General medicine

In the absence of evidence of infection with the hepatitis C virus (HCV), detecting the immunological disorder of mixed cryoglobulinaemia is a challenge. Only after extensive investigation did we suspect that our patient’s recurrent acute dyspnoea, lower limb paraesthesia and renal impairment with active urinary sediment were attributable to the rare phenomenon of non-HCV-related mixed essential cryoglobulinaemia — our suspicion was confirmed by significant serum levels of cryoglobulins. (MJA 2010; 194: 142-144) Clinical recordIn October 2008, an 84-year-old man with increasing dyspnoea on exertion for 1 week was referred for hospital admission by his general practitioner. His medical history included rheumatic heart disease leading to aortic valve replacement (AVR) in 1973. In 2001, he underwent a redo AVR, a mitral valve replacement (non-mechanical) and coronary artery bypass grafting. He then required implantation of a permanent cardiac pacemaker for complete heart block. He had chronic kidney disease (Stage 3) of unknown cause and mild, well controlled asthma. He was a lifelong non-smoker and occasionally drank alcohol. At presentation, he was afebrile and haemodynamically stable, with a respiratory rate of 20 breaths per minute and oximetry of 95 per cent on room air. There were no signs of fluid overload or peripheral stigmata of infective endocarditis. Chest auscultation revealed bibasal crackles, and loud first and second heart sounds in keeping with previous valve surgery. Mild stasis eczema was the only notable skin lesion. He reported experiencing, for the past few months, lower limb paraesthesia and sicca-like symptoms. His daily medications included perindopril 2.5 mg, digoxin 125 μg, frusemide 40 mg and warfarin at varying doses. For asthma, he was prescribed a daily inhalation of fluticasone 250 μg, with salmeterol 25 μg, and inhalations of salbutamol 100 μg as needed. Results of blood, urine and sputum tests done at presentation are shown in Box 1; results showed an inflammatory response and renal impairment with active urinary sediment (repeat urinary analysis a week after presentation also revealed active urinary sediment). An electrocardiogram showed no arrhythmias. Chest x-ray at presentation showed air bronchograms at the right lower zone (Box 2). Our patient was admitted and treated for right lower lobe pneumonia with intravenous antibiotics. He was also prescribed high-dose oral steroids, with gradual tapering of doses. A computed tomography scan showed probable right lower chest infection. During the early weeks of his hospitalisation, the patient had further episodes of acute dyspnoea, and repeat chest x-rays showed bilateral migratory opacities (Box 3). Acute episodes of dyspnoea were treated with high-dose oral steroids and intravenous antibiotics; a regular regimen of low-dose steroids was maintained between episodes. During each acute episode, his biochemistry results showed an inflammatory response, with varying elevated serum levels of C-reactive protein (CRP): 243 mg/L; 332 mg/L; 73 mg/L; 16 mg/L; 148 mg/L; and 90 mg/L (reference range [RR], < 5.0 mg/L). With treatment, the CRP level fell to 5.3 mg/L. Repeated blood and urine cultures produced no growth. A transthoracic echocardiogram revealed a normal left ventricular ejection fraction and no regurgitation from the prosthetic valves, and a transoesophageal echocardiogram showed no valvular vegetations. The serum level of B-type natriuretic peptide was 246 ng/L (RR, < 100 ng/L), making acute left ventricle failure unlikely in view of the patient’s renal impairment. No respiratory viruses were detected in nasopharyngeal aspirate. The patient’s serological tests were negative for hepatitis B virus, hepatitis C virus (HCV), HIV, cytomegalovirus, mycoplasma, Chlamydia, Legionella pneumophila, Legionella longbeachae, Brucella, Histoplasma, and Toxoplasma. The result of the QuantiFERON-TB Gold assay (Celeste) was indeterminate. Serum electrophoresis was negative and no Bence–Jones protein was detected in urine. Liver ultrasound showed no evidence of chronic liver disease. Screening for autoimmune discrepancies was significant but inconclusive — test results for serum levels of rheumatoid factor (RF) and antinuclear antibody were positive but other antibody test results were negative or within reference ranges (Box 4). On further investigation (5 weeks after admission), the patient’s serum levels of complement components C3 and C4 were 0.77 g/L (RR, 0.70–1.60 g/L) and < 0.02 g/L (RR, 0.10–0.30 g/L), respectively; repeated test results were C3, 0.74 g/L and C4, < 0.02 g/L. Such a result — low C4 with normal C3 levels — may be due to cryoglobulinaema, C4 null alleles, hereditary angioedema or activation of the classical complement pathway. Types and levels of cryoglobulins found in the patient’s serum were: monoclonal IgM/kappa, 0.4 g/L and polyclonal IgG, 0.1 g/L. HCV RNA was not detected. On the basis of the presence of cryoglobulins in serum and supported by evidence of lung and inflammatory involvement, a diagnosis of mixed essential cryoglobulinaemia (Type II cryoglobulinaemia) was made. The patient was reviewed by an immunologist, who agreed with the diagnosis. To exclude lymphoma, particularly B-cell lymphoma which is the most frequent malignant complication of mixed cryoglobulinaemia, a bone marrow biopsy was done; no significant population of B-cell biomarkers (CD19+/CD20+ cells) was found, nor any other suggestion of lymphoma. Despite the investigative effort, we did not identify a cause for our patient’s cryoglobulinaemia. He gave informed consent for all investigations. DiscussionCryoglobulins are single or mixed immunoglobulins that, in serum and other body fluids, undergo reversible precipitation at low temperatures (below 37°C in serum). According to the Brouet classification, cryoglobulinaemia is grouped into three types based on the composition of the detected cryoglobulins. Type I cryoglobulinaemia, or simple cryoglobulinaemia, is the result of a monoclonal immunoglobulin, which rarely has RF activity and is not known to activate complement in vitro. The cryoglobulins of Types II and III cryoglobulinaemia (mixed cryoglobulinaemia) contain RF, which forms complexes with the “fragment crystallisable” (Fc) portion of polyclonal IgG. The actual RF may be monoclonal immunoglobulin (in Type II cryoglobulinaemia) or polyclonal immunoglobulin (in Type III cryoglobulinaemia). Types II and III cryoglobulinaemia represent 80% of all occurrences of the disease. HCV is associated with most cases of mixed cryoglobulinaemia, with the prevalence of anti-HCV antibodies or HCV RNA ranging from 70% to almost 100%.1 The clinical manifestations of cryoglobulinaemia are generally caused by the inflammatory effects of circulating immune complexes on multiple organs. The criteria for diagnosing mixed cryoglobulinaemia are: detection in serum of mixed cryoglobulins, along with purpura and leukocytoclastic vasculitis; or detection in serum of mixed cryoglobulins, along with peripheral neuropathy, membranoproliferative glomerulonephritis, chronic hepatitis or skin rashes.1 Signs and symptoms that our patient showed fulfilled the latter set of criteria. Although our patient had no skin lesion typical of the disease (and suitable for biopsy), nor evidence of liver disease, he had lower limb paraesthesia and tested positive for renal impairment and active urinary sediment. The success of steroid treatment indicated an inflammatory component to the problem. Furthermore, lung involvement is reported to be quite frequent in mixed essential cryoglobulinaemia,2 and migratory lung lesions have been associated with the disease.3 What is notable about this case is the lack of evidence of HCV infection. To the extent that we are able to establish (two PubMed searches of English-language articles were undertaken), it is the first reported case of mixed essential cryoglobulinaemia with migratory lung lesions and unrelated to HCV infection. 1 Results of patient’s blood, urine and sputum investigations at presentation Test Result Blood Haemoglobin 110 g/dL (RR, 135–180 g/dL) White cell count 9.2 x 109 cells/L (RR, 4.0–11.0 x 109 cells/L) Neutrophils 6.5 x 109 cells/L (RR, 2.0–8.0 x 109 cells/L) Platelets 174 x 109 cells/L (RR, 140–400 x 109 cells/L) C-reactive protein 243 mg/L (RR, < 5.0 mg/L) Sodium 138 mmol/L (RR, 135–145 mmol/L) Potassium 4.8 mmol/L (RR, 3.5–5.1 mmol/L) Urea 13.3 mmol/L (RR, 2.9–8.2 mmol/L) Creatinine 160 μmol/L (RR, 64–108 μmol/L) Cultures (three sets) No growth after 1 week incubation Urine Microscopic analysis Active sediment* Dipstick Moderate blood, 2 + leukocytes, trace protein Culture No growth after 1 week incubation Sputum Culture Normal respiratory flora RR = reference range. * Active urinary sediment is sediment found in a centrifuged urine sample and showing red cells, red cell casts and at times white cells and white cell casts; it indicates active kidney inflammatory disease such as glomerulonephritis, interstitial nephritis or vasculitis. 2 Patient’s chest x-ray at presentation showing air bronchograms at right lower zone (2 October 2008) 3 Patient’s chest x-rays several weeks after presentation showing bilateral migratory opacities (A, 16 November 2008; B, 24 November 2008) 4 Results of patient’s autoimmunity screening tests at presentation and 4 weeks after presentation Test Initial result Result at 4 weeks Rheumatoid factor (RR, < 20 IU/mL) 51 IU/mL < 20 IU/mL Anticyclic citrullinated peptide antibody (anti-CCP) < 6 U/mL — Antinuclear antibody (ANA) (RR, < 40 titre) > 2560 titre 640 (homogenous) titre Anti-double-stranded DNA antibodies negative — Anti-Sjögren’s syndrome A / anti-Sjögren’s syndrome B antibodies (anti SSA/SSB antibodies) negative — Direct Coombs test negative — Antithyroid peroxidise antibodies (RR, < 50 IU/mL) 1 IU/mL — Antithyroglobulin antibodies (RR, < 100 IU/mL) 7 IU/mL — Antitissue transglutaminase antibody (anti-TTG [IgA]) (RR, < 5 U/mL) 0 U/mL — RR = reference range

