Letters

To the Editor: There is danger of a perception developing that, to ensure patient confidentiality, quality assurance (QA) activities in health care should be regarded as research. The Australian Law Reform Commission (ALRC) has delivered proposals for the review of the federal Privacy Act 1988 (Cwlth) that may lead to all but the most basic monitoring of health care activities being characterised as research.1 Recommendation 65–3 emphasises that “research” should include “the compilation or analysis of statistics” and the ALRC also stated that “some funding, management, planning, monitoring, improvement and evaluation activities also may be characterised as research”. This drives the possibility for policy interpretation of QA activities into the realm of research necessitating ethics approval and/or informed consent, rather than retaining the current level of exemption. Australian governments are crying out for increased transparency to improve safety, but labelling QA activities as formal research could seriously compromise and retard patient safety efforts. A key to enabling optimal patient safety is the implementation of evidence by practitioners competent in judgement, skill and knowledge within an environment characterised by leadership and adequate resources (for example, through morbidity and mortality meetings and clinical audits).2 Implementing clinical monitoring (eg, antibiotic use, so essential to optimal outcomes and to minimising antibiotic resistance) requires audit of patients’ files. Improvement in current practices requires scientific, planned, data-driven study with ongoing review, which includes elements that could easily be characterised as research. If these activities and resultant quality improvement efforts are now regarded as research, their progress may be impeded. It should be considered unethical not to act on established evidence. It would be dangerous to label as research surveillance and QA activities that are designed to ensure implementation of such evidence, even if they fall within the broad definition of research. Patient privacy and confidentiality must be managed within a transparent regulatory framework without impeding safety mechanisms with research frameworks that would inevitably lead to delays and increased costs, as well as seriously discouraging staff from implementing them. These effects are well documented overseas where the enactment of similar privacy rules relating to the use of patient information has resulted in detrimental unintended consequences.3,4 Work undertaken to discover new and better evidence needs to be regarded as research, not work to ensure that established evidence-based practice is properly implemented. Herein lies the difference. Although the National Health and Medical Research Council (NHMRC) provides advisory guidelines,5,6 the proposed privacy (health information) regulations to be developed by the Office of the Privacy Commissioner1 will provide the legal basis for the use of health information. The public benefit of QA activities with appropriate privacy management and regulation that avoids designation as research requires strenuous championing during development of the regulations to ensure continued improvement in patient safety.

Anthony P Morton · Susan E Smith · Peter R Croll · R Michael Whitby

To the Editor: In the 3 November 2008 issue of the Journal, Millar recommends against routine thromboprophylaxis in medical patients.1 The evidence base for clinical decision making regarding thromboprophylaxis in medical patients remains limited. Although its overall benefit may be low, the absolute benefit to the community is significant. As up to 40% of cases of venous thromboembolism (VTE) occur in patients recently hospitalised for medical illness,2-3 there is a significant burden of disease that justifies prophylaxis in patients at high risk of VTE. The challenge is to identify medical patients at greatest risk of VTE, and to provide appropriate pharmacological prophylaxis, but to avoid using prophylaxis in patients at lower risk of VTE. Millar states that aspirin is as effective as heparin, with reference to the Pulmonary Embolism Prevention (PEP) trial.4 However, the PEP trial compared aspirin with placebo, and many participants also received heparin — it did not compare aspirin with heparin. Participants were undergoing surgery for hip fracture, and none were medical patients. A reduction in the endpoint of fatal pulmonary embolus (PE) is difficult to demonstrate in trials where imaging is used to detect disease at an early stage. This prompts treatment of asymptomatic deep vein thrombosis and modifies the natural history, leading to low reported PE rates. Rather than recommend for or against routine thromboprophylaxis in medical patients, we advise that patients should have a VTE risk assessment and that appropriate prophylaxis should be given according to evidence-based guidelines such as those of the American College of Chest Physicians5 and the International Consensus Statement6 (which we have attempted to summarise and condense into a practical, pocket-sized booklet7).

John P Fletcher · Donald MacLellan · Harry Gibbs · Geoff Matthews

To the Editor: “What is the health service for?”1 In essence, this is a question of definition and ownership. What is the definition of quality health care and who decides how it is defined? Who are the recipients of health services, the funders, those who stand to lose or benefit from the way in which health care is delivered? The answer is citizens. When we define quality, we are making a value judgement; we are saying what it is about health care that we consider important and worthy of achieving. In a democratic society, we expect that the values of citizens will be reflected in the definition of health care quality. The United States Institute of Medicine initiative, “Crossing the quality chasm”, emphasises “patient-centered(ness)” and care “customized according to patient needs and values” as system attributes for delivering quality health care to individuals.2 Yet, a broader perspective is suggested in the following statement on the objectives of health care systems from the World Health Organization: The objective of good health itself is really twofold: the best attainable average level — goodness — and the smallest feasible differences among individuals and groups — fairness. Goodness means a health system responding well to what people expect of it; fairness means it responds equally well to everyone, without discrimination.3 Implicit in both definitions is knowing what people expect, need and want from their health service. What do Australians expect, need and want from their health service at an individual, local and national level? How can we engage citizens effectively to answer these questions? We need a process of informed public consultation, a process that is constructive, efficient and representative, to guide the vision and values that form the basis of our health system. Menadue highlights the Canadian Romanow-led Royal Commission as an example of community engagement.1 A similar initiative underlies the United Kingdom’s “Our NHS [National Health Service] our future”, where a process involving consumer consultation has been employed at all levels of health care reform and in the development of an “NHS Constitution”.4 Mooney suggests “citizens’ juries” and a “National Citizens’ Summit”.5 Whatever our Australian national solution, as key stakeholders in the health system, as its patients and its health workforce, citizens need to be given a genuine opportunity to influence and contribute to the future direction of Australian health care.

