Volume 195 Issue 6

Time to examine a system harming the health of both detainees and detention centre staff On 29 July this year, Commonwealth Ombudsman Allan Asher confirmed that his office would undertake an investigation into suicide and self-harm in Australian immigration detention facilities.1 The investigation will examine rates of suicide and self-harm relative to those in the broader Australian community, and factors such as length of time in detention and the design of mental health services for detainees. Our view is that the Ombudsman is right to undertake such an inquiry. Simply put, there is a crisis within the detention system, requiring an urgent need to identify contributory factors. More than 1100 incidents of threatened or actual self-harm across all places of detention were reported in the 2010–11 financial year.1 Fifty-four incidents of self-harm were reported during the first week of July this year alone. After a lengthy period of no suicides,2 there have been five since September 2010.3 There have been reports of many “near-miss” cases and of a culture of hopelessness and despair inside detention centres.3 Given that suicidal behaviour can be considered as a continuum of thoughts and behaviours, ranging from suicidal ideation to completed suicide,4 we think the need for such an investigation raises important questions about how much is known within immigration detention centres about: the determinants of detainee self-harm and suicide risk;5 a detainee’s preparatory acts toward imminent suicidal behaviour (eg, locating ligature points and assembling the necessary apparatus); how detainees are managed after a serious suicide attempt; the type and cultural appropriateness of the support being provided to detainees; the possibility of possible contagion surrounding suicide and self-harm; and how effective existing policies and staff training are in preventing suicidal behaviour. These considerations are important because the detention environment is known to harm both mental and physical health. Detainees express their distress in ways that are in keeping with their culture and the setting they are in. Strong evidence confirms poor health among immigration detainees, which deteriorates over time, and shows a clear association between time in detention and rates of mental illness.6 Overcrowding within immigration detention is a major concern and most likely magnifies mental ill health through factors such as tense patterns of interaction and an inability to buffer stressful events or uncomfortable physical factors such as heat. Living in limbo and uncertainty can manifest in feelings of fear, anxiety, sleep disturbance and self-harm, along with irritability and frustration. A recent systematic review of studies investigating the impact of immigration detention on the mental health of children, adolescents and adults identified high levels of mental health problems in detainees.7 Time in detention was found to be associated with severity of distress. Anxiety, depression and post-traumatic stress disorder were commonly reported, as were self-harm and suicidal ideation. There is evidence for an initial improvement in mental health shortly after release, although mental health effects may be prolonged, extending well beyond the point of release into the community.8 In the months leading up to the Commonwealth Ombudsman’s announcement, significant incidents had been unfolding, including detainees stitching their lips together, hunger strikes, violent confrontations and property damage. There are also reports of isolation cells being converted into full-time behaviour management units where detainees who are distressed or disturbed, or who try to kill themselves, are fitted with soft helmets and handcuffs to stop them cracking their heads against the floor or walls or harming themselves in other ways.9 Such claims must be examined. They raise serious issues about the commitment of the detention system to human rights. In addition to these matters, the detention environment is also known to impact heavily on the mental and physical health of the people who work there. A national humanitarian solution is critical. Without this, the consequences will be catastrophic for all who are engaged in this system. We urge the government to act swiftly to prevent more human tragedy.

Louise K Newman MB BS, PhD, FRANZCP · Nicholas G Procter PhD, MBA, RN · Michael J Dudley MB BS, BD, FRANZCP

A carbon price is vital for the public good; complementary policies should protect low-income households Anticipating the Australian Government’s announcement of a carbon tax, the Royal Australasian College of Physicians (RACP) stated that, while it accepted the need to take action on climate change, it recommended caution about a carbon tax because it could exacerbate health inequalities.1 Some in the media inferred that the RACP’s primary concern was the potentially negative health impact of a carbon tax.2 It is reasonable for health professionals to be concerned about the welfare of low-income households, because people in these households usually spend a disproportionate share of their income on energy and food. However, the larger policy issue is the incontrovertible evidence that climate change is occurring3 and will have profoundly negative health impacts.4,5 A longer lens tells us that a carbon price is especially in the interests of those with low incomes, whose lives will be more disrupted by climate change than will the lives of the wealthy, and among whom the negative health impacts will be greater.6 If the level of global warming is to be constrained below 2°C, all countries must take extraordinary policy actions. This temperature increase is the optimistic “guardrail” beyond which we are unlikely to be able to maintain the climatic stability on which our current civilisation depends. It is far from clear that we have the global geopolitical will to prevent warming in excess of this 2°C level. Because climate change is occurring at the same time as we have passed the peak of conventional oil supplies,7 and unconventional methods of oil extraction involve even more greenhouse gas emissions, all developed countries must now take urgent and effective policy action on climate change to protect human health and planetary ecosystems. Taxation is one of the most powerful policy tools avail-able to governments, but it is also one of the most politically controversial. Individuals who pay a particular tax are not necessarily those who will benefit from the revenue raised. Carbon taxes and other environmental taxes cannot be seen in isolation; such taxes should be judged by their overall distributional effect, as the revenues are disbursed through transfers or government expenditure. Putting a price on carbon will inevitably cause increases in energy prices, and failing to compensate low-income households for these increasing costs would be regressive and could lead to low-income households having to make unhealthy choices about whether “to heat or to eat”. However, governments with a clear strategic intent to reduce health inequalities have many policies available to ensure that their overall policy package is progressive, as well as effective in cutting emissions. At the same time as the Australian Government announced the carbon tax, they announced other tax changes, with more than half the money raised by the carbon tax to be redistributed to households by way of tax cuts and increases in pensions, allowances and family payments. The taxation, benefit and expenditure arrangements in developed economies constitute an integrated system, and the outcomes of any policies should be assessed by effects on overall measures of income and wealth distribution. For example, the roll-out of the United Kingdom’s Decent Homes Programme — requiring homeowners and landlords to bring their houses up to a decent standard — has made a positive contribution to lowering energy costs for low-income households.8 Similarly, American research has shown that home energy assistance programs for low-income households can reduce nutritional and health risks among children under 3 years of age.9 In New Zealand, in contrast to the recent Australian housing insulation debacle, successive governments have subsidised insulation and more effective, non-polluting heaters. This popular policy was based on evidence that these measures increased the energy efficiency of houses and lowered the household’s energy expenditure.10,11 There were also broader social and health benefits that outweighed the costs of subsidising these programs by local and national governments.12 These are all examples of policies that have required increased initial expenditure — in some cases by both households and governments — for medium- and long-term broad benefits. They are policies that balance targeting and universalism, and are appropriately proportionate to need. Putting a price on carbon, via a tax or other means, likewise enables societies to manage their carbon emissions more efficiently, creating incentives to reduce emissions where it is easiest to do so. The Intergovernmental Panel on Climate Change concluded that the greatest sectoral emission reductions can be made in the buildings sector.13 The World Health Organization has recently published a report highlighting that while there are inevitably costs involved in reducing carbon emissions in buildings and in household use of energy, the co-benefits for health are significant, particularly for low-income households.14 Health sector organisations should support putting a price on carbon and should take care with their media releases, lest any statements be taken out of context and misused by opponents of carbon pricing. These organisations need to highlight the potential health benefits of public policies15 while monitoring policy packages to ensure that, overall, they reduce inequalities in income and health.

Philippa L Howden-Chapman MA, DipClinPsych, PhD · Ralph B Chapman BE, MPA, PhD · Anthony G Capon MB BS, PhD, FAFPHM · Nick Wilson MB ChB, DIH, MPH

Australian database linkages could be used for postmarketing surveillance of antidiabetic therapy side effects Several incretin hormone-based therapies for type 2 diabetes are marketed in Australia. These are exenatide (the glucagon-like peptide-1 [GLP-1] analogue) and sitagliptin, vildagliptin and saxagliptin (inhibitors of the enzyme dipeptidyl-peptidase-4 [DPP-4]). These drugs are attractive because they improve blood glucose control without weight gain and with less hypoglycaemia than insulin and its secretagogues. Their distinct mode of action means that they improve glycaemic control when added to more established blood glucose-lowering therapies. This underlies their current Pharmaceutical Benefits Scheme listing as part of dual or, in the case of exenatide, triple therapy with metformin and/or sulfonylurea treatment. With increasing use of these drugs, more data relating to their adverse effects have emerged. A case linking pancreatitis with exenatide therapy was described 5 years ago,1 and further case reports have meant that specific warnings are now included in the product information for all GLP-1 analogues and DPP-4 inhibitors. Animal studies with the GLP-1 analogue liraglutide (registered but not currently available in Australia) raised the possibility of medullary (C-cell) thyroid cancer. Although an increased risk of this tumour was not evident in humans in preregistration trials, liraglutide is contraindicated in patients with a personal or family history of medullary thyroid cancer and in patients with multiple endocrine neoplasia syndrome type 2 (http://www.novo-pi.com/victoza.pdf). Inhibition of DPP-4 may predispose to hypersensitivity reactions through prolonged action of neuropeptides such as substance P,2 and alter immune function, with a possible increased risk of infections.3 However, the relative infrequency of adverse effects such as pancreatitis, C-cell cancer and severe allergy means that large case–control databases are needed to provide accurate estimates of their incidence and predictors. In an attempt to provide better information on incretin therapy-associated adverse effects, United States researchers led by Peter Butler recently used the US Food and Drug Administration (FDA) publicly available Adverse Event Reporting System (AERS). An initial accepted report containing the results of these analyses appeared in February 2011 on the website of the journal Gastroentrology. The main findings were of a significantly increased risk of pancreatitis and pancreatic cancer with exenatide and sitagliptin (the two most-used incretin-based therapies in the US), as well as an increased risk of all thyroid cancer (not just medullary) with exenatide. After the validity of these findings was challenged by the manufacturers,4 the paper was withdrawn but a modified version subsequently reappeared online and in print.5 The use of AERS to identify adverse drug effects is controversial and its substantial limitations are acknowledged by the FDA itself. Reporting is uncontrolled, voluntary, from multiple sources and often incomplete. Overreporting of events for new drugs, especially during the first 2 years and for serious outcomes, is well recognised.6 The choice of comparator treatments, from which odds ratios for the occurrence of index events are generated, has a bearing on the results, as does knowledge of other therapies or patient factors that might also increase the risk of an event. For pancreatitis, this includes the association between diabetes and obesity, as well as drugs that have relatively high use in type 2 diabetes, such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, statins and fibrates. Although mining of data from the AERS has successfully found previously unrecognised adverse effects, a study of 21 unrelated therapies suggests that only about 50% of the signals thus identified subsequently appear in the product information or lead to regulatory actions, while an equivalent number of clinically important signals are missed.7 In the case of incretin-based therapies, the FDA’s automated algorithm Empirica, which is designed to signal AERS safety alerts, did not do so. In addition, one unrelated retrospective analysis of a large US medical and pharmacy claims database, involving 786 656 patients, did not show either exenatide or sitagliptin to be associated with an increased pancreatitis risk.8 The Butler group state that their analyses do not establish that pancreatitis, pancreatic cancer and thyroid cancer are caused by incretin-based therapy but suggest that appropriate studies are required to rule out these associations.5 Accurate incidence of pancreatitis will be difficult to obtain without adequately powered long-term prospective studies, but at least the product information for these drugs warns of this infrequent potential adverse effect. For the possible association between cancer and incretin-based therapy (and since other diabetes treatments including glargine insulin9 and pioglitazone10 might be cancer-promoting), it seems sensible to urgently develop coordinated links between diabetes prescription databases and cancer registries. Available Australian databases and links mean that government agencies could take a lead in this and provide independent, postmarketing observational data for the two incretin-based classes and individual drugs that are more robust than those generated by systems such as AERS. The history of diabetes treatment, from phenformin to rosiglitazone and even newer compounds, illustrates the continuing requirement for comprehensive preclinical and clinical safety and efficacy data before registration. Robust multifaceted postmarketing surveillance and data for important adverse effects, even if they are uncommon, are also necessary. Analyses such as those by the Butler group4 should not direct clinical decision making, but are part of the pharmacovigilance process that aims to provide regulatory authorities, clinicians and patients with the best evidence of the risks and benefits of individual blood glucose-lowering therapies.

