Letters

In reply: Jalaludin and colleagues query the potential effects that serial correlation and confounding by school holiday time periods may have had on our finding of an association between particulates derived from bushfire smoke and asthma presentations.1 As previously discussed by Schwartz, time series analyses are important to control for serial correlations, particularly those due to the effects of seasonality and weather fluctuations.2 Our study did not cover a number of seasons. It was conducted during one tropical dry season, a period characterised by remarkably stable day-to-day weather conditions.3 For this reason, we believe that the effects of any autocorrelation would have been negligible. It is of interest that the development of statistical methods for analysing time series of count data during the 1990s, and analysis of large studies of particulate pollution using these methods, did not have an important effect on the conclusions reached by earlier studies.4 There is evidence that hospital admissions for asthma fall during school holidays.5 Anecdotal reports of more regional fires suggest that, if anything, particulate concentrations over Darwin might increase at these times. A reanalysis of our data including school holiday periods as a potential confounding factor did not appreciably alter our results in either the continuous (revised incidence rate ratio [IRR],1.26; 95% CI, 1.12–1.41, compared with original IRR, 1.20; 95% CI, 1.09–1.34) or categorical analysis (see Table). Asthma presentations and exposure levels of PM10* (μg/m3) Rate ratio for asthma presentations (95% CI) Same-day PM10 category (μg/m3) Original analysis† Revised analysis‡ < 10 1.0 1.0 10–< 20 0.90 (0.60–1.35) 0.84 (0.43–1.63) 20–< 30 1.11 (0.74–1.69) 1.13 (0.58–2.18) 30–< 40 1.18 (0.72–1.97) 1.21 (0.58–2.50) ≥ 40 2.38 (1.46–3.90) 2.47 (1.21–5.01) * Particles of 10 microns or less in aerodynamic diameter per cubic metre. † Adjusted for influenza-like illness and weekday. ‡ Adjusted for influenza-like illness, weekday and school holiday periods.

Fay H Johnston · Anne Kavanagh · David MJS Bowman · Randall K Scott

To the Editor: The editorial by Steven and Shanahan on work-related stress1 indicated that claiming Medicare benefits for a workers compensation injury is specifically precluded. It also identified a need for guaranteed certainty of cost reimbursement for treatment. Medicare benefits are payable for professional services that are wholly covered by workers compensation, unless there is a reimbursment arrangement with the insurer.2 The patient may be bulk billed or given a private account. The recovery of any benefits paid once a settlement or judgement is made does not involve the practitioner. It is not claiming the benefit which is precluded, but keeping it if an outcome favourable to the plaintiff ensues. My understanding is that unsuccessful claims are rebatable under Medicare for clinically relevant medical services. The medicolegal expenses incurred, for example for reports, do not qualify, as they are not medically necessary. The fees are a private matter, as are any treatment charges in excess of the Medicare rebate. Herein lies the uncertainty.

Raymond L Carroll

In reply: What Carroll says is correct, but Section 3.6 of the general explanatory notes of the Medicare benefits schedule book also states that "The only exception to this is where a person has entered into a reimbursement arrangement with a compensation insurer. In such cases a Medicare benefit is not payable".1 While it may be arguable as to what actually constitutes a reimbursement arrangement, the situation is further clarified by Section 13.2.1 of the same schedule, which states: "Medicare benefits are not payable in respect of a professional service in the following circumstance: (b) where the medical expenses for the services are in relation to a compensable injury or illness for which the patient's insurer or compensation payer has accepted liability. However, if medical expenses relate to a compensable injury or illness and the insurer or compensation payer is disputing liability, Medicare benefits are payable until liability is accepted".

Ian D Steven · Michael Shanahan

To the Editor: In an article in the 1 April issue of the Journal,1 Sturm et al reported on a GP-based stroke audit ("ASAP") and stated that "the information obtained is likely to be representative of most Australian general practice environments". Without further information, we cannot be as confident. First, their sampling strategy was unconventional. Of all registered GPs from five Australian States and one Territory who were initially approached in May 2000, only 10.2% (n = 1850) of eligible GPs expressed interest in participating in the study. From each of 22 "geographical regions", up to 18 GPs were recruited, initially by random sampling and then by replacement, to obtain a sample of 396 GPs, of whom 321 (81%) provided data. No GP data by State and Territory or "geographical region" were provided to allow readers to judge the possibility of sampling bias. Unpublished data from our own GP survey about stroke issues in New South Wales raise this possibility. We conducted a postal survey of 490 randomly selected GPs from November 2000 to February 2001 (response rate, 60%). None of the 296 participating GPs stated they were enrolled in a stroke clinical audit. Second, although patients were clustered within GPs, no intracluster correlations (ICCs) were reported. Outcomes (eg, disease morbidity and risk factors) for patients recruited from general practices tend to be correlated at the GP level.2 ICCs quantify the extent to which individuals within clusters (such as a GP's practice) are similar to each other relative to individuals from other clusters. Conventional formulas for calculating confidence intervals assume that the ICC is zero (ie, no clustering). Yet, where correlation within clusters does exist (ie, ICC > 0), the effective sample size is reduced and the associated CIs are inevitably wider. For any given ICC greater than zero, larger cluster sizes also further reduce the effective sample size. Applying appropriate formulas,3 we calculated effective sample sizes for risk factors in the ASAP study, assuming three different magnitudes of ICCs, ranging from relatively modest (0.015) through more substantive (0.1) (see Box). Given the large denominator of the ASAP study, our methodological concern may be only minor in terms of the width of the CIs reported, but the reader is unable to judge whether or not this is the case, as no ICCs were reported. As sample-size calculations for future interventional studies would be informed by publication of ICCs,4 we encourage such reporting in future. Third, we believe the authors' quantitative findings would have been most useful if they had been age-adjusted in line with Australian community norms. Effective sample size, assuming three different magnitudes of intracluster correlation (ICC) Risk factor Actual n Effective n if ICC = 0.015 Effective n if ICC = 0.05 Effective n if ICC = 0.1 Total Hypertension 14 280 8643 4499 2670 Hypercholesterolaemia 12 516 7973 4317 2608 Smoking 14 297 8649 4500 2670 Diabetes 13 767 8455 4449 2653 Atrial fibrillation 14 194 8611 4490 2667 Stroke/transient ischaemic attacks 14 321 8657 4502 2671

