Letters

To the Editor: More than 2000 graduates of South African medical schools have migrated to Australia since 1948. Unlike many immigrants from Europe before and after World War II, all were fluent in English and most were able to start practising almost immediately. In chronicling this unique migration and its contribution to Australian health care, I am trying to contact, by email, as many as possible of the 1800 South African doctors now practising here, as well as surviving spouses or children of the 100 or so who have died since arrival. As a 1961 graduate of the University of the Witwatersrand in Johannesburg, I have a particular personal interest in this migration. Assisted by a sociologist and a statistician, I have prepared an email questionnaire. Responses will be de-identified before analysis. I would be grateful if graduates of South African medical schools would contact me by email.

Peter C Arnold

To the Editor: Although there are data on the population needs for residential aged-care facilities (RACFs)1 and models of engagement by general practitioners once someone is resident in a facility,2-4 there are ongoing administrative barriers for people trying to secure a place in an RACF. The aim of requesting data before admission is to provide continuity and quality of care, but the burden of paperwork currently falling on family members and GPs is of concern. We initiated an audit when it became apparent that local acute public and private hospital inpatient units had a policy of insisting that once an inpatient was eligible for RACF residency, he or she was required to be placed on waiting lists for 8–10 different RACFs. As part of a broader project to coordinate better care at times of transition, all RACFs in southern Adelaide (feeder population 400 000) were approached to provide us with the forms that need to be completed before someone can be placed on their waiting list. All 22 facilities in southern Adelaide provided a copy of the application pack that they normally give to a family member. A median of 4.5 forms had to be completed before a person could be placed on a waiting list (range, 0–13). The most frequently requested forms were an Aged Care Assessment Team form (17 facilities), an application form (15 facilities), a medical history form (12 facilities), and an assets declaration (9 facilities). One RACF required direct debit payment forms to be filled out before considering an application, and another required documentary evidence of funeral arrangements. By contrast, four RACFs required no forms at all. GPs were responsible for the medical history form. This form was unique to each RACF, with the result that similar data had to be provided multiple times in different formats. GPs were also potentially required to witness several other forms for each different application. There is an inherent challenge in balancing the need to run a financially viable RACF and provide best care from the moment a resident arrives with minimising the paperwork that frail spouses or busy family members are often expected to generate or replicate for many facilities simultaneously. These forms, most of which will never be used, create a burden on family members at an already stressful time. An agreed national industry standard for an Aged Care Assessment Team form, an assets form and a medical history form (to be filled out once by a GP) would ease stress at arguably one of the more difficult transitions any person and his or her family can face.

Aine G Greene · Bernadette Kenny · David C Currow

To the Editor: In the January issue of the Journal, Harvey et al raised some serious concerns about the listing system for complementary medicines.1 In particular, they suggest scrapping the listing system (AUST L) and requiring complementary medicine (CM) products to be evaluated by the Therapeutic Goods Administration (TGA) for efficacy. Scrapping the system would be a significant setback for natural medicines, which have an important role to play in the health system. Such a move would be likely to remove products from the market, while the problem outlined by Harvey et al is more about the claims made for products rather than the products themselves. Certain CM products play a valuable role in many chronic diseases, in situations where existing synthetic products are often lacking. The regulatory system should encourage evidence-based CM products, and appropriate sanctions and enforcement should downgrade the claims made on products that don’t have a specific evidence base. CMs, especially herbal medicines, are complex products with numerous biologically active components. This means that the evidence is specific to the product and cannot be extrapolated. This fact has two important consequences for practitioners and the health system as a whole: the “generic” concept of synthetic pharmaceuticals (eg, interchangeability of paracetamol-containing products) is invalid for CM, meaning that a prescription for “St John’s wort” for example is not reliable, as St John’s wort is not one substance; and meta-analyses and systematic reviews of a “substance” (eg, a herb, or glucosamine) are easily misinterpreted because the products made from that “substance” are so different, any conclusions drawn can only be applied to the particular products that have been trialled.2 While the health system fails to discriminate between products that have specific trial evidence and those that do not, practising evidence-based complementary medicine will remain difficult. Encouraging evidence-based use of CM products, including supporting specifically clinically proven products, will lead to further research and better integration of CM into our health system for the benefit of the Australian public.

Nigel A Pollard

To the Editor: I am writing in response to the recent article by Harvey and colleagues about complementary medicines in Australia.1 Rottapharm is the developer and manufacturer of DONA glucosamine, a patented form of glucosamine. DONA is a registered medicine in 54 countries, in many on the equivalent of the Pharmaceutical Benefits Scheme. DONA is the leading glucosamine product in the world measured by specific trial evidence, sales and registration approvals. The fundamental issue is that different products that contain glucosamine and other complementary medicine (CM) products should be considered to be distinct products. Standards of active ingredients and methods of manufacture of finished products are substantially different between companies. Specific clinical trial evidence for glucosamine is essential because of: formulation differences (DONA glucosamine is a patented formulation of crystalline glucosamine sulfate, which is not comparable with glucosamine hydrochloride or other glucosamine sulfate formulations); bioavailability of glucosamine sulfate (unlike all other formulations on the Australian market, DONA has proven plasma concentrations and synovial fluid levels consistent with a clinical effect at a dosage of 1500 mg once a day, and is the only glucosamine product available with proven human bioavailability and pharmacokinetics);2 and results of specific clinical trials (studies of non-DONA glucosamine products [unknown formulations] have had mixed results while DONA has shown consistent efficacy across all trials, and has been assigned level 1A evidence by the European League Against Rheumatism).2-6 Not requiring sponsors to have evidence to support claims made about their products encourages low quality. For example, the market-leading glucosamine products in Australia have not been subject to independent peer review to establish whether they are effective. As the claims allowed on such products are identical to the claims allowed on DONA, there is no incentive for the industry to source the “real thing” or conduct their own clinical trials. In the interests of their patients, we believe that health professionals have a right to be able to identify specific products that have been clinically proven. Use of CMs that is not evidence-based is likely to lead to failure to realise significant health benefits of CM for the Australian public.

