Letters

To the Editor: The increasing overcrowding on public transport, particularly trains, in many Australian cities makes for considerable discomfort. As the problem deteriorates, concerns about attributable illness and even death have been raised.1 Overcrowding on public transport also contributes to the spread of respiratory diseases such as influenza (pandemic or otherwise).2 The risk of contracting influenza is greatest for people who are within 1 m of an infectious person, through exposure to respiratory droplets, particularly for periods of more than 15 minutes.3,4 Seasonal influenza, which infects millions of Australians annually — resulting in an estimated 2000 deaths and 10 000 hospitalisations5 — is a major health concern. As a resident of Melbourne and regular train commuter, personal observation supports recent claims of severe overcrowding,1 with the average number of people sitting or standing within 1 m of another person on Melbourne trains during peak periods having increased markedly over the past few years. If an average peak commuter is now placed within 1 m of 10 people for a prolonged period twice a day (a conservative estimate), at least 100 infectious influenza contacts potentially occur each week. With annual attack rates for seasonal influenza of 5%–10%,5 the likelihood of contracting infection while crammed into under-resourced train networks is significant. In the context of an influenza pandemic, with higher attack rates, the risk is even greater. Substantial community resources have appropriately been invested in pandemic planning and mitigation strategies. Perhaps we should devote some of these resources to public transport services to reduce overcrowding. Our national pandemic plan advises that A very simple way of reducing the chances of being infected or passing on infection is to stand or sit back from other people in public or in the workplace. Where possible, you should try to maintain a distance of at least a metre, which is about a large step.4 Such advice is impossible to follow on peak-period train services, certainly in Melbourne. Investment in train services to reduce the spread of infections would not only help delay the onset of the next influenza pandemic, but would also reduce seasonal influenza and other respiratory virus transmission. Furthermore, it could avert injuries and illness due to crushing and overheating/dehydration, and could conceivably reduce the road toll by taking cars off roads during peak hours. Few pandemic influenza planning investments could deliver such diverse public health dividends while we ride out the latest influenza pandemic and await the inevitable next one.

Benjamin C Cowie

To the Editor: Nosocomial infections caused by Pseudomonas aeruginosa often prove difficult to treat because of their resistance to multiple drugs. Carbapenems play a pivotal role in the management of severe multidrug-resistant gram-negative Enterobacteriaceae and P. aeruginosa infections. However, reports in Australia of carbapenem resistance due to production of a variety of carbapenemases, including metallo-β-lactamases (MBLs), have been increasing alarmingly.1,2 We wish to report the first clinical case of a VIM-1-producing MBL in Sydney. To our knowledge, this is the first reported locally acquired case of a P. aeruginosa strain producing acquired VIM-1 MBL in Australia. The patient was an 81-year-old man with chronic rheumatoid arthritis, managed with prednisone. He had a prosthetic knee infection that was first diagnosed in 1997 and, because of multiple recurrences, had been managed with oral moxifloxacin since 2003. The patient had not travelled outside the Sydney area since before his knee surgery. He was hospitalised in November 2005, when he underwent repair of a colovesical fistula. Carbapenem-resistant P. aeruginosa was isolated repeatedly from both urine and sputum cultures from December 2005 until February 2008, when further testing was performed using newly available molecular real-time polymerase chain reaction (PCR) technology with VIM generic and specific primers and DNA sequencing. This testing detected a VIM-1 gene. The P. aeruginosa isolates were routinely screened for antibiotic susceptibility. Multiresistance to numerous antibiotic classes was detected, with high minimum inhibitory concentrations for meropenem, gentamicin, ciprofloxacin, ceftazidime, cefepime, piperacillin–tazobactam, and ticarcillin–clavulanic acid. The isolates were susceptible to polymyxin B and aztreonam, and had intermediate resistance to amikacin. Multiresistant P. aeruginosa is a therapeutic challenge when managing patients with such infections.3 In the context of facilities such as large burns units or intensive care units, the presence of plasmid-transmissible carbapenem resistance within the gram-negative bacterial population has serious infection control implications. Until novel molecular real-time PCR methods became available, the underlying mechanism of carbapenem resistance in these organisms could not be adequately delineated. The increasing availability of such molecular technology and its routine application in the diagnostic laboratory will support appropriate antibiotic prescribing practices and enhance infection control measures in the hospital setting. Identification of a plasmid-mediated carbapenem-resistant strain is a concern in our hospital and throughout Australia, as outbreaks of VIM-1 resistance have been reported in Europe and the United States.4 As demonstrated by our isolates, such strains have a broad spectrum of hydrolytic activity against amino-, carboxyl- and ureido-penicillins, cephalosporins, cephamycins and carbapenems, but not monobactams. Our isolate was susceptible only to polymyxin and aztreonam.

John Merlino · Harold W Stokes · Elaine Y-L Cheong · Thomas Gottlieb

To the Editor: A 79-year-old man from Gatton, 80 km west of Brisbane (Box 1), presented in July 2008 with an extensive area of cellulitis on the right knee surrounding a central ulcer 2 cm in diameter (Box 2). Gram staining of swabs taken from the ulcer showed polymorphs and gram-negative bacilli. An oxidase-positive, gentamicin-resistant, gram-negative bacillus was cultured. It had the biochemical profile and characteristic colonial morphology of Burkholderia pseudomallei, the causative organism of melioidosis. The identity of the organism was confirmed by polymerase chain reaction. Blood and urine cultures were negative, and a chest x-ray was normal. The patient was treated with intravenous ceftazidime 2 g four times a day for 10 days, as well as oral cotrimoxazole 320/1600 mg twice a day for 6 months. The infection appeared to be localised, and the patient made a successful recovery. Melioidosis can have a wide spectrum of clinical manifestations.1 Skin and soft tissue infections, as seen in our patient, may lead to fulminating systemic infections if treatment is inadequate.1 There were also several factors that predisposed our patient to melioidosis, including type 2 diabetes, renal impairment, and concurrent steroid treatment (for persistent sinusitis). The patient had a history of recent local exposure to floodwaters and soil: he had spent several hours kneeling in wet mud repairing a burst water pipe. Within a few days, an abrasion on the knee had developed into the presenting lesion. The patient denied visiting any areas where tropical melioidosis was endemic. In Australia, melioidosis is generally considered endemic in areas north of 20°S. In subtropical Australia, below 20°S, sporadic endemic infections in domestic animals and humans have occurred in south-eastern Queensland2-6 and south-western Western Australia.7 Three fatal human cases have been reported from the Brisbane River valley (two in 1996, near a reservoir 20 km north of Gatton;4 one in 1999, 5 km from Ipswich city centre5). All three patients were exposed to floodwaters, two had infected skin lesions, and all three progressed to fulminating pneumonia. All three also had alcohol-associated pathology, a recognised comorbidity.1 There were also two less well documented (but apparently local) human cases from the Brisbane region in 19676 and 1974.4 Recent molecular typing of five strains of B. pseudomallei isolated from south-eastern Queensland showed them to be genetically distinct from each other and from isolates obtained from tropical Australia, suggesting that this subtropical focus is most likely a natural phenomenon from ancient times.5 The reticulated water supply to our patient’s house was sourced from the Wivenhoe Dam. The source of the bacteria was most likely the local soil, which is of a heavy clay type suitable for this organism. The Brisbane River valley appears to be a subtropical endemic area for melioidosis, and further sporadic cases can be expected. 1 Location of melioidosis cases reported in Queensland 2 Area of cellulitis around a central ulcer on the patient’s right knee

