Volume 195 Issue 2

The difficulties of knowing when, and to whom, to refer patients with a mental disorder Recognising one’s clinical limitations and the need for them to be augmented by others’ specialised knowledge and experience is a key component of professional reflectiveness and humility. Referring a patient to a specialist should never be experienced as a reflection of inadequacy or as a slight upon the quality of one’s care. It is an opportunity to provide enhanced treatment and to draw collaboratively upon the specialisation and wisdom of a respected colleague.1 It is also an important ethical obligation.2 By contrast, a failure to be conscious of one’s limitations can lead to insensitivity to the repercussions of patients’ symptoms, erroneous diagnoses and treatment, and a failure to attend adequately to risk factors. There are many possible reasons for this, which have been described in some instances as potentially including narcissism, grandiosity or a sense of omniscience,3 or therapeutic nihilism.4 Depending on the clinical outcome, non-referral can result in actions for negligence and disciplinary consequences. Mental illness is, by nature, episodic, with symptoms waxing and waning at different periods of a patient’s life and in response to different triggers and vulnerabilities. This highlights the need for a longitudinal perspective on the course of a mental disorder to identify improvement, deterioration or the existence of cycles of symptoms, all of which can give rise to therapeutic opportunities. Continuing evaluation of the need for pharmacotherapy, psychotherapy or any other modality is important. Matters can be complicated by patients resorting to unorthodox forms of intervention, such as “vitamin therapies”, past-life therapy and counselling from unqualified practitioners, all of which have the potential to exacerbate or briefly camouflage symptoms and warning signs.5 Practitioners’ perspectives of their patients’ mental states are inevitably snapshots taken at times that might not be representative of the course or trajectory of the illness. This is especially so in relation to bipolar disorder. Bipolar II disorder poses particular clinical challenges because of the risk that a practitioner seeing a patient irregularly will fail to identify hypomanic episodes and misdiagnose by reference only to observed or reported depression or anxiety. This risk is graphically illustrated in this issue of the Journal by Parker, in the context of the coronial inquest into the death of Charmaine Dragun.6 It is incumbent upon practitioners to be alert to dangerously labile moods suggestive of bipolar I or II disorder. Where signs of bipolar disorder are identified, there is frequently a need to refer the patient to a psychiatrist to manage and to titrate medication. Such referrals must be informed and suitably selective. Indiscriminate referrals run the risk of using the services of a psychologist or a counsellor in cases where such practitioners may not be the most suitable providers of treatment. This can be a particular issue in the era of mental health care plans, in which there can be pressures on general practitioners, driven by financial considerations, to refer to non-medically qualified practitioners who may not be the best equipped to deal with psychiatric illness. A survey of psychiatrists in the United Kingdom and the United States identified early referral to appropriate specialist care as being one of the “highest priority needs” in the effective management of patients diagnosed with bipolar disorder.7 Such patients are at real and foreseeable danger of lifestyle harm (such as severe embarrassment and financial loss), of taking risks that might endanger their own or others’ safety, and of suicide. These dangers can be avoided by timely referral to specialists with experience in the diagnosis and treatment of patients with bipolar disorders. However, the advantages of suitable and timely referral go beyond the practice of prudent and defensive medicine. Such referral enables focused and intensive provision of treatment for patients who might have limited insight into their illness and the need for treatment, as well as ambivalence about seeking assistance for their symptoms. In the legal context, the scenarios in which failures to refer have most commonly been litigated have been in relation to cancer investigations, when malignant tumours have been misdiagnosed as benign or have not been identified at all,8 and when there has been the potential for, or reality of, a boundary blurring or transgression. An example of the latter is when moves have commenced toward the creation of an unethical romantic or sexual relationship between practitioner and patient, and the doctor has not referred the patient to another practitioner. The principle underlying the obligation to refer in both scenarios is the same — that another practitioner is better positioned to advance the patient’s interests and that non-referral will disadvantage the wellbeing of the patient, breaching the obligation to exercise reasonable care and skill in the provision of professional advice and treatment.9,10 However, the referral must be clinically appropriate. In a New South Wales case, this was illustrated by a GP being found civilly liable to his patient for referring him to a chiropractor from whom he received treatment that was foreseeably clinically contraindicated because the patient had degenerative cervical changes and neurological symptoms from a disc injury.11 The same issue arises in respect of patients who might have bipolar disorder. This is not to say that a suitably experienced GP might not be able to treat such patients adequately; rather, that it can be negligent not to take active steps to enable patients to avail themselves of the specialist care that might be able to manage their illness most intensively at the time. Such a referral is also a significant protection for the practitioner, should allegations of insufficient or inadequately informed care be made later by the patient or the patient’s dependants.

Ian R Freckelton SC, LLB, PhD · George Mendelson MD, FRANZCP, FFPMANZCA

New data from the Health in Men Study raise questions about the role of testosterone supplementation in ageing men Ageing of the “baby boomer” generation foreshadows a future shaped by demographic change, with increasing numbers of older Australians. The large, longitudinal Western Australian Health in Men Study (HIMS) is therefore timely, as it examines the endocrinology of male ageing and predictors of health in community-dwelling older men.1,2 As part of HIMS, my colleagues and I surveyed 3274 men aged 75–95 years in 2008–2009 using a questionnaire that included items on sexual activity.3 Of 2930 men who reported on the importance they attached to sex, 48.8% considered it important, and of the 2783 men who provided data on sexual activity, 30.8% had at least one sexual encounter (defined as any mutually voluntary activity with another person that involves sexual contact, whether or not intercourse or orgasm occurs4) in the previous 12 months.3 Of these older sexually active men, 56.5% were satisfied with the frequency of sex, while 43.0% would have preferred sex more frequently.3 These findings indicate that many older Australian men consider sexual activity important and desirable. In HIMS, factors that predicted reduced sexual activity were increasing age, osteoporosis, prostate cancer, diabetes, antidepressant use, β-blocker use, and partner’s lack of interest or physical limitations.3 Living with a partner and having a non-English-speaking background were associated with increased sexual activity. Interestingly, a 1 SD increase in testosterone level, measured in blood samples collected in 2001–2004, was associated with a 20% increased likelihood of being sexually active in 2008–2009. Therefore, while older men with lower testosterone levels are likely to report symptoms such as reduced frequency of sexual thoughts and erectile difficulties,5 higher testosterone levels predict sexual activity several years into the future. This raises the question of whether giving exogenous testosterone to induce a comparable increase in circulating total testosterone levels (+ 5.6 nmol/L) would increase the frequency of sexual activity for older men. Epidemiological studies such as HIMS show that men with testosterone levels in the low-normal range have poorer health outcomes; for example, those with testosterone levels in the lowest quartile (< 11.7 nmol/L) have increased risk of stroke or transient ischaemic attack.6 Lower testosterone levels are associated with mortality in older men.7 Studies of testosterone therapy in older men show favourable effects on body composition, with increased lean mass and bone mineral density and, to an extent, improved muscle strength.8 However, there is no evidence as yet that testosterone therapy reduces cardiovascular events or mortality, or that it increases sexual activity in older men. In fact, administering higher doses of testosterone to older men with limited mobility might result in an excess of adverse cardiovascular events.9 More data are needed to help design optimal studies to clarify the role of testosterone supplementation in ageing men. In HIMS, the mean serum total testosterone level in 3638 men aged 70–89 years was 15.4 nmol/L (reference range, 8–35 nmol/L), and only a minority would have been classified as having unequivocally low testosterone levels.1 Uncertainty remains around the extent to which lower testosterone levels reflect underlying comorbidity; appropriate testosterone thresholds for the diagnosis of androgen deficiency in older men; and effects of testosterone therapy on cardiovascular risk.8 The current Testosterone Trial (ClinicalTrials.gov identifier NCT00799617) in the United States, due for completion in 2015, is recruiting older men with lower testosterone levels and will examine the effect of transdermal testosterone gel on end points of walking speed, sexual activity, vitality, memory and anaemia correction. So while the question of whether testosterone therapy might protect against cardiovascular events remains unresolved, its impact on sexual activity in the setting of a randomised controlled trial might not be known for another 4 years. Under these circumstances, the clinical approach to ageing men with symptoms of testosterone deficiency must be prudent, taking both known risks and potential benefits into account.8 Testosterone supplementation could be considered in men who are clearly hypogonadal. Symptoms of androgen deficiency should be assessed, and the diagnosis based on at least two unequivocally low early-morning testosterone levels, preferably assayed using a mass spectrometry-based methodology.10 Men should be counselled as to the risks and benefits of testosterone therapy, and treatment should be accompanied by safety monitoring, including prostate evaluation and monitoring of prostate-specific antigen levels and haematocrit. The anticipated effect of testosterone therapy would be to increase libido, and this should be included in the discussion of benefit and risk. While higher testosterone levels are associated with sexual activity in older men, non-hormonal factors are also important. HIMS found that increasing age predicted declining sexual activity; after adjusting for this and other covariates, men were four times more likely to be sexually active if they were living with a partner.3 Conversely, they were much less likely to be sexually active if their partner lacked interest in sex or had physical limitations. Medical comorbidities including diabetes and use of antidepressants were also associated with reduced likelihood of being sexually active. Therefore, social and medical factors are key determinants of whether ageing men remain sexually active. The increasing numbers of men transitioning from middle to older age should be encouraged to maintain their personal health and the health of their relationships to maximise their chances of having sex in future years.

