Letters

W Ian Cameron Chief Executive Officer, New South Wales Rural Doctors Network, Level 3, 133 King Street, Newcastle, NSW 2300. icameronAT.nswrdn.com.au To the Editor: Bourke is a small rural town in far northwest New South Wales with a population of about 3500. The Bourke Shire Council has recently published a fascinating small book entitled 100 lives of Bourke, which uses Bourke cemetery as a “window to the past”.1 Included in the 100 vignettes based on headstones in the cemetery is one for Dr George Faithfull, Bourke’s third doctor. Dr Faithfull was born in Calcutta, India. He started medical studies in Edinburgh, Scotland, but did not complete them. He travelled to Australia, arriving in Victoria, and worked his way north (Dr Don Faithfull, grandson of George, personal communication). By 1885, he was working as a chemist in Bourke.2 In view of his experience as a “medical man” and his previous medical studies, he later became registered as a medical practitioner under Clause 3 of Act 70, The Medical Practitioners Further Amendment Act of 1900, where it was stated that: It shall be lawful for the Medical Board or its Doctors to place upon a separate register the name of any person who has passed through a course of study as Medical Practitioner in NSW during five years before the passing of this Act. Dr Faithfull was a doctor in Bourke and Goodooga from 1900 to 1908. He must have been one of the very first doctors to have gained what is now termed in NSW “conditional registration in an area of need”. To have become conditionally registered while practising as a chemist in Bourke, he must also be an early example of rural-based distance learning — a cornerstone of our new regionalised general practice training. Dr George Faithfull and his wife, Mary Faithfull (née Whitfield). (Photo, Dr Don Faithfull.) It is sobering to think that the changes made over the last few years by medical boards, and the streamlining of processes outlined in MedicarePlus, had precursors over a hundred years ago. Doctors and their families were not exempt from the morbidity and mortality of the time. Three of Dr Faithfull’s 11 children died young and are buried in Bourke cemetery. Another Bourke doctor, Dr Sides, had three children die in infancy, and Dr Dey lost a six-month-old son. In 1901, a locum doctor died of heat stroke. More recently, in 1992, Bourke cemetery became the final resting place for another overseas-trained doctor, Professor Fred Hollows, who achieved international recognition for his work in ophthalmology in disadvantaged populations, particularly Indigenous Australians.

W Ian Cameron

Robert W Pegram,* Lisa Valenti† *Senior Lecturer, Department of General Practice, University of Adelaide, Adelaide, SA; †Senior Analyst, General Practice Statistics and Classification Unit, University of Sydney, Wentworthville, NSW. robert.pegramATadelaide.edu.au To the Editor: Young and Dobson’s article1 examining the bulk-billing status of services provided to women generated much debate.2,3 To add to that debate we undertook an analysis of 5546 Medicare-claimable general-practice encounters. Data were provided by 200 general practitioners between May and July 2002, using the BEACH (Bettering the Evaluation and Care of Health) methodology.4 We examined which encounter, GP and patient characteristics determine billing status (patient-billed or bulk-billed). From time and day of service we determined which consultations were “after hours”. Over two-thirds of services (69.8%; 95% CI, 65.4%–74.3%) were bulk-billed. One in fourteen services (7.1%; 95% CI, 2.2%–12.1%) were delivered “after hours” as defined by the Australian Government Department of Health and Ageing5 (ie, between 6 pm and 8 am on weekdays or between 1 pm Saturday and 8 am Monday on weekends). The results after simple and multiple logistic regression analysis are shown in the Box. After-hours consultations were significantly more likely to have been bulk-billed than those held during standard office hours (odds ratio [OR], 1.9). Patients aged < 15, 15–24 years and > 75 years were significantly more likely to be bulk-billed than working-age adults (P < 0.0001). Also significantly more likely to be bulk-billed were patients from non-English-speaking backgrounds (OR, 7.3), living in an urban area (OR, 2.6), holding a healthcare card (OR, 3.5) and/or coming from a low socioeconomic status background (OR, 2.3). There was no significant association between the likelihood of being bulk-billed and the age or sex of the GP, the practice size or the number of problems managed at the encounter. Interestingly, the variable with the largest impact on bulk-billing rates was whether patients were from a non-English-speaking background. These patients were over seven times more likely to be bulk-billed than patients from an English-speaking background. This study adds further support to the findings of Young and Dobson1 that patients in urban areas were significantly more likely to be bulk-billed for general practice consultations than their rural counterparts. We can go one step further and say that consultations given after hours were also significantly more likely to be bulk-billed. The conclusion is that bulk-billing decisions by GPs are not uniformly influenced by timing, location and patient characteristics. This has implications for assessing the likely impact of bulk-billing strategies such as MedicarePlus.6 Factors influencing the likelihood of bulk-billing in Australian general practice* Simple logistic regression analysis Multiple logistic regression analysis OR (95% CI) (n = 5546) Adjusted OR (95% CI) (n = 4793) Time of consultation “After hours” status (standard hours : after hours) 1.5 (0.9–2.5) 1.9 (1.1–3.3) Other variables Non-English-speaking background (no : yes) 8.8 (4.8–16.3) 7.3 (3.8–14.0) Aboriginal or Torres Strait Islander descent (no : yes) 2.0 (0.7–6.0) ns Patient new to practice (new : not new) 1.5 (1.0–2.2) ns Rural/urban place of residence (rural : urban) 2.2 (1.3–3.7) 2.6 (1.5–4.7) Having health care card (no : yes) 3.4 (2.4–5.0) 3.5 (2.3–5.2) Socioeconomic status† (higher SES : low SES) 3.2 (1.8–5.7) 2.3 (1.2–4.5) Practice size (5+ GPs : solo GP) 2.4 (1.0–5.8) ns (5+ GPs : 2–4 GPs) 1.4 (0.9–2.3) ns Patient age (years) (25–64 : < 15) 1.5 (1.1–2.0) 1.4 (1.0–1.9) (25–64: 15–24) 1.4 (1.2–1.8) 1.4 (1.1–1.9) (25–64 : 65–74) 1.8 (1.4–2.5) 1.2 (0.8–1.6) (25–64 : ≥ 75) 2.5 (1.7–3.8) 1.7 (1.1–3.8) Patient sex (female : male) 1.1 (0.9–1.3) ns GP age (years) (25–54 : ≥ 55) 1.6 (1.0–2.8) ns GP sex (female : male) 1.1 (0.7–1.8) ns Number of problems managed per encounter‡ 1.0 (0.9–1.2) ns GP = general practitioner. ns = not significant at 5% level. OR = odds ratio. * For each variable, the first-mentioned category is the reference. † Assessed by SEIFA (Socioeconomic Indexes for Areas) categories of the Australian Bureau of Statistics. ‡ The reference point for this variable is the number of problems managed (1, 2, 3 or 4), measured against whether the patient is bulk-billed. The OR here indicates that for each unit increase in problems managed the odds of the encounter being bulk-billed do not change.