Sandy Middleton · Neil J Donnelly · Jeanette E Ward

In reply: We thank Middleton et al for their interest in our article. As 96% of questionnaires in our ASAP study1 were completed by September 2000, their study (as yet unpublished) and ours were not concurrent. Statistically, based on the information given by Middleton et al, we would expect 5.5 GPs (296 x 333/18066) to be involved in both studies. Chance, or because direct involvement in the ASAP study had finished months earlier, may explain why none of the doctors in the survey by Middleton et al stated that they were involved in a stroke audit. In answer to the claim that "no GP data by State and Territory" were provided, we did in fact indicate in our article how many GPs from each State and Territory participated. Intracluster correlations (ICCs)2 for each risk factor in our study are shown in the Box. ICCs have a greater effect on sample size than on CIs, because CI width is inversely proportional to the square root of the sample size. The large sample size of ASAP means that the study has acceptable precision, even after allowing for ICCs. Overall estimates for risk factors were provided for the population of people consulting GPs, which is the relevant population. We would not necessarily expect the same distribution of risk factors in people not attending GPs. Age- and sex-specific risk-factor prevalences, shown in Box 3 of our article,1 can be used to calculate age- and sex-standardised rates for any desired population. We are confident that the information obtained in our study is likely to be representative of most Australian general practice environments. Intracluster correlations (ICCs) for stroke risk factors in the ASAP stroke audit1* Risk factor All Men Women Current smoker 0.07 0.09 0.08 Hyper-cholesterolaemia 0.06 0.06 0.07 Hypertension 0.06 0.05 0.07 Diabetes 0.04 0.05 0.07 Past TIA/stroke 0.018 0.024 0.013 Atrial fibrillation 0.016 0.017 0.023 TIA = transient ischaemic attack. * Calculated using the analysis of variance (ANOVA) method.2

Jonathan W Sturm · Stephen M Davis · John G O'Sullivan · Miriam E Vedadhaghi · Geoffrey A Donnan

To the Editor: Reactions to insect bites are unpleasant and can be dangerous.1 Kumar2 commented that people who react to mosquito bites with local itching and inflammation appeared less likely to develop malaria than those with no reaction. In a later personal communication, he gave me unpublished data showing an inverse linear relationship between the severity of the reaction to mosquito bites and the incidence of clinical malaria. Ross River virus infection is endemic in all Australian states. A specific serological test is available to confirm suspicious clinical illnesses. Some people have serological signs of past infection without any history of clinical disease. With Kumar's findings in mind, I asked people with a past history of clinical Ross River virus infection, proven by serology, whether they reacted to mosquito bites. All seven asked said that they had had no reaction. Their main complaint was the noise made by predatory mosquitoes. I then asked patients who were in the same age range and general social class, who lived in the same area and were attending clinics with other diseases, whether they had had any clinical illness diagnosed as Ross River virus infection. Of the 18 asked, none had had the clinical disease or serological tests for the disease. All 18 had moderate to severe reactions and itching with mosquito bites. The Box shows these results Fisher's exact test gives the probability of this finding as 0.0000003. These observations have not explored all aspects of the problem, so this level of probability may be optimistic, but, even so, it makes pointless any further informal collection of data. These findings justify a formal epidemiological study, including antibody titres. It should include those who react to mosquito bites and those who do not, and those with and without a past history of the clinical illness. This informal study suggests that reactions to mosquito bites protect against Ross River virus infection, and parallels Kumar's findings in malaria. There may be behavioural and biological explanations for this finding. People who itch with mosquito bites may take greater precautions to avoid them. Conversely, people who do not itch may spend more time outdoors and be more likely to be bitten. Biologically, reactions to bites may be examples of a generalised protective effect of local reactions against insect-borne diseases. The inflammatory reaction with itching may be a factor in defence against infection3 by limiting or destroying injected parasites and viruses locally or through a more vigorous generalised response that prevents disease or limits infection to a subclinical level. Investigation of local inflammatory response might provide clues to effective prevention and treatment. Reactions to mosquito bites among people with and without evidence of Ross River virus (RRV) disease No reaction Moderate to severe reaction Past RRV disease 7 0 No past RRV disease 0 18

Alan E Dugdale

To the Editor: We write to express our concern at the publication of the recent supplement "Essential role of fats throughout the lifecycle", adorned by the sponsor's logo.1 It was an interesting counterpoint to an accompanying article in the main journal regarding the need for industry–academia collaborations to "strike a balance".2 While the issue of relationships between industry and doctors is complex, and few of us are truly independent, the publication of such a branded document is disquieting. Directed sponsorship, beyond mere advertising, undermines the credibility of such supplements and the Journal itself, regardless of the authors' expertise, objectivity and the importance of the topic. Unfortunately, we are left with the taste that this is a spread designed to butter us up.