Amanda E James

To the Editor: Wills and Coory emphasise maternal smoking as a risk factor for preterm birth and low birthweight, with exaggerated effects apparent in Indigenous women.1 They suggest that governments have a responsibility to ensure that interventions are offered to help women quit. Unfortunately, there are adverse effects of smoking cessation that mitigate the gains of cessation and introduce a caveat to that otherwise laudable motive. It has been shown that young women who cease smoking almost always gain significant weight.2 The fall in smoking rates in women over the past 20 years appears to have been in inverse proportion to the rise in rates of obesity in pregnancy, suggesting a possible relationship. The adverse maternal and fetal effects of overweight and obesity in pregnancy have been confirmed in numerous studies,3-5 and equal or exceed those of smoking. Typical odds ratios (ORs) from the literature3-6 are shown below. Maternal overweight (body mass index [BMI], 25–30 kg/m2) and obesity (BMI, > 30 kg/m2) are associated with significant increases in pre-eclampsia (OR for overweight, 1.8; OR for obese, 3.0), gestational diabetes (1.8; 3.2), macrosomia (1.6; 2.4), shoulder dystocia (2.9 for obese), obstructed labour, caesarean delivery (1.5; 2.0), postpartum haemorrhage (1.2; 1.5), wound infection (1.3; 2.2), venous thromboembolism (1.3; 2.8) and maternal death. Further, overweight and obesity are also associated with increased rates of infertility, fetal abnormality (OR, 1.3–3.5), miscarriage (1.2–3.0), stillbirth (1.5; 2.0), admission to neonatal intensive care (1.2; 1.4) and neonatal death (1.6–2.7 for obese). In addition, the adverse effects of excessive weight gain during pregnancy are very similar to those detailed above.7 The long-term effects on the offspring of women who were obese in pregnancy (increased rates of obesity, diabetes and components of the metabolic syndrome) are well documented,8 and at least equal in severity to the consequences for the children of smokers. What then should we do? Should we condone smoking during pregnancy? No one would agree. Ideally, women should never start smoking, or they should give up without gaining weight, but these are elusive aims. At the very least, the conscientious practitioner must provide weight-control counselling, referral to a dietitian and an exercise program lest the gains of smoking cessation be overwhelmed by the losses accompanying excess maternal weight gain, overweight and obesity in pregnancy.

Barry N J Walters

To the Editor: Macneil and colleagues1 present evidence of how inadequate resourcing of acute kidney stone care for public patients in New South Wales is compromising their surgical outcomes compared with private patients. In our experience, the same difference exists elsewhere in Australia. Macneil and colleagues show how poorly planned, under-resourced and badly coordinated acute surgical services lead directly to adverse surgical outcomes. All too often, a lack of appropriate modern lasertripsy equipment, staff trained to operate it, or provision of adequate emergency theatre time leaves public patients languishing with a double-J stent (inserted as a temporising measure) for an extended period. Not treating stones definitively at presentation (in cases where surgery is appropriate) adds unnecessary morbidity and necessitates readmission, further compounding the inefficiencies of an already overstretched public system. Given such important findings, it is disappointing that the Journal chose only to publish Macneil’s study as a letter. The conclusions of this study should provide an impetus for addressing proper coordination and resourcing of surgical services in the public system throughout Australia.

Robert J Davies · R Denby Steele · John Kourambas

To the Editor: Access to timely, definitive management of kidney stones after initial short-term management in the New South Wales public hospital system has long been a source of frustration for urological surgeons and their patients. These patients will, for the most part, ultimately receive treatment that is successful. Although this may be reflected in final outcome data, the financial and personal costs associated with unacceptable delays between staged treatment episodes is unlikely to be documented. The assessment of kidney stone management by the Greater Metropolitan Clinical Taskforce reported by Macneil and colleagues highlights the types of problems that are endemic in NSW,1 and is based on strong input from clinicians who are not under pressure to manipulate data to give the most favourable assessment of the state of health care delivery. It has broader implications regarding appropriate and timely management of staged treatment of other acute conditions that require surgery — in particular, the treatment of urinary retention due to benign prostatic obstruction. Until now, the saving grace for the NSW Department of Health with respect to these issues has been a lack of resources and will to capture this information. Such information creates embarrassment regarding an inadequately resourced and organised approach to the staged care of acute conditions requiring surgery. Inadequate basic access to kidney stone treatment in the public hospital system is just the “tip of the iceberg”, and is one of many examples of the substantial divide that exists between access to optimal health care in public versus private hospital systems. The real state of health in NSW has been spared from exposure by a lack of resources and will to define the true extent of problems. It seems unlikely that the problems that have been exposed in the public hospital system are isolated to NSW.

Henry H Woo · Michael P Wines

To the Editor: Critics of the proposal to legalise trade in kidneys have pointed out the low rates of renal transplantation in Australia compared with the United States,1 where the trade in organs is also illegal. However, it is unclear if the lower rate of renal transplantation in Australia is a result of a shortfall in transplants from living or deceased donors. First, I ranked renal transplantation rates in 2005 in US states and from Australia using the numbers of transplants from deceased and living donors from the United States Renal Data System (Beth Forrest, Coordinating Center, US Renal Data System, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md, personal communication), the Australia and New Zealand Dialysis and Transplant Registry,2 and populations from the US Census Bureau.3 In 2005, there were 12.1 per million population renal transplants from living donors in Australia. All of the states of the US except Oklahoma had higher rates of renal transplantation from the living, and the rate in Minnesota was four times higher. In contrast, the rate of renal transplantation from deceased donors in Australia was 18.6 per million population, which was higher than 24 American states and lower that 26 states and the District of Columbia. Some US states had twice the Australian rate of kidney donation from the deceased. I then used multiple linear regression to examine associations between rates of renal transplants from the deceased and rates of homicide, suicide and motor vehicle accident deaths in US states.4 Rates of renal transplantation from living donors were included as a covariable to control for differing degrees of development in US state transplant services. Homicide rates were associated with rates of transplants from the deceased (R = 0.607, R2 = 0.386; Box), but deaths from suicide and motor vehicle accidents were not. Hence, the higher rate of renal transplantation from deceased donors in the US appears to be the result of greater availability of organs from homicide victims. The high mortality and morbidity associated with endstage renal failure, despite renal dialysis treatment, suggests a need for new approaches to increasing the availability of donor kidneys. Assumed consent for organ donation might increase donation rates from the deceased, but this has been resisted in both Australia and the US on the grounds that failure to opt out might only indicate lack of forethought and not consent. While Australia continues with an opt-in system for deceased donation, measures to encourage live donation might have more realistic prospects of success than attempts to increase the rate of renal transplantation from the deceased.