Bu B Yeap MB BS, FRACP, PhD

Building on a successful program to extend PBS copayment relief to more patients Cost is a well established influence on both access to medicines and medication adherence rates. Prescription fees can lead to patients forgoing essential medications and to a decline in health care status among needy populations,1,2 an observation that is very familiar to Aboriginal community-controlled health services (ACCHSs). While capped patient copayments and the Pharmaceutical Benefits Scheme (PBS) Safety Net minimise the medication cost burden on all Australians, these mechanisms are ineffective for many Aboriginal and Torres Strait Islander peoples. The reasons for this include high rates of unrecorded concession and Safety Net status, disproportionately higher rates of chronic disease and comorbidity, extended social and family obligations, “shame” in accessing prescriptions in culturally alienating settings, high patient mobility, and poor health literacy. PBS utilisation is further reduced in this population by factors that preclude medicines storage and adherence, such as overcrowding, and disease profiles that are inconsistent with medicines listed on the PBS. The Council of Australian Governments (COAG) National Indigenous Reform Agreement of November 2008 led to strategies designed to close the gap in Aboriginal and Torres Strait Islander people’s life expectancy.3 One of these strategies is the $88.7 million “Subsidising PBS Medicine Co-payments” measure,4 which commenced in July 2010 and is predicted to provide financial assistance to “over 70 000 Indigenous people”, to improve their access to PBS medicines.3 This measure was, in fact, built on an existing program — Quality Use of Medicines Maximised for Aboriginal and Torres Strait Islander Peoples (QUMAX)5 — the details and outcomes of which have been kept under wraps until the recent release of the findings of an independent evaluation.6 The QUMAX program, which commenced in November 2008, aimed to overcome a range of known barriers to Aboriginal and Torres Strait Islander peoples’ access to medicines, and was jointly developed and managed by the National Aboriginal Community Controlled Health Organisation and the Pharmacy Guild of Australia, and funded by the Australian Government under the Fourth Community Pharmacy Agreement (2005–2010). Aboriginal and Torres Strait Islander patients could access the QUMAX program through ACCHSs in rural, regional and urban (ie, non-remote) areas. The cost of medicines for eligible needy and disadvantaged patients (as defined in the business rules for the program6) was subsidised through an online system of coordinated, secure and accountable copayment relief arrangements between ACCHSs and participating community pharmacies. The program also supported local quality use of medicines (QUM) initiatives through support pharmacists assigned to each ACCHS, provided QUM education for ACCHS staff, provided dose-administration aids and transport for the delivery of medicines, focused attention on patients’ PBS Safety Net entitlements, and fostered collaboration with community pharmacies — all within the context of culturally appropriate primary health care. Administration of QUMAX was lean, with the majority of the funds appropriately devolved to supplying medicines. The independent evaluation showed almost universal participation by ACCHSs (69 of 70) and involvement of 541 community pharmacies. The capped nature of QUMAX funding to each ACCHS meant that only 20% of the services’ Aboriginal and Torres Strait Islander clients (nearly 34 000 of the 171 094 patients who attended the participating services annually) could receive support for medicines and medication aids. Over 271 000 medicines were dispensed to these patients with the PBS copayment waived.6 Between November 2009 and April 2010, the proportionate increase in the number of PBS medicines dispensed to patients of non-remote ACCHSs was nearly five times greater than the increase in medicines dispensed to all Australians, and exceeded the increase seen in remote areas by a factor of seven. Greater access to medicines for chronic disease (lipid-lowering, antihypertensive and asthma medications) accounted for most of the increase. This increase occurred on a background of substantial inequities in access to medicines. In the 2006–07 financial year, for every dollar per person spent on PBS medicines for non-Indigenous Australians, only 60 cents was spent on Indigenous Australians.7 Among Aboriginal and Torres Strait Islander peoples, geographical disparities in access to medicines had been the reverse of those expected — Aboriginal peoples in non-remote parts of Australia had lower PBS expenditure per person than those in remote locations ($159 in major cities versus $223 in remote and very remote areas).7 This is probably due to the enduring success of another scheme — the special PBS arrangements under section 100 of the National Health Act 1953 for the supply of medicines to remote-area Indigenous health services.8 It is unclear if QUMAX has alleviated the PBS expenditure inequities, but the evaluation report states that, for Aboriginal and Torres Strait Islander peoples, there is “strong evidence that the QUMAX program has helped to overcome the financial barrier to accessing PBS medicines in non-remote areas”.6 In addition to patients of non-remote ACCHSs, the new PBS medicine copayment measure now extends copayment relief to eligible Aboriginal and Torres Strait Islander people who have, or are at risk of, chronic disease and are patients of any private general practice. Although the QUMAX program no longer includes the copayment relief element, it has been extended until 2015 under the Fifth Community Pharmacy Agreement to continue to augment QUM within ACCHSs. PBS listings have also improved, with more medicines now available for conditions that predominate in the Aboriginal and Torres Strait Islander population.9 There is no doubt that ACCHSs have substantially improved access to medicines for their disadvantaged Aboriginal and Torres Strait Islander patients and will continue to do so — to a level likely to eliminate disparity. They are able to do this through multifaceted strategies built on their intense community knowledge and involvement. When gauging the impact of the Subsidising PBS Medicine Co-payments scheme, it will be crucial for data on PBS utilisation by Aboriginal and Torres Strait Islander peoples to be disaggregated by “service type”. While ACCHSs participating in QUMAX have transitioned readily to the new copayment measure, its effectiveness in the private general practice sector now needs to be explicitly understood.10

Sophie Couzos FRACGP, FACRRM, FAFPHM · Vicki Sheedy BA, BEd · Dea Delaney Thiele PGDipHlthMgt

Objective: To estimate the number of deaths among people released from prison in Australia in the 2007–08 financial year, within 4 weeks and 1 year of release.Design, participants and setting: Application of crude mortality rates for ex-prisoners (obtained from two independent, state-based record-linkage studies [New South Wales and Western Australia]) to a national estimate of the number and characteristics of people released from prison in 2007–08.Main outcome measures: Estimated number of deaths among adults released from Australian prisons in 2007–08, within 4 weeks and 1 year of release, classified by age, sex, Indigenous status and cause of death.Results: It was estimated that among people released from prison in 2007–08, between 449 (95% CI, 380–527) and 472 (95% CI, 438–507) died within 1 year of release. Of these, between 68 (95% CI, 56–82) and 138 (95% CI, 101–183) died within 4 weeks of release. Most of these deaths were not drug-related.Conclusion: The estimated annual number of deaths among recently released prisoners in Australia is considerably greater than the annual number of deaths in custody, highlighting the extreme vulnerability of this population on return to the community. There is an urgent need to establish a national system for routine monitoring of ex-prisoner mortality and to continue the duty of care beyond the prison walls.

Stuart A Kinner PhD · David B Preen BSc(Hons), PhD · Azar Kariminia BSc, MSc, PhD · Tony Butler PhD, MSc · Jessica Y Andrews BHSci/Comm(Hons) · Mark Stoové PhD · Matthew Law MA, MSc, PhD

Objective: To determine the Australian native ant species associated with ant sting anaphylaxis, geographical distribution of allergic reactions, and feasibility of diagnostic venom-specific IgE (sIgE) testing.Design, setting and participants: Descriptive clinical, entomological and immunological study of Australians with a history of ant sting anaphylaxis, recruited in 2006–2007 through media exposure and referrals from allergy practices and emergency physicians nationwide. We interviewed participants, collected entomological specimens, prepared reference venom extracts, and conducted serum sIgE testing against ant venom panels relevant to the species found in each geographical region.Main outcome measures: Reaction causation attributed using a combination of ant identification and sIgE testing.Results: 376 participants reported 735 systemic reactions. Of 299 participants for whom a cause was determined, 265 (89%; 95% CI, 84%–92%) had reacted clinically to Myrmecia species and 34 (11%; 95% CI, 8%–16%) to green-head ant (Rhytidoponera metallica). Of those with reactions to Myrmecia species, 176 reacted to jack jumper ant (Myrmecia pilosula species complex), 18 to other jumper ants (15 to Myrmecia nigrocincta, three to Myrmecia ludlowi) and 56 to a variety of bulldog ants, with some participants reacting to more than one type of bulldog ant. Variable serological cross-reactivity between bulldog ant species was observed, and sera from patients with bulldog ant allergy were all positive to one or more venoms extracted from Myrmecia forficata, Myrmecia pyriformis and Myrmecia nigriceps.Conclusion: Four main groups of Australian ants cause anaphylaxis. Serum sIgE testing enhances the accuracy of diagnosis and is a prerequisite for administering species-specific venom immunotherapy.

Simon G A Brown MB BS, PhD, FACEM · Pauline van Eeden BAppSci(MLS), PhD · Michael D Wiese BPharm, MClinPharm, PhD · Raymond J Mullins PhD, FRACP, FRCPA · Graham O Solley MB BS, FACP · Robert Puy MB BS, FRACP · Robert W Taylor PhD · Robert J Heddle PhD, FRACP, FRCPA

Objectives: To determine issues that affect newly resettled refugees in accessing an emergency department (ED).Design, setting and participants: We conducted a descriptive community survey using a semistructured questionnaire. Newly resettled refugees from the Middle East and Africa were interviewed, statistical analysis was performed, and standard content analysis methods were applied to free-text responses.Main outcome measures: Emergency health-seeking behaviour, sociocultural barriers and beliefs about Australia’s emergency health services.Results: Half the African refugees (53/106) (50%), compared with only 15/49 (31%) of the Middle Eastern refugees, preferred an ED service over other forms of care for an urgent medical condition (P = 0.024). Qualitative data revealed that most newly resettled refugees understand how to use the emergency health services. However, while most indicated that they were able to make a call for emergency medical help, a substantial number of our respondents revealed that they were afraid to make such a call for fear of security implications, on the basis of experiences from their home countries.Conclusion: Reasons for differences in preferences of health care access, and determining how best to educate the community on the use of ED services, warrant further investigation. From a policy perspective, the increasing health care needs of refugees need re-examination when planning health care provision to refugees.

