Editorials

Sydney 2000: guarding against disasters Planning for the unexpected and practising responses is the critical task now MJA 1997; 166: 517-518 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - ©MJA1997 In this issue of the Journal, Nocera describes the consequences of a grenade explosion in a munitions factory that injured four women, two of them critically. The report is a reminder of the ingenious creativity of the human race in weapons and war, with its impetus to do as much harm as possible -- but it might also remind us that some major advances in care for trauma patients have been spawned by wars, particularly methods to decrease the time from injury to first aid and advanced resuscitation techniques. In the incident described by Nocera, the prompt response by emergency services was the key to the survival of the injured. The first ambulance arrived five minutes after the explosion, followed by two more in the next six minutes. As part of the controlled response, a helicopter was put on stand-by nine minutes after the accident and took off five minutes later, carrying universal donor (O Rh-negative) blood, a paramedic and an emergency medicine doctor. The obvious cooperation between all personnel involved -- including police, fire, ambulance officers and helicopter staff -- enabled appropriate deployment of resources, prompt triage and transportation (making allowances for peak hour traffic and matching the capabilities of the hospitals in the area with the patients' conditions). "it is too late to plan a response once a disaster occurs" On a more general note, the article prompts us to review our preparations for disasters in general. Sydney is hosting the Olympics and many other mass gatherings in 2000. What if something happens: explosion, fire or mass transport accident . . . ? Are we prepared? A disaster may be defined as "Any incident, involving large numbers of casualties, which overwhelms the capacity of available resources to cope with it."1 A disaster is, obviously, unexpected, but we might expect Murphy's Law to operate. The recent history of the Olympics includes the tragedies of Munich (1972) and Atlanta (1996). Disaster preparedness was part of our successful bid for the Games in 2000. The response plan was based on DISPLAN/MEDPLAN. MEDPLAN has now been superseded by HEALTHPLAN,2 which defines the command structure and standard operating procedures to be followed in a disaster by the New South Wales health services (ambulance, medical, mental health and public health). These disaster-response plans have been tested and refined through the challenges of bushfires, the Newcastle earthquake, bus crashes and mass gatherings such as visits by two Popes, Royalty and United States Presidents, at rock concerts,3 City to Surf runs and many other occasions. The New South Wales State Emergency and Rescue Management Act 1989 has required increased disaster planning and preparedness at local government, district, area health and State levels. Training and certification of selected health professionals and practical texts4 are now readily available. A glimpse of the complexity of the overall picture of disaster response is provided by the table of contents (10 pages) of the Commonwealth's Australian emergency manual: disaster medicine,5 which covers all aspects of disasters through to recovery. Both this manual and the New South Wales HealthPlan2 have been revised for 1997. Disaster planning brings forth apathy, denial, squabbles about resources, turf battles and many committees representing various disciplines creating camels,* as well as serious professionals trying to plan for "What if . . . ?". The Olympic Health and Medical Working Committee, with senior representatives from the Sydney Olympic Games Organising Committee, the NSW Department of Health and other agencies, is setting up the framework for events in 2000. There are several established principles in disaster planning: In disasters, do the greatest good for the greatest number (a reversal of the usual clinical emphasis on quality of care for the individual). This explains why any disaster scene has to be declared safe by fire officers, why police are in charge overall, why systems are set up to evacuate "walking wounded" before attention is given to the mortally injured. Both military and civilian experience has confirmed that in a disaster a rigid chain of command is essential (doctors, with their individualistic training and professional independence, are poor at this), and that personnel should perform tasks similar to their normal duties (e.g., that surgeons should continue in surgery and not be called upon to organise transport). Overall service command must be led by a controller off site . Each service must have liaison officers from all other major agencies involved. The biggest problem is always communication: this must be organised by those agencies with the relevant expertise and equipment. Emergency physicians are the appropriate controllers of the medical response to a disaster: ". . . they are familiar with the system and personnel providing care before hospitalization; they are practiced in rapid assessment, basic treatment, and triage; and they have a good working rapport with other specialists needed during the response."6 As Waeckerle states in an article on disaster planning, it is too late to plan a response once a disaster occurs.6 Disaster response will always be a team collaborative effort which must be planned and practised. As everybody's time and resources are short, we have to use tabletop exercises, mass gatherings and even expensive exercises with moulaged victims to practise to get it right well before 2000. Gordian W O Fulde Director, Emergency Department St Vincent's Hospital, Sydney A Senior Commander, NSW Healthplan . * "A camel is a horse designed by a committee and an elephant is a mouse built to military specifications" -- Caxton C Foster Ambrose G. Disaster medical planning. In: Fulde GWO, editor. Emergency medicine: the principles of practice. 2nd ed. Sydney: Maclennan and Petty, 1992: 13-19. NSW Healthplan . Functional area supporting plan to the NSW State Disaster Plan (NSW DISPLAN). Sydney: Department of Health, 1997. Fulde GW, Forster SL, Preisz P. Open air rock concert: an organised disaster. Med J Aust 1992; 157: 820-822. Hodgetts TJ, Mackway-Jones K, editors. Major incident medical management and support. The practical approach. London: BMJ Publishing, 1995. Australian emergency manual: disaster medicine. Canberra: Commonwealth Department of Human Services and Health, 1995. Waeckerle J. Disaster planning and response. N Engl J Med 1991; 324: 815-821. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

HTLV-I and blood safety: let the community decide Discussion on screening of blood for rare viruses must go beyond the blood transfusion services MJA 1997; 166: 454Subsequently cited in Moaven L. Should we be screening blood donors for hepatitis G virus? The case for screening. MJA 1998; 169: 373-374 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - ©MJA1997 Despite the steady reduction over time in the risks associated with blood transfusion, there has been a parallel increase in the community's expectations of the safety standards that must be met by blood and blood products. In the past, the acute complications of transfusion were perhaps viewed by the community as acceptable risks. The contamination of blood products by HIV changed all that; here was a bloodborne infection that produced life-threatening complications years after transfusion. Virtually all patients who received HIV-contaminated blood or blood products became chronically infected and progressed to AIDS and a premature death. Furthermore, in the community, HIV was widely perceived as being associated with society's stigmatised or marginalised groups. Human T-cell lymphotropic virus type I (HTLV-I) was discovered before HIV, but screening of blood for HTLV-I was not implemented with the same degree of urgency as for HIV. In most developed countries, HTLV-I was considered to be an exotic infection which posed a minimal threat to the blood supply. Even in countries endemic for HTLV-I, less than 5% of people with the infection develop serious disease.1,2 There is so little HTLV-I-related morbidity in Australia that single cases still merit case reports.3 Nevertheless, by the mid 1980s HTLV-I screening tests were ready for mass use, and Japan, the only industrialised country with a substantial prevalence of HTLV-I infections, began screening blood for the virus. With litigation arising from HIV infection with transfusion of blood or blood products in full swing in the industrialised world, the American Red Cross in 1988 decided to screen all donations for HTLV-I.4 Can a decision be made to reduce the safety of the blood supply, even if only to a very small degree? In Australia, a response was required. The national peak blood transfusion advisory body, the Red Cross National Blood Transfusion Committee, recommended universal screening of blood donors in 1989 and again in 1991, but the National Health and Medical Research Council did not concur because, it was argued, the costs of universal screening far outweighed any public health benefit.5 Despite these differences in professional judgements, by early 1993 all Australian Red Cross blood banks had introduced HTLV-I screening. In this issue of the Journal, Whyte outlines for the first time in Australia the results of this screening and shows that Australian blood donors have among the lowest HTLV-I prevalence rates ever recorded. He then goes on to implicitly ask whether it is time to review the screening policy. The answer to this question depends very much on the perspective being taken. For blood transfusion services wishing to reduce the risk to the recipients of their products, not to mention their medicolegal vulnerability, the decision to screen all donations for HTLV-I can seem very logical, even if the prevalence of infection is very low. In the United Kingdom, where HTLV-I prevalence in blood donors is some five times higher than in Australia,6 universal screening has not been adopted, but there have been recent calls to review this policy.7 From the point of view of governments and tax-payers, facing ever-increasing demands on health care and escalating health budgets, perhaps health expenditure in other areas may have had a greater impact in value-for-money terms. Screening blood donations for HTLV-I in Australia has an annual cost of two to three million dollars per year in test kits alone, and laboratory staff and handling costs probably account for seven million dollars (E Dax, Director, National Serological Reference Centre, personal communication). The contrasting recommendations of the Australian Red Cross and the National Health and Medical Research Council on HTLV-I screening highlight a deficiency in the decision-making processes on aspects of blood transfusion in Australia. While governments fund State and Territory blood transfusion services and strongly influence their functioning, the Australian Red Cross is the legal entity liable for the blood products. The decisions by the blood transfusion services may inevitably be based on a narrower view of the issues involved than that shared by the community. Is it possible to reconsider the decision to screen blood donations for HTLV-I? Put in another way, can a decision be made to reduce the safety of the blood supply, even if only to a very small degree? If the answer is yes, the process of re-evaluation should take place in a broader context than has been adopted in the past. A framework must be established so that the decision is made by the community as a whole, not just by the blood transfusion services. The recent establishment by the Australian Health Ministers Advisory Council of a Blood and Blood Products Committee, and the national restructuring of the State and Territory Red Cross blood transfusion services into a single corporate entity (see page 453 of this issue of the journal), are valuable steps towards integrated decision-making, but these changes do not go far enough. These two entities need to be brought closer together and utilise expertise in public health, health economics and other areas, as required. A review of HTLV-I screening would ideally be carried out in the context of other infectious agents that can be transmitted by blood. It may be more cost-effective to screen for agents such as parvovirus B19 (which causes pure red cell aplasia), although susceptibility is limited to a very small proportion of the population. Hepatitis G virus and human herpesvirus type 8 (associated with Kaposi's sarcoma and B-cell body cavity lymphoma) are newly discovered viruses that may also require consideration for routine screening once tests become available.8 If deliberations about blood screening are to take place in a broader context, thought must also be given to legal changes that shift the burden of sole liability from the blood transfusion services. The New Zealand "no-fault" compensation model has long been discussed as one possible solution. Another approach may be legislated protection of the blood transfusion services against litigation, provided bloodscreening policies were determined and implemented according to specified guidelines. Although HTLV-I-related disease has been rare in Australia, HTLV-I infection is present at relatively high levels in some populations of indigenous people, and probably also in some migrant groups. If it is decided to reconsider HTLV-I screening of donations, its abandonment is not the only alternative to the status quo. A policy of screening only new donors would have detected all 21 HTLV-I-positive individuals in the time period of Whyte's study and reduced the extent of testing required by over 80%. Therefore, it may be sufficient to screen blood donors only once and thereafter assume that their HTLV-I status remains unchanged, or carry out testing again after five or 10 years. Another approach could be to use the donor interview to identify people who may be at higher risk of HTLV-I. Screening on the basis of country of birth, for example, would have detected a third of the individuals confirmed positive for HTLV-I in Whyte's study. Blood transfusion will never be risk-free. With the risk-benefit balance now many times more favourable than it has ever been, perhaps the time is right to engage the community in a discussion that brings both public health and economic issues into decision-making about blood safety. John M Kaldor Deputy Director and Professor of Epidemiology National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW. Morris JDH, Eddleston ALWF, Crook T. Viral infection and cancer. Lancet 1995; 346: 754-758. Kondo T, Kono H, Miyamoto N, et al. Age- and sex-specific cumulative rate and risk of ATLL for HTLV-I carriers. Int J Cancer 1989; 43: 1061-1064. Kirkland MA, Frasca J, Bastian I. Adult T-cell leukaemia lymphoma in an Aborigine. Aust N Z J Med 1991; 21: 739-741. Centers for Disease Control. Licensure of screening tests for antibody to human T-lymphotropic virus type I. MMWR Morb Mortal Wkly Rep 1988; 37: 736-740, 745-747. National Health and Medical Research Council, Communicable Diseases Standing Committee. HTLV-I screening: outcome of consideration by the Executive. Canberra: NHMRC, 4 December 1992. Brennan M, Runganga J, Barbara JAJ, et al. Prevalence of antibodies to human T cell leukaemia/lymphoma virus in blood donors in north London. BMJ 1993; 307: 1235-1239. Pagliuca A, Pawson R, Mufti GJ. HTLV-I screening in Britain. BMJ 1995; 311: 1313-1314. Allain J-P. Screening blood donors for markers of new viruses. Lancet 1997; 349: 584-585. World Health Organization, International Agency for Research on Cancer. Human Immunodeficiency viruses and human T-cell lytmphotropic viruses. Monographs from the meeting of an IARC Working Group on the Evaluation of Carcinogenic Risks to Humans; 1996 June 11-18; Lyon. Geneva: WHO, 1996. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

John M Kaldor

Endemic STDs in remote communities: the challenge for STD control High rates of STDs in Australian Aboriginal communities point to limitations in current surveillance and control methods MJA 1997; 166: 456 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - ©MJA1997 A recent MJA editorial recognised Australia's achievements in controlling sexually transmitted disease (STD), but emphasised that the necessary aim must be "striving to eliminate endemic disease".1 Two articles in this issue of the Journal2,3 highlight the problems in the path of this objective -- and some of the potential solutions. Our information on the extent of STD in the population is largely derived from a passive notification system. Sentinel sites that routinely screen their client population for STDs and community surveys supplement the data from notification systems. Sentinel surveillance for HIV is conducted at urban sexual health clinics and data are collated nationally by the National Centre for HIV Epidemiology and Clinical Research, but there is no national collection of sentinel data for STD outside sexual health clinics. Our understanding of the epidemiology of STD outside the cities and towns is incomplete. What you test for is what you see, and our passive notification systems may be blind to much STD in the community Nationally, notifications of gonorrhoea and syphilis have declined in recent years,4 but celebration may be premature. The community-based survey reported in this issue by Skov et al. demonstrates that our notification systems may not provide an accurate picture of STD distribution in Australia.2 Their study found a far higher rate of gonorrhoea and chlamydia than would have been expected from previous notification data. Notifications made as a result of their community screening were responsible for a significant part of the 59% increase in notifications of gonorrhoea in South Australia in 1995.5 What you test for is what you see, and our passive notification systems may be blind to much STD in the community. At present, notifications are more often received from communities that recognise STD as an important health issue. Thus, communities that act on their responsibility for sexual health and STD control run the risk of being denigrated because of their apparently high rates of STD, while other communities not active in sexual health may have similar or bigger problems that remain largely hidden. The problem of detecting cases of STD is also an issue in evaluating the extent of their complications, which often form the greatest burden of disease. As shown in the report by Mein and Bowden (page 464 of this issue of the Journal),3 this burden falls heavily upon women in Aboriginal communities. What is perhaps most alarming in their case review is that only 45% of patients admitted to a gynaecological ward with suspected pelvic inflammatory disease were tested appropriately for STD (by endocervical swab). The rates of infection calculated by Mein and Bowden are therefore only the minimum estimate of gonococcal and chlamydial infection in pelvic inflammatory disease. The effort to control STD in Aboriginal communities can be facilitated by using new technology. In particular, tests based on the polymerase chain reaction (PCR) can diagnose chlamydia and gonorrhoea from urine samples. Such samples can be collected and processed more easily than swabs, and the procedure is more acceptable to Aboriginal people. This application of PCR technology is still in its infancy, and there may be some interpretation problems. The PCR test detects DNA or RNA, but does not tell us if the material comes from an infectious organism or from non-infectious remnants of a resolving infection. Another problem is that PCR testing does not allow the determination of antibiotic sensitivity patterns. Sentinel surveillance activities (involving culture for gonorrhoea to determine trends in antimicrobial resistance) must continue so that control efforts are not frustrated by drug resistance. PCR technology can be used in two ways in STD control. Firstly, in community surveys, such as that described by Skov et al.2 This survey, a collaborative effort between Aboriginal and government health services, required considerable infrastructure and community consultation, which were facilitated by the TriState STD/HIV Project (funded by the Western Australian, South Australian, Northern Territory and Commonwealth health departments). The collaborative approach of the TriState STD/HIV Project offers a model for undertaking surveys of this nature. A second application is through increased opportunistic testing by health care workers at consultations unrelated to sexual health. This approach is not necessarily easier than community surveys and represents a challenge to Aboriginal communities with limited access to health resources and a different cultural perspective on sexual matters. Opportunistic testing cannot be undertaken without prior consultation with the community and the development of guidelines on who should be tested and when. The risk of acquiring an STD is not evenly distributed within Aboriginal communities and a better understanding of social and sexual networks is needed. Mechanisms will need to be in place to inform people of test results and to ensure their treatment, and that of their contacts. The provision of adequate and acceptable community-based health services that recognise the importance of STD and have the capacity and will to detect, follow up and treat cases should be a priority. This will involve the active participation of the communities concerned and is perhaps the biggest challenge facing funders and providers of health services. HIV is already present in Aboriginal communities but its extent is limited at present.6 Experience in Africa (where the main focus of successful prevention programs is the provision of quality STD health services, encouragement of early presentation and availability of effective treatment) suggests that our ability to control bacterial STD will be a major determinant in controlling the spread of HIV.7 The two reports published in this issue of the Journal2,3 suggest that we have a long way to go in controlling STD in remote communities. We have the technology to enable non-invasive testing for gonorrhoea and chlamydia. We now have to use it effectively to detect, treat and reduce the level of endemic disease. The challenge is there for public health professionals and involved communities. Russell G Waddell Clinic Manager, STD Control Branch South Australian Health Commission Fairley CK. Sexual health -- reaching out [editorial]. MJA 1997; 166: 341-342. Skov SJ, Miller P, Hateley W, et al. Urinary diagnosis of gonorrhoea and chlamydia in men in remote Aboriginal communities. MJA 1997; 166: 468-471. Mein J, Bowden FJ. A profile of inpatient STD-related pelvic inflammatory disease in the Top End of the Northern Territory of Australia. MJA 1997; 166: 464-467. Hart G. STD epidemiology in Australasia: syphilis and gonorrhoea. Venerology 1992; 5: 115-120. South Australian Health Commission 1996. Sexually transmitted diseases in South Australia. Epidemiologic report no. 9 -- 1995. Adelaide: SAHC, 1995. Feachem RGA. Valuing the past, investing in the future: evaluation of the National HIV/AIDS strategy 1993-1994 to 1995-1996. Canberra: Department of Health, Housing and Community Services, 1995. Grosskurth H, Mosha F, Todd J, et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial. Lancet 1995: 346; 530-536. - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Russell G Waddell

Salt intake, cardiovascular disease and public health We need to do more than take the salt shaker off the table MJA 1997; 166: 396 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - - ©MJA1997 The contribution of dietary salt intake to cardiovascular morbidity and mortality is a subject of ongoing discussion and controversy.1,2 What is unquestionable is that the average salt intake of most people in most nations exceeds physiological requirements (10-20 mmol/day) by a factor of between five and 30, and this relatively high intake contributes significantly to the average blood pressure of a population, and hence to the prevalence of hypertension.3 The relationship between blood pressure levels and morbidity and mortality from heart attack and stroke suggests that any reduction in levels of salt intake in a population would result in a corresponding reduction in cardiovascular morbidity and mortality. For example, it has been argued that a mean reduction in sodium intake of 50 mmol per day across the whole population in the United Kingdom would reduce coronary death rates there by 16% and stroke death rates by 22%, and create substantial monetary savings from the reduced prevalence of these and related diseases.4 there is unlikely to be much further progress in reducing Australians' salt intake unless more low-salt foods which are easily identifiable and affordable become available Such epidemiological observations have led national and international health authorities to set targets for reductions in population salt consumption.5,6 The Australian Government has set a target sodium intake of 100 mmol per day to be achieved by the year 2000. It is reasonable to ask whether this target (or any other for salt intake) is justified on public health grounds and whether it is achievable. For such a target to be appropriate requires that it be both safe and cost effective in reducing cardiovascular morbidity and mortality . Despite the consistent epidemiological data and experimental evidence, clinical trial data are limited. There are no randomised controlled trials of effects of varying sodium intake on cardiovascular outcome other than on blood pressure levels per se. However, there is experimental and limited clinical trial data suggesting that salt intake influences left ventricular mass independently of blood pressure,7 which is relevant in that left ventricular hypertrophy is itself a powerful predictor of cardiovascular morbidity and mortality. Is a target of 100 mmol/day realistic in countries like Australia? In this issue of the Journal Beard et al. have attempted to measure salt intake in an Australian population sample in the light of our national target for the year 2000. Using 24-hour urine collections to estimate sodium excretion, they found that only 6% of men and 36% of women had reached the year 2000 target. As only 52% of the eligible population were studied and as there was underepresentation of younger people and lower socioeconomic groups, these figures are likely to underestimate the true levels of sodium intake and to overestimate the extent to which the target was reached. Interestingly, among both men and women, and among both those who did and those who did not comply with the sodium intake target, most stated that they never or rarely added salt to food. This apparent anomaly may raise doubts about the reliability of the participants' reports, but is probably more readily explained by the poor reliability of a single 24-hour urine specimen for estimating usual sodium intake, and the high proportion of dietary salt hidden in food.8 The actual values for the percentage of the population complying with targets should perhaps be taken with "a pinch of salt", while the estimates of population average salt intake are in accord with other Australian data and those from countries (such as the United States) with similar dietary habits and are probably realistic. If the target of less than 100 mmol/day is desirable for most of the population why are we so far from achieving it, and is it realistic? As Beard et al. point out, at least 75% of salt in the British diet and those of other affluent societies comes from processed foods.8 Given the proportion of participants in the study by Beard et al. who claim not to add salt to food or in cooking, the figure may be higher in Australia. Bread is a major source of dietary salt, along with canned foods and preserves. Take-away foods are more likely to be salted, and the growing habit of eating out leaves the consumer with less control over salt intake. The smaller body mass, and hence lower total food consumption, of women compared with men may at least partly explain their lower salt intake -- perhaps the target for sodium intake for women should be lower than that for men. Beard et al. point out that there has been relatively little publicity about the national dietary target for salt and that, although some food manufacturers have taken initiatives to reduce salt use, shoppers receive relatively little advice or encouragement. The picture is perhaps not quite as bleak as it seems. The National Heart Foundation and State health departments have long been publicising the benefits of reducing salt intake as part of a more general healthy diet that includes eating more fresh fruit and vegetables and reducing saturated fat intake. These measures may have much greater value in cardiovascular health if adopted in combination with other lifestyle changes.9-11 However, there is unlikely to be much further progress in reducing Australians' salt intake unless more low-salt foods which are easily identifiable and affordable, as well as being economically viable for the food industry, become available. This will require more concerted efforts and cooperation between the food industry, government, consumers and food scientists. Novel approaches should be explored, such as the use of salt substitutes, which has resulted in long term blood pressure reduction in older patients with hypertension in Holland.12 Perhaps it is timely that the National Health and Medical Research Council consider a fresh approach to the problem that includes working with the food industry and food scientists to make it easier for consumers to reduce unnecessarily high and harmful levels of salt intake. A randomised controlled trial that showed that reducing salt intake decreased morbidity and mortality would undoubtedly dispel any lingering doubts on this issue and accelerate efforts. While purists might argue that such evidence should be as rigorously demanded of lifestyle changes as of new drugs or surgery, in the case of dietary salt we are in something of a "Catch-22" situation -- it is unlikely that an adequate trial could be mounted unless low salt foods were much more widely available than they are at present. However, a precedent for major public health initiatives in the absence of definitive clinical trial data has been set with the multitude of campaigns against cigarette smoking. The cumulative evidence for the benefits of moderating dietary salt intake is sufficient to justify more active public health initiatives now. Lawrie J Beilin Professor, Department of Medicine, University of Western Australia, Perth, WA Dyer AR, Stamler R, Elliot P, Stamler J. Dietary salt and blood pressure. Nature Med 1995; 1: 994-996. Wardener HL, Kaplan NM. On the assertion that a moderate restriction of sodium intake may have adverse health effects. Am J Hypertension 1993; 6: 810-814. Intersalt Cooperative Research Group. Intersalt: an international study of electrolyte excretion and blood pressure. Results of 24 hour urine sodium and potassium excretion. BMJ 1988; 297: 319-328. Law MR, Frost CD, Wald MJ. By how much does dietary salt lower blood pressure? III. Analysis of data from trials of salt reduction. BMJ 1991; 302: 819-823. National High Blood Pressure Education Program. National High Blood Pressure Education Program Working Group report on primary prevention of hypertension. Arch Intern Med 1993; 153: 186-208. Health Targets and Implementation (Health for All) Committee. Health for all Australians. Canberra: AGPS, 1988: 38. Langenfeld MRW, Schmeider RE. Salt and left ventricular hypertrophy: what are the links? J Hum Hypertens 1995; 9: 909-916. James WPT, Ralph A, Sanchez-Castillo CP. The dominance of salt in manufactured food in the sodium intake of affluent societies. Lancet 1987; 1: 426-429. Ascherio A, Rimm EB, Giovanucci EL, et al. A prospective study of nutritional factors and hypertension among US men. Circulation 1992; 86: 1475-1484. Beilin LJ. Non-pharmacological management of hypertension: optimal strategies for reducing cardiovascular risk. J Hypertens 1994; 12 Suppl 10: S71-S81. Jennings GL, Sudhir K. Initial therapy of primary hypertension. Med J Aust 1990; 152: 198-203. Geleeijnse JM, Witteman JCM, Bak AAA, et al. Reduction in blood pressure with a low sodium, high potassium, high magnesium salt in older subjects with mild to moderate hypertension. BMJ 1994; 309: 436-440. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Lawrie J Beilin