Alex A Padiglione · Catherine E Marshall · Tony M Korman

In reply: "Oh what a feeling" to receive a congratulatory letter! But the euphoria was short lived, as, on closer inspection, congratulations turned to castigation. The offending event was the Journal's publication of an industry-supported supplement,1 and its practice of branding supplements with the logos of their sponsoring bodies. Although sponsorship by government agencies or non-profit health organisations rarely provokes comment, industry sponsorship is another matter. As industry support for research and other health-related activities will inevitably increase in the future, we at the Journal are pleased that Padiglione and colleagues have aired their anxiety. Irrespective of the source of sponsorship, the Journal's policy governing the publication of supplements follows the recommendations of the International Committee of Medical Journal Editors.2 These include that: the journal's editor must take full responsibility for policies, practices and content of supplements, must approve the appointment of the editors of supplements, and must retain the authority to reject articles; and the source of funding should be clearly stated and prominently located in supplements, preferably on each page. To these principles the Journal has added its own requirements.3 These include the need for peer review and that editors of and contributors to supplements declare competing interests and compensations. These were clearly identified on the title page of the offending publication.1 For our readers, the Journal is the bread and its supplements the butter. One can always refuse to taste the butter. But, for those who hanker after a little fat, we aim to ensure, through churning by external peer review and transparent sponsorship of the product, that "butter is better".

Martin B Van Der Weyden

To the Editor: Linezolid is the first of a new class of oxazolidinone antibacterials which was first registered in Australia in September 2001. It represents an important advance in the treatment of infections caused by some enterococci resistant to vancomycin and staphylococci resistant to methicillin.1 In clinical trials, the most commonly reported drug-related adverse events which led to discontinuation of linezolid therapy were headache, diarrhoea, nausea and vomiting.2 We describe a patient who developed peripheral and optic neuropathy while being treated with linezolid. A 76-year-old man was hospitalised in November 2000 for the third revision of a left total hip joint prosthesis. This was complicated by infection with methicillin-resistant Staphylococcus aureus (MRSA) isolated from hip joint washout. The organism was sensitive to vancomycin, teicoplanin, rifampicin and fusidic acid, and resistant to ciprofloxacin. Vancomycin therapy was commenced, but had to be replaced by rifampicin and fusidic acid when the patient developed fever (40°C), rigors, rash and eosinophilia. However, the patient developed severe, generalised pruritus. Therapy with rifampicin and fusidic acid was ceased and oral linezolid (600 mg twice daily) was given. Linezolid was initially well tolerated. However, about six months after starting treatment with the antibiotic, the patient presented to his general practitioner with numbness of his hands, feet and legs below the knee, intermittent sharp pain in both feet and blurred vision. He was hospitalised and linezolid therapy ceased. On admission, peripheral sensory loss in a glove-and-stocking distribution was noted. Nerve-conduction studies showed severe sensory-motor axonal neuropathy, more severe in the lower limbs than the upper limbs. Formal visual field testing showed patchy field damage, suggestive of drug-induced toxicity. The patient declined further ophthalmological review. Five months after he stopped taking linezolid, he reported subjective resolution of visual impairment, but the peripheral neuropathy persists. The patient's alcohol intake had been negligible. Ongoing medications include digoxin, irbesartan, frusemide, omeprazole, piroxicam and diazepam. We are not aware of any published articles describing peripheral or optic neuropathy associated with linezolid therapy. This information was not included in the original product information, but has been added to the revised version under the heading "Post-marketing surveillance".3 Up to June 2002 there had been only 13 reports of adverse reactions to linezolid to the Australian Adverse Drug Reactions Advisory Committee (ADRAC). Four of these, including our report, describe peripheral neuropathy and involve adult males who had received 1.2 g of linezolid daily for six to nine months. No patient's neuropathy had resolved at the time of reporting. Moreover, linezolid was the sole suspected drug in all four reports. It is important to note that the maximum duration of treatment with linezolid in clinical trials has been 28 days. Reports of neuropathy received by the manufacturer have primarily involved patients treated for longer than 28 days.3 Our report highlights the importance of postmarketing surveillance and reporting of adverse drug reactions, especially when a drug is used outside original indications or duration.

Carmela E Corallo · Amalie E Paull

To the Editor: I read with interest the article on cervical screening by Dickinson.1 Cervical screening has been the most successful public health measure introduced for the prevention of cancer, and the Pap test has been highly effective in reducing cervical cancer mortality and morbidity. In New South Wales, between 1972 and 1999, the age-standardised incidence and mortality of cervical cancer fell by 49% and 66.6%, respectively.2 The overseas experience is similar, with the best screening programs reporting a 70% reduction in mortality rates, with slight annual mortality increases since 1986.3 That women continue to die from this potentially preventable disease emphasises the limitations of the current screening method and highlights the need for new directions. The conventional Pap test is "yesterday's tool for today's world", let alone tomorrow's! The Pap test is prone to errors at all levels, but, most importantly, at specimen collection and cytological interpretation. Consequently, relatively high numbers of false negative results are associated with the test. Further, the Pap test is only partially successful in predicting the biological behaviour of the cytological abnormality. As Dickinson states, minor abnormalities that come and go are unimportant, and can cause unnecessary alarm. These minor and transient abnormalities often lead to colposcopy, biopsy, surgical treatment and subsequent cytological and clinical or colposcopic follow-up, at a considerable cost to individual women, the screening program and taxpayers.4 Recent developments in cervical cytology and molecular biology have opened up new horizons.5 Liquid-based cytology, human papillomavirus (HPV) DNA testing and new molecular markers will help us to accurately select the patients who are likely to have biologically aggressive disease with a high probability of progression.4,5 With refinements, these new technologies will not only dramatically reduce the frequency of Pap test screening, but they may postpone the age for starting screening from 18 years to perhaps 25 or even 30 years. These new technologies come at a price. Liquid-based cytology costs about $30 and HPV DNA testing is about $90, and no Medicare rebates are currently available for these tests. The additional cost of these new technologies should be considered in the context of the cost of diagnosis, treatment and subsequent cytological and clinical follow-up of biologically insignificant disease. The money saved from improved patient selection for treatment and reduced frequency and late commencement of screening would allow more resources to be allocated to enrolling women (who are currently underscreened) and to funding these new technologies.