Timothy M E Davis MB BS, DPhil, FRACP

The full content of this article is available by downloading the PDF.

The full content of this article is available by downloading the PDF.

Health reporter Ray Moynihan welcomes the side effects of prescriptions to fight climate change As one of the planet’s most polluting populations, it’s perhaps understandable that many Australians have a good deal of fear and loathing about cleaning up our act. What might lift our mood for change is the growing evidence that strategies to reduce greenhouse gas emissions can directly improve the length and quality of human life. The World Health Organization is currently assessing the health impacts of different climate change mitigation strategies, and it’s come to some compelling, though still tentative, conclusions. The project, called Health in the Green Economy, has found that although many policies will have benefits for both health and the environment, “some of those having the largest impact on mitigation may also deliver the largest health gains”.1 In housing design, for example, natural ventilation and better insulation are obvious energy-efficient measures, but they may also reduce allergies, asthma and, in some places, illnesses associated with cold and damp. In kitchens throughout the developing world, cleaner, more fuel-efficient stoves could cut rates of childhood pneumonia and adult lung cancer and chronic obstructive pulmonary disease, while also reducing greenhouse gas emissions in the residential sector. In the area of transport, the WHO has some strong words about the health benefits of shifting focus from the private car to public transport, pedal-power and pedestrians. Such a shift, it says, could reduce respiratory and heart disease from air pollution, cut injuries from road accidents, and help prevent obesity, diabetes and cancer by boosting physical activity, potentially saving millions of lives every year. “A shift to active transport (walking and cycling) and rapid transit/public transport”, says the WHO review of the evidence, “can yield much greater immediate health ‘co-benefits’ compared with improving fuel and vehicle efficiency, yet the latter has been the mitigation strategy most emphasized by the Intergovernmental Panel on Climate Change”.1 The health care sector itself has been identified as another key climate change culprit, with estimates that it contributes perhaps 8% of all greenhouse gas emissions in the United States.2 Energy-intensive activities, gaseous wastes and huge use of water and transportation all contribute to health’s unhealthy carbon footprint, which until now has failed to attract much attention from those seeking to slow global warming. The WHO review again suggests win–win strategies, including the “greening” of health care facilities, by using more renewable energy and procuring fewer medical products that ultimately remain unused. “[The health care] sector is worthy of special attention due to its size, its growth, and its direct impacts on health”, says the review.1 Other groups, such as the global non-government organisation Health Care Without Harm, are already working on more “ecologically sound” alternatives to existing health care practices. One of its current campaigns is promoting more sustainable management of toxic medical waste in a demonstration project across eight nations, designed to reduce polluting gases and improve the health and safety of health care workers.3 A futuristic vision of health care in the post-peak oil world appeared in the BMJ last year, complete with dreams of less energy-intensive therapies and non-petroleum-based pharmaceuticals, delivered via hospitals that are accessible to all by foot, bicycle and public transport.4 Whether that future appeals to you or not, it’s clear that as we finally face up to climate change, the business of health will increasingly be exposed to the glare of environmental scrutiny. In Australia, the newly formed Climate and Health Alliance is stressing the potential win–wins for health and the environment,5 and in December the world’s first Global Climate and Health Summit will meet in Durban, South Africa. For anyone simply interested in an evidence-informed approach to decision making, the WHO is putting some fascinating new facts on the table that are helping to show which climate change strategies might have the biggest health benefits, and which carry risks. At the launch of the Health in the Green Economy project earlier this year in Washington, DC, a leading WHO figure called for a “new alliance” of policymakers across the climate change, housing, transport and health sectors. Let’s hope the call was heard loud and clear down under.

Ray Moynihan BA

The 2010 trivalent influenza vaccine (TIV) manufactured by CSL Biotherapies (CSL) was associated with increased febrile reactions, including febrile convulsions, among Australian children. CSL is one of the few manufacturers that use deoxycholate as the virus-splitting agent in the manufacture of TIV. Clusters of adverse events following immunisation (AEFI) have been previously linked to other deoxycholate-split TIV formulations in Europe and Canada. We hypothesise that suboptimal virus splitting or other mechanisms related to the use of deoxycholate may have played a role in adverse events linked to the 2010 CSL TIV. This hypothesis garners support from a recent United States Food and Drug Administration warning letter indicating that CSL failed to determine optimal splitting conditions for new virus strains and that assays to assess virus splitting had not been validated. While there may be other causes, the use of deoxycholate should be further explored. Comprehensive and timely investigations of AEFI, especially those involving children, are necessary to prevent their recurrence and to maintain public confidence in vaccination programs.

Heath A Kelly BSc, MB BS, MPH · Danuta M Skowronski MD, FRCPC · Gaston De Serres MD, PhD · Paul V Effler MD, MPH

To the Editor: Recently, there has been an increase in the popularity and use of baby slings to transport infants. A sling is a soft fabric carrier, worn around a parent or caregiver’s neck, in which the infant is suspended. Slings are often promoted as a secure and easy way to carry an infant, that maintains close contact with the child. An issue has arisen concerning the safety of such devices, in that infants may be placed in a position where there is excessive flexion of the neck (chin-to-chest positioning) or obstruction of the mouth and nose that may cause suffocation. Warnings have recently been issued by the Australian Competition and Consumer Commission.1 Sixteen deaths attributed to the use of slings have occurred in the United States and Canada,2,3 resulting in calls for mandatory standards by the US Consumer Product Safety Commission.2 We report a South Australian case of a 2-day-old boy, born at 38 weeks’ gestation by normal vaginal delivery, who was placed into a cloth sling worn under his mother’s shirt and jumper and was subsequently noted by his mother to be cold and not breathing. At autopsy, there were no significant abnormalities identified, with no injuries visible on x-ray or physical examination. Results of toxicological, metabolic, virological and bacteriological studies were normal. In the absence of definitive pathological findings, the cause of death was undetermined, although the baby sling was considered a risk factor. It is well recognised that infants placed in certain positions, such as in car safety seats, may be at risk of significant oxygen desaturation, and even death, due to upper airway compromise. This applies particularly to preterm and low-birthweight infants.4 It appears that a similar situation occurs with certain slings, albeit rarely, as the soft and rounded sleeping surfaces may promote a potentially dangerous posture that impedes normal respiration. Certain infants may also be quite vulnerable to airway occlusion, with deaths being reported while breastfeeding, for example.5 Given the cases of infant death associated with baby slings in North America, and this Australian case, it is important that parents and carers are made aware of potential safety issues with the use of these devices, particularly in very young infants. Constant monitoring of infants in slings is advised, to ensure that the infant’s head is facing outwards, with no covering of the face.