Sexual health -- reaching out Australia should continue to improve its sexual health services, especially access to them, and strive for zero endemic prevalence of sexually transmitted diseases MJA 1997; 166: 341 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - - ©MJA1997 Sexually transmitted diseases (STDs) greatly facilitate the transmission of human immunodeficiency virus (HIV) and have significant and expensive complications.1,2 It is therefore crucial to place the control of STDs high on the public health agenda. The tragic consequences of not getting this right are now evident in the United States, where high STD endemicity has contributed to HIV now being the leading cause of death of Americans aged 25 to 44 years, and to one in 92 Americans aged between 27 and 39 being infected.3,4 There is no reason why Australia cannot aim for a near-zero prevalence of some endemic STDs Australia should aim for world best practice in STD control. This means striving to eliminate endemic disease. As our HIV control strategies are among the most successful in the world, we should have the same aim for STD control.5 A necessary part of achieving this is reviewing our sexual health clinics, as reported by Marks and colleagues in this issue of the Journal. This group surveyed sexual health clinics in Australia and New Zealand in 1993, and compared their findings with those of a similar study by Bradford and Philpot a decade earlier.6 The number of services provided and staff had increased and the complexity of medical conditions had broadened. There was still, however, a marked urban predominance of sexual health clinics, possible underuse of non-medical staff and, most importantly, there were deficiencies in tracing contacts of patients with STDs. Encouragingly, Australia's diagnosis and treatment of STDs complies well with the published guidelines. The key question, then, is how can we use this information to improve the quality of care provided by our sexual health facilities and ensure that this results in a further fall in the prevalence of STDs? The answer relies on understanding what determines the prevalence of an STD. The prevalence of a given STD at endemic equilibrium in a community is dependent on three factors: The duration an individual is infectious; The probability of transmission during sexual intercourse; and The rate of sexual partner change.7 Sexual health clinics and sexual health physicians do encourage the use of condoms to reduce the probability of transmission, but their greatest potential influence is likely to be on reducing the infectious period. This means providing very early treatment after each infection, and to do this effectively sexual health services must be highly accessible to all members of the community (no matter how geographically or socially isolated) and contact tracing must be very effective. Contact tracing reduces the duration of infectiousness, particularly among asymptomatic individuals. It is as critical to the control of STDs as is choosing the right antibiotic. Disturbingly, the study of Marks et al. found that some clinics did not trace contacts, while others did so for only some STDs. Among the majority who did trace contacts, different methods were employed, suggesting that an optimal method has not been clearly established. We should use the inconsistencies identified by Marks et al. to improve our sexual health system. Specifically, we should establish the most efficient method for contact tracing and ensure that it is widely used by all who treat STDs. In determining this most effective strategy, what should be kept in mind are the important lessons learnt with HIV control strategies, which focus on harm reduction rather than on a punitive approach. Clearly, improved access to health services will reduce the duration of infectiousness. The practical difficulties of providing screening and treatment to Australia's geographically dispersed population may be largely overcome with the development of self-administered methods for collecting samples for STD diagnosis (e.g., tampons and first-void urine specimens for analysis by polymerase chain reaction) and the availability of single-dose treatments. With these innovations, it is to be hoped that substantial reductions in the currently high prevalence of STDs in many Aboriginal communities will not be long in coming. Even within large capital cities access to treatment may be difficult for some. The 25 000 homeless Australians under the age of 25 may be so caught up with day-to-day survival that they find it impossible to attend a sexual health clinic.8 Access could be improved by simple measures such as long opening hours, free treatment, anonymous services and a flexible appointment system. The finding of Marks et al. that outreach services were provided by 60% of clinics is encouraging, as is the development of innovative services like the "Youth Health Bus". This bus is provided by the Inner South Community Health Service in Melbourne, and travels around in the evenings to areas where homeless people congregate. Funding for STD control is likely to be included in HIV/AIDS funding in the near future. As the treatment of HIV/AIDS is being incorporated into large teaching hospitals, some may consider that this is the most appropriate place for the treatment of STDs. However, this is likely to be counterproductive as it would make services less accessible, thus transgressing one rule of STD control. There is no reason why Australia cannot aim for a near-zero prevalence of some endemic STDs. After all, Sweden has nearly eliminated gonorrhoea.9 Our clinics have improved greatly over the past 10 years, and Marks et al. have highlighted areas that could be further improved. The most important benefit of decreasing the prevalence of STDs within our community is that it would reduce the risk of a tragic HIV epidemic among heterosexuals like the one currently occurring in the US. Christopher K Fairley Senior Lecturer in Infectious Disease Epidemiology, Department of Epidemiology and Preventive Medicine, Monash Medical School, Melbourne, VIC. Wasserheit JN. Epidemiological synergy. Inter-relationships between human im munodeficiency virus infection and other sexually transmitted diseases. Sex Trans Dis 1992; 19: 61-77. Laga M, Manoka A, Kivuvu M, et al. Non-ulcerative sexually transmitted diseases as risk factors for HIV-1 transmission in women: results from a cohort study. AIDS 1993; 7: 95-102. First 500 000 AIDS cases -- United States, 1995. MMWR Morbid Mortal Wkly Rep 1995; 44: 849-853. Rosenberg PS, Biggar RJ, Goedert JJ. Scope of the AIDS epidemic in the United States. Science 1995; 270: 1322-1375. Coates TJ, Aggleton P, Gutzwiller F, et al. HIV prevention in developed countries. Lancet 1996; 348: 1143-1148. Bradford DL, Philpot CR. A survey of sexually transmitted disease centres in Australia. Br J Vener Dis 1983; 59: 330-334. Aral SO, Holmes KK. Sexually transmitted diseases in the AIDS era. Sci Am 1991; 264: 18-25. Burdekin B, chairman. Report of the national inquiry into homeless children. Canberra: Human Rights and Equal Opportunity Commission, 1989. Cronberg S. The rise and fall of sexually transmitted diseases in Sweden. Genitourin Med 1993; 69: 184-186. Reprints: Dr C K Fairley, Department of Epidemiology and Preventive Medicine, Monash Medical School, Monash University, Alfred Hospital, Prahran, VIC 3181. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Christopher K Fairley

Hepatitis C: waiting for the Grim Reaper Encouraging drug users to adopt non-injecting routes of administration may be the most effective way of controlling the hepatitis C epidemic MJA 1997; 166: 284 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - - ©MJA1997 Until the controversial Grim Reaper campaign alerted Australians to the seriousness of its newly recognised AIDS epidemic, citizens of the Lucky Country were complacent about infections. Fortunately, the HIV epidemic has been stabilised among injecting drug users (IDUs) in Australia by a harm reduction/public health approach to intravenous drug use. Now we have evidence of another important viral epidemic -- hepatitis C. Despite it being arguably the commonest life-threatening infection in Australia, alarm bells have not yet been rung for hepatitis C. We are beginning to recognise hepatitis C as a public health problem comparable in magnitude with HIV The incidence and prevalence of hepatitis C in Australia are far higher than those of HIV infection. An estimated 130 000 Australians have been infected with hepatitis C virus (HCV) over the last 20 years, with about 6000 new chronic infections a year through injecting drug use alone.1 In contrast, an estimated 15 450 people have been infected with HIV by all routes of transmission, with about 500 new infections a year between 1994 and 1996.2 Although a smaller proportion of individuals infected with HCV experience serious morbidity and mortality, and only after a longer delay (10%-20% are estimated -- conservatively -- to develop cirrhosis within 20 years and 5% of these develop hepato cellular carcinoma within five years),3 the far larger pool of infected people and longer duration of illness suggest that the total health and economic burden of hepatitis C in Australia is considerable and may well surpass HIV before too long. The task of bringing hepatitis C under control is daunting. While the pieces of the hepatitis C jigsaw puzzle are still being assembled, injecting drug use is undeniably the major mode of transmission in Australia and other developed countries. In this issue of the Journal, Sladden and colleagues found that 85% of hepatitis C notifications involved IDUs. Their epidemiological study analysed notifications of hepatitis C from a community sample and assigned risk factors for a high proportion of respondents. However, the high non-response rate of 53% and the statistically significant differences between respondents and non-respondents qualify their findings. In contrast to Sladden and colleagues' results, a United States study estimated a much lower proportion of IDUs among hepatitis C notifications, but could not assign risk factors for as high a proportion of respondents.4 As official policy in the US advocates "zero tolerance" for any illicit drug use, it is hardly surprising that many American IDUs were apparently intimidated from revealing their risk behaviour. Australian national surveillance data (of uncertain quality) accord with Sladden and colleagues' results -- about 85% of hepatitis C virus infections involve IDUs.1 Current hepatitis C incidence in IDUs is now estimated to be about 15 per 100 person-years.1 IDUs entering prison on more than one occasion are at even greater risk.5 These alarming figures are consistent with those for other countries.6 Hepatitis C seroprevalence in a large cohort of IDUs in the United States was 65% for those who had injected for one year or less and 85% when the cohort was followed up for 49-72 months.7 Indeed, a recent review1 of published studies of the epidemiology of hepatitis C among Australian IDUs traces the epidemic back to at least 1971, soon after injecting drug use became established in this nation. Clearly, the epidemic will be halted only if it is controlled among IDUs. Could a harm reduction/public health approach control hepatitis C among IDUs? Such an approach, which includes needle exchange and methadone treatment programs, has already been successful in stabilising the HIV epidemic among IDUs in Australia. In contrast, the US "War on Drugs", which has resulted from the official policy of "zero tolerance" for any illicit drug use, has had catastrophic public health consequences. In 1994, IDUs accounted for only 2.5% of AIDs cases in Australia,8 compared with 28% in the US in 1993.9 While the prevalence of AIDS (per million population) in the United States was 4.3 times that in Australia in 1988, by 1992 this ratio had increased to 6.4,10 fuelled by an uncontrolled epidemic among IDUs and a secondary epidemic among heterosexual contacts of HIV-positive IDUs in the US. Despite the success of the harm reduction/public health approach in controlling the HIV epidemic and slowing the spread of hepatitis B among IDUs in Australia, it appears not to have reduced the incidence of hepatitis C.1 There is a very real possibility that hepatitis C transmission among IDUs requires only minimal breaches of infection control guidelines.1 Hepatitis C virus is an order of magnitude more infective than HIV,11 and hepatitis C has a far higher baseline prevalence than HIV infection. Consequently, while expanding needle exchange and methadone treatment programs may reduce hepatitis C incidence, this is unlikely to control the epidemic. The approach of eliminating importation or global production of injectable drugs continues to enjoy some support, especially during long election campaigns, but it is increasingly apparent that this is an expensive fantasy. Even a major architect of Nixon's "War on Drugs", the former White House adviser John Erlichman, testified to a US Senate Subcommittee: "the people in the federal government . . . know darn well that the massive war they have mounted on narcotics is only going to be effective at the margins. If they don't know it, they ought to know it."12 Reducing drug supply or demand is seemingly a more realistic objective, but the evidence of past decades provides little grounds for optimism. While attempts to eliminate harm from illicit drugs almost universally fail, efforts to reduce harm generally succeed. Therefore, encouraging drug users to adopt non-injecting routes of administration (sniffing, smoking, snorting or swallowing) appears to offer our best hope for achieving hepatitis C control among IDUs. Smoking of heroin has overtaken injecting in popularity in many parts of the United States, the United Kingdom and the Netherlands.13 Reasons differ between these countries but are thought to include, in the US, the scarcity of sterile injecting equipment, coupled with drug users' fear of contracting HIV infection through needle sharing, and (most importantly) the recent drop in price and increase in purity of available heroin. In other countries, the increased availability of heroin base, which has a lower melting point than heroin hydrochloride and is thus more suitable for smoking, has played a part. A strategy of promoting non-injecting routes of administration also offers the hope of reducing the growing epidemic of drug overdoses, which claim about 500 young Australian lives each year. We are beginning to recognise hepatitis C as a public health problem comparable in magnitude with HIV. The recent inclusion of hepatitis C in the Third National HIV/AIDS Strategy means that it will at least be included in a national policymaking apparatus, which delivered splendid, internationally recognised results for HIV/AIDS. Only when there is a national commitment to raise levels of awareness about the seriousness of this epidemic will Australia stand a chance of controlling hepatitis C. Until Australia embarks on a major national awareness-raising exercise, such as a "Grim Reaper"-style public education campaign, the band will continue to play on for hepatitis C as it once did for HIV. Alex Wodak Director, Alcohol and Drug Service, St Vincent's Hospital, Sydney, NSW. Crofts N, Jolley D, Kaldor J, et al. The epidemiology of hepatitis C virus infection among injecting drug users in Australia. J Epi Comm Health. In press. National Centre in HIV Epidemiology And Clinical Research. An epidemiological assessment of the HIV epidemic in Australia. Technical Appendix 1. Evaluation of the HIV/AIDS Strategy 1993-4 to 1995-6. Canberra: AGPS, 1996: 9-16. Albertis A, Realdi G. Parenterally acquired non-A, non-B (type C) hepatitis. In: McIntyre N, Benhamou J-P, Bircher J, et al., editors. Oxford textbook of clinical hepatology. Oxford: Oxford University Press, 1991: 605-617. Alter MJ, Hadler SC, Judson FN et al. Risk factors for acute non-A, non-B hepatitis in the United States and association with hepatitis C virus infection. JAMA 1990; 264: 2231-2235. Crofts N, Stewart T, Hearne P, et al. Spread of blood borne viruses among Australian prison entrants. BMJ 1995; 310: 285-288. MacDonald M, Crofts N, Kaldor J. Transmission of hepatitis C virus: rates, routes and cofactors. Epidemiol Rev. In press. Garfein RS, Vlahov D, Galai N, et al. Viral infections in short-term injection drug users: the prevalence of the hepatitis C, B human immunodeficiency and human T-lymphotropic viruses. Am J Pub Health 1996; 86: 655-661. National Research Council and Institute of Medicine. Preventing HIV transmission. The role of sterile needles and bleach. Washington DC: National Academy Press. 1995. National Centre For Epidemiology And Clinical Research. Australian HIV surveillance report. 11: 14. April. 1995. Feachem RGA. Valuing the past -- investing in the future. Evaluation of the national HIV/AIDS strategy 1993-94 to 1995-96. Canberra: Commonwealth Department of Human Services and Health, AGPS, 1995. Gerberding JL. Management of occupational exposure to blood-borne viruses. N Engl J Med 1995; 332: 444-451. Baum D. Smoke and mirrors. The war on drugs and the politics of failure. Boston: Little Brown and Company, 1996. Wodak A, Crofts N. Once more unto the breach: controlling hepatitis C in injecting drug users. Addiction 1996; 91: 181-184. - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Alex Wodak

Asthma management plans: progress and problems Research on the usefulness, applicability and effectiveness of the Australian Asthma Management Plan should ultimately improve quality of life for people with asthma MJA 1997; 166: 287 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - - ©MJA1997 There have been considerable improvements in morbidity and mortality from asthma in Australia since the publication of the Australian Asthma Management Plan (AMP) in 1989.1,2 The Australian plan was a milestone and many national (e.g., British3 and United States4 ) and international asthma management guidelines (e.g., Global Initiative for Asthma5 ) followed. It outlines six components of good asthma management: (1) assess severity, (2) achieve best lung function, (3) maintain best lung function -- identify and avoid triggers, (4) maintain best lung function with optimal medication, (5) develop an action plan, and (6) educate and review regularly. Within Australia, the AMP was widely disseminated to doctors and allied health professionals by the National Asthma Campaign through the Asthma management handbook, which has since undergone two revisions, the latest in 1996. Any major public health initiative should be rigorously evaluated before its recommendations become established practice, and the National Asthma Campaign has been monitoring asthma management practices and outcomes since 1990.6 What is the role of an AMP if less than half of asthma sufferers report receiving one? In this issue of the Journal, Beilby and colleagues shed more light on current asthma management and the use of the Australian AMP. As part of a larger general population survey, they included questions on asthma which enabled assessment of the use of whole or part of the AMP. It is important to distinguish between an AMP (the complete six-step package) and specific elements within it, such as having an action plan or having identified trigger factors with one's doctor, as research is still needed to assess the usefulness and applicability of the different components of the AMP. For example, action plans can play a vital role in preventing hospital admissions and death from asthma,7 but not all patients will find them helpful or use them when needed.8 The essential ingredients of an action plan should enable a patient to identify an exacerbation (e.g., by increased bronchodilator use or nocturnal asthma or a decrease in peak flow), increase medication and add oral corticosteroids appropriately and seek timely medical attention. A peak flow meter is not essential to this process, although it is extremely valuable for some patients. Those most likely to benefit from using a peak flow meter include those with previous life-threatening asthma, a history of emergency visits and hospital admissions, and a history of poor perception of airway obstruction. Gibson et al.9 have shown that the more severe an asthma exacerbation, the less frequently will patients prefer self-management or use of an action plan. In addition, the elderly are more likely to seek advice from their doctors at the time of an acute attack of asthma, rather than make autonomous decisions based on an action plan. Garrett et al.8 have also shown that, among patients admitted to hospital with acute asthma, a minority used their action plans. On the other hand, many patients manage their asthma effectively at home, and avoid the need for emergency medical treatment, possibly as a result of effective use of action plans, although this has been more difficult to quantify. In long-term management, AMP adherence is better in those with more severe asthma, and use of a self-management plan can reduce unscheduled acute care visits, courses of antibiotics and oral corticosteroids, and improve quality of life.7,10 The finding of Beilby et al. that 46% of respondents with asthma reported being given an AMP is very similar to the 42% estimated in the 1994 NSW Health Promotion Survey,11 and the National Asthma Campaign evaluation in 1993.6 However, they found that only a quarter of this 46%, or 11%-12% overall, had a written AMP. This is lower than the 1993 National Asthma Campaign estimate of 20% and is cause for concern. There is evidence that written advice is more effective than verbal advice alone in improving patient adherence to medication instructions and management strategies.12 Audit data indicate a low rate of use of action plans among people who attend accident and emergency departments with asthma exacerbations. For these reasons the low rate of written AMPs (and therefore, it is assumed, action plans) identified in all studies needs to be addressed. As highlighted by Beilby et al., lack of time in general practice consultations and uncertainty about how to write an action plan may be impediments to more widespread uptake of this important component of the AMP. These observations raise the issue of which components of the AMP matter most. The Australian AMP was written as an expert consensus statement. It provides a systematic and methodical approach to asthma care, but it was not formulated as an evidence-based document -- its recommendations were not based on systematic reviews and have not been ranked according to the strength of the evidence supporting them. Had we waited for this to be done, we would have delayed guidelines which were desperately needed at a time when the prevalence of asthma in Australia was rising,13 asthma mortality was high and morbidity was proving a major cost to the Australian community.14 An evidence-based review of the AMP has been advocated in the National asthma strategies15 and a systematic review of the evidence for the sixth step of the AMP -- educate and review regularly -- is already being undertaken by members of the Thoracic Society of Australia and New Zealand through the Cochrane Collaboration Airways Group. The article by Beilby and colleagues makes an important contribution to monitoring the use of the AMP. Several positive points emerge. Good management was more likely among those who had a regular doctor, and action plans were more common among those who had moderate or severe asthma. The combination of specialist and GP care resulted in the highest rate of possession of an AMP (82%). This finding concurs with other studies showing the benefits of integrated care,16 and highlights the need to improve communication and joint management strategies between specialists and GPs, hospitals and the community. Further work and consultation are needed to address the barriers to wider use of written action plans and to help facilitate this process for GPs. Considerable resources are needed to clarify which aspects of the AMP are making the greatest contributions to improving asthma outcomes, but this investment will be important in developing the AMP into more strongly evidence-based guidelines. Christine R Jenkins Visiting Thoracic Physician, Concord Hospital, Sydney, NSW, and Chairman, National Asthma Campaign Adrian E Bauman Associate Professor of Public Health, School of Community Medicine, University of New South Wales, Sydney, NSW Woolcock AJ, Rubinfeld AR, Seale JP, et al. Asthma management plan 1989. Med J Aust 1989; 151: 650-653. Australian Bureau of Statistics. Deaths due to diseases and cancers of the respiratory system, 1979-94. Canberra: ABS, 1996: 6-7. (Catalogue No. 3314.0.) Guidelines for management of asthma in adults: I -- chronic persistent asthma. BMJ 1990; 301: 651-653. National Asthma Education Program. Expert panel report. Guidelines for the diagnosis and management of asthma. Bethesda, Md.: United States Department of Health and Human Services, August 1991. (Publication No. 91-3042.) Global Initiative for Asthma. Global strategy for asthma management and prevention. NHLBI/WHO workshop report. Bethesda, Md.: National Heart, Lung and Blood Institute, 1995. Comino EJ, Mitchell CA, Bauman A, et al. Asthma management in eastern Australia, 1990 and 1993. Med J Aust 1996; 164: 403-406. Lahdensuo A, Haahtela T, Herrala J, et al. Randomised comparison of guided self management and traditional treatment of asthma over one year. BMJ 1996; 312: 748-751. Garrett J, Mercer Fenwick J, et al. Peak expiratory flow meters (PEFMs) -- who uses them and how and does education affect the pattern of utilisation? Aust N Z J Med 1994; 24: 521-529. Gibson PG, Talbot PI, Toneguzzi RC, et al. Self-management, autonomy and quality of life in asthma. Chest 1995; 107: 1003-1008. Charlton I, Charlton G, Broomfield J, Mullee MA. Evaluation of peak flow and symptoms only self management plans for control of asthma in general practice. BMJ 1990; 301: 1355-1359. Howell S, Bauman A. NSW health promotion survey databook, December 1995. Sydney: NSW Department of Health, 1995. Jones K, Tilford S, Robinson YK. Compliance. Health education. London: Chapman and Hall, 1991: 127-130. Peat JK, van de Berg R, Green WF, et al. Changing prevalence of asthma in Australian children. BMJ 1994; 308: 1591-1596. National Asthma Campaign. Cost of asthma in Australia. Melbourne: Boston Consulting Group, 1993. National Asthma Campaign. National asthma strategies: strategies and implementation. Melbourne: NAC: 1996. Osman LM, Abdulla MI, Russell IT, et al. Integrated care for asthma: matching care to the patient. Eur Respir Dis 1996; 9: 444-448. - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Christine R Jenkins · Adrian E Bauman

