Letters

To the Editor: Few reports have been published on bone mineral density (BMD) among randomly sampled populations. Organisations such as Osteoporosis Australia and the Australian and New Zealand Bone and Mineral Society rely on research to supply reliable data that are representative of the Australian community. This information informs practitioners, researchers and policymakers of the size of the problem of osteoporosis in Australia. Our study aimed to document the proportion of individuals who have reduced BMD. The Geelong Osteoporosis Study recruited a random population-based sample of individuals from the Barwon Statistical Division, an area surrounding Geelong, Victoria. This region is well suited to epidemiological research as it is geographically well defined and has a large, stable population (259 000) with sufficient socioeconomic diversity for it to be representative of the Australian population.1,2 Age-stratified random samples of 1494 women (median age 54.0 years; range 20–94 years; recruited 1994–1997)3 and 1467 men (median age 56.0 years; range 20–97 years; recruited 2001–2006)4 were drawn from electoral rolls. Participation rates were 67% for men and 77% for women. We measured BMD at the spine and femoral neck by dual energy x-ray absorptiometry (Lunar; GE Healthcare, Madison, Wis, USA). Reference ranges for BMD in men4 and women3 have been published previously. We categorised BMD as normal (T score, > − 1.0), osteopenia (T score, − 2.5 to − 1.0) or osteoporosis (T score, < − 2.5) using the osteoporosis and osteopenia thresholds developed for postmeno-pausal women. Among those with discordant BMD, the site with the lower BMD was used in this classification. Normal BMD was predominant among men aged < 50 years (Box). A consistent proportion of men older than 50 years, including those aged > 80 years, had osteopenia (range, 49%–64%); 19% of those aged > 80 years had osteoporosis. Most women aged < 55 years had BMD in the normal range. Osteopenia was most prevalent among those aged 55–79 years, and osteoporosis dominated (51%) among those aged > 80 years. The osteoporosis and osteopenia thresholds developed for postmenopausal women may not be the most appropriate cut-points for diagnosis in younger women and in men; however, we used them because they are the currently accepted thresholds. Although sex-specific thresholds for defining osteoporosis might best be defined on the basis of absolute fracture risk, until such data are available, T-score criteria continue to be used. After standardising for age and sex to the 2006 Australian population,5 we found that 5.9% of men and 22.8% of women aged 50 years and over, and 12.9% of men and 42.5% of women aged 70 years and over, would be classified as having osteoporosis. Proportion of participants in the Geelong Osteoporosis Study with osteoporosis or osteopenia, by age group, according to bone mineral density at the spine or femoral neck Men* (no. [%]) Women† (no. [%]) Age group (years) Osteoporosis‡ Osteopenia§ Normal¶ Osteoporosis‡ Osteopenia§ Normal¶ 20–24 0 (0) 14 (15.7%) 75 (84.3%) 1 (1.0%) 21 (20.6%) 80 (78.4%) 25–29 0 (0) 24 (26.1%) 68 (73.9%) 0 (0) 24 (22.2%) 84 (77.8%) 30–34 1 (1.1%) 29 (30.9%) 64 (68.1%) 0 (0) 25 (22.5%) 86 (77.5%) 35–39 0 (0) 31 (30.7%) 70 (69.3%) 2 (1.7%) 41 (35.3%) 73 (62.9%) 40–44 4 (3.8%) 36 (34.3%) 65 (61.9%) 1 (0.9%) 32 (29.9%) 74 (69.2%) 45–49 4 (3.9%) 34 (33.3%) 64 (62.7%) 2 (1.8%) 32 (28.1%) 80 (70.2%) 50–54 3 (2.5%) 60 (50.0%) 57 (47.5%) 5 (4.7%) 43 (40.6%) 58 (54.7%) 55–59 2 (1.9%) 61 (58.7%) 41 (39.4%) 9 (8.9%) 57 (56.4%) 35 (34.7%) 60–64 4 (3.9%) 50 (48.5%) 49 (47.6%) 22 (21.0%) 54 (51.4%) 29 (27.6%) 65–69 6 (5.7%) 67 (63.8%) 32 (30.5%) 24 (24.0%) 48 (48.0%) 28 (28.0%) 70–74 9 (7.5%) 72 (60.0%) 39 (32.5%) 43 (32.6%) 70 (53.0%) 19 (14.4%) 75–79 14 (13.1%) 63 (58.9%) 30 (28.0%) 32 (42.7%) 33 (44.0%) 10 (13.3%) 80+ 34 (18.5%) 107 (58.2%) 43 (23.4%) 105 (51.0%) 88 (42.7%) 13 (6.3%) * Recruited 2001–2006. † Recruited 1994–1997. ‡ T score, < − 2.5. § T score, − 2.5 to − 1.0. ¶ T score, > − 1.0.

