Letters

Simon G A Brown Emergency Physician, Fremantle Hospital & Health Service, and Clinical Senior Lecturer in Emergency Medicine, University of Western Australia, Department of Emergency Medicine, Fremantle Hospital, Alma Street, Fremantle, WA 6160. simon.brownAThealth.wa.gov.au To the Editor: Gawarammana et al present an interesting study of premedication to prevent adverse reactions to snake antivenom,1 but I have concerns with the data presentation and analysis. The 95% confidence intervals presented in Box 3 of their article are impossibly narrow. For example, recalculation of the first cell (hypotension rate for treatment A) by the binomial method gives a 95% confidence interval of 12%–62%, not 30%–36% as presented. Also, my analysis of the aggregate endpoint differs. Using the Fisher exact test to compare reaction rates in the hydrocortisone + antihistamine group (11/21) with placebo (13/16), for the difference in proportions of 0.29 I obtain a 95% confidence interval of 2 0.04 to 0.58. This has a P value of 0.14 using a 2-tailed test, according to the program Analyse-it.2 This comes as no surprise given that steroids take hours to work, and that histamine is just one of many mediators released during anaphylaxis, rising early and only transiently during severe and protracted anaphylactic reactions.3 Although antihistamines reverse the effects of histamine infusions which mimic anaphylaxis, animal studies indicate that they are ineffective for treating anaphylaxis mediated by mast-cell degranulation.4,5 Human studies have shown that H1 blockade is useful in preventing mild reactions to immunotherapy that are confined to the skin, but do not appear to prevent severe reactions.6,7 One human study has compared H1 + H2 blockade with H1-only blockade for the management of mild allergic reactions, finding a small benefit of combined H1 + H2 blockade.8 However, a confounder was that adrenaline was administered more frequently in the combined H1 + H2 antihistamine treatment group. A study of reactions to immunotherapy has failed to show any benefit from H1 + H2 blockade.7 I suspect that, instead of proceeding to study combination prophylaxis with antihistamines, steroids and adrenaline, it might be better to examine the preparation for and management of allergic reactions to antivenom. Many doctors fear intravenous adrenaline infusions, but in our experience this approach to managing anaphylaxis is safe, well tolerated and immediately effective, without the unpredictable, unpleasant, and (in the setting of venom-induced coagulopathy) potentially dangerous side effects sometimes seen with intramuscular, subcutaneous and intravenous bolus injections.9 Perhaps it is time for a trial of premedication with subcutaneous adrenaline versus an “as required” approach using a carefully titrated intravenous infusion.

Simon G A Brown

S Abeysingha M Kularatne,* Indika B Gawarammana† * Senior Lecturer, † Lecturer, Department of Medicine, Peradeniya University, Sri Lanka. samkulATsitnet.lk In reply: Brown has pointed out some interesting observations about antihistamines and mediators such as histamine, released during anaphylactic reactions. First, we must address the statistical issues. We are grateful to Brown for detecting an important error in Box 3 of our article.1 When we were asked to calculate confidence intervals for the percentages, we used a formula recommended by Spiegel.2 As this formula was not available in our software packages, we programmed it ourselves. We made an error in our programming and we apologise for this. (See Correction, page 428.) For the difference in reaction rates for the treatment regimens, we used the following calculation. The difference P1 – P2 = − 0.2887 To calculate the confidence interval, we calculated the standard error (SE) of the difference by the following formula. This interval does not include 0, so Brown’s P value of 0.14 is not reasonable. We do accept that the statistical significance is marginal. We agree that antihistamine is ineffective as a prophylactic agent in anaphylaxis. This was observed in studies in Sri Lanka and Brazil, where chlorpheniramine and promethazine, respectively, were used to prevent reactions to antivenom.3,4 However, we defended the observed reduction of mild to moderate acute reactions to antivenom in our study by highlighting the counter-effect of antihistamine on released histamine after mast-cell degranulation.1 Our study was to test the usefulness of an established practice in Sri Lanka, where steroid infusion is used to counter reactions to antivenom. The crux of the problem is the highly antigenic antivenom preparations used in Sri Lanka, despite ever-increasing reaction rates, because of the lack of facilities for developing purified antivenom. The proposal of using intravenous adrenaline infusion to reduce allergic reactions is novel and exciting. This should be tested by randomised controlled trials.

Indika B Gawarammana

Val J Gebski Principal Research Fellow, NHMRC Clinical Trials Centre, Level 5, Building MO5, Mallett Street Campus, University of Sydney, NSW 2006. valATctc.usyd.edu.au Comment: Kularatne and Gawarammana compared the proportion of side-effects given in their table above using the well-known (and easily understood) test of the difference between two proportions using the normal distribution. However, as each of these proportions follows a binomial distribution (13 “successes” out of 16 trials and 11 “successes” out of 21 trials), the normal approximation is only useful if the number of trials is greater than 30. Because of the small sample sizes, “exact” methods better reflect the true difference (in terms of P values and confidence intervals) between the two proportions. The more complicated methods (different formulations of the exact test) and the resulting confidence intervals provide a clearer indication of whether the proportions are indeed different (statistically). In this instance, the evidence is not sufficient to declare the two proportions statistically different.

Val J Gebski

Michael A Quinn Director, Oncology and Dysplasia Unit, Royal Women's Hospital, 5th Floor, 132 Grattan Street, Carlton, VIC 3053. michael.quinnATmaynegroup.com To the Editor: A recent article by Zorbas et al1 highlights some of the many difficulties experienced by Australian women in accessing multidisciplinary care after they have been diagnosed with breast cancer. A multidisciplinary approach to women with gynaecological cancer has been the cornerstone of care since the establishment of gynaecologic oncology units in Australia in the early 1980s. Over 20 years’ experience has reinforced the value of this approach. By and large, however, the success of this model has very much depended not only on the skills of the multidisciplinary team but also on the readiness of referring doctors — in this case, specialist gynaecologists — to refer patients for management that is often surgical and could easily be done by themselves. Reinforcing the concept that care of the patient is holistic and that surgery plays an important (but not definitive) role in overall care has led to increased referrals, but there are still many to convince. For instance, a survey published in the Journal in 20022 showed that in the late 1990s more than half the women with ovarian cancer in Victoria were still being operated on outside established gynaecologic oncology units or by a non-gynaecological oncologist. It is to be hoped that new National Health and Medical Research Council guidelines on the management of ovarian cancer (soon to be released) will reduce this deficit and thereby improve outcomes for women with ovarian cancer. Much of the development of this benchmark care has come from patients, who, thankfully, are becoming increasingly articulate in their expectations of optimal clinical outcomes. The question of rural patients is an extremely important one. In Victoria, over a period of more than 10 years, the three major metropolitan gynaecologic oncology centres have established satellite clinics in country towns to facilitate patient follow-up, often involving local specialists and family doctors. This system seems to have worked well and is worthy of assessment as a model that might be transferable to other specialties. In conclusion, it is all very well setting up multidisciplinary teams, but the key to their success has to be the recognition of professional equality. If teams are based on a hierarchical setup they are likely to fail in their major aim, which is to provide the best care available based on input from a broad range of professionals and from patients themselves.