Robert W Pegram · Lisa Valenti

Susan D Huckson Project Manager, National Institute of Clinical Studies, 499 St Kilda Rd, Melbourne, VIC 3004. shucksonATnicsl.com.au To the Editor: Stacey, in his recent editorial on preventing pressure ulcers, stated that it is a major challenge to successfully implement guidelines in clinical practice and that a combination of strategies is required.1 In this context, your readers may be interested in the new pressure ulcer resource guide, developed by the National Institute of Clinical Studies (NICS).2 The resource guide provides health professionals and consumers with easy access to: the latest guidelines; literature reviews; health professional and consumer information resources; current Australian research activities, journal articles and papers; and links to a range of groups undertaking significant work in this area. The guide was developed in consultation with leading experts and professional groups with a strong interest in the management of pressure ulcers in Australia. This guide is an example of the efforts of NICS to help healthcare organisations and practitioners improve patient care by providing them with access to the best available evidence, proven strategies, tools and resources. The guide can be freely accessed from the NICS website www.nicsl.com.au (under “Quick Links”).

Susan D Huckson

Adrian B Wenban Associate Governor, Australian Spinal Research Foundation, PO Box 1047, Springwood, QLD 4127. adrianwenbanATwanadoo.es To the Editor: Bogduk, in his recent clinical update on management of chronic low back pain, stated that “zygapophysial joint pain can be relieved by radiofrequency neurotomy (E2, E3), and techniques are emerging for treating sacroiliac joint pain and internal disc disruption (E2, E3, E4)”.1 (E2, E3 and E4 refer to the levels of evidence: E2 evidence is obtained from at least one properly designed randomised controlled trial; E3 from pseudorandomised controlled trials or comparative studies; and E4 from case series, either post-test or pre-test and post-test.) I have two concerns about this statement. Both involve the fact that at least three systematic reviews (E1 level of evidence) have now been published on treatment of lumbar zygapophysial joint-mediated low back pain with radiofrequency procedures.2-4 Together, these three reviews cast considerable doubt on Bogduk’s claim about the role of radiofrequency neurotomy. My first concern is that the earliest of those systematic reviews,2 which came to a very different conclusion from that of Bogduk, was published in 2001, well before he submitted his clinical update to the Journal on 16 July 2003. Yet, he does not mention that review, even though he was obviously aware of it, as evidenced by his letter to the journal Regional Anesthesia and Pain Medicine expressing concern with the methods underpinning the review.5 Even if Bogduk disagrees with the conclusions of that review, justification for excluding it from the evidence base of his recent clinical update seems warranted. Secondly, two more recent systematic reviews3,4 have come to conclusions very different from those of Bogduk on the role of radiofrequency neurotomy in treatment of lumbar zygapophysial joint pain. The first of those two reviews, from the Cochrane Collaboration Back Review Group, concludes: “There is . . . conflicting evidence for its [radiofrequency denervation] effectiveness for lumbar zygapophysial joint pain. There is limited evidence suggesting that intradiscal radiofrequency may not be effective in relieving discogenic low back pain. Further high-quality randomized controlled trials are needed, with larger patient samples and data on long-term effects, for which current evidence is inconclusive.”3 The second review concludes: “Current studies fail to give more than sparse evidence to support the use of interventional techniques [zygapophysial injections and radiofrequency denervation] in the treatment of lumbar zygapophysial joint-mediated low back pain. This review emphasizes the need for larger, prospective, randomized controlled trials with uniform inclusion and exclusion criteria, standardized treatment, uniform outcome measures and an adequate duration of follow-up period so that definitive recommendations for the treatment of lumbar zygapophysial joint-mediated pain can be made.”4 In summary, authors who knowingly exclude important relevant evidence from clinical updates should at a minimum justify the exclusion of that evidence. Given the collective weight of recent relevant systematic reviews, considerable doubt now exists about the role of radiofrequency procedures in the treatment of lumbar zygapophysial joint pain.

Adrian B Wenban

Nikolai Bogduk Director, Department of Clinical Research, Royal Newcastle Hospital, David Maddison Building, Newcastle, NSW 2300. mgillamATmail.newcastle.edu.au In reply: Although systematic reviews have identified three studies of lumbar radiofrequency neurotomy, they do not take into account technical errors in the procedure. Neither the study of Gallagher et al1 nor that of Leclaire et al2 used techniques that could coagulate the target nerves accurately, consistently, and thoroughly.3 Therefore, these studies are not a measure of the efficacy of the procedure when performed correctly and have no place in a systematic review. Nor are systematic reviews permitted to include complementary, observational studies like that of Dreyfuss et al.4 Yet, this study sets the benchmark for what outcomes can be achieved, if and when correct techniques are used. The “conflicting” evidence reported by systematic reviews arises because inaccurate surgical techniques are used. When studies using inaccurate techniques are eliminated, there is no conflict. The literature reduces to one controlled study5 and one complementary study.4 These were the studies that I cited in the clinical update on chronic low back pain.6 In the face of that literature, the conclusion that I proffered, and which Wenban has quoted, is valid. Zygapophysial joint pain can be relieved by radiofrequency neurotomy. Perhaps the extra words that are required are provided that correct techniques are used.

Nikolai Bogduk

Winston Chong Chair, Interventional Radiology Reference Group, Level 9, 51 Druitt Street, Sydney, NSW 2000. ranzcrATranzcr.edu.au To the Editor: I refer to the recent editorial on “Metformin and serious adverse effects”.1 I would like to highlight the position of the Royal Australian and New Zealand College of Radiologists (RANZCR) on the use of metformin hydrochloride when administering intravascular contrast media. The RANZCR has adopted an evidence-based approach in formulating its guidelines. The College guidelines on metformin hydrochloride and intravascular contrast media are available at <www.ranzcr.edu.au/open/policies/diagnostic_imaging/pol1_2.htm>. The current guideline is that there is no need for patients to stop taking metformin hydrochloride for 24–48 hours before administration of an intravascular contrast medium. Stopping or continuing to take metformin depends on the patient’s renal status, and the likelihood of inducing renal dysfunction when intravascular contrast is administered. If discontinuation is required, then the drug only needs to be stopped for 48 hours, commencing on the day of administration of intravascular contrast.

Winston Chong

Janelle C Nisbet,* Joanna M Sturtevant,† Johannes B Prins‡ * Endocrinology Registrar, † Renal Specialist Pharmacist, ‡ Director of Diabetes and Endocrinology; and Professor of Endocrinology, University of Queensland, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, QLD 4102. jprinsATsoms.uq.edu.au In reply: Chong’s letter highlights some important issues, and his points are well made. As we imply in our editorial,1 the evidence base on which to base guidelines and decisions is poor, which is one of the reasons that the guidelines differ widely between countries and organisations. Specialty-specific guidelines must also take into account practicalities. We elected to follow the more conservative end of the guideline spectrum in our suggestions, accepting that, in many circumstances, these would be difficult or impossible to follow. From a radiological perspective, it would require a significant change in practice to implement guidelines such as those we suggested, and the evidence base supporting such a change does not exist. Metformin is a short-acting drug and stopping it at the time of a potentially hazardous procedure will almost always be effective in preventing drug-related complications. Overall, the aim of our article was to raise awareness of the potential hazards of metformin use, and to encourage practitioners to follow available and relevant guidelines.