Ibrahim M Zardawi

To the Editor: Life expectancy in developed countries increased by an average of about 20 years during the 20th century. An editorial in the Journal by Rodger referred to mortality in populations having screening mammography.1 Data quoted indicated that there had been only slight changes in breast-cancer mortality in Australia up to 1996. Data for 1999 are available in the report of the Australian Bureau of Statistics Causes of death, published in December 2000.2 The standardised all-causes death rate per 100 000 for all persons in 1989 was 758.9 and in 1999 was 584.2, a reduction of 23.0%. For women, the standardised death rate attributable to breast cancer in 1989 was 27.2 and in 1999 was 22.1, a reduction of 18.75%. Recent decreases in breast cancer mortality of similar magnitude have also been observed in the United Kingdom and the United States.3 However, screening mammography could only be responsible for a small portion of these changes, because population screening has been in place for little more than a decade and the benefits of earlier detection and treatment would take more than five years to become evident. The causes of these dramatic reductions in death rates are not yet understood. Regarding the effect of population screening mammography on mortality rates, this is limited to breast-cancer-specific mortality and cannot be expected to translate into a reduction in overall mortality. In a recent overview of the situation in Sweden,4 breast-cancer-specific mortality in the screened group was 22% lower than in the non-screened group. However, the age-adjusted relative risk for total mortality was 1.00 (95% CI, 0.98–1.02). In other words, the mammographically screened population died less frequently from breast cancer, but nevertheless died at the same rate as the non-screened population (from other causes such as heart disease and other cancers). If we consider that, in the age group 40–79 years, breast cancer accounts for about 3% of total mortality, a reduction in breast cancer mortality of 25% would be 25% of 3%, or 0.75%. This change is so small that it would probably never be possible to show an effect of breast-cancer screening on overall population mortality. It is therefore realistic to regard the benefits of screening mammography as limited to early detection and treatment (possibly with improved quality of survival) and a reduction in breast-cancer-specific mortality.

In reply: I agree with Gough and welcome the more recent data showing up to an 18.75% reduction in breast cancer mortality in Australia in the 10 years from 1989. Obviously, this cannot be attributed solely to the now 10-year-old National Mammographic Screening Program, but it may result from a combination of the screening program, ad-hoc screening before the program, and the more rigorous use of adjuvant therapies based on the results of clinical trials. That breast screening is unlikely to have an impact on overall population mortality gives the lie to the conclusions of Olsen and Gøtzsche's overview,1 which are based only on overall mortality. Nevertheless, Gough and I agree that screening mammography is likely to deliver other benefits through detection of earlier-stage disease and a reduction in deaths from breast cancer.

To the Editor: I would like to compliment Coiera et al for their very interesting article about communication in an emergency department.1 Nearly a third of communication events were classified as interruptions, thus having an adverse effect on communication within the department. In trying to reduce this level of interruption, perhaps it is time to rethink the role of the on-call emergency physician in an emergency department. In most large Australian emergency departments, the emergency physician is also the admitting officer, who is responsible for coordinating the non-elective admissions of the day. This involves being readily available for external and internal phone calls, usually by mobile phone. Thus, as well as the normal clinical workload of an emergency physician, he or she needs to respond immediately to the summons of a mobile phone — a recipe for interruptions and less efficient communication. It is not optimal for the person who has clinical responsibility for the emergency department to also be the person through whom most of the communication is channelled. One possible solution is to channel calls about patients whom the referring doctor considers definitely need assessment in the emergency department to non-medical clerical staff. They could enter the details in a computerised "expected patients" database, which would be available for viewing by emergency department staff. Only calls about patients where there is some uncertainty, and advice calls, would be channelled to the emergency physician on call. This would facilitate both planning of the emergency department workload and also provide access to advice for the referring doctor. This change in process would reduce the number of phone calls received by the on-call emergency physician — and thus the number of interruptions — and improve overall communication within the emergency department.

Alan E O'Connor · Antony Nocera · Thomas Hamilton · Enrico W Coiera

To the Editor: Coiera et al1 should be congratulated for highlighting the excessive communication workloads of emergency department clinical staff, and the potential for these to be a source of errors and adverse events. However, their article fails to discuss the confounding variables, making it difficult to assess the validity of the communication strategies the authors propose to remedy the problem, or the applicability of their findings to other institutions. Emergency department overcrowding results from lack of access to hospital beds.2,3 Situations in which the number of patients exceeds the number of available beds (as depicted in the emergency department shown on the cover of the same issue of the Journal) are of particular concern, and would be expected to be a significant factor in the communication workload of clinical staff. Furthermore, many emergency departments do not have ward clerks, which means emergency department clinical staff perform the functions delegated to ward clerks in other hospital areas. The lack of direct telephone access to patients in the emergency department means that telephone calls from family members to a patient have to be directed through clinical staff. This increases the exchange of information between clinical staff, especially when the emergency department is overcrowded and patients are moved within the department to accommodate new patients. It is not clear, from the communication workload identified in Box 3,1 whether these factors were relevant in the institutions surveyed. In addition, Coiera et al do not indicate the seniority of the six doctors they studied. This is important given that the ratio of staff specialists to registrars or junior staff in emergency departments may be two to three times that of inpatient wards, increasing the number of times staff specialists communicate to junior medical staff in the emergency department. Finally, there is no mention of the adequacy of nursing staff numbers during the survey periods. If there were a lack of nurses, or if there were nurses on duty who normally do not work in the emergency department, one would expect an increase in communication between nurses. When emergency department infrastructure is so stressed, important studies, like that of Coiera et al, need to describe their findings in context, because of the likelihood of communication problems emerging as a result of health system failures.

