but without diabetes, hypertension or reduced GFR, increased urinary albumin predicts both cardiovascular and all-cause mortality.17 In patients with coronary disease or previous myocardial infarctions, proteinuria confers a greater risk of mortality than reduced GFR, although both adversely influence outcomes.18 Not only the likelihood but also the time to development of a cardiovascular event is accelerated significantly by the presence of proteinuria at any GFR.19 About 78% of non-diabetic subjects with normal serum creatinine levels undergoing percutaneous coronary interventions have demonstrable CKD when screened more stringently for renal function (estimated GFR, urinary protein).20 As well as being a likely factor in accelerating development of coronary disease in these patients, the presence of CKD has been associated with an increase in other risks, including haemorrhagic complications, contrast nephropathy, re-stenosis, and death.10 Thus, multiple studies now confirm that proteinuria is a graded risk factor for CVD independent of GFR, hypertension and diabetes, and that this risk extends down into ranges of albumin excretion generally considered “normal”.21,22 Moreover, this increased cardiovascular risk has been well demonstrated in several studies where only dipsticks were used to screen for increased protein excretion.6,18,23 Although there has been concern that CKD diagnosed by reduced GFR alone identifies predominantly older adults at increased risk because of age alone,24 the connection between proteinuria as an independent risk factor for cardiovascular mortality has been confirmed by meta-analysis of 22 separate, general population, cohort studies and in both older (> 65 years of age) and younger (< 65 years of age) people of several nationalities and racial groups.23 Can treatment of CKD reduce CVD?Finally, and most importantly from a clinical perspective, there are provocative data to suggest that renal-targeted interventions designed to reduce proteinuria and slow progression of CKD can reduce CVD risk as well. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers are of documented benefit in slowing progression of established diabetic and non-diabetic CKD.25-29 The incidence of CVD in patients with CKD is significantly higher than in patients without CKD, with more rapid reduction of GFR independent of other risk factors, suggesting that interventions that slow progression of CKD may also reduce CVD.19 A 44% reduction in cardiovascular mortality over 4 years has been reported in patients from a general population who were screened and showed no cardiovascular risk factors except increased albumin in the urine, for which they were treated with renal-targeted ACE-inhibitor therapy.30 This effect was seen primarily in people with albumin excretion rates > 50 mg/day in a pilot study, and the intervention was shown to be cost-effective in that population.31 Cardiovascular endpoints were significantly reduced in direct proportion to the reduction of albuminuria with ACE-inhibitor therapy, and albuminuria proved to be the only predictor of cardiovascular outcome.32 Other studies have also demonstrated that changes in proteinuria in people with diabetes better predict cardiovascular outcomes than changes in blood pressure achieved with ACE-inhibitor therapy.33 The potential benefit of renal-targeted therapies has recently been highlighted by observations that doses of renin-angiotensin system blockers that are higher than those required for blood pressure control alone can further reduce proteinuria independent of their effects on blood pressure or GFR.34 Restricting salt intake and adding diuretics, both very inexpensive interventions, have also been found to further enhance the proteinuria-reducing effect of renin-angiotensin system blockade.35 Data are not yet available to establish whether screening for CKD and subsequent interventions will reduce cardiovascular mortality and be cost-effective in people younger than 55 years of age.36 However, it is now known that albuminuria is a better predictor of renal and cardiovascular events than blood pressure alone, that reducing proteinuria confers more renal and cardiovascular protection than lowering blood pressure alone, and that identification of CKD can improve cardiovascular outcomes. As celebrations of the sixth World Kidney Day approach, it is worth noting that before the past decade, kidney disease was seen by most government and public health authorities as largely confined to patients with ESRD — thankfully, a rare condition because the enormous cost of renal replacement therapy disproportionately consumes scarce health care resources and is well beyond the means of countries inhabited by over 80% of the world’s population.37,38 Much has changed. We now appreciate that kidney disease is not rare — some 10% of the population has evidence of renal dysfunction. And we know these individuals are not of concern just because a few will progress to ESRD, but more because they carry a greatly enhanced risk of premature death from CVD, the single largest and most expensive health care threat we confront at a global level.1 Just as progress is being made in treating most of the traditional cardiovascular risk factors, CKD has emerged as yet another one that independently causes substantial vascular toxicity. Fortunately, there is good news as well. Biomarkers of CKD (proteinuria, estimated GFR) are easy and relatively inexpensive to detect or estimate, and one of these, proteinuria, emerges early in the evolution of generalised vascular disease. Thus, kidney-targeted detection and prevention programs seem to offer a valuable opportunity to institute early preventive measures that go beyond traditional cardioprotective approaches. There is now compelling evidence that including selective screening for CKD in global health programs designed primarily to reduce CVD will significantly improve the outcomes of not only renal disease but especially the non-communicable diseases like diabetes and CVD that dominate future health care strategies. Roadmaps for accomplishing this have already been presented for both developed39,40 and emerging1,41 countries. However, effective implementation of such strategies will only come when both the general public and the renal community work together to convince health authorities that it is in the public interest to do this. It is our sincere hope that worldwide celebration of World Kidney Day 2011 will provide an opportunity to reinforce the message that kidney disease is indeed common, harmful and treatable, and that protecting your kidneys is an important health strategy that may save your heart.

for the Joint International Society of Nephrology and International Federation of Kidney Foundations World Kidney Day 2011 Steering Committee*

Objectives: To establish how frequently supervision was explicitly identified as a factor in coroner-certified unintentional drowning deaths of children in Australia, and to determine the percentage of cases where failure of supervision may have been a contributing factor; also, to identify the proportion of cases with coroners’ recommendations relating to supervision and unintentional child drownings.Design and setting: Retrospective case-series analysis of unintentional drowning deaths of children (aged 0–14 years) in Australia from 1 July 2000 to 30 June 2009, based on data from the National Coroners Information System (NCIS).Main outcome measures: Number of unintentional child drownings and the extent to which supervisory factors were formally reported by coroners as a contributing factor; proportion of cases with coroners’ findings that also had coroners’ recommendations.Results: 339 relevant child drownings were identified within the 9-year period. Supervision (or lack thereof) was identified as a contributing factor in 71.7%. However, specific detail about the nature and extent of supervision varied across these cases. The availability of text documents describing the findings (police reports, coroners’ findings, autopsy reports, toxicology reports), and the level of detail within these documents, also varied considerably across jurisdictions. Despite almost half (47.2%) of the closed cases having coroners’ findings attached, only 15% of these also included specific coroners’ recommendations.Conclusion: Lack of adequate supervision, or lack thereof, is a significant problem associated with fatal drownings of children in Australia. There is a need to improve the standard and consistency of information contained in text documents within the NCIS to provide more useful information for preventing child drowning deaths.