Janelle C Nisbet · Joanna M Sturtevant · Johannes B Prins

To the Editor: We report a case in which routine use of transesophageal echocardiography (TOE) during cardiac surgery almost certainly prevented a patient’s death. This is important, as the Australian Government Department of Health and Ageing has recently decided that TOE during routine coronary artery cardiac surgery should not attract a Medicare benefit as there is no Level 1 or 2 evidence of its efficacy.1 A 65-year-old man with critical aortic valve stenosis and severe left ventricular dysfunction, requiring an intra-aortic balloon pump, was scheduled for mechanical aortic valve replacement. He had been in atrial fibrillation intermittently, but was in sinus rhythm for the 24 hours before surgery and his heparin had been at therapeutic levels since balloon pump insertion 36 hours before. Like most cardiac anaesthetists in Australia, we routinely perform TOE during cardiac surgery. Following induction of anaesthesia, TOE examination confirmed severe aortic stenosis and poor left ventricular function, but the left atrial appendage was not specifically examined and a routine preoperative transthoracic echocardiogram had shown no other abnormalities. With the patient on cardiopulmonary bypass, the diseased valve was replaced. Before weaning the patient from bypass, a TOE examination showed a large free 2.5 × 2 cm mass in the left atrium resembling thrombus (Box [a]). The surgeon then reported having invaginated the left atrial appendage while de-airing. While the patient was still on bypass, a large organised clot was removed from the left atrium (Box [b]) — this had presumably developed sometime during the preoperative period. Subsequent separation of the patient from bypass was uneventful, and he made a good recovery. The thrombus would not have been suspected or found without the TOE, and almost certainly would have migrated from the left atrium into the left ventricle following the return of cardiac output, and would likely have precipitated a sudden cardiac arrest with acute valvular obstruction. Despite the lack of Level 1 or 2 evidence, most cardiac anaesthetists and surgeons consider TOE an invaluable diagnostic and monitoring tool, particularly for assessment of left ventricular function and filling. While TOE has not rendered the Swan–Ganz catheter obsolete, it provides similar information with fewer complications. This case is a dramatic illustration of the usefulness of TOE during cardiac surgery, but less dramatic examples occur much more frequently. The Department of Health and Ageing decision not to support TOE (except in valve repair or replacement) seems shortsighted. While we support the Department’s evidence-based approach, it would be interesting to know how many procedures listed in the Medicare Benefits Schedule would withstand the same scrutiny. Randomised trials are difficult to perform, but, at the very least, TOE has excellent peer consensus, strong anecdotal evidence and large series reviews2,3 supporting its routine use in cardiac surgery. Atrial thrombus in left atrium detected by transoesophageal echocardiography during cardiac surgery (a) Echocardiogram showing the mass. (b) The clot that was removed.

Chris J Cokis · John Faris

Sebastiaan J M van Hal,* Jeffrey J Post† * Advanced Trainee, † Infectious Diseases Physician, Prince of Wales Hospital, Barker Street, Randwick, NSW 2031. j.postATunsw.edu.au To the Editor: Community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) infection is an increasingly recognised cause of skin and soft tissue infection, as well as more serious manifestations, including necrotising pneumonia, endocarditis, osteomyelitis and severe sepsis.1,2 We report another serious manifestation of CAMRSA infection. A 24-year-old Australian-born white, HIV-negative, male prison inmate was transferred to hospital. He had previously injected drugs, but not for more than 2 years. He reported a 10-day history of cervical neck pain, left-sided pleuritic chest pain and a 2-cm occipital carbuncle, which developed after a laceration on the scalp from a close haircut with barber’s shears. Examination revealed a temperature of 37.9°C, sinus tachycardia, profound neck stiffness and signs of left basal consolidation with a left pleural effusion. There were no focal neurological signs or other signs of meningism. Investigations revealed a neutrophil leukocytosis of 22.7 × 109/L (reference range, 1.7–7.0 × 109/L) with mild elevation of hepatic transaminases and hypoalbuminaemia. CAMRSA was isolated from blood cultures and a swab of the occipital carbuncle. The organism was susceptible to erythromycin, vancomycin, rifampicin and fusidic acid. A chest radiograph showed extensive left-sided consolidation consistent with pneumonia. A magnetic resonance imaging scan of the entire spine revealed asymmetric thickening and enhancement of the epidural tissue from C2 to C5, with no discrete abscess, osteomyelitis or discitis. The patient made a full recovery after 4 weeks of intravenous therapy with vancomycin (1 g every 12 hours) and clindamycin (600 mg every 6 hours). This is the first reported case of epidural tissue infection (epiduritis) caused by CAMRSA, and adds to the spectrum of potential clinical manifestations. In addition, this is the first reported case of CAMRSA infection occurring in an Australian prison inmate. There have been several reported outbreaks of CAMRSA in US correctional facilities.3,4 Although no similar outbreaks have been described in Australia, clinicians should be aware that correctional facilities may contribute to the spread of CAMRSA. The most common manifestations of CAMRSA infection in the prison setting in the United States are skin and soft tissue infections, with invasive infection occurring in 1.7% of patients.4 Clinicians providing care to inmates should be aware that strategies have been identified to reduce the incidence of CAMRSA infection.5 Clinicians need to be aware of the increasing incidence of CAMRSA infection, the diverse and potentially severe manifestations, and the treatment and preventive strategies available.

Sebastiaan J M van Hal · Jeffrey J Post

Sandy Reid Head, School of Rural Health, University of New South Wales, PO Box 5695, Wagga Wagga, NSW 2560. s.reidATunsw.edu.au To the Editor: The editorial by Wearne and Wakerman on the subject of rural training and its relationship to rural practice is timely.1 There is widespread belief that the rural problem lies in small country centres, and it is generally not realised that most of the regional centres, in New South Wales at least, are seriously short of both general practitioners and specialists. The statistics are highly unreliable, as many people, such as me, are listed as GPs even though we do not practise. It seems likely that improved selection processes and the undergraduate rural training initiatives will increase student interest in rural practice. Many students express intent to practice in a rural or regional centre, but are later deflected from this by the necessity for training after graduation. Several large centres are not primary allocation centres, so a student who trained there may never get back. (The Australian Medical Students’ Association study puts the figure for rural internships as 9% of the total.)2 All too often, regional centres are understaffed, and junior staff lack adequate supervision and educational possibilities. Their negative experience is highly visible to students. The allocation of registrars and senior resident medical officers, who supervise or make time for consultants to supervise, rests between the major hospitals and the various colleges. Regional hospitals are often low on their priority list when shortages occur. Yet there are regional hospitals that rate very highly in the quality of the training experience they provide. Regional hospitals that do not enjoy this reputation need to take active steps to improve their training and supervision or their plight will worsen. Training packages also need to be developed for those who express an interest in rural practice so they can plan their future. This must be a collaborative process between the different seconding agencies: without such a process, much of the impetus of the undergraduate initiatives will be lost.