Roger W Byard · John D Gilbert

To the Editor: Few reports have been published on bone mineral density (BMD) among randomly sampled populations. Organisations such as Osteoporosis Australia and the Australian and New Zealand Bone and Mineral Society rely on research to supply reliable data that are representative of the Australian community. This information informs practitioners, researchers and policymakers of the size of the problem of osteoporosis in Australia. Our study aimed to document the proportion of individuals who have reduced BMD. The Geelong Osteoporosis Study recruited a random population-based sample of individuals from the Barwon Statistical Division, an area surrounding Geelong, Victoria. This region is well suited to epidemiological research as it is geographically well defined and has a large, stable population (259 000) with sufficient socioeconomic diversity for it to be representative of the Australian population.1,2 Age-stratified random samples of 1494 women (median age 54.0 years; range 20–94 years; recruited 1994–1997)3 and 1467 men (median age 56.0 years; range 20–97 years; recruited 2001–2006)4 were drawn from electoral rolls. Participation rates were 67% for men and 77% for women. We measured BMD at the spine and femoral neck by dual energy x-ray absorptiometry (Lunar; GE Healthcare, Madison, Wis, USA). Reference ranges for BMD in men4 and women3 have been published previously. We categorised BMD as normal (T score, > − 1.0), osteopenia (T score, − 2.5 to − 1.0) or osteoporosis (T score, < − 2.5) using the osteoporosis and osteopenia thresholds developed for postmeno-pausal women. Among those with discordant BMD, the site with the lower BMD was used in this classification. Normal BMD was predominant among men aged < 50 years (Box). A consistent proportion of men older than 50 years, including those aged > 80 years, had osteopenia (range, 49%–64%); 19% of those aged > 80 years had osteoporosis. Most women aged < 55 years had BMD in the normal range. Osteopenia was most prevalent among those aged 55–79 years, and osteoporosis dominated (51%) among those aged > 80 years. The osteoporosis and osteopenia thresholds developed for postmenopausal women may not be the most appropriate cut-points for diagnosis in younger women and in men; however, we used them because they are the currently accepted thresholds. Although sex-specific thresholds for defining osteoporosis might best be defined on the basis of absolute fracture risk, until such data are available, T-score criteria continue to be used. After standardising for age and sex to the 2006 Australian population,5 we found that 5.9% of men and 22.8% of women aged 50 years and over, and 12.9% of men and 42.5% of women aged 70 years and over, would be classified as having osteoporosis. Proportion of participants in the Geelong Osteoporosis Study with osteoporosis or osteopenia, by age group, according to bone mineral density at the spine or femoral neck Men* (no. [%]) Women† (no. [%]) Age group (years) Osteoporosis‡ Osteopenia§ Normal¶ Osteoporosis‡ Osteopenia§ Normal¶ 20–24 0 (0) 14 (15.7%) 75 (84.3%) 1 (1.0%) 21 (20.6%) 80 (78.4%) 25–29 0 (0) 24 (26.1%) 68 (73.9%) 0 (0) 24 (22.2%) 84 (77.8%) 30–34 1 (1.1%) 29 (30.9%) 64 (68.1%) 0 (0) 25 (22.5%) 86 (77.5%) 35–39 0 (0) 31 (30.7%) 70 (69.3%) 2 (1.7%) 41 (35.3%) 73 (62.9%) 40–44 4 (3.8%) 36 (34.3%) 65 (61.9%) 1 (0.9%) 32 (29.9%) 74 (69.2%) 45–49 4 (3.9%) 34 (33.3%) 64 (62.7%) 2 (1.8%) 32 (28.1%) 80 (70.2%) 50–54 3 (2.5%) 60 (50.0%) 57 (47.5%) 5 (4.7%) 43 (40.6%) 58 (54.7%) 55–59 2 (1.9%) 61 (58.7%) 41 (39.4%) 9 (8.9%) 57 (56.4%) 35 (34.7%) 60–64 4 (3.9%) 50 (48.5%) 49 (47.6%) 22 (21.0%) 54 (51.4%) 29 (27.6%) 65–69 6 (5.7%) 67 (63.8%) 32 (30.5%) 24 (24.0%) 48 (48.0%) 28 (28.0%) 70–74 9 (7.5%) 72 (60.0%) 39 (32.5%) 43 (32.6%) 70 (53.0%) 19 (14.4%) 75–79 14 (13.1%) 63 (58.9%) 30 (28.0%) 32 (42.7%) 33 (44.0%) 10 (13.3%) 80+ 34 (18.5%) 107 (58.2%) 43 (23.4%) 105 (51.0%) 88 (42.7%) 13 (6.3%) * Recruited 2001–2006. † Recruited 1994–1997. ‡ T score, < − 2.5. § T score, − 2.5 to − 1.0. ¶ T score, > − 1.0.

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

To the Editor: Childhood communication disorders (CCD) affect up to 20% of 4-year-old children.1 Early intervention is important2 and a variety of health and education professionals may provide assistance, including speech pathologists (SPs), paediatricians, general practitioners and others. The type and amount of help provided to preschool-aged children in Australia is unknown, nor are the costs empirically described. Using data from the Early Language in Victoria Study (ELVS),1,3 a prospective study of a large Australian cohort of children, we describe the use of services for CCD, out-of-pocket costs to families and costs to the health system. ELVS participants were recruited at 8 months of age, at routine child health checks in maternal and child health centres in Melbourne during 2002. Parents completed questionnaires at baseline (when the child was 8 months of age) and at each birthday.3 In-depth questions about use of services were included for the first time at 5 years. These questions covered SP assessment and treatment, visits to other professionals for CCD concerns, and out-of-pocket expenses for all services, within the preceding 12 months (ie, when children were in their fourth year). Of the original cohort, 983 families (51%) completed the service-use questionnaire. Sixteen per cent had used services (one-third of whom used more than one service); 11% had accessed SP treatment, and 6% had accessed other professionals. The number of service occasions per year for each professional, and the associated costs, are shown in the Box. Children accessing SP treatment received a median of 10.8 therapy hours within 12 months (interquartile range, 4.3–17.3; range, 0.5–104); 28% received ≤ 5 hours and 13% received > 25 hours. Costs of all services accessed in the period, including health system costs and parent out-of-pocket expenses, varied from $34 to $16 546. Our data show that some children received very little intervention for CCD within a 12-month period. Given the critical importance of communication skills to school achievement, this is of concern. We also demonstrate a substantial financial outlay associated with the treatment of CCD in Australia. These data are likely to be generalisable given the nature of this prospective cohort and the reliability of our health care cost estimates. The results highlight the immense variability in service use and the potential burden of cost to government and families associated with CCD. Our data do not describe service use before 4 years of age, nor have we included indirect costs such as travel and parental time away from work. Thus, they represent a starting place for understanding total costs. Costs to the health care system and families for childhood communication disorders services provided to children aged between 4 and 5 years in the Early Language in Victoria Study cohort Cost per family for 1 year using the service Service Median number of visits per year (IQR; range) Health care system cost* per visit ($) Median health care system cost ($) (IQR; range) Median out-of-pocket costs ($) (IQR; range) Median combined costs (health care system + out-of-pocket) ($) (IQR; range) Speech pathologist (treatment) 15.2 (6.5–26; 1–52) 49 742 (318–1273; 49–2545) 498 (173–1040; 0–4117) 1061 (472–2256; 49–6662) Paediatrician 2 (1–3; 1–10) 119 (initial) 59 (subsequent) 178 (119–237; 119–296) 250 (120–320; 0–500) 328 (178–511; 119–776) General practitioner 2 (1–4; 1–10) 34 (standard) 67 (34–151; 34–336) 40 (0–75; 0–294) 101 (34–181; 34–495) Psychologist 3 (1.5–4.5; 1–8) 49 147 (61–233; 49–392) 575 (105–889; 0–1300) 502 (157–1027; 49–1545) Otolaryngologist 2 (1–3; 1–8) 119 (initial) 59 (subsequent) 178 (119–237; 119–534) 210 (120–358; 65–1200) 239 (119–438; 119–1734) Hearing specialist 1 (1–2; 1–4) 49 49 (49–98; 49–196) 0 (0–2; 0–1000) 50 (49–98; 49–1098) Early intervention† 10 (1.5–28; 1–48) 240 2400 (300–8160; 240–11 520) 112 (0–600; 0–720) 2400 (300–8638; 240–12 240) All services na na 661 (238–1273; 34–14 426) 413 (91–1306; 0–4500) 1061 (335–2460; 34–16 546) IQR = interquartile range. na = not available. * Health care system costs were Medicare Benefits Schedule (MBS) fee rates charged at the applicable rebatable level (ie, 100% for GP services and 85% for other services).4 † Early intervention services, which are not covered by the MBS, were estimated from existing cost estimates.5

Jemma Skeat · Lisa Gold · Melissa Wake · Obioha C Ukoumunne · Sheena Reilly

To the Editor: Australian bat lyssavirus (ABL) has the potential to cause fatal encephalitis in humans exposed to infection through bat bites or scratches. There is no cure for rabies currently available, so postexposure prophylaxis with rabies vaccine and rabies immune globulin is recommended following potential human exposure, such as after bites or scratches. People who work with or handle bats should be vaccinated, should regularly monitor their rabies antibody levels to ensure maximum protection, and should seek immediate medical attention for all potential ABL exposures.1 We report the case of a 42-year-old man bitten by a black flying fox (Pteropus alecto) during the retrieval of the bat from a suburban Brisbane, Queensland, backyard. The bat had been found on the ground in the daytime, vocalising and acting aggressively. The patient was a member of a local organisation which cares for injured bats. The Logan and West Moreton Public Health Unit was notified the day after the incident. The patient reported that he had been vaccinated against rabies previously, and that his rabies virus-neutralising antibody titres were adequate. However, the patient’s available titres were below 0.50 IU/mL in 2002 and 0.43 IU/mL in 2008 (no boosters were given), both of which were below the World Health Organization recommended level that confers protection against rabies virus.2 The bat was euthanased for testing (because it had bitten a person, as per Qld Health protocol), and tests on the brain tissue showed it to be reactive for lyssavirus antigen (using an immuno-fluorescence antibody test) and lyssavirus RNA (using a TaqMan assay). In view of the patient’s recent serological tests indicating subprotective antibody levels and definite exposure to an ABL-positive bat, he was given postexposure prophylaxis comprising rabies immune globulin into the wound and five doses of rabies vaccine. He is currently well. The Public Health Unit determined that others were not potentially exposed to the bat. The prompt reporting of all potential ABL exposures to public health units is especially important because bat carers may underreport potential ABL exposures.3 Current guidelines recommend that bat carers with ongoing potential exposure to ABL should check their rabies virus-neutralising antibody titres every 2 years and have a booster if the titre is reported as inadequate (< 0.5 IU/mL). Alternatively, booster doses may be offered every 2 years without determining antibody levels.1 Further education of the bat-handling community and their doctors is necessary to maintain awareness and best practice to protect the people who do this potentially dangerous work.