Roger W Guard · Peter J Morero · Win Yi · Maureen J Mackay

To the Editor: Rickettsia australis is the causative organism of Queensland tick typhus, also known as Australian spotted fever. It is an obligate, intracellular organism that invades endothelial cells, causing vasculitis.1,2 Its transmission to humans is via Ixodes tick species, which can occur along the east coast of Australia, but predominantly occur in the north-east.3 R. australis was previously thought to have a low complication rate; however, severe sequelae such as multiorgan failure, severe pneumonia and digital necrosis have emerged in recent years.1 A 54-year-old woman with type 1 diabetes presented to a rural hospital in Queensland with a 1-week history of vomiting, diarrhoea, rigors, and fevers to 39.4°C. Her blood sugar level on arrival was 31 mmol/L (reference range [RR], 3.0–7.8 mmol/L) and diabetic ketoacidosis was diagnosed. Despite initial treatment, her condition continued to decline, and she was transferred to a tertiary referral centre. Her condition deteriorated into multiorgan failure, requiring ventilation and inotropic support. Triple antibiotic therapy comprising ciprofloxacin, meropenem and doxycycline was initiated. Results of blood cultures for anaerobic and aerobic bacteria and a vasculitic screen were negative. The patient underwent serial chest x-rays, which demonstrated a resolving left lower lobe collapse/consolidation and a right-sided pleural effusion. Paired sera from Day 1 and Day 11 of admission to the tertiary hospital were tested in parallel for antibodies to R. australis. A rise in R. australis antibody titre, from 256 to 1024 (RR, < 32), supported a diagnosis of rickettsial disease. Serum from Day 1 was negative for antibodies to Mycoplasma, Leptospira, and Brucella species. A family conference later suggested that the patient may have been bitten by an insect; however, no suspicious lesion was identified. Her treatment was changed to intravenous doxycycline monotherapy, and slow improvement was noted. Two days after admission, the patient developed widespread bullae and dermal necrosis with large areas of affected dermis sloughing off (Box), as well as digital and proximal foot ischaemia. A skin biopsy showed changes consistent with septic vasculitis. The patient was reviewed by a dermatologist, who concluded that it was unlikely to be from a drug reaction. Thirty-six days after admission, she underwent bilateral below-knee amputations. Formalisation of the stumps was delayed to ensure viable tissue for coverage. Necrotic areas of her lower limbs and arms were also debrided and grafted, and seven of her fingers were amputated at the level of the proximal interphalangeal joint. The patient was discharged to a smaller centre for ongoing rehabilitation and support. This case highlights the possible severity of R. australis infection, which can be complicated by septic shock, coagulopathy, multiorgan failure and digital gangrene. In addition, diabetes and the resultant ketoacidosis contributed to a compromised host and an unusually severe clinical course. Bullae and dermal necrosis on the legs of a patient with severe rickettsial disease

Theo F Birch · Michael Muller

To the Editor: In Australia, patients with type 1 diabetes and private health insurance are eligible for rebates on the purchase price of insulin pumps if deemed necessary for treatment. In contrast, hospital-funded or donated pumps are often used by non-insured patients. Hospitals may provide pumps to certain patients for various reasons — for example, to pregnant women (to improve their glycaemic control), to patients who want to try the pump to determine their preference or their ability to use it, or to patients waiting for private health insurance cover to be activated. Patient selection is important, as insulin pumps are cost-effective only if they reduce levels of glycated haemoglobin (HbA1c) and the frequency of hypoglycaemia1 — although quality of life may also be an important benefit. We conducted a study to compare outcomes for patients with public hospital-funded pumps (Group A) with outcomes for those with private health insurance-funded pumps (Group B). All pump starts between June 2000 and January 2008 at Fremantle Hospital and Rockingham General Hospital in Western Australia were assessed. HbA1c levels before and 6 months after pump initiation were recorded. Diabetes-related hospital admissions over a 1-year period before and a 1-year period after pump commencement were recorded using hospital software (TOPAS KEA! 340, version 5.106) that tracked admissions to all hospitals within the greater metropolitan area of Perth. Patients were excluded from our study if they had type 2 diabetes; had commenced pump use at a different hospital; had moved during the study period to a region not captured on the database; or had used a pump for less than a year (this last exclusion criterion was to ensure that admission rates for the subsequent 12 months were representative of the influence of pump therapy). We identified 109 patients (32 in Group A, 77 in Group B). There were no significant differences between the two groups in age, diabetes duration, initial HbA1c levels (9.2% v 8.7%; P = 0.29) or sex, although the proportion of females was higher in both groups (65.6% and 70.1%, respectively). Patients in Group A had more hospital admissions than those in Group B before and after commencement of pump therapy (0.7 v 0.2 admissions/year before [P = 0.02]; 0.7 v 0.2 admissions/year after [P = 0.04]). After commencing pump therapy, HbA1c levels fell significantly in Group B patients (8.7% v 8.0%; P < 0.005) but not in Group A patients (9.2% v 8.9%; P = 0.17). The mean interval between pump initiation and follow-up HbA1c readings was similar in both groups (10.3 months [Group A] v 10.8 months [Group B]; P = 0.70). There was no significant difference in diabetes-related admissions before and after commencement of pump therapy in either group.

Ken Y Thong · P Gerry Fegan · Bu B Yeap

To the Editor: I have read with interest your recent series of articles on access block.1-3 While access block is clearly bad for patients, it is a measure that is focused on emergency departments and not patients. Access block only measures the first part of the process of admission to hospital. Surely, the best measure of access into a hospital is not the rapidity with which patients get out of the emergency department but how long before patients get into the ward that is most suited for their care. At my hospital, patients are shuffled out of the emergency department into a variety of “holding pens”. By this I mean wards (often temporary) whose sole purpose is to act as an overflow area while the patient is waiting to obtain a bed in the home ward of the medical or surgical unit that is looking after the patient. The purpose is to allow the emergency department to function better, but also to allow the hospital to look good from an “access block” point of view. This is hardly optimal patient care. A recent survey at my institution of 136 medical patients at high risk of delirium showed that over 43% had three or more ward moves during their admission, and 60% had three or more bed moves. No wonder they become confused. Patients who are moved to holding pens have intrinsic disadvantages to their care. They are often seen late in the day by medical teams; the medical and nursing teams are not used to working together; allied health professionals may change from ward to ward, and holding pens often have no allied health staff; patient’s belongings, pathology and radiology requests get lost in the transition to different wards; patient meals can be substandard in holding pens (because they are ordered at short notice); and there are multiple handovers between many different groups of nurses. Medications are missed. So, hospitals should not be allowed to play games with this metric. The time for patients to get into the home ward (or the most appropriate ward) of the admitting medical or surgical team needs to be part of the equation.