Margaret J Henry · Julie A Pasco · Geoff C Nicholson · Mark A Kotowicz

To the Editor: Childhood communication disorders (CCD) affect up to 20% of 4-year-old children.1 Early intervention is important2 and a variety of health and education professionals may provide assistance, including speech pathologists (SPs), paediatricians, general practitioners and others. The type and amount of help provided to preschool-aged children in Australia is unknown, nor are the costs empirically described. Using data from the Early Language in Victoria Study (ELVS),1,3 a prospective study of a large Australian cohort of children, we describe the use of services for CCD, out-of-pocket costs to families and costs to the health system. ELVS participants were recruited at 8 months of age, at routine child health checks in maternal and child health centres in Melbourne during 2002. Parents completed questionnaires at baseline (when the child was 8 months of age) and at each birthday.3 In-depth questions about use of services were included for the first time at 5 years. These questions covered SP assessment and treatment, visits to other professionals for CCD concerns, and out-of-pocket expenses for all services, within the preceding 12 months (ie, when children were in their fourth year). Of the original cohort, 983 families (51%) completed the service-use questionnaire. Sixteen per cent had used services (one-third of whom used more than one service); 11% had accessed SP treatment, and 6% had accessed other professionals. The number of service occasions per year for each professional, and the associated costs, are shown in the Box. Children accessing SP treatment received a median of 10.8 therapy hours within 12 months (interquartile range, 4.3–17.3; range, 0.5–104); 28% received ≤ 5 hours and 13% received > 25 hours. Costs of all services accessed in the period, including health system costs and parent out-of-pocket expenses, varied from $34 to $16 546. Our data show that some children received very little intervention for CCD within a 12-month period. Given the critical importance of communication skills to school achievement, this is of concern. We also demonstrate a substantial financial outlay associated with the treatment of CCD in Australia. These data are likely to be generalisable given the nature of this prospective cohort and the reliability of our health care cost estimates. The results highlight the immense variability in service use and the potential burden of cost to government and families associated with CCD. Our data do not describe service use before 4 years of age, nor have we included indirect costs such as travel and parental time away from work. Thus, they represent a starting place for understanding total costs. Costs to the health care system and families for childhood communication disorders services provided to children aged between 4 and 5 years in the Early Language in Victoria Study cohort Cost per family for 1 year using the service Service Median number of visits per year (IQR; range) Health care system cost* per visit ($) Median health care system cost ($) (IQR; range) Median out-of-pocket costs ($) (IQR; range) Median combined costs (health care system + out-of-pocket) ($) (IQR; range) Speech pathologist (treatment) 15.2 (6.5–26; 1–52) 49 742 (318–1273; 49–2545) 498 (173–1040; 0–4117) 1061 (472–2256; 49–6662) Paediatrician 2 (1–3; 1–10) 119 (initial) 59 (subsequent) 178 (119–237; 119–296) 250 (120–320; 0–500) 328 (178–511; 119–776) General practitioner 2 (1–4; 1–10) 34 (standard) 67 (34–151; 34–336) 40 (0–75; 0–294) 101 (34–181; 34–495) Psychologist 3 (1.5–4.5; 1–8) 49 147 (61–233; 49–392) 575 (105–889; 0–1300) 502 (157–1027; 49–1545) Otolaryngologist 2 (1–3; 1–8) 119 (initial) 59 (subsequent) 178 (119–237; 119–534) 210 (120–358; 65–1200) 239 (119–438; 119–1734) Hearing specialist 1 (1–2; 1–4) 49 49 (49–98; 49–196) 0 (0–2; 0–1000) 50 (49–98; 49–1098) Early intervention† 10 (1.5–28; 1–48) 240 2400 (300–8160; 240–11 520) 112 (0–600; 0–720) 2400 (300–8638; 240–12 240) All services na na 661 (238–1273; 34–14 426) 413 (91–1306; 0–4500) 1061 (335–2460; 34–16 546) IQR = interquartile range. na = not available. * Health care system costs were Medicare Benefits Schedule (MBS) fee rates charged at the applicable rebatable level (ie, 100% for GP services and 85% for other services).4 † Early intervention services, which are not covered by the MBS, were estimated from existing cost estimates.5

Jemma Skeat · Lisa Gold · Melissa Wake · Obioha C Ukoumunne · Sheena Reilly

To the Editor: Australian bat lyssavirus (ABL) has the potential to cause fatal encephalitis in humans exposed to infection through bat bites or scratches. There is no cure for rabies currently available, so postexposure prophylaxis with rabies vaccine and rabies immune globulin is recommended following potential human exposure, such as after bites or scratches. People who work with or handle bats should be vaccinated, should regularly monitor their rabies antibody levels to ensure maximum protection, and should seek immediate medical attention for all potential ABL exposures.1 We report the case of a 42-year-old man bitten by a black flying fox (Pteropus alecto) during the retrieval of the bat from a suburban Brisbane, Queensland, backyard. The bat had been found on the ground in the daytime, vocalising and acting aggressively. The patient was a member of a local organisation which cares for injured bats. The Logan and West Moreton Public Health Unit was notified the day after the incident. The patient reported that he had been vaccinated against rabies previously, and that his rabies virus-neutralising antibody titres were adequate. However, the patient’s available titres were below 0.50 IU/mL in 2002 and 0.43 IU/mL in 2008 (no boosters were given), both of which were below the World Health Organization recommended level that confers protection against rabies virus.2 The bat was euthanased for testing (because it had bitten a person, as per Qld Health protocol), and tests on the brain tissue showed it to be reactive for lyssavirus antigen (using an immuno-fluorescence antibody test) and lyssavirus RNA (using a TaqMan assay). In view of the patient’s recent serological tests indicating subprotective antibody levels and definite exposure to an ABL-positive bat, he was given postexposure prophylaxis comprising rabies immune globulin into the wound and five doses of rabies vaccine. He is currently well. The Public Health Unit determined that others were not potentially exposed to the bat. The prompt reporting of all potential ABL exposures to public health units is especially important because bat carers may underreport potential ABL exposures.3 Current guidelines recommend that bat carers with ongoing potential exposure to ABL should check their rabies virus-neutralising antibody titres every 2 years and have a booster if the titre is reported as inadequate (< 0.5 IU/mL). Alternatively, booster doses may be offered every 2 years without determining antibody levels.1 Further education of the bat-handling community and their doctors is necessary to maintain awareness and best practice to protect the people who do this potentially dangerous work.

Heidi J Carroll · Bradley J McCall · David Looke · Bruce Fraser

To the Editor: There is international recognition of the substantial threat that global warming presents to human health and of the challenges that it poses to health service delivery. The World Health Organization has estimated that global warming and climate change-related natural disasters account for over 60 000 deaths globally per year.1 Global warming will also have implications for surgery and surgical practice. The Victorian “Black Saturday” bushfires of February 2009 saw 414 people presenting to hospital emergency departments, stretching hospital resources,2 and 173 deaths were attributed to the bushfires. Nineteen patients were admitted to the Alfred Hospital (Melbourne’s burns service) with burns to more than 30% of their bodies. The care of severe burns victims is complex and highly labour-intensive, often with a patient–nurse ratio of 1 : 1. There would have been even more burns victims if the fire had been less ferocious and had not resulted in such a high loss of life.3 In other words, there were fewer injuries because this intense fire killed people outright; a less intense fire may kill fewer people but leave more injured. The extreme weather that led to the fires is an example of the type of event that may become more frequent as global warming increases. The Garnaut climate change review predicts more frequent extreme wind, rain and intense tropical cyclones, and predicts that category 3–5 storms are likely to increase in intensity by 60% by 2030, and by 140% by 2070.4 Increasing population densities along the northern Queensland coast will also expose more people to the risks of floods, storms and cyclones. These natural disasters often produce wounds which are highly contaminated, and primary wound care services may face increased demand. One of the practical implications of research in the field of surgery and climate change will be the need for modelling of future demands for surgical intervention in Australia. The range of trauma impact due to climate change needs to be defined, and the incidence with which this is likely to occur needs to be determined, based on climate change modelling. With this information, models of future demand for surgical interventions can be determined.

