Volume 195 Issue 8

A sustained and coordinated multisectoral approach is vital Recent research has shown a striking association between gender-based violence (GBV) and lifetime mental disorders among Australian women.1 Data from the 2007 National Survey of Mental Health and Wellbeing2 offer important lessons for advancing policy and practice in this key area of human rights and public health. More than a quarter of the 4451 women surveyed had experienced one of the common forms of gender-based violence (GBV): rape (8.1%), other forms of sexual assault (14.7%), physical intimate partner violence (7.8%) and stalking (10.0%). Sexual assault and rape often occurred for the first time at an early age (median 12 and 13 years, respectively). GBV was strongly associated with a wide range of mental disorders including mood, anxiety and substance-use disorders; women exposed to one form of GBV had double the rate of any lifetime mental disorder (58%) of unexposed women (27%). GBV was also strongly associated with severity and comorbidity of mental disorder, suicide attempts, disability, poor quality of life, unemployment and overall socioeconomic disadvantage. Although major advances have been made in developing practice guidelines and policy to prevent and respond to GBV in Australia, there has been little focus on the mental health component. This oversight continues to be evident in the Australian Government’s 12-year action plan,3 which otherwise offers a comprehensive approach to the problem. The prevalence and consequences of GBV mean that it needs to be regarded as a mainstream problem for all health care providers. The primary care level is of pivotal importance. General practitioners need to be aware of the likelihood that undisclosed GBV may underlie unexplained physical injuries and mental health symptoms, particularly among repeat attenders. There is a risk that the culture of silence on this issue will hinder detection of the problem.4 Women justifiably fear that they will not be believed or that their disclosures will put them at risk of further abuse, and clinicians may be hesitant to raise this sensitive topic. The presence of partners at consultations can further inhibit disclosure. GPs may benefit from additional training in gender-sensitive interviewing techniques, to ensure accurate detection of GBV in a manner that builds trust.5 National protocols need to be implemented for referral and coordination among agencies so that women have access to protection (shelters and/or the removal of perpetrators from the household), legal advice, support for at-risk children, and financial assistance. Access to quality mental health services should be a priority, given that the disorders identified by the national study were complex in nature, disabling and associated with suicide risk. Specialised agencies, including mental health, rape crisis and domestic violence services, need to recognise more fully the close interaction between GBV and mental disorder. Mental health professionals should maintain a high level of suspicion that GBV may underlie common mental disorders. Sensitive inquiry into a history of abuse is an integral part of assessment. Abused women should be protected from situations that increase feelings of insecurity; for example, mixed-gender facilities or settings where male partners can gain ready access. Services for sexual assault and domestic violence require better resourcing to ensure seamless referral to mental health professionals with the necessary skills to address the psychological consequences of gender-related abuse. The process of referral needs to allay the woman’s fear of being labelled in a context where perpetrators commonly try to discredit reports of abuse by claiming the survivor is mentally disturbed. The study findings1 point to the importance of childhood, adolescence and early adulthood as targets for interventions. It is during these early developmental phases that women commonly are first exposed to sexual abuse, which is the harbinger of further violations as well as of a lifetime of mental disorder and disability. A greater focus on school-level and family interventions may prove valuable. The family is the setting of highest risk, but it is also the unit with the greatest potential to provide protection. At a wider level, public health campaigns are needed to change attitudes and mores that sanction the culture of patriarchy and silence surrounding GBV in our society.6,7 The strength of the nationwide epidemiological study1 is that it offers a lifespan perspective on the recursive problem of GBV, in which women are at risk of repeated exposure to abuse of various forms, and of developing a range of comorbid mental disorders and associated disabilities. Socioeconomic disadvantage and marginalisation compound the problem. Women with limited resources and alternatives are less able to leave a violent relationship. Indigenous women and women from refugee backgrounds may be confronted with additional problems related to discrimination and isolation.8-10 A sustained and coordinated multisectoral approach, in which mental health has an integral role, is vital to bringing about fundamental change to the life-course trajectory of adversity associated with GBV. The overarching aim should be to provide a comprehensive approach to intervention that empowers women to make the changes required to promote recovery and resilience.

Susan J Rees MSocPol(Hons), PhD · Derrick M Silove MD, MB ChB(Hons), FRANZCP

It is never too late, or too early, to listen to patients about what they want How people die remains in the memories of those who live on. Cicely Saunders, Pain and impending death1 Isn’t it rather odd that, only a few decades ago, dying was a normal part of life? You would most likely be cared for and die at home, surrounded by family. While all the advances in medicine that treat disease and enable us to live much longer have been welcomed, what has been pushed off the agenda is that the mortality rate for all of us remains at 100%. It is in this context that advance care planning is beginning to be recognised as a pivotal part of end-of-life care. In the 19th century, when little was understood about disease processes and few effective treatments existed, Sir William Osler famously said, “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has”. As modern medicine evolved, with rapid scientific discoveries and technological advances, the focus shifted profoundly to cure — to defeating disease and saving or prolonging life at all costs. Early in the 21st century, it has become increasingly apparent that one of these costs has often been the quality of the patient’s survival. Modern medicine has started to focus equally on the disease and the patient. There is much wisdom in the code of ethics for Catholic health and aged care services, which clearly states that if a treatment is overly burdensome or the burdens outweigh the benefits, the patient may legitimately forgo the treatment.2 To do everything possible just because it is possible, without regard to the patient’s goals, values and wishes, is ethically unsound and not good medical practice. Yet it is remarkable how often this occurs. How many times have doctors, both senior and junior, said that they were continuing or commencing treatment because the family wanted it, and not because they thought that it was right for the patient and was supported by evidence in the medical literature? Our common law duty of care as doctors is to always act in the patient’s best interests. One of the most practical ways to put this into action is to regularly ask ourselves, “Am I caring for this patient or family the way that I would want myself or my family to be cared for, by taking the time to identify their personal, spiritual or religious views and take these into account when I am making decisions?”. There are three opportunities to check whether the care we are providing is patient-centred. The first is with competent patients, by ensuring that their consent to treatment is fully informed, by understanding their goals and values that are relevant to their current or future treatment, and by identifying their wishes regarding treatment if they become seriously ill and can no longer decide or communicate what they want. This process of enquiry is called advance care planning. It may be as simple as identifying who the patient’s substitute decisionmaker would be and ensuring that this person is someone who has a clear idea about the patient’s goals, values and wishes. It may also include assisting patients to put their future wishes in writing. It is crucial to enquire what the patient would regard as an acceptable outcome, rather than make a shopping list of acceptable versus unacceptable treatments. Where is the patient’s line in the sand — his or her acceptable level of ability to communicate or of cognitive or physical function? The second opportunity is when caring for a patient who is no longer competent. At this time, we need to look for any documents, such as an advance care plan, that record the patient’s wishes, and speak to the family and the substitute decisionmaker, if appointed. We should ask them what the patient would want rather than what they want, with the focus on what the patient would regard as an acceptable outcome,3 through questions such as, “If your father could sit with us here, right now, what would he tell us to do?”. The third opportunity is when caring for a patient approaching the end of life. A study in which patients were interviewed identified five factors that patients regard as important to having a “good death”: avoiding suffering, avoiding the prolongation of dying, achieving a sense of control, relieving burdens placed on the family, and strengthening relationships with loved ones.4 Apart from providing good palliative care, the most effective way to achieve these goals is to know ahead of time what a person would want. More than half of us are not in a position to express these preferences at the end of life. In a randomised controlled trial published last year, we showed that advance care planning improved end-of-life care for elderly patients admitted to hospital, increased respect for the patients’ wishes at the end of life, improved patient and family satisfaction with regard to hospital care, and reduced the likelihood of anxiety, depression and post-traumatic stress in the surviving relatives of patients who died.5 The skills needed to effectively facilitate advance care planning are learnable. Through the Respecting Patient Choices Program, medical and non-medical health professionals can be trained to discuss these personal, intimate subjects with patients and their families in a sensitive, compassionate way.6 It is never too late, or too early, to listen to patients about what they want. The importance of involving patients in decisions about their care was acknowledged by a maxim in a recent white paper from the Department of Health in the United Kingdom: “no decision about me without me”.7