Charles P Denaro

To the Editor: Duke and colleagues recently reported the excess mortality and extra bed-days caused by intensive care access block in metropolitan Melbourne.1 Access block is an important patient safety issue, and we report here additional data that support their results. The Australasian Clinical Indicator Report: 2001–2007, published by the Australian Council on Healthcare Standards (ACHS), reported that the national rate of intensive care access block was 5.9% in 2007, a statistically significant (P < 0.001) increase from 5.3% in 2001.2 There were large differences between states, with higher rates in Victoria in 2006 and 2007. In 2007, the rate of cancellation or postponement of elective major surgery due to lack of intensive care beds was 3.1%, and the rate of interhospital transfer was 1.3%.2 Other rates reported were: the rate of discharge from the intensive care unit delayed more then 12 hours (16.6%) and the rate of after-hours (between 18:00 and 06:00) discharge (17.5%).2 The Victorian rate of after-hours discharge from the intensive care unit, calculated from seven participating hospitals in 2007 (21.6%),2 is comparable with the rate of after-hours step-down to a low-acuity ward found in Duke et al’s study — 18.6% for the period July 2004 to June 2006.1 The ACHS Clinical Indicator Program provides national and peer-group benchmarking to health services participating in its accreditation program, the Evaluation and Quality Improvement Program (EQuIP). Through its annual Clinical Indicator Report, the data are analysed and allow identification of unsatisfactory rates and wide variations in practice. Such national data can help health policymakers identify areas for potential improvement in the standards of health care delivery, particularly in areas where indicators address access. Duke and colleagues’ salient article illustrates the importance of such data being utilised for this purpose.

Helen E Stark · Chris N Maxwell · Robert W Gibberd

To the Editor: Cameron and colleagues are to be congratulated on their article outlining strategies that do and do not help improve the access of emergency medical patients to public hospital ward beds.1 The authors fail to mention one strategy that is particularly relevant to rural hospitals, namely, referring privately insured medical patients who present to emergency departments directly to tertiary medical services at private hospitals. This strategy has the dual benefit of providing a hospital bed for a patient in a rural emergency department who requires hospital admission, and relieving some of the external pressures on metropolitan tertiary referral public hospitals to provide beds. Traditionally, private health insurance has been thought of as providing patients with the ability to obtain treatment from the doctor and hospital of their choice. Increasingly, private health insurance is giving patients the ability to choose between staying on an emergency department trolley and being able to access a hospital bed in a timely manner. It is worth noting that privately insured patients who require services that are not provided at our hospital (such as interventional cardiology, neurosurgery, cardiothoracic surgery and faciomaxillary surgery) can sometimes access a bed in a private hospital about 500 km away sooner than we can find them a bed in our hospital prior to transfer to a tertiary public hospital. A significant impediment to this process for some privately insured patients is the inability of private hospitals to perform insurance fund checks out-of-hours. While most private health insurance funds provide internet authorisations and confirmations of a patient’s insurance status to private hospitals, some do not. In one case, this meant the wife of a patient with unstable angina pectoris had to provide a cash guarantee of $28 000 on a Sunday so that her husband could have an angiogram the next day. Even though they had “top-level” private health insurance cover, the private hospital could not confirm their insurance status and obtain an authorisation from their health insurance fund on a weekend. Patients with private health insurance should be able to use the benefits of their insurance 24 hours a day, 7 days a week. Private health insurance funds that do not provide 24-hour authorisations to private hospitals for hospital admission should state this limitation clearly in their insurance product as a part of their statutory product disclosure statements. Such disclosure would provide relevant information to consumers to enable them to make an informed choice about their private health insurer.

Antony Nocera

To the Editor: In March 2008, nicotine patches (15 mg per 16 hours) were authority-listed for Aboriginal and Torres Strait Islander people by the Pharmaceutical Benefits Advisory Committee (PBAC) as part of efforts to improve access to medications.1,2 Although timely and welcome, the decision to list only 15 mg patches should be revisited, as it is not consistent with current smoking cessation clinical guidelines.3-5 Neither is it consistent with evidence from a 2008 tobacco survey that we conducted in remote Aboriginal communities in Arnhem Land, Northern Territory. Clinical guidelines advise that smokers will require more intensive support to quit smoking if they: (i) demonstrate a high level of dependency; (ii) have had more than one short quit attempt; (iii) still smoke or experience cravings when using nicotine replacement therapy (NRT); and/or (iv) are frequently exposed to other smokers.3,4 This support includes appropriate medication and counselling, which are more effective in combination.5 Under-dosing is a common problem, given that NRT products deliver nicotine plasma levels well below that delivered by a cigarette.3 Higher-dose NRT products (eg, 4 mg gum) or combination nicotine therapies (eg, patches with gums) are effective for highly dependent smokers.3,5 In the Arnhem Land survey, we interviewed 397 people (aged ≥ 16 years) about tobacco. Of these, 77% were current smokers. Among the current smokers, 17% were attempting to quit or had tried to quit, and 58% were contemplating quitting. Dependency was common, with 55% of smokers reporting they smoked first thing in the morning or during the night. With many dependent smokers, high rates of smoking and widespread “cue” exposure, there is a high need for intensive quit support. We also interviewed 24 smokers interested in quitting who were offered 21 mg patches, and 4 mg and 2 mg gums and lozenges. All used the gums; four combined gum with 21 mg patches, with one of these initially trying lozenges. Modest increases in periods of abstinence and reduction in daily consumption were documented in the 11 participants followed up so far. This evidence, albeit limited, challenges the PBAC rationale for listing patches but not gums for Aboriginal and Torres Strait Islander people, namely: “this population eschews oral aids for smoking cessation”.1 Some Aboriginal and Torres Strait Islander smokers wanting to quit may benefit from combination NRT or gums alone. A wider range of NRT products including gums should therefore be considered by the PBAC.

