Letters

To the Editor: The levels of ferritin and folate in the blood are regarded as the “gold standards” for measuring deficiencies in iron and folate, but they are complex and expensive tests. The red cell distribution width (RDW-CV%) measures variability in red blood cell (RBC) size, helps in early detection of deficiencies and is available in all automated analyses of RBCs. It is seldom listed on haematology reports, though it can be printed out at no extra cost. A raised RDW-CV% should prompt the treating doctor to consider underlying latent deficiencies and to order specific tests. Pasricha and colleagues outlined the most efficient ways of diagnosing and managing iron deficiency anaemia.1 However, they did not mention RDW-CV%. Haemoanalysers measure the haemoglobin (Hb) content and size of individual RBCs. The average RBC size is the mean cell volume (MCV), and the variation in sizes is calculated as a standard deviation (SD). The haemoanalyser converts the MCV and SD to a coefficient of variation (CV) using the formula: Normal RBCs vary slightly in size, so the normal value of the RDW-CV% is 10%–15%. Greater variability gives a higher RDW-CV%. When a person becomes iron deficient, he or she forms small RBCs. The circulation will then contain a mixture of older normal RBCs and increasing numbers of newer small cells, until all the normal cells reach the end of their 120-day lifespan. It therefore takes several weeks for the Hb level and MCV to drop low enough to diagnostic levels for iron deficiency. However, the mixture of normal and small RBCs rapidly increases the variability in the size of circulating RBCs, so the RDW-CV% reaches pathological levels before other RBC measurements do.2 A raised RDW-CV% is the first haematological sign of iron deficiency. My computer model demonstrating the mechanism and timing of changes in Hb level and RDW-CV% showed a large and early rise in the initial stages of iron deficiency before anaemia (Box).3 In the anaemia of thalassaemia, the RDW-CV% is usually normal. In combination with other parameters, the RDW-CV% helps to classify anaemias. The sensitivity and specificity for diagnoses is about 80%,4 so the RDW-CV% result should be used as a screening tool to alert the clinician to a possible disorder that can be investigated using standard tests. I recommend the RDW-CV% be included in all routine blood reports. Computer model of changes in haemoglobin (Hb) levels and red cell distribution width (RDW-CV%) in developing iron deficiency anaemia. Iron deficient red blood cells were formed from Day 0

Alan E Dugdale

To the Editor: Van Der Weyden states that “obesity” has negative connotations and the capacity to stigmatise.1 “Intending to give minimal offence and shifting the focus from the person to the condition”, people substitute politically correct terms.1 Medical practice should be scientifically, rather than politically, correct. Language aside, obesity is a blind spot in clinical practice because of the lack of any useful and accurate measure to categorise the condition. Body mass index (BMI) is the universal standard, but it is a very flawed measure. The results of epidemiological studies that support its use depend on huge population numbers, ethnic homogeneity and the exclusion of confounders including smoking and coexisting chronic disease. There is an absence of any epidemiological data showing that reducing overweight or obesity improves outcomes, despite them being frequently cited as risk factors. However, bariatric surgery has been shown to reduce cardiovascular disease, diabetes and cancer incidence.2 Central obesity is a much more powerful predictor of total mortality and cardiovascular disease mortality than BMI.3 In particular, the waist-to-hip ratio (WHR) is useful in population studies, showing precision and a lack of bias over a wide range of ethnic groups.4 Waist circumference is a better predictor than BMI but, like BMI, requires ethnic-specific criteria and is difficult to implement in today’s multiracial societies. WHR performs better as a predictor of cardiovascular disease than all lipid fractions, including total cholesterol and low-density lipoprotein cholesterol.3,5 Lowering lipid levels by drug therapy in the clinical trial setting reduces cardiovascular end points by 20% to 25%. In this context it is pertinent to note that the cost of subsidising prescriptions for lipid-lowering drugs in the financial year 2009–10 was almost $1.5 billion.6 In contrast, there is no simple prescription available to reduce levels of obesity. Healthy eating will always be important. And to make an impact on obesity, 60–90 minutes of moderate physical activity daily is required,7 but the importance of exercise is constantly overlooked and underprescribed. Studies in the United States show that physical activity, recorded daily, reduces cardiovascular disease mortality by about 37%–53%.8 Japan has undertaken an ambitious campaign to identify and counsel employees with excessive waistlines.9 This initiative will be followed with interest. A public health focus on early identification and prevention of central obesity is therefore at least as important in reducing cardiovascular disease mortality as is the measurement and treatment of lipids and hypertension. People with central or abdominal obesity have a serious health hazard and should be informed. “Political correctness” describes a practice that avoids giving offence to minorities. In view of the current epidemic of obesity, the language that we use should be explicit.

Timothy A Welborn · Satvinder S Dhaliwal

To the Editor: We read with interest the recent editorial by Nordin,1 which makes several imprecise observations on our recent position statement in the Journal.2 Here, we analyse some of his statements, as we believe that they are misleading to your readers and hazardous to institutionalised older persons. The Consensus Conference on Treatment of Osteoporosis in Residential Aged Care Facilities (RACFs) was organised as a unique type of meeting in which Australian experts in osteoporosis and geriatric medicine, including representatives from the Australian and New Zealand Bone and Mineral Society (ANZBMS) and Osteoporosis Australia, participated in multiple interactive sessions with 50 geriatricians and general practitioners who practise in RACFs. The goals were to appraise current evidence in the field of falls and fracture prevention in RACFs and to define practical, evidence-based recommendations. A similar meeting took place in 2004 in Canada,3 where conclusions played a pivotal role in optimising osteoporosis care in RACFs. Conclusions of the Australian meeting and recommendations subsequently published in the Journal are products of both the general consensus of the participants in the final plenary session and contributions of all the coauthors.2 Our article states, “In adults with a baseline calcium intake of 500–900 mg/day, increasing or supplementing this intake by a further 500–1000 mg/day has a beneficial effect on BMD [bone mineral density]”.2 In light of the evidence that we cited4 and more recent evidence,5,6 it is Nordin’s responsibility to highlight the potential risks of excessive calcium intake, from dietary sources plus supplements, in a population that is at high risk of cardiovascular disease.7 Moreover, we are not alone in raising this concern — a recent statement from the American Society for Bone and Mineral Research has expressed similar concern.8 In addition, Nordin cites the seminal work of Chapuy and colleagues; although this study was carried out in nursing homes and apartments for older people, it only looked at independent, ambulatory older people.9 Furthermore, the statement regarding calcium compliance is again supported by a study performed in ambulatory populations, in which compliance is likely to differ from that in our population of interest. Finally, Nordin asserts that our article promotes the use of bisphosphonates, particularly the intravenous variety, and makes the unfounded suggestion that the recommendation of bisphosphonates was due to the relationship between the sponsor and some of the coauthors. This is inaccurate. The University of Sydney, funded by a medical education grant, organised the Consensus Conference. Also, both the ANZBMS and Osteoporosis Australia endorsed the meeting and the integrity of the funding process. Indeed, maintaining independence from the sponsor was a major goal of the Consensus Conference, which was attested to by the feedback from participants. In conclusion, a basic knowledge of geriatric pharmacology and a good understanding of the current literature on geriatric medicine are enough to value the recommendations presented in our article.