Mohamud Sheikh DrPH, MHSc, MIPH · Peter I Nugus PhD · Zhanhai Gao PhD · Anna Holdgate MB BS, MMed, FACEM · Alison E Short PhD · Ayman Al Haboub BPharm, MIPH · C Raina MacIntyre FRACP, MAppEpid, PhD

Academic GP Marie Pirotta says some alternative therapies are worthy of consideration Yes The use of complementary and alternative medicine (CAM) is hugely popular — each year, over half of the Australian population uses some form of CAM, at a total cost of $A1.8 billion.1 Importantly, most of this use of CAM is not a substitute for conventional therapy. Indeed, CAM is often used together with conventional therapies to treat particular conditions. CAM is usually considered a homogenous static entity, or a creed, to be either believed in or not. However, the “CAM” label incorporates a disparate range of therapeutic approaches, from the esoteric and bizarre through to therapies with accumulating evidence of effectiveness, such as St John’s wort for mild to moderate depression. If the first principle of medicine is to do no harm, is it ethical for general practitioners to actively recommend CAM? Indeed, how should the profession respond ethically to the challenge of CAM generally? One apparent hurdle is that much CAM currently lacks high-quality evidence. However, this should not be taken as proof that a given CAM is ineffective or harmful. To place this in context, it is estimated that as little as a quarter of conventional medicine is based on level-1 evidence.2 CAM research is slowly gaining momentum. It is hampered by factors including lack of financial reward for research investment for products already in widespread use, and few trained independent researchers. With increasing interest and research capacity, no doubt, evidence will accumulate for some CAM, which may be adopted into our armamentarium and become “mainstream”. Yet we cannot ignore CAM while awaiting the results of these trials. A framework for responsible engagement with CAM is needed now: its use is already widespread, even among GPs, and patients want to get their information about CAM from GPs.3 Encouragingly, CAM is largely safe. In Australia, CAM is regulated to pharmaceutical standards by the Therapeutic Goods Administration, so the risk of poor-quality, contaminated or adulterated products is low. While side-effects and interactions do occur, CAM is generally safer than pharmaceuticals.4 So in the context of widespread use, a slowly developing evidence-base, patients’ wish for their GP to provide CAM advice and its relative safety, is it ethical for GPs to recommend CAM? Ethical recommending of any treatment takes place within the framework of a careful history, examination and diagnosis. GPs contribute their clinical experience and scientific knowledge, while maintaining respect for patients’ preferences and values. Patients may value different aspects of treatment than their GP, such as “naturalness”. Together, patients and their GPs explore the risks and benefits of the proposed treatment, relative to other available treatments. Any treatment decision must be monitored for harm and benefit. Discussion of CAM options (including recommending or discouraging use, as appropriate) can be ethically incorporated into this framework. Where evidence is lacking, GPs can turn to the accumulated knowledge over time (sometimes millennia) of the historical use and safety of the CAM. In fact, it is important for GPs to discuss CAM options with patients to ethically fulfil their role as trusted primary care providers. Doctors who do not engage in discussion about CAM may harm the doctor–patient relationship in the longer term — use of potentially harmful CAM may remain undetected, and patients may seek information from less reliable sources. Further, it may be unethical not to inform patients in situations where evidence-based CAM options exist.5 Is it ethical to bill these consultations to Medicare? Of all CAM treatments, only medical provision of acupuncture has its own Medicare item number. Using the framework I describe for ethical, responsible discussion of CAM, I believe it is appropriate to bill Medicare. There are certain circumstances in which recommending CAM would be unethical. These include: if the GP has inadequate knowledge to avoid harm;6 if the use of CAM causes delays in treating serious illness where evidence-based conventional therapies exist; if there is evidence that a CAM is not effective; or if (and this is unusual) unproven or ineffective practices are recommended to vulnerable patients for exploitative financial gain. Further, potential for conflict of interest exists for GPs who recommend and sell CAM. The Australian Medical Council Code of Conduct provides clear guidelines, including declaring to patients one’s professional and financial interest in any product endorsed or sold from one’s practice, and not making an unjustifiable profit from the sale or endorsement.7 Ethical prescribing of CAM is possible within good general practice if GPs have an adequate knowledge of CAM and have their patients’ best interests at heart. Generally, GPs need to keep up-to-date as evidence grows about CAM, and maintain a respectful relationship with patients so they feel able to ask questions about CAM and thus maintain their enviable position as trusted primary care providers.

Marie V Pirotta MB BS, MMed, PhD

Emeritus Professor John Dwyer says doctors should not give alternative therapies their sanction No While the answer to the question in most situations is a definite “no”, the issues associated with the need to ask the question are important and troublesome. In this most scientific of ages, when orthodox medicine is committed to embracing an ever more evidence-based approach to clinical practice (and still has a long way to go), consumers of health care are increasingly exposed to a plethora of nonsense (non-science) claims that waste their money, distance them from effective care strategies and, not infrequently, cause harm. More than half the population will partake of some form of alternative or complementary therapy each year, spending more than two billion dollars to do so!1 Of course it is important to understand why this is so. A reporter from The New Yorker magazine contacted me a few years ago after I had discussed health care fraud in an article for Reader’s Digest. “You don’t seem to understand”, she told me, “that in this postmodern age, people are yearning for simplicity, panaceas and a little bit of magic in their lives”. This is surely a dangerous romanticism given that it is people’s health, and therefore happiness and productivity, we are discussing. Many patients have told me that “alternative practitioners” are likely to give you an hour of their time, a bit of a massage, and send you away with a cocktail of therapies from their shelves. In orthodox medicine, we rightly regard prescribing and dispensing medicines for financial gain an unacceptable conflict of interest. However, we know that enough time with a general practitioner to allow patients to vent their concerns satisfactorily is very often unavailable. Consumers, of course, are bombarded with fraudulent advertising telling them vitamins cure stress and provide energy,2 weight loss is guaranteed with this herbal preparation, glucosamine will take you from your wheelchair to the golf course,3 foot vibrators will cure your ankle oedema, and detoxification will cleanse your body of all those accumulated poisons compromising your health.4 The list is virtually endless. How often do we hear consumers being assured that “natural is best” when exactly the opposite is true. Significant numbers of doctors are advertising their practice of “integrative medicine”, a mixture of the best treatments available from the orthodox and alternative medical universes! I know of no scientific study exploring the motivation for such an approach, so some may believe they are offering superior care while others are, no doubt, responding to commercial opportunities to capitalise on the popularity of complementary approaches. To do so, however, is to abandon scientific medicine — which strives for evidence, rejects the “therapeutic” use of the placebo effect and addresses the psychological nature of many symptoms — for an approach that does not believe in testing, is happy to exploit the placebo effect and rejects a psychological influence on health. Pick up any copy of an alternative health care magazine and you will see doctors and nurses advertising intravenous vitamin therapies for a range of problems, and “chelation” therapy for everything from cancer to heart disease. Our profession should be worried by these trends, which see many doctors practising a form of medicine that would be rejected by most of their peers. To see how professional standards can be consumed by the attractions of less scientifically rigid approaches, one has only to look at what has happened to the scientifically trained men and woman of pharmacy, whose shelves are stacked with useless products they knowingly promote to trusting customers. The scientific study of many of alternative medicine’s claims is taking place in many universities. This is important because, of course, there is really only “good” medicine and “bad” medicine. Scientific studies that determine that an approach, supported previously only by anecdote, has evidence-based merit, should be embraced by orthodox medicine if it fills a therapeutic gap. Claims about therapies that turn out to be inaccurate when studied, would, if they are still propagated, represent bad medicine, and prescribing such therapies would be unethical. Science is the key to converging the approaches we have been discussing.5 However, we don’t need to wait to warn the public in the strongest terms that many alternative strategies are already known to be useless. Homoeopathy, iridology, reflexology, healing touch, and many of the claims made for acupuncture6 are some examples. Private insurance funds that “cover” a number of these totally unacceptable practices give them a totally undeserved imprimatur, and so do doctors who prescribe alternative and complementary procedures. In our national health scheme, Medicare dollars are precious, and it is surely unethical to ask the taxpayer to foot the bill for unproven, highly suspect or useless treatments. In this era of the endless information highway, the community should be able to depend on their doctors for education on just how people should seek out for themselves the evidence supporting proposed care plans. Doctors also need to impress on their patients the importance of divulging what alternative preparations they may be using, as severe complications from chemical interactions may occur. Finally, doctors need to avoid supporting the alternative “last-resort” approach that may be suggested by desperate patients, because the extraordinary expense, false hope and removal from skilled end-of-life care can add so much to suffering.

John M Dwyer AO, MB BS, FRACP, PhD

A coronial inquest into the suicide of television newsreader Charmaine Dragun identified that a likely contributory factor to her death was the failure of many health practitioners to diagnose a bipolar II disorder and to provide more specific treatment for her condition. Lack of awareness about bipolar II disorder among practitioners and the public, as well as screening and detection problems, may have contributed to the failure to diagnose this disorder over the course of a decade. Detection and management of bipolar II disorder generally differs from that for a unipolar disorder, in that mood stabilisers rather than antidepressants are more often a priority. The diagnosis therefore has distinctive implications for management and course of the illness. The Coroner recommended “increased awareness by health professionals of the need to exclude a bipolar disorder in all patients presenting with signs and symptoms of depression” and highlighted the need for “readily available” screening tools.