Enrico W Coiera PhD, FACMI

To the Editor: I was interested in the report by Coiera et al1 about communication in the emergency department and the accompanying editorial by Vincent and Wears2 (from the United Kingdom and the United States, respectively, where, incidentally, the practice of emergency medicine differs significantly from that in Australia). In no other discipline is facility in communication between doctors, nurses, patients and relatives, as well as colleagues in other departments, of greater importance, given the paucity of information at presentation and the time constraints for assessment, management and appropriate referral — all within a time frame of a few minutes to several hours, depending on the severity of the presenting complaint. Vincent and Wears allude to the "fluidity and complexity of the clinical environment" and rightly suggest that studies need to be designed to embrace a "need to appreciate clinicians' decision making and cognitive load". It was therefore disappointing that, after so much effort, Coiera et al did not correlate their data with severity of clinical condition and/or outcome (eg, requiring resuscitation, assessment for possible admission, treatment solely in the emergency department, or discharge to outpatients clinic or home, to name but a few possible groupings). These may, of course, be intended for future publication. Regrettably, it is not stated how much input, if any, in the design and conduct of the study was obtained from staff in the unidentified emergency departments, and their contribution goes largely unacknowledged. As Richardson3 has pointed out, the active participation of at least one member of the emergency medicine staff (preferably senior and experienced) in such studies enhances motivation in staff busy with other priorities, and facilitates cooperation and collaboration (which can thereafter properly be recognised in co-authorship). There is also a danger that in the current litigious climate an inadvertent emphasis on "errors and poor outcomes" may prejudice the real benefits of the worthwhile objective of assessing the nature, relevance and value of improved communication between those engaged in clinical practice. Nonetheless, it is encouraging to deduce from this report that, in emergency departments, doctors and nurses regularly speak to each other, presumably with an optimal outcome for the patient in mind. For one who spent two decades as head of a busy, metropolitan emergency department, it is reassuring to find, in a discussion of informatics, advocacy2 for a return to the "white board", which, even today, remains the mainstay of patient information and tracking in many emergency departments.

Alan E O'Connor

In reply: We know little about communication systems in healthcare, and our study is still only one of a handful that quantify communication processes. Consequently, the aim of our pilot study, as well as reporting specific emergency department communication patterns, was to develop a robust general observational methodology, and measures of communication load.1 With the evidence that communication load is an issue, the next stage in the research would be to design studies to identify variables that could, in principle, affect communication load, as suggested by both Nocera and Hamilton. Indeed, there are many such variables — staff level and experience, organisational structure, clinical task, patient acuity, communication infrastructure, departmental policy, etc. The difficulty we will face is to control for many of these variables, and this will require longitudinal studies and samples from multiple sites. Hence, we are not yet able to make specific recommendations about interventions to "improve" communication in emergency departments. Indeed, there are no benchmarks against which to compare these data, so we cannot even say whether the data reflect good practice. Given these uncertainties, we agree with Nocera that it is too early to say which interventions would be appropriate to the specific circumstances of emergency departments, and we made no specific recommendations ourselves, but rather summarised commonly suggested interventions. Nocera and O'Connor also suggest other interventions which in their clinical experience may improve communication loads in emergency departments. It is likely that the variability of organisational settings will mean most such interventions will need to be customised to local conditions and needs. Hamilton is correct to highlight the tension in reporting data on organisational performance, and the risks of these data being misinterpreted or misused. Given these risks and the lack of comparative benchmarks, we explicitly chose not to comment on performance, nor to identify the organisations or participating clinicians. However, we would not have been able to carry out the study without the full cooperation of the staff at both hospitals, and, while they remain anonymous, we are deeply indebted to them for their willingness to welcome us into their workplace, volunteering to be subjects, and allowing us to observe them as they carried out their work.

Alan E O'Connor

To the Editor: The recent editorial by McCarthy and Garrow1 eloquently articulates a case for a coordinated national approach to controlling parasite infections in Aboriginal populations, based predominantly on the authors' experience with chemotherapeutic intervention in one remote community in Western Australia. While sympathetic to their motives, I am not so optimistic about the outcome of their proposal. For 20 years, Queensland maintained a centrally coordinated Aboriginal health program designed to monitor and eradicate parasitic infections. The program, which used targeted chemotherapy as its core strategy, was very successful with regard to intestinal worms, suppressing trichuriasis almost to extinction (unpublished observation) and virtually eradicating hookworm.2 However, the prevalence of gut protozoan infections (such as giardiasis and cryptosporidiosis) was hardly affected, for the obvious reason that these are relatively short-lived and spread directly person-to-person, which means that personal hygiene is much more crucial to their control. Systematic surveillance ceased after the program was dismantled (for political reasons) in 1990, and anecdotal reports since indicate that hookworm is now returning to Queensland. Again, this is not surprising given the mobility of Indigenous people, and the ability of infective larvae of Ancylostoma duodenale, the local hookworm species, to persist in a dormant state in host tissues, where they are refractory to currently available treatment.3 In support of their case, McCarthy and Garrow presented lymphatic filariasis in Australia as but one successful precedent, implying that it was eradicated "through sustained control programs conducted by dedicated public health agencies . . . using effective drugs".1 This is not supported by historical facts; the disease did disappear from endemic areas, but well before effective chemotherapy became available, and for reasons that are still debatable4 (although mosquito suppression, resulting more from general improvements in living conditions with rising community affluence than from any coordinated activity, is the most likely explanation). At the community level, parasitic infections of the gut represent not so much a primary problem as a symptom of a more fundamental societal malaise. They will disappear from Aboriginal communities only with a sustained improvement in living conditions (including nutrition, sanitation and personal hygiene), driven by the people themselves when armed with effective public health knowledge. This is a challenge that continues to dwarf the capabilities of all our governments and politicians, at all levels.