Michael A Quinn

Susan C Pendlebury,* Katherine J Clark,† Martin H N Tattersall‡ * Radiation Oncologist, † Palliative Care Physician, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050; ‡ Professor of Cancer Medicine, University of Sydney, Sydney, NSW. spendlebATemail.cs.nsw.gov.au To the Editor: Zorbas et al1 have highlighted both the complexities and resource intensiveness of multidisciplinary care for women with early-stage breast cancer. The same arguments exist in advanced disease, where input from many disciplines is the norm. However, there is no evidence that such a process improves outcomes in the Australian setting. The references the authors draw upon relate to regions in which breast cancer outcomes have historically been poor. Evidence from Australian studies suggests higher standards of care and appropriate changes over time. 2,3,4 The National Health and Medical Research Council (NHMRC) Clinical practice guidelines for the management of early breast cancer5 provide an evidence-based strategy for managing the disease. Enshrined within them is the concept that many different treatment approaches are equivalent and that patient preferences are important. Patient input into multidisciplinary case conferences is frequently minimal. Case conferences can be confusing for patients, and it may not be clear to them who is their doctor. Many clinics include a breast nurse, who commonly acts as a patient advocate. Zorbas and colleagues note the different models of multidisciplinary care, but the minimum approach required to achieve good outcomes has not been established. It is not surprising that 34% of rural surgeons find it difficult to implement a service in which all women have access to a full range of treatment options in a multidisciplinary setting. There is no evidence, however, that their patients are more unhappy or that management outcomes are inferior. Similarly, the guidelines correctly promote the importance of psychosocial support for patients, but the suggestion that this can be better achieved by a psychologist via teleconferencing rather than by the patient’s general practitioner is purely speculative. None of the multidisciplinary models suggested by Zorbas et al addresses the management of patients at relapse, and yet data and clinical experience indicate this is the time of greatest stress for patients, 6 a time when input from a number of specialties — medical care, radiation oncology, palliative care — is the norm. Multidisciplinary care appears to be beneficial regardless of the stage of disease. However, the execution of some of the models is resource-intensive. We need to evaluate not only whether the objectives of the NHMRC guidelines are met, but whether patient satisfaction and participation are enhanced, survival outcomes are improved and care through all stages of the disease is optimal. Currently, by such measures, multidisciplinary care has not been shown to be superior to a small number of well-directed, evidence-based selective consultations.

Susan C Pendlebury · Katherine J Clark · Martin H N Tattersall

Helen M Zorbas,* Bruce H Barraclough,† Katherine J Rainbird,‡ Karen A Luxford,§ Sally Redman¶ * Clinical Director, ‡ Manager, Treatment Program, § Program Director, National Breast Cancer Centre, Locked Bag 16, Camperdown, NSW 1450; † Director of Cancer Services, Department of Surgery, Royal North Shore Hospital, St Leonards, NSW; ¶ Director, Institute for Health Research, Sydney, NSW. karenlATnbcc.org.au In reply: We agree with the comments by Pendlebury et al that knowledge about outcomes for patients receiving multidisciplinary care in Australia is limited. Hence, the National Breast Cancer Centre has investigated the application of multidisciplinary care and outcomes for women with breast cancer. Our article focused on the “Principles of multidisciplinary care” developed as a basis for a subsequent project (outcomes yet to be published). It was necessary to define such principles at the outset, as there is not yet an agreed view about what constitutes “multidisciplinary care” within the Australian healthcare context. We also agree that the standard of clinical care in Australia is generally good. However, delivery of care is often fragmented and inconsistent.1 In other countries with high quality services, multidisciplinary meetings have been found to result in care that is more in accord with the evidence than non-multidisciplinary care.2 The Principles emphasise the role of the general practitioner, while recognising that some patients will require appropriate specialist referral.3 They also state that living in a rural area should be no impediment to accessing care. We agree that multidisciplinary care is as important in advanced breast cancer as it is in early disease. The Principles were developed before the release of the guidelines for advanced breast cancer and it would be useful to extend them in the future. The importance of one main contact for women is acknowledged. The purpose of a multidisciplinary case conference is to identify treatment options and their relative merits. This ought to assist communication with women and enable them to make a more informed choice.

Helen M Zorbas · Bruce H Barraclough · Katherine J Rainbird · Karen A Luxford · Sally Redman

John Fraser,* Christian Alexander,† Berniece Simpkins‡ * Director, † Senior Research Fellow, ‡ Health Career Promotion Project Officer, New England Area Rural Training Unit, New England Area Health Service, PO Box 83, Tamworth, NSW 2340 jdfraserATdoh.health.nsw.gov.au To the Editor: We read with interest the recent article concerning Australian medical workforce issues.1 Brooks et al comment on feminisation, lifestyle changes, increased community demand and globalisation as major issues for the future medical workforce. Here, we present data from recent rural high school health career promotion activities, describing student interest in health careers. These data further support this trend in feminisation. Promotion of health careers in high schools is a core long-term rural workforce strategy in Australia.2 It is justified, as rural origin is an important predictor of medical graduates pursuing a rural health career.3 The New England Area Rural Training Unit (NEARTU) promotes rural health careers to school students, undergraduates and postgraduates in north-west New South Wales. Multidisciplinary regional health career expos were offered to all high school students in Years 9 to 12 from 2000 onwards in the regional centres of Armidale, Tamworth and Moree. Medical, nursing and allied health professionals and undergraduates (of both sexes) staffed the expos. Inquiries were recorded by sex, year at school and health career. Students could enquire about multiple careers. In 2000, 453 high school students (394 female; 59 male) expressed an interest in health careers at expos. The Box displays that, for both female and male Year 9 to Year 11 students, interest in a nursing career far exceeds interest in either allied health or medicine, and, for Year 12 students, an interest in allied health far exceeds interest in either nursing or medicine. Enquiries were more frequent from females than from males, ranging from just over four times (medicine) to eight times more frequent (nursing). In 2000, 60% of these students’ enquiries (270 enquiries) referred to nursing, 33% (151 enquiries) referred to allied health and 7% (32 enquiries) referred to medicine. Compared with the Australian Bureau of Statistics 2001 data, which showed a 50.4 to 49.6 ratio of females to males in the region’s high schools, our increased interest by females is statistically significant (P < 0.01). In other careers projects by NEARTU in 2000–2002 (eg, work experience placements, and health career promotion at local agricultural field days), similar sex differences were observed (female-to-male ratio range, 10:1 to 3.5:1). Increased interest by female high school students is consistent with other reports of high school students’ health career preferences in the United States. 4,5 Registering interest is only the first step in considering a health career. The higher proportion of females expressing this interest in rural high schools is important for rural workforce planning. Interest in health careers by high school students in 2000