Muhammad Kashif Nadeem MB BS, MRCP · Mohammed A Khateeb MB BS, FRACP

Not so long ago, The Australian ran a story1 that instantly reminded me of the memorable misquoted line from the Kevin Costner movie Field of Dreams: “If you build it, they will come”. The headline boldly proclaimed: “Another super clinic to get by with no doctors”. It continued: A second Gillard government GP super clinic is destined to open its doors without a doctor. The $7 million clinic ... will not have a doctor but will be staffed by up to 40 allied health workers, including psychologists, nurses and diabetes educators. ... [it is but one] of the original 36 GP super clinics promised during the 2007 election campaign. The appearance of super clinics without the necessary complement of doctors on staff contravenes government policy that GP super clinics must include general practitioners. This phenomenon prompted the Opposition primary health spokesman to observe that the GP super clinic program had “become like a rolling episode of Yes Minister. Another day, another GP super clinic without a doctor, another example of how three years on this program had been mismanaged, overly promoted and under-delivered.” This turn of events is but another example of the political and bureaucratic bloody-mindedness so alive in health these days. What folly, to never for one moment consider the uneasiness of GPs and organised medicine about the utility of GP super clinics. The political decision has been made, and money is no object. It is reminiscent of the roll-out of the Divisions of General Practice some years ago. Apparently, the Divisions are now destined to metamorphose into Medicare Locals. And the wheel goes around and around! Costner’s character in Field of Dreams desperately wanted a baseball field. But if the story of GP super clinics in Australia were to be made into a movie, would Nicola Roxon, the federal Minister for Health, transform the memorable line to: “We will build it ... but will they come?”

Martin B Van Der Weyden

Procedures to select medical specialist trainees aim to predict which junior doctors will become the best specialists. A 1998 review of Australian postgraduate selection processes recommended use of the principles of good assessment. Australia has expertise in national procedures used by medical schools to select students for undergraduate and graduate courses, but little experience in national specialist training program selection. A system for selection into postgraduate general practitioner training, based on a national “selection-centre” approach used in the United Kingdom, is being piloted in Australia. Initial evaluation shows the piloted system to be feasible but further evaluation is needed. Any selection-centre approach must be adapted to the Australian health care context and have the confidence of the trainees, the professional colleges, the training providers and the public.

Christopher Roberts FRACGP, MMedSci, PhD · John M Togno MB BS, FRACGP, GradCertHEd

Timeliness is important only to the extent that high-quality patient care is preserved Increasing demand for emergency care has worsened access to acute hospital services across the developed world. Australia’s response has been a mixture of time-based emergency department (ED) targets to drive process improvements, efforts to divert patients from EDs into community-based services and changes to accelerate hospital-wide processes and patient discharges. There has also been increased investment in bed capacity, although not commensurate with rising demand. Seasonal planning has been undertaken for both acute and sub-acute sectors. Despite these initiatives, access to acute hospital care has become measurably worse.1 The Australian Government has announced the introduction of a 4-hour rule that guarantees all emergency patients access to a hospital bed within 4 hours of arrival if clinically appropriate; the target will apply to critically ill patients (triage category 1) by January 2011, and to all patients by January 2015.2 Almost simultaneously, the United Kingdom Government has announced that it will replace England’s 4-hour standard with measures of patient outcome and safety,3 designed to deliver continuous improvements in standards in EDs. A look at the experience in England and why the decision has now been taken to move away from a time-based standard may reveal lessons for Australia about how to implement its new rule. The 4-hour emergency access standard in England is different from the guarantee announced in Australia because it allows for fewer exceptions, requiring that all ED patients be admitted, transferred or discharged within 4 hours of arrival in the ED. It has been in place for nearly 10 years, with a 98% operational threshold since 2003 to allow for the small number of patients who need more than 4 hours of ED care. Despite some obvious attempts at gaming and data manipulation,4 it has genuinely reduced length of stay overall in EDs and won patients’ approval.5 Before the introduction of the standard, there was evidence of patients having long waits in EDs before being seen by a doctor and before being transferred to a ward. The causes of delays were variable between hospitals.6 Also as a direct consequence of the 4-hour standard, innovations7 to manage patient care more efficiently have been introduced, including new models of care (eg, clinical decision units to fast-track care of patients with minor injuries). However, initiatives to reduce ED attendances have had little success. In fact, they may have led to poor practice in some hospitals, such as premature discharge and transfer of patients from the ED, resulting in preventable deterioration and mortality.8 Investment in the UK National Health Service (NHS) has doubled in recent years,9 with increased hospital staffing and capacity, increased resourcing of EDs and increased investment in community social care. The 4-hour standard has been the single major performance measure of the processes of the UK’s emergency care system. NHS organisations were strongly performance managed against this standard, with penalties for not achieving it. Hence, a lot of effort was expended to meet the target. In most EDs, accurate data collection systems are now in place to track patients, but are not necessarily available throughout the rest of the patient journey. Research has shown a link between length of stay in the ED and various outcomes, but it is not known whether overall patient outcomes have improved or deteriorated as a result of the 4-hour target. The Mid Staffordshire Trust review10 found that an excessive focus on time-based targets caused a significant increase in patient mortality and a major outbreak of hospital-acquired infection. But an independent report from Harvard University found “no evidence for any of the dysfunctional effects”.11 A recent Nuffield Trust report5 suggested that the emphasis on time in EDs had resulted in increased referral of patients between agencies, but no real improvement in efficiency and possible decline in efficiency. The over-focus on time-based medicine may result in work dissatisfaction for staff and decreased training opportunities. Additionally, the patient contact time may be reduced or hurried, potentially decreasing both patient and doctor satisfaction. The evolving approach in England aligns to the incoming UK coalition government’s commitment to freeing the NHS from what it sees as unnecessary micro-management through the imposition of process targets. Its more holistic approach is to hold the NHS to account for clinical outcomes and the quality of patients’ experiences, and to allow local decisions on processes and structure; results of a dashboard of clinical quality indicators will be published to encourage continuous improvement. Nevertheless, the UK Government recognises the clinical importance of timeliness of care and has said that it will include it in the dashboard of indicators. The lesson for Australia is that although introduction of a rigid time-based target to empty EDs is seductively simple and potentially effective in solving a single problem, there are significant dangers. Measurement systems should be in place to ensure that patient safety and quality of care are not compromised at any stage of the emergency care pathway. This requires a significant investment in information technology and highly developed monitoring of patient care processes and outcomes, including national registries for high-risk, high-cost patients and national audits of important standards of care. Clinicians in both countries agree that best care combines optimal outcome, patient experience and timeliness, and involves looking at the whole emergency care pathway from the first call for help until return home.