Sandy Reid

Barney J McCusker Orthopaedic Surgeon, Wavell House, PO Box 1998, Mount Gambier, SA 5290. To the Editor: I recently had the opportunity to analyse the home postcodes of medical students at the University of Adelaide over five recent consecutive years. Although this analysis is rather simplistic, its findings are quite startling (see Box). Between 50 and 60 students per year were from the Adelaide metropolitan area. My colleagues in the Department of Human Services tell me that we struggle every year to fill the junior posts at our metropolitan public hospitals. A considerable number of students (25–41) were from outside South Australia. It is only natural that these students would want to go home after completing their degree, and I believe that considerable effort is made every year to encourage these students to stay and staff junior positions in our hospitals. There has been much discussion about students from outside Australia and I will not add to the debate on this complex issue. The most alarming feature is the small number of students from rural South Australia. This ranged from zero to three or four. Moreover, I have included in this category students whose home address was in the Adelaide Hills, which is between 5 and 20 km from the Adelaide metropolitan area. We spend a lot of time encouraging students who grew up and were educated in cities to come to rural settings, using various schemes of bonding and financial inducement, with limited success. After 18 years’ practice in a rural area, I am firmly of the belief that we should be starting much earlier. If a person is born and reared in the country, and has their secondary schooling in the country, it is much easier to transplant that person back to the country after tertiary eduction. If these figures of students’ home residence are representative, we will always be fighting an uphill battle to attract doctors to rural areas. This is not the fault of our universities, as they are constrained by federal regulations. I believe the solution lies in Canberra. In our parliaments, we have proportional representation. As far as medical students are concerned, I think South Australia has disproportionate representation. Medical students attending the University of Adelaide, by area of residence (determined by home postcode) (years not specified) Total number of students 145 139 131 110 107 Students from metropolitan Adelaide 56 50 60 50 53 Students from outside South Australia 32 41 36 28 25 Students from outside Australia 53 45 35 28 26 Students from rural South Australia 4 3 0 4 3

Barney J McCusker

S Bruce Dowton,* Danielle Brown† * Chair, † Executive Officer, Committee of Deans of Australian Medical Schools, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052. b.dowtonATunsw.edu.au Comment: Data collected by the Committee of Deans of Australian Medical Schools (CDAMS) would appear to broadly support the pattern of medical student origins reported by McCusker from the University of Adelaide. CDAMS has been collecting medical student statistics annually for the past few years. Box 1 sets out the basic enrolment figures for Australian and international students across all years in 2003. In 2003, CDAMS also commenced collecting data on interstate mobility (ie, students attending medical school in another state) among first-year medical students at the 12 medical schools. As a general principle, some level of interstate mobility brings positive benefits by fostering diversity in the medical student body and broadening educational and social opportunities for individual students. However, as McCusker rightly points out, this can create problems when interstate medical graduates choose to return to their home states (or move to other states) when they enter their intern training years. In this regard, South Australia faces particular problems, as it has the highest proportion of students entering medicine from interstate. Box 2 shows that just under half of all commencing medical students at Adelaide and Flinders medical schools in 2003 were from other states. This may well have an impact when these students come to choose their intern training locations. Box 3 sets out state averages for first-year students with a rural background. The figure for South Australia as a state suggests that it is reasonably comparable with other states. However, there is a sizeable gap between the rural student cohorts at Flinders and Adelaide medical schools: in 2003, 26% compared with 12%, respectively, were from a rural background. All medical schools in Australia have committed their energies to a range of collaborative programs, together with the Australian Department of Health and Ageing, aimed at ensuring a sustainable medical workforce that is equitably distributed across the nation. 1: Australian and international medical students at Australian medical schools, 2003 No. of students Percentage of total (n = 8684) Australian students, all years 7111 82% International students, all years 1573 18% 2: Interstate mobility (number of students attending medical school in another state — first-year Australian students, 2003) State No. of students Total (%) SA 85 174 (49%) Tas 25 64 (39%) Vic 82 344 (24%) Qld 62 346 (18%) NSW 63 446 (14%) WA 14 140 (10%) National total 331 1514 (22%) 3: Rural background (first-year Australian students, 2003) State No. of students Total (%) SA 31 174 (18%) Tas 14 64 (22%) Vic 80 344 (23%) Qld 93 346 (27%) NSW 71 446 (16%) WA 20 140 (14%) National total 309 1514 (20.5%)

S Bruce Dowton · Danielle Brown

To the Editor: We read with interest the article by Mitchell et al and the editorial by Cole on comparatively adverse outcomes in adolescents and young adults with cancer.1,2 The improvements in cancer survival, most remarkably demonstrated in children, have failed to similarly benefit older adolescents and young adults, a population with a higher and increasing incidence of cancer.3 Most authors advocate increasing research, networking resources and information, enhancing support for clinical trials and facilitating participation in them. Recently announced funding for a comprehensive cancer-care program for adolescents and young adults at the Peter MacCallum Cancer Institute in Melbourne is a welcome step towards these goals. The specific emotional and psychosocial needs of this age group are also poorly addressed within traditional models of care.4 Patients in this group express strong preference for peer support, opportunities to be cohorted with each other and access to specific support services.4 The short and long term sequelae of cancer, as well as of its treatment, in adolescents and young adults create particular challenges for both healthcare professionals and the broader community. In December 2003, an entire issue of the European Journal of Cancer was dedicated to adolescent oncology — this science, clinical care and the needs of the patient population.5 An important development in the United Kingdom has been the establishment of eight “teenage cancer units” with a comprehensive approach to all aspects of care.6 Preliminary research in Australia and New Zealand by one of our group (J E) highlights gaps in service and support perceived by consumers, concerns yet to be addressed by appropriate policy and funding.7 The paediatric model of care has provided not only excellent survival but also an exemplary family-centred and comprehensive support system. The recent emphasis on the transition process for adolescents with a variety of chronic illnesses has highlighted systemic differences between the paediatric and adult models. Some paediatric oncologists, especially in the United States, have proposed raising the upper age limit for eligibility to childhood cancer units as a solution. A more realistic approach, particularly in Australia, requires establishing specialist facilities operated in partnership between (preferably collocated) adult and paediatric units, with subspecialisation of the multidisciplinary workforce, an age-appropriate environment and peer support from groups like the Australian Organisation for Young People Living with Cancer (CanTeen). This approach is capable of addressing all of the above issues, from better science through to psychosocial expertise appropriately targeted for age. The ideal number and distribution of such centres/partnerships should be guided by the paediatric track record for balancing centralisation and quality with access and family focus.