Antonino Santoro

To the Editor: The article by Harvey et al raises important concerns about the complementary medicine (CM) industry, particularly with respect to inappropriate marketing and advertising by some sponsors.1 The role of the Therapeutic Goods Administration (TGA) in setting standards and regulation of CMs should not be taken lightly. Australia has one of the highest quality standards for CMs internationally. Many CM products in Australia are assessed by expert authorities within the Office of Complementary Medicines and the Complementary Medicines Evaluation Committee of the TGA for safety and (where appropriate) efficacy relating to claims made for products.2 This is not fully appreciated by the authors. While many CMs may lack high-quality research to validate efficacy, this does not necessarily mean they are not clinically effective. Many clinicians and consumers find CMs to be of clinical value in improving health status. By suggesting that “the listing system should be scrapped, and CAMs [complementary and alternative medicines] . . . be assessed for efficacy and delisted if evidence is lacking” would be to deny consumers choice of treatment and potential health benefits, and lead to a “black market” or buying products from overseas which may not compare in quality. The authors fail to acknowledge that much of the drive for CM sales is actually coming from consumers through their choice of health care treatment.3 Consumers have the right to trial CMs. It is our role to ascertain safety issues and encourage clinical trials where they are lacking. For thousands of years, populations have relied on some CMs for health benefits, not having the advantage of any trials, but relying solely on traditional use. If the risk of harm to human health from the use of a CM outweighs any proven or unproven efficacy, consideration should be given to delisting the product or restricting its use. More research is required to assess safety data and efficacy for CMs. Australia has come a long way in regulating CMs. To say the “listing system should be scrapped” does not appreciate the tremendous efforts and gains made by the TGA compared with international efforts to enforce good manufacturing practice and various methods to better safeguard consumers. The authors do raise a valid point in saying that sponsors should provide “key evidence supporting each indication of the ARTG [Australian Register of Therapeutic Goods] . . . [which] should be publicly available on the Internet”. This may be useful for consumers and health practitioners, but requires appropriate funding to be viable. Furthermore, codes of conduct and complaints procedures for CMs, such as through the Complaints Resolution Panel, need to be strengthened, particularly with respect to breaches in the advertising code.4 To date, the Parliamentary Secretary has asked the TGA for advice on the proposals put forward by Harvey and colleagues.1,5 The government will consider its response to these proposals in the context of taking forward legislative changes that were deferred in anticipation of the establishment of an Australian New Zealand Therapeutic Products Agency (TGA advice, 28 May 2008).

Vicki Kotsirilos

To the Editor: Harvey et al1 have a right to be concerned about the parlous state of regulation in the billion-dollar complementary medicine (CM) industry. They are not alone, with various leaders from CM doctor groups and other leaders also expressing concern.2,3 Predictably, those in the CM industry itself are denying any problems exist, and just repeat their mantra that their products are safe and effective.3 As business people, the leaders of the CM industry must be pleased with the unchallenged run they have had over the past 20 years (except for one challenge with the Pan Pharmaceuticals debacle4). Consider one company (Mannatech) whose multilevel marketed products are promoted by their associates (natural drug representatives) as useful for arthritis, diabetes, dementia, attention deficit hyperactivity disorder, Parkinson’s disease, asthma, cancer and various other chronic diseases. The associates promoted claims that a product, Ambrotose, would assist with the above conditions using literature that did not carry the company logo, and used the company literature for non-specific claims and testimonials, thus absolving the company of responsibility. The Therapeutic Goods Administration is helpless in such a situation, and it was only when a medical practitioner started selling Mannatech products, including Ambrotose, from his surgery that the state medical board took an interest.5 However, the medical board has no jurisdiction over the company, and when the doctor was deregistered, he would have been able to keep marketing the product for the company. Mannatech launched Ambrotose in Australia, quoting the benefits of their product from a trial conducted and published in the Journal of the American Nutraceutical Association by American immunologist Dr See and colleagues.6 Eighteen months later, the published trial was the subject of much controversy.7 There was little if any effect on the company from this, in stark contrast with what one would expect in the pharmaceutical industry. Yes, Harvey and colleagues are just starting to scratch the surface of controversies that are decades old in this unregulated industry. For the good of the public and for the good of the CM industry, there needs to be a watchdog, similar to Medicines Australia, to regulate CM.

C Scott Masters

In reply: We agree with Kotsirilos that the current listing process of the Therapeutic Goods Administration (TGA) provides some protection for consumers by ensuring that complementary medicines (CMs) are manufactured in accordance with good manufacturing practice. The TGA claims that about 25% of new listings are assessed in detail each year for compliance with requirements, including that sponsors must hold evidence to support promotional claims made.1 However, we understand that the TGA does not assess this evidence for quality, and that literature searches are not performed to see if more recent evidence2 contradicts that submitted by the sponsor.3 In addition, sponsors can make a conservative claim at the time of listing but then make very different claims in promotional campaigns. An under-resourced, laboriously slow and largely impotent complaint system provides little disincentive to such unethical (but profitable) behaviour. While the Medicines Australia code of conduct (for prescription medicines) still has room for improvement, we agree with Masters that it currently provides more effective sanctions for breaches (eg, fines up to $200 000) than the options currently available to the TGA. Medicines Australia also proactively monitors compliance with the code of conduct and provides useful annual reports.4 Regardless, claims for CM that cannot be substantiated by appropriate evidence are better dealt with at the time of a marketing application rather than many months after advertisements have been published and when consumers have long been misled. We also recommended that therapeutic equivalence of the product in question should also be assessed at this time; a point reiterated by Santoro and Pollard. We support the right of consumers to choose from a variety of therapeutic modalities offered in the market place. However, good decision making requires evidence-based information about risks and benefits, regardless of whether the medicine in question requires a prescription, can be obtained over the counter or is a CM. Even if the risks of CMs are relatively low, the financial and opportunity cost for consumers can be significant. A pragmatic compromise to delisting CMs that lack evidence of effectiveness would be an opt-in system, funded by an additional fee, that would independently evaluate the effectiveness of specific CM products. A product with reasonable evidence of effectiveness could be awarded a symbol similar to the the National Heart Foundation “red tick”. Implementing this measure, together with the disclaimer and other recommendations we made in our article,5 would assist consumer choice and provide a market advantage for the sponsors of evidence-based, ethically promoted CMs. These proposals have received support from health professional and consumer organisations as well as sections of the CM industry. They have been put to the Parliamentary Secretary who assists the Minister for Health and Ageing.3