Joseph W Smith · Guy J Maddern

To the Editor: Scott and Guyatt are absolutely correct that as much transparency as possible is required in the process by which any clinical guidelines are formulated.1 I also agree that this must include careful management of conflicts of interest, particularly in the selection of the members of the expert panels required to formulate guidelines and in the functioning of those panels.1 However, transparency does not necessarily require adopting the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system or any other hierarchical system for formulating guidelines, nor does it necessarily require seeking formal feedback from external stakeholders. The GRADE system, like most hierarchical systems, assumes there is at least some evidence in the literature that addresses the relevant clinical problem — thus, it gives its lowest grade to observational studies with a very uncertain estimate of effect. But, often, practitioners most want help with the complex and multifaceted clinical problems on which there are not even formal observational studies. The GRADE system would presumably put these problems in the category of “You’re on your own, chaps, and don’t expect us to help you”. Recommendations on the problems that are most vexing to practitioners will be mainly (and inevitably) based on clinical experience and circumstantial evidence — in other words, expert opinion. Most practitioners looking for guidance will be well aware that such recommendations are likely to be based on expert opinion rather than excellent formal evidence. When deciding whether or not to trust the recommendations, they will be much more concerned that any conflicts of interest for the experts making the recommendations have been recognised and appropriately redressed, rather than that the level of evidence has been rigorously graded. Seeking formal feedback from stakeholders is also a separate issue from transparency. Potential users should be well represented on any writing panel, and their feedback is obviously essential — there is no point in producing guidelines that don’t address the problems that the potential users are facing. However, many stakeholders — for example, the pharmaceutical industry — will have much more serious conflicts of interest than do the members of the expert panel, and these can be impossible to deal with. Of course, feedback should be sought where appropriate, but to make it an absolute requirement under the guise of transparency seems nonsensical. It is clearly essential that users of clinical guidelines must be able to have confidence that they have been developed as rigorously as possible, but an excessively doctrinaire approach to their development will almost certainly lead to a decline in usefulness without a counterbalancing increase in trustworthiness.

Robert F W Moulds

To the Editor: Bismark, Spittal and Studdert observed that complaints clustered around certain doctors.1 They state that, in Victoria, extrapolations from their findings indicate that 1% of the medical workforce in private practice accounts for nearly 20% of complaints, and that male surgeons who have practised for more than 30 years are the doctors who are most complained about.1 Bismark and colleagues established that complaint-prone doctors are more likely to be male, surgeons or psychiatrists, to have trained in Australia and to have been in practice for at least 30 years. They agree with previous studies that suggest that the inherent risks of surgical procedures and the relative visibility of poor surgical outcomes are likely to play a role, and also note that the potential for power imbalances between doctor and patient is high in both surgery and psychiatry. That training outside of Australia was found to have a “protective effect” may seem surprising, but this fits my view about what most often motivates a patient to complain about a doctor when something goes a little astray. My belief, based on a long period of surgical practice and of observing other doctors, largely surgeons, is that a common stimulus to make a complaint when there is a degree of dissatisfaction is a perception that the doctor was overconfident, perhaps to the point of arrogance, and had little personal interest in the patient’s welfare. The lower self-confidence of some overseas-trained surgeons could therefore lessen the likelihood of complaints being made about them, whereas the supreme confidence of some highly experienced Australian-trained surgeons may go against them when something goes wrong. Good manners, kindness, demonstrations of personal interest and concern, and a degree of humility all discourage complaints! In an article subtitled “Arrogance: the biggest sin of all”,2 in the United Kingdom Telegraph, in 2009, Dr James LeFanu appropriately commented, “The virtues of generosity, cheerfulness and discretion should be the hallmark not just of medicine, but of all the liberal professions. How many doctors live up to these ideals is, of course, impossible to quantify, but certainly some readers of this column take a rather jaundiced view”.2

John A Buntine

To the Editor: Recent media reports queried whether Australia could experience a serious outbreak of foodborne disease, such as the massive outbreak in May this year of Shiga toxin-producing Escherichia coli (STEC) serotype O104:H4 in Germany.1 Australia is potentially vulnerable to foodborne disease outbreaks from contaminated fresh produce, and health and food safety authorities need to plan for these events and assess our capacity to respond. Australian health agencies investigate 100–150 outbreaks of foodborne illness each year, although < 10% are associated with fresh produce.2 Australia has a very high-quality food supply, but we are still vulnerable to outbreaks. In 1991, norovirus-contaminated orange juice served by airlines infected 25 000 people, despite the juice being sourced from a single small factory.2 Foodborne outbreaks can become very large and spread internationally before health agencies identify a vehicle of transmission. In 2009–2010, an outbreak of hepatitis A infection in more than 400 people in multiple Australian states, France and the Netherlands was associated with consumption of semidried tomatoes from Turkey.3 The recent outbreak of STEC O104:H4 also occurred in other European countries and was associated with a common source of fenugreek seeds used for growing sprouts.4 Seed sprouts have caused many outbreaks of foodborne illness, including two outbreaks of Salmonella Oranienburg in Western Australia and Victoria in 2005–2006 where alfalfa sprouts were implicated.2 STEC outbreaks overseas have implicated seeds originating from Australia.5 Seeds may become contaminated during plant growth, particularly due to livestock and feral animal grazing, or during storage, neither of which can be effectively controlled by disinfection at sprouting facilities.5 In light of the recent European STEC outbreak, Australian food safety agencies should urgently assess the risks posed to the food supply by sprouted seeds. Australia does have well functioning plans to respond to multijurisdictional outbreaks and national food safety incidents,2 but has not had to respond to a massive outbreak. German investigators reported 3222 outbreak cases of STEC, including 810 cases of haemolytic–uraemic syndrome, in less than 2 months.1 The health system resources required to manage such an outbreak would be immense and costly. In Australia, treatment and other costs for two cases of haemolytic–uraemic syndrome totalled an estimated $14 000 each, despite neither patient requiring dialysis, developing end-stage renal disease or requiring a transplant.6 As with other national plans for responding to epidemics, government agencies need to ensure that possible impacts on the health system and industry are taken into account.