Helping heart attack victims to save their own lives Reperfusion techniques can save both lives and heart muscle, but the key is prompt treatment MJA 1997; 166: 228 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - - ©MJA1997 The outlook for a person in the early hours after the onset of a myocardial infarction remains grim. Of the 40% who will die in the first month, a third will die in the first hour and up to a half in the first day.1 While some deaths are sudden and not amenable to treatment, the outcome in many cases can be improved by appropriate modern medical treatment, such as defibrillation and coronary reperfusion strategies, if administered early enough. publicise the symptoms of a possible heart attack, emphasise the importance of reporting them, and ensure that the message is aimed at all educational levels The risk of sudden cardiac death from ventricular fibrillation can be reduced by access to and use of a defibrillator. Coronary care ambulances with skilled paramedical staff have saved many lives since their introduction to Australia in the late 1960s.2 Increasingly, strategic placement of semi-automatic defibrillators -- for example, in large passenger aircraft and football stadiums -- is being considered, to further improve out-of-hospital survival. Once the patient reaches hospital, modern reperfusion strategies such as thrombo lysis and acute angioplasty can save lives, limit myocardial damage and reduce subsequent cardiac disability.3,4 Improved understanding of myocardial infarction from angiographic and postmortem studies has reaffirmed that most cases are indeed due to coronary thrombosis. The need to achieve coronary reperfusion as early as possible has long been recognised from pathophysiological studies and clinical trial experience.3,4 Since the mid 1980s, thrombolytic therapy has been studied in over 200 000 patients,3 and a recent overview has shown very clearly that streptokinase and recombinant tissue plasminogen activator (t-PA) are effective thrombolytic agents in acute myocardial infarction. Their appropriate use in patients with suspected myocardial infarction can save 20-30 lives per 1000 patients treated over the first 35 days,3 and there is the prospect of even better outcomes with new thrombolytic agents. More recently, reperfusion with acute coronary angioplasty has been shown to be equivalent to thrombolysis in most centres and to have superior outcomes in some centres, particularly those with a high level of expertise and readily available angioplasty services.4 The use of intracoronary stents adjunctive to angioplasty may improve even further the early outcome, with a reduced risk of late restenosis. The average loss of life per hour of delay of thrombolytic therapy is 1.6 lives per 1000 patients treated.3 The myocardial infarction triage and intervention trial in Seattle demonstrated even more accurately the importance of urgent treatment in the first hour.5 For patients surviving to hospital and being treated within 70 minutes of symptom onset, the 28-day mortality rate was 1.2% and only 5% of the left ventricular mass was infarcted; those treated later than 70 minutes had a mortality rate of 8.7% and 11% of myocardium was infarcted. These benefits were demonstrated with thrombolytic regimens now known to achieve early patency and restoration of normal coronary blood flow in less than half the patients treated. With the more aggressive reperfusion strategies now available the prospects are even brighter. The first hour after the onset of coronary thrombosis is indeed the "golden hour" of opportunity for preserving heart muscle and saving lives. These developments represent a quantum shift in what can be achieved in treating coronary thrombosis. Clinical management which allowed a passive acceptance of inevitable cardiac damage and high mortality rates is now out of date. The aim now is preservation of both life and myocardium by early restoration of coronary blood flow. From a mortality rate for hospitalised patients of 30% in the 1960s to 10%-15% after the introduction of coronary care units, a 28-day death rate of below 5% should now be achievable for coronary care patients after their first myocardial infarct.6,7 Given what can be achieved with early treatment, the reluctance of patients who suffer a heart attack to present to hospital is disappointing. Previous Australian studies8,9 have shown avoidable delays in presentation of up to several hours from the onset of symptoms. In this issue of the Journal Dracup and colleagues provide further evidence of this risk-taking behaviour -- they report an unusually long median delay of 6.4 hours, even longer than the approximately two-hour delay reported by Leitch et al.8 in a Sydney-based study in 1989 and the approximately 1.2-hour delay found by Bett et al.9 in a study of 22 centres in 1988-89. The difference is probably partly due to differences in the definition of time of onset. Dracup et al. report the duration from onset of the first symptoms until hospital presentation, whereas Leitch et al. reported the time of onset of the symptom which initiated action until hospital presentation8 (which does not take into account the duration of any preceding intermittent symptoms), and Bett et al. reported the time from onset of the symptom which initiated action to when "help was first sought"9 (as opposed to hospital presentation). Thus, the latter studies would be expected to give a shorter average interval than that reported by Dracup et al. It is noteworthy that Dracup et al. conducted their study before the May 1996 Heart Foundation Heart Week campaign, which emphasised how to recognise symptoms of heart attack, with posters and television commercials depicting squeezing chest pain as a python-like grip, and the need for early action by patients suffering symptoms of a heart attack. Dracup et al. found that the patients who recognised their symptoms as cardiac in origin had only one-third the response time of those who did not. It would be interesting to see if a follow-up study showed any effect of the 1996 campaign. Although the complex human response to chest pain is more likely to be instinctive rather than knowledge-based,9 Dracup and colleagues provide further useful insight into factors that cause delay. The independent predictors of delay were educational status (slower response times in less educated patients), a desire not to cause trouble, failure to recognise symptoms as being cardiac in origin, and an intermittent pattern of symptoms. The message for future public education campaigns is clear -- publicise the symptoms of a possible heart attack, emphasise the importance of reporting them (no-one ever died of embarrassment), and ensure that the message is aimed at all educational levels. The message for health professionals is especially clear -- a third of patients reported that they learnt about heart attack symptoms from a health professional. Doctors and nurses dealing with existing heart patients or those with substantial risk factors for myocardial infarction have many opportunities to educate patients about heart attack symptoms and to give clear instructions on how -- and why -- they should summon an ambulance and get to a hospital fast. Paul E Langton Cardiology Research Fellow, Sir Charles Gairdner Hospital, Perth, WA Peter L Thompson Clinical Professor, Department of Cardiovascular Medicine, Sir Charles Gairdner Hospital, Perth, WA Tunstall-Pedoe H, Kuulasmaa K, Amouzel P, et al. Myocardial infarction and coronary deaths in the World Health Organization MONICA project. Circulation 1994; 90: 563-612. O'Rourke MF. Acute myocardial infarction: prehospital coronary care. In: Thompson PL, editor. Coronary care manual. London: Churchill-Livingstone, 1997: 429-433. Fibrinolytic Therapy Trialists Collaborative Group. Fibrinolytic therapy -- indications in suspected acute myocardial infarction. Lancet 1994; 343: 311-322. Ryan TJ, Anderson JL, Autman EM, et al. ACC/AHA Guidelines for the management of patients with acute myocardial infarction: executive summary. Circulation 1996; 94: 2341-2350. Weaver WD, Cerqueria M, Hallstrom AP, et al. for the MITI project group. Prehospital-initiated v. hospital-initiated thrombolytic therapy. The myocardial infarction triage and intervention (MITI) trial. JAMA 1993; 270: 1211-1216. DeVreede JJM, Gorgels AP, Verstraaten GMP, et al. Did prognosis after myocardial infarction change during the past 30 years? J Am Coll Cardiol 1991; 18: 698-706. Jamrozik K, Broadhurst R, Parsons RW, et al. Ten year trends in medical management and case fatality in acute myocardial infarction [abstract]. J Am Coll Cardiol 1996; 27: 278A. Leitch JW, Birbara T, Freedman B, et al. Factors influencing the time from onset of chest pain to arrival at hospital. Med J Aust 1989; 150: 6-8. Bett N, Aroney G, Thompson PL. Impact of a national education campaign to reduce patient delay in possible heart attack. Aust N Z J Med 1993; 23: 157-161. Reprints: Dr P E Langton, Sir Charles Gairdner Hospital, Verdun Street, Nedlands, WA 6009. - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Paul E Langton · Peter L Thompson

Laparoscopic hysterectomy Perhaps the most important role of laparoscopic hysterectomy has been to show that many more women are suitable candidates for vaginal hysterectomy than was once thought MJA 1997; 166: 172 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - - - ©MJA1997 If LAVH is more acceptable to patients, not more dangerous and no more expensive than TAH, why is it not performed more commonly? Laparoscopically assisted vaginal hysterectomy (LAVH) was pioneered by Reich in the United States in 1989 and introduced to Australia the same year. Like all new techniques in medical practice, it has its share of ardent supporters and cynical detractors. The supporters quote advantages for the patient -- lower postoperative analgesia requirements, shorter hospital stay, and more rapid return to work and normal activities1,2 -- when compared with total abdominal hysterectomy (TAH). The detractors don't dispute this, but are mainly concerned with complications of LAVH and the cost of the procedure. Unfortunately, most of the data on complication rates of LAVH have come from small retrospective studies. A recent meta-analysis of 29 such studies3 showed an overall complication rate of 15.6% for LAVH, compared with 24.5% for vaginal hysterectomy (VH) and 42.8% for TAH.4 These figures for VH and TAH are from a large prospective multicentre study in 1982, but this study has provided the benchmark for comparison for most of the published series of LAVH complications. Many small, uncontrolled retrospective studies have been published within the last three years and have consistently found no evidence that LAVH has an unacceptably high complication rate. Of three recent studies comparing complication rates between LAVH, TAH and VH, one found very little difference between the groups,5 while the other two6,7 found the complication rate for LAVH to be intermediate between that for the vaginal and abdominal procedures. The greatest concern would appear to be a suggestion of a higher proportion of more serious complications with LAVH. The study of Dicker et al. showed a urinary tract injury rate of 1.6% for VH and 0.5% for TAH.4 A retrospective audit of all cases of LAVH in South Australia from 1991 to 1994 showed that urinary tract injury occurred in 2.4%,8 while rates of up to 4.8% have been reported elsewhere.9 Both of these studies may reflect an earlier stage in the learning curve of the procedure. The meta-analysis study by Garry and Phillips included only "skilled gynaecological laparoscopists" and they reported urinary tract damage in 1.38% of cases.3 Trochar injuries occurred in 2.57% of cases. If we accept that, in skilled hands, LAVH is not more dangerous for the patient than VH or TAH, the detractors are then left with the argument that LAVH is much more expensive than the traditional options, and several American studies have certainly shown this.2,5,6,10 However, the cost of LAVH can be reduced substantially by the use of non-disposable instruments. In this issue of the Journal, Tsaltas and colleagues present the first cost analysis of LAVH compared with TAH in an Australian hospital casemix setting. They found that, at least in this context, LAVH is no more expensive than traditional abdominal hysterectomy -- even with the use of disposable trochars and stapling devices. The shorter hospital stay is the main factor offsetting the increased cost of disposable instruments and longer theatre time, as was also found in a British study where LAVH was shown to be cheaper than TAH.1 If LAVH is more acceptable to patients, not more dangerous and no more expensive than TAH, why is it not performed more commonly? An analysis of the Health Insurance Commission Medicare computer data11 has shown that in Australian private hospitals in 1994-1995 7.4% of hysterectomies were performed with laparoscopic assistance, while 57.5% were performed abdominally and 34.9% vaginally. In 1991-1992 the incidence of TAH was 70.5%, with 29.5% of hysterectomies being performed vaginally. Thus, since the advent of LAVH there has not only been a decrease in the rate of TAH, but also an increase in the number of vaginal hysterectomies. At least two prospective randomised controlled trials12,13 have failed to show that LAVH has any advantage over VH, and that, without gross pelvic disease, VH can be successfully completed in most women who would have previously been considered to have relative contraindications to vaginal surgery. This includes the need for oophorectomy, which can be accomplished vaginally in the vast majority of patients. The obvious conclusion is that too many hysterectomies are still being performed by the abdominal route, and that the vaginal route should be chosen where possible. LAVH has given gynaecologists the opportunity to re-evaluate vaginal surgery and has facilitated the removal of many of the traditional contraindications to this approach. So, is there still a place for LAVH or has it been overtaken by the rediscovery of vaginal hysterectomy? The major technical advantage of LAVH is that it allows a panoramic view of the pelvis not afforded by VH. Thus, there will still be cases of pelvic adhesions and adnexal disease where LAVH will allow the patient to avoid a laparotomy and the associated increased postoperative pain and longer recovery period. It is reassuring for the health economists among us to see that, in an Australian hospital casemix setting, LAVH does not overburden the system with unnecessarily increased cost. Barbara A Hall Visiting Gynaecologist, Mater Hospital, Brisbane, QLD Raju KS, Auld BJ. A randomised prospective study of laparoscopic vaginal hysterectomy versus abdominal hysterectomy each with bilateral salpingo-oophorectomy. Br J Obstet Gynaecol 1994; 101: 1068-1071. Phipps JH, Nayak JS. Comparison of laparoscopically assisted vaginal hysterectomy and bilateral salpingo-oophorectomy with conventional abdominal hysterectomy and bilateral salpingo-oophorectomy. Br J Obstet Gynaecol 1993; 100: 698-700. Garry R, Phillips G. How safe is the laparoscopic approach to hysterectomy? Gynecol Endosc 1995; 4: 77-79. Dicker RC, Greenspan JR, Strauss LT, et al. Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. Am J Obstet Gynecol 1982; 144: 841-848. Redwine DB. Laparoscopic hysterectomy compared with abdominal and vaginal hysterectomy in a community hospital. J Am Assoc Gynecol Laparosc 1995; 2: 305-310. Harris MB, Olive DL. Changing hysterectomy patterns after introduction of laparoscopically assisted vaginal hysterectomy. Am J Obstet Gynecol 1994; 171: 340-344. Boike GM, Elfstrand EP, DelProire G, et al. Laparoscopically assisted vaginal hysterectomy in a university hospital: report of 82 cases and comparison with abdominal and vaginal hysterectomy. Am J Obstet Gynecol 1993; 168: 1691-1701. O'Shea RT, Petrucco OM. Laparoscopically-assisted vaginal hysterectomy -- Adelaide complication audit 1991-94 [abstract]. In: Abstract Book, Annual Scientific Meeting of the Australian Gynaecological Endoscopy Society. 1996 Sep; Queenstown, SA. Morphettville, SA: The Society, 1996. (Abstract No. 23.) Baggish MS. The most expensive hysterectomy. J Gynaecol Surg 1992; 8: 57-58. Nezhat C, Bess O, Admon D, et al. Hospital cost comparison between abdominal, vaginal and laparoscopically-assisted hysterectomies. Obstet Gynecol 1994; 83: 713-716. Molloy D, Crosdale S. National trends in gynaecological endoscopic surgery. Aust N Z J Obstet Gynecol 1996; 36: 27-31. Richardson RE, Bournas N, Magos AL. Is laparoscopic hysterectomy a waste of time? Lancet 1995; 345: 36-41. Summitt RL, Stoval TG, Lipscombe GH, Ling FW. Randomized comparison of laparoscopy-assisted vaginal hysterectomy with standard vaginal hysterectomy in an outpatient setting. Obstet Gynecol 1992; 80: 895-901. To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Barbara A Hall