Heidi J Carroll · Bradley J McCall · David Looke · Bruce Fraser

To the Editor: There is international recognition of the substantial threat that global warming presents to human health and of the challenges that it poses to health service delivery. The World Health Organization has estimated that global warming and climate change-related natural disasters account for over 60 000 deaths globally per year.1 Global warming will also have implications for surgery and surgical practice. The Victorian “Black Saturday” bushfires of February 2009 saw 414 people presenting to hospital emergency departments, stretching hospital resources,2 and 173 deaths were attributed to the bushfires. Nineteen patients were admitted to the Alfred Hospital (Melbourne’s burns service) with burns to more than 30% of their bodies. The care of severe burns victims is complex and highly labour-intensive, often with a patient–nurse ratio of 1 : 1. There would have been even more burns victims if the fire had been less ferocious and had not resulted in such a high loss of life.3 In other words, there were fewer injuries because this intense fire killed people outright; a less intense fire may kill fewer people but leave more injured. The extreme weather that led to the fires is an example of the type of event that may become more frequent as global warming increases. The Garnaut climate change review predicts more frequent extreme wind, rain and intense tropical cyclones, and predicts that category 3–5 storms are likely to increase in intensity by 60% by 2030, and by 140% by 2070.4 Increasing population densities along the northern Queensland coast will also expose more people to the risks of floods, storms and cyclones. These natural disasters often produce wounds which are highly contaminated, and primary wound care services may face increased demand. One of the practical implications of research in the field of surgery and climate change will be the need for modelling of future demands for surgical intervention in Australia. The range of trauma impact due to climate change needs to be defined, and the incidence with which this is likely to occur needs to be determined, based on climate change modelling. With this information, models of future demand for surgical interventions can be determined.

Joseph W Smith · Guy J Maddern

To the Editor: Scott and Guyatt are absolutely correct that as much transparency as possible is required in the process by which any clinical guidelines are formulated.1 I also agree that this must include careful management of conflicts of interest, particularly in the selection of the members of the expert panels required to formulate guidelines and in the functioning of those panels.1 However, transparency does not necessarily require adopting the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system or any other hierarchical system for formulating guidelines, nor does it necessarily require seeking formal feedback from external stakeholders. The GRADE system, like most hierarchical systems, assumes there is at least some evidence in the literature that addresses the relevant clinical problem — thus, it gives its lowest grade to observational studies with a very uncertain estimate of effect. But, often, practitioners most want help with the complex and multifaceted clinical problems on which there are not even formal observational studies. The GRADE system would presumably put these problems in the category of “You’re on your own, chaps, and don’t expect us to help you”. Recommendations on the problems that are most vexing to practitioners will be mainly (and inevitably) based on clinical experience and circumstantial evidence — in other words, expert opinion. Most practitioners looking for guidance will be well aware that such recommendations are likely to be based on expert opinion rather than excellent formal evidence. When deciding whether or not to trust the recommendations, they will be much more concerned that any conflicts of interest for the experts making the recommendations have been recognised and appropriately redressed, rather than that the level of evidence has been rigorously graded. Seeking formal feedback from stakeholders is also a separate issue from transparency. Potential users should be well represented on any writing panel, and their feedback is obviously essential — there is no point in producing guidelines that don’t address the problems that the potential users are facing. However, many stakeholders — for example, the pharmaceutical industry — will have much more serious conflicts of interest than do the members of the expert panel, and these can be impossible to deal with. Of course, feedback should be sought where appropriate, but to make it an absolute requirement under the guise of transparency seems nonsensical. It is clearly essential that users of clinical guidelines must be able to have confidence that they have been developed as rigorously as possible, but an excessively doctrinaire approach to their development will almost certainly lead to a decline in usefulness without a counterbalancing increase in trustworthiness.

Robert F W Moulds

To the Editor: Bismark, Spittal and Studdert observed that complaints clustered around certain doctors.1 They state that, in Victoria, extrapolations from their findings indicate that 1% of the medical workforce in private practice accounts for nearly 20% of complaints, and that male surgeons who have practised for more than 30 years are the doctors who are most complained about.1 Bismark and colleagues established that complaint-prone doctors are more likely to be male, surgeons or psychiatrists, to have trained in Australia and to have been in practice for at least 30 years. They agree with previous studies that suggest that the inherent risks of surgical procedures and the relative visibility of poor surgical outcomes are likely to play a role, and also note that the potential for power imbalances between doctor and patient is high in both surgery and psychiatry. That training outside of Australia was found to have a “protective effect” may seem surprising, but this fits my view about what most often motivates a patient to complain about a doctor when something goes a little astray. My belief, based on a long period of surgical practice and of observing other doctors, largely surgeons, is that a common stimulus to make a complaint when there is a degree of dissatisfaction is a perception that the doctor was overconfident, perhaps to the point of arrogance, and had little personal interest in the patient’s welfare. The lower self-confidence of some overseas-trained surgeons could therefore lessen the likelihood of complaints being made about them, whereas the supreme confidence of some highly experienced Australian-trained surgeons may go against them when something goes wrong. Good manners, kindness, demonstrations of personal interest and concern, and a degree of humility all discourage complaints! In an article subtitled “Arrogance: the biggest sin of all”,2 in the United Kingdom Telegraph, in 2009, Dr James LeFanu appropriately commented, “The virtues of generosity, cheerfulness and discretion should be the hallmark not just of medicine, but of all the liberal professions. How many doctors live up to these ideals is, of course, impossible to quantify, but certainly some readers of this column take a rather jaundiced view”.2

John A Buntine

To the Editor: Recent media reports queried whether Australia could experience a serious outbreak of foodborne disease, such as the massive outbreak in May this year of Shiga toxin-producing Escherichia coli (STEC) serotype O104:H4 in Germany.1 Australia is potentially vulnerable to foodborne disease outbreaks from contaminated fresh produce, and health and food safety authorities need to plan for these events and assess our capacity to respond. Australian health agencies investigate 100–150 outbreaks of foodborne illness each year, although < 10% are associated with fresh produce.2 Australia has a very high-quality food supply, but we are still vulnerable to outbreaks. In 1991, norovirus-contaminated orange juice served by airlines infected 25 000 people, despite the juice being sourced from a single small factory.2 Foodborne outbreaks can become very large and spread internationally before health agencies identify a vehicle of transmission. In 2009–2010, an outbreak of hepatitis A infection in more than 400 people in multiple Australian states, France and the Netherlands was associated with consumption of semidried tomatoes from Turkey.3 The recent outbreak of STEC O104:H4 also occurred in other European countries and was associated with a common source of fenugreek seeds used for growing sprouts.4 Seed sprouts have caused many outbreaks of foodborne illness, including two outbreaks of Salmonella Oranienburg in Western Australia and Victoria in 2005–2006 where alfalfa sprouts were implicated.2 STEC outbreaks overseas have implicated seeds originating from Australia.5 Seeds may become contaminated during plant growth, particularly due to livestock and feral animal grazing, or during storage, neither of which can be effectively controlled by disinfection at sprouting facilities.5 In light of the recent European STEC outbreak, Australian food safety agencies should urgently assess the risks posed to the food supply by sprouted seeds. Australia does have well functioning plans to respond to multijurisdictional outbreaks and national food safety incidents,2 but has not had to respond to a massive outbreak. German investigators reported 3222 outbreak cases of STEC, including 810 cases of haemolytic–uraemic syndrome, in less than 2 months.1 The health system resources required to manage such an outbreak would be immense and costly. In Australia, treatment and other costs for two cases of haemolytic–uraemic syndrome totalled an estimated $14 000 each, despite neither patient requiring dialysis, developing end-stage renal disease or requiring a transplant.6 As with other national plans for responding to epidemics, government agencies need to ensure that possible impacts on the health system and industry are taken into account.

Martyn D Kirk

To the Editor: Echoing Scott and colleagues’ recent call for caution regarding the use of hospital standardised mortality ratios for benchmarking and public reporting,1 we have concerns about the use of infection rates as hospital quality indicators. The National Healthcare Safety Network (NHSN) at the United States Centers for Disease Control and Prevention defines central line-associated bloodstream infection (CLABSI) as occurring where the patient has “a recognized pathogen cultured from 1 or more blood cultures and organism cultured from blood is not related to an infection at another site”.2 This and other criteria (for organisms associated with skin contamination and in children) are also used as quality indicators by VICNISS (the Victorian hospital-acquired infection surveillance system) and the Australian Commission for Safety and Quality in Health Care. The infection prevention unit at Alfred Health in Melbourne recently assessed three cases of hospital-acquired bacteraemia as having met the NHSN/VICNISS definition of CLABSI. This assessment was disputed by Alfred Health’s intensive care unit and we sought further opinions from other infectious diseases physicians and infection control practitioners to adjudicate, in the absence of established criteria to determine whether the bacteraemia was due to infection at a site other than the central line. We received conflicting advice. These three cases would have comprised a third of the CLABSI cases at our hospital in the 6 months to April 2011, and thus significantly impact on our reported quality assurance indicators. Similar common situations may arise in considering cases of bacteraemia in patients who have central lines in the context of chemotherapy-related mucositis; in patients with extensive burns; where cultures are only taken from central lines (rather than from peripheral venepuncture); where there are single blood cultures of enterococci of doubtful clinical significance; and where there are unconfirmed clinical foci of deep infection.3 Previous published work suggests that interrater agreement remains poor, despite changes to the definition of CLABSI.4 Other infection rates are associated with other problems as outlined by Scott and colleagues.1 For example, the current NHSN risk stratification system for infection (http://www.vicniss.org.au/Resources/HCWType1Manual/Type1Manualv6_0708.pdf) related to coronary artery graft surgery is poorly discriminatory, as most patients fall into risk index categories 1 or 2, and statistical calibration of this system is poor.5 Interrater reliability of classification of superficial infections has also been shown to be poor.6 The relatively low rate of infections in patients undergoing coronary artery surgery may result in large stochastic variation, particularly in hospitals performing relatively few such procedures. Public reporting of infection rates is probably inevitable. However, such data should be restricted to indicators that have been shown to validly reflect preventable infections, using definitions that are reliable, and with the appropriate caveats regarding their limitations.