on behalf of Jacqueline J Close, Julien P de Jager, Peter R Ebeling, Charles Inderjeeth, Stephen Lord, Andrew J McLachlan, Ian R Reid, Bruce R Troen and Philip N Sambrook

To the Editor: The report by Leyden and colleagues highlights the value of examining the total experience of stroke thrombolysis in one population.1 The results are devastating: protocol violations in more than a third of cases (consistent with other reports of up to 50%2), and a 10% symptomatic intracranial haemorrhage (ICH) rate (representing a number needed to harm [NNH] of 10). As a clinician, I would be “gutted” if my treatment harmed every 10th patient. The 22% mortality at 3 months is consistent with real-world evidence that stroke thrombolysis increases mortality.3 Although the authors state that the rate of symptomatic ICH was not statistically significantly different to that in the National Institute of Neurological Disorders and Stroke (NINDS) study, an absolute increase of 3.6% (10% versus 6.4%) is clinically important to patients and their families. Presumably, this is largely related to the age protocol violations: 10 of 53 resulted in symptomatic haemorrhage (19%; NNH = 5), including seven cases of intracerebral haemorrhage and five deaths. In all, there were 39 cases of any ICH (25%; NNH = 4). The article highlights that 54% of thrombolysis cases were not on the Safe Implementation of Thrombolysis in Stroke (SITS) registry. This result adds to the concerns of a selection bias in the SITS registry. As the authors point out, the sample size is small — too small, in my opinion, to draw any rigorous conclusions. This highlights that registry results should, at best, be hypothesis generating. However, it has also been highlighted that patients in the SITS International Stroke Thrombolysis Register do worse than those in the placebo group of the European Cooperative Acute Stroke Study III (ECASS III).4 The authors also refer to the ECASS III results, which contend that the time window for stroke thrombolysis should be extended to 4.5 hours. However, methodological and analytical flaws in this study, as well as the NINDS study, cast doubt on this statement.5 A recently published independent review of evidence on stroke thrombolysis concluded, “There is no consistent or proven benefit to thrombolytics”; it included all 11 clinical trials, of which nine had no benefit (with four of these causing harm).6 There are multiple examples in medicine where small studies suggest a benefit, but larger more definitive studies confirm otherwise. Hence, it is very important to look at the totality of the evidence.7 While I agree with the authors that poor access to acute stroke units is deplorable, the real challenge is to define the role, if any, for thrombolysis in acute stroke. Pronouncements that we need to be thrombolysing more are a disservice to those who seek the truth.

Daniel M Fatovich

In reply: To a carpenter, everything looks like a nail, and to a stroke thrombolysis sceptic, every study seems to confirm their opinion. A result cannot be “clinically important” yet statistically not so. We found no difference in symptomatic intracranial haemorrhage rates between our study and others using the same definition. The most widely accepted estimates of the true number needed to harm (for functional outcome at 3 months, following treatment within 3 hours) is about 30, as opposed to a number needed to benefit of around three.1 Our study does not suggest that thrombolysis increases mortality. Mortality cannot be compared between different populations, with different aetiology and severity. We have demonstrated a large number of relative “protocol violations” according to 2007 guidelines, the most common of which was that the patient was older than 80 years, but there is robust evidence that thrombolysis is safe and effective in this cohort.2 The benefit of a therapy cannot be assessed by a tally of “positive” and “negative” trials. A recent meta-analysis of all tissue plasminogen activator trials (seven trials, 2199 patients),3 and the relevant Cochrane review,4 confirm benefit in appropriate patients treated with tissue plasminogen activator within 4.5 hours. Stroke thrombolysis is effective. We must overcome the barriers to administering it frequently, safely and rapidly.

Tim Kleinig · James M Leyden · Andrew Lee · Jim Jannes

To the Editor: A 61-year-old man presented to the emergency department (ED) of a tertiary hospital seeking treatment for alcohol withdrawal after 36 hours of abstinence. He reported central chest pain radiating to the jaw and left arm that had been present for 2 hours before his arrival at the hospital. He had no history of cardiac disease and no known risk factors for coronary artery disease. An electrocardiogram (ECG) showed sinus tachycardia with T-wave inversion in leads V1, V2 and V3. Two hours after the patient’s arrival at the ED, he tested positive for troponin-T. Over the next hour, his ECG showed development of ST elevation of 1–2 mm in leads V3, V4 and V5. Because of severe alcohol withdrawal, his clinical status precluded urgent coronary angiography; and after treatment with diazepam was commenced, the ST elevation that was evident no longer met criteria for urgent angiography. The patient was given standard medical therapy for acute coronary syndrome, including aspirin, clopidogrel and intravenous heparin, while in the ED, along with ongoing diazepam for alcohol withdrawal. He was later admitted to the coronary care unit with a diagnosis of acute coronary syndrome. The next day, an ECG showed development of widespread T-wave inversion in leads V1 to V5. The dynamic ECG changes were not associated with ongoing chest pain. On Day 3 of the patient’s admission, coronary angiography showed normal coronary arteries, and ventriculography showed apical ballooning of the left ventricle, consistent with a diagnosis of takotsubo cardiomyopathy (Box). Treatment with an angiotensin-converting enzyme inhibitor and a β-blocker was commenced. Three months later, follow-up echocardiography showed a return to normal regional and global left ventricular function. Takotsubo cardiomyopathy takes its name from a traditional Japanese octopus trap that has a similar shape to the abnormally contracting left ventricle seen with this condition.1 Typical findings in a patient with takotsubo cardiomyopathy are chest pain associated with emotional or physical stress, with ST segment changes on electrocardiography and apical ballooning on ventriculography, which is generally expected to resolve within weeks to months; troponin level may or may not be positive. The mechanism of this condition has not yet been determined, but it appears likely that it is due to hyperadrenergic-hypercatecholaminergic states (such as alcohol withdrawal) resulting in localised or diffuse coronary vasospasm.2 Takotsubo cardiomyopathy has only rarely been associated with alcohol withdrawal, and has once been reported in a patient with alcohol withdrawal associated with seizures.3,4 Coronary ventriculography image showing apical ballooning of the left ventricle