Lauren A Petrass BEd(PE)(Hons), GradDip(Outdoor · Jennifer D Blitvich MPE, DipEd, PhD · Caroline F Finch BSc, MSc, PhD

Objective: To examine age and sex differences in the leading causes of prevalent disability in young Australians.Design, setting and participants: We analysed data from the 2003 Australian Burden of Disease and Injury Study, which estimated the prevalent disability burden attributable to 170 diseases and injuries, for younger adolescents (10–14 years), older adolescents (15–19 years) and young adults (20–24 years).Main outcome measures: The broad categories of disease and injury that are the main contributors to prevalent disability and the 10 leading disease and injury causes of prevalent disability, according to sex and age group.Results: Total prevalent disability rates are lowest in younger adolescents and highest in young adults. Mental disorders are the largest “contributor” to disability in young Australians, and anxiety and depressive disorders are the leading single cause. In young males, autism and attention deficit hyperactivity disorder cause similar levels of disability as do anxiety and depression. In young females, eating disorders are the second leading cause of mental disorder disability. Alcohol use disorders and schizophrenia make important contributions to disability in young adult males. Asthma is the most prominent cause of physical disability in all three age groups.Conclusions: There are substantial changes in both the pattern and level of disability burden across the three age groups that we studied. The increase in total prevalent disability that occurs from early adolescence to young adulthood should focus attention on the delivery of accessible and youth friendly health care as well as the effectiveness of transitions from child health services to adult health services.

Rebecca R S Mathews MPH · Wayne D Hall PhD · Theo Vos PhD · George C Patton MD, FRANZCP · Louisa Degenhardt PhD

Objective: To explore factors associated with the frequency of multidisciplinary Team Care Arrangements (TCAs) and the impact of TCAs on patient-assessed quality of care in Australian general practice.Design and setting: Data were collected as part of a cluster randomised controlled trial conducted in 60 general practices in New South Wales, the Australian Capital Territory and Victoria between July 2006 and June 2008. Multilevel logistic regression analysis evaluated factors associated with the frequency of TCAs recorded in the 12 months after baseline, and multilevel multivariable analysis examined the association between TCAs and patient-assessed quality of chronic illness care, adjusted for patient and practice characteristics.Main outcome measures: Frequency of TCAs; Patient Assessment of Chronic Illness Care (PACIC) scores.Results: Of 1752 patients with clinical audit data available at 12-month follow-up, 398 (22.7%) had a TCA put in place since baseline. Women, patients with two or more chronic conditions, and patients from metropolitan areas had an increased probability of having a TCA. There was an association between TCAs and practices with solo general practitioners and those with greater levels of teamwork involving non-GP staff for the control group but not the intervention group. Patients who had a TCA self-assessed their quality of care (measured by PACIC scores) to be higher than those who did not.Conclusions: Findings were consistent with the purpose of TCAs — to provide multidisciplinary care for patients with longer-term complex conditions. Significant barriers to TCA use remain, especially in rural areas and for men, and these may be more challenging to overcome in larger practices.

Mark F Harris MD, FRACGP · Upali W Jayasinghe MSc(Maths), GradDipStats, PhD · Jane R Taggart MPH, BEd, DipEd(PE) · Bettina Christl DipPsych, MIPH · Judith G Proudfoot BEd(Hons), MA(Psych), PhD · Patrick A Crookes PhD, BSc(Nursing), RN(NSW) · Justin J Beilby MB BS, MD, FRACGP · Gawaine Powell Davies BA, MHA

Objective: To assess iodine status and the factors that influence iodine status among a cohort of pregnant women living in Gippsland.Design, participants and setting: Cross-sectional study of 86 pregnant women (at ≥ 28 weeks’ gestation) conducted in hospital antenatal care services and private obstetrician clinics across the Gippsland region of Victoria, Australia, from 13 January 2009 to 17 February 2010.Main outcome measures: Overall proportion of pregnant women with a urinary iodine concentration (UIC) > 150 μg/L; proportion of pregnant women with a UIC >150 μg/L after the mandatory iodine fortification of bread; use of supplements containing iodine; intake of foods known to be good sources of iodine; intake of bread.Results: The percentage of pregnant women with UIC >150 μg/L (indicative of iodine sufficiency) was 28%. There was no statistically significant difference in UICs before and since iodine fortification of bread. The median UIC before fortification was 96 μg/L (interquartile range [IQR], 45–153 μg/L) and since fortification was 95.5 μg/L (IQR, 60–156 μg/L). The dietary intake of iodine-rich food (including bread) and the use of appropriate supplements was insufficient to meet the increased iodine requirements during pregnancy.Conclusions: The UICs in this cohort of pregnant women are of concern, and seem unlikely to be improved by the national iodine fortification program. Pregnant women in Gippsland urgently need effective iodine education programs and encouragement to either consume iodine-rich foods or take appropriate supplements.

Ashequr Rahman MB BS, MSc, MPH · Gayle S Savige GradDipDiet, PhD · Nicholas J Deacon PhD · Janice E Chesters PhD · Barbara C Panther PhD