Allen C Cheng · Pauline Bass · Carlos Scheinkestel · Tim Leong

To the Editor: Australia is already a hot country and the frequency of hot spells looks set to increase over coming decades.1 Health care professionals will therefore need to consider the effect that medications can have on people’s capacity to respond to hot conditions. Medications can directly increase body temperature by altering thermoregulatory mechanisms, pharmacological action, idiosyncratic reactions, or hypersensitivity reactions.2-4 Uncommon side effects — including toxic states, anticholinergic poisoning syndrome, serotonin syndrome and neuroleptic malignant syndrome — can also generate heat. Indirect impairment of physiological response to thermal stress may occur by preventing adjustment to hypotension, or by interfering with behavioural responses. Despite these risks, hyperthermia and reduced sweating each rate only one mention in the 2010 Australian medicines handbook (in relation to anticholinergics).5 The handbook does not list heat stress as an adverse reaction to dexamphetamine,5 which can impair thermoregulation by increasing metabolic rate. Medications can affect thermoregulation by:2-5 impairing sweating triggered by the parasympathetic nervous system — eg, anticholinergics, phenothiazines; impairing sweating by carbonic anhydrase inhibition — eg, topiramate, zonisamide; impairing cardiac output or causing hypovolaemia — eg, antihypertensives, alpha-blockers, diuretics; impairing behavioural responses to heat (such as drinking or taking cooling action) — eg, sedatives and hypnotics, anxiolytics, phenothiazines, illicit drugs; or rarer effects, such as increasing metabolic rate — eg, monoamine oxidase inhibitors, thyroxine, amphetamines, cimetidine. Elderly people with impaired thermoregulation, the socially disadvantaged and people with mental illness have been identified as being most at risk from heat stress.6 Although the risk of medications directly impairing physiological responses to heat is low, thermoregulatory effects can be cumulative. People in certain occupations (eg, outdoor labourers and tradespeople, indoor workers in hot industries such as metal manufacturing) may be at increased risk of heat exposure, and there are anecdotal reports of tourists suffering heat stress in climates that are hotter than those to which they are accustomed. There is a need to educate workers, the public and health practitioners about the relationship between certain medications and heat. Professional associations and trade unions have a responsibility to warn and educate their members. It may be helpful for the Therapeutic Drugs Administration to actively solicit reports of adverse events related to medicine use, heat and thermoregulation via the Australian Adverse Drug Reaction Reporting System. Carers of elderly and chronically ill people might flag patients on certain medications for extra care during hot spells. Additionally, health practitioners can ensure that these people are on appropriate heatwave notification and emergency support lists, which are being developed by Australian state and territory health departments and emergency service agencies.

Peter W Tait

A practical guide to common and important problems in clinical neurology It has been a long-held perception that neurology is a descriptive discipline, limited to careful diagnostic assessment but offering few therapeutic options for the care of patients, who are generally the responsibility of other medical practitioners. To some extent, these testaments hold true today: there has been distressingly little progress in the treatment of common and disabling neurodegenerative diseases — in particular, Alzheimer’s disease and motor neurone disease — despite tantalising clues to their aetiology. Major gaps remain in the availability of comprehensive specialist services, such as acute-care stroke units, despite nearly two decades of evidence from randomised trials supporting the benefit of such models of service delivery. However, considerable advances in many areas have transformed neurology into a very active discipline. For example, although the initiating factors for multiple sclerosis remain hidden, knowledge of the pathophysiological mechanisms has enabled development of treatments that target specific aspects of the immune system. The prognosis for young adults diagnosed with this chronic disease is, therefore, much more optimistic than it has been in the past. The development of sophisticated imaging technologies has radically increased the diagnostic certainty of a wide range of neurological conditions. Where neurologists once had to incrementally improve their diagnostic certainty by doing postmortem examinations months or years after a clinical encounter, there is now a range of investigations that can be used to determine the location and pathophysiological basis of lesions during life. This gives us a window of time during which therapeutic intervention may reverse an underlying process. The improvement in imaging techniques such as computed tomography, magnetic resonance imaging and ultrasound has dispelled much of the mystery of the neurological examination. Clinical neurophysiology, once a laboratory curiosity, is now widely available as the standard procedure to reliably diagnose nerve injuries and muscle disease. This technology has also enabled better use of surgical and medical therapies for conditions such as carpal tunnel syndrome, radiculopathies, and inflammatory myopathies and neuropathies. On a background of advances in neuroscience and neuroimaging has come enormous growth in the availability of therapeutic compounds. The pharmacology of neuroscience probably had its birth in the development of combination levodopa and dopa-decarboxylase inhibitor therapy for Parkinson’s disease in the 1960s. This was the first specifically targeted neuropharmacological treatment and heralded the subsequent arrival of a range of compounds that target specific receptors in the nervous system. In addition, recently developed high-potency biological compounds such as monoclonal antibodies offer the potential for unprecedented levels of efficacy, but those which target specific receptors in the immune system carry the risk of catastrophic side effects such as fatal opportunistic infection. The complexity of available therapies has meant that both doctors and patients need to be well informed to make appropriate management decisions. The unsung heroes of neurological therapies are epidemiological studies and clinical trials — these have formed an evidence base for practice that goes beyond knowledge derived from biological rationale, case series analyses and pattern recognition. Until recently, for example, every stroke admission provoked an arcane discussion about the role of heparin and/or aspirin, and other interventions to “thin the blood”. It took large, well controlled studies to show that the risks of such therapies, other than aspirin, outweighed any potential benefits in the acute-care setting. Similarly, such studies have debunked neurological dogma over the hazards of blood-pressure lowering in acute stroke and have established that such therapy is the most efficacious medical treatment for improving long-term outcomes. Large-scale clinical trials are usually funded by pharmaceutical companies, yet important questions have been, and will continue to be, solved by academics who work in collaboration and use public funding. Given that governments spend so much on health care, often with poor supporting evidence for how it should be best spent and monitored, the level of funding for such studies, and medical research in general, is parsimonious. Practical neurology is a series of articles that examine common and important problems in clinical neurology in the context of advances in basic neuroscience and neurological investigations. The quality of evidence that supports the available therapeutic options (see Box) is also included. Despite the advances in this discipline, neurology remains one of the bastions of clinical medicine, where simple but finely tuned bedside skills can readily establish a diagnosis, prognosis and management plan. The cases presented in this series therefore emphasise key aspects of patient history and clinical signs, which are still the most cost-effective way of establishing a neurological diagnosis and making management decisions. Grading system for recommendations in Practical neurology* Grade A: “Excellent” — evidence from large randomised controlled trials (RCTs), or systematic reviews with meta-analyses of multiple RCTs Grade B: “Good” — one or more RCTs with limitations, or high-quality and persuasive non-randomised cohort studies Grade C: “Satisfactory or poor” — non-randomised case series and opinions of experts * Adapted from the National Health and Medical Research Council.1

Leo Davies MB BS, MD, FRACP · Craig S Anderson MB BS, PhD, FRACP

Subacute unilateral visual impairment accompanied by pain on eye movement is characteristic of optic neuritis. Most cases of optic neuritis resolve spontaneously, and acute treatment with intravenous steroids hastens recovery but does not alter the ultimate visual outcome. Brain magnetic resonance imaging (MRI) may permit a diagnosis of multiple sclerosis (MS) to be made after a single clinical demyelinating event such as optic neuritis. Current evidence supports the introduction of disease-modifying therapy in patients with a single clinical event such as optic neuritis and brain MRI compatible with MS. The diagnosis of MS is a confronting life event associated with significant personal, social and financial burdens. The diagnosing neurologist should provide a detailed explanation of the disease and its clinical spectrum and introduce the patient to the wide range of support services, educational material and MS clinics.

Michael H Barnett MB BS, PhD, FRACP · Gurjit Chohan MB ChB · Leo Davies MB BS, MD, FRACP