Matthew M Large

To the Editor: A 60-year-old Hispanic woman, who had lived in the United States for 10 years, presented with a 1-day history of altered mental status. Physical examination revealed ascites and enlarged right axillary lymph nodes. Magnetic resonance imaging (MRI) of the brain showed multiple intracranial lesions (Box, A). Computed tomography of the chest and abdomen showed massive adenopathy in the right axilla, multiple nodules in upper lung fields, ascites and retroperitoneal adenopathy. Her cancer antigen (CA) 125 level was 1469 U/mL (reference range, 0–35 U/mL); CA27.29 and CA19-9 levels were within the upper limit of the normal ranges. She was initially thought to have metastatic cancer of unknown primary site. However, a right axillary node biopsy revealed necrotising granulomas and no malignancy; an acid-fast bacteria (AFB) stain was negative. Ultrasound-guided retroperitoneal lymph node biopsy showed necrotising granulomas and no malignancy; an AFB stain was positive. We began investigations for disseminated tuberculosis (TB). A QuantiFERON-TB Gold test (Cellestis, Valencia, Calif, USA) and sputum and right axillary node cultures were positive for Mycobacterium tuberculosis; peritoneal and cerebrospinal fluid cultures were negative. Polymerase chain reaction (PCR) of samples of peritoneal fluid and from bronchoalveolar lavage was negative for M. tuberculosis DNA, but a sample from the retroperitoneal lymph node tested positive. The patient was started on four-drug therapy for TB and her condition progressively improved. Follow-up MRI of the brain 5 months later showed a decreased size of all intracranial lesions (Box, B), and her CA125 level was 84 U/mL. Peritoneal TB can mimic advanced ovarian cancer because of similarities in clinical signs and symptoms, such as ascites, abdominal pain and elevated CA125 levels.1 The association of peritoneal TB with high CA125 levels was first described in 1987.2 The positive predictive value of CA125 levels to detect malignancy is estimated at 60%, rising to 98% in postmenopausal women.3-4 In most reported cases of peritoneal TB, CA125 levels were below 500 U/mL; rarely, levels up to 1200 U/mL have been seen.1-4 Culture is of limited clinical usefulness, as results take up to 6 weeks. Although microscopy is rapid, cheap and highly specific, its sensitivity has been shown to be as low as 31% for extrapulmonary TB.5 PCR is of limited value in diagnosing peritoneal TB. Detecting M. tuberculosis DNA by PCR in ascitic fluid poses many challenges — differences in technique, contamination with other bacteria, and the variable number of acid-fast bacilli in samples have been shown to influence its reliability.4-5 Negative results from microscopy, culture and PCR should not distract from a diagnosis of TB. In the face of a growing international incidence of TB, it is important to consider this transmissible and treatable disease in the context of abdominal symptomatology, ascites and raised serum CA125 levels — especially in ethnic groups in which TB prevalence is high. Misdiagnosis or delayed diagnosis can lead to infertility, premature menopause and death. Magnetic resonance (MR) imaging of the brain before and after treatment A: B rain MR image showing multiple intracranial lesions involving the left cerebellum, left occipital lobe, left parietal lobe and corpus callosum. B: MR image of the brain 5 months post-treatment, showing a decrease in the size of all intracranial lesions.

Riad O El Fakih · Bassem M Chehab · Rami A Mortada · Maha Assi

To the Editor: Keogh and Clifton’s call for salt reduction in the food supply1 comes when the National Heart Foundation is telling doctors who treat patients with hypertension that they should “recommend low-salt and reduced-salt foods as part of a healthy eating pattern”.2 Humans evolved while eating foods that (with rare exceptions) are low in salt — fresh fruit, vegetables and nuts, supplemented sometimes with fresh meat, poultry or fish — and these foods are still abundant. Using cooking methods that conserve flavour and any of about 300 herbs and spices, they make delicious meals that are low in fat, saturated fat, sugar and salt. Keogh and Clifton’s point is that we need more processed foods that are low in salt. This could be brought about if all doctors prescribed low-salt diets for their patients with hypertension.2 The food industry could hardly fail to respond to an unprecedented demand from the 3.7 million hypertensive Australians who need low-salt foods. Low-salt foods (sodium ≤ 120 mg/100 g) are easy to prescribe, requiring neither a diet nor a dietitian. In Britain, “traffic light” labels identify them at a glance, with green lights for salt. Australian consumers wishing to identify them have to check the mandatory sodium figure in the nutrition information panel provided on all processed food packages for a value of 120 mg/100 g or less. Further information to help consumers identify low-salt foods is available on the SaltMatters website (http://www.saltmatters.org), and a comprehensive handbook for practitioners and motivated patients has also been published.3 A low-salt diet is also particularly important for patients with Ménière’s disorder, because sodium excretion < 50 mmol/day is “more effective and less troublesome than diuretics” for controlling their vertigo.4 This level of sodium excretion occurs when all meals are low in salt.5 The National Heart Foundation’s marginally easier limit of 65 mmol/day allows room for a small mistake or a reduced-salt food, but practitioners must remember that the “combination of diuretic treatment and low dietary salt intake may result in unacceptable volume depletion and hyponatraemia”.6 The National Heart Foundation recommends 24-hour urine sample collections for monitoring dietary compliance (see “Measuring Salt Intake” at the SaltMatters website).