Foreign body oesophageal obstruction is a medical emergency. It may be accidental, particularly in children, or deliberate, for example with suicide attempts. We present two cases illustrating accidental oesophageal foreign body impaction occurring after consumption of food that had been heated in a plastic container in a microwave oven, then cut and eaten directly from the softened container. To date, we are not aware of any similar reports. In view of potential complications, care needs to be taken when food is eaten directly from plastic takeaway containers. (MJA 2011; 194: 245-246) Clinical recordsPatient 1In April 2009, a 79-year-old woman was admitted to hospital with acute dysphagia. She had a history of hypertension, osteoporosis and hypercholesterolaemia. In the past she had also had a transient ischaemic attack. Her medications were felodipine, alendronate, atorvastatin and clopidogrel. Before presentation she had been eating quiche that had been heated in a plastic (polypropylene) container. At subsequent gastroscopy, a solid wedge-shaped piece of plastic 4 cm in length was found to be lodged in her upper oesophagus (Box 1). This was removed endoscopically with the aid of a stand ard Roth Net retriever (US Endoscopy, Mentor, Ohio, USA) (a snare with a mesh basket) leaving a longitudinal mucosal tear (Box 2). There was no evidence of oesophageal perforation and she made a rapid and complete recovery, being discharged after 48 hours on pantoprazole in addition to her usual medications. At follow up after 2 weeks, she remained well and pantoprazole was ceased. Patient 2In October 2009, a previously well 45-year-old woman presented with sudden onset of odynophagia and dysphagia localised to the lower oesophagus after eating fish that had been stored and reheated in a clear polypropylene container. Initial ear, nose and throat assessment showed no evidence of fish bones in the tonsil area or oropharynx. A subsequent chest and neck computed tomography (CT) scan identified an opaque, linear foreign body within the subcarinal region of the oesophagus. There was no extraluminal gas or mediastinitis. An urgent gastroscopy was arranged and revealed a superficial linear ulcer caused by a 3 cm × 2 cm plastic foreign body lodged in the mid-oesophagus. Attempted retrieval with grasping forceps failed and a Roth Net retrieval device was used to remove the piece of plastic through an overtube. A minor oesophageal mucosal tear was seen afterwards. The patient recovered uneventfully and was discharged after 24 hours. DiscussionForeign body impaction is an important cause of sudden-onset dysphagia and is a medical emergency. Foreign bodies can be classified either as food or true foreign bodies. In a recent retrospective series of 988 patients, the five most common foreign bodies resulting in impaction were food boluses (17.1%), coins (15.6%), fish bones (12.6%), dental prostheses (8.6%) and chicken bones (6%).1 The most common sites of impaction are the cricopharyngeus, aortic arch, left main branch bronchus and cardio-oesophageal junction, where physiological narrowing occurs. Objects greater than 2 cm have difficulty traversing the normal adult oesophagus.2 Risk factors for obstruction include young age, dentures, psychiatric disorders, neurological conditions such as motor neurone disease and strokes, developmental delay, impairment by alcohol and underlying oesophageal pathology.3 Oesophageal pathology includes inflammatory or fibrotic strictures, Schatzki rings, eosinophilic oesophagitis, malignancy and diverticula.4 Certain forms of obesity surgery, such as gastric banding, may also be complicated by dysphagia. Clinical manifestations of oesophageal obstruction include chest pain, dysphagia, odynophagia, regurgitation and hypersalivation. Swelling, tenderness and crepitus may represent oropharyngeal or proximal oesophageal perforation. It is crucial to assess for airway compromise such as stridor, choking and coughing. This may result when the impaction occurs at the level of the upper oesophageal sphincter leading to tracheal compression. Complications of foreign body ingestion include obstruction, perforation, aspiration, tracheo-oesophageal fistula, aorto-oesophageal fistula, and abscess formation.5 Imaging such as x-ray or CT scan may demonstrate the location of the foreign body. Fish and chicken bones, glass, plastic, or food boluses may not always be seen on plain x-ray. Most foreign bodies pass spontaneously, although up to 20% require intervention. Intravenous glucagon, which relaxes the oesophageal smooth muscle, may be administered before endoscopic therapy but is of limited value.6,7 Effervescent agents such as carbonated drinks are often given but evidence of their efficacy is limited and based on case series only. Management is determined by the patient’s clinical condition and the anatomical location of the ingested material. Airway compromise or obstruction at the level of the cricopharyngeus may require consultation with an ear, nose and throat specialist. Otherwise, flexible endoscopy is the mainstay of foreign body removal.8 Success rates of 94% have recently been reported.1 In all cases, removal within 24 hours is recommended to avoid pressure-induced ischaemia and to minimise the risk of perforation.9 Urgent endoscopic removal is required when a sharp object is ingested or if evidence of high-grade obstruction is present. The foreign body may be removed using various instruments or by the push technique.3 The latter involves pushing the foreign body into the stomach with the endoscope but carries an increased risk of perforation. Sharp objects represent a medical emergency due to the risk of perforation, which has been estimated to be as high as 35%.2 They are less common than other foreign bodies but more difficult to remove. Endoscopic removal with minimal mucosal injury can generally be achieved using a retrieval device such as a Roth Net, as in our cases, or polypectomy snares with use of an overtube.10 An algorithm for managing a suspected sharp oesophageal foreign body is outlined in Box 3. The two cases we describe involved inadvertent ingestion of plastic as a result of cutting food in a heated, softened food container, resulting in a sharp foreign body oesophageal impaction and subsequent mucosal tear. To our knowledge, there have not been similar case reports in the literature. Given that takeaway food containers are widely used, these cases highlight the need for care to be taken when heating food in such containers and then consuming directly from them. 1 Gastroscopy image showing a solid piece of plastic wedged in the patient’s upper oesophagus 2 Gastroscopy image after removal of the plastic foreign body, showing a longitudinal mucosal tear 3 Algorithm for managing a suspected sharp oesophageal foreign body

Marianne Guirgis MB BS, BPharm, FRACP · Robert Nguyen MB BS, FRACP · Christopher Pokorny MB BS, FRCP, FRACP