Jan A Robertson · David J MacLaren · Alan R Clough

To the Editor: The article by Calver and colleagues on the use of gastrostomy tubes in older Western Australians raises important issues regarding decision making for gastrostomy tube insertion and ongoing care of gastrostomy-fed patients. Calver et al report a high incidence of readmissions within 1 year for gastrostomy tube replacement or gastrostomy-related complication (25%) and a high 1-year mortality rate (54%)1 Extrapolation of New South Wales data suggests that about 11 000 Australians rely on gastrostomy feeding at home as their sole source of nutrition and hydration.2 In NSW, about 2300 gastrostomy and jejunostomy procedures are performed each year in public health care facilities, for which about 60% of patients are discharged home. Of these patients, 40% require tube feeding for 2 or more years, and 11% for 5 or more years. In the financial year 2004–05, there were about 700 reported presentations to emergency departments of patients requiring percutaneous endoscopic gastrostomy tube replacement or experiencing tube-associated feeding complications (eg, stoma site infection, tube blockage, buried bumper syndrome, and diarrhoea related to tube feeding); 15% of these presentations resulted in ward admission.2 Many complications can be prevented or treated effectively in the community, provided that patients, carers and health professionals are adequately trained and supported, and that formula, consumables and equipment are affordable. Of particular concern are situations where patients who have multiple comorbidities and disabilities and who cannot advocate for themselves are discharged to nursing homes and group homes. The NSW Ombudsman reported the deaths of two people in 2006 as a result of poor management of their gastrostomy tube feeding and recommended that minimum care standards be introduced.3 Enteral nutrition is an orphan therapy, with no single professional group taking ownership of it. Hospitals release their responsibility when they discharge a patient, as the patient is no longer admitted, and there are limited community services to take over care. Patients are left to fend for themselves, resulting in poor outcomes. How a patient will manage tube feeding at home should be an important part of the decision-making process that occurs before a tube is inserted, rather than an afterthought. As the use of therapies that can be performed at home increases (eg, dialysis and enteral nutrition), there needs to be increased investment in community-based health services to support patients in caring for themselves at home. This will bring social and economic benefits to both patients and the health care system.

William H Watt · Kate A Needham · Peter L Talbot · Janet P Bell · Glen J Pang

To the Editor: We applaud the attempt by Boyes and colleagues to ascertain the level of psychological distress experienced by patients over the years following diagnosis with cancer, through a retrospective, cross-sectional survey of New South Wales cancer registrants.1 However, we believe several methodological limitations ought to reduce the confidence with which the authors drew their conclusions. The authors’ comment that “life after cancer is not all doom and gloom” was, perhaps, intended to be a little facetious. From a scientific point of view, however, such a statement is also very difficult to ever disprove — of course it isn’t all doom and gloom. Further, the authors’ assertion that psychosocial wellbeing several years after cancer diagnosis is comparable with that of the general population cannot be substantiated by studies conducted by this method. As the survey was cross-sectional, we have no information about the level of distress experienced during the years since diagnosis. A longitudinal design is now de rigueur in this field for this reason. Certainly, clinical experience shows us that many patients actually do experience “doom and gloom” often, indeed, arising from “insidious and relentless disease” — this group may not, however, be well represented by a cancer registry survey sampling 5 years after diagnosis. Selection bias is a major problem. Of the sample of 2029 eligible, randomly selected people, 655 (32%) were deemed ineligible, with one of the exclusion criteria being not “mentally capable of participating”. Could this sizable subgroup have included those who were distressed? Also, of the eligible sample of 1374, 366 (27%) declined to participate. What were the reasons for refusal? Were some too distressed to participate? In summary, how were the 37% who did not participate in the study faring 5 years after diagnosis? The Hospital Anxiety and Depression Scale (HADS), used by Boyes et al to detect psychological distress in early-stage breast cancer, under-reports distress when recommended cut-off scores are used, compared with a structured clinical interview validated to provide Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV2) diagnoses.3 In other words, the HADS is known to lack sensitivity and positive predictive power in the cancer setting. Other cancer researchers found the same.4,5 Further, measuring distress only in terms of anxiety and depression 5 years into the adjustment process fails to capture the quality of continuing distress and the degree to which traumatic growth and other forms of meaning-based adjustment have been achieved. The limitations of the HADS should have been better acknowledged.

Jeremy W Couper · Anthony W Love · Annabel C Pollard · Sidney Bloch

In reply: We thank Couper and colleagues for their interest in our article,1 but reiterate that we focused on anxiety and depression experienced by long-term cancer survivors, specifically at 5–6 years after diagnosis. We agree that longitudinal studies are vital for understanding the level of psychological distress experienced during the years since diagnosis, and as discussed in our article, we are currently undertaking a longitudinal study with a diversity of cancer patients to assess a comprehensive range of physical, psychological, social and lifestyle effects of cancer. Although opinions on the performance of the Hospital Anxiety and Depression Scale (HADS) vary, it is one of the most popular measures of psychological distress, and has been used extensively across the cancer continuum.2 A recent review of the validity of the HADS concluded that it performs well in screening for caseness of anxiety disorders and depression in a range of patient populations, including patients with cancer, and in the general population.3 We acknowledge that our study had the strengths and limitations normally associated with recruiting through a population-based cancer registry.4 Nevertheless, our results are consistent with a growing body of evidence indicating that most cancer survivors are doing well 5 or more years after diagnosis.5 We believe our conclusions are justified.

Allison W Boyes · Afaf Girgis · Alison C Zucca · Christophe Lecathelinais

To the Editor: Sikic and colleagues state that the 1990 legislation making helmets compulsory for bicyclists in Victoria was associated with a decrease in non-fatal head injuries and fatalities.1 However, of the three citations given to support this statement (references 8–10 in Sikic et al),1 one is a study performed before the helmet law was introduced, another is an editorial, and the third makes the common error of attributing to helmet use the effects of economic recession and road safety campaigns. These together reduced all road deaths in Australia by about a third.2 Careful analysis takes account of such factors. Western Australia and New Zealand offer good datasets of injuries to cyclists and control groups through the period of increasing helmet use and enforcement: neither dataset shows evidence that mass helmet use reduced the occurrence of serious head injuries to cyclists.3 With fewer serious crashes, there were fewer serious head injuries, and a general reduction in severity of injury in road accidents for all road users. These observations make it hard to accept that cycle helmets reliably confer significant protection. Sikic et al further state that “Wearing an approved safety helmet substantially reduces the risk of serious head injury in cyclists who fall or are involved in collisions with motor vehicles”,1 citing case–control studies. Such studies are known to have serious weaknesses when applied to voluntary behaviour in a socially disparate population.4,5 Risk assessments do not justify helmet laws for cyclists alone. Analysis of Australian Government data (1988–1990) showed that cyclists faced a lower risk of death per hour than car occupants (0.41 v 0.46 fatalities per million hours of use).6 Wider risk assessment based on European data confirms that cycling risks are in the same range as for walking and driving.7 Sikic et al ask for further research to identify factors other than helmet wearing that contribute to preventing cycling injuries. One important factor is already well known: an increase in cyclists on the roads means less risk per cyclist.8 Considerable experience is now available to show that mass helmet use has not been effective in preventing serious head injuries in cycling populations.3 Enforced helmet laws in Australia may deter people from cycling9 and getting the major health benefits of moderate exercise.10

Malcolm J Wardlaw

In reply: The main conclusion of our population-based study1 was that a consistent increase in bicycle-related injuries occurred over the study period. Our study was not designed to analyse the effect of helmet wearing. The potential benefits of helmet wearing were identified in the discussion as a means of reducing the increasing burden of injury. There has been opposition to legislation enforcing helmet wearing in Australia.2 The response to this opposition has been adequately addressed by Canadian researchers.3,4 In addition, a number of Cochrane systematic reviews have arrived at different conclusions to Wardlaw.5,6 Although there are no randomised controlled trials, the weight of evidence would suggest that wearing helmets reduces head injuries in the bicycle-riding population and the imposition is worth the inconvenience to bicycle riders.