Deaths, dying and the euthanasia debate in Australia The findings of a study of end-of-life medical decisions in Australia may provide ammunition for both supporters and opponents of euthanasia MJA 1997; 166: 173 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - - - ©MJA1997 General trends have emerged: there is majority community support for euthanasia or physician-assisted suicide The debate on euthanasia in Australia shifted abruptly from abstraction to reality with the passage of the Rights of the Terminally Ill Act by the Northern Territory Parliament in May 1995. Overnight, euthanasia and physician-assisted suicide became a legal choice for people with terminal illness.1 The Act has focused and polarised opinions on issues relating to medical decisions at the end of life. The deaths of three Australians (to date) under the provisions of the Act have been accompanied by an outburst of variously composed Greek choruses: citizens, ethicists, doctors, politicians, and media commentators. What should have been dignified and private affairs have been transformed into public events. The intent and provisions of the Act are supported by, among others, the Doctors' Reform Society, the Euthanasia Society, and the AIDS Council of New South Wales. They are opposed by the Australian Medical Association (AMA),2 the Australian Association for Hospice and Palliative Care,3 mainstream religions, Right To Life Australia, and organisations representing the aged and those with disabilities. The Act has been challenged in the High Court of Australia by Dr Chris Wake, the President of the Northern Territory Branch of the AMA, and Dr Djiniyinni Gondarra, an Aboriginal minister of the Uniting Church, who sought special leave to appeal the decision of the Northern Territory Supreme Court upholding the validity of the Northern Territory euthanasia law. The High Court has adjourned the hearing of this application,4 pending the outcome of the Euthanasia Laws Bill introduced in the Federal Parliament of Australia by Mr Kevin Andrews, a Member of the House of Representatives. The intention of the Bill is to deny the Northern Territory legislative power over euthanasia, and to render Northern Territory law null and void. It has passed through the Lower House, and the Australian Senate has referred the Euthanasia Laws Bill to its Legal and Constitutional Legislation Committee, which reports to the Senate in late February this year. Despite the strong arguments advanced by both sides of the debate, a critical component absent from the assertions are actual data on end-of-life medical decisions. Most Australian surveys have used hypothetical models.5-9 The limitations of these studies include notional concepts; inconsistent definitions of euthanasia and other medical decisions at the end of life; lack of information about non-responders to surveys; and lack of validation. Doubts have also been expressed about the representativeness of the cohorts sampled. Despite these qualifications, general trends have emerged: there is majority community support for euthanasia or physician-assisted suicide9,10 and for legislation to allow these practices.9 However, the converse is true for the majority of the medical profession.8,9 Despite this medical disapproval, there is evidence that euthanasia and physician-assisted suicide are practised by some Australian doctors.5-7 Similar findings have been reported in the United Kingdom.11 However, these surveys give no quantitative indication of the extent of these practices in Australia. In this issue of the Journal, Kuhse and her colleagues report such data, obtained by an adaptation of the methods used to determine these practices in the Netherlands.12,13 In the Netherlands, euthanasia and physician-assisted suicide have been accepted for over 20 years. While these practices are illegal, and punishable by imprisonment -- 12 years for euthanasia and 3 years for physician-assisted suicide -- they are condoned by strong public support and have a legal basis in the force majeure, whereby the doctor must act.14 Dutch doctors can be reasonably sure that they will not be prosecuted if they follow the guidelines for the practice of euthanasia issued in 1984 by the Royal Dutch Medical Association and endorsed by the Dutch Government.14 End-of-life medical decisions in the Netherlands have been scrutinised by two government-initiated surveys, one in 1990,12 and the other in 1995.13 The latter survey conducted two separate studies: one based on interviews of a stratified sample of doctors, and the other on responses to questionnaires mailed to physicians identified on death certificates of about 6000 deaths (in the Netherlands, for all deaths the cause must be reported on a uniform death certificate, forwarded to a central authority -- Statistics Netherlands). In the study of Kuhse et al. an English version of the Dutch questionnaire was forwarded to 3000 Australian doctors, stratified to mimic the broad categories of doctors in the Dutch study. The categories and definitions of end-of-life medical decisions in both studies were identical. A broad overview of the outcomes of the Australian and Dutch studies is of interest. Kuhse et al. report that end-of-life medical decisions were made in approximately 65% of deaths in Australia (corresponding Dutch 1995 estimate, 42%). The estimated Australian incidences for specific end-of-life medical decisions in 1995 were: euthanasia, 1.7% (corresponding Dutch 1995 estimate, 2.4%); physician-assisted suicide, 0.1% (0.2%); ending of life without the patient's explicit request, 3.5% (0.7%); alleviation of pain and symptoms with opioids, with probable life-shortening effects, 30.9% (19.1%); and decisions to forgo treatment, 28.6% (20.2%). The estimated time (days) by which life was shortened by end-of-life medical decisions was comparable in the two studies. How does the Australian and Dutch experience compare with that in other developed industrialised countries? In the United States, euthanasia and physician-assisted suicide are illegal. However, the US Supreme Court will decide later this year whether to uphold the decisions of two US Courts of Appeals to permit doctors to help terminally ill patients commit suicide.15 In a recent survey of physicians in the State of Washington,16 12% said that they had been asked in the last 12 months to assist suicide and 4% had been asked to perform euthanasia; physicians had complied with a quarter of the euthanasia requests, giving a percentage for euthanasia comparable with that found by Kuhse et al. in Australia. The American Hospital Association has estimated that about 70% of US hospital deaths occur after decisions to forgo treatment,17 but there are no readily retrievable US data on how often the use of opioids for symptom relief in terminally ill patients has hastened death. Will the report by Kuhse et al. influence the anti- and pro-euthanasia positions in Australia? Considering the intransigent attitudes of both groups, this seems unlikely. Those who support euthanasia will argue that the findings of Kuhse et al. of the practice of both euthanasia and physician-assisted suicide, and their large estimate for the number of patients for whom end-of-life medical decisions were made without an explicit patient request (albeit more than 50% were mentally not competent), warrant the development of guidelines, and independent audits to assure compliance. Legislation for euthanasia is the best way to ensure this. Moreover, removal of a legal threat by decriminalisation will also remove the need for anonymity and allow an open review of practices. Proponents will further argue that the longitudinal data from the 1990 and 1995 Dutch studies indicate that fears about the "slippery slope" (such as voluntary euthanasia leading to non-voluntary euthanasia) are not justified. For the proponents of euthanasia the Australian estimates for end-of-life medical decisions, other than for euthanasia and physician-assisted suicide, will represent experiences in which patients are presumed to have endured pain and suffering, and which, out of respect for autonomy and compassion, they should be able to relieve by choosing euthanasia. For many supporters of euthanasia and physician-assisted suicide, the distinction between euthanasia and refusal of treatment, or the use of palliative treatments that may hasten death, is logically, philosophically and morally ambiguous. These "moral-equivalence" arguments have been challenged (see Ashby, this issue of Journal). For opponents of euthanasia the findings of Kuhse et al. will be seen as potent reasons for enhancing access to, and quality of, palliative-hospice care and mental health services in Australia. For many, the findings of both the Australian and Dutch studies will not extinguish fears of the "slippery slope", at the end of which are loss of the sanctity of life, a broadening of the criteria for euthanasia, and a change in the values of society and the ethos of medicine. For others, the study findings will highlight the complexities of clinical decisions and circumstances, which, in themselves, have been neglected in the euthanasia debate in the medical, legal and ethical arenas; the law and ethics cannot operate in a vacuum. The opponents of euthanasia will argue that, although they respect patient autonomy, this cannot be divorced from the intricacies of the patient-doctor relationship, or, for that matter, the patient-family and other important relationships. Finally, despite the findings of Kuhse et al., opponents of euthanasia legislation will argue that the law lacks the sensitivity and compassion required to deal with such a complex event as dying, and that intrusion of the law into this area will have unforeseen consequences. For the neutralists in the euthanasia debate, the findings of Kuhse et al. will emphasise how little is known about how and where people die in Australia. They will say the results underscore the inadequacies of training programs for the care of the dying, and draw attention to the complexities and vicissitudes of the communications between patients and doctors. Finally, they will call for programs that both explore the issues of death and dying, and ensure that the circumstances of this inevitable event are compassionate and humane. Martin B Van Der Weyden Editor, The Medical Journal of Australia Sydney, NSW Ryan CJ, Kaye M. Euthanasia in Australia -- the Northern Territory Rights of the Terminally Ill Act. N Engl J Med 1996; 334: 326-328. Australian Medical Association Position Statement on Care of Severely and Terminally Ill Patients. Canberra: AMA, May 1996. Australian Association for Hospice and Palliative Care. Voluntary active euthanasia -- position statement. Perth: AAHPC, October 1995. High Court defers to MPs on euthanasia. The Weekend Australian 1996; Nov 16: 9. Kuhse H, Singer P. Doctors' practices and attitudes regarding voluntary euthanasia. Med J Aust 1988; 148: 623-627. Baume P, O'Malley E. Euthanasia: attitudes and practices of medical practitioners. Med J Aust 1994; 161: 137-144. Stevens CA, Hassan R. Management of death dying and euthanasia: attitudes and practices of medical practitioners in South Australia. J Med Ethics 1994; 20: 41-46. Waddell C, Clarnette RM, Smith M, et al. Treatment decision-making at the end of life: a survey of Australian doctors' attitudes towards patients' wishes and euthanasia. Med J Aust 1996; 165: 540-544. Steinberg MA, Najman JM, Cartwright CM, et al. End-of-life decision making: community and medical practitioners' perspectives. Med J Aust 1997; 166: 131-135. Vote life death choice. The Bulletin 1996; Sep 17: 18-22. Ward BJ, Tate PA. Attitudes among NHS doctors to requests for euthanasia. BMJ 1994; 308: 1332-1334. van der Maas PJ, Van Delden JJM, Pijnenborg L, Looman CWN. Euthanasia and other medical decisions concerning the end of life. Lancet 1991; 338: 669-674. van der Maas PJ, van der Wal G, Haverkate I, et al. Euthanasia, physician-assisted suicide, and other practices involving the end of life in the Netherlands, 1990-1995. N Engl J Med 1996; 335: 1699-1705. van der Wal G, Dillmann RJM. Euthanasia in the Netherlands. BMJ 1994; 308: 1346-1349. Angell M. The Supreme Court and physician-assisted suicide -- the ultimate right. N Engl J Med 1997; 336: 50-53. Back AL, Wallace JI, Starks HE, Pearlman RA. Physician assisted suicide and euthanasia in Washington state: patients requests and physicians responses. JAMA 1996; 275: 919-925. Brief of the American Hospital Association as amicus curiae in support of petitioner Nancy Beth Cruzan, Lester L and Joyce Cruzan. Chicago: American Hospital Association, 1 September 1989. - - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

The fallacies of death causation in palliative care While the debate about euthanasia continues, society should focus more on palliative care which is clinically safe and ethically sound MJA 1997; 166: 176 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - - - ©MJA1997 The most important thing is promoting the comfort, dignity and autonomy of people who are dying In studies which generated the first data on the incidence of euthanasia in the Netherlands,1-3 the practice was categorised as a type of "medical decision at the end of life", defined as: "all decisions by physicians concerning courses of action aimed at hastening the end of life of the patient or courses of action for which the physician takes into account the probability that the end of life of the patient is hastened." Two other categories which van der Maas and colleagues created were the administration of "high" doses of opiates that "almost certainly would shorten the life of the patient" and decisions in which "life-prolonging" treatment was withheld or withdrawn.4 In this issue of the Journal, Kuhse et al. report the results of their Australian study based on the approach taken by these studies. One line of argument advanced by those in favour of legalising euthanasia is to suggest that if doctors already cause (or hasten) death by stopping "active" treatment or by palliative interventions, such as the use of escalating morphine doses for pain control, they should not object to the administration of a lethal injection or the supply of the means to commit suicide at the explicit request of a terminally ill patient. By demonstrating a high incidence of so-called "medical decisions at the end of life" which are argued to cause death (approximately 65% of deaths in the study by Kuhse et al.), advocates of the legalisation of voluntary active euthanasia presumably hope to show that existing medical practice is inconsistent in both its principles and processes. There are two major false premises which need to be challenged. Firstly, it is a common belief, and the basis of a considerable body of legal and legislative opinion, that the dose of morphine (or other opioid) per se is the main determinant of whether the drug causes or hastens death.5 In fact, there is no such determinative dose. What matters is the relationship of a dose to the previous dose. In pain management gradual dose escalation by 50%-100% of the previous dose is usual practice, although substantially higher increases can usually be well tolerated by patients who are not new to the drug. It is therefore the size of the initial dose, and the rate of subsequent increases, which are important. Unlike most other forms of drug treatment, there are no predetermined dose ranges of morphine for achieving satisfactory control of cancer pain. Therefore, treatment has to be skilfully adjusted on an individual basis. For most adults a daily dose in the range 30-200 mg, orally, will achieve initial pain control. The accepted practice, used safely for at least 20 years, is to adjust the regular dose (usually) upwards according to the requirements to keep the pain under control, balanced against the occurrence of side effects. Many doctors still believe that they are causing or hastening the death of patients by this process, despite an extensive and sustained international campaign by the World Health Organization and a lack of any evidence to support this view. Like any drug, morphine is dangerous if used without clinical skill. Appropriate opioid use is surrounded by myths and fears among both the general public and health care professionals, appearing to be largely attributable to the history and non-medical use of this class of drugs.6 Secondly, surely nobody benefits from lines of argument which equate the cessation of treatment or decisions not to treat when a person is dying (even if treatment is potentially life-prolonging) with giving a lethal injection to end a life. "Moral-equivalence" arguments based on outcome cannot ignore the assessment of clinical proportionality and appropriateness. Although Keyserlingk has argued against overemphasis on "but-for" causality in this debate,7 the death is surely caused only if the treatment can be demonstrated to be clinically effective in the circumstances, and the underlying condition is potentially reversible (i.e., there is a disruption of a pre-existing chain of causation).8 For a competent patient who expresses a wish to reject any medical treatment whatsoever, this has been clearly accepted as morally and legally permissible, and the issue is not controversial. While van der Maas et al.9 and Kuhse et al. are right to draw attention to situations in which patients were not consulted about medical decisions, treatment abatement cannot be negotiated with incompetent dying people. Unfortunately, incompetence due to organic brain dysfunction is fairly common during the dying process and medical decisions do have to be taken.10 Although the Australian doctors in the report by Kuhse and colleagues may be reflecting a degree of honest pragmatism, this finding clearly needs more exploration -- with particular emphasis on the transparency of process, negotiation and consultation. Kuhse et al. state that death was the "partly or explicitly" intended outcome of a medical decision to end life in 36.5% of all Australian deaths. While they attempted to ascertain intention, neither their study nor the Dutch studies validate the doctors' responses by examining clinical data and prescription records. In the absence of formal training in palliative care -- a relatively recent advent in most medical schools -- doctors' attitudes and clinical behaviour are complex and variable. They range from abrupt cessation of treatment, minimalist palliative care and treatment directed at bringing about a rapid dying process, to excessive caution about being seen to be instrumental in causing the death, particularly with regard to providing pain and symptom relief, withdrawal or non-initiation of artificial hydration and alimentation, and cardiopulmonary resuscitation.11 While academic study in this area is essential and welcome, neither reliance on empirical research12 (despite its attractiveness to doctors and policymakers) nor the generation of increasingly ingenious ethical or legal arguments will resolve the issue of euthanasia. The debate has become stagnant, circular and divisive and it distracts our society from the on-going task of improving care and decision-making at the end of life. The most important thing is promoting the comfort, dignity and autonomy of people who are dying. Divergence about whether third-party assistance (medical or non-medical) to die is permissible reveals a deep and complex fault line in modern Western democracies, as they chart their courses based more on individual conceptions of liberty and autonomy than those of organised religion and deontological codes.13 This process is ongoing and resolution will not come easily. Society's energy should be more focused on palliative care, about which we can nearly all agree, and where modest investments have yielded excellent results for patients and families by improving care and decision-making at the end of life. There is much still to do. Euthanasia should be narrowly defined as "the deliberate action to terminate life by someone other than, and at the request of, the patient concerned",14 which is the matter at stake in the on-going societal debate. The Australian public need to have complete confidence that there is a safe and morally sound body of modern palliative care practice which is clearly and unambiguously distinguished from euthanasia. Palliative care practitioners are confident to give this re assurance. Michael Ashby Professor of Palliative Care, Monash University, Melbourne, VIC. van der Maas PJ, van Delden JJM, Pijnenborg L, Looman CWN. Euthanasia and other medical decisions conerning the end of life. Lancet 1991; 338: 669-674. Pijneneborg L, van Delden JM, Karduan WPF, et al. Nationwide study of decisions concerning the end of life in general practice in the Netherlands. BMJ 1994; 309: 1209-1212. van der Maas PJ, van der Waal G, Haverkate I, et al. Euthanasia, physician-assisted suicide, and other practices involving the end of life in the Netherlands, 1990-1995. N Engl J Med 1996; 335: 1699-1705. van der Maas PJ, van Delden JJM, Pijnenborg L. Euthanasia and other medical decisions at the end of life. Amsterdam: Elsevier, 1992. Ashby M. Hard cases, causation and care of the dying. J Law Med 1995; 3: 152-160. Reidenberg MM. Barriers to controlling pain in patients with cancer. Lancet 1996; 347: 1278. Keyserlingk EW. Assisted suicide, causality and the Supreme Court of Canada. McGill Law J 1994; 39: 708-718. Consent to Medical Treatment and Palliative Care Act 1995 (South Australia). Division 2 -- the care of people who are dying. Pijneneborg L, van der Maas PJ, van Delden JJM, Looman CWN. Life terminating acts without explicit request of patient. Lancet 1993; 341: 1196-1199. Bruera E, Miller L, McCallion J, et al. Cognitive failure in patients with terminal cancer: a prospective study. J Pain Symptom Manage 1992; 7: 192-195. Waddell C, Clarnette RM, Smith M, et al. Treatment decision-making at the end of life: a survey of Australian doctors' attitudes towards patients' wishes and euthanasia. Med J Aust 1996; 165: 540-544. Pellegrino ED. The limitation of empirical research in ethics. J Clin Ethics 1995; 6: 161-162. Somerville M. "Death talk in Canada: the Rodriguez case". McGill Law J 1994; 39: 602-617. Australian Association for Hospice and Palliative Care. Voluntary Active Euthanasia -- Position Statement, 27th October 1995. Perth: The Association, 1995. To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Michael Ashby

A cruel and unusual punishment Sentencing prisoners to hepatitis infection as well as to loss of liberty is a violation of human rights MJA 1997; 166: 116 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - ©MJA1997 Prison authorities and governments must realise that the responsibility for the infection of a prisoner with a bloodborne virus, because means for prevention were not available within the prison, rests with them. We justify depriving people of their liberty for transgressing social norms on the grounds of protecting society or rehabilitating the person. However, in the case of illicit drug use, there is little evidence that either of these objectives is achieved by current approaches. Imprisonment exposes injecting drug users to greater risks of infection with bloodborne viruses (such as hepatitis B and C) than in the community. About half of all injecting drug users have histories of imprisonment; about half of all prisoners have histories of injecting drug use; and about half of all imprisoned injecting drug users inject drugs in prison.1 Infection with hepatitis C virus (HCV) is common among Australian injecting drug users and prisoners. Butler and colleagues' study of prisoners entering the New South Wales correctional system (in this issue of the Journal) showed that almost a third were seropositive for HCV, rising to two-thirds of those with a history of injecting drug use. HCV infection was significantly associated with a history of previous imprisonment, which accords with the results of other studies.2 Similarly, surveys of Australian injecting drug users find that histories of incarceration are among the strongest associations with HCV seropositivity. 3 A major survey of prison entrants in Victoria found high incidences of infection with both HCV and hepatitis B virus (HBV) among returning prison entrants -- 41 per 100 person-years among young male injecting drug users.4 While these data do not prove that infections are acquired in prison, the prison environment makes spread of blood-borne viruses more likely. The boredom, frustration and hopelessness felt by many prisoners potentially contribute to drug use. Many prisoners have no investment in the future, which will probably contain little except unemployment, further drug use and further imprisonment -- 64% of prison entrants in Victoria have been imprisoned previously. 5 They may believe they have nothing to lose (and some escape to gain) from drug use. In addition, prison policies may aggravate the problem of disease transmission. For example, sharing of injecting equipment is much more common in prison (where equipment is very scarce) than outside (where it is relatively freely available). 1 Efforts to detect drug use, such as urine screening, may drive prisoners from smoking marijuana (which has metabolites that can be detected in the urine for many days) to injecting heroin and amphetamines (which are rapidly cleared from the body). Prison practices may also prevent prisoners taking precautions against spread of bloodborne viruses. For example, despite official policy, urine screening is alleged by prisoners to be anything but random; in some prisons, prisoners claim that a request for bleach (for disinfecting injecting equipment) is followed the next day by a urine test. 6 Sanctions against drug use, such as loss of contact visits as punishment for a "dirty" urine, simply reinforce the original reasons for drug use. 6 Prisons take people from diverse settings who would not otherwise meet, create the opportunity to spread bloodborne viruses among them and then send them back to their original social networks as potential sources of infection. The situation varies for different bloodborne viruses. Despite the opportunities for transmission by injecting drug use, there has been very little transmission of HIV in Australian prisons. 7 However, this is not because conditions are not right for such transmission. It is because there is very little HIV among prison entrants as a result of harm reduction programs in the general community -- fewer than 5% of Australian injecting drug users were seropositive for HIV. 4 The recognition that reducing the spread of HIV is a more urgent priority than eradicating drug use (were the latter possible) has allowed our national AIDS and drug strategies to adopt such harm-reduction approaches (e.g., needle and syringe exchange and methadone maintenance programs). On the other hand, HCV is causing an epidemic among Australian injecting drug users that will be difficult to control. 2 Prisons are a key to this control; without rational approaches to the twin problems of injecting drug use and of HCV transmission in prisons, the epidemic will continue. The first step should be the recognition that incarceration offers nothing but ill to most injecting drug users. Alternative approaches to their problems will benefit both them and society. A serious reconsideration of the opportunities for spread of bloodborne viruses in prisons is the next step. Measures should include everything from lowering the cost to prisoners of razors and toothbrushes (so they will not share them), to provision of sterile injecting and tattooing equipment, peer education programs, transition programs to assist movement back to society (including referral to needle exchanges), proper drug substitution and drug treatment programs and hepatitis B vaccination. 8 It cannot be said often enough that the punishment is deprivation of liberty, and that is all. Prisoners should have available to them all the means for protecting themselves against infection with bloodborne viruses that are available outside prison, without qualification. Prison authorities and governments must realise that the responsibility for the infection of a prisoner with a bloodborne virus, because means for prevention were not available within the prison, rests with them. Nick Crofts Head, Epidemiology and Social Research, The Macfarlane Burnet Centre for Medical Research, Melbourne, VIC. Crofts N, Webb-Pullman J, Dolan K. An analysis of trends over time in social and behavioural factors related to the transmission of HIV among injecting drug users and prison inmates. Evaluation of the National HIV/AIDS Strategy 1993-94 to 1995-96, Technical Appendix 4. Canberra: AGPS, 1996. Crofts N, Stewart T, Hearne P, et al. Spread of blood-borne viruses among Australian prison entrants. BMJ 1995; 310: 285-288. Crofts N, Jolley D, Kaldor J, et al. The epidemiology of hepatitis C virus infection among Australian injecting drug users. J Epidemiol Community Health. In press. Kaldor JM, Elford J, Wodak A, et al. HIV prevalence among IDUs in Australia: a methodological review. Drug Alcohol Rev 1993; 12: 175-184. Victorian Correctional Services Annual Prison Census, 1995. Melbourne: Department of Justice, 1996. Crofts N, Thompson S, Wale E, Hernberger F. Risk behaviours for blood-borne viruses in a Victorian prison. Aust N Z J Criminol 1996; 29: 20-28. Dolan K, Hall W, Wodak A, Gaughwin M. Evidence of HIV transmission in an Australian prison [letter]. Med J Aust 1994; 160: 734. Dolan K, Wodak A, Penny R. AIDS behind bars. AIDS 1995; 9: 825-832. - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Nick Crofts