Australia’s coal conundrum is that all political parties say they are concerned about climate change while sanctioning an unprecedented expansion of coalmining and coal seam gas extraction in Australia. Australia’s coal contributes to climate change and its global health impacts. Each phase of coal’s lifecycle (mining, disposal of contaminated water and tailings, transportation, washing, combustion, and disposing of postcombustion wastes) produces pollutants that affect human health. Communities in which coalmining or burning occurs have been shown to suffer significant health impacts. The health and climate costs of coal are unseen, and when costs to health systems are included, coal is an expensive fuel. Coalmining and healthConcerns about the expansion of coalmining are growing and, as a result, medical practitioners and other health experts are being asked about coal and its effects on health. While there has been no Australian overview of the health effects of coalmining on inhabitants of coalmining areas, evidence from the United States indicates that coalmining communities in West Virginia had an increased risk for developing cardiopulmonary disease, chronic obstructive pulmonary disease (COPD), hypertension, other lung diseases and kidney disease.1 Mortality rates for these diseases were higher in coalmining areas compared with non-mining areas of the region.2 Potentially confounding risk factors, such as smoking rates, were not reported. Coal-processing chemicals, fumes from diesel powered equipment, explosives, toxic impurities in coal and dust from uncovered coal trucks could all have affected the health of respondents. Deaths and injuriesMining is a dangerous occupation. Coalminers die and suffer more lost time from injuries than all other miners,3 most often from fires and structural instability of underground mines. Hazards arise from collapse of parts of a mine, explosions and gaseous asphyxiation, as well as machinery malfunction and misuse. The risks to coalminers from suffocation or explosion from release of methane and other toxic gases were demonstrated at the Pike Hill coalmine near Greymouth in New Zealand on 19 November 2010 when 29 miners died. Despite some evidence that fatalities and injuries are decreasing in Australia with tighter legislation, there are still significant health and safety concerns.4 Pneumoconiosis, dust and contaminationHowever careful the operator, miners’ lungs can be damaged by coal dust. According to the National Institute for Occupational Safety and Health, pneumoconiosis was responsible for about 10 000 deaths in the US in the 10 years to November 2009.5 In Australia, the incidence of coal workers’ pneumoconiosis has fallen with diligent monitoring of dust levels and better occupational health measures.6 Dust exposure in 33 longwall coalmines in New South Wales exceeded the Australian National Standard of 3 mg/m3 in 6.9% of measurements, and the risk of pneumoconiosis and lung fibrosis was estimated to be about 2% after a 40-year working life.7 Road traumaCoal is transported from mine to railhead, or mine to port, by road, increasing the risk of accidents and traffic fatalities and releasing greenhouse gases. Data on coal-related road trauma for Australia are unavailable; however, in Kentucky, between 2000 and 2004, 53 people were killed and 536 injured as a result of accidents with vehicles licensed to transport coal.8 Environmental damage, water and healthCoalmining poses a significant threat to the integrity of aquifers, which may be hydrologically connected to other groundwater-dependent ecosystems including farm dams, bores and rivers. Water from coalmines must be disposed of and waste material is often held within the surface lease of a mine, introducing a risk of contamination of human food sources. Pollution of the environment can also occur through windblown dust during transportation, where coal is washed and at export ports. In 2010, coal seam gas operations in Queensland were held up at two sites because groundwater had become contaminated with a potentially dangerous combination of benzene, toluene, ethylbenzene and xylene (BTEX).9 Similar contamination occurred after an underground coal gasification trial near Kingaroy.10 The Queensland government has recently banned BTEX chemicals from coal-bed fracturing fluids. Social and mental health impactsCoalmining can change the lifestyle and character of a community. Higginbotham and colleagues detailed the social and political consequences that result.11 Medical practitioners in coalmining areas have reported that increases in asthma, stress and mental ill health have become more common.12 As more coalmines are opened, as has occurred in parts of the Hunter Valley in New South Wales, the social fabric of a region changes, the role and function of a township alters, and many inhabitants of these regions have developed depression, anxiety and ill health.13 Coal combustion: coal-fired power generationOnce coal is mined, it is burned, usually to generate electricity or to make steel. Burning coal emits many pollutants that harm human health and increase the major public health problems facing the industrialised world. An Australian review of air pollution by Kjellstrom and colleagues, while not specifically focusing on the effects of coal combustion, summarises the effects of particle exposure on health.14 These include respiratory symptoms such as cough, aggravated asthma, the development of chronic bronchitis and decreased lung function; arrhythmias, non-fatal heart attacks and premature death in people with heart or lung disease; the effects of absorption of toxic material; and allergic or hypersensitivity effects. The smallest particles, particulate matter (PM) 2.5, are the most damaging.15 Many PM 2.5 particles are produced during coal-fired power generation. Specific data in Australia are lacking; however, in the US, the Physicians for Social Responsibility examined the evidence for health damage caused by coal.5 The risk of premature death for people living within 30 miles of coal-burning power plants has been quoted to be three to four times that of people living at a distance.8 Fifty thousand deaths each year have been attributed to air pollution,5 and in Canada, it is estimated to cause more than 5000 deaths each year.16,17 In the US, air pollution from combustion of coal, diesel fuel and wood was estimated to account for 5% of male and 3% of female cancer deaths between 1970 and 1994.18 Other toxic elements released with coal combustion include arsenic, mercury, fluorine, cadmium, lead, selenium and zinc. Mercury is of greatest concern. Over a third of all mercury emissions attributable to human activity come from coal-fired power stations.5 It enters the environment and accumulates in the food chain, particularly in fish. In 1999–2000, 15.7% of American women of childbearing age had blood mercury levels that could have affected the brain development of an unborn child.5,19 Australian dataThe limited evidence on the impacts of air pollution from burning coal in Australia suggests that the health impacts are similar to those reported from other developed countries.20 A 1993 study reported an increase in symptoms of childhood wheeze and asthma-like breathing difficulties from a community near a coal-fired power station.21 Climate change, health and the environmentThe World Health Organization states that climate change is the greatest emerging threat to public health and to the environment. Coal-fired power stations are potent emitters of greenhouse gases and are important contributors to climate change. Climate change will profoundly affect some of the most fundamental prerequisites for good health: clean air and water, sufficient food, adequate shelter and freedom from disease.22 These health impacts are beginning to be felt in Australia. The elderly, the very young and those with existing heart and respiratory disease are vulnerable to the increase in heat waves due to climate change. Drought has affected farming communities who have suffered from stress, social disruption and depression. More extreme weather events can be expected with threats to food and water security; rising sea levels; changes in vector-, food- and water-borne diseases; exacerbation of air pollution; increases in aeroallergens and impacts on mental health. An increase in the number of climate refugees is likely.23 Costs of burning coal in AustraliaThe most recent and comprehensive study on the negative effects of power generation was released by the Australian Academy of Technological Sciences and Engineering (ATSE) in March 2009.24 ATSE calculated the greenhouse impacts and health damage costs of different power generation technologies including coal, gas, wind, solar photovoltaic, solar thermal, geothermal, carbon capture and storage, and nuclear energy. The health costs of burning coal are equivalent to a national health burden of around $A2.6 billion per annum. Coal-fired power stations also produce more greenhouse gases (such as CO2) per unit of energy than any other type of power station. Combining greenhouse and health damage costs for Australia gives representative total external costs of $A52/MWh for brown coal, $A42/MWh for black coal and $A19/MWh for natural gas.24 By the ATSE analysis, carried out before the costs of the 2011 Fukushima nuclear meltdown could begin to be calculated (ATSE specifically excluded nuclear disaster costs), the external costs of nuclear power would have been around $A7/MWh. The external costs of genuinely renewable sources of power generation, such as wind and solar power, are even less. If the external costs of burning coal were recovered by a coal tax, coal would be the most expensive of all energy-generating fuels. Epstein and colleagues recently reported an analysis of the health and environmental costs of coal in the US and concluded that the damage caused by coal should double or triple the costs of coal-generated electricity.25 DiscussionElectricity contributes to economic growth and a higher standard of living. It produces opportunities for better health and gains in longevity, but in Australia, coal produces 84% of the nation’s power, and its combustion is responsible for a significant proportion of the country’s greenhouse emissions. Australia is the world’s largest exporter of coal. Although it may well produce economic benefit, it will also have injurious effects on the health of the populations of recipient countries, and contribute to global greenhouse gas emissions. Under our present accounting system, these external negative factors are excluded; coal-generated power is falsely represented as the cheapest source of electrical power. Although burning coal no longer causes London’s smogs or cancer of the scrotum in young chimney sweeps, and acid rain from uncontrolled sulfur dioxide emissions has abated (proof that an emissions trading scheme can work), there is overwhelming evidence that coalmining and the burning of coal is harmful to physical and environmental health, and can have a significant impact on local communities. Regrettably, peer-reviewed environmental health studies from Australian coal towns are sparse. When a new mine is proposed for a particular area, Australian mining Acts (designed for protection and certainty in the mining industry) do not protect communities who can suffer years of frozen assets, apprehension and future risks to health when a new mine is proposed in their locality. State environmental protection authorities (EPAs) are the statutory independent bodies charged with assessing the environmental safety of proposed mines. Australia’s international obligations under the agreement reached at the United Nations Conference on Environment and Development (UNCED June 1992) give EPAs permission to use the precautionary principle — that an action should not be taken if the consequences are uncertain and likely to be dangerous to the public or the environment — in their assessments. This is rarely, if ever, invoked in the case of approving new coalmines. Health impact statements for proposed mines are not requested by state governments, so the EPAs have, unwittingly, become responsible for the protection of significant aspects of public health. The time has come for EPAs to take the precautionary principle into account during their deliberations on new coalmining applications. To persist in mining and burning coal will condemn future generations to catastrophic climate change, which is clearly the biggest health problem of the future. Australia is a rich and technologically sophisticated country with the second-highest human development index in the world.26 It should have the ability to gradually phase out the use of coal and to expand the generation of electricity from renewable energy sources. Such a change will have the greatest benefit for Australian and global health and for protection of the environment. Recently, the Australian government has announced it will introduce a carbon tax to mesh seamlessly into an emissions trading scheme. This initiative to put a price on carbon is an important public health measure.

William M Castleden MS, FRCS, FRACS · David Shearman PhD, FRACP · George Crisp MB BS, MRCGP · Philip Finch MB BS, FFARCS

Objective: To review the uptake of seasonal influenza vaccination among hospital health care workers (HCWs) in Australia to date.Data sources: We searched MEDLINE and EMBASE (up to September 2010) and bibliographies of relevant reports for studies examining seasonal influenza vaccination (uptake, attitudes and/or programs) among Australian hospital HCWs. Studies relating to pandemic (H1N1) 2009 influenza vaccination or other types of health care facilities were excluded.Study selection: 15 articles were assessed, of which 10 met inclusion criteria.Data synthesis: The 10 studies were conducted between 1997 and 2008 and reported vaccination rates of hospital HCWs of 16.3%–58.7%. Two of three studies documenting uptake rates of > 50% were associated with active implementation of vaccination policies or interventions. Uptake rates by occupational group ranged from 29% to 58.3% for physicians, 19% to 56.4% for nurses, 23% to 57.7% for allied health professionals, and 18% to 66.7% for ancillary or support staff. Coverage rates in hospitals that provided the vaccine free of charge to staff (with or without an informational campaign) were no higher than in other hospitals.Conclusion: While seasonal influenza vaccination uptake was higher in hospitals with documented intervention programs, coverage is still low and does not appear to be affected by the provision of free vaccine to staff. State or institutional policies or mandates are likely needed to increase HCW uptake of seasonal influenza vaccination.