Trevor C Beard

To the Editor: We read with great interest Drini and colleagues’ recent report of hepatosplenic T-cell lymphoma (HSTCL) associated with inflammatory bowel disease. The occurrence of this rare lymphoma is partly driving a move away from the use of combination thiopurine and anti-tumour necrosis factor alpha therapy. It is important to recognise that risk of HSTCL is not only associated with exposure to thiopurine drugs with or without infliximab. It is associated with immunocompromise in general, and also occurs de novo. Explaining relative risks to patients is never easy and needs to be balanced with the need for treatment in properly selected patients. Contrary to a comment by Drini and colleagues, HSTCL has been reported in association with exposure to adalimumab, another anti-tumour necrosis factor alpha agent.2 Two of these cases occurred in patients with prior exposure to thiopurines and infliximab, and the third occurred in a patient with rheumatoid arthritis who was not exposed to thiopurine or infliximab. There has been a recent spate of reports of HSTCL in patients with inflammatory bowel disease treated with immunomodulator therapy, but most HSTCL appears to occur in patients without exposure to immunosuppressants.3 Also, although cases predominantly occur in young men (under 22 years), HSTCL is not limited to the paediatric age group.3,4 The presentation also occurs in females, including during pregnancy. More generally, in patients with inflammatory bowel disease, treatment with thiopurines appears to increase the risk of lymphoma two- to fourfold.5 Assuming a fourfold increase in risk, this translates into one additional lymphoma per year for every 4357 patients treated with thiopurines at age 20–29 years.5 This should be compared with the lifetime attributable risk of death from any cancer due to a single abdominal computed tomography scan performed at the age of 20, which is in the order of 1 : 2000.6 Currently, it is difficult to completely disentangle the many different factors — including patient age; severity, duration and course of disease;7 type of immunosuppression; and exposure to radiation — when considering the risk of lymphoma in inflammatory bowel disease. However, in many patients with severe disease, this risk appears to be outweighed by the benefits of adequate medical control.

Daniel C Burger · Timothy H J Florin

To the Editor: The article by Outram and Nair on peer physical examination1 misses the point that consent by medical students for physical examination by their peers can never be freely given. It always contains elements of coercion. Ethics committees usually do not allow medical students to enter clinical trials run by staff, who at some point may be their assessors, because there may be subtle duress to participate. Even if consent for peer physical examination is sought by staff who will be neither assessors nor tutors of these students, non-consenting students are immediately apparent to their colleagues, creating peer pressure to participate. The emotionally vulnerable are the most likely to accede to this and the most likely to be distressed. It is unsafe to rely on all staff seeking consent and behaving appropriately at all times. In one Australian medical school, students were told that they all had to “bring their swimmers” to wear so that they could be examined by other students. The statement that peer physical examination “has high acceptability”1 is not supported by the cited literature, and it is not clear to whom it is highly acceptable. There are good arguments for learning physical examination skills on the healthy. If young bodies are needed for this, universities are full of students from other faculties, and medical schools are not so poor they cannot pay the small amounts of money valued by these students for their participation.

John E Marley

In reply: Marley states that consent for peer physical examination “always contains elements of coercion”. It could be argued that this applies equally to medical practice and research, as one can never be 100% sure that participants have not felt some coercion. The ethical imperative is to balance the issues, to gain the best outcome. The article by Nair and myself reviewed the literature, reported additional research in the main area where difficulties had been noted (culturally and linguistically diverse students) and, on the basis of that evidence, suggested best practice.1 Contrary to Marley’s assertion, the articles we reviewed do support high levels of acceptability: 98%,2 97%,3 and 94%,4 respectively. Marley’s statement that emotionally vulnerable students are most likely to accede to peer physical examination and then be distressed may sound correct, but there is no evidence for this. In our experience, medical students are assertive, including those from the minority groups surveyed. Although the cost of direct payment to non-medical university students acting as “models” may be relatively small, the process of recruitment, training and processing by overstretched academic staff has significant opportunity costs. Additionally, medical students acting as models have the opportunity to experience the patient’s perspective. We acknowledge some criticisms of the practice of peer physical examination. However, it is currently widely used and will continue to be. The intent of our article was to draw attention to unforeseen difficulties and to improve practice.

Suzanne Outram

In developing its first seven standards for implementation by all health service providers in Queensland, the Health Quality and Complaints Commission (HQCC)1 considered the questions raised by Brand and colleagues2 regarding health care standards. We believe that the HQCC standards fit the framework suggested by Brand et al in that they are regulated, the measures of processes and outcomes are quantitative, and the criteria used for their development are evidence-based. In seeking to minimise conceptual confusion, the HQCC has “regulated” existing clinical guidelines and health standards with the aim of improving the quality of health services by requiring providers to establish systems to monitor and report on key aspects of care. The standards address the following areas: Review of hospital-related deaths; Management of acute myocardial infarction on and following discharge; Surgical safety, including antibiotic prophylaxis, prevention of venous thromboembolism, and correct surgery; Hand hygiene; Credentialling and scope of clinical practice; Complaints management; and The duty of health providers to improve the quality of care. The HQCC is now establishing a responsive regulatory framework to monitor compliance with the requirement for all health service providers to implement and maintain quality improvement processes. Brand and colleagues are critical of initiatives that burden providers with data collection and potentially distract from efforts to improve quality.2 But we contend that, without collection, analysis and review of data, the capacity to improve quality is limited. Since July 2007, the HQCC has required all acute care facilities to regularly report against the standards. Our intention is not to make the HQCC into a data repository, but rather to ensure that providers have the ability and the motivation to measure and monitor their own performance. Nevertheless, as a consequence, a unique dataset has been created that reflects wide variation across the state. This approach aligns with the model of metaregulation (or enforced self-regulation) and triple-loop learning espoused by Healy and Braithwaite.3 Ultimately, the purpose of health care standards is to improve the quality of care and drive a culture of quality improvement. Although the HQCC designed its compliance framework to evaluate the impact of its standards on quality and culture of the health system over an extended period, there are already promising indications of a positive effect after only 12 months.