Antonina A Mikocka-Walus · Francis T McDermott · Peter A Cameron

To the Editor: Following the letter by Kitson et al, about a patient with asymptomatic ocular syphilis,1 we describe another unusual presentation of syphilis, with perioptic neuritis that mimicked papilloedema. A 28-year-old man presented with blurry central vision of his right eye on waking. He had had flu-like symptoms 2 days before presentation. There were no symptoms suggestive of meningitis, no raised intracranial pressure and no obvious ocular infection or inflammation. He had been diagnosed with type 2 diabetes mellitus at age 15 years, and had no known microvascular complications. His only medication was metformin. His visual acuity was 6/12 in the right eye and 6/6 in the left. The right eye had an enlarged blind spot with a small paracentral scotoma, with a central relative scotoma to red. The visual field in the left eye was normal. There was no relative afferent pupillary defect, and the anterior chambers were normal. Fundoscopy confirmed bilateral swelling of the optic discs (Box). Computed tomography and magnetic resonance imaging of the brain excluded space-occupying lesions and demyelination. Examination of the cerebrospinal fluid (CSF) showed: normal opening pressure; a white cell count of 66 × 109/L (reference range, 4–11 × 109/L), 100% lymphocytes; a protein concentration of 1.12 g/L (reference range, 0.15–0.45 g/L); a glucose concentration of 8.9 mmol/L (reference range, 2.7–4.4 mmol/L); and no bacterial growth. Findings of a baseline blood analysis were normal, but with an elevated glycated haemoglobin (HbA1c) level of 10.5% (reference range, < 6%), indicating poorly controlled diabetes. We thus initially considered diabetic papillopathy and non-arteritic ischaemic optic neuropathy, but the patient subsequently (about a week later, after most other investigations gave negative results) reported having had unprotected sexual intercourse with different men about 5 months previously. He recalled having a transient palmar maculopapular rash 2 months before presentation. Neurosyphilis was then confirmed with a strongly positive result on an absorbed fluorescent treponemal antibody (FTA-ABS) test in CSF. Results of serological tests for syphilis were positive (reactive [3+] on a Treponema pallidum particle agglutination test and a markedly elevated titre on a rapid plasma reagin test [1:128]), but results of tests for HIV and hepatitis were negative. Contact tracing was initiated. After 21 days of treatment with intravenous penicillin, the vision in his right eye was completely restored. At 9-month follow-up, the bilateral swelling in his optic discs had resolved, and there was a tenfold decline in the rapid plasma reagin test titre (1:8). This case illustrates syphilitic perioptic neuritis with optic disc swelling that is indistinguishable from papilloedema. Perioptic neuritis describes inflammatory involvement of the optic nerve sheath without inflammation of the nerve itself. The affected eye often has normal visual acuity with no visual field defect except for an enlarged blind spot.2,3 The prevalence of infectious syphilis has been rising in recent years, especially in Victoria and New South Wales, predominantly among men who have sex with men.4,5 Endemic syphilis should also be considered in patients with HIV co-infection and Indigenous patients, particularly those in the remote communities of Western Australia. Physicians should be vigilant in looking for neurosyphilis in any sexually active individual with unexplained eye or neurological signs. The swollen optic discs of a patient with syphilitic perioptic neuritis

Grace S H Low · Robert H Edis

To the Editor: We report a case of a 13-year-old girl with cystic fibrosis (CF) and chronic Pseudomonas aeruginosa lung infection who developed an unusual infection that was challenging to manage. At a regular review, and with no obvious change in clinical respiratory status, the patient’s forced expiratory volume in 1 second (FEV1) was 70% of the predicted value — a drop from her usual 90%. A subsequent 3-week admission, including treatment with standard antipseudomonal antibiotics, physiotherapy and addition of nebulised dornase alfa, did not significantly improve her lung function. She was discharged home on a trial of azithromycin. One month later, she had a non-productive cough, and a bronchoalveolar lavage specimen showed no growth on culture. Four months later, the patient presented with increased non-productive cough and sudden further deterioration in FEV1 to 52% of the predicted value. She was admitted and given standard intravenous antipseudomonal antibiotics. Culture of a repeat bronchoalveolar lavage specimen grew Mycobacterium abscessus, sensitive to clarithromycin, imipenem and amikacin; hence, the patient was given intravenous imipenem and amikacin for 3 weeks. During this period, high-resolution computed tomography (CT) of the patient’s chest showed mucus plugging, marked diffuse parenchymal involvement with typical “tree-in-bud” appearance and, surprisingly, given her poor lung function, only moderate bronchiectasis (Box). Two years earlier, results of a chest CT scan were normal. The patient was discharged home on long-term nebulised amikacin, oral ciprofloxacin and oral clarithromycin. Her lung function gradually improved after discharge and, 6 months later, her FEV1 was 69% of the predicted value and a sputum culture produced no growth. CF is a risk factor for non-tuberculous mycobacterial (NTM) lung disease, which is notoriously difficult to eradicate. A recent multicentre prospective study in the United States estimated that, in patients with CF who are older than 10 years, the prevalence of non-tuberculous mycobacterium was around 13%. The most common species were M. avium complex (72%) and M. abscessus (16%).1 Another study suggested that M. abscessus was more common in paediatric patients.2 Clinical signs and symptoms of NTM infections are usually difficult to distinguish from those of chronic respiratory infections that occur during the advanced stages of CF. High-resolution CT often reveals features of parenchymal involvement, as demonstrated in our patient. No guidelines exist for treating NTM infections in the CF population. However, for M. abscessus infection, oral clarithromycin in combination with intravenous amikacin and either cefoxitin or imipenem for 2–4 months has been recommended, with sputum surveillance for at least 12 months after a negative culture result.3 Suppressive maintenance therapy with clarithromycin, intermittent intravenous antibiotics and aerosolised amikacin have all been reported, but not confirmed by controlled studies. Surgical resection may be curative in localised disease. As the life expectancy of patients with CF improves, the prevalence of NTM infections is likely to increase. The American Thoracic Society recommends that all patients with CF who are on macrolide therapy should be screened annually for atypical mycobacteria.3 Atypical mycobacteria should always be borne in mind when treating patients with CF and an unexplained decline in lung function. Computed tomography scan showing diffuse parenchymal involvement, mucus plugging and moderate bronchiectasis in a girl with cystic fibrosis and non-tuberculous mycobacterial lung disease