Holly Seale BSc, MPH, PhD · C Raina MacIntyre MB BS, PhD, FAFPHM

Objective: To describe the frequency, characteristics, and outcomes of medicolegal disputes over informed consent.Design and setting: Retrospective review and analysis of negligence claims against doctors insured by Avant Mutual Group Limited and complaints lodged with the Office of the Health Services Commissioner of Victoria that alleged failures in the informed consent process and were adjudicated between 1 January 2002 and 31 December 2008.Main outcome measures: Case frequency (by medical specialty), type of allegation, type of treatment.Results: A total of 481 cases alleged deficiencies in the informed consent process (218 of 1898 conciliated complaints [11.5%]; 263 of 7846 negligence claims [3.4%]). 57% of these cases were against surgeons. Plastic surgeons experienced dispute rates that were more than twice those of any other specialty or subspecialty group. 92% of cases (442/481) involved surgical procedures and 16% (77/481) involved cosmetic procedures. The primary allegation in 71% of cases was that the clinician failed to mention or properly explain risks of complications. Five treatment types — procedures on reproductive organs (12% of cases), procedures on facial features excluding eyes (12%), prescription medications (8%), eye surgery (7%) and breast surgery (7%) — accounted for 46% of all cases.Conclusions: The typical dispute over informed consent involves an operation, often cosmetic, and allegations that a particular complication was not properly disclosed. With Australian courts now looking to patient preferences in setting legal standards of care for risk disclosure, medicolegal disputes provide valuable insights for targeting both quality improvement efforts and risk management activities.

Andrew J Gogos MB BS · Richard B Clark DHSc · Marie M Bismark MB ChB, LLB · Russell L Gruen MB BS, PhD · David M Studdert LLB, ScD, MPH

Objective: To define the effectiveness of recent efforts by the Australian Division of World Action on Salt and Health, and the Heart Foundation in New Zealand to reduce sodium levels in breads in Australia and New Zealand.Design and setting: Data on the sodium contents of packaged sliced bread products sold in Australian and New Zealand supermarkets were collected from the product labels of 157 breads in 2007 and 167 breads in 2010, and were compared overall, by bread type, by manufacturer, and between nations.Main outcome measures: Mean sodium values in bread and proportions of breads meeting the targets of 400 mg/100 g in Australia and 450 mg/100 g in New Zealand.Results: Overall mean sodium content in bread in Australia was 434 mg/100 g in 2007 and 435 mg/100 g in 2010; corresponding values for New Zealand were 469 mg/100 g and 439 mg/100 g. The proportion of Australian breads meeting the national target increased from 29% in 2007 to 50% in 2010; the proportion of New Zealand breads meeting the national target increased from 49% in 2007 to 90% in 2010. There were clear differences between the results achieved by different companies.Conclusions: Voluntary efforts by non-governmental organisations have had some impact on sodium levels in bread, particularly in New Zealand. However, substantial room for further improvement remains. If additional reductions are not achieved under the current voluntary arrangements, legislated approaches may be required.

Elizabeth K Dunford MPH · Helen Eyles MSc, PhD · Cliona Ni Mhurchu BSc(Hons), PhD · Jacqui L Webster MA, PhD · Bruce C Neal MB ChB, PhD

Objective: To determine whether an association exists between distance from radiotherapy facilities and survival outcomes of people diagnosed with rectal cancer.Design and setting: Descriptive population-based study using data from the Queensland Cancer Registry.Patients: All patients aged 20–79 years (n = 6848) diagnosed with invasive rectal cancer between 1 January 1996 and 31 December 2006.Main outcome measure: Cause-specific survival.Results: The 5-year cause-specific survival was 62% (95% CI, 61%–64%); it was strongly influenced by stage at diagnosis (American Joint Committee on Cancer, Stages I–IV), ranging from 86% (Stage I) to 9% (Stage IV). After adjusting for age, sex, and stage at diagnosis, patients who lived 100–199 km, 200–399 km and 400 km or more from a radiotherapy facility were 16%, 30%, and 25%, respectively, more likely to die from rectal cancer than patients living within 50 km of such a facility. On average, there was a 6% increase in mortality risk (95% CI, 3%–8%; P < 0.001) for each 100 km increment in distance from the nearest radiotherapy facility. Shared frailty models showed that this association persisted after adjusting for the correlation between individual cancer patients living in the same remoteness or area-level socioeconomic status categories.Conclusions: While centralisation of cancer treatment services has merit, our study provides evidence of a shorter survival for people with rectal cancer who live relatively far from radiotherapy facilities. It remains a priority to develop and implement policy, cultural and clinical measures to reduce the burden faced by rural and remote patients with rectal cancer.

Peter D Baade PhD, MMedSc, BAppSc(Hons) · Paramita Dasgupta PhD, MSc, BSc(Hons) · Joanne F Aitken PhD, MSc, BSc(Hons) · Gavin Turrell PhD, BA(Mgt/Adm)

Two children in far northern Western Australia tattooed their arms with maangga berries (Grevillea pyramidalis ssp. leucadendron), which resulted in unintentional, caustic, partial thickness skin burns requiring specialist burn care. An understanding of the chemistry of the burn agent (5-n-alkyl resorcinol), appropriate first aid management and referral, and possible physiological sequelae are essential for optimal medical management and preventive community education. Clinical recordsPatient 1A 10-year-old Aboriginal girl with burns was referred to the Princess Margaret Hospital burns unit by a local general practitioner in far northern Western Australia. Relatively little was known about the nature of her burns or the potential toxic chemical sequelae and, because of the distances involved, it was decided to bring her to Perth. The patient had used local berries to “tattoo” both her forearms, causing bilateral caustic burns to 1% of her body surface area (Box 1, A). After consultation with the burns unit, the area was washed thoroughly with water to remove any remaining traces of caustic substance and the pH of the area was repeatedly tested. The berries had induced a partial thickness burn with blistering of the skin. The blisters were deroofed and washed and the pH checked again. The child was observed overnight for systemic and metabolic effects. The burns were initially treated with nanocrystalline silver dressing and hydrocolloid dressing, which were changed every 2 days (Box 1, B and C). These were later replaced with calcium alginate dressing and hypoallergenic polyacrylate adhesive, which were changed every 2 days until complete resolution 3 weeks later. The patient was advised to massage and moisturise the area and to use sunscreen protection. Patient 2Almost exactly 1 year later, a 14-year-old Aboriginal girl with burns was referred to the burns unit from the same area as Patient 1. The maangga berry was confirmed as the seed pod she had used. She had burns on her right forearm, cubital fossa and distal arm. The area was washed with soap and water and irrigated while determining the pH of the wound area. She was admitted for wound dressing, observation and treatment for metabolic derangement. She sustained partial thickness burns to 3% of her body surface area. Her forearm was treated with nanocrystalline silver dressing and hydrocolloid dressing, which were changed every 2 days, then replaced with calcium alginate dressing and hypoallergenic polyacrylate adhesive, which were changed every 3 days until complete resolution after 3 weeks. She was advised to massage and moisturise the affected area and protect it from direct sunlight. DiscussionMost caustic burns are secondary to accidental ingestion of a corrosive substance, causing significant oesophageal stricture or perforation, or from topical exposure to agricultural or building chemicals.1,2 According to some studies, almost half the burns described are in children (despite them comprising less than 3% of all burns), and burns have significant cultural and psychological sequelae.3,4 Excluding a few case series of self-inflicted garlic burns and fruit juice mouthwash gingivitis, as far as we are aware, no described cases exist of caustic burns from plant matter, especially plants that have cultural significance for the Aboriginal people of Australia.5 Of further interest is that the topical chemical burn also may have significant systemic consequences related to the burn chemical. Regional and national poisons centres were contacted for advice, but staff were unable to advise on the management of the patients because little is known about this berry internationally. The patients were from an area that is a natural habitat for Grevillea pyramidalis ssp. leucadendron. The tree is also known as the konkerberry, maangga berry or caustic tree, which are generic terms for many different species of berry shrubs. These berries have traditionally been used by local Aboriginal people for tattooing; the berry is used to puncture the skin, and the fluid released from the berry causes a greenish discoloration of the skin followed by permanent black tattooing. The elders of the various tribes within the relevant region have been made aware (after liaising with the burns unit) of the potential harmful effects of the berries when used incorrectly by inexperienced users. High-performance liquid chromatography has been used to isolate the corrosive substance, identified as 5-n-alkyl resorcinol, a phenol derivative, which is also a precursor for tetrahydrocannabinoid (the psychoactive chemical in marijuana). There has been a resurgence of interest in 5-n-alkyl resorcinol because of its antioxidant, antigenotoxic and cytostatic characteristics. It is a phenolic lipid metabolite of plants, animals, fungi and bacteria during normal development, as well as during times of stress, such as when infection or wounds are present or when the organism is affected by ultraviolet radiation. It has also been found to inhibit bacterial, fungal, parasitic and protozoal growth, and to reduce the efficacy of viral transfection.6 Chemical burning seems to occur when 5-n-alkyl resorcinol binds with proteins to form esters that irreversibly bind calcium. This interferes with cellular mitochondrial performance, leading to cellular anoxia and energy deprivation, causing protoplasmic poisoning and necrosis. This organic compound also binds and dissolves the lipid membrane of the skin cells, leading to proteinaceous structural disruption. In a medical setting, naturally derived 5-n-alkyl resorcinol could be used as a potent heat shock protein-90 (Hsp-90) inhibitor. Hsp-90 is instrumental in the regulation of oncoproteins Her2, Akt, Bcr-Abl, c-Kit, EGFR and mutant BRAF, and when these oncoproteins are dysregulated, they lead to solid and haematological cancers.7 Clinically, Hsp-90 is the active compound in endodontic fillings and vascular glue and has been used extensively as a peeling agent.8 5-n-alkyl resorcinol has many side effects, including theoretical goitrogenic consequences, and G. pyramidalis is listed as poisonous in the United States Food and Drug Administration Poisonous Plant Database (http://www.accessdata.fda.gov/scripts/plantox/index.cfm). The fact that G. pyramidalis berry juice causes haemolysis is of concern, but the cardiac glycosides it contains may be of more concern, even though ingestion (not skin penetration) is required for a lethal dose. Other effects of cardiac glycosides include blurred vision, nausea, vomiting, bradycardia, confusion and lethargy, and people showing these signs after contact with G. pyramidalis should be referred to an emergency department immediately. We hope this article may be educational for doctors in far northern Western Australia and anyone coming into contact with the Grevillea species, some of which (eg, G. banksii and G. robusta) contain trace cyanide and grow in residential Australian gardens. We believe these two cases offer a unique insight into a region-specific phenomenon. 1 Partial thickness burns to the left arm of a 10-year-old Aboriginal girl (Patient 1), secondary to self-tattoo with berries from Grevillea pyramidalis ssp. leucadendron A. Day 1. B. Day 3 (after 2 days’ dressings). C. Day 6 (after 5 days’ dressings). 2 Grevillea pyramidalis ssp. leucadendron Photography by Lynley Wallis. Used with permission (http://florabase.dec.wa.gov.au/help/copyright). 3 Geographic distribution of Grevillea pyramidalis ssp. leucodendron Map data by Paul Gioia and the Western Australian Herbarium. Used with permission (http://florabase.dec.wa.gov.au/help/copyright).