The agony of "ecstasy" How can we avoid more "ecstasy"-related deaths? MJA 1997; 166: 117 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - ©MJA1997 "Ecstasy" (MDMA; 3,4-methylenedioxymethamphetamine) was developed by E Merck in 1914 as an appetite suppressant, but was never used clinically for that purpose. In the 1970s, it was used as an adjunct in psychotherapy, principally in the United States, but was banned in that country from 1985 because of its toxicity and potential for abuse.1 Over the past decade, the recreational use of MDMA has increased substantially, both in Australia and elsewhere.2 This use has been associated particularly with "dance parties" and "raves" and has recently captured public attention because of deaths from acute MDMA toxicity. it is currently impossible to predict which users will be most liable to experience toxic effects MDMA has a range of effects that can lead to acute toxic reactions, including hyperthermia, raised blood pressure, raised heart rate, cardiac arrhythmias and coagulopathy.3 Hypertension may lead in turn to stroke, and hyperthermia to rhabdomyolysis, dehydration and renal failure. These effects appear to be caused by the action of MDMA on serotonergic and dopaminergic systems, resulting in increased release of neurotransmitters.4 This may explain the overlap of signs and symptoms of MDMA toxicity with those of the serotonin syndrome.5 Chronic toxicity has also been reported in animal models, with lesions of serotonergic neurons in the central nervous system after a few doses of MDMA. In primates, recovery of such lesions is slow and possibly incomplete.6 It is not known whether such toxicity occurs in humans. Some of the metabolites of MDMA (e.g., methylenedioxyamphetamine and dihydroxymethamphetamine) may contribute to the toxicity of the drug.7,8 While certainly the best-known derivative of amphetamine, MDMA is only one of a range that have been used illicitly. Numerous other amphetamine analogues have appeared since the 1960s, either as recreational drugs in their own right, or as contaminants in illicit drug samples. Their popularity and availability have varied. Paramethoxyamphetamine (PMA) is one analogue of current importance in Australia. Ingestion of PMA, either alone or combined with MDMA, has resulted in several "ecstasy" deaths in this country over the last two years. It appears that in most of these cases, the drug users thought they were taking MDMA, but PMA was present as a contaminant. As there is no central collection of information on drug overdoses in Australia, it is difficult to determine accurately the number of ecstasy-related deaths. There have been about 12 such deaths in Australia over the last two years, with at least six of these involving PMA, either alone or combined with MDMA (Dr R James, Senior Forensic Pathologist, South Australian Forensic Science Centre, Adelaide, SA, personal communication). There is no published information on the number of individuals who required hospital admission or suffered non-fatal serious consequences from MDMA-PMA ingestion. It is important to recognise that the number of deaths related to MDMA is relatively small compared with the likely frequency of its use. Deaths from heroin overdoses are certainly a much more significant problem in Australian society; 152 heroin-overdose deaths were identified in NSW in 1992.9 Nevertheless, MDMA deaths are particularly puzzling as they are unpredictable. In some cases, other people appear to have taken similar quantities of ecstasy from the same source as the overdose victim, with only minor toxic effects. One theory is that variations in metabolism of the drug caused by genetic differences or concurrent use of other drugs may result in differential susceptibility to MDMA overdose.10 The causes of death after MDMA ingestion are not well documented. Certainly, hyperthermia and its consequences seem to be of major importance, and results of animal studies suggest that environmental temperature may be a critical determinant of susceptibility.11 This is the basis for recommendations about access to cool environments in nightclubs and other dance venues. However, the case reported by Parr and colleagues in this issue of the Journal suggests something different -- excessive consumption of fluids was the cause of death. Similar conclusions have been reached in cases of apparent MDMA toxicity in the United Kingdom. 12 The reason for such excessive fluid consumption is not understood, although MDMA is known to induce thirst. 13 In addition, high doses of amphetamine and amphetamine derivatives induce repetitive behaviours in animals and humans. 14 It is possible that the combination of thirst and repetitive behaviour patterns leads to excessive fluid intake. If urine output is also low, because of dehydration, impending renal failure and (possibly) other unidentified causes, then there is considerable potential for fluid overload and its consequences. What is the appropriate action to reduce further deaths from MDMA? Firstly, guidelines for its use should be considered. These should include recommendations on provision of suitable environments at venues where the drug is likely to be taken (e.g., adequate ventilation and access to "cooling-off" areas). Other guidelines need to address educating users about appropriate fluid intake, the dangers of combining ecstasy with other drugs (both illicit and prescribed), and the warning signs of toxicity. The latter are particularly important, as obvious signs of acute toxicity have been ignored in several cases, possibly through ignorance or concern about risk of arrest for possession of an illegal substance. The preparation of such guidelines is currently under way in Australia. A report on the toxic effects of MDMA 15 has been published by the Commonwealth Department of Health and Family Services, to form the basis for guidelines to be prepared by the individual States and Territories. We also need to know what drugs are available in the illicit market and the toxicity of each. The magnitude of the problem can be accurately assessed only if there is a national coordinating body to collate information from each of the State and Territory jurisdictions. In addition, while relatively little is known about MDMA, even less is known about PMA, and both drugs should be the subject of further research. Differences in individual susceptibility to MDMA-induced acute toxicity must also be addressed, as it is currently impossible to predict which users will be most liable to experience such effects. Jason M White Senior Lecturer, Department of Clinical and Experimental Pharmacology, University of Adelaide, Adelaide, SA Felix Bochner Professor of Clinical Pharmacology, University of Adelaide, and Head of Clinical Pharmacology, Royal Adelaide Hospital, SA Rodney J Irvine Research Fellow, Department of Clinical and Experimental Pharmacology, University of Adelaide, Adelaide, SA Steele TD, McCann UD, Ricaurte GA. 3,4-Methylenedioxymethamphetamine (MDMA, "Ecstasy"): pharmacology and toxicology in animals and humans. Addiction 1994; 89: 539-551. Solowij N, Hall W, Lee N. Recreational MDMA use in Sydney: a profile of ecstasy users and their experiences with the drug. Br J Addiction 1992; 87: 1161-1172. Henry JA, Jeffreys KJ, Dawling S. Toxicity and deaths from 3,4 methylenedioxymethamphetamine ("ecstasy"). Lancet 1992; 340: 284-287. McKenna DJ, Peroutka SJ. Neurochemistry and neurotoxicity of 3,4-methylenedioxymethamphetamine (MDMA; "Ecstasy"). J Neurochem 1990; 54: 14-22. Nierenberg DW, Semprebon M. The central nervous system serotonin syndrome. Clin Pharmacol Ther 1993; 53: 84-88. Ricaurte GA, Martello AL, Katz JL, Martello MB. Lasting effects of (+)-3,4-methylenedioxymethamphetamine (MDMA) on central serotonergic neurons in nonhuman primates: neurochemical observations. J Pharmacol Exp Ther 1992; 261: 616-622. Harvey JA, McMaster SE, Romano AG. Methylenedioxyamphetamine: neurotoxic effects on serotonergic projections to brainstem nuclei in the rat. Brain Res 1993; 619: 1-14. Hiramatsu M, Kumagai Y, Unger SE, Cho AK. Metabolism of methylenedioxymethamphetamine: formation of dihydroxymethamphetamine and a quinone identified as its glutathione adduct. J Pharmacol Exp Ther 1990; 254: 521-527. Zador D, Sunjic S, Darke S. Heroin-related deaths in New South Wales, 1992: toxicological findings and circumstances. Med J Aust 1996; 164: 204-207. Tucker GT, Lennard MS, Ellis SW et al. The demethylenation of methylenedioxymethamphetamine ("ecstasy") by debrisoquine hydroxylase (CYP2D6). Biochem Pharmacol 1994; 47: 1151-1156. Gordon CJ, Watkinson WP, O'Callaghan JP, Miller DB. Effects of 3,4-methylenedioxymethamphetamine on autonomic thermoregulatory responses of the rat. Pharmacol Biochem Behav 1991; 38: 339-344. Matthai SM, Davidson DC, Sills JA, Alexandrou D. Cerebral oedema after ingestion of MDMA ("ecstasy") and unrestricted intake of water. BMJ 1996; 312: 1359. Greer G, Tolbert R. Subjective reports of the effects of MDMA in a clinical setting. J Psychoactive Drugs 1986; 18: 319-327. Ellinwood EH, Lee TH. Dose- and time-dependent effects of stimulants. In: Asghar K, De Souza E, editors. Pharmacology and toxicology of amphetamine and related designer drugs. National Institute on Drug Abuse Research Monograph Series. Rockville, MD: US Department of Health and Human Services, 1989. White JM, Irvine RJ, Bochner F. Toxic effects of MDMA. Canberra: Commonwealth Department of Health and Family Services, 1996. - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Jason M White · Felix Bochner · Rodney J Irvine

A recent study has provided evidence that testosterone increases muscle strength, but does this translate to enhanced performance? Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia". strength increased considerably in subjects who received placebo, but who were told they were receiving anabolic steroids For almost half a century, athletes have believed that use of anabolic-androgenic steroids can improve sporting performance. The United States physician John Zeigler was so convinced of their positive effects that on his return from the World Powerlifting Championships in Vienna in 1954 he worked on the development of methandrostenolone as a means of enhancing sporting performance. 1 This belief has persisted, leading to the widespread and much-publicised use of these drugs at all levels of sport (professional and amateur). It has been promoted by the banning of these drugs by sporting bodies to ensure fair competition. 2 Media reports and "underground" guides to anabolic steroids have also propagated the use of anabolic-androgenic steroids, which has spread from elite athletes to recreational bodybuilders, amateur athletes and adolescents. 3 Are the athletes and their coaches mistaken in their belief? Theoretically, anabolic-androgenic steroids should improve athletic performance by increasing muscle mass (via increased protein synthesis, nitrogen retention and antiglucocorticoid actions), as well as by increasing aggression and motivation. Moreover, recent isotope uptake studies in humans indicate that androgens may increase muscle protein synthesis, possibly through stimulation of intramuscular insulin-like growth factor-I (IGF-I) gene expression. 4 However, clinical studies have, in general, been inconclusive, partly because of the many unique methodological problems in studying the effects of anabolic-androgenic steroids (see below). In 1991, 16 randomised, placebo-controlled studies that used objective measures of performance were analysed by Elashoff et al. 5 They concluded that, while the possibility of anabolic-androgenic steroids improving sporting performance could not be excluded, "the data are insufficient to allow any firm conclusion about the efficacy of anabolic steroids in enhancing overall athletic performance". Since then, apart from a non-placebo-controlled study that showed an increase in lean body mass in healthy male volunteers receiving weekly injections of testosterone enanthate, 6 there were few real developments in the area until Bhasin et al. 7 published their study in July 1996. This study will probably become, in time, one of the most-cited articles on drugs and sport. Funded by the National Institutes of Health (US), the study examined the effect of high doses of testosterone enanthate in sesame oil (600 mg/week intramuscularly for 10 weeks); the authors made every attempt to remove confounding variables (such as diet, training, and weightlifting experience), and used standardised measures. Forty-three experienced weightlifters were randomly assigned to one of four groups (placebo with or without exercise, or testosterone with or without exercise). Strength was measured by two single weightlifts -- upper-body strength by benchpress, and lower-body strength by squatting. Fat-free body mass was measured by underwater weighing, and muscle size by magnetic resonance imaging. Forty subjects completed the study. Body weight increased only in the two testosterone-treated groups, and fat-free body mass only in the exercise groups, with the greatest change in fat-free mass in the testosterone plus exercise group (increase, 6.1 kg). Percentage body fat did not change in any group. Muscle size increased more in the testosterone groups than in either placebo group. Strength increased in both testosterone groups, as well as in the exercise group receiving placebo, but was greater in the exercise group with testosterone than in the exercise group with placebo. No significant adverse drug reactions were reported. Hence, for the first time, in a well designed study, supraphysiological testosterone did appear to increase muscle strength. One other placebo-controlled study has used higher doses of anabolic steroids (methandrostenolone, 100 mg/day for six weeks). 8 Reported 20 years ago, it used a crossover design, with attempts to control for most variables. The active drug was found to be no better than placebo in increasing strength. However, some caveats should be considered in assessing Bhasin et al.'s data. A placebo response has not been completely eliminated. It was not stated that the placebo was identical to the active drug in terms of pH, viscosity and other factors that may have allowed the code to be broken by either the administrator or recipient of the drug. Indeed, in a controlled study of oral anabolic steroids, all subjects correctly identified the active drug when directly asked. 9 The importance of the placebo response was shown by Ariel and Saville, who found that strength increased considerably in subjects who received placebo, but who were told they were receiving anabolic steroids. 10 Bhasin et al.'s subjects were experienced weightlifters. Although they reported that they had not taken anabolic steroids, these medications are illicit, and thus self-reporting may not be reliable. As 38%-58% of bodybuilders and weightlifters have been reported to use anabolic steroids, 11,12 some of Bhasin et al.'s subjects may well have been able to identify the active drug. Before generalising these results to athletes who use anabolic-androgenic steroids in the community, it should be remembered that they receive and use their supplies in very different ways to the controlled circumstances of Bhasin et al.'s study. Street supplies are often veterinary or illegally manufactured preparations, often combined with other medications such as diuretics and stimulants. Doses and duration are often well in excess of those used in this study. Although no major side effects were reported, the well documented long-term adverse effects of anabolic-androgenic steroids on cardiovascular risk, gynaecomastia, carcinogenesis, prostate and sexual function would not have been evident in a study of this duration. 13 On considering the available evidence, it appears that anabolic steroids definitely increase muscle size, and probably strength, but the mechanism is unknown. Further studies, using a crossover design, including inexperienced as well as experienced weightlifters, and the same drug vehicle for both placebo and active drug, with confirmation of subject blinding, should probably be conducted to confirm these findings. In addition, whether androgen-induced muscle hypertrophy translates into improved performance in sports that require skill as well as strength remains to be determined. But such studies should not overshadow the need for significant research into the prevention of anabolic-androgenic steroid abuse. Michael C Kennedy Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital; and Manly Hospital, Sydney, NSW. Anthony J O'Sullivan Departments of Medicine and Endocrinology, St George Hospital, Sydney, NSW. Wade N. Anabolic steroids: Doctors denounce them, but athletes aren't listening. Science 1972; 176: 1399-1403. Skolnick AA. Tougher drug tests for Centennial Olympic Games. JAMA 1996; 275: 348-349. Buckley WE, Yesalis CE, Friedl KE, et al. Estimated prevalence of anabolic steroid use among male high school seniors. JAMA 1988; 260: 3441-3445. Urban RJ, Bodenburg YH, Gilkison C, et al. Testosterone administration to elderly men increases skeletal muscle strength and protein synthesis. Am J Physiol 1995; 269: E820-E826. Elashoff JD, Jacknow AD, Shain SG, Braunstein GD. Effects of anabolic-androgenic steroids on muscular strength. Ann Int Med 1991; 115: 387-393. Forbes GB, Porta CR, Herr BE, Griggs RC. Sequence of changes in body composition induced by testosterone and reversal of changes after drug is stopped. JAMA 1992; 267: 397-399. Bhasin S, Storer TW, Berman N, et al. The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men. N Engl J Med 1996; 335: 1-7. Hervey GR, Hutchinson I, Knibbs AV, et al. "Anabolic" effects of methandienone in men undergoing athletic training. Lancet 1976; 2: 699-702. Freed DLJ, Banks AJ, Longson D, Burley DM. Anabolic steroids in athletics: crossover double-blind trial on weightlifters. BMJ 1975; 2: 471-473. Ariel G, Saville W. Anabolic steroids: the physiological effects of placebos. Med Sci Sports 1972; 4: 124-126. Perry HM, Wright D, Littlepage BNC. Dying to be big: a review of anabolic steroid use. Br J Sports Med 1992; 26: 259-261. Delbeke FT, Desmet N, Debackere M. The abuse of doping agents in competing body builders in Flanders (1988-1993). Int J Sports Med 1995; 16: 66-70. Kennedy MC. Anabolic steroid abuse and toxicology. Aust N Z J Med 1992; 22: 374-381. Reprints: Dr M C Kennedy, Manly Non-Invasive Cardiac Laboratory, Level 4, 22 Darley Road, Manly, NSW 2095.

Michael C Kennedy · Anthony J O'Sullivan

Medical women and men are struggling with the problems of outdated work structures and geographic maldistribution Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia". - ©MJA1996 Recent Australian medical workforce data indicate dramatic changes in the structure and culture of medicine in this country. Women now comprise some 47% of general practitioners under 35 years of age; 1 men are working fewer hours and retiring earlier; 2 and the proportion of women doctors in the medical workforce is forecast to increase by 12% from the present level by the year 2025. 3 Reports, such as that of the (then) Department of Human Services and Health, 4 usually emphasise the particular needs of women doctors, including family responsibilities, child care and spousal career needs. Such conclusions imply that women alone have family responsibilities and ignore the reality that men, too, are making adjustments in these areas. Women have made huge efforts to accommodate work structures that were designed for male workers with invisible domestic support The influx of women into all areas of paid professional work has brought about a cultural revolution, one that challenges the traditionally invisible personal life of the worker. "He" is no longer regarded, implicitly, as a sexless, childless, work-driven automaton. Except perhaps in medicine, where expectations persist that "dedicated" doctors will be infinitely available to their patients and immune to fatigue. Consequently, exhausted and demoralised young doctors -- both men and women -- are retreating from oppressive hospital posts. 5 Changes are needed, including the provision of options -- available to both men and women -- such as job-sharing and permanent part-time work. 3 The challenge in the future may be to match the community's needs with working patterns for health professionals that are closer to reasonable working patterns in the general community. For all doctors to work around 40 hours per week (and why shouldn't we?) would require an increase in the medical workforce of about 15%. 3 But Government policy is moving in the opposite direction (e.g., the restrictions on provider numbers aimed at limiting new graduates from private medical practice). Indeed, a two-tiered system may be evolving, with a predominantly young and female "cottage industry" 5 of general practitioners -- supplemented by (chiefly female) paramedicals -- functioning as "gate-keepers", 2 referring patients to the male-dominated, high-technology (high-prestige, high-income) medical specialties. Women comprise only 12% of all private specialists. 1 They are best represented in dermatology (29%), psychiatry (24%), radiology (19%), pathology (17%) and anaesthetics (16%). 1 (Figures vary somewhat according to source [e.g., those of the Australian Institute of Health and Welfare are slightly different]. 6 ) These career choices may reflect the attraction of more flexible working hours in these specialties, but they may also reflect structural constraints, such as resistance to women doctors in other fields, rather than female predilections. The fact that surgery remains 96% male, 1 while anaesthetics has a relatively high female representation, suggests that Colleges play a significant role in facilitating (or impeding) the participation of women. Both surgery and anaesthetics are more technical than relational -- perhaps one training program is more "woman-friendly" than the other? The same question might be asked about training in obstetrics and gynaecology. Women represent only 11% of this specialty in Australia, 3 whereas they comprise 70% in France. 7 Structural impediments to the progress of women, such as the lack of part-time or job-sharing posts and inadequate mentorship of women trainees, must also be significant in hospitals and in academic institutions; in both these arenas the increasing influx of women (35% of all hospital doctors and 50% of all medical undergraduates) is not reflected in a corresponding "upward mobility". Mostly, the findings of the various reports available come as no surprise and accord very much with my personal experience of women in medicine and psychiatry. 8 One notable exception is the data on retirement. Based on the 1991 Census figures of the Australian Bureau of Statistics, it appears that, beyond the age of 65, half of male doctors continue to work, compared with a quarter of female doctors. 2 For me (born in 1943), these figures were counterintuitive, and a quick "straw poll" of my peers brought forth responses similar to mine. No-one in good health was thinking of retiring. The only sense I can make of these data is that they refer to an earlier generation (born in or before 1926 [i.e., those aged 65 or over in 1991]) that differs from subsequent generations. These early-retiring older women are likely to have had a more traditional type of marriage, an older husband and more children. They may feel obliged to retire when their (older) husbands do, rather than (as my peers seem to) regard the postchild phase of life as a new opportunity for increased career activity. My guess would be that the retirement age for later cohorts of older women will not differ so dramatically from that of their male peers, given the economic imperative for two incomes, as well as the rising divorce rates, which will result in more women doctors who are sole parents. Women have made huge efforts to accommodate work structures that were designed for male workers with invisible domestic support. Male doctors are beginning to make lifestyle changes too, perhaps to accommodate family needs. Work structures must be redesigned to accommodate these changes. The result will be a medical workforce that is more expensive, but less exhausted. Without this redesigning, a two-tiered and gender-stratified system of general practitioners and specialists may develop. However, neither of these scenarios deals with what most reports identify as the single most resistant medical workforce problem: geographic maldistribution. 2,3,9 The poor supply of doctors outside metropolitan areas is a major political issue. While even fewer women doctors than men may be willing to accept a rural placement (with women comprising only 12.7% of rural general practitioners, compared with 27% of metropolitan general practitioners 3 ), the issues involved are common to both. Neither women nor men are keen to work the longer hours of rural practice, where they must offer more complex medical services and practise without the support of colleagues, but where, as general practitioners, they gain no more overall remuneration than they would in the city. The professional needs of spouses pose another problem with rural placements. Both women and men may have spouses to consider, and this problem seems to impact more upon women doctors than on their male counterparts -- accommodating to spousal career needs is reported to be a significant restraint for women. 4 "Conscription" is not a pleasant word, and neither women nor men practitioners are likely to welcome moves in that direction, but the new policy of regulating provider numbers, if successfully implemented, seems likely to usher in just such a system. The desirability, indeed the necessity, for doctors to be granted the same privileges as those that exist in the workforce as a whole should not be construed as a gender issue. A 40-hour week and reasonable allowances for family needs and obligations are the entitlements of all workers -- they do not reflect the "special needs" of women doctors. Carolyn Quadrio Visiting Fellow, School of Psychiatry, University of New South Wales, Sydney, NSW. Australian Bureau of Statistics, Private Medical Practitioners Survey 1996. Canberra: ABS, 1996. (Australian Medical Association Document 325/1/96.) Conn W. Medical workforce participation: males and females 1981, 1986 and 1991. Labour Force Unit, Australian Institute of Health and Welfare. Canberra: AIHW 1995. Australian medical workforce benchmarks. Australian Medical Workforce Advisory Committee (AMWAC) report 1996. Sydney: AMWAC, 1996. (AMWAC used the statistics of the National Health Labour Force for 1994 6 to arrive at this estimate.) Women in the medical workforce: the changing gender profile and its implications. Canberra: Commonwealth Department of Human Services and Health, State Financing Branch (Discussion paper) December 1995. Douglas RM, Dickinson J, Rosenman S, Milne H. Too many or too few? Medical practice and general practice in Australia. National Centre for Epidemiology and Public Health, Australian National University. Canberra: National Capital Printing, 1991. (Discussion Paper No 5.) Australian Institute of Health and Welfare. Medical labour force 1994. Canberra: AGPS, August 1996. Kincaid-Smith P. Where are the women specialists? Australian Medicine 1995; Aug 21: 10. Quadrio C. Women in Australian and New Zealand Psychiatry: the fat lady sings. Australian and New Zealand Journal of Psychiatry 1991; 25: 95-110. Papers from 1995 Australian Medical Association Medical Workforce 2000 Summit. Canberra: Australian Medical Association, August 25-26, 1995.