Abdullah A Yousef · Adam Jaffé

To the Editor: Since colonial times, alcohol has been central to Australia’s political, cultural and social fabric.1 In the past year, concern about alcohol misuse has re-emerged as a dominant feature in the political landscape. We analysed the New South Wales emergency department (ED) data collection, on the NSW Department of Health’s HOIST (Health Outcomes and Information Statistical Toolkit) database, to describe the epidemiology of ED attendances due to acute alcohol problems. Data from 43 hospitals that contributed reasonably complete diagnosis information since 2000 were used. Attendances were selected using codes for alcohol intoxication, alcohol dependence/withdrawal, or drug or alcohol blood test from the ninth and 10th revisions of the International classification of diseases (ICD-9 and ICD-10) or from the Systematized Nomenclature of Medicine — Clinical Terms (SNOMED-CT). Population rates by age, sex and year were calculated. To assess the association between alcohol-related ED presentations and large public social events, time series of 24-hour counts ending at midday were used (because most presentations for acute alcohol problems occur at night).2 Between 2005 and 2008, the rate of ED presentations for acute alcohol problems rose sharply from around 110 to almost 150 per 100 000 population (Box 1). Between 2000 and 2008, the highest rates of ED attendance involved 18–24-year-olds of both sexes, and 25–64-year-old men. The largest increase was among 18–24-year-olds. Notably, in that age group, the rate in women converged with that of men at 228 per 100 000 in 2004 and was then higher until it re-converged in 2008 at around 390 per 100 000. In all years, the rate of presentation in 10–17-year-olds was slightly higher for females than for males (Box 2). Among children aged less than 10 years, the rate was under four per 100 000 in all years. Many peaks in ED attendance coincided with large public gatherings, including New Year’s Eve celebrations and the closing of the 2000 Sydney Olympic Games. In 2007 and 2008 especially, the Sydney Gay and Lesbian Mardi Gras was associated with marked increases (Box 3), which may reflect underlying increases in alcohol use in the younger age groups that might be attracted to this now mainstream event. Because the coverage of the ED data collection was limited, these figures underestimate the true incidence. Nevertheless, most urban and larger rural hospitals were included. We were unable to include the far greater number of ED presentations in which alcohol use was a factor, but not the primary reason for presentation.3 The trends and rates we observed were similar to those found in a recent Victorian study of young people.4 The small decline in overall rate from 2000 to 2002 (Box 1) is consistent with declining per-capita consumption of beer and spirits, while the subsequent increase in young people, which flattened out in 2008, is similar to the trend in consumption of ready-to-drink alcoholic beverages over the same period.5 Studies of the types of beverages used before ED presentation are urgently required to assess whether this is a causal association. Analysis of routine ED databases can provide a timely insight into the social and epidemiological context of high-risk drinking. The rise in alcohol-related presentation among teenagers and young adults bodes poorly for subsequent long-term alcohol use disorders and other risk behaviours and their consequences.6 The correlation between peaks in ED presentations and large-scale social events suggests that the development of cultural norms may have a strong influence on individuals’ behavioural choices. 1 Number and rate of presentations to 43 emergency departments for acute alcohol problems, New South Wales, 2000–2008 Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 Number 6400 6215 6203 6762 6826 7652 9112 10119 10382 Rate per 100 000 population* 98.7 94.5 93.6 101.3 101.7 113.2 133.7 147.1 149.4 * Rates are an underestimate because not all NSW emergency departments are included. 2 Population rate of presentations to 43 emergency departments for acute alcohol problems,* by year, sex and age,† New South Wales, 2000–2008 * Rates are an underestimate because not all NSW emergency departments are included. † Values not shown for people aged < 10 years because all values were below 4/100 000 population. 3 Daily counts* of presentations to 43 emergency departments for acute alcohol problems, New South Wales, 2000–2008 * Counts are aggregated over 24-hour periods, ending at midday.

David J Muscatello · Sarah V Thackway · Daniel A Belshaw · David McGrath

To the Editor: Recycling water from sewage into drinking water was recently discussed in the Journal.1 Although this is technically feasible, we need to be very wary. Such recycling is associated with very high ongoing monetary and energy costs, but, most importantly from a health perspective, is a “very high-risk”2 proposal that reverses 150 years of good public health policy of striving to keep sewage out of our drinking water supplies. When we need to recycle water from highly contaminated sources, it is much safer to do so for industrial purposes using separated pipelines (as is done in Singapore and Brisbane). The most extensive scientific review on this issue concluded that putting it into drinking water should be a “last resort”, that should be adopted only if other measures — including other water sources, nonpotable reuse, and water conservation — have been evaluated and rejected as technically or economically infeasible.3 Sewage contains very high concentrations of pathogens and drugs. Viruses (the most difficult pathogens to remove) can occur in concentrations higher than 106 per litre — orders of magnitude higher than in even the most polluted rivers. The technical and human performance needed to remove viruses safely will have to be proportionately higher than current practice — difficult to achieve, as we already have skills shortages. We would also need to ensure that the system will work all the time. Reverse osmosis (RO) is the most effective way to remove viruses and drugs from sewage, and should remove virtually all viruses and drugs. Surprisingly, few in-use data are available to check this. RO membranes seem to leak. One study found that RO only removed 92% of antibiotics.4 Recent safety reviews, including an Australian review5 (based on the previous study3), showed viruses were still detected post-treatment at three of seven sites on some occasions. The calculated virus removal ranged from 87% to > 99.995%, which equates to a “log reduction” of 1 to 5. However, to produce safe drinking water from sewage, we need a consistent 9.5-log reduction for enteroviruses.2 Even Giardia was not always removed. This less than optimal performance was when the system was not known to be malfunctioning; lowered performance might occur as often as 5 days a year.6 Current surrogate testing (eg, organic carbon) can only detect a membrane leak (or bypass) of at least 1%, which is well short of meeting the 9.5-log reduction we need for virus removal and reasonable safety.2 We need real-time tests to show that there is adequate virus removal, rather than none at all or only becoming aware of a problem after processed but contaminated water is already in our reservoirs.