Teresa A Lynne

To the Editor: The article by Statham and colleagues raises important issues about the accuracy of diagnosis by primary eye care providers, with all professionals in the study recording a diagnostic accuracy rate of less than 50%.1 From the general practice perspective, the authors raise a number of important contributors — lack of equipment, ophthalmological expertise and time. Additional factors, such as undergraduate and postgraduate exposure, and targeted training in the diagnosis of sight-threatening acute eye conditions, are also crucial considerations. From a postgraduate point of view, the Royal Australian College of General Practitioners offers a comprehensive continuing professional development program to support broad-based GP training, including in eye disease.2 The Master of Medicine (GP) offered by the University of Queensland also includes a dedicated subject on primary eye care, with particular emphasis on sight-threatening presentations.3 The Division of General Practice in which one of the sites in the report by Statham and colleagues1 sits is currently working with that hospital’s Department of Ophthalmology to institute an education/continuing professional development reform program to better target hospital eye referrals from primary care (Shelley Kleinhans, Health Systems Improvement Program Manager, GPpartners [Brisbane North] Division of General Practice, personal communication). It is very important to describe accurately the dimension of missed diagnosis within primary care — the ensuing challenge is to address it by harnessing the significant momentum within the primary care community for quality improvement.

Claire L Jackson

To the Editor: Between 1997 and 2006, suicide rates fell in all mainland Australian states and territories.1 Despite a rise in the small-population jurisdictions of Tasmania (1997–2006)1 and an earlier rise in the Northern Territory (1981–2002),2 the overall unadjusted national suicide rate has fallen steadily, from 14.7 per 100 000 in 1997 to 9.06 per 100 000 in 2006, the year for which the most recent statistics are available. Trends in suicide occurrence are usually examined with reference to suicide rates. However, because there has been population growth in all parts of Australia, examination of the actual number of suicide deaths in each region is also useful to ascertain whether the demographic changes accompanying population growth can alter unadjusted suicide rates. Annual suicide mortality statistics by state and territory from 1975 to 20061,3,4 show that the number of suicides peaked in every mainland state in 1997 or 1998. Since then, the number of suicides has fallen in New South Wales by 46.5%, in Victoria by 33.5% and in Queensland by 36.4% (Box). There has been larger variation in the number of suicides over time in NSW than in other states. Suicides in NSW rose from under 600 per year (approximately 11 per 100 000 population) in the early 1980s to a peak of 935 suicides in 1997 (14.9 per 100 000) and then fell to 504 suicides (7.4 per 100 000) in 2006. Data available to 2002 indicate that the decline in suicides occurred in almost every NSW health service area and was mainly due to a reduction in the number of suicide deaths in males, including young males.5 By 2006, NSW had the lowest suicide rate in Australia of 7.69 per 100 000 compared with 9.73 per 100 000 for other states and territories. The reasons for the steeper rise and subsequent fall in suicide in NSW compared with other states are unclear, but warrant further investigation with a combined clinical and epidemiological approach. The decline in suicide in NSW coincided with a change to the Mental Health Act 1990 in 1997 that broadened criteria for involuntary care and allowed more people to be treated. However, this factor alone would not explain the extent of the decrease nor the continued decline over a decade. It is possible that programs to prevent suicide or measures to improve access to psychiatric care in NSW have been more successful than those in other parts of Australia. Annual number of suicides in Australian states and territories, 1975–2006* * Data are from the Australian Bureau of Statistics.1,3,4

Matthew M Large · Olav B Nielssen · Steven M Lackersteen

To the Editor: We evaluated follow-up by SMS (short message service) text messaging of contacts of a patient with meningococcal disease. An 18-year-old woman from south-western Sydney was diagnosed with invasive meningococcal disease in July 2008 after presenting to hospital with a rash that appeared after a 2-day prodromal illness. The Sydney South West Public Health Unit identified the patient’s household and similar contacts, and arranged for these individuals to be treated with clearance antibiotics. The patient had visited a bar with friends 3 days before symptom onset. The extent of contact with people in this social network did not warrant treating them with clearance antibiotics. However, it was appropriate to warn them about meningococcal disease as recommended by national guidelines.1 A list of mobile phone numbers of 14 people who visited the bar with the patient was compiled by one of her friends. A text message was sent 2 days after the patient’s diagnosis to everyone on the list via a broadcast messaging service: Message from public health. A friend of yours has meningococcal disease. Watch out for symptoms. Please read the fact sheet at http://www.health.nsw.gov.au/factsheets/infectious/meningococcal.html or call 9515 9420. The message sender appeared as “SMS4U”. Two weeks later, one of us (J E C) made up to three attempts to telephone each of the contacts, explaining that this was a follow-up about a text message they may have received from the Public Health Unit. Contacts were asked whether or not they remembered receiving the message, had viewed the website, and found the information helpful. Twelve were contacted (six men, six women; age range, 18–24 years); all remembered receiving the message, nine looked at the website, and 11 found the message helpful. All were happy to receive the information this way. Some knew of their friend’s illness through other social contacts. This is the first time we have used SMS to communicate information to social contacts of a patient with meningococcal disease. To our knowledge, this is the first reported use of SMS for this purpose, although email and the Internet have been used previously.2 SMS communication appeared highly acceptable to these young people and provided useful information, but it may be less useful in other age groups. SMS has been used successfully in other health contexts — appointment and vaccination reminders3,4 and diabetes education.5 It enables delivery of a concise, timely and consistent message that can easily be broadcast to large groups. There are potential pitfalls: limited information can be conveyed; there is uncertainty regarding whether the message is received (the broadcast service we used provided a “successful send” receipt but not a “message opened” receipt); those without mobile phones cannot be contacted; those without Internet access cannot access web-based resources; and some recipients may not understand the message. The authority of a message from SMS4U (the only available option) was also of concern. We did not exploit the capability of forwarding an SMS message and, by doing so, “snowballing” the information. This could be valuable for alerting large contact networks. Our study was small, and we recommend further evaluation of SMS communication in larger groups.