Carolyn Quadrio

The euthanasia debate The end of life: We need a humane and informed framework, not only a medical model, to deal with death and dying MJA 1996; 165: 535 Readers may print a single copy for personal use. No further reproduction or distribution of the articles in whole or in part should proceed without the permission of the publisher. For copyright permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - - ©MJA1996 Dealing with death and dying (which includes requests for euthanasia) is an integral part of the practice of medicine. Surveys of health care professionals in Australia and overseas now consistently show that a considerable proportion of them support euthanasia or physician-assisted suicide under certain conditions. 1-4 A minority of health care professionals also admit to having practised euthanasia or physician-assisted suicide. For example, the most recent Australian survey found that one in seven doctors had helped a 0atient to die. 5 Other surveys have reported that 19 per cent of doctors in South Australia 6 and 29 per cent of doctors in Victoria had taken active steps to hasten death in patients with terminal or incurable disease who had requested they do so . 7 In one of the most detailed surveys of the practice of euthanasia in Holland, van der Maas et al. 4 found that in 1.8 per cent of all deaths a lethal drug was administered, at the patient's request, to end life, and in 38 per cent of all deaths doctors had taken medical decisions concerning the end of life that may have shortened the patient's life. van der Maas et al. 4 concluded that medical decisions concerning the end of life were common in medical practice and should be the subject of increased research, teaching, and public debate. Other recent international studies have reported similar findings. 1,2 Surveys of community attitudes also show increasing support for euthanasia and physician-assisted suicide. In 1962 only 47 per cent of Australians, when asked "if a patient in great pain, with no hope of recovery, asks for a lethal dose, should a doctor be allowed to administer one?", replied in the affirmative. In 1996, 76 per cent gave the same response. Correspondingly, the response "not give lethal dose" declined from 39 per cent in 1962 to 17 per cent in 1996. 8 The study by Waddell et al. reported in this issue of the Journal makes a significant contribution to the euthanasia debate in Australia. Unlike most previous Australian studies that elicited doctors' responses to general questions concerning end-of-life treatment decisions, 5,6 this study used real and comprehensive clinical scenarios. Based on a recent Canadian study, 9 Waddell et al. used a questionnaire that presented clinical cases in which the patients' sociodemographic characteristics, mental competence, severity of illness and wishes for treatment varied. (One of these clinical vignettes involved the issue of physician-assisted death requested by a 56-year-old competent man with a debilitating, but not imminently terminal, condition.) The respondents were asked to state what they would do. A major finding was that Australian doctors did not make consistent decisions in the treatment of severely and terminally ill patients. The doctors' decisions were influenced by their medical training and sociodemographic background, and the data suggested that there were no clear criteria to guide doctors in managing these clinical situations. Waddell et al. suggest that the capacity of doctors to treat severely and terminally ill patients in accordance with the patients' wishes may be aided by the informed-consent process, as well as by advance care planning. The study also revealed that only a small minority of doctors would have complied with the wish of the patient for euthanasia. This study again raises questions about medical decisions concerning the end of life -- questions that deserve an informed public debate. Why are most doctors against the legalisation of euthanasia? 3 Are public interests in Australia served by existing medical practices that deal with the dying patient? Several factors may explain the opposition of doctors to euthanasia. First, in general, in modern medicine death is viewed as a failure; hence the reluctance of medical professionals to reinforce this perception by accepting euthanasia and physician-assisted suicide. The response of modern medicine to the complex set of problems surrounding the dying patient is to provide effective and accessible palliative care. Second, the various surveys mentioned earlier suggest that dealing with death and dying is seen as an integral part of the practice of medicine. Doctors would prefer to keep this management within their professional practice to allow them the flexibility to respond to the very complex realities of differing clinical situations, in which decisions must take into account the unique nature of the suffering of the individual patient and the availability of the appropriate medical facilities to care for the patient. The regulation of death and dying through a formal legal process could make it difficult for doctors to respond to the individual needs of the patient and could also subject doctors to unreasonable and extended legal scrutiny. The intrusiveness of legislation into the doctor-patient relationship was alluded to by Brendan Nelson, the former federal President of the Australian Medical Association, when he stated: "We can't reach for a legislative pen every time we have a problem or we see something in life we'd like to regulate. In the end doctors will continue to do what they believe to be right in the interests of the patient and his or her immediate family." Dr Nelson also said that euthanasia should not be legalised, as this could lead to its unethical use. 10 The opposition of doctors to euthanasia and physician-assisted suicide may also be related to their "self-image". As Lickiss 11 points out, putting someone to death will fundamentally change the character of the doctor; and the contribution of doctors to carrying out requests for euthanasia may have profound effects on their image in our society. Doctors see themselves as the bringers of life, hope and healing -- not as the bringers of death. Legalisation of euthanasia also raises a serious moral dilemma for those doctors who may be opposed to it on religious or ethical grounds. The community's unease about the legalisation of euthanasia is related to the concerns of some religious and ethnic groups that, besides violating the ultimate human value -- the sanctity of life -- such legislation may render the less privileged and the poor in the community more vulnerable to unethical practices. However, notwithstanding the concerns of the medical profession and some key groups in society, the debate about the right of an individual to make a decision about his or her own death is not going to disappear. Society will ultimately have to resolve the issue by balancing two central human values: sanctity of life and human dignity. Legislation now before the European Parliament stipulates that human life cannot be reduced to mere biological functions. Is it desirable that, as a civilised society, in our efforts to protect and celebrate the sanctity of life we may have to compromise human dignity? A civilised society must protect, cherish and celebrate both the sanctity of life and human dignity. 3 Society needs an informed and humane framework to deal with death and dying. In Australia, the Northern Territory Rights of the Terminally Ill Act presents an opportunity to assess whether the legalisation of euthanasia may help us to meet this need. Allowing this legislation to function would be consistent with the values of a pluralistic democracy. Riaz Hassan Professor of Sociology, The Flinders University of South Australia, Adelaide, SA Asch DA. The role of critical case nurses in euthanasia and assisted suicide. New Engl J Med 1996; 334: 1374-1379. Emanuel EJ, Fairclough DL, Daniels ER, Clarridge BR. Euthanasia and physician-assisted suicide: attitudes and experience of oncology patients, oncologists, and the public. Lancet 1996; 347: 1805-1810. Hassan R. Euthanasia and the medical profession: an Australian study. Aust J Social Issues 1996; 31: 239-252. van der Maas PJ, van Delden JJM, Pijnenborg L, Looman CWN. Euthanasia and other medical decisions concerning the end of life. Lancet 1991; 338: 669-674. Baume P, O'Malley E. Euthanasia: attitudes and practices of medical practitioners. Med J Aust 1994; 161: 137-144. Stevens C, Hassan R. Management of death, dying and euthanasia: attitudes and practices of medical practitioners in South Australia. J Med Ethics 1994; 20: 41-46. Kuhse H, Singer P. Doctors' practices and attitudes regarding voluntary euthanasia. Med J Aust 1988; 148: 623-627. Walsh K-A . Will to die: Australians expect the freedom to manage their lives -- so why not their deaths? The Bulletin , September 17, 1996. Molloy W, Guyatt GH, Alemayehu E, et al. Factors affecting physicians' decisions on caring for an incompetent elderly patient: an international study. Can Med Assoc J 1991; 145: 947-952. Zinn C. Euthanasia bill divides Australian doctors and MPs [News]. BMJ 1995; 310: 421. Lickiss N. Chapter In: Chapman S, Leeder S, editors. The last right? Australians take sides on the right to die. Melbourne: Mandarin 1995. - - To top of article - ©MJA 1996 <URL: http://www.mja.com.au/> © 1996 Medical Journal of Australia.

Riaz Hassan

Alternative cancer treatments We must let patients know we are on their side and make every effort to ascertain and deliver what it is they seek from treatment MJA 1996; 165: 536 Readers may print a single copy for personal use. No further reproduction or distribution of the articles in whole or in part should proceed without the permission of the publisher. For copyright permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - - ©MJA1996 In this issue of the Journal, Begbie and colleagues show once again the continued attraction of alternative medicine or unproved remedies. In many developed countries, a large proportion of the general public (nearly half over 12 months, according to a recent survey in South Australia 1 ) attend alternative practitioners, use unconventional therapies, or both. It seems not to matter whether the country has a universal health scheme or not; the public is prepared to spend large sums on alternative treatment, as shown in studies from both the United States 2 and the United Kingdom. 3 Several of the surveys have shown that among users of alternative practitioners and alternative remedies there is a bias towards younger, fitter people, towards women and towards the better educated. However, it is not just the healthy who turn to alternatives. As the paper by Begbie and colleagues, and others, 4 shows, among cancer patients the use of alternative therapy is widespread. Why is this so and what can the medical profession learn from this? Some of the attractions of alternative treatments for cancer are perhaps self-evident. When faced with an illness incurable by medical science, patients and their families understandably turn to those who claim that their remedies are effective, "natural" and harmless. Thus, alternative therapies abound not only for cancer but also for conditions such as multiple sclerosis and rheumatoid arthritis. These therapies do, however, come and go. Where now is copper ointment for rheumatoid arthritis? Where now is ozone treatment for HIV? For cancer, where now Krebiozen (a treatment popular in the 1950s), Milan Brych's secret remedy (of the 1970s) and Laetrile (from the 1980s)? Although these have gone, others have replaced them. In Australia, the most popular currently are diets, and psychological measures such as relaxation and meditation. As quoted by Begbie et al., there are "no unproven treatments for universally curable diseases". 5 It might also be relevant that there are few unproven treatments for conditions that can be more readily understood than cancer, such as pneumonia, bone fractures and venous thrombosis. When medical science has an effective treatment, even if it's not a cure, the alternative industry has little to offer. An important message is that the profession should use its available treatments to best advantage. The current trend to "evidence-based medicine" will strengthen our hand, and guide doctors to the most effective treatments. For example, the publications on early breast cancer distributed by the National Breast Cancer Centre 6,7 should provide an effective answer to many patients' questions and may limit their need to seek help from the un qualified. Patients may not necessarily seek a "cure" -- effective symptom relief, using modern palliative care, may fulfil the needs of many. It is also important for medical practitioners to gain patients' confidence so that they do not feel inhibited about discussing alternative treatments. The discussion may reveal that the patient feels pressured into trying some alleged cure by a well-meaning, but ill-informed, friend or relative. Straightforward scientific information about the lack of evidence of the "remedy" in question may be all that the patient is seeking. If the doctor is unfamiliar with the particular treatment, a Cancer Council will provide the information needed. The discussion may reveal that what patients really seek is something that may be as readily available through orthodox channels as the unorthodox. All of the State and Territory Cancer Councils run their own support and self-help groups, or can refer patients to those organised by approved organisations and institutions. Meditation, social support and a sympathetic ear can also be found, if not through the Cancer Councils, then the oncology department of the local hospital should be able to point patients in the appropriate direction. Should we be concerned? That so many patients seek "alternatives" not only indicates certain failings in the services provided by the profession, it actually exposes patients to potential harm. 8-10 Many so-called cancer diets are nutritionally inadequate, the costs may be substantial and "natural" does not necessarily equate to "harmless". Some natural substances that are far from harmless include snake venom, strychnine, toadstools, potato leaves and tobacco. Laetrile and comfrey, previously recommended for the treatment of cancer, carry their own dangers. Some allegedly natural herbal medications conceal their real ingredients. 11 There is also the danger that patients may forgo proven effective treatments for cancer, and their only chance of cure. None of this discussion denies the many shortcomings of orthodox medicine nor the potential dangers of our own prescriptions. Nor does it lessen the need for the scientific study of folk remedies in the hope of finding new effective "natural" treatments to follow, for example, aspirin (from willow bark) or paclitaxel (from the Pacific yew tree). It is important for the public to know that we are on their side. With treatments for cancer, cure is the aim whenever possible, but always and above all else the aims are comfort and relief of suffering. The medical profession must ensure that a wide range of treatments and support services is available to cancer patients. Their needs can best be met by a doctor-patient partnership, by free discussion, and by use of measures of proven effectiveness. Raymond M Lowenthal Director of Medical Oncology, Royal Hobart Hospital, TAS MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of alternative medicine in Australia. Lancet 1996; 347: 569-573. Lerner IJ, Kennedy BJ. The prevalence of questionable methods of cancer treatments in the United States. CA Cancer J Clin 1992; 42: 181-191. Downer SM, Cody MM, McClusky P, el al. Pursuit and practice of complementary therapies by cancer patients receiving conventional treatment. BMJ 1994; 309: 86-89. Sawyer MG, Ganom AF, Toogood IR, et al. The use of alternative therapies by children with cancer. Med J Aust 1994; 160: 320-322. Cassileth BR. The social implications of questionable cancer treatments. CA Cancer J Clin 1989; 39: 311-316. Clinical practice guidelines. The management of early breast cancer. Canberra: National Health and Medical Research Council, 1995. A consumer's guide. Early breast cancer. Canberra: National Health and Medical Research Council, 1995. Lowenthal RM. On eye of newt and bone of shark. The dangers of promoting alternative cancer treatments. Med J Aust 1994; 160: 323-324. Lowenthal RM. Can cancer be cured by meditation and "natural therapy"? A critical review of the book You can conquer cancer by Ian Gawler. Med J Aust 1989; 151: 710-715. Abbot NC, White AR, Ernst E. Complementary medicine. Nature 1996; 381: 361. Bayly GR, Braithwaite RA, Sheehan TMT, et al. Lead poisoning from traditional remedies in the West Midlands -- report of a series of five cases. Human Exp Toxicol 1995; 14: 24-28. - - To top of article - ©MJA 1996 <URL: http://www.mja.com.au/> © 1996 Medical Journal of Australia.

Raymond M Lowenthal

Caring for adolescents with asthma: do we know how to? What is needed now is research based on an understanding of adolescents MJA 1996; 165: 463 Readers may print a single copy for personal use. No further reproduction or distribution of the articles in whole or in part should proceed without the permission of the publisher. For copyright permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - - ©MJA1996 Australian data show that the prevalence of asthma among teenagers is approximately 20%. 1 Estimated conservatively, at least half a million young adolescent Australians aged 10-19 years suffer from asthma. In Australian children the prevalence of asthma has increased substantially in the past three decades, 1,2 but most children with mild asthma do not have asthma in adolescence and adulthood. 3 However, for many, their childhood asthma per sists through adolescence into adult life. 4 Identified risk factors for this persistence of asthma into adult life include female sex, onset after two years of age, more than 10 attacks throughout childhood, lower peak flow rates in childhood, and parental atopy. 3 Personal atopy is also a major determinant of outcome. 2 Objective measurement of the physiological disturbances of asthma are well accepted as part of medical care for acute asthma. In addition, various asthma management plans imply that measurement of airflow obstruction has a role in ongoing interval asthma management. Indeed, in specialist practice this is a routine component of care. In this issue of the Journal, Hewson et al. ( page 469 ) provide firm evidence to support this view in a general practice setting. They found unexpectedly low values for forced expiratory volume in one second (FE V 1 ) and/or forced mid expiratory flow (FEF 25%-75% ), both calculated as a percentage of normal values, in patients in whom clinical and personal assessment had indicated no need to change asthma treatment. This occurred at 30% of assessment opportunities in general practice in adolescents undergoing review or attending for acute exacerbation of asthma. Presumably, had these results been available to their treating doctors, drug therapy would have been altered. That measurement of airflow obstruction by spirometry in general practice has the potential to contribute to fine tuning of asthma therapy is of substantial significance. Ambulatory monitoring of peak flow rate is promoted as assisting in diagnosing asthma, measuring its severity, assessing response to treatment and recognising any deterioration. 5 The limitations of peak flow rate monitoring are also well known, 5 and incidentally highlighted in the article by Hewson et al. While use of a peak flow monitor at home (70% of the study population) may have resulted in patients attending their general practitioner for assessment (reasons for consultation are stated only as acute deterioration or asthma management review), it did not result in appropriate medication change. Just as there are limitations in the testing of peak flow rate, there are also limitations in the use of spirometry. Training in the performance and interpretation of spirometry, as completed by the physiotherapist who performed the tests in the study by Hewson et al., is vital to the achievement of valid and reproducible results. 6 Although measurement of disease severity is an important factor in the management of adolescents with asthma, it is becoming increasingly apparent that assessment of the broad health status of adolescents with asthma is equally important. The evidence is only just emerging that the prevalence of smoking in young people with asthma appears to be the same as their peers without asthma. 7 Adolescence is a critical period for determining future smoking behaviour -- over 90% of adult smokers begin smoking by 19 years 8 -- and achieving an effective early intervention during adolescence has the potential to have an immense impact. Moreover, what is less well understood is that smoking in young people is more than just an exacer bating factor in asthma or a major risk factor for heart d isease and cancer. It is an important symptom of, or marker for, other adolescent health problems. Specifically, symptoms of anxiety and depression are strongly associated with smoking in adolescents, 9 and heavy tobacco use is a feature of concurrent abuse of drugs such as alcohol and marijuana. 10 Monitoring the health status of the adolescent process is of itself an important component in assessing the health status of young people. 11 A young person's development involves physical, cognitive and psychosocial maturation. Medically, we are well trained to assess the physical changes of adolescence, but we receive far less training in other aspects of adolescent maturation. How independent of their parents are these young people? How personally and socially responsible is their behaviour? What are their educational and vocational goals? What activities do they enjoy? In comparison with measuring airflow obstruction by spirometry, a suitable method of measuring adolescent developmental progress is less well defined. Frameworks have been promulgated to assist practitioners to obtain a psycho social history sensitively, 12 but it is only by placing these frameworks into the broader context of adolescent development that we can start to address adolescents' health needs. It is important that this lack of knowledge and competence in adolescent health, well recognised by general practitioners, 13 is redressed by improved training in adolescent medicine. Specific behaviours, such as smoking, or poor adherence to medication regimens or medical review appointments, are important factors because of their detrimental effect on asthma management in adolescents. However, they are also important as potential "beacons of distress". Putting these behaviours into the context of adolescent development can be more helpful in the development of key strategies to improve asthma management than the typical medical "disease-perspective" model. Research in asthma epidemiology has increased our understanding of the extent of asthma, and guided the development of major public health interventions for disease management. What is now needed is research based on an understanding of adolescents themselves. For adolescents with asthma, we need to define more clearly the problems they face as adolescents, not simply the problems they face because they have asthma. For example, research is required to determine the extent and nature of adherence to asthma medication regimens, and to identify young people's understanding of the effect of smoking on asthma. This may then be used to develop strategies that better engage young people in regular medical care and better target smoking. Appropriately, the recent National Asthma Week (6-12 October) targeted asthma and adolescents. We have a good understanding of the management of asthma. What we need now is an accompanying understanding of how best to care for adolescents with asthma. Susan Sawyer Senior Lecturer Glenn Bowes Professor Centre for Adolescent Health, University of Melbourne Royal Children's Hospital, Melbourne, VIC Robertson CF, Heycock E, Bishop J, et al. Prevalence of asthma in Melbourne schoolchildren: changes over 26 years. BMJ 1991; 302: 1116-1118. Peat JK, van den Berg RH, Green WF, et al. Changing prevalence of asthma in Australian children. BMJ 1993; 308: 1600-1604. Jenkins M, Hopper JL, Bowes G, et al. Factors in childhood as predictors of asthma in adult life. BMJ 1994; 309: 90-93. Oswald H, Phelan PD, Lanigan A, et al. Outcome of childhood asthma in mid-adult life. BMJ 1994; 309: 95-96. The Thoracic Society of Australia and New Zealand. Peak flow meter use in asthma management. Med J Aust 1996; 164: 727-730. American Thoracic Society. Pulmonary function laboratory personnel qualifications. Am Rev Respir Dis 1986; 134: 623-624. Wakefield M, Ruffin R, Campbell D, et al. Smoking-related beliefs and behaviour among adults with asthma in a representative sample. Aust N Z J Med 1995; 25: 12-17. Miller SK, Slap GB. Adolescent smoking. A review of prevalence and prevention. J Adolesc Health Care 1989; 10: 129-135. Patton GC, Hibbert M, Rosier MJ, et al. Is smoking associated with depression and anxiety in teenagers? Am J Public Health 1996; 86: 225-230. Patton GC, Hibbert M, Rosier J, et al. Patterns of common drug use in teenagers. Aust J Public Health 1995; 19: 393-399. Blum RW. Transition to adult health care: setting the stage. J Adolesc Health 1995; 17: 3-5. Goldenring JM, Cohen E. Getting into adolescent heads. Contemp Paediat 1988; July: 75-90. Veit FC, Sanci LA, Young DY, Bowes G. Adolescent health care: perspectives of Victorian general practitioners. Med J Aust 1995; 163: 16-18. - - To top of article - ©MJA 1996 <URL: http://www.mja.com.au/> © 1996 Medical Journal of Australia.