Ken J Harvey · Viola S Korczak · Loretta J Marron · David B Newgreen

To the Editor: The recent article by de Crespigny and Savulescu1 is nominally about the medical care of pregnant women, but its ramifications extend more widely into power relations, law and ethics, and matters of life and death. The article is entirely adult-centred: its authors never hint that a doctor who is treating a pregnant woman has not one but two patients. There is never the faintest suggestion that the fetus is a separate human being with his or her own medical interests. The “research” reported is a survey of 20 obstetricians, who all agree with the authors on abortion for fetal abnormality. Unsurprisingly, most said they would prefer fewer constraints on such abortions. Which abnormalities are grounds for termination? The authors never say, although terminations are performed in Victoria for conditions as readily treatable as cleft lip.2 The authors cite an estimate that where Down syndrome is identified in Victoria, 95% of pregnancies are terminated. Yet people with Down syndrome do not appear to find their lives intolerable: is the misery we want to put Down syndrome children out of their misery, or their parents’? The authors insist that in Victoria, “uncertain laws compromise good prenatal care”. The prenatal care they seem to have in mind can hardly be called care of the child: can it be called care of the mother? In one of the cases cited, a woman at Melbourne’s Royal Women’s Hospital was threatening suicide unless her pregnancy was terminated after a diagnosis of dwarfism at 31 weeks.1 Instead of providing her with urgent psychiatric care (had they never encountered a suicidal patient before?), the doctors terminated her pregnancy. If she had demanded the amputation of her left arm, would they have called in the surgeons? The surgical mutilation of an adult patient would not have been considered for a moment, but the surgical killing of a fetal patient was an available and practised routine. This woman was already not well, and the “prenatal care” she received put her further at risk. This case illustrates how true prenatal care is compromised, not by the few remaining legal limits on child destruction and abortion, but by their ready availability. Readers of the literature on post-abortion syndrome will have encountered many other illustrations of what should be obvious: that you are not likely to help a woman by destroying her child. Experienced and attentive general practitioners and psychiatrists will be able to give their own examples. Doctors need to pay close attention to the short paragraph on conscientious objection.1 The authors declare that “a doctor’s conscience should not be allowed to interfere with medical care” and that if “some individuals or institutions have moral objections ... those objections cannot compromise patient care”. If that does not mean that the authors want to exclude anyone who disagrees with them about what constitutes “medical care” from medical practice, what does it mean? There could hardly be a plainer threat to doctors’ personal professional judgement.

Edward D Watt

To the Editor: Superficially, de Crespigny and Savulescu make a compelling case for clarifying late-term abortion law.1 However, at a deeper level, it is disappointing that alternative points of view were not discussed in their article. The only solution offered in the case of a potentially imperfect child is to abort the pregnancy and try again. Unfortunately, this ignores several important issues. First, the consequences of abortion for the mother, both physical and psychological, are neglected.2 Our experience, as general practitioners, is that late-term abortions only lead to heartache and regret, even depression and anxiety, as the mother tries to deal with what has happened to her. Every time she sees either a “normal” or an “abnormal” child, her loss is re-lived. A patient of one of us (S B G) has developed Asherman syndrome as a result of a late-term abortion; she is now infertile. Second, without a definition of “child”, any discussion regarding abortion law is, at best, futile; at worst, it is emotionally charged and reliant on anecdotes. If a fetus is defined as a child, then that child has a right to live, whatever the disability. If not, then any disability up to the defined age could potentially justify “abortion” (ie, destruction). Third, the references given to support the assertion that women might “refuse to consider motherhood” without genetic testing described women who carry germline monogenic abnormalities (eg, thalassaemias, Huntington genotypes). These women would be eligible for earlier antenatal screening, such as pre-implantation genetic diagnosis, amniocentesis and chorionic villus sampling — all of which are available well before the current legal time frames in question. Fourth, de Crespigny and Savulescu’s premise for allowing late-term abortion is that there is a life-threatening fetal abnormality and the mother wishes to have children. However, a consequence of liberalising the law for the benefit of these women would be that women with non-life-threatening fetal abnormalities, and also those who simply did not want a child, could also access late-term abortion more easily. This is obviously a major concern. Finally, use of the term “child destruction” in the law is important when considering these situations. A helpful definition of the purpose of the law is to prevent injustice.3 As seen by the ability for women to access “legal” abortion before 20 weeks’ gestation, any law that protects children needs to stand. The pregnant woman clearly has a voice; unfortunately, the unborn child does not have the same ability to state his or her case before an ethics committee.