Johanne E Cochrane · Chris Lowbridge · Patrick Maywood · Stephen J Conaty

To the Editor: We concur with Aratchige and colleagues that mumps in young adults is a “forgotten” disease,1 and believe that mumps control in Australia has suffered from both the successes and failures of our measles elimination program. Among residents of Sydney’s eastern and southern suburbs, 100 cases of mumps were notified in the second half of 2007. Sixty-three per cent of those who contracted the disease were aged 20–29 years, and 65% were male. This compares with an average of 13.6 cases (range, 4–32 cases) notified per annum from 1999 to 2006. During the second half of 2007, one institution managed three cases of severe orchitis in men aged 25–29 years whose diagnosis was confirmed by a positive mumps IgM test. In all three, initial fever and transient parotitis were followed after 7–10 days by severe testicular pain and swelling. Fever and testicular pain continued for a further 1–2 weeks, precluding their return to work. None had been vaccinated. Although mumps vaccine was introduced in Australia in 1980, mumps control has not been an explicit priority compared with measles.2 It seems that public health authorities in industrialised countries have assumed that measles control efforts based on two doses of the measles–mumps–rubella (MMR) vaccine would lead to simultaneous mumps control. While doubt has been cast over the effectiveness of this approach and raised the possibility of a three-dose schedule,3 we agree with the view of Schmid and colleagues that public health authorities should focus on adequate vaccination coverage and adherence to the recommended two-dose MMR vaccination scheme.4 The Australian birth cohort reported by Aratchige et al to have a dip in mumps immunity was the cohort born in the years 1978–1982.1 This group may have avoided natural measles (as well as mumps), missed the Measles Control Campaign in 1998 (which targeted primary-school children with MMR vaccine), and was subject to an ineffective national effort in 2001 to target young adults with MMR vaccine.2 At the time of the 2007 mumps outbreak, this cohort was aged 25–29 years and was the hardest hit. Concerted action to raise the level of two-dose coverage among young adults is urgently needed. Novel strategies exist for targeting this highly communication-aware age group through convergent Internet and mobile phone technologies. Social network sites such as MySpace and Facebook are heavily used by young people, and the proportion of mobile phones with Internet access is increasing. Sporting clubs and major entertainment events are another avenue to be considered with respect to both their physical and virtual locations (eg, posters at the clubs or events, advertisements on their websites). A comprehensive guide has recently been produced for Internet-based prevention of sexually transmitted diseases.5 It is well and truly time to adapt such methods to the promotion of MMR vaccination.

Mark J Ferson · Pam Konecny

To the Editor: The University of Sydney recently established a Chair of Radiology and appointed Professor Ming Wang as the first full Professor of Radiology in New South Wales. This long overdue appointment resulted from a bequest of Arthur Parker-Hughes, after whom the Chair is named. Likewise, it was largely through the generosity of Edgar John Rouse that the first university department of radiology in Australia was established at the University of Melbourne in 1965; I was appointed Foundation Professor. Considering the role of radiology in modern medicine, it is remarkable that to date in Australia, establishing Chairs of Radiology depends largely on private sponsorship. Soon after Roentgen’s discovery of x-rays in 1895, Scandinavian countries promoted the triad of medicine, surgery, and roentgenology, as it was then designated, as the basis of clinical management. Radiology departments were nurtured in their universities, and were leaders in research. European medical schools followed suit, and since about 1960, university radiology departments in the United States have been at the forefront of research. In Australia, university clinical departments developed relatively late, and, when they did, the Australian Universities Commission recognised the need to provide space and basic staffing for these new departments to achieve the desired academic standard.1 In recent decades, development of new university radiology departments has languished. Established in 1975, the radiology department at Flinders University closed in 2002. The radiology department at the University of Queensland began in 1977. Currently, medical schools rely on busy radiologists employed by teaching hospitals for academic input, and provide them with various adjunct titles. The range of diagnostic imaging modalities and interventional radiological procedures continues to expand, providing significant research opportunities. Medical science students should understand what is available, the benefits and limitations, inherent risks, and should appreciate the economic burden on the community from inappropriate use. Also, radiology provides an excellent means of teaching basic medical subjects, such as anatomy and pathology. Considering the importance of radiology in the health system, and how its academic status is recognised by leading overseas universities, surely it is reasonable that each medical school in Australia should include a department of radiology, or, at least, a full Professor of Radiology, financed primarily from within the university.

William S C Hare

To the Editor: The author of “High levels of confusion for cholesterol awareness campaigns”1 identifies my comment as the source of her perplexity. My remark, which Hall quotes in relation to the “Test the Nation” campaign, was actually given in response to a question about the Pfizer-sponsored “National Cholesterol Awareness Campaign”, which ran simultaneously. It seemed too inconsequential to request correction of the relevant newspaper article,2 because public health guidelines differ in regard to the target population for lipid testing. My comment reflected conservative Australian guidelines.3 It is well known that other sources recommend more widespread testing of adults.4 Hall’s confusion was a rhetorical device to justify her discussion of “condition branding” and to “explore the motivations” of the campaigns. Hall’s article attacks two programs that promote diet and lifestyle management of cardiovascular risk. It also criticises pharmacological treatment, thus eliminating all available options to address this important problem. The article undermines the tenuous availability in Australia of plant sterol-containing products, such as yoghurt, but provides no alternative strategies. It fails to take responsibility for its potential negative impact on the implementation of nutritional and other life-saving interventions. It is disconcerting that such a negative article has emanated from a so-called Centre for Health Initiatives. The cholesterol awareness campaigns are likened to “an unnecessary focus on an unimportant health problem” and disparagingly compared with a program devoted to public awareness of fungal nail infections. Understandably, the latter led to professional irritation and frustration. By contrast, the formal involvement of the Royal Australian College of General Practitioners in the Test the Nation–National Cholesterol Education Program of Australia (NCEPA) represents an effort to ensure that the initiative was justified, that the content was relevant, and that the logistics were attuned to primary care practice. The participation of professional organisations reinforced the quality, relevance and independence of the information provided. The dietary advice that was distributed by the NCEPA was widely acclaimed. Dyslipidaemia accounts for 49% of the attributable risk of coronary heart disease.4 Full implementation of risk factor guidelines could massively reduce cardiovascular disease,5 but public and professional adherence to guidelines is suboptimal.6 Chen and colleagues report that, in addition to those with diabetes or coronary heart disease, over 700 000 Australians are at high risk,7 but most Australians are unaware of the consequences. It seems extraordinary that anyone with a professed interest in public health could be so opposed to public education about risk factor management. Consequently, Hall’s article itself generates further confusion. The health sector is in the process of responding to calls for greater independence from commercial interests. Both cholesterol programs illustrate the implementation of many of the suggested changes. Unfortunately, Hall’s article suggests an open-ended list of demands that will be impossible to satisfy. Calls for further change need to be more constructive and clearly enunciate realistic proposals, supported by evidence that the net impact on Australian health care has been (or will be) beneficial. The article implies restrictions that would be impractical in other sectors. Standards for the interaction between industry and the health sector should be an example to emulate, rather than a soft target that loses step with normal practice.