Les White · Jane Ewing · Anne M Senner · Madeleine King · Belinda Goodenough

To the Editor: It has been claimed that patients are missing out on the most effective current treatments if they are not given an opportunity to enrol in clinical trials. Such statements are misleading and have the potential both to create concern in those without access to trials and to reduce the likelihood of true informed consent for involvement in trials. Trials are, by definition, just that — trials. Treatment in the “innovative” arm(s) may result in worse outcomes. The finding that those involved in trials have a better outcome (eg, 5-year survival) may have numerous explanations. It is unlikely that the innovation is an adequate explanation for the finding — confounding factors such as selection bias, adherence to best current practice, and intensity of monitoring are more likely explanatory factors. Furthermore, it is important to focus on other outcomes of therapeutic endeavour, such as quality of life, and the impact of the illness on other family members. Patients who live some distance away from tertiary referral centres or trial centres may have a greater adverse effect from involvement in a trial than other patients who live close to such centres. Well designed trials are a crucial part of advancing medical therapeutics. However, the recent editorial by Cole1 and the article by Mitchell and colleagues2 in the Journal have been picked up by the news media as demonstrating that only through involvement in clinical trials can patients get best-quality care. It is not surprising that this is the way that the message has been received. The truth is importantly different. It is only through the conduct of clinical trials that best practice can be defined. However, patients anywhere in the country should be able to access current best-practice treatment even if they do not want to be involved in a clinical trial. Encouragement to participate in clinical trials should be based on arguments about the “greater good” and not about issues of quality of care. To use the latter as the basis for argument must be seen as coercion and as unethical.

Alex N Thomson

In reply: Thomson is correct in stating that patients involved in clinical trials have better 5-year survival rates when compared with patients not recruited into clinical trials. There may, as Thomson points out, be numerous possible explanations for this finding. Nonetheless, this improvement in survival is well documented and has been recognised for some time.1 Although it is becoming increasingly important to focus on other therapeutic outcomes, such as quality of life, it is incorrect to assume that involvement in clinical cancer trials equates to impairment of quality of life and an increase in adverse effects. In fact, the primary end-point of numerous clinical cancer trials is improved quality of life.2 We agree with Thomson when he states that patients anywhere in the country should be able to access current best-practice treatment. We agree that best-practice treatment can only be defined through the conduct of clinical trials. Hence, well designed clinical trials are necessary, and indeed crucial, to the advancement of cancer therapy. In the context of adolescents and young adults with cancer, the lower than expected improvement in survival may be explained, in part, by a low rate of participation in clinical trials.3 There is no doubt that participation in late-phase clinical trials provides a “benchmark” and ensures the provision of quality medical care. Rural and regional settings should not, a priori, be a barrier to trial participation. Adequate infrastructure and support should be available for such centres to participate. Greater cooperation between all adult and paediatric clinicians involved in the care of adolescents and young adults with cancer is essential to ensure that the inequity in survival is corrected.

Anne E Mitchell · Deborah L Scarcella · Gemma L Rigutto · David M Ashley · Vicky J Thursfield · Graham G Giles · Maree Sexton

John Orchard,* Caroline Finch† * Sports Physician, Sports Medicine Unit; † Director, NSW Injury Risk Management Research Centre, University of New South Wales, 111 Anzac Parade, Kensington, NSW 2033. johnorchardATmsn.com.au To the Editor: We agree with very few of the conclusions in the recent article by Mitton et al.1 It is fascinating that the authors single out elite athlete funding as being the only notable area of discretionary government spending that prevents more from being spent on healthcare. We suspect that the authors share the widely-held view within the healthcare professions that sport is an indulgence rather than a contributor to the good health of this nation. Sports medicine is the only recognised branch of medicine in Australia that is considered an “area” of medicine (all other recognised branches being considered “specialties”), a view held by both the Health Insurance Commission and the Australian Medical Association. Therefore, an Australian athlete who suffers a sports injury and is referred to a sports physician receives lower Medicare rebates for the visit than all other patients referred elsewhere in the system, and is unable to claim any Medicare rebate if he or she requires a magnetic resonance imaging scan for an injury, again the only such example in the Australian healthcare system.2 Injuries which occur as a result of traffic accidents, workplace accidents, falls, assaults and suicide attempts are all monitored by various government departments, with priority funding specifically directed towards their prevention. The federal government in Australia directs no funding towards sports injury monitoring or prevention3 and does not devote sufficient resources towards making the population more active.4 The article by Mitton et al ignores the concept of efficiency (in terms of prolonging life) within healthcare spending. Health promotion and prevention of illness and injury are far more efficient ways of prolonging life than treating existing disease (compare smoking cessation programs with coronary care units). Lack of sport and exercise is an increasingly prevalent risk factor for major diseases.4 The use of elite athletes as role models may or may not contribute to a more active population — we suspect the former. We also believe that the disrespect shown within the Australian healthcare system towards sports injuries (compared with other injuries and illnesses) is a major disincentive for Australians to become more active. This is a disincentive for which we will pay a high penalty in terms of decreased life expectancy and increased healthcare costs in the future.

John Orchard · Caroline Finch

Craig R Mitton,* H Dele Davies,† Cam Donaldson‡ * Assistant Professor, Department of Health Care and Epidemiology, University of British Columbia, 4480 Oak Street, E414 A, Vancouver, BC V6H3V4, Canada; † Professor, Pediatrics and Human Development, Michigan State University, USA; ‡ Professor, School of Population and Health Sciences and Business School, University of Newcastle, UK. cmittonATcw.bc.ca In reply: We thank Orchard and Finch for their letter about our article comparing spending on the Sydney Olympics to expenditure on healthcare for Australia, Canada and Britain.1 The reason we “singled out elite athlete funding” was simply to choose a high profile expenditure as an illustration that government does indeed make decisions about priorities with the limited societal resources available. While we would strongly agree, and in fact state, that “spending more on athletics may improve the health of the population”,1 the necessary public debate about how societal resources should be best spent is lacking. In our view, such a debate should be informed by the costs and wide-ranging benefits of government expenditure and be based on clearly articulated public values. Contrary to the claim that we “ignore the concept of efficiency”, it is precisely here, when costs and benefits of alternative claims on limited resources are explicitly compared (both within healthcare and across government sectors), that the notion of efficiency is addressed.2 Upstream investment in promotional activities may well be an appropriate way to spend health and non-health dollars — let’s just make these choices, and the underlying values, explicit.