Simon B Gerber · John T Wenham

In reply: Watt seems to wish to return to the days of no prenatal testing; we believe today’s women reject this paternalistic view. However, Watt is correct in saying our article is “adult-centred” — it is not self-evident that the fetus is a patient, nor is this view consistent with those of most liberal legal jurisdictions. It has been found that 81% of Australians,1 including a majority in all major Australian religious groups,2 agree with a woman’s right to choose an abortion. Only 4% of Australians consider abortion wrong.3 We echo Amnesty International’s call for abortion to be decriminalised globally.4 Abortion laws should no longer discriminate against pregnant women with fetal abnormalities. Contrary to Watt’s claims, it is well documented that an experienced psychiatrist was central in managing the pregnant woman who had an abortion at 32 weeks at the Royal Women’s Hospital. In addition, we do not believe abortion has been demonstrated to cause psychiatric “post-abortion syndrome”,5,6 nor that abortion is analogous to amputating a healthy limb. We do not challenge doctors’ personal judgements. All individuals must be free to make their own value judgements for their own lives, including doctors. However, doctors have a duty to inform patients of all appropriate treatments. When a patient requests abortion and the doctor has a moral objection to providing it, the doctor must refer the patient to another practitioner.5 Contrary to Gerber and Wenham’s claims, we did not suggest that “to abort the pregnancy and try again” is the only option for fetal abnormality. Abortion — or continuing the pregnancy — must be the woman’s decision. One of us (L J d C) has 30 years’ experience of prenatal testing, including treating many women after terminations for fetal abnormality. Such women are sad about the diagnosis and outcome, extremely worried during subsequent pregnancies, and regret having had to make an awful decision. However, none have said that they made the wrong decision. Regarding Gerber and Wenham’s comments about the definition of “child”, our position is that (before birth) the fetus does not have the rights of a child.7 The data we cited show that prenatal testing for Huntington disease “allows” at-risk women, who might otherwise choose not to conceive, to have children. Personal experience (of L J d C) shows that women with a past history of other serious fetal disorders are no different. We did not suggest that late abortion should be available only in cases of life-threatening fetal abnormality. Indeed, our article clearly related to “pregnant women with fetal abnormalities” (not necessarily life-threatening). The claim that women would request late abortion simply because they don’t want a child demeans women’s integrity. We need clear abortion laws so that pregnant women and their doctors can know when abortion is lawful. Developing clear laws necessitates removing the crime of child destruction.8

Lachlan J de Crespigny · Julian Savulescu

To the Editor: We believe that Tang and Nordin1 misunderstood the findings of our recent study of calcium supplementation.2 We disagree with their claim that the increase in the number of women with self- or family-reported myocardial infarction, stroke or sudden death became non-significant after adjustment for covariables. They correctly noted that the increased number of women experiencing the composite endpoint of cardiovascular events (after adjudication of events and inclusion of unreported events from hospital records) was not statistically significant. However, the increased event rate for this composite endpoint with calcium was statistically significant (rate ratio, 1.43; 95% CI, 1.01–2.04; P = 0.043). Thus, in our study, the number of women needed to treat with calcium for 5 years to cause one cardiovascular event was 29, and the corresponding number to prevent one fracture was 50.2 Tang and Nordin then meta-analysed data from five studies of calcium and vitamin D supplementation to conclude that calcium supplementation does not increase mortality.1 We disagree. For one of the studies, they classified a subgroup of participants who received annual vitamin D but no calcium supplements as having received “calcium supplementation”.3 Further, for the RECORD (Randomised Evaluation of Calcium Or vitamin D) study, they compared the number of deaths between people receiving and not receiving vitamin D (16.5% v 17.4%) rather than between those receiving and not receiving calcium (17.7% v 16.2%).4 The trend for increased deaths with calcium supplementation in RECORD was greater when analysis was restricted to those treated with calcium monotherapy (18.5%) and placebo (16.3%). As our study was of calcium monotherapy, the results of Tang and Nordin’s meta-analysis are of questionable relevance to our findings. In addition, ours was a 5-year study, and the differences in vascular events between the groups only emerged after 2 years.2 Only one study in Tang and Nordin’s meta-analysis had an average follow-up duration of more than 25 months.4 Further, there is evidence from other studies of trends towards vascular events occurring more frequently in people who take calcium monotherapy.2,5,6 In three out of four studies that reported mortality, there were trends towards increased death rates in people receiving calcium.2,4-6 As we concluded,2 these data are not definitive, but flag cardiac health as an area of concern in relation to calcium use. Finally, we did not suggest that calcium supplementation should not be given to older women. However, in view of the evidence that any fracture risk reduction with calcium is small (< 10%),7,8 and the suggestions that calcium supplementation might increase the risk of hip fractures9-11 and vascular events, it seems reasonable and timely to reassess the role of calcium supplementation.

Mark J Bolland · Andrew B Grey · Ian R Reid

In reply: In Table 5 of Bolland and colleagues’ study, the P value after allowing for covariables was 0.08,1 which is not significant. This was without including smoking, which would undoubtedly have reduced the significance further as there were more smokers in the calcium group. Based on Bolland and colleagues’ suggestion, we reanalysed the data by removing the group receiving vitamin D but no calcium supplements in the NoNOF (Nottingham Neck of Femur) study,2 and using data for those treated with calcium monotherapy (18.5%) compared to placebo (16.3%) in the RECORD (Randomised Evaluation of Calcium Or vitamin D) study.3 The reanalysis still failed to show any evidence of an increase in mortality (relative risk, 1.05; 95% CI, 0.88–1.26; P = 0.56).

Benjamin M P Tang · B E Christopher Nordin

To the Editor: My attention was drawn to the Snapshot of an apical lung hernia published in the Journal last year.1 Persons with emphysematous hypertrophic lungs are often found to have clinically discernible supraclavicular swellings (Box). The finding of these swellings is a surprisingly common sign that is little remarked upon in clinical descriptions. These swellings are the bullous expansions of the apices of the lungs. Supraclavicular swelling in patients with emphysematous hypertrophic lungs A woman (A) and a man (B) with visible supraclavicular swellings.