Peter A Cameron MD, FACEM · Matthew W Cooke PhD, FCEM, DipIMC

The Canadian Medical Association Journal recently ran a commentary entitled “Who you calling obese, Doc?”.1 It noted that in most Western nations, obesity, as defined by a body mass index of 30 kg/m2 or higher, has assumed epidemic proportions, and the word, like many others in the medical lexicon, has been absorbed into the vernacular. However, the word “obesity” is weighed down with negative connotations, both personal and social. Because of the capacity of the pejoratives “obese” or “obesity” to stigmatise, people use these words with great care and strip away as much of the implicitly judgemental language as possible by substituting terms such as “a person with obesity” or by suggesting that an individual is “medically obese”. The motivation underpinning such verbal gymnastics is idealistic and laudable, intending to give minimal offence and shifting the focus from the person to the condition. It has become an integral part of the new medical lexicon, removing the bluntness of certain medical terms and replacing them with more politically correct (PC) language. However, this fear of hurting an individual’s sensibilities can drive language into foggy territory. This is as true in medicine as it is in other areas of human endeavour. Dr Sally Satel, psychiatrist and resident scholar at the American Enterprise Institute for Public Policy Research in Washington, DC, has published her thesis on the weakening and dilution of medical language in PC, M. D. How political correctness is corrupting medicine.2 She claims that twisting language to avoid occasioning hurt can sometimes be more insulting than edifying: “You are basically sending the message that people are so fragile that they can’t tolerate reality”. A further example of the handiwork of the PC brigade in medicine is the substitution of the traditional term “patient” with “consumer”, “customer” or “client”. As some wag has noted, in our more socially restrictive past, the term “clients” was notoriously reserved for “customers” of the sex industry! However, to fall back on a well worn cliché: there is nothing new under the sun. Euphemisms have always been embedded in our language as we have habitually sought to cushion our emotional response to taboo subjects, such as these examples noted elsewhere: death (“going to sleep”), pregnancy loss (“born still” or “stillborn”) and menstruation (“time of the month”).1 Moreover, this watering down of language can also be found in everyday medical parlance. We now speak of “cardiac impairment” or “cardiac insufficiency syndrome” instead of “heart failure”. This filtering and twisting of reality through feel-good rhetoric may well come back to haunt us in the long run. Interestingly, political correctness is not the only movement changing the medical vernacular. Another is the corporate world. We witness daily the many ways, subtle and not so subtle, that the incompatible corporate structures of the world of business, with their bureaucratic language and allure of success and fortune, have intruded into the medical world. Indeed, the purist may well claim that the medical world has been traduced by corporatisation and business modelling. Like many other things in medicine, we have lost control of our language. Martin B Van Der Weyden

Martin B Van Der Weyden

On 8 June 2009, I started work as a locum gastroenterologist on the other side of the world and in a very different environment to the one I was used to. The inspiration for my visit came from an article in the careers supplement to the BMJ.1 A specialist trainee in infectious diseases wrote of his experiences working in Royal Darwin Hospital in the “Top End” of Australia’s Northern Territory. He described the hospital as modern and well equipped, but lacking a full-time gastroenterologist. On an impulse, I offered my services for 3 months, and my offer was accepted. I applied for a 3-month sabbatical — my first sabbatical — from my post of 18 years as a gastroenterologist at the Royal Victoria Hospital, Belfast, and a senior lecturer at Queen’s University Belfast, Northern Ireland, United Kingdom. I must confess that I wasn’t entirely naïve about life and work in Australia. I had previously worked at the Austin and Heidelberg Repatriation hospitals in Melbourne for 18 months in 1990–1991, and I had been back “Down Under” on holiday in 2007, visiting Sydney and Melbourne, as well as Uluru (Ayers Rock) and Port Douglas. Having enjoyed both my previous trips to Australia, I was keen to work there again, especially in the Top End with its particular challenges, not least of which is its remote tropical location, far from Australia’s major cities. After my impulsive decision, I had plenty of time to get used to the idea — negotiating my leave of absence and completing all the necessary paperwork for the Australian authorities took almost 2 years. With Australia’s NT designated as “an area of unmet need”, I was sponsored by the NT Government to obtain an advanced competency registration with the Australian Medical Council and a temporary residency visa for 3 months. I arranged to go during the European summer so that my wife and our two youngest children (who were on school holidays in July and August) could join me for a good part of the time. This also meant we would be in Darwin in the dry, winter season, when the daytime temperature is a comfortable 32°C with moderate humidity, and avoid the very humid wet season. On my first day at the hospital, I was given the role of general physician and put in charge of one of four admission teams, each consisting of a consultant, a registrar and one or two junior doctors. Each team was on duty for 24 hours one weekday per week, and one weekend day for three out of four weekends, and responsible for 15–30 patients at any time, with up to 15 patients admitted on a take-in day. The hospital has an excellent emergency department as well as a rapid assessment planning unit, which was used jointly by physicians and surgeons to assess their patients in the first 24 hours after admission. I soon discovered that there were three main categories of patients at Darwin Hospital: Aboriginal people from the Darwin area and much further afield; other local Darwinians, most of whom had moved to Darwin from other parts of Australia and South East Asia; and older, retired Australian tourists who come to the NT to escape the southern winter (the “grey nomads”). Patients from outside Darwin are brought in by air ambulance. The Royal Flying Doctor Service (RFDS) does not operate in the Top End of the NT, which has its own air ambulance service, but occasionally patients are flown to Darwin by the RFDS from Alice Springs or from areas of Western Australia and Queensland. It is often quicker to fly to Darwin than to one of the other major cities because of the immense distances involved. Although about 30% of the NT population are Aboriginal and Torres Strait Islander people, most living in remote areas, they make up a disproportionate 40%–60% of the patient population at the hospital. This reflects the relatively poor health status of Indigenous Australians compared with the non-Indigenous population. Their high level of diabetes, chronic renal disease, hypertension, heart failure and alcoholism is a disturbing fact, as is their lower life expectancy; the life expectancy gap at birth between Indigenous and non-Indigenous people is 12 years for males and 10 years for females.2 Furthermore, perinatal and infant mortality rates are two to three times non-Indigenous rates.2 My stay helped me to appreciate the complex reasons for this situation, which encompass social and economic as well as educational factors, not to mention the difficulties of delivering health care to remote communities. I greatly enjoyed the challenge of medical practice in a new environment. As well as the usual presentations of patients with neurological, cardiorespiratory and hepatic conditions, we were faced with cases of severe sepsis, tuberculosis, melioidosis (Burkholderia pseudomallei), rheumatic heart disease, severe complications of diabetes, meningitis and infected scabies. The radiological findings discussed at multidisciplinary meetings seemed to have been drawn from a textbook of septic complications. This contrasted with multidisciplinary meetings in the UK, which have been specifically set up to deal with patients with cancer. I rapidly learnt to prescribe ceftriaxone with or without gentamicin as the initial antibiotic regimen, which proved to be life-saving in many situations. My sabbatical coincided with the height of the swine flu outbreak; typically, six or more patients with this condition were admitted each day. The severity ranged from relatively mild to critically ill, with patients in the latter category requiring ventilation and intensive care. Darwin is soon to have its own medical school, but for many years it has functioned as a satellite centre for training students from the medical schools at James Cook University in Townsville, Queensland, and Flinders University in Adelaide, South Australia. I was hugely impressed by the high level of medical care delivered by all the staff in the hospital. Their dedication and professionalism were very evident and, in conversation, I became aware of a strong vocational motivation that elsewhere is becoming lost in an increasingly cynical world. Many of my colleagues relished the challenges of working in Darwin. They were all Australians but, with the exception of the senior physician, Dr Diane Howard, none were originally from Darwin. Their experience of medicine in the major cities in Australia, where they had previously trained and practised, was similar to mine in the UK. They looked upon their time in Darwin as something of an adventure, not dissimilar to my own experience. Of particular value were the hospital’s cultural awareness seminars, which enabled new staff to gain some understanding of the culture of Indigenous people. The key points that I gained from these seminars were an appreciation of the complexity and richness of Aboriginal culture, and the profound personal disruption for Aboriginal people that admission to hospital entails. Hospital admission is traumatic for anyone, but for people who live in small, isolated communities with strong family relationships, it is deeply disturbing and bewildering. First, they have to cope with being unwell, and then with being flown several hundred kilometres to a place which must seem alien in virtually every respect — uncomfortably cold air-conditioning, different food, a different language, and frightening procedures. I learnt that even small things like eye contact, which we regard as a polite courtesy when talking to another person, may be threatening and confrontational to Aboriginal people. Great efforts are made to bridge this cultural gap by providing interpreters and Aboriginal liaison officers, and by encouraging a friend or relative to travel with patients and stay with them at the hospital. These current efforts contrast with some of the misguided government interventions of the past, most notably in relation to the “stolen generation”, when Aboriginal children were removed from their families “for their own good”. I found that these events are still vividly remembered and resented. During my trip, I was fortunate in being able to visit a health clinic in Oenpelli (Gunbalanya), in West Arnhem Land, about 300 km from Darwin. I particularly noticed a mural in the clinic, prominently displaying the word “Reconciliation”. Coming from Belfast and having lived through “the Troubles”, I could not help thinking of the parallels with the situation in Northern Ireland, with our community also struggling with reconciliation — two cultures trying earnestly to understand one another and come to a working arrangement. Health care is often on the frontline of cultural divisions. In Northern Ireland, the health service served both sides faithfully and impartially and was undoubtedly a force for good. I sensed that the health services in the NT are in a similar position. I have now returned to my normal job in Belfast, facing up to old challenges and some new ones. On reflection, I consider myself very fortunate and privileged to have practised medicine in Darwin, to have been accepted so generously by new colleagues, and to have learnt so much from them and from the patients we cared for. I found it refreshing, humbling, often thought-provoking and at times inspiring. It is an experience that I and my family will never forget. Murals promoting Aboriginal health and reconciliation at the Oenpelli (Gunbalanya) Health Clinic, West Arnhem Land, NT (published with permission). I am dwarfed by one of the Northern Territory’s magnetic termite towers, with its accurate north-south alignment to control temperature.