William Silvester MB BS, FRACP, FCICM · Karen Detering MB BS, FRACP, MHEth

Will children be “crowded out” of non-acute and preventive care visits? As a society ages, adults become a larger proportion of the population. However, in Australia, the demographic reality is that while children have become a smaller proportion of the population, their absolute number has increased modestly.1,2 Thus, solutions for the increased care requirements for older people cannot be intentionally or unintentionally associated with a diminution of the medical workforce required for children. Ensuring an adequate health care workforce is of vital importance to all countries. Much interest is being focused on the importance of caring for the increasing numbers of the aged in many developed nations.1,3 The proportion of the populations of both the United States and Australia who are aged over 65 years is increasing rapidly1,2 and the health care needs of these individuals will require additional workforce resources.1,4 In Australia, primary care is delivered by general practitioners.5 To address the growing needs of the older population, there has been a significant effort to increase the number of GPs to ensure primary care access.6 At the same time, there are unrecognised demographic trends currently taking place in the composition of GP practices nationally that parallel the demographic trends of the population as a whole. These trends have important implications for the current and future care of children in Australia. One of these demographic trends is also occurring in the US among family physicians. For example, as older people have increasing life expectancy, and family physicians have relatively static numbers of patients in their patient panels, “turnover” in general practices and the opportunity to add new (paediatric) patients is increasingly limited.7 In Australia, examination of Bettering the Evaluation and Care of Health (BEACH) data from the past decade demonstrates a significant decrease in the proportion of GP visits by patients under 15 years of age across the country. This is despite an increase in the survival of children with chronic diseases.8 Whether the absolute number of visits for children has fallen is currently unclear but must be investigated. Regardless, such findings demonstrate a change in the demography of GP practices, with a trend towards GPs providing proportionally less care to children relative to the care they provide to adults. Even with the expected increase in the overall number of GPs in Australia in the next decade, this finding raises significant issues for the health care system. As children become a smaller proportion of GP practices, it is realistic to question whether GPs will continue to devote the time and effort needed to stay up to date on paediatric issues when they will have fewer opportunities to use such knowledge. GPs will constantly be challenged with the ever-increasing complexity of caring for more adults with multiple chronic conditions in their practices. The situation also begs the question as to whether some GPs will begin to limit or discontinue providing care to children, especially in specific locations with smaller proportions of children and a more rapidly ageing population. New strategies may also emerge in which some GP practices become “adult only” or “older people only” to provide care for this population. This trend is already believed to be occurring among some family physicians in the US.7 Another related issue is whether the nature and duration of consultations that children receive in general practices are changing. Recent consumer satisfaction data in Australia demonstrate ready availability for acute paediatric problems (eg, ear infection).9 However, the increased complexity of multiple chronic conditions among the ageing population will require an increased number of longer consultations. If GPs’ patient bookings become more commonly filled with such visits for older people, questions arise as to whether children will receive fewer longer consultations for preventive care (eg, nutrition counselling, developmental assessments) and chronic illness. In other words, will children be “crowded out” of non-acute and preventive care visits? The decrease in the proportion of children in the overall population also has important implications for the future training of GPs. Already, some GP training programs are concerned about their ability to provide both inpatient and outpatient clinical settings with sufficient children having common chronic illnesses (eg, asthma) for their trainees to gain competency in their acute and longitudinal care. Such deficiencies may become more common as the ageing population trend continues. With childhood obesity, mental health problems and other antecedents of adult illness now occurring more frequently, this would be a worrisome trend. In the US, shortages in the health care workforce for children are mostly found in the paediatric subspecialties, especially in rural areas.10 There has been little research in Australia regarding the availability of paediatric subspecialty care, especially for Indigenous populations and children living in rural areas.6,8 With increasing survival of children with complex conditions and chronic diseases, the demand for paediatric subspecialty care in Australia is rising. The proportion of such care actually provided by paediatric-trained subspecialists rather than adult-trained subspecialists is currently unknown. This must be determined to assess the true need for such providers nationwide, both inside and outside major metropolitan areas. Exploration of these issues is important and urgent for medical workforce planning. Government and professional entities entrusted with assessing provision of the continuum of health care for the children of Australia, monitoring GP training, and overseeing the continuing education of GPs should investigate whether changes have been occurring that may lead to a decrease in the quality of care for this important segment of the population. Such efforts will ensure that the unique needs of children are not unintentionally lost in the current emphasis on the growing ageing population.

Gary L Freed MD, MPH · Jillian R Sewell MB BS, FRACP · Neil A Spike MB BS, FRACGP

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 explores disturbing new data about the ever-popular pills After analysing antidepressant use among older people in Britain for more than a decade, a team of researchers has come up with some alarming new findings. Released recently, their study barely raised a murmur in Australia, but its implications are potentially enormous.1 If the new data are to be believed, for older people, the most commonly prescribed drugs for depression may be associated with an increased risk of serious health problems and death compared with less common antidepressants or none at all. Conducted as part of the Health Technology Assessment program, this British prospective cohort study investigated the risks associated with antidepressants being used by people aged 65 years or older during the decade or so to 2008. Its database included more than 60 000 people from 570 general practices across the United Kingdom who had been newly diagnosed with depression. Results published in the BMJ show that more than half of the antidepressant prescriptions issued to this group were for drugs from the selective serotonin reuptake inhibitor (SSRI) class, almost a third were for older tricyclics, and just over one in 10 were for other antidepressants.1 Eleven per cent of the people in the study did not take any drugs for depression. For those who did take antidepressants, the median duration of use was 1 year. Interestingly, more than two-thirds of the older people had the severity of their depression classified as mild, a quarter as moderate, and just under 5% as severe — and these proportions were similar for those who were and those who were not prescribed antidepressants. The researchers then compared the adverse events experienced by people during the time they were taking the drugs with those experienced by people during periods when they weren’t taking the drugs, and it was these comparisons that produced the unexpected and disturbing associations. The absolute risk of death from all causes over 1 year was 10.6% for patients taking SSRIs, 8.1% for those taking tricyclics, 11.4% for those taking other antidepressants, and 7.0% for people not taking any antidepressants. Moreover, those taking antidepressants suffered a significantly greater number of serious adverse events: All classes of antidepressant drug were associated with significantly increased risks of all cause mortality, attempted suicide/self harm, falls, fractures, and upper gastrointestinal bleeding compared with when these drugs were not being used.1 Despite being heavily promoted as better than the older medicines, the study found that, compared with tricyclic antidepressants, the newer SSRI class “may be associated with an increased risk of ... all cause mortality, stroke/transient ischaemic attack, falls, fracture, epilepsy/seizures, and hyponatraemia”. The obvious limitation here is that the study was observational, rather than a randomised controlled trial. However, as is made clear in their full 200-page report for the Health Technology Assessment program,2 the researchers went to great lengths to identify a wide range of potentially confounding variables, including age, sex, comorbidities and the severity of depression. Yet after adjusting the results for the confounding variables, key associations were largely unaffected. For example, after adjusting for confounders, taking SSRIs was still associated with a roughly 50% higher chance of death in relative terms, as well as an increased risk of serious adverse events including attempted suicide, falls and fractures, compared with those diagnosed with depression who were not taking antidepressants. In discussing the findings of their observational study, the authors highlight the difficulty of untangling the effect of the drugs from the effect of the underlying condition, particularly as they were unable to adjust for the way the severity of a patient’s depression might have changed during the decade of the study. Putting their results in the context of other data, the researchers conclude that their findings of higher rates of attempted suicide for all classes of antidepressants “suggest an effect of depression itself rather than a direct causal effect” of the drugs.2 By contrast, they conclude their findings of higher rates of falls, fractures and hyponatraemia associated with some antidepressants are generally in line with existing data. Importantly, the study’s limitation is also its strength. Looking at the serious health problems experienced by many thousands of people taking antidepressants over a long period, these real-world results are potentially more relevant than small, short-term, company-funded trials with extensive exclusion criteria, which may lead to overstating benefits and playing down harms of drugs. Whatever your view of the benefits of these heavily marketed medicines, this latest study provides important new information about their associated downsides.

Ray Moynihan BA

Clinical guidelines are being increasingly produced to improve quality of care, but are vulnerable to bias. Only 15% of guidelines on the National Health and Medical Research Council portal from the most prolific developers have published conflict of interest statements, and fewer detail the processes used to manage conflicts. Comprehensive disclosure of conflicts is needed to safeguard the integrity of clinical guidelines and the medical profession. Peak bodies and clinicians should seek to promote an improvement to current poor practice.