Paul Prociv · Stuart C Garrow · James S McCarthy

In reply: While specific details of control strategies for intestinal parasites vary according to parasite species, available anthelmintic agents and tools for environmental intervention, it is widely accepted that sustained, coordinated programs supported by government, community and health professionals with agreed methods and targets are the key to success.1 Prociv describes the outcome of just such a program for hookworm in Queensland, and the subsequent recrudescence of infection once the program was scrapped. The program in northern Western Australia succeeded because of commitment by government, community involvement entailing community debate and ownership of the program,2 education, and behavioural change, and improvement in public sanitation facilities as well as chemotherapy.3 We believe that a critical determinant of the outcome of our program was the inclusion of the community in designing the program. We agree with Prociv that control of filariasis and malaria was achieved in Australia by mosquito control; our statement about the role of sustained public health programs refers to the control of leprosy.4 With respect to the prospects for control of intestinal protozoa as well as helminths, a single-dose regimen with broad-spectrum activity would be ideal. While albendazole shows some useful clinical activity in giardiasis, single-dose regimens of this drug are insufficient to effect cure, as was observed in our study. While the social and environmental hurdles may appear to "dwarf the capabilities of government", we believe that there is a continuing need for Aboriginal health organisations, health professions and health departments at state and national levels to tackle parasitic infections. The logical approach is to model wider programs on successful local programs, and to avoid drifting into policy and program nihilism.

Stuart C Garrow · James S McCarthy

To the Editor: The possible impact of the Internet revolution has been much discussed.1-3 In two surveys, conducted in 1999 and 2001, we surveyed oncology patients from two teaching hospitals in central Sydney to explore the experience and impact of Internet use among Australian oncology patients. In November 1999, a questionnaire was mailed to 240 eligible patients selected from 617 sequential registrations to the oncology units. Eligible patients were those who were alive, competent, had cancer, were of known address and whose attending medical officer was participating. In the second survey, to obtain a more representative sample, we invited all oncology patients visiting the outpatient clinics over a three-month period (September to December 2001) to participate. We received completed questionnaires from 142 patients (response rate, 59%) in 1999 and from 153 patients (number of refusals unknown) in 2001. Of these, 33% (47/142) in 1999 and 46% (70/153) in 2001 had accessed the Internet for information relating to their illness, either personally or through family and friends. In both surveys, most users accessed the Internet from home, the information sought was mainly in relation to treatment, and the most-visited Internet sites were those of cancer centres. Patient perceptions of the impact of Internet-acquired information on their experience of cancer are summarised in the Box. Most patients viewed its impact as positive. The advantages of using the Internet reported by patients included its speed, convenience, privacy, currency, diversity of viewpoints, and usefulness as a support tool. Many reported that they had sought corroboration of Internet information with information from other sources, especially their doctor. Problems identified with the Internet were its impersonal nature, time costs, overabundance of information, and concerns about the discovery of inappropriate, inaccurate or distressing information. Most respondents emphasised that they were able to recognise these limitations, but, notwithstanding, considered the Internet a valuable resource. For example, one respondent wrote: "I felt my capacity to cope with the illness and treatment greatly improved because I learned enough from the Internet to challenge my oncologist and thereby learn to trust him and his advice." Despite concerns expressed by many doctors, these oncology patients assessed impacts as either positive or neutral in overall influence. Increasing Internet use by patients and their families should not be viewed as a problem, but as an opportunity for patients and their treatment teams to work together, ensuring that patients have up-to-date information about their illness and its treatment and are aware that they are not alone in the fight against cancer. Perceived influence of Internet-acquired information among oncology patients in 1999 and 2001 Better No change Worse Question not answered 1999 survey (n = 47) Relationship with doctor 12 (26%) 30 (64%) 0 5 (11%) Discussions with doctor 20 (43%) 22 (47%) 0 5 (11%) Treatment decisions 22 (47%) 19 (40%) 1 (2%) 5 (11%) Coping with illness 26 (55%) 15 (32%) 1 (2%) 5 (11%) 2001 survey (n = 70) Relationship with doctor 24 (34%) 34 (49%) 2 (3%) 10 (14%) Discussions with doctor 42 (60%) 18 (26%) 1 (1%) 9 (13%) Treatment decisions 37 (53%) 25 (36%) 0 8 (11%) Coping with illness 32 (46%) 31 (44%) 1 (1%) 6 (9%)

Julia ML Brotherton · Stephen J Clarke · Susan Quine

To the Editor: The article on acute community-acquired meningitis and encephalitis by Beaman and Wesselingh1 provides a comprehensive and up-to-date review of diagnostic and management issues relevant to general clinicians. However, the section on vaccines for preventing meningococcal C and pneumococcal diseases is not as contemporary. Contrary to the authors' statements that "a conjugate vaccine covering serogroup C [meningococcus] will be available in Australia shortly", and "a conjugate vaccine [for pneumococcus] is currently under trial in Australia", conjugate vaccines for both diseases are available and registered for use in Australia. Conjugate vaccines have the advantage that they can be used in children from six weeks of age and are expected to provide long-term protection. Meningitec is a meningococcal group C conjugate vaccine approved for use in children from six weeks of age, adolescents and adults. Meningitec has been available from Wyeth Australia since October 2001, but is not part of the National Childhood Immunisation Scheme and, as such, can only be obtained on private prescription at present. Prevenar (pneumococcal septavalent conjugate vaccine) is also approved for use and has been available from Wyeth Australia since January 2001. Prevenar is indicated for active immunisation of infants and children from six weeks to nine years of age against invasive disease, pneumonia and otitis media caused by Streptococcus pneumoniae.