George R Crowe

To the Editor: The Rural Doctors Association (RDA) of New South Wales, of which I am President, has been involved in desperately trying to keep maternity units close to people’s homes. The conclusion formed by Ford and colleagues in their recent report,1 that women with a previous postpartum haemorrhage should only deliver in units with a blood transfusion service, appears extraordinary and contradictory to their own findings. The authors based this conclusion on their finding that 5.8% of women had a postpartum haemorrhage in their first pregnancy, even though their definition of this was remarkably subjective and largely unscientific. They recognised in their study that the incidence of postpartum haemorrhage requiring transfusion is only 0.7%. Therefore, 88% of women defined as having a postpartum haemorrhage do not require a blood transfusion. I am bemused why the authors think 88% of women who did not require a blood transfusion but had a “postpartum haemorrhage” should only deliver in a unit with blood transfusion services. I doubt any of my colleagues would wish to deliver women who required a blood transfusion for a previous postpartum haemorrhage in a small unit. I refer Ford and colleagues, and readers, to a study by Tracy et al reported in January 2006.2 This was a much larger study of 750 491 women giving birth during 1999–2001. This study concluded that “In Australia lower hospital volume is not associated with increased adverse outcomes for low risk women”. In the past 10 years, we have seen the loss of 50% of our maternity units in NSW, and the rest are under severe stress due to the lack of staffing. I doubt that the sort of extraordinary conclusion made by Ford and colleagues will help us maintain services in rural NSW.

Leslie A Woollard

In reply: Safety and appropriateness are important principles underlying the provision of health care. Maternity care in Australia requires that women are offered care in an environment that is appropriate to their level of risk. Such a risk-management approach requires accurate data to inform the process, including accurate identification of women who may access local services as well as those who may benefit from higher levels of care. The aim of our study was to present risk estimates of recurrent postpartum haemorrhage (PPH) to better inform decision making by both clinicians and women about subsequent pregnancies. While we are aware of the struggles faced by rural maternity units, we estimated that only 0.2% of women giving birth in New South Wales would be affected by our suggestion that women with a history of PPH consider delivering at a hospital with onsite cross-match facilities. The definition of PPH that we used is consistent with that of the International classification of diseases1 and the NSW Department of Health’s PPH policy;2 this policy resulted from a review of hospital PPH policies sparked by a coronial inquest into a maternal death.3 In contrast to Tracy et al’s study, which only considered low-risk women and had no maternal morbidity outcomes,4 our study calculated risk among all women. Women with a PPH are at increased risk of transfusion, intensive care unit admission, unplanned procedure in the operating theatre, hysterectomy and major maternal morbidity.3 Where we have information about an increased risk of a potentially life-threatening event, surely we should communicate and act on this knowledge to achieve the best possible outcome for women and babies. In Canada, which has similar geographical challenges to those in Australia, it is recommended that where risk factors for PPH are identified, additional precautions such as intravenous access, coagulation studies, and availability of anaesthesia should also be considered.5 The key to successful regionalised maternity care is ensuring that women give birth in risk-appropriate settings.

Jane B Ford · Christine L Roberts · Jane C Bell · Charles S Algert · Jonathan M Morris

To the Editor: Pesce’s criticism of midwifery practice at Mareeba District Hospital1 requires rebuttal. His implication that the service is inefficient or pandering to “the powerful sway of maternity care politics” is incorrect and insults those who struggle to provide woman-centred care in a system focused on doctors. A private obstetrician in Sydney cannot understand midwifery workloads in a rural hospital without knowing the local environment and other impacts on the way clinicians work. The small group of midwives in Mareeba provide a highly valued service in their community, with few of the ancillary services taken for granted in metropolitan areas. In routine antenatal care, Dr Pesce presumably orders blood tests and then reviews the results filed in the chart or placed on his desk. A Mareeba midwife providing the same service will also perform the venepuncture, prepare a slide and spin the blood, arrange transport to the laboratory, make the next appointment, and file the results in the chart. A Mareeba midwife’s workload includes, among other things: Comprehensive perinatal care of inpatient midwifery clients; Postnatal and neonatal transfers from Cairns Base Hospital (CBH) (eg, to establish breastfeeding for low birthweight babies); 35–40 paediatric admissions per month; Emergency stabilisation and transfer of high-risk presentations (eg, a woman planning delivery with a private obstetrician in Cairns will nevertheless present to Mareeba when in labour at 32 weeks); Follow-up of high-risk or disadvantaged women who should attend CBH, but won’t for various social reasons; Lactation and parenting support for Mareeba women, regardless of where their deliveries occur; Pap smears and vaccinations; and Indirect care, including policy development, data collection, compilation of reports, professional development, inservice training and education. Pesce also criticised the low level of epidural use at Mareeba, which he says reflects a lack of access. However, models that provide one-to-one care in labour and promote continuity of care have been shown to decrease all interventions and increase maternal satisfaction.2,3 Perhaps the high use of epidurals and other interventions in modern tertiary units reflects a lack of access to such beneficial, woman-centred models of care.

L Gay Hawksworth

In reply: I am surprised that Hawksworth feels my editorial1 was critical of the Mareeba birth unit. There is no criticism of midwifery practice at Mareeba contained in the editorial. Several midwives have commended me for my support of the need for rural maternity units to evolve sustainable models of care based on the local workforce and infrastructure. Conversely, I received a few snide remarks from some obstetricians who felt that I had been too supportive. I have usually felt that when one is criticised by both sides in a controversial debate, one’s view is likely to be reasonable. I stand by my comments that the resourcing of the unit, based on staff–patient ratios and the availability of a nearby alternative service, would be the envy of many rural medical, surgical or community health teams. I also stand by my comments that a 1% rate of epidural use is more likely to reflect lack of access to an epidural service, rather than true patient preference. Reviews by a well known midwife of birth centre care and continuity of care confirm that these models of care decrease the use of epidural anaesthesia but are still associated with a 15% epidural rate.2,3 I am certain that if an epidural service were available, at least some of the Mareeba women would be grateful to have access to it.