Angus G Thompson · Joseph Hung

To the Editor: We would like to congratulate Gandy and colleagues on their recent article in which they assess outcomes and patient flow in an acute care surgery (ACS) model.1 We have also performed a retrospective historical control study that examined the effect of an ACS model on assessment time and time to operation for acute appendicitis. Our findings were presented in poster format at the Royal Australasian College of Surgeons Annual Scientific Congress in Perth in May 2010.2 We introduced an ACS model in 2007 at Nambour General Hospital, a 350-bed regional hospital on Queensland’s Sunshine Coast. Our model differs in certain details from the model used by Gandy and colleagues at Prince of Wales Hospital, but is similar in principle. The aim of the ACS model was to provide an in-house consultant surgeon to be more available and more directly involved in the care of emergency surgical patients. In our study, the outcome measures included time to assessment of the patient in the emergency department by the surgical registrar, and time to operation after this assessment. We performed a retrospective chart audit of 569 patients who underwent emergency appendicectomy in the calendar years 2006 and 2008. The ACS model resulted in an increase in both time to assessment (198 minutes in 2006 compared with 263 minutes in 2008; P < 0.0001 [t test]) and time to operation (597 minutes in 2006 compared with 793 minutes in 2008; P < 0.0001 [t test]). These results surprised us. Various explanations were postulated, including the trend of an expanding local and regional population on the Sunshine Coast placing a greater demand on the emergency theatre through the study period. Like us, Gandy and colleagues did not see a reduction in time to theatre and in fact “observed no significant change in time from presentation to arrival in theatre”. This was explained on the basis of “an increase in the number of patients treated conservatively overnight”. We have reviewed our data and found a similar trend, with 35% of patients in 2006 and 54% in 2008 managed conservatively overnight. This may, to some extent, explain our surprising results. Our appendicectomies in both historical control patients and those treated in the ACS model were all performed laparoscopically, thus removing one of the confounders experienced in the Prince of Wales Hospital data. A comparison of these two sets of data emphasises the fact that to measure time to assessment and time to operation in isolation misses the important concept of reduction in complication rates, as successfully demonstrated by Gandy and colleagues1 (we did not record complication rates in our study). This process of assessment could be taken a step further with a cost–benefit analysis looking at the presumed reduction in costs associated with the anticipated lower rate of complications resulting from the involvement of the consultant surgeon.

Simone L Geere · Ratna Aseervatham · David Grieve

To the Editor: Further to the recent article by Anstey and colleagues on community-acquired Klebsiella pneumoniae liver abscesses,1 we report two similar cases at our hospital in late 2010. Case 1: A 55-year-old Indonesian-born man was referred from general practice in October 2010 with a 5-day history of fever and progressive epigastric pain. He did not have diabetes, but did have dyslipidaemia. He had migrated from Indonesia in the 1980s; his most recent visit to Indonesia was in January 2010, for 3 weeks. As he had mildly deranged liver function test results, he was investigated with abdominal ultrasound and computed tomography (CT). Both showed a large multiseptate collection in the left lobe of the liver (Box, A). The liver collection was drained under radiological guidance, yielding a pure growth of K. pneumoniae. Urine culture was also positive for an identical isolate of K. pneumoniae. This man had a rapid clinical response to percutaneous drainage and was discharged on oral ciprofloxacin therapy. Case 2: A 25-year-old Indonesian-born man presented to our emergency department in early November 2010 after 2 days of headache, high fever and abdominal cramps, culminating in an acute confusional state. He had no significant medical or surgical history and had last visited Indonesia in March 2010, for 2 weeks. Initial therapy and investigations were aimed at excluding a diagnosis of meningitis. Results of a CT scan of the brain and of cerebrospinal fluid analysis were unremarkable. The patient remained acutely unwell and developed diarrhoea and right upper quadrant abdominal pain. Blood cultures were positive for K. pneumoniae within 48 hours of admission. Abdominal CT showed a large multiloculated abscess in the right lobe of the liver (Box, B). The liver abscess aspirate grew a pure culture of K. pneumoniae. The patient responded to treatment with ceftriaxone and large-volume percutaneous drainage. In both these cases, an antibiotic sensitive mucoid strain of K. pneumoniae was cultured. These cases add weight to the possibility raised by Anstey and colleagues that community-acquired K. pneumoniae liver abscess is indeed an emerging phenomenon in Australia. Further, the extended length of time between our patients’ travel to Indonesia and the clinical presentation (9 and 8 months, respectively) is suggestive of local (Australian) acquisition of the disease. Clinicians should consider abdominal imaging in cases of bacteraemia due to K. pneumoniae. Abdominal computed tomography scans showing Klebsiella pneumoniae liver abscesses

Kudzai N Kanhutu · Jeffrey J Post · Kate R Clezy · Hong Y L Foo

To the Editor: Interest in alternative therapies for Clostridium difficile infections (CDIs) is increasing as these infections become important causes of patient morbidity and mortality. Recurrent CDIs can be severe and difficult to treat. In-vitro data,1 followed by reports of the efficacy of tigecycline in the treatment of severe refractory cases of CDI,2 suggest that tigecycline should be considered as an alternative or adjunctive antimicrobial agent in these situations. To date, it has been used mostly as a “salvage” strategy in combination with other antibiotics in the face of clinical deterioration.2,3 We report the successful use of tigecycline monotherapy in the treatment of a patient with recurrent C. difficile colitis. An 83-year-old woman was admitted to hospital in July 2009 with acute diverticulitis. She was treated with intravenous cefotaxime (1 g three times daily for 6 days): her presenting fever and abdominal pain resolved but she developed watery diarrhoea. Despite positive stool cultures for toxigenic C. difficile, initial toxin testing by enzyme immunoassay (EIA [TechLab C. Difficile Tox A/B II]) of stool specimens was negative. After a 7-day course of oral metronidazole 200 mg three times daily, the diarrhoea abated. One month after discharge, our patient re-presented with anorexia, severe abdominal pain and diarrhoea. Six days of oral metronidazole, prescribed by her local doctor, had little effect. A computed tomography scan of the abdomen revealed diffuse thickening of the colon from the ileocaecal junction to the rectum, consistent with a pancolitis. Sigmoidoscopy showed grossly abnormal mucosa with pseudomembranes present. A diagnosis of C. difficile pseudomembranous colitis was made. After 10 days of oral vancomycin 250 mg, four times daily, her symptoms had resolved, and repeat sigmoidoscopy showed reversal of the mucosal changes. Six days later, the pseudomembranous colitis recurred. She rapidly responded to the recommencement of oral vancomycin, given as a tapering course over 6 weeks. Twelve days after completing the 6-week course of vancomycin, the patient presented with her third episode of colitis. Most reported strategies for recurrent CDI, such as faecal transplantation, probiotics or novel antimicrobials,4 were not practicable or available for timely use for our patient. Tigecycline, a broad-spectrum glycylcycline antibiotic, is available as part of the hospital formulary for the treatment of complicated skin and soft-tissue infections and complicated intra-abdominal infections. Encouraged by recent reports of success using tigecycline as adjunctive therapy for severe cases of CDI,2 we prescribed, as monotherapy, intravenous tigecycline 50 mg twice daily for 2 weeks. Our patient’s condition improved over 1 week. At 3-month follow-up, she remained asymptomatic, with repeat stool cultures and polymerase chain reaction (PCR) testing for C. difficile toxin negative at Days 75 and 107 following the last episode of colitis. Our case also highlights a diagnostic matter. In general, use of EIA to detect C. difficile toxin A or B is highly specific. However, in clinical settings where the prevalence of CDI is low, the positive predictive values for these assays are inadequate to rule in the diagnosis of CDI. Confirmatory laboratory testing using an alternative method (in this case, PCR) proved more reliable in the diagnosis of our patient’s recurrent CDI. Typing showed that our patient’s isolate was not PCR ribotype 027, a hypervirulent strain in Europe and North America associated with high mortality.5 We recommend consideration of tigecycline as a useful antimicrobial agent in the management of both recurrent and severe CDI.