Deborah C Saltman · Miles H Beaman · Steven L Wesselingh

In reply: We thank Saltman for up-to-date information on Wyeth vaccines. Readers will appreciate that our article1 was commissioned in January 2001, and the manuscript delivered in August that year, before the licensing of Meningitec. As the article discussed, group C meningococcus is a minority strain in most regions of Australia. Hence, the vaccine will not prevent most cases of what is already an uncommon disease. Conjugate pneumococcal vaccines should have much wider application in the future, but currently are subsidised for use in only a minority of the at-risk population.

Deborah C Saltman MD, FRACGP, FAFPHM · Miles H Beaman FRACP, FRCPA · Steven L Wesselingh FRACP, PhD

To the Editor: As noted in the letter by Chapman and Jamrozik,1 there was substantial prescribing of bupropion sustained release (Zyban SR; GlaxoSmithKline) following its Pharmaceutical Benefits Scheme (PBS) listing from 1 February 2001. The drug has been the subject of extensive publicity following reports of adverse drug reactions and deaths of patients while taking bupropion. Although bupropion has been shown to be effective in two key clinical trials,2,3 there are no studies of effectiveness when prescribed in the context of Australian general practice. We conducted a study of short-term effectiveness involving 11 general practice registrars working in eight practices in south-west and southern Sydney. Each registrar identified from practice prescribing records 10–15 patients prescribed bupropion after 1 February 2001. These patients were followed up via a telephone questionnaire 10 weeks after the date of prescription. The questionnaire elicited information on the use of bupropion, patient-reported abstinence rates, adverse effects and use of support services. Biochemical validation of smoking status was not conducted. Interviews with 151 patients were conducted between April and August 2001 (see Box). Patients completing seven weeks or more of therapy were significantly more likely to report both continuous abstinence (P = 0.01) and point-prevalence abstinence (P = 0.002). Eighty-three patients reported adverse effects, the five most common being insomnia (14%), headaches (11%), nausea (8%), dry mouth (5%) and irritability (4%). No convulsions were reported. Patients who made use of one or more support services for cessation counselling were no more likely to report point-prevalence abstinence at follow-up than those who did not (P = 0.8). Our study was not based on a random sample of GPs or patients, and we did not collect data on the total number of patients treated with bupropion in these practices over the study period. Bearing in mind these limitations, the study has a number of notable findings. Despite the wording of the PBS authority "for use within a comprehensive treatment program'', fewer than half the patients reported using any support service. There was also a low rate of completion of the recommended course of treatment (less than 20% of patients). While the short-term abstinence rates among the patients followed up were encouraging, and not dissimilar to rates found in clinical trials,2,3 there is clearly a need to look at strategies to encourage patients to adhere to the prescribed course of treatment and to make use of cessation support services. We suggest patients be invited back for at least two follow-up GP visits following prescribing of bupropion, as well as being made aware of other support services. Ten-week follow-up survey of patients prescribed bupropion sustained release (Zyban SR) for smoking cessation (n = 151) Patients taking all or part of course of drug therapy 124 (82%) Mean duration of therapy (weeks) 4.6 (range, 1–12) Patients completing at least seven weeks of therapy 24 (19% of those who took all or part of course) Patients reporting continuous abstinence at 10 weeks 47 (31%) Patients reporting point-prevalence abstinence at 10 weeks 57 (38%) Patients reporting adverse effects 83 (68% of those who took all or part of course) Patients accessing one or more support services (general practitioner, Quitline, ZAP*) 69 (46%) *ZAP = Zyban Action Plan (trademark of GlaxoSmithKline)

Nicholas A Zwar · Alia Nasser · Elizabeth J Comino · Robyn L Richmond

To the Editor: In November 1999, the National Health and Medical Research Council (NHMRC) released Guidelines for the prevention, early detection and management of colorectal cancer.1 One chapter addressed screening for colorectal cancer (CRC), citing Level 1 evidence in support of faecal occult blood testing (FOBT) as the preferred modality for population-based CRC screening. Colonoscopy and sigmoidoscopy were not recommended. In a postal survey conducted in 1998, before release of these guidelines, we found mixed views among Australian surgeons about CRC screening.2 In February 2001, we conducted a follow-up (post-guidelines) survey which included three questions about CRC screening that had been asked in the pre-guidelines survey. Using a pre–post design, we evaluated the impact of the NHMRC guidelines on surgeons' views. Of the 172 surgeons confirmed still to be in active practice at the time of follow-up, 114 (66%) returned questionnaires. One hundred and three (90%) agreed to matching of their baseline and follow-up responses. Of these, 101 (98%) provided valid responses to each of the three questions on both occasions. Surgeons' views about population-based CRC screening by FOBT changed significantly between the surveys (Box). At baseline, half "strongly agreed" or "agreed" that population-based FOBT should be introduced for all Australians over the age of 50 years. At follow-up, the proportion had increased significantly to more than two-thirds (McNemar's χ2 = 13.0; P < 0.001). There was no significant change in the percentage of surgeons who "strongly agreed" or "agreed" that colonoscopy is preferable to FOBT (McNemar's χ2 = 0.9; P = 0.3). In contrast, there was a significant decrease in the percentage who "strongly agreed" or "agreed" that sigmoidoscopy is preferable to FOBT (McNemar's χ2 = 4.4; P = 0.04). Although the influence of events unrelated to the NHMRC guidelines cannot be entirely excluded from uncontrolled evaluation designs such as this, our data provide some reassurance that the guidelines have had an impact. However, as argued elsewhere,3 substantially more effort is required to ensure that patients with CRC detected through screening receive evidence-based management. More rigorous study designs with control groups are recommended to identify strategies effective in changing surgical practice. Finally, surgeons' increased enthusiasm for CRC screening contrasts with public hesitancy.4 Surgeons' views about screening for colorectal cancer before and after publication of national guidelines1 (n = 101) Strongly agree Agree Neutral Disagree Strongly disagree Population-based screening by FOBT should be introduced for all Australians over 50 years of age Before After 17% 26% 34% 44% 28% 23% 18% 8% 4% 0 Colonoscopy is preferable to FOBT as a population-based screening method Before After 6% 7% 23% 28% 21% 22% 42% 37% 9% 7% Sigmoidoscopy is preferable to FOBT as a population-based screening method Before After 2% 1% 23% 13% 13% 23% 55% 55% 8% 9% FOBT = faecal occult blood testing. Due to rounding, row percentages do not necessarily sum to 100%.