Clinical record A previously well 43-year-old Australian lawyer was hiking the Kokoda Track in Papua New Guinea in August 2008. She awoke with a headache on the second day and, suspecting dehydration, consumed about 7 L of fluid while hiking. By late afternoon she complained of increased headache and nausea, which was exacerbated by her lying supine. She developed seizures several hours after profuse vomiting. Temazepam and metoclopramide were administered rectally due to limited medical resources. Three doctors present provisionally diagnosed dilutional hyponatraemia but had no facilities for intravenous therapy. Arrangements were made for urgent repatriation by helicopter to Port Moresby but this was later abandoned due to bad weather. She deteriorated overnight, becoming unresponsive to painful stimuli and lapsing into coma. Her vomiting and convulsions continued. With no rescue imminent, salt solution approximating normal saline was administered rectally. There was some improvement in eye-opening and verbal responses on the Glasgow Coma Scale. Fortuitously, an American naval hospital ship anchored outside Port Moresby retrieved her via helicopter the following afternoon. Her plasma sodium on arrival to intensive care was 114 mmol/L. After she was intubated and treated with intravenous hypertonic saline, the patient made a good recovery. Exercise-associated hyponatraemia (EAH) is a modern, life-threatening condition first described in 19851 after introduction of guidelines promoting excessive fluid intake during exercise.2 EAH is defined as hyponatraemia occurring during or up to 24 hours after prolonged exercise (generally > 4 hours duration).3 This “conditioned overhydration” — drinking beyond thirst, variously influenced by misunderstanding of exercise physiology, media including sports-drink advertising,4 and forced rehydration protocols5 — has been reported among hikers,6 military personnel5 and long-distance sports participants.7 Despite being well documented in scientific literature, those most at risk are unaware of this preventable condition. EAH is common, with reported incidences of hyponatraemia (serum sodium concentration, < 135 mmol/L) and critical hyponatraemia (serum sodium concentration, < 120 mmol/L) during the 2002 Boston Marathon of 13% and 0.6%, respectively.7 At least eight fatalities have been documented8 — likely an underestimation given difficulties with postmortem diagnosis.9 The unexplained deaths in 2009 of four previously well hikers on the Kokoda Track in similar conditions provide urgency to the need to raise awareness of the association between overhydration and EAH. Extensive research confirms EAH is primarily dilutional secondary to overhydration,10 manifest as weight gain during exercise. That only a small proportion of individuals exposed to overhydration develop hyponatraemia suggests a role for associated underlying defects in free water excretion. These include exercise-induced non-osmotic antidiuretic hormone secretion,11 while the recent description of an activating mutation of the arginine vasopressin receptor 212 may explain the undetectable antidiuretic hormone levels found in other cases.13 Excessive-sweat sodium losses associated with subclinical cystic fibrosis have also been described.14 Identified risk factors for EAH8 include excessive drinking behaviour, weight gain during exercise, female sex, slow performance pace, high availability of drinking fluids, > 4 hours’ exercise duration and hot environmental conditions consistent with our scenario. Female sex hormones inhibit cellular sodium–potassium–ATPase function, which may explain the observed higher risk of EAH and cerebral oedema among women.8 Slow performance pace may reflect insufficient physical training and provides the opportunity for overhydration. Lessons from practice Military personnel, hikers and endurance sports participants are at risk due to overhydration during prolonged exercise. Non-specific symptoms are commonly mistaken for dehydration. Diagnosis requires a high degree of suspicion, and biochemical testing. Water should be consumed according to thirst and guided by weight comparison before and after exercise. Weight gain should be avoided, aiming for a 1%–2% weight loss during prolonged exercise. Education of at-risk groups is essential for prevention. Symptoms include lethargy, dizziness, headache, nausea and vomiting, with progression to confusion, ataxia, seizures and coma.3 Importantly, EAH cannot be easily distinguished clinically from heat exhaustion, with subsequent mistaken “rehydration” exacerbating the condition. EAH requires a high index of suspicion to facilitate timely evacuation for biochemical diagnosis and treatment. Specific clinical features include euvolaemia and polyuria. A recent review of 145 United States military cases identified that the training cadre often mistook EAH for dehydration, and treatment by aggressive water rehydration had fatal consequences in three cases.15 Overhydration was encouraged by well-meaning guides and colleagues in another near fatal case on the Kokoda Track reported in 2008.5 In this context, a prominent tour operator’s media assertion that “dehydration” in “the death zone”16 caused the recent deaths among young healthy Kokoda Track hikers may perpetuate a dangerous culture of conditioned overhydration. It is of grave concern that, in 2009, a second fatality occurred shortly after media speculation that dehydration was the cause of the first. Available evidence suggests that, in an environment of excess water (most trekkers carry > 4 L water per day), hikers on the Kokoda Track should be more concerned with severe EAH secondary to overhydration, rather than with dehydration. Initial treatment of EAH is fluid restriction to avoid exacerbation of hyponatraemia. Those with critical hyponatraemia or symptomatic, biochemically confirmed EAH require treatment with intravenous hypertonic saline (100 mL of 3% saline solution over 10 minutes) in a supervised environment. This is based on the assumption that the hyponatraemia is acute (< 48 hours) and that no cases of osmotic demyelination syndrome have been reported in treating EAH.3 No single preventive fluid intake regimen can be recommended to cover all activities. The Second International EAH Consensus Development Conference statement3 recommends drinking to thirst instead of a predetermined protocol. The aim should be never to gain weight during endurance exercise and to expect a small percentage weight loss (1%–2%) due to substrate use.3 Fluid intake requirements could be estimated for guided treks by comparison to baseline weight. Point-of-care electrolyte testing could be used. There is insufficient evidence to recommend salt tablet use.3 Importantly, there is no evidence that commercial sports drinks prevent hyponatraemia3 — in fact, given their sodium hypotonicity relative to normal saline (10–20 mmol/L v 145 mmol/L), excessive consumption could worsen hyponatraemia. At a public health level, education of those leading and participating in high-risk activities is critical. The number of EAH casualties at a New Zealand ultradistance event was reduced by spacing the distance between, and volume of fluid available at, drinking stations.17 EAH is a modern, life-threatening condition which is preventable through adherence to sensible fluid intake during prolonged exercise. Although American sports and military bodies have revised their guidelines, researchers have been critical of the sports-drink industry’s role in perpetuating a culture of overhydration.18 As medical practitioners, it is our responsibility to ensure the wider community is aware of the risks of conditioned overhydration during exercise in the face of lay misinformation and commercial interests.

David A Pattison MB BS · Tomos E Walters MB BS, BMedSci · Eric Seal MB BS, FRACP, PhD

Objective: To describe the proportion of 16–29-year-olds tested for chlamydia by Australian general practitioners in a 12-month period.Design and setting: Between October 2007 and September 2008, the national chlamydia testing rate in 16–29-year-olds was calculated by dividing the number of Medicare-reimbursed chlamydia tests by two denominators: (i) Medicare-reimbursed GP consultations; and (ii) estimated resident populations adjusted for the proportion who were sexually active.Main outcome measures: GP chlamydia testing rates in 16–29-year-olds per 100 patients attending a GP consultation and per 100 sexually active population, by patient age and sex, state/territory of residence, and remoteness area.Results: Among the estimated Australian population of 16–29-year-olds, 85.6% of females and 64.4% of males had at least one GP consultation in the 12-month period. The national GP chlamydia testing rate per 100 patients was 8.9% (95% CI, 8.88%–8.94%). The national GP chlamydia testing rate per 100 sexually active population was 8.0% (95% CI, 7.92%–7.98%). The rate per 100 sexually active population was higher in females (12.5%) compared with males (3.7%) (P < 0.01); higher in 20–24-year-olds (9.0%) compared with 16–19-year-olds (8.7%) and 25–29-year-olds (6.6%) (P < 0.01); higher in those living in non-metropolitan areas (11.0%) compared with metropolitan areas (8.4%) (P < 0.01); and highest in those living in the Northern Territory (21.4%) compared with other jurisdictions (P < 0.01).Conclusions: Despite clinical guidelines recommending annual chlamydia testing for sexually active 15–29-year-olds, our analysis showed that a high proportion of young people aged 16–29 years attend a GP each year, but few of the sexually active population in this age group were tested for chlamydia in general practice. Strategies are needed to support GPs to enhance chlamydia testing in young people.