Elaine Y L Cheong · Thomas Gottlieb

To the Editor: In their editorial, Terpening, Hodges and Cordato argue for routine screening for dementia in Australia.1 Most of the editorial is devoted to discussing which test should be used, and the authors contend that the most-used test — the mini-mental state examination — has such poor test characteristics that it would be a very poor basis for routine screening. However, the discussion about which test to use ignores the elephant in the room — should we screen for dementia in the first place? In their 1968 World Health Organization public health paper on screening for disease, Wilson and Jungner stipulate that “There should be an accepted treatment for patients with recognized disease”.2 There is no evidence whatsoever that this is the case with dementia. Terpening and colleagues cite an article in their editorial in support of their assertion that “development of effective dementia treatments depends on earlier and more accurate identification of disease”.3 However, that article only states that early intervention might help to slow some forms of cognitive decline or progression to dementia. This is a very slim evidence base for routine mass screening. The development of effective treatments can never be a justification for routine population-wide screening. Even in a study environment, screening the study population with a view to developing treatments rather than testing them, would struggle to find ethics approval. The evidence is clear — there is no basis for screening for dementia. It would produce many false positives and false negatives, and would cause much anxiety without any benefit from early treatment. As long as no effective treatments are available, the case for screening for dementia is void.

Jan J Barendregt

To the Editor: Roberts-Thomson and colleagues1 raise important questions about the implications of introducing masters-level medical degrees with doctorate-level nomenclature (ie, Doctor of Medicine [MD]) to Australia. In particular, the potential consequences for postgraduate training deserve further attention. As graduate numbers rapidly increase,2 competition for training positions will further intensify. At the prevocational level, perceptions of enhanced work-readiness could favour applicants with masters-level MD qualifications, such that other graduates might be displaced from popular, metropolitan teaching hospitals. At the vocational level, rigorous college selection processes (which typically include assessing a candidate’s interview performance, curriculum vitae and academic achievements) could favour graduates of new-age MD programs if they specifically reward the attainment of postgraduate qualifications (as is currently the case for some specialties3). Graduates might also lay claim to advanced standing and additional recognition of prior learning on the basis of their academic status. The extent to which these situations materialise will depend on whether masters-level medical programs claim, and deliver, a superior quality in education. For example, the University of Melbourne has committed to producing “outstanding graduates with advanced clinical skills”4 through its new model.5 In the short term, there is unlikely to be any objective evidence of difference in outcomes between the pathways, and demonstrating this would be both complex and contentious. At present, Australian Medical Council standards do not differentiate between qualifications, and new programs will continue to be accredited according to the same rigorous process. Alternatively, if masters-level MD programs lay no claim to enhanced quality over their undergraduate cousins, then the rationale for change should be examined. A purely market-driven deviation from recognised nomenclature could have important unintended consequences, and would be out of step with international efforts to standardise nomenclature (such as the Bologna Process in Europe). An important aspect of the University of Melbourne graduate-school model is the reintroduction of full-fee-paying places for professional-entry degrees. This brings with it significant implications for student debt, both for the trainee (in terms of debt accumulation, career choice and wellbeing) and the community (in terms of workforce distribution).6 Some commentators have suggested that the principle of merit-based entry is compromised by the presence of full-fee-paying places.7 It is unknown exactly how masters-level MD courses will differentiate themselves from undergraduate programs, and what their impact will be. The divide between so-called academic and vocational programs will probably be exaggerated,8 with potential implications for postgraduate training and workforce development. Whatever eventuates, the call for national consistency in higher education nomenclature deserves serious consideration, and the drivers behind any such process must be enhanced quality and equity of access at all stages of training.

Rob D Mitchell · Michael A Bonning · Alex L Markwell

To the Editor: The recent article by Lewis and colleagues highlights the important role of long-acting reversible contraceptives (LARCs) in reducing unintended pregnancy in Australian teenagers.1 LARCs are defined as contraceptives that are administered less than monthly and include hormonal implants and injections, and intrauterine devices (IUDs).2 The critical importance of improving access to LARC methods has been recognised in the United Kingdom by the National Institute of Health and Clinical Excellence, which produced guidelines for implementing this policy in 2005.2 The United States has recently followed this lead. In 2009, expanding access to intrauterine devices and other LARCs, particularly for younger women, was declared a national public health priority by the US Institute of Medicine.3 Our particular interest is to expand Australian women’s access to intrauterine contraception, including the copper devices and the levonorgestrel-releasing device (LNG-IUD). IUDs provide highly effective long-term contraception, and the LNG-IUD offers additional benefits for women with heavy menstrual bleeding.2 Although IUDs are the most widely used reversible contraceptives in the world, they are underused in Australia; the most recent available data suggest use by about 1.2% of women using contrceptives,4 compared with 17% in France and 21% in Sweden.5 The reasons for the low uptake of IUDs are undoubtedly complex, but appear to include lack of information, and misinformation in relation to infection risk and their unsuitability for younger women. There is now good evidence that modern devices present minimal risk of infection and no increased risk of subsequent infertility. There is increasing experience of their use in younger women, and nulliparity is not considered a contraindication.6 To investigate barriers to acquiring an IUD, we surveyed 334 of the 366 women who attended for IUD insertion over 3 months in 2009 at family planning clinics in New South Wales and Queensland. Excluding the 16 women (5%) for whom there were missing data, 16% of respondents (51 of 318) had not found it easy to obtain IUD-related information and almost a fifth (58; 18%) had been told it was not a suitable method for them by either a health professional or a friend or family member (or both), despite these women meeting appropriate medical eligibility criteria at the family planning clinic. Although family planning organisations are currently engaged nationally in developing and delivering IUD-insertion training for general practitioners, we suggest that increasing appropriate use of IUDs in line with other countries will only be achieved if the misperceptions of the risks relating to modern IUDs among consumers and health professionals are addressed. This is crucial to reducing the burden of unintended pregnancy, particularly in young women.