Susan Sawyer · Glenn Bowes

Depression, decisions and the desire to die All patients who request withdrawal of non-futile life-sustaining treatment should first undergo psychiatric assessment MJA 1996; 165: 411 Sadness and despair are normal responses to the news that one is gravely ill. However, as many as one in five seriously ill people go beyond this normal response to develop major depression.1-4Major depression is far more than a disorder of emotion; its effects on reason and the intellect may be just as profound. As it takes hold, it steadily infiltrates and infects its victim's every thought. Everything comes to be seen through a veil of despondency and despair. As time passes, sadness turns to emptiness and emptiness turns to pain. Increasingly, there seem fewer and fewer options. Often, toward the end, the patient can see no way out of the blackness and all hope is lost. Ten percent commit suicide. Some seriously ill people, like those with end-stage renal failure or potentially terminal cancer, require medical treatments to continue to live. In Australia, there is a legal right to refuse such treatment. The laws that bestow this right are based upon the principle of maximising autonomy, which asserts that competent adults should be allowed to make their own choices about their own lives, provided these choices do not cause harm to others. This principle assumes that the choices are not influenced by mental illness. However, one would expect that a patient with major depression might be more likely to refuse life-sustaining treatment, because of the cognitive effects of the depression. In this issue of the Journal, Hooper and colleagues (page 416) provide empirical evidence that depression does influence choice about life-sustaining treatment. They asked a cohort of elderly, depressed people to imagine which life-sustaining treatments they would reject in two hypothetical situations. They found that, on average, people rejected more life-sustaining treatments when they were depressed than when they had later recovered. Major depression is eminently treatable. If it can influence the seriously ill to refuse treatment, then some of those who do refuse treatment might be depressed and might change their minds if the depression were treated. Other recent studies have also shown a link between depression and a desire to die. Chochinov et al. found that 47% of terminally ill people who expressed a serious desire for death suffered from major depression.5 Emanuel et al. found that oncology patients who seriously considered and prepared for euthanasia or physician-assisted suicide were significantly more likely to be depressed.6 Taken together, these studies underline the importance of recognising and treating major depression before meeting a request to withdraw life-sustaining treatment. Unfortunately, the diagnosis of major depression in the gravely ill is very difficult. Low spirits are to be expected in serious illness, and many of the other features of major depression (such as weight loss and sleep disturbance) are also common in physical illnesses. The difficulty of diagnosis is reflected in studies that reveal that non-psychiatrically trained doctors miss up to half of cases of major depression in the medically ill.7-9 Life-sustaining treatments are often withdrawn in situations where their continuation would provide no tangible benefit to the patient. The decision to withhold these futile treatments will be based upon many factors besides patient preference. However, when a treatment is not futile, patient refusal is usually central to a decision to stop. A doctor caring for a patient in this situation has a duty to ensure that the refusal is not motivated by a major depression. Given the difficulties of accurate diagnosis, this duty is best fulfilled by asking a psychiatrist to review the patient. Advance directives ("living wills") are documents that allow their users to specify in advance which life-sustaining treatments they would accept if needed in the future. If an advance directive is made while a patient is depressed, it is unlikely to be a valid indication of that patient's future preferences. The same arguments outlined above apply. Advance directives made in the context of a serious illness should only be completed after psychiatric review. Without this review, doctors should be cautious about complying with the directive. The Northern Territory legislation that permits active voluntary euthanasia demands a psychiatric review before a patient can be assisted to die.10,11 This provision was included to provide patients with the best protection against the possibility of meeting a request driven by a treatable depression. Our duty to protect those with a desire to die extends far beyond those who request active euthanasia. Any patient who refuses life-sustaining treatment, and for whom such treatment would not be futile, should receive psychiatric review before that request is met. Christopher J RyanConsultation-Liaison Psychiatrist, Department of Psychiatry, Westmead Hospital, Sydney, NSW Bukberg J, Penman D, Holland JC. Depression in hospitalised cancer patients. Psychosom Med 1984; 46: 199-212. Maj M. Psychiatric aspects of HIV-1 infection and AIDS. Psychol Med 1990; 20: 547-563. Craven JL, Rodin GM, Johnson L, et al. The diagnosis of major depression in renal dialysis patients. Psychosom Med 1987; 49: 482-492. Clarke DM, Minas IH, Stuart GW. The prevalence of psychiatric morbidity in general hospital inpatients. Aust N Z J Psychiatry 1991; 25: 322-329. Chochinov HM, Wilson KG, Enns M, et al. Desire for death in the terminally ill. Am J Psych 1995; 152: 1185-1191. Emanuel EJ, Fairclough DL, Daniels ER, et al. Euthanasia and physician-assisted suicide: attitudes and experiences of oncology patients, oncologists and the public. Lancet 1996; 347: 1805-1810. Feldman E, Mayou R, Hawton K, et al. Psychiatric disorder in medical patients. QJM 1987; 63: 405-412. Nielson C, Williams TA. Depression in ambulatory medical patients: Prevalence by self-report questionnaire and recognition by nonpsychiatric physicians. Arch Gen Psychiatry 1980; 37: 999-1004. Clarke DM, Smith GC. Consultation-liaison psychiatry in general medical units. Aust N Z J Psychiatry 1995; 29: 424-432. Ryan CJ, Kaye M. Euthanasia in Australia. N Engl J Med 1996; 334: 1668-1669. Northern Territory Rights of the Terminally Ill Act. Legislative Assembly of the Northern Territory (Act No. 12 of 1995).

Christoper J Ryan

Teaching resuscitation on the newly deceased: do we want to know? Time for public scrutiny and debate MJA 1996; 165: 412-413 Using the newly deceased for the teaching of resuscitation techniques has been debated in the mainstream journals and medical ethics literature overseas for more than a decade, but in this issue of the Journal (page 445) Ginifer and Kelly bring the subject into the public domain for the first time in Australia. In their survey of selected Australian emergency departments, the practice of teaching resuscitation techniques using the bodies of newly deceased patients was found to be widespread but relatively infrequent. Consent from relatives was rarely obtained, and most emergency departments had no written policies governing this practice. Ginifer and Kelly question the educational need for such experience and raise ethical and legal issues. In considering the need for teaching of resuscitation techniques, it is important to distinguish between minimally invasive procedures such as endotracheal intubation (by far the most commonly practised procedure), central venous cannulation and pericardiocentesis and more extensive procedures such as tracheostomy or emergency thoracotomy. The performance of emergency thoracotomy for any reason in the emergency department is exceedingly rare, typically being undertaken only by surgeons on patients with penetrating chest trauma with profound shock or recently lost vital signs. When it is performed in these circumstances in the hope of restoring life, the procedure is outside the terms of this debate. Endotracheal intubation is a lifesaving procedure. The need for certain clinicians to be skilled in the technique is unequivocal, but at present there is no adequate animal model or manikin that can satisfactorily substitute for training in the skill; it can be gained only on human subjects with typical neck tissue resilience (that is, the newly deceased or patients anaesthetised for surgery). 1 It is self-evident that the former cannot be harmed, while the latter, even with the closest supervision, may potentially suffer from any of the complications of the procedure. It is pertinent to note that the need for clinical training in resuscitation techniques, its benefit to society and the educational value of practice on the newly deceased have not been seriously questioned in the medical literature. However, legal and ethical issues will inevitably arise. If law reports are any guide, this issue is not one of great public, judicial or coronial concern. In Australia, and even in the litigious United States, I have been unable to find a single successful criminal or civil prosecution of a doctor or hospital for permitting or performing a minimally invasive resuscitation technique on a newly deceased person. In Australia, coroners in several jurisdictions have raised no objection to the practice, provided such events are noted in the patient record. In both law and ethics, consent for clinical interventions is central to most arguments. If an advance directive has been made and is known, the situation is clear, but this circumstance is rare. Typically, death has been sudden and unexpected and relatives are often not available for some time. Obtaining consent from relatives is therefore frequently impractical, and indeed it has been suggested that, because of the additional stress and psychological harm that might result, it may be unethical to seek consent to procedures from relatives just confronted with the sudden death of a loved one. The literature provides little guidance in the analysis of this debate, but Bratteb¿ et al. showed, in a random public survey in Norway, that 70% of people would consent to being used for teaching intubation during anaesthesia and 60% would consent to the procedure being performed on a newly deceased relative.2 In this study, only four of 971 respondents considered these practices "unethical". Most other published studies on this subject have reported similar results, but the views of Australian society have never been surveyed and extrapolation of information from other cultures and legal systems may be inappropriate. Our society needs to consider three possible options if it believes that there is a benefit to having doctors skilled in resuscitation. The first is to create a requirement for explicit proxy consent from the next of kin. This would be frequently impractical, might cause psychological distress for some people, and might not represent a true substituted judgement of the deceased. The second option is for the States and Territories to legislate to sanction a range of procedures on the basis of presumed consent. Here, society would be agreeing, through its elected representatives, that the net benefit of the educational practice is significant, and would assume that its members wish to act beneficently in death. At least 15 countries currently have presumed-consent laws. The final option is to maintain the status quo, but with more explicit arrangements. For this option, institutional guidelines and review of practice are mandatory. The public must be assured that the deceased will always be treated with respect and that their known wishes will be followed. The procedures practised on the deceased should be those required to save lives in emergency situations, and should be conducted in a defined educational program by medical or paramedical personnel under specialist supervision. The supervisor should be responsible for the sensitive and appropriate selection of both clinical material and procedure, having regard to such matters as the circumstances of death, any religious considerations, forensic relevance and the voluntarily expressed views of any relatives or staff present. Informed consent from the senior available next of kin should be obtained for any procedure to be performed after the deceased has been removed from the resuscitation area. Proxy consent would not need to be obtained for the performance of minimally invasive procedures undertaken in accordance with institutional guidelines in the immediate postresuscitation period. Also, the supervisor would not need to specifically inform relatives unless directly questioned, but all procedures should be recorded in the patient record, and these should be routinely reviewed for appropriateness as part of clinical audit and quality management processes. Teaching resuscitation on the newly deceased is an important educational tool in medicine, but there are complex social issues involved. It is therefore inappropriate and unnecessary for the practice to be hidden from public scrutiny and debate. It is equally inappropriate for the practice to occur other than in the context of strict institutional guidelines and review. This is a matter which could be addressed by many Australian hospitals immediately. Richard AshbyDirector, Department of Emergency Medicine Royal Brisbane Hospital, Brisbane, QLD Orlowski JP, Kanoli GA, Mehlman MJ. The ethics of using newly dead patients for teaching and practising intubation techniques. N Engl J Med 1988; 319: 439-441. Brattebo G, Wisberg T, Solheim K, Oyen N. Public opinion on different approaches to teaching intubation techniques. BMJ 1993; 307: 1256-1257.

Richard Ashby

Laparoscopic surgery: time for re-evaluation In the era of evidence-based medicine, the time has come for rigorous evaluation of laparoscopic surgery MJA 1996; 165: 355 Readers may print a single copy for personal use. No further reproduction or distribution of the articles in whole or in part should proceed without the permission of the publisher. For copyright permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - - ©MJA1996 The laparoscopic surgical revolution in Australia began in 1989. The aggressive marketing of innovative technology with advanced optics, and a receptive surgical fraternity, ensured that virtually no area of surgery was immune from the laparoscopic onslaught. It was predicted that 80 percent of surgery would be performed laparoscopically, a claim that proved to be optimistic. 1 An eager media reported laparoscopic surgery as quick, painless and safe. Patients asked "Am I having the easy or hard operation?", not "Am I having the safe operation?". With the enthusiastic implementation of the laparoscopic technique by surgeons, reports on personal and institutional series soon appeared, with the superiority of the new technique over open surgery held to be self-evident. The more cautious called for prospective randomised controlled trials comparing open and laparoscopic procedures, but these proved difficult to establish. 1-3 It has been suggested that laparoscopic surgery may be inherently more dangerous than open surgery. 3 It carries the risks of open surgery together with the risks specific to the technique. Injuries to vascular structures and the intestine resulting from the introduction of needles and trochars or from electrical arcing of instruments, while uncommon, are not rare, 4 and CO 2 gas embolus is unique to laparoscopy. Open cannula placement, rather than the blind stab to produce a pneumoperitoneum, 5 and the introduction of trochars under the guidance of various imaging methods, may reduce, but will not eliminate, the risk of injury. The rate of bile duct injury of 0.5% reported by the Health Department of Western Australia audit (1988-1993) of laparoscopic cholecystectomy was two to three times higher than that for open surgery. 6 While this may be dismissed as representing the "learning curve", in such a common operation it cannot be ignored. There have been delays in the diagnosis of both bile duct and intestinal injuries. 4 These injuries can be explained, in part, by the limited field of view, lack of depth perception and off-camera incidents (where an instrument not under vision can cause unrecognised damage) that are characteristic of laparoscopic imaging systems. The delays indicate the need for a high index of suspicion in the postoperative phase and the realisation that repeat laparoscopy to identify complications may be inadequate. 4 In 1996 it is possible to say that some laparoscopic procedures, such as cholecystectomy, have lived up to expectations, in that most patients can be offered a procedure which is safe and allows early discharge and return to normal activity. Reports on laparoscopic fundoplication for the treatment of oesophageal reflux look promising, as the early results appear similar to those achieved by open surgery, but the results of long term studies with adequate numbers are required. Both these procedures reproduce, laparoscopically, the successful open techniques. 7 The results of other procedures, such as laparoscopic inguinal hernia repair, have been mixed. 8 There is still debate about the place of laparoscopic hernia repair, but it may be more expensive than open surgery. The role of laparoscopic surgery in malignancy has yet to be established. Experience with cancer of the gallbladder and the ovary has led to the recommendation that, if they are recognised, open surgery is the appropriate manage ment. 9-11 Early enthusiasm for laparoscopic colon and rectal surgery for malignancy has been tempered by reports of port-site recurrence 12 and early dissemination in apparently curative resections of colon and rectal cancer. 13 The role of laparoscopic surgery in colon and rectal malignancy remains to be defined, but the warning is clear. The importance of trials is demonstrated by the results of a recently reported prospective randomised trial that compared laparoscopic with small-incision cholecystectomy. 14 The strengths of this study were that an adequate number of patients were enrolled, both the patients and their carers were blinded to the operative procedure, and three weeks after the operation the patients were reviewed by a research nurse similarly blinded to the type of operation. No indication of likely length of convalescence was given to patients in either group, and their general practitioners were specifically requested not to take any steps to influence the time they took to return to work. Patients were encouraged to begin full activity as soon as they felt fit enough. (These steps help to remove or reduce the influence of observer bias on patient outcome.) The study showed no difference between the two groups in time to first meal, complications, time to discharge and time to return to work. 14 This finding does not diminish the importance of laparoscopic cholecystectomy and is a victory for minimal-access surgery, whether laparoscopic or open. One benefit of this study may be to encourage early conversion from laparoscopic to open cholecystectomy when difficulties are encountered, in the realisation that the patient will not be significantly dis advantaged. There is, however, a lack of good quality prospective randomised trials. 3 The challenge ahead, as laparoscopic surgery advances, is to evaluate critically the advantages compared with open surgery, and, where appropriate, when compared with minimal-access open surgery. In this context, historical controls are of limited value, as, historically, incision size was not considered to be a critical factor in postoperative morbidity and small-incision surgery was not generally done. 14 Personal audit, which is now a requirement of the Royal Australasian College of Surgeons for recertification, is one way. However, in personal audits problems can be ignored or forgotten. 3 Clinicians must have an accurate picture of trends as new procedures develop so that they are informed and can, in turn, accurately inform their patients. Cost must also be a factor in any study, both in terms of instruments, which, despite their technological sophistication, are increasingly being manufactured as disposable, and operating time, which has a cost. If outcomes are similar, the purchaser (i.e., the patient) will choose the cheapest procedure. The College of Surgeons must become involved in multicentre trials to answer the questions, so that the profession possesses the information to lead the debate rather than have it run by governments or health funds. The prospective randomised trial remains the best method of comparison. Trials such as the proposed Royal Adelaide Multicentre Study comparing open and laparoscopic fundoplication, while difficult and expensive, must be supported. 3 Such studies of laparoscopic surgery are of crucial importance to the quality of patient care and outcome. This is patient-centred research worthy of support. Treacy PJ, Johnson AG. Is the laparoscopic bubble bursting? Lancet 1995; 346 (Suppl): 23. Watson DI, Johnson AG. Randomized trials for laparoscopic surgery. Aust N Z J Surg 1994; 64: 813-814. Edis AJ, Sheiner HJ. Laparoscopic surgery: an ethical dilemma. Aust N Z J Surg 1996; 66: 201. Hayes C, Ambazidis S, Gani JS. Intensive care admissions following laparoscopic surgery: what lessons can be learned. Aust N Z J Surg 1996; 66: 206-209. McMahon AJ, Baxter JN, O'Dwyer PJ. Preventing complications of laparoscopy. Br J Surg 1993; 80: 1593-1594. Hockey RL, Thomson N. Laparoscopic cholecystectomy: morbidity and mortality, Western Australia, 1988-1993. Perth: Health Department of Western Australia, 1995. Jamieson GG. Recent developments in upper gastrointestinal surgery. Aust N Z J Surg 1996; 66: 46-49. MacIntyre IMC, Miles WFA. Critical appraisal and current position of laparoscopic hernia repair. J R Coll Surg Edinb 1995; 40: 331-336. Wibbenmeyer LA, Wade TP, Chen RC, et al. Laparoscopic cholecystectomy can disseminate in-situ carcinoma of the gallbladder. J Am Coll Surg 1995; 181: 504-510. Clair DG, Lautz DB, Brooks DC. Rapid development of umbilical metastases after laparoscopic cholecystectomy for unsuspected gallbladder carcinoma. Surgery 1993; 113: 355-358. Blanc B, D'Ercole C, Nicoloso E. Laparoscopic management of ovarian cysts: a 78-case national survey. Part 2: follow-up and final treatment. Eur J Obstet Gynecol Reprod Biol 1995; 61: 147-150. Wexner SD, Cohen SM. Port site metastases after laparoscopic colorectal surgery for cure of malignancy. Br J Surg 1995; 82: 295-298. Jacquet P, Averbach AM, Jacquet N. Abdominal wall metastasis and peritoneal carcinomatosis after laparoscopic-assisted colectomy for colon cancer. Eur J Surg Oncol 1995; 12: 563-570. Majeed AW, Troy G, Nicholl JP, et al. Randomised prospective single-blind comparison of laparoscopic versus small-incision cholecystectomy. Lancet 1996; 347: 989-994. William R Johnson Senior Surgeon, Alfred Hospital, Melbourne, VIC <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia. We appreciate your comments.

William R Johnson

The new genetics: legal and ethical implications for medicine Community discussion and informed guidelines for medical practitioners are needed MJA 1996; 165: 301-303 Readers may print a single copy for personal use. No further reproduction or distribution of the articles in whole or in part should proceed without the permission of the publisher. For copyright permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - Register to be notified of new articles by email - - ©MJA1996 The achievements and potential of "the new genetics" were recently described as follows: The human genome has now been completely mapped and by the year 2000, virtually all genes will have been isolated and sequenced . . . The technology exists to allow analysis of all persons for mutations causing single gene disorders, probably very early in pregnancy or using IVF . . . [Next] will be predicting risk of multifactorial, common diseases of later life, including cancer. (Professor Bob Williamson, Director of the Murdoch Institute of Research into Birth Defects. The new genetics -- for good or ill , Dean of Medicine's Lecture Series, University of Melbourne, 1996.) These developments have enormous potential for good. About 8000 currently recognised single gene defects 1 afflict at least 1% of the population, more than half with serious consequences. In addition, links have been increasingly recognised between genetic factors and conditions such as cancer and heart disease. Many people are already affected by genetic testing. However, genetic testing raises important legal and ethical issues that must be investigated and resolved expeditiously. Information and consent: General legal principles dictate that genetic testing should be voluntary and based on appropriate information. The High Court of Australia stated in Rogers v Whitaker that a patient is entitled to be informed of "material risks" of a procedure and that a risk is "material" if "a reasonable person in the patient's position . . . would be likely to attach significance to it". 2,3 A patient having a genetic test should obviously be told the purpose and nature of the test, the implications of a positive result and other diagnostic options. As test results may affect other family members, discussion and counselling need to be wider and to include explanations of the information implicit in the family pedigree, as well as who will be told the results and by whom. If information from medical records or genetic test results is needed from relatives (living or dead), permission should be sought, even if tissue is already available for testing. Although there may be no legal requirement, this respects their autonomy and right to privacy. Prenatal screening: Prenatal screening of pregnant women for genetic abnormalities such as Down's syndrome is now routine in Australia. However, there is a chance of both false positives and false negatives and, even if a genetic abnormality exists, there are no tests for severity of impairment. As termination itself is a subject of debate, testing and termination of pregnancy should remain voluntary, and a woman who chooses not to terminate a pregnancy should not be penalised by health or social welfare providers. Confidentiality and access to information: Genetic information may have serious consequences, not only for patients, but also for their families. Although pretest counselling would encourage most patients to share results with their family, some may refuse permission for disclosure. An amendment to the Australian Medical Association Code of Ethics in February 1996 acknowledged that "Exceptions [to the obligation of confidentiality] may arise where the health of others is at risk . . . ". 4 The law also recognises that it may be lawful to breach confidentiality where there is a serious risk to others (note that the law requires the risk to be "serious"). 5 Thus, it is arguable that a doctor who knows a patient carries a harmful genetic mutation would be justified, both ethically and legally, in advising a relative who could take measures to avoid or minimise disease, or who is about to start a family, to undertake testing for the mutation. Indeed, it may be argued that genetic information is "common" to the family, rather than "belonging to" the individual alone, so that a doctor might be justified in always telling family members that the genetic mutation exists in the family (but not that a particular person has, or does not have, the gene). Of course, even people who have been tested may not wish to know the result. For example, many people do not want to know that they will develop a late-onset illness for which there is no treatment, such as Huntington's disease. Both ethics and law support this; patient autonomy entitles people not to know, just as much as to know. Use of genetic information: Life and disability insurers may require that genetic test results be disclosed for risk classification before cover is granted; currently, they do not initiate genetic tests. The Life, Investment and Superannuation Association of Australia states: "Effective underwriting relies upon an assessment of all factors that impact upon the life to be insured." 6 The Association considers that an applicant for insurance who has information that the insurer does not have (such as genetic test results indicating a high risk of premature death) should not be permitted to "anti-select" against the insurer by taking out a very large insurance policy. Denying insurers genetic information could cause a "shift in the risk profile of people taking out insurance". 6 However, others may be concerned that the "genetically handicapped", who are perhaps in most need of disability cover, will find it unobtainable or very expensive. Perhaps, people seeking genetic tests should be warned that they will have to supply results to an insurer if they apply later for insurance; they may be better advised to obtain insurance before rather than after the test. Employers and government agencies, such as the police, may also seek access to genetic information, so it is essential that it be held securely, with strict controls on its potential applications. How to resolve these issues: In Australia, various recommendations have been made 7-12 or are being considered. The Cancer Genetic Ethics Committee of the Australian Cancer Network and the Anti-Cancer Council of Victoria, chaired by Professor Emeritus Richard Lovell, is currently preparing guidelines for genetic testing in relation to cancer. The Australian Research Council has given a three-year grant for research and report on legal issues related to the Human Genome Project, and many conferences have been held on related issues (e.g., Community and the New Genetics, convened by the Human Genetics Society of Australasia in 1995). However, more thought should be given to developing integrated Australia-wide policies and to involving patients and the general community in decision-making. Traditionally, new medical research has been regulated through ethical guidelines prepared by the National Health and Medical Research Council (NHMRC). Although these do not have the force of law, they are generally observed and are flexible, being readily amended in the light of experience and community opinion. The guidelines being prepared by the broadly based Cancer Genetic Ethics Committee, informed by detailed legal and ethical research, could provide the foundation for NHMRC guidelines and community discussion. It is important to get the ethics right first. If legislation is needed on specific topics, it can be developed later. Loane Skene Associate Professor and Director of Studies, Health and Medical Law, Law School, University of Melbourne, Melbourne, VIC. Max Charlesworth Emeritus Professor of Philosophy, Deakin University, Geelong, VIC. On-line Mendelian Inheritance in Man, OMIM (TM). Baltimore (MD): Center for Medical Genetics, Johns Hopkins University, and National Center for Biotechnology Information, National Library of Medicine, 1996 [cited 1996 Aug 5]. OMIM Statistics. World Wide Web URL: http://www3.ncbi.nlm.nih.gov/omim/ Rogers v Whitaker (1995) 109 ALR 625 at 634. Nuffield Council on Bioethics. Genetic screening: ethical issues. London: the Council, 1993. Australian Medical Association. AMA Code of Ethics. Canberra: AMA, 1996. W v Egdell [1990] 1 All England Reports 835. Life, Investment and Superannuation Association of Australia. Draft policy regarding genetic testing. Sydney: LISA, 1996. Medical Research Ethics Committee of the National Health and Medical Research Council. Report to the NHMRC. Ethical aspects of research on human gene therapy. Canberra: AGPS, 1987. National Health and Medical Research Council. Statement on human experimentation. Supplementary Note 7, Somatic cell gene therapy and other forms of experimental introduction of DNA and RNA into human subjects. Canberra: NHMRC, 1982: 21-22. Medical Research Ethics Committee of the National Health and Medical Research Council. Report to the NHMRC. Guidelines for the use of genetic registers in medical research. Canberra: AGPS, 1991. Victorian Law Reform Commission. Genetic manipulation. Melbourne: the Commission, 1988. Report No 26. House of Representatives Standing Committee on Industry, Science and Technology. Genetic manipulation: the threat or the glory? Canberra: AGPS, 1992. Federal Privacy Commissioner. Privacy implications of genetic testing. Exposure Draft 1995. Sydney: Human Rights and Equal Opportunity Commission. 1996 . - Register to be notified of new articles by email - - To top of article - ©MJA1996 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia. We appreciate your comments.