Fabian Y S Kong BPharm, MEpi · Rebecca J Guy BAppSc, MAppEpid, PhD · Jane S Hocking MPH, MHthSc(PHP), PhD · Tony Merritt MB BS, MPH · Marie Pirotta MB BS, FRACGP, PhD · Clare Heal MB ChB, FRACGP, PhD · Isabel Bergeri PharmD, MSc, DTMPH · Basil Donovan MD, FRCPI, FAChSHM · Margaret E Hellard MB BS, FRACP, PhD

Under state laws, a medical practitioner will not be found negligent if they acted in a manner that was widely accepted in Australia, by a significant number of respected practitioners in the field, as competent professional practice in the circumstances. This is known as the “peer professional practice defence”. The professional opinion being relied on must not be unreasonable (Victoria and Western Australia) or irrational (New South Wales and other states). The peer professional practice defence does not apply to claims of negligence arising from failure to warn patients about risks associated with medical treatment. This reinforces the importance of warning patients of material risks as determined by the High Court of Australia in Rogers v Whitaker. Recent cases demonstrate the successful operation of the peer professional practice defence, but also highlight its limitations. In practice, the legislation may not shield doctors from negligence claims as fully as originally intended.

Patrick D Mahar MB BS(Hons), LLB(Hons) · Justin A Burke MB BS(Hons), LLB(Hons), FANZCA

New health roles and models are needed to address future workforce shortages in Australian health care. A pilot trial of introducing two United States-trained physician assistants (PAs) at Queen Elizabeth Hospital, from October 2008 to October 2009, demonstrated difficulties in introducing PAs into the South Australian health system. Unforeseen delays in planning and implementing the trial occurred. This led to a loss of personnel and a second round of recruitment. The PAs’ scope of practice was limited, and they could not demonstrate their work as they do in the US. Full use of their prescribing licence was not allowed until 3 months into the trial, and their authority to order radiology tests was limited. The issues faced at Queen Elizabeth Hospital could be avoided in future trials, ensuring a smoother trial period.

Phyllis B Ho MB BS · Guy J Maddern MB BS, PhD, FRACS

We do not have a health system with collaboratively oriented values. Reforms that former prime minister Kevin Rudd initiated, which are now Prime Minister Julia Gillard’s to prosecute, do not support such a health system. Reformers have consistently ignored present and potential values. A plan for reform of the health system must take into account differing stakeholders’ objectives and values and incorporate new values. This requires an agreement by stakeholders to embrace the common good. It will also need strong leadership and a willingness to embrace fundamental change.

Jeffrey Braithwaite MBA, PhD, FCHSM · Clare A Skinner MB BS, MPH, BA(Hons) · Mei Ling Döéry MB BS, BMedSci

Trade in human tissue in Australia is prohibited by state law, and in ethical guidelines by the National Health and Medical Research Council: National statement on ethical conduct in human research; Organ and tissue donation by living donors: guidelines for ethical practice for health professionals. However, trade in human tissue products is a common practice especially for: reconstructive orthopaedic or plastic surgery; novel human tissue products such as a replacement trachea created by using human mesenchymal stem cells; biomedical research using cell lines, DNA and protein provided through biobanks. Cost pressures on these have forced consideration of commercial models to sustain their operations. Both the existing and novel activities require a robust framework to enable commercial uses of human tissue products while maintaining community acceptability of such practices, but to date no such framework exists. In this article, we propose a model ethical framework for ethical governance which identifies specific ethical issues such as: privacy; unique value of a person’s tissue; commodification of the body; equity and benefit to the community; perverse incentives; and “attenuation” as a potentially useful concept to help deal with the broad range of subjective views relevant to whether it is acceptable to commercialise certain human tissue products.

Nicholas Tonti-Filippini MA, PhD, FHERDSA · Nikolajs Zeps BSc(Hons), PhD

A 66-year-old woman presented to the emergency department with sudden-onset, severe thoracic back pain associated with dyspnoea and diaphoresis after consuming lunch. She was otherwise well, and her only medical history of note was gastro-oesophageal reflux disease. Examination showed a large right-sided pneumothorax, which was confirmed by chest x-ray. A pleural catheter was inserted, which resolved the pneumothorax, but the patient’s pain continued. A computed tomography scan showed a 2.7 cm transverse, linear foreign body in the patient’s oesophagus at the level of the aortic arch (Figure, arrow). This had caused perforation, pneumothorax, pneumomediastinum and pneumopericardium. The chicken bone was removed surgically, and the patient made an uneventful recovery.

Philippa J Bunting

To the Editor: Australia is in the process of making the most important change to its health care system since the implementation of Medicare.1 We agree with Cameron and Cooke that there are important lessons for Australia from the implementation of the 4-hour rule in the United Kingdom.2 As in Robert Zemeckis’s 1985 movie classic, Back to the future, the old question of “If I had the opportunity to do something again, what would I have done differently?” applies. We challenge the assumption that Australia is embarking on something that the UK has recently abandoned. The UK has not actually abandoned the 4-hour rule but expanded it into a suite of eight indicators that include three time-based measures, including total time in the emergency department (ED).3 Our concerns are about how the lessons learned by the UK can be applied in Australia in 2011 and beyond. Cameron and Cooke state that “Measurement systems should be in place to ensure that patient safety and quality of care are not compromised at any stage of the emergency care pathway”.2 The systems we have are neither universal nor integrated across the country. We need substantial data infrastructure, including comparable data linkage services across states. Of all the states, Western Australia has the most advanced national data linkage system. Yet even with the most sophisticated data systems in the world, proper impact assessment studies are required. Australia’s evaluation of the changes being made to rules and systems is neither systematic nor well standardised — to be safe and effective, innovation needs to be evaluated in coordinated and systematic ways.4 We also need systems-thinking approaches and simulation technologies to avoid repeating past mistakes. It is important to link theory and data to learn about the complex dynamics of ED patient flow and safety, and understand the consequences of our interventions.5 As suggested by Cameron and Cooke,2 we should focus on real-time, clinically relevant, consistent and comparable quantitative and qualitative data about patients, staff, processes, outcomes and facilities. We must learn to improve daily performance rather than sanction variable outliers. In conclusion, the lessons learned from the 4-hour target are relevant and appropriate for Australia. Cameron and Cooke have highlighted some of the dangers, including those of inadequate measurement.2 We need timely, integrated and linked data and an explicit theory of performance. We should aim to manage the risks by appropriately funded research and implementation strategies to improve this significant policy intervention while maintaining patients’ outcomes, experience and safety, and the timeliness of instigating their care.

