Editorials

Closing a regulatory gap to ensure patient safety in all surgical proceduresHealth services are delivered in a variety of settings, including public and private hospitals, day surgeries and practitioner offices. Office-based surgery has been practised safely in the United States for many years,1 and has been embraced by surgical specialties such as otolaryngology,2 vascular surgery,3 ...

F A Hugh Bartholomeusz OAM, MB BS, FRACS

A new drug with great promise, but be very aware of the risksDabigatran is the first new oral anticoagulant for the prevention of embolism in patients with non-valvular atrial fibrillation (AF) that has been recently ...

Ross I Baker BMedSc, FRACP, FRCPA · Paul Harper MD, FRCP, FRACP · Claire McLintock MB ChB, FRACP, FRCPA

A few achievable strategies could improve translation of clinical research to practice. Randomised controlled trials (RCTs) provide the most internally valid method of evaluating new pharmaceuticals and, appropriately, provide the core evidence for marketing approval. However, ...

Jennifer H Martin MB ChB, FRACP, PhD · Michael D Coory MB BS, PhD, FAFPHM

Inadequacies persist in pain management Pain in patients has long been underestimated, and sufferers poorly served and stigmatised by previous health care approaches which have lagged behind the advances and recommendations of the time. Undertreatment of acute pain in Australia has been discussed over the past 24 years in editorials1 and guidelines,2 as have proposals for improved treatment.2,3 Cancer pain is in a similar situation to that of acute pain, with 50% of adults4 and children5 being undertreated, despite effective treatment being possible for most patients. Patients with chronic non-cancer pain face a worse situation; they are frequently stigmatised,6,7 and a large majority do not gain “access to appropriate assessment and treatment of the pain by adequately trained health care professionals”.8 Absences of data on the prevalence of pain and the associated costs of treatment have conspired to make pain almost invisible as a national health priority. But epidemiological studies by Blyth and colleagues revealed that chronic pain has a prevalence in Australia of close to one in five,9,10 similar to the prevalence in the United States.7 However, a more comprehensive view of pain has finally emerged to address these problems. In Australia, a draft National Pain Strategy (NPS) was prepared with input from health care and consumer organisations, and finalised by more than 130 health care organisations, including medical colleges, consumer groups, insurers and work safety organisations, at the National Pain Summit in March 2010. The resulting NPS (http://www.painaustralia.org.au/the-national-pain-strategy/national-pain-strategy.html) is the first worldwide pain plan with goals and strategies to address inadequacies in pain management. In response to the NPS, the Queensland Government allocated $39 million to a Statewide Persistent Pain Health Services Strategy, the Western Australian Government developed a Spinal Pain Model of Care (and supported the formation of Painaustralia), and the New South Wales government indicated it would introduce a statewide pain management program. A key idea identified is the “underlying principle of chronic pain as a disease in itself”.7 This concept was initially proposed in 2004,11 based on evidence of nervous system changes in people with chronic pain, and of pain-related psychological and environmental changes. Brain imaging studies suggest structural and functional changes which are reversible if appropriate treatment can be applied.12 The International Pain Summit (IPS) (http://www.iasp-pain.org/Content/NavigationMenu/Advocacy/InternationalPainSummit/default.htm) developed a broad framework suitable for use by any country (http://www.iasp-pain.org/PainSummit/DesirableCharacteristics_Nov 2011.pdf). Perhaps the most important outcome of the IPS was the Declaration of Montréal on pain management.6 The 2011 council of the World Medical Association resolved that “people facing pain have a right to appropriate pain management” (http://www.wma.net/en/30publications/10 policies/p2). Also in 2011, the European chapters of the International Association for the Study of Pain developed a transnational document on the impact of pain (http://www.efic.org/index.asp?sub=YMQ39bfQ m3D8IA). Chronic pain is no longer relegated to the background, but is now considered a clinical entity in its own right, requiring specialised, multifaceted care that brings real improvements to patient wellbeing. But there is still some way to go before the Australian health system can deliver such improvements. The Australian NPS details the barriers to improved treatment in the current model of care. A multidisciplinary pain management network is proposed, with emphasis on the primary care level, but also on community care for information, education, self-help, and support. The NPS provides goals and 120 strategic actions, which include: destigmatisation of people with pain education for all health professionals on treating chronic pain as a chronic disease adequate management of acute pain to minimise the risk of it progressing to chronic pain a monitoring system (now introduced) for opioid prescriptions to reduce the risk of inappropriate use. These recommendations show that, in both acute and chronic pain, change is necessary, but also achievable, to deliver the best possible care.

Michael J Cousins AM, MD(Syd), DSc, FFPMANZCA

Drug subsidy recommendations should be informed by active assessment of current evidence and emerging treatments Decisions about which medicines should be subsidised by the Australian Government on the Pharmaceutical Benefits Scheme (PBS) are based on recommendations made by the Pharmaceutical Benefits Advisory Committee (PBAC) — an independent statutory body appointed by the government.1 The PBAC lists among its goals maximising the “value” that Australia derives from its health expenditure and “meet[ing] the health needs of the majority of the Australian community”.2 While the PBAC is generally thought to have in place good processes for working towards these goals, its decisions are increasingly contested by consumers, governments, clinicians and the pharmaceutical industry.3 For example, concern has been expressed about the PBS’s subsidisation of ranibizumab (Lucentis), a vascular endothelial growth factor (VEGF) inhibitor used for the treatment of wet age-related macular degeneration (AMD), when a far cheaper and probably equally effective alternative — bevacizumab (Avastin), a VEGF inhibitor listed for cancer but not for AMD — was available.4 The listing of ranibizumab, it was argued, was inconsistent with the goals of the PBAC and PBS because it is about 40 times more expensive than bevacizumab, and costs taxpayers over $200 million each year (second only to atorvastatin and rosuvastatin). A recent development has brought the issue to light once again: Bayer Healthcare and Regeneron Pharmaceuticals are, together, likely to seek PBS listing for yet another VEGF inhibitor, aflibercept (VEGF Trap-Eye), recently approved by the Therapeutic Goods Administration,5 to treat wet AMD. Although aflibercept has not been shown to have greater efficacy than ranibizumab, patients only need an injection every 2 months, compared with monthly for ranibizumab.6 But even if this did provide some benefit to patients and reduced the cost of therapy, which it is only likely to do by a small degree, it would still leave bevacizumab unlisted, and taxpayers would still be paying significantly more than they need to, overall, to cover the cost of treatment for wet AMD. One possible explanation for such a situation is that the PBAC currently relies entirely upon interested parties putting forward submissions for listing, rather than proactively seeking submissions in the public interest. In practice, this means that almost all submissions come from commercial sponsors, and the agenda of the PBAC is largely determined by the interests of the pharmaceutical industry. This is potentially problematic, because commercial sponsors are unlikely to go to the trouble of listing medicines for indications that are not commercially attractive. In theory, there is nothing to stop professional societies or consumer organisations from making their own submissions to the PBAC in the public interest. However, non-commercial organisations seldom have the resources and expertise to conduct and synthesise the research into clinical effectiveness, cost-effectiveness and the broader impacts of health technologies that is needed to make a case for PBS listing. But need this be the case? Some overseas agencies charged with health technology appraisal (eg, in the United Kingdom7 and Canada8) place more emphasis on setting their own priorities for health technology assessment than does the PBAC. We suggest that it may be possible to expand the role of the PBAC so that it has the power to, first, identify emerging or established pharmaceutical agents that might require evaluation on the basis of likely public interest (“horizon scanning”); second, invite professional societies to prepare submissions in these priority areas; and, third, provide the necessary financial and scientific support to these organisations so that they do not need to be burdened by prohibitive costs or legal liability. Orphan drug provisions, which allow the PBAC to waive submission fees for medicines that have no sponsor or are not commercially viable,9 go some way towards redressing the imbalance between commercial and non-commercial interests; but, even here, the onus is on professional and consumer organisations to initiate and prepare submissions. In this regard, it is noteworthy that, in Australia, efforts have been made to initiate horizon scanning for non-pharmaceutical health technologies through the Australia and New Zealand Horizon Scanning Network (ANZHSN), which makes recommendations to the Medical Services Advisory Committee (MSAC).10 Horizon scanning may: identify new technologies with major implications for the health system; control the adoption and use of technologies; and, identify underused technologies, as might be the case with the listing of bevacizumab for the treatment of AMD.10 Expanding the role of the PBAC would not be easy. It would probably require the establishment of a separate government-funded body that would conduct horizon scanning, make recommendations to the PBAC, seek submissions from relevant professional organisations and provide these organisations with the financial and administrative support that they would need to conduct or commission the necessary health technology assessments. A subcommittee of the PBAC, to whom the horizon-scanning body could make its recommendations, would probably also need to be formed. And even if such a mechanism could be established, questions would remain, such as: Who should set priorities for seeking PBS listings? What criteria should be used for prioritising potential listings (eg, novelty, financial impact, clinical impact, disease burden)? What processes should be used to identify areas of need (eg, specialty mapping, forecasting, public ranking exercises)? And how can such processes be inclusive and transparent?8,10 Such practical difficulties are evident in the non-pharmaceutical medical technology sector in Australia, where, despite the existence of a separate government-funded horizon-scanning body, the impetus for the MSAC to conduct a health technology assessment almost always stems from an application by a commercial sponsor.10 But, unless steps are taken in this direction regardless of such difficulties, the PBAC will be unable to reach its full potential as an agency committed to universal benefits and the systematic application of evidence-based decision making.11