R G Peter Watson MD, FRCP(UK), FRCPI

The pen & the stethoscope. Leah Kaminsky, editor. Melbourne: Scribe Publications, 2010 (x + 223 pp). ISBN 9781921640735. “Medicine is my lawful wife and literature my mistress; when I get tired of one, I spend the night with the other.” This quote from Anton Chekhov, perhaps the most famous doctor–writer, appears in the flyleaf of The pen & the stethoscope, a collection of stories by doctor–writers. Despite my misgivings about presenting fiction and non-fiction in the same volume, this is a seamless set of narratives by doctors, from varying specialties, who are also accomplished writers. It demonstrates that we, as doctors, have moved beyond the 19th century and Chekhov’s need to separate our scientific and humane selves in the clinical setting. Leah Kaminsky, herself an award-winning author and practising family physician in the United States, has assembled an international cast of doctor–writers who illuminate issues such as the challenge of ageing, suicide of a colleague, and guilt at failure but also success in medicine. We are treated to an insightful exploration of the thoughts and feelings of doctors in their daily work. The point of view of patients and their loved ones is also elaborated with great skill. Ethan Canin, in his exquisite tale, “We are nighttime travellers”, details the disintegration of a man and his marriage over many years, and his final very moving redemption. In “The checklist”, Atul Gawande details a doctor’s simple but ingenious idea that has saved lives. “Do not go gentle”, by Irvin Yalom, is an account of a psychiatrist who can identify with his patient who hoards the letters of a long-lost lover. Oliver Sacks, in “The lost mariner”, writes about a neurological conundrum with his usual fluidity and flair. Jacinta Halloran, in “Finding Joshua”, exposes every doctor–mother’s fear that a demanding job will not leave enough time for her children. I enjoyed reading The pen & the stethoscope. The stories are well written, thought provoking and appealing to both doctors and lay people. Medical students may find these narratives particularly enlightening. I recommend this collection as a good addition to the Christmas holiday reading list.

Sue Ogle

101 top tips in medicine: cynical and otherwise. John Larkin. Oxford: Radcliffe Publishing, 2010 (131pp). ISBN 9781846193989. JOHN LARKIN is a consultant physician and rheumatologist from Glasgow and, if his writing is anything to go by, is clearly not someone who will ever be accused of taking himself too seriously. His self-described absence of any superior qualifications, testimonials or, indeed, literary merit appear to make him perfect for this “cynical” take on hospital life in the follow-up to his 2005 debut book, Cynical acumen. 101 top tips in medicine is an on-call-style book, but with the sort of home truths we would only have previously expected from the “Fat Man” in the satirical novel The house of God by Samuel Shem (pen-name of psychiatrist Stephen Bergman). The 101 top tips are divided into categories — cynical, survival, clinical, career and miscellaneous — although the majority have the wry, tell-it-how-it-is style that Larkin does so well. Included are a number of practical day-to-day tips to help you through internship and early residency years, as well as those classic gems that are generally only offered by senior doctors after you’ve learnt them the hard way. Everything from “don’t answer a telephone if it’s not for you” to “always touch a bed before sitting on it” is explained and justified (a hand is far easier to wash than pants, after all). While you’d be hard pressed to call this a “medical text”, it’s the only one I’ve ever been able to sit down and read from cover to cover. Anyone will be entertained by Larkin’s anecdotes and the liberal use of footnotes that provide a humorous narrative style, but the intended audience is clearly medical students and junior doctors. This book would make a great light read for any junior doctor (or consultant whose sense of humour is still intact) or gift for a fresh graduate.

Daniel J Scherer

Objectives: To explore the perceived impact of medicolegal concerns on how Australian doctors practise medicine and to compare doctors who have experienced a medicolegal matter with those who have not.Design and setting: Cross-sectional survey (posted in September 2007, with reminder 4 weeks later) of Australian doctors from all major specialty groups, trainees and a sample of general practitioners who were insured with a medical insurance company.Participants: 2999 respondents of 8360 who were sent the survey.Main outcome measures: Perceived practice changes due to concerns about medicolegal issues, beliefs about medicolegal issues, and the influence of medicolegal issues on both career choices and how doctors relate to their patients.Results: Respondents reported changes in practice behaviour due to medicolegal concerns, with 43% of doctors stating that they referred patients more than usual, 55% stating that they ordered tests more than usual, and 11% stating that they prescribed medications more than usual. Respondents also reported improved communication of risk (66%), increased disclosure of uncertainty (44%), developed better systems for tracking results (48%) and better methods for identifying non-attenders (39%) and for auditing clinical practice (35%). Concerns about medicolegal issues led to 33% considering giving up medicine, 32% considering reducing their working hours and 40% considering retiring early. These proportions were all significantly greater for doctors who had previously experienced a medicolegal matter compared with those who had not.Conclusions: This Australian study, like international studies, confirms that doctors’ concerns about medicolegal issues impact on their practice in a variety of ways. There is a greater perceived impact on those doctors who have previously experienced a medicolegal matter.

Louise M Nash MB BS(Hons), BA, FRANZCP · Merrilyn M Walton BA, MSW, PhD · Michele G Daly BSc(Hons), MSc · Patrick J Kelly BMath(Hons), PhD · Garry Walter BMedSc, PhD, FRANZCP · Elizabeth H van Ekert BA, DipEd, MMedHum · Simon M Willcock MB BS, PhD · Christopher C Tennant MD, MPH, FRANZCP

The Victorian Department of Health reviewed its Hospital in the Home (HIH) program in 2009, for the first time in a decade. Annual reimbursements to all Victorian hospitals for HIH care had reached $110 million. Nearly all Victorian hospitals have an HIH program. Collectively, these units recorded 32 462 inpatient admissions in 2008–09, representing 2.5% of all inpatient admissions, 5.3% of multiday admissions and 5% of all bed-days in Victoria. If HIH were a single entity, it would be a 500-bed hospital. Treatment of many patients with acute community- and hospital-acquired infections or venous thromboembolism has moved into HIH. There is still capacity for growth in clinical conditions that can be appropriately managed at home. The review found evidence of gaming by hospitals through deliberate blurring of boundaries between acute HIH care and postacute care. The Victorian HIH program is a remarkable success that has significantly expanded the overall capacity of the hospital system, with lower capital resources. It suggests HIH with access to equivalent hospital remuneration is necessary for a successful HIH policy. Hospitals should invest in HIH medical leadership and supervision to expand their HIH services, including teaching. HIH is a challenge to the traditional vision of a hospital. Greater community awareness of HIH could assist in its continued growth.