Craig R Mitton · H Dele Davies · Cam Donaldson

Donald M Clark Obstetrician, PO Box 503, Mount Lawley, WA 6929. To the Editor: Giles et al1 have “poisoned the well” for future research by attacking the obstetricians who took the trouble to help them with their study on management of hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV. Many of the discrepancies noted between current practice and the recommendations/guidelines are easy to explain: Failure to screen. Many obstetricians were told that it is discriminatory to screen for HIV and HCV without extensive pretest counselling. The advice is obsolete, but old habits die slowly. Failure to recommend caesarean section for women with HIV. Many obstetricians have never seen a case of HIV and would most certainly phone for advice if the situation arose. Failure to promote breastfeeding. Many obstetricians leave advice on breastfeeding to the midwives and paediatricians. However, the article does concede that mother-to-baby transmission is a theoretical risk, so patients are entitled to be informed. Failure to adhere to guidelines. Many obstetricians regard guidelines issued by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) as just that — guidelines, not gospel.

Donald M Clark

Dale W Hanson,* Herbert R Sadlier,† Reinhold Muller‡ * Tom and Dorothy Cook Research Fellow, James Cook University; † Director, Emergency Department, Mackay Base Hospital, PO Box 5580, Mackay Mail Centre, Mackay, QLD 4741; ‡ Associate Professor, School of Public Health and Tropical Medicine, James Cook University, Townsville, QLD. dwhansonATmackay.matilda.net.au To the Editor: It has been argued that reduced levels of bulk billing have resulted in emergency department (ED) overcrowding due to an increase in non-emergency, primary care ED presentations.1 In the 2001–02 financial year, Queensland EDs experienced a 7.1% growth in caseload compared with 2000–01 (Mr D Searle, Surgical Access Team, Queensland Health, personal communication, Nov 2002). During the same period, there was a 1.5% decline in the proportion of general practice services bulk billed in Queensland. Before December 2000, no dedicated general practice bulk-billing clinics existed in Mackay. The opening of two bulk-billing clinics, one within 1 km of Mackay Base Hospital, provided an opportunity to assess the effect of the increased availability of bulk-billing services on ED presentations. The Mackay region had a full-time-equivalent GP : patient ratio of 1 : 1648 in 2002, compared with a Queensland average of 1 : 1143.2 In the September quarter of 2000, 58.4% of GP consultations were bulk billed in Mackay, compared with 85.7% in Brisbane (Ms D-A Kelly, Federal Member for Dawson, personal communication, Jun 2003). The Mackay Base Hospital ED provides 24-hour, 365-day emergency medical services to the Mackay region, and managed 34 558 presentations in the 1999–00 financial year, admitting 15% of its caseload. On the Australasian Triage Score (ATS) classification, 0.2% of presentations were category 1, 4% category 2, 20% category 3, 54% category 4, and 21% category 5. Since the bulk-billing clinics were established, there has been an average of 237 extra bulk-billing consultations per day, with a resultant 7.3% increase in the proportion of GP consultations bulk billed in the federal electorate of Dawson (Ms D-A Kelly, Federal Member for Dawson, personal communication, Jun 2003) (91% of the electorate lives in the Mackay region). However, ED presentations have remained stable, with a median 93 presentations per day (Box). Changes in the proportion of ATS 3, 4 and 5 presentations were observed (25%, 55% and 14%, respectively), but were associated with internal organisational changes (shifting surgical and orthopaedic dressing clinics out of the ED and into the outpatient department, and a review of triage policy), and cannot be reliably attributed to the influence of the bulk-billing clinics. In Mackay, the implementation of two bulk-billing GP clinics did not result in a measurable reduction in the absolute number of ED presentations. These results are consistent with previous studies that suggest that non-emergency, primary care ED presentations are not a major determinant of ED overcrowding.3 Effect of general practice bulk-billing presentations on average daily emergency department presentations, Dawson electorate, Queensland

Dale W Hanson · Herbert R Sadlier · Reinhold Muller

Ian F Knox President, Australasian College for Emergency Medicine, 34 Jeffcott Street, West Melbourne, VIC 3003. iknoxATgil.com.au Comment: The report by Hanson et al1 comes at an important time in the debate regarding emergency departments, especially at the onset of winter, a time of high demand and stretched resources. The authors describe the effect of the opening of two bulk-billing clinics on attendances at the emergency department (ED) of a provincial Queensland hospital. Despite the clinics seeing 2.5 times the number of patients seen at the emergency department each day, this resulted in no reduction in ED attendances. This should give pause for thought to those who maintain there is a simple and direct relation between the level of bulk billing of general practitioner services and ED workloads. The nature of the relation between GP services and ED attendances has never been clearly defined, but it is likely to be complex. Similarly, the nature of ED workloads is also complex, and more than just a matter of the total attendances.2 In the Journal last year, Cameron and Campbell cited the major causes of access block and overcrowding as being the reduction in hospital beds and aged care facilities, along with changes in workforce and community attitudes.3 In that issue, the Journal published a series of articles that essentially represented a national audit of responses to ED overcrowding. Only one article described the opening of a GP clinic as a response; the authors noted that this was unsuccessful in reducing access block.4 Thus, the findings of Hanson and colleagues are neither new nor surprising. Overcrowding is the single most important barrier to quality in ED care. It is a symptom of a serious and growing mismatch between demand and supply for acute healthcare services. Solutions require a whole-of-systems approach. Efforts to improve the flow of patients through acute-care hospital beds are needed, as are strategies to divert some current inpatient flow to community-based subacute services. There is an important role to be played by GPs in coordinating the management of patients with chronic and complex health problems, to reduce the demand for acute-care admissions to hospital, and in working in partnership with the acute-care sector in coordinating community-based subacute alternatives to hospital care. Such initiatives will only come about if state and Commonwealth governments and health departments work together.

Ian F Knox

Elizabeth J Comino Senior Research Fellow, School of Public Health and Community Medicine, University of New South Wales, Liverpool Hospital, Liverpool, NSW. E. CominoATunsw.edu.au To the Editor: The Australian Bureau of Statistics recently released details of asthma mortality for 2002. These figures indicate that asthma mortality has continued to decline in 2002 and that deaths in young people aged 5–34 years are at their lowest level since the early 1950s (Box). In this age group, the number of deaths fell from 43 in 2001 to 33 in 2002 (a 23.3% drop), and for all ages the number of deaths fell from 422 in 2001 to 397 in 2002 (a 5.9% drop). This suggests that the various asthma awareness activities, spearheaded by the National Asthma Council and other interest groups, have been successful in raising awareness of asthma and its management. Or does it? Emerging evidence suggests other changes in the epidemiology of asthma in Australia. Robertson recently reported a 26% decrease in the prevalence of asthma in Melbourne school children between 1993 and 2002, but increased reporting of rhinitis and eczema over the same period.1 The significance of these findings is difficult to interpret without measures of airway function. A second study supported these results and also observed a small decline in the prevalence of parent-reported asthma, but found little change in atopy or airway hyperresponsiveness.2 Age-adjusted hospital separation rates for asthma decreased by 31.1% in young people and 31.4% in all ages between 1989–90 and 1999–00.3 There is little evidence of improved management of asthma in the general practice setting. Data published from the BEACH (Bettering the Evaluation and Care of Health) survey of general practice activity indicates a significant reduction in rates of presentation for asthma among children but not adults, with no changes in indicators of severity over time.4 Our recent research in south-western Sydney, examining uptake of the “asthma 3+ visit plan”5,6 by general practitioners and their patients, is disappointing. It suggests reluctance on the part of both GPs and patients to participate in the plan. Clearly, there remains much that we do not understand about the natural history of asthma.7 We need to continue to monitor asthma through regular surveys and routine data collection in order to understand more about fluctuations in asthma prevalence, the relationship to changing child-rearing practices (such as use of childcare facilities) and the impact of management practices. Asthma mortality in Australians aged 5–34 years, 1920–2002* * Points on the graph represent 3-year “moving” averages — for example, the 2001 value is the average of 2000, 2001 and 2002 data; the 2000 value is the average of 1999, 2000 and 2001 data, etc. This technique is used to smooth annual fluctuations that occur in data of this kind.