Gordon B Parker AO, MD, PhD, FRANZCP

Amanda Leach (centre), coauthor of the winning article and recipient of the 2010 MJA/Pfizer Research Award, with Bill Ketelby, Country Medical Director of Pfizer (left), and Annette Katelaris, Editor of the MJA (right). I am pleased to announce the winner of the Medical Journal of Australia/Pfizer Australia Research Award for 2010. This $10 000 award recognises and rewards the best original research published each year in the Journal, and was presented at the annual Australian Medical Association National Conference in May this year. This year, the Journal’s Content Review Committee awarded the 2010 prize to Peter Morris and his colleagues from the Menzies School of Health Research, Charles Darwin University and the Northern Territory Clinical School of Flinders University in Darwin and Royal Prince Alfred Hospital in Sydney for their article, “Single-dose azithromycin versus seven days of amoxycillin in the treatment of acute otitis media in Aboriginal children (AATAAC): a double blind, randomised controlled trial”. This trial was funded by the National Health and Medical Research Council and the report was published in the Medical Journal of Australia on 4 January 2010. Acute otitis media, particularly perforation of the tympanic membrane, is a major public health problem among Aboriginal children. Only one in 10 children has bilaterally normal ears and hearing. This research group has previously found that long-term antibiotic treatment resolves middle ear effusion and prevents perforation. Because of often poor compliance with treatment regimens over several days, this trial compared a one-off intervention with a standard 7-day regimen. They found that single-dose azithromycin was more effective than a 7-day course of amoxycillin at eliminating the bacterial pathogens, but it was not more effective at curing acute otitis media in this population. Disturbingly, both treatments failed in half the cases treated. The group is now evaluating a double-dose regimen of azithromycin. This was the first randomised controlled trial of antibiotic treatment of acute otitis media in a population with high rates of acute and chronic tympanic membrane perforation. Because single-dose therapy virtually ensures treatment compliance, the findings of this study are potentially practice changing. This award has been sponsored by Wyeth Australia since 1995. We are grateful for their support over the years, and now welcome Pfizer, who acquired Wyeth in 2009, as our cosponsor. The award was presented by Dr Bill Ketelby, Country Medical Director of Pfizer. Pfizer had no role in the study or in the choice of a winner, and it was purely coincidental that a drug that is manufactured by the company was used in the study.

Annette Katelaris MB BS, MPH, FRACGP

The Australian Government’s decision to raise taxes on ready-to-drink spirit-based beverages (RTDs; “alcopops”) in 2008 caused great controversy. Interest groups have selectively cited evidence to support their points of view. The alcohol industry cited Victorian data from the Australian Secondary Students’ Alcohol and Drug Survey (ASSADS) as evidence that the tax had failed, but closer examination of the data suggests that fewer students are drinking, and fewer are drinking at risky or high-risk levels. Excise data from the first full year after the tax came into effect showed a more than 30% reduction in RTD sales and a 1.5% reduction in total pure alcohol sold in Australia. Although understanding the impact of the alcopops tax will require critical analysis of a range of evidence, sales and ASSADS data suggest that the tax has resulted in reduced consumption of RTDs and total alcohol. The most effective and cost-effective measures for reducing consumption and harm are a comprehensive graduated volumetric alcohol taxation system, a minimum price per standard drink, and special measures for particular products that may cause disproportionate harm. While welcoming the alcopops tax, public health advocates have consistently argued for a comprehensive package of reform that covers pricing, availability and promotion of alcohol, as well as education and treatment services.

Steven J Skov MB BS, MPH, FAFPHM · Tanya N Chikritzhs BA(Hons), GradDipEpidBioStats, PhD · Kypros Kypri BA(Hons), PhD · Peter G Miller PhD · Wayne D Hall BSc, PhD · Michael M Daube BA(Hons), HonDSci · A Rob Moodie MB BS, MPH, FAFPHM

A 62-year-old woman with an autoimmune disease presented with panuveitis and was treated with immune suppression. She subsequently developed herpetic acute retinal necrosis and later died of herpes simplex encephalitis. Acute retinal necrosis usually occurs months to years after herpes simplex encephalitis. In our case, the ocular findings were present for 5 weeks before the encephalitis presented. To our knowledge, this is the first Australian case of acute retinal necrosis preceding herpes simplex encephalitis. (MJA 2011; 195: 87-88) Clinical recordA 62-year-old woman was referred to our hospital after a left-sided uveitis failed to respond to both topical and systemic steroids. She was known to have systemic lupus erythematosus (SLE) with severe arthritic changes, but had not received immunosuppressive therapy. She had right temporal lobe surgery in 1995 for a benign brain tumour. In 2005, she had Legionella pneumonia that had resulted in an intensive care unit admission with multiorgan failure and acute respiratory distress syndrome. As part of the diagnostic work-up during her previous admission, she was diagnosed as having herpes simplex virus (HSV) type 1 and was treated with aciclovir. She had no known history of genital or oral herpetic lesions. She had no significant ophthalmic history. When she was first reviewed at our hospital, she had been symptomatic for 3 weeks. She had been diagnosed as having an SLE-related panuveitis and had been treated with topical, regional and systemic steroids for 2 weeks with no response; on presentation, she was taking oral prednisolone, 1 mg/kg/day. She described a loss of appetite for 6 weeks but had no headache, fever, rash, pleuritic chest pain or shortness of breath suggestive of a lupus flare. Her initial visual acuity was 6/9 in her right eye and “hand movements” in her left eye. There was a relative afferent pupil defect in her left eye. Her anterior chamber had large mutton-fat keratic precipitates, fibrin and posterior synechiae — all indicative of a granulomatous uveitis. There was no fundal view of the left eye. An ultrasound scan of the left eye showed vitreous debris and a retinal detachment. Fundal examination of the right eye showed one or two small scattered intraretinal haemorrhages (Box 1, A). Fluorescein angiography (Box 1, B) of the right eye showed mild leakage from the disc and vessels in keeping with an early vasculitis. There was no view of the left fundus. An anterior chamber tap and vitreous biopsy were taken from the left eye. Bacterial and fungal microscopy and culture were negative; results of cytological analysis were normal. There was insufficient specimen for viral polymerase chain reaction (PCR). (This is a common occurrence for aqueous and vitreous samples, in which the amount taken averages 0.4 mL.) Blood sampling showed an antinuclear antigen positive to a titre of 1 : 2560 (> 1 : 160 considered positive for probable autoimmune disease), an erythrocyte sedimentation rate of 38 mm/hour (reference range, < 20 mm/hour for women aged > 50 years), and anti-DNA antibodies > 100 IU/mL (reference range, < 6 IU/mL); a white cell count and serum angiotensin-converting enzyme levels were normal, and human leukocyte antigen (HLA)-B27 was not detected. Serological testing was negative for syphilis and HIV. Blood culture was negative. An echocardiogram and chest x-ray were non-contributory. At this stage, the differential diagnosis included a masquerade syndrome (intraocular lymphoma), active lupus, or an endogenous, infective endophthalmitis. The patient was referred for a surgical vitreous biopsy. She continued to take oral prednisolone 1 mg/kg/day. Two days later, there was a marked deterioration in the patient’s vision. Her visual acuity was recorded as “no perception of light” in both eyes. She had no headache, but she was febrile. Her right eye now had anterior chamber and vitreous cells and widespread retinal haemorrhages (Box 1, C). Magnetic resonance imaging (MRI) of the patient’s brain showed an area of encephalomalacia in keeping with her previous surgery. Inflammatory changes and a retinal detachment were noted in the left globe. The optic nerves appeared normal. No orbital masses were noted, and no cavernous sinus pathological features were observed (Box 2, A). A surgical vitreous biopsy was performed on her left eye. The next day, she was found to have a deteriorating neurological status. She was delirious and seemed unable to hear and follow commands. She remained febrile. A lumbar puncture was performed. PCR of cerebrospinal fluid and vitreous fluid samples were positive for HSV type 1. In addition, the cerebrospinal fluid had 75 lymphocytes/mm3 and normal cytological features. She was commenced on intravenous aciclovir. A repeat MRI scan 8 days after the initial scan showed increased signal on flair involving the thalamus, occipital, temporal lobes and brainstem in keeping with an encephalitis (Box 2, B). She failed to improve clinically and died 3 weeks later. An autopsy was refused by the family, but the cause of death was pressumed to be herpes simplex encephalitis (HSE). DiscussionAcute retinal necrosis (ARN) associated with HSE has been well described. Most published reports describe the ocular findings following the encephalitis with a variable time course; the mean interval is 6 months but it can range between 10 days and 20 years.1-6 To our knowledge, there has been only one report published of HSE following ARN.7 When ARN follows HSE, it is assumed that a reactivated latent virus is axonally transmitted from the brain to the retina. A retrospective study published in 2008 examined the causative virus among 52 patients with ARN.8 It found that 14% had a history of previous HSE. There were no cases in which ARN preceded the encephalitis. In one case report, the authors noted that there have been 20 cases of ARN following HSE published in the past 20 years, and only one case of HSE following 3 weeks after ARN.9 HSE remains a serious illness with significant risk of morbidity and death. A high index of suspicion is required to diagnose HSE. Neurons undergo lysis associated with haemorrhage — a process similar to that seen in the eye with ARN. The exact mechanism of cell death is postulated to be a combination of direct virus-mediated and indirect immune-mediated processes.8,10 Without treatment, the brain undergoes severe inflammation and necrosis. ARN typically causes panuveitis with a distinctive pattern of retinal involvement. Patients may develop painful, severe visual impairment over a few days, or experience an insidious onset with mild visual symptoms such as floaters. Ophthalmic examination shows evidence of a granulomatous uveitis, vitritis, peripheral retinal periarteritis, retinal infiltrates, retinal necrosis, and sometimes retinal detachment. The posterior pole (macula) is usually spared until late; thus vision may remain fairly good despite surrounding necrosis. Diagnosis is made using PCR-based assays of aqueous and vitreous fluid. Treatment of ARN is intravenous aciclovir for 14 days followed by oral valaciclovir for 3 months. Systemic steroids are started a few days after initiation of antivirals to lessen the immune-mediated retinal necrosis. Our patient had a history of HSV years before the current presentation. There was, however, no history of preceding encephalitis. We hypothesise that the unguarded use of steroids may have caused reactivation of the virus and subsequent spread to the brain via retrograde axonal transport from the eye or from a generalised viraemia. This case highlights the importance of considering a viral aetiology in cases of atypical uveitis. ARN may herald systemic or cortical disease. Viral PCR should be performed before commencing systemic steroids. Herpetic disease may remain latent for many years before presenting in a previously uninvolved tissue. Intraocular inflammation remains a diagnostic challenge frequently encountered in ophthalmic practice. It remains imperative that all patients presenting with a possible uveitis be referred to an ophthalmologist. 1 Photographs of the patient’s right fundus A. Initial presentation of the right eye with small intraretinal haemorrhages. B. Fluorescein angiogram of the right eye at initial presentation. C. Two days after initial presentation. 2 Magnetic resonance imaging of the patient’s brain and orbits A. Old area of encephalomalacia on the right, and inflammatory changes in the left globe. B. Repeat scan showing increased signal on flair settings.