Deborah Bateson · Caroline Harvey · Julia Williams · Kirsten I Black

To the Editor: Hereditary haemorrhagic telangiectasia (HHT) or Osler–Weber–Rendu syndrome manifests as vascular dysplasia involving the nose, skin, lung, brain and gastrointestinal tract. It is an inherited disorder manifesting as unbalanced angiogenesis.1 Bevacizumab is a recombinant, humanised monoclonal antibody that binds to and neutralises vascular endothelial growth factor (VEGF), preventing its association with endothelial receptors. VEGF binding initiates angiogenesis (endothelial proliferation and the formation of new blood vessels). VEGF and transforming growth factor β play a role in the pathogenesis of HHT, with affected patients having increased levels of these factors.2 Anecdotal reports have demonstrated the effectiveness of bevacizumab in patients with HHT. To date, good responses have been documented in patients presenting with epistaxis, haemoptysis, anaemia,3 pancreatic arteriovenous malformations4 and hepatic vascular abnormalities.5 We were referred a 71-year-old man who related a 45-year history of recurrent nose bleeds, pulmonary and gastrointestinal haemorrhage and significant facial and oral telangiectasias. He had a history of multiple hospital admissions for haemoptysis and malaena necessitating blood and iron transfusions. The patient averaged three blood transfusions and four iron infusions a year, and his haemoglobin level ranged from 90 to 120 g/L. The patient also received argon laser treatment for his gastric and duodenal telangiectasias, and was taking bovine colostrum for nosebleeds with minimal effect. Shaving resulted in regular bleeding as a result of his facial telangiectasias. Because of his significant morbidity, the patient was referred for a trial of bevacizumab therapy and underwent six cycles at 5 mg/kg by means of fortnightly intravenous infusion from March to May 2010. This treatment has resulted in an effective and tangible response. Since completing the treatment, the patient has been followed up monthly, and he reports only two nosebleeds compared with daily bouts before therapy. Further, the telangiectasias on his face and in his mouth have reduced considerably, and he has had only one gastrointestinal bleed, which occurred after heavy lifting. His haemoglobin level 2 weeks after treatment was 163 g/L and has remained stable since that time. A follow-up gastroscopy in November 2010 showed that his multiple vascular lesions had reduced to just one angiodysplastic lesion in his gastric body (Box). The only adverse effect he experienced from the bevacizumab was poor sleep with associated tiredness, but the patient was able to tolerate this in light of the amelioration of the symptoms of his HHT. Other reported side effects of bevacizumab such as hypertension, proteinuria and thrombosis did not manifest in this patient. With growing anecdotal evidence of the effectiveness of bevacizumab in treating symptomatic HHT, an argument for using bevacizumab as an adjunctive or even first-line treatment for HHT is becoming stronger. Gastroscopic images of the patient’s stomach before and after treatment with bevacizumab

Ross P Cruikshank · Boris W Chern

To the Editor: Nash and colleagues have produced another report on medicolegal matters and Australian doctors.1 This report, and one that preceded it in 2009,2 are derived from responses to a questionnaire from nearly 3000 doctors. The survey showed that 65% of respondents had been involved in “medicolegal matters”. From a mass of data, the authors conclude that medicolegal concerns impact on doctors’ practice of medicine. As potential benefits of medicolegal matters, they list improved communication of risk to patients, disclosure of diagnostic uncertainty, and better methods to track test results and non-attenders. Negative impacts included increased referral to specialists, ordering more tests, and seeing fewer patients. The authors recommend targeted training in patient safety and medicolegal aspects of practice to help doctors to be “better informed”. However, as 65% of the group had been involved in medicolegal matters, it seems unlikely they need to be better informed about them. In the title and throughout the article, there is much emphasis on the word “perceived”. With this heavy emphasis on perception, it might be thought that the key finding was that fear of a medicolegal matter was greater than the reality. In fact, the reverse was found. Of those who had experienced medicolegal matters, 46% had considered retiring early, 39% considered giving up medicine and 38% considered reducing hours of work. The respective figures for those who had not experienced medicolegal matters were 29%, 22% and 21%. The difference was highly significant. An inescapable conclusion is that medicolegal matters result in large numbers of demoralised doctors. The reality is worse than the perception. Unfortunately, the obvious question — What was the outcome of the medicolegal matter? — was not included in the survey. Given the numbers involved, it seems likely that for many doctors, although the outcome was favourable, the process had a profoundly negative effect on their work. Forty-one per cent now regard every patient as a potential litigant. A logical response to these data might have been to ask: (1) Could there be a problem with the way medicolegal matters are conducted? and (2) Is the demoralisation of a large percentage of the medical workforce good for society? Neither question was asked here. This is perhaps not surprising as, in their previous article, the authors questioned, without embarrassment and on the basis of a questionnaire, whether “psychiatric morbidity in doctors is a cause or effect of the medicolegal process”.2 This study is “one of the largest [of its kind] in the world”. Sadly, the authors’ negativity towards doctors and their unquestioning allegiance to current medicolegal practice have greatly diminished its value.

Padraic J Grattan-Smith

In reply: I agree with Grattan-Smith that current medicolegal processes have profoundly negative effects on doctors. I do not agree that my coauthors and I have “negativity” towards doctors and an allegiance to current medicolegal practice. Our aim was to investigate the impact of medicolegal matters on Australian doctors — their emotional response and their practice changes.1,2 We have shown that doctors who have a current medicolegal matter have higher levels of psychiatric morbidity,2 and that most doctors believe they change how they practise due to medicolegal concerns — more so in the case of doctors who have experienced a medicolegal matter.1 Justice Ipp and colleagues,3 when reviewing the law of negligence for the Commonwealth of Australia in 2002 with the objective of limiting liability and damages arising from personal injury or death, made note of the lack of empirical evidence in the submissions they received. We have now provided some empirical evidence of medicolegal matters from the doctors’ perspective. If such a review were conducted now, I would suggest the current medicolegal systems are not good for patients, for doctors, or for the health system in general. The evidence from our studies1,2 now allows a more informed conversation on this issue to take place.

Louise M Nash

To the Editor: The supplement of the Journal published on 16 August 2010 — “Bipolar disorder: new understandings, emerging treatments”1 — illustrates a number of features of the current implementation of the Journal’s supplement policy that are problematic. While it is clearly stated that the supplement “was supported by an unconditional grant from AstraZeneca Neuroscience”, the amount of sponsorship, to whom it was paid, and how it was used were not disclosed. Such information is particularly pertinent as evidence suggests that the pharmaceutical industry has financial motivation to see a widening of the diagnostic boundaries of bipolar disorder and a rebadging of atypical antipsychotics as “mood stabilisers”.2 The provenance of the articles is not revealed — it is not clear whether the articles were solicited, part of a symposium, or from some other source. Bipolar disorder is a controversial area in psychiatry,3 yet despite much useful information in the articles in the supplement, discussion of this controversy is a minor feature and no significant critical appraisal is offered. To give a more balanced view to readers, it would have been desirable to have included articles that highlight the controversy regarding bipolar II and bipolar spectrum diagnoses and discuss the ways in which personality disorders arising from developmental trauma and attachment problems can present with mood and behavioural disturbances that can be confused with bipolar disorder.

Jon N Jureidini · Peter I Parry · Catherine M Houen · Malcolm W Battersby

In reply: Jureidini and colleagues raise legitimate issues pertinent to our Medical Journal of Australia supplement on bipolar disorders, and we are pleased to respond. First, the extent of sponsorship from AstraZeneca was for publication only. One of us (D J C) discussed the idea of the supplement with the Editor of the Journal, and AstraZeneca expressed interest in supporting the project. Neither the Journal editors nor any of the supplement authors were involved in the sponsorship negotiations between AstraZeneca and the publisher of the Journal, and neither received any financial or other assistance or reimbursement from AstraZeneca. Second, as Coordinating Editors of the supplement, we determined the content of the supplement without any input from AstraZeneca, and we directly solicited articles from leading experts of our choice in appropriate fields. All articles were subject to the usual review process accorded all publications in the Journal. Regarding the general issue of the boundaries of the bipolar concept, we are very much aware of the ongoing debate. This is a pervasive issue for a discipline devoid of biological markers that can be used to define a plane of cleavage. Indeed, we highlighted this in the second paragraph of our editorial1 as an “immediate area of controversy”. We also solicited the article by Tiller and Schweitzer specifically to address the diagnostic problems in the area of mood instability; in that article, there is specific mention of both the bipolar spectrum and mood instability in the so-called personality disorders.2 With respect, Jureidini and colleagues fall into a common trap by considering that the use of some atypical antipsychotics in bipolar disorder is a rebadging exercise. This is silliness. One could equally argue that sodium valproate, carbamazepine and lamotrigine are not legitimate mood stabilisers but, rather, rebadged anticonvulsants. Tricyclic antidepressants started life as antihistamines. What matters to us as clinicians and researchers is that people with bipolar disorder are offered the best possible care, irrespective of labels. We are also very much aware of the undeniable burden associated with mood instability and hope that the supplement we helped produce will assist general practitioners, in particular, to deliver better care to patients so afflicted.