Roberto Forero · Geoff D McDonnell · Sally M McCarthy · Peter Nugus · Jeffrey Braithwaite · Kenneth M Hillman · Daniel M Fatovich · David Mountain · Frank F Daly · Gerard J Fitzgerald · Drew B Richardson

To the Editor: The article by Nelson and colleagues1 is a welcome contribution to understanding trends in varicella zoster virus (VZV) disease epidemiology in Australia, particularly ambulatory medical attendance, for which few data sources are available. They report a decline in general practitioner encounters for varicella (chicken pox) since the introduction of varicella vaccine that is consistent with the observed 69% reduction in national hospitalisation rates in children aged 1.5 to 4 years seen from January 2006 to June 2008, 2.5 years into the National Immunisation Program (NIP).2 Nelson et al also report a trend towards higher GP encounter rates for herpes zoster (HZ [shingles]) over time. Although it may be tempting to take this rise on face value, additional analyses are required for a full understanding of patterns in HZ-related health care use, particularly accounting for age and changes in the use of prescription medications, including antivirals and opioid analgesics. Increased HZ-related health care use commencing before varicella vaccine availability has been reported in countries with universal vaccination programs, including the United States3 and Australia,4 as well as in countries where varicella vaccination is not recommended universally, including the United Kingdom.5 In Australia, prescribing of antiviral drugs for HZ increased between 1995 and 1999.6 Australia’s ageing population will contribute to the increasing prevalence of HZ over time due to the propensity of the virus to reactivate with advancing age. An analysis that we conducted shows that an increase in crude national hospitalisation rates for HZ preceded varicella vaccine availability, and that there was no increase over time in age-specific and age-standardised rates (National Centre for Immunisation Research and Surveillance, unpublished data). In addition, the suggestion from modelling studies that HZ may increase under a universal varicella vaccination program because of reduced opportunity for immune boosting in adults has yet to be observed in the US, the country with the longest-standing universal program of varicella vaccination.3 These complexities in monitoring VZV-related diseases highlight the need for very sensitive and well validated surveillance systems for both varicella and HZ in Australia. Although the authors request consideration for a universal HZ vaccination program for those over 65 years, they may not have been aware that since April 2009 The Australian immunisation handbook, ninth edition, online version has had new guidelines on HZ vaccination recommending a single dose of live attenuated VZV vaccine from the age of 60 years.7 In March 2008, the Pharmaceutical Benefits Advisory Committee recommended that this vaccine was suitable for inclusion in the NIP for those aged 60 years, with a catch-up dose for all individuals aged 61 to < 80 years. A decision regarding NIP funding has not been made, possibly because of a shortage of vaccine due to manufacturing problems.

Anita E Heywood · Kristine K Macartney

To the Editor: In Australia, addition of thiamine to bread flour (at 6.4 mg/kg) was made mandatory on 1 January 1991 in an effort to reduce the incidence of Wernicke’s encephalopathy and Korsakoff psychosis.1 Recently, an isocratic high-performance liquid chromatography (HPLC) method for the assessment of thiamine, thiamine monophosphate and thiamine diphosphate (TDP) in human erythrocytes has been described.2 This direct method of measuring thiamine in blood is superior to measuring red blood cell transketolase. We used an HPLC reagent kit (Chromsystems Instruments and Chemicals GmbH, Munich, Germany) to measure whole blood TDP concentrations in a population of 156 people who had alcohol use disorders. They were consecutive cases presenting between June and September 2010 at a driver assessment clinic in South Australia after they were convicted of two or more drink-driving offences. Thirty-two people taking a thiamine-containing medication or vitamin supplement were excluded. Based on the Diagnostic and statistical manual of mental disorders, fourth edition, text revision, of the remaining 124 people, 42 fulfilled criteria for “alcohol dependence” and 82 fulfilled criteria for “alcohol abuse” in the preceding 12 months.3 Of those tested, none had biochemical thiamine deficiency (defined as 2 standard deviations below the reference mean TDP concentration [< 66.5 nmol/L]). The lowest whole blood TDP concentration was 106 nmol/L. The highest concentration found was 362 nmol/L. The mean concentration was 217 nmol/L. This value is 2.5 standard deviations above the mean for the reference population (mean, 133 nmol/L; SD, 33 nmol/L).4,5 The reference range (66.5–200 nmol/L) was derived from a population that did not receive thiamine supplementation in foods. The characteristics of the distributions of thiamine concentrations in the Australian and reference populations are shown in the Box. The mean age of our population was 36 years, the youngest person was aged 19 years and the oldest, 73 years. The mean body mass index was 26.6 kg/m2 and the lowest was 18 kg/m2, so this group was not malnourished. The mean daily alcohol intake reported was 22 g/day but there was wide variation (range, 0–272 g/day; SD, 35 g/day). The results from the population with alcohol use disorders show remarkably elevated thiamine concentrations and no evidence of thiamine deficiency. The very high mean concentration of thiamine shows that this population is not at immediate risk of thiamine deficiency. It also suggests that mandatory supplementation of flour with thiamine has raised the baseline concentration of thiamine in Australians. Distribution of thiamine diphosphate (TDP) concentration in an Australian population with alcohol use disorders compared with a reference population4,5

Philip M Crowley · Matt D Gaughwin

To the Editor: Eades and colleagues identify the scarcity of data on the health and health care needs of Aboriginal Australians.1 This is particularly so for Aboriginal children in urban settings. The Gudaga Study2 has actively worked to redress this shortcoming. The Gudaga Study (Gudaga being an Aboriginal word meaning healthy baby) is a longitudinal study of a birth cohort of Aboriginal infants born at a large outer urban hospital.2 Gudaga staff use methods that respect the values and beliefs of Aboriginal Australians3 to systematically collect information on the health, development, and service use of study participants at 6-monthly intervals. The Gudaga research team is working with the stakeholders in Aboriginal health in the region to discuss the implications of the information for policy and practice. A number of scientific articles are currently being prepared for publication. These include articles on birth outcomes, breastfeeding, universal health home visiting, health status and service use, development, and vaccination. Information collected by the Gudaga Study is contributing to the development of services for Aboriginal families in the region, and is changing the ways that service providers think about the health and service needs of Aboriginal families in the region. For example, the lack of data created difficulty in securing funding for services for pregnant Aboriginal women. Enumeration of the high rates of sudden infant death syndrome (3/149) and the removal of children by the Department of Community Services among participating infants (11/149 over 4 years) as a part of the Gudaga Study had two important effects. It influenced the public health service response to close the gap on Aboriginal disadvantage and influenced the decision to reorient child and family services and establish the Bulundidi Gudaga program with ongoing funding. The Bulundidi Gudaga program provides sustained home visiting of pregnant Aboriginal women and their infants by nurses, commencing during pregnancy and continuing until the infant is aged 2 years.4 This research developed over several years. It began during discussions with the Aboriginal community at Tharawal Aboriginal Corporation, Campbelltown, who raised concerns about the health of their children, difficulties in securing funding for an Aboriginal infant and maternal home visiting service that commenced 1999, the lack of relevant data on the needs of Aboriginal children, and receipt of National Health and Medical Research Council funding in 2003. The Gudaga Study commenced in 2005, and the first of the participating children are turning 5 years of age. The research is now part of a strong research program at the University of New South Wales into the health and development of Aboriginal children in urban settings.