Andrew F Pesce

To the Editor: Millar and colleagues recently described their comparison of the national inpatient medication chart (NIMC) with 14 other medication charts.1 They concluded that the NIMC contained design features that were adverse and therefore inferior to the medication chart previously used in their hospital. They also stated that the advantages expected by the Western Australian Director-General of Health in introducing the national chart were not experienced at their hospital. Millar et al failed to mention that the NIMC underwent an extensive process of piloting and evaluation in over 30 sites across the country in a structured before-and-after study.2 Failure to recognise (i) the benefits of standardisation as medical, nursing and pharmacy staff move between sites, (ii) the opportunities for structured safe medication practice training,3 and (iii) the value of the collaborative methods used will inhibit the possibility of overcoming problems like those identified by Millar et al in future redesign processes. Millar and colleagues themselves noted that “marked heterogeneity of chart design has been abolished by the NIMC”. The national pilot study considered the entire medication management cycle using a broad definition of medication error (“A prescribing decision or prescription writing process that results in an unintentional, significant reduction in the probability of treatment being timely and effective or increases the risk of harm, when compared with generally accepted practice”4). The NIMC was designed to reduce the risk of errors that prescribers have identified with previous charts.5 The NIMC also reduced the need for all staff to interpret unclear or incomplete prescriptions, thereby further reducing the risk of medication errors.2 We support the comments by Millar and colleagues that the process of implementing clinical practice change must involve significant buy-in and championing by clinicians. The implementation of the NIMC in Queensland recognised the importance of top-down support from senior health officials, combined with the need to increase clinicians’ awareness of risks of current systems and the need for a clear demonstration of the benefits of a revised system to bring about any substantial change in behaviour. We understand that the Australian Commission on Safety and Quality in Health Care has established a quality assurance process which operates at jurisdictional and national levels to adjust the NIMC on the basis of issues raised. This important platform will succeed in addressing the issues raised by Millar et al provided clinicians participate in this collaborative approach to medication safety. We have a rare opportunity, in which Australia is taking a leading role, to address one of the critical safety risks facing patients today. Let us all work together and criticise constructively within a framework of collaboration.

Ian D Coombes · Danielle A Stowasser · Carol M Reid · Charles A Mitchell

In reply: It is understandable that the designers of the national inpatient medication chart (NIMC) should wish to defend it against criticism, especially after 5 or more years of hard work and the major administrative achievement represented by the “top-down” implementation. It is regrettable that the chart at the centre of this otherwise admirable activity turns out to have significant weaknesses compared with the previous medication chart used at Royal Perth Hospital, and that the designers acknowledge this only obliquely by allowing for “future redesign”. Rather, they emphasise secondary outputs such as cross-border familiarity (which we discussed in our article1), “training in structured safe medication practice”, and “collaborative methods”. These supposed advantages are but small crumbs of comfort compared with the imposition of an unsatisfactory chart, loss of local autonomy and increased hazard for patients. There is no evidence that the NIMC has decreased medication errors, defined in relation to patient harm. There was indeed a pilot study, and we referred to it in two different contexts in our paper, but it assessed the chart on the basis of unsatisfactory process-based criteria similar to those employed after the chart was implemented. Perhaps a better indication of the problems of the pilot chart lies in the hundreds of suggested changes made from pilot sites to the NIMC Oversight Committee.2 We note that Coombes and colleagues do not dispute our scientific findings or the design faults we described. Their response repeats unverified claims of benefit that we discussed in our article, and seeks to reassure readers that a process is in place to “adjust the NIMC on the basis of issues raised”, thus acknowledging that “issues” exist. However, readers should be aware that the process referred to is subject to a set of ground-rules which prohibit changes to several design aspects of the chart that we criticised (eg, the block design of the pro re nata [PRN] section).3 Thus, the possibility that the NIMC will be substantially improved is remote. A more likely outcome is that Australia will be left with a chart that satisfies the superficial attraction of national standardisation but contains significant design flaws which represent a hazard to patients. A better approach would be to agree on binding national standard design elements and to restore to individual hospitals or health areas the right to design their own charts within these constraints — “think globally, act locally”.4

J Alasdair Millar · Robyn C Silla · Glenda E Lee · Ann Berwick

To the Editor: I wish to comment on Collignon’s recent editorial on methicillin-resistant Staphylococcus aureus (MRSA).1 The crux of the piece is his argument that what we need is interventional studies, not more studies documenting the extent of environmental contamination. This echoes the sentiment held by me and other colleagues working in the areas of infectious disease, microbiology and infection control. We do need more research and we need good data to evaluate interventions. However, we need to go one step further — a step that can and should be taken now, across the country. In 2006, I was part of a small team that reviewed the infection control program of a major teaching hospital in New South Wales. It became very clear that what is needed in infection control is a change in governance. At present, there is little ownership of nosocomial infections by clinicians or hospital administrators. Infection control intervention is perceived as belonging to the infection control practitioners, and not really the business of the doctors, nurses and other health workers who are caring for the individual patient. At worst, this attitude regards the necessary barrier precautions as an annoying, meddlesome burden imposed by some external agency. Clearly, such an attitude is unlikely to result in good compliance with containment measures. Infection control units have a very important role in terms of providing advice, consultancy and monitoring. But as long as there remains a general perception that nosocomial infections are solely the province of these units, progress in control is likely to be slow. One of the recommendations of our review was to change the governance structure as it relates to nosocomial infection. Elements of this included the following: Introducing infection control into the job descriptions of senior hospital executives and heads of departments; Conducting performance appraisals of these personnel to include infection control indicators; Seeking explicit agreement from all senior medical staff regarding compliance with infection control interventions; Requiring all departments to regularly and frequently review infection control indicators; and Requiring all departments to have regular, formal education sessions in infection control for all medical and nursing staff, including junior staff. We need a change in the mindset of clinicians. They must accept responsibility for what happens to their patients, including MRSA infections. These complications are no different from any others their patients may experience during their encounter with the hospital system.