Michael Montalto MB BS, PhD, FRACGP

Objectives: To review the literature on different models of clinical governance and to explore their relevance to Australian primary health care, and their potential contributions on quality and safety.Data sources: 25 electronic databases, scanning reference lists of articles and consultation with experts in the field. We searched publications in English after 1999, but a search of the German language literature for a specific model type was also undertaken. The grey literature was explored through a hand search of the medical trade press and websites of relevant national and international clearing houses and professional or industry bodies. 11 software packages commonly used in Australian general practice were reviewed for any potential contribution to clinical governance.Study selection: 19 high-quality studies that assessed outcomes were included.Data extraction: All abstracts were screened by one researcher, and 10% were screened by a second researcher to crosscheck screening quality. Studies were reviewed and coded by four reviewers, with all studies being rated using standard critical appraisal tools such as the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Two researchers reviewed the Australian general practice software. Interviews were conducted with 16 informants representing service, regional primary health care, national and international perspectives.Data synthesis: Most evidence supports governance models which use targeted, peer-led feedback on the clinician’s own practice. Strategies most used in clinical governance models were audit, performance against indicators, and peer-led reflection on evidence or performance.Conclusions: The evidence base for clinical governance is fragmented, and focuses mainly on process rather than outcomes. Few publications address models that enhance safety, efficiency, sustainability and the economics of primary health care. Locally relevant clinical indicators, the use of computerised medical record systems, regional primary health care organisations that have the capacity to support the uptake of clinical governance at the practice level, and learning from the Aboriginal community-controlled sector will help integrate clinical governance into primary care.

Christine B Phillips MA, MPH, FRACGP · Christopher M Pearce MFM, PhD, FRACGP · Sally Hall RN · Joanne Travaglia BSocWk, PhD · Simon de Lusignan MB BS, MSc, MD(Res) · Tom Love MPH, MSc, PhD · Marjan Kljakovic MB BS, PhD

Trevor Beard was born on 11 May 1920 in Gloucester, United Kingdom. He studied medicine and surgery at the University of Cambridge and worked as a Resident Medical Officer at St Bartholomew’s Hospital and the City of London Maternity Hospital. In 1951, he moved from the UK to Australia and began general practice at Campbell Town in Tasmania. During this time, he vigorously spearheaded a successful campaign to eliminate human hydatid disease in Tasmania — the first jurisdiction in the world to declare provisional eradication of hydatid disease. He was formally recognised for this work when he was made an Officer of the Order of the British Empire (OBE) in 1966. Trevor devoted his life to improving public health. In the 1970s, he joined the Department of Health in Canberra in a senior public health policy role, and in the early 1980s, he moved into cardiovascular research at Canberra’s Woden Valley Hospital. After his official retirement in 1986, Trevor returned to Tasmania in 1987 and took up an Honorary Research Fellowship at the Menzies Research Institute in Hobart. Right up to the end, he remained active in his research on hypertension and salt intake, and was involved in various research projects, including the first large community survey of sodium intake in Australia. He wrote a guide to adopting a low-salt diet,1 and went on to develop a related website (http://www.saltmatters.org). He passionately promoted the use of low-salt diets to prevent hypertension and vigorously lobbied many areas of the food industry and government, playing a pivotal role in persuading the government to lower the official sodium intake recommendations in Australia in 2005. At a local level, he advocated successfully for the Royal Hobart Hospital and Meals on Wheels to provide low-sodium meals. Trevor actively campaigned for the introduction into Australia of the UK’s “traffic light” food-labelling system (which uses colour-coding to designate low, medium and high levels of total fat, saturated fat, sugar and salt in foods). In 2010, at the age of 90, he set a challenge for Drysdale House in Hobart — training ground for future chefs in Tasmania — to reconcile gastronomy with health by providing monthly lunches that would meet low fat, sugar and salt requirements. In addition to his OBE, Trevor received many other honours. He was awarded a Winston Churchill Fellowship in 1966, the Johnston Medal from the Royal Society of Tasmania in 1987, honorary life membership of Nutrition Australia in 1997, and honorary Fellowship of the Royal Australian College of General Practitioners in 1995. He was declared Senior Australian of the Year 2006 for Tasmania. Trevor died on 2 September 2010 of acute myocardial infarction following a successful total knee replacement and is survived by his four children, Tony, Jane, Simon and Lily. One of the many privileges of working with Trevor was witnessing his passion for his work. He was a man of formidable intellect, tenacity, good humour and personal warmth. We have lost a truly remarkable colleague and friend.

Fiona A Horwood

Health systems are increasingly recognised to be complex adaptive systems (CASs), functionally characterised by their continuing and dynamic adaptation in response to core system drivers, or attractors. The core driver for our health system (and for the health reform strategies intended to achieve it) should clearly be the improvement of people’s health — the personal experience of health, regardless of organic abnormalities; we contend that a patient-centred health system requires flexible localised decision making and resource use. The prevailing trend is to use disease protocols, financial management strategies and centralised control of siloed programs to manage our health system. This strategy is suggested to be fatally flawed, as: people’s health and health experience as core system drivers are inevitably pre-empted by centralised and standardised strategies; the context specificity of personal experience and the capacity of local systems are overlooked; and in line with CAS patterns and characteristics, these strategies will lead to “unintended” consequences on all parts of the system. In Australia, there is still the time and opportunity for health system redesign that truly places people and their health at the core of the system.

Joachim P Sturmberg MFM, PhD, FRACGP · Diana M O’Halloran FRACGP, MHPEd, FAICD · Carmel M Martin PhD, FRACGP, FAFPHM

Des McGarry was born on 16 May 1931 in Concord, Sydney, at the peak of the Depression. He was educated by the Christian Brothers and Redemptorist Fathers, and initially trained to be a teaching brother and priest. In 1950, deciding he wasn’t suited to the religious life, he set his sights on medicine, but first had to save enough money to finance his studies. He worked as a jackeroo, a labourer and a penciller for a bookmaker, then joined the Royal Australian Navy (RAN) as a medical undergraduate at the University of Sydney. After graduation in 1960, Des spent a year at the Mater Hospital in Brisbane before returning to Sydney to complete 4 years as a Medical Officer for the RAN. In 1965, Des and his wife Marie moved to Longreach in central Queensland. Des and I set up practice together. We had met as interns and conceived a plan to provide a first-class, city-type practice to a remote rural region — and in the mid 60s, there were few places in Queensland more remote than Longreach. It was exciting and satisfying delivering good medical care to the region. Des proved in every way to be the complete general practitioner. Skilful at procedures, astute in the diagnosis and management of illness, caring and understanding, his gentleness, his air of quiet authority and common sense engendered in his patients a trust and confidence. He was a genuine all-rounder who also brought a great sense of humour to his work. He was awarded a Fellowship of the Royal Australian College of General Practitioners in 1974. In 1976, Des left to set up practice in Brisbane with Terry Bennett. Des tutored junior medical officers at the Royal Brisbane Hospital, and was a foundation member of the Medico-Morals Committee advising Catholic hospitals in Queensland. He was a long-time member of the Australian Medical Association. Des was easily likeable and enjoyed company, a beer, and good cigars. He loved sport, especially boxing, surfing and rugby league. He was also a serious thinker, and enjoyed reading and deep conversations. His life experience fitted him well for the role of GP, but beneath that charm and worldliness lay a much deeper emotion — a deep spirituality and love of God. He died on 7 September 2009 from metastatic cancer of the lung, leaving behind his wife Marie and their four children Patrick, Joanne, John and Paul.