Wendy L Lipworth MB BS, MSc, PhD · Ian Kerridge MPhil, FRACP, FRCPA · Richard O Day MD, FRACP

A new series explores contemporary issues shaping medical school education Educating our future doctors has never before been such a high-stakes activity. The explosion of medical knowledge, new models of health care delivery, workforce imperatives and demands for greater social accountability are changing educational practice at an international level. Over the past decade, Australian medical schools have been at the forefront of many of these changes, as educators seek to consolidate our reputation as a provider of high-quality medical education. A major priority has been to ensure that the content of medical school programs is relevant and evidence-based. With competing demands on curriculum time, there has been a pressing need to define the core knowledge, skills and attitudes required by medical students to be practice-ready for their junior doctor years. This continues to be a complex and challenging exercise. There has been, for example, robust and at times acrimonious debate about the required depth of bioscience knowledge in entry-to-practice medical programs, in part fuelled by publication of the Australian Medical Education Study.1 Medical schools have also faced the task of extending the core curriculum to reflect changing emphases in health care delivery. Specific expertise is required to sustain new models of practice, such as interprofessional practice, effective management of the diseases of ageing, and chronic condition self-management support. The importance of laying the foundations of this expertise in medical school is increasingly being recognised, particularly within the broader context of the quality and safety movement.2 Considerable energy has also been devoted to optimising the efficiency and efficacy of medical school education.3 New theoretical models of learning, as well as the outcomes of educational research, are being used to define best practice.4 There has been an increasing emphasis on developing pedagogical approaches that help students to effectively appraise information and apply problem-solving frameworks. Substantial progress has also been made in the area of clinical skills acquisition, by applying techniques such as simulation-based learning, hypothesis-driven physical examination and deliberate practice.5 At the same time, the delivery of quality medical school education in Australia has been challenged by economic, logistic and workforce imperatives. One of the main reasons has been the need to overcome the shortage of medical practitioners, particularly in rural areas. This, combined with the expansion of the international student market, has led to a dramatic surge in medical student numbers in Australia, from 1287 in 2004 to a projected 3018 by 2014.6 The increasing demand for places has been accompanied by a growth in the number of medical schools between 2000 and 2008 from 10 to 19, with at least four other universities currently pursuing the right to establish medical programs. Significant challenges in coordinating clinical placements have arisen as a result of increasing student numbers and changing educational practices. The tertiary teaching hospital is no longer the sole provider of clinical education, and teaching now occurs in a wide variety of locations, including community settings and laboratories for simulation-based learning. Considerable effort has been required to foster consistency of curriculum delivery across these dispersed learning environments. Various bodies, such as the Australian Medical Council and Health Workforce Australia, are working to ensure medical students receive high-quality supervision as well as suitable clinical experience.7 Maintaining a well trained medical education workforce, nevertheless, remains at the heart of educating our future doctors. Several programs, such as Teaching on the run,8 are now offered to help clinical teachers enhance their expertise. Furthermore, a range of postgraduate qualifications is available for those wishing to explore the discipline in more depth or to assume leadership roles in medical education. A greater emphasis on academic development has contributed to strengthening of relationships with other areas of medical education. The continuum of learning is more clearly articulated than in the past; specifically, the Australian Curriculum Framework for Junior Doctors now provides a pivot between medical school education and vocational training.9 Medical schools are also strengthening their relationships with the wider community, in recognition of their social obligations. This has been exemplified by the development of the Indigenous Health Curriculum Framework,10 and selection procedures that aim to provide equity of access for disadvantaged applicants and shape the medical workforce so that it better serves diverse patient populations. With these developments has come a greater recognition of the need to evaluate the efficacy and cost-effectiveness of innovation in medical school education. It must be acknowledged that much of the reform in medical education has preceded rigorous inquiry, and the discipline has been rightly criticised for this.11 Accordingly, there has been a greater commitment to undertaking programmatic research and implementing strategies that feed outcomes back into educational policy and practice. In recognition of the importance of educating our future doctors, the MJA today begins a series of articles exploring the changes taking place in medical school education in Australia. For each article in this Medical Education series, there will be a one-page summary in the MJA’s print edition, and the complete text will be published on the MJA’s website (mja.com.au). doi: 10.5694/mja11.10968

Jennifer J Conn FRACP, MClinEd, BSc(Hons) · David A Ellwood MA, DPhil(Oxon), FRANZCOG(CMFM) · James M Hillis MB BS(Hons), BMedSc

Staff safety is improved by clear procedures for managing abuse and assault. Hopper and colleagues describe a scenario familiar to many hospital clinicians and managers: staff reports of verbal abuse and physical assaults from patients.This is often in an organisational context of scarce reliable data about the phenomenon, an ad-hoc management response and no specific training of staff to manage aggression....

Brett McDermott MD, FRANZCP, CertCAPsy

Assessing health status is only the beginning. Decisions to remove children from their biological parents are never taken lightly. Such decisions are reinforced by the growing body of evidence of the adverse short- and long-term outcomes of child maltreatment,1 which are increasingly seen to be mediated through the effects of abuse on early brain development.

Graham V Vimpani PhD, FRACP, FAFPHM · Susan M Webster MPHC · Meredith J Temple-Smith BSc, MPH, DHSc