Raymond C Chan

In reply: I heartily endorse Chan’s comments. To control infections in our hospitals, we desperately need not only a change in governance, but also a change in attitude. Chief executives of all hospitals, as well as all clinicians (nurses and doctors), need to take personal responsibility for serious infections that occur frequently in our hospitals. To do so, they also need to know how often these infections occur. We need robust and transparent measures — for example, data on health care-associated Staphylococcus aureus bloodstream infections, including methicillin-resistant S. aureus (MRSA),1 and deep-seated prosthetic joint infections. In recent years, faced with rising numbers of health care-associated infections, especially MRSA infections, the United Kingdom embraced necessary changes in governance. These included the promotion and use of seven key actions,2 with active surveillance and investigation being the first on the list. One of these mandatory surveillance measures was of all bloodstream infections caused by S. aureus (including MRSA)2,3 and the investigation of all episodes caused by MRSA with a “root-cause analysis”.2,4 There are early indications that the changes have successfully reduced the number of MRSA infections: from a peak of 3955 episodes of MRSA bloodstream infection occurring between October 2003 and March 2004, the number had fallen by over 40% to 2376 episodes in the period April 2007 to September 2007.3 Prevention and control of health care-associated infections must be a core part of clinical governance and patient safety programs in all hospitals. Chief executives and all clinical directors need to be aware of the numerous factors that must be given careful attention in order to reduce health care-associated infections. More importantly, they need to ensure that all appropriate steps are taken to prevent infection. This includes basic issues such as making sure that surfaces in clinical areas are adequately cleaned5 and that hand hygiene protocols are complied with — not just some of the time, but all of the time.

Peter J Collignon

To the Editor: Parasitic infections of the respiratory tract are rare causes of haemoptysis in Western communities, and are often clinically indistinguishable from pulmonary tuberculosis.1 We report a case of a 19-year-old Burmese factory worker who presented to our outpatients department with a history of haemoptysis for 4 years. He was born in Myanmar (Burma) and lived in Malaysia for 2 years before migrating to Australia. He had no past history of significance, and denied having any contacts with tuberculosis. He was a non-smoker and was taking no regular medications. His haemoptysis started in Myanmar, but increased in frequency after he migrated to Australia. He coughed up both fresh and old blood mixed with some sputum, and complained of weight loss of 6 kg, intermittent chest pain and headaches. He had no fever, night sweats, shortness of breath, dysuria, or gastrointestinal or neurological symptoms. He appeared well, and findings of a general physical examination were unremarkable. Chest x-rays from before this presentation, which included migrant screening x-rays, were normal, but his most recent chest x-ray revealed a round lesion posteriorly. A computed tomography scan organised by the patient’s general practitioner showed an area of consolidation at the base of his left lung, not typical of tuberculosis which was the primary suspect in this case. Blood tests showed a raised white cell count of 14. 5 × 109/L (reference range [RR], 4.0–11.0 × 109/L) with a neutrophil count of 11.33 × 109/L (RR, 2.0–7.5 × 109/L) and an eosinophil count of 0.51 × 109/L (RR, 0.04–0.4 × 109/L), an erythrocyte sedimentation rate of 44 mm/h (RR, 1–10 mm/h) and C-reactive protein level of 20 mg/mL (RR, < 5 mg/mL). The result of a QuantiFERON-TB Gold test for tuberculosis was negative. Attempts to obtain sputum samples were unsuccessful, and the patient underwent a bronchoscopy that revealed white milky mucous secretions within the lower lobe of the left lung, where a bronchial lavage was performed. Microscopy of bronchial washings revealed the presence of parasitic structures consistent with Paragonimus westermani (Box 1). Therapy with praziquantel was initiated at a dose of 1200 mg orally, twice daily for 2 days. His condition improved quickly and, on review in the outpatients department 4 weeks later, he had no clinically or radiologically evident recurrence of infection. Paragonimiasis is a common endemic infection in South-East and East Asia, particularly in India, China, Japan and the Philippines. Humans acquire the infection by eating raw or undercooked crayfish and freshwater crab, in which the metacercariae encyst. Once the organisms reach the duodenum, they excyst, penetrate the gut wall, and travel through the peritoneal cavity as immature flukes. They then migrate through the diaphragm and pleural space to reach the lungs, where they form adult worms.2 Early after infection, pleuritic chest pain may develop, in some cases accompanied by a pneumothorax or pleural effusion. Later, with invasion of the lung parenchyma, low-grade fever, cough or streaky haemoptysis may develop. Once the adult worms inhabit the lungs, usually after 2 months, recurrent haemoptysis becomes the cardinal symptom.3 Pulmonary paragonimiasis is most commonly misdiagnosed as tuberculosis, owing to many similarities in the clinical pictures of the two infections (Box 2).4,5 In a patient from a known endemic area, differential diagnoses should be considered and every effort should be made to obtain sputum samples or bronchial washings to distinguish between these two conditions. Serological tests are available if sputum or washings cannot be obtained. 1 Paragonimus westermani eggs detected on microscopy of bronchial washings 2 Similarities in the clinical pictures of paragonimiasis and tuberculosis Both are endemic in the same areas Neither responds to standard antibiotics Both produce chronic symptoms Symptoms of both include: Haemoptysis Weight loss Pleural effusion Chest pain