Michael J Williams* BA(Hons), LLB(Hons) · Dev A S Kevat* MB BS, LLB(Hons), MPH(Oxon) · Bebe Loff LLB, MA(Lond), PhD

A failure of practice, or a failure of evidence? Drug treatment of rheumatoid arthritis (RA) has evolved significantly in recent decades, owing to increasing evidence supporting early intervention with disease-modifying therapies and the advent of novel biological therapies that specifically target the immunological and cellular mediators of disease. In the past 10 years, there have been over 60 systematic reviews and meta-analyses of pharmacotherapy in RA, reflecting the growth in development of new drugs and the shifting landscape of treatment regimens. Although these reviews vary in scope and focus, there is considerable overlap of the studies that are included. The findings of these reviews are mostly consistent and support early use of disease-modifying antirheumatic drugs (DMARDs) titrated appropriately for control of the disease process; the safety and efficacy of methotrexate as a first-line agent; and the clinical utility of corticosteroids in managing disease flares.1 Over 30 of these reviews have focused on the use of biological agents, such as infliximab and etanercept, in the management of RA refractory to traditional (synthetic) DMARDs. The published literature generally supports the short-term efficacy and safety of biological agents as adjuncts or alternatives to traditional DMARDs.2 During this same period there have been more than 10 major clinical practice guidelines produced for the management of RA. We analysed 10 of these guidelines and found that seven were government funded (although some contributors declared the receipt of support from industry), one had industry sponsorship and two were produced by private companies. Eight of these guidelines explicitly outlined their search strategies, their criteria for including studies and their methods for assessing studies according to levels of evidence. The guidelines’ assessments of the evidence base for pharmacotherapy in RA are highly concordant. This is not only true for recommended strategies, such as the early use of DMARDs, but also for identification of some areas of continuing uncertainty, including the routine use of corticosteroids, the role of intra-articular steroid injections, and the use of complementary and alternative medicines.3 The subjection of the literature to such careful and repeated analysis and the consistent findings of the systematic reviews and clinical practice guidelines might appear to provide reassurance about the guidance available for practitioners in the clinical management of RA. Yet, despite the clarity of the assessment of the evidence base, closer inspection reveals significant limitations of the evidence that is available to those who produce and implement guidelines. While early use of methotrexate has a solid evidence base, data remain incomplete on its efficacy and its safety at varying doses, particularly among certain ethnic groups and during pregnancy and breastfeeding.4 And despite the fact that numerous trials of individual biological agents have demonstrated their short-term efficacy and safety, it is difficult to compare them as there have been few head-to-head trials of these drugs.5 This is problematic clinically, because different agents may confer different benefits and harms in different patients; and economically, because it compromises comparative cost-effectiveness analysis. Data are also lacking on the long-term safety and efficacy of biological agents, and the relative and absolute benefits of these agents when they are used at different time points in the clinical course of patients with RA, although some long-term safety data are beginning to emerge.6 Finally, there is considerable uncertainty about the various ways in which the synthetic DMARDs and the newer biological agents should be combined.7 Against the background of these limitations and the consistent support for early use of DMARDs, what are rheumatologists’ prescribing habits? A French study found little conformity between rheumatologists’ prescribing practices and clinical practice guidelines — 34% of patients with early RA did not receive any DMARD.8 A Canadian study also found an inappropriately low rate of prescribing; 84% of patients who regularly saw a rheumatologist were prescribed a DMARD, as were 73% of patients who consulted a rheumatologist intermittently.9 One common explanation for these findings is that clinicians are slow to translate research into practice, even where the evidence appears to be clear, as is the case for early use of DMARDs. An alternative explanation is that clinicians are cognisant of deficiencies in the evidence base, sceptical of the content of guidelines, sensitive to “non-clinical” concerns such as the cost of medicines, and wary of generalising data from systematic reviews and meta-analyses to the care of individual patients. It might not be that clinicians are resistant to change — apparent “failures” in translation might equally be attributable to problems in the evidence base (and the potentially confusing proliferation of clinical practice guidelines by diverse stakeholders and for various target audiences10) as they are to habit, lack of motivation, and external barriers such as lack of time, resources and organisational support.11 This has a number of practical implications. First, concordance among systematic reviews and agreement among clinical practice guidelines should not obscure important deficiencies in the evidence regarding RA. But neither is it enough for commentators and expert bodies to simply identify gaps in the literature. Health care and research communities both have a responsibility to question the evidence upon which guidelines are based. The absence of head-to-head studies and long-term data from postmarketing surveillance studies should raise questions about possible biases arising from industry sponsorship of clinical trials and from trials designed according to the requirements of regulatory agencies.12 The relative absence of data on non-pharmacological therapies in RA should also raise questions about the dataset and the emphasis in clinical research on pharmacotherapies. While Australia’s National Medicines Policy provides a framework for improving prescribing practices through advocating the quality use of medicines,13 this relies upon a comprehensive and clinically relevant evidence base, and all stakeholders have a responsibility to ensure that the right research questions are asked and the right methods are used to answer them.

Shafqat Inam BSc(Med)Hons, MB BS · Wendy L Lipworth MB BS, MSc, PhD · Ian H Kerridge B(Med), FRACP, FRCPA · Richard O Day MB BS, MD, FRACP

To the Editor: Since 2008, the Australian Capital Territory’s public acute health care system has successfully been using multiple-parameter and single-parameter track, trigger and response (TTR) systems in parallel for the recognition of and response to clinical deterioration in patients. Jenkins and colleagues correctly identify that there is a general lack of agreement on the use of TTR systems around Australia, although they note that the most commonly used rapid response system is the medical emergency team (MET) alert which is triggered by a single parameter, a vital sign derangement, or a concern for the patient.1 As Jenkins et al suggest, a multiple-parameter TTR system may trigger a response earlier than might occur with MET parameters. In 2007 at Canberra Hospital, a multifaceted before-and-after intervention study of the recognition of and response to patients’ deteriorating conditions found improvements in both patient outcomes and measures of processes of care for patients whose condition was deteriorating.2 The intervention included the installation of a multiple-parameter TTR system, using a modified early warning score3 generated from the degree of derangement of all vital signs and end organ function. Individual vital sign early warning scores were then colour-coded and embedded within newly formatted, human-factors-designed observation charts. Further, before the new system commenced, about 90% of all health care workers (210/234) participated in an education program.4 This program comprised both an e-learning package and a 3-hour, face-to-face, low-fidelity simulation package. It aimed to promote the understanding of the physiological principles of vital signs, and reasons for their measurement and their derangement; it also provided a structure for succinct communication and initial resuscitation. The multiple-parameter TTR system has now been successfully rolled out to all areas of the hospital, including the emergency medical unit, emergency department and medical assessment and planning unit, alongside our MET system. The multiple-parameter TTR system has been a useful tool to engage parent medical teams in reviewing patients at risk of critical illness, and has empowered nurses to call for a MET review, given that the modified early warning score provides further evidence that the patient’s condition is deteriorating. With the use of the systems in parallel and the mandatory training package, MET use has doubled and delays in calling for a MET review have decreased. We would welcome further investigation of the multiple-parameter TTR system that we have adopted, particularly in a multicentre setting.

Imogen A Mitchell · Mary-Ann Kulh · Heather McKay

To the Editor: We would like to congratulate the Central Line Associated Bacteraemia in NSW Intensive Care Units Collaborative for reducing central line-associated bacteraemia (CLAB), and showing that this reduction was associated with compliance with evidence-based aseptic central venous line (CVL) insertion, which included a patient bundle and a clinician bundle, as reported by Burrell and colleagues.1 As part of a quality improvement program in Western Australia, we conducted a collaborative cohort study (unpublished) in two major Perth teaching hospitals with adult intensive care units (ICUs), from April 2007 to September 2008, covering 36 ICU-months and 15 459 catheter-days. Both ICUs implemented the WA Safety and Quality Investment for Reform central line bundle.2 Compliance was monitored by an observer with a checklist. Adherence to all components of the central line bundle was required for compliance to be recorded. This measure was reported monthly. CLAB and catheter-days were monitored by the hospitals’ infection control practitioners. Compliance with the bundle increased from a mean of 10% to greater than 90%. Infection rates declined over the study period from more than six infections per 1000 catheter-days to zero (P = 0.019 for Hospital 1 and P = 0.10 for Hospital 2). In the final 8 ICU-months (4 months in both hospitals), there was no CLAB. The New South Wales study demonstrated the importance of the clinician bundle components over the patient bundle components, which should inform future quality improvement initiatives. We note the comment that the hat, mask and eyewear components of the bundle were unpopular with clinicians. However, there is a risk of recontaminating disinfected skin with aerosolised organisms from the clinician’s hair and upper respiratory tract, whereas eyewear is principally intended to protect the clinician from splash injury and potential blood-borne virus infection. Maximal sterile barrier precautions are endorsed by the 2010 National Health and Medical Research Council guidelines,3 the 2011 Centers for Disease Control and Prevention guidelines,4 and the epic2 study in the National Health Service in England.5