Elizabeth J Comino · Lisa R Jackson Pulver · Jenny A Knight

To the Editor: Two studies in nursing homes in Sydney, New South Wales, in the 1990s1,2 showed inappropriately high use of psychotropic medications. A similar study was conducted in 2003.3 Over time, revision of management guidelines, warnings about potentially lethal side effects, and introduction of new drugs have contributed to changes in the pattern of use of psychotropic medications in aged care facilities. Following the same procedure as the earlier studies, in 2009, we examined medication use in nursing homes in half the catchment area of Sydney South West Area Health Service (SSWAHS). We obtained details of drugs prescribed for residents from medication record cards in 44 of the area’s 48 nursing homes and checked whether medications had been given as prescribed. If given regularly on at least 25 of the previous 28 days, use was recorded as regular. We noted whether medication prescribed “as required” had been taken. The SSWAHS ethics review committee approved the study. Medication cards of all 2465 residents (895 men, 1570 women; mean age, 78.7 and 84.2 years, respectively) were reviewed. The mean number of all medications charted per resident was 8.7. Data obtained from all four surveys on patients taking psychotropic medication regularly are shown in the Box. The catchment area expanded between the 1998 and 2003 surveys. However, half the nursing homes open in 1993 closed before 2009. Use of antipsychotic agents fell between 1993 and 1998. By 2003 there had been a change from conventional antipsychotics to a two-to-one preference for atypical antipsychotic medication. Since 2003, regular use of antipsychotic medication has increased by about 19%, although at a lower mean dosage than previously. The rise is mainly attributable to increased prescription of risperidone and needs continuing review to monitor for morbidity. The proportion of residents taking antipsychotic medication only as required has remained almost the same in each survey (range, 1.2%–1.4%). Regular use of anxiolytic and hypnotic medication has decreased, and of antidepressants has increased, since the 1990s. Only 3.5% of residents were regularly taking a tricyclic antidepressant in 2009. The proportions of residents prescribed anxiolytic or hypnotic medication only as required have also fallen (to 3.8% and 2.3%, respectively, in the 28 days preceding our audit). Our findings cannot be generalised. Recent evidence from Tasmania4 showed that 42% of residents were taking benzodiazepines regularly. Nevertheless, changes in medication use should provoke discussion. Number (%*) of Sydney nursing home residents taking psychotropic medication regularly Medication 19931 (n = 2414) 19982 (n = 1975) 20033 (n = 3093) 2009 (n = 2465) Any psychotropic† 1422 (58.9%) 957 (48.5%) 1461 (47.2%) 1170 (47.5%) Antipsychotics‡ 662 (27.4%) 447 (22.6%) 730 (23.6%) 690 (28.0%) Conventional‡ 662 (27.4%) 401 (20.3%) 251 (8.1%) 182 (7.4%) Haloperidol 190 (7.9%) 159 (8.1%) 167 (5.4%) 121 (4.9%) Thioridazine 354 (14.7%) 193 (9.8%) 17 (0.5%) — Chlorpromazine 53 (2.2%) 24 (1.2%) 25 (0.8%) 20 (0.8%) Trifluoperazine 57 (2.4%) 30 (1.5%) 16 (0.5%) 8 (0.3%) Pericyazine 15 (0.6%) 3 (0.2%) 10 (0.3%) 13 (0.5%) Fluphenazine 44 (1.8%) 23 (1.2%) 10 (0.3%) 11 (0.4%) Flupenthixol — 2 (0.1%) 9 (0.3%) 7 (0.3%) Zuclopenthixol — — — 9 (0.4%) Atypical‡ 48 (2.4%) 506 (16.4%) 537 (21.8%) Olanzapine — 8 (0.4%) 225 (7.3%) 180 (7.3%) Risperidone — 40 (2.0%) 219 (7.1%) 286 (11.6%) Quetiapine — — 18 (0.6%) 63 (2.6%) Amisulpride — — 4 (0.1%) 7 (0.3%) Clozapine — — 3 (0.1%) 7 (0.3%) Aripiprazole — — — 4 (0.2%) Hypnotics‡ 641 (26.6%) 335 (17.0%) 350 (11.3%) 274 (11.1%) Temazepam 530 (22.0%) 313 (15.8%) 307 (9.9%) 255 (10.3%) Nitrazepam 105 (4.3%) 17 (0.9%) 35 (1.1%) 17 (0.7%) Anxiolytics‡ 207 (8.6%) 123 (6.2%) 127 (4.1%) 117 (4.7%) Diazepam 113 (4.7%) 77 (3.9%) 92 (3.0%) 71 (2.9%) Oxazepam 72 (3.0%) 40 (2.0%) 32 (1.0%) 26 (1.1%) Antidepressants‡ 377 (15.6%) 316 (16.0%) 635 (20.5%) 630 (25.6%) Tricyclics 249 (10.3%) 120 (6.1%) 110 (3.6%) 86 (3.5%) Mianserin 87 (3.6%) 37 (1.9%) 22 (0.7%) 8 (0.3%) Moclobemide 21 (0.9%) 40 (2.0%) 20 (0.6%) 9 (0.4%) SSRIs 18 (0.7%) 103 (5.2%) 354 (11.4%) 338 (13.7%) Venlafaxine — — 81 (2.6%) 61 (2.5%) Mirtazapine — — 51 (1.6%) 126 (5.1%) Lithium 11 (0.5%) 8 (0.4%) 24 (0.8%) 17 (0.7%) — = Drug not approved for use or not prescribed in year of survey. SSRI = selective serotonin reuptake inhibitor. * All percentages are proportion of total number of residents. † Clonazepam and other anticonvulsants (apart from diazepam) were not included as psychotropic drugs. ‡ Numbers do not add to totals as some patients were prescribed more than one drug and some little-used psychotropic drugs are not listed.