Murad G Ibrahim · Richard Bunter · Stanley Rajasooriar · Francis Thien

To the Editor: In recent years, solaria have multiplied across Australia. Solaria can emit higher concentrations of ultraviolet radiation than the midday summer sun.1 As exposure to ultraviolet radiation is a risk factor for skin cancer, including melanoma,2 it is not surprising that there is mounting evidence that solarium use increases melanoma risk.1,3-4 Public attention to this issue increased following coverage of Clare Oliver’s story in August 2007.5 Clare was dying from melanoma, which she attributed to her use of solaria. In the last weeks before her death, Clare publicly warned of the dangers of solaria. She featured in a television advertisement promoting the message “No tan is worth dying for”, launched nationally in February 2008. There is evidence that public awareness of the cancer risk of solaria increased after this media coverage. We surveyed adult Western Australians in September 2006, and again in 2007, about their perceptions of cancer risk factors. The survey was conducted by computer-assisted telephone interviewing using random-digit dialling from the Perth White Pages (2006, n = 196; 2007, n = 250). Ethical approval was granted by the Curtin University of Technology Human Research Ethics Committee. Participants were read a list of 16 factors (including solaria) and asked how each factor affected cancer risk (response categories: increase a lot; increase a little; decrease a little; decrease a lot; no effect). While risk perceptions for the other 15 factors remained constant, there was a substantial increase in the proportion of “increase a lot” responses for solaria (40% in 2006 v 72% in 2007; P = 0.001). Total “increase” responses were 71% in 2006 and 92% in 2007 (P < 0.001). In addition, Clare’s advocacy may have been a factor in increased regulation of the solarium industry. Until recently, the Australian solarium industry was unregulated, but operated under a voluntary code of practice. There is evidence that compliance with this code was lacking.6 The Australian Government has explored making the code of practice mandatory. As of 1 February 2008, the Victorian Government enacted regulations to tighten the control of solaria under the Radiation Act 2005 (Vic). Similar regulations were introduced in South Australia on 14 March 2008 and in Western Australia on 4 April 2008. There have been no campaigns about the dangers of solarium use in the general population, so it is very likely that this increase is due to the media coverage of Clare’s story. This and responses to other individuals’ personal stories7 provide evidence of how such stories can increase the community’s awareness of a health issue and gain support for legislative change.

Geoffrey Jalleh · Robert J Donovan · Chad Lin · Terry Slevin

To the Editor: We were interested to read the article on health services research (HSR) in Australia,1 and the previous editorial and articles on health technology assessment (HTA).2-5 In contrast to Australia’s prominent role in applying HSR and HTA to new pharmaceuticals, there has been very little local development of these techniques in evaluating new diagnostic technologies. The Quality Use of Diagnostic Imaging program of the Royal Australian and New Zealand College of Radiologists recently examined the introduction of new imaging technologies in Australia, with particular attention to Medicare Benefits Schedule funding. The major findings were: Delays of up to 7 years between the emergence of evidence for benefit from a new technology and Medicare listing. A large part of this delay was in the period before application to the Medical Services Advisory Committee (MSAC). A lack of significant permanent infrastructure for evidence-based assessment and prioritisation of new imaging technologies. This is in stark contrast to the situation for new pharmaceuticals and surgical procedures. Where some published evidence of clinical efficacy exists, but does not meet MSAC requirements, there is no mechanism to trigger targeted trials on questions of safety, efficacy, and cost-effectiveness. The generation of such evidence is costly, but, arguably, cost-effective in the longer term. Data collection by the Australian and New Zealand Association of Physicians in Nuclear Medicine during the interim funding of positron emission tomography has cost $2.5 million. This “coverage with evidence” approach is used in other countries, like the United States and the United Kingdom, to generate relevant evidence about the performance of emerging technologies when this does not exist in the published literature The current restriction of MSAC reviews to examining existing evidence, rather than sponsoring projects designed to provide specific relevant evidence, ensures continuing delays in the approval of new technologies for Medicare funding.

Nicholas J Ferris · Stacy K Goergen · Makhan S Khangure

To the Editor: The review of issues faced when training international medical graduates (IMGs) by Pilotto and colleagues is indeed timely.1 Their systematic presentation of these issues resonates loudly with many of the daily challenges of hospital practice. While their review referred to the shortfall of doctors, it failed to emphasise how critical this shortfall already is in some areas of hospital practice. As workloads escalate, IMGs increasingly underpin the provision of critical care clinical services. Among trainees in my department, the rise in the proportion of IMGs whose first language is not English has been dramatic, increasing from 22% of trainees in 2000 to 83% in 2007 (Box). In my experience, these doctors arrive with high expectations of the system that will train them to be critical care specialists, and place enormous pressure on themselves to achieve this. IMGs with English as a second language require greater early supervision to orient them to differences in hospital systems and language. Later, they require more assistance in preparing for the Fellowship examinations than IMGs whose first language is English. Between 2000 and 2007, an increasing clinical workload has left less time and resources for their training, and currently the needs of these IMGs are often not being met. These doctors are crucial to the provision of clinical services in our hospital, and their needs should not be ignored. Anecdotally, we are already seeing IMGs previously desperate for any training position now “cherry picking” hospitals with better resourced training programs. On average, compared with Australian medical graduates, IMGs with English as a second language spend longer in Fellowship training programs and are more likely to reattempt examinations; and the registration, training and examination fees for IMGs are considerable. The specialist medical colleges should already be in a position to fund initiatives for IMGs whose first language is not English. However, regrettably, as far as I am aware, they receive no specific help in undertaking the language-rich examination process for a Fellowship in critical care medicine. When I reflect on my specialty training, the thought of having to pursue this in an unfamiliar language is overwhelming. Not surprisingly, IMGs constantly perform under the pressure of “not measuring up”. Their appreciation of the help and training they receive is immense. However, I think one of my more important tasks as Supervisor of Training, particularly early in their training, is to remind IMGs of the great clinical work they perform day in, day out. The debt we owe them is also immense — who needs whom the most? Number of critical care trainees at Flinders Medical Centre, Adelaide, South Australia, 2000–2007, by origin and English-speaking status IMG = international medical graduate.

Andrew W Holt