Chantal S Ferguson · Victoria C D’Abrera · Helen J Van Gessel · Dorothy Jones

To the Editor: The article by Ramsey-Stewart and colleagues1 reports a welcome addition to supplemental anatomy education in graduate-entry medical courses in Australia. Increasing medical student numbers are increasing pressure on teaching resources, further propagating the nationally recognised deficiency in anatomy teaching.2,3 In 2010, the University of Queensland Discipline of Surgery developed an extracurricular applied anatomy course to meet the needs of clinical students (Years 3 and 4) with varying foundations in anatomy.4 The course is based on a clinically oriented anatomy education model, using prosected specimens and computer resources, which has been shown to deliver learning outcomes.5 Student representatives were involved in all facets of curriculum development and evaluation. The course was taught by surgeons and provided an overview of whole-body applied anatomy in an interesting and engaging way. As the course had no seed funding, a modest course fee of $90, which was intended to be easily affordable but enough to encourage committed attendance, was charged. Class size was restricted to 44 students, with selections from the 150 applicants (from about 800 students across both years) made on a first-come, first-served basis. Over seven Saturday mornings, the students received 2-hour tutorials from surgeons with expertise in specific fields of regional anatomy. This scheduling minimised disruption for both surgeons and students. Various educational resources, including three-dimensional virtual modelling and potted pathology specimens, were used. Participants completed a short multiple choice test before each week’s tutorial. The course concluded with a wet laboratory session, staffed by surgeons using prosected cadaveric specimens at multiple stations, with a one-to-five surgeon–student ratio. Students completed a post-course exam of collated pre-tutorial multiple choice questions, as well as five-point Likert-scale evaluation forms. The students evaluated the course well (mean Likert score: 4.6 at 4 weeks, 4.8 at 8 weeks). Post-course exam scores demonstrated a small but significant improvement (mean ± SD: pre-course, 43% ± 16.7% v post-course, 50% ± 10.6%; P = 0.004). Scores were correlated with attendance. The course was highly valued by students and surgeons, effectively improved students’ knowledge and satisfied their desire for further anatomy education. The course structure is time-efficient and cost-effective. However, this course, like that of Ramsey-Stewart et al,1 is extracurricular and does not deliver educational benefit to an entire cohort of students. Further development and evaluation are required to extrapolate the benefits of these extracurricular courses into the wider medical curriculum within the constraints of graduate MB BS programs. Our model has expanded to two courses in 2011.

Matthew J Roberts · Bavahuna Manoharan · Marianne Vonau · Russell W Stitz · Owen A Ung

To the Editor: We read with interest the article by Patel and colleagues,1 which suggests a high rate of critical adverse events occurring for medical students undertaking remote placements in the Northern Territory. We note also that there is significant potential for over- or under-reporting because of the incompleteness of useable documentation in their sample. Regardless, the reported figure of one-sixth of students experiencing a “critical incident” during their placement is concerning. In answer to the question in the title of Patel et al’s article — “Safeguard or mollycoddle?” — the answer is surely neither. There is obvious benefit for students in being removed from their personal, cultural, geographical and clinical comfort zones. After all, challenging and evaluating one’s preconceptions and personal boundaries is essential for personal and professional development. However, it is vital that this is done in a safe and well supported manner, such that both the student and the community into which he or she is placed benefit from the experience. As noted by Patel et al, there is evidence from the United Kingdom that structured placements that are regularly evaluated, adequately planned and firmly grounded in clinical ethics are able to maximise the placement experience for both students and communities.2 In our minds, the key to quality in clinical placements is excellent administrative support and clinical supervision that is appropriate for the level of the student. Recently, there has been a concerted push in medical training to encourage students to gain experience in rural and Aboriginal communities. This is generally well received by Australian medical students. In light of increasing student numbers, it is likely that these alternative clinical training environments will see an increase in student traffic in the coming years. The article by Patel et al1 has highlighted that not all experiences in these settings are positive. Due to persisting rural workforce shortages, we are concerned that students who are unwilling and potentially unsuitable to undertake remote placements may be forced to do so through their medical programs or bonded medical places. We strongly urge the providers of placements and those who fund them to critically evaluate their current practices surrounding clinical placement planning and support. Most importantly, adequate supervision, matched to the individual attributes of the student, should be an absolute requisite for any placement.

Andrew D Webster · Robert D Marshall · Lee J Fairhead · Trent Little · Falk Reinholz

To the Editor: The commissioned article by Pirotta, dealing with the ethics of prescribing alternative complementary treatments that may lack an evidence base,1 contains a number of statements which, if the article had been subjected to peer review, might well have finished up on the cutting-room floor. For example, the statement “it is estimated that as little as a quarter of conventional medicine is based on level-1 evidence” is not backed up by the only monograph cited in support of it.2 Whatever relevance a lack of level-1 evidence may have to the practice of dermatology (for which it is claimed), it plays little part in either modern medicine or the revolutionary advances in surgery, few being the result of a systematic review of multiple well controlled randomised trials. Having said that, the reference to complementary or alternative treatments that lack any evidence base as “medicine” gives a misleading legitimacy to practices that may be — and frequently are — based on cultural, historical or spiritual beliefs, or even just plain wacky approaches to healing. Regrettably, Pirotta adds nothing new to the (uncited) definitive 2004 article by Kerridge and McPhee.3 How times have changed. Not only are doctors now expected to have sufficient knowledge of complementary and alternative medicine to be able to advise their patients of therapeutic alternatives, but we may well have reached the stage where a failure to alert patients of such alternative treatment options may constitute negligence at common law. The New South Wales case of McGroder v Maguire4 is instructive. In that case, the plaintiff, a truck driver, had suffered a neck injury in the course of his employment. Despite a lengthy period of treatment, he continued to suffer from tingling in his arm. The defendant, a general practitioner retained by the plaintiff’s employer, although not having examined the patient, nevertheless referred him to a chiropractor. This referral was held to have been negligent, not because of the referral per se, but because of the patient’s condition. This came to light in the evidence given by a neurosurgeon and orthopaedic surgeon at the trial of the action, both of whom agreed that this case was not one for chiropractic manipulation of the plaintiff’s neck and back. Despite subsequent neurosurgery, the plaintiff became totally incapacitated for work. In the result, both the referring GP and the chiropractor were held to be liable in negligence.

Paul Gerber

To the Editor: We read with interest the commentaries by Pirotta and Dwyer on complementary and alternative medicines (CAMs).1,2 This debate has a long history, spanning more than two decades,3 and the pessimism continues to ignore good science.2 Firstly, integrative medicine (IM), which combines alternative and conventional medical practices, is not and never has been synonymous with CAMs. IM is a global paradigm shift that expands the conventional model of medical care with evidence-based laboratory and clinical research. IM embraces the foundations of medicine, such as (i) the critical role of the doctor–patient relationship, (ii) the importance of lifestyle, and (iii) improving the wellbeing and promoting the natural healing potential of people afflicted with disease.4 Secondly, a thinly disguised commentary on the ineffectiveness of CAMs,2 while dismissing a large body of scientific clinical evidence, is broadly misleading. This is significantly remiss, failing to cite the value of prebiotics and probiotics in digestive diseases,5 the effect of omega-3 essential fatty acids on endothelial function,6 the efficacy of acupuncture for some forms of pain,4 mindfulness-based stress reduction and mindfulness-based cognitive therapy for mental health,7 and emerging modalities such as yoga for menopausal symptoms4 and tai chi for fibromyalgia,4 and many more.4 Moreover, such deliberate carelessness serves only to confuse researchers and clinicians, as well as the public. Evidence-based medicine is critical in expanding the medical model of care; of this there can be no doubt. Adhering to biologically plausible mechanisms of action is the key foundation that will always guide scientific evidence, including that for CAMs. As an example, we have recently scientifically challenged the validity of the antioxidant effect to abrogate free radicals that are purported to contribute to the development of chronic diseases.8 Therapies that deviate from the conventional medical model still elicit an unhealthy cynical response2 that hinders the progress of scientific and medical investigations. If Florey and Fleming had adopted such cynicism and dismissed the biologically far-fetched notion of an antimicrobial mould in a Petri dish (Penicillium notatum), they most probably would not have pursued and contributed to the discovery of the antibiotic penicillin. Thus there is no place in science and medicine for the imprimatur of distrust and scepticism that is levelled without respite at novel concepts, even those with scientific plausibility.

Luis Vitetta · Shoshannah L Beck · Samantha Coulson · Avni Sali

To the Editor: I am concerned that the viewpoints by Dwyer1 and Pirotta2 were published without establishing a clear definition of “complementary and alternative medicine” (CAM). The term CAM is not ideal as it groups many non-evidence-based therapies that have little in common, such as iridology and homoeopathy, with more evidence-based complementary therapies such as acupuncture, nutritional medicine, meditation and some herbal medicines that have demonstrated efficacy. To date there is a growing body of research, including Cochrane reviews, to support the use of some complementary therapies (Box). The fact that many complementary therapies have not been tested and subjected to high-quality research does not necessarily mean they do not work.3 For other complementary therapies, there are mixed findings (negative trials balanced by positive trials, as seen in Cochrane reviews), so one needs to ask why the differences in results? Were there differences in dosage, the quality of the substance or method of the therapy tested? Would you argue with patients who find symptomatic relief for troublesome symptoms of menopause from herbs when they are intolerant to hormone replacement therapy, or relief from osteoarthritic pain from complementary medicines and acupuncture if non-steroidal anti-inflammatory medications are contraindicated because of a peptic ulcer? Demand for complementary therapies in Australia is actually coming from consumers. If they found the therapies unhelpful, why would they continue with them? A better term for complementary and alternative medicine is integrative medicine (IM), defined as: the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing.4 The aim of IM is to find common ground and respect for the patients who choose to use complementary therapies and to understand their use. General practitioners have been shown to be very interested in learning about complementary therapies, with one study finding that about 30% of Australian GPs identified themselves as practising IM and most (more than 80%) requesting more education and research in complementary therapies.5 It is important that doctors balance clinical decisions between the risks associated with any therapy, the evidence and the therapeutic clinical outcome (effectiveness) to inform patients appropriately.