Loane Skene · Max Charlesworth

Urinary incontinence: the Cinderella subject The general practitioner can do much to manage incontinence and to promote continence MJA1996; 165: 124-125. Readers may print a single copy for personal use. No further reproduction or distribution of the articles in whole or in part should proceed without the permission of the publisher. For copyright permission, contact the Australasian Medical Publishing Company Urinary incontinence regularly disrupts the lives of about 5% of home-dwelling adults; 1 it afflicts 3% of children aged 7-12 2 and 27% of adults over the age of 60. 3 Of the 75 000 people in Australian nursing homes, about 50% are "wet". 4 Extrapolation of the prevalence figures in the three overseas studies above 1-3 to the Australian population indicates that more than one million people in this country suffer from urine leakage. In the United States, the use of continence pads costs US$1000 per person every year, as estimated by the US Consensus Conference on Incontinence. 5 Thus, by extrapolation, incontinence, in terms only of the use of continence pads, costs Australians more than one billion dollars (US) each year, not including the costs incurred by nursing home residents (which are poorly documented in this country). It would seem fortunate that this common and costly problem is eminently treatable in the community setting. However, many family doctors have scant knowledge about the different types of incontinence or their underlying causes, and do not understand how to assess or treat the problem. 6 Why is this so? Incontinence is a Cinderella subject. Most doctors now in practice would have received little or no training about the issue in medical school, as much of our knowledge has developed in the last two decades. The condition is not glamorous: on the screen, movie stars might swoon with migraine or collapse with a heart attack; they seldom wet themselves. Nobody dies from incontinence. Patients often do not want to talk about it: history-taking can be time-consuming, examination may be embarrassing, and the temptation to refer to a specialist may be overwhelming. It is a pity that more general practitioners do not do more for their incontinent patients. What is required is a short, focused history to distinguish stress leak from urge leak or obstructive symptoms; this, combined with a simple examination to exclude obstructive prolapse or prostatomegaly, a urine culture and a postvoid ultrasound of residual urine volume, can establish a working diagnosis in most instances. Why should the family doctor be managing such patients? Because many studies have shown that conservative regimens, which are readily administered by community caregivers, are highly efficacious. Bladder-training programs for detrusor instability have success rates of up to 85% of cases. 7 Pelvic floor muscle exercise regimens for stress incontinence are successful in up to 65% of cases. 8 In both detrusor instability and stress incontinence, earlier treatment of less severe symptoms, avoiding the delay often incurred by specialist referral, is very advantageous. Other problems, such as neuropathic or overflow incontinence, may be treated by intermittent clean self-catheterisation, with success in 90% of cases. 9 Such treatment programs should be initiated, at the very first mention of the problem, by general practitioners, working together with community-based specialist nurse continence advisers. Only when these simple measures fail should more sophisticated and invasive tests, such as video- urodynamic studies, cystoscopy, dynamic urethroscopy, transvaginal ultrasound or other "high-tech" methods, be employed to establish a more precise diagnosis. General practitioners are also ideally placed to implement strategies that promote continence. Important risk prevention regimens include avoidance of obesity, correction of constipation, treatment of chronic cough, and administration of topical or systemic oestrogens to women with urogenital atrophy. In the elderly, correction of impaired mobility, maintenance of adequate hydration (together with prevention of bacterial cystitis) and avoidance of a -blocking antihypertensive drugs (such as prazosin) that relax the bladder neck are all helpful in maintaining continence. 10 General practitioners can, and should, contribute in all of these areas. This is particularly important for older patients, because incontinence may precipitate a family's decision to institutionalise an elderly relative. Continence care in Australia, centred on the Continence Foundation of Australia, has made great advances over the last 10 years. Continence advice centres and clinics have been established, and the Foundation's efforts to educate the public and the medical profession about conservative treatment options have made appropriate care more accessible for both young and old. Australia has a relatively high concentration of nurse continence advisers who are skilled in assessing patients. These advisers can also institute appropriate conservative regimens, which are aimed at curing the problem, rather than just recommending pads or appliances. This source of local expertise can be reached through the national office of the Continence Foundation of Australia (phone 03-941-60857) or through the Bladder Helpline (FREECALL [outside Sydney metropolitan area] 1-800-069-789. Within Sydney, call the Continence Promotion Centre, phone 630 0477). Surgical advances have also been made worldwide. A recent meta-analysis of outcomes for stress incontinence surgery showed that colposuspension and sling procedures were significantly more effective than needle suspensions and vaginal repairs. 11 A recent 20-year follow-up of colposuspension showed a 90% success rate at one year and success in 69% of cases in the long term. 12 By contrast, periurethral collagen injections were successful in 48% of cases at two years. 13 The field is still evolving. Outcome data such as these obscure the reality that, for some patients, a minor procedure with a lower success rate may be more acceptable or safer than a major abdominal procedure. For many elderly people, a reduction in the number or severity of incontinence episodes (rather than total cure) may be the desired outcome, as it may enable them to stay at home and maintain their quality of life rather than seek institutional care. Hence the value of conservative treatment. Pharmacological advances have been slow. However, the world standard anticholinergic agent, oxybutynin, was recently approved by the Australian Drug Evaluation Committee for general use in Australian patients with detrusor instability. Also, desmopressin spray is now NHS-listed for refractory nocturnal enuresis in childhood. Aids and appliances schemes have also become more consumer-focused and effective. The federal Continence Aids Assistance Scheme (CAAS) for disabled patients, the federal Program of Aids for Disabled People (PADP) and the Continence Products Discount Service (in Victoria) make these options more accessible and more affordable. But the future of such schemes, from a political perspective, will depend on public awareness of the burden of incontinence. The message is clear. Urinary incontinence is costing the people of Australia a great deal of money. As the population becomes older, the costs will become greater. Despite its Cinderella status, most incontinence can now be significantly ameliorated or cured. Too little is being done, too late, by too few. A major new initiative, funded by a forward-thinking government, is required to increase doctors' treatment skills and awaken public opinion generally if the escalating costs of incontinence are to be curtailed. If not, the problem will need more than a glass slipper to put it right. Richard J Millard Associate Professor of Urology, Prince Henry Hospital, Sydney, NSW Kate H Moore Senior Lecturer, The Pelvic Floor Unit, St George Hospital, Sydney, NSW Thomas TM, Plymat KR, Blannin J, Meade TW. Prevalence of urinary incontinence. BMJ 1980; 281: 1243-1245. Bower WF, Moore KH, Shepherd RB, Adams R. Childhood enuresis in Australia: epidemiology and family attitudes. Br J Urol 1996; 78: in press. Diokno AC, Brock BM, Brown MB, Herzog AR. Prevalence of urinary incontinence and other urological symptoms in the non-institutionalised elderly. J Urol 1986; 136: 1022-1025. Ouslander JG. Urinary incontinence in the nursing home. J Am Geriatr Soc 1990; 38: 289-291. Hu TW. Impact of urinary incontinence on health care costs. J Am Geriatr Soc 1990; 38: 292-295. Brocklehurst JC. Professional and public education about incontinence. The British experience. J Am Geriatr Soc 1990; 38: 384-386. Millard RJ, Oldenburg BF. The symptomatic, urodynamic and psychodynamic results of bladder re-education programs. J Urol 1983; 130: 715-719. Hahn I, Milsom I, Fall M, Ekelund P. Long-term results of pelvic floor training in female stress urinary incontinence. Br J Urol 1993; 72: 421-427. Murray K, Lewis P, Blannin J, Shepherd A. Clean intermittent self-catheterisation in the management of adult lower urinary tract dysfunction. Br J Urol 1984; 56: 379-380. Agency for Health Care Policy and Research. Publication No. 96-0682. Urinary incontinence in adults: acute and chronic management. Rockville, MD: AHCPR, US Department of Health and Human Services, 1996. Jarvis GJ. Review; surgery for genuine stress incontinence. Br J Obstet Gynaecol 1994; 101: 371-374. Alcalay M, Monga A, Stanton SL. Burch colposuspension: a 10- to 20-year follow-up. Br J Obstet Gynaecol 1995; 102: 740-745. Stanton SL, Monga AK, Robinson D. Periurethral collagen for female genuine stress incontinence: results at 2- to 3-year follow-up. Neurourol Urodyn 1994; 13: 449-450. < URL: http://www.mja.com.au/> © 1996 Medical Journal of Australia.

Richard J Millard · Kate H Moore

Ensuring quality in all phases of the pathology cycle Laboratories need to monitor and improve their procedures to ensure that they always deliver the correct test results for the correct patient to the correct doctor MJA1996; 165: 125-126. There is an unfortunate perception that pathology laboratories are only interested in performing tests, whereas, in reality, they are responsible for a cycle of activities which begin before and conclude after the actual testing. These activities include consultation between the clinician and pathologist, accurate identification of the patient and referring doctor, correct collection and storage of the specimen, timely and accurate delivery and readability of the result, and, if necessary, more consultation between the pathologist and the clinician. As a consequence of more than 30 years of the Royal Col lege of Pathologists of Australasia (RCPA) leading the provision of well-organised proficiency testing programs, and the advent of medical (pathology) laboratory accreditation with mandatory National Association of Testing Authorities-RCPA registration in 1986, 1 the quality of analysis in Australian laboratories is as good as, if not better than, that in most developed countries. However, it has been recognised that there are still significant problems with the activities that surround analysis in many laboratories. In this issue of the Journal, Khoury et al. ( page 128 ) present an insight into the extent of the problem. Although there were an equal number of laboratories which compared less than favourably with their peers in each of the analytical and transcription-error aspects of the study, the error rate would appear to be much higher in the latter. While some of the 14 laboratories they looked at had near-perfect records in transcribing patient details, median error rates for various elements of the data were in the order of 3%. One laboratory documented an overall transcription-error rate of nearly 40%. If these findings are extrapolated to all laboratory activity in Australia, errors must abound in alarming numbers. In a similar study of 417 laboratories (eight from Australia), Nakhleh and Zarbo 2 found deficiencies of identification and recording in 6% of surgical pathology requests. While neither of these studies addressed the question of whether such errors affect patient outcomes, there is indirect evidence that a minor, preventable systems error can have serious consequences. 3 The Quality in Australian Health Care Study 4 showed that a significant number of patient adverse events were related to system errors. These were often errors of omission related to investigations, such as failure to act upon results of findings, or failure to carry out indicated tests. In such cases it is likely that one health care worker's error of omission results from another's error of commission, such as the incorrect delivery of a report. It is likely that most errors occur because of system problems. Typical examples are poor staff training and non-existent work manuals. Inadequate computer systems with insufficient internal audit checks and poor or no access to the hospital Master Patient Index and ward information system are the bane of many laboratories' existence. Despite a belief that those in private practice are more skilled at the activities surrounding analysis, the article by Khoury et al. indicates that the problems are widespread in both public and private sectors. Where then does the remedy lie? The first step in rectifying this situation is to recognise and document that the problems exist. Pathology laboratories should recognise that their professional responsibility encompasses a whole cycle of events, starting with the requesting doctor initiating an investigation necessary for the management of a patient, right through to recognising the significance of the results for the management of the patient. Then, laboratories should be given, and accept, the authority and responsibility necessary to fulfil their professional obligations to both patient and clinician. Australian pathology laboratories have been slow to adopt total quality improvement processes. Unfortunately, there are even those who believe that too much money is already being spent on mandatory quality activities. This near-sighted stance ignores the significant costs to both patients and the community of preventable adverse events, not to mention potentially expensive medicolegal exposure. Without some mechanism for documenting the problems they experience or cause, laboratories are in no position to begin improving the quality of their services. An example of such documentation stipulating the requirements for laboratory quality systems has been provided by the International Standards Organisation. 5 Because so few laboratories monitor their pre- and post-analytical activities, there is little information from which to develop the necessary benchmarks. The College of American Pathologists has introduced "quality probes" programs to gather data from which realistic benchmarks may be re commended. These programs also document the features of laboratory operations and organisation that correlate with better quality outcomes. A good example of this is a study of wristband identification errors which showed that hospitals with the lowest error rate had systems where the pathology phlebotomists played a crucial role in monitoring wristband conformity to the required standard. 6 Such peer review techniques, which have delivered improvement in the quality of laboratory analysis, may bring about similar improvement in these other areas of laboratory operations. Another technique that has been productive in other procedural areas is incident monitoring. 7 It may very well yield fruitful results if applied to laboratory activities. There is obviously much scope for documenting, understanding and minimising the types of laboratory errors highlighted by Khoury et al. However, a systematic and co ordinated approach will be required from those involved in laboratory medicine to achieve the all-round quality of performance that clinicians and their patients should come to expect. Stewart J Bryant General Manager, SouthPath, St George Hospital Campus, Sydney, NSW Maynard JH. The regulation of medical laboratories in Australia. Clin Lab Med 1991; 11: 777-791. Nakhleh RE, Zarbo RJ. Surgical pathology specimen identification and accessioning. Arch Pathol Lab Med 1996; 120: 227-233. Craig JC, Knight JF, Smith GH. Communication breakdown: a preventable cause of acute renal failure in a newborn infant. Med J Aust 1996; 164: 663-664. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471. International Standards Organisation guide 25. General requirements for the competence of calibration and testing laboratories. 3rd Ed. Geneva: International Standards Organisation, 1990. Renner SW, Howanitz PJ, Bachner P. Wristband identification error reporting in 712 hospitals. A College of American Pathologists' Q-Probes Study of Quality Issues in Transfusion Practice. Arch Pathol Lab Med 1993; 117: 573-577. Runciman WB, Sellen A, Webb RK, et al. The Australian Incident Monitoring Study. Errors, incidents and accidents in anaesthetic practice. Anaesth Intensive Care 1993; 21: 506-519. To top of article ©MJA; 1996 < URL: http://www.mja.com.au/> © 1996 Medical Journal of Australia.

Stewart J Bryant

Screening for colorectal cancer: too early to be dogmatic The emotive, ethical and economic issues raised by population screening programs remain a challenge ©MJA1996; 165: 68-69 Readers may print a single copy for personal use. No further reproduction or distribution of the articles in whole or in part should proceed without the permission of the publisher. For copyright permission, contact the Australasian Medical Publishing Company Support for screening for colorectal cancer in Australia has been gradually brewing, with reports in the national and international literature, 1-3 and evidence suggesting that colorectal cancer is increasing in prevalence. Despite improvements in surgical technique and adjuvant therapies, overall survival in the symptomatic phase of the disease has remained static. Now a well performed, randomised controlled trial of repetitive faecal occult blood testing has shown, for the first time, a small survival benefit from screening, 1 and evidence from case-control studies suggests that flexible sigmoidoscopy screening may have an even greater mortality benefit. 2,3 In this issue of the Journal, two articles -- a review of screening for colorectal cancer by Macrae ( page 102 ), and a pilot study of flexible sigmoidoscopy screening for colo rectal cancer by Olynyk et al. ( page 74 ) -- highlight this renewed interest in screening for colorectal cancer. Clinical epidemiology and the assessment of screening have evolved into a science, with epidemiologists, clinicians and statisticians collaborating in government working parties throughout the world to assess preventive practices for cancers. 4 In 1996 the momentum for screening prompted an Australian Health Technology Advisory Committee Working Party on colorectal cancer screening to try to sort out the evidence for and against screening, and to establish guidelines for national programs. This is no small task. MEDLINE alone detects over 800 relevant publications on bowel cancer screening, and, as computer searches miss more than 50% of randomised controlled trials, there is obviously a vast ocean of written "evidence" to be found and assessed. 5 Despite reviewing the same body of evidence, collaborating on initial interpretations and adopting a scientific approach to the assessment of screening for colorectal cancer, the Task Forces of Canada and the United States have made different recommendations. 6,7 A stepwise approach to assessing colorectal cancer screening identifies the point in the assessment where the two bodies disagree and the Australian Working Party must adjudicate for the Australian population (Box). 4 The major differences relate to the interpretation of one randomised controlled trial of faecal occult blood testing and two case-control studies of flexible sigmoidoscopy, although the much-awaited results of two further randomised controlled trials of faecal occult blood testing should be available in the near future. 1-3 There is agreement that the Minnesota trial 3 has shown a statistically significant cancer-specific mortality benefit and that this equates to 2.95 lives saved per 1000 people repetitively screened annually with faecal occult blood testing for 13 years. A 10% false positive rate and the 86% quoted compliance would mean an estimated colonoscopy procedural cost alone of over $100 000 per life saved after 13 years in Australia. The United States and Canadian Task Forces have agreed on the efficacy, effectiveness and efficiency of the data (Steps 1-3), but differ in their assessment of the small but expensive cancer-specific mortality benefit of faecal occult blood testing and the allocation of limited resources (Step 4). Interpretation of case-control studies for flexible sigmoid o scopy has remained at the proof-of-efficacy stage (Step 1). Does an 18% difference in rates of flexible sigmoidoscopy for those who died from colorectal cancer equate to a survival benefit in the control subjects who have not died from this disease? 2 The alternative hypothesis is that this difference is due to selection bias inherent in this retrospective study design. 7 The lack of detection of any colorectal cancer in the control group, and the detection of adenoma in only 1% of control subjects, imply no mortality benefit from their 24% sigmoidoscopy rate. 2 True mortality benefit would have to come from an intervention that detected early cancers or high risk adenomas and resulted in successful treatment. This would suggest that the cases and controls are not comparable and that a randomised controlled trial is still required to answer this question. The Fremantle pilot project reported by Olynyk et al. ( page 74 ) detected colorectal cancer at their estimated cost of $500 per screened patient (unpublished data). Thus, the true cost of detecting a cancer with flexible sigmoidoscopy in Australia may be $85 000, with no evidence as yet of a mortality benefit. The same data can and will be interpreted differently by different authors, health departments, societies and foundations. To some extent screening can be supported by the current data, but dogmatic conclusions and recommendations remain controversial and raise issues for discussion. Currently, these revolve around the statistical versus clinical significance of the small cancer-specific mortality benefit of annual faecal occult blood screening; the lack of detection of any cancers or significant polyps in the control groups of case-control studies of flexible sigmoidoscopy to explain any mortality benefit from sigmoidoscopy; and the lack of compliance with many of the screening programs. There is also a lack of research into the potential adverse effects of national screening programs, such as physical complications and problems arising from labelling or mis labelling of people screened (which may have psychological effects and also life and medical insurance repercussions). Even the earlier detection of incurable disease may have adverse effects. 4 The general population's desire for cancer screening may not be as great as that of its advocates; non-compliance would then impact upon efficacy. There is little doubt the emotive and ethical issues raised by population screening programs will challenge us for many years to come. Costs need to be compared with number of lives saved, and screening programs balanced against other programs competing for the limited available health care resources. Programs are often promoted by interested parties with more rhetoric than scientific evidence. The exciting advances of recent years -- that colorectal cancer can be detected and treated in the asymptomatic phase with improvement in mortality -- have encouraged clinical researchers, but the best means of achieving this has yet to be established. It may be that the advances and ethical quandaries of genetic testing hold the key to the future and will be the focus of this debate. Michael J Solomon Colorectal Surgeon Director of Research, University of Sydney, and Central Sydney Departments of Colorectal Surgery, Sydney, NSW Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal cancer by screening for faecal occult blood. N Engl J Med 1993; 328: 1365-1371. Selby JV, Friedman GD, Quesenberry CP, Weiss NS. A case-control study of screening sigmoidoscopy and mortality from colorectal cancer. N Engl J Med 1992; 326: 653-657. Newcomb PA, Norfleet RG, Stoner BE, et al. Screening sigmoidoscopy and colorectal cancer mortality. J Natl Cancer Inst 1992; 84: 1572-1575. Hunt J, Solomon MJ. Screening for cancer: the science behind the rhetoric. Int J Surg Sci 1995; 2: 161-167. Solomon MJ, McLeod RS, Laxamana A, Devore L. Randomized controlled trials in surgery. Surgery 1994; 115: 707-712. US Preventive Sevices Task Force. Guide to clinical preventive services. 2nd ed. Baltimore : Williams & Wilkins, 1996: 89-104. Solomon MJ, McLeod RS and the Canadian Task Force on the Periodic Health Examination. Periodic Health Examination, 1994 update: 2. Screening strategies for colorectal cancer. Can Med Assoc J 1994; 150: 1961-1970. - Register to be notified of new articles by email - - To top of article - ©MJA; 1996 < URL: http://www.mja.com.au/> © 1996 Medical Journal of Australia.

Michael J Solomon