Martyn D Kirk

To the Editor: Echoing Scott and colleagues’ recent call for caution regarding the use of hospital standardised mortality ratios for benchmarking and public reporting,1 we have concerns about the use of infection rates as hospital quality indicators. The National Healthcare Safety Network (NHSN) at the United States Centers for Disease Control and Prevention defines central line-associated bloodstream infection (CLABSI) as occurring where the patient has “a recognized pathogen cultured from 1 or more blood cultures and organism cultured from blood is not related to an infection at another site”.2 This and other criteria (for organisms associated with skin contamination and in children) are also used as quality indicators by VICNISS (the Victorian hospital-acquired infection surveillance system) and the Australian Commission for Safety and Quality in Health Care. The infection prevention unit at Alfred Health in Melbourne recently assessed three cases of hospital-acquired bacteraemia as having met the NHSN/VICNISS definition of CLABSI. This assessment was disputed by Alfred Health’s intensive care unit and we sought further opinions from other infectious diseases physicians and infection control practitioners to adjudicate, in the absence of established criteria to determine whether the bacteraemia was due to infection at a site other than the central line. We received conflicting advice. These three cases would have comprised a third of the CLABSI cases at our hospital in the 6 months to April 2011, and thus significantly impact on our reported quality assurance indicators. Similar common situations may arise in considering cases of bacteraemia in patients who have central lines in the context of chemotherapy-related mucositis; in patients with extensive burns; where cultures are only taken from central lines (rather than from peripheral venepuncture); where there are single blood cultures of enterococci of doubtful clinical significance; and where there are unconfirmed clinical foci of deep infection.3 Previous published work suggests that interrater agreement remains poor, despite changes to the definition of CLABSI.4 Other infection rates are associated with other problems as outlined by Scott and colleagues.1 For example, the current NHSN risk stratification system for infection (http://www.vicniss.org.au/Resources/HCWType1Manual/Type1Manualv6_0708.pdf) related to coronary artery graft surgery is poorly discriminatory, as most patients fall into risk index categories 1 or 2, and statistical calibration of this system is poor.5 Interrater reliability of classification of superficial infections has also been shown to be poor.6 The relatively low rate of infections in patients undergoing coronary artery surgery may result in large stochastic variation, particularly in hospitals performing relatively few such procedures. Public reporting of infection rates is probably inevitable. However, such data should be restricted to indicators that have been shown to validly reflect preventable infections, using definitions that are reliable, and with the appropriate caveats regarding their limitations.

Allen C Cheng · Pauline Bass · Carlos Scheinkestel · Tim Leong

To the Editor: Australia is already a hot country and the frequency of hot spells looks set to increase over coming decades.1 Health care professionals will therefore need to consider the effect that medications can have on people’s capacity to respond to hot conditions. Medications can directly increase body temperature by altering thermoregulatory mechanisms, pharmacological action, idiosyncratic reactions, or hypersensitivity reactions.2-4 Uncommon side effects — including toxic states, anticholinergic poisoning syndrome, serotonin syndrome and neuroleptic malignant syndrome — can also generate heat. Indirect impairment of physiological response to thermal stress may occur by preventing adjustment to hypotension, or by interfering with behavioural responses. Despite these risks, hyperthermia and reduced sweating each rate only one mention in the 2010 Australian medicines handbook (in relation to anticholinergics).5 The handbook does not list heat stress as an adverse reaction to dexamphetamine,5 which can impair thermoregulation by increasing metabolic rate. Medications can affect thermoregulation by:2-5 impairing sweating triggered by the parasympathetic nervous system — eg, anticholinergics, phenothiazines; impairing sweating by carbonic anhydrase inhibition — eg, topiramate, zonisamide; impairing cardiac output or causing hypovolaemia — eg, antihypertensives, alpha-blockers, diuretics; impairing behavioural responses to heat (such as drinking or taking cooling action) — eg, sedatives and hypnotics, anxiolytics, phenothiazines, illicit drugs; or rarer effects, such as increasing metabolic rate — eg, monoamine oxidase inhibitors, thyroxine, amphetamines, cimetidine. Elderly people with impaired thermoregulation, the socially disadvantaged and people with mental illness have been identified as being most at risk from heat stress.6 Although the risk of medications directly impairing physiological responses to heat is low, thermoregulatory effects can be cumulative. People in certain occupations (eg, outdoor labourers and tradespeople, indoor workers in hot industries such as metal manufacturing) may be at increased risk of heat exposure, and there are anecdotal reports of tourists suffering heat stress in climates that are hotter than those to which they are accustomed. There is a need to educate workers, the public and health practitioners about the relationship between certain medications and heat. Professional associations and trade unions have a responsibility to warn and educate their members. It may be helpful for the Therapeutic Drugs Administration to actively solicit reports of adverse events related to medicine use, heat and thermoregulation via the Australian Adverse Drug Reaction Reporting System. Carers of elderly and chronically ill people might flag patients on certain medications for extra care during hot spells. Additionally, health practitioners can ensure that these people are on appropriate heatwave notification and emergency support lists, which are being developed by Australian state and territory health departments and emergency service agencies.

Peter W Tait

To the Editor: I endorse the viewpoint expressed by Jenkins and colleagues.1 They refer to the dearth of hospital medical generalists, at a time of increasing numbers of elderly patients with multiple comorbidities. Nowhere is this lack of appropriate clinical skill to match demand so apparent as in our regional centres. More often than not, junior doctors are responsible for older patients, and are required to manage disparate inputs from several medical and/or surgical subspecialists. Particularly for surgical patients with medical comorbidities, the junior resident medical officer (generally supervised by a visiting surgeon) is an inappropriate medical “case manager”. There is a desperate need in our regional centres to train and employ hospital-based generalists. At the same time, there is a need to move away from the visiting medical officer (VMO) fee-for-service model, designed around the needs of private practitioners, and move towards a hospital-based specialist model, in which specialists are available, accessible and part of the fabric of our hospitals. While the VMO model has been useful, it is no longer appropriate as a basis for default clinical care arrangements. Only by moving towards a hospital-based generalist model, as suggested by Jenkins et al, will we see an improvement in hospital culture, junior doctor supervision and training, and, most importantly, medical governance for best patient care in our regional hospitals.

Joanna R Sutherland

To the Editor: I commend Jenkins and colleagues for an engaging article on the future of general medicine in Australia.1 It mirrors a debate that is occurring in many acute-care hospitals, particularly in the context of a nationwide shortage of acute-care beds and increasing numbers of older patients presenting with chronic and multisystem disease.2 Currently, emergency physicians see the majority of acutely unwell patients who present to Australasian hospitals, particularly large urban centres, which is of great benefit to these patients.3-5 Thus, creating a new specialty of acute-care physicians to look after these undifferentiated patients seems like unnecessary duplication of service. Indeed, this duplication is one of the main issues in the journey of patients through the acute-care hospital system, particularly in tertiary institutions. After presentation to an acute-care hospital, patients often experience multiple consultations in multiple venues before admission to a home medical ward. They are often seen by a junior emergency doctor, then a senior emergency doctor, then a registrar from a subspecialty, and finally by the general medical registrar — and only then are they “admitted” and the often lengthy wait for a hospital bed commences. This journey could be dramatically improved by a single emergency department consultation with a senior emergency doctor (registrar or above), with stabilisation and immediately necessary investigations being done at that stage. After this, the patient could be either discharged to the community or admitted directly to a home medical ward where they can be seen by the home inpatient team. This would abolish much of the duplication that currently occurs and ultimately make the hospital visit safer for the patient and more cost-effective for the hospital.