Thomas J Murphy

Introducing an innovative, evidence-based resource for use in the emergency department In early 2008, the National Institute of Clinical Studies (NICS) Stroke Clinical Reference Group was formed to develop an acute stroke care resource for use in emergency departments (EDs) in Australian hospitals. The NICS reference group used a care bundle approach to develop a guideline implementation tool based on specific recommendations from the 2007 National Stroke Foundation (NSF) Clinical guidelines for acute stroke management relevant for ED care.1 Although these guidelines were already available, there are well known barriers to guideline implementation in the ED. These include increasing demand and acuity, and the broad diversity of clinical presentations. Clinical information provided for ED clinicians needs to be concise and relevant to the emergency care context. The nine-member NICS reference group represented a collaboration between stroke and ED specialists, prehospital providers and managers of state-based stroke networks, with additional guidance from the NSF. Over the following 12 months, a consultative process took place, with a combination of face-to-face and teleconference meetings and email exchanges. The reference group used a Delphi process to reach consensus. In December 2009, the NICS released two documents — the Emergency department stroke and TIA care bundle: information and implementation package and the accompanying Summary for clinicians. These are available on the National Health and Medical Research Council (NHMRC) website (http://www.nhmrc.gov.au/nics/programs/emergency/stroke_tia.htm). This editorial presents a précis of the care bundle. Care bundles have already been shown to improve guideline compliance and lead to improved patient outcomes in several settings, including the ED.2-6 A care bundle is made up of a small number of best-practice recommendation components, is not as comprehensive as a guideline, and aims to identify critical recommendations relating to areas in which there is a significant practice gap or to act as a trigger to other best practice.7 The NICS care bundle needed to bring together several components to help clinicians provide quality care to adult patients who present to the ED with suspected stroke or transient ischaemic attack (TIA) by reducing morbidity and mortality and optimising patient outcomes (Box 1). The criteria for a component’s inclusion in the care bundle were determined by the model developed by the Institute for Healthcare Improvement in the United States:7 each component must be based on sound evidence; the delivery of each component must need improvement; the delivery of each component must be achievable in terms of universally available resources; no component should be a major source of controversy; and the delivery of each component must be measurable. Two components — stroke unit care and thrombolysis — are not included in the care bundle. We acknowledge the importance of stroke unit care — and thrombolysis for patients who meet the criteria for its use — when appropriate resources are available. The NSF recommendations, along with similar international guidelines, state that thrombolysis should only be given under the authority of a specialist team with expert knowledge of stroke management and with pathways and protocols in place to guide the acute phase.1,8-10 Although there is level I evidence that thrombolysis and stroke unit care are effective early interventions for stroke,2 currently thrombolysis is only offered in 28% of acute hospitals that manage stroke patients, and stroke unit care is only available in a third of hospitals across Australia.8 The reference group considered all of these factors and decided, by consensus, not to include thrombolysis and stroke unit care in the care bundle, as the necessary resources to support these are not universally available. However, the reference group believes that an emphasis on the first component of the bundle — a rapid initial stroke screen — could lead to earlier referral to stroke specialists and rapid access to computed tomography or magnetic resonance imaging to confirm the diagnosis and develop a management plan that would consider thrombolysis if clinically appropriate.11 This illustrates how the components of the care bundle may trigger additional best-practice recommendations as a natural consequence and establish joint clinical decision making with other disciplines to improve patient care (Box 2). The NICS clinical reference group is planning to collaborate with key stakeholders in 2010 to evaluate the effectiveness of the care bundle, both as a format for providing specific guideline recommendations to a target audience and in terms of the impact on stroke care in the ED. An implementation plan and auditing tool have also been developed to assist in the uptake of the recommendations. The NICS care bundle is based on the 2007 NSF clinical guidelines,1 and its recommendations are consistent with the current draft of the 2010 NSF guidelines. It is intended that the care bundle will evolve to ensure that recommendations relevant to the ED remain current. 1 Components of the NICS care bundle Rapid initial stroke screen (grade C; level II)* ABCD2 assessment† for suspected TIA (grade B; level II) Urgent‡ CT or MRI (grade A; level I) Nil by mouth until bedside swallow screen (within 24 hours) for stroke (grade C; level I) Aspirin as soon as possible,§ if haemorrhage excluded (grade A; level I): 150–300 mg one-time loading unless contraindicated Physiological monitoring and treatment Neurological status (grade C; levels II and III-2): regular monitoring to establish baseline and identify change Blood glucose (grade B; level II): cautious treatment of markedly elevated blood glucose levels; early, intensive maintenance of euglycaemia is not recommended. Avoid hypoglycaemia Blood pressure (consensus¶): cautious lowering by no more than 10%–20% if extremely high (≥ 220/120 mmHg); monitor for neurological deterioration Hydration status (grade B; level II): maintain euvolemia NICS = National Institute of Clinical Studies. TIA = transient ischaemic attack. CT = computed tomography. MRI = magnetic resonance imaging. * Evidence-based grades and levels as per 2007 National Stroke Foundation clinical guidelines.1 † A seven-point score calculated from age, blood pressure, clinical features, duration of symptoms, and diabetes status. ‡ “Urgent” means as soon as possible, but certainly within 24 hours.1 § “As soon as possible” means within 48 hours.1 ¶ Recommended best practice based on clinical experience and expert opinion. 2 Application of the NICS care bundle* Case study 1: a 68-year-old man presents to a hospital emergency department (ED), having woken with marked weakness of his left arm. Enquiry establishes that he was fine when he went to bed 7 hours earlier. The patient’s blood pressure (BP) at triage is 186/99 mmHg. The triage nurse is concerned that the patient is having a stroke. Case study 2: a 74-year-old woman with a history of type 2 diabetes mellitus and hypertension presents to a metropolitan tertiary hospital ED. She is unable to speak and has no strength in her right arm or right leg. Her friend states that the symptoms started only 2 hours ago. The patient’s BP is 170/95 mmHg; her heart rate is 80 beats/min and the heart is in sinus rhythm; and her blood glucose level is 9 mmol/L. The following care is provided for these patients, consistent with the use of the care bundle: as part of the patient’s assessment, and based on clinical findings, conduct a rapid initial stroke screen using a validated stroke screening tool to determine whether the patient is likely to have had a stroke. If a stroke is suspected, promptly refer the patient for expert stroke management — this may include referral to a stroke unit, or thrombolytic treatment (which is likely for the patient in case study 2); order an urgent computed tomography (CT) scan of the brain; ensure no oral intake until the patient undergoes a swallow screen for dysphagia; maintain hydration via intravenous or nasogastric fluids; administer aspirin (150 mg) within 48 hours if the brain CT scan excludes haemorrhage (if the patient in case study 2 proceeds to thrombolysis, delay aspirin treatment until 24 hours after thrombolysis); monitor the patient’s neurological status, blood glucose level, BP and hydration status to prevent further deterioration. NICS = National Institute of Clinical Studies. * The NICS care bundle was written for the care of stroke patients while in the ED. If the patient is transferred out of the ED early in his or her care, it is anticipated that the remaining components of the bundle will still be provided in the new setting.

Jayantha I Weeraratne MB BS, FACEM · Annette J Lenstra BSc, GradDip(Gov) · Andrew W Lee MB BS, MPH, FRACP · Kelvin M Hill BAppSci(Physio), GradDip(BusComm) · Susan D Huckson BAppSci, RN, ICU(Cert) · Jodie L Clydesdale BNurs, GradDip(ClinNurs)

Objective: Design, setting and participants: Cross-sectional study of consecutive patients attending the Joondalup Health Campus public antenatal clinics in WA in January 2010.Intervention: Audit of uptake of the H1N1-specific vaccine.Main outcome measures: Rate of H1N1-specific vaccination, and reasons for not being the vaccinated.Results: 479 of 541 women who attended the clinics (88.5%) were included in the audit. Three women had been infected with pandemic influenza in the preceding influenza season, leaving 476 women who were eligible for vaccination in pregnancy. Of these 476 women, only 33 (6.9%) had been vaccinated. Of the remaining 443 women who were eligible to receive the vaccine but had not been vaccinated, 63.9% had not been offered vaccination despite multiple visits to their general practitioners during pregnancy, 19.6% had been advised by their GPs against vaccination in pregnancy, and 61.6% stated that they would decline vaccination if offered because of safety concerns.Conclusions: Uptake of H1N1-specific influenza vaccine in pregnant women was poor. Reasons for this relate both to vaccination not being offered to or actively sought by the women, as well as concerns — of both the women and their GPs — about vaccine safety in pregnancy. Uptake in this setting may improve if vaccination is offered through public antenatal clinics with concurrent safety education for obstetricians and vaccination providers.