Elizabeth J Comino

John R Gowardman,* Maria Brosnan,† Joy Whiting,‡ Peter Collignon§ * Intensive Care Physician, † Medical Student, ‡ Data Manager, Intensive Care Unit, § Director, Infectious Diseases Unit and Microbiology Department, The Canberra Hospital, PO Box 11, Woden, ACT 2607. peter.collignonATact.gov.au To the Editor: In most serious infections associated with intravascular devices, the device is a central venous catheter (CVC).1,2 Good clinical practice dictates that these devices should be removed when no longer needed.3 Our intensive care unit maintains a clinical practice of prompt removal of CVCs once they are no longer required. In addition, CVCs are to be removed before patients are discharged from the unit (for “general” patients) or within 24 hours (for cardiothoracic surgical patients). We conducted an audit to determine how often this practice was followed and whether it had unintended adverse clinical consequences (eg, need to reinsert a CVC). The audit was conducted over 8 weeks in 2001 and included 126 CVCs in 103 patients. Fifty-eight CVCs (46%) were removed by the predetermined time, and 68 (53%) were retained past this time (Box). The data demonstrated: Low removal rates, with 31% (23/74) of CVCs removed in general patients, but higher rates in cardiothoracic surgical patients (67%; 35/52). APACHE II scores, ventilation times and lengths of stay in the intensive care unit were similar in the group who had the CVC removed and the group who retained the CVC, implying that severity of illness was not a factor biasing retention. Among patients who had a CVC removed, none had another CVC reinserted; cannulation rates with short peripheral catheters were low and acceptable. Retention of the CVC past the predetermined time resulted in significant prolongation of CVC in-situ time (eg, general patients 7.0 v 3.2 days). The reason given for CVC retention in general patients was antibiotic administration for 37/40 (93%) (vancomycin, 6; β-lactams, 20; aminoglycosides, 9; and quinolones, 2), while total parenteral nutrition and poor peripheral access were factors in only seven (18%). In the 13 cardiothoracic surgical patients, the reason given was inotrope infusion in four (30%) and amiodarone infusion in four; no reason could be ascertained in the other five. Two issues emerge from this audit. Firstly, there did not appear to be good reasons for retaining many of these CVCs. Drug therapy was most often quoted, but many of these drugs (antibiotics and amiodarone) could have been safely administered via a short peripheral intravenous cannula, with markedly lower risk of infection.2-5 We believe that when a patient left the intensive care unit with a CVC, it most likely remained in place as a “convenience” factor for busy nursing and junior medical staff on the wards. However, this was at the cost of a significant increase in CVC in-situ times, increasing the risk of both mechanical and infectious complications. Secondly, implementation of predetermined CVC removal appears safe in our hospital. Although removal rates were lower than expected, nearly half of all CVCs inserted over the 8-week study period were removed as per “clinical practice”, without any need for CVC reinsertions. We have now further refined our clinical practice and introduced a formal written policy that: All CVCs should be removed and replaced with a suitable alternative before patient discharge from the intensive care unit, unless there is a specific indication for retention. Retention of a CVC should be based on simple guidelines, such as need for total parenteral nutrition, poor peripheral venous access, or use of drugs that require central access. We recommend implementation of this simple policy in other intensive care units. Characteristics of patients and central venous catheters (CVCs) in the audit General ICU patients Cardiothoracic patients CVC removed CVC retained P CVC removed CVC retained P Number of patients 20 40 30 13 Number of CVCs 23 51 35 17 APACHE II score (mean [SD]) 14 (3) 16 (6) 0.13 13 (4) 13 (2) 1.00 Length of ICU stay (d) (mean [SD]) 3.9 (5.4) 2.4 (3.5) 0.2 1 (0) 2.1 (3.7) 0.1 Ventilation time (h) (mean [SD]) 61 (86) 47 (51) 0.5 17 (3.5) 20 (15.6) 0.3 % Of patients ventilated* 60% 41% 100%‡ 100%‡ CVC in-situ time (d) (mean [SD]) 3.2 (3.2) 7.0 (5.6) 0.003 2.1 (0.25) 4.5 (3.8) 0.001 Number of peripheral IV catheters† (mean [SD]) 1.8 (1) 0.6 (0.6) < 0.001 0 0.07‡ Number of CVCs reinserted 0 na 0 na ICU = intensive care unit. IV = intravenous. na = not applicable. * Mechanically ventilated in the intensive care unit. † At 7-day follow up. ‡ Only one peripheral catheter was inserted in one patient.

John R Gowardman · Maria Brosnan · Joy Whiting · Peter Collignon

Jennifer H Barralet,* Neil R Parker† * Epidemiologist, Communicable Diseases Unit, † Public Health Physician, Darling Downs Public Health Unit, Queensland Health, GPO Box 48, Brisbane, QLD 4001. Neil_ParkerAThealth.qld.gov.au To the Editor: Queensland has a small but increasing number of Q fever notifications in children. This is of concern to public health services in the Darling Downs and south-west Queensland where most Q fever notifications originate (Box). Little is known about Q fever in children, especially in Australia, as the disease is primarily diagnosed in adults following occupational exposure to Coxiella burnetii. Here we report a case series examining clinical presentation, exposure to risk factors and disease outcomes in children. Twenty-one children aged 3–14 years notified with Q fever from the Darling Downs and south-west Queensland in 2001 and 2002 were followed up. In acute cases the febrile illness was similar to that in adults from the same region. The one child with chronic Q fever had no known acute illness and presented with osteomyelitis of the wrist. All the children recovered, although relapsing symptoms were reported in two children and three reported persisting fatigue for 3 months or more after diagnosis. All but one patient reported contact with cattle, sheep or goats (13 lived on a farm and 7 had visited a farm). The single exception reported contact with kangaroos and feral pigs through hunting. Prolonged exposure to animals or the farm environment was not necessary for infection. Twelve of the children had high risk exposure to C. burnetii (contact with animal births, newborn animals, or animal carcasses). With increasing age, exposure of children from rural properties approaches that of their parents as they participate in the same activities. An effective vaccine is available,1 but use in people younger than 15 years is not recommended because of the lack of safety and efficacy data. Although avoidance of high risk situations such as shearing, animal births or on-farm butchering will decrease the chance of infection, these measures may be impractical for rural children. Realising this, some practitioners choose to vaccinate younger children who assist with animal births and butchering. Increasing notifications in children may reflect increased awareness that Q fever is not confined to adults with occupational exposures. Increased awareness leading to recognition of infection would give children access to effective treatment and may contribute to prevention of chronic disease. However, much remains unknown about Q fever in children, including how often the infection is asymptomatic, the spectrum and outcome of disease, and if there are effective preventive strategies. As many rural children cannot avoid potential exposure to Q fever, our study highlights the need for a safe and effective vaccine for children. Q fever notifications in children aged 0–14 years, 1997–2002