Peter J Collignon

In reply: We agree that augmentation of drinking water sources with recycled sewage goes against the traditional policy of separating the two, and that many factors including cost and energy use need consideration in securing future water supplies. Our editorial1 was not written to promote potable recycling, which ultimately is a political and societal decision, but rather to point out that the carefully considered Australian guidelines for water recycling2 have been developed to ensure that, if this form of recycling is contemplated, it is done in a manner that safeguards public health. Main messages in the recycling guidelines include the importance of risk assessment for each individual scheme; avoidance of complete reliance on any single technical step (including reverse osmosis) for removal of contaminants, via a “multiple barrier” approach; adequate operational and water quality verification monitoring; and optimising training and skills management within water treatment facilities. Importantly, credits given for “log removal” for each treatment step are based on verifiable on-line performance, not theoretical values.2 These practical messages are also fundamental to the way we manage our conventional drinking water supplies.3 Consequently, discussions about recycling help reinforce the importance of continual assessment of water management, regardless of the source, and help ensure we do not become complacent.

Karin S Leder · Joanne E O’Toole · Martha I Sinclair

To the Editor: The recent withdrawal of faulty faecal occult blood testing (FOBT) kits by the government highlights the flaws in the National Bowel Cancer Screening Program (NBCSP), with 475 000 kits needing to be replaced. In their recent editorial,1 Ee and Olynyk attempted to persuade us that the NBCSP, which has now temporarily suspended the issuing of new invitations to participate, is both rational and appropriate for an affluent country such as Australia. The facts about bowel cancer mortality are not disputed — it is second only to lung cancer, equating to about 12 Australian deaths per day from a potentially preventable cancer. There are only two serious contenders for bowel cancer screening: FOBT and colonoscopy. Annual FOBT has the potential to reduce mortality by 15% (realistic) to 33% (optimistic).2 Colonoscopy is both diagnostic and preventive, with a predicted reduction in mortality of 76% (realistic) to 90% (optimistic).3 Recent United States guidelines advocate colonoscopy at 10-yearly intervals as the test of choice.3 Cost and potential mortality are two major issues raised by proponents of FOBT versus colonoscopy. However, Australian data using all costs, including infrastructure, colonoscopy, surgery, pathology, anaesthesia, chemotherapy and disinfection, have shown that 10-yearly colonoscopy is of equal cost–benefit to annual FOBT.4 A recent publication from Germany highlights some important facts.5 In a study of 269 144 colonoscopies, the completion rate (ie, reaching the caecum) was high, at 97.3%. The perforation rate was low (0.02%), as was the incidence of bleeding (0.16%), though this was predictably greater in those requiring polypectomy (0.8%). There were no deaths attributable to perforation or bleeding. Colonoscopy is therefore a rational option for screening, with the potential for prevention — a feature not shared by FOBT. The NBCSP’s letter of invitation and FOBT kit are sent only to individuals aged 50, 55 and 65 years. It ignores other age groups and gives no educational advice about alternative strategies such as colonoscopy. Ee and Olynyk1 clearly believe that centrally organised government screening programs are to be preferred, and they disapprove of colonoscopy screening “driven by patients”. Recent case series show colonoscopy to be safe and to have a higher completion rate than older series.5 Current initiatives in Australian colonoscopy training programs should improve safety and completion rates further. For those with no active interest in their health, centralised, directive programs are likely to be the most effective. For the informed, however, discussion about lifestyle changes, screening programs and healthy dietary alternatives should be their right.

Terry D Bolin · Melvyn G Korman · Alistair E Cowen

To the Editor: Australia’s world-leading government-funded National Human Papillomavirus (HPV) Vaccination Program for women aged 12–26 years is made up of two components: an ongoing school-based program and a time-limited catch-up program delivered through schools, general practices and community vaccination services. The catch-up program started in April 2007 and was due to finish by July 2009, but has been extended to 31 December 2009 to allow women to complete the three-dose schedule. Assessing the coverage achieved by the National HPV Vaccination Program will be an important measure of the Program’s success, particularly in terms of ensuring equity in vaccine uptake — so that the current gap in cervical cancer incidence and mortality between Indigenous and non-Indigenous women is reduced, not widened.1 Vaccination coverage data are also needed to monitor vaccine effectiveness in preventing cervical lesions and cancer. Accordingly, an integral part of the Program was the establishment, enabled by legislation passed in August 2007, of Australia’s first national adult vaccine register — the National HPV Vaccination Program Register. The Register began collecting data in mid 2008 and is currently uploading notifications of the 5 million doses of HPV vaccine distributed in Australia to date. Initial coverage estimates from the Register will be published by the end of the year, with all notifications from the catch-up program due to be submitted to the Register by March 2010. General practitioner incentive payments of $6 per notification will be available until that time. Interim coverage data provided by various jurisdictions are encouraging; school-based program data for 2007 from New South Wales and Victoria estimate one-dose coverage of more than 80% and three-dose coverage of approximately 70%.2 Unfortunately, there are no routine systems in place to provisionally estimate coverage in women vaccinated outside of schools. In a small population-based telephone survey that was conducted by the Cancer Council Victoria 3 months after the Program commenced, 35 of 90 women aged 18–26 years (39%) had received HPV vaccine. Australian women are taking advantage of Australia’s most expensive vaccination program to date. We encourage vaccination providers to notify the Register3 of doses administered to ensure that this facet of Australian women’s health can be followed into the future. Although we anticipate complete notification of vaccinations given at schools, the accuracy and completeness of total coverage data will depend on GPs notifying the Register.

Julia M L Brotherton · Robyn M Mullins

To the Editor: Over a third of women seeking a termination of pregnancy (TOP) in Melbourne are aged 30 years or over.1 Between 1996 and 2006, there was a 29% increase in the number of women aged 30–50 years having a TOP.2 Possible reasons for this trend are not immediately apparent. We audited the files of 50 consecutive women aged 35 years and over attending a private termination service in metropolitan Melbourne in February 2007 to determine reasons for deciding on a TOP and the women’s prior and intended contraceptive use. Of the 50 women, 38 were working in paid employment, 28 had private health insurance, 39 had at least one child, 22 had had at least one previous TOP, and 43 were in an ongoing relationship. Sixteen separate reasons for TOP were elicited (Box), with nearly three-quarters of the women citing more than three reasons for terminating their pregnancy. Over a third of the women cited financial pressures, a focus on career or studies, having dependent children, or emotional unpreparedness for children as reasons for having a TOP. Contraceptive methods used by the 29 women who indicated their prior contraceptive practice were as follows: none (9), condoms (8), natural family planning (NFP) (4), the combined oral contraceptive pill (COCP) (4), withdrawal (3), and the mini pill (1). After the TOP, contraceptive methods chosen were the COCP (11), vasectomy (10), an intrauterine device (10), condoms (8), the mini pill (5), an etonogestrel implant (4) and NFP (1). Although ours was a small retrospective audit, the contraceptive findings and reasons given for TOP in our study were similar to those of other studies.1-4 However, some of the reasons given for TOP in this age group have not previously been described — for example, having ageing parents to care for, recent migration to Australia, and ambivalence towards parenting. Furthermore, although recent Australian studies have reported a high level of contraceptive use,2,5 women in our study often relied on less effective forms of contraception or no contraception at all. Further qualitative research is needed in women of this age group to explore their understanding of fertility and pregnancy risk, barriers to effective contraceptive use, and additional supports and interventions that could prevent unplanned pregnancy in these women. Reasons for termination of pregnancy among 50 women aged ≥ 35 years Reason Number citing reason Already have dependent children 17 Focus on career or studies 17 Emotionally unprepared for a child 16 Financial pressures 16 Completed family 15 Relationship factors 14 Too old to raise a child 10 Partner factors, including partner not wanting children 9 Physical or psychological health issues 8 Concerns about congenital anomalies 7 Does not want single parenthood 6 Bad timing (recent job change, move home, move to Australia) 4 Uncertain of wanting children or does not want children 4 Exposure to medications or agents that might harm fetus 1 Pregnancy from sexual assault 1 Other factors (other life plans, uncertain paternity, poor social supports, aged dependent parents) 9