Scott W White MB BS · Rodney W Petersen MB BS, MBA, FRANZCOG · Julie A Quinlivan MB BS, PhD, FRANZCOG

We identify key lessons learned from the international experience of pay-for-performance and use them to formulate questions for Australia to consider before such a scheme is introduced. Discussion of lessons learned is based on a narrative review of the literature. We examined international evidence on factors to consider when designing pay-for-performance schemes, and the impact of these schemes on primary care practitioner behaviour and on primary care funding. Pay-for-performance schemes evolve over time, and usually involve several complex interventions including accreditation, education, quality improvement programs, investment in information technology and data collection systems, professional support and regional structures. These are all necessary conditions for linking financial incentives to quality of care. There is a strong argument for changing the existing service incentive payments program and investing the resources into revised outcome payments that provide rewards for annual improvements in numbers of patients receiving completed cycles of care. If pay-for-performance is to be introduced in Australia, several key lessons should be learned from the experiences of other countries. Pay-for-performance should be used as part of a wider strategy for quality improvement; it should not be seen as a panacea. Pay-for-performance should be used to drive quality improvement, not simply to reward those who are already providing high-quality care.

Stephen M Campbell BA(Hons), MA(Econ), PhD · Anthony Scott BA(Hons), MSc, PhD · Rhian M Parker BSc(Econ)(Hons), MSc, PhD · Lucio Naccarella BSc(Hons), GDipMHS, PhD · John S Furler MB BS, FRACGP, PhD · Doris Young MB BS, FRACGP, MD · Peter M Sivey BSc(Hons), MSc, PhD

Making sense of acute medicine. A guide to diagnosis. Paul F Jenkins, Paula H Johnson. London: Hodder Arnold, 2010 (xii + 308 pp). ISBN 9780340984253. Medical diagnosis is traditionally learnt at the patient’s bedside in the presence of an experienced clinician. Time and workload pressures restrict the teacher–student relationship within a hospital. Sometimes, the clinical signs and wisdom are pieced together independently or, at best, with fractured feedback. Clinical decisions can be delayed by plentiful, irrelevant and risky investigations. Jenkins and Johnson’s book provides the inexperienced doctor or medical student with memorable material to facilitate clinical decision making. It has competition internationally but is peerless. The authors’ excellent work focuses in a very practical way on history taking and physical examination, and the rational use of investigations. Both authors have experience in Australian general medicine. Jenkins was also one of the founders of acute medicine — the specialty responsible for diagnosis and initial management of most admissions to hospital — in the United Kingdom. Acute medical units have transformed hospital general medicine overseas and are doing the same in Australia and New Zealand. Such units are a great environment for learning about diagnosis. The text is structured to cover, in a systematic way, common medical presentations (eg, “dizziness”, “breathlessness” and “weakness”). It is well organised and indexed and has easy-to-read hints and highlights that keep the reader engaged. The lists are not exhaustive but are clinically relevant to an Australian readership. X-rays illustrate common pathological lesions in the differential diagnosis. The intended readership includes medical students and junior medical trainees rather than senior clinicians. The book has limited scope; it will assist diagnosis of common conditions and prevent unnecessary investigations rather than guide prognosis, inform treatment or detail complicated pathophysiology. Overall, it is an excellent balance between affordability, portability, readability, erudition and necessary detail. I have difficulty in wresting it away from any student who visits my office.

Campbell Thompson

Objective: To evaluate whether systematic asthma care involving a register-recall system, postcard prompts for review, and education for general practitioners and staff in Australian general practice improves the quality of care and health outcomes for adult patients with moderate to severe asthma.Design and setting: Cluster randomised controlled trial in 40 general practices in urban and rural South Australia and New South Wales over the 2 years 2004 and 2005; practices were randomly allocated to the intervention or control group.Participants: 565 adult patients of these randomly allocated practices who had doctor-diagnosed moderate to severe asthma and were taking inhaled corticosteroids.Main outcome measures: Clinical asthma indicators, quality of care, acceptability of the intervention to patients, quality of life, and asthma self-management skills at baseline, 6 months and 12 months.Results: Although 46% of patients in the intervention group practices responded to the postcard prompts, only 32% actually attended for their asthma review. At 12 months, there was a statistically significant difference in provision of written asthma action plans (rate ratio, 1.9; 95% CI, 1.0–3.5; P = 0.04) for intervention group patients compared with control group patients; there was no significant difference in other indicators.Conclusion: We found little objective evidence of improvement in patient management and outcomes resulting from a systematic model of asthma care.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12605000091606

Christine H Holton GDAcc, GDPH, CPA · Justin J Beilby MD, MPH, FRACGP · Mark F Harris MB BS, MD, FRACGP · Clare E Harper BSc(Hons), MMedSci(Human Nutr) · Judith G Proudfoot GradDipSpEd, MA(Psych), PhD · Emmae N Ramsay BSc(Ma · Richard E Ruffin MD, FRACP, AM

General practitioners are often consulted for first presentations of bipolar disorder and are well placed to coordinate patient care. They can assist with early identification of bipolar disorder and monitoring for manic and depressive episodes. Delayed and incorrect diagnoses are common in bipolar disorder, and unipolar depression is a frequent misdiagnosis. Characteristics that can be used to distinguish bipolar I depression from unipolar depression (when no clear prior manic episodes are evident) include the course of illness, symptoms, mental state signs and family history. Manic episodes can be caused by poor adherence to medication, substance misuse, antidepressants and stressful events, and are often preceded by early warning signs. Early warning signs are less commonly observed for depressive episodes. Daily mood charts are useful for providing an overview of patient progress and for identifying and managing early warning signs. Families and carers can also play an active role in supporting patients with bipolar disorder.

Philip B Mitchell AM, MB BS, MD, FRANZCP, FRCPsych · Colleen K Loo MB BS, MD, FRANZCP · Bronwyn M Gould AM, MB BS, DipPaed, MPsycholMed

Inside chronic pain. An intimate and critical account . Lous Heshusius. New York: Cornell University Press, 2009 (xvii + 167 pp). ISBN 978 0 8014 4796 9. The lessons contained in this concise, personal narrative of an articulate patient crippled by chronic pain present a number of challenges to all who read it. There is a brief, scholarly foreword by David Morris, Professor of English at the University of Virginia, that sets the scene — conceptually, all chronic illness must be constructed at the crossroads of biology and culture. And there is an excellent coda by Scott Fishman, Professor of Anesthesiology and Pain Medicine at the University of California, Davis, which emphasises that the story you’ve just read is not unique. We have to ask ourselves, how can we consistently access all the options to put it together for these patients? How often do we even say, “I will go through this journey with you, and be your consultant”? More often than we care to admit, we neglect the social, spiritual and cultural dimensions of our patients’ experience in favour of a medical model of disease. The patients bear the largest burden on the journey towards recovery. How does one competently advocate for oneself when emotion and dysfunctional cognitions unduly influence the processes? Support systems are needed to negotiate a maze of clinicians, contradictory information and advice, and adversarial bureaucracies, yet time has to be spent alone in the present — not in the past or future — practising individualised coping strategies. This book will make you annoyed and frustrated — with the writer, her health care professionals, yourself, and with the system. Perhaps, you may also reflect on your management of chronic pain, and open new communication channels with your patients and your colleagues. Even undergraduates can learn from this little book, but I think it would be best read and digested by experienced clinicians. The only real downside is its North American setting. However, I can assure readers it all happens here too.