Vicki Kotsirilos

To the Editor: The Journal is to be commended for this important discussion on quality improvement (QI) by Millar1 and Runciman.2 It is important to understand that if doctors are not engaged in changes to health service provision, including QI, such changes will be ineffective.3 Not surprisingly, unengaged doctors can “prove” the lack of an effect of a QI initiative and return to doing what they have always done. Millar comments on the “division between QI and clinicians”.1 Why this division? Why is there a lack of engagement, and a lack of common purpose, values, and beliefs? Professional responsibilities as defined by the American College of Physicians (ACP) in 2002 include “commitments” to, among others, “improving quality of care”, “improving access to care”, and “a just distribution of finite resources”.4 The 2009 Royal Australasian College of Physicians Professional Qualities Curriculum provides a very similar list of responsibilities for all physicians.5 It may be time for many doctors to step onto the common ground and out of the ivory tower. It is time that doctors become able to view themselves as only one part of a larger system that exists solely to provide health care for patients and the population. Teamwork and collaboration with non-medical health professionals (including managers) may often be undervalued from a “doctor-centric”, and often “hospital-centric”, perspective. It is also high time that health organisations and many managers become serious about involving clinicians, initiating “true” clinical leadership, and engaging and communicating in a meaningful way. Clinical leadership, clinical governance and “teamwork” have unfortunately become almost slogan-like, stale entities that appear in health policy plans and strategy documents without much meaning or consequence. One day, clinical care may be better and have more resources because of better implementation of QI that actually engages clinicians.

Roland J Meyer

To the Editor: I would have thought that, in 2011, any debate pitting fee-for-service against salary models of remuneration was both stale and futile. These debates, such as the one entered into by Peat1 and Travis,2 have been around since Bismarck introduced health insurance for workers in Germany. Surely we have come to realise, after more than a century of varied health insurance schemes and health services around the world, that it is a matter of horses for courses. A single payment system, whatever it is, will be inappropriate if applied universally in any country. There is a place for fee-for-service delivery, accompanied by insurance; there is a place for salaried service; and there is even (heresy for some!) a place for that form of salary called “capitation”. Each system has its merits and its faults, which have been discussed ad nauseam by health economists too numerous to refer to (two publications serve as examples3,4); there is nothing new under the sun. Debates such as this generalise the behaviour of a few miscreants to all salaried or fee-for-service practitioners. This is clearly unfair to both groups. Australia is fortunate that, back in the 1970s, our profession was able to stave off a Canadian-style, single-payer system. Our graduates can choose their method of remuneration — and, however they have been paid, we have distinguished colleagues who have achieved much and, regrettably, a few rogues. In the latter respect, we are no different from any other profession or trade. Why not abandon the ideologies underlying both sides of the debate, face these facts and have both systems in place, where each is appropriate, rather than trying to apply a single solution everywhere? I am reminded of the wisdom of Anthony Ashley Cooper, third Earl of Shaftesbury; “The most ingenious way of becoming foolish is by a System”.5

Peter C Arnold

To the Editor: The recent article by Hebden and colleagues on the frequency and content of fast-food advertising on Australian television concluded that the industry self-regulatory initiatives currently in place are ineffective in reducing children’s exposure to advertising of non-core foods.1 As the managers of these self-regulatory initiatives, we consider this conclusion to be misleading to your readers. The Australian food and beverage industry recognises the level of community concern in relation to food and beverage advertising to children. There are currently two self-regulatory initiatives in place to moderate advertising of non-core foods and beverages to children: the Responsible Children’s Marketing Initiative, that covers products found in retail outlets; and the Australian Quick Service Restaurant Industry Initiative for Responsible Advertising and Marketing to Children, that covers foods sold in quick-service restaurants. These initiatives are designed to restrict advertisements aimed at children by means of the nature of the advertisement and/or the medium by which it is delivered. Hebden et al base their conclusion on a broad definition of “advertising to children” that captures all advertisements screened between 5.30 pm and 10.30 pm on weekdays, and between 7.30 am and 11 am and 4.30 pm and 11 pm on weekends. Specific time periods are not, in fact, covered in the industry initiatives as these periods capture programs that are watched primarily by adults. If children are watching these programs, they are likely to be doing so accompanied by an adult who can provide guidance on appropriate food consumption. However, industry does recognise that times when children are watching television alone and advertisements that are designed particularly to target children are a different matter, and that it must act responsibly in these areas. The success of the initiatives should not be measured by advertising frequencies during certain time periods, as implied by Hebden and colleagues. Nevertheless, the data presented by Hebden et al actually suggest a significant reduction in the frequency of non-core-food advertisements (excluding fast food) in just the first year of operation of the initiatives, which, in terms of what the authors perceive to be “advertising to children”, should be viewed as a positive finding. The Australian Food and Grocery Council is committed to monitoring the self-regulatory initiatives and makes the results available to all stakeholders to help evaluate the effectiveness of what the initiatives set out to achieve.

Peta E Craig · Geoffrey Annison

In reply: Children’s exposure to advertising of unhealthy foods is of concern because children are exposed to a large volume of such advertisements. The World Health Organization has clearly stated that any efforts to address this issue must reduce children’s exposure to unhealthy food advertising.1 Our research article2 was based on such measures. The viewing times applied in our research were specifically those when the highest numbers of children aged 5–12 years watch commercial television, according to Australian audience data for Sydney commercial television stations, and thus are exposed to advertising. Craig and Annison refer to a decrease in the relative proportion of advertisements for unhealthy fast foods over the first year of the industry initiatives. However, readers should be aware that our research showed that the total amount of fast-food advertising increased over this period, so that the frequency of unhealthy fast-food advertisements that children were exposed to remained the same. To make meaningful changes to what advertising children see, time-based restrictions would form a more responsible approach for regulation than the current industry specifications.

Lana Hebden · Lesley King · Anne Grunseit · Bridget Kelly · Kathy Chapman

Back pain is very common; it has a point prevalence of 25% and is the third most common reason for consultation in Australian general practice. A thorough history and examination can identify the minority of patients who require urgent neuroimaging or other targeted investigations. Careful correlation of clinical and radiological findings is required when abnormal neurological findings are detected. Radiological investigations may detect abnormalities at multiple levels but cannot confirm which level is primarily responsible for a patient’s symptoms. A trial of conservative treatment is appropriate, even in cases of radiculopathy. Most patients with an acute episode of back pain recover within 6–12 weeks, but at least a third go on to have a recurrent episode within 1 year. Various invasive treatments, such as transforaminal steroid injection and discectomy, may speed up recovery from radiculopathy, but the long-term benefits of invasive treatment are uncertain.

Timothy J Kleinig MB BS(Hons), FRACP, PhD · Brian P Brophy MB BS, FRACS · Chris G Maher BAppSc(Phty), PhD

Fever is an important mechanism of intrinsic resistance against infectious disease. A variety of studies point to a potential detrimental effect of temperature lowering in infectious disorders, but high-quality evidence from randomised controlled trials is lacking. In ambulatory care settings, we need to know whether antipyretics influence the severity and duration of illnesses and, in critically ill patients, whether antipyretics affect mortality.

Paul J Young BSc(Hons), MB ChB, FCICM · Manoj K Saxena MB BChir, FRACP, FCICM · Richard W Beasley MB ChB, DSc, FRACP

Objective: To evaluate mammography screening outcomes in women with a personal history of breast cancer (PHBC), who have an increased risk of recurrent or new breast cancer, relative to women without PHBC.Design, setting and participants: Retrospective study of 713 191 screening mammograms from two groups of women — those with versus those without PHBC — who participated in the BreastScreen WA program in Western Australia between 1997 and 2006.Main outcome measures: Cancer detection rate (CDR), recall to assessment rate, recall positive predictive value (PPV) for cancer, and distribution of cancer characteristics within and between the two groups.Results: Screening detected 4125 breast cancers: CDR per 10 000 screens was significantly higher in women with PHBC (95.5; 95% CI, 78.3–112.7) than in women without PHBC (57.2; 95% CI, 55.4–58.9). Recall to assessment rate per 10 000 screens was lower in women with PHBC (385.2; 95% CI, 350.6–419.8) than in women without PHBC (504.9; 95% CI, 499.7–510.2). Recall PPV was higher for women with PHBC (24.8%; 95% CI, 21.0%–28.9%) than those without PHBC (11.2%; 95% CI, 10.9%–11.6%). Cancer characteristics were consistent with early detection (most were smaller than 2 cm and node-negative) and were similarly distributed in both groups, except for tumour grade, with PHBC women having fewer low-grade cancers and slightly more high-grade cancers than women without PHBC.Conclusions: The relative rate of cancer detection between women with PHBC and women without PHBC who attended an Australian population-based breast screening program was similar to estimates from international studies. Recall rates were within national standards. Screen-detected cancers had similar characteristics in both groups, except for tumour grade. These data support national integration of mammography screening for women with PHBC into BreastScreen, although evaluation of interval cancers will be necessary.