Highest quality research, faster publication and easier access Einstein noted that we go beyond our limits once we recognise what they are. At the MJA, we recognised that we could go further as a journal of scientific record in this country and as a means of communication within the medical profession, and this led to a year of change in 2011. Revitalising internal processes for the handling of research manuscripts, developing new content and relaunching the print journal were the key changes. In 2012, there will also be considerable development, much of it focused on changes in our web-based platform. Our new website, soon to be launched, is benchmarked against industry (not medical journal) standards and will feature markedly improved functionality, including ease of login (we have heard you!) and a world-class search function that is fast and discerning. It will offer increased capacity for timely publishing of research and educational content (including rapid online publication and publication ahead of print). In the print journal, this will allow more logical grouping of related material and topics. The MJA is primarily a vehicle for the dissemination of high-quality medical research and information, and it is differentiated from other publications by this focus, by detailed peer review of submissions, by the active involvement of an experienced team of medical editors and by a stringent and careful editing process that is free from commercial influence. We highly value good research, and we are keen to nurture our position as Australia’s premier general medical journal and to further improve the dissemination of research to benefit researchers, clinicians and patients. To this end, we have revised our access policy to make all research articles freely available online, with full and continuing open access from the time they are first posted online. In 2011, a record number of submissions allowed us to be more selective in what we published and to focus on material of higher quality — an important benefit for readers. For authors, we reduced the time taken to reach a decision about publication through our new manuscript handling processes. In conjunction with our new open-access policy for research articles, this means important research findings will be published faster and be immediately available to an unlimited national and international audience. We are planning to launch MJA Open for other material, such as individual research articles or clusters of articles on specific topics, similar to our previous Supplements. New content was a significant feature of the MJA in 2011 — for example, our Practical Neurology series, which has been very well received. As doctors, we don’t lack information, but what we really need is relevant information that we can trust. Little in the medical press is as thoroughly researched and reviewed, and as meticulously cross-checked, as the MJA’s clinical series. Later this year, we will be publishing further series on medical education and ethics, with more in the pipeline. We plan to cluster Journal content throughout the year, and to work closely with the various Colleges to offer publication of important research to coincide with its presentation at major conferences. An expanded web presence will also offer the ability to present material in new ways. We will be able to receive and post your comments, to allow immediate debate of important issues. We are also keen to utilise the multimedia capability of the new website and we will provide peer review for multimedia material, just as we do for written material. We want to expand the role of the MJA as a provider of medical education, and we see an increasing need for recognition of the work of good medical educators. While researchers are able to gather citations for excellent research, educators have difficulty proving their worth in the same way. To this end, we will offer the option of submitting educational material, including tutorials and lectures, in a multimedia format for posting on the MJA website. Presentations will be peer reviewed before acceptance and, once posted, will be accompanied by a précis in the MJA, so that the presenter’s work is citable. Our goal is to provide an inclusive, interactive forum for the best medical information and research in this country. Changes in the MJA are all designed to meet this goal, each establishing a platform for further development. As Einstein emphasised, all effective change begins with knowing who you are. The MJA is Australia’s premier general medical journal, and our aim is to be your preferred choice for medical information and communication.

Annette Katelaris MB BS, MPH, FRACGP

The first Australian report is welcome and should help inform policy Traumatic brain injury (TBI) continues to be a significant public health issue in Australia. Despite advances in acute medical care and decreases in mortality, those affected experience long-term morbidity and have an increased late mortality rate. TBI is the leading cause of death and disability among young people, and the incidence of severe TBI is higher in men than women at a ratio of 3.5 : 1.1 The leading causes of TBI include: motor vehicle accidents (50%); falls (21%); violence (12%); and sports and recreation (10%).2 In Australia in 2008, there were 2493 new cases of TBI (about 1000 of these were severe),2 and the estimated total cost of care was $8.6 billion. Across Australia, lifetime cost per incident case of severe TBI was estimated at $4.8 million.2 In 2007, more than 16 000 patients were admitted to hospitals with TBI,3 with an average length of stay of 6.1 days in acute care, 64.2 days in rehabilitation and 84.1 days in other care. These patients characteristically have multiple disabilities and, in addition to health care services, they frequently receive other disability support services (eg, case management, individual therapy support, life skills development). Many factors affecting outcomes after TBI are modifiable, and influenced by medical management. Multidisciplinary assessments early in the course of the disease guide medical care and provide predictive information about the potential for recovery. Rehabilitation interventions have documented benefit in patients with TBI.4 Research into rehabilitation in severe TBI is challenging because of: the heterogenous manifestations of sequelae of severe TBI; the unpredictable course of the disease; the range and variety of rehabilitation services; and inconsistent use of appropriate outcome measures.4 Few studies tackle long-term outcomes in this population, so evidence is insufficient for establishing optimum integrated care, agreement on a minimum clinical dataset for effective communication between clinicians, and incorporation of patient and caregiver perspectives. The multicentre study by Baguley and colleagues in this issue of the Journal5 adds clarity by describing the long-term mortality pattern in adults with severe TBI, and identifies the risk factors associated with mortality. Among their 2545 patients with severe TBI discharged from tertiary rehabilitation units of the New South Wales Brain Injury Rehabilitation Program, with a mean follow-up period of 10 years, there were 258 recorded deaths. The authors report an increased risk of death up to 8 years after discharge from rehabilitation services that was 3.2 times greater than that for the general population, and higher than rates in previous reports (range of long-term mortality estimates, 1.1–3.1).6 The mortality rates remained higher than for the general population for up to 5 years after discharge from rehabilitation. True mortality rates may be underestimated; similar data for late mortality after TBI in children and Indigenous people are needed. The findings of Baguley and colleagues have implications for health service use and health modelling. The study by Baguley et al is the first long-term mortality report of Australian data, and shows an increased risk of death among patients with more severe TBI, greater functional dependence, previous drug and alcohol misuse, epilepsy before their TBI and older age at injury; these findings are consistent with those of other studies.7,8 Compared with the general population, those with severe TBI had a particularly high risk of death from respiratory disorders, and a high risk of death from nervous system, mental and behavioural, and digestive disorders. Discharge to an aged care facility was identified as a risk factor independent of functional dependency at discharge from rehabilitation, and needs further investigation. Older patients are considered at risk because of an altered pathophysiological response in the ageing central nervous system. Further, health, lifestyle and social deprivation have been linked with survival.9 Other reports suggest that TBI itself provokes lifestyle and behavioural changes, or defines a subgroup in the population at higher risk of death for other reasons.7 Future research should target interventions for general preventive measures to maintain health, and social and lifestyle changes in people discharged to the community after a TBI.7 The important elements of service provision for patients with TBI are similar to those in other conditions requiring neurorehabilitation:10 involvement and support of primary health practitioners; education of doctors, patients and caregivers about mortality, declining health and high-risk behaviours for targeted intervention; clinical guidelines to include routine postdischarge follow-up over a longer time, and a flexible health care delivery system that prioritises the rehabilitation needs of patients with TBI; and a clear plan of action and compliance, including indications for referral to specialised multidisciplinary services. Policy recommendations to establish services for continuity of care (acute to subacute and community care) for patients with TBI include:4,10,11 develop rehabilitation services (including infrastructure and personnel) for patients with severe TBI; provide services to meet the complex needs of those with severe TBI, to identify unmet needs for assistance and reduce reliance on informal assistance; link TBI rehabilitation programs with the existing Australian Rehabilitation Outcomes Centre dataset for long-term collection of clinical data, using standardised common data elements; computerise national monitoring systems in real-time to document mortality and morbidity in TBI, and monitor patterns of recovery; review policy and implement rigorous assessment of the impact of quality care to decrease mortality rates and harm from ineffective or insufficient treatment; expand national insurance schemes to fund non-compensatable TBI rehabilitation; and maintain a sustained public health information campaign to publicise issues and promote strategies for implementation in patients with TBI.