Robert D Helme

Evidence-based practice. Across the health professions. Tammy Hoffman, Sally Bennett, Chris Del Mar, editors. Sydney: Churchill Livingstone, 2009 (xiv + 349 pp). ISBN 9780729539029. Putting evidence into practice is a challenge for all health professionals; not just knowing the evidence, but being able to interpret it and put it into practice in the face of a range of barriers and constraints. The editors of this book are specialists in evidenced-based practice and have led classes in the subject for students from a range of health professions. Tammy Hoffman and Sally Bennett are both lecturers at University of Queensland’s School of Health and Rehabilitation Sciences, while Chris Del Mar is Professor of Primary Care Research at Bond University and a Coordinating Editor of the international Cochrane Collaboration. Contributors include experts from Australia and overseas, who provide a wealth of examples on how evidence-based clinical decisions are made by different health professionals. The book takes the reader from formulating the question to finding and evaluating the evidence required to answer it. This is not for the faint-hearted — the various chapters describe in detail how to appraise the validity (and bias) of intervention trials and how to interpret the significance of their findings. It may be pretty heavy going for many clinicians. However, the book then goes on to work through examples encountered by different health professionals in a wide variety of real-life clinical settings. For example, the questions about the efficacy of interventions range from cognitive behavioural interventions by practice nurses to adjuvant temozolomide with radiation therapy for glioblastoma. Most of the chapters focus on appraising individual studies. This is a good way to illustrate the use of appraisal skills and avoids the risk of providing simplistic answers to clinical questions. However, much of routine practice may be more appropriately informed by systematic reviews of the literature (such as Cochrane reviews) and systematically developed evidence-based guidelines. These are covered in Chapters 12 and 13, but without the in-depth case study analysis used in the earlier chapters. This is a little disappointing. Despite these reservations, I found this to be a surprisingly readable and thorough introduction to the appraisal of evidence for multidisciplinary clinical practice.

Mark F Harris

Objectives: To describe the health service attendance patterns of urban Aboriginal and Torres Strait Islander (Aboriginal) Australians and make comparisons with those of the general Australian population.Design and setting: General practitioner-completed survey of all attendances over two separate 2-week periods in 2006 at an urban Aboriginal health service in Canberra, which provides services for about 3500 patients per annum.Main outcome measures: Standardised attendance ratios (SARs) for a range of health problems, using patients attending Australian general practice for the same reasons as the reference population.Results: Patients attending the Aboriginal health service were significantly younger than the Australian general practice patient reference population. The most common conditions managed were psychological, encompassing substance misuse; psychological problems accounted for 24% of all attendances. Patients attending the Aboriginal health service had higher rates of attendance for psychological conditions (SAR, 2.14; 95% CI, 2.01–2.28), endocrine conditions (SAR, 2.44; 95% CI, 2.29–2.60) and neurological conditions (SAR, 2.90; 95% CI, 2.71–3.09), as well as for circulatory, digestive and male and female genital conditions, than the reference population. Patients attending the Aboriginal health service had significantly lower attendance rates than the Australian population for respiratory illnesses, and conditions related to eyes or ears.Conclusions: At this urban Aboriginal health service, attendance patterns reflected complex health care needs that are different from those expected of a population of this age. Urban Aboriginal health service attendance appears to reflect significant ill health among the patients, aligning more with Aboriginal health statistics nationally rather than health statistics for urban non-Aboriginal Australians.

Karen M Flegg MB BS(Hons), FRACGP, MIPH · Christine B Phillips MB BS, MPH, FRACGP · Anne L Collins BA, BSc · Peter G Sharp MB BS · Meetali Kanagasundaram BSc(Hons), BBiomedSc, MB BS · Ray W Lovett BN, BHSc, MAppEpi · Marjan Kljakovic MB ChB, FRNZCGP, PhD

To the Editor: We read with interest the article by Cleland and colleagues describing an urban–rural comparison of weight status among women living in socioeconomically disadvantaged neighbourhoods.1 After adjusting for socio-demographic factors, the authors reported no difference in prevalence of obesity, determined using women’s self-reported height and weight, between urban and rural areas. We would like to provide further evidence for the suggestion that obesity might be attributable to sociodemographic composition of areas. We have previously examined the association between area-based socioeconomic status (SES) and different measures of obesity in a randomly selected, population-based female cohort (aged 20–93 years, 77% participation)2 and in a similarly recruited male cohort (aged 20–96 years, 67% participation)3 within the Barwon Statistical Division in Victoria. An inverse association between SES and obesity was observed for both sexes,2,3 and was evident across three different SES indices developed by the Australian Bureau of Statistics (ABS).4 Within our female cohort, we investigated body mass index (BMI) in urban versus rural areas across the SES continuum, for 192 participants aged 20–45 years. We used standard geographical classification5 of 2006 ABS Census data to define participants’ residences as urban or rural (incorporating rural and semi-rural areas). Participants were further grouped according to the 2006 ABS Index of Relative Socio-economic Disadvantage, based on Barwon Statistical Division cutpoints. In our multivariable regression analysis, SES was categorised into the lower 30% (most disadvantaged), mid 40%, and upper 30% (least disadvantaged). Approval for this analysis was obtained from the Barwon Health Human Research Ethics Committee. No differences in unadjusted BMI were observed between participants residing in urban and rural areas (Box). These results were sustained after adjusting for age (data not shown). No interactions were identified between SES and urban or rural residence. No differences in BMI between urban and rural residence were observed for any SES group. These data suggest the lack of difference in BMI between urban and rural residents may be consistent across the SES spectrum. SES was associated with BMI (P = 0.001), while urban–rural residence was not (P = 0.5). Given these data, we suggest that SES is a stronger driving force for BMI than urban or rural residence. In our population, participants in the most disadvantaged group were more likely to be resident in urban areas. This is indicative of Geelong, the main urban centre of the Barwon Statistical Division, being one of the largest public housing areas in Victoria; urban areas provide more low-cost housing options than do rural areas. In contrast, residence in rural areas may be influenced by factors such as the “sea change” movement or prestigious real-estate options, such as the scenic coastal areas located away from the urban centre of Geelong. Mean body mass index (95% CI) of 192 women aged 20–45 years in the Barwon Statistical Division, Victoria, by area of residence Socioeconomic status* Urban† Rural† P‡ Lower 30% (most disadvantaged) 29.5 (26.8–32.1) 37.4§ 0.3 Mid 40% 27.8 (26.1–29.4) 25.3 (21.8–28.9) 0.2 Upper 30% (least disadvantaged) 25.5 (21.2–29.7) 25.5 (24.1–26.9) 1.0 Total population 27.3 (26.3–28.4) 26.1 (23.4–28.7) 0.43 * Defined by the Australian Bureau of Statistics (ABS) Index of Relative Socio-economic Disadvantage of the Socio-economic Indexes for Areas using 2006 Census data, and cutpoints of Barwon Statistical Division for 2006. † Defined by the 2006 ABS Australian Standard Geographical Classification Urban Centres/Localities. ‡ For pairwise difference. § There was only one participant in this category.

Sharon L Brennan · Margaret J Henry · Geoffrey C Nicholson · Julie A Pasco

A 38-year-old woman presented with sudden onset of haematemesis and melaena. She had no abdominal pain or jaundice, and she had not taken drugs before the bleed. On examination, she had cutaneous features of neurofibromatosis (Figure, A). Upper gastrointestinal endoscopy showed a smooth polypoidal mass, with central umbilication, in the body of stomach (Figure, B). A contrast-enhanced computed tomography scan of the abdomen showed an exophytic mass confined to the stomach. Following another haematemesis, the patient underwent an emergency sleeve resection of the mass. Histopathological examination of the removed tissue revealed spindle-shaped neoplastic cells with elongated nuclei arranged in fascicles (Figure, C), and immunostaining (Figure, D) was positive for CD117 (c-KIT), confirming gastrointestinal stromal tumour (GIST). The prevalence of GIST in neurofibromatosis type 1 (NF1) varies between 4% and 25%.1 The clinical presentation of GIST associated with NF1 is similar to sporadic GIST but differs in being multiple; large, often involving the small intestine; and having a favourable prognosis.1 Several cutaneous syndromes are associated with gastrointestinal haemorrhage as a prominent feature. Prompt recognition of these disorders is required as early intervention can be life saving.

Pazhanivel Mohan · Mohan Kaduganoor Ramakrishnan · Jayanthi Venkataraman