David R Sullivan

In reply: My article1 was submitted for debate when two separate, industry-sponsored cholesterol awareness campaigns were simultaneously targeting the Australian public. There is potential for public confusion following exposure to concurrent campaigns with differing sponsors, creative techniques, and messages such as “Test the Nation”. My article did not diminish the importance of cholesterol screening (nor of the prevention of or treatment for hyperlipidaemia), and indeed it reiterated the National Heart Foundation guidelines. Its intent was to raise debate about industry-sponsored disease awareness campaigns, as there is growing concern in Australia about “disease mongering”2 and the evidence that this is occurring in the cholesterol market in the United States.3 I agree with Sullivan that the Australian public needs education about asymptomatic risk factors, including hypertension and hyperlipidaemia. Ideally, this would include clear information and non-emotive marketing techniques to convey who is most at risk, as well as transparent disclosure of sponsor interests.4 Contrary to Sullivan’s charge, I believe there are many opportunities for quality health education and behaviour change programs, several of which the Centre for Health Initiatives is currently undertaking.5 The intent of my article was to generate critical analysis of industry-sponsored campaigns in order to improve their public health benefit.

Danika V Hall

To the Editor: The recent article by Penington, highlighting the apparent neglect by Australian hospitals of actively participating in research over the past two decades,1 is both timely and concerning. During this time, many of our hospitals have seen themselves increasingly as clinical service providers, with teaching and research perceived as additional costs rather than contributions to their status, to the quality of patient care and to clinical and scientific discovery. My point is not simply to add weight to Penington’s eloquent historical, contemporary and strategic analysis of the nexus between hospitals and universities, but to explore areas that he touched on that need more detailed examination. I refer to the potential link between hospitals and community-based primary care. As Penington points out, “health care is increasingly provided outside hospitals”, yet this vital link between hospitals and primary care is often defunct, particularly when it comes to general practice. When Penington refers to hospitals working with “general practice networks” to meet the demands of an ageing population and chronic disease, we need to ask: which hospitals and which networks? In Melbourne, we have health networks that include groups of hospitals with extended primary care and community facilities and responsibilities. Driven by casemix funding, the hospitals or health networks have a vested interest in primary care to ensure short patient stays. However, not all states are the same and not all hospitals have similar links with the community. The other issue of concern is that general practice networks are often politicised and factionalised. Divisions of General Practice do not speak with a single voice, and their state-based organisations and national body do not always represent the views of regional Divisions. Added to the mix of 120 Divisions, we have 22 regional general practice training providers, the colleges (Royal Australian College of General Practitioners, Australian College of Rural and Remote Medicine), the Rural Doctors Association, the Australian Association for Academic General Practice, the Australian Medical Association, etc. Integration of the research, teaching and training activities of general practice or primary health care with hospital networks can only be achieved at a regional level. We need to think globally, but act regionally. This calls for the formation of new regional consortia including universities, health networks (hospitals), Divisions and regional training providers (responsible for general practice registrar training) to work together on national clinical and health service research agendas in large and well defined geographic regions. If the National Health and Hospitals Reform Commission is to take its role seriously, it will need to move beyond the confines of traditional hospital settings and explore opportunities in the community.

Leon Piterman

To the Editor: Penington identifies the appointment of a National Health and Hospitals Reform Commission (NHHRC) and the suspension of 5-year Australian Health Care Agreements as a “once in a generation” opportunity to rediscover university teaching hospitals for Australia.1 He identifies changes to health funding in Australia since 1975, the growth of “cost shifting” between federal and state governments, and reduced funding for university functions in hospitals as important contributors to the decline of university teaching hospitals in Australia.1 We agree with this analysis, but propose that the privatisation of many outpatient clinics as a result of cost shifting has had a disastrous effect on the clinical training of medical students, residents and registrars. Moreover, the reduced funding of university functions in hospitals has been replaced in “teaching” and community hospitals by industry funding, and the perception that industry has “bought” patients for their “research” agenda by providing data management services through per capita payments and gifts or perks for clinicians. The infrastructure sustaining clinical research should not be so reliant on industry. Funding from the federal government (in partnership with state governments) is needed to nurture independent research in university teaching hospitals. Penington highlights the fact that the key element of the university teaching hospital model was leadership of all units by academic clinicians with questioning minds. Since 1975, we believe leadership of units in “teaching” hospitals has changed such that very few are now led by academic clinicians. We recently experienced a lack of interest by medical specialists in supporting clinical research that had been approved and funded by the National Health and Medical Research Council (NHMRC). The project will evaluate doctor–patient communication about treatment options in oncology, including clinical trials. Participating doctors were required to post letters of invitation to patients and audio-record one consultation per patient recruited (20 per doctor). Specialists in all major teaching hospitals in New South Wales and Victoria were contacted; 17 of 41 specialists contacted in NSW (41%) and 15 of 52 contacted in Victoria (29%) have agreed to participate. The most common reasons doctors gave for not participating was that they were too busy or that there was no reward for participation. It is notable that no specialist from two major teaching hospitals — one in Sydney (3 contacted) and one in Melbourne (6 contacted) — agreed to participate. A concerning theme is that the motivation to participate in trials is driven by financial incentives rather than the importance of the question being addressed or interest in supporting novel investigator-initiated clinical research. A starting point for improving the quantum and calibre of “independent” clinical research in university teaching hospitals would be to support clinical research infrastructure by providing per capita payments for recruited patients — a model used by industry. Rebuilding independent research capacity in university hospitals will improve the standard of research in this country, and foster clinical research training. We believe reviving the university teaching hospital model in Australia is an important task for the NHHRC.