Wendy Lee · Danielle Mazza

To the Editor: We agree with Stockigt that clinical accountability is needed in the production of consumer medicines information (CMI).1 However, providing CMI is a great deal more complex. The ways in which consumers access and absorb medical information are still largely unknown, and the most important issue is potentially that consumers are not receiving CMI. The benefits of involving consumers in shaping health research and medical policy are widely acknowledged.2,3 We recently completed a study funded by the National Health and Medical Research Council (NHMRC) on improving medication safety and chronic disease outcomes in people aged over 65 years, which was accepted for presentation at the national General Practice and Primary Health Care Research Conference in Melbourne, July 2009. Three community forums co-facilitated by the Health Consumers’ Council of Western Australia raised key issues around the safe use of medicines, and an expert panel of consumers aged over 65 years was convened to guide the study. The safe use of medicines was then qualitatively explored in a series of focus groups and individual interviews. Our findings add to those of Vitry and colleagues,4 and suggest that campaigns urging consumers to request CMI may fall short of what is required to make a difference. We found that most study participants did not know they could ask for a CMI printout at the pharmacy. They noted that if the pharmacist was busy, they would not ask for advice or CMI, even if they were uncertain of dosages or potential side effects or interactions. Given that medication side effects and interactions were the greatest concerns for this age group, it is troubling that CMI is not getting to those who need it. In addition, it was noted that participants were not selective in accessing alternative web-based information about medicines, believing it to be reliable because it is “written by medical professionals”. A further issue raised by participants was a perception of undue influence of pharmaceutical companies on the prescribing choices of general practitioners, leading to mistrust of medicines information provided by doctors. Clearly, there is still more to be done to ensure consumers receive the right information at the right time about their medicines.

Caroline E Bulsara · Anne McKenzie

To the Editor: We share Millar’s concerns about the conflicts of interest that influence the genesis and adoption of clinical guidelines1 specifically, and the lack of independent assessment regarding information provided by the pharmaceutical industry generally. Iain Chalmers puts it succinctly: I do not blame industry for trying to get away with anything that is normally considered to be its primary purpose, which is to make profits and look after its shareholders’ interests. It is our profession that has colluded in all of this and been prepared to go along with it — we are the people to blame because we need not have stood for it.2 We believe the reasons behind this acquiescence are complex, but worthy of discussion. A strong and viable pharmaceutical industry is essential for clinical improvement. Similarly, clinical involvement in industry research is necessary. We would not debate either of these statements, but we are concerned about the failure of our profession to stand back and exercise careful scrutiny of data. Classic examples are thalidomide in the 1960s and, more recently, the cyclooxygenase-2 (COX-2) inhibitors, but many less dramatic examples can be found, such as gatifloxacin or rosiglitazone. This failure on our part harms both patients and the standing of our profession. A recent article in this Journal suggested this failure of physician leadership may in part be due to the comfortable position we cultivate with industry,3 relationships that go beyond the business transaction of providing independent medical advice for a consulting fee. Further, the role of “key opinion leaders”, cultivated by industry, is reinforced by criteria for hospital accreditation and university promotion, leading to disproportionate value being placed on service to company boards (which is often paid and of modest time commitment) compared with service on hospital, state and national regulatory and quality committees (which is usually time-consuming and unpaid). The presupposition in this discrepancy is that physicians on the company circuit are better physicians than those who are not. We should all support the recommendations of Millar,1 Olver and Haines,3 and Van Der Weyden,4 including those for true independence and transparency of guideline development and dissemination, strengthening ethical administrative structures and placing appropriate value on public service. Upskilling of clinicians in epidemiology and critical analysis is thus urgently needed so the incremental benefit and costs of new therapies can be objectively examined.

Jennifer H Martin · Christopher Beer · Raymond G Morris · Matthew P Doogue

To the Editor: Articles by Olver and Haines1,2 have catalysed robust discussion about the relationship between the pharmaceutical and device industries and the medical profession.3 These authors advocate changes in the direction of clinical cancer research and in health policy.2 In an era in which research into medicines is dominated by industry, they argue for greater scrutiny of data in a resource-constrained environment, and for fundamental changes in the collection, interpretation and ownership of data. We find their arguments sound and equally applicable to other areas of medicines research and health policy. Their primary recommendation is for “. . . a system to follow up and evaluate the outcomes of all treatments . . .” That is, that we exercise our duty to patients by monitoring and analysing existing clinical data to inform health care policy. There is a great deal of valuable clinical data collected that are not readily accessible because of ownership or privacy issues. For example, much business involving public health dollars is labelled “commercial in confidence”, and laboratory data held in many pathology databases are not accessible at all. The likely benefits to patients and society of transparency and data linkage in health care are greater than possible benefits to individuals of secrecy and privacy. Quality use of medicines (QUM) is one of the central objectives of Australia’s national medicines policy. QUM means selecting management options wisely; choosing suitable medicines if a medicine is considered necessary; and using medicines safely and effectively.4 Olver and Haines also identify issues relating to quality use of research. Quality use of research might include: supporting research into monitoring clinical outcomes related to drug use; supporting research into better use of existing drugs; and supporting truly independent guideline development. There continue to be advances. For example, registration of trials in public databases, such as the Australian New Zealand Clinical Trials Registry, should reduce publication bias.5 However, the decline of independent public sector clinical drug research and the marketing-based design of phase III and, increasingly, phase II industry-funded studies contribute additional bias to the available information. Olver and Haines’ arguments apply to all therapeutics, and particularly to all drug therapies. We strongly support their proposals for health data linkage and for quality use of research. These fit within existing health policy, and our continued failure to make full use of clinical data is an ethically compelling reason for improved political and clinical governance.

Matthew P Doogue · Kathleen M Knights