John Fraser · Christian Alexander · Berniece Simpkins

Andie S Lee,* John R Dyer† * Registrar, † Senior Infectious Diseases Physician, Department of Microbiology and Infectious Diseases, Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042. John.dyerATfmc.sa.gov.au A 79-year-old man presented with 5 days of right-leg pain, high fever, severe headache and deteriorating conscious state. He was previously fit and healthy and took no medications. The patient appeared unwell, had a temperature of 39.5°C, moderate irritability and depressed conscious state. There was marked neck stiffness and his left wrist and right knee joints appeared swollen and inflamed. There was a cardiac systolic murmur, but no stigmata of bacterial endocarditis. Aspirates of the left wrist and right knee yielded purulent fluid containing numerous gram-positive cocci. The patient was admitted to the intensive care unit and treated with high dose benzylpenicillin plus vancomycin. A cerebral computed tomography scan was normal; lumbar puncture was not performed. The affected joints were washed out within 24 hours. All cultures of blood and synovial fluid yielded a Lancefield Group C β-haemolytic streptococcus, identified further using the ID 32 Strep strip (BioMerieux, Marcy l’Etoile, France) as Streptococcus equi subspecies zooepidemicus (S. zooepidemicus) based on its ability to ferment sorbitol and not trehalose. This isolate was shown to be sensitive to penicillin (minimum inhibitory concentration, < 0.1 mg/L). Intravenous penicillin therapy was continued. Transoesophageal echocardiography showed echodensities close to the aortic valve which suggested vegetations. The patient’s condition improved steadily, and he ultimately received intravenous antibiotics for 6 weeks. Further history revealed that the patient collected fresh horse manure for his garden daily from a local paddock. He reported no direct contact with animals or ingestion of unpasteurised dairy products. S. zooepidemicus could not be cultured from a single specimen of horse manure collected from the paddock, and it was not possible to collect clinical specimens directly from any of the horses that used the paddock. Human infection with S. zooepidemicus can usually be traced to an animal source.1 Outbreaks associated with ingestion of unpasteurised milk and cheese have also been described.2,3 Likely entry routes include the respiratory or gastrointestinal tract and skin.1 Severe sequelae of S. zooepidemicus infection include endovascular infection, meningitis, septic arthritis, and epidemic post-infectious glomerulonephritis. Our patient’s clinical picture indicated multifocal sepsis, with polyarthritis, endocarditis, and probable meningitis. In a recently reported case of S. zooepidemicus meningitis, pulsed-field gel electrophoresis showed molecular identity between patient isolates and a throat swab isolate from a horse with which the patient had been in close contact.4 Our patient was most likely infected via the respiratory or cutaneous routes, or by ingestion after contact with respiratory secretions of horses deposited in the environment. Exposures in the garden can lead to a variety of severe infections.5 This is the first reported case where S. zooepidemicus infection appears to have been acquired through gardening. Severe disease with this organism can be a particular hazard in elderly gardeners with comorbid conditions.1

Andie S Lee · John R Dyer

John Coutsouvelis,* Carmela E Corallo† * Oncology Pharmacist, † Deputy Director of Pharmacy, Box Hill Hospital, Nelson Road, Box Hill, VIC 3128. John.coutsouvelisATboxhill.org.au To the Editor: Thalidomide has recently been approved for use in treating recurrence of erythema nodosum leprosum and multiple myeloma after failure of standard therapies. Common side effects of thalidomide treatment include drowsiness, sedation, rash and paraesthesiae.1 Dizziness, hypotension and bradycardia occur less commonly.1-3 Of 91 patients treated with thalidomide (80 with multiple myeloma), we have had one case of symptomatic bradycardia. We describe this patient, who was able to continue treatment on a reduced dose of thalidomide. A 71-year-old woman, with a history of breast cancer (treated with radiotherapy and tamoxifen), arthritis, crush fractures, and hip and knee replacement, was diagnosed with multiple myeloma. She was prescribed intravenous pamidronate 90 mg every month and oral therapy with melphalan, but she experienced haematological toxicity and the melphalan was stopped. After progression of the disease, 100 mg of thalidomide was commenced at night, with the aim of increasing the dose by 100 mg every fortnight until a response was achieved. Three weeks later, the patient presented to hospital for pamidronate infusion complaining of a 2-week history of shortness of breath, especially on exertion. There was no oedema present, and her blood pressure was 135/70 mmHg. Electrocardiography showed sinus bradycardia, with a heart rate of 46 beats/min. The dose of thalidomide had been titrated to 200 mg at night. Thalidomide was stopped, and the patient was referred to a cardiologist, who performed an echocardiogram, 24-hour Holter monitoring and a stress test. The results from these tests showed no underlying cardiac disease or abnormalities. Six weeks later, on review, the bradycardia had resolved (heart rate, 60 beats/min). Thalidomide was recommenced at 100 mg daily. However, after a further 6 weeks, her heart rate had decreased again to 45 beats/min, and the dose of thalidomide was reduced to 100 mg on alternate days. Thalidomide therapy has been continued in this patient at 100 mg on alternate days. Her heart rate has stabilised between 50 and 55 beats/min, and she has remained asymptomatic. The multiple myeloma is responding to treatment, as indicated by symptom control and serial measurements of IgG kappa. She continues to take hydroxychloroquine, rofecoxib and sertraline. Bradycardia is a rare side effect of thalidomide therapy, with an incidence of 0.12%.1,2 The mechanism is unknown, but could be related to thalidomide’s central sedative effect.1 There are isolated published case reports of thalidomide-induced bradycardia; in all cases the drug was stopped.2-5 Thalidomide is being used for various conditions for which no alternative therapy exists. As the drug is now commercially available in Australia, its use is likely to increase. In all patients taking thalidomide, we recommend measuring heart rate; and in those with underlying heart disease, or who are taking medications that can precipitate bradycardia, we recommend electrocardiographic monitoring. Our findings in this patient suggest that thalidomide-induced bradycardia can be successfully managed with dose reduction and regular monitoring.

John Coutsouvelis · Carmela E Corallo

Kerry-Ann F O’Grady,* Terence M Nolan† * Senior Research Officer, Vaccine and Immunisation Research Group, Murdoch Children’s Research Institute, Flemington Road, Parkville, VIC 3052; † Head, School of Population Health, University of Melbourne, Melbourne, VIC. k.ogradyATunimelb.edu.au To the Editor: In Australia, personal and health information that identifies an individual cannot be used or disclosed for research without specific requirements being met.1 Even if these requirements are met, data custodians may still refuse access if their views are discordant with those of the relevant human research ethics committee (HREC). It is now evident that there are adverse consequences of this well-meaning legislation. Our research group conducts community-based vaccine trials. Recently, we attempted to use school enrolment lists to mail information to parents about a study. Despite approval from the Royal Children’s Hospital HREC, one major governing body of Victorian public schools rejected our proposal on privacy grounds, as did several independent schools. Only a small number of schools raised no privacy concerns at all. The main concern expressed was that the use of these registers for health research was not related to the primary purpose of collection, and families had not consented to this use. The net result was substantially reduced access to the population eligible for recruitment. We now have a situation in which the legislation may actually do more harm than good. This is an emerging issue here in Australia and overseas.2,3 Even more worrying are the findings of an Australian survey in which 61% of adults believed that even their de-identified health information should not be used for research purposes without their consent.4 Health research is dependent on access to population datasets to recruit participants, monitor health indicators, identify risk factors and inform interventions. Non-representative access threatens a study’s validity, resulting in poorly informed interventions, policy and funding decisions. The situation may now have progressed beyond reasonable trade-offs between the public good and individual privacy to the point where important research cannot be done at all, and the opportunity for advances in health are lost. Despite statutory guidelines,1,5 there are widespread differences in interpretation of the legislation, particularly regarding the terms “practicable” and “public good”. Amendment of the legislation in this respect is therefore urgently required, together with clauses which facilitate a researcher’s ability to inform the public of a particular project and enable individuals, not organisations, to decide whether they wish to participate. There needs to be greater effort in gaining public understanding of the legislation and its intent with respect to research. In addition, upfront declarations and “opt-out” clauses about the use of personal information for health research must also be included in the privacy statements that organisations are now legally required to provide to individuals at the point of data collection.

Kerry-Ann F O’Grady · Terence M Nolan

Paul Chadwick,* Beth Wilson† * Information Privacy Commissioner, † Health Services Commissioner, Office of the Victorian Privacy Commissioner, GPO Box 5057, Melbourne, VIC 3000. enquiriesATprivacy.vic.gov.au In reply: We are familiar with concerns such as those expressed by O’Grady and Nolan, and we are grateful for this opportunity to respond, so that readers can consider the views side by side. Privacy is not new. Ethical obligations of confidentiality in medical settings date back to Hipprocrates. New privacy legislation — Health Records Act 2001 (Vic); Information Privacy Act 2000 (Vic); Privacy Act 1988 (Cwlth) — clarifies these obligations and also sets a higher standard of accountability. (Other states and territories also have legislation or are contemplating it.) The new laws cover all sorts of personal information, but health information is especially delicate. Wrongly handled, it can lead to discrimination — not just embarrassment or loss of dignity. In Victoria, this was recognised by Parliament when it passed the Health Records Act as a separate piece of legislation to deal specifically with health information. The policy behind the privacy laws is aimed at promoting trust between health service providers and the public by reassuring them that their personal information will be respected, particularly in an electronic age in which information can be speedily transmitted far and wide. If surveys show the public to be wary about the use of their health information for research, it would seem to be in the best interests of the research community to embrace new standards rather than to seek to unravel or avoid them. Privacy legislation was drafted after extensive consultation, taking into account competing factors and the need to balance respect for privacy with other public interests, including research. Research is very important, and privacy is a cherished and longstanding value. Reputable research can coexist with the recent statutory expressions of privacy, just as reputable research has always coexisted with respect for privacy. Many data custodians perhaps do not yet realise that privacy laws rarely require an existing legitimate practice to cease completely, but rather may require the practice to be adapted to meet new standards. For example, for researchers seeking to recruit subjects for a study, the data custodian may disseminate the researchers’ initial letter rather than hand over lists of names and addresses to researchers. Once recipients opt in, direct consensual dealings with the researchers proceed as usual. Researchers can always use properly de-identified information, or they may use information with the consent of the subject. As with all new laws, the privacy laws will become better understood with time and experience. Some data custodians are understandably overcautious, while others have blamed privacy laws for preventing them from providing information in situations in which disclosure is permitted. Many adapt with ingenuity and effectiveness. Privacy Commissioners and the Health Services Commissioner are available to explain the laws. We, along with everyone with an interest in collecting and using the sensitive information of others, must recognise and consider the subtleties inherent in balanced privacy protection.

Paul Chadwick · Beth Wilson

Robert N Atkinson Orthopaedic Surgeon, 135 Hutt Street, Adelaide, SA 5000. wattle135ATozemail.com.au To the Editor: In response to Leeder,1 there is no community in this world that can provide free, at the point of contact, healthcare for all its citizens to the current limits of modern medical technology. This problem will in fact become greater as the technology increases and becomes more expensive. Within the available healthcare resources, there is some medical treatment that is essential and there is some that is quality-of-life treatment; where the two merge depends on one’s point of view. If you choose to play sport and injure your knee, the question of who should pay for the treatment arises. If you smoke or have any other lifestyle risk factors, how much should be funded by you, and how much by others? And, within a healthcare system where there is patient contribution, does this contribution empower and encourage individuals to adopt a healthy lifestyle? In essence, I believe the debate in healthcare should be about accessibility of limited resources. Who draws the line, how is the line drawn, and at what level is it drawn? Pouring money into the public health sector may well parallel the analogy of adding another lane to the motorway. We must be careful to share the responsibility of healthcare between the individual and the healthcare providers in an inclusive and not exclusive manner.

Robert N Atkinson

Elizabeth Harris,* Sarah J Simpson,† Rosemary Aldrich,‡ Jenny Stewart Williams§ * Director, † Program Manager, Centre for Health Equity Training Research & Evaluation (CHETRE), University of NSW, LMB 7103, Liverpool BC, NSW 1871. ‡ Conjoint Academic, School of Medical Practice and Population Health, § Research Officer, Newcastle Institute of Public Health; University of Newcastle, Newcastle, NSW. elizabeth.harrisATswsahs.nsw.gov.au To the Editor: Leeder rightly points out that increased funding of the healthcare system does not necessarily result in improved equity within the health system or better health outcomes for the population.1 This challenges us to develop ways of systematically examining how current healthcare practices either increase or decrease equity. The following two Australian initiatives illustrate how we might work to achieve equity in health — that is, provide opportunities for all Australians to achieve their full health potential.2 Clinical practice guidelines (CPGs) are one mechanism frequently used to facilitate improvements in the quality of clinical practice and healthcare. However, the evidence on which CPGs are based often excludes, or does not consider, the needs of relatively disadvantaged populations.3-5 Recognising this gap, the Health Advisory Committee of Australia’s National Health and Medical Research Council published a handbook for developers of guidelines about ways to access, review and collate evidence of the effect of socioeconomic position on health, and apply that evidence when developing CPGs.5,6 At the policy level, Health Impact Assessment (HIA) is gaining increasing recognition as a tool for assessing the potential effects of a policy or program on health. Health Impact Assessment that systematically addresses equity may also offer a way of incorporating equity concerns into the decision-making process. However, HIA is a comparatively new field, and decision makers are not usually trained in assessing the impact of policy decisions on equity. Through the Public Health Education and Research Program, the Australian Government has commissioned the development of an HIA framework to assist decision makers in systematically identifying potential health equity impacts of policies. This equity-focused HIA framework is currently being tested (through case studies in Australia and New Zealand) to assess whether and where it adds value to the decision-making processes. These two examples illustrate practical ways in which decisions by practitioners and policy makers can routinely incorporate equity issues in the Australian healthcare system. Ongoing investment and commitment is required to evaluate whether such initiatives make a real difference in achieving equity in health.

Elizabeth Harris · Sarah J Simpson · Rosemary Aldrich · Jenny Stewart Williams

James Tibballs,* Sharon Kinney† * Associate Director, Intensive Care Unit, Royal Children’s Hospital, Flemington Road, Parkville, Melbourne, VIC 3052; † Lecturer, School of Nursing, University of Melbourne, Melbourne, VIC. james.tibballsATrch.org.au To the Editor: The introduction of a medical emergency team (MET) at the Austin Hospital significantly reduced cardiac arrest and deaths, and reduced time spent by survivors of cardiac arrest in the intensive care unit (ICU) and in hospital.1 We note that the evaluation of the MET was preceded by a 12-month period of education and a 2-month “run-in” period before the effects of the MET were analysed. We would be interested to know the incidence of death and cardiac arrest, and the duration of ICU and hospital admission in survivors of cardiac arrest during these two periods. Another MET service also claimed substantial benefits in patient outcomes,2 but was criticised on the basis that the results may have been due to better education of ward staff in recognising the antecedent signs of cardiac arrest and/or the creation of more “do-not-resuscitate” orders.3 While the latter criticism cannot be levelled at the study by Bellomo et al, no attempt is made to separate out the effects of the lengthy education period and the operation of the MET. This is a pity, because it would have been a relatively simple matter to do so without detracting from the obvious benefit of the service. Why was a 2-month “run-in” period between education and operation of the MET allowed before analysis of results? Was this a post-hoc decision or were there foreseeable difficulties during the introduction of the MET? Did patient outcomes change during these two periods compared with the period before the MET?

James Tibballs · Sharon Kinney

Rinaldo Bellomo Director, Department of Intensive Care, Austin and Repatriation Hospital, Studley Road, Heidelberg, VIC 3084. Rinaldo. BELLOMOATarmc.org.au In reply: Tibballs and Kinney raise important questions about our trial of a medical emergency team (MET).1 My colleagues and I are, in fact, currently studying these issues. Preliminary (not fully double-checked) data show that during the education period there were 69 cardiac arrests — an average of 23 cardiac arrests per 4-month block. This is a clear reduction from the 63 recorded during the 4-month control period and similar to the 22 cardiac arrests reported during the 4-month MET period. These 69 cardiac arrests led to a total of 227 intensive care unit bed-days or a 75 bed-day average for each 4-month block, about 50% of the number recorded during the control period, but more than twice as many as during the MET period. These patients remained in hospital for a total of 986 hospital bed-days or 328 days per 4-month block, close to an 80% reduction compared with our control period, and twice as many as the number achieved during the MET period. Unfortunately, although we are pursuing mortality data, we won’t be able to provide them for another 6 months because of a changeover in the computer system at our hospital. Tibballs and Kinney are invited to contact me directly by mid-2004. The 2-month run-in period was chosen prospectively, as we expected that the uptake of the MET (a major change of culture) might be slow and require time and encouragement. We were wrong: the MET was taken up with zest and enthusiasm. The histogram (Box 4) in our article1 shows no cardiac arrests during the run-in period, not because they were not recorded, but because there were literally none for 2 months in a row! Obviously, there were also no post-cardiac-arrest bed-days. Again, mortality figures for this period should be available by mid-2004. As we stated in the Discussion of our article, the educational program associated with the MET may indeed have been partly responsible for the findings. We were careful at all times to say that introducing the MET was effective, not the MET per se (see Conclusion).1 We are not aware of any prospective studies testing the effectiveness of introducing a hospital-wide education program aimed at increasing awareness of the significance of physiological instability. Our findings support a powerfully beneficial role of education, but only represent a post-hoc analysis and require validation in other settings and institutions. The role of education was prospectively and separately investigated in the recently completed multicentre cluster-randomisation MERIT study (Medical Early Response Intervention and Therapy). Its results should be available in the second half of this year.

Rinaldo Bellomo

Timothy H J Florin Director of Gastroenterology, Department of Medicine, University of Queensland, Mater Health Services’ Adult Hospital, South Brisbane, QLD 4101. t.florinATuq.edu.au To the Editor: In their article on adoption of celecoxib and rofecoxib by Australian general practitioners, Kerr et al noted that “the increase in COX-2 [cyclooxygenase-2] prescribing coincided with a period of energetic marketing to the medical profession, which promoted the message that the new C2SNs [COX-2-selective non-steroidal anti-inflammatory drugs] were ‘safer’ than traditional NSAIDs [non-steroidal anti-inflammatory drugs].”1 The implication is that the decision of Australian GPs to prescribe these new drugs may have been less than independent or rationally informed. The reason for prescribing C2SNs is that, like traditional NSAIDs, they relieve arthritic pain and so promote mobility, although, unlike traditional NSAIDs, they do not inhibit cyclooxygenase-1. While the power of advertising is undeniable, the simple message about C2SNs is that there is an approximate 50% reduction in clinically significant gastrointestinal (GI) complications compared with traditional NSAIDs.2 There are over a dozen articles to support the better GI side-effect profile of C2SNs. Most data support a non-cumulative, reversible, but constant, risk of peptic and other, more distal GI bleeds, or perforation, with the coefficient of risk being significantly greater for NSAIDs.3 Although the data from the CLASS study did suggest that the higher GI morbidity of NSAIDs seemed to diminish with time,4 that of celecoxib remained at a constantly lower rate.5 This is clinically important for all our patients, and especially for our ageing population with their comorbid conditions and polypharmacy. I suggest that it is for this single reason that many doctors have been quick to take up C2SNs for their patients. The better GI safety enfranchised patients who previously could not take NSAIDs safely, and could explain why the overall anti-inflammatory market increased by 20%.1 However, no one suggests that the C2SNs are free of non-GI side-effects. To the best of my knowledge, COX-2-specific NSAIDs have not been promoted as being free of non-GI side-effects or better than COX-1-specific NSAIDs in this regard. While agreeing with the last sentence of Dowden’s editorial that “new is not always better”,3 the opposite — that “new is sometimes better” — is also true. Thus, we persuaded the accountants in our hospital, who rightly participate in the determination of which drugs are available on its formulary, to accept one of the COX-2 drugs because of its better GI complication profile. While this will not reduce its pharmacy budget, it is anticipated to reduce overall hospital costs in this area,5 which should allow a reapportionment of its budget to other areas of need. Of course, the hospital is watching carefully for any unforeseen “serious adverse effects which sometimes only emerge after marketing”.3

Timothy H J Florin

Stephen J Kerr,* Andrea Mant,† Fiona E Horn,‡ Kevin McGeechan,§ Geoffrey P Sayer¶ * Decision Support Coordinator, National Prescribing Service, PO Box 1147, Strawberry Hills, NSW 2012; † Area Advisor, Quality Use of Medicines, South East Health, Sydney Hospital, Sydney, NSW; ‡ Research Analyst, § Senior Research Analyst, ¶ General Manager — Research, Health Communication Network, St Leonards, NSW. skerrATnps.org.au In reply: The advantage of the COX-2-selective NSAIDs (C2SNs) is the reduction in clinically significant gastrointestinal complications compared with conventional NSAIDs, but, as Florin agrees, other toxicities, including the risk of renal failure and heart failure, are similar for C2SNs and the older drugs.1 We speculated that doctors may have been more aware of the differences between the new and the conventional anti-inflammatories rather than the similarities: between 4.7% and 7.9% of patients in our study cohorts were treated with a combination of drugs which placed the patient at risk of renal complications. Florin points out that there is an approximate 50% reduction in clinically significant gastrointestinal (GI) complications with C2SNs compared with conventional NSAIDs. If, in a population, the annual incidence of serious GI complications with NSAID use is around 1.4%,2 then the absolute risk reduction is 0.7%. This means that about 140 patients would need to be treated with a C2SN for one year to prevent one serious GI complication. Messages conveyed in this way may be more pertinent to clinical decision making than a statement about relative risk reduction. Florin also notes the problems with elderly patients who often take multiple medications, and are probably at increased risk of upper-GI events with NSAIDs. Our data demonstrated very high prescribing rates in patients who were not elderly. Over 20% of patients in our cohorts were aged less than 50 years, and over 50% were aged less than 65 years. Furthermore, between 34.5% and 61.3% had no pain medication prescribed in the 12 months before the first C2SN prescription, suggesting that C2SNs may have been used as a first-line pain medication in these patients. Quality use of medicines advocates prescribing which is safe, judicious, effective and cost-effective. Recent pharmacoeconomic studies suggest the cost-effectiveness may only be realised when prescribing of C2SNs is confined to patients who are at high risk of GI complications.3,4

Stephen J Kerr · Andrea Mant · Fiona E Horn · Kevin McGeechan · Geoffrey P Sayer

John S Dowden Editor in Chief, Australian Prescriber, Suite 3/2 Phipps Close, Deakin, ACT 2600. jdowdenATnps.org.au In reply: The general practitioners’ decision to prescribe COX-2 inhibitors was rational, but the information underpinning their decision was less than independent. A big reduction in short-term relative risk can be persuasive, even if the absolute benefit is small. General practitioners deal with whole patients, so they consider the overall risks of treatment, and not just one adverse effect. While COX-2 inhibitors may have gastrointestinal advantages, they may have cardiovascular disadvantages. Treatments for chronic conditions should be based on long-term data. The observation that most of the ulcer complications in the second half of the CLASS study were in patients taking celecoxib is therefore important.1 Undoubtedly, some patients who could not take non-selective non-steroidal anti-inflammatory drugs (NSAIDs) were able to tolerate COX-2 inhibitors. However, Kerr et al found that up to 61% of patients given a COX-2 inhibitor had not previously been prescribed any analgesia.2 It seems unlikely that so many people suddenly required analgesia that only a COX-2 inhibitor could provide. The Pfizer-funded study by MacDonald et al shows that UK general practitioners tended to prescribe COX-2 inhibitors for patients at risk of gastrointestinal haemorrhage.3 This follows the advice of the National Institute of Clinical Excellence (NICE). However, NICE also recommended against the routine use of COX-2 inhibitors.4 A review by the Canadian Co-ordinating Office for Health Technology Assessment has also concluded that COX-2 inhibitors may have no significant safety advantage over diclofenac.5 Solomon et al conclude that the cost of adverse effects of NSAIDs in low-risk elderly patients is modest.6 However, there is no comparison with COX-2 inhibitors, so we do not know if they reduce this cost. Hospital accountants may be interested to know that researchers at the Mayo Clinic concluded that, in terms of averting gastrointestinal events, the most cost-effective analgesic is paracetamol.7

John S Dowden

Alan Rodger Director, and Professor of Clinical Oncology, Beatson Oncology Centre, Western Infirmary, Dumbarton Road, Glasgow, Scotland G11 6NT, UK. alan.rodgerATnorthglasgow.scot.nhs.uk To the Editor: In their amusing Postcard from the UK, Jamrozik, Heller and Weller1 paint a picture familiar to most of us in the National Health Service (NHS), but, as with most art, some licence has been permitted. Comparing the size of the UK NHS workforce with that of the Chinese army is unfair: there are, as they know, four different health services in the UK (England, Scotland, Wales and Northern Ireland), which function separately and distinctly. The NHS Jamrozik et al describe is much more the English model. In Scotland, targets for cancer care have been set, although they will not be applied for over a year yet. In the meantime, NHS Scotland has awarded the three Scottish regional cancer networks an extra £25 million (A$62.5 million) to improve and enhance agreed cancer services to assist them achieve the agreed targets on waiting times, etc. Another example of the difference between the Scottish and English NHS can be found in the detail of the new consultant contract. Scotland is offering its consultants a sabbatical and England does not. I am reliably informed by one of the negotiators that the seed of that idea was sown by me when I was recounting enthusiastically some of the better experiences of working in Australia’s own, if complex, national health service. Finally, those of us who laboured during the 1990s at the coal face of Victoria’s health service will not be unfamiliar with targets. Infringement of targets set for the upper levels of the waiting list (no one in Category 3 could ever expect treatment, so no target was set), and for 12-hour waits in the emergency department, carried huge financial penalties for the institution. The good old NHS is far from unique in its fondness for targets.

Alan Rodger

John B Dixon Senior Research Fellow, Monash University Department of Surgery, Alfred Hospital, Commercial Road, Melbourne, VIC 3181. john.dixonATmed.monash.edu.au To the Editor: I am concerned about a possible misrepresentation in the Journal. A recent Practice Essentials article included a case report describing the management of type 2 diabetes.1 The case involved a 51-year-old man with a 6-year history of type 2 diabetes and body mass index (BMI) of 32 kg/m2. The case report included a photograph, but this was not of a man with a BMI of 32 kg/m2. Ten consecutive professional staff working at a large Melbourne centre for bariatric (obesity) surgery were asked to estimate the man’s BMI. Estimates varied from 50 to 65 kg/m2. None accepted that his BMI was 32 kg/m2. All estimates placed this gentleman in the obesity class III category (BMI > 40 kg/m2). A man with a true BMI of 32 kg/m2 is shown in the Box. If indeed the man depicted previously has class III obesity, he is likely to suffer significant obstructive sleep apnoea,2 physical disability and poor quality of life, in addition to the metabolic syndrome and type 2 diabetes. The case report focused on the management of an unacceptable level of glycosylated haemoglobin (HbA1c) of 8.9%. The management may, arguably, be appropriate if his BMI were 32 kg/m2, although treatment options may promote weight gain. Unfortunately, the options and discussion were inadequate for the man depicted. This ill, disabled man deserves better assessment and care. His obesity-related conditions should be fully explored. The only management likely to have a significant effect on conditions related to class III obesity (diabetes, metabolic syndrome, sleep apnoea, physical disability and poor quality of life) is significant weight loss. The only treatment that reliably provides significant sustained weight loss for those with class III obesity is surgery. Obesity surgery therefore should be an essential inclusion in his treatment options. The beneficial effects of modern obesity surgery on type 2 diabetes, the metabolic syndrome, sleep and quality of life are well documented.3,4 I believe the inclusion of this illustration is a serious misrepresentation. Editor's note: We agree with Dr Nixon's remarks, and have replaced the inappropriate illustration in the article with the image he has kindly supplied. Patient with a body mass index of 32 kg/m2 (height, 172 cm; weight, 96 kg)

John B Dixon

Sanjaya N Senanayake,* Mark J Ferson,† Susan J Botham,‡ Roslyn T Belinfante§ * Infectious Diseases Physician, † Director and Medical Officer of Health, ‡ Infectious Diseases Team Coordinator, § Environmental Health Officer, South Eastern Sydney Public Health Unit, Locked Bag 88, Randwick, NSW 2031. djayaATbigpond.com To the Editor: Keeping fish as pets, as with other animals, carries the risk of zoonotic infections. A 2000 review of bacterial zoonoses that can be acquired topically from fish commented on infection with Aeromonas hydrophila, Edwardsiella tarda, Erysipelothrix rhusiopathiae, Mycobacterium marinum, Streptococcus iniae, Vibrio vulnificus and Vibrio damsela.1 Our public health unit was recently notified of a case of Salmonella infection acquired from a fish tank. In October 2003, a 14-month-old boy was admitted to hospital with a 2-day history of fever, vomiting and diarrhoea. Culture of three stool specimens revealed a Salmonella isolate. This was identified by serotyping (at the Institute of Medical and Veterinary Science, Adelaide, South Australia) and phage typing (at the Microbiological Diagnostic Unit, Melbourne, Victoria) as Salmonella enterica serotype Paratyphi B var Java phage type Dundee. The child had no recent history of overseas travel or overseas visitors. Other family members were well, and their stool specimens were negative for Salmonella spp. However, the family kept a tropical fish tank, and the child’s parents reported that he would place his hands in the water to help feed the fish. Culture of water from the tank revealed a Salmonella isolate identical to that in the stool specimens. We believe that the boy became infected after touching the water while feeding the fish. The fish tank contained red-eyed tetras, bala sharks, silver dollars and angel fish, which had been purchased from three local aquariums several years previously. None appeared sick at the time of the child’s illness. It is important for clinicians to recognise that Salmonella infections are not always foodborne in origin. Salmonellosis is a well-known zoonosis that can be found in a variety of pets, including cats, dogs, birds, rodents and even reptiles.2 In fact, an estimated 90% of all reptiles shed Salmonella spp. in their faeces.3 Salmonella spp. have been isolated from tropical fish aquariums previously; unusual Salmonella serotypes were found in eight of 100 tropical aquariums sampled in Wales.4 Fish can excrete Salmonella without appearing unwell.5 Our patient was a 14-month-old child. In a Canadian outbreak of S. enterica serotype Paratyphi B linked to aquariums, five of seven cases were also in children aged under 10 years.5 This may reflect a combination of immature immunity and behaviour — young children may not wash their hands properly (or at all) before eating or touching their mouths. This case highlights the importance of good handwashing at all times after contact with an aquarium, regardless of the appearance of the fish. It may also be worthwhile recommending close supervision of children under 5 years of age around aquariums.

Sanjaya N Senanayake · Mark J Ferson · Susan J Botham · Roslyn T Belinfante

Lyndon E Llewellyn,* Cedric E Robillot,† Andrew P Negri‡ * Principal Research Scientist, Bioactive Molecule Discovery; † Senior Research Specialist, Bioinnovation; ‡ Senior Research Scientist, Bioinnovation, Australian Institute of Marine Science, PMB 3, Townsville, QLD 4810. L. LlewellynATaims.gov.au To the Editor: Seafood is not only consumed as food, but also as dietary supplements and complementary medicines. Examples are capsules of freeze-dried oysters and mussels, or freeze-dried extract of shellfish meat, sold as reputed antihypertensives, cardioprotectants, and anti-inflammatories, among other medical claims. However, oysters and mussels can become dangerously toxic after they ingest poisonous microscopic algae. If these molluscs are sold as food in Australia, they are subject to the Food Standards Code,1 under which their sale is prohibited if biotoxin levels per kilogram of wet shellfish meat exceed 800 g of paralytic shellfish poisons, 200 mouse units of neurotoxic shellfish poisons, 200 g of diarrhoetic shellfish poisons, or 20 mg of amnesic shellfish poisons. Shellfish capsules can be simply manufactured by milling dried meat and encapsulating the powder, a process unlikely to degrade shellfish biotoxins, which are stable to heat, pressure and freeze-drying. 2,3 Such capsules may then become subject to regulation by the Australian Therapeutic Goods Administration (TGA), which distinguishes therapeutics from food, on the basis of whether there is a “tradition of use as a food in the form presented”, especially if there is an associated health claim. Such complementary medicines can be either “registered” or “listed”. Registered medicines require extensive safety, quality and efficacy data. Listed medicines are considered to pose a lower risk than registered medicines, and regulations allow product sponsors to “self-assess” products. Listing is a route commonly taken for complementary medicines. A pertinent example is the TGA listing of therapeutic goods containing dried green-lipped mussel (Perna canaliculus).4 Where manufacturers of shellfish capsules have undertaken the responsibility of ensuring product safety, they invariably adopt existing biotoxin testing protocols developed for food safety. However, as the allowable biotoxin level is based on wet weight, and the dry weight of bivalve shellfish is only 10%–15% of the wet weight,5 safety limits for shellfish meat as food are incorrect by an order of magnitude, and potentially more for capsules containing extracts of shellfish meat. While important for acute exposure to these toxins, this may be even more relevant in chronic exposure. Okadaic acid, the cause of diarrhoetic shellfish poisoning, is a tumour promoter,6 and epidemiological studies suggest that rates of cancer have increased in regions with regular dietary exposure to low levels of this toxin.7 Capsules are available that contain 500 mg of dried shellfish meat, which may equate to 5 g of wet shellfish meat.5 Unlike a shellfish meal, which may be considered equivalent to a single acute exposure, recommended doses for shellfish capsules can be as many as five capsules a day for many weeks, if not months, therefore magnifying the risk of chronic exposure. It is known that different classes of biotoxins can co-occur in shellfish, adding to the potential hazard outlined here.8 Further complications arise because some shellfish capsules include other natural extracts (such as ginseng) or pharmaceutical formulations that might affect toxin uptake. While this situation needs to be subjected to risk assessment, testing products in accordance with an inappropriate standard can make them seem safe when they might not be. This is especially so for products which are usually self-prescribed, and where patients can exceed recommended doses in the belief that more is better. For products such as shellfish capsules that straddle the food/therapeutic divide, it is better for manufacturers to test the final consumer product and not the raw supply.

Lyndon E Llewellyn · Cedric E Robillot · Andrew P Negri

Shanthi Kannan,* Christine H Rowland,† Gregory I Hockings,† Peta M Tauchmann,‡ Edwin A Blackwell§ * Endocrine Advanced Trainee, † Endocrinologist, ‡ Nurse Educator, § Haematologist, Greenslopes Private Hospital, Brisbane, QLD. Correspondence: Dr Christine Rowland, Greenslopes Private Hospital, Newdegate Street, Greenslopes, Brisbane, QLD 4120. c.rowlandATmailbox.uq.edu.au To the Editor: Intravenous immunoglobulin preparations containing maltose (eg, Intragam P [CSL Limited]) can interfere with the readings of blood glucose monitors that use test strips with glucose dehydrogenase, such as Advantage (Roche).1 Glucose dehydrogenase is an enzyme of the Pyrroloquinolinequinone class which reacts with the disaccharide isomer maltose present in Intragam P at concentrations of 10 g/100 mL,2 resulting in falsely elevated blood glucose level results. Blood glucose monitors, such as Precision (Medisense products), Medisense (Medisense products)3 or Accutrend (Roche), that use the glucose oxidase system, do not react with maltose and can be safely used for patients receiving Intragam P. We have had two patients in whom capillary blood glucose levels were over-estimated. One was a 64-year-old woman with type 2 diabetes who was being treated with haemodialysis, and who received Intragam P for immune-mediated thrombocytopenic purpura. Before being admitted, her diabetes was reasonably controlled by 10 units of protophane twice daily. She received prednisone (100 mg/day) from Day 1 to Day 13 and Intragam P intravenously each day from Day 2 to Day 6 and from Day 14 to Day 18. While the patient was receiving Intragam P, the Advantage monitor gave persistently higher readings than both the Precision monitor and plasma glucose level measurements. The following paired readings were obtained: Advantage capillary glucose reading of 9.3 mmol/L while the plasma glucose level was 2.3 mmol/L; and Advantage capillary glucose reading of 24.4 mmol/L while the plasma glucose level was 10.4 mmol/L. During the second course of Intragam P we noted that readings with the Precision monitor were equivalent to the measured plasma glucose level. This patient developed hypoglycaemia because her insulin doses were increased on the basis of falsely elevated capillary glucose readings as measured on Advantage blood glucose strips. A Precision monitor was used for this patient until after the haemodialysis treatment which followed the final dose of Intragam P. After this time Advantage blood glucose readings approached those obtained with the Precision monitor. A second patient — a 35-year-old woman who was not known to have diabetes, but was having her glucose levels monitored while undergoing total parenteral nutrition — was given Intragam P for idiopathic thrombocytopenic purpura. While receiving Intragam P, capillary glucose levels by the Advantage monitor were elevated by 13–20 mmol/L compared with concurrent (and normal) plasma glucose level measurements. It has previously been reported that icodextrin, used in some peritoneal dialysis fluids, can have similar effects, as it is hydrolysed to oligosaccharides, including maltose, maltotriose and maltotetraose.4,5 The reaction with maltose has important clinical implications. Although it is stated in the product information for Advantage test strips that glucose readings may be affected by maltose levels over 16 mg/dL (0.89 mmol/L), clinicians may not be aware that Intragam P is in a maltose solution. For patients receiving Intragam P, the Advantage monitor is not suitable, and the Precision, Medisense or Accutrend blood glucose monitors, which use glucose oxidase which does not react with maltose, should be used instead. We have reported our experience to the Australian Red Cross Blood Service as an adverse event.

Shanthi Kannan · Christine H Rowland · Gregory I Hockings · Peta M Tauchmann · Edwin A Blackwell

Anna Peeters,* Jason Ting,† Mark R Nelson,‡ John J McNeil§ * Research Fellow, Department of Epidemiology and Preventive Medicine, Monash University, and Department of Public Health, Erasmus Medical Centre, PO Box 1738, Rotterdam, 3000DR, The Netherlands; † Intern, Geelong Hospital, Geelong, VIC; ‡ NHMRC Research Fellow; § Head, Department of Epidemiology and Preventive Medicine, Monash University, Prahran, VIC. a.peetersATerasmusmc.nl To the Editor: Coronary heart disease (CHD) risk prediction for primary prevention now focuses on multifactorial risk,1-3 and various risk calculation tools exist.1-3 The need for such tools depends on the degree to which risk status can be estimated by healthcare professionals. We performed a study to assess general practitioners’ intuitive calculation of multifactorial CHD risk for patients likely to be considered for lipid-lowering therapy. In 1999 we posted a survey to a random sample of 400 GPs in Victoria, and received back 155 completed surveys (39% response rate). The respondent population was demographically similar to the Australian GPs and trainees who billed Medicare in 1998–99. GPs were asked to estimate 5-year absolute risk of CHD for four vignettes (two primary prevention and two secondary prevention), each based on the average characteristics of a published lipid-lowering clinical trial cohort4-7 (vignette descriptions are available from the authors). For the primary prevention vignettes, GPs were also requested to estimate the risk relative to other Australians of the same age and sex. Estimated risks were compared with reported risks to derive risk ratios. GPs accurately estimated the relative CHD risk for the two vignettes of patients with no prior CHD, with mean risk ratios of 0.84 (95% CI, 0.77–0.91) and 1.23 (95% CI, 0.97–1.49). However, they overestimated absolute risk, with risk ratios ranging between 2.79 (95% CI, 2.61–2.96) and 6.43 (95% CI, 5.59–7.27). The proportion of GPs estimating within 10% of the actual risk was 9% for a 62-year-old man with prior CHD and average cholesterol level, 13% for a 60-year-old woman with prior CHD and high cholesterol level, 17% for a 55-year-old man with no prior CHD and high cholesterol level, and 43% for a 58-year-old man with no prior CHD and average cholesterol level. Although the two primary prevention vignettes had 5-year absolute CHD risks below 10%, most GPs’ estimates (93% and 71%, respectively) were greater than 10%. In conclusion, GPs in Victoria have a good understanding of a patient’s relative risk of CHD, but they consistently overestimate absolute risk. The problem with absolute risk estimation may not be the sophisticated multifactorial calculations required, but rather a general overestimation of risk within the population, at least for middle age. The GPs’ estimates of absolute risk for the four vignettes were correctly ranked, suggesting that they recognised the degree to which a risk was lower or higher, but were unfamiliar with the scale. This overestimation led most GPs to categorise patients such as those from the AFCAPS/TexCAPS trial, with only a 3.3% 5-year risk of CHD,6 as having a risk of greater than 10%. GPs would therefore incorrectly consider these patients appropriate for lipid-lowering therapy according to national and international guidelines. 1-3 Education may improve understanding and accuracy of risk communication for CHD in middle-aged patients, but tools for accurate assessment of coronary risk are needed in routine clinical practice.

Anna Peeters · Jason Ting · Mark R Nelson · John J McNeil

Keri Lockwood,* Ian D Cameron,† Susan E Kurrle‡ * Coordinator, Hip Protector Studies Unit; ‡ Director, Rehabilitation and Aged Care Service, Hornsby Ku-ring-gai Hospital, Hornsby, NSW; † Head, Rehabilitation Studies Unit, University of Sydney, PO Box 6, Ryde, NSW 1680. iancATmail.usyd.edu.au To the Editor: Hip protectors may be an effective means of preventing hip fracture in residents of aged-care facilities, if there is adequate compliance with their use.1 Research studies conducted in the Northern Sydney and Illawarra health regions2,3 have found that, if a hip protector is worn at the time of a fall, the chance of hip fracture is reduced by about 80%. We wished to determine the extent to which hip protector use had become a routine part of healthcare in residential aged-care facilities generally, and whether there was a greater uptake of their use in areas where the research had been conducted. A brief questionnaire about hip protector use was sent to all residential aged-care facilities in the Northern and South Eastern Sydney health regions, and the region covered by the New South Wales Southern Area Health Service. The response rate was 60% in each region, and responses are summarised in the Box. Only 30 residential aged-care facilities participated in the previous study, and the results indicate that use is now much more widespread. Another contrast is that, in the research study, hip protectors were provided free of charge, whereas most current users pay for hip protectors. Overall, the survey indicates that 61% of aged-care facilities across three regions of NSW are either using hip protectors or have used them in the past. Hip protector use was similar in Northern Sydney and Southern NSW; however, comparing Northern Sydney (where previous research had been conducted) with the other two regions combined showed a greater prevalence related to conducting previous research. Issues such as cost, laundering of the hip protectors, and comfort are seen as major barriers to their use, but many aged-care facilities continue to use them for selected residents at high risk of hip fracture. It is our impression that the more residents within a facility who wear hip protectors, the better the adherence to hip protector use and the management of these issues. It is also evident that hip protector research encourages use of hip protectors. We are unsure of the mechanism involved, but believe that knowledge and enthusiasm for use of hip protectors is spread by word of mouth between health professionals, staff working in nursing homes and hostels and, in some cases, through relatives of the residents of residential aged-care facilities. Hip protector use in residential aged-care facilities in three health service regions of New South Wales Region (no. of residential aged-care facilities) Any hip protector use* Northern Sydney (99) 74% South Eastern Sydney (104) 43% Southern NSW (35) 75% * χ2 = 7.5, df = 1, P = 0.006 for comparison of frequency of use in Northern Sydney with use in the other two area health services combined.

Keri Lockwood · Ian D Cameron · Susan E Kurrle