David J Castle · Michael Berk · Barbara M Hocking

To the Editor: I found Van Der Weyden’s editorial “Whither medicine? The expansion of non-doctor practice”1 to be an unduly negative view of the emerging new clinical roles, such as nurse practitioners, in our health system. To imply, for example, that the access to prescribing rights for nurse practitioners is a significant challenge (rather than a help) to doctors is contrary to the experience of many such implementations of these roles. I have a clear view of the role of doctors. They should: be in charge and lead the decision-making process of multidisciplinary teams; be responsible for the cognitive and integrative aspects of clinical care, including the initial assessment and planning of management for undifferentiated patient presentations in all care settings; and provide high-level complex care, including procedural and diagnostic services that require their level of expertise. Doctors should not continue to provide clinical services that are not a good use of their considerable training and experience. These services, that could be provided by nurse practitioners, include routine monitoring and prescribing (under protocol and medical leadership) of maintenance treatments (such as haemodialysis treatment or routine diabetes review), and simple repetitive diagnostic or therapeutic procedures. In my experience, many doctors are bored with these intellectually limited aspects of their practice and find the quality of their clinical life substantially enhanced when given the opportunity to work in partnership with nurse practitioners. Again, in my experience, some tertiary-educated nurses are also bored with their limited clinical roles (still dominated by personal care) and can offer much more to the clinical team by focusing on the higher end of their skill base. There are clear differences between doctors and nurses in terms of selection process, education and training. However, this does not preclude both professional groups from looking at their scope of practice and focusing on the tasks that best use their expertise, rather than retaining roles based on custom and practice that are no longer relevant. If doctors embrace and lead the role redesign program, they can ensure that sensible delegations of their clinical tasks to other health practitioners can occur with benefit to all. Resistance and disengagement of doctors will not stop role redesign, as we clearly cannot sustain a health workforce in the future with a staffing model that has not changed materially for 100 years. Resistance and disengagement are more likely to lead to dysfunctional new roles being produced, without the necessary strong relationship with the medical profession required for the best patient care.

Brendan F Murphy

To the Editor: In his recent editorial,1 Van Der Weyden laments the “displacement” of doctors in modern health care by nurse practitioners and physician assistants, and bemoans the fact that discussion and debate about these matters is largely confined to medical tabloids such as Australian Doctor. In this context, the editorial cites unsubstantiated and inflammatory comments from Australian Doctor correspondents claiming that nurse practitioners place patients at risk.2,3 Remarks that nurse practitioners are “a disaster unfolding” and “people will die”3 are not only inflammatory but also inaccurate. Medical and nursing insiders have made these claims with self-appointed legitimacy and without evidence. They demonstrate a surprising level of ignorance about the role of nurse practitioners and the evidence base that supports their practice, particularly in emergency care.4 In an era where the drum of quality and safety in health care and evidence-based practice beats the loudest, where is the evidence to support such claims? Perhaps the lack of evidence is the reason why such claims implying that nurse practitioners present a risk to patients are housed in medical tabloids, where they escape the rigorous scrutiny of peer review that would otherwise expose this deficit. Van Der Weyden bewails that nurse practitioners are the only health professionals “whose skills and talents are extolled”.1 We doubt whether such trivialities are at the forefront of the minds of emergency nurse practitioners, who comprise a large proportion of nurse practitioners in Australia. As part of the broader health care team, their focus — and the focus of their physician, nurse and allied health colleagues — would be on the immediate and ongoing needs of their patients. Van Der Weyden asserts that an assumption of the equivalence of nurses and physicians underpins the political and industrial agenda for “doctor displacement” in general practice in Australia. Such an assertion is entirely moot. High-quality and safe health care cannot be realised by a monopoly of nurses, or physicians, or any other health profession. Nurses and physicians are only two of the many threads in the tapestry of high-quality, safe and evidence-based health care. Their success lies in symbiotic mutualism, not commensalism, amensalism, or parasitism. And, just like in tapestry, pulling any one thread from the fabric renders the picture incomplete.5 Unless there is substantial evidence to the contrary, bringing the safety of nurse practitioners into question is senseless, particularly given the well deserved support they have from their peers in the wider health community and their patients, both in Australia and overseas.

Ramon Z Shaban · Julie M Finucane · Dianne J Crellin

In reply: I welcome the comments of Murphy and of Shaban and colleagues on my recent editorial,1 which explored, as Shaban et al say, the “displacement of doctors in modern health care by nurse practitioners and physician assistants”. The main focus of the editorial was on the current philosophical relativism muddying the definition of what a doctor is and the academic qualifications underpinning all professional training. It calls for equally rigorous criteria to be applied to non-doctor practitioners and their scope for independent practice. Undoubtedly, the potential utility of non-doctor practice is dependent on bilateral mutualism, with a clearly defined scope of practice. However, the push for independent practice remains problematic. Whether there is a genuine commitment for bilateral mutualism to occur, beyond the usual rhetoric, is of concern — witness the recent difficult negotiations on defining the framework for cooperative practice, and the reticent views of doctors on the suitability of nurse practitioners and their scope for independent practice, as reported in Australian Doctor.2-4 The fundamental question, which must be addressed, is whether the granting of Pharmaceutical Benefits Schedule and Medicare Benefits Schedule privileges to non-doctors is simply a political strategy to create a two-tiered health system under the illusion of cost containment.