Fary Khan MB BS, MD, FAFRM

Health professionals should educate families about risk factors for accidental asphyxiation in shared-sleeping arrangements Over the past two decades, great advances have been made in identification of hazardous sleeping environments for infants and young children, with significant reductions in numbers of deaths.1 However, one issue that continues to incite heated debate is whether adult caregivers should sleep on the same surface as infants,2 referred to as “shared sleeping”. It is recognised that infants who sleep in the same room as their carers have a reduced risk of sudden infant death syndrome (SIDS),3 possibly due to an increased level of direct supervision.4 However, what of infants who sleep in the same bed as their parents or carers? First, it is important to clarify terminology. Although it is claimed that shared sleeping increases the risk of SIDS, it is perhaps more accurate to state that it is associated with an increased risk of infant death generally. An indication that shared-sleeping deaths may be different to “classical” SIDS deaths that occur among infants sleeping on their own is a finding of an almost equal sex ratio in shared-sleeping deaths, compared with the 2 : 1 male–female ratio among infants who died of SIDS.5 If some of the risk factors for shared-sleeping death (eg, parental obesity, fatigue, soft sleeping surfaces) are examined in isolation, accidental suffocation appears to be a more likely mechanism of death than subtle processes leading to SIDS.5 These apply to any shared-sleeping surface, not just to beds. It is difficult to formulate absolute recommendations on shared sleeping, as the current incidence in most communities is unknown, and the form that it takes varies greatly between families. There are also cultural issues to take into consideration — for example, shared sleeping is very common in South-East Asian communities, but with low incidences of unexpected infant deaths.6 However, a study from Avon, United Kingdom, found a disturbing percentage increase in shared-sleeping deaths among two cohorts of infants who died of “SIDS”, from 12% (17/147 in 1984–1988) to 50% (18/36 in 1999–2003) (P < 0.001).7 The authors noted that although the number of shared-sleeping deaths that were not on sofas dropped (from 16 to 14), the decrease was not as great as that among infants who were sleeping on their own, perhaps explaining the increased proportion of unexplained infant deaths found in shared-sleeping situations. This difference may be due to mechanisms of death being different in the two circumstances. A similar effect was noted in South Australia, where the proportion of shared-sleeping deaths increased from 7.5% of “SIDS” deaths (23/306 in 1983–1990) to 32.3% (21/65 in 1991–1993).8 The percentage of deaths in shared-sleeping situations in the early part of the study also showed an overrepresentation compared with the shared-sleeping rate of 1.5% in the general community in 1988.8 As some infants are particularly vulnerable to the effects of airway occlusion,9 and as there is often no clinical predictor of this vulnerability, all that can be stated is that certain infants may be inherently at increased risk in a shared-sleeping situation. It is generally agreed that in Western cultures, the safest place for an infant is in a cot that meets recommended safety features and is positioned beside the caregiver’s bed.1,2 Supporters of shared sleeping cite advantages that include an increased incidence and longer duration of breastfeeding, enhanced maternal–infant bonding and improved settling.1 However, it has been reported that 50% or more of infants who are found unexpectedly dead are sleeping with an adult.10 The suggestion of possible accidental asphyxia by a parent “overlaying” a shared-sleeping child has been criticised, because it has been assumed that a parent would always arouse. However, parents can fail to wake if they are sedated or overly fatigued. There is an increased risk of infant death when caregivers have taken illicit drugs, smoked, or consumed more than two units of alcohol.10 In addition, it is not necessary for an adult to be lying over an infant completely for respiration to be compromised, as an infant who has rolled into a trough between a parent’s much larger body and a soft mattress may also be at risk.11 This is exemplified by the dangers of shared sleeping on a sofa.7 On occasion, parents state that they successfully slept in the same bed as all of their children without any deaths occurring. While such anecdotes are undoubtedly true, few risks are absolute and so it cannot be used as definitive evidence that shared sleeping is always a safe practice. The key to assisting with this issue lies in adequately informing caregivers of potential risks. Clinicians should discuss with caregivers the risk factors for accidental asphyxiation in shared-sleeping arrangements, such as sedation, excessive fatigue and hazards predisposing to suffocation. This may help prevent infant deaths in the future.

Roger W Byard MB BS, MD

Do you need to “know your numbers”? “Know your numbers” was the public catchcry on World Hypertension Day 2011, and doctors were once again admonished to measure their patients’ blood pressure levels. The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom has gone one step further and now recommends that all patients in whom hypertension is suspected be offered ambulatory blood pressure monitoring to confirm the diagnosis.1 A recent report suggested this approach is cost-effective,2 although other research findings suggest that the precise measurement of blood pressure may not be very important when selecting whom to treat.3-4 Indeed, a recent report suggested that age alone might be a sufficient basis for decision making.5 What then is the role of ambulatory blood pressure monitoring in clinical practice? The past few decades have seen huge advances in our understanding of how blood pressure causes illness. At the heart of these advances has been the recognition that blood pressure causes disease in a progressive way across a broad range of blood pressure levels, and not just when an individual crosses a diagnostic threshold for “hypertension”.1 “Hypertension” cut-points, as variously set over the past half century, are now recognised as arbitrary levels on a continuous scale; and while they were a pragmatic solution at the time, their limitations are now widely understood.6 The development of risk-based approaches to allocating blood pressure-lowering treatment has been equally important.7 Under the risk-based model, the effects of blood pressure, age, sex, blood lipid levels and the presence or absence of smoking and diabetes all play a role in the decision whether or not to treat the patient with blood pressure-lowering therapy. Further, it is the blood pressure level, not the presence or absence of hypertension, that is incorporated into the decision-making process. Compared with traditional hypertension control programs, strategies that allocate blood pressure-lowering treatment based on measures of risk are projected to avert more disease for fewer people treated and at lower cost.8 Risk-based strategies are superior in this way because they direct treatment towards those most likely to gain from therapy. A diagnosis of hypertension on its own is a poor discriminator of risk, and assessment based on multiple risk factors is much better for identifying those who will benefit.8 The discriminatory power of risk-based strategies is only marginally improved by more precise measurement of the risk factors.3 The usual day-to-day variability of blood pressure for an individual is large, which means that many, many measurements are required to define an individual’s blood pressure level with real precision.9 This is a real problem when trying to categorise a patient as above or below a hypertension cut-point, but less important when blood pressure is treated continuously and is just one of half a dozen factors influencing the treatment decision. In deciding the potential value of ambulatory blood pressure monitoring to clinical practice, it is important to understand that showing that ambulatory blood pressure is more strongly associated with risk is not in itself sufficient. To be of real clinical value, it must also more reliably select those who will benefit from intervention. Recent economic analyses2 showed that routine ambulatory blood pressure measurement was superior compared with strategies based on home or clinic measurements because it made more reliable diagnoses of hypertension and saved treatment costs. However, the analysis did not report how ambulatory blood pressure performed compared to a risk-based approach. This is a serious shortcoming, because it is in this context that NICE makes its recommendations.8 Furthermore, in those cost-effectiveness analyses, ambulatory measurements were assumed to have perfect sensitivity and specificity for the diagnosis of hypertension, and blood pressure-lowering treatment was assumed to provide no benefit to individuals classified as non-hypertensive. Both are dubious assumptions that work substantively in support of strategies based on ambulatory measurements, and, when varied, will change the conclusions drawn.2 Making more measurements to get a better estimate of an individual’s true blood pressure is an inherently appealing concept deeply rooted in clinical practice. But as the evolving evidence shows, it’s not that simple. However precisely blood pressure is measured, it is unlikely to ever be as good a discriminator as an assessment based on multiple risk factors. And while the widespread use of ambulatory blood pressure measurement will more reliably pin down someone’s true blood pressure and better define who has hypertension, it is very unlikely to deliver the clinical and economic benefits that could be achieved by switching to a risk-based strategy.8 The National Vascular Disease Prevention Alliance has released an Australian risk assessment tool10 that supports a risk-based strategy, and management guidelines will follow. Rapid nationwide uptake of this approach to deciding who to treat has the potential to revolutionise the prevention of blood pressure-related diseases. Against this background, ambulatory blood pressure measurement will remain an excellent research tool but will add little to clinical decision making for most patients.