K Nadia Wittles MB ChB, FCOPHTH(SA), FRANZCO · Lucy A Goold MB BS · Jagjit S Gilhotra MB BS, MMed (ClinEpid), FRANZCO

Objective: To examine the frequency of deaths in low-mortality diagnosis-related groups (LM-DRGs) and the patient and hospital characteristics associated with them.Design, setting and patients: Retrospective cohort study of 2 400 089 discharge episodes for adults (> 18 years) from 122 Victorian public hospitals from 1 July 2006 to 30 June 2008.Main outcome measures: Frequency of episodes of death in LM-DRGs (defined as DRGs with mortality < 0.5% over the previous 3 years or < 0.5% in any of the previous 3 years); associations between characteristics of patients and hospitals with deaths in LM-DRGs.Results: There were 1 008 816 LM-DRG episodes with 0–15 LM-DRG deaths per hospital in the 2006–07 financial year and 0–20 deaths per hospital in the 2007–08 financial year. Increased age, level of comorbidity, being male, admission from a residential aged care facility, interhospital transfer, emergency admission and lower hospital volume were associated with an increased risk of death in LM-DRG episodes in both years. Metropolitan location and teaching/major provider status were not associated with LM-DRG deaths (P > 0.10). More than 40% of LM-DRG deaths were among patients aged 83 years or over, who had a length of stay of less than 1 day and had a medical DRG classification. Standardised mortality ratios (SMRs) that adjusted for the patient and hospital characteristics identified nine outlier hospitals with high frequencies of deaths in LM-DRGs in the 2006–07 and six in the 2007–08 financial year compared with 59 hospitals flagged by the death-in-LM-DRG indicator.Conclusions: The use of the LM-DRG indicator requires further investigation to test its validity. LM-DRG deaths are infrequent, making it difficult to identify temporal changes and outlier hospitals. Patient characteristics unrelated to quality of care increase the likelihood of death among LM-DRG patients. The SMR analysis showed that failure to adjust for these characteristics may result in unfair and inaccurate identification of outlier hospitals. The increased risk of death associated with interhospital transfer patients and low-volume hospitals requires further investigation.

Anna L Barker PhD, MPhty(Geriatrics), BPhty · Caroline A Brand MB BS, FRACP, MPH · Sue M Evans BN, GDip ClinEpi, PhD · Peter A Cameron MB BS, MD, FACEM · Damien J Jolley MSc(Epidemiology), MSc(Statistics), AStat

Paediatric empyema thoracis occurs in 0.7% of pneumonias in Australia and general paediatricians may only see a few cases in their career. A recent survey demonstrated a lack of consensus in management across Australia, highlighting the need for a local guideline. Empyema is an accumulation of infected fluid in the pleural space caused by a disruption in the equilibrium of pleural fluid secretion and absorption by the pleural lymphatic drainage system. Children with empyema typically present with symptoms and signs of pneumonia. A persistent fever despite 48 hours of appropriate antibiotic treatment may indicate development of empyema. Children with empyema should be managed in a hospital with paediatric expertise — preferably by or in consultation with respiratory paediatricians, and in conjunction with paediatric surgeons (recommendation [R], strong; evidence [E], low quality). If feasible, children should be transferred to a tertiary paediatric centre; treatment of paediatric empyema is very different to that of adult disease. A chest x-ray should be carried out for children in whom empyema is suspected (R, strong; E, high quality); a routine lateral film is not needed. A lateral decubitus or erect film may be used to differentiate a simple parapneumonic effusion from an empyema if ultrasound is not available (R, strong; E, none). Daily x-rays are not necessary to monitor progress as changes on chest x-ray lag behind clinical status (R, strong; E, none). Ultrasound is the central investigation in the management of paediatric empyema; it should be used for all children with empyema as it is the best technique for differentiating pleural fluid and consolidation, estimating effusion size and grading complexity, demonstrating the presence of fibrinous septations and guiding chest drain placement (R, strong; E, high quality). A preoperative chest computed tomography (CT) scan should not be routinely performed (R, strong; E, moderate quality) but should be reserved for complicated cases in which the condition has not responded to treatment or there is concern that another pathological condition, such as a tumour, is involved. Blood tests such as blood culture (R, strong; E, high quality), full blood count and measurement of C-reactive protein level (R, strong; E, none) may help in supporting the diagnosis and monitoring the progress of the disease, but there is no role for routine blood tests. Children with empyema should receive high-dose, intravenous antibiotic therapy to ensure pleural penetration (R, strong; E, high quality). The majority of causative organisms in Australia are Streptococcus pneumoniae (in particular, serotypes 1, 3 and 19A), Streptococcus pyogenes, methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus (MRSA). In the absence of a positive culture result, the initial choice depends on the local hospital infection control policy for managing community-acquired pneumonia. Appropriate antibiotics should cover at least S. pneumoniae and S. aureus (R, strong; E, high quality). Consideration should be given to coverage of MRSA for children from communities with a high prevalence of MRSA (R, strong; E, high quality). Anaerobic infection should be considered in children who are at risk of aspiration. Macrolides should be used when Mycoplasma pneumoniae is thought to be the causative organism but should not be used routinely (R, weak; E, moderate quality). Moderate to large effusions require drainage. There is no role for diagnostic thoracocentesis. If there is a need to access the pleural cavity, the placement of a drain should be considered, thus ensuring that the child undergoes only one invasive intervention (R, strong; E, high quality). Pleural fluid should be sent for cytological testing, microscopic examination and culture, including culture for Mycobacterium tuberculosis (R, strong; E, high quality). Ideally, pleural fluid should be tested using enhanced molecular techniques such as polymerase chain reaction (R, strong; E, high quality). There is currently no role for pleural biochemical markers to guide therapy in children (R, weak; E, low quality). Chest drainage with a large bore drain alone is not recommended (R, strong; E, moderate quality). Instead, percutaneous small bore drainage with a fibrinolytic agent (preferably urokinase) or video-assisted thoracoscopic surgery (VATS) is recommended (R, strong; E, moderate quality). Open thoracotomy is not recommended as it has largely been superseded by the use of VATS. Children with an oxygen saturation level below 93% on room air should be given supplemental oxygen (R, strong; E, high quality). Other standard therapy includes fluid replacement (R, strong; E, none), use of antipyretic agents (R, strong; E, none specific to empyema) and analgesia (R, strong; E, none). There is no role for chest physiotherapy — apart from early mobilisation and encouragement of deep breathing and coughing, particularly after surgical intervention or tube drainage (R, strong; E, low quality) — and no indication for routine bronchoscopy in children with empyema (R, strong; E, weak). If a child has been afebrile for 24 hours, a change from intravenous to oral antibiotic therapy can be considered (R, weak; E, none). The choice of oral antibiotic depends on the organism identified (if any) or the class of antibiotic that was successfully used by intravenous therapy. There is no consensus on duration of oral antibiotic therapy, which varies from 1 week to 6 weeks (R, weak; E, none). A follow-up chest x-ray should be carried out 4–6 weeks after discharge from hospital to confirm that changes are resolving (R, weak; E, none). Further imaging is not required unless there are persistent clinical symptoms or complications (R, weak; E, none). There is no need for routine investigations to identify a possible underlying cause in previously healthy children without a history of recurrent infections (R, weak; E, very low quality). The full position statement is available at http://www.thoracic.org.au/ professional-information/position-papers-guidelines.

on behalf of the Australian Research Network in Empyema (ARNiE)

Neil Orr was born on 19 October 1919 on a property called “St Helens” in Toowoomba, Queensland, the only child of Scottish immigrants. Neil attended school at Toowoomba Grammar and studied medicine at the University of Sydney. At university, he stayed at Wesley College, where he was in the rowing team. Neil graduated in 1944 and served his internship at Royal Prince Alfred Hospital, Sydney. He then set sail for England as a ship’s surgeon on the HMS Bellerophon, which stopped on the way at Batavia to collect the Dutch gold that had been sent there for safety at the beginning of the First World War. He arrived in England in 1947, where he worked at several hospitals, including Hillingdon Hospital, Uxbridge, where he undertook most of his surgical training. In 1960, he was awarded Fellowship of the Royal College of Surgeons. In the early 1960s, Mona Vale Hospital opened on Sydney’s northern beaches and Neil was appointed its first Medical Superintendent. He helped set up the hospital and recruit staff. A house in the hospital grounds was built for the Superintendent, with a magnificent view over the ocean and golf course. Neil was a keen surf swimmer and swam regularly. Neil remained in this role until he retired in 1986. As Superintendent, Neil regularly visited all sections of the hospital and knew all who worked there, including nurses, pharmacists, and kitchen and ground staff. Although he no longer practised as a surgeon, he maintained his interest by assisting consultant surgeons at the hospital. In his later years, he helped his close friend Dr Josephine Wiseman in her nuclear medicine practice. She subsequently looked after him in his last few years when he was confined to a wheelchair. After a long illness, Neil died on 9 August 2010. James B Roche