Alan E O’Connor

To the Editor: Kelly and colleagues are to be applauded for their call for a no-fault compensation scheme.1 If only such a scheme had been available in the early 1960s, when my sister (who has approved this letter) developed encephalitis secondary to a vaccinia inoculation. Then she, and our parents, would have been spared decades of struggling with the sequelae of this acquired brain injury in a “fault averse” system. The few who have been seriously harmed should not be forgotten by the millions who have benefited.

Mark R Nelson

To the Editor: This year marks 10 years of successful operation of the Sydney Medically Supervised Injecting Centre — Australia’s only supervised injecting facility (SIF). It is one of 90 such facilities globally, with SIFs operating in eight different countries for up to 25 years. Legislation to lift the trial status of the Sydney centre was passed in the lead-up to the recent New South Wales state election, nearly a decade after the centre opened. Despite not having explicitly supported the centre while in opposition, at the Centre’s 10-year anniversary event on 6 May 2011, the newly elected Liberal–National coalition government signalled its willingness to contribute to bipartisan support of the centre. While the Sydney SIF has survived this transition into institutional “adulthood”, operation of the only other SIF in the English-speaking world, located in Vancouver, Canada, remains a politically sensitive issue. Indeed, the Supreme Court of Canada is currently deciding whether the right to establish and operate a SIF lies with the provincial or the federal government. The Australian and Canadian SIFs have much in common: both have a history of politicisation, both were established under trial conditions, and both have been subject to rigorous independent scientific evaluations. They have each contributed much to the large body of evidence showing the benefits provided by SIFs to individual drug users and to surrounding communities. Specifically, SIFs have been shown to reduce numbers of deaths from drug overdose,1 reduce numbers of ambulance call-outs2 and hospital admissions, improve client outcomes,3 enhance referral to drug treatment programs,4 improve public order (eg, by reducing injecting drug use and syringe disposal in public locations),5 and be cost efficient.6 No adverse consequences have been associated with their operation. There is widespread support for SIFs. This includes many Australasian specialist medical colleges as well as the Australian Medical Association and many scientific and research institutions. The majority of the Australian population also support SIFs, as shown in the recent National Drug Strategy Household Survey.7 Yet despite this, and the continually accumulating evidence showing the public health benefits of SIFs, the idea of establishing new facilities remains politically charged in the Australian context. In Melbourne, a local council recently urged the Victorian state government to consider establishing a SIF in an area with entrenched, street-based drug use. However, this was swiftly rejected, and calls for SIFs in other Australian states have been similarly refused by state governments. Indeed, the current legislation in NSW precludes the operation of any additional SIFs. But for the Sydney SIF, it appears that the repeated political hurdles which characterised its first decade of operation have finally diminished. In this single instance at least, the scientific evidence on SIFs has prevailed. Editor’s note: Ironically, after this letter was accepted for publication, the New South Wales Christian Democrat Fred Nile (Member of the Legislative Council) gave notice of intention to submit a Bill to close down the operation of the Sydney Medically Supervised Injecting Centre. No further details are available at time of going to press.

Marianne E Jauncey · Ingrid A van Beek · Allison M Salmon · Lisa Maher

To the Editor: A report in the Weekend Australian earlier this year described an increase in oxycodone-associated deaths, in parallel with an increase in prescriptions for the drug, sometimes known as “hillbilly heroin”.1 These increases are likely to reflect a change in doctors’ prescribing behaviour. Strong opioids were traditionally prescribed for cancer pain, often in the terminally ill, but since the 1980s they have been increasingly used for treating chronic non-cancer pain, despite an absence of new evidence of effectiveness or of whether opioids provide net benefit or harm to patients in this setting.2 Cancer patients are likely to die from their illness before the opioids have a chance to injure them, but patients with chronic non-cancer pain are not, and this is where oxycodone-associated deaths are more likely to occur. A contemporary view is that chronic non-cancer pain should be regarded as “a disease entity”,3 but equating a symptom with disease means that the patient becomes the sole arbiter of whether he or she is ill. The prescribing doctor has no means by which to objectively determine treatment outcomes. The notion of chronic non-cancer pain as a disease entity is based on neuropathological changes described as “central sensitisation”, which may result from nerve damage or from persistent peripheral nociceptive input.3 The concept is not intellectually challenging where there is objective evidence of either nerve damage or injury to somatic or visceral structures. Now, however, when medically inexplicable pain follows injury that may be so subtle as to be unassociated with any discernible abnormality, central sensitisation is invoked as the explanation du jour, without a critical assessment based on anatomical and physiological principles. Prescribing opioids in this setting may have inadvertently contributed to the reported increase in oxycodone-associated deaths. Guidelines exist for prescribing oral controlled-release opioid analgesics for chronic non-cancer pain.4-6 They advocate a signed patient–doctor agreement covering, among other things: the necessity for a single prescriber; a recommendation for all drug dispensing to be from the same pharmacy; no replacement for lost, stolen or destroyed prescriptions; and a requirement for consent for random urine and blood screens. However, these are just guidelines, not mandated, and there are no Australian data on compliance with them. Based on international data,7 the guidelines are likely to be more honoured in the breach than the observance. I advocate that a signed patient–doctor agreement should be mandatory in Australia before the prescription and dispensing of opioids for chronic non-cancer pain. This should be sighted by Pharmaceutical Benefits Scheme authorities before such dispensing is authorised, and a copy should be held by the dispensing pharmacy. A review of prescription guidelines for opioid analgesics in chronic non-cancer pain might reduce the epidemic of prescription drug misuse4 and mortality.