Bruce C Neal MB ChB, MRCP, PhD · Les Irwig MB BCh, PhD

Teaching children how to behave around dogs can reduce the incidence Dogs never bite me. Just humans. Marilyn Monroe (1926–1962) Dogs have been companions of humans for over 12 000 years and have become an inseparable part of rural and urban life. Many breeds continue to do valuable work — managing livestock on farms, guiding the visually impaired, sniffing out contraband, and as guard dogs. Most of the 3.4 million dogs in Australia are family pets, with 36% of households owning a dog.1 Unfortunately, as a result of this close relationship, dog bites are common. Statistics on dog bites often seem alarming, but most bite injuries are relatively minor, not requiring hospital admission.2 In 2008 and 2009, 928 children aged 0–14 years attended accident and emergency departments in Queensland with dog bites, equating to nine bites per week (Access Information Service, Queensland Health). The Queensland Trauma Registry (QTR) contains data on 186 children (aged 0–14 years; mean age, 5.5 years) who were admitted to Queensland hospitals for more than 24 hours in 2003–2009, equating to one such hospitalisation for a dog bite injury every 2 weeks (own unpublished data). No children died from dog bites in this period. Of the dog bite injuries recorded in the QTR, 88% occurred in the home environment, and almost all (98%) required at least one operation under general anaesthetic. In 2003, the Royal Children’s Hospital conducted a telephone survey on 45 consecutive children who were admitted with serious dog bites during 1997–2002. This survey showed that the child had physically interacted with the dog immediately before the attack in 63% of cases. Most attacks (92%) occurred in a setting familiar to the child, usually the family house or garden, or that of a relative or friend. Most bites were to the head and neck region (72%) and most children (93%) were left with permanent cosmetic scarring (own unpublished data). These results are consistent with those of other Australian studies.2,3 While most dog bite reports attempt to identify the breed, this information is commonly not documented in the patient record and, when stated, relies on correct identification by the family. No one breed stands out, but breeds commonly mentioned in Australian articles include Rottweilers, German Shepherds, Cattle Dogs and the Bull Terrier group.2,3 Data on an array of other breeds and cross-breeds provide evidence that any dog is capable of biting. An American study examined 238 dog-bite-related deaths over 20 years to 1998, and identified at least 25 different breeds.4 Breed identification may not be accurate. For example, the general public might have difficulty differentiating between several breeds in the Bull Terrier group. Staffordshire Bull Terriers, American Staffordshire Terriers and American Pit Bull Terriers all appear very similar. To add further confusion, a recent Queensland Supreme Court ruling stated that there was no distinction between the American Staffordshire Terrier and the American Pit Bull Terrier. Dogs are highly regulated in Australia with mandatory registration laws. It is now prohibited to import certain breeds, including American Pit Bull Terriers, Japanese Tosa, Dogo Argentino and Fila Brasiliero. State laws on the ownership of such breeds vary, but generally require desexing (unless registered for breeding), microchipping, the use of a leash and muzzle in public places and a locked enclosure at home with a warning sign. The laws are based not so much on evidence that these breeds are inherently dangerous, but rather that they are breeds which have been traditionally used for dog fighting. Much debate continues whether this is good and fair legislation, as studies have failed to show improvement in the incidence of bites after the legislation was passed.5 Breed-specific legislation fails to take into account that any breed of dog can be dangerous in the hands of an irresponsible owner who fails to provide good and early training. Further, these restrictions may create the risk of higher numbers of unregistered animals or irresponsible owners simply turning to other breeds. It is clear that all breeds bite, and that the severity and commonality is related to the size of the dog and how many of a particular breed exist.6 In the Netherlands, where good data on breeds and bites exist, breed-specific legislation was repealed because they found no one breed more dangerous than any other. They recommended there be a focus on owners of dogs in cases where the people bitten did not interact with the dog that bit them.6 Training for dogs and education for dog owners and children can reduce the incidence of dog bites. A recent United States study reported that knowledge about dog bite prevention among young, school-aged children is poor.7 However, education programs in the primary school setting have been shown to alter a child’s interaction with dogs.8 In general, children should be taught: to ask permission from the owner before slowly approaching an unfamiliar dog; never to run from a dog or scream; to stand still if approached by a strange dog and, if knocked over, roll into a ball and lie still; to avoid eye contact with the dog by looking at their own feet; not to disturb a dog that is sleeping, eating, or caring for puppies; and not to pat a dog without supervision or without allowing it to see and sniff them first.9 Furthermore, dog owners should take their dogs to obedience classes, and dogs should be taught to obey commands from all family members. Dogs used for hunting or as guard dogs should not be allowed to mix with children.9

Roy M Kimble MD, FRCS, FRACS · Natalie Dallow · Richard Franklin PhD · Belinda Wallis BBEnv(Dist)