Martin B Van Der Weyden

To the Editor: Australia is in the process of making the most important change to its health care system since the implementation of Medicare.1 We agree with Cameron and Cooke that there are important lessons for Australia from the implementation of the 4-hour rule in the United Kingdom.2 As in Robert Zemeckis’s 1985 movie classic, Back to the future, the old question of “If I had the opportunity to do something again, what would I have done differently?” applies. We challenge the assumption that Australia is embarking on something that the UK has recently abandoned. The UK has not actually abandoned the 4-hour rule but expanded it into a suite of eight indicators that include three time-based measures, including total time in the emergency department (ED).3 Our concerns are about how the lessons learned by the UK can be applied in Australia in 2011 and beyond. Cameron and Cooke state that “Measurement systems should be in place to ensure that patient safety and quality of care are not compromised at any stage of the emergency care pathway”.2 The systems we have are neither universal nor integrated across the country. We need substantial data infrastructure, including comparable data linkage services across states. Of all the states, Western Australia has the most advanced national data linkage system. Yet even with the most sophisticated data systems in the world, proper impact assessment studies are required. Australia’s evaluation of the changes being made to rules and systems is neither systematic nor well standardised — to be safe and effective, innovation needs to be evaluated in coordinated and systematic ways.4 We also need systems-thinking approaches and simulation technologies to avoid repeating past mistakes. It is important to link theory and data to learn about the complex dynamics of ED patient flow and safety, and understand the consequences of our interventions.5 As suggested by Cameron and Cooke,2 we should focus on real-time, clinically relevant, consistent and comparable quantitative and qualitative data about patients, staff, processes, outcomes and facilities. We must learn to improve daily performance rather than sanction variable outliers. In conclusion, the lessons learned from the 4-hour target are relevant and appropriate for Australia. Cameron and Cooke have highlighted some of the dangers, including those of inadequate measurement.2 We need timely, integrated and linked data and an explicit theory of performance. We should aim to manage the risks by appropriately funded research and implementation strategies to improve this significant policy intervention while maintaining patients’ outcomes, experience and safety, and the timeliness of instigating their care.

Roberto Forero · Geoff D McDonnell · Sally M McCarthy · Peter Nugus · Jeffrey Braithwaite · Kenneth M Hillman · Daniel M Fatovich · David Mountain · Frank F Daly · Gerard J Fitzgerald · Drew B Richardson

To the Editor: The article by Nelson and colleagues1 is a welcome contribution to understanding trends in varicella zoster virus (VZV) disease epidemiology in Australia, particularly ambulatory medical attendance, for which few data sources are available. They report a decline in general practitioner encounters for varicella (chicken pox) since the introduction of varicella vaccine that is consistent with the observed 69% reduction in national hospitalisation rates in children aged 1.5 to 4 years seen from January 2006 to June 2008, 2.5 years into the National Immunisation Program (NIP).2 Nelson et al also report a trend towards higher GP encounter rates for herpes zoster (HZ [shingles]) over time. Although it may be tempting to take this rise on face value, additional analyses are required for a full understanding of patterns in HZ-related health care use, particularly accounting for age and changes in the use of prescription medications, including antivirals and opioid analgesics. Increased HZ-related health care use commencing before varicella vaccine availability has been reported in countries with universal vaccination programs, including the United States3 and Australia,4 as well as in countries where varicella vaccination is not recommended universally, including the United Kingdom.5 In Australia, prescribing of antiviral drugs for HZ increased between 1995 and 1999.6 Australia’s ageing population will contribute to the increasing prevalence of HZ over time due to the propensity of the virus to reactivate with advancing age. An analysis that we conducted shows that an increase in crude national hospitalisation rates for HZ preceded varicella vaccine availability, and that there was no increase over time in age-specific and age-standardised rates (National Centre for Immunisation Research and Surveillance, unpublished data). In addition, the suggestion from modelling studies that HZ may increase under a universal varicella vaccination program because of reduced opportunity for immune boosting in adults has yet to be observed in the US, the country with the longest-standing universal program of varicella vaccination.3 These complexities in monitoring VZV-related diseases highlight the need for very sensitive and well validated surveillance systems for both varicella and HZ in Australia. Although the authors request consideration for a universal HZ vaccination program for those over 65 years, they may not have been aware that since April 2009 The Australian immunisation handbook, ninth edition, online version has had new guidelines on HZ vaccination recommending a single dose of live attenuated VZV vaccine from the age of 60 years.7 In March 2008, the Pharmaceutical Benefits Advisory Committee recommended that this vaccine was suitable for inclusion in the NIP for those aged 60 years, with a catch-up dose for all individuals aged 61 to < 80 years. A decision regarding NIP funding has not been made, possibly because of a shortage of vaccine due to manufacturing problems.

Anita E Heywood · Kristine K Macartney

To the Editor: In Australia, addition of thiamine to bread flour (at 6.4 mg/kg) was made mandatory on 1 January 1991 in an effort to reduce the incidence of Wernicke’s encephalopathy and Korsakoff psychosis.1 Recently, an isocratic high-performance liquid chromatography (HPLC) method for the assessment of thiamine, thiamine monophosphate and thiamine diphosphate (TDP) in human erythrocytes has been described.2 This direct method of measuring thiamine in blood is superior to measuring red blood cell transketolase. We used an HPLC reagent kit (Chromsystems Instruments and Chemicals GmbH, Munich, Germany) to measure whole blood TDP concentrations in a population of 156 people who had alcohol use disorders. They were consecutive cases presenting between June and September 2010 at a driver assessment clinic in South Australia after they were convicted of two or more drink-driving offences. Thirty-two people taking a thiamine-containing medication or vitamin supplement were excluded. Based on the Diagnostic and statistical manual of mental disorders, fourth edition, text revision, of the remaining 124 people, 42 fulfilled criteria for “alcohol dependence” and 82 fulfilled criteria for “alcohol abuse” in the preceding 12 months.3 Of those tested, none had biochemical thiamine deficiency (defined as 2 standard deviations below the reference mean TDP concentration [< 66.5 nmol/L]). The lowest whole blood TDP concentration was 106 nmol/L. The highest concentration found was 362 nmol/L. The mean concentration was 217 nmol/L. This value is 2.5 standard deviations above the mean for the reference population (mean, 133 nmol/L; SD, 33 nmol/L).4,5 The reference range (66.5–200 nmol/L) was derived from a population that did not receive thiamine supplementation in foods. The characteristics of the distributions of thiamine concentrations in the Australian and reference populations are shown in the Box. The mean age of our population was 36 years, the youngest person was aged 19 years and the oldest, 73 years. The mean body mass index was 26.6 kg/m2 and the lowest was 18 kg/m2, so this group was not malnourished. The mean daily alcohol intake reported was 22 g/day but there was wide variation (range, 0–272 g/day; SD, 35 g/day). The results from the population with alcohol use disorders show remarkably elevated thiamine concentrations and no evidence of thiamine deficiency. The very high mean concentration of thiamine shows that this population is not at immediate risk of thiamine deficiency. It also suggests that mandatory supplementation of flour with thiamine has raised the baseline concentration of thiamine in Australians. Distribution of thiamine diphosphate (TDP) concentration in an Australian population with alcohol use disorders compared with a reference population4,5