Mark S Awerbuch

To the Editor: In his thought-provoking editorial in the May issue of the Journal,1 Tait made reference to an apparent recent improvement in the life expectancies of Indigenous Australians by citing a 2010 Australian Bureau of Statistics (ABS) report entitled The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples, Oct 2010.2 In this report, the life expectancy for Indigenous Australians was quoted as 67.2 years for males and 72.9 years for females, compared with 78.7 and 82.6 years for non-Indigenous males and females, leaving a “gap” of 11.5 years and 9.7 years, respectively. These figures are from 2005–2007 (which includes the 2006 Census year), and are quoted again in this year’s update report from the Australian Institute of Health and Welfare.3 At first glance, they appear to be a startling improvement on the figures from 1996–2001, which quote (as late as 2005) Indigenous life expectancies of 59.4 and 64.8 years for males and females respectively, representing a “gap” of about 17 years for both.4 Unfortunately, the apparent improvement represents not a miraculous leap forward in Indigenous health care and outcomes, but rather a change in the methodology used to calculate life expectancies around the time of the 2006 Census. The essence of the change was from an indirect to a direct demographic method of compiling life-expectancy estimates, which entailed correcting Indigenous death registration data before calculating death rates. The ABS anticipated the potential for confusion (not to mention premature celebration), and so included warnings that comparisons should not be made between published estimates of Indigenous life expectancies on their website and in subsequent reports, as well as producing a discussion paper outlining and justifying the changes.5 The October 2010 ABS report explicitly stated that: “Differences should not be interpreted as measuring changes in Aboriginal and Torres Strait Islander life expectancy over time”.2 As with any statistical analysis, the underlying issue is the quality of the data. As we continue to work to narrow the “true” Indigenous life-expectancy gap, we need to be mindful of the importance of accurate record-keeping, including the identification of Indigenous status, if future analysis of mortality statistics is to stand up to scrutiny.

Lachlan J McIver

To the Editor: Since publishing its first national report on mortality data from 2009,1 the Australian and New Zealand Audit of Surgical Mortality (ANZASM) has provided coverage of surgical mortality in participating hospitals across Australia. In their recent article promoting the role of clinical-quality registries in improving the quality of health care in Australia, Evans and colleagues2 describe the importance of national registries, particularly in high-cost areas of medicine. Evans et al present the proposed national quality indicators from a 2009 Australian Institute of Health and Welfare report3 and categorise them as current national indicators, indicators requiring data development and those for which a suitable data source has not been identified or substantial development is required to operationalise the indicator. Indicator 36, “Independent peer review of surgical deaths”, is categorised as the third type. The rationale for this indicator stated that the template of the Scottish Audit of Surgical Mortality had been adapted for use in Australia by some states and territories. The report recommended that data from these sources be reported nationally, ensuring that methods of collecting the data would become standardised across the participating states and territories. We wish to highlight that this is now the case. The ANZASM is an independent, peer review audit process overseen by the Royal Australasian College of Surgeons (RACS) and funded by state and territory health departments. The audit is designed to identify and monitor improvements in the quality of surgical care through the collection and analysis of patient mortality data. It aims to improve the the delivery of safe, efficient and effective surgical care by identifying, improving and preventing system and process errors. The database is standardised across all sites. In January 2010, to ensure complete participation by RACS Fellows in this activity in all states and territories across Australia, participation was deemed a mandatory continuing professional development activity (Category 1, surgical audit and peer review). Feedback is provided to individual surgeons on their cases, and overall results are summarised in a de-identified manner as case-note reviews and annual reports that discuss system issues arising on a state and national basis. These issues are analysed further, and recommendations for quality improvement in surgery are disseminated by the ANZASM to the broader surgical community and the respective regional departments of health through its annual reports, case-note-review booklets and, more recently, through workshops and seminars.

Guy J Maddern · Julian A Smith · Wendy Babidge · Gordon S Guy

To the Editor: The research by Rosenwax and colleagues1 and Lowthian and colleagues2 published in the Journal highlights the need for increased capacity in end-of-life care within primary care to reduce the inappropriate use of acute health care services at the end of life. Providing high-quality care for people diagnosed with advanced chronic conditions is among the most complex challenges for general practitioners.3 GPs and other primary care providers are able to provide appropriate palliative and end-of-life care when they are well supported by relevant specialists.3 For patients to be well cared for in the community, it is also necessary for informal carers to have the strength, the will and the skill to provide such care, as well as timely access to support and medical care. The recent National Health and Hospitals Reform Commission’s report4 and the Australian Government’s National Primary Health Care Strategy5 both recognise the need to build “the capacity and competence of primary health care services”4 to support their dying patients. These documents make recommendations that begin to address the current difficulties of caring for these patients in the community. Of significance are recommendations for increased support for carers; improved shared-care arrangements; and better access to specialist palliative care, support and funding for advance care planning and improved access to primary health care professionals.4 This includes a commitment to address workforce shortages and improving out-of-hours access to medical care.5 Such recommendations are positive and will be helpful when they are fully realised. However, issues within primary care — both at the community and individual general practice levels — also need to be addressed. People for whom a palliative approach is appropriate need to be systematically and proactively identified in a timely way. Needs assessment and care planning should be undertaken to ensure that problems and preferences for care are identified and mechanisms are put in place to support such care. To promote optimal end-of-life care, a coordinated, multidisciplinary approach is as important in the community as it is in the hospital setting. Good communication and collaboration between primary care providers, the patient’s specialists and specialist palliative care providers are imperative. Also essential is an ongoing dialogue with the patient and family to enable a clear understanding of the goals of treatment and to proactively plan for likely adverse events. Routinely planning for likely scenarios will potentially reduce the use of acute services and encourage the provision of care in more appropriate environments.

Claire E Johnson · Geoffrey K Mitchell

To the Editor: The finding of Wilkinson and colleagues1 that the Undergraduate Medicine and Health Sciences Admission Test (UMAT) score and medical school performance are only weakly correlated came as no surprise. Another shortcoming of the UMAT process has been its inability to recognise the effects that failure in the test can have upon applicants. The Selection Committee for the School of Medicine at the University of Notre Dame in Fremantle rejected the UMAT from the outset. We considered its content to be arbitrary, and that there was no evidence to suggest that it could predict a medical student’s performance, let alone a medical practitioner’s sensitivity and empathy. My concern with the need for fairness and sensitivity in the selection process evolved from my experience of being approached by applicants to other medical schools who were distressed by their failure to pass the UMAT hurdle. What upset them most was that the UMAT literature claimed that one could not study for the test as it tested “aptitude”. Rejected applicants therefore felt that they intrinsically lacked the necessary personal characteristics to be a good doctor. The truth was that they had not performed as well as others in an idiosyncratic test, which included tests of “spatial orientation” and other arcane matters. At the University of Notre Dame, we recognise the great disappointment that unsuccessful applicants feel and counsel those who contact us. We reassure them that they can try again the next year, and are likely to have a better chance of success then. We never imply that they are not suitable to be a doctor. Medical educators can only expect students to possess fairness, empathy and understanding of the suffering of others if we demonstrate the same qualities to them. In the case of the UMAT — an experiment that has dominated medical student selection in Australia for more than a decade — those qualities have been lacking. I believe that the UMAT has left a scar on many unsuccessful applicants and on the perception of the Australian selection process that was used in many universities over those years. Let us remember that doctors’ responsibility to be caring, sensitive and humane extends beyond the consulting room.