Nehmat Houssami MB BS, FAFPHM, PhD · Janette J Tresham BSc(Agric) · Lin Fritschi MB BS, FAFPHM, PhD · Liz E Wylie MB BS, FRANZCR

Objective: To determine the current level of knowledge of first aid for a burn injury and sources of this knowledge among the general population of New South Wales.Design, setting and participants: People aged 16 years or older were interviewed as part of the 2007 NSW Population Health Survey, a continuous telephone survey of NSW residents.Main outcome measure: Weighted proportion of the population with optimal first aid knowledge for burns.Results: In total, 7320 respondents were asked questions related to burn injuries and first aid. Of the surveyed population, 82% reported that they would cool a burn with water, and 9% reported that they would cool the burn for the recommended 20 minutes. Few respondents reported that they would remove the patient’s clothing and keep the injured person warm. The most common sources of first aid information were a first aid book (42%) and the internet (33%). Speaking a language other than English at home, and being over 65 years of age were associated with a lack of first aid knowledge.Conclusions: A minority of people living in NSW know the optimal time for cooling a burn injury and other appropriate first aid steps for burns. This study demonstrates a gap in the public’s knowledge, especially among non-English speaking people and older people, and highlights the need for a clear, consistent first aid message.

Lara A Harvey BSc, MPH · Margo L Barr BSc, MPH · Roslyn G Poulos MB BS(Hons), PhD, FAFPHM · Caroline F Finch BSc, MSc, PhD · Shauna Sherker BSc, MSc, PhD · John G Harvey MB BS, FRACS, FRCS

Objective: To use population-level data to monitor the impact on smoking cessation activity of the April 2010 Australian tobacco tax increase.Design and setting: The Cancer Institute NSW [New South Wales] Tobacco Tracking Survey (CITTS) is a continuous tracking telephone survey conducting about 50 interviews per week. Data from February to September in 2009 and 2010 were analysed (ie, data on people who quit smoking in the 3 months before and 5 months after the tax increase in 2010 were compared, and quitting activity over the same period in 2009 was also analysed).Participants: Adult smokers and smokers who had stopped smoking in the previous 12 months; 2009 (n = 1604); 2010 (n = 1699).Main outcome measure: Recent quitting (defined as stopping smoking or trying to quit within a 1-month period).Results: 22% of the sample reported that they had quit smoking in May 2010, compared with 13% in April 2010 and 12% in May 2009. Respondents interviewed in the 3 months after the tax increase (May–July) were significantly more likely to report quitting than those interviewed in the 3 months before the tax increase (odds ratio, 1.84; 95% CI, 1.26–2.69; P < 0.01). This increase in quitting activity was not sustained in the subsequent months (August–September).Conclusions: The tobacco tax increase was associated with a short-term increase in the rate of smoking cessation among NSW adult smokers and recent quitters, suggesting that regular increases in tobacco tax may further encourage quitting activity.

Sally M Dunlop PhD · Trish F Cotter BSc, MPH · Donna A Perez BSc

Clinical recordA frail 68-year-old woman of European ancestry presented to the emergency department with partial seizures of her left hand and mild left hemiparesis. Magnetic resonance imaging (MRI) scans of the brain revealed a non-enhancing lesion in the right precentral gyrus that was thought to represent infarction (Box, A and B). Over the following 2 months the lesion increased in size. A brain biopsy was performed, as the patient experienced ongoing seizure activity despite anticonvulsant therapy. The patient was married to a retired police officer and had three children. She had been raised in a country town and her father had kept cattle, pigs and sheep on their property and slaughtered meat. She had trained as a nurse and had worked in a tuberculosis ward. During early adulthood she had visited Papua New Guinea for 2 months. The patient’s background medical history was extensive. Coeliac disease was diagnosed 16 years before her current presentation. Within the past 4 years she was diagnosed with ulcerative proctitis, was twice hospitalised for pneumonia, was treated for bronchiectasis and required bone resorptive therapy for osteoporosis. She had had a hysterectomy 25 years previously. Results of the brain biopsy were inconclusive; it showed an unusual lymphoid infiltrate and the presence of cytological atypia. There was no evidence of necrosis, malignancy or granulomas; and no organisms were noted on stains for bacteria, fungi, mycobacteria and parasites. The slides were referred for a second opinion. Dexamethasone therapy was added to help reduce the frequency of seizures. A chest x-ray showed right apical pleural thickening consistent with past tuberculosis exposure, and a computed tomography (CT) scan of the abdomen showed small axillary and intra-abdominal lymph nodes; no hepatosplenomegaly or mass lesions were seen. A positron emission tomography scan showed a focus in the bowel. She was referred to a haematologist due to suspicion of lymphoma. The patient was cachectic and weighed 38 kg. Clinical examination showed no evidence of lymphadenopathy or hepatosplenomegaly. Results of serum biochemical analysis were normal except for a low albumin level of 30 g/L (reference range, [RR], 37–46 g/L). She had a haemoglobin concentration of 82 g/L (RR, 115–160 g/L) and a normal white cell count. A blood film showed some atypical lymphocytes. Iron studies were not suggestive of iron deficiency and there was no haemolysis present. The C-reactive protein level was 15 mg/L (RR, < 5 mg/L) and the erythrocyte sedimentation rate was 100 mm/h (RR, < 15 mm/h). Paraprotein was not observed on immune electrophoresis. An HIV test was positive on two occasions with a confirmatory western blot immunoassay. The CD4 count was 214 × 106 cells/L with a plasma HIV viral load of 382 000 copies/mL (log10 5.58). Serological testing was negative for hepatitis B, hepatitis C, syphilis, Toxoplasma gondii infection, cryptococcal infection, hydatid disease, toxocariasis and schistosomiasis, although there was evidence of past exposure to Epstein–Barr virus and cytomegalovirus. HIV infection was likely to have been acquired during a blood transfusion after her hysterectomy 25 years earlier. Subsequently, an Australian Red Cross Blood Service lookback confirmed that one of two units she received was from a blood donor who subsequently died of HIV-related complications. Her husband was a regular blood donor and had repeatedly screened negative for HIV infection at each donation. Upon further review, the brain biopsies were thought to be consistent with progressive multifocal leukoencephalopathy (PML) with a florid mononuclear infiltrate, atypical astrocytes and prominent eosinophils. Immunohistochemical analysis was positive for John Cunningham virus (JCV). The patient’s cerebrospinal fluid (CSF) was acellular and had normal biochemical features, but the HIV viral load was 51 200 copies/mL, suggesting significant HIV replication in the brain. Polymerase chain reaction did not detect JCV DNA in the CSF. Follow-up gastroscopy revealed lymphocytic gastritis and moderate villous atrophy of the small bowel mucosa, but no malignancy or parasitic infection. Colonoscopy revealed synchronous adenocarcinomas. After careful consideration, the patient underwent proctocolectomy with ileostomy formation. Histopathology revealed tumour–node–metastasis (TNM) stage III disease with clear margins of excision and minimal node involvement. The colon had a diffuse chronic inflammatory mucosal infiltrate but this was not suggestive of ulcerative colitis, and there was no parasitic or opportunistic infection. She was assessed as not requiring adjuvant chemotherapy. After surgery, the patient began highly active antiretroviral therapy (HAART) with a regimen comprising Trizivir (abacavir, lamivudine and zidovudine) and ritonavir-boosted indinavir. She experienced symptomatic improvement, weight gain and reduced partial seizures within a few weeks. The plasma HIV viral load was undetectable within 8 weeks of commencing HAART and a repeat MRI scan at that time confirmed a significant reduction in size of the cerebral lesion (Box, C). Unfortunately, at the same time, routine biochemistry revealed acute renal failure with an elevated serum creatinine of 295 μmol/L (RR, 50–90 μmol/L). An abdominal CT scan showed hypodense liver lesions, a large peripancreatic lesion, an enhancing lesion in the left renal collecting system, and a mass lesion encasing the left ureter. There was a significant amount of abdominal ascites. A fine-needle aspirate confirmed the presence of metastatic adenocarcinoma. Comfort measures were instituted and the patient died 4 days later. The last case of HIV transmission from an infected blood transfusion in Australia was recognised by the Blood Service 9 years before this one (Australian Red Cross Blood Service, personal communication), and further cases from the prescreening era (before 1985) were thought unlikely to be identified due to the passage of time. This case of transfusion-acquired HIV infection was missed by routine Blood Service tracking and the family of the deceased patient were eligible for compensation. DiscussionOur patient presented with PML as her AIDS-defining illness with synchronous colonic neoplasms on a background of multiple medical conditions. With hindsight, these conditions were all linked to immunosuppression due to unrecognised HIV infection. It is likely that prolonged HIV replication in sanctuary sites, such as the gastrointestinal tract and brain, were responsible for her small bowel, colonic and central nervous system (CNS) disease manifestations. Impaired immune dysregulation may have contributed to the aggressiveness of the tumour behaviour. PML is a demyelinating disease of the CNS caused by JCV, a human polyomavirus. The condition generally occurs in the setting of prolonged immunosuppression among individuals with decreased cell-mediated immunity, such as HIV infection.1 In the pre-HAART era, the prognosis for PML was very poor, with median survival times no greater than 6 months.2 With the advent of HAART, the survival time has improved to 15 months or more, but mortality rates can still be as high as 30% to 50%.3 PML has also been documented among patients who receive certain immunosuppressive drugs, such as fludarabine, rituximab, corticosteroids,2 and shortly after the introduction of HAART as a form of immune-reconstitution inflammatory syndrome.4 In HIV infection, HAART is the only therapeutic option for PML, but the efficacy of these agents in controlling JCV replication in the CNS is variable and clinical response is not uniform. Antiretroviral agents with good CNS penetration have been used to optimise therapy for patients with PML.3 Previous studies have suggested the mean time to AIDS diagnosis from HIV acquisition after transfusion was 7 years,5 although a cohort of “non-progressors” who acquired a variant strain of HIV containing the nef gene deletion has been well documented.6 Our patient had delayed progression to AIDS, even in the absence of HAART, a clinical pattern that has been linked to several other genetic factors, including chemokine coreceptor type 5 (CCR5) status.7, 8 CCR5 is a coreceptor required for HIV to enter T cells and macrophages. Homozygosity for the Δ32 gene deletion in the CCR5 gene (CCR5-Δ32) is associated with resistance to HIV infection (although people can still be infected with T-tropic strains of the virus, which use the CXC chemokine receptor type 4 for cell entry), whereas heterozygosity confers delayed progression to disease. Our patient was confirmed as being heterozygous for CCR5-Δ32. In the United States, the frequency of the allele is 11% among white people and 1.7% among black people.8 Targeting the CCR5 receptor to interrupt HIV transmission offers new therapeutic possibilities. Maraviroc, a CCR5 inhibitor, has been introduced with success when used as part of a HAART regimen for patients with R5 (M-tropic) virus.9 Transplantation of stem cells from a donor homozygous for CCR5-Δ32 to a patient with acute myeloid leukaemia and HIV infection resulted in continued virological suppression after transplantation in the transplant recipient and discontinuation of HAART.10 Our case highlights problems associated with delayed diagnosis of HIV infection due to the absence of perceived risk factors. In Australia, rates of HIV screening in the community, outpatient and inpatient clinical settings appear to remain suboptimal. Factors associated with decreased uptake of HIV testing include issues surrounding consent and counselling, or lack of appreciation of risk exposures by doctors and patients. A reduced threshold for performing HIV testing in these settings is required. We recommend an HIV screening test in the workup of all patients with cerebral lesions or an unusual illness pattern when the diagnosis is not easily apparent. One approach to help identify individuals who are unaware that they have HIV infection is the “opt-out” HIV testing strategy proposed by the US Centers for Disease Control and Prevention in 2006.11 All people aged 13–64 years in health care settings would have routine HIV testing. Importantly, pretest counselling and signed consent would not be required, and the test would be performed unless the patient declined. Patients with known risks for HIV infection should be tested annually.11 This testing strategy would allow undiagnosed patients earlier access to medical care with an anticipated reduction in HIV transmission and infection related morbidity and mortality.12 The World Health Organization endorsed these recommendations in 2007, expanding the scope of uptake to the developing world.13 Drawbacks to this approach include concerns about stigmatisation and discrimination of individuals with HIV,14 and increased cost implications15 for health authorities from increased test numbers, including confirmatory immunoblot assays, and a requirement for more expertise to interpret true and indeterminate results. We encourage further debate about improved uptake of HIV testing for the Australian health setting by the appropriate governing bodies. Magnetic resonance imaging of the brain A: T2 coronal sequence at initial presentation. B: Axial fluid-attenuated inversion recovery (FLAIR) sequence at initial presentation. C: Axial FLAIR sequence after 2 months of highly active antiretroviral therapy.