Rachel F Dear · Martin H N Tattersall

To the Editor: A causal connection between alcoholic mothers and developmental delays and physical abnormalities in their babies was identified in the 1970s and termed fetal alcohol syndrome (FAS). Other less extreme but still disabling effects fall under the umbrella term of fetal alcohol spectrum disorder (FASD).1 Some studies have found higher prevalences of FAS among indigenous children in several countries, including Australia.2-4 However, none are as high as those cited in a webcast video program produced by the Rural Health Education Foundation and accredited by (and examinable for professional development points awarded by) the Royal Australian College of General Practitioners, Australian College of Rural and Remote Medicine, Pharmaceutical Society of Australia, Royal College of Nursing Australia, and the Australian Physiotherapy Association.5 In this program, an Indigenous Australian health worker states that 540 out of 614 children aged under 12 in an (unnamed) Indigenous community are “already showing signs of primary and secondary disabilities associated with FAS and FASD”.5 These findings are not sourced and therefore not verifiable. We believe that unsubstantiated claims such as this can fuel racism against Indigenous children. Research conducted within a Queensland Aboriginal community school found that teachers were using information such as that provided in the video program to explain students’ poor school performances, when no formal diagnoses of FASD had been made for the children.6 It is racially discriminatory to impute a lifelong and incurable disability to Indigenous children when no teratogenic condition has been diagnosed. The prevalence of FAS and FASD has not been comprehensively established in Indigenous or non-Indigenous communities in Australia. There are other reasons why Indigenous students might not be succeeding in school, such as hearing impairments, being taught in Standard English (which is not their first language), or being assessed with culturally and linguistically biased school and IQ tests.6,7 Stigmatising them as intellectually impaired can lead to low self-esteem, behavioural problems, and absences from school. These outcomes have been noted here and overseas,7 yet some educationalists persist in blaming prenatal factors (including “bad genes”) rather than addressing the more difficult issues of systemic racism in the educational setting. In light of the federal government’s campaign to protect Indigenous children and to encourage their educational potential, as well as its general attack on binge drinking, it is essential to fund programs that address FAS and FASD in both Indigenous and non-Indigenous communities. Further, all governments need to support the dissemination of clear and substantiated information on this preventable cause of intellectual impairment.

Loretta R de Plevitz · Judith S Gould · Terrina M Smith

In reply: The Rural Health Education Foundation is sorry that a statement on its live-to-air, interactive program was interpreted as being racist. We can see how this has occurred and have added an addendum to the program’s website description to avoid any future misinterpretation of what the presenter was intending to communicate.1 The research on fetal alcohol spectrum disorder (FASD) quoted in the Foundation’s program by an Australian Aboriginal health worker is currently unpublished, and was undertaken in 2000 during a fieldwork placement as a requirement for a Master of Applied Epidemiology (Indigenous Health).2 This research identified that 540 out of 614 children aged under 12 in an (unnamed) Indigenous community had prenatal exposure to alcohol that exceeded the National Health and Medical Research Council (NHMRC) recommendations on alcohol consumption during pregnancy,3 and were subsequently at risk of primary and secondary disabilities associated with fetal alcohol syndrome (FAS) and FASD. During the program’s live discussion, the panel member incorrectly stated that the research cohort was already showing signs of primary and secondary disability related to FAS and FASD. Two individual projects within the Masters research contributed to the findings. The first, examining the risks of maternal alcohol use for child physical and psychological development, involved retrospective, longitudinal analysis of a data subset from an existing study over a 5-year period of 8556 women who received antenatal care, with subsequent follow-up of the mothers and their children when the children were 5 years old. The second was a descriptive study involving all women in the (unnamed) Indigenous community who gave birth within a 5-year period immediately before the research. Medical record audit and focus groups (talking circles) were conducted. This research is currently being expanded in the context of PhD studies, and the candidate intends to submit the new findings for publication in the near future. The video program content was developed in consultation with a group of health professionals with expertise in the area of Australian Indigenous health and FASD. At all times, the Rural Health Education Foundation seeks to provide positive examples of “what works” in its location-based filmed case studies. The Foundation and its representatives in no way meant to infer racism or discriminate against this (or any other) group of Indigenous Australians.

Brian D Bowring · Amanda Little

To the Editor: The randomised controlled trial recently reported by Blashki and colleagues does not support their hypothesis.1 The drop-out rates in both arms of the trial were very high — only 62% of general practitioners in the intervention group and 54% in the control group completed the trial. One cannot have any confidence in their conclusion that a short training course can improve GP skills in the provision of cognitive behavioural strategies (CBS). For example, what if the 38% of GPs in the intervention group who dropped out actually deteriorated in their CBS skills and therefore declined to be videotaped? Furthermore, only 56 of 1021 GPs in Victoria were willing to enrol in the trial. The authors concluded that their findings could only be applied to GPs who have a special interest in mental health. Perhaps the low participation rate indicates another more relevant idea — that GPs have had enough of “training models” being imposed on their lives. A recent systematic review has confirmed the low impact that educational training programs have on GPs for the management of mental health problems.2

Marjan Kljakovic