New editor, new print journal, new website If you’re reading this in the print Journal, you’ll know that the MJA has changed. If you’re reading this online, you might not yet be aware that the print MJA was relaunched in September with a clean new look, easier-to-read page designs and an expanded menu of articles (including medical news, investigative features, educational series, and an increased focus on the medical humanities). We urge you to open a print Journal and have a look. But rest assured we have not forgotten our online readers. Redeveloping our ageing website is a huge task, but it’s well underway, and the new electronic version of the MJA is scheduled to go live with our next issue in January. The trifecta? New print Journal, new website — and new Editor. Dr Annette Katelaris took over as MJA Editor in February, and has already wrought sweeping changes. The MJA is the only Australian journal for the whole medical profession, and driving Dr Katelaris’ changes is the goal of providing an inclusive interactive forum of the best medical information for all doctors, whatever their field of practice. As a peer-reviewed research journal, attracting the highest quality of research is paramount. In a relatively small medical community such as Australia, this is not without difficulty. We already have our Content Review Committee (CRC), an external group of eminent clinicians who meet monthly by teleconference to advise on difficult manuscript decisions and provide input to improving Journal content. We have recently recruited an additional team of experts in several disciplines to become Specialist Editorial Advisers. These advisers will help us less formally, to expedite manuscript assessment, keep us informed about important specialty issues as they arise, and encourage high-quality submissions from a broader range of contributors. The CRC members and our new advisers are listed on the next page — we are very grateful for their dedication and commitment. Also listed in the following pages are all those who have reviewed manuscripts for us this year — we thank them very much for their time and effort in helping to ensure that the MJA publishes the best possible manuscripts in the best possible format. One of the things that matters most to contributors is rapid manuscript handling and timely publication. We’ve recently changed a number of our internal processes so that we can communicate our decisions faster and get your articles published sooner. Some delays in manuscript handling will always be beyond our control, but we anticipate being able to report better results from now on (Box). Our new website will allow us to increase the number of articles published “online first”, further removing publication delay. The new website will also, at long last, offer an option to comment on articles. While letters to the Editor provide an excellent quality of postpublication review and additional insights, the process has major limitations and the immediate debate of important issues is missing. We look forward to hearing from you often, when our online rapid-response option opens for business. There are more changes in the pipeline for 2012. In April, the MJA will hold its inaugural Research Summit to promote excellence in research, translation of research to practice, and knowledge sharing between major research bodies. We also hope that the Summit will identify priorities for lobbying government and other stakeholders to improve the landscape of clinical research. In addition to our prestigious prize for the best research article published in the MJA, and the Dr Ross Ingram Memorial Prize, now extended to include artworks as well as essays about Indigenous health, we will be offering new MJA awards for excellence in research or writing. These include a Global Health prize, for an article about personal experience working in a developing community (the prize will include a Public Health Leadership course at the Nossal Institute), a research prize for medical students, and the MJA Dr Eric Dark creative writing prize, in conjunction with Varuna, the Writers’ House (with prizes including a writing retreat and workshops). While we’re giving away awards, we have managed to win some ourselves. At the Publishers Australia Excellence Awards in November, the MJA was runner-up in two categories: “Relaunch of the Year” and “Custom Magazine of the Year”. We hope you’ve taken advantage of the informal news and opinion forum offered by our free online newsletter, MJA InSight (www.mjainsight.com.au) this year. If not, be sure to sign up in the new year and add your voice to what has become a very lively weekly conversation. MJA Careers, which has now moved to the back of the print Journal and is freely available online as an e-mag, has become a valuable resource for junior doctors needing information to help them choose a career path, and for those contemplating a sea change or just wanting to know what other doctors actually do. As always, we welcome your feedback and suggestions and we look forward to continuing to be a leader in quality scientific and medical communication — whatever that might look like as the digital age continues to transform every facet of our lives. Reviewers Specialist Editorial Advisers Derek Chew Richard Day David Ellwood Paul Fitzgerald Leon Flicker Mark Harris Noel Hayman Michael Horowitz Craig Mellis Martin Tattersall Bruce Waxman Gary Wittert David Wood Content Review Committee Craig S Anderson Leon A Bach Flavia M Cicuttini Jennifer J Conn Marie-Louise B Dick Mark F Harris Tom Kotsimbos Campbell Thompson Tim P Usherwood Elmer V S Villanueva E Haydn Walters Bruce Waxman Jane Young Jeffrey Zajac Reviewers (reviews submitted 01/11/2010 – 31/10/2011) Bizhan Aarabi Max W Abbott Penelope A Abbott Ehtesham A Abdi Sarah J Abrahamson Stephen P Ackland Jason P Acworth Stephen Adelstein Michael A Adena Hairul A Ahmad Sreedevi A Aithal Rebecca M Albury Chris P Alderman Heather G I Alexander Charles Algert Carolyn A Allan Clive C Allcock Katrina J Allen Roger W G Allison Steve J Allsop Lisa H Amir Craig S Anderson Ian P S Anderson Warwick P Anderson James A Angus Nigel R Armfield Bruce K Armstrong Jason M Armstrong Peter C Arnold Constantine N Aroney Michael A Ashby Lisa Askie John J Atherton Philip E G Aylward Oyekoya T Ayonrinde Peter D Baade Leon A Bach Nadia Badawi Christopher J Baggoley Peter A Baghurst Ian J Baguley Michael J Bailey Paul M Bailey Ross S Bailie Peter G Baker Philip R Baker Ross I Baker John I Balla Mohammed S Ballal Zsolt J Balogh Lilon G Bandler Michael P Barbato Amanda Barnard Ross StC Barnetson Adrian G Barnett Fay H Johnston Damien J Jolley D Brian Jones Graham R D Jones Ian S C Jones Mark A Jones Philip D Jones Sandra C Jones Anthony F Jorm Christine M Jorm Matthew D Jose David J L Joske Catherine M Joyce Craig A Juresevic Ian Joseph Kamerman Max Kamien Margaret Patricia Kay Anthony C Keech David Keegan Gerben B Keijzers Marc J N C Keirse Margaret A Kelaher Anne-Maree Kelly Michael J Kelly Patrick J Kelly Andrew S Kemp Michael C Kennedy Lizbeth M Kenny Ross K Kerridge Alison M Kesson Soo Keat Khoo Warren J Kidson Susan W Kim Thomas E Kimber James F King Scott Kinlay Vikki E Knott Simon A Koblar Bogda Koczwara Paul A Komesaroff Steven Kossard Mark A Kotowicz Vicki Kotsirilos Gabor T Kovacs Emma E Kowal Ludwig N Kraus Vicki L Krause Paul A Kubler Dennis L Kuchar Susan E Kurrle Antony R A Lafferty Daniel J Lalor Tai Pong (Daniel) Lam Stephen B Lambert Anthony D LaMontagne Louis I Landau Andrew J Langley Paul E Langton Sarah L Larkins Matthew G Law David M Lawrence Mark K Lawrie Julie Leask Karin S Leder Nicole Lee Warwick Bruce Lee Peter A Leggat James Leigh Nat P Lenzo Christopher R Levi Lucy N Lewis George T Lewith Joel Lexchin Siaw-Teng Liaw Rebecca J Linke Wendy L Lipworth Andrew F Little Mark Little Sing Kai Lo Kah-Seong Loke David F M Looke Ruth Lopert Julie A V Lord