Archie A Darbar MB BS, FRACP, FRCPA · Luke A Coyle MB BS, FRACP, FRCPA

When a patient’s wishes conflict with “best practice” The question of whether a person has the capacity to make decisions for him- or herself is one that has increasing relevance throughout clinical practice. It is especially relevant in palliative medicine, where practitioners often pride themselves on offering patient choice, particularly when it comes to selecting a venue for receiving care. Patients seen by palliative care services frequently have impaired cognition, often due to delirium.1 Such cognitive impairment places patients at risk of not understanding the ramifications of the decisions that they make. This is likely to become an increasing problem, as palliative care services care for an ageing population, with a significant comorbid burden, who are more at risk of diminished capacity due to the prevalence of illnesses such as dementia. The four ethical principles of health care — non-maleficence (doing no harm), beneficence (doing good), respect for autonomy, and justice2 — remain the foundation for ethical clinical practice. However, in the course of our duties, these principles may come into conflict. Deciding to act in the patient’s best interestsAn 85-year-old man with metastatic rectal cancer, who received domiciliary palliative care support following an “unsafe discharge” from an inpatient palliative care unit, was readmitted against his express wishes and subsequently died in hospital. This article explores the resulting sense of unease among the responsible clinicians, arising from our decision to act with beneficence and, arguably, humanity, in overriding a patient’s dying wishes. The patient was diagnosed with a stenosing rectal cancer, with lung and bone metastases, following presentation with advanced cachexia and symptomatic anaemia. The diagnosis came as a shock to the patient, who denied any previous major health issues and had infrequent contact with his family doctor. He had been a lifetime smoker of 60 pack years, and smoking was one of the few passions of his now-isolated existence. The patient was a worldly man, born in Malta, who had travelled extensively in his youth before settling in metropolitan Melbourne and raising a family. Unfortunately, his wife’s death in 1989 heralded a slow withdrawal from his friends and family. By the time of his presentation, he was living a squalid existence and reluctantly came to hospital at the insistence of his adult children. Options for palliative surgery, chemotherapy and radiotherapy were discussed and declined by the patient. A brief period at home resulted in a further presentation with symptomatic anaemia due to ongoing rectal blood loss and faecal incontinence. He was referred and admitted to inpatient hospice care, but again asked to be discharged almost immediately following blood transfusion. His insistence on discharge and refusal to discuss options to improve his physical care and safety at home led his palliative care providers to organise an assessment of his decision-making capacity by a neuropsychologist and consultation liaison psychiatry team. He was found to have decision-making capacity during these assessments, although it was noted that he was an avoidant historian and lacked some insight into the ramifications of his decisions. Plans were made to support the patient at home, as was his wish, with extra community services, community palliative care and family involvement. Unfortunately, the situation unravelled quickly at home. He refused many of the services that had been organised. He was reluctant to let his family help him more and they felt powerless to compel him. The community palliative care team attempted to act as mediator but made little progress. During this time, he became progressively frail until no personal care or safe use of medications was deemed possible. He had a fall at home 6 weeks after discharge, and an ambulance was called when he was found on the floor, unable to rise. Despite his frail condition, he remained both vocally and physically resistant to paramedic attempts to transfer him to hospital, and he finally sent them away. He was also left alone by his family, who felt both unable to provide care for their father at home and powerless to compel him to go to hospital. He remained on the floor for several hours, until urgent re-review by the community palliative care physician. By this time, the sun had set, and his home was shrouded in darkness and cold. He told the physician that he was lying on the floor only because he wished to do so and that he wished to remain where he was, although he was intermittently not orientated to place or person. Under Victorian legislation, he was assessed by the palliative care physician as being incompetent due to delirium3 and was transferred to hospital as an involuntary patient. This required police attendance and the ambulance service to transport him safely. His involuntary status was upheld for a further 48 hours by subsequent independent psychiatric review. No reversible cause of delirium was found on investigation when he was hospitalised, although his cognition did improve. He deteriorated over a course of weeks and died comfortably in hospital without requesting discharge again. Weighing up the ethical issuesThe decision that led to the patient’s removal from his home against his wishes, and his subsequent death in hospital, continues to rest uneasily on the team, given that clinical decisions are usually made not only for the benefit of the patient, but are also informed by respect for patient autonomy, non-maleficence and justice. In this instance, less invasive interventions, including enlisting family support, appointing a guardian, or urgent review by community-based psychiatric services were considered but judged to be inadequate or not possible within the time frame required. Subsequent peer-review discussions raised the probability of similar situations of isolated people living and dying without support in poor conditions. While this is likely true, there is a clear distinction between knowing the detail of a specific unfolding clinical scenario and not intervening, and theoretical events outside our direct knowledge. In the end, the contention returns to the dilemma that this patient had decided not to comply with what we would regard as “a good death”. In doing this, the consequences of his actions were detrimental not only to his comfort and condition but to the physical and psychological wellbeing of his family and carers, who were placed in the unenviable situation of having to provide inadequate care in an inappropriate environment. The clinical decision was made that drastic action was necessary, even to the point of forcing his compliance against his will. At the time of the decision to compel his removal from his home, it became less about his competence to make decisions, and more about our recognition of his humanity. To leave him to die alone, cold and probably in pain, in the midst of one of our well resourced cities, with medical and health care professionals in full awareness of his predicament, without acting, would have been a betrayal of our responsibility as his medical carers. We would have been inappropriately allowing respect for his autonomy to outweigh all other ethical considerations, despite his changed circumstances and limited realistic choice to remain as he was. While this is a pragmatic principlist approach, other ethical theories, such as virtue ethics, accord with our decision, which was guided by compassionate interest in the patient’s wellbeing. Was this an act of excessive medical paternalism, resulting in the denial of a person’s last wish to die at home? Undoubtedly there are those who would argue on both sides. However, even with the passage of time, we remain comforted that, after acknowledging the patient’s autonomy, our intervention was carried out in his best interests.