Robert J Knight MB BCh, MRCS · Tania McWilliams BScNurs · Dawn Reeler MB ChB, DA · Liz Whan FRACS · Fiona Wood FRACS, AM

A city specialist consulting in the country ponders the tyrannies of life, including health care, in the bush One of the many privileges I had while in clinical practice as a gastroenterologist was to work in the country. I consulted and did procedures in the beautiful regional city of Bairnsdale — in East Gippsland, about 3 hours’ drive from Melbourne — for 2 days in 1 week every month, for several years. The secretaries in my rooms in Melbourne used to dread my “Bairnsdale weeks”, because I would leave the office with a large suitcase half-full of files, and return with the same suitcase completely full of files, plus multiple dictation tapes. They also dreaded the letters, which were very long because they usually contained detailed information about the patients for the referring general practitioners, so that much of the management of the patients could be done without the need to see me again, given that I was not in Bairnsdale full-time. Bairnsdale is a lucky town when it comes to medicine. It has an outstanding collection of GPs, many of whom have worked in developing countries, so they have excellent skills in anaesthetics and obstetrics which they are keen to maintain. They are empathic, compassionate and strong advocates for their patients. Bairnsdale has a few specialists of its own, and used to have an unusually strong program of visiting specialists. But the Bairnsdale visiting specialist program has been cut back severely. People can get to the city, can’t they? Just give them a subsidised train fare. Apparently it is better to make 60 patients travel a 600 km round trip, rather than just one doctor. On my drives back to Melbourne I would have the feeling that I had done more good in 2 days’ regional practice than in a month of city practice. It felt similar to my thoughts on returning from a trip to the developing countries in which I had worked — Samoa and Zimbabwe, for example. The people of Bairnsdale, I gradually came to realise, faced multiple tyrannies, starting with the tyranny of distance. I remember once apologising to a patient for running late. “I’ve had a 3-hour drive this morning, from Melbourne”, I said. “Well so have I”, the patient shot back, “from Mallacoota” (240 km from Bairnsdale). Another patient commented to me somewhat bitterly that city folk were always reluctant to come to the country, but country people have no choice but to make trips to the city: “It’s a lot longer from Melbourne to Bairnsdale than Bairnsdale to Melbourne”. But it was not only the tyranny of distance: it was the tyranny of poverty. I could see its mark in many of the patients I saw. There were demographic patterns — the young drug users, now clean because they had moved away from “the valley” (the industrial Latrobe Valley, an hour’s drive to the west of Bairnsdale). There were the thin, careworn young mothers of four children by four different fathers, one child with autism, one or two with ADHD, and one with epilepsy. A history of childhood and domestic abuse seemed to be the rule rather than the exception. There were the toddlers destroying the consulting room — in the city, toddlers did not often come with their mothers; perhaps there was more support at home. And there were the young men with alcohol dependence, perhaps chronic pain syndrome, living in trailers in forestry towns, who could never come to Bairnsdale for review because of the cost of petrol. The tyranny of isolation meant that middle-aged farmers with body mass indices over 30, waist measurements over a metre, and abnormal liver function couldn’t walk for exercise because they didn’t have the time or company. Single mothers with chronic hepatitis C could not join an interferon program because there was no one to support them or help with the children. And then there was the tyranny of nature: in January 2003, many men and women, including all the orderlies in the hospital, had gone to fight bushfires, and the town’s economy was suffering. In February, Bairnsdale itself was threatened, the sky dark and the sun red. In March, a farmer with tears in his eyes told me about his cattle burning, and then — laughing sarcastically about government bushfire “relief” — that the authorities decided the new funded fences (replacing the burnt ones) had to be dingo-proof, with wires down to 10 cm from the ground. His farm had steep ups and downs, and this new fencing was “bloody impossible to build”, “bloody expensive” and “bloody stupid”. In April, his new fences all washed away into the Gippsland Lakes during floods. In my work in Bairnsdale, I know I changed peoples’ lives — people with gastro-oesophageal reflux disorder, hepatitis C and colitis. If I had not gone there, those people would still be suffering; they just could not, or would not, have come to the city. Subsidised train fares for them to come and see me in Melbourne would not have fixed their problems. However, many other specialties easily available in Melbourne are just not available in East Gippsland, even though we, in both the city and the country, all pay (and are effectively paid by) the same taxes. Overservicing in the city and no servicing in the country? Yes, it’s a long way from the city to the country, and distance is not the only tyranny.

Katrina J R Watson MB BS, FRACP, MPH

The death of John Buckingham on 29 March 2011, after a courageous battle with pancreatic cancer, robbed the Canberra medical community of its leading breast cancer surgeon, whose knowledge and skill was paired with devotion and kindness to his patients. John was born in Sydney on 19 July 1947. He attended St Ignatius College and graduated in medicine from the University of Sydney in 1971. He completed his advanced surgical training in the United States at Mayo Clinic in Rochester, Minnesota. In 1978, John returned to Australia and attained Fellowship of the Royal Australasian College of Surgeons in 1979. In that year, he commenced as a consultant general surgeon at the newly opened Calvary Hospital in Canberra, where he concentrated his practice for his entire career. In addition to his clinical commitments, he filled roles in the hospital as Head of the Division of Surgery and Chairman of the Medical Staff Council. His inclusive style and collegiate approach allowed all views to be heard and acknowledged. His wise counsel was valued by the Sisters of the Little Company of Mary, board members and clinicians. Throughout his career, John was involved in the broad expanse of general surgical conditions. He was a cautious, methodical and technically proficient operator, who was diligent and attentive in the postoperative care phase. Over time, he came to concentrate exclusively on breast cancer surgery. He developed a comprehensive model of care, involving colleagues from nursing, radiology and oncology, and suffusing it with his virtues of care and compassion. The development of a graduate medical program at the Australian National University Medical School in Canberra allowed John to expand his interest in teaching to both students and registrars. His excellence in this role was recognised with his appointment as Clinical Associate Professor when he retired in 2011. His contribution to the wider ACT community was recognised when he was named ACT Senior Australian of the Year in 2010. John was a remarkable man, who, despite his many achievements, was humble and self-effacing. He was interested in the lives of his coworkers and was unfailingly courteous to everyone he encountered. He was a man of deep religious conviction, and his Catholic faith sustained him in his final illness. Indeed, he lived all his life demonstrating the faith principles he so strongly embraced. John is survived by his wife Sue and children James, Peter, Kate and Michael.

Michael J Gillespie · Stephen A Deane

Current practice in forensic medicine. John Gall, Jason Payne-James, editors. Oxford: Wiley-Blackwell, 2011 (327 pp, $120.00). ISBN 9780470744871. Recent times have seen a growing interest in forensic medicine among members of the public, although not necessarily among medical practitioners. An involvement in forensic medicine requires more than just a passing interest, and this publication examines aspects of the discipline that apply to both the living and the dead. The editors are both specialists in the field. John Gall is a forensic physician with the Victorian Paediatric Forensic Medical Service in Melbourne and Jason Payne-James is a forensic physician based in the United Kingdom and is editor-in-chief of the Journal of Forensic & Legal Medicine. In this book, they cover many areas of clinical forensic medicine and also touch on aviation disasters, but not toxicology. At least once in their careers doctors are likely to be called upon to give evidence in court. This book includes excellent instructions on how to prepare reports for medicolegal cases. For this alone it is a worthwhile reference text for a medical practitioner. For those who practise forensic medicine relating to the living, as in the case of sexual assault, this book should be required reading — it covers essential areas, such as how to assess, describe and interpret injuries, and how to collect specimens for biological or toxicological purposes. The book goes into some detail about the proper classification and description of wounds. However, it cautions against being too robust in attributing causes for wounds in medicolegal cases unless practitioners have the experience to back their judgement. The editors of this text have compiled an authoritative review of the topic, with contributions from leading international experts in the field. They provide enough detail about the forensic sciences to give practitioners some insight into these areas without attempting to turn them into experts.

Tony F Moynham

Med J Aust 2011; 195 (6 Suppl).