Charles W Lott Gregory A Lovell Raymond M Lowenthal Fabio Fabio Luciani Guy L Ludbrook Joanne N Luke Kehui K Luo Karen A Luxford Linda M Luxon Zaza Lyons Ian G Barr Bruce H Barraclough Alexandra L Barratt Christopher A Barton Michael B Barton Roger W Bartrop Robert G Batey Diana Battistutta Louise A Baur Richard Beasley Justin J Beilby Mary K Belfrage Derek Bell John F Beltrame Cino L Bendinelli Aric P Bendorf Carol J Bennett Christine C Bennett David L Bennett Derrick A Bennett Jill Benson David I Ben-Tovim Roy G Beran Lynda B Berends Michael Berk Andrew D Bersten James A Best James Donovan Best John P Best J H Nicholas Bett Barbara E Biggins Beverley-Ann Biggs Sara Bird Frances A Birrell Deborah A Black Peter S Blair Andrew F Bleasel C Leigh Blizzard Jared A Blum Neville Board Felix Bochner Nikolai Bogduk India K Bohanna Terry D Bolin Michael D Bollen Barbara J Booth Clare V Boothroyd Robert Booy Craig S Boutlis Ronaldo J Bova Francis J Bowden Carol I Bower Simon D Bowler John Boyages Ian W Boyd Michael J Boyer Frances M Boyle Michael J Boyle David L Bradford Pamela J Bradshaw George Braitberg Kerry J Breen Joan M Brewster David B Brieger Jo-anne E Brien Esther M Briganti Nancy E Briggs Timothy A Brighton Peter J Bristow Helena C Britt Warwick J Britton Kaye E Brock Carolyn R Broderick Peter M Brooks Julia M L Brotherton Simon G A Brown Wendy A Brown David G Bruce Fiona J Bruinsma Heather A Buchan David J Buckley John F Buckley Nicholas A Buckley Anne E Buist Michael D Buist Jonathan G W Burdon John R Burgess David Burgner Bryan H Burmeister Leslie Burnett Colin D Butler James R G Butler Linda Butler Julie E Byles Petra T Bywood Désirée Mészáros Kristine K Macartney Graham J Macdonald Dorothy E M Mackerras Donald G Maclellan A Roderic MacQueen Finlay A Macrae Richard Madden William (Bill) J Madden Guy J Maddern Ian Maddocks Parker J Magin Graeme Paul Maguire Peter K Maitz Donna B Mak Kathy Malera-Bandjalan Linda Mann Lynette M March Paul D Mark Tania P Markovic Paul G Marks Caroline Marshall Nathaniel Stuart Marshall Robert D Marshall Roger J Marshall Andrew J Martin Katherine E Martin Sarah J Martin Toni Annissa Mason Francis L Mastaglia C Scott Masters Timothy H Mathew John D Mathews Danielle Mazza Jeremy M McAnulty Morag McArthur Kristin Emma McBain-Rigg W John H McBride Bradley J McCall James S McCarthy Nicole Jean McCarthy Sally M McCarthy Brian C McCaughan Geoffrey W McCaughan Kieran A McCaul Geoffrey J McColl Joseph G McCormack Geoffrey B McCowage Robyn A McDermott Fiona J McDonald Suzanne P McEvoy Alexander C McFarlane Neil W McGill Barry P McGrath Katherine M McGrath Elizabeth C McInnes Catherine A McIntosh Peter B McIntyre Andrew J McLachlan Robert I McLachlan Rick McLean Andrew P McLean-Tooke Anthony J McMichael Gabrielle M McMullin Alan A McNab Gregor B S McNeill Bernadette M McSherry Graham N Meadows Alan C Meek Wayne D Melrose Paul Christopher Memmott Muhammed A Memon Richard M Mendelson Tracy Lee Merlin Geoffrey Metz Caroline Meyer Antonina A Mikocka-Walus Graeme C Miller Mark K Miller Carole Millichip Michael J Millward Helen Milroy Riyana (Mira) Miranti Charles A Mitchell Christopher D Mitchell Geoffrey K Mitchell Paul J Mitchell Philip B Mitchell Paula J Mohacsi Mohammed M Mohsin Lindsay C Mollison Harry G Mond Michael Montalto John F Cade Will Cairns Adrian J Cameron Ian D Cameron Peter A Cameron Terence J Campbell Ben J Canny Gideon A Caplan John B Carlin Allan Carmichael A Simon Carney Nicholas F Carr Vaughan J Carr Robin W Carrell Phillip J Carson Andrew C Carter Owen B J Carter Armand Casolin Erin Cassell David J Castle Enrico Cementon Steven J Chadban Donald R C Chalmers Alex J Chamberlain Albert K F Chan Jeremy R Chapman Kathryn E Chapman Michael G Chapman Simon Chapman Julia A Charkey-Papp Patrick G P Charles Mark D Chatfield Barry E Chatterton Celia Shin-Wen Chen Jian Sheng Charles Chen Allen C Cheng Elaine Y L Cheong Ian R Cheong N Wah Cheung Derek P B Chew Tien Chey Donald J Chisholm Christopher Y P Choong Peter F M Choong Helen Christensen MacDonald J Christie Flavia M Cicuttini Peter A Cistulli Ian D Civil Caroline F Clarke David M Clarke Stephen J Clarke Alan R Clough Harvey L C Coates Milton L Cohen Stephen Colagiuri Catherine H Cole Stephen A Cole Justin J Coleman Brian T Collopy Peter G Colman Elizabeth J Comino Christopher A Commens Jennifer J Conn Kathryn A Cook Matthew C Cook Raymond J Cook Nicholas B Cooling Alan J Cooper Caroline L Cooper Chris W Cooper Gabrielle M Cooper Michael D Coory Charles Cope Stephen J Corbett Peter Hani Tawfik Cosman Yvonne E Cossart Anthony J Costello Richard T L Couper Sophie Couzos Benjamin C Cowie Terry J Coyne Paul S Craft Patrick C Cregan Michelle A Cretikos John L Crompton David B Cross Gary J Croton Robert G Cumming Anthony L Cunningham David C Currow Hannah G Dahlen Phil Dalgarno Andrew Dalton Craig B Dalton A Rob Moodie Gavin H Mooney David J Moore Elizabeth M Moore Vera Anne Morgan Frederick M Morgan, Jr. Peter Morley Kathy Mott Robert F W Moulds David Mountain Bryan John Mowry Alison M Mudge Brian P Mulhall H Konrad Muller Raymond J Mullins Blair J Munford Craig F Munns Michael Murray Richard B Murray Arthur (Bill) W Musk Kenneth A Myers Sydney M L Nade Alison J Nankervis Geraldine A Naughton Matthew T Naughton Joel Negin Rose K Neild Mark R Nelson John C Newman Harvey H Newnham Janice G Newton Hanh T T Ngo Tuan V Nguyen Kathleen M Nicholls Suzanne Nielsen Graeme R Nimmo Gillian Nisbet Paul Nisselle Rosemary L Nixon Anita Nolan B E Christopher Nordin Richard P Norman Trevor R Norman Susan Norris Robert E Norton Caryl Nowson Jeremy J N Oats Tony J O'Connell Kerin O'Dea Christopher J O'Donnell Stephen J O'Leary Jake H Olivier Ian N Olver John H Olver Susanne P O'Malley Michael F O'Rourke Peter K O'Rourke Harry Owen Don Packham Robert T A Padbury Colin B Page Mark A Paine Jeyaraj D Pandian Francesco Paolucci Vanita R Parekh Malcolm H Parker Rhian M Parker Robert M Parker Jennifer S Parsons Mark W Parsons Julie A Pasco Dennis R Pashen Anushka A Patel Hedley G Peach Louis G Peachey Martin Pera Sumathy Perampalam Gavin F Pereira Paul L Pers Kathy Petoumenos Lynne Pezzullo Peter I Pillans S Praga Pillay Louis S Pilotto Carole B Pinnock Marie V Pirotta Leon Piterman Christopher S Pokorny Hans C Pols Rene G Pols Cynthia Porter Jennifer R Powers David A Powis Frank F S Daly Diona L Damian John Daniels Anthony M Dart Nicholas Daunt Philip K Davies Joshua S Davis Timothy M E Davis Richard O Day John F de Campo David J de Carle Caroline M de Costa Julien P de Jager Nicholas H de Klerk Gregory M de Moore Carmine G De Pasquale Christopher B Del Mar Martin B Delatycki Stephen Anthony Della-Fiorentina Charles P Denaro Justin T Denholm Graeme J Dennerstein Louise Dennis Catherine A D'Este Peter G Devitt Helen M Dewey Terrence H Diamond James A Dickinson Paul M Dietze Geoffrey J Dobb Malcolm D H Dobbin Timothy A Dobbins Annette J Dobson Jodie M Dodd Dorota A Doherty Susan M Donath Basil J Donovan Michael J Dooley Evan Doran Gregory J Dore Jo A Douglass Robert P Dowsett Francis J Dudley Johan A Duflou Trevor Duke David W Dunbabin James A Dunbar Emma L Duncan Elizabeth K Dunford David N Durrheim John M Dwyer Judith M Dwyer John R Dyer Sandra J Eades Kathy Eagar Arul Earnest Creswell J Eastman Bernadette I Eather Peter R Ebeling Phillip S Ebrall John A Eden Carl W Edmonds David Jan Edvardsson Hooi C Ee Garry J Egger John W Eikelboom Robert H Eikelboom John A Eisman Diann S Eley Jaklin A Eliott Ron Elisha Kathryn S Elkins David A Ellwood J Mark Elwood Michael W N Epstein Edzard Ernst Guy D Eslick Adrian J Esterman Julie A Evans Daniel P Ewald Paul A Fagan Paul P Fahey Christopher K Fairley Kieran E Fallon H John Fardy Elizabeth A Farmer K Chip Farmer Annabelle Farnsworth Cynthia M Farquhar A Michael Fasher Bruce J Fasher Robert G Fassett Thomas A Faunce Michael R Fearnside Claude G Preitner Brian Gregory Priestly Richard L Prince David L Prior