James B Roche

Illness in colonial Australia. FB Smith. Melbourne: Australian Scholarly Publishing Pty Ltd, 2011 (371 pp, $49.95). ISBN 9781921509193. Emeritus Professor Francis Barrymore “Barry” Smith, at the Australian National University, Canberra, is one of Australia’s most influential historians. His latest work is both a scholarly review, packed with an immense amount of well supported data, and a collection of largely ill founded opinions from the health professionals of the time, on the origin, causes and management of illness and disease. Smith also considers the influence of public policy and the conflicts between business and health management as, for example, in the avoidance of quarantine. It is clear that the doctors were concerned about the financial impact of quacks and paramedical providers, especially midwives, undercutting their fees. Nothing new! The devastation of Aboriginal communities by illness is described in detail. Smith notes the geographical variation in death rates and the greater ease with which squatters acquired land in some areas as a result. It is clear that these were dangerous times for all. Deaths in the white population were also at phenomenal rates in today’s terms. Parents often put children in contact with sick children to “get it over with”, accepting high rates of death. Unfortunately, the book suffers from poor editing. There are many irritating, long and contorted sentences. In an interesting chapter on tuberculosis, the same quote appears twice within the space of five pages. Chapter Six, “Children”, is not particularly about children, but more to do with the epidemiology of small pox and its management. However, there is an excellent bibliography and a reasonable index. One reads history for information, for entertainment, for general interest and especially to learn where we are coming from and, perhaps, where we are going. It is unclear who the target audience is for this book. Smith does not tie the book together with any conclusions but leaves us to draw our own. Despite its literary failings, this book provides a fascinating insight into illness, and life, in colonial times. We have more evidence today but the nature of man has not changed.

Elliot Rubinstein

The life and work of Dr Ross Ingram (1967–2003) have inspired many Aboriginal and Torres Strait Islander people to send their stories and ideas to the Medical Journal of Australia. It was with much pleasure, therefore, that we welcomed three members of Ross’s family to the presentation of the Dr Ross Ingram Memorial Prizes, at the National Conference of the Australian Medical Association, in Brisbane on 27 May 2011. Ross’s partner, Julie Neville, presented the prizes on behalf of the Australasian Medical Publishing Company. The Competition now has two categories: best essay, and best original artwork. It took us a few years, but the MJA editors finally realised that words are not everything — images can tell powerful stories too! Lindy Moffatt, a Wakka-Wakka, Dunghutti and Gumbaynggirr woman with family ties to both Cherbourg, Queensland, and Grafton on the North Coast of New South Wales, won the essay category, for her story, “Mental illness or spiritual illness: what should we call it?”. Lindy has worked extensively in community work and counseling, and is now an Indigenous Visiting Research Fellow at the Australian Institute of Aboriginal and Torres Strait Islander Studies in Canberra. Her essay vividly describes her son’s journey with mental illness, and explores the effects of transgenerational trauma on Aboriginal and Torres Strait Islander people. It was published in the 16 May 2011 issue of the Journal. Also published in the 16 May 2011 issue, were an excerpt from, and a link to, the winning artwork: an animation called “Alfie the tooth fairy”. Accepting the prize in this category was Alison Dimer, a senior woman of the Madawonga-Galagoo people, the Fire People of the Eastern Goldfields, Western Australia. In her role as an Aboriginal Health Worker, Alison produced the animation for the Western Desert Kidney Health Project of the Rural Clinical School of Western Australia. She worked with animation artist Steven Aiton, local artist Catherine Howard and the children at three local schools to produce the piece, which uses an engaging story to promote the benefits of a healthy lifestyle. Entries for next year’s Dr Ross Ingram Memorial Competition are currently open. For full details see http://www.mja.com.au/public/information/RossIngramCompetition.html. Left to right: Douglas Johnson, Karen Johnson and Julie Neville (members of Dr Ross Ingram’s family), Alison Dimer (producer, best artwork), Lindy Moffatt (winner, best essay), Annette Katelaris (Editor, MJA), Catherine Howard (artist and narrator, best artwork), Ruth Armstrong (Deputy Medical Editor, MJA).

Ruth Armstrong BMed

To the Editor: The number of vulvoplasty or labioplasty procedures rebated by Medicare Australia has more than doubled over the past 10 years;1 in the United Kingdom, a similar trend was observed in the National Health Service (NHS) (Box).2 Recent media debate in Australia highlights this as a concerning problem.3 The community assumes that surgical operations are clinically effective treatments performed for identifiable pathological features. In the context of female genital cosmetic surgery (FGCS), there is a blurring between disease and dissatisfaction, the latter being at least partly informed by cultural pressure about physical appearances. In addition, there is an absence of evidence on clinical effectiveness,4 and an apparent lack of commitment to monitor adverse events. This raises the question of how clinicians justify referring women for FGCS. A recent audit of referral letters for labioplasty in an NHS gynaecology clinic in the UK (University College London Hospitals project no. 03/0173) offers interesting insights. Of the 48 letters reviewed, the mean age of the women referred was 25 years (range, 9–50 years). Complaints about genital appearance were identified in 34/48 (71%) of letters (eg, embarrassment about undressing in public changing rooms). Physical discomfort was mentioned in 23/48 (48%) letters (eg, difficulty with activities such as cycling). Sexual problems were mentioned in 21/48 (44%) letters (eg, a reluctance to engage in sexual relationships). In two of the letters, the referrers mentioned disparaging comments by previous sexual partners, and one mentioned harassment by other girls at school. Alarmingly, a further seven letters (15%) alluded to concerns being flagged by the girls’ mothers. Only 77% of referrers reported examining the patient. A third of referrers judged the labia to be “normal”, yet nevertheless requested surgery for their patients. Pejorative language such as “leathery in appearance” or “pendulous and elongated” was used in 12 (25%) of the letters. Medical training may cover basic vulval anatomy, but detailed study of morphology is not included. This knowledge gap would have been less problematic in the past. However, in recent years, where intense marketing of FGCS5 is contributing to soaring demand, medical practitioners may not be sufficiently informed about female genital anatomy to assess and advise women about their concerns. Reasons for the increasing prevalence of female distress about genital appearance are likely to be complex and rooted in social and cultural changes. In the absence of identifiable diseases, referral for operations may not be the most appropriate way of managing women’s body insecurities. Labioplasty and vulvoplasty operations rebated by Medicare Australia1 and covered by the United Kingdom National Health Service2 over the past 10 years* INR = international normalised ratio. * Graph shows abbreviated, not daily, data. Intervals are weekly up to Week 9, then vary according to when INR was measured.

Rebecca Deans · Lih-Mei Liao · Naomi S Crouch · Sarah M Creighton

To the Editor: Animal and human studies confirm the view that colonisation by non-typeable Haemophilus influenzae (NTHi) of airways already damaged by inhaled toxins initiates a second major pathway of damage in chronic obstructive pulmonary disease (COPD). This provides a framework for novel and effective management strategies for this condition, which has previously been considered to be a self-induced disease of elderly people for which nothing can be done.1 Acute exacerbations of COPD are recognised as critical determinants of acute and long-term outcomes. They represent a shift within the bronchus of the balance between two pressures — colonising NTHi and protective recruitment of phagocytic cells — that favours the bacteria and results in an inappropriate and excessive inflammatory response. A novel oral vaccine that reduces acute exacerbations in COPD is currently undergoing an advanced clinical trial in 21 centres across Australia. Oral immunotherapy with enteric-coated inactivated NTHi enhances the efficiency of mucosal immune protection (Box). In a rodent model, specific T cells, derived from stimulation of Peyer’s patches by orally administered NTHi, enhanced clearance of bacteria from the bronchus by recruiting and activating phagocytes.2 In mice co-infected with NTHi and influenza virus, oral administration of NTHi abrogated the increase in levels of both bacteria and virus, suggesting NTHi is a final common pathway for both viral and bacterial infections.2 In humans who smoke, seasonal increase in circulating specific T cells was significantly augmented after oral immunotherapy with NTHi, blocking access of inhaled NTHi into peripheral airways.3 These data support a mechanism whereby NTHi increases physiological protection based on aspiration of bronchus content into the gut. Qualitative2-4 and quantitative2,3 sputum analysis showed that protection was correlated with a reduction of all pathogens and a significant 3-log fall in NTHi, as expected from specific activation of a non-specific clearance mechanism (phagocytosis). In COPD, T cell-recruited neutrophils within sputum undergo a phenotypic change characterised by longevity and enhanced phagocytosis, maintained by autocrine loops.2 Early clinical trials4 of oral immunotherapy showed reductions in the frequency and severity of exacerbations, with consistent decreases in antibiotic usage of more than 50%. A potent and well characterised NTHi isolate with broad cross-protection in screening assays has now been developed for use as the vaccine HI-164OV (unpublished data). Phase II clinical studies of the vaccine have shown it is safe and effective3 and resulted in significant reductions in exacerbations treated with systemic corticosteroids (63%) and hospital admissions (90%)5 among patients with severe COPD taking best-practice treatment. Phase IIb trials are now underway. Evidence of IgE antibody to NTHi in both COPD and treatment-resistant asthma predicts broader clinical value for oral therapy with HI-164OV, through its capacity to prevent inhaled bacteria (allergens) penetrating into small airways.3 Enhancement of mucosal immune protection by oral immunotherapy with enteric-coated inactivated non-typeable Haemophilus influenzae1 Aspiration of bronchus content (including bacteria) into the gut (1) stimulates Peyer’s patches (3) to release T lymphocytes that “home” to the bronchus (4). T lymphocytes — directly or indirectly — secrete cytokines and chemokines that augment recruitment and activation of phagocytes (5). Phagocytes reduce the colonising load of bacteria in the damaged bronchus mucosa. Ingestion of inactivated non-typeable Haemophilus influenzae (2), as a vaccine, augments this protective loop.