John Snowdon · Daniel Galanos · Divya Vaswani

To the Editor: While clinicians often communicate with patients and families, documentation of these conversations is inconsistent. Documentation is critical for continuity of patient care, medicolegal reasons and research,1 and is particularly important in the intensive care unit (ICU), where discussions regarding prognosis and withdrawal of care occur frequently. There are scant published data on documentation of conversations with patients in ICUs and their families. We conducted a retrospective audit of patients admitted to the ICU of Wesley Hospital (a 500-bed private teaching hospital in Brisbane) between 1 January and 31 August 2009 to: determine levels of documentation of communication with patients and their families by the ICU medical staff; and compare this with documentation of communication by the primary physician before and after admission to the ICU. After obtaining Wesley Hospital ethics committee approval, all patients who were cared for in the general ICU for more than 5 days were studied. During the study period, there were 862 ICU admissions, 100 of which met our inclusion criteria. The charts of only 82 patients could be successfully retrieved and these were used for final analysis. These patients had a mean age of 64 years (SD, 14 years), and a mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 17 (SD, 7). Sixty patients (73.1%) survived to hospital discharge. In the ICU, there were 39 family conferences at any stage between an ICU clinician and the families documented for 24 patients (29% of patients; 1.6 conferences per patient). Eleven of these conferences took place in the first 48 hours, eight between 2 and 4 days, and 20 beyond 96 hours of ICU admission. The Box shows that there was a greater proportion of documented family conferences for patients who died compared with those who survived at both 2–4 days (27% v 3%; P < 0.01) and beyond 96 hours (86% v 1.5%; P < 0.001). Of note, there was no documented communication between the hospital’s admitting physician and patients or families before ICU admission or after discharge from the ICU. Intensivists use any prior discussions to make decisions about continuing or withdrawing care.2 The absence of documentation before ICU admission is clinically relevant in this context. Potential reasons for inadequate documentation include (i) discussions occurring informally at the bedside or outside of the ICU (corridor conversations) and (ii) nurses providing updates in the clinician’s absence. Better documentation in the charts of dying patients may reflect their longer ICU stays, which provide more opportunity for communication. Moreover, discussions on treatment withdrawal are more likely to be documented as they are often a shared decision-making process. Globally, levels of documentation vary (10%–90%).3,4 Potential strategies to improve documentation include: bedside reminders (such as “have you documented family conferences?”); availability of a communications officer; an internal appointments system for formal discussions; and the use of communication kits.5 Despite being a retrospective study, our findings suggest a need to improve levels of documentation, and may prompt clinicians to examine their documentation practices and develop protocols to improve record keeping. Comparison of the documented communication rates for intensive care unit (ICU) patients who died and those who survived

Riad L Silcock · Bala Venkatesh · Ranald L Pascoe · Dianne K Fisher

Omission: In “Detecting undiagnosed diabetes using glycated haemoglobin: an automated screening test in hospitalised patients” in the 21 February 2011 issue of the Journal (Med J Aust 2011; 194: 160-164), the following were omitted:

Nyoli A Valentine MB BS · Tariq M Alhawassi BScPharm, MClinPharm · Greg W Roberts BPharm, FSHP, BCPS · Parind P Vora MB BS, MPH · Stephen N Stranks MB BS, FRACP · Matthew P Doogue MB ChB, FRACP

NO LAUGHING MATTER Patients receiving nitrous oxide as part of general anaesthesia for surgery may be at increased long-term risk of myocardial infarction (MI), say Melbourne researchers. Leslie and colleagues analysed data from the ENIGMA trial of 2 050 patients undergoing non-cardiac surgery, who were randomly assigned to receive anaesthesia with or without nitrous oxide. They found that odds of MI were nearly 60% higher in those receiving nitrous oxide. However, there was no significant increase in the risk of death or of stroke. The significance of the link between nitrous oxide and MI is unclear, and the findings need to be confirmed by larger studies, the authors say. Anesth Analg 2011; 112: 255-257 CANNABIS MADNESS Cannabis use may bring forward the onset of psychosis in some people. Large and colleagues, from the University of New South Wales and the Emory University School of Medicine, Atlanta, Georgia, did a meta-analysis of 83 published studies which compared the age of onset of psychosis in people who used cannabis and other psychoactive substances with the age of onset of psychosis in those who did not. Those who used cannabis developed psychosis, on average, when they were aged 2.7 years younger than those who did not; while those who used other psychoactive substances developed psychosis about 2 years earlier. The use of alcohol alone was not associated with an earlier onset of psychosis. Reducing cannabis use could delay or prevent some cases of psychosis, the authors say. They say there’s a need for heightened public health warnings about the link between cannabis and psychosis. Arch Gen Psychiatry 2011. Published online 7 Feb doi:10.1001/archgenpsychiatry.2011.5 MORE MAMMOGRAMS, YOUNGER? In Australia, on cost-benefit grounds, breast screening is offered free and recommended every 2 years for women from the age of 50 years — though women aged 40-49 years are also screened free of charge. But perhaps they should be having annual mammograms from the age of 40. US researchers Hendrick and Helvie reviewed evidence obtained by the US Preventive Services Task Force, which recommends screening every other year in women aged 50-74 years (in contrast to the American Cancer Society, which recommends annual screening in women 40-84 years). After modelling different screening scenarios and outcomes, the authors found that annual mammograms beginning at age 40 reduce breast cancer deaths by 40%. In comparison, screening every 2 years, beginning at age 50, reduces breast cancer deaths by 23%. This equates to 71% more lives saved if annual screening begins at age 40, they say. Am J Roentgenol 2011; 196: W112-W116 MÉMOIRE METABOLIC Older people with metabolic syndrome may be at a higher risk for memory loss, say French researchers. Raffaitin, from the French National Institute of Health Research, and colleagues studied 4 323 women and 2 764 men aged 65 and older from three French cities. Participants were tested for metabolic syndrome and its individual components and were also tested for memory and cognitive function, verbal fluency, and visual retention. Those with metabolic syndrome were 20% more likely to show decline in memory and cognitive function (though not of verbal fluency). Higher serum triglyceride and low serum high-density lipoprotein cholesterol levels were associated with diminished memory and cognitive function; diabetes (but not higher fasting blood sugar level) was associated with diminished verbal fluency and visual retention. Neurology 2011; 76: 518-525 POLYPILLOMANIA A single pill to prevent heart disease? That’s the idea behind the “polypill”; a combination of statins, aspirin and antihypertensives designed as a low-cost alternative to traditional multidrug regimens, and promising better patient compliance. Now another version is being trialled. The Wolfson Institute of Preventive Medicine in London is conducting a trial to determine the effect on blood pressure and cholesterol of a combination of simvastatin and three antihypertensives on healthy people older than 50 years of age. In response, an editorial in the Drug and Therapeutics Bulletin, (published by the BMJ Group) has questioned the whole notion of the polypill. Trials of various polypills have measured short-term outcomes such as the effect on serum cholesterol level and blood pressure, rather than more important long-term outcomes such as reductions in heart attacks and strokes, or reduced death rates, the editorial says. There are too many combinations of different drugs, at different dosages, targeting different populations (some healthy, others with established heart disease). In short, the polypill is overhyped; a “solution that is desperately seeking a problem, rather than the other way round”, the editorial says. Drug Ther Bull 2011; 49: 2

Peter Lavelle