Jennifer H Barralet · Neil R Parker

Nicola Petrosillo,* Vincenzo Puro,† Giuseppe Ippolito‡ * Clinical Director, † Epidemiologist, ‡ Scientific Director, National Institute for Infectious Diseases “L. Spallanzani”, Rome, 00149, Italy. petrosilloATinmi.it To the Editor: In their article describing the Australian experience of border screening for severe acute respiratory syndrome (SARS), Samaan and coworkers add new insights about the low efficacy of this measure in identifying SARS cases at entry into a country.1 To our knowledge, this is the first report on this issue from a low-risk area for SARS.2 Indeed, as summarised by Samaan et al, other available data derive from countries where people with SARS, entering at the early stage of the epidemic, generated a sustained local transmission of SARS-associated coronavirus (SARS-CoV) disease. Among the reasons for a low sensitivity of entry screening, Samaan suggests that subjects may evade screening by making false declarations or by taking anti-pyretic drugs, or by simply being in the incubation period with no symptoms or only mild symptoms. To contribute to this debate, we report the experience of our Institute, which was designated as a referring centre for SARS by the Italian Ministry of Health. In Italy, where only four imported probable cases of SARS were identified and no local transmission occurred,3 entry screening was implemented at the two international airports of Milan and Rome. In particular, travellers and crews arriving from World Health Organization SARS-designated areas, directly or after transiting in other EU countries, were provided with health alert cards and screened for body temperature.4 Suspected SARS cases identified at Rome airport were to be referred to our institute. However, of the 72 subjects attending our admission unit for clinical evaluation for possible SARS, none was referred by the airport authorities. Among these patients was one of the four people with SARS arriving in Italy: an airline flight crew member coming from a SARS-designated area who passed both exit and entry screening, despite complaining of mild fever before his departure. He was admitted 6 days after arrival, at which time the clinical picture had evolved into full-blown SARS. He was discharged after 2 weeks. Among the measures recommended by WHO to reduce SARS-CoV spread, the identification of symptomatic subjects at border departure screening was the only measure with some evidence of efficacy, although this only reduced on-flight transmission.5 Conversely, evidence from several sources, including Samaan et al, showed that screening travellers (visual inspection and screening for fever) as they disembark identifies very few SARS cases and is of questionable value.1 We agree with the conclusions of Samaan et al that, in the light of a possible resurgence of SARS or similar diseases (avian flu), entry screening should, at least, be more focused, and needs further evaluation, including cost-effectiveness analysis.

Nicola Petrosillo · Vincenzo Puro · Giuseppe Ippolito

Julia E Fawcett,* Anthony P Shakeshaft,† Mark F Harris,‡ Alex Wodak,§ Richard P Mattick,¶ Robyn L Richmond** * PhD Candidate, † NHMRC Research Fellow, ¶ Director, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052; ‡,** Professors, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW; § Director, Alcohol and Drug Service, St Vincent's Hospital, Sydney, NSW. A. ShakeshaftATunsw.edu.au To the Editor: Revised Australian Alcohol Guidelines1 were released in 2001. Although general practitioners (GPs) can be influential in initiating and supporting behaviour change to reduce levels of alcohol misuse among their patients,2,3 the extent to which their advice remains relevant and effective depends largely on the extent to which screening tools can be modified to take account of revised versions of such guidelines. The Alcohol Use Disorders Identification Test (AUDIT)4 is a clinical instrument used widely to screen patients for problematic alcohol use. The aims of our study were to examine the ability of AUDIT to classify general practice patients’ alcohol consumption into the categories specified in the revised Australian guidelines, and to identify any additional information needed for such classification. Patients aged at least 16 years attending a general practice surgery in western Sydney were asked by receptionists to complete a health-related survey by means of a hand-held computer while waiting for their consultation. Items covered a number of domains, including demographics, the AUDIT, and two additional questions about consumption of specified quantities of alcohol. The use of computers ensured patients were only asked questions relevant to them. Risk of harm in the long term: Respondents’ average number of standard drinks per week was calculated from the first two AUDIT questions, using a previously devised method.5 Risk of harm in the short term: AUDIT question 3 is not specific enough to distinguish short-term risk of harm, so additional, sex-specific questions on how many occasions in the previous 30 days the patient had consumed “7–10” and “11 or more” (men) or “5–6” and “7 or more” (women) standard drinks were asked. Of the 115 patients who completed the survey, 62% were female; their mean age was 42 years; 10% were unemployed; 34% had had tertiary education; 65% were married or in a de facto relationship; and 80% were born in Australia. Their alcohol consumption patterns are shown in the Box. AUDIT is a reliable and valid instrument, and is widely used as a clinical tool. However, as national guidelines are updated, clinical tools such as AUDIT need to remain consistent with them. Ideally, revisions would build on the benefits of existing tools rather than rendering them obsolete. For example, a major advantage of AUDIT is that it measures a number of drinking dimensions within the one, brief, validated instrument. This multidimensionality could be preserved while promoting AUDIT’s consistency with new guidelines by adding two items, with high face validity, to more accurately assess risk of harm in the short term. Incorp-orating the two additional consumption items we used in this study with AUDIT allows drinkers to be classified according to the guidelines as “low-risk”, “risky” or “high-risk” both in the long term and short term, with minimal additional response time. Alcohol consumption patterns in one general practice in western Sydney, as defined by the recently revised Australian Alcohol Guidelines1 Characteristic Males (%) Females (%) Total (%) Abstinent 18.2 29.6 25.2 Long-term harm Low-risk 68.2 67.6 67.8 Risky 11.4 1.4 5.2 High-risk 2.3 1.4 1.7 Short-term harm Low-risk 61.4 52.1 55.7 Risky 9.1 8.5 8.7 High-risk 11.4 9.9 10.4 Bold text represents categories that cannot be distinguished using AUDIT alone.

Julia E Fawcett · Anthony P Shakeshaft · Mark F Harris · Alex Wodak · Richard P Mattick · Robyn L Richmond