Robert L Clancy · Margaret Dunkley

To the Editor: The Australian state of Queensland has one of the highest rates of melanoma and non-melanoma skin cancer in the world.1,2 Solar ultraviolet (UV) radiation is the most important environmental risk factor,3 highlighting the need for sun safety education and skin cancer screening among outdoor workers in Queensland. Many such programs are currently in place, including the Sunsafe Workplace Program developed by the University of Queensland in collaboration with the Queensland Skin and Cancer Foundation in 2007. In August 2010, we attended an outdoor workplace in Brisbane, with extensive sun safety policies already in place, to perform free voluntary skin checks on employees. Of 55 people invited to participate, 39 accepted. Of these, 36 were male, the median age was 35 years (range, 19–62 years), and 28 were of British and/or Irish ancestry. Eighteen participants reported spending 5–8 hours a day outdoors mid week and 20 reported the same at weekends. Six reported that at the start of summer, they never tanned and always burned, and 31 reported burning first, then tanning. Nearly half reported having had more than five painful sunburns in their lifetime. Despite these results, only a third of participants (13) reported wearing sunscreen, less than half (17) reported wearing a hat, and two-thirds (26) reported wearing sunglasses more than 50% of the time. Of the 39 participants, we referred one to his general practitioner for management of two non-melanoma skin cancers. About half of the participants reported having had formal skin checks before. Of these, one had previously had melanoma and five had non-melanoma skin cancers, and 10 had one or more suspicious naevi removed in their lifetimes. The main reasons given for not having had a previous skin examination were fear of skin cancer diagnosis and difficulty attending appointments during working hours. We found that providing easy access to free on-site skin examinations reduced interference to the work day, made appointments more accessible (both physically and financially), and enabled us to provide personalised information about participants’ skin and skin cancer risks and reassure those who had been anxious about receiving skin cancer diagnoses. We found that workers were relieved when told they had nothing suspicious presenting on the day, and that they seemed less anxious about seeking skin checks in the future. Despite many public awareness campaigns on skin cancer and the establishment of sun safety programs in the workplace, we found there is still room for improvement. Although clinical guidelines do not currently recommend routine skin cancer screening for the general population,4 the success of our visit leads us to encourage workplaces that are exposed to solar UV radiation to consider providing on-site skin examinations for employees, as well as ongoing sun safety education. We believe such services can help to break down barriers that prevent people from seeking medical assessment and management, and can help to spread the safety-in-the-sun message.

Nicola C Douglas · Laura Baillie · H Peter Soyer

To the Editor: In their report on the findings in Hope v Hunter and New England Area Health Service,1 Mahar and Burke suggest that some of the judge’s reasoning “may reasonably cause apprehension for clinicians relying on the peer professional practice defence”.2 In her Editor’s Choice, Katelaris mirrors this apprehension.3 But the judge’s findings are not nearly so troubling. Mahar and Burke state that “the court considered ... that because the defendant had completed much of his training in the United Kingdom and the United States, the evidence that he gave was not necessarily indicative of professional practice in Australia”. However, the judge had said: Without at all intending any criticism of Associate Professor Haertsch [expert witness for the defendant] ... his practice was in accordance with what he had learnt in his training in Edinburgh, Scotland and in Michigan, USA which was not, of itself, evidence as to peer practice in this country.1 The judge’s point was not about the defendant having trained overseas — the judge made no mention of where the defendant had trained. The judge was concerned about the expert witness who was testifying as to what extent the technique used by the defendant was peer practice in Australia. In doing this, the expert witness described how he conducted this sort of procedure, drawing on his overseas training. Quite reasonably, the judge regarded this as “not, of itself, evidence as to peer practice in this country”. Also, Mahar and Burke state that because the same expert witness had consulted a colleague about her practice concerning ganglion excision, the “court noted that this witness ... was in sufficient doubt to consult another practitioner” and “this may have partly informed the court’s decision to reject the expert’s evidence for the purposes of the defence”. However, the judge had said: I also consider it telling that Associate Professor Haertsch appeared to be in sufficient doubt about the matter that he thought it was necessary to consult Dr Gschwind for her views and for details of her practice concerning ganglion excision. I infer from the fact of such consultation, together with the fact that Associate Professor Haertsch has only operated on little rice grain sized ganglia ... that he has not had the same breadth of experience as Associate Professor Connolly [expert witness for the plaintiff] as to what constituted widely accepted professional practice ... concerning the excision of a half centimetre sized ganglia of the type that the plaintiff had presented for removal. In this regard I prefer the evidence of Associate Professor Connolly to that of Associate Professor Haertsch.1 Seen in context, it is hard to draw the conclusion that the testimony of the expert witness “was discounted because ... he consulted a colleague about her views on the case”.3 If the consultation with a colleague discounted the testimony, it was a very minor factor.

Christopher J Ryan

To the Editor: The Journal recently drew attention to circumstances in which courts have not accepted professional opinions on standard of care required in negligence cases.1,2 These include opinions formed after consulting colleagues, from doctors trained overseas or unrepresentative of national peer professional practice. In a veterans’ entitlements case in 2004 (Linton and Repatriation Commission3), in which I was an expert witness for the Department of Veterans’ Affairs, the Administrative Appeals Tribunal did not accept an opinion on appropriate clinical management in the past from an expert whose memory of peer professional practice was contradicted by documents that were in use at the time in question, preferring the latter. However, contrary to the circumstances described by Mahar and Burke, the Tribunal did accept opinions from a doctor who consulted others and from me, even though I trained overseas. The Repatriation Medical Authority produces “statements of principles” that enumerate factors which connect veterans’ health to service under the Veterans’ Entitlements Act 1986 [Cwlth].4 Inability to obtain appropriate clinical management is a factor in many of these statements. Tribunals have relied on professional opinion to determine the appropriateness of clinical management received by veterans. In Linton and Repatriation Commission, a veteran claimed in 2004 that withholding corticosteroids during the 1970s constituted inappropriate management of asymptomatic hilar lymphadenopathy due to sarcoidosis.3 There was disagreement between expert witnesses. One expert, a graduate of 12 years and a newly qualified Fellow of the Royal Australasian College of Physicians (FRACP) in the early 1970s, believed that the veteran should have been offered corticosteroids. Another FRACP, who was 15 years younger and graduated in the mid 1970s, after consulting colleagues who had practised at the time in question, believed corticosteroids would reasonably have been withheld. Despite being trained in the United Kingdom, the Tribunal accepted evidence from me on three important issues.3 First, the Tribunal accepted that textbooks used in the 1970s may contain statements of what should have been done at that time to manage sarcoidosis. Second, the Tribunal accepted that, based on the textbook on which Australian physicians probably relied during the 1970s, patients with the veteran’s condition were unlikely to have been treated with corticosteroids owing to an expectation that the condition would resolve spontaneously. Third, the Tribunal accepted that early clinical trials of corticosteroids in the treatment of pulmonary sarcoidosis between 1967 and 1976 were inconclusive and gave doctors no reason to believe that steroids would alter the long-term outcome of the condition. In addition, a 2000 Cochrane review found that the long-term effect of steroids was still unclear.5 The Tribunal, therefore, found that the veteran’s condition was managed appropriately. Comparing the circumstances under which civil courts and the Administrative Appeals Tribunal have not accepted opinions on standard of care would reveal any systematic differences between the jurisdictions.

Hedley G Peach

To the Editor: By focusing on the observed low correlations between the Undergraduate Medicine and Health Sciences Admission Test (UMAT) and academic scores at the University of Queensland (UQ), Wilkinson and colleagues1 conclude that the UMAT is a poor predictor of medical student performance. Alternatively, one could focus on the very high mean and low variance grade point average (GPA) scores of the UQ student cohort and conclude that the use of UMAT scores was clearly very successful in identifying a high-performing group of students. However, before making any conclusions based on these data, we should draw on the vast literature that highlights common problems that significantly affect validity coefficients.2 Range restriction is one such problem, and Wilkinson and colleagues rightly used Thorndyke case 2 to correct for this in their UMAT scores. Although they achieved little change in observed correlation values, a recalculation using the mean standard deviation of the entire UMAT cohort for the period 2005–2009 actually takes the 0.14 correlation between Section 1 and Year 1 GPA to 0.27. Despite this considerable increase, Thorndyke case 2 only accounts for direct range restriction of the predictor (UMAT scores). However, in the context of medical student selection, there are other important sources of error that need to be accounted for in order to better appreciate predictive validity. First, use of a high cut-off on the high school examination score is very likely to add indirect range restriction on the UQ UMAT scores. This may be further attenuated by not including measures of non-cognitive ability (interviews). Second, selection on cognitive ability tests (UMAT and high school results) also creates range restriction on the largely cognitive criterion (GPA) that would further reduce observed validity correlations. The UQ study illustrates such restriction. Third, the unreliability of the criterion itself needs to be accounted for, especially when more subjective ratings are included, such as ratings of clinical performance. The problem of relatively small samples in selection studies is well documented.2 Given the evidence of extreme range restriction of predictor and criterion variables used in medical school selection research, more primary studies (followed by meta-analysis) are necessary before accurate conclusions can be made about the use of the UMAT, or of any other predictor used in this high-stakes selection context.