Barry N J Walters

To the Editor: The Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study, a large, blinded, multinational study, showed an increased risk of adverse maternal and neonatal outcomes in relation to maternal glycaemia, at glucose levels below the current Australian criteria for diagnosing gestational diabetes mellitus (GDM).1 The International Association of Diabetes and Pregnancy Study Groups (IADPSG), an international consensus group, has proposed new criteria for the diagnosis of GDM.2 As a result, these new criteria have been adopted by the American Diabetes Association, which predicts a significant increase in the prevalence of GDM.3 The new criteria were discussed at the Australasian Diabetes in Pregnancy Society annual scientific meeting in 2010. Moses and colleagues accurately outline the increased prevalence of GDM if IADPSG criteria are adopted in Australia.4 An increased prevalence has implications for resource allocation, and the anticipated increase in workload can be managed by appropriate planning and exploration of alternative models of care. We surveyed attitudes to the management of GDM among general practitioners already involved in antenatal shared care programs in the Liverpool and Fairfield areas of Sydney (GDM is not currently part of the shared care program in this urban area, which has a high prevalence of diabetes). Around 120 GPs are enrolled in the antenatal shared care program in the Liverpool and Fairfield areas. Forty-six of these GPs attended an educational meeting at which the survey was distributed, and of the 46 (who all completed the survey), only seven believed that GDM can always be managed in the antenatal shared care program. Seventeen felt that, due to lack of time or lack of access to appropriate resources, GDM cannot be managed at all by GPs as part of shared antenatal care; eight of these 17 indicated that they never initiated insulin for patients with type 2 diabetes. Only two indicated that no up-skilling was required for them to manage GDM. These attitudes may be limited to GPs in urban practices. Whether the involvement of GPs in the management of GDM is appropriate is unclear, and the provision of supporting resources requires further review. Additionally, as determined by Moses and colleagues,4 the predicted increase would come from older women who are possibly more likely to have other comorbidities that make them less suitable for shared care.

Barbara Depczynski · Vincent W Wong · Hamish D Russell · Nicole Opie

To the Editor: Contrast induced nephropathy (CIN) is one of the most important and frequent complications of invasive coronary procedures.1 We have previously reported a multicentre randomised trial comparing use of iso-osmolar and low osmolar contrast agents (iopromide and iodixanol, respectively) in patients with pre-existing renal impairment.2 The overall proportion of patients developing CIN by Day 7 was around 25%, and there was no statistical difference between the different contrast media. There have been few prospective randomised controlled trials to determine the late effects on renal function and outcomes in relation to dialysis and mortality in patients who developed CIN after invasive coronary procedures. We report here on the long-term follow-up of patients enrolled in our initial study. Of the original cohort of 191 patients, 21 were excluded because of lack of follow-up information. We divided patients into two groups based on whether or not they had initially developed CIN, defined as an absolute increase in the serum creatinine concentration of at least 44 μmol/L or by a relative increase of at least 25% from the baseline value on Day 2 or 7 after exposure to the contrast media. The primary end point was persistent renal impairment, which we defined by these same criteria for serum creatinine, and alternatively, by an absolute reduction in estimated glomerular filtration rate (eGFR) of at least 10 mL/min/1.73 m2 (accounting for the coefficient of variation of creatinine and also the age-related decline in GFR3-5). The secondary end point was a composite of death and need for dialysis. Median length of follow-up was 43 months (interquartile range, 31–48 months). Latest serum creatinine results were available from physicians, hospital records or private laboratories for 157 patients. Significantly higher proportions of patients who had CIN at baseline showed evidence of persistent renal impairment compared with patients who did not have CIN at baseline, based on both serum creatinine results (20/40 v 31/117; P = 0.006) and eGFR (22/40 v 28/117; P < 0.001). Mortality was determined for all 170 patients by direct contact or from the national death registry. A significantly higher proportion of patients who had CIN at baseline (2/41) compared with those who did not have CIN (3/129) needed dialysis (P = 0.60). Twelve patients who had CIN at baseline had outcomes of death, dialysis or both, compared with 32 in the other group (P = 0.57). Multivariate analysis showed CIN at Day 2 or 7 was an independent predictor of persistent renal impairment (odds ratio, 3.31 [95% CI, 1.39–7.86]; P = 0.007). Age, diabetes mellitus, sex, hypertension, body mass index, contrast type and baseline eGFR were not predictive. This long-term follow-up showed that CIN after invasive coronary procedures is associated with increased risk of persistent renal dysfunction in patients with pre-existing renal dysfunction. Physicians should be alert to this complication.

Akash Dhawan · Devang Parikh · Ibrahim Shugman · John French · Hisham Hallani · Clyne Fernandes · Craig P Juergens

To the Editor: Comparing Australian medical school policies regarding conflict of interest (COI) to their United States counterparts, Mason and Tattersall1 conclude that within Australia there is “a need for improved self-regulation”. The authors are applauded for highlighting this important aspect of medical education and organisational practice; however, the comparisons made fail to acknowledge a number of contextual differences that undermine the conclusions drawn. First, significant cultural differences exist between Australia and the US with respect to historical market practices and commercial sponsorship within the tertiary education sector.2 The persistent failure of self-regulation in the US recently culminated in the passing of the Physicians Payment Sunshine Provision, which now mandates transparent disclosure of all (> $10) payments, gifts and sponsorships, and imposes significant penalties for failure to report.3 Arguably, it is this changing legislative landscape that has encouraged US medical schools to develop more robust COI policies, rather than a proactive commitment to manage COI. Second, unlike in the US, most of Australia’s 20 medical schools sit within publicly funded universities, where central policy regulation of COI prevails. Mason and Tattersall’s1 suggestion that each school have its own COI policy without reference to the overarching university’s COI policy is flawed, particularly in a wider academic environment where industry sponsorship of education and commercialisation in research are increasingly encouraged as a desirable strategy to supplement falling levels of Commonwealth resourcing. Third, despite the lack of policies in Australian medical schools, positive performances with respect to COI in the curriculum were noted,1 demonstrating that lack of policy does not necessarily hinder appropriate curriculum content. Finally, on becoming doctors, medical students are bound by their professional codes of practice, codes of ethics, organisational policies and state and federal legislation, which outline the obligation to act within the recognised standards of the profession.4 While medical schools have a significant role to play in preparing future doctors to effectively recognise bias and appropriately manage COI,5 their ability to enforce more rigorous standards than those that apply within the professional community at large is doubtful. The adequacy of current professional codes is a matter for further debate. Medical schools exist within the wider context of the university, the community and the overarching political and legal landscape that governs their resourcing and practices. These factors must be taken into account when judging the actions of medical schools. To present Australian medical schools as lacking1 on the basis of a decontextualised comparison with US schools may be overly simplistic.