Brian H Le MPH, FRACP, FAChPM · Michael D Chapman MB BS

Hardworking rural doctors make an unrecognised but large difference During my career as a city-based gastroenterologist, I was fortunate to make many trips to Victorian country towns to give educational talks. I often met inspiring people, and one of these was a senior country surgeon on the verge of retirement. This is his story. The older surgeon and I had been chatting with a younger surgeon, new to the town. The new surgeon had proudly told us about the lovely home he had just purchased, some 2 kilometres from the local hospital. The older surgeon sighed and confided to me that he would never have been able to live so far from the hospital, but had always lived within 500 metres because he often had to get to the hospital quickly. He had taken almost no holidays in 35 years of practice because there was rarely anyone to cover his absence. The surgeon gave me an example of his lifestyle over that time. One Easter Thursday he was having his first mouthful of dinner, thinking it was quiet and that he might even get a rest over the Easter break. The phone rang — a multiple-car crash had occurred on the Princes Highway, with a couple of fatalities and several casualties — and that was his Easter gone. He tried to send the patients with head injuries to Melbourne. He rang four hospitals and gave the same details to four admitting officers, to be told four times that there were no beds for them. So he managed the head injuries as best he could, together with all the other injuries, and spent most of his Easter in theatre. The city folk all survived, and were eventually transferred to city hospitals. There were no thanks and no chocolates. In fact, he said he could not remember ever receiving a thankyou letter from any city-based patient. A couple of years later, a trauma helicopter service was introduced and he was informed most decidedly, in a castigatory tone, that he must never manage any neurosurgical patient again. There was no thankyou for past services. I knew this surgeon had an outstanding local reputation for dedicated, expert and compassionate care, but such a reputation would not have carried much weight with city doctors. He had known the limits of his expertise, and had asked for help when appropriate, but often had not received it. His story moved me profoundly. It reminded me of an event from my distant past, when I was a first-year intern in another Victorian country town, on rotation from a city hospital. There were two of us interns, and we thought we were pretty smart. We also thought all the local general practitioners were basically hopeless — they could not read echocardiograms, knew nothing about electrolytes and prescribed old-fashioned drugs. One Sunday morning I was in the shower about to wash my hair, having been in the wards most of the weekend, and my beeper went off. I grudgingly got out of my shower. “It’s the children’s ward; Jason doesn’t look too well; he’s had diarrhoea all weekend.” I wanted to wash my hair and knew I would not get a chance for the rest of the day, so said I’d be there shortly, and continued washing my hair. My beeper went off again: “Jason doesn’t look too well at all,” and I thought “What a nuisance, I’m not even dressed.” Jason was a thin, pale child aged about 5 years who seemed to have been in hospital for weeks, appeared to have no proper family, was always sniffly and was frequently being treated for head lice or scabies; he was none too adorable. Then a third page sounded: “You’d better come right away, Jason has collapsed.” I hurried to the hospital and ran to discover a cold, clammy, blue Jason with a thready pulse and no detectable blood pressure. I panicked: I tried butterfly needles in his hand and in his foot, but it seemed there were no accessible veins. “Should we call Dr Jones?” asked the nurses. “Yes!” I squeaked in desperation. Fortunately, Dr Jones (one of the “hopeless” local GPs) was close by. He did a cut-down in Jason’s cubital fossa, found a vein and ran some fluid in. Jason started to pick up with a bit of saline: his blood pressure became recordable, he opened his eyes, and suddenly seemed quite adorable after all. He lived. I learned many lessons from that episode: that I should always trust the nurses and respond quickly to their call for help; that I, in turn, must ask for help quickly when I need it; that looking after someone engenders love; and that country doctors actually do know quite a lot. So, what of the senior country surgeon? I hope he is happy and relaxed in retirement. Many people owe their lives to him — not only country people, but city people who have been scraped off the roads into his care. I sent a summary of his life to the staff of Australian story (ABC Television), suggesting that he would be a great subject for the program. They never wrote back. Maybe they didn’t think it was much of a story after all.

Katrina J R Watson MB BS, FRACP, MPH

Peter Schmidt was born on 29 December 1922 in Beaudesert, Queensland, where his father managed a sawmill. He was the youngest of three children. Peter attended St Joseph’s Nudgee College in Brisbane and studied medicine at the University of Queensland. After graduating in 1945, he took up residency at the Mater Hospital in Brisbane. In 1948, he established a general practice in Greenslopes, Brisbane, which he maintained until he fully retired in 1996. Peter had a long association with the Queensland Faculty of the Royal Australian College of General Practitioners (RACGP). In 1967, he became a member of its Board, where he served for over 20 years. In 1970, Peter gained Fellowship of the RACGP. He served on the medical education committee, was Chairman of the courses committee for several years before the formation of the Family Medicine Programme in 1974, and was elected Chairman of the accreditation committee, a position he held with distinction until 1997. From 1975 to 1996, Peter was Director of the postgraduate medical education committee of the University of Queensland. The Australian Medical Association acknowledged his services to medicine when he was elected to Fellowship in 1984. In 1993, Peter was awarded a Medal of the Order of Australia, in recognition of his services to postgraduate medical training and to his local community. Peter died on 18 June 2011. He was predeceased by his wife Fay and is survived by his children Peter and Mary.

John A Comerford

Fast facts: brain tumours. 2nd ed. Lauren E Abrey, Warren P Mason. Oxford: Health Press, 2011 (143 pp, $19.50). ISBN 9781905832873. Brain tumours are the cause of the greatest loss of life-years per person from any cancer, but account for only 2% of all cancers. The first Australian Guidelines were published only in 2009. There is overwhelming consensus that brain tumours should be managed by a dedicated multidisciplinary team of neurosurgeons, medical and radiation oncologists, and nursing, social work rehabilitation and palliative care specialists. It is not clear who needs Fast facts. The authors, a neurologist and medical oncologist from major oncology centres in North America, have written it in a style that is only suitable for clinicians. Specialists will not find much that is new. Allied health practitioners new to neuro-oncology and medical students may be interested in a concise précis of current practice for the modest price of $20 but may prefer the Australian Guidelines, which are more detailed and are available for free from the Cancer Council Australia website. A version of the guidelines has been written for patients and carers. Fast facts discusses epidemiology, diagnosis and treatment and includes chapters on the more common types of brain tumours; however, rehabilitation, palliative care and supportive care are not covered. Brain tumour patients are rarely fit to drive, yet this important restriction is not mentioned. Older people are frequently undertreated because of concerns about their prognosis. The authors recommend treatment strategies based on the fitness of the patient rather than their age. The standard of illustration is good with many images of a wide range of clinical conditions. Brachytherapy, a disproved technique, is illustrated but radiosurgery is not. References are lacking but further reading is given at the end of each chapter, although some of the readings are over a decade old. The management of brain tumours should not be in the hands of those who need to fill gaps in knowledge “fast”. It is a complex and difficult area best managed by expert multidisciplinary teams.

Michael B Barton