Barbara N Griffin

To the Editor: I spent my fifth-year medical student elective at Alice Springs Hospital and a remote Aboriginal settlement in the north-west of South Australia in the early 1980s. I organised this myself and came away with a fairly firm belief that the health of the Indigenous population in remote areas was unlikely to improve. Between 1995 and 2009, I visited remote Aboriginal settlements and hospitals in Darwin and Alice Springs as a specialist physician. Nothing I have seen in that time has changed the view I formed as a student. During my time in these settings, I have seen in the Indigenous population extreme examples of poverty, severe neglect of children and adults with disability, and examples of physical and sexual abuse. On occasions I have been threatened, and at times I have needed to be escorted for my safety. When staying overnight on settlements, I have been provided with secured accommodation. I have walked in fear of feral and diseased camp dogs and have been hurried along in my work to avoid cultural incidents. The article by Patel and colleagues explores some of the issues in this area as they affect medical student training.1 I think it is good that they have done so, but to dress it up with quasi-scientific methodology is unnecessary. My view is that it is not possible to provide or sustain health services of any reasonable standard in small and remote communities that have no economic basis for development and where the population is poor, poorly educated and has little prospect to share in this country’s fortune. There is a reason that we are failing to improve the health of the Indigenous population in remote areas, and that is that we cannot. It is an unrealistic expectation. This needs to be acknowledged, and we all need to move on.

Adrian N Winsor

To the Editor: In their editorial about risks to medical students in rural and remote placements, Peachey and McBain-Rigg stated: But there is a danger that, in focusing only on possible harms, we underestimate the power of difficult circumstances to enhance the very attributes that are required for the long haul in rural and remote practice.1 They referred to such issues as a “philosophical quandary” and went on to use a metaphor about a breaking bungee rope. The editorial conflated two important issues: safety and character-building experiences. The safety of visiting medical students and workers is not a philosophical quandary. Requirements of occupational safety are a practicable matter and a matter of law. Employers are required to assess and manage risks. The editorial’s authors are from Queensland, where the current relevant legislation is the Workplace Health and Safety Act 1995. Assistance is available from state workplace safety bodies, such as Workplace Health and Safety Queensland. Patel and colleagues made a good empirical assessment of adverse events that have happened to medical students in remote areas.2 Such an assessment could contribute to a safety management plan and system. Patel et al stated that “a ‘distressing’ incident does not necessarily lead to an overall negative placement and may in fact be a powerful learning experience”. They gave the example of a female student who was not met when she got off a bus at a remote community at 3 am, which concluded with the student’s words that the placement was a “good placement medically”. A worker might implicitly or explicitly approve of any risk that he or she is exposed to, but this does not relieve the employer of its obligations to the worker’s safety. Inviting readers to look on the bright side of safety shortcomings is not in the best interests of medical students, the permanent workforce or the population of rural and remote areas.

Andrew W Nielsen

In reply: It saddens us that Winsor’s experiences as a remote visiting specialist are so depressingly familiar, but his nihilism is even more disturbing. There has in fact been improvement in the health of the Indigenous population in remote communities; examples of this include the evidence provided by articles in the very same issue of the Journal, by Margolis and colleagues (falling rates of serious injury retrieval) and Ward and colleagues (declining syphilis rates).1,2 An understanding of the social determinants of health is essential to accepting that we can indeed work towards improving health, perhaps not through focusing on specialist medical services but rather in the broader primary health care context. Our students and patients deserve clinicians and mentors who might inspire and look for solutions, rather than retreat into despair. Progress in closing the gap will be far slower than many imagine, but it is not impossible, as we have already seen. We totally refute that we used a “quasi-scientific methodology”. Our study is a simple retrospective audit with not a P value in sight,3 and it has no pretensions to be otherwise. It aims to present a clear story from a defined group, and to add to the many individual anecdotes, such as Winsor’s, that on their own do not gain the attention of employers, policymakers, or government. By building a body of evidence, surely we will be able to more effectively advocate for systemic changes. Collaborating with interested colleagues such as remote area nurses who have published more widely on their own adverse experiences4 is another key strategy in influencing change. We agree wholeheartedly with Nielsen’s viewpoint that obligations to workplace health and safety legislation and to company policy and procedures should be paramount. However, this breaks down when individuals employed or contracted in various capacities are incompetent, ignorant, stupid or just have a sheer disregard for the rules. In addition, there appears to be a lack of scrutiny in remote areas where lower standards are somehow acceptable, and legal frameworks somewhat more fluid. The romanticisation of the bush and the culture of “making do” is partly responsible for the laissez-faire attitude to occupational health and safety. Perhaps our metropolitan colleagues could assist in challenging the status quo and the deeply entrenched beliefs, attitudes and systems that collude in silencing questioners and burnt-out staff.

Ameeta Patel · Margaret Vigants

CorrectionMean number of days in hospital incorrectly expressed: In “Hospital and emergency department use in the last year of life: a baseline for future modifications to end-of-life care” in the 6 June 2011 issue of the Journal (Med J Aust 2011; 194: 570-573), the mean number of days in hospital was given per hospital admission for decedents with and without cancer. This should have read: “Decedents with cancer had a mean number of hospital admissions of 7.6 (SD, 10.2; median, 5) with the mean number of days in hospital per decedent of 41.3 (SD, 35.2; median, 34). Decedents with non-cancer diagnoses had a mean number of hospital admissions of 8.1 (SD, 23.1; median, 3) with the mean number of days in hospital per decedent of 49.6 (SD, 60.0; median, 30).” The html and pdf versions of this article are corrected

Lorna K Rosenwax · Beverley A McNamara · Kevin Murray · Rebecca J McCabe · Samar M Aoun · David C Currow

Autism linked to SSRIs Exposure to selective serotonin reuptake inhibitors (SSRIs) during pregnancy may increase the risk of autism spectrum disorders (ASD), according to a study of 298 children with ASD and 1507 control children. The population-based, case-controlled study is the first to systematically address the association between prenatal SSRIs and ASD risk. The researchers found that children whose mothers took SSRI antidepressants in the year before delivery were twice as likely to develop ASD. SSRI use in the first trimester was associated with a threefold increased risk. The results held after controlling for the underlying mental health indication. No increased risk was found in children whose mothers had a history of mental health treatment but hadn’t taken SSRIs during pregnancy. Despite the significant association between SSRI use and autism, the researchers cautioned that only a small number of women were exposed to SSRIs in the study, and called for further research on the topic. The potential risk of SSRIs also needs to be balanced with the risks to the mother or fetus of untreated mental illness, the researchers added. Arch Gen Psychiatry 2011; 4 July (online) Pregnancy safe in MS Between one-fifth and one-third of women with multiple sclerosis (MS) bear children after disease onset, but research on the effect of MS on pregnancy outcomes has had conflicting results. A new study using information from a large Canadian database, which captures 99% of births in British Columbia, may be reassuring for women with MS and their doctors. The research found that MS was not associated with a significantly different mean gestational age or birthweight, nor was it associated with higher rates of assisted vaginal delivery or caesarean section. However mothers with more severe MS had slightly higher odds of caesareans and assisted vaginal births but this did not reach statistical significance. Researchers said this warranted further study. Ann Neurol 2011; 27 June (online) Grog on the job It seems that bar staff are taking a “one for you, one for me” approach to service, with 18.6% of Australian hospitality workers reporting that they usually drink alcohol at work. The secondary analysis of a large, nationally representative survey found that overall, 8.7% of Australian workers usually drink alcohol at work and 0.9% usually take drugs at work. The analysis of data on 9828 Australian workers aged 14 or older also found that 5.6% reported attending work under the influence of alcohol, and 2% attended work under the influence of drugs. Hospitality workers were the most likely to drink at work (18.6%), followed by financial services workers (14.7%) and construction workers (10.6%). “In general, workers who were younger, male, never married, frequent drinkers and had no dependent children were more likely to drink at work or attend work under the influence of alcohol than other workers”, the researchers wrote. Addiction 2011; 27 June (online) Do the fat potato If you’re trying to lose weight, put down the potatoes. Using three large population studies, US researchers examined the association between increased intake of various foods and long-term weight gain among 120 877 men and women. Within each 4-year period, the participants gained an average of 1.5 kg. Weight gain was most strongly associated with increased intake of potato chips, potatoes and sugar-sweetened beverages. Increased intake of yoghurt was associated with the largest weight loss, followed by nuts, fruits and whole grains. The researchers suggest that weight loss strategies may be more effective when specific foods are targeted for increased or decreased consumption. N Engl J Med 2011; 364: 2392-2404 Trial by marketing The pharmaceutical industry plays a major role in supporting scientific research, but new research suggests that commercial interests may sometimes outweigh the scientific goals. A recent review of documentation relating to a trial of an epilepsy drug, gabapentin (Neurontin), concluded that it was a “seeding trial” designed to promote the drug.1 A related editorial describes a seeding trial as an “important and expensive form of marketing” where the primary objective is to introduce a new product and induce clinicians to use it, rather than to answer a scientific question.2 The researchers, who had access to trial documents because they were consultants in a lawsuit involving the drug, discovered that documents consistently described the trial itself as a marketing tactic. The researchers also said the study’s validity was undermined by its poor trial design, which used an uncontrolled, unblinded methodology. 1 Arch Intern Med 2011; 171: 1100-1106 2 Arch Intern Med 2011; 171: 1107-1108 Sophie McNamara, MJA

Sophie McNamara