Philip M Crowley · Matt D Gaughwin

To the Editor: Eades and colleagues identify the scarcity of data on the health and health care needs of Aboriginal Australians.1 This is particularly so for Aboriginal children in urban settings. The Gudaga Study2 has actively worked to redress this shortcoming. The Gudaga Study (Gudaga being an Aboriginal word meaning healthy baby) is a longitudinal study of a birth cohort of Aboriginal infants born at a large outer urban hospital.2 Gudaga staff use methods that respect the values and beliefs of Aboriginal Australians3 to systematically collect information on the health, development, and service use of study participants at 6-monthly intervals. The Gudaga research team is working with the stakeholders in Aboriginal health in the region to discuss the implications of the information for policy and practice. A number of scientific articles are currently being prepared for publication. These include articles on birth outcomes, breastfeeding, universal health home visiting, health status and service use, development, and vaccination. Information collected by the Gudaga Study is contributing to the development of services for Aboriginal families in the region, and is changing the ways that service providers think about the health and service needs of Aboriginal families in the region. For example, the lack of data created difficulty in securing funding for services for pregnant Aboriginal women. Enumeration of the high rates of sudden infant death syndrome (3/149) and the removal of children by the Department of Community Services among participating infants (11/149 over 4 years) as a part of the Gudaga Study had two important effects. It influenced the public health service response to close the gap on Aboriginal disadvantage and influenced the decision to reorient child and family services and establish the Bulundidi Gudaga program with ongoing funding. The Bulundidi Gudaga program provides sustained home visiting of pregnant Aboriginal women and their infants by nurses, commencing during pregnancy and continuing until the infant is aged 2 years.4 This research developed over several years. It began during discussions with the Aboriginal community at Tharawal Aboriginal Corporation, Campbelltown, who raised concerns about the health of their children, difficulties in securing funding for an Aboriginal infant and maternal home visiting service that commenced 1999, the lack of relevant data on the needs of Aboriginal children, and receipt of National Health and Medical Research Council funding in 2003. The Gudaga Study commenced in 2005, and the first of the participating children are turning 5 years of age. The research is now part of a strong research program at the University of New South Wales into the health and development of Aboriginal children in urban settings.

Elizabeth J Comino · Lisa R Jackson Pulver · Jenny A Knight

To the Editor: Two studies in nursing homes in Sydney, New South Wales, in the 1990s1,2 showed inappropriately high use of psychotropic medications. A similar study was conducted in 2003.3 Over time, revision of management guidelines, warnings about potentially lethal side effects, and introduction of new drugs have contributed to changes in the pattern of use of psychotropic medications in aged care facilities. Following the same procedure as the earlier studies, in 2009, we examined medication use in nursing homes in half the catchment area of Sydney South West Area Health Service (SSWAHS). We obtained details of drugs prescribed for residents from medication record cards in 44 of the area’s 48 nursing homes and checked whether medications had been given as prescribed. If given regularly on at least 25 of the previous 28 days, use was recorded as regular. We noted whether medication prescribed “as required” had been taken. The SSWAHS ethics review committee approved the study. Medication cards of all 2465 residents (895 men, 1570 women; mean age, 78.7 and 84.2 years, respectively) were reviewed. The mean number of all medications charted per resident was 8.7. Data obtained from all four surveys on patients taking psychotropic medication regularly are shown in the Box. The catchment area expanded between the 1998 and 2003 surveys. However, half the nursing homes open in 1993 closed before 2009. Use of antipsychotic agents fell between 1993 and 1998. By 2003 there had been a change from conventional antipsychotics to a two-to-one preference for atypical antipsychotic medication. Since 2003, regular use of antipsychotic medication has increased by about 19%, although at a lower mean dosage than previously. The rise is mainly attributable to increased prescription of risperidone and needs continuing review to monitor for morbidity. The proportion of residents taking antipsychotic medication only as required has remained almost the same in each survey (range, 1.2%–1.4%). Regular use of anxiolytic and hypnotic medication has decreased, and of antidepressants has increased, since the 1990s. Only 3.5% of residents were regularly taking a tricyclic antidepressant in 2009. The proportions of residents prescribed anxiolytic or hypnotic medication only as required have also fallen (to 3.8% and 2.3%, respectively, in the 28 days preceding our audit). Our findings cannot be generalised. Recent evidence from Tasmania4 showed that 42% of residents were taking benzodiazepines regularly. Nevertheless, changes in medication use should provoke discussion. Number (%*) of Sydney nursing home residents taking psychotropic medication regularly Medication 19931 (n = 2414) 19982 (n = 1975) 20033 (n = 3093) 2009 (n = 2465) Any psychotropic† 1422 (58.9%) 957 (48.5%) 1461 (47.2%) 1170 (47.5%) Antipsychotics‡ 662 (27.4%) 447 (22.6%) 730 (23.6%) 690 (28.0%) Conventional‡ 662 (27.4%) 401 (20.3%) 251 (8.1%) 182 (7.4%) Haloperidol 190 (7.9%) 159 (8.1%) 167 (5.4%) 121 (4.9%) Thioridazine 354 (14.7%) 193 (9.8%) 17 (0.5%) — Chlorpromazine 53 (2.2%) 24 (1.2%) 25 (0.8%) 20 (0.8%) Trifluoperazine 57 (2.4%) 30 (1.5%) 16 (0.5%) 8 (0.3%) Pericyazine 15 (0.6%) 3 (0.2%) 10 (0.3%) 13 (0.5%) Fluphenazine 44 (1.8%) 23 (1.2%) 10 (0.3%) 11 (0.4%) Flupenthixol — 2 (0.1%) 9 (0.3%) 7 (0.3%) Zuclopenthixol — — — 9 (0.4%) Atypical‡ 48 (2.4%) 506 (16.4%) 537 (21.8%) Olanzapine — 8 (0.4%) 225 (7.3%) 180 (7.3%) Risperidone — 40 (2.0%) 219 (7.1%) 286 (11.6%) Quetiapine — — 18 (0.6%) 63 (2.6%) Amisulpride — — 4 (0.1%) 7 (0.3%) Clozapine — — 3 (0.1%) 7 (0.3%) Aripiprazole — — — 4 (0.2%) Hypnotics‡ 641 (26.6%) 335 (17.0%) 350 (11.3%) 274 (11.1%) Temazepam 530 (22.0%) 313 (15.8%) 307 (9.9%) 255 (10.3%) Nitrazepam 105 (4.3%) 17 (0.9%) 35 (1.1%) 17 (0.7%) Anxiolytics‡ 207 (8.6%) 123 (6.2%) 127 (4.1%) 117 (4.7%) Diazepam 113 (4.7%) 77 (3.9%) 92 (3.0%) 71 (2.9%) Oxazepam 72 (3.0%) 40 (2.0%) 32 (1.0%) 26 (1.1%) Antidepressants‡ 377 (15.6%) 316 (16.0%) 635 (20.5%) 630 (25.6%) Tricyclics 249 (10.3%) 120 (6.1%) 110 (3.6%) 86 (3.5%) Mianserin 87 (3.6%) 37 (1.9%) 22 (0.7%) 8 (0.3%) Moclobemide 21 (0.9%) 40 (2.0%) 20 (0.6%) 9 (0.4%) SSRIs 18 (0.7%) 103 (5.2%) 354 (11.4%) 338 (13.7%) Venlafaxine — — 81 (2.6%) 61 (2.5%) Mirtazapine — — 51 (1.6%) 126 (5.1%) Lithium 11 (0.5%) 8 (0.4%) 24 (0.8%) 17 (0.7%) — = Drug not approved for use or not prescribed in year of survey. SSRI = selective serotonin reuptake inhibitor. * All percentages are proportion of total number of residents. † Clonazepam and other anticonvulsants (apart from diazepam) were not included as psychotropic drugs. ‡ Numbers do not add to totals as some patients were prescribed more than one drug and some little-used psychotropic drugs are not listed.

John Snowdon · Daniel Galanos · Divya Vaswani