Perry A Pugno Carolyn Quadrio Julie A Quinlivan Geetha Ranmuthugala Beverley Raphael Stephen J Read Julie Redfern Tom S Reeve C Martyn Regan Christopher M Reid Ian R Reid Joseph M Rey Alun H Richards Drew B Richardson Jeff R Richardson Malcolm D Riley Richard H Riley Thomas V Riley Helen E Ritchie Christopher Roberts Iain Kilpatrick Robertson Roy M Robins-Browne David M Roder Alan Rodger Leigh Roeger Maureen Rogers Wendy A Rogers Kathlyn J Ronaldson Jeffrey V Rosenfeld Glynis P Ross Ian James Roth Beverley J Rowbotham Tilman A Ruff Richard E Ruffin Bruce David Rumbold William B Runciman Darren B Russell Grant M Russell Lesley M Russell Christopher J Ryan Peter F J Ryan Peter Sainsbury Matthew R Sanders Kristy Sanderson W Peter Saul Carlos D Scheinkestel Patrick M Schlievert Philip J Schluter Hans-Gerhard F Schneider Deborah J Schofield Peter R Schofield Thomas R Schulz Max A Schwarz Anthony Scott Ian A Scott James Graham Scott Russ J Scott Ego Seeman Markus J Seibel Warwick S Selby Linda A Selvey Sanjaya N Senanayake Narelle E Shadbolt Shaouli Shahid Anthony Shakeshaft G Dennis Shanks Mary-Jane S Sharp David R Shaw Jonathan E Shaw Dale C Sheehan Julia M Shelley John Shine David Alan Sholl Bruce H Short Rupendra N Shrestha Stephen P Shumack David W Sibbritt William Sievert Kenneth A Sikaris Jerzy (George) M Sikorski Morry Silberstein Derrick M Silove Ian J Simpson Judy M Simpson Rodney D Sinclair Andrew Harris Singer Vitali Sintchenko Freddy Sitas Roderick J Sitlington Brooke Elizabeth Ferguson John K Ferguson Mark J Ferson David W Firman Colleen M Fisher Jane R W Fisher Malcolm McD Fisher D James Fitzgerald Gerard J FitzGerald Mark C B Fitzgerald Michael P Fitzharris Louisa Flander Karen M Flegg John I Fleming David R Fletcher Felicia R Fletcher Janice M Fletcher Simon J Fletcher Victoria Flood Eleanor M Flynn Peter A Foley Kwun M Fong Therese (Terri) M Foran Roberto Forero Brett H Forge S Lesley Forster Kevin D Forsyth Gillian K Fox Ian S Fraser Saul B Freedman Matthew Y Frei Simon D French Lin Fritschi Mark Frydenberg Victor SC Fung John S Furler Isabelle Gaboury T Eng Gan Ed John Gane Robert (Frank) A Gardiner Andrew P Garnham Coral E Gartner Kevin J Gaskin Paul A Gatenby Melina Gattellari Matt D Gaughwin Paul H Gavel Graham J Gee Paul Gerber Richard P Gerraty Mounir N Ghabriel Davina Ghersi Kay L Gibbons John Gibson Peter G Gibson Peter R Gibson Alan J Gijsbers Sabrina Gill Sanjeev Singh Gill Marisa T Gilles James Gillespie Amanda K Gilligan Conor Gilligan Jonathan Gillis Rodney C Givney Nicholas J Glasgow Katie Glass Paul P Glasziou John D Glover Michael S Gold Paul N Goldwater Phillip D Good David L Gordon Michael S Gordon Alexandra S Gorelik Des F Gorman Iain B Gosbell Geraldine A Goss Thomas Gottlieb C Roger Goucke Andis Graudins Stephen E Graves M Lindsay Grayson Peter H R Green Peter B Greenberg Kelly Jane Greenop Scott D Grosse Sonia R Grover Michele A Groves Jane M Gunn Jillian A Guthrie Paul S Haber Wendy E Hague Ian E Haines Mary M Haines George Halasz Loane L C Skene Steven J Skov Richard A Smallwood Joanne M Smart Christine H Smith David E Smith Jacky A Smith Julian A Smith Mitchell M Smith Richard S W Smith Tony Neil Smith William B Smith Richard Speare Denis W Spelman W John Spicer Allan D Spigelman Andrew Spillane Katrina Spilsbury Arn Sprogis Tim W Sprott Geoffrey K Spurling D James B St John E Greg Stafford Margaret P Staples Richard J Stark Efty P Stavrou Amanda M Stephens Jessica R Stephens Matthew Stevens Christopher E Stevenson Cameron Stewart Robert J Stillman Jim R Stockigt Nigel P Stocks Timothy R Stockwell Johannes U Stoelwinder Alina Stoita H Victor Storm Roger P Strasser Simone I Strasser Alison M Street Annette F Street Rhonda L Stuart Christina O Stubbs Stephen L Stuckey David M Studdert Joachim P Sturmberg Carolyn M Sue Rajah Supramaniam Rand S Swenson Brian Symon Peter W Tait Michael L Talbot Martin H N Tattersall Tracey M Tay Hugh R Taylor Penny S Taylor Francis C K Thien Jill E Thistlethwaite David P Thomas Merlin C Thomas Campbell H Thompson Napier M Thomson David R Thorburn Anne Marie T Thow Peter F Thursby Dominic S Thyagarajan Mark L H Tie Joseph Y S Ting Stephen H D Tisch Bernadette M Tobin Robert J Todd Ronald P Tomlins Anne L Tonkin Nicholas A Tonti-Filippini Michael J Toole Les J Toop Duncan J Topliss Adrienne J Torda Paul J Torzillo Joanne F Travaglia Stephen C Trumble A Stewart Truswell David Vaile Lisa Anne Valenti Marina Jill Vamos Anneke Van Der Walt Martin B Van Der Weyden Mieke L van Driel Samuel D Vasikaran Luis Vitetta Lesley Marian Voss Mark L Wahlqvist Robert G Hall John D Hamilton Alan W Hampson Peter J Hand David J Handelsman Elizabeth Handsley Graeme J Hankey Terry J Hannan Paul L Harper Richard W Harper Anthony Walter Forster Harris David C Harris Elizabeth Harris Mark F Harris Phillip J Harris Bernie T Harrison Simon J Harrison Rosemary Anne Harrup Roger J Hart Ken J Harvey Michael P Harvey Nicholas J Hawkins Noel E Hayman Richard B Hays Colleen P Hayward Robert N S Heard Christopher Hamilton Heath William F Heddle John C P Heggie Tim R M Henderson Melinda B Henne David A Henry Margaret J Henry Ana Herceg Wayne M Herdy David G Hewett Ian K Hewitt Kenneth M Hillman Lybus C Hillman Darryl J Hodgkinson John Hoey Christopher D Hogan Patrick G Hogan Geoffrey G Hogg Brien A Holden Stephen R Holdsworth Andrew J A Holland C D'Arcy J Holman Peter W Holmes Stephen Honeybul Sean Hood Danielle Rebekah Horyniak Kenneth F Hossack Nehmat Houssami Kirsten Howard Mark E Howard Benjamin P Howden Peter Phillip Howley Rae-Lin Huang Bernard J Hudson Clifford F Hughes James T Hughes Michael A Hull Jennifer M Hunt Leonie G Hunt Roger W Hunt Peter C Hunter Susan F Hurley Joseph E Ibrahim Francesco L Ierino Timothy J J Inglis David M Irby Donald H Irvine Timothy W Isaacs Geoffrey K Isbister James P Isbister Rowena G Ivers Assen V Jablensky Claire L Jackson Lisa R Jackson Pulver Peter A Jacoby Stacey K Jankelowitz Robert P S Jansen Edward D Janus Tania (Tatiana) Janusic Heather E Jeffery George A Jelinek V Michael Jelinek Christine R Jenkins Rebecca A Jenkinson Garry L R Jennings Richmond W Jeremy Moyez Jiwa William R Johnson Judith H Walker Kate A Walker Robert James Walker Robyn M Walker Euan M Wallace Marina Wallace John P Walsh Nick M Walsh Barry N J Walters Darren L Walters E Haydn Walters Han Wang Zhiqiang Wang Gregory John Ward Helena Mary Ward James S Ward Michael R Ward Peter D Ward Robert S Ware Lachlan J Warren Grant W Waterer John A Waterston David I Watson David O Watson David A K Watters Gerald F Watts John R Waugh Bruce P Waxman Susan M Wearne Edward W Weaver Lynn M Weekes Peter Wein John M Weiner Philip Weinstein Timothy A Welborn Beres C A Wenck Michel J P Wensing Steven L Wesselingh Johanna I Westbrook Andrew V White Benjamin P White Joshua P White Leslie White John S Whitehall Maxine Anne Whittaker Judith A Whitworth Bridget M Wilcken Kay A Wilhelm Garry John Wilkes David Wilkinson Simon M Willcock Ian R Willett Isla M Williams Trevor J Williams Anna B Williamson Donald Andrew Wilson Ian G Wilson John W Wilson Chris Winder Lindon M H Wing Adam R Winstock Gary A Wittert John H Wlodarczyk Alex D Wodak Max Wolf Fiona M Wood Richard J Woodman Michael C Woodward Ian J Woolley Paul S Worley Stephen G Worthley Elizabeth J Wylie Ian A Yang Piers J Yates Kwang C Yee Lisa N Yelland Michael J Yelland Stephen Lloyd Yelland Neville D Yeomans John Yiannikas Choong Siew Yong Danny Youlden Christine Younan Doris Y L Young Stephanie Young Dennis K-S Yue Jeffrey D Zajac Yuejen Zhao Stephen R Zubrick Tamara L Zutlevics Nicholas A Zwar Anthony B Zwi Manuscripts received 2010–2011 Manuscripts accepted/received (%) Total 584/1547 (38%) Research 97/535 (18%) Cases 33/230 (14%) Reviews 9/50 (18%) Letters 211/314 (67%) Mean days to decision To reject 37 (research articles, 37) To accept 82 (research articles, 145) Reviewers used 1657 Impact factor (2010) 2.68

Bronwyn Gaut