Eleanor Milligan · Allan W Cripps

In reply: The medical community in Australia regulates itself through various non-binding codes and guidelines, but these have not been shown to reduce industry influence on doctors or medical students. In contrast, the existence of institutional policies can limit the influence of industry, resulting in medical students and doctors who are less influenced by industry marketing.1,2 University conflict-of-interest (COI) policies must reflect the context in which they exist, but it is unlikely that a general university policy covering all faculties could address the specific challenges presented by medical student education. Policy development, while difficult, is possible, and the University of Melbourne is scheduled to complete a policy framework covering staff and students in health-related degrees this year. Arguably, it was the failure of the medical profession in the United States to self-regulate that led to the legislative changes that stimulated the recent COI policy advances in US medical schools. This could also occur in Australia. Despite the logistical difficulties of developing effective self-regulation within medical schools, there are increasing societal expectations that COI be dealt with effectively. If we ignore this sentiment, we risk the imposition of perhaps excessive and punitive legislation. Medical schools should embrace their influential position, and act now to demonstrate their leadership.

Paul R Mason · Martin Tattersall

To the Editor: In their recent article on unintentional child drowning deaths, Petrass, Blivitch and Finch refer to the “limited detail within both police reports and findings” for South Australian cases of drowning.1 Since 2005, South Australia’s Child Death and Serious Injury Review Committee (CDSIRC), which I chair, has considered the circumstances and causes of all child deaths in SA. The legislation governing the CDSIRC’s work quite rightly precludes the publication of individual details of children’s deaths, but, since 2005, the CDSIRC’s annual report has given a summary of the circumstances and causes of drowning deaths for children in each year. Children drown in a variety of circumstances — in fish ponds, rivers, lakes, dams, buckets of water and in boating accidents — but the greatest number, especially among those under 4 years of age, drown in backyard swimming pools.2 In these incidents, time and again I read about failures of supervision, gate closure and adherence to pool fencing regulations and the maintenance of this fencing. Although the extent and nature of supervision may be of academic interest, the prevention of childhood drowning would best be served by the ongoing promulgation of well researched public health campaigns, such as those delivered by the Royal Life Saving Society — Australia and Kidsafe Australia, and attention to legislative changes that will ensure the regular inspection and maintenance of swimming pool fencing. The CDSIRC’s review of child drownings in SA is based on the detailed information obtained by SA police from witnesses present at the time of the event. This almost always provides a great depth of detail that enables the identification of the key risk factors present in the circumstances of the death. It is unfortunate if this information was not available to Petrass and colleagues, but it is incorrect to infer that such information is not collected in SA. The CDSIRC’s annual reports are available from its website.3 Similar reports are produced by child death review committees or teams in Queensland, New South Wales and Victoria.

Dymphna Eszenyi

In reply: Information made available by South Australia’s Child Death and Serious Injury Review Committee is similar to that in other Australian states that have a Child Death Review Committee; all produce an annual report of circumstances related to child deaths, including child drowning. While we are aware of these reports, for our study of child drowning, individual case details were required that cannot be extracted from compiled summaries in annual reports. By contrast, the National Coroners Information System (NCIS) provides access to original documents for individual drowning cases. Details for South Australian child drownings in the NCIS database were very limited, although at no point in our article did we infer that this information is not collected in SA; rather we stated that that coroners findings were only available for 38.1% of cases in the NCIS, and that autopsy and toxicology reports are not routinely uploaded.1 Further, the recently revised position paper of the National Drowning Prevention Alliance (NDPA) states that neither a single device nor a single solution can prevent child drownings, and recommended that caregivers, aquatic facility owners, managers and operators use “layers of protection” to aid in child drowning prevention.2 We certainly agree that the ongoing promulgation of well researched public health campaigns is an important layer in the prevention of child drowning, although, to date, no published studies have investigated the effectiveness or rigorously evaluated Australian aquatic death prevention campaigns (such as Keep Watch, Kids Alive — Do The Five, SafeWaters and Play it Safe by the Water). However, the NDPA did identify that supervision is the one layer that should be ever-present, regardless of what other layers are used.2

Lauren A Petrass · Jennifer D Blitvich · Caroline F Finch

To the Editor: A review by Harper and Lefkovits favoured increased use of prehospital thrombolysis (PHT) for the management of ST-elevation myocardial infarction (STEMI).1 The acknowledged importance of early reperfusion and the ready application of PHT make this a sound recommendation for settings that are remote from percutaneous coronary intervention (PCI) centres. However, the recommendation of using PHT for patients presenting within 2 hours of symptom onset in metropolitan areas is more controversial. Recent enthusiasm for this strategy has been buoyed by the 5-year data from the randomised CAPTIM study that compared PHT with primary PCI.2 This French study, conducted from 1997 to 2000, was prematurely terminated after recruiting 840 of the planned 1200 patients. There was no difference in the primary composite end point at 30 days. A post-hoc analysis subsequently reported that among the 460 patients randomly assigned to PHT or PCI within 2 hours of symptom onset, there was a trend towards lower mortality among those receiving PHT (2.2% [five patients] v 5.7% [13 patients] at 30 days; P = 0.058).3 By 5 years, an additional eight patients receiving PHT and 12 patients receiving primary PCI had died, resulting in a P value of 0.04 for mortality difference.2 This result reflected one component of a composite end point in a post-hoc subgroup analysis from a prematurely terminated, underpowered trial. Harper and Lefkovits comment that French registry data support the CAPTIM findings. However, data from a more than 10-fold larger Swedish registry do not.4 Important to the successful implementation of PHT is the transport of patients directly to PCI centres where early angiography can be performed if required. However, PCI and fibrinolysis do not make good bedfellows — a lesson learnt through the counterintuitive results of facilitated PCI trials, which showed no benefit and some harm when offering thrombolysis as a prelude to PCI.5,6 This adverse interaction is ameliorated if PCI is deferred for 3 to 24 hours after thrombolysis; however, there is a real risk that early PCI will be overused when STEMI patients arrive rapidly at a staffed PCI facility after receipt of PHT. We need stronger evidence than currently exists to be sure that, in metropolitan settings, the temptation for zealous application of PCI after PHT does not effectively result in over-application of a facilitated PCI strategy, with untoward consequences. In metropolitan regions, the current focus on reducing delays from onset of symptoms to percutaneous revascularisation should remain. Based on the evidence to date, PHT may be a cost-effective but not clinically superior alternative for reperfusion, and should be encouraged as the strategy of choice in circumstances when logistic or resource constraints limit ready access to primary PCI.

David B Brieger