Annie Cooney · Neil J Donnelly · Melina Gattellari · Jeanette E Ward

To the editor: Large randomised trials have confirmed that treatment with cholecalciferol (vitamin D3) and calcium reduces hip and non-vertebral fractures.1,2 In public health terms, calciferol compounds are cost-effective,3 simple to monitor and generally free of side effects. Ergocalciferol (vitamin D2) is the only single prohormonal form of vitamin D available in Australia.4 As compliance rates for this medication have not, to our knowledge, been evaluated, we decided to conduct our own study of compliance. At the Royal Perth Hospital, between June and September 2001, we identified 106 people with hip fracture who were vitamin D insufficient (defined as a serum 25-hydroxyvitamin D level < 50 nmol/L) and began treatment with ergocalciferol. Three months after discharge, we interviewed patients to determine whether they were complying with treatment and, if not, the reasons for non-compliance. Of the 106 patients identified, 53 were interviewed (the remaining 53 patients were not contacted for various reasons: 38 did not live in the metropolitan region, eight had died, one refused interview and six were lost to follow-up). Of the patients interviewed, 33 (62%) had complied with therapy. Reasons for non-compliance among the remaining 20 (38%) are outlined in the Box. Reasons for non-compliance with vitamin D therapy Reason Number of patients Not on discharge script from orthopaedic ward/ Reason for taking medication unknown by patient and/or carer 9 Stopped by general practitioner or doctor from another hospital/ Not continued after hospital supply used up 6 Patient refusing all medication/ Patient moribund 4 Side effects/ Intolerance of medication 1 The most common reason for non-compliance was poor communication between the hospital and the general practitioner. The second most common cause of non-compliance — failure to continue treatment on discharge or active cessation by the attending physician following discharge — indicates either that medical practitioners are ambivalent about the treatment of vitamin D deficiency or that patient-specific factors are at work. Ergocalciferol is not listed under the Pharmaceutical Benefits Scheme. It is available directly from pharmacy outlets without a prescription and the cost of treatment (currently about $17.50/month for 60 × 1000 IU tablets) must be borne entirely by the patient. Thus, continuation of treatment is largely dependent on patient initiative, and, in our survey, cost may have been a disincentive to continue the medication once the hospital discharge supply was depleted. Side effects of the medication were a very minor reason for non-compliance — only one patient out of 20 stopped therapy because of ergocalciferol intolerance. Our audit had several limitations: the sample size was small, treatment was not blinded, and only patients living within the inner Perth metropolitan area were interviewed, which may have introduced bias. Vitamin D deficiency remains a common and undertreated cause of osteoporotic hip fracture in elderly people, both in Australia and elsewhere.5 Our study suggests that the rate of non-compliance with ergocalciferol therapy is unacceptably high.

Jane M Noble · Marjory McGuiness · Paul Glendenning

To the Editor: The practice of radiology and pathology has changed dramatically in the past two decades. Increased use of multidisciplinary assessments and interventional techniques has meant greater exposure of patients to radiologists and pathologists. When patients undergo investigations, they are invariably anxious, usually expect the worst, and want the result as soon as possible. Therefore, there is pressure to provide an immediate answer to the problem at hand. In most instances, it would be possible to offer a diagnosis. However, many radiologists and pathologists are reluctant to discuss investigations with patients in detail.1 During interventional procedures, radiologists and pathologists see patients only briefly; they often don't know all the facts about them, and are not ultimately responsible for their clinical management.1 As the patient is only temporarily in the care of the radiologist or the pathologist, it is not appropriate to discuss complex issues or offer opinions and advice. Such advice may put the patient's doctor in an awkward position, forcing the referring practitioner to follow a course of action which may not be in the best interests of the patient. At a patient's insistence, radiologists and pathologists can sometimes indicate to someone who has a clearly benign condition that the problem under investigation is unlikely to be serious.2-4 This may be the case with screening mammography, as, in most cases, the results are either normal or indicate a non-malignant condition. However, in diagnostic radiology and pathology, such an opinion is usually based on a preliminary impression, which may change when all the facts are considered. The cost of providing on-the-spot written reports to the patient has to be factored into the equation. It has been estimated that the additional cost of immediate reporting of results of screening mammography is about US$28.22. When additional equipment and space were not required, the cost would increase by US$4.38. Although most patients in the study preferred immediate reporting, they were unwilling to pay the additional fees.5 With respect to pathology, a formal fine-needle aspiration result can be delivered within an hour, but, for the reasons outlined above, this would not be advisable. Further, the pathologist's contract is with the referring doctor and the report is written in scientific language, which may not be easily understood by the patient, leading to unnecessary anxiety. Giving bad news to a patient is not an easy task even for trained professionals. It is even harder for radiologists and pathologists who are not generally equipped to provide counselling and support, and who may not be indemnified by their insurers to carry out such tasks. Further, neither radiology departments nor pathology laboratories are suitable settings for giving bad news,1 as very few support avenues are usually available to patients there. Predicting the impact that bad news will have on a patient is extremely difficult, and radiologists and pathologists should, for compassionate and for medicolegal reasons, refrain from providing immediate answers to